Pa. Code 5240.41

Individual records

This regulation requires Intensive Behavioral Health Services (IBHS) agencies in Pennsylvania to maintain a comprehensive individual record for each child, youth, or young adult served, including identifying information, written service orders, assessments, individual treatment plans (ITPs), documentation of each service provided, consent forms, discharge summaries, and any use of manual restraints. Records must be legible, signed and dated, reviewed for quality within six months of initial entry and at least annually thereafter, and retained for a minimum of four years after the last date of service. The chapter context indicates this applies to IBHS agencies delivering services including ABA and other behavioral health services to minors.

55 Pa. Code § 5240.41 - Individual records 

 State Regulations 

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(a)
 An IBHS
 agency shall maintain a record for each child, youth or young adult it serves
 that includes the following:
(1)
 Identifying
 information.

(2)
 A written order
 for IBHS in accordance with §§
 
1155.32
(a)(1)
,
 
1155.33
(a)(1)
 or
 
1155.34
(a)(1) 

 (relating to payment conditions for individual services; payment conditions for
 ABA services; and payment conditions for group services).

(3)
 An assessment and any updates to the
 assessment in accordance with §§
 
5240.21
,
 
5240.85
,
 
5240.95
 or
 
5240.102
.

(4)
 Presenting problems.

(5)
 The ITP and any updates to the ITP in
 accordance with §§
 
5240.22
,
 
5240.86
,
 
5240.96
 or
 
5240.102
.

(6)
 A treatment plan if services are being
 provided prior to the completion of the ITP.

(7)
 Documentation of any efforts to
 coordinate care with other services and community supports if needed.

(8)
 Documentation of each service provided
 that includes the following: 
(i)
 Date and
 time services were provided, duration of services and setting where services
 were provided.

(ii)
 Identification
 of the service provided to address a goal in the ITP.

(iii)
 Description of the outcome of the
 services provided.

(iv)
 Signature
 of the staff person providing the service.

(9)
 If services are not provided in
 accordance with the ITP and written order, an explanation of the reason why
 services were not provided in accordance with the ITP and written
 order.

(10)
 Consent to treatment
 and consent to release information forms.

(11)
 Discharge summary in accordance with §
 
5240.32
 (relating to discharge
 summary).

(12)
 Documentation of any
 use of a manual restraint and a description of how the use was in accordance
 with §
 
5240.6
 (relating to restrictive
 procedures), including the following: 
(i)
 The
 specific behavior addressed.

(ii)

 The less intrusive methods of intervention used to address the behavior prior
 to initiating the manual restraint used.

(iii)
 The specific manual restraint
 used.

(iv)
 The name and training of
 the staff person who used the manual restraint.

(v)
 The duration of the manual
 restraint.

(vi)
 The name of the
 trained individual who observed the child, youth or young adult during the
 application of the manual restraint.

(vii)
 The child's, youth's or young adult's
 condition following the manual restraint.

(viii)
 The date and time the manual restraint
 was used.

(ix)
 The date and time
 the treatment team was notified of the use of a manual restraint and the
 members of the treatment team who were notified.

(b)
 The record must be: 
 
(1)
 Legible.

(2)
 Signed and dated by the staff person
 writing in the record.

(3)
 Reviewed
 for quality by the administrative director, clinical director or designated
 quality improvement staff within 6 months of the initial entry. After initial
 review, subsequent reviews may be limited to new additions to the record and
 must occur at least annually.

(c)
 The record shall be maintained for a
 minimum of 4 years after the last date of service.

Notes

55

 Pa. Code §
 
5240.41

This section cited in 55 Pa. Code §
 
1155.22
 (relating to ongoing
 responsibilities of providers); 55 Pa. Code §
 
5240.6
 (relating to restrictive
 procedures); and 55 Pa. Code §
 
5240.98
 (relating to requirements
 for group services in school
 settings).

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