Regulation detail

Pa. Code 5230.63

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Pa. Code 5230.63 active

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Jurisdiction: PA Agency: Pennsylvania Department of Human Services (OMHSAS) and Department of Drug and Alcohol Programs (DDAP)
OUTPATIENT (60%)
Plain-English summary

This section requires Psychiatric Rehabilitation Services (PRS) agencies to complete weekly progress notes for each service provided to an individual, documenting the service in relation to the goal, the individual's response, and their level of engagement. Staff must sign and date each weekly progress note. PRS agencies must also maintain daily attendance records showing each individual's start time, end time, and activity attended, and make those records available to the Department upon request.

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Regulation text
55 Pa. Code § 5230.63 - Documentation 

 State Regulations 

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(a)
 A PRS agency
 shall complete a progress note on a weekly basis for each service provided to
 an individual that summarizes the following: 
 
(1)
 The service provided in the context of
 the goal.

(2)
 The individual's
 response to the service.

(3)
 The
 individual's level of service engagement during the week.

(b)
 Staff providing the service shall sign
 and date the weekly progress note.

(c)
 A PRS agency shall keep daily attendance
 records of individuals served, including each individual's actual attendance
 time, which includes a start time, end time and activity or session attended. 
 
(1)
 The attendance record is not required to
 be maintained in the individual's record.

(2)
 The daily attendance records must be
 available to the Department.

Notes

55

 Pa. Code §
 
5230.63

Amended by
 
Pennsylvania
 Bulletin, Vol. 55, No. 03, January 18, 2025
, effective
 
1/18/2025

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