Pa. Code 5230.21

Content of individual record

This regulation requires Psychiatric Rehabilitation Services (PRS) agencies to develop and maintain individual client records containing specific elements: identifying information, eligibility and diagnosis, referral details, signed consent documents, assessments, the Individual Recovery Plan (IRP) and outcome documentation, coordination-of-services records, and a discharge summary. It is a record-keeping standard that applies to licensed PRS agencies overseen by Pennsylvania's OMHSAS and DDAP. Compliance staff must ensure all enumerated components are present and properly documented in each client's record.

55 Pa. Code § 5230.21 - Content of individual record 

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A PRS agency shall develop and maintain a record for an
 individual served containing the following:

(1)
 Information that identifies the
 individual.

(2)
 Eligibility for PRS,
 including diagnosis.

(3)
 Referral
 source, reason for referral and recommendation by an LPHA.

(4)
 A signed set of documents providing the
 following:
(i)
 Documentation of consent to
 receive PRS that is in accordance with Federal and State laws and regulations
 on obtaining consent to treatment.

(ii)
 Documentation of consent to release
 information that is in accordance with Federal and State laws and regulations
 on obtaining consent to release records.

(iii)
 Verification that the individual
 received and had an opportunity to discuss the oral and written versions of the
 PRS statement of rights under §
 
5230.41
 (relating to PRS statement
 of rights).

(iv)
 Documentation that
 the individual has chosen to receive PRS as required by §
 
5230.31
(d) 

 (relating to admission requirements).

(5)
 An assessment and updates.

(6)
 The IRP.

(7)
 Staff documentation of IRP
 outcomes.

(8)
 Staff documentation of
 coordination with other services and supports including the following: 
 
(i)
 Outreach and engagement efforts with
 natural supports, including family members, as directed by the
 individual.

(ii)
 Ongoing contacts
 and involvement with formal supports.

(9)
 Discharge summary.

Notes

55

 Pa. Code §
 
5230.21

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

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