Regulation detail

Pa. Code 5230.22

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Pa. Code 5230.22 active

Documentation standards and record security, retention and disposal

Jurisdiction: PA Agency: Pennsylvania Department of Human Services (OMHSAS) and Department of Drug and Alcohol Programs (DDAP)
OUTPATIENT (40%) RECOVERY_RESIDENCE (40%)
Plain-English summary

This section establishes documentation standards for individual records maintained by a PRS (Pennsylvania Recovery Support) agency, requiring legibility, individual identification on each page, signed and dated entries, daily progress notes, secure storage, a minimum four-year retention period, and confidentiality-protective disposal. As a record-keeping section within Chapter 5230, it inherits the scope of that chapter, which is administered jointly by OMHSAS and DDAP and governs recovery support services. Operators must ensure all individual records comply with these standards at all times.

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Regulation text
55 Pa. Code § 5230.22 - Documentation standards and record security, retention and disposal 

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A PRS agency shall ensure that an individual record meets
 the following standards:

(1)
 The record
 must be legible throughout.

(2)
 The
 record must identify the individual on each page.

(3)
 Entries shall be signed and dated by the
 responsible staff.

(4)
 The record
 must indicate progress at each day of service, changes in service and response
 to services.

(5)
 Updates of the
 record shall be signed and dated.

(6)
 The record shall be kept in a permanent,
 secure location.

(7)
 The record
 shall be maintained for a minimum of 4 years.

(8)
 Records shall be disposed of in a manner
 that protects confidentiality.

Notes

55

 Pa. Code §
 
5230.22

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

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