Current through Register Vol. 56, No. 18, September 16, 2024
(a) YCM
providers shall keep such individual records as are necessary to fully disclose
the kind and extent of services provided.
(b) Each YCM provider shall maintain the
following data in support of all claims:
1.
The name and address of the child, youth or young adult;
2. The reason for the initial
referral;
3. The name, credentials
and title of the staff member(s) providing the service(s);
4. The exact date(s), time(s) and location(s)
of the case management service(s) provided;
5. The total number of complete units of
service provided per day;
6. The
length of face-to-face contact with, or on behalf of, the child, youth or young
adult (excluding travel to or from child, youth or young adult contact or
collateral contact);
7. The name of
individual(s) with whom face-to-face contact was maintained on behalf of the
child, youth or young adult;
8. A
summary of services provided in accordance with the goals of the service plan;
and
9. The length of time spent in
collateral activities which support the provision of YCM services.
(c) Each YCM provider shall
maintain an individual service record for each child, youth or young adult
which shall contain, at a minimum, the following information:
1. The date(s) of service and total number of
units of service received;
2. The
diagnosis provided with initial referral;
3. The reason for referral to YCM and
involvement;
4. The individual
service plan, including all amendments;
5. Documentation and reporting of any and all
crisis or emergency situations that occur during the provision of the services,
including a summary of the corrective action taken and resolution of the
situation; and
6. Progress notes
which include quantifiable measurements toward defined goals, as stipulated in
the child, youth or young adult or young adult's service plan. Progress notes
shall be completed for each contact with, or on behalf of, the child, youth or
young adult. If not completed by a licensed professional, the progress notes
shall be reviewed and signed off by the program supervisor.
(d) Each YCM provider shall meet
all Management Information Systems specifications as defined by the Contract
Systems Administrator (CSA) or other Department of Children and
Families-designated agent.
(e) Each
YCM provider shall make the records described in (a) through (c) above
available to the Department of Human Services, the Contract Systems
Administrator, or other Department of Human Services or Department of Children
and Families-authorized agents, as requested.
