Current through Register Vol. 56, No. 6, March 18, 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.
