Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Record requirements. The project shall maintain a client
record on an individual. In addition to the requirements contained in §
115.32 (relating to contents), the
client record shall include the following:
(1) Histories, which include the following:
(i) Medical history.
(ii) Drug or alcohol history.
(iii) Personal history.
(2) Drug and alcohol consent forms.
(3) Psychosocial evaluation.
(4) Referral contact.
(5) Record of services provided.
(b)
Additional
information. If applicable, the project shall include the following
items in the client record:
(1) Drug and
alcohol treatment and rehabilitation plans.
(2) Follow-up information.
(c)
Client access to
records. A client has the right to inspect his own records. The
project director may temporarily remove portions of the record prior to the
inspection by the client if the director determines that the information may be
detrimental if presented to the client. Reasons for removing sections shall be
documented and kept on file.
(d)
Confidentiality.
(1) A
written procedure shall be developed by the project director which shall comply
with 4 Pa. Code §255.5 (relating to projects and
coordinating bodies; disclosure of client-oriented information). The procedure
shall include, but not be limited to:
(i)
Confidentiality of client identity and records.
(ii) Staff access to client
records.
(2) The project
shall obtain an informed and voluntary consent from the client for the
disclosure of information contained in the client record. The consent shall be
in writing and include, but not be limited to:
(i) The name of the person, agency,
organization to whom disclosure is made.
(ii) The specific information
disclosed.
(iii) The purpose of
disclosure.
(iv) The dated
signature of client or guardian.
(v) The dated signature of witness.
(vi) The expiration date of the
consent.
(3) A copy of a
client consent shall be offered to the client and a copy maintained in the
client records.
(4) Where consent
is not required, the project personnel shall:
(i) Fully document the disclosure in the
client records.
(ii) Inform the
client, as readily as possible, that the information was disclosed, for what
purposes, and to whom.
