Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Record requirements. There shall be a complete client record
on an individual which includes information relative to the client's
involvement with the project. In addition to the requirements in §
115.32 (relating to contents), the
client record shall include the following:
(1) Drug and alcohol consent forms.
(2) Record of services provided.
(3) Referral contact.
(4) Progress notes.
(5) Individualized drug and alcohol treatment
and rehabilitation plan.
(6)
Aftercare plans, if applicable.
(7)
Follow-up information.
(b)
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.
(c)
Confidentiality.
(1) A
written procedure shall be developed by the project director which complies
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, or
organization to whom disclosure is made.
(ii) The specific information
disclosed.
(iii) The purpose of
disclosure.
(iv) The dated
signature of the client or guardian.
(v) The dated signature of a
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.
