	Risk Prevention and Management

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PA-RPM 7: Case Records*

Case records contain sufficient, accurate information to:

identify the consumer;
support decisions about interventions or services; and
document the delivery of services.

Update: Revised Third Note, Added Second NA - 03/01/11; Update: Added Third Note, Deleted First NA, Added First NA - 12/01/10

PA-RPM 7 Original Third Note:

PA-RPM 7 does not apply to Community Change Initiatives (PA-CCI), Early Childhood Education (PA-ECE), Out-of-School Time (PA-OST), and/or Youth Development (PA-YD) programs. However, if agencies provide both those and other services, the standards will apply to the agency and should be implemented in all programs/services other than PA-CCI, PA-ECE, PA-OST, and PA-YD. Agencies that provide other types of non-clinical group or crisis intervention services should contact their Accreditation Coordinator if they have questions about the applicability of these standards.

PA-RPM 7 Original First NA - 12/01/10:

The agency provides non-clinical group or crisis intervention services.

Interpretation: In addition to supporting the delivery of services, case records are an important risk management tool. Well-maintained records can help shield the agency from allegations of misconduct and negligence, while poorly-maintained records and improper documentation are a known liability.

Independent contractors who provide direct services to agency clients, maintain records for those clients in accord with PA-RPM 7.

Note: See PA-DV 17 for further guidance about the information to be included in case records for Domestic Violience Services (PA-DV).

Note: Please see Checklist: Case Records in the Tools Index for additional assistance with this standard.

Note: If the agency operates a program that qualifies for an NA but also provides other types of services, the standards should be implemented in all programs aside from those that qualify for the NA.

NA The agency provides only Community Change Initiatives (PA-CCI), Early Childhood Education (PA-ECE), Out-of-School Time (PA-OST), and/or Youth Development (PA-YD) Services.

NA The agency provides only non-clinical group, crisis intervention, and/or information and referral services.

NA The network management entity does not provide screening, assessment, service authorizations, or other services for specific clients.

PA-RPM 7.01

The agency maintains a case record for each person or family.

PA-RPM 7.02

Case records comply with all legal requirements and contain information necessary to provide services, including:

demographic and contact information;
the reason for requesting or being referred for services;
up-to-date assessments;
the service plan, including mutually developed goals and objectives;
copies of all signed consent forms;
a description of services provided directly or by referral;
routine documentation of ongoing services;
documentation of routine supervisory review;
discharge or aftercare plan;
recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and
a closing summary entered within 30 days of termination of service.

Interpretation: PA-RPM 7.02 describes the basic elements to be included in individual case records. COA recognizes that in some cases not all listed information is obtainable for a person or family. In these cases, an explanation should be placed in the case record. The listed information may not be routinely available due to the nature of the service, e.g., a low demand shelter or drop-in center.

PA-RPM 7.03

The case record contains essential legal and medical information, including, as applicable:

psychological, medical, toxicological, diagnostic, or other evaluations;
copies of all written orders for medications or special treatment procedures; and
court reports, documents of guardianship or legal custody, birth or marriage certificates, and any legal directives related to the service being provided.

NA The agency does not obtain legal or medical information.

PA-RPM 7.04

Case record entries are made by authorized personnel only, and are:

specific, factual, relevant, and legible;
kept up to date from intake through case closing;
completed, signed, and dated by the person who provided the service; and
signed and dated by supervisors, where appropriate.

Interpretation: Case records and signatures can be paper, electronic, or a combination of paper and electronic

PA-RPM 7.05

Progress notes comply with legal requirements and are entered:

at least quarterly; or
monthly, or as required by law or regulation for individuals receiving protective services, out-of-home care, day treatment, or frequent or intensive counseling or treatment.

Update: Added Interpretation - 06/01/10

Added Interpretation

Interpretation: For credit counseling agencies providing DMPs, disbursement records can suffice as evidence of progress made.

PA-RPM 7.06

Service recipients may add a statement to their case records, and:

any response by personnel is added with the service recipient’s knowledge; and
the service recipient is given the opportunity to review and comment on such additions.

PA-RPM 7.07

At case closing, case records are reviewed and unsummarized notes, personal observations, and impressions are expunged.

Update: Added NA - 06/01/10

Added NA

NA The agency only provides Financial Education and Counseling services.

QUICK JUMP TO


	PURPOSE: Comprehensive, systematic, and effective risk prevention and management practices reduce the agency's risk, loss, and liability exposure.

RELATED FILES


	PREVENTION Actions taken to minimize and/or eliminate social, psychological, or other conditions. Prevention can occur at the individual, group, community, and societal levels and enhances opportunities to achieve positive fulfillment.


	PRACTICE Established actions or ways of proceeding in the regular performance of organizational duties. Policies and procedures often guide practice.


	CASE RECORD A written compilation that describes the client and the services delivered. Records can be in hard copy and/or electronic format. The case record can be used as a source of information for quality improvement or other evaluation activities, for research purposes, or to demonstrate accountability to funding bodies.


	CONSUMER The individual, family, group, or community that seeks or receives services.


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	RISK MANAGEMENT A systematic process of evaluating and reducing potential risks that may befall personnel, clients, an organization, or a facility. Risk management activities are directed toward reducing an organization's legal and financial exposure, especially to lawsuits.


	INDEPENDENT CONTRACTOR An independently employed individual who contracts with an organization to do a piece of work according to his/her own methods and is subject to an employer's control only as to end product or final result of the work, not as to the means whereby it is to be accomplished.


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	CRISIS INTERVENTION The immediate response to the acute needs of a person in crisis including referral to appropriate community resources, advocacy, support, or direct assistance.


	MANAGEMENT See ADMINISTRATION


	LIABILITY An obligation, responsibility, or debt.


	CLIENT See service recipient.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	PROGRAM A system of services offered by an organization. For example, an organization providing a mental health service may offer several mental health programs to different populations, e.g., a mental health program for adolescent teens. The word "program" can be used interchangeably with the word "service" or to describe specific programs.


	SERVICE PLAN A written plan of action based on the assessment of consumer needs and strengths that identifies problems, sets goals, and describes a strategy for achieving those goals and engaging in joint problem solving with the consumer. Also known as a "treatment plan".


	OBJECTIVE A sub-goal stated in operational terms, i.e., a statement that makes clear what expected results are to be measured or assessed.


	AFTERCARE Additional services provided beyond the period of primary care that offer continuity and supportive follow-up.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	EVALUATION The review and assessment of organizational operations, programs and services.


	MEDICATION A prescribed or over-the-counter drug that is injected, taken orally, applied topically, or otherwise administered.


	SPECIAL TREATMENT PROCEDURES Any procedure that interferes with the right of a consumer to self-determination, involves risks about which a consumer should be informed, involves physical or psychological pain, or has the potential for harm. Examples may include, but are not limited to: interventions with consumers who resist treatment for drug or alcohol problems, wilderness/recreational activities that challenge physical abilities and contain inherent risks, or unusual approaches to behavior management, the use of physical restraint, and the use of psychotropic medication. This term is synonymously used with HIGH-RISK TREATMENT.


	CUSTODY The care, control, and maintenance of a child. The court legally can award custody to an agency in abuse and neglect cases or to parents in divorce, separation, or adoption proceedings. Child welfare departments retain legal custody and control of major decisions for a child in foster care; foster parents do not have legal custody of the children for which they provide care.


	PERSONNEL The body of employees and/or volunteers that carries out the organization's tasks under the organization's administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards


	INTAKE The client's entry point for services at which eligibility is assessed against established criteria and a preliminary evaluation of the presenting problem occurs.


	CASE CLOSING A voluntary or involuntary process which occurs when an organization no longer assumes responsibility for providing services to a particular individual, group, or family. Also known as "termination" or "discharge."


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.