Case records contain sufficient, accurate information to:
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.
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.
The agency maintains a case record for each person or family.
Case records comply with all legal requirements and contain information necessary to provide services, including:
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.
The case record contains essential legal and medical information, including, as applicable:
NA The agency does not obtain legal or medical information.
Case record entries are made by authorized personnel only, and are:
Interpretation: Case records and signatures can be paper, electronic, or a combination of paper and electronic
Progress notes comply with legal requirements and are entered:
Update: Added Interpretation - 06/01/10
Interpretation: For credit counseling agencies providing DMPs, disbursement records can suffice as evidence of progress made.
Service recipients may add a statement to their case records, and:
At case closing, case records are reviewed and unsummarized notes, personal observations, and impressions are expunged.
Update: Added NA - 06/01/10
NA The agency only provides Financial Education and Counseling services.