Section 21.60. Recordkeeping

(a) Confidentiality.

(1) Client record information is confidential and may not be disclosed or made use of, directly or indirectly, except in the legitimate performance of domiciliary care services, and in monitoring and evaluation of the service by State and local officials.

(2) If names and other identifying information are disguised, material from client records may be used for other legitimate functions such as:

(i) Teaching and research purposes.

(ii) Development of understanding and knowledge of agency services by the placement agency.

(iii) Other similar educational purposes.

(b) Client records.

(1) A case record for each applicant and client reflecting an assessment of the applicant or client, and a clearly defined and periodically updated service plan for each client as specified under § § 21.54 and 21.55 (relating to AAA care plan responsibilities; and AAA placement activities) shall be maintained. A record shall include, from intake until the termination of service, a description of the responsibilities assumed by the AAA and the manner in which these responsibilities are carried out, either directly or through assignment to another agency, as well as periodic evaluations of the service delivered to the client. The evaluations shall include the appropriateness of the service from the perspective of the client and the agency.

(2) Documentation pertaining to the applicant or client, including medical and psychiatric reports; forms required by the Department to implement the domiciliary care program; and other relevant information, including relevant information regarding client and provider contract, shall be filed in the case record.

(c) Home records.

(1) A record shall be maintained for each of the homes for which an application for certification as a domiciliary care home is filed. A record shall contain information obtained from the interviews with the provider, the home inspection and the written references described in § 21.28 (relating to provider application and home certification process).

(2) Documentation pertaining to the certification of the home and application of the provider, including forms required by the Department, shall be filed with the home records.