Part V. Records Management
Article 6
Behavior Interventions
12VAC35-105-870. Records management policy.
A. The provider shall develop and implement a written records management policy that describes confidentiality, accessibility, security, and retention of records pertaining to individuals, including:
1. Access, duplication, dissemination, and acquisition of individual information only to persons legally authorized according to federal and state laws;
2. Storage, processing, and handling of active and closed records;
3. Security measures to protect records from loss, unauthorized alteration, inadvertent or unauthorized access, disclosure of information, and transportation of records between service sites;
4. Strategies for service continuity and record recovery from interruptions that result from disasters or emergencies, including contingency plans, electronic or manual back-up systems, and data retrieval systems; and
5. Disposition of records in the event that the service ceases operation. If the disposition of records involves a transfer to another provider, the provider shall have a written agreement with that provider.
B. The records management policy shall be consistent with applicable state and federal laws and regulations related to privacy of health records, including:
1. Section 32.1-127.1:03 of the Code of Virginia;
2. 42 USC § 290dd;
3. 42 CFR Part 2; and
4. The Health Insurance Portability and Accountability Act (Public Law 104-191) and implementing regulations (45 CFR Parts 160, 162, and 164).
C. The policy shall specify what information is available to the individual.
D. Active and closed records shall be kept in areas that are accessible to authorized staff and protected from unauthorized access, fire, and flood.
E. Entries in the individual's record shall be current, dated, and authenticated by the person making the entry. Errors shall be corrected by striking through and initialing.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-880. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; repealed, Virginia Register Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-890. Individual's service record.
A. There shall be a separate primary record for each individual admitted for service. A separate record shall be maintained for each family member who is receiving individual treatment. The provider shall maintain each individual's record in accordance with § 32.1-127.1:03 of the Code of Virginia.
B. All individuals admitted to the service shall have identifying information readily accessible in the individual's service record. Identifying information shall include the following:
1. Identification number unique for the individual;
2. Name of individual;
3. Current residence, if known;
4. Social security number;
5. Gender;
6. Marital status;
7. Date of birth;
8. Name of authorized representative, if applicable;
9. Name, address, and telephone number for emergency contact;
10. Adjudicated legal incompetency or legal incapacity, if applicable; and
11. Date of admission to service.
C. In addition, an individual's service record shall contain, at a minimum:
1. Screening documentation;
2. Assessments;
3. Medical evaluation, as applicable to the service;
4. Individualized services plans and reviews;
5. Progress notes; and
6. A discharge summary, if applicable.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-900. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; repealed, Virginia Register Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-910. Retention of individual's service records.
The provider shall retain an individual's service record for the time period specified by state or federal requirements.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-920. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; repealed, Virginia Register Volume 41, Issue 18, eff. June 19, 2025.
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