Part V. Records Management
Article 6
Behavior Interventions
12VAC35-105-870. Paper and electronic records management policy.
A. The provider shall implement a written records management policy that describes confidentiality, accessibility, security, and retention of paper and electronic records pertaining to individuals, including:
1. Access and limitation of access, duplication, or dissemination of individual information to persons who are authorized to access such information according to federal and state laws;
2. Storage, processing, and handling of active and closed records;
3. Storage, processing, and handling of electronic records;
4. Security measures that protect records from loss, unauthorized alteration, inadvertent or unauthorized access, disclosure of information, and transportation of records between service sites;
5. 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;
6. Designation of the person responsible for records management; and
7. 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 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).
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 05, eff. December 7, 2011.
12VAC35-105-880. Documentation policy.
A. The provider shall define, by policy, all records it maintains that address an individual's care and treatment and what each record contains.
B. The provider shall define, by policy, and implement a system of documentation that supports appropriate service planning, coordination, and accountability. At a minimum this policy shall outline:
1. The location of the individual's record;
2. Methods of access by employees or contractors to the individual's record; and
3. Methods of updating the individual's record by employees or contractors including the frequency and format of updates.
C. Entries in the individual's record shall be current, dated, and authenticated by the persons making the entries. For paper records, errors shall be corrected by striking through and initialing the incorrect information. If records are electronic, the provider shall implement a written policy to include the identification of errors and corrections to the record.
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 05, eff. December 7, 2011.
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.
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 05, eff. December 7, 2011.
12VAC35-105-900. Record storage and security.
A. When not in use, active and closed paper records shall be stored in a locked cabinet or room.
B. Physical and data security controls shall exist to protect electronic records.
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 05, eff. December 7, 2011.
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 05, eff. December 7, 2011.
12VAC35-105-920. Review process for records.
The provider shall implement a review process to evaluate both current and closed records for completeness, accuracy, and timeliness of entries.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.