{"ref":"PA-HC-REC-01","title":"Consumer Records and Documentation of Services","category":"Records","summary":"Sets out what goes in each consumer record, how direct care workers document every visit, how entries are corrected, how electronic records are kept, who may see records, and how long records are kept before secure destruction. Chapter 611 sets no record contents or retention period, so the Agency’s own standards are stated, together with the documentation the Department of Health inspects under §611.57(d) and the Medical Assistance retention periods for waiver services.","inShort":["Complete your visit note at every visit, before you leave, with your real arrival and departure times.","Mark every task done, not done or refused, and say why if it was not done.","Write facts only. If you notice a change, an injury or a concern, call the office too.","To fix a paper mistake, draw one line through it, write the correction, and initial and date it. Never erase or use correction fluid.","Never change, back-date or throw away a record. Keep records in the home private."],"primaryCitation":"28 Pa. Code §611.57(d)","citations":["28 Pa. Code §611.57(d)","28 Pa. Code §611.55(b)(8)","28 Pa. Code §611.57(c)","55 Pa. Code §52.15","55 Pa. Code §52.29","55 Pa. Code §52.43(h)","55 Pa. Code §52.43(k)","55 Pa. Code §52.43(l)","55 Pa. Code §1101.51(e)"],"federalCitations":["45 CFR §164.530(j)","45 CFR §164.316(b)(2)"],"surveyorAsks":["Show me this consumer’s record: the information packet, the signed acknowledgment, the service plan and the last month of visit notes.","How does a worker correct a mistake in a visit note?"],"forms":[{"ref":"PA-HC-REC-01-A","title":"Daily Visit Note and Task Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (28 Pa. Code §611.57(d))","5. Contents of the Consumer Record","6. Documenting Visits","7. Rules for Every Entry","8. Electronic Records","9. Access, Storage, and Records in the Home","10. Retention and Destruction","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"pa-hca","state":"Pennsylvania","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}