Title: Section 69-4.26 - Content and retention of child records
69-4.26 Content and retention of child records.
(a) Municipalities shall maintain an early intervention record for each child referred to the program which documents the performance of all activities required to be completed by early intervention officials or their designees on behalf of eligible children under Article 25 of Title II-A of Public Health Law. The early intervention record shall be maintained in a confidential manner in accordance with section 69-4.17(c) of this subpart. The early intervention record shall include the following:
(1) the original or a copy of intake and referral documents, which must include the date the child's referral was received by the municipality;
(2) Medicaid and third party payor information required for claiming, including the date such information was obtained and updated;
(3) documentation signed by the parent acknowledging receipt of information regarding the rights afforded parents under the Early Intervention Program;
(4) copies of all required written notices to the parent, which shall set forth the date the notice was sent to the parent;
(5) original or copy of signed and dated consent from the parent for the child's and family's participation in the Early Intervention Program;
(6) documentation identifying the child's and family's initial service coordinator and the date on which the such service coordinator was assigned to the child and family;
(7) where applicable, documentation of the designation of a surrogate parent for a child, including the date assigned, the surrogate parent's name and contact information, and circumstances leading to the designation of a surrogate parent;
(8) any evaluation and diagnostic reports, including family assessments and any medical records and correspondence to/from primary care physician(s) that are part of the evaluation record and demonstrate ongoing physician involvement;
(9) the child's and family's individualized family service plan and related documentation, including required six-month reviews, annual evaluations, amendments to the plan and any progress notes and other reports and documentation used at individualized family service plan meetings;
(10) originals or copies of all correspondence to/from the municipality regarding the child and family. Municipalities shall also maintain in the child's record notations of any relevant discussions with parents, providers or others regarding the child and the child's family and their participation in the Early Intervention Program, except as otherwise prohibited by law;
(11) for children in the care and custody or custody and guardianship of the local social services commissioner, originals or copies of any correspondence with the Commissioner or designee of the local social services districts. Municipalities shall also maintain in the child's record notations of any relevant discussions with the Commissioner or designee of the local social services district regarding the child's participation in the EIP;
(12) all records pertaining to any due process proceedings, except as otherwise prohibited by law, related to the child's and family's participation in the Early Intervention Program;
(13) original or copies of all correspondence with the local school district regarding the child's transition from the Early Intervention Program to services under section 4410 of the Education Law. Municipalities must also maintain in the child's record notations of all actions taken to ensure a smooth transition for the child from the Early Intervention Program to services under section 4410 of Education Law;
(14) reasons for a municipalities closure of a child's case in the Early Intervention Program and date of the closure;
(15) any other documentation and records pertaining to municipal actions and responsibilities pertaining to the child's and family's participation in the Early Intervention Program.
(b) Agency and individual providers shall maintain Early Intervention Program records for each eligible child for whom the provider is authorized to deliver service coordination services, evaluations, and early intervention services. The early intervention record shall be maintained in a confidential manner in accordance with section 69-4.17(c) of this subpart and shall document the performance of activities required to be completed by the provider on behalf of the child and family, including:
(1) written correspondence with or regarding the child/family and documentation of any relevant discussion with parents, other providers, or municipalities regarding the child and family;
(2) signed and dated parental consents relevant to delivery of services to the child and/or family;
(3) signed and dated consents related to the disclosure and/or exchange of information with other parties regarding services provided and/or the child's and family's participation in the Early Intervention Program;
(4) copies of any written notice(s) sent to the parent by the provider, which shall contain the date of such notice;
(5) the child's and family's individualized family service plan and related documentation, including required six-month reviews, annual evaluations, amendments to the plan and periodic progress notes and other reports and documentation used at individualized family service plan meetings;
(6) documentation of all authorizations by the municipality to provide early intervention services to the child and/or the child's family;
(7) documentation of accidents and incidents that have been reported to the early intervention official;
(8) written orders or recommendations from specific medical professionals when required for the services being provided to the child;
(9) reports pertaining to the child and/or family, including evaluation reports, ongoing assessments related to the services provided, and relevant professional and medical reports produced by or transmitted to the provider with parental consent;
(10) periodic progress notes shall be made by the provider and included in the child's record summarizing the effectiveness of the service and the progress being made toward outcomes included in the child's and family's individualized family service plan;
(11) where applicable, originals or copies of all written correspondence to/from the provider regarding discontinuation of services to the child and reasons why early intervention services were discontinued;
(12) documentation necessary for submission and substantiation of early intervention claims for payment by the municipality, third party payer, including the medical assistance program, and state aid reimbursement, including recipient identification (name, sex, and age of child); information on any insurance policy, plan, or contract under which the child has coverage; unit and specific type of service provided; date(s) of service; signature of parent or caregiver verifying the service was delivered; ICD diagnostic code for the condition or reasons for which care is provided; where applicable, the appropriate procedure code(s) for the service(s) provided; and, the name, address, and license, registration, certification, or where applicable, national provider identification number, of the professional delivering the service; and,
(13) any other documentation relevant to activities performed and services rendered related to the child's and family's participation in the Early Intervention Program.
(c) Individual providers who directly render services to a child and family, or an approved provider agency, shall maintain original signed and dated session notes, following each child and family contact, which shall include the recipient's name, date of service, type of service provided, time the provider began delivering therapy to child and end time, brief description of the recipient's progress made during the session as related to the outcome contained in the individualized family service plan, name, title, and signature of the person rendering the service, and date the session note was created; and a service log signed by the parent or caregiver which documents that the service was received by the child on the date and during the period of time as recorded by the provider.
(1) Qualified personnel who are licensed, registered, or certified under state education law and who deliver early intervention services shall, in addition to the provisions of this subpart, retain records in accordance with the laws and regulations that apply to their professions.
(2) A provider agency in contract with individual providers may request or require submission of copies of such providers' session notes for provider agency records.
(3) Original early intervention records generated by qualified personnel who are employees of a municipality or provider agency shall be retained by the respective municipality or provider agency.
(4) Qualified personnel shall supply original session notes upon the request of a municipality, the Department, or provider agency for programmatic monitoring and fiscal audit purposes.
(d) Agency and individual providers of initial and/or ongoing service coordination services shall document all activities related to the performance of their duties as set forth in sections 69-4.6 and 69-4.7 of this subpart, including recipient's name; date of service; a description of the specific service coordination activity performed; name, date of contact, and purpose of contact for providers or others contacted on behalf of the child and family as necessary to implement the IFSP; start and end time for each contact; and, name, title and signature of the service coordinator, as applicable.
(e) Early intervention records pertaining to a child and family shall be retained by all municipalities and agency and individual providers for a minimum of six years from the date that care, services, or supplies were provided to the child and family.
(i) Individual early intervention providers who are licensed, registered, or certified under state education law must retain child and family records for the period of time set forth in the laws and regulation that apply to their profession.
(ii) All municipalities, except New York City, shall retain early intervention program records, including but not limited to case record and screening, assessment, and referral records as follows:
(a)individual case records shall be retained until the child reaches the age of 21; and,
(b)screening, assessment, and referral records not found in individual case records must be retained for seven (7) years.
VOLUME A-1a (Title 10)