Mains’l retains all records related to people receiving services and programs in a secure location for the period of time required by law. 

When services are provided in a licensed home, the access to the current records is maintained at the home either on paper or electronically. For services provided in the person’s own home, records are maintained at the program services office either on paper or electronically. Mains’l protects service recipient and program records against loss, tampering, and unauthorized disclosure.

The following people have access to the information in a person’s record, in accordance with applicable state and federal laws, regulations, or rules:
1.    the person, the person's legal representative, and anyone properly authorized by the person;
2.    the person's case manager;
3.    Mains’l’s employees providing services to the person, unless the information is not relevant to carrying out the coordinated service and support plan or coordinated service and support plan addendum; 
4.    the county child or adult foster care licensor, when services are also licensed as child or adult foster care; and
5.    the DHS licensor or investigator as required under the Human Services Licensing Act, Minnesota Statutes, Chapterand Chapter 245A.

The following documents are in each service recipient record per 245D.095:

  1. Admission form signed by the person or legal representative that includes:
  • the person’s legal name, date of birth, address, and telephone number; and 
  • the name, address and telephone number of the person’s legal representative, primary contact, case manager, family members, or other people identified by the person.

2.    Service information, including:

  • service initiation information
  • bverification of the person's eligibility for services 
  • documentation verifying that services have been provided as identified in the Support Plan or Support Plan addendum 
  • date of admission or readmission

3.    Health information, including medical history, special dietary needs, and allergies.
4.    When Mains’l is assigned responsibility for meeting the person's health service needs, documentation of:

  • current orders for medications, treatments, or medical equipment;
  • signed authorization from the person or the person’s legal representative to administer or assist in administering the medication or treatments;
  • signed statement authorizing the program to act in a medical emergency when the person’s legal representative cannot be reached or delayed in arriving;
  • medication administration procedures for the individual person;
  • medication administration record that documents implementation of medication administration procedures, and medication administration record reviews, including any agreements for administration of injectable medications by the program; and
  • medical appointment schedule.

5.    A copy of the person’s current coordinated service and support plan or the portion assigned to
6.    A copy of the individual abuse prevention plan/safety plan.
7.    Copies of service planning assessments required under section 245D.071, subdivisions 2 and 3
8.    A record of other service providers, including: contact person, telephone number, services being
provided, and names of staff responsible for coordination of services.
9.    Documentation of orientation to service recipient rights and maltreatment reporting policies and
10.    Copies of authorizations to handle a person’s funds.
11.    Documentation of complaints received and grievance resolutions.
12.    When requested by the person, legal representative, case manager or team: copies of written
reports regarding the person including: progress review reports, progress or daily log notes recorded by the program, and reports received from other agencies involved in providing services or care of the person.
13.    Summary of ending services, if applicable.
14.    Service suspension/termination and related documentation, if applicable.

Retention guidelines are as follows:

Category  Longest Retention Period


Requiring Retention

Service Recipient Records
Program File
Medical File
Financial File

Program Records
Licensing Documents
Incident Reports
Behavior Intervention Report Forms
Policies and Procedures



All records related to a person who is currently receiving services, are maintained for the duration of their services. Once a person’s services have ended, records are retained for seven (7) years. 

Program incident reports, BIRFS, contracts, and licensing documents are retained for seven (7) years.

Program policies and procedures are maintained until no longer required or until the policy and procedure is replaced by a new policy or procedure

MN Statute 145.30, 145.32
MN Rule 9505.2190
MN Rule 4658.0470    
MN Rule 245D.095



Service Recipient Records

Documents that are created or received by Mains’l that pertain to a person receiving services are saved in the person’s secure electronic record or paper file.  

For paper files, after a County Foster licensing review, information is removed from the individual’s medical and plan file and scanned into the Mains’l document management system.  At this time, information that has been summarized into another format (e.g. data into a progress review) may be discarded. Managers organize the information to be scanned as follows:

1.    Separate the documents into the categories of:
a.    Program
b.    Medical
c.    Financial
2.    Incorporate all documents from work books into the primary file and remove pages that are          duplicates or are general in nature and not specific to the individual.
3.    Prepare all documents for scanning:
a.    Within the categories above, arrange them in the order they appear in the plan file or medical file, according to the table of contents 
b.    Organize all pages chronologically and orient all pages within the pile the same direction
c.    Remove all staples
d.    Straighten all folded, curled edges at the top of the page
4.    Scan documents into the appropriate category within the Fortis  system.
5.    Once scanning is complete, verify that all pages have been scanned and are readable      before destroying the original.

Program Records

1.    The program services, support services and human resources departments are responsible for scanning these documents:
a.    Incident Reports        
b.    Contracts            
c.    Licensing documents        
d.    Policies and Procedures
2.    Prepare all documents for scanning as follows:
a.    Organize all pages chronologically and orient all pages within the pile the same direction
b.    Remove all staples
c.    Straighten all folded, curled edges at the top of the page
3.    Scan documents into the appropriate category within the document management system
4.    Once scanning is complete, verify that all pages have been scanned and are readable before destroying the original.


                    (Rev. 1/8/19; SR