SERVICE RECIPIENT AND PROGRAM RECORD RETENTION

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
Mains’l.
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
procedures.
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: