La. Admin. Code tit. 67 § III-6951

Current through Register Vol. 50, No. 11, November 20, 2024

Section III-6951 - Documentation of Services

A. Guiding Principles. These standards require that family violence programs establish common quality intervention services. Participation in intervention services shall be voluntary.

B. Critical Minimum Standards

1. Standard 19.1. The program must have written policies and procedures to ensure that all services provided are documented in written or electronic form and that those records are maintained in a manner that protects the confidentiality and privacy rights of individuals and families receiving services.

2. Standard 19.2. Written records of services provided in individual, group, and family settings must be maintained by the program in a secure, locked storage area that is accessible only by staff members, authorized volunteers, and administrative staff members who are responsible for supervision and internal review of service records for quality assurance purposes.

3. Standard 19.3. The program must ensure that electronic records of services to survivors are accessible only to those listed in 19.2 and that the records cannot be accessed remotely by anyone outside of the organization.

C. Minimum Standards

1. Standard 19.4. Programs must have policies in place defining record retention that includes the length of time specific records are retained and the procedures for destroying both paper and electronic records.

2. Standard 19.5. Written records documenting services must be denoted in the following manner:

a. notes are entered in chronological order;

b. notes have the full signature of the advocate or counselor documenting the service;

c. entries are to be made immediately after all survivor contacts;

d. white-out is not to be used;

e. notes are not to contain any diagnoses or clinical assessments;

f. notes on one survivor do not include other survivors names;

g. errors are to be corrected by drawing a line through the error and then writing "error" above the line along with the initials of the writer; and

h. only necessary facts are recorded.

3. Standard 19.6. Advocacy, counseling, and individual service planning documentation should include the following:

a. demographic data;

b. danger and lethality assessments;

c. history of abuse;

d. safety planning;

e. description of the abuser;

f. consent for services for the survivors and their children, if applicable;

g. individual service plans;

h. childrens assessments, if applicable;

i. notification of limitations of confidentiality;

j. release of liability forms;

k. release of confidentiality forms, if applicable; and

l. service notes.

4. Standard 19.7. All personnel of a domestic violence program with access to records of direct services provided by the program must have a signed confidentiality agreement on file. Programs should identify in their confidentiality policies the specific staff members, as identified by job responsibility and title; that will have access to confidential information, records, and information systems.

5. Standard 19.8. A data collection and record keeping system must be developed that allows for the efficient retrieval of data needed to measure the domestic violence programs performance in relation to its stated goals, objectives, and the accounting of funds received for contracted services.

La. Admin. Code tit. 67, § III-6951

Promulgated by the Department of Children and Family Services, Economic Stability Section, LR 4438 (1/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:2121-2128.