Recordkeeping - 6 Pa. Code § 21.60

Each area agency on aging providing domiciliary care services must maintain a case record for each client receiving services; these records must contain an assessment of the client and a clearly defined and periodically updated service plan.  Documentation pertaining to the client, including medical and psychiatric reports, must be filed in the case record.  All client records are confidential and may not be disclosed or used, except in the performance of services and for monitoring and evaluating of the services by state and local officials.  Information from such records that does not identify the client may be used for teaching and research purposes.