2022 Edition

Program Administration (CA-PRG) 2: Access to Case Records

Access to case records is appropriately limited.
NA The organization provides only Early Childhood Education (CA-ECE) and/or Out-of-School Time Services (CA-OST).

NA The organization provides only non-clinical group, crisis intervention, and/or information and referral services.

Currently viewing: PROGRAM ADMINISTRATION (CA-PRG)

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Purpose

Service delivery practices guide the administration of safe, effective programs that respect personal dignity and self-determination.
Related Standards:
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-PRG 2 Practice standards.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the CA-PRG 2 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the CA-PRG 2 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PRG 2 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Case record access policies
  • Case record access procedures
No On-Site Evidence
  • Interviews may include:
    1. Information systems manager
    2. Program directors
    3. Relevant personnel
  • Observe case record room/files and information systems accessibility observation

 
Fundamental Practice

CA-PRG 2.01

Access to confidential case records is limited to:
  1. the service recipient or, as appropriate, a parent or legal guardian;
  2. personnel authorized to access specific information on a “need-to-know” basis;
  3. former service recipients;
  4. individuals requesting records of deceased service recipients; and
  5. auditors, contractors, and licensing or accrediting personnel consistent with the organization’s confidentiality policy.
Note: Please see the Facility Observation Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record access policy or procedure needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Record access policy or procedure needs significant strengthening; or
  • In a few instances the organization does not comply with the standard.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 2.02

Service recipients may review and, when desired, add a statement to their files in accordance with applicable laws and regulations, and:
  1. reviews are conducted in the presence of professional personnel on the organization’s premises;
  2. reviews are carried out in a manner that protects the confidentiality of family members and others whose information may be contained in the record;
  3. any personnel responses to service recipient additions are added with the service recipient’s knowledge; and
  4. the service recipient is given the opportunity to review and comment on personnel responses.
Examples: Organizations using electronic record keeping systems can provide safe access to case records by, for example, creating a separate user portal or printing the case record.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record access policy or procedure needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Record access policy or procedure needs significant strengthening; or
  • In a few instances the organization does not comply with the standard.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 2.03

If the organization determines that serious harm would likely ensue if an individual were to review their case record, and applicable law, regulations and/or contracts provides no guidance on case record access, then:
  1. senior management reviews, approves in writing, and enters into the case record the reasons for refusal; and
  2. procedures permit a qualified professional to review records on behalf of service recipients, provided the professional signs a statement that information determined to be harmful will be withheld.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record access policy or procedure needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Record access policy or procedure needs significant strengthening; or
  • In a few instances the organization does not comply with the standard.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.