Section 500.110  Recordkeeping

a)         All service providers, service coordinators, and regional intake entities shall collect, compile and maintain appropriate records as required in this Part and as required by pertinent professional standards regarding services provided under this Part.

b)         The early intervention record shall contain at least:

1)         Identifying information, including name, All Kids recipient identification number, address and telephone number, sex, date of birth, primary language or method of communication, emergency contact or parent or parent substitute, date of initial contact and initiation of early intervention services, third party coverage, and source of referral;

2)         Documentation of appropriate consents for early intervention services and releases of information;

3)         Evaluation reports;

4)         A current and any past IFSP, progress notes and reviews, and documentation of the relationship of the services to the IFSP goals and child and family progress;

5)         Documentation of known child and family movement (referral/transfer) during any active service period to or from the provider's programs or to or from other providers;

6)         Documentation of any refusal of services and/or referrals;

7)         Direct service reports to support each early intervention service rendered;

8)         Periodic reviews, minimally at six month intervals, describing the child's overall progress; and

9)         If closed, a case closure summary documenting the outcome of interventions and, as necessary, the linkages for continued services.

c)         Service providers, service coordinators and regional intake entities shall permit access to records by the Department as the lead agency, by the federal Office of Special Education Programs or its designees, and by its regional intake entity. Each shall obtain consent from clients, upon initiation of services, as may be necessary, to allow the release of records to the State and federal entities for the purpose of providing services, paying for services, and monitoring the provision of services.

d)         The compilation, maintenance, storage of and access to records shall be governed by written policies and procedures that comply with the confidentiality provisions of Sections 500.150 and 500.155.

e)         Facilities for the handling, processing and storage of records, whether hard copy, magnetic tapes, computer files, or other automated systems, shall be secured from unauthorized access, theft, loss, or fire or other natural occurrences.

f)         All entries to records shall be current, legible and dated and the author shall be designated.  If hard copy, the author shall sign the entry.

g)         The regional intake entity is responsible for maintaining a complete early intervention record as set forth in subsection (b) for each enrolled child in the intake region.

h)         Each service provider is required to keep documentation adequately supporting early intervention services provided.

i)          All records described in this Section shall be maintained for at least six years from the child's discharge from early intervention services, or until any outstanding audit reviews or exceptions are closed to the satisfaction of the Department, or until any active or pending legal action, hearing request, complaint or other administrative or legal proceedings regarding them are resolved, whichever comes later.  Destruction of records shall be consistent with pertinent laws.

(Source:  Amended at 32 Ill. Reg. 2161, effective January 23, 2008)