a. Associated with Restraints and altercations
A body check of the student is to be conducted by the nurse within 24 hours or sooner if indicated, whenever any of the following conditions are met:
1. A physical intervention has been difficult, severe or such that injury may have occurred, regardless of the duration of the hold or restraint e.g., the student has struggled and the staff has had to apply some degree of force to maintain safety.
2. The student has been involved in a floor hold (i.e., prone, on the floor-not seated).
3. The restraint exceed 20 minutes
4. The student reports any pain or discomfort, or the student appears to be in pain or uncomfortable, regardless of whether or not he/she reports or confirms pain or discomfort.
5. After a physical altercation between students that meets any of the criteria outlined above (i.e., difficulty, severity or duration of physical altercation; report or appearance of injury, pain or discomfort).

If there is no nurse on duty at the time of the incident, the on call nurse will be consulted by telephone. If it is determined that the on call nurse need not come to the program to do a body check; the body check will be done as soon as possible at the beginning of the next nurse’s shift on campus.

b. Documenting Body Checks Associated With Multiple Restraints
It is sometimes necessary to restrain a student more than once and sometimes with little time in between restraints and before a body check can be conducted. In such cases the body check and finding (e.g. “minor injury”) will be documented only on the most recent or last Physical Intervention Report form for the series, even though there will be a PI form completed for each restraint (incident).
On the most recent or final PI form in a series, the nurse conducting the body check will include the following note: “Body check for multiple physical interventions”.
On all other PI forms in that same series, the nurse conducting the body check will include the following note: “See the most recent PI form” with both date and time of the final PI form noted.
Sequential PI forms should be clearly marked to show the sequence of events.

c. Prior to and on return from unsupervised leave of absence
A body check is also done prior to and upon returning from, an unsupervised home visit or an unsupervised off-campus visit. This is not a contraband check; it is a visual inspection looking for signs of illness or injury.

d. Student Refusal of Body Check
If a student refuses a body check, the supervisor is notified and the event is documented on the Incident Report form and in the case record Progress Notes. Additional attempts are made until the body check is completed.

Incident Reports and Physical Intervention Reports must be completed and submitted to a supervisor as soon as possible but not later than the end of the shift in which the incident takes place. The report must then be processed according to the procedures at each campus.

Documenting Physical Interventions

1. Physical Intervention Reports
Every physical intervention with a student, including holds and restraints, requires a Physical Intervention Report form to be completed by the staff member who initiated the restraint.

Documentation for the continuous monitoring of a restraint and the 15 minute assessments of a restraint will also be made in the appropriate section on the Physical Intervention Form, not in the chart progress notes. If the restraint is continued for more than 2 hours, an additional PI form must be attached for documentation of the 15 minute assessments.

Physical Intervention Reports are reviewed daily by clinicians, nursing and administrative staff

2. Progress Notes
The supervisor on duty, or the LP who ordered the restraint, if he/she is on site, must write a progress note in the student’s case record that fully describes the incident, the reasons why a less intrusive measure was not justified or was ineffective, the process of reassessment and an explanation of how the child’s rights were maintained. The progress note will also concisely describe the final progression at the end of the restraint, time the restraint ended, student behavior and the processing of the restraint with the student, the student’s return to program or to a Time Out.

3. Written Approval of Verbal LP Orders for Restraint
within 72 Hours
If an LP orders a restraint, or the continuation of a restraint, by telephone, and the supervisor on duty writes the progress note, the LP who ordered the restraint will sign and date the progress note, with his/her title, in the margin beside the note, within 72 hours of the time he/she gave the order to restrain/continue the restraint.

In these instances, as long as the LP agrees that the supervisor’s progress note is accurate, it is not necessary for the LP to write an additional note. He/she will simply sign and date the supervisor’s note in the margin beside the note.

In the event that the LP does not believe the supervisor’s note to he accurate, he/she will discuss the differences with the supervisor and a program administrator. If any corrections are necessary, they will be explained in a progress note, and a final, accurate note will be made. The Physical Intervention report will also he checked for accuracy and corrections made and initialed as necessary.

The safety, continuity of care and coordination of interdisciplinary treatment for any Hillcrest student depend in part on the accurate and timely documentation of services provided to, and significant events in the student’s life. Effective case documentation also serves to support the student’s treatment plan and effective clinical decision-making, and it constitutes part of the legal record for that student.
Hillcrest utilizes many different forms of case documentation including the Progress Note, an important record written by staff who directly provide care and services to the student. All progress notes at HEC are in electronic form and are accessible through a secure privileging system assigned to clinical and administrative staff. Electronic progress notes are backed up and stored off site on a daily basis. They are periodically archived to DVD media on a yearly basis. Progress notes for, at least, the previous 24 months are always available in the online system.
It is commonly considered to be “best practice” for Progress Notes that, to the extent possible:
• They reflect the chronology or order of service and care events as they happen, and,
• They are written as soon as possible after the service or event, because the closer the documentation is recorded to the actual event, the more accurate and reliable the documentation tends to be.
It is Hillcrest’s policy that, whenever possible, the Progress Note will be entered into the student record on the day or the day following the provision of the service or the occurrence of the event. If circumstances prevent the entry by the end of the day following the provision of the service or the occurrence of the event, the entry is made as soon as possible after that day, and is classified as a late entry.
The following format and protocol are used when making a late entry.
• The current date and time are written in the left hand column.
• The entry begins: “Late entry for (date the service or event occurred)”, followed by the identification of the service or event. For example, “Late entry for 1/24/049. Weekly Individual Therapy x 45 minutes.”

Progress Notes – Time of Day In Progress Notes
Traditionally at Hillcrest we have required that the time of day at which a Progress Note is being written be included under the date of the PN in the left hand margin. However, in addition to sometimes causing confusion (i.e., is it the time the note is written or the time the service was provided?), we have determined that only HEC policy requires this inclusion of the time in the Progress Notes of all disciplines. It is apparently not required by any regulatory agency or accreditation body, and it is not commonly considered standard practice among behavioral health care providers.

Therefore, after consultation with other managers, we have determined that from this point forward, with the exception of Nursing PNs, it will not be necessary to enter the time of day under the date on a PN. Nurses will continue to note the time of day.

Student charts may be “thinned” according to the following guidelines:
• A notice must be placed at the end of the section that has been “thinned” that states, “additional information on this student may be found…” (each campus statement may vary, i.e., one may say on the first shelf in the records room, one may say on the second shelf in the records room, etc.)
• The “thinned” material is placed in a file folder with the student’s name easily visible.
• The “thinned” material is kept in the same room that the original chart is kept to ensure its safety/confidentiality.
• When a student has been discharged from a particular campus, the “thinned” information is integrated back into the student’s original chart before being transferred to another campus or the file being archived.

Thinning of Student Charts

Green Binder:
Face Sheets – keep most recent only.
Preplacement Packet – may remove
after 45 days.

Blue Binder:
Treatment Plans-(IEP/CTP, Quarterlies)-may remove after one year.
Student Contacts – may remove as needed.
Incidents/ PI’s – may remove as needed.
 
Areas that may not be thinned

Green Binder:
Psychiatric
Psychological
Psychosocial
Doctors Orders
Medical Consents
Physical
Dental
Healthcare Services-Eye, Ear, Speech
Neurology
Residential
Nutrition
Physical Therapy
Other Medical Labs
Medication Records
Progress Notes (never remove, never copy)

Blue Binder
Education
Legal
Financial
Correspondence
Discharge

The case record for a student who has been discharged from HEC is stored at the program site for 6 months following the student’s discharge.

The procedures for archiving closed student records are as follows.

• Pull Ed Records (put in manila folder marked “Ed Records” with student’s name on it). Pull CD Rom information – most recent face sheet, most recent psychosocial, immunization record, discharge summary (put in manila folder marked “CD Rom” with student’s name on it). These records will be kept permanently and should be put in a box with other students’ Ed and CD Rom records for archiving. When you have a full box, label accordingly, add to your lists and send to the archive.
• All the rest of the student’s file should be placed in another box. Please put file in manila folders and put the student’s name and discharge date on the side so you can see it when you place the folders in the box. Once you have a full box of files, label accordingly, add to your lists and send to the archive. These files may be destroyed seven (7) years from the date of the most recent student’s discharge date (i.e., if you have four files in a box and discharge dates are 1/00, 2/00, 3/00, 4/00 – the destroy date will be 5/07).
• Send your updated lists to the designated person in Admissions at AO. All campus lists must be in the same format (as per attached – alphabetical list and box list)

Once a month you will receive a Data Storage Warehouse Inventory Report from The Archive. Please review the report for accuracy. If you have any discrepancies, please call The Archive (442-4472) and ask them to fix the error (check your box number, contents, and destroy date).

You may also send other records to be archived – Supes Logs, Travel/Trip Slips, etc. These should also be recorded by campus as “other” files – please do not include with student files (see attached example). This information may be destroyed using the seven (7) year rule as above.

Reference: JC Standard IM.6.10
“The organization has a complete and accurate clinical/case record for every individual assessed, cared for, treated, or served.”
EP 14.
“The retention time of clinical/case record information is determined by the organization
based on law and regulation, and on its use for client care, treatment, and services; legal,
research, and operational purposes; as well as educational activities.”

The case record for a student who has been discharged from HEC is stored at the program site for 6 months following the student’s discharge.

The remaining documentation is then divided and retained as follows:

Kept forever:
One file containing:
All Education Records
One file containing:
Face Sheet
Most recent Psychosocial Summary
Immunization Record
Discharge Summary

The rest of the record is retained in either physical or electronic long-term storage for 7 years after which it is destroyed by an appropriately secure measure (e.g., burning, shredding).

Reference: Joint Commission Standard IM.6.10
“The organization has a complete and accurate clinical/case record for every individual assessed, cared for, treated, or served.”
EP 14.
“The retention time of clinical/case record information is determined by the organization based on law and regulation, and on its use for client care, treatment, and services; legal, research, and operational purposes; as well as educational activities.”

Student records are stored in the records room, which is locked when unattended. The key to the records room is under limited distribution. A staff access log is provided, for noting sign-out and sign-in dates of records. Any record signed out of the records room must be returned immediately following its use. Records may not be signed out overnight. In addition, each student file has an access log for non-staff personnel such as authorized state agency officials requiring the reason for accessing the file. Student files may not leave the campus unless subpoenaed by the court. Parents and students have the same right of access to students’ records as do parents and students of Massachusetts public schools. Electronic progress notes are accessible only through a strict privileging system assigned to clinical and administrative staff. Unauthorized access is a serious matter and is addressed in the Security section of the Employee Policies & Procedures Manual.

1) The privacy and confidentiality of student records at HEC is protected by one of the nation’s strongest privacy and protection laws, the Family Educational Rights and Privacy Act (FERPA). FERPA regulations provide stringent rules regarding a broad range of records and information that encompasses all paper and electronic documents in an educational environment.

All staff members receive specific training regarding the confidential nature of student information during their initial pre-service training and the general staff receive yearly training updates on this subject. Confidentiality of student information is addressed specifically in the Personnel Policies and Procedures in Section 3.8.
The HEC Charts Committee, a standing committee with cross campus and interdisciplinary representation, routinely audits existing charts, communicates procedural policies or changes regarding access to the chart, and facilitates any modification to the structural content of the chart.
Although the FERPA standard does not require specific security routines regarding electronic documentation, the Information Services Department has embraced the computer security requirements found in the Health Insurance and Portability and Accountability Act (HIPAA) and administers strict security access and disaster recovery procedures. Continuity of information is maintained using a comprehensive off-site data warehousing/backup system of mission-critical data and a schedule of routine hardware and software maintenance.
Given that all electronic communication between HEC staff and the agencies they serve is potentially a part of the student record, ALL electronic communication at HEC is archived in real time in a secure facility that meets all Federal , State, and local requirements for secure electronic document storage.

2) Hillcrest Educational Center staff, students and trainees will regard as confidential all information that might identity a person as a HEC client, as well as all information concerning events and conditions as they relate to particular clients. Staff and students will act in every instance to protect such material in accordance with the client’s wishes, and with applicable laws and regulations.
a. Staff are only authorized to see records of clients with whom they are involved in a service or supervisory capacity. Staff may look at other client case records only with the express permission of the client’s Program Director.
b. Case records are the physical and legal property of Hillcrest Educational
Centers, Inc.
Staff will NOT automatically release records when subpoenaed. Instead, staff will check with their Program Directors who, on the basis of possible harm to the client and with the approval of their supervisor, may seek to have the subpoena legally nullified.
Staff will NOT release physical records, electronic records. or components or copies of them to a client, a former client, or to a client or former client’s parent/guardian before securing approval from the Program Director.
c. On each occasion in which a staff removes a client record from either a campus Records Room or from long term storage, the staff must sign out each record being removed, and must sign the record back in upon return to the Records Room or to storage. Staff assumes responsibility for any case record in their possession, and unless they are responding to a court order, and with the knowledge and approval of their Program Director, staff must never remove a client record from a Hillcrest site or property.

Student-specific data and information are contained in the students’ Chart. The Chart exists to facilitate client care, treatment, and services, serve as a financial and legal record, support decision analysis, and guide professional and organization performance improvement. On each HEC campus, student Charts are maintained in a designated secure area. Their access is defined by FERPA regulations and additional guidelines generated by the Chart committee.
Given that HEC is part of the New York State SACWIS system (CONNECTIONS) and anticipates eventual integration with other statewide automated child welfare information systems, the Management team is studying the efficacy of moving to an electronic record system.

HA_Current_Meds_ReEnrollment_Form

HA_MedConsent_Form

HA_OTC_Med_Consent_Form

HA_Re_Enrollment_Form

Pre_Placement_Physical_Form