| (a) This subsection applies to counseling records of
an LCDC's private practice. Documentation of professional services
rendered in another setting shall be created and maintained in accordance
with any legal requirements for documentation applicable to the particular
setting in which they were provided.
(1) The counselor shall establish and maintain a record
for every client at the time of initial service delivery. The client
record shall include:
(A) client identifying information;
(B) assessment results, including a statement of the
client's problems and/or diagnosis;
(C) plan of care;
(D) documentation of all services provided, including
date, duration, and method of delivery; and
(E) a description of the client's status at the time
services are discontinued.
(2) The counselor shall maintain a record of all charges
billed and all payments received.
(3) All entries shall be permanent, legible, accurate,
and completed in a timely manner.
(4) All documents and entries shall be dated and authenticated.
Authentication of electronic records shall be by a digital authentication
key.
(5) When it is necessary to correct a record, the error
shall be marked through with a single line, dated, and initialed by
the counselor.
(6) The counselor shall protect all client records
and other client-identifying information from destruction, loss, tampering,
and unauthorized access, use or disclosure. Electronic client information
shall be protected to the same degree as paper records and in accordance
with applicable law and accepted security standards for electronic
health records prevailing at the time, and shall have a reliable backup
system.
(7) The counselor shall comply with all applicable
state and federal laws relating to confidentiality, including the
requirements of Texas Health and Safety Code, Chapter 611 (relating
to Mental Health Records) and Code of Federal Regulations, Title 42,
Part 2 (relating to Confidentiality of Alcohol and Drug Abuse Patient
Records).
(8) The counselor shall not deny clients access to
the content of their records except as provided by law, including
Texas Health and Safety Code, §611.0045 (relating to Right to
Mental Health Record).
(9) Client records shall be kept for at least five
years. Records of adolescent clients shall be kept for at least five
years after the client becomes eighteen years of age.
(b) This subsection applies to an LCDC in private practice
using the internet or telephone to provide chemical dependency counseling
services.
(1) The counselor must reside in and perform the services
from Texas.
(2) The department maintains its authority to regulate
the counselor regardless of the location of the client.
(3) The counselor is subject to the applicable laws
of other states and countries where the client may reside or receive
services by electronic means, including any laws limiting the counselor's
practice.
(4) The counselor's provision of services by electronic
medium must comply with applicable law and accepted security standards
at the time, including, as applicable, Code of Federal Regulations,
Title 42, Part 2 (relating to Confidentiality of Alcohol and Drug
Abuse Patient Records), Texas Health and Safety Code, Chapter 611
(relating to Mental Health Records), and the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) (P.L. 104-191), and Health
Information Technology for Economic and Clinical Health Act (HITECH
Act), Title XIII of Division A and Title IV of Division B of the American
Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5 (Feb. 17,
2009), and their implementing regulations, including 45 Code of Federal
Regulations Parts 160 (relating to General Administrative Requirements),
164 (relating to Security and Privacy), and 170 (Health Information
Technology Standards, Implementation Specifications, And Certification
Criteria And Certification Programs For Health Information Technology).
(5) The counselor must be able to verify the identification
of the client and ensure the client's appropriate age.
(6) If a counselor uses the Internet as the electronic
means by which counseling is provided or transfers client or other
protected health information through the Internet, the counselor must
comply with the following:
(A) counseling, client, and other protected health
information may only be transferred using encryption that meets or
exceeds the Security Standards for the Protection of Electronic Protected
Health Information under 45 Code of Federal Regulations Part 164,
Subpart C, that are in effect at the time;
(B) e-mail communication containing counseling, client,
and/or other protected health information is subject to the restrictions
set forth in subparagraph (A) of this paragraph; and
(C) the counselor must provide technical backup for
system problems by providing a phone number to the client to call
for technical support and a contingency plan for the client when a
technical problem occurs.
(7) The counselor must provide services that utilize
audio or video in real time.
(8) The counselor must provide a description of all
services offered to the client in writing and describe who is appropriate
for the services. The description must include:
(A) a grievance procedure and provide a link to department
information for filing a complaint when using the Internet and the
toll-free number for the department when counseling by telephone;
(B) the counselor's credentials, education level, and
training;
(C) a link to the licensure verification page when
using the Internet and the toll-free number for the department when
counseling by telephone;
(D) the difference between electronic counseling and
traditional counseling; and
(E) the potential risk regarding clinical issues, security
and confidentiality.
(9) Services may only be offered by licensed chemical
dependency counselors.
(10) The counselor must provide an emergency contact
person and phone number and emergency procedures to the client in
writing.
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