1. A. A licensee shall maintain a current, separate case record for each child in care. The record shall be readily accessible to persons providing services to the child and shall include at least the following information:

   1. 1. The name, gender, race, religion, birthdate, and birthplace of the child;
   2. 2. The name, address, telephone number, and marital status of the child’s parents;
   3. 3. The date of admission and source of referral;
   4. 4. The name, address, telephone number, and relationship to the child of the person with whom the child was living prior to admission, if other than the child’s parent;
   5. 5. All documents related to the child’s referral and admission of the child to the facility;
   6. 6. Documentation of the current custody and legal guardianship of the child;
   7. 7. The child’s court status, if applicable;
   8. 8. Consent forms signed by the placing agency or person at the time of placement, allowing the licensee to authorize necessary medical care, medications, routine tests, and immunizations;
   9. 9. Service plans and all reviews, revisions, notes, and updates reflecting the child’s and family’s goals, and progress towards achievement of goals;
   10. 10. A plan for permanent placement of the child;
   11. 11. Education records and reports;
   12. 12. Vocational training and employment records, if applicable;
   13. 13. Treatment and clinical records and reports; and
   14. 14. The discharge summary required by R6-5-7442(B).
2. B. A licensee shall have the medical records required by R6-5-7455. While the child is in care, the licensee may keep the child’s medical records in a location separate from the records described in this Section. If the licensee keeps medical records in a separate location, the child’s main record shall identify the location of the medical record.
3. C. All record entries shall be made in permanent ink or electronically. The licensee shall require personnel to date and legibly sign entries in a child’s records.

4. D. If a licensee maintains a child’s records in more than one place, the licensee shall:

   1. 1. Identify, in one location that is readily accessible to inspection by the Licensing Authority, the location of all parts of the record; and

   2. 2. Consolidate all records and notes into one case file, at one location, within 15 days following either:

      1. a. A request for consolidation from the Licensing Authority; or
      2. b. The date of the child’s discharge from the facility.

5. E. A licensee shall maintain a child’s record for the longest of the following time periods:

   1. 1. At least five years after the child’s last discharge from the licensee’s care;
   2. 2. At least three years after the child’s 18th birthday; or
   3. 3. Another time period specified by applicable law or contract.
6. F. A licensee shall dispose of expired records in a manner that maintains confidentiality.

Historical Note

Adopted effective July 1, 1997; filed with the Secretary of State’s Office May 15, 1997 (Supp. 97-2).