Current through Register 1531, September 27, 2024
(1)
Residents' Records. Except as provided in 606 CMR
3.10(1)(k), the licensee shall maintain a written record for each resident
which includes:
(a) a face sheet which
identifies each resident by the following information, where available:
1. the name, date of admission, date of
birth, place of birth, citizenship, and primary language of the resident, if
other than English;
2. father's
name, mother's name and parents' marital status;
3. name, address and telephone number of
parents, legal guardian, and closest relative available in case of
emergency;
4. sex, race, height,
weight, color of hair, color of eyes, and identifying marks;
5. medical condition significant to the
resident's well being, including allergies and current medications;
6. description of the resident's ability for
self-preservation;
7. referring
agency, name of social worker and telephone number;
8. custody, guardianship and/or commitment
status;
9. date of discharge and
resident's location after discharge;
10. individual or agency responsible for
follow-up contact with the resident.
(b) copy of complete evaluations as required
by 606 CMR 3.05(1)(f) and (g);
(c)
documentation of intake services, as required by 606 CMR 3.05(3)(c);
(d) written assessment of needs and the
individual service plan as required by 606 CMR 3.05(4);
(e) written reports of periodic reviews as
required by 606 CMR 3.05(5);
(f)
written report of the discharge conference and summary as required by 606 CMR
3.05(7);
(g) written summary of any
follow-up services provided, as required by 606 CMR 3.06(12);
(h) health records may be included in the
case record or maintained at a designated health location, such as a nurse's
office, provided that coordination of records occurs. Health records indicating
resident's health while enrolled in a program shall include:
1. documentation of physical and dental
examinations as required by 606 CMR 3.06(4);
2. a record of prescribed medications
administered to the residents.
(i) all necessary authorizations and
consents, including the placement agreement required by 606 CMR 3.05(2)(d), all
consents required for the medical care of the resident and Interstate Compact
Documents, where applicable;.
(j)
copies or originals of all correspondence relating to the placement, treatment,
progress and discharge of the resident;
(k) copies of all incident reports as
required by 606 CMR 3.04(3)(h) and (i);
(l) Programs serving teen parents shall
maintain a written record for each child of a teen parent which includes at the
least:
1. written information as specified in
606 CMR 3.10(1)(a), (g), (i), and (j);
2. service plan information required by 606
CMR 3.10(1)(c) shall include documentation of health care, routine child care,
and if relevant, behavior support and education;
If the licensee maintains a separate record for the child(ren)
of teen parents, the parent's record and the child's record shall be
cross-referenced. One discharge plan and summary of services provided may be
completed for the resident and his or her family unit.
(2)
Shelter
Home Records. The licensee shall maintain a written record for
each shelter home which includes:
(a) shelter
home parents' written application;
(b) summary of shelter home study and
assessment of shelter home parents;
(c) documentation of a completed background
record check in accordance with
606 CMR 14.00:
Criminal Offender and Other Background Record Checks on
shelter home parent applicants and all household members 15 years of age or
older prior to approval as shelter home parents;
(d) documentation of telephone reference
checks;
(e) record of each child
placed in the shelter home, including the child's full name, date of placement,
and date of discharge;
(f) periodic
progress reports, at least annually, as required by 606 CMR 3.09(13);
(g) copy of the licensee's written agreement
or contract with shelter home parents;
(h) all correspondence concerning the shelter
home;
(i) any other information
necessary to furnish a basis for review, study, and assessment of the shelter
home;
(j) at any time when a
shelter home is closed, the date and reasons for the closing and a copy of the
written notification to the shelter home parents.
(3)
Authentication and
Updating. The licensee shall maintain records and logs which shall
be legible, dated and signed by the individual making the entry. The licensee
shall continually update all information in each resident's record.
(4)
Maintenance. The
maintenance, retention, dissemination, duplication, storage and periodic
destruction of resident's records shall accord with the following:
(a) If a licensed program is subject to
approval by the Massachusetts Department of Elementary and Secondary Education,
the licensee shall maintain, retain, disseminate, duplicate, store and destroy
all resident's records in a manner which complies with the Massachusetts
Student Records Regulations (MSRR)
603 CMR
23.00: Student Records, and shall not
be bound by 606 CMR 3.10(4)(b);
(b)
If a licensed program is not subject to MSRR, the licensee shall maintain its
resident's records for a period of seven years in the following manner:
1. Information contained in a resident's
record is privileged and confidential.
2. Such information may be distributed or
released as necessary to persons directly related to implementing the
resident's service plan without written consents.
3. Such information may not be distributed or
released to persons not directly related to implementing the resident's service
plan unless appropriate consents are obtained.
(5)
Access to
Records. Residents' records shall be the property of the licensee
who shall have written procedures which provide for:
(a) accessing a resident's records by a
resident (taking into account his or her capacity to understand), parent(s),
person other than the parent who has custody or a person not directly related
to the service plan;
(b)
identifying person(s), if any, whose consent(s) is required before information
in a resident's records may be released;
(c) duplicating and costs for duplicating, if
any;
(d) releasing information
contained in a resident's record;
(e) making available summaries of progress
reports in lieu of the entire case records;
(f) securing the information contained in a
resident's record against loss, defacement, tampering or unauthorized
use;
(g) storing and preserving a
resident's record.
(6)
Storage and Preservation. If a program intends to
cease operation, it shall submit to the Department a written plan for the
storage and preservation of residents' records at least 120 days before ceasing
operation.
(7)
Communication Logs. Each licensee shall maintain a log
or record system to assure communication among staff and continuity of service.
The log shall be in writing and kept on a daily basis unless the size or
staffing pattern require another frequency.
(8)
Admissions
Register. Each shelter program shall keep and maintain a current
register of all children admitted to and discharged from the program,
documenting at a minimum, the child's name, date and time of admission, date
and time of discharge, location after discharge and person
responsible.
