Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.97 - LICENSURE OF YOUTH CARE FACILITIES
Subchapter 37.97.1 - General Requirements
Rule 37.97.127 - YOUTH CARE FACILITY (YCF): CASE RECORDS
Universal Citation: MT Admin Rules 37.97.127
Current through Register Vol. 18, September 20, 2024
(1) A YCF shall maintain a written case record for each youth which shall include administrative, treatment, and educational data from the time of admission until the time the youth is discharged from the YCF. A youth's case record must include but is not limited to the following:
(a) the name, sex, and
birth date of the youth;
(b) the
name, address, and telephone number of the parent(s) or guardian of the youth;
(i) therapeutic group homes must maintain
contact information on all known family members and document outreach
efforts;
(c) date of
admission and placing agency;
(d)
if the youth was not living with the youth's parents prior to admission, the
name, address, telephone number, and relationship to the youth of the person
with whom the youth was living;
(e)
date of discharge, reason for discharge, and the name, telephone number, and
address of the person or agency to which the youth was discharged;
(f) all documents related to the referral of
the youth to the facility as provided by the placing agency;
(g) current custody and legal guardianship
documents as provided by the placing agency;
(h) the youth's court status, if
applicable;
(i) a copy of the
youth's birth certificate or a written statement of the youth's birth date,
including the source of this information;
(j) consent forms signed by the parents or
guardian prior to placement allowing the YCF to authorize all necessary medical
care, routine tests, immunization, and emergency medical or surgical treatment;
(k) cumulative health records
including medical history and immunization records as provided by the placing
agency;
(l) education records and
reports, including but not limited to, reports cards and individual education
plan (IEP) reports;
(m) treatment
or clinical records and reports;
(n) records of special or critical
incidents;
(o) case plans,
treatment plans, and related material;
(p) social assessment that is current to date
of placement; and
(q) an immediate
needs assessment and assigned responsibilities.
(2) In addition to the requirements in (1), therapeutic group homes must maintain an updated copy of the youth's clinical assessment.
AUTH: 52-2-111, 52-2-603, 52-2-622, MCA; IMP: 52-2-113, 52-2-603, 52-2-622, MCA
Disclaimer: These regulations may not be the most recent version. Montana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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