37.99.145    PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL PROGRAMS: CASE RECORDS

(1) A program must maintain a written case record for each program participant which contains administrative, treatment, and educational data from the time of admission until the time the program participant is discharged from the program.

(2) The case record must include:

(a) the name, sex, and birth date of the program participant;

(b) the name, address, and telephone number of the parent/legal guardian of the program participant;

(c) date of admission;

(d) current immunization records and documentation of exemptions per program policy;

(e) date of discharge, person and signature whom the program participant was released to, and signed discharge summary;

(f) all documents related to the referral of the program participant to the program;

(g) current custody and parent/legal guardianship documents or other documents verifying legal custody of the parent/legal guardian placing the program participant per program policy;

(h) the program participant's court status, if applicable;

(i) a copy of the program participant's birth certificate;

(j) consent forms signed by the parent/legal guardian prior to placement allowing the program to authorize all necessary medical care, routine tests, immunization, and emergency medical or surgical treatment;

(k) cumulative health records including medical history provided by the parent/legal guardian;

(l) education records and reports, including but not limited to report cards and individual education plan (IEP) reports;

(m) treatment or clinical records and reports;

(n) records of physical restraints and special or serious incidents;

(o) case plans, treatment plans, all updates and related material;

(p) social assessment that is current to date of placement; and

(q) an immediate needs assessment and assigned responsibilities.

(3) A copy of the signed physical examination form must be maintained in the file for outdoor programs.

(4) Program participant records must be maintained at the program for a minimum of six years.

 

History: 52-2-803, 52-2-805, MCA; IMP, 52-2-803, 52-2-805, 52-2-809, MCA; NEW, 2019 MAR p. 2029, Eff. 11/9/19.