10A NCAC 70G .0506. CLIENT RECORDS

(a)  The agency shall maintain an individual record for each child receiving foster care services which contains:

(1)           an application for services that includes:

(A)          demographic information about the child, including name, address, sex, race, birth date, birth place, educational information, medical information and client record number;

(B)          demographic information about the parents or guardian of the child, including names, addresses, telephone numbers, birth dates, races, religion and marital status;

(C)          demographic information about the siblings and other relatives of the child, including names, addresses, and telephone numbers;

(D)          the reasons the child was removed from the home of his or her parents;

(E)           a record of the child's prior placements with names and addresses of foster parents and other caregivers and dates of care provided by each foster parent or caregiver, and

(F)           the services the agency shall provide the child and his or her parents or guardian. 

(2)           legal documents of importance to the child including a birth certificate and any court dispositions;

(3)           pre-admission medical examination report or a medical examination report completed within two weeks of admission (unless the child's health status indicates the completion of a medical examination report sooner) and copies of subsequent medical examination reports;

(4)           medical reports including medical history, cumulative health history, immunization records, and available psychological and psychiatric reports; and if applicable:

(A)          documentation of mental illness, developmental disabilities or substance abuse diagnosis coded according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Revised DSM IV;

(B)          documentation of screening and assessment;

(C)          medication orders and Medication Administration Record (MAR);

(D)          documentation of medication administration errors;

(E)           documentation of adverse drug reactions; and

(F)           orders and copies of lab tests;

(5)           educational assessments, records and reports of school-age children;

(6)           intake study which includes initial social assessment and background of parents or guardian and the circumstances leading to the decision to place the child;

(7)           signed out-of-home family services agreement or person-centered plan along with out-of-home family services agreement or person-centered plan reviews which reflect the status of the child, parents or guardian in relation to the out-of-home family services agreement or person-centered plan and any progress or lack of progress in the goals of the out-of-home family services agreement or person-centered plan;

(8)           documentation of services provided;

(9)           documentation which reflects the dates and content of social worker's or case manager's visits with  the child;

(10)         documentation of the agency's involvement with the parents, guardian or legal custodian, including services offered, delivered, or rejected;

(11)         documentation which includes the content of any administrative or service reviews;

(12)         a visitation and contact plan that specifies the child's contacts with parents, guardian, siblings and other family members and individuals who may have contact with the child;

(13)         consents for release of information;

(14)         a signed statement from the parents, guardian or legal custodian, granting permission to seek emergency care from a  hospital or licensed medical provider;

(15)         emergency information for each child that shall include the name, address and telephone number of the person to be contacted in case of sudden illness or accident and the name, address and telephone number of the child's preferred licensed medical provider;

(16)         authorization from the parents, guardian, legal custodian or licensed medical provider to administer non-prescription medications;

(17)         consents for overnight travel and other travel consents based on the requirements of the parents, guardian or legal custodian;

(18)         consents for time-limited audio-visual recordings signed by the parents, guardian or legal custodian, and child, if 12 years of age or older;

(19)         documentation of searches for drugs, weapons, contraband or stolen property, including date and time of the search, action taken by foster parents and the agency, name of foster parent informing the agency, the date and time the agency is informed of the search, the date and time of the notification to the child's parents, guardian or legal custodian; and

(20)         discharge summary including date and time of discharge, the name, address, telephone number, and relationship of the person or agency to whom the child was discharged, a summary of services provided during care, needs which remain to be met, and plans for the services needed to meet these goals.

(b)  If the agency maintains a separate record on the parents and guardians of children whom they place into care, the parents' or guardians' record  shall contain:

(1)           demographic information including names, addresses, birth dates, races, religion, family composition;

(2)           social histories, including any psychological or psychiatric reports and medical histories;

(3)           strengths and needs of the parents or guardian and the services required;

(4)           signed agreements between the agency and parents or guardian;

(5)           summary of dates of contacts and progress toward goals;

(6)           case review reports; and

(7)           discharge summary.

(c)  Documentation shall be entered into the child's, parents' or guardian's records within five days of occurrence.

(d)  The agency shall keep separate records for each family foster home which contains:

(1)           application;

(2)           mutual home assessment;

(3)           medical examination reports;

(4)           fire inspection safety report;

(5)           environmental conditions checklist;

(6)           proof of high school diploma or GED;

(7)           dates and content of worker's contacts with the foster family;

(8)           training record that includes all required and ongoing training;

(9)           foster parent agreement signed by foster parents and agency representative;

(10)         discipline agreement signed by foster parents and agency representative;

(11)         three references relevant to the role and responsibilities of a foster parent;

(12)         annual assessment of strengths and needs of the foster family in providing foster care to children;

(13)         chronological record of all placements of children receiving care in the home, including the dates of their care and an assessment of the care;

(14)         written approval letter from executive director or his or her designee authorizing foster parents to administer physical restraint holds, if applicable;

(15)         signed statement by the foster parents and adult members of the household that they have not been found to have abused or neglected a child or have not been a respondent in a juvenile court proceeding that resulted in the removal of a child or has had child protective services involvement that resulted in the removal of a child;

(16)         signed statement by the foster parents and adult members of the household that they have not been confirmed or substantiated for abusing, neglecting or exploiting a disabled adult;

(17)         documentation of the results of the search of the Responsible Individual's List as defined in 10A NCAC 70A .0102 for all adult members of the household that indicate they have not had child protective services involvement resulting in a substantiation of child abuse or serious neglect;

(18)         signed statement by the foster parents and adult members of the household that they have not been a domestic violence perpetrator;

(19)         documentation of the results of the search of the North Carolina Sex Offender and Public Protection Registry of all adult members of the household;

(20)         documentation of the results of the search of the North Carolina Health Care Personnel Registry pursuant to G.S. 131E-256 of all adult members of the household;

(21)         copies of waivers, as specified in 10A NCAC 70L .0102; and

(22)         when closed, a summary containing reasons for the closing of the home and an assessment of the strengths and needs of the foster family in providing foster care to children.

 

History Note:        Authority G.S. 131D-10.5; 143B-153;

Eff. October 1, 2008;

Amended Eff. May 1, 2010.