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(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;

(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.

History: 52-2-111, 52-2-603, 52-2-622, MCA; IMP, 52-2-113, 52-2-603, 52-2-622, MCA; NEW, 2011 MAR p. 387, Eff. 3/25/11.

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