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37.97.843    YOUTH SHELTER CARE: CASE RECORDS

(1) The provider shall maintain a written case record for each youth which shall include, at a minimum, the following:

(a) name and sex of the youth;

(b) date of admission and placing agency; and

(c) educational data from the time of admission until the time the youth leaves the youth shelter care facility;

(d) date of discharge, reason for discharge and the name, telephone number and address of the person or agency to whom the youth was discharged; and

(e) the name, address and telephone number of the parent(s) or guardian of the youth.

(2) If available, each youth's case record shall include:

(a) the birthdate and birthplace of the youth;

(b) if the youth was not living with his parents prior to admission, the name, address, telephone number and relationship to the youth of the person with whom the youth was living; and

(c) the youth's social security number.

(3) Within 72 hours of the youth's placement, the provider shall take steps to obtain the following:

(a) all documents related to the referral of the youth to the facility as provided by the placing agency;

(b) documentation of the current custody and legal guardianship as provided by the placing agency;

(c) youth's court status, if applicable;

(d) a copy of the youth's birth certificate or a written statement of the youth's birth date including the source of this information;

(e) consent forms signed by the parents or guardian prior to the youth's admission to the youth shelter care facility allowing the provider to authorize all necessary medical care, routine tests, immunization and medical or surgical treatment;

(f) cumulative health records including medical history and immunization records as provided by the placing agency;

(g) dental records;

(h) education records and reports; and

(i) treatment or clinical records and reports.

(4) An initial assessment of the youth's emotional, medical, developmental, social and behavioral status shall be conducted within 8 hours of the youth's admission.

(5) A case plan shall be initiated within 3 days for any youth whose projected stay is anticipated to be longer than 1 week. At a minimum the case plan shall include:

(a) the projected length of the youth's stay;

(b) a plan for assessing and addressing critical needs;

(c) a day program plan for youth who will not be enrolled in the school system;

(d) an immediate needs assessment and assigned responsibilities; and

(e) a plan for the youth's transition out of placement.

History: Sec. 41-3-1103, 41-3-1142 and 52-2-111, MCA; IMP, Sec. 41-3-1142 and 52-2-113, MCA; NEW, 1998 MAR p. 489, Eff. 2/13/98; TRANS, from DFS, 1998 MAR p. 663.

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