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(1) A YCF shall maintain a written or electronic 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 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:

(a) an updated copy of the youth's clinical assessment;

(b) a list and contact information of all known family, as provided by the entity placing the youth, and family known to the TGH through their work with the youth; and

(c) documentation of all outreach efforts to identified family, to build a positive network to support the wellbeing of the youth. Documentation must include:

(i) a minimum of two attempts to contact all identified family;

(ii) results of each contact; and

(iii) how the TGH will support and facilitate regular contact with identified family as outlined in the youth's treatment plan.


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; AMD, 2021 MAR p. 1217, Eff. 10/1/21.

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