10A NCAC 70G .0506 CLIENT RECORDS

(a) The agency shall maintain an individual record for each child receiving foster care services that 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 court dispositions;

(3) pre-admission medical examination report or a medical examination report completed within two weeks of admission (unless the child's health 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 latest edition of the Diagnostic and Statistical Manual of Mental Disorders;

(B) documentation of screening and assessment;

(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 that includes initial social assessment and background of parents or guardian and the circumstances leading to the decision to place the child;

(7) one of the following:

(A) a signed out-of-home family services agreement and reviews that reflect the status of the child, parents, or guardian, and any progress or lack of progress in the goals;

(B) a person-centered plan and reviews that reflect the status of the child, parents, or guardian, and any progress or lack of progress in the goals; or

(C) a person-centered plan along with an out-of-home family services agreement and reviews that reflect the status of the child, parents, or guardian, and any progress or lack of progress in the goals;

(8) documentation of services provided;

(9) documentation that reports 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 that 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 time-limited audio-visual recordings signed by the parents, guardian, or legal custodian, and the child if 12 years of age or older;

(18) documentation of searches for drugs, weapons, contraband, or stolen property, including date and time of the search, and 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

(19) 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 and needs which remain to be met, and plans for the services needed to meet these goals.

(b) The agency shall document events and enter information required by the Rule in the record of the child within five days of the event or receipt of the information by the agency.

(1) the agency application;

(2) the mutual home assessment;

(3) the medical examination reports;

(4) the fire inspection safety report;

(5) the environmental conditions checklist;

(6) proof of high school diploma or GED of each foster parent;

(7) the dates and content of contacts with the foster family by an agency representative;

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

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

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

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

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

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

(15) a 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) a 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 described 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 never committed an act of domestic violence upon another person;

(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, authorized by 10A NCAC 70L .0102;

(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;

(23) documentation of the results of criminal record checks of all adult members of the household;

(24) fingerprint clearance letters of all adult members of the household;

(25) documentation of the results of child abuse and neglect registry checks of every state where the foster parent resided in the past five years; and

(26) documentation of the results of the search of the North Carolina Department of Public Safety, Division of Adult Correction, Offender Information for all adult members of the household.

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

Eff. October 1, 2008;

Amended Eff. August 1, 2017; May 1, 2010;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. October 3, 2017.