North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 70 - CHILDREN'S SERVICES › Subchapter I - MINIMUM LICENSING STANDARDS FOR RESIDENTIAL CHILD-CARE › Section .0500 - SERVICE PLANNING › Section 70I .0506 - CLIENT RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) A residential
				  child-care facility shall maintain a client record for each child that contains
				  the following:
(1) documentation of placement
				  authority by parents, guardian, or legal custodian;
(2) written placement consent and
				  agreement;
(3) intake study and
				  related documents;
(4) the
				  completed application for services that includes demographic information on the
				  child and the child's family;
(5)
				  documentation that verifies the child's birth;
(6) the 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;
(7) immunization records;
(8) the out-of-home family services agreement
				  and reviews;
(9) any court
				  orders;
(10) visitation and contact
				  plan, including type, duration, location both on-site and off-site, and
				  frequency, as well as any rationale for restrictions on family
				  involvement;
(11) documentation of
				  all visitation;
(12) consents for
				  release of information;
(13)
				  consent for emergency medical treatment;
(14) consents for overnight activities
				  outside the direct supervision of the caregiver for periods exceeding 72
				  hours;
(15) consents for
				  time-limited audio-visual recording signed by both the child and parents or
				  guardian, and legal custodian (if applicable);
(16) ongoing record of medical and dental
				  care;
(17) documentation of medical
				  insurance;
(18) progress
				  notes;
(19) a discharge summary
				  including date of discharge, time of discharge and 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 that remain to be
				  met, and plans for the services needed to meet these goals;
(20) medical reports including medical
				  history, cumulative health history, and available psychological and psychiatric
				  reports, and, if applicable:
(A) documentation
				  of mental illness, developmental disabilities, or substance abuse diagnosis
				  coded in accordance with the Diagnostic and Statistical Manual of Mental
				  Disorders that was current at the time of diagnosis. The Diagnostic and
				  Statistical Manual of Mental Disorders, Fifth Edition ("DSM-5"), which is
				  incorporated by reference, including subsequent amendments and editions, may be
				  purchased from the American Psychiatric Association at cost of two hundred and
				  ten dollars ($210.00) at
				  https://www.psychiatry.org/psychiatrists/practice.dsm;
(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;
(21) documentation of searches for
				  drugs, weapons, contraband, or stolen property, including date and time of the
				  search, action taken by direct care staff, the date and time the direct care
				  staff informed the residential child-care facility of the search, and the date
				  and time of the notification to the child's parents, guardian, or legal
				  custodian; and
(22) authorization
				  from the parents, guardian, legal custodian, or licensed medical provider to
				  administer non-prescription medications.