Record Keeping

PURPOSE: This rule sets forth the records, documents and reports, which an agency shall maintain and, upon request, submit to the residential licensing unit. (1) The agency shall maintain a register of all children currently receiving care, including information concerning the child’s name, sex, birthdate and person or agency legally responsible for each child. (2) Individual case records for all children accepted for care shall be maintained for at least five (5) years after a child is discharged from care and shall include: (A) The child’s full name, date of birth, complete social history including reason and date of placement and medical history; (B) Reports of any pre-placement visits and conferences; (C) The admission assessment, including information concerning the religious, educational, economic and cultural background of the family; information about the child’s development, health history, personality, school placement and adjustment; previous placements; attitudes toward separations; family relationships; (D) Documents pertinent to current legal custody and guardianship status; (E) Written agreements with parent(s), guardian, or legal custodian; (F) School reports for each semester, including the child’s grades, progress, and adjustment; (G) The initial treatment plan and subsequent treatment plan reviews; (H) Chronological case recording and progress summary completed at least monthly which identifies the child’s progress and services provided to the family; (I) Plans for discharge, aftercare, and supervision; (J) Reports from recreational and other adjunctive staff involved with the child and family. All recreational activity shall be documented separately in each child’s record; (K) Copies of critical incident reports, which shall include, but not be limited to, injury of a child during physical restraint; serious physical or sexual aggression by or toward the child; significant physical injuries requiring medical attention; allegations of sexual abuse; criminal conduct involving the child; elopement; attempted suicide; fire setting; child death; and information which must be reported to the child abuse and neglect hotline pursuant to section 210.115, RSMo; and (L) Admission and periodic health, vision, and dental examination information, physician’s written instructions with regard to special dietary or health care, and record of all medications and treatments. AUTHORITY: sections 210.481, 210.486, and 210.506, RSMo 2000.* This rule originally filed as 13 CSR 40-71.090. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Emergency rescission and emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency rescission and emergency rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994. Rescinded and readopted: Filed Nov. 1, 1993, effective June 6, 1994. Moved to 13 CSR 35-71.090, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014. *Original authority: 210.481, RSMo (1982), amended 1985 and 210.486 and 210.506, RSMo (1982), amended 1993.