Wis. Admin. Code Department of Children and Families DCF 52.49 - Resident records
(1) GENERAL REQUIREMENTS.
(a) A center shall provide safeguards against
loss or damage of resident records by fire, theft or destruction.
(b) Child-placing agencies and county
departments shall have access to the case records of children they
place.
(c) Student interns may have
access to resident records only under the supervision of center staff and after
signing the confidentiality statement under s.
DCF 52.12(7)
(d).
(d) When a center closes, the center shall
arrange for safe and secure storage of resident case records.
(2) INDIVIDUAL CASE RECORDS.
(a) A center shall maintain a case record on
a resident at the licensed location where the resident resides. A resident's
case record is confidential and shall be protected from unauthorized
examination pursuant to ss.
48.78 and
938.78, Stats., or, where
applicable, s. 51.30(4),
Stats., and ch. DHS 92. The center shall maintain a resident's case record for
7 years after the resident's discharge or until the child reaches age 19,
whichever is later.
(b) Each
document in a resident's case record shall be legible, dated and signed by the
person submitting the document. A resident's case record shall include all of
the following:
1. A treatment record which
contains all of the following:
a. A history
of the resident and resident's family.
b. The pre-admission screening required under
s.
DCF
52.21(2).
c. The written needs assessment and treatment
plan required under s.
DCF
52.22(2).
d. Treatment progress notes and
implementation and review documentation required under s.
DCF
52.22(3).
dm. Reasonable and prudent parenting decision
records required under s.
DCF 52.415(2)
(e).
e. Progress reports on residents receiving
non-center professional services, as required under s.
DCF 52.12(8) (a)
3. and, if applicable, follow-along or
support efforts under s.
DCF 52.12(8)
(b).
f. The aftercare plan required under s.
DCF 52.23(1)
(b).
g. The discharge summary required under s.
DCF
52.23(3).
h. All signed written consents required under
s.
DHS
94.03, including consent to non-emergency use of
psychotropic medications under s.
DCF 52.46(5) (c)
2. and consent for locked unit use under s.
DCF 52.42(7) (a)
3. d.
i. Documentation of denial of resident rights
and copies of the resident's grievances and responses to them.
j. Incident reports under ss.
DCF 52.41(1)
(a) 10. and 52.42 (6).
k. A recent photo of the resident.
L. Any report of child abuse or neglect under
s.
DCF
52.12(9).
2. A health record which contains all of the
following:
b. Written informed consents for medical
services required under s.
DCF
52.21(5).
c. Documentation about any special
nutritional or dietary needs identified by a physician or dietician, and a copy
of the resident's nutritional care plan if required under s.
DCF 52.44(2)
(c).
3. The educational record required under s.
DCF
52.43(5).
4. All of the following information:
a. The name, sex, race, religion, birth date
and birth place of the resident.
b.
The name, address and telephone number of the resident's parent or guardian and
legal custodian, if any, at the time of admission.
c. The date the resident was admitted and the
referral source.
d. Documentation
of current court status if applicable, and current custody and guardianship
arrangements. Documentation shall include copies of any court order, placement
agreement or other authorization relating to the placement and care of the
resident.
e. For a resident from
another state, interstate compact approval for placement required under s.
DCF 52.21(3)
(a).
f. Any records of vocational training or
employment experiences.
g. Records
on individual resident accounts under s.
DCF
52.41(8).
(3) OTHER RECORDS ON
RESIDENTS.
(a) A center shall maintain the
following additional records relating to residents:
1. A register of all residents as required
under s.
DCF
52.21(9). The register shall be kept
permanently.
2. Records under s.
DCF
52.11(9) of all complaints and
grievances received and of investigation of complaints and grievances conducted
within the licensing period.
3. All
reports to the department under s.
DCF
52.11(10) concerning the
hospitalization or death of a resident.
(b) A center shall maintain the records under
par. (a) 2. and 3. at least 5 years after the date of the final
entry.
(4) ELECTRONIC
RECORD STORAGE. A center may store records electronically if it obtains the
approval of the department and follows department procedures.
Notes
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