Section 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) .

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:

a. All health and medications information and documentation required under ss. DCF 52.45 and 52.46 .

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.

History: Cr. Register, February, 2000, No. 530 , eff. 9-1-00; corrections in (2) (a), (b) and (3) (a) made under s. 13.92 (4) (b) 7. , Stats., Register November 2008 No. 635 .