Ariz. Admin. Code § 21-7-121

Current through Register Vol. 31, No. 2, January 10, 2025

Section R21-7-121 - Records and Reports: Contents; Maintenance; Destruction

A. The licensee shall maintain and report accurate data on children receiving services, and staff employed, as requested by the Department.

B. The licensee shall maintain a current, separate record for each child in care in the following manner:

1. The record shall be readily accessible to the child's parent, guardian or persons providing services to the child unless prohibited by law or court order and shall include at least the following information:

a. The name, gender, race, religious preference, birthdate, and birthplace of the child;

b. The name, address, telephone number, marital status of the child's parents, and any court orders regarding custody;

c. The date of admission and source of referral; and

d. The name, address, telephone number, and relationship to the child of the person with whom the child was living prior to admission, if other than the child's parent;

2. Each record shall be kept up-to-date, confidential, consistently organized, and contain the following information:

a. All documents related to the child's referral and admission of the child to the facility;

b. Documentation of the current custody and guardianship of the child;

c. The child's court status, if applicable;

d. The terms of the child's probation, if applicable;

e. Consent forms signed by the Child Placing Agency or authorized person at the time of placement, allowing the licensee to authorize necessary medical care, medications, routine tests, and immunizations;

f. Contact information for the child's primary care physician, primary dental physician, behavioral health provider, and any other medical professional or health care provider involved in the child's care;

g. The Agency's service plan for each child in their care and all reviews, revisions, notes, and updates reflecting the child's goals, family's goals, and Child Placing Agency's goals, if applicable, and progress towards achievement of goals;

h. Education records and reports;

i. Vocational training and employment records, if applicable;

j. Treatment and clinical records and reports; and

k. The discharge summary required by R21-7-215; and

3. The licensee shall maintain health records for each child in care, including the child's medical, dental and behavioral health insurance information. The records shall include the following information, if available to the licensee:

a. Any medical records provided to the licensee by any medical, dental, or behavioral health provider, the Department, parent or guardian, or another source;

b. The name of the person or Agency bearing financial responsibility for the child's health care;

c. The child's past medical history and current medical record while in care, including:

i. Well-child visits;

ii. Diagnosis;

iii. Visit or after care summaries;

iv. Immunizations administered in the past and those provided while in care;

v. Serious illness or injury;

vi. Surgery;

vii. Allergies;

viii. Adverse drug reaction;

ix. Record of vision and hearing screening and physical and dental examinations;

x. Record of any treatment provided for a specific illness or medical emergency, including the name and location of the medical personnel who provided treatment;

xi. Developmental history;

xii. Medication history, in the past and provided while in care;

xiii. History of any alcohol or substance abuse or treatment;

xiv. Record of any medication errors; and

xv. Documentation showing the licensee's efforts, consistent with the terms of the placing agreement, to obtain glasses, hearing aids, prosthetic devices, corrective physical or dental devices, or any other health equipment recommended by a child's attending medical professional, or dentist.

4. Documentation of reasonable efforts to obtain all required information.

C. Licensee shall transfer the medical records to the Department if the child is in the custody of the Department or to an authorized person when the child in care is discharged from the licensee's care. Licensee shall maintain proof of transfer in the child's record.

D. Licensee shall ensure all record entries are made in ink or electronically. The licensee shall require staff to date and legibly sign entries in a child's records. The licensee shall ensure records are properly maintained, secured, and protected against loss or corruption.

E. If the licensee maintains a child's records in more than one place, the licensee shall:

1. Identify, in one location that is readily accessible for inspection by the Department, the location of all parts of the record; and

2. Consolidate all records and notes into one case file, at one location, within 15 calendar days following either:

a. A request for consolidation from the Department; or

b. The date of the child's discharge from the facility.

F. The licensee shall maintain a child's record for the longest of the following time periods:

1. Five years after the child's last discharge from the licensee's care;

2. Three years after the child's 18th birthday; or

3. Another time period specified by applicable law or contract.

Ariz. Admin. Code § R21-7-121

New Section made by final rulemaking at 29 A.A.R. 2231, effective 11/6/2023.