Md. Code Regs. 16.03.01.01

Current through Register Vol. 51, No. 24, December 2, 2024

Section 16.03.01.01 - Individual Case Records

A. Required. Each facility or other program to which a youth is principally assigned shall maintain a case record for each youth assigned to that program.

B. Contents. The case record shall include:

(1) Identifying information about the youth and the youth's parents, guardians, or care-givers;

(2) A recent photograph of the youth;

(3) Prior placement information;

(4) A treatment service plan adopted under Courts and Judicial Proceedings Article, § 3-8 A-20.1, Annotated Code of Maryland;

(5) Documentation of services provided during the youth's detention or commitment;

(6) Documentation of services provided or offered to the youth in the community;

(7) Written reports about the youth;

(8) Health records, including health, mental health, substance abuse, and other evaluations of the youth, including suicide risk;

(9) Educational records;

(10) Legal documents;

(11) Classification and assessment documents;

(12) A discharge plan that specifies the required level of supervision and services;

(13) Disciplinary incident documentation; and

(14) Progress notes.

C. Retention Period. The Department shall retain the case record for each youth in accordance with its most currently approved records retention schedule.

Md. Code Regs. 16.03.01.01