OAR 419-470-0170: Information About Children in Care

(1) Case files of children in care. For each child in care a residential care agency accepts for placement, the residential care agency must maintain an individual record that includes a summary sheet containing all of the following information: (a) The name, gender, date of birth, religious preference, and previous address of the child in care. (b) The name and location of the child in care's previous and current school. (c) The date of admission to the program. (d) The status of the child in care's legal custody, including the name of each person responsible for consents and authorizations. (e) The name, address, and telephone number of: (A) The child in care's parents. (B) The child in care's legal guardian, if different than parents, and documentation of his or her legal relationship to the child in care. (C) Other family members or other persons identified by the family as significant to the child in care. (D) Other professionals to be involved in service planning, if applicable. (f) Any required signed consents and authorizations. (2) Service planning. (a) All documentation, including, but not limited to service plans, daily notes, assessments, progress reports, medication records, and incident reports, must be written in terms that are easily understood by all persons involved in service planning. (b) Intake documentation. A residential care agency must complete a written intake document containing screening information on the date the residential care agency accepts a child in care for placement except in the case of an emergency placement, when the intake document must be completed within 48 hours of admission. (c) Each child in care must be served according to an individual written service plan developed by staff of the residential care agency and by, whenever possible, the child in care, the child's family, and other professionals involved with the child in care or family. This document must outline goals for services and care coordination. (d) Assessment. A comprehensive assessment must be completed within the first 45 days of placement. This assessment must include relevant historical information, current behavioral observations, any identified needs for services, and a description of how the residential care agency will provide or coordinate services. (e) Service plan and review. (A) Within 60 days of placement, a formal service plan must be developed by staff of the residential care agency in conjunction with the child in care and his or her parents or legal guardians, and any other persons who are actively involved with the family, as appropriate. (B) The service plan must reflect how the residential care agency will address the child in care's issues, describe the anticipated outcomes of the placement, and be reviewed and approved by the child in care and the legal guardian or parent, unless contraindicated. (C) The service plan must be reviewed by the residential care agency at least quarterly. (D) Service plans must be revised at any time additional information becomes available indicating that other services should be provided. (3) Case management. (a) The residential care agency must document services provided, and track and monitor progress toward the achievement of service plan goals. (b) Discharge. The residential care agency must identify how a child in care's progress will be evaluated, and how the determination is made of readiness for discharge or unsuitability for continued stay. (c) Discharge planning. Discharge planning for children in care must be a participatory decision-making process between the child in care, staff of the residential care agency, the parents or legal guardian, and significant others. As used in this rule, "significant others" mean relatives, friends, or interested members of the community. (d) Discharge Summary. The child-caring agency must prepare a written discharge summary of each child in care served by the program and retain this document in the child in care’s file. The document must include: (A) Current medications; (B) Name of physician or qualified medical professional who prescribed each medication; (C) Any outstanding medical or other appointments; (D) A summary of the child in care’s participation in the program and the progress achieved; (E) Results of evaluations of the child in care; (F) Recommendations regarding services; and (G) Discharge destination. (e) Follow-up services. The residential care agency must identify any transitional or aftercare services or service coordination that will be offered by the program. (f) Incident reporting. A written description of any injury, accident, or unusual incident involving a child in care must be placed in the individual child's record. (4) Financial records. A residential care agency must keep a separate written record for each child itemizing all money received or disbursed on behalf of the child in care. The record must include all of the following: (a) The date of each receipt and disbursement and the amount of each. (b) The source of income. (c) The purpose of each disbursement. (d) The signature of the person making each entry. (e) The signature of the child in care for each entry. (5) Personal possessions records. An individual written inventory must be maintained for each child in care of all personal possessions belonging to the child in care. The record must be updated as needed. (6) The residential care agency will ensure, in policy and practice, that: (a) Disallowable items are either stored, or returned to the parent or legal guardian; and (b) All money and personal belongings are returned to the child in care at the time of discharge.