Section 411.175  Client Files

a)         A master record file shall be established and maintained on a current basis for each child or youth.

b)         The master record file shall include, at a minimum, the following applicable information: the child's or youth's name, age, sex, place of birth, and race or nationality; initial intake information form, including documented reason for admission to the secure child care facility; current photographs of the child or youth; case and social history; medical consent form; name, relationship, addresses and phone numbers of parents, guardians, and significant others; driver's license, social security, Department record and Medicaid numbers; court records, individual treatment plan and program goals; signed release of information forms, where required; progress reports; program rules and disciplinary policy signed by the child or youth; disciplinary and grievance records; referrals to other agencies; discharge report; visitors list; Guardian ad Litem and/or attorney of record; administrative case review documentation; and child or youth-related correspondence. Health and educational records are also considered part of the child master record file, but may be maintained in separate locations.

c)         Master record file entries shall be dated and the source of the information and the author of the entry shall be identified.

d)         Master record files are confidential and shall be safeguarded from unauthorized and improper access, disclosure, and loss.  Access to computerized records shall be controlled and restricted on a need-to-know basis. Security measures shall be taken to ensure the integrity and confidentiality of any computer record.

e)         Whenever a child or youth is discharged from the secure child care facility, a copy of the child or youth master record file, including individual medical and educational records, shall be provided to the child's or youth's caseworker.

f)         The licensing representative and the child's or youth's caseworker shall have access to master record files upon request. Disclosure of child or youth master record file material to others is subject to procedures outlined in 89 Ill. Adm. Code 431 (Confidentiality of Personal Information of Persons Served by the Department) and Section 411.300 of this Part.