Section 370. Case record requirements

A. The licensee shall maintain a separate organized case file for each child, the child's birth parents, and each approved home provider and in addition for adoption cases, a separate organized file for the adoptive family. The case file may be electronic.

B. Each use of electronic records, files, or signatures shall comply with the provisions of the Uniform Electronic Transactions Act, §§ 59.1-479 through 59.1-497 of the Code of Virginia.

C. In addition to the requirements in the Uniform Electronic Transaction Act, the use of electronic signatures shall be deemed to constitute a signature and have the same effect as a written signature on a document as long as the licensee:

1. Develops, implements, and maintains specific policies and procedures for the use of electronic signatures;

2. Ensures that each electronic signature identifies the individual signing the document by name and title;

3. Assures that the documentation cannot be altered after signature has been affixed;

4. Assures that access to the code or key sequence is limited;

5. Assures that all users have signed statements that they alone have access to and use the key or computer password for their signature and will not share their key or password with others; and

6. Provides for nonrepudiation that is strong and substantial to make it difficult for either party to claim that the electronic representation is not valid.

D. All entries in each case file shall be legibly written in ink, contain the signature of the individual performing the service, the date the entry was made and, if the licensee operates more than one office in Virginia, the entry shall identify the office that provided the service. Unless otherwise specified in state or federal law, multiple dated entries made on the same page by the same author may be authenticated by the author's initials behind each entry as long as the author signs his name at the bottom of the page of entries.

E. All correspondence and information received by or produced by the licensee shall be treated as confidential information and shall be maintained as part of the case file.

F. Each case file shall be kept up to date and in a uniform organized manner.

G. All services and treatments provided to the child or his family shall be documented chronologically in the respective file.

H. When not in use, active and closed files shall be maintained in:

1. A location that allows the department's licensing representative complete access to the files within a reasonable and short period of time following the representative's request to review files;

2. An area accessible to staff;

3. An area protected from unauthorized access, fire, flood, and uncontrolled climate control; and

4. A locked, metal file cabinet or other metal compartment if the files are stored on site at the licensee's licensed location.

I. Whether stored on site or off site, the licensee shall demonstrate that the file storage system has the protections in place required by subdivisions H 3 and 4 of this section for unauthorized access, fire, flood, and climate control.

J. The case files shall be retained as follows:

1. Upon entry of a final order of adoption or other final disposition of a matter involving the placement of a child for adoption, the licensee shall forward all reports and collateral information in connection with the case to the commissioner;

2. The licensee who holds custody of the child shall retain a copy of the child's subsidy record as long as the child receives a subsidy;

3. If a minor child has been reunited with his birth family, case files shall be retained until one year after his 21st birthday;

4. When the foster care case is closed for services, the case file, whether written or electronic, shall be maintained in accordance with the Library of Virginia's Record Retention and Disposition Schedule General Schedule No. 15 - County and Municipal Governments Social Services Records (May 2010); and

5. When the licensee ceases operations, it shall immediately submit written information to the department about the location for retention of all files.

K. A person 18 years of age and older who was not adopted and was a child for whom all parental rights and responsibilities were terminated shall not have access to any information from the licensee with respect to the identity of the birth family unless all requirements established in § 63.2-105 B of the Code of Virginia have been met.

L. The licensee shall follow all provisions of §§ 63.2-1246 and 63.2-1247 of the Code of Virginia in regard to disclosure of information pertaining to finalized adoptions.

M. The licensee shall maintain documentation in the file of the home provider for all initial approvals and subsequent approvals. Each file shall include:

1. An application;

2. Documentation of the approval process;

3. Completed home study and supporting documentation, including approval decision;

4. Required reference letters received by the licensee;

5. Driving record checks;

6. Dates of receipt of background checks and driving record checks;

7. Summary of results of background checks;

8. Copy of the approval certificate issued to the provider;

9. Documentation of completed orientation and training received by the approved provider;

10. Required medical information, including results of tuberculosis screening;

11. Results of observations and findings from monitoring visits to the home;

12. A face sheet listing the names and dates of birth of all members of the household and the relationship of each member to the provider;

13. A narrative account of the preparation of the family for each child placed in the home;

14. A list of children's names, birth dates, dates of placement in the home and, if applicable, removal dates and reasons for removal;

15. Copies of all signed agreements;

16. When applicable, the date and reason for home closure;

17. Copy of the signed prohibition on corporal punishment;

18. Written updates and addenda to the home study and re-evaluations of the home provider and home; and

19. Any other correspondence or information pertaining to the home including a narrative of any concerns the licensee has about the status of the home; record of all complaints involving the foster parents; the licensee's investigation report and findings; and, if appropriate, the findings of child protective services and law enforcement.

N. The licensee shall maintain documentation in each child's file. Each file shall include:

1. A face sheet completed within five working days of the date of the child's placement. The face sheet shall address the child's name, date of birth, place of birth, gender, race, social security number, and Medicaid number, if known; and for adoption cases, the face sheet shall also contain the child's height, weight, hair color, eye color, and identifying marks;

2. Names, addresses, telephone numbers, and marital status of the child's birth parents;

3. Names and addresses of the child's siblings, if available;

4. Names, addresses, and telephone numbers of the person or agency holding legal custody of the child;

5. Names, addresses, and telephone numbers of persons to be contacted in an emergency;

6. Services provided to the child;

7. A copy of the entrustment agreement or the placement agreement between the placing agency and the licensee;

8. Other information pertaining to a child in foster care, treatment foster care, short-term foster care, and independent living arrangements as required by this chapter;

9. For adoption cases, the child's file shall also contain:

a. The legal documents required for adoption if the licensee holds custody of the child;

b. A record in the narrative dictation of the child's and family's preparation for the placement; and

c. Other information required by this chapter; and

10. An original birth certificate for the child whenever possible and when the licensee holds custody of the child.

O. If services are provided to the child's birth family, the licensee shall maintain a file on each child's birth parents. The file may be separate from the child's file or combined and maintained in the child's file. The file shall include:

1. An up-to-date face sheet documenting:

a. Names, addresses, telephone numbers, and marital status of each parent;

b. Names of known members of the birth family;

c. Current whereabouts, addresses, and telephone numbers, when available, of each known member of the birth family; and

d. A cross reference to the file of the child unless the birth family's information is maintained in the child's file;

2. A chronological narrative or summary of contacts the licensee has made with the family. This information shall include visits of the parents with the child and the child's visits, or attempts to visit, with the parents;

3. A summary of services provided to the family; and

4. Other information relating to the birth parents as required by this chapter.

P. The licensee shall maintain a file on each adoptive family. The file shall include:

1. The completed application;

2. A copy of any written information given to the adoptive parents concerning the child, including the agreed upon plan of discipline;

3. Summaries of supervisory visits and closing summary;

4. The home study and related documents;

5. Documentation of orientation and training completed;

6. Narrative account of the child-placing agency's preparation of the family for the placement of the child;

7. Fees charged and agreement between the licensee and the applicant;

8. Documentation of any complaints or investigations conducted by child protective services; and

9. Other information relating to adoptive parents as required by this chapter.

Q. Narrative case notes shall be current within 30 days, documented in the file of the child or youth in chronological order, signed and dated by the individual making the entry, and address elements required by this chapter including:

1. Treatment and services provided;

2. All contacts related to the child;

3. Visitation between the child and his family;

4. Other significant events, if any; and

5. Other documentation required by this chapter.

R. The licensee shall maintain documentation in provider and child files as required by this chapter and including:

1. Completing documentation within specified time frames; and

2. Placing documentation in the appropriate file within 30 days unless otherwise specified by this chapter.

Historical Notes

Derived from Volume 28, Issue 10, eff. May 1, 2012.

Statutory Authority

§§ 63.2-217 and 63.2-1734 of the Code of Virginia.