ARM 37.98.7

ARM 37.98.7 Youth Records and Program Entrance Provisions

This regulation governs record-keeping and program entrance requirements for youth enrolled in Montana's licensed residential outdoor/wilderness treatment programs (ARM 37.98 chapter). Operators must maintain comprehensive case records for each youth from admission through discharge, conduct physical examinations and admission assessments prior to enrollment, develop individualized case plans within 14 days of admission, and complete discharge summaries within 10 business days of a youth leaving the program. Requirements cover youth rights documentation, assessment of medical and mental health suitability for outdoor expedition activities, and ongoing case plan reviews every 90 days.

37.98.701
 YOUTH CASE RECORDS 

(1)
 
A program shall maintain a written case record for each youth which must include administrative, treatment and educational data from the time of the youth's admission until the time the youth leaves the program. A youth's case record must include the following: 

(a)
 
the name, sex and birth date of the youth; 

(b)
 
the name, address and telephone number of the parent(s) or guardian of the youth; 

(c)
 
date of admission and placing agency; 

(d)
 
if the youth was not living with his or her parents prior to admission, the name, address, telephone number and relationship to the youth of the person with whom the youth was living; 

(e)
 
all documents related to the referral of the youth to the program as provided by the placing agency; 

(f)
 
documentation of the current custody and legal guardianship as provided by the placing agency; 

(g)
 
the youth's court status, if applicable; 

(h)
 
consent forms signed by the parents or guardian prior to placement that allow the program to authorize all necessary medical care, routine tests, immunization and emergency medical or surgical treatment; 

(i)
 
health records including medical history and vaccination record as provided by the placing agency; 

(j)
 
education records and reports; 

(k)
 
treatment or clinical records and reports; 

(l)
 
records of special or serious incidents; 

(m)
 
case plans and related material; 

(n)
 
social summary current to date of placement; 

(o)
 
report stating reason for placement; 

(p)
 
quarterly progress reports on the youth's reaction to the placement and services provided; 

(q)
 
date of discharge, reason for discharge, and the name, telephone number and address of the person or agency to whom the youth was discharged; and 

(r)
 
all other youth records and documentation as required by these rules. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.702
 YOUTH RIGHTS 

(1)
 
A program shall develop and maintain a youth's rights policy that supports and protects the fundamental human, civil, constitutional and statutory rights of all youth. These rights shall include, but are not limited to the following: 

(a)
 
each youth has the right to be free from abuse, neglect and unnecessary physical or chemical restraint; 

(b)
 
if the program operates during the school year, every youth has the right to educational services in accordance with Montana state law; 

(c)
 
the dignity of every youth and family must be recognized and respected in the delivery of services; 

(d)
 
each youth has the right to receive care according to individual need; 

(e)
 
service must be provided within the most appropriate setting; 

(f)
 
each youth has the right to personal privacy, and the program must allow privacy for each youth when not contrary to treatment and safety of the youth; 

(g)
 
contact with the family will be maintained by mail and phone, if accessible, as long as this contact is not contrary to the treatment and safety needs of the youth; and 

(h)
 
each youth has the right to have his or her opinions and recommendations considered and documented in the development of his or her case plan. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.705
 PHYSICAL EXAMINATION 

(1)
 
All physical examinations must be completed by an appropriate licensed practitioner. A youth must have a physical examination: 

(a)
 
within 30 days prior to admission into the program; 

(b)
 
at least annually after entering the program; and 

(c)
 
at any time when circumstances indicate that an updated examination would be appropriate. 

(2)
 
The result of the physical examination must be recorded on a standard form provided by the program. The form shall clearly identify to the examining practitioner the type and extent of physical activity which the youth will be asked to participate in. 

(3)
 
The physical examination must include: 

(a)
 
a complete blood count (CBC) , a urinalysis and an electrolyte screen, if deemed necessary by the examining practitioner; 

(b)
 
a pregnancy test for each female if deemed necessary by the examining practitioner; 

(c)
 
a physical assessment to determine the youth's fitness for the climate and temperature in which the youth will be participating and the youth's age, weight and physical condition; 

(d)
 
a determination of whether detoxification is indicated for the youth prior to entrance into the program; 

(e)
 
identification of any physical problems which would limit the youth's physical activity; 

(f)
 
identification of any special care which the youth will need; 

(g)
 
a record of immunizations as defined in ARM 
37.114.701
 through 
37.114.716
. In addition the immunization record must include: 

(i)
 
evidence of hepatitis A series, if deemed necessary by a practitioner; 

(ii)
 
evidence of hepatitis B series, if deemed necessary by a practitioner; 

(h)
 
a history of communicable diseases and serious illnesses or operations the youth has had; 

(i)
 
identification of any known drug reactions and allergies; 

(j)
 
identification of medications being taken during the six months prior to the examination, and a description of any possible special needs due to the use of medication in an outdoor, high impact environment; 

(k)
 
identification of any necessary special dietary requirements; and 

(l)
 
identification of any hereditary health issues that may affect the youth. 

(4)
 
If a youth is in a risk group for circulatory or auto-immune syndrome disorder, written approval must be included on the physical examination form by the practitioner for participation in the program. 

(5)
 
The practitioner conducting the examination must give written approval on the examination form for participation in the program, taking into consideration the factors specified in this rule and any other factors the practitioner deems to be relevant to the youth's participation in the program. The practitioner conducting the physical examination must give separate written approval on the examination form for the youth's participation in the following situations or activities: 

(a)
 
strenuous exercise; 

(b)
 
exposure to cold and hot temperatures; and 

(c)
 
activities that may occur in altitudes over 5000 feet. 

(6)
 
A program may not admit a youth who is not approved by the examining practitioner for admission to the program. The program shall comply with all restrictions or limitations placed on a youth by the examining practitioner. 

(7)
 
The original physical examination form must be maintained at the field office and a copy must be carried by staff in a waterproof container when the youth is away from the field office. The physical examination form must be maintained in a manner that assures the confidentiality of all medical and identification information. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.706
 ASSESSMENTS 

(1)
 
A program shall have written admission and assessment policies, procedures and forms. 

(2)
 
Prior to enrollment in the program, an admission assessment must be done for each youth by a program professional staff member. This admission assessment must include a review of the youth's social history, psychological history, medical history and physical examination. The assessment must review the following topics: 

(a)
 
allergies; 

(b)
 
medications; 

(c)
 
a record of immunizations as defined in ARM 
37.114.701
, 
37.114.702
, 
37.114.704
, 
37.114.705
, 
37.114.708
, 
37.114.709
, 
37.114.710
, 
37.114.715
 and 
37.114.716
; 

(d)
 
hospitalizations; 

(e)
 
medical diagnoses; 

(f)
 
medical problems that run in the family; 

(g)
 
pregnancy status and any complications; 

(h)
 
special dietary needs; 

(i)
 
illnesses; 

(j)
 
injuries; 

(k)
 
dental problems; 

(l)
 
mental health issues; 

(m)
 
emotional problems; 

(n)
 
ongoing medical care needs; 

(o)
 
history of aggressive or violent behavior; 

(p)
 
substance abuse history; 

(q)
 
sexual history or behavior patterns that may place the youth or other youth at risk; 

(r)
 
known or suspected suicide or self-injury attempts or gestures; 

(s)
 
emotional history indicating a predisposition for self-injury or suicide; and 

(t)
 
history of fire setting. 

(3)
 
The program shall establish a minimum body mass index. Body mass for each youth must be assessed to assure that the youth has sufficient body mass to fully participate in the strenuous elements of the program. 

(4)
 
A program professional staff member shall determine at the time of admission if the youth is currently appropriate for placement in the program. The youth may not be admitted if the youth: 

(a)
 
is determined to be an unsuitable candidate because of a limiting medical factor; 

(b)
 
requires secure psychiatric attention; 

(c)
 
requires secure detention; or 

(d)
 
is an imminent risk of being a danger to self or others. 

(5)
 
A subsequent assessment must be done before the youth leaves for the expedition portion of the program. The subsequent assessment must include the following evaluations: 

(a)
 
Each youth must be observed by an appropriate program professional staff member trained to identify noticeable evidence of any illness, communicable disease or signs of abuse. 

(b)
 
Youths that have special medications or treatment procedures, dietetic restrictions, known allergic reactions or any known physical limitation must meet with senior field staff and an appropriate program professional staff member to define special needs and services required while on expedition. On the basis of this evaluation, the program professional staff member shall decide whether the youth will be allowed to enter the expedition portion of the program. A written summary of this evaluation, including special needs of the youth and services required of the expedition staff, must be placed in the youth's file before the youth enters the field. 

(c)
 
For a youth with a history of mental illness, a psychological assessment must be prepared by an appropriate program professional staff member prior to the youth's entrance into the expedition portion of the program. On the basis of this psychological assessment, the program professional staff member shall decide whether the youth will be allowed to enter the expedition portion of the program. A written summary of this assessment, including special needs of the youth and services required of the expedition staff, must be placed in the youth's file before the youth enters the field. 

(d)
 
The senior field staff member assigned to the outdoor experience shall interview the youth prior to entrance into outdoor activities to determine the youth's suitability for planned outdoor activities. On the basis of this evaluation, the senior field staff member shall decide whether the youth will be allowed to enter the expedition portion of the program. A written summary of this evaluation must be placed in the youth's file before the youth enters the field. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.707
 DEVELOPMENT AND CONTENT OF THE CASE PLAN 

(1)
 
A case plan for each youth must be developed within 14 days of admission and prior to entering into the expedition portion of the program. The case plan team must include at minimum the appropriate members of the program professional staff and the field director. Members of the case plan team shall develop and sign the case plan. The youth's parent, guardian and/or the placing agency staff, along with the youth, if appropriate, must be encouraged to participate in the development of the case plan 

(2)
 
The case plan must address, at a minimum, the following: 

(a)
 
the youth's physical and medical needs; 

(b)
 
behavior management issues; 

(c)
 
mental health treatment methods; 

(d)
 
addictive disorder treatment methods; 

(e)
 
education plans; 

(f)
 
measurable goals and objectives; 

(g)
 
the responsibilities of the youth and staff for meeting the goals and objectives; 

(h)
 
the minimum number of hours per week the youth will receive individual and/or group counseling; 

(i)
 
discharge and aftercare planning, to include referrals to other agencies; 

(j)
 
type and frequency of therapeutic intervention activities; 

(k)
 
interventions to be used should the youth refuse to participate in any prescribed activity; and 

(l)
 
interventions to be used should the youth become a danger to self or others. 

(3)
 
The case plan must be reviewed and updated by the case plan team every 90 days or whenever there is a significant change in the youth's condition. The youth's parent, guardian, and/or the placing agency must be informed that case plan reviews are available for inspection. 

(4)
 
Copies of the case plan must be provided to the senior field staff and placed in the youth's file immediately upon completion or update. 

(5)
 
Copies of the case plan must be sent to the placing agency, and to the parents or legal guardians within 10 days of completion or update. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.715
 DISCHARGE SUMMARY 

(1)
 
Within 10 business days of the discharge of a youth from the program, a discharge report must be completed, including: 

(a)
 
a written summary of services provided, the youth's participation and progress, results of evaluations, condition of the youth, briefings and debriefings, compliance with program policies, procedures and recommendations; and 

(b)
 
the signature of the staff member who prepared the report and the date of preparation. 

(2)
 
The original discharge report must be maintained by the program in the youth's file, and a copy shall be provided to the placing agency and to the parents or legal guardians within 10 days of completion. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.