65C-46.010. Child Records and Confidentiality Requirements

(1) The child-caring agency shall maintain a permanent record of all resident children and document efforts to obtain the information which shall be made available to the Department upon request. The record shall include the following:

(a) The name and birth date of the child;

(b) The name and address of the child’s parents or guardians or child-placing agency;

(c) The child’s dates of admission and discharge; and,

(d) The child’s custody status.

(2) The child-caring agency shall maintain individual records for each child and document efforts to obtain the information. The child’s record shall include the following:

(a) The name, gender, race, religion, birth date, and birthplace of the child;

(b) The name, address, and telephone number of the parent or guardian, siblings, grandparents, or other persons significant to the child;

(c) A social history of the child, the child’s family and other significant persons, and any other information required by the child-caring agency;

(d) Copies of legal documents relating to the child;

(e) Date of admission, source of referral, and any available assessments from the referring agency including the Comprehevsive Placement Assessment, incorporated by reference in Rule 65C-28.004, F.A.C., and the Comprehevsive Behavioral Health Assessment, referenced in Rule 65C-28.014, F.A.C.;

(f) Child’s placement agreement, also known as the precautionary or behavioral agreement;

(g) Medical history, health record, treatment and clinical records, progress reports, prescriptions, and any psychological and psychiatric reports;

(h) Educational records and reports;

(i) Vocational exploration and training and employment records, if applicable;

(j) Records of special or critical incidents in the child’s life;

(k) The child’s case plan, treatment plan, and service plan reviews and revisions reflecting the child’s and family’s goal achievement, as applicable to the population served (i.e. dependency youth, community youth, etc.);

(l) Visitation schedule outlining frequency of contact with parents, relatives, friends, or others with whom the child may have a significant relationship;

(m) Referrals to other agencies; and,

(n) Discharge summary.

(3) Information in case records shall be kept confidential. This includes sharing information with other children in the group home.

(4) Staff entries in case records shall be dated and signed.

(5) The case record shall be maintained for a minimum of five (5) years after a child has been discharged.

(6) The child-caring agency shall dispose of conficential records in a manner that protects the clients privacy and security of their protected health information.

(7) The identity of any child who has tested positive for the HIV virus shall be disclosed to an employee of the Department or child-caring or child-placing agency directly involved in the placement, care, or custody of such child and only when the employee needs to know such information in order to safely perform job duties. An employee has a need to know the identity of a child and the child’s test results if:

(a) The employee is involved in case specific services, such as assessing needs, determining eligibility, arranging care, monitoring case activities, permanency planning and providing care for the child in residential placement, or

(b) The employee is involved in case specific supervision or monitoring of cases for eligibility or legal compliance or casework services, or

(c) The employee is involved in providing case specific clerical and vouchering support.

(8) The identity of a child who has tested positive for the HIV virus must be disclosed to a foster family, or child-caring or child-placing agency licensed pursuant to Florida Statutes, who is directly involved in the care of such child and has a need to know such information. The identity of the child shall be disclosed only after the following conditions have been met:

(a) The Department or child-placing or child-caring agency has provided all available information, including HIV test results, social information and special needs, in a manner that does not permit identification of the child; and,

(b) The decision to place the child in a specific placement has been confirmed.

(9) The child-caring, child-placing agency, foster home or adoptive home who has accepted an HIV infected child for care shall be given a statement in writing which includes the following language: “This information has been disclosed to you from confidential records. The confidentiality of this record is protected by state law. State law prohibits you from making any further disclosure of such information without the specific written consent of the person to whom such information pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.”

(10) The child’s record shall contain documentation that the written statement was given to the child-caring, child-placing agency or to the foster or adoptive parents.

(11) The case files shall not be segregated or flagged in any way which would permit their identification as case files of HIV infected children.

Rulemaking Authority 409.175(5), 381.004(2)(e)11. FS. Law Implemented 409.175(5)(b)1., 9., 13., 381.004(2)(e)11., (f) FS. History–New 7-1-87, Formerly 10M-9.031, Amended 10-20-16, 5-26-21, Formerly 64C-14.022.