Division D: Reporting And Documentation

Front 1

What is a serious incident?

Back 1

A serious incident is a non-routine occurrence that has or may have dangerous or significant consequences on the care, supervision, and/or treatment of a child.

Front 2

(1) A child dies while in your care.

Back 2

1) Licensing: Report as soon as possible, but no later than 24 hours after the incident or occurrence.
2) Parents:Immediately.
3) Police: Immediately.

Front 3

(2) A critical injury or illness that warrants treatment by a medical professional or hospitalization, including dislocated, fractured, or broken bones; concussions; lacerations requiring stitches; second and third degree burns; and damage to internal organs.

Back 3

Licensing:Report as soon as possible, but no later than 24 hours after the incident or occurrence.

Parents: Report as soon as possible, but no later than 24 hours after the incident or occurrence.

Police: DO NOT NEED TO INFORM

Front 4

(3) Allegations of abuse, neglect, or exploitation of a child; or any incident where there are indications that a child in care may have been abused, neglected, or exploited.

Back 4

Licensing: As soon as you become aware of it. Including whether you plan to move the child until the investigation is complete.

Parents: As soon as you become aware of it. Including whether you plan to move the child until the investigation is complete.

Police: DO NOT NEED TO INFORM

Front 5

(4) Physical abuse committed by a child against another child. For the purpose of this subsection, physical abuse is:
physical injury that results in substantial bodily harm and requiring emergency medical treatment, excluding any accident; or failure to make a reasonable effort to prevent an action by another person that results in physical injury that results in substantial bodily harm to the child.

Back 5

Licensing:Report as soon as possible, but no later than 24 hours after the incident or occurrence.

Parents: Report as soon as possible, but no later than 24 hours after the incident or occurrence.

Police: DO NOT NEED TO INFORM

Front 6

(5) Sexual abuse committed by a child against another child. For the purpose of this subsection, sexual abuse is:
conduct harmful to a child’s mental, emotional or physical welfare, including nonconsensual sexual activity between children of any age, and consensual sexual activity between children with more than 24 months difference in age or when there is a significant difference in the developmental level of the children; or failure to make a reasonable effort to prevent sexual conduct harmful to a child.

Back 6

Licensing:Report as soon as possible, but no later than 24 hours after the incident or occurrence.

Parents: Report as soon as possible, but no later than 24 hours after the incident or occurrence.

Police: DO NOT NEED TO INFORM

Front 7

(6) A child is indicted, charged, or arrested for a crime, not including being issued a ticket at school by law enforcement or any other citation that does not result in the child being detained.

Back 7

Licensing:Report as soon as possible, but no later than 24 hours after the incident or occurrence.

Parents: Report as soon as you become aware of it.

Police: DO NOT NEED TO INFORM

Front 8

(7) A child developmentally or chronologically under 6 years old is absent from a foster home and cannot be located, including the removal of a child by an unauthorized person.

Back 8

Licensing: Within 2 hours of notifying law enforcement.

Parents: Within 2 hours of notifying law enforcement.

Police: Immediately upon determining the child is not on the premises and the child is still missing.

Front 9

(8) A child developmentally or chronologically 6 to 12 years old is absent from a foster home and cannot be located, including the removal of a child by an unauthorized person.

Back 9

Licensing: Within 2 hours of notifying law enforcement.

Parents: Within 2 hours of notifying law enforcement.

Police: Within two hours after determining the child is not on the premises and the child is still missing.

Front 10

(9) A child 13 years old or older is absent from a foster home and cannot be located, including the removal of a child by an unauthorized person.

Back 10

Licensing: No later than 24 hours after the child has gone missing.

Parents: No later than 24 hours after the child has been missing.

Police: No later than 24 hours after determining the child is not on the premises and the child is still missing.

Front 11

(10) A child in your care contracts a communicable disease that the law requires you to report to the Department of State Health Services (DSHS) as specified in 25 TAC Chapter 97, Subchapter A, (relating to Control of Communicable Diseases).

Back 11

Licensing: As soon as possible, but no later than 24 hours after you become aware of the communicable disease, unless the information is confidential.

Parents:As soon as possible, but no later than 24 hours after you become aware of the communicable disease. If their child has contracted the communicable disease or has been exposed to it.

Police: DO NOT NEED TO BE INFORMED

Front 12

(11) A suicide attempt by a child.

Back 12

Licensing: As soon as you become aware of the incident.

Parents:As soon as you become aware of the incident.

Police: DO NOT NEED TO BE INFORMED

Front 13

Misc. Information on SIRs

Back 13

(b) Foster parents must report any serious incident directly to the Child Abuse Hotline if the incident involves a child under the care of the foster parent.
(c) If there is a serious incident involving an adult resident, you do not have to report the incident to Licensing, but you must document the incident. You do have to report the incident to law enforcement, as outlined in the chart above. You also have to report the incident to the parents, if the adult resident is not capable of making decisions about his own care.

Front 14

) Any incident that renders all or part of your operation unsafe or unsanitary for a child, such as a fire or a flood.

Back 14

Licensing: As soon as possible, but no later than 24 hours after the incident.

Parents:As soon as possible, but no later than 24 hours after the incident.

Front 15

A disaster or emergency that requires your operation to close.

Back 15

Licensing: As soon as possible, but no later than 24 hours after the incident.

Parents:As soon as possible, but no later than 24 hours after the incident.

Front 16

) An adult who has contact with a child in care contracts a communicable disease noted in 25 TAC 97, Subchapter A, (relating to Control of Communicable Diseases).

Back 16

Licensing: As soon as possible, but no later than 24 hours after you become aware of the communicable disease, unless the information is confidential.

Parents:As soon as possible, but no later than 24 hours after you become aware of the communicable disease.

Police: DO NOT NEED TO BE INFORMED

Front 17

An allegation that a person under the auspices of your operation who directly cares for or has access to a child in the operation has abused drugs within the past seven days.

Back 17

Licensing: Within 24 hours of hearing the allegation.

Parents: DO NOT NEED TO BE INFORMED

Front 18

(5) An investigation of abuse or neglect by an entity (other than Licensing) of an employee, professional level service provider, volunteer, or other adult at the operation.

Back 18

Licensing: Within 24 hours of finding out about the investigation.

Parents: DO NOT NEED TO BE INFORMED

Front 19

) An arrest, indictment, or a county or district attorney accepts an “Information” regarding an official complaint against an employee, professional level service provider, or volunteer alleging commission of any crime as provided in §745.651 of this title (relating to What types of criminal convictions may preclude a person from being present in an operation?).

Back 19

Licensing: Within 24 hours of finding out about the situation.

Parents: DO NOT NEED TO BE INFORMED

Front 20

What constitutes a suicide attempt by a child?

Back 20

A suicide attempt is a child’s attempt to take his own life using means or methods for causing his death, including any act a child commits intending to cause his death, but excluding suicidal gestures where it is clear that the act was unlikely to cause death. Suicidal thoughts are not reportable as a suicide attempt.

Front 21

(1) Medically pertinent incidents, such as seizures, that do not rise to the level of a serious incident.

Back 21

Licensing: You do not need to inform, however, you must document the type of incident including the date, time, action taken, and child’s name.

Parents: Within seven days.

Front 22

(2) Changing your child-placing agency administrator.

Back 22

Licensing: In writing within seven days after the action is taken.

Parents: DO NOT NEED TO BE INFORMED

Front 23

How do I make a report of a serious incident or occurrence to Licensing?

Back 23

(a) All serious incident reports must be made to the Child Abuse Hotline.
(b) Occurrences that are required to be reported to Licensing in writing must be forwarded to your Licensing representative (See §749.507 (2) and (3) of this title (relating to When must I report other occurrences?)).

Front 24

How must I document a serious incident?

Back 24

A serious incident must be documented in a written report that includes the following information:
(1) The name of the foster home or adoptive home, physical address, and telephone number;
(2) The time and date of the incident;
(3) The name, age, gender, and date of admission of the child or children involved;
(4) The names of all adults involved and their role in relation to the child(ren);
(5) The names or other means of identifying witnesses to the incident, if any;
(6) The nature of the incident;
(7) The circumstances surrounding the incident;
(8) Interventions made during and after the incident, such as medical interventions, contacts made, and other follow-up actions;
(9) The treating licensed health-care professional’s name, findings, and treatment, if any; and
(10) The resolution of the incident.

Hint 24

Regarding subsection (3), this requirement is not intended to conflict with confidentiality laws or rights. Identifying information for one child should not be placed in the record of another child. You may choose to 1) write one incident report that is filed centrally (not in each child’s record) and de-identified when released as part of a child’s record, 2) write one incident report that is filed in each child’s record, with each copy de-identified to not show the full name of other children involved in the incident, or 3) write a separate incident report for each child, with only the first name or initials of each other child involved. Regarding subsection (5), witnesses to the incident are persons who were present when the incident occurred and can give a first-hand account of what they experienced during the incident. A person is not automatically a witness because he lives in the same unit or cottage as the child involved in the incident. Witnesses may also be persons unaffiliated with the operation, such as a visitor to the operation who was present at the time of the incident.

Front 25

What additional documentation must I include with a written serious incident report?

Back 25

(1) Child death, suicide attempt, or a critical injury reportable under §749.503(a)(1), (2), and (11) of this title (relating to When must I report and document a serious incident?).---Any emergency behavior interventions implemented on the child within 48 hours prior to the serious incident.

(2) Any critical injury reportable under §749.503(a)(2) of this title that resulted from a short personal restraint.---Documentation of the short personal restraint, including the precipitating circumstances and specific behaviors that led to the emergency behavior intervention.

(3)Child absent without permission.---
(A) Any efforts made to locate the child;
(B) The date and time you notified the parent(s) and the appropriate law enforcement agency and the names of the persons with whom you spoke regarding the child’s absence and subsequent location or return to the foster home; and
(C) If the parent cannot be located, dates and times of all efforts made to notify the parent regarding the child’s absence and subsequent location or return to the foster home.

(4) Any abusive behavior among children reportable under §749.503(a)(4) or (5) of this title---The difference in size, age, and developmental level of the children involved in the abusive behavior.

Front 26

Where must I keep incident reports?

Back 26

(a) You must keep a copy of the incident report on file for two years.
(b) You must permit Licensing to make a copy of incident reports, as requested.

Front 27

If I keep electronic records, what procedures must I have for those records?

Back 27

(a) If you keep electronic records, you must develop procedures that address what must be in the external paper file and what can be in the electronic file.
(b) You must limit access to your electronic files to:
(1) Persons within your agency authorized to see specific information; and
(2) Others outside of your agency authorized by law to have access to specific information.
(c) You must develop policies that address the following:
(1) Computer security systems, including confidentiality, passwords, and employee procedures to ensure security of the system;
(2) Requirements for routine back up of data; and
3) Anti-virus protection systems.

Front 28

What procedures must I have for protecting records?

Back 28

You must have procedures for protecting electronic and paper records from destruction, loss, and unauthorized access.

Front 29

How current must a record be?

Back 29

(a) All documentation must be in the record:
(1) No later than 30 days after the occurrence or event;
(2) Within 15 days from the end of the month for monthly summaries; or
(3) As otherwise specified in this chapter.
(b) Copies of any records kept by the foster parents must be submitted to you each month. You must file these records in the child’s record.

Front 30

Must I make records available for Licensing to review?

Back 30

(a) You must make all active records available for our immediate review and reproduction.
(b) You must make all archived records available for our review and reproduction within 48 hours.
(c) We must have reasonable access to your storage and file areas in order to monitor your record keeping.

Front 31

Where must I maintain personnel records?

Back 31

(a) You must maintain active personnel records at the agency. This may include electronic records per §749.531 of this title (relating to If I keep electronic records, what procedures must I have for those records?).
(b) You must maintain archived personnel records at the agency and/or in a central administratively designated location.
(c) You may archive entire closed personnel records electronically.
(d) Your system for maintaining all personnel records must be uniform throughout the agency.
(e) You must maintain a master list of active and archived personnel records and their location in the main office of the agency.

Hint 31

Helpful Information
Regarding subsection (d), most child-placing agencies either keep all personnel records at the main office or keep each personnel record at the location in which the person is working. Any system is acceptable as long as it is consistently implemented throughout the child-placing agency. You are not required to keep duplicate records at a branch office if you choose to maintain all personnel records at your main office.

Front 32

What information must the personnel record of an employee include?

Back 32

For each employee, excluding foster parents, the personnel record must include:
(1) Documentation showing the date of employment;
(2) Documentation showing how the person meets the minimum age and qualifications for the position;
(3) A current job description;
(4) Evidence of any valid professional licensures, certifications, or registrations the person must have to meet qualifications for the job position, such as a current renewal card or a letter from the credentialing entity verifying that the person has met the required renewal criteria;
(5) A copy of the record of tuberculosis screening conducted prior to the person having contact with children in care showing that the employee is free of contagious tuberculosis as provided in §749.1417 of this title (relating to Who must have a tuberculosis (TB) examination?);
(6) A notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, §42.059;
(7) A statement signed and dated by the employee that he has read a copy of the:
(A) Operational policies; and
(B) Personnel policies;
(8) A statement signed and dated by the employee indicating that he must immediately report any suspected incident of child abuse, neglect, or exploitation to the Child Abuse Hotline and the agency’s administrator or administrator’s designee;
(9) Proof of request for background checks required by Chapter 745, Subchapter F of this title (relating to Background Checks);
(10) For each person who transports a child, a copy of:
(A) The person’s valid driver’s license; or
(B) A driver’s license check conducted through the Texas Department of Public Safety within the last 12 months;
(11) A record of training and training hours;
(12) Any documentation of the person’s tenure with the agency; and
(13) The date and reason for the person’s separation from the agency, if applicable.

Front 33

What information regarding personnel must be kept confidential?

Back 33

All background check results must be kept confidential, in accordance with Human Resources Code §40.005, subsections (d) and (e). Background check results must be protected from unauthorized access or release.

Front 34

How long must I maintain personnel records?

Back 34

(a) You must maintain annual training records for current personnel for the last full training year and current training year.
(b) With the exception of subsection (a) of this section, you must keep personnel records for a year after an employee’s last day on the job, or until any investigation involving the employee is resolved, whichever is longer.

Front 35

What client records must I maintain?

Back 35

You must maintain master records for all clients. The records must be individualized, current, and complete. The master record may include electronic records per §749.531 of this title (relating to If I keep electronic records, what procedures must I have for those records?).

Front 36

Where must I maintain active master records for clients?

Back 36

(a) You must maintain the active master case record for a child at the office where the child placement staff that is managing the child’s placement is located.
(b) You must maintain the active master record for a foster or adoptive home at the office where the child placement staff that is managing the home is located.
(c) You must maintain a master list of active client records and their location in the main office of the agency.

Front 37

What is an active record for a child?

Back 37

An active child record consists of the child’s record for the most recent 12 months of service.

Front 38

What information must an active child record include?

Back 38

For each child, the active record must include:
(1) The child’s full name and another method of identifying the child, such as a client number;
(2) Documentation of known allergies and chronic conditions on the exterior of the child’s record or in another location where the information is clearly visible to persons with access to the record, including a notation of “no known allergies” when applicable; and
(3) The date of each data entry and the name of the person who makes the data entry.

Front 39

How must I maintain an active child record?

Back 39

On an on-going basis, you must ensure that each child’s record is:
(1) Kept accurate and current;
(2) Locked and kept in a safe location or locations; and
3) Kept confidential as required by law.

Front 40

Where must I maintain archived client records?

Back 40

(a) You must maintain archived client records at the agency and/or in a central administratively designated location.
(b) You may archive entire closed client records electronically.
(c) Your system for maintaining all client records must be uniform throughout the agency.
(d) You must maintain a master list of archived client records and their location in the main office of the agency.

Front 41

Who must consent to the release of a child’s record?

Back 41

Unless you are releasing information to a parent, to us, or as required by law, you may not release any portion of a child’s record to any agency, organization, or individual without the written consent of the person legally authorized to consent to the release.

Front 42

How long must I maintain client records?

Back 42

(a) For children placed in adoption, you must maintain complete child, birth parent, and adoptive family records permanently or transfer them, as appropriate, to the Bureau of Vital Statistics.
(b) You must maintain a foster child’s complete record from admittance to discharge for two years from the date of discharge, or until the resolution of any investigation involving the child, whichever is longer.
(c) You must maintain records for foster homes for at least five years after the foster home is closed. This includes foster homes that did not receive placements.
(d) You must maintain records for approved adoptive applicants with whom you did not place a child for at least five years after the family withdraws or you close consideration of the family for a placement.
(e) You must maintain records for applicants for foster or adoptive homes whom you did not approve for at least one year after denial of the application.
(f) You do not have to maintain records of foster or adoptive home applicants who drop out before the completion of a home study

Front 43

How must I handle adoption records if I cease operating?

Back 43

(a) If you cease operating, you must transfer adoption records to:
(1) The Department of State Health Services, Bureau of Vital Statistics, and provide written notification to Licensing of the transfer; or
(2) Another licensed child-placing agency. If you transfer your records to another child-placing agency, you must inform the Bureau of Vital Statistics, in writing, of the closing and of the location of the adoption records. You must send a copy of the letter you send to the Bureau of Vital Statistics to the local Licensing office.
(b) You must transfer the records within the time frame specified by the Bureau of Vital Statistics.
Texas