Each Local Early Steps is required to collect, develop and maintain individual records for each child referred to Early Steps. There may be limited items in the Early Steps record for children for whom contact is not successful, eligibility is never determined, or an IFSP is never developed. The Local Early Steps must maintain a record of the evaluation conducted (IFSP Form D) on each referred infant and toddler who is determined ineligible for Early Steps by the eligibility evaluation team. This record will include conclusions of the team evaluation, documentation of notification to the parents of the team's determination, and provision of information concerning the parent's rights if they do not agree with the eligibility determination.
Child Records
If an initial IFSP has been developed, the Early Steps record maintained by the LES must, at a minimum, consist of the following:
Referral information
Consent for Evaluation and Use of Insurance form (CMS ES Form 1064)
Written Prior Notice documentation
Consent for Release of Information
Log of Access to Confidential Record (DH-CMS Form 1063)
Individualized Family Support Plan(s)
Participation in IFSP Meeting Documentation form(s)
Progress Reports
Service Coordination/Targeted Case Management case notes
Consultation Among Service Provider Team Members form(s).
Medicaid Freedom of Choice form (if applicable)
All Correspondences related to the status of the child/family
Additional documentation such as court order granting legal guardianship, documentation of resident alien status, documentation of insurance, as appropriate
Fiscal records and service payment documentation, including documentation of service provision by service providers
Any medical documentation related to the diagnosis or medical condition of the recipient, including history and services
Record Organization
The Early Steps record should be maintained in the format specified in 12.5.1(D) of the Policy and Handbook Operations Guide. The record may be divided into sub-sections and additional sections may be included at the discretion of the Local Early Steps.
Program Transfer
If an Early Steps eligible infant is transferred to another Local Early Steps, the service coordinator must ensure that a copy of the child's record is transferred to the receiving Local Early Steps within five (5) calendar days of the child's move.
Program Discharge
Upon the discharge of a child from a Local Early Steps, the service coordinator will close the case record in the Early Steps data system within ten (10) calendar days of program discharge.
Closed Case Records Closed case records must be maintained by the Local Early Steps and its service providers for a minimum of five (5) years from the date of closure.
