428.3 Uniform case record requirements.
(a) All social services districts must establish and maintain a single
uniform case record for each family for whom a case record is required pursuant to section
428.1 of this Part.
(b) (1) Each uniform case record must include, but need not be limited
to the following items in the form and manner prescribed by OCFS:
(i) a common
application form;
(ii) family assessments
and service plans at regularly scheduled intervals in accordance with subdivision (f) ofv
this section;
(iii) plan amendments,
as required by section 428.7 of this Part completed for each status change; and
(iv) all forms for the
child care review service pursuant to section 406.4 and 465.1 of this Title, for as long
as that system remains the official system of record of OCFS.
(v) Each uniform case
record must also include the following additional information
and/or documents:
(a) face sheet;
(b) progress notes in the form and manner prescribed by OCFS;
(c) all official documents and records of any judicial or administrative proceedings
relating to the district's contact with a child and/or a family, including but not limited
to records of petitions, court orders, probation reports, voluntary instruments or
agreements, fair hearings, administrative reviews, and the results of any examinations or
evaluations ordered by a court;
(d) all correspondence between the family, the district and/or purchase of service
agencies;
(e) information received from private or public purchase of service agencies, concerning
casework contacts with achild and/or his or her family receiving family and children
services; and
(f) all documentation relating to the establishment of categorical eligibility for any
funding source for which the child or family may be eligible.
(vii) all official documents and records of any judicial or
administrative proceedings relating to the district's contact with a child and/or a
family, including but not limited to records of petitions, permanency hearing reports and
notices, court orders, probation reports, voluntary instruments or agreements, fair
hearings, administrative reviews, and the results of any examinations or evaluations
ordered by a court;
(2) For foster care placement cases, additional
information and documents must also include:
(i) data and official
documents relating to the identification and/or history of a child and/or his/her family,
including but not limited to certified copies of birth certificates, documentation of
religion, documentation of immigration status, and any consent forms and/or religious
preference forms signed by the parent or guardian;
(ii) all reports of
medical or clinical examinations or consultations, including medical examinations,
psychiatric or psychological examinations or consultations (either court-ordered or
voluntary), dental examinations; and medical consent forms signed by the parent or
guardian, by the commissioner of the social services district, or by the child if the
child has capacity to consent, as applicable, regarding medical treatment for any child in
foster care placement including documentation that the child has been assessed for risk
factors relating to HIV infection in accordance with section 441.22(b) of this Title, and,
if one or more risk factors have been identified, a description of the procedures that
werte followed to arrange for appropriate HIV-related testing including the necessary
written informed consent for such testing;
(iii) any educational
and/or vocational training reports and evaluations indicating the educational goals and
needs of each foster child, including school reports and Committee on Special Education
evaluations and/or recommendations; and
(iv) If the child has
been placed in foster care outside of the state, a report prepared every 12 months by a
caseworker either of the authorizing agency with case management and/or case planning
responsility for the child or by the state in which the placement home or facility is
located, documentng the caseworker's visit(s) with the child at his or her placement home
or facility within the 12 month period.
(c) A single family assessment and service plan must be completed as
specified in sections 428.6 of this Part, for all family members at the intervals
described in subdivision (f) of this section. The assessment and ser vice plan must
include a description of the collaborative efforts of the case planner and all case
workers assigned to the case.
(d) Each family assessment and service plan, must document the
involvement of the parent(s) or guardian and, where appropriate, child(ren) 10 years or
older, including children in foster care and their siblings or half-siblings and children
placed by a court in the direct custody of a relative or other suitable person pursuant to
Article 10 of the Family Court Act, in the development of the plan, or must document
efforts to involve them in the development of the plan. Such efforts must include, but are
not limited to:
(1) encouraging parent(s) or guardian and the children to participate in the development and review of the plan, and attempting to obtain the parent(s)’or guardian’s signatures documenting their review of the plan; and
(2) where the parent(s) or guardian and/or children are not able to participate in the development of the plan and arrangements cannot be made to allow participation, conveying the contents of the service plan and any recommendations to them, and attempting to obtain the parent(s)’ or guardian’s comments and signatures documenting their review of the plan.
(e) For foster care cases and for children placed by a court in the
direct custody of a relative or other suitable person pursuant to Article 10 of the Family
Court Act, the service plan review requirements of section 428.9 of this Part also apply.
(f) Case process flow.
(1) Social services districts must initiate a
uniform case record for a family on the case initiation date as defined in section
428.2(a) of this Part.
(2) On the case initiation date, the following
must be completed and become part of the uniform case record:
(i) a common
application form; and
(ii) face sheet or
equivalent in accordance with section 428.4 of this Part.
(3) Documentation of casework activity and
contacts in progress notes must begin on the case initiation date or, for cases where a
report has been accepted by the Statewide central register, casework activity must be
recorded in progress notes from the date of receipt of the report of suspected abuse or
maltreatment.
(4) Except for open indicated child abuse and
maltreatment cases, an initial family assessment and service plan must be completed by the
social services district or by a provider agency providing services pursuant to a purchase
of service agreement, and must be approved by the case manager within 30 days from the
case initiation date. For open indicated child abuse and maltreatment cases, an initial
family assessment and service plan must be completed by the social services district or
the provider agency providing services pursuant to a purchase of service agreement, and
approved by the case manager within seven days of the date that a report to the Statewide
central register is determined to be indicated.
(5) A comprehensive family assessment and
service plan must be completed by the social services district or by a provider agency
providing services pursuant to a purchase of service agreement and must be approved by the
case manager within 90 days from the case initiation date.
(6) The first family reassessment and service
plan must be completed by the social services district or by the provider agency providing
services pursuant to a purchase of service agreement, and must be approved by the case
manager no later than 210 days from the case initiation date. All subsequent family
reassessment and service plan reviews must be completed by the social services district or
by the provider agency providing services pursuant to a purchase of service agreement, and
must be approved by the case manager six months from the due date of the previous
reassessment and every six months thereafter.
(7) A plan amendment must be completed by
the social services district or by the provider agency providing services pursuant to a
purchase of service agreement, and must be approved by the case manager for the case, in
accordance with the requirements of section 428.7 of this Part, whenever a significant
change occurs in the status of the case.
(g) Each initial familyassesment, comprehensive family assesment and
reassessment developed in accordance with this Part must contain, as applicable: a written
consideration of whether it is safe for the child to remain in his or her home: or whether
it is safe for the child to remain in his or her current foster care placement, and
whether it is safe to discharge the child from foster care.
(h) The name or other information identifying the reporter abd/or the
source of a report of suspected child abuse or maltreatment, as the agency, institution,
organization, and/or program with which such person(s) is associated must only be recorded
or documented in progress notes and such documentation must be recorded in the manner
specified by OCFS.