428.5 Progress notes (record of service provision).
(a) Progress notes must begin on the case initiation date as defined in
section 428.2(a) of this Part or upon receipt of a report of suspected abuse or
maltreatment for child protective service cases, and must continue until the case is
closed to all services. Progress notes must be made as contemporaneously as possible with
the occurrence of the event or the receipt of the information which is to be recorded.
(b) Each progress note entry must include the date of the entry, the
date of the event, and the name or initials of the author and person making the entry.
(c) Progress notes must include, but are not limited to:
(1) descriptions of contacts with children and
parent(s) receiving services, including missed or cancelled appointments, and the reasons
therefor;
(2) actions taken in the investigation of a
reported case of child abuse or maltreatment, including emergency and/or controlling
interventions taken, and descriptions of collateral contacts and other activities relating
to the collecting of information needed to formulate an assessment, and/or assist with
making a determination regarding the report of abuse or maltreatment; provided, however,
the name or other information identifying the reporter and/or the source of a report of
suspected child abuse or maltreatment, as well as the agency, institution, organization,
and/or program with which such person (s) is associated, must be recorded in the manner
specified by OCFS;
(3) efforts made to engage the family members
in the development of the service plan, their level or degree of participation in the
process and the family and children's reactions to services;
(4) referrals and communications with other
service providers involved in the case, and information received from specialized
rehabilitative and supportive service providers concerning casework contact activities
with a child and/or family receiving preventive and/or protective services;
(5) referrals and communications with the local
probation department regarding a child in the case;
(6) descriptions of contacts with
educational/vocational personnel on behalf of a child;
(7) court hearings or other legal activities;
(8) significant events such as births,
marriages, and divorces; and
(9) documentation of caseworker / supervisor
conferences, including a description of the nature of the discussions and any required
follow-up activities.
(10) For children in foster care or an
alternative placement setting, progress notes must also include:
(i) casework contacts
with child's parent(s), guardian, and/or relatives, the child and the child's day-to-day
caretaker(s) including casework contacts required in accordance with section 441.21 of
this Title;
(ii) descriptions of
activities related to medical and dental examinations required on a regularly scheduled
basis, including the initial medical examination, and any significant results, diagnosis,
referrals and prescribed medications arising from such medical and dental examinations in
accordance with section 441.22 of this Title;
(iii) descriptions of
parental and/or guardian visits with a child, and any missed visits and the reasons
therefor;
(iv) descriptions of
other visits with the child, including but not limited to visits with siblings and/or
half-siblings not placed with the child, potential permanency resources and any other
persons of significance to the child;
(v) chronological
documentation of diligent efforts, as required under section 430.12 of this Title, by an
authorized agency to assist, develop and encourage a meaningful relationship between the
parent(s) or the guardian and the child;
(vi) efforts by
parent(s) or guardian to provide an adequate home and provide parental care for the child,
or when it is determined that permanency for a child cannot be achieved within the child's
own family, discussions between the parent(s) and the authorized agency regarding the
pursuit of adoption or another permanency planning goal for the child;
(vii) documentation that the parent(s) or guardian were advised of the possible consequences if a child remains in foster care for 15 of the most recent 22 months, and of discussions with the parent(s) or guardian regarding the possible deleterious effects of foster care on the child and the child’s need for permanency;
(viii) any information acquired about an absent or non-respondent parent that is in addition to information recorded pursuant to paragraph (1) of subdivision (c) of section 428.4, and the results of an investigation into the location of any relatives, including grandparents of a child, subject to Article 10 of the Family Court Act or section 384-a of the Social Services Law; and
(ix) documentation of the case consultation(s) held for each child subject to the provisions of Article 10-A of the Family Court Act and section 428.9 of this Part in preparation for each permanency hearing.
(11) For children in foster care with
certified or approved foster parent(s):
(i) documentation that
the foster parent(s) have been informed of the visiting plan for the child's parent(s),
guardian(s), siblings or half-siblings, or others for whom a
visiting plan with the child exists;
(ii) documentation that
the foster parent(s) or prospective foster parent(s) have been asked whether they will
accept a sibling group, if appropriate;
(iii) documentation
that the foster parent(s) have been provided with information on the existence and
location of all siblings or half-siblings of any child placed with them;
(iv) documentation that
the foster parent(s) have been apprised of any special needs that the foster child has and
the available supports and services to address the special needs; and
(v) documentation that
the foster parent(s) have been informed that diligent efforts will be made to facilitate
regular biweekly visitation or communication between minor siblings or half-siblings who
have been placed apart, unless such contact would be contrary to the health, safety or
welfare of one or more of the children or unless the lack of geographic proximity
precludes visitation.
(d) Progress notes need not include clinical notes, daily logs or other
written material created by service providers who act in roles other than caseworker,
child protective services monitor, case planner or case manager.