Prompt and adequate documentation in the case record shall include a description of the actions taken, current progress toward the goal and objectives stated in the Out of Home Family Services Agreement (dss-5240), a current copy of the NC Division of Social Services Child Placement and Payment Report (dss-5094) or dss-5095 for adoption assistance, and the rationale for agency involvement and services delivery on an ongoing basis. Case documentation shall be current to within seven working days.
The agency shall maintain an individual record for each child or sibling group that contains:
1. Demographic Information should include:
• the name, address, sex, race, Social Security number, birth date, and birth place of the child;
• the names, addresses, telephone numbers, Social Security numbers, birth dates, races, religion, and marital status of the child's parents; and
• the names, addresses, and telephone numbers of siblings and other significant relatives and kin.
Many agencies provide this information on a standardized face sheet in the case record. It is extremely important that this information be updated as new information is acquired and as changes develop.
2. Annual Pictures of the Child
The record shall contain annual pictures of the child. At the time that permanency is achieved, the pictures shall be given to the adult assuming responsibility for the child’s care. It is also a good idea to attach copies of current pictures of the child to the agency’s report to the court at each review hearing. Pictures in the case record and with the court report keep those involved with the child focused on the child’s sense of time and the urgency for permanence.
All additional pictures of the child can be maintained in the record or life book so that they are available to the child, his/her family or his/her adoptive family after resolution of the case.
3. Placement History
A log shall be maintained in each child’s record which outlines the child’s placement history. This log should contain a record of the child's prior placements with names of caregivers, addresses, dates of placement, and specific reasons for the move. Copies of required notifications to parents regarding a change in a child’s placement must be included in the record.
4. Out of Home Family Services Agreement
All applicable parts of the Out of Home Family Services Agreement, including the health and education components, must be in the case record and signed by all appropriate parties. (Refer to Section 1201, Out of Home Family Services Agreements for more information on required forms and documentation).
Refer to Section 1201, Case Reviews, for more information on required documentation.
5. Court Documents
All court documents need to be maintained in the case record, including the original petition, all motions for review, all court orders, all procedural notices, and court reports.
6. Legal Documents
Legal documents of importance to the child, including a birth certificate must be maintained in the record.
7. Reports and Evaluations
Medical reports and psychological reports, including history, written assessments, and immunization records should be maintained in the case record.
8. Educational Information
Educational records and reports for school-age children, including IEP's when appropriate should be maintained in the case record.
9. Written Assessments
Any assessments of relatives or kin who may be considered as a potential placement resource for the child and assessments for consideration of a child for Independent Living must be included in the case record. Refer to the Instructions for Kinship Care Assessment (dss-5204ins) for information on kinship assessment and to 1201, Adolescent Services for information on Transitional Living Plan.
10. Interstate Compact Documents
All required documentation for accessing the Interstate Compact must be included in the case record.
Letters of attempts to contact parents, relatives, and kin; reminder letters of scheduled visits and reviews; and referral letters to service providers should be carefully maintained in the case record. These letters constitute legal evidence and document attempts to contact missing parents and attempts to provide services. Maintaining correspondence from parents, relatives, and kin document the family’s response to these attempts. Also, copies of notifications to participants in the Permanency Planning Action Team meetings shall be maintained in the child’s record, unless all are maintained centrally.
Dictation should reflect the dates and content of the social worker's face-to-face and telephone contacts with the child, the parents, the foster parents or other caregivers, and collaterals. Not only does the dictation need to document the frequency of case worker visits (monthly contact required), but it should also document reasons that justify when the requirements for a particular child are adjusted or not met.
More importantly, dictation should document progress that the social worker is making in providing the services reflected in the Out of Home Family Services Agreement. This documentation is important to show that reasonable efforts toward reunification or another identified permanent plan are being made.
When reunification is the plan, dictation should document the progress or lack of progress that the parent is making toward the goals and objectives identified in the Out of Home Family Services Agreement. This documentation should focus on parental behaviors and efforts that relate to the central problem that must be corrected in order for the child to return home safely. Documentation of visits between the parent and the child should reflect the dates and length of visits, as well as the substantive interactions between the child and parent during the visit. Since visitation is an indicator of progress or lack of progress in achieving case plan objectives, quality documentation of visits can be used to support decision-making.
Dictation should also document issues related to compliance with the Indian Child Welfare Act and the Multi-Ethnic Placement Act. (Refer to Section 1201, Placement Decision-Making, for information about the Indian Child Welfare Act and the Multi-Ethnic Placement Act.
13. Form DSS-5094, Child Placement and Payment System
A current copy of the dss-5094 must be maintained in the case record (unless these forms are maintained centrally elsewhere in the agency). This form must be updated as required and whenever there are changes related to any field. Entries on this form are critical for accurate payments to caregivers. Furthermore, data is now being collected from other fields that are used for statistical analysis. This data is being used for the Children’s Services Outcomes Reports for counties and for the Report on Experiences of Children Entering Child Welfare Custody in N.C. Data from county departments of social services is being scrutinized in identifying strengths in the child welfare system and areas for program improvement. The accuracy of data is critical in this analysis. Data is provided on request to the NC General Assembly, county commissioners, county managers, media, public officials, etc.
14. Form DSS-5027, SIS Client Eligibility Form
A current copy of the dss-5027 must be maintained in the case record (unless these forms are maintained centrally elsewhere in the agency.) As with the dss-5094, this form should be updated as required and when there are any changes related to any field. All fields are important and are used for statistical analysis.
15. Eligibility Forms
All relevant eligibility forms, including the IV-E Eligibility Determination forms, must be maintained in the case record. Please see Chapter XIII of the Family Services Manual for specific requirements.
The agency shall follow the confidentiality requirements which are contained in law and policy.
N.C.G.S. §108A-80 applies in general to all County Department of Social Services records. It provides that all information pertaining to applicants and recipients of public assistance and social services shall be confidential and may only be disclosed for “purposes directly connected with the administration of the programs.”
N.C.G.S.§7B-2901(b) requires that the County Department of Social Services maintain a record of cases of juveniles in protective custody or placement by the Court and that the following types of confidential information should be included:
The records may be examined only by order of the judge, except that the juvenile shall have the right to examine them.
17. Sharing Information from the Record with Other Agencies
Agencies may share information from the record with other agencies and service providers that are serving a child in foster care, as that sharing of information is needed to facilitate services for a child and family.
State law requires that the Chief District Court Judge in each district shall designate by standing order certain agencies in the district as “agencies authorized to share information.” Agencies that are authorized shall share information, upon request, that is relevant to any case in which a petition is filed alleging that a juvenile is abused, neglected, or dependent, and shall continue to do so until the juvenile is no longer subject to the juvenile jurisdiction of the Court. Designated agencies may include:
N.C.G.S. §7B-2901 (c) provides that, ”in the case of a child victim, a judge may order the sharing of information among such public agencies as the judge deems necessary to reduce the trauma to the child victim.”
Any information shared among agencies pursuant to the law shall remain confidential, shall be withheld from public inspection, and shall be used only for the protection of the juvenile.
N.C.G.S. §7B-1404-1413 sets rules of access for community and State multidisciplinary teams that review cases of child abuse/neglect and child deaths to identify gaps or deficiencies in the delivery of services to children and families. The State Child Fatality Task Force, the State and Local Child Fatality Prevention Teams, and the Community Child Protection Teams have access to all medical records, hospital records, and records maintained by the state, county or local agency as needed to carry out their legislated responsibilities. Information shared with these teams remains confidential and is not subject to discovery or introduction into evidence in any proceedings. The information may only be disclosed as necessary to carry out the purposes of the teams.
18. Confidentiality Policy Statements
Agencies shall have a written confidentiality policy that ensures protection and appropriate use of information contained in all Children’s Services records. The policy shall clearly define, in accordance with law:
It is recognized that foster parents and residential care providers have a need to know the HIV status of children in their care. Infections or viruses that are less serious in a non-infected child can be fatal to an HIV-infected child, and foster parents must be aware of symptoms that require immediate medical attention. However, prior to disclosure of a child’s HIV status, DSS must consider and protect the child’s right to confidentiality. While concern for confidentiality exists throughout the service delivery system, information regarding persons infected with HIV requires special consideration. This is due to the potential social and psychological damage that can be caused by inappropriate sharing of such information.
G.S. 130A-143 provides that HIV status and information is strictly confidential and shall not be released or made public except under certain circumstances. One such circumstance provides that release of all or part of the medical record can be made with the written consent of the person or persons identified or their guardian. In this context, guardian applies to a local DSS having authority to release HIV status and information on a child in its custody on a need to know basis to foster parents and residential care providers.
Information on the child’s HIV status should be shared only with persons who have a need to know, and persons informed should be told that re-disclosure of the information is prohibited without consent of the child, the parent or guardian. Best practice would suggest involving the parents in these decisions to the extent possible and appropriate.
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.