New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter C - Social Services › Article 2 - Family and Children's Services › Part 428 - STANDARDS FOR UNIFORM CASE RECORDS AND FAMILY AND CHILD ASSESSMENTS AND SERVICE PLANS › Section 428.5 - Progress notes (record of service provision)

Current through Register Vol. 46, No. 28, July 10, 2024
(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 or
			 family assessment response for 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, and descriptions
			 of family and collateral contacts and other activities relating to the
			 provision of a family assessment response; 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 or the completion of a family led assessment guide, 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) description of contacts with
			 educational/vocational personnel on behalf of the child, including, but not
			 limited to, contacts made with school personnel in accordance with sections
			 430.11(c)(1)(i) and
			 430.12(c)(4) 
			 of this Title;
(7) court hearings
			 or other legal activities;
(8)
			 significant events such as births, marriages, and divorces;
(9) documentation of caseworker/supervisor
			 conferences, including a description of the nature of the discussions and any
			 required follow-up activities; and
(10) for children not residing with a parent
			 who are in foster care or an alternative placement setting, progress notes, as
			 applicable, 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 section
			 428.4(c)(1) 
			 of this Part, 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 the
			 efforts to identify and provide notification to grandparents and other adult
			 relatives in accordance with the requirements of section
			 430.11(c)(4) 
			 of this Title;
(ix) a description
			 of the reasonable efforts made to finalize the child's permanency plan,
			 including, but not limited to, where the permanency goal is other than the
			 return of the child to the parent, identification of in-State and out-of-state
			 placement options; and
(x)
			 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;
(12) for children in foster care placed with
			 relative foster parent(s) whose permanency plan is placement with such
			 relative(s) and receipt of kinship guardianship assistance payments:
(i) the steps taken to determine that it is
			 not appropriate for the child to return home or be adopted;
(ii) the reasons for any separation of
			 siblings during placement;
(iii)
			 the reasons why a permanent placement with a fit and willing relative through a
			 kinship guardianship assistance arrangement is in the child's best interests,
			 including the compelling reasons for determining that the return home of the
			 child and the adoption of the child are not in the best interests of the child
			 and are not appropriate permanency goals;
(iv) the ways in which the child meets the
			 eligibility requirements for a kinship guardianship assistance
			 payment;
(v) the efforts made to
			 discuss adoption by the child's relative foster parent as a more permanent
			 alternative to legal guardianship and, in the case of a relative foster parent
			 who has chosen not to pursue adoption, documentation of the reasons
			 therefore;
(vi) the efforts made to
			 discuss with the child's parent or parents the kinship guardianship assistance
			 arrangement, or the reasons why the efforts were not made; and
(vii) the steps taken to hold age appropriate
			 consultation with the child regarding the kinship guardianship arrangement,
			 including the consultation conducted with a child who is 14 years of age or
			 older and the steps taken to secure the consent of a child who is 18 years of
			 age or older to the kinship guardianship arrangement.
(13) for children in foster care with a
			 permanency planning goal of another planned living arrangement with a
			 permanency resource:
(i) the intensive,
			 ongoing and unsuccessful efforts to return the child home or to secure a
			 placement for the child with a fit and willing relative, including adult
			 siblings, a legal guardian or legal custodian, or an adoptive parent, including
			 efforts made that utilize technology, including social media, to locate family
			 members of the child;
(ii) the
			 child's foster home or child care facility in which the child is placed is
			 following the reasonable and prudent parent standard set forth in section
			 441.25 
			 of this Title; and
(iii) the child
			 has regular, ongoing opportunities to engage in age or developmentally
			 appropriate activities, including by consulting with the child in an
			 age-appropriate manner about the opportunities to participate in such
			 activities.