10A NCAC 70A .0112. CASE RECORDS FOR PROTECTIVE SERVICES

(a)  The county director shall maintain a separate case record or a separate section in a case record on a child for whom protective services are initiated or who is placed in the custody of the county department of social services by the court.  The case record documentation shall be kept confidential. Information from the case record shall be released only in accordance with Chapter 7B, Subchapter I, of the North Carolina General Statutes and the Rules of this Subchapter.

(b)  The protective services case record shall document the investigation.  In addition, when applicable, the protective services case record shall include:

(1)           summary documentation of the results of the check of the central registry of abused, neglected, and dependent children whenever a report is accepted for investigation unless the agency has conducted such a check in the 60 days prior to the new report, or the agency is providing ongoing children's services to the family;

(2)           copies of all comprehensive family assessments, including safety assessments, risk assessments, assessments of family strengths and needs, re-assessments of family strengths and needs and assessments of the child's and family's progress or lack of progress in completing the items documented in the Family Services Case Plan; 

(3)           documentation of any safety response plan that was developed to ensure the child's safety during the course of the investigation;

(4)           documentation of the case decision, the basis for the case decision, and the names of those participating in the decision;

(5)           documentation of notifications to parents, caretakers, the alleged perpetrator, or others specified in Rules .0107, .0108, .0109 and .0114 of this Section regarding the case decision;

(6)           documentation of contacts with and services provided to the family, current within seven days of service delivery.  Documentation may be taped for transcription, typed or legibly handwritten, and shall include information about the family's response to and use of services, as well as any change in the assessment of safety or risk to the children;

(7)           the Family Services Case Plan developed at the beginning of the treatment phase, with any subsequent revisions to the plan;

(8)           documentation of reviews of the Family Services Case Plan, current within three months, which reflect an assessment of the plan's effectiveness, the family's use of services, and the need for continued agency involvement;

(9)           copies of the following:

(A)          Intake/Screening Form provided by the Division for all reports concerning the family whether these reports have been received while a case was active or while a case was closed;

(B)          notices to the reporter;

(C)          requests made of other county departments of social services for information relating to prior contacts by that agency with the family, when applicable; and

(D)          DSS 5104, Application/Report to the Central Registry.

(10)         copies of the following reports or documents, when applicable:

(A)          petitions relating to the legal or physical custody of children while receiving child protective services;

(B)          reports to the court;

(C)          reports or notifications to prosecutors;

(D)          reports to law enforcement agencies;

(E)           Child Medical Evaluations and Child Mental Health Evaluation requests, consents, and reports;

(F)           any other medical, psychological, or psychiatric reports;

(G)          notifications to licensing agencies; and

(H)          any other reports, notifications, or documents related to the provision of child protective services.

(11)         summaries of the following information, when not otherwise documented in the case record:

(A)          at the time treatment services begin, a summary of the reasons services are being provided;

(B)          when filing a petition for custody, the reasons custody is being sought; and

(C)          at the time treatment services are terminated, a summary of the basis for the decision.

 

History Note:        Authority G.S. 7B-302; 7B-306; 7B-311; 7B-312; 7B-313; 7B-314; 7B-315; 7B-2901; 143B-153;

Eff. January 1, 1980;

Amended Eff. May 1, 2006; April 1, 2003; September 1, 1994; January 1, 1983.