Item 6930 has been replaced in its entirety by new content and new sub-items.
6930 Documentation Requirements for Substitute Care
CPS March 2005 September 2007
Staff must document contacts, assessments and services provided to children in substitute care and to their families, and key decisions and actions that take place during this time that affect such children and families. The record of these activities:
· is essential to good casework practice;
· promotes continuity of care; and
· is required, in many cases, to maintain federal funding.
Substitute-care documentation consists of what is:
· entered into IMPACT (Information Management Protecting Adults and Children in Texas); and
· filed in external documentation.
Legal Requirements for Documentation
The Child and Family Services Improvement Act of 2006 (CFSIA) requires that DFPS have standards for the content and frequency of visits for children in foster care that at a minimum ensure monthly visits that are well-planned, focused on relevant case planning issues and service delivery. The purpose of the standards is to ensure the safety, permanency and well-being of the child.
These requirements are based on findings from Child and Family Services Reviews, which found a strong correlation between frequent caseworker visits and positive outcomes, including permanency and well-being for children in care. The federal goal is for 90 percent of children in care to be visited monthly with the majority of visits in the child’s residence.
P.L. 109-288
The Social Security Act, including Title IV-B, Section 422; Title IV-E, and Sections 472 and 475.
Texas Family Code, including §263.102 Service Plan Contents, §263.3025 Permanency Plan, §263.303 Permanency Progress Report, and §263.502 Placement Review Report.
DFPS Rules, including40 TAC Chapter 700, Subchapter M, Substitute-Care Services; and Chapter 749, Minimum Standards for Child-Placing Agencies.
For additional information about:
· basic case documentation policy, which includes the requirement to document activities within seven days of occurrence, see 1400 Case Records and Workload Management;
· supervisory options for approving case actions in IMPACT, see 1432 Supervisory Approval Process; and
· substitute-care case records, see Appendix 1422: Instructions and Tables of Contents for Case Record Dividers.
Maintaining Documentation in Each Open Stage
When a substitute-care stage (SUB) is opened in IMPACT, a family stage (FSU) is also opened. If siblings have been removed in a case, there are additional SUB stages in the case. Over time, some of these stages may be closed for various reasons. When these various stages are open at the same time in a case, staff must ensure that required information is entered into each open stage.
When a child is placed in an adoptive placement, the ADO stage is opened. Documentation requirements for the SUB stage also apply to the ADO stage.
General Requirements
As noted in 1430 Case Recording, case documentation that is entered into IMPACT must be entered as soon as possible, but no later than seven calendar days from the event. Placement entries and Medical Consenter entries have shorter time frames. See 6931 Documentation of Contacts in Substitute Care and its sub-items.
6931 Documentation of Contacts in Substitute Care
6931.1 Documentation of Monthly Contacts and Visits
CPS September 2007 NEW ITEM
The caseworker must document his or her contacts and visits during the month in IMPACT. This includes any contacts and visits that take place with the child, the child’s caregiver, the child’s family, the child’s attorney and guardian ad litem, professionals, collaterals, and community resources.
The caseworker must also document any other DFPS action in the case and the parents’ and children’s interactions with DFPS.
For technical information about how and where to record this information in IMPACT, see 6931.3 Documenting Contacts and TCM in IMPACT.
The content and frequency of some of these contacts are specifically required by law. Documenting these contacts is critical for maintaining federal funding.
Contacts and Visits With the Child and Family
The caseworker must document a face-to-face contact with each child in substitute care each month, and document a face-to-face visit with the child at the child’s residence in a majority of the months of a year. To meet legal requirements, the caseworker must document each contact as discussed in 6511.2 Conducting Visits With the Child.
A checklist is an excellent tool for easy documentation of the preparation for a visit, or the caseworker may make a list of issues, information, and questions to be addressed during the visit
For additional information about:
· contacts with the child’s substitute caregiver, see 6620 Services to the Substitute Caregiver .
· contacts with the child’s family when a child is in care, see 6611.2 Conducting Visits With the Family .
CPS Contact With Court and Other Parties
All contacts, conferences, and agreements with the court, the parents, or other parties to the lawsuit or their attorneys must be documented. For additional information about documenting contacts with the child’s attorney and guardian ad litem, see 5311 Working with the Child's Attorney and Guardian Ad Litem.
Supervisor Consultation
All significant consultations between supervisors and workers regarding a case must be documented, including date, subject and relevant conclusions.
6931.2 Monthly Targeted Case Management (TCM) Activity
CPS September 2007 NEW ITEM
It is especially critical that DFPS caseworkers document routine casework as TCM activities when the casework meets the TCM criteria. Each month, the caseworker may claim a maximum of one unit of TCM service, if the proper casework activity was completed. TCM generally includes activities needed to aid children in accessing medical, social, education, and other services.
Types of TCM Activities
The four specific types of TCM activities correspond to the Purpose categories on the Contact Detail page in IMPACT.
1. Assessment
Assessment includes activities that focus on identifying needs, such as evaluating a child to determine the need for medical, education, social, and other services.
For CPS this includes contact with child and consultation with professionals, the caregivers, and other parties to evaluate needs.
2. Case Planning
Case planning includes collaborating with all parties to develop a focused plan to meet the assessed needs of the child. The case plan contains goals and identifies a course of action to respond to the assessed medical, social, educational, and other needs.
The CPS child’s service plan serves as the case plan for TCM purposes.
3. Referral and Linkage (Service Coordination)
Referral and Linkage includes activities that help connect children with medical, social, and educational providers, and other programs or services that can meet the child’s needs. It also includes activities and contacts that are necessary to ensure that the service plan is effectively implemented and is adequately addressing the needs of the child.
For CPS, such activities can include telephone, electronic, and face-to-face contacts to ensure timely resolution of problems and to monitor the progress of service providers.
4. Monitoring and Follow-up (Case Plan Reassessment)
Monitoring and follow-up includes making adjustments to the service plan and service arrangements with providers, as needed.
For CPS, activities may include telephone, electronic, and face-to-face contacts with all involved parties to reevaluate case planning (case staffing).
See Medicaid TCM policy.
Preference in Selection
The first choice for a TCM contact is a monthly face-to-face contact with the child at the child’s residence, as long as it includes at least one of the four qualifying TCM activities listed above.
Other types of contact also meet TCM requirements. The alternative options, in order of priority, are:
1. face-to-face contact with the child at any location that accomplishes one of the four required TCM activities;
2. any contact with the child that accomplishes one of the four required TCM activities; and
3. any contact with the caregiver or a professional that accomplishes one of the four required TCM activities regarding the child.
6931.3 Documenting Contacts and TCM in IMPACT
CPS September 2007 NEW ITEM
In the various stages in IMPACT, staff record contacts on the Contact Detail page, with the entry of several data items and the recording of a narrative within seven days of the occurrence. Staff must also open a Contact Monthly Evaluation within seven days of the first contact of the month. See 1431 Narrative Guidelines.
Avoiding Duplication of Contact Documentation
To relieve the caseworker of having to re-enter the same contact information in different related stages of substitute care, some procedural accommodations have been made.
Accommodation #1
An accommodation for the FSU and various SUB stages allows caseworkers to record most contact information in the one open FSU stage, if there is one, or in the oldest child’s SUB stage if there is a sibling group. The caseworker must note in each child’s stage the stage name where the Contact Details and Monthly Summary are recorded.
If two or more siblings have open ADO stages, most contact information can be documented in the oldest child’s ADO stage under the same arrangement.
Accommodation #2
In substitute care, with some limitations, caseworkers may elect to document most contacts in IMPACT in one of two ways: either under Contact Details or under Monthly Evaluations. See:
6931.31 Documenting Contacts Using Contact Details
6931.32 Documenting Contacts Using Monthly Evaluations
6931.31 Documenting Contacts Using Contact Details
CPS September 2007 NEW ITEM
A caseworker may record most contacts as Contact Details with supervisory approval, using a separate Contact Detail page for each contact and narrative. With this option, the Monthly Evaluation is also required to comply with IMPACT prompts, but the contents under the subsection headings of the Monthly Evaluation can be short summaries.
6931.32 Documenting Contacts Using Monthly Evaluations
CPS September 2007 NEW ITEM
A caseworker may also elect to record most contacts in the Summary section of the Monthly Evaluation page. If this method is used, certain contacts (described in 6931.33 Required Contact Detail Documentation) must be recorded in the Contact Detail page so that the information can be pulled for reporting purposes. If using this option, the caseworker must meet the following requirements:
· Open the Monthly Evaluation within seven days of the first contact of the month;
· Prepare the Summary section. The contacts and narratives must be entered in the Summary section within seven days of each contact. Each contact should include the date, location, persons contacted, and type of contact (including TCM activity, if appropriate). Each significant contact should include a narrative, but a single narrative can address more than one brief contact. See 6931.34 Required Narrative Content.
· Complete the Evaluation and Plan sections at the end of the month.
· Evaluation: This section must reflect the overall progress of the child, family (if involved), and DFPS in meeting service planning goals. The Monthly Evaluation must contain an assessment of the safety, permanency, and well-being of the child, including the child’s medical, social, and educational needs. For details on assessments, see:
6511 Contact With the Child
6611.2 Conducting Visits With the Family
6620 Services to the Substitute Caregiver
6611.5 Provide Services After a Child is Returned
6851 Supporting the Adoptive Placement
· Plan: The plan should address steps for the next month.
6931.33 Required Contact Detail Documentation
CPS September 2007 NEW ITEM
These requirements apply whether the Contact Detail or the Monthly Evaluation is used as the location of the primary documentation.
All contacts must be recorded within seven days of the event. If the narrative is recorded under Monthly Evaluation, the following information must be recorded as a Contact Detail:
· Record at least one face-to-face contact with each child who has an open SUB or ADO stage
Contact must be at child’s residence for the majority of the months in a year, and separate entries must be made for siblings if they do not reside together.
If siblings with an open SUB stage are seen at the same location, and each child did in fact receive a face-to-face contact, the caseworker can document by selecting each child as a principal in the same contact in the one stage without additional Contact Detail entries in other stages.
· Record at least one contact for each child who has an open SUB or ADO stage with a TCM Purpose selected, if the appropriate activity did occur;
Contacts for children can be combined as long as each child is selected as a Principal on the Contact Detail page.
Each TCM activity requires the caseworker to document:
· the date;
· name of the child and the person providing the services;
· the nature and extent of the services; and
· the place where the services were provided.
· Any other specific contact that requires entry of a date for reporting purposes.
6931.34 Required Narrative Content
CPS September 2007 NEW ITEM
A narrative statement is necessary to explain the purpose, content, and circumstances of a contact. At least one narrative is required monthly for each face-to-face contact with the child and for each contact with the child’s caregiver regarding the caregiver’s observations, needs, or concerns. Descriptions of the issues discussed, the child’s needs, quality of services, need for additional services or supports, the case goals, and any other issues related to safety, permanency, and well-being are essential for the monthly face-to-face contact.
6931.35 Required Monthly Evaluation Content
CPS September 2007 NEW ITEM
The Monthly Evaluation consists of sections for Summary, Evaluation, and Plan.
· Open the Monthly Evaluation within seven days of the first contact of the month;
· Summary section. If most contacts are entered in the Contact Detail, the Summary can be brief and completed at the end of the month.
· Complete the Evaluation and Plan sections at the end of the month.
· Evaluation: This section must reflect the overall progress of the child, family (if involved), and DFPS in meeting service planning goals. The Monthly Evaluation must contain an assessment of the safety, permanency, and well-being of the child, including the child’s medical, social, and educational needs. For details on assessments, see:
6511 Contact With the Child
6611.2 Conducting Visits With the Family
6620 Services to the Substitute Caregiver
6611.5 Provide Services After a Child is Returned
6851 Supporting the Adoptive Placement
· Plan: The plan should address steps for the next month.
6931.36 Supervisor Approvals
CPS September 2007 NEW ITEM
Workers must submit Monthly Evaluations to the supervisor for approval. The caseworker enters the Contact Summary time period, then saves and submits to the supervisor. This sends the Monthly Evaluation with a log of related Contract Detail entries to the supervisor.
Supervisors review the Monthly Evaluation and related Contact Detail entries and approve or request changes. Approval is documented in the Approval Status page, which is accessed from the Staff To-Do page in IMPACT.
6932 Documentation of Legal Activity
CPS September 2007 NEW ITEM
Legal Status
Enter information about changes in a child’s legal status in relation to DFPS on the Legal Status page in the SUB or ADO stages.
Legal Action
Enter information about specific legal events on the Legal Actions page. These include orders for services, affidavits of relinquishment, conservatorship orders, and special orders. Enter descriptions of these events as necessary under the Comments section on the Legal Action page.
6933 Documentation of Child’s Biographical Data
CPS September 2007 NEW ITEM
Much of the information about the child should be entered under the Person tab in the child’s SUB stage when it is opened. If not, this information must be added to the SUB stage as soon as possible:
· Social Security number
· Income
· Child’s citizenship or immigration status and country of origin
· Child-placement characteristics
· Marital status
· Ethnicity
The Case Plan
The Child’s Service Plan and, if appropriate, the Family Service Plan and Transition Plan must be completed. See 6420 The Case Plan, 6430 Case Plan Review and 6423 The Transition Plan for details.
Placement Information
Staff must document placements and placement changes in the SUB and ADO stages in IMPACT within 24 hours of the placement. Staff must also complete a Placement Transfer Summary form that is given to the new caretaker when placements are made. See 6317 Make the Placement.
Health Information
In each child’s SUB and ADO stages in IMPACT, staff must complete the Medical/Developmental History page.
Current medical and dental information must be entered on the Medical/Mental Assessment page.
Copies of relevant documents must be filed in external documentation (see 6938 External Documentation).
Medical consenter information must be entered within 24 hours of the designation or change and must be kept current.
Education Information
Current education information must be entered in the Education section on the Person Detail page of each child’s SUB and ADO stages in IMPACT and in external documentation on an ongoing basis.
6934 Documentation of Information on Case Principals
CPS September 2007 NEW ITEM
Personal information, including address and contact information, must be documented and updated for all case principals on the Person List page in the SUB, FSU, and FRE stages in IMPACT.
6935 Documentation of Services to Parents and Caregivers
CPS September 2007 NEW ITEM
Services, referrals, and information provided to the child’s parents and caregivers must be documented. See:
6123.1 Services to the Parents
6610 Services to the Child’s Family When the Child Is in Substitute Care
6123.3 Services to the Caregiver
6620 Services to the Substitute Caregiver
6936 Documentation of Permanency Planning Meetings
CPS September 2007 NEW ITEM
Permanency planning meetings that are held when a child is in substitute care must be documented on the Permanency Planning Meeting pages in the SUB stage in IMPACT. See:
6437.3 Permanency Planning Meetings
6437.4 Permanency Planning Meetings for Youth 16 and Older.
6937 Documentation of Transfer and Closing Summaries
CPS September 2007 NEW ITEM
A Transfer Summary is completed when the stage remains open and is being transferred to another worker.
A Closing Summary is completed in the SUB stage when services to the child have ended. A Closing Summary is completed in the FSU or FRE stages when services to the child and family have ended in that particular stage.
6938 External Documentation
CPS September 2007 NEW ITEM
External documents must be listed in the IMPACT External Documentation page and filed in the child’s paper case record. The following are required external documents:
· Birth, citizenship, or immigration status documents
· Health records, including a copy of a recent medical exam
· School records
· Signed Foster Care Assistance Application forms
· Court reports
· Signed court orders, affidavits, and other court documents
· Signed service plans
· Notices sent regarding Permanency Planning Meetings
· Placement and medical authorizations
· Placement Transfer Summary forms
· Correspondence, photographs, authorizations, and similar documentation