Current through Register Vol. 47, No. 5, March 10, 2024
A. The
county department shall thoroughly document all Adult Protective Services (APS)
reports and case information in CAPS. There shall be no parallel paper or
electronic system used to enter APS documentation. Documentation shall include
all aspects of the APS case, including:
1.
Initial report;
2.
Investigation;
3.
Assessment;
4. Case plan;
5. Contact records for the client, alleged
perpetrator, reporter, and all support network individuals;
6. All collaterals;
7. Ongoing case notes;
8. Case closure; and,
9. Any other processes related to the
case.
B. All documents
and evidence relevant to the investigation, assessment, and identification of
needed services for the client shall be scanned into CAPS, to include:
1. A release of information form(s) signed by
the client, when appropriate;
2. A
copy of a power of attorney, living will declaration, and/or other advance
directive if the county department receives or discovers information that the
client has one in place, except when:
a. The
client has fiduciary authority in place but the client or the fiduciary refuses
to provide copies of the document, the county department shall attempt to
review the documents to determine the authority provided within.
b. If unable to obtain or review relevant
documentation for good cause the county department shall document all attempts
to obtain a copy and review the document(s), and if able to review the
document(s) shall document the authority provided.
3. A copy of all associated documents if the
county department is appointed guardian, conservator, or representative payee
or receives or discovers information that the client has one in place, the
county department shall scan and upload documentation as follows:
a. All court documents, court reports, Social
Security Administration appointments, correspondence, and other documents
related to the county-held guardianship, conservatorship, or representative
payeeship shall be scanned and uploaded to CAPS.
b. A copy of the court order or
representative payee assignment for non-county held guardianship,
conservatorship, or representative payeeship shall be scanned and uploaded to
CAPS, except when:
i. The client has a
guardianship, conservatorship, or representative payeeship in place but the
client or the fiduciary refuses to provide copies of the document, the county
department shall attempt to review the documents to determine the authority
provided within.
ii. If unable to
obtain or review relevant documentation for good cause the county department
shall document all attempts to obtain a copy and review the document(s), and if
able to review the document(s) shall document the authority provided
within.
4.
Other documentation and evidence collected during the investigation and
assessment, such as medical reports, results of psychiatric evaluations,
photographic documentation, etc. If unable to obtain relevant documentation for
good cause the county department shall document all attempts to collect the
evidence and why the evidence was unattainable.
C. All documentation pertaining to APS
reports and cases, including interview and case notes, evidence gathered, such
as photos, medical records, and bank statements shall be kept in a secure
location until documented in CAPS and then shall be destroyed.
1. Hardcopy and electronic APS files created
prior to July 1, 2014 shall be kept in a secured location.
2. All APS files created July 1, 2014 or
later shall be documented in CAPS and the file/notes destroyed.
3. Original legal documents such as
guardianship, representative payeeship, birth certificates, or tax documents
may be retained in a hardcopy file, in addition to CAPS, that is in a secured
location.
D. The county
department shall use CAPS to document all other APS program activities,
including Adult Protection team activities, APS staff qualifications, FTE, new
worker and continuing education received, cooperative agreements, and other
activities required by rule.
E.
Case records that do not pertain to substantiated perpetrators shall be
retained for a minimum of three (3) years, plus the current year, after the
date of case closure.
F. Case
records pertaining to substantiated perpetrators shall be retained
indefinitely.
