Code of Massachusetts Regulations
651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS
Title 651 CMR 5.00 - Elder Abuse Reporting and Protective Services Program
Section 5.18 - Casework Practice and Case Record Documentation
Universal Citation: 651 MA Code of Regs 651.5
Current through Register 1531, September 27, 2024
(1) Casework Practice.
(a) Throughout the provision of Protective
Services Casework, the Protective Services Caseworker shall:
1. Inform the Elder of his or her rights
regarding consent, including consequences and choices in the acceptance or
refusal of Protective Services;
2.
Clearly explain all available service and legal options to the Elder and assist
the Elder in accessing the options that he or she has chosen;
3. Involve the Elder to the greatest extent
feasible in all aspects of service provision;
4. Respect the wishes of the Elder to the
greatest extent feasible, consistent with the Elder's Decisional Capacity to
consent, in all aspects of service provision, and seek to provide the least
restrictive, appropriate service alternatives;
5. Maintain contact with the Elder consistent
with the service needs and service plan of the Elder and at a minimum of one
home visit or in-person interview per month;
6. Continue to develop an ongoing objective
assessment of the risk factors affecting the Elder;
7. Make casework decisions with supervisory
consultation.
(b)
Designated Protective Services Agencies shall monitor the provision of
Protective Services Casework through a minimum of weekly supervision of
Protective Services Caseworkers.
(2) Case Record Documentation. Written documentation describing the Protective Services Caseworker's actions, contacts, and findings shall be maintained in the Protective Services case record. Case record documentation shall be kept current to within five business days of contacts or actions. Case record documentation shall include, but not be limited to:
(a) Intake information regarding reports and
collateral contacts in accordance with
651 CMR 5.08
and
5.09;
(b) Investigation information describing
causes, incidences, nature, and extent of Abuse as well as information
describing the social, physical, and Decisional Capacity of the Elder in
accordance with
651 CMR
5.10;
(c) Statements and actions by which the Elder
indicated his or her refusal to participate in the Protective Services
Investigation in accordance with
651 CMR
5.11.
(d) Progress notes shall be added to the case
file immediately following the decision to screen in the report and shall
include, but not be limited to:
1. All
activity conducted during the Investigation.
2. The name of the person contacted including
their agency affiliation or family relationship.
3. The date (and time when responding to
Emergencies), type, location and purpose of contact.
4. Documentation of facts to support casework
decisions including options weighed, supervisory input, and rationales for
decisions made.
5. Actions taken on
the client's behalf and projected time lines for proposed actions.
6. Descriptions of activities of other
persons and agencies providing services or assistance to the Elder.
7. Progress notes should clearly identify the
name of the Caseworker or supervisor writing the entry.
(e) Supporting documentation such as reports,
evaluations, and Investigations obtained from case managers, nurses, doctors,
lawyers, psychotherapists, police officers, coroners, and other
professionals;
(f) Service plan(s)
describing services recommended, provided or arranged in accordance with
651 CMR
5.13.
(g) Consent for services describing services
provided or arranged in accordance with
651 CMR
5.15 through
5.17. The way
in which consent was provided or refused, if consent is other than written
(i.e. verbal or an affirmative act), shall be documented in
the progress notes. The unsigned consent form should refer to the progress note
which documents the way in which consent was provided by the Elder. Continued
efforts should be made to obtain written consent to services where
appropriate.
(h)
Supervisory Review. Designated Protective Services
Agencies shall monitor the overall provision and documentation of Protective
Services through supervisory review of case records.
1. When a Protective Services Caseworker
submits a completed investigation for approval, a Protective Services
Supervisor shall complete the approval process within five business
days.
2. When a Protective Services
Caseworker submits a completed Service Plan or Service Plan reassessment for
approval, a Protective Services Supervisor shall complete the approval process
within five days.
3. The Protective
Services Supervisor shall document his or her review of the case record and
approval of case actions in the progress notes.
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