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)
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 428.5
Current through Register Vol. 46, No. 39, September 25, 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.
(d) Progress notes need not include clinical notes, daily logs or other written material created by service providers who act in roles other than caseworker, child protective services monitor, case planner or case manager.
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