(A) Each county department of job and family
services (CDJFS) or its designated agency shall maintain information required
pursuant to section
5101.631
of the Revised Code, as the official adult protective services case record for
each adult who is the subject of a referral of abuse, neglect, or exploitation.
This case record shall document all activities performed by the CDJFS or its
designated agency from the time of receipt of the referral of abuse, neglect,
or exploitation until the closing of the case.
(B) The CDJFS or its designated agency shall
record all case record information in the Ohio database for adult protective
services information system (ODAPS) maintained by the Ohio department of job
and family services (ODJFS). The information contained in ODAPS will constitute
the actual, official, and permanent case record.
(C) The case record shall contain all
information, pictures, documents, and
communications pertaining to the investigation of a report of abuse, neglect,
or exploitation, and the provision of services to alleviate any indicated
concerns.
(D) The case record shall
contain case notes which document chronologically all activities performed
during the investigation, assessment, case planning, and provision of services.
The case notes shall include but are not limited to:
(1) Phone calls.
(2) Personal interviews.
(3) Reason and date for adult protective
service termination.
(4) Dates(s)
of receipt and preparation of documentation or communication as specified in
paragraph (C) of this rule.
(E) Each case record prepared, maintained, and permanently kept in accordance with paragraphs
(A) to (D) of this rule shall contain, but not be limited to, the following
information, as applicable:
(1) Information on
each referral received by the CDJFS or its
designated agencyalleging abuse, neglect,
or exploitation, including the screening decision pursuant to rule
5101:2-20-11
of the Administrative Code.
(2)
Information on each referral received by the CDJFS or its designated agency that is categorized and screened as an
information and/or referral intake pursuant to rule
5101:2-20-11
of the Administrative Code.
(3)
Documentation that the CDJFS or its
designated agency has attempted to locate
the correct address of the principals of the report, and make required
face-to-face contacts with the principals of the report as required in rule
5101:2-20-12
of the Administrative Code.
(4)
Justification for all extensions and waivers executed for failing to complete
any information gathering activity as set forth in rule
5101:2-20-12
of the Administrative Code.
(5)
Documentation of the CDJFS's or its
designated agency's request for assistance
from law enforcement during the course of the investigation/assessment and the
corresponding rationale for the request.
(6) Copies of all assessments used in
assessing/investigating abuse, neglect, and exploitation reports, or
determining the need for continued services.
(7) Case notes concerning the activities and
statements of persons involved in the case, describing the activity or
statements, naming the persons involved, and stating the dates of occurrence.
(a) Case notes shall be prepared at or near
the time of the occurrence being recorded and shall be prepared by or under the
supervision of the staff member with the most direct knowledge of the
occurrence.
(b) Opinions of CDJFS
staff, its designated agency staff, and others included in case notes or
dictation shall be identified as such.
(8) Documentation of verbal, written, or
electronic referrals made by the CDJFS or
its designated agency on behalf of the
client and all principals being served by the CDJFS or its designated agency to community service providers, including other
public agencies and private agencies.
(9) Documentation of the decision to transfer
the case, or make a referral regarding the case, to a CDJFS or its designated
agency in another county.
(a) The case record
shall include a narrative of the discussion held with the proposed receiving
CDJFS or its designated agency and any decisions made during that
discussion.
(b) If the proposed
receiving CDJFS or its designated agency declines to accept the transfer of the
case, the CDJFS responsible for the case, or its designee, shall make a
referral to the proposed receiving CDJFS or its designated agency and document
this in the case record before closing the case.
(10) Documentation of the services provided
directly by the CDJFS or its designated
agency staff to the client and other
principals, including the dates of service.
(11) Reports from service providers,
including but not limited to medical, educational, psychological, diagnostic,
and treatment services.
(12) Copies
of written notification to the prosecuting attorney when a mandated
referent/reporter fails to make a report of abuse, neglect, or
exploitation.
(13) Documentation
and/or copies of all required assessment/investigation notifications and
referrals.
(14) Documentation of
any assessment/investigation information provided to a county interdisciplinary
team (I-team) or evaluation team for case review.
(15) Required notations and copies of any
forms for any release of information including written permission from the
director or his designee, when information is released as set forth in rule
5101:2-20-05
of the Administrative Code.
(16) A
copy of all complaints, motions, petitions, pleadings, and other documents
submitted to the court by the CDJFS, its designated agency, or any other
party.
(17) A copy of all court
orders, findings, written determinations, and
journalized entries from the court.
(18) Copies of applications for financial or
social service support programs.
(19) Documentation that the CDJFS or its designated agency has verified the citizenship or immigration
status of the client, as applicable.
(20) Documentation of all visits and
communications with the principals of the case as required in rule
5101:2-20-16
of the Administrative Code.
(21)
Documentation of case plan development, review, necessary amendments, and
signatures as required by rule
5101:2-20-16
of the Administrative Code.
(F) Any case information or documentation
that cannot be directly entered into ODAPS shall be uploaded into the system
and maintained as part of the electronic case record.
(G) The case record shall be considered
confidential and not public record. Information contained in the case record
shall, upon request, be made available by the CDJFS or its designated agency to
the adult who is the subject of the report, and legal counsel for the adult as
required in rule
5101:2-20-05
of the Administrative Code.