Section 361.12 - Individual case records.

361.12 Individual case records. (a) When required. The case manager must maintain an individual case record for each eligible adolescent who participates in at least the initial interview and assessment.

(b) Contents. Each individual case record must include, but need not be limited to:

(1) summaries of the initial and comprehensive needs assessments findings;

(2) copies of any specialized needs assessments, such as medical, educational or vocational assessments, obtained by the case manager in order to complete the assessment, planning and monitoring activities;

(3) identification of the short- and long-range goals which the assessments indicate the adolescent needs to achieve in order to maintain and strengthen family life and to attain or retain the capability for maximum self-support and personal independence, and estimates of the time periods necessary to achieve those goals;

(4) identification of the services and assistance the adolescent needs in order to attain those short- and long-range goals and of the services and assistance providers available in the community to help the adolescent attain those goals and any unavailable service or assistance;

(5) the adolescent's personal plan;

(6) documentation of the referrals made on behalf of the adolescent to services or assistance providers, including the dates the referrals were made and the times the appointments were to occur;

(7) a list of all services or assistance rendered by the district and by other public and private agencies in the community;

(8) documentation of the follow-up actions taken to ensure the adolescent received needed services or assistance and any action taken to remove any barrier impeding the maximum efficiency of services or assistance delivery;

(9) a list of the types of, and whenever possible, the costs of and funding sources for the services and assistance the adolescent received. The case manager and case management staff may perform the activities necessary to determine such information; and

(10) documentation of oral communications with, and copies of written communications to or from, the adolescent and communications with any other individuals or agencies made on behalf of the adolescent.

(c) Confidentiality. Individual case records, whether developed by the social services district or by other agencies from which the district has purchased case management activities, are confidential and must be maintained in accordance with the provisions of section 136 of the Social Services Law and Part 357 of this Title.

(d) Case record activities. Case managers and case management staff may perform the activities necessary to maintain individual case records and to collect aggregate data about the adolescents participating in case management activities.

(e) Retaining records. The agency which maintains individual case records, whether the social services district or any other agency from which the district has purchased case management activities, must retain an adolescent's individual case record until the adolescent becomes 21 years old or for six years after the case management activities performed on behalf of the adolescent are terminated, whichever comes later.

(f) Department inspection. The agency which maintains individual case records, whether the social services district or any other agency from which the district has purchased case management activities, will make such records available for department representatives to inspect and will forward photostatic copies of such records to the department upon request.

(g) Records of services and assistance providers. When referrals for services and assistance are made by case management staff to providers receiving funds under other State programs or paid directly by the social services district, the district may ask the providers to obtain and transmit to case management staff the information necessary to perform the case management activities described in this Part. Whether case management staff may or may not redisclose such information depends on the statutory confidentiality requirements applicable to the particular type of information.

 

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