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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

III

Case Management

Chapter:

C

Case Oversight and Management

5-10-2010

Subchapter:

6

Case Recording

Issuance:

100

Case Recording

 

 

Purpose:

 

This issuance establishes the policies and procedures for the documentation of CP&P case information.

Authority:

 

      N.J.S.A. 9:6-8.10, Reports of Child Abuse

      N.J.S.A. 9:6-8.40, Records Involving Abuse or Neglect

      N.J.S.A. 30:4C, Dependent and Neglected Children

      N.J.S.A. 30:4C-53, Placement of Child Outside Home; Notice; Filing; Form; Contents; Jurisdiction of Court; Notice of Permanent Placement

      N.J.A.C. 10:122D-1.5, Developing the visitation plan

      N.J.A.C. 10:122D-2.5, Health care services

      N.J.A.C. 10:122D-2.6, Educational services

      N.J.A.C. 10:133, Service Delivery General Provisions

      N.J.A.C. 10:133D-1, Case Plan

      N.J.A.C. 10:133D-1.6, Process of developing the case plan

      N.J.A.C. 10:133D-2.7, In-person visitation when a child is placed out of his or her own home

Policy:

 

A)   System of Record

New Jersey Spirit (NJS) is the official CP&P system of record. All official CP&P Casework must be documented, reviewed, approved, maintained and stored within that system.

B)   Documentation of Case Information

Workers must document case assessment, planning and progress in NJS as it is gathered. Recording must be sufficiently concise to make their use practical; brevity is important, but not at the expense of clarity and accuracy.

C)   Supervisory Approval

Workers complete case recording with supervisory input and guidance. All recordings must be reviewed by a Supervisor to ensure completeness and accuracy.

D)   Attorney Client Privilege

As a matter of policy, all communications between a DCF employee and an attorney in the Division of Law is subject to attorney-client privilege and must be labeled accordingly in NJS.

Procedures:

 

A)   Documenting Case Information in NJS

When initiating case recording, the Worker needs to acknowledge the community in which individuals and families live and the way in which that community facilitates or hinders individual and family maintenance, growth and development.

Many factors contribute to problems such as child abuse and neglect. Vulnerable clients must be protected, while circumstances which precipitate family violence must be identified and corrected if maintenance or reunification is to be achieved.

Document case assessment, planning, and progress in the NJ SPIRIT application based on the nature of a case and the length and extent of CP&P involvement. NJS provides the system of record, where official CP&P case work is documented, reviewed, approved, maintained, and stored.

All NJ SPIRIT (NJS) forms utilized for Case Recording are accessible through the NJS Desktop>Create> Case Work>Case Plan Window>Visitation Plan Tab>Options Dropdown.

All of the child's and family's descriptive information is recorded in NJ SPIRIT, resulting in the creation and completion of CP&P Form 26-81a/b, Family Summary/Case Plan. For cases to be heard at court, complete CP&P Form 26-80, Court Report, in NJS. When a determination is made that adoption is the appropriate goal for the child, complete CP&P Form 26-53c, Individual and Family Assessment Outline – Adoption

Descriptions of contacts entered on the Contact Sheet, CP&P Form 26-52, are important to assessment and planning. They detail the specific data that support the decisions that have been made. Descriptions differentiate opinions and/or hearsay from observations, as well as present the basis for formulating those opinions.

In protective services cases, case recording includes a thorough investigation/documentation of all allegations including what has happened to the child, the degree of risk and the appropriate intervention necessary to protect the child.

The Worker, on an ongoing basis, ascertains, assesses, reports, and documents risk to a child, including a child in out-of-home placement.

Institutional Abuse Investigation Unit (IAIU) investigations are documented in the NJ SPIRIT application as well. NJS provides the system of record for IAIU files. See IAIU policy at CP&P-IV-E-1-100, IAIU Case Recording.

B)   Worker Case Recording for Children Residing in Their Own Homes

Complete investigation narrative (see CP&P-II-C-5-100) or CWS assessment when CP&P intervention is completed within 60 calendar days of SCR assigning a CPS report or a CWS referral to a field office for response, and there were no additional contacts.

For cases being opened for services, complete a Resource Sheet, CP&P Form 26-50, and a Family Summary/Case Plan, CP&P Form 26-81, within 60 calendar days of SCR assigning the CPS report or CWS referral to a field office for response.

Complete Contact Sheet, CP&P Form 26-52, for the first contact or event after documenting the initial response on the investigation narrative/CWS assessment write up. Record entries as soon after the contact as possible but no later than seven days after the contact or event.

Complete Case Summary for Closing/ Transfer, CP&P Form 26-57, within 60 calendar days, when CP&P intervention is completed within 60 calendar days of SCR assigning a CPS report or a CWS referral to a field office for response, and the investigation narrative/CWS assessment does not describe the situation and reason for terminating agency intervention.

C)   Case Recording Requirements When a Child Enters Placement Outside the Home.

Conduct an out-of-home child safety assessment within five (5) working days of placement and annually thereafter. Complete the CP&P Form 22-5, New Jersey Child Safety Assessment Resource Family Homes COVER SHEET, and the CP&P Form 22-6, New Jersey Child Safety Assessment (Resource Homes) in the NJS application.

See CP&P-IV-A-2-100, Assessing Safety in Out-of-Home Placement Settings, for detailed policy and procedures, including when and how to complete a Safety Protection Plan. See instructions for the forms in the on-line Forms Manual.

Complete an education record, providing the resource parent(s) with the child's education record at the time of the initial placement using the CP&P Form 5-16, Child's Education Record. Update the education record as needed, sharing education information as required. See CP&P Form 5-15 and CP&P-VII-A-1-100, Educational Services.

Complete a medical record, providing the resource parent with a health care record which documents health information concerning the child using the CP&P Form 11-10, Health Passport and Placement Assessment. Complete the form template located in NJ SPIRIT within thirty (30) calendar days of the child's placement, ensure the child receives a comprehensive medical examination (CME) and update medical records. Share updated health care information as required.

Determine the child's eligibility for Medicaid in the NJS application, in the Medicaid Eligibility Determination Windows, and update the Medicaid Eligibility Status File. See CP&P Form 11-69, Medicaid Eligibility File Demographic Changes. Forward the completed CP&P Form 11-69 to the Office of Information, Technology and Reporting Medicaid Unit.

Complete CP&P Form 5-47, Notice of Placement, in the NJS application. Submit the form to the court within five (5) calendar days of placement.

After three (3) months of placement and every three (3) months thereafter, complete, CP&P Form 22-27, New Jersey Family Reunification Assessment.

Update outcomes by completing the CP&P Form 26-87, Family Summary/Case Plan/Court Report Strength and Needs, Desired Outcomes and Specific Activities, in the NJS application. Attach the form to the CP&P Form 26-81a/b.

Record all contacts in NJS in the Contact/Activity Notes Window in NJS, printable as CP&P Form 26-52, Contact Sheet.

When domestic violence is alleged or present, see CP&P-VIII-B-1-100, Domestic Violence.

D)   Required Verification of all Client and Provider (e.g., resource parent) Information for Case Management and Service Delivery

Verification of client and provider (e.g., resource parent) information is required for case management and service delivery. Verify information during:

      The initial case recording and assessment;

 

      The placement of a child;

 

      The resource home study period;

 

      Adoption processing and finalization, and

 

      Other periods of CP&P involvement with a child or family members, when needed.

 

Examples of specific events that require verification include:

      The birth of a child or an adult;

 

      The marriage, civil union, or domestic partnership of a birth or legal parent(s) or provider(s);

 

      The divorce or dissolution of a civil union or domestic partnership of a birth or legal parent(s) or provider(s);

 

      The death of a child or adult, or

 

      An individual's citizenship or immigration status.

 

A Worker verifies information by:

      Obtaining a certified copy of a particular document from the State or local Bureau of Vital Statistics (BVS) or other agency. The DCF BVS Liaison, located in the Office of Facilities and Support Services, obtains certified long form copies of birth, death, marriage, civil union, and domestic partnership certificates from the NJ State Bureau of Vital Statistics, located in the NJ Department of Health. See CP&P Form 26-8, Request for NJ birth/Death/Marriage/Civil Union/Domestic Partnership Certificate.

 

      Contacting an agency (such as county welfare) and receiving confirming information;

 

      Viewing a copy of a document shown by a client or provider:

 

-       The providers or prospective providers supply the required copies of the documents for verification to the Division and for submission to the court, if needed (see CP&P-IV-B-4-100).

A certified document is a copy of a birth (long form), death, or marriage, civil union, or domestic partnership certificate which has been verified by the issuing agency as being true and correct. Documents issued by a State Bureau of Vital Statistics agency, a court, or a government agency usually contain a stamped or embossed imprint indicating the authenticity of the document and the name of the issuing entity.

When the records of a business, hospital, or other agency will be introduced as evidence in court, then each document must be accompanied by a completed CP&P Form 21-8, Certification of Documents. See the computerized Forms Manual for a copy of the form and its instructions.

The documents obtained and used to verify a birth, death, marriage, civil union, or domestic partnership, or a divorce or dissolution of a civil union or domestic partnership (e.g., certified Bureau of Vital Statistics certificates, court decrees, or other documents) contain personal information which is confidential and can only be disclosed as permitted under agency policy.

Upon receipt of a certified copy of a certificate, court decree, or other documentation, file it in the child's case record in the appropriate section (e.g., copy of birth certificate in medical section, death certificate, marriage/civil union/domestic partnership certificate or divorce/dissolution decree in the legal section), so the document is available as needed.

If a certificate is removed or given out for a specific reason (e.g., submitted to court), document to whom it was given and where it was sent. Update this documentation in the case record.

When Requesting Long Form NJ State Bureau of Vital Statistics (BVS) Certificates from DCF BVS Liaison, the following is required:

      For out-of-state certificates: The DCF BVS Liaison obtains long form birth, death, and marriage, civil union, or domestic partnership certificates from the NJ State Bureau of Vital Statistics. Before making a request, check to see if a long form BVS certificate is in the child's case record.

 

      If an additional copy of a certificate is needed, request it at the same time. Provide justification for the request. (Example: Request a second copy of the birth certificate for the child's Life Book.)

 

      Complete the CP&P Form 26-8, Request for NJ Birth/Death/Marriage/ Civil Union/ Domestic Partnership Certificate and forward it to the DCF BVS Liaison by:

 

-       Interoffice mail at CC # 933,

-       Fax at 609-292-7772, or

-       E-mail at dcfbvs@dcf.state.nj.us.

The DCF BVS Liaison processes the request with the NJ State Bureau of Vital Statistics and, upon receipt of the certificate, forwards the original to the child's office of supervision. If the certificate is not available, the DCF BVS Liaison sends an explanation to the Worker.

Note: Only use CP&P Form 26-8 to obtain NJ State Bureau of Vital Statistics certificates from the DCF BVS Liaison. The form is not used to obtain local, out-of-state, or foreign certificates.

If CP&P has guardianship of a child, the DCF BVS Liaison may assist a Worker in changing or correcting birth data on the birth certificate. The BVS Liaison may also assist the Worker in making requests to amend death or marriage, civil union, or domestic partnership certificates. See CP&P-III-C-9-100, Amendments to Birth, Death, Marriage, Civil Union, or Domestic Partnership Certificates, and CP&P Form 26-8.

To obtain a local vital statistics certificate, contact the Registrar (Bureau) of Vital Statistics located in the municipality where the event occurred (e.g., birth, death). Names and addresses of the local Registrars may be accessed via the NJ State Bureau of Vital Statistics website at: http://www.nj.gov/health/vital/order-vital/local-vital-records/.

 Note: Some local certificates may not include all the information that is found on a NJ State Bureau of Vital Statistics long form certificate. Obtain a long form certificate whenever possible.

For out-of-State Certificates:

 

      Contact the appropriate state vital statistics agency in the specific State. Use the following Web site which provides a directory of out-of-State vital statistics agencies and links directly to these agencies: http://www.cdc.gov/nchs/w2w.htm;

 

      Request the certificate by completing the appropriate forms, and Send the appropriate fee.

 

Obtaining Foreign Certificates:

      If a certified copy of a certificate is needed from a foreign country, use the following Federal Web sites:

 

-       http://www.cdc.gov/nchs/w2w/foreign.htm(provides information on foreign certificates); and

-       http://www.state.gov/s/cpr/rls/dpl/32122.htm (provides links to foreign embassies in the United States).

If a certified copy of a required document for verification of client information or an event cannot be obtained from the NJ State, local, or out-of-state Bureau of Vital Statistics, the event can also be verified through other sources.

For birth dates, hospital, physician, or health agency birth records (e.g., Visiting Nurse Association, Baby-Keep-Well stations. These organizations often know the child from birth or early infancy.);

      Midwife's records;

 

      Physician's affidavit;

 

      Immunization records;

 

      Naturalization records;

 

      Voter registration records;

 

      Baptismal certificate;

 

      Family Bible or register, (useful, if it: records main events in the family, such as births, marriages, deaths and divorces; shows that the birth was recorded when it occurred, by being in chronological order; and if there are no erasures or changes);

 

      Adoption papers, passports, immigration papers, marriage, civil union, or domestic partnership records, wills and other legal papers;

 

      Service records, including military records of the Adjutant General of the State where the individual was accredited at the time of entering service. Inquiries should be directed to the local Selective Service or recruiting office.

 

      Newspaper obituary notice.

 

E)   Supervisory Input, Guidance and Final Approval of Case Recording

The Worker completes NJ SPIRIT case recording with supervisory input and guidance. All recording is reviewed by the Supervisor to ensure that it is complete and accurate. The Supervisor indicates agreement with, and approval of, case recording in NJ SPIRIT by electronic approval. The Worker also acknowledges the approval of his or her work electronically in NJS as well.

Following the Supervisor’s review of all case recording documents/ forms when completed, he or she signs as required to indicate approval, and reviews the contact sheets every 30 days at minimum. However, if the case is court-involved, the Supervisor reviews and approves all Contact Sheet entries prior to the next court date. Other occasions may arise that require the Supervisor to review Contact Sheet entries more frequently.

When a Supervisor accompanies a Worker into the field, the Supervisor records the contact or event directly on the Contact Activity Notes Window in NJ SPIRIT, the system of record, within three (3) days of the contact or event. See CP&P-III-C-5-100, the section titled Field Visits. The Supervisor and Worker complete separate Contact Activity Notes in NJS.

Regarding the verification and certification of documents as covered in Section 4, the Worker’s Supervisor is responsible to review and approve the use of all documents and certificates.

F)   Case Recording of Confidential Information -- Attorney-Client Privilege

Attorney-Client Privilege belongs to the client (DCF/CP&P), not the attorney. CP&P Management has determined that virtually all conversations between DCF staff and any attorney in the Division of Law is privileged under attorney-client privilege.

During the course of case recording, the Worker marks information which he or she believes may be confidential "privileged," and stores it in a separate part of both the electronic and "paper" case record, to assist the Deputy Attorney General (DAG) in his or her effort to avoid disclosure in error. The Worker will not be responsible for the ultimate determination of whether something is privileged.

The Worker informs the DAG when he or she believes there is a need to protect particular material from discovery, giving the DAG the specific reasons for the need for protection. In turn, the DAG issues advice about whether these items are eligible for the privilege to be exercised. As a matter of practice, CP&P has directed that all items eligible for the attorney-client privilege should be treated as if they are privileged.

If the DAG does not find a basis for protection of information, but Local Office Management believes there is good cause, the case is referred to the Area Director for resolution.