Casework Practice and Case Record Documentation

(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.