Circles of Care Documentation Manual

1. Circles of Care Documentation Manual 2019

2. Care Provider documentation is important, required and imperative. Care Providers live and care for children 24/7 and we realize they know the children the best. There are many people who oversee the children’s care and must learn about the child through documentation. This includes Circles of Care Case Managers and other Administrative staff, State Licensing Auditors, State Contract Representative Auditors and Youth for Tomorrow (YFT), who determines a child’s’ Level of Care or Service Package. All documentation should be neat and legible and reflect the professional that you are. Circles of Care is subject to routine audits by the State and YFT, and we are judged on the way our files look and read which consist of Care Provide Documentation. All documentation must be kept current and turned in to Circles of Care at every Case Manager visit or beforehand if needed. Documentation is required as a foster parent; and is part of your contract to be licensed. Not completing the documentation in a timely manner or correctly can lead to corrective action and in some instances home closure. Not all the documents are completed on a regular basis, as some are completed on an as-needed basis. Each form below will be explained in detail.

3. Child Weekly Progress Notes • Complete one (1) report WEEKLY for each Specialized and/or Treatment Services child in your care. • Reports should cover 7 days, for example Sunday to Saturday, not just weekdays. • These need to be turned in by the 10th of the following month • Please be child specificanddetailed regarding the child’s behaviors. • Weekly documentation may be requested for basic children that need to be reviewed by YFT for a service level review. Weekly documentation will also be requested for moderate children during the annual YFT audit in March for the month prior.

7. Basic Needs, Medical, and Dental: This section should discuss the level of supervision needed for the child during that week, as well as any medical complaints, concerns or appointments. If there are no appointments or concerns “healthy this week” should be noted. • Educational: This section should discuss how the child is doing in school this week, both with grades and behaviorally. If there are any concerns (ISS, detention, etc.) or testing scheduled it should also be noted here. • Developmental/Life Skills and Emotional: This section should discuss how does the child do on day to day responsibilities such as assigned chores, skill abilities, emotional status and therapy information. If a child was seen for therapy during the reporting period, it should be documented. • Nutrition, Hygiene, & Grooming: This section should discuss how the child appetite, hygiene, and if the child needs assistance in their daily grooming. Also if a child suffers from Encopresis or Enuresis, the average number of times the accidents happened during the week should be documented. • Encopresis is the soiling of underwear with stool by children who are past the age of toilet training. • Enuresis also known as urinary incontinence is the loss of bladder control by children who are old enough to control his or her bladder.

8. Supportive Services: This section needs to be filled out if a child attended any therapies for development such as ECI, OT, PT, or Speech. Also if a child received any medical equipment or nursing hours were utilized during the week, this section is where to document. The dates of service and any progress made needs to be discussed. • Independent Living Skills: This section is only for children that are age 16 and older. Each child should be learning and taking participating in daily living skills to prepare them for Adulthood. It is recommended that children that are of age, seek employment opportunities as long as they do not interfere with their school. If a child is employed this section should include the name of the employer, how many hours the child worked during the reporting period and there were any concerns or accomplishments. • Recreational/Social: This section must document the activities that a child participated in during the week which could include school, church, extra-curricular, etc. activities. This section can also discuss any family outing. Any behaviors of the child during the activities should also be documented

9. Behavioral: This section must be completed in two parts. In the grid there are a variety of behaviors listed and any behavior that the child exhibited during the week of the report can be selected. In the comments section, any behavior checked must be elaborated on. At no time should a report be turned in without an explanation to why each box was checked in the grid. If a restraint took place during the reporting period, the box under the comment section must also be checked. Additional documentation will be required (i.e. Incident Report) • Visitation/Involvement with Family: This section will document any supervised as well as unsupervised visits the child had during the week, with whom the visit was with and how the child did after any approved visits. This section would also document if the child had any contact with anyone that was not approved by the child’s legal parties.

10. Monthly Fire or Emergency Procedure Review: It is best practice to conduct a fire or severe weather drill on a monthly basis or when a new child is placed in the home. This section is where the drill would be documented as well as any concerns noted • Addition of Clothing and Personal Items: This section should discuss any substantial items a child received during the week. It should include clothing as well as personal belongings such as jewelry, electronics, toys, etc. This section should have ample updates during back to school shopping, birthdays, Christmas, and any other time an abundance of items are received. If the child is of age, they need to sign that they acknowledge receipt of the items. • Special Concerns/other issues/misc.: This section is to discuss any other concerns that were not listed in the previous section. This is NOT an area to prescribe diagnosis, whether they should be a different service level, or vent about issues regarding the child’s case.

11. Incident Report/Restraint Documentation • An incident constitutes anything out of the ordinary i.e. severe tantrums/anger outbursts, behavior that constitutes in the result of 24 hour restriction to foster home, hitting, any/all injuries, restraints, running away, youth becoming under the influence of drugs/alcohol, or suicide/homicidal threats to name a few. • All incidents should be reported to Circles of Care as soon as possible but no later than 24 hours from the incident. • Some incidents must be reported to the Child Abuse Hotline per the State Minimum Standards (i.e.: abuse/neglect of child by caregivers, child-on-child behavior that results in observable injury, suicide attempts, severe life-altering injury or death) THIS IS NOT AN INCLUSIVE LIST. If an incident is in question, contact your Circles of Care case manager or Program Director immediately.

15. Incident Report Example • Identifying Information: This section must include the full name of the child that the incident is concerning, DOB, and gender, the date of the incident, the home that the child is residing in as well as any other children that may have been involved to include their age and DOB. For confidentiality purposes only the first initial of the first name and the full last name of the child or visa versa should be listed. If any other individuals were involved in the incident that were not children then they also must be listed as well as their title. • Nature of the Incident: This section must give a brief description of what the incident report is being completed. The detailed account will be provided on the next page. The check box must be completed if the report needed to be called into State Licensing. Should the incident fall under the SERIOUS INCIDENT category in State Minimum Standards, then the Child Abuse Hotline must be contacted with the information. • A serious incident is a non-routine occurrence that has or may have dangerous or significant consequences on the care, supervision, and/or treatment of a child. The different types of serious incidents are noted in State Minimum Standard §749.503

16. Description of the Incident: This section must give a detailed description of the incident to include what was happening before or what lead up to the incident and what interventions were used to avoid the incident/crisis/or restraint if possible. This section should be documented so a legal party that reviews this section should have a sense of being present during the incident. • This section also should have any other youth that were present during the incident de-identified for confidentiality purposes.

17. Medical Interventions: If a child needed medical treatment due to the incident, this section would need the name of the health care professional, what the medical findings were and what treatment was required. If a medical intervention was needed, a Professional Service Report must also accompany the Incident report. • Restraint Incidents: This section ONLY needs to be completed if a restraint was completed. A restraint is any restriction of movement. The person completing the form must check if a restraint occurred. If checked no then move on to page 5. This section must describe the type of restraint used, the time the restraint started as well as ended, who preformed the restraint as well as what relation that person is to the child. If anyone witnessed the restraint to include any other children, they need to be listed in this section. The person restraining must be detailed in the following questions: ~What attempts were made to explain to the child what behaviors were necessary to be released from the restraint? ~ What actions were taken to help the child return to routine activities after a restraint? As well as note the following: Did you provide 15 min. of eye to eye contact/supervision after the need for a restraint?

18. Various Discussions also need to take place when a child is retrained. The person restraining must be detailed when answers in the following questions: ~Discuss the child’s behavior and circumstances leading to the restraint. How did the child feel their behavior led to the need for the restraint? ~How did the child feel regarding the caregiver’s reaction to the situation? ~Discuss the strategies used by the caregiver before the restraint and how the child felt these worked or did not. How can this be improved in the future so the caregivers can help the child avoid a restraint? ~Discuss the restraint itself. What does the child think and feel about the restraint? ~What can the child do in the future to regain control of their behavior to avoid a restraint? ~How was privacy insured during the discussion? ~If any other children witnessed the restraint how was this processed with them? ~Date and time discussion with the child was offered and the child’s reaction to the opportunity for the discussion. ~Date and Time when the discussion took place with the child (must be within 48 hours).

19. Notification: This section must document if Circles of Care was notified of the incident. If so the method, date and time need to be listed as some incidents are time sensitive to report. If the Child Abuse Hotline had to be contacted for a SERIOUS INCIDENT, the time the call was placed as will as the Hotline Reporting Number that is given after the incident has been reported must be listed. • Signatures: It is imperative that all incident reports are signed by the person completing the report and then sent to the Circles of Care Case manager in a timely manner so they can be work flowed to executive staff and sent to the Department.

20. Documentation Do’s and Don’t • Do not label the behavior a child is exhibiting. For example, do not document a child is depressed unless the child told you they were “depressed”. Most of us are not clinicians and are not in a position to make an assessment. Document exactly what the child did or said. • Document dates and times. This is important to gauge the frequency and time frame of a child’s behavior. • Document all discipline interventions and the child’s response to the intervention. This is necessary to understand what has been attempted and how well that intervention has worked. • Document both appropriate and inappropriate behavior. Not only is it important for us to know what inappropriate behavior the child is exhibiting, it is also important to understand the strengths and helps clinician’s gauge the prognosis of a child. • Do not document your personal opinion of the child or the child’s behavior. Your personal opinion is your own and may not be the same as others involved in the child’s treatment. • Document all progress notes in a clear, concise and professional manner. Keep in mind that your documentation will be read by other professionals and may even be read by a judge in a court of law. • Be specific and document only the facts. Most assessments of children are made by considering only the facts. You also want to avoid documenting information that may not be necessary. Documenting the facts will also conserve time. • Do not document your own assessment of a child. Most of us are not clinicians and are not in a position to make an assessment. • Document with the understanding that the person reviewing your documentation may not know anything about the child, the behavior or an incident. • Always turn in documentation as required and on time. Keep in mind there are time frames and requirements in accordance with State Minimum Standards and Circles of Care policies that must be met.

21. Daily Schedules • Daily Schedules are completed just twice per year on each child in your care; One for the School year and one for the Summer months. Daily Schedules are a Youth For Tomorrow requirement. Youth for Tomorrow wants to see that the home has some type of daily structure or routine. • The Daily Schedule is a “snapshot” of your overall schedule/ structure, such as; what time do the children wake, what time does your family eat meals, what routine or regular scheduled things do you do.

24. Recreation Logs • Recreation logs are a requirement for therapeutic children as well as children listed as Treatment Services. This is a Youth for Tomorrow ( YFT) requirement. YFT wants to see that families have daily recreation activities for children and the children know some of what is planned. The daily activity and the person responsible for supervision must be listed on the recreation log. • You must complete a Recreation Log once a month, for each Therapeutic (Moderate or Specialized) or Treatment Services child in your care. The must be filled out daily and turned in to the office by the 10th of the following month • The Recreation logs are planned or projected/tentative recreation/activities. Some examples would be: Going to the park; Going Camping; Having friends over to play; Going Skating; Going shopping/mall; going to the movies; Boys and Girls Club; Church Youth group/Church Activities; Sports Tournament • School is not a recreational activity and should not be used on the Recreation Log. • When completing Progress Notes, you must discuss some of the recreation activities you did have that correspond to your Recreation Logs and discuss how the children did while participating. • Your Recreation Log should be age appropriate for the child and to their IQ level. For example, you should not have “reading” as a recreation for a child who has an IQ of 45.

27. Medical/Dental/Vision/Hearing Examination Form (FORM 2403) • This form is to document all Medical, Dental, Vision, Hearing and Emergency medical services. • Care Providers must have and take these forms with them any time a child receives any form of medical or dental services whether it is routine, follow-up, or emergency. Care Providers must have the doctor or doctors staff complete the form. • Care Providers should insure that the doctor or doctor staff complete the form in its’ entirety. Any verbal instructions given to the Care Providers by the doctor or doctor staff should also be documented on this form. If the Medical or Dental staff will not complete the documentation, the caregivers can complete; however best practice would be for the printout received after the appointment to be attached. • The doctor or doctor staff should be specific on any follow up required or not required. There is a place for this on the form, and Care Providers should insure that the doctor or doctor staff specify if no follow up is needed or what follow up is needed. • Care Providers must turn these completed forms in to Circles of Care as soon as possible or but not later than the 3rd business day after the appointment. It is a requirement that the agency provide the documentation to legal parties within a timely manner.

29. 3-Day Medical Exam • Within 3 business days, children entering DFPS care must visit a doctor to see if they are hurt or sick and get any treatments they need. • The 3-Day medical exam assists in knowing about a child’s health when they enter foster care. The person caring for the child can learn about the child’s medical needs and how to care for them. The person caring for the child can also get medicines for a child that may not have been taken at the time of removal, such as an asthma inhaler or eczema cream. • The 3-Day medical exam much be completed by a Texas Health Steps Provider and Form 2403 must be turn in completed in its entirety.

30. 3 Day Medical Exam Example

31. Texas Health Steps Medical Checkup • An initial Texas Health Steps Exam is required for ALL children entering care within 30 calendar days of placement in your home. • The exam must include all screening listed (to include vision and hearing screening) for the age of the child on the THSteps Medical Checkup Periodicity schedule for Infants, Children, and Adolescents. • Annual Texas Health Steps exams are required for children 3 years and older on or shortly after their birthday. • Texas Health Steps exams are required for infants at 2 weeks, 2, 4, 6, 9, 12, 15, 18, 24, 30, and 36 months regardless of when child had their initial exam. • The Texas Health Steps exams much be completed by a Texas Health Steps Provider and Form 2403 must be turn in completed in its entirety.

32. Texas Health Steps Medical Checkup Example

35. Texas Health Steps Dental Exams • The initial exam is due no later than 60 days after placement in care. They should be scheduled as soon as possible when the child is placed in the home so they can be completed prior to the date that it is due. • Exams are required for all children 6 months and older (Even if they have no teeth yet) • Semi-annual exams are required generally every 3-6 months depending on dentist. • Make sure to ask when the follow up should take place (3 or 6 months) and Best Practice is to schedule the exam prior to leaving the initial appointment • The dental exams much be completed by a Texas Health Steps Provider and Form 2403 must be turn in completed in its entirety.

36. Texas Health Steps Dental Exam Example

37. Illness/Inquiry/Other • Be specific in details i.e. cough, runny nose, fever, fell off bicycle, scraped knee, or needs fillings. • If child needs to see a specialist state the type and reason for visit i.e. cardiologist for heart murmur, or orthopedist for foot problem. • The diagnoses should be added on the second page in the diagnoses section, not here. • Any time a child sees a doctor for illness or injury, it must be a Texas Health Steps Provider and Form 2403 must be turn in completed in its entirety.

38. Illness/Injury/Other Example

39. Medication Logs • Medication logs are used to document any medication that is administered or given to a child whether they be prescribed or over the counter. Any medication that is administered to a child to include topical ointments/creams must be documented. • Medication logs should clearly indicate when medications were started and stopped/discontinued by noting it on the log. • Medication logs must match the way the doctor prescribed the medication; meaning days should not be missed or skipped and times should be within an hour of the time the medication was prescribed for. • The exact time a medication was given must be written; such as 8:03, 8:16, 8: 34. AM and PM must also be used. Do not document the exact same time every day, as to give a medication at the exact same time every day is almost impossible. You must document the exact time you administered the medication. • Each dosage of medication must be listed individually and cannot be entered on the same line on the medication log. If additional logs are needed due to numerous medications, an extended log can be provided by your case manager or office manager. • Initials of the person administering the medication must be present after each administration. The persons full signature should also appear on the log. • Medication logs must be turned in by the 10th of the following month to the case manager or branch office for any children who were administered medication. • Case Managers will be doing spot checks at each home visit to determine that the log is being filled out correctly and that the medication log is being stored with the medication.

42. Psychiatric Service Report • Some children are on psychotropic medications that require regularly scheduled appointments with a psychiatrist. If they do not have their own form then the psychiatrist or foster parent must fill out the treatment form for psychotropic drugs and the psychiatrist MUST sign it. • Children on psychotropic drugs must be seen at least every 60-90 days.

44. Psychotropic Medication Treatment Consent Form 4526 • The person legally authorized to consent to medical care on behalf of a child in DFPS conservatorship must use Form 4526 to document informed consent for a new psychotropic medication. • This form must be turned into the local Circles of Care branch office when a new psychotropic medication within 24 hours. Circles of Care in turn must provide to the CPS caseworker immediately after receipt.

45. Family Request for Removal /Discharge • If you want a child removed or discharged from your home you must complete this form and turn it into Circles of Care immediately. You cannot simply inform or tell Circles of Care verbally that you need a child removed. We must have it in writing to insure there is no miscommunication. • The reason why a family requires, needs or asks for a child to be discharged is many, to include: • The child is just not doing well in the home and is having to many problems for the Care Providers to handle. • The family may have a family emergency. • Your contract with Circles of Care states how much notice you must give us and the amount of time you must give us to properly move a child. You cannot expect Circles of Care to remove a child immediately, unless someone is in danger of hurting themselves or someone else.

46. Voucher Form • A Voucher Form should be completed by Care Providers when they are requesting reimbursement for a covered expense. • Circles of Care currently reimburses for the following foster care expenses: • Fire Inspections (maximum 75.00) • Health Inspections (maximum 50.00) • Gas Inspections (maximum 100.00) • TB testing (maximum 10.00) • CPR/First Aid classes • Training expenses that come out of your annual training fund • FBI check for household members turning 14 and all initial FBI checks for licensure. • Care Providers must attach the receipt from/for the qualifying expense to a Voucher form and turn it into Circles of Care. Care Providers should turn in the receipt, attached to a Voucher form, as soon as possible and no later than 60 days from when the expense was incurred. • No expenses turned in more than 60 days from the date the expense was incurred will be reimbursed.

47. Mileage Expense Report Form • Mileage is reimbursed to Care Providers for non-routine events. Qualifying events would be: • Court appearances. • Family Visits • Psychiatric care and appointments. • Mileage is not reimbursable for routine transportation/trips as this is factored into your daily payments you receive on children in your care.. • Non-qualifying events are such things as: • Regular medical and dental care. • To and from Recreation • School • Church or church activities. • For qualifying events, Mileage is reimbursed only after 60 miles. Care Providers must subtract 60 miles for each qualifying trip, they will then be reimbursed for any remaining miles after the 60 miles is subtracted. • The Mileage Expense Report should be specific, giving starting address and ending address of the trip as well as the purpose for each trip. • A Mileage Expense Report Form must be completed and turned in no older than 60 days in order for Care Providers to be reimbursed.

49. Training Record Form • This form is to be used to document when a Care Provider has training. It is used for all your continuing education hours that you must receive to maintain your license. • The form must be completed in its entirety in order to meet State requirements. • Care Providers must have the form signed by the presenter if there was one. For correspondences courses, books or videos; simply note that in the line where the presenter is supposed to sign. • Turn in these forms to Circles of Care as soon as possible so they can be entered into our Date Base program and made part of your file.