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CASE FILE DOCUMENTATION

Lakota Oyate Wakanyeja Owicakiyapi

BACK GROUND

Documentation of case events in the Activities section is critical to providing up-to-date progress toward individual case goals and overall agency goals. In addition, documentation provides evidence of compliance with the requirements and mandates of social services agencies at a variety of levels, including federal, state and tribal. This activity is integral to each major service delivery phase. The depth of documentation will depend on the nature of the information received during the contact, the case situation, the social worker’s clinical judgment and the Service Program. Supervisor provides clinical supervision and review of activities section, documentation as appropriate.

DOCUMENTATION GOALS CASE FILE

Guide the CPS process.

Provide accountability for the agency and the caseworker.

Serve as a therapeutic tool for the caseworker and the family.

Organize the caseworker's thinking about the work.

CASE FILE DOCUMENTATION TRAINING OBJECTIVES

•To ensure consistent program-wide processing and documentation of LOWO client case files so that the data is complete and accurate in order to support the Wakanyeja Na Tiwahe Woope (Children & Family Code), LOWO Practice Standards, Lakota Practice Model and Federal IV-E requirements.

•Review of LOWO required case file documents, required State & LOWO Program forms, importance of case narratives.

•The importance of telling the “Families Story”, how your role is to tell the story from a strength-based point of view so that you can assist the family in reaching their goals.

Federal & Tribal Child Welfare Laws & LOWO Practice Standards

LOWO Practice Standards – Documentation

OST Child & Family Code: Section 406.4

OST Child & Family CodeSection 402.3

OST Child & Family Code: Section 406.5

SECTION 1 – DEMOGRAPHICS

LEGAL

Petition for Temporary Emergency Custody

Temporary Emergency Custody Order (Removal Order)

Notice of Court Hearing

Subpoenas

LOWO Court Order

CASA/Guardian Ad Litem Court Order/Report

Consent for Services

Client Rights and Responsibilities

Authorization for Disclosure

Administrative Hearing

Permanency Planning Review Team Meeting

INTERESTATE COMPACT

•CP – 548 ICPC 100 A and ICPC 100B &

• ICPC Home Study

FUNDING SOURCES

IV-E Hypothetical Application & Eligibility/Denial

Medicaid Application & Eligibility/Denial Memo

Social Security Application & Benefits (OWN Funds)

IV-B Funded

State IV-E/BIA 638 Case File Reviews

CHILD IDENTIFICATION

Birth Certificate Social Security Card

Degree of Indian Blood Medicaid Card

Child/Family Photographs Paternity Affidavit

ACTIVITY – STORY TELLING

• Count off by 2’s

• Please read case scenario and answer the questions in each of your respective roles and then switch roles when you have answered the questions. Report back to the large group how you answered the questions

SECTION II – EN’GHAHAN WOSECUPI (TEMPORARY CHOOSING, TEMPORARY CARE)

WOPASI – INVESTIGATION

Wakanyeja (Child) Abuse & Neglect Reporting Form

LOWO Inquiry Form

Wopasi – Risk/Family Assessment

Safety Plan

Forensic Interview

Public Safety/Law Enforcement Reports that CA/N referral

Out of Home Care Investigation

Orientation to the Oglala Lakota Practice Model

PLACEMENT AGREEMENT

Child Placement Agreement (Kinship, Foster Care & Group/Residential

Care)

Monthly Reporting Form

OTAKUYE OKILEPI – RELATIVE SEARCH

Relative Search Form

Tiyospaye Interpreter Report

SECTION II – EN’GHAHAN WOSECUPI (TEMPORARY CHOOSING, TEMPORARY CARE)

WOPASI – INVESTIGATION •Wakanyeja (Child) Abuse & Neglect Reporting Form

•LOWO Inquiry Form

•Wopasi – Risk/Family Assessment

•Safety Plan

•Forensic Interview

•Public Safety/Law Enforcement Reports that CA/N referral

•Out of Home Care Investigation

•Orientation to the Oglala Lakota Practice Model

PLACEMENT AGREEMENT

Child Placement Agreement (Kinship, Foster Care &

Group/Residential Care)

Monthly Reporting Form

OTAKUYE OKILEPI – RELATIVE SEARCH

Relative Search Form

Tiyospaye Interpreter Report

SECTION III – WOKICUNZE KAGHAPI ((MAKING A COMMITMENT) (BELONGING) (KINSHIP PERMANENCY)

Case Service Plan

Crisis Intervention & Support Plan

Spiritual Assessment

Lakota Cultural Assessment

Family Group Decision Making Referral and Services

INITIAL ASSESSMENT & SERVICE PLAN

ACTIVITY – DOCUMENT

Count off by 3’s Role Play Case Scenario 1 family member; 2 case worker; 1

observer Report back to large group

HUNKAPI WICOGHAN – MAKING OF RELATIVES

Hunkapi (Making of Relatives) Ceremony

Lakota Mental Health Diagnosis and Treatment

INDIAN CHILD WELFARE ACT

ICWA Case Transfer Meeting

FAMILY PRESERVATION SERVICES

In-Home Services Referral

In-Home Services Plan

Wakanyeja/Tiwahe (Child & Family) Visitation Schedule

Kinship Home Study

Foster Home Study – Initial & Renewal Studies & Permission to

Screen for Central Registry

FAMILY DEVELOPMENT, TRAINING & SUPPORT

SECTION IV TIWAHE EYECINKA (THE FAMILY MOVING FORWARD)

TIWAHE EYECINKA EGLOIYAPI NAHAN OP UNPI KTE

Inipi (Sweat Lodge)

Nagi Kicopi (Calling Back the Spirit)

Wasigla Ekignakapi (Wiping of Tears)

Other Lakota Healing Ceremonies Transition Services

AFTER CARE & CLOSURE

In-Active (Closing Summary & Referral for On-Going

Services)

After Care Plan

(Assessment & Service Plan)

GROUP - BRAINSTORMING

If the family choose cultural services to assist the healing process how would you document the agencies efforts to assist the family in the case file?

SECTION V GROUP/RESIDENTIAL CARE

Psychiatric Residential Treatment Facility Referral (PRTF)

PRTF Correspondence

Residential/Group Care Reports

Residential/Group Care Treatment Plans

Residential/Group Discharge Summary

Residential/Group Incident Reports Facility Applications and Consent Forms

GROUP/RESIDENTIAL CARE

 

SECTION VI – WICOZANI (HEALTH)

MEDICAL RECORDS Immunization Records Medical Records  EDUCATION RECORDS School Report Cards Individual Education

Reports (IEP) Auxiliary Placement

Documents

MENTAL HEALTH Psychological/

Psychiatric Evaluations

Therapy Progress Notes

Parent’s Mental Health

SUBSTANCE ABUSE Alcohol/Drug

Evaluation

Treatment Progress Notes/Reports

Treatment Discharge Summary

INDEPENDENT LIVING SKILLS

ILS Assessment

ILS Forms and Documents

SECTION VII – CORRESPONDENCE

WAKANYEJA (CHILD) REFERRAL LETTERS

Acceptance Letter for Risk Assessment Denial Letter for Services Letter to Federal Bureau of Investigation & Bureau

of Indian Affairs CI All Risk Assessment Letters Central Registry Letter Letter Requesting Birth Certificate Letter Requesting School Records Letter Requesting Medical Records Letter for Relative Search Letter to School Notifying of Foster/Kinship Care Letter to SD DSS Economic Assistance of

Foster/Kinship Care Letter to PPRT Participant

WRAP UP!

What is the most important topic you learned this session?

How will you apply this to your work? Why do you think documenting (Written

format) is important in the job you do?