Department of Health & Human Services Human Services Standards, Client File Audit Tool, January Page 1 of 14 CLIENT FILE AUDIT TOOL

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1 CLIENT FILE AUDIT TOOL No identifying information is to be recorded during the file audit. The file number (1-10) is to be used if making any reference in the comments section. Name of Organisation: Site: Date: Criteria In Client File or Other Record (Satisfactory (S), Not Satisfactory (NS) 1 or Not Applicable (NA) COMMENTS All Services Where relevant, evidence of information provided by department to organisation at point of referral as applicable, or other intake information Client Information Provision Includes Evidence of rights and responsibilities being discussed and/or provided to client Evidence of information being provided to clients regarding their information privacy rights and the organisation's obligations (under legislation and the department's Service Agreement) Evidence of information being provided to clients about the organisation, services offered, other support services available and how to access or re access the service 1 Not Satisfactory would apply when the process was not completed or partially completed, e.g. where there wasn t full compliance such as care planning. It does not apply where the file precedes policy changes and the organisation was compliant at that time, or, if it is a new file and within appropriate timelines, e.g. if a new client (<6 months at service) has not had the initial Looking After Children Assessment and Progress Record completed. Page 1 of 14

2 Evidence of information being provided to clients about fees to be charged, what the fees cover, timelines for payment, the process for addressing difficulties in making payment and process for making a complaint about fees and/or information about fees (as applicable) Financial assistance (e.g. brokerage) Details recorded: type, amount and date Relevant Information Collected Appropriate contact details are documented Identification of the person s safety, age, culture, gender and, for children, stage of development Country of birth, preferred language and whether an interpreter is required Relevant current and historical information (e.g. family/carer information, housing, health and developmental history, experience of abuse and neglect, including cultural abuse, protective notifications and out-of-home care history) Page 2 of 14

3 Immediate risk factors / alert issues Evidence any critical incidents involving the clients are reported as required within the Critical Client Incident Management Instruction Assessment and Planning (Aligned with the Best Interests Case Practice Model if applicable) Individual goals, strengths, needs and wishes are identified at assessment Individual support plans are linked to the assessment Evidence of active client participation, input and decision-making in the assessment and planning process, Evidence of client preference regarding family, friend and/or advocate involvement in the assessment process being identified and supported Evidence that the clients communication needs have been assessed and strategies are implemented to support these Page 3 of 14

4 As appropriate, evidence of joint planning and case coordination with other services Evidence of client preferences regarding their cultural spiritual and language connections Evidence of client preferences regarding connection to their Aboriginal and Torres Strait Islander culture and community Individual support planning includes health care planning as appropriate (e.g. annual visit to GP, dentist) Evidence of individual plans signed, dated and received by client/client representative Monitoring and Review Evidence of regular assessment / review of assessment / planning Client outcomes are documented and align with individual goals Page 4 of 14

5 Individual plans are assessed and updated as required to reflect changes in client needs, strengths, wishes and goals Exit / transition planning and case closure Evidence of exit / transition / Leaving Care planning including goals and strategies/actions and timelines Family, Youth and Early Parenting Services only Child and Family Action Plan for family and early parenting services and Youth and Family Action Plan for youth services - Tasks/goals to be undertaken are listed, including the caseworker and/or family member responsible and timelines Out of Home Care Services Only Evidence of essential identification records (e.g. birth certificate, Medicare, health care card etc). Refer to the program requirements for residential care and home-based care including Kinship care Essential Information Record completed within two weeks of placement (four weeks for Kinship Care) and reviewed minimum every six months Page 5 of 14

6 Initial Care and Placement Plan placement (or Care and Transition Plan completed for young person aged 15 years +) is completed within two weeks of placement (or four weeks for Kinship Care) CSO convening care team (essential care team members included e.g. Parent/s, Child Protection Practitioner, Placement Agency Worker and Carer) Each member of care team involved in the development of the care and placement plan / care and transition plan receives a copy of the plan and any revised plans in a format that facilitates understanding Assessment and Progress Record completed within six months of the placement commencing Care team seeks child/young persons input in completion of the Assessment and progress record Assessment and Progress Record reviewed annually (six monthly for children under 5 years) Page 6 of 14

7 Health care assessment for young people in entering residential care for the first time or entering for the first time during the current period is undertaken as soon as possible or within three months of placement Mandatory notifiable issue if satisfactory not 100% Health care assessment for children/young people in home-based care undertaken as soon as possible or within one month of placement (e.g. Doctor) Mandatory notifiable issue if satisfactory not 100% Health Care Assessment reviewed at least annually Mandatory notifiable issue if satisfactory not 100% Individual Education Plan including evidence of involvement in Student Support Groups NB: Whilst the responsibility for this is with the school, CSOs are expected to have evidence of being proactive in supporting clients educational needs Evidence any allegations regarding Quality of care Concerns are responded to in accordance with the Guidelines for responding to quality of care concerns in out-of-home care CSOs ensures Care and Placement Plan / Care and Transition Plan is reviewed every 6 months Statutory Case Planning (including Stability Planning and Reunification Planning) Evidence of the CSO placement worker and carers participating in the development of the Statutory Case Plan and attendance at Statutory Case Plan Meetings where appropriate NB: Whilst the responsibility for this is with Child Protection, CSOs are expected to have evidence of being proactive in supporting clients needs Evidence of CSO developing strategies to support the cultural needs of children and young people from culturally and linguistically diverse backgrounds. Page 7 of 14

8 For Aboriginal children on Guardianship to Secretary Orders or a Long Term Guardianship to Secretary Order, evidence of CSO working in accordance with Cultural Support Plan (as applicable) is documented NB: Whilst the responsibility for this is with Child Protection, CSOs are expected to have evidence of being proactive in supporting clients cultural needs Evidence of building client s Personal records / Life Book e.g. details of a child or youth s placement, their experiences and achievements, photographs, of meaningful and significant events, and the names of significant people, medical and school records Where a client has left residential care, evidence of post-care follow up support after leaving care in accordance with their Care and Transition Plan. Housing and Homelessness Services Specialist Homelessness Services support period data collected, including: Family composition inclusive of all children as required Housing history Reasons for requesting a service Page 8 of 14

9 Employment, student or income status Care arrangements (for client under 18yo) where there is a care or protection order in place Consent to collect some or all information signed, dated and on file Evidence of client being assessed against eligibility criteria Specialist Homelessness Services data collected for service provision, including: Housing needed, provided or referral arranged General services needed, provided or referral arranged Specialised services needed, provided or referral arranged Page 9 of 14

10 Immediate basic comfort and safety needs identified Options for housing identified Assessment of client needs and risks completed and appropriately prioritised Client needs matched to appropriate/available supports Specialist Homelessness Services Accommodation data recorded Type of accommodation provided Start and finish date of accommodation Interim response includes: Page 10 of 14

11 Evidence of appropriate short term response Referral to specialist services/case management as required Evidence of interim support or referral where appropriate supports not available Disability Services Restrictive interventions Evidence of organisation being approved to do interventions and registered on Restrictive Intervention Data System (RIDS) Mandatory (if required) notifiable issue if satisfactory not 100% A behaviour support plan (including proactive and reactive strategies) Mandatory (if required) notifiable issue if satisfactory not 100% Evidence of monthly reporting to the Office of Professional Practice via RIDS Mandatory (if required) notifiable issue if satisfactory not 100% Page 11 of 14

12 The type of restrictive intervention to be implemented, including evidence of least restrictive option available The criteria that are applicable for the use of a restrictive intervention Who is responsible for authorising and implementing the intervention Evidence of consultation with the person and/or their nominated representative regarding the restrictive interventions to be used Involvement of an independent person (name and contact number listed) Length of time restrictive intervention will be in place Dates for and evidence of review of restrictive practices There is evidence that Behaviour Support Plans are reviewed regularly (not more than 12 months) and adjusted to reflect the client s support needs overtime Page 12 of 14

13 Outcomes of behaviour support plans are documented Residential Statements (for activities (residential institutions) and (supported accommodation) Evidence that a copy of residential statement has been provided to the client in a format that will facilitate their understanding Inclusion of the amount of the residential charge in the residential statement, and whether the following service components are included or excluded from this charge: utilities communications including telephone bedding and linen food general household consumable supplies communal furnishings and whitegoods household equipment and utensils replacement of items specified above following wear and tear or accidental damage Evidence that the residential statement has been explained to the client Evidence that the residential statement has been provided to family, friend or other support person as chosen by the resident Page 13 of 14

14 Comments Page 14 of 14