Shelter centers must provide training on confidentiality policies, procedures,
and recording information to all staff and volunteers who have any
contact with residents or nonresidents.
It is recommended that an attorney with expertise in confidentiality
issues help train staff and volunteers.
Content of Case Files
The content of client files must be limited to information necessary
for:
Statistical and funding purposes.
Establishing goals for the counseling and advocacy relationship.
Documenting the need for and delivery of services.
Protecting the liability of the shelter program and its staff, volunteers,
and board members.
Shelter centers must have written policy and procedures regarding entries
into resident and nonresident files.
Each entry into resident and nonresident files must be signed and dated
by the staff or volunteer entering the information.
Resident and nonresident files must not include the names of other residents
or nonresidents.
It is recommended that:
All entries are limited to those remarks that the staff or volunteer
is comfortable sharing with the resident or nonresident.
Case notes not contain diagnosis, labels, direct quotes, or judgements
about a victim and/or the children.
Warnings or notations regarding violations of cooperative living agreements
not be filed in the resident's file.
No personal papers of residents or nonresidents are retained in the
case files.
Counseling notes kept by student interns for the purpose of refining their
skills and for supervision is kept in the students' supervision
files and not be considered program records. All identifying material
should be removed from the notes, including the names of residents,
nonresidents, staff, volunteers, and other students.
Child resident and nonresident case files may be filed separately or may
be included in the parent file.
Access to Case Files
Shelter centers must have written policy and procedures ensuring that
residents and nonresidents may review, comment, and have access
to their own case file.
Residents and nonresidents must be allowed to review all information in
their own file.
If the case file entry is not removed and the resident or nonresident
contests it, the shelter center must make a notation in the case
file stating that the resident or nonresident believes the entry
to be inaccurate.
Resident and nonresident files must be kept under lock. The files must
not be removed from the shelter center program premises without
the written permission of the custodian of the records.
It is recommended that shelter centers require residents and nonresidents
to provide a written request for a copy of their case file and require
that the file be reviewed in the presence of a staff person.
Release of information
Shelter centers must obtain a written release of information from the resident
or nonresident before releasing information orally or in writing.
The release of information must include:
The name of the person or agency to which the information is being
released.
The specific information to be released.
The beginning and ending dates that the release is effective, not
to exceed the resident's stay and not to exceed 45 days total
for nonresidents.
The release of information must be signed and dated by the resident
or nonresident and staff or volunteer.
Only one agency or person must be informed that they may revoke this
consent at any time. This revocation must be submitted in writing.
Report of Child/Elder Abuse and Duty to Warn
A person having cause to believe that a child's physical or mental
health or welfare has been or may be adversely affected by abuse
or neglect by any person shall immediately make a report.
If a professional has cause to believe that a child has been or may
be abused or neglected, the professional shall make a report not
later than the 48th hour after the hour the professional first
suspects that the child has been or may be abused or neglected.
A professional may not delegate to or rely on another person to
make the report.
The requirement to report applies without exception to an individual
whose personal communications may otherwise be privileged, including
an attorney, a member of the clergy, a medical practitioner, a
social worker, and a mental health professional.
The identity of an individual making a report under this chapter is
confidential and may be disclosed only on a court order or to
a law enforcement officer for the purposes of conduction of a
criminal investigation of the report.
The law (Section 261.101 of the Texas Family Code) is that a person
having reasonable cause to believe that an elderly or disabled person
is in the state of abuse, exploitation, or neglect must report the
information to the Human Services Department.
Shelter centers must have written policies and procedures for reporting
Child abuse or suspected child abuse, elder, and disabled abuse and
must comply with state law.
To appropriate mental health or law enforcement authorities, circumstances
in which a victim of family violence may be harmful to self or
others.
Retention and Destruction of Records
Shelter centers must develop written policies and procedures for retention
and destruction of all records, including but not limited to:
Case notes, case content, and case files.
State to state communications.
All documentation required by funders.
It is recommended that staff-to-staff communications that cannot be
made verbally due to staffing patterns be destroyed as soon as possible.
In determining which records to retain, it is recommended that shelter
centers weigh the program's need for information against the potential
for misuse of the record.
It is recommended that a shelter center have a compelling purpose for
the retention of any identifying information after a resident or
nonresident leaves the shelter center program.
Resident and Nonresident Rights
Shelter centers must:
Provide written resident and nonresident rights to all residents and nonresidents.
Post resident and nonresident rights in a visible area within all shelter
center facilities.
It is recommended that adult rights be written and included in the
resident's or nonresident's orientation. It is recommended that
shelter centers develop specific children's rights that are appropriate
for the various age groups (e.g., young children and adolescents).
Children's rights may be presented to children in a group setting.
