SOP 219.01: Case Management - Records Maintenance

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|
|Policy Number: 219.01|Effective Date: 11/15/2019|Page Number: 1 of 6|
|Authority:
Commissioner|Originating Division:
Inmate Services Division|Access Listing:
Level I: All Access
|

I. Introduction and Summary:

It is the policy of the Georgia Department of Corrections (GDC) to maintain adequate
and appropriate records of offender contacts with behavioral observations of these
contacts and to document the offenders’ progress or lack of progress towards’ meeting
the needs identified on the Case Plan. This policy also governs institutional file and
SCRIBE management which includes, but is not limited to, the establishment, use of
content, privacy, security, preservation and destruction of institutional files.

II. Authority:

A. GDC Board Rules: 125-1-1-.09, 125-2-4-.03, 125-2-4-.05, 125-4-1-.06, and 125
4-1-.07;

B. O.C.G.A. §§ 42-5-36(c) and 50-18-70, et seq.;

C. GDC Standard Operating Procedures (SOPs): 107.01, Purpose and Objectives
Counseling Services, 107.04, Risk & Needs Assessment, 209.06, Administrative
Segregation, 210.05, Inmate Probation Programs, 219.03, Access to Facility
Inmate/Probationer Records, 220.03, Classification Committee; and 222.07
Release Procedures for Offenders; and

D. ACA Standards: 2-CO-1E-01, 2-CO-1E-03, 2-CO-1E-09, 4-4095, 4-4096, 4-4098,

4-4099, 4-ACRS-5A-15, 4-ACRS-7D-08, 4-ACRS-7D-09, 4-ACRS-7D-10, 4ACRS-7D-11, and 4-ACRS-7D-37.

III. Definitions:

A. Behavioral Terms - In writing about the offender, words and phrases that describe

the offender’s behavior observed in objective terms.

B. Case Plan - For all facilities, the Next Generation Assessment is used to assess

needs and develop a Case Plan.

C. Next Generation Assessment (NGA) - GDC’s assessment tool to identify

programming for the offender population.

D. Data Assessment Plan (DAP) - Format for documenting clinical work.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|
|Policy Number: 219.01|Effective Date: 11/15/2019|Page Number: 2 of 6|
|Authority:
Commissioner|Originating Division:
Inmate Services Division|Access Listing:
Level I: All Access
|

IV. Statement of Policy and Applicable Procedures:

This policy is applicable to all administrative and counseling staff in all State, County,
Private Facilities, Probation Detention Centers (PDC), Transitional Centers (TC),
Residential Substance Abuse Treatment facilities (RSAT) and Integrated Treatment
Facility (ITF) where Counseling Services are available.

A. An on-going record of offender contacts and behavioral observations will be

recorded in SCRIBE case notes. These notations shall track at a minimum,
behavior recommended services and strategies toward meeting the offender’s Case
Plan, as well as institutional/center adjustment. These records will provide a
progressive recording of the offender’s progress or lack of progress towards
meeting the identified needs from the Case Plan.

1. The date of arrival of the offender to the facility will be recorded as part of the

initial entry in SCRIBE and in the institutional file.

2. There shall be a minimum of one (1) meaningful contact utilizing the Data

Assessment Plan (DAP) format (every 90 days) for State and Private facilities.
For Transitional Centers, Offender Boot Camps, Pre-Release Centers,
Probation Detention Centers, and Probation Boot Camps there will be one (1)
meaningful contact utilizing DAP format per month. These contacts will be
done in accordance with SOPs 107.01, Purpose and Objectives - Counseling
Services and 220.03, Classification Committee.

3. The initial interview counseling session (this is not the Admissions and

Orientation (A & O) contact) will be conducted within seven (7) calendar days
of assignment to the permanent counselor’s caseload and documented in
SCRIBE. During the initial interview, suicide awareness and prevention shall
be discussed. The permanent counselor shall document a conversation about
suicide awareness and prevention at least once per calendar year (the initial
contact regarding suicide awareness counts as an annual contact). Offenders
housed in the TIER 1 housing unit should be asked questions regarding suicidal
thoughts a minimum of once per month. This conversation should be
documented in SCRIBE within 24 hours from contact. The documentation
should include ways to report and the hotline # 1-800-273-TALK (8255).
Offenders housed in TIER II housing unit should be asked questions regarding
suicidal thoughts during the weekly rounds. This conversation should be

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|
|Policy Number: 219.01|Effective Date: 11/15/2019|Page Number: 3 of 6|
|Authority:
Commissioner|Originating Division:
Inmate Services Division|Access Listing:
Level I: All Access
|

documented in SCRIBE within 24 hours from contact. The documentation
should include ways to report and the hotline # 1-800-273-TALK (8255).

4. The initial interview will include, but is not limited to: program referrals, goals

for reaching program needs, offender individual goals, etc.

5. Case note entries will include, but are not limited to the following:

a. Actions taken by the offender and/or counselor toward addressing the Case

Plan identified needs including groups, programs and work details
currently involved with or completed, referrals, and follow-up activity;

b. Summary of contacts with the offender regarding progress or lack of

progress written in Behavioral Terms, to include: disciplinary reports (date,
offense, disposition), program coordination, family contacts, counseling
sessions, classification, job performance as rated on the work activity
performance report, case conferences, etc.;

c. Significant contacts by anyone other than the counselor will be documented

and discussed with the offenders’ counselor if it involves an unusual
situation or if the counselor needs to be notified immediately. Significant
contact can be contact by family members, teachers, detail officers or other
staff members reporting positive or negative behavior; and

d. Pertinent outside agencies contacted concerning the offender, including

phone conversations regarding these services.

6. If the offender has been re-assigned a new counselor, this new counselor will

document:

a. The date the offender was added to their caseload;

b. Conduct a face to face contact with the reassigned offender within fourteen

(14) business days from assignment to caseload, during the face to face
contact a review of the Case Plan must be done. Counselors will be
responsible for documenting the 90-day meaningful contact for this face to
face interaction; and

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|
|Policy Number: 219.01|Effective Date: 11/15/2019|Page Number: 4 of 6|
|Authority:
Commissioner|Originating Division:
Inmate Services Division|Access Listing:
Level I: All Access
|

c. If a new counselor assumes a newly assigned caseload from a previous

counselor and the caseload is too large for all offenders to contacted within
seven (7) days of assignment, the counselor will be responsible for making
a statement in SCRIBE indicating the following:

i. The date of assignment for each offender on the caseload;

ii. The date the case-plan for each offender was reviewed; and

iii. Whether the 90-day meaningful contact for each offender was in
compliance. If a 90-day meaningful contact is not in compliance with
DAP standard the counselor will have 30 business days from
assignment to caseload to make the meaningful contact.

d. Offender records will be maintained, organized and reviewed per

established departmental procedures and utilized to plan counseling
strategies, as well as for professional consultations with other treatment
staff.

7. Counselors will provide documentation necessary for use by the Facilities

Division, the Georgia State Board of Pardons and Parole (P&P), or others as
requested.

B. The offender institutional files shall contain all documents, orders, and actions

taken concerning the offender. The files must be uniformly organized per
Attachment 3, Organization of Offender Institutional File, to assure necessary
access, retrieval or audit of specific information and adequate maintenance. Audits
of offender institutional files shall be conducted with the expectation that all such
files are organized and maintained as directed. A minimum of 10% of the
institutional files and SCRIBE case files for the offender population at each facility
shall be audited annually by the Deputy Warden of Care and Treatment or the
Warden’s/Superintendent’s designee. It is also the responsibility of the Counseling
Supervisor to review a minimum of five (5%) percent case file review in SCRIBE
on each counselor monthly. Any patterns of irregularities shall be noted and
reported to the Warden/Superintendent. The Warden/Superintendent of each
facility will be responsible for compliance.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|
|Policy Number: 219.01|Effective Date: 11/15/2019|Page Number: 5 of 6|
|Authority:
Commissioner|Originating Division:
Inmate Services Division|Access Listing:
Level I: All Access
|

C. All offender institutional files shall be organized and maintained in a legal size (8

½ X 14”) file folders and stamped “Confidential” in RED letters on the outside of
the folder.

D. When an offender is received from another facility, the offender records room staff

shall mark a starting point for the entries for the facility. This "flagger" will state
““ _Facility Name_ ” records begin here", along with the date of the offender's arrival
to facility.

E. Offender records are confidential state secrets under O.C.G.A. § 42-5-36(c) and

must be kept in a locked file cabinet behind a locked door. Access to offender
records is restricted. The Warden/Superintendent will designate appropriate staff
to be granted access to the records room. A list of these staff will be posted on the
door. Offender records will be signed out by the Records Clerk to appropriate
requesting staff and the file movement reason must be recorded. (refer to
Attachment 4, File Movement Reasons for the list of appropriate reasons to
document when the file is removed from the records room). Under no
circumstances should an offender record be kept after 3:00 p.m. on the day it has
been signed out without prior approval by the Deputy Warden of Care and
Treatment/Assistant Superintendent or Warden/Superintendent.

F. As outlined in the Open Records Act, O.C.G.A. § 50-18-70, _et seq_ ., the public and,

as their representatives, the media have the right to inspect "public records" of
government agencies. Those records are defined as "material prepared and
maintained or received during the operation of a public office or agency." Offender
institutional files, including SCRIBE entries, remain in the official custody of the
Georgia Department of Corrections and are classified as confidential state secrets
under O.C.G.A. § 42-53-36(c). All requests for offender related records (SCRIBE,
central and offender institutional files) shall be immediately forwarded to the GDC
Office of Legal Services for review and processing.

G. A “Release of Information” consent form that complies with applicable federal and

state regulations will be used prior to release of any releasable offender
information, such as Case Plan progress or lack of progress, to any family member
or other such person that may need such information. The offender is required to
sign the consent form prior to the release of information and a copy of the form

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|Policy Name: Case Management-Records Maintenance|
|Policy Number: 219.01|Effective Date: 11/15/2019|Page Number: 6 of 6|
|Authority:
Commissioner|Originating Division:
Inmate Services Division|Access Listing:
Level I: All Access
|

will be maintained in the offender’s institutional file and documented in SCRIBE
case notes.

H. Upon receipt of a transfer order to transfer an offender to another state prison the

offender’s updated Institutional File, Medical File, and Mental Health File must
be moved with the offender. Confidentiality of the Medical File and Mental Health
File shall be maintained. Under no circumstances should offender files be delayed
longer than 72 hours.

I. Upon release of an offender from GDC custody, the facility will package all

offender files and maintain as noted in the Department’s Records Retention
Schedule.

J. Refer to Release Procedures for Offenders (SOP 222.07) for special instructions

concerning sex offender release file processing.

K. Other files or records (i.e. medical, general office, or special programs, etc.) are

not included in the above requirements.

V. Attachments:

Attachment 1: Five Percent (5%) Review Form
Attachment 2: Institutional File Review Form
Attachment 3: Organization of Offender Institutional File
Attachment 4: File Movement Reasons

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, Attachments 1 and 2 shall be maintained for two (2) years in the
Chief Counselor's office and then destroyed. Attachments 3 and 4 are lists and shall
be maintained or utilized as instructed in this SOP until obsolete or replaced.