Department ofHealth and Human Services – Human Services Standards, Client File Audit Tool, August 2017

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.
The sample is the square root of the total number of open and closed client files in the last 12months, plus one or rounded up.
Name of Organisation:Site:Date:
Criteria / In Client File or Other Record (Satisfactory (S), Not Satisfactory (NS)[1] or Not Applicable (NA)
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 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
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)
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, inputand 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
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
Individual plans are assessedand 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
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 Recordcompleted 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 Recordreviewed annually (six monthly for children under 5 years)
Health care assessmentfor young people in entering residential care for the first time or entering for the first time during the current periodisundertaken as soon as possible or within three months of placement / Mandatory – notifiable issue if ‘satisfactory’ not 100%
Health care assessmentfor children/young people in home-based careundertaken 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.
For Aboriginal children in out-of-home care, evidence of CSO working in accordance with Cultural 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 carein 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
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
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:
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 organisationbeing 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%
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
Outcomes of behaviour support plans are documented
Residential Statements (for activities 17017 (residential institutions) and 17016 (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
Comments

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[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.