Department for Community Based Services

Standards of Practice Online Manual

4.24 SSW's Ongoing Contact with the Birth Family and Child, Including the Medically Complex Child

Cabinet for Health and Family Services

Department for Community Based Services
Division of Protection and Permanency
Standards of Practice Online Manual
Chapter:
Chapter 4-Out of Home Care Services (OOHC)
Effective:
3/30/2018
Section:
4.24 SSW's Ongoing Contact with the Birth Family and Child, Including the Medically Complex Child
Version:
14

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Legal Authority/Introduction

LEGAL AUTHORITY:

 

From the moment of the initial contact with the family, the SSW and the department are obligated under federal and state law to make reasonable efforts to keep families intact whenever possible; and in removal situations, to make reasonable efforts to reunify children with their families.  As part of this obligation, the SSW is required to maintain personal contact with families and children.  Ongoing contact with the family provides information that contributes to a thorough assessment of whether or not the family has reduced the risks that initially lead to the involvement of DCBS. 


Caseworkers are required to conduct face to face visits with children placed in department foster/adoptive homes at least once every calendar month. 

Features of an acceptable pattern of visits to parents or other significant family members include: 

  • Face to face contact frequently enough to evaluate the family’s progress;
  • Sufficient meaningful discussion of case planning tasks and objectives; and
  • Sufficient opportunity to observe the residence(s) of the parent(s) and child(ren), or other family members significant to the case.

Through the life of the case, the burden is on the SSW to locate and maintain contact with family members.

Procedure

Ongoing Contact with the Child

Following any placement (initial or move) the SSW: 

  1. Uses face to face contact to evaluate the safety of the child's placement and to ensure the child's assessed needs are being served appropriately through correct services referrals;
  2. Must return within ten (10) calendar days to have an additional private face to face visit with the child; 1
  3. Has phone contact with the child within five (5) calendar days of placement, if the child is age appropriate to respond by phone; if not age appropriate, the SSW assesses the child’s transition to placement and any placement needs through child’s caretaker;
  4. Has a face to face visit with the child in their placement at least once every calendar month in order to assess progress toward case plan goals and objectives and to assess adjustment to the out of home care placement;
  5. Visits a child designated as medically complex:
    1. Jointly with the CCSHCN nurse within thirty (30) calendar days of the child’s designation as medically complex for the initial visit; then
    2. At least one (1) time per calendar month, in the placement setting, which includes DCBS foster/adoptive homes, private child placing foster homes, private child caring facility, psychiatric or medical hospital, supports for community living (SCL) programs or a relative placement as determined by the child's needs; 2 and 
    3. Face to face annually in the placement setting, when the child is placed out of state, or as often as needed, based on the child’s needs;
    4. Monthly by phone contact in order to receive the child’s medical updates for out of state placements;
    5. Enters into TWIST that the CCSHCN nurse had face to face contact with the child as reported on his/her contact note;
  6. Has private face to face contact in the child’s placement setting at least quarterly if the child is in a private child caring (PCC) facility or in private child placing (PCP) foster care;
  7. Has private face to face contact in the child’s placement setting annually if the child is placed out of state;
  8. Utilizes the DPP-1294 Rehabilitation Services Monthly Report submitted by the PCC/PCP to document monthly face to face contact between the PCC/PCP personnel and the child, but contacts the facility's treatment/clinical staff, by telephone, at least monthly (when no visit is scheduled) to assess the child's progress towards case plan goals, objectives and tasks; and
  9. When a child is placed out of state, uses progress reports, collected at least every 6 months, from a caseworker for the state agency where the placement is located or from the placement provider, to document monthly face to face contact and assess the child’s progress towards case plan goals, objectives and tasks;
  10. Has monthly phone contact with the child or the child’s placement when a child is placed in an out-of-state setting.

Ongoing Contact with the Birth Family

The SSW:

  1. Conducts face to face visits with parents and other household members frequently enough to:
    1. Facilitate reasonable efforts; 
    2. Communicate effectively about case plan objectives ;
    3. Identify and resolve barriers to case objectives; and
    4. To assess parental progress in reducing risk.3
  2. Accomplishes case specific intervention tasks during the contact, as well as:
    1. Assesses for safety issues, high risk behaviors, or risk factors
    2. Evaluates the family’s progress at reducing the immediate safety issues and/or reducing the risks that necessitated case action;
    3. Reviews the family’s progress toward accomplishment of their case planning tasks and those of other service providers;
    4. Identifies and resolves barriers to case objectives;
    5. Provides the family with information about their child, especially placement and well-being issues;
    6. Prepares for a case planning conference, periodic review or court hearing; and
    7. When appropriate, prepares an aftercare plan;
  3. Thoroughly documents:
    1. Observations regarding the family and the home setting;
    2. Progress towards each task on the family case plan;
    3. The family’s response to services they receive to other providers;
    4. Additional assessment and planning information provided by the family; and
    5. That the family has been provided information about the child’s:
      1. Placement;
      2. Physical and mental health;
      3. Education; and
      4. Activities;
  4. Documents in their ongoing assessments any barriers to their ability to maintain contact with the family including, but not limited to:
    1. The parent’s whereabouts are unknown;
    2. Written determination by the FSOS that family members are or may be violent; or
    3. Family members refuse to participate in ongoing visits.

Practice Guidance

Ongoing Contact with the Child

  • The SSW may utilize the Caseworker Visit Template during the face to face contact with the child. 
  • If a child is in a supports for community living (SCL) program, the SSW may use the Support for Community Living Program Visit-Review of Records and Facility Form at each monthly visit to the child’s placement setting, providing a copy to the central office SCL liaison. 
  • The SSW may contact the central office SCL liaison if there are concerns, questions or a need for a MRDD case consultation after reviewing the Supports for Community Living Tip Sheet and the Resource Manual for Youth with Disabilities in Foster Care.

Ongoing Contact with the Family

  • he SSW makes face to face contact with parents, in their residences, at a minimum of once per calendar month.  However, the appropriate frequency of visit is guided by the case specific circumstances.  When the overall pattern of face to face visits is not monthly (once per calendar month), the SSW enters an explanation for the pattern of contact into the next case plan evaluation/ongoing assessment.he SSW makes face to face contact with parents, in their residences, at a minimum of once per calendar month.  However, the appropriate frequency of visit is guided by the case specific circumstances.  When the overall pattern of face to face visits is not monthly (once per calendar month), the SSW enters an explanation for the pattern of contact into the next case plan evaluation/ongoing assessment.
  • In addition to face to face contact, the SSW may utilize telephone, mail, or email; however, the case specific circumstances should guide the overall pattern of contact within the case.
  • The SSW documents a pattern of visits with the children and parents that will appropriately demonstrate reasonable efforts to reunify children who have been removed from their homes or finalize an appropriate permanency plan for children.
  • Workers are not required to execute monthly visits to parents if there is a no contact order prohibiting contact, or if a judge has granted a waiver of efforts on the case.  Workers will document the issuance of such orders in their ongoing assessment until the no contact order is lifted, or until case closure.
  • A worker is prohibited from documenting that a face to face contact occurred, unless an actual face to face visit was completed by department personnel or personnel contracted to make a visit.  An entry reflecting a face to face contact when none actually occurred is considered falsification of records, and is an ethical violation (refer to chapter 2.1 Employee Conduct in the Personnel Procedures Handbook).

Ongoing Contact with the Medically Complex Child

  • The CCSHCN nurse visits a child designated as medically complex at least one (1) time per calendar month in the placement setting, which includes, but is not limited to a DCBS resource foster/adoptive home, a private child placing foster home, psychiatric or medical hospital, independent living or a supports for community living (SCL) program, as determined by the child's needs
  • The CCSHCN nurse forwards documentation of the monthly home visit to the SSW who then enters it into contacts.
  • The CCSHCN nurse sends a copy of the contact note to the SSW, which is filed in the hard copy case.   
  • The SSW, medically complex liaison or caregiver may request consultation at any time with the Medical Support Section regarding a medically complex child.
  • The Medical Support Section may:
    • Upon request, provide consultation and a visit to the medically complex child and/or placement; and
    • Notify the FSOS responsible for the child if the Medical Support Section determines a condition that warrants additional attention.
  • The SSW, R&C worker or CCSHCN nurse reviews and discusses the following, as related to the specific needs of the medically complex child during the home visit (as applicable):
    • MCO case management;
    • Transportation arrangements for the child;
    • Home health referrals and/or durable medical equipment (CCSHCN nurse may assist);
    • Availability of all medications and medical technology to care for the needs of the child;
    • Supportive services to the caregiver(s);
    • Future needs of the caregiver(s);
    • Respite and/or babysitting issues;
    • Upcoming service needs;
    • Child/youth action plan and individual health plan with the caregiver and the child, when appropriate;
    • Current diet and eating pattern;
    • Medical passport, including medication logs;
    • Transition planning; and
    • Other information including:
      • The child's weight;
      • Alertness;
      • Physical condition;
      • Current diet and eating patterns;
      • Mental health needs;
      • Medication log;
      • Current medical services;
      • Any illness or medical change since the last visit; and
      • Recent or future medical appointments.
  • The foster/adoptive parent, relative and/or out of state placement provider completes the DPP-104C Medically Complex Monthly Report and submits it to the SSW, who forwards it on to the:
    • CCSCHN nurse;
    • Region's medically complex liaison; and
    • Medical Support Section, if issues are identified on the report.
 

Footnotes

  1. This is in addition to the initial visit when the child is taken to the placement for the first time.
  2. When the Cabinet has custody, the CCSHCN nurse accompanies the SSW on visits to children in relative placements.  This meets the agency’s requirement of two (2) visits per month.
  3. The SSW may also contact the incarcerated parent in between quarterly visits by using mail, telephone or technology such as Skype, if appropriate.

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