Department for Community Based Services

Standards of Practice Online Manual

4.18 Ongoing Case Planning

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:
10/6/2020
Section:
4.18 Ongoing Case Planning
Version:
19

When a section of SOP has been revised users will see the following: Added {This is added material}, Deleted {This is deleted material}. The bold and strikethroughs will appear on the site for fifteen (15) days after a modification and will then be removed.

Legal Authority/Introduction

LEGAL AUTHORITY:

Following a child’s entrance into out-of-home care (OOHC), federal law requires that the Department for Community Based Services (DCBS/department) conduct periodic case reviews to ensure appropriate service provision and evaluation of the family’s progress.  Periodic reviews are held every six (6) months from the date the child entered OOHC. 

A well-executed periodic review should include a review of the needs and strengths from prior case conferences, a current assessment of whether or not the family has a continued need for department intervention, and whether or not a safety issue necessitates the child’s continued placement in OOHC.   At the first periodic review, a case plan evaluation/ongoing assessment will be completed in TWIST, which will document the ongoing progress of the family since the prior case plan.  This will include safety and risk assessments, and the family's progress towards permanency.  OOHC case plans are also expected to make appropriate plans to ensure the child’s mental health, educational stability, physical health, and the establishment and support of a stable placement for the duration of the child's time in OOHC.  Additionally, for a child in OOHC, the SSW and the department are responsible for creating a plan that demonstrates reasonable efforts to obtain a safe, permanent placement that permits the child to exit foster care in a reasonable timeframe.  The components of a well-designed case plan include documentation around all these efforts. 

Key strategies for the achievement of an appropriate case plan include the engagement of family members and use of a family team meeting (FTM) model when appropriate, appropriate implementation of concurrent case plan goals when appropriate, and the development of the key family level and individual level objectives that identify key benchmarks for the evaluation of the family’s progress.  The SSW, in collaboration with the family, the family's support network, service providers, and other community professionals develops a family assessment to identify safety threats and problematic behaviors.  The SSW then collaborates with the family to identify strategies and interventions to facilitate needed changes

Once the SSW has completed the assessment, the information must be incorporated into an effective, thoughtful case plan.  The case plan provides a framework for case decision making and addresses the following questions:

  • What are the family outcomes that, when attained, will indicate that safety threats have been successfully addressed, risk has been reduced, and the effects of maltreatment have been successfully mitigated?
  • What tasks must be undertaken to attain these outcomes?
  • What intervention approaches or services will facilitate the successful attainment of outcomes and achievement of goals?
  • How and when will progress in implementing tasks, attaining outcomes, and achieving goals be evaluated?
     

Practice Guidance

  • SSW, parents, and caregivers will review the DCBS Partnership Plan and determine if any updates are needed to address any identified needs. 
  • It is important to ensure the case plan is realistically related to the underlying needs of the family.
  • In cases where domestic violence has been identified, the SSW consults with the FSOS to determine how to best plan for the safety of the non-offending parent and children.
  • Recognizing the importance of both formal and informal community supports to the family is an important aspect of case plan development.
  • The SSW may convene an FTM, when appropriate, for the development of the case plan and may include any or all of the following community partners:
    • Parent, guardian, or custodian (including noncustodial parent);
    • Child (if age and developmentally appropriate);
    • Foster and adoptive parent(s);
    • Relative or fictive kin caregiver;
    • Court-appointed special advocate (CASA);
    • Guardian ad litem (GAL);
    • Private child placing agency (PCP) or private child care agency (PCC);
    • Formal and informal supports; and
    • SSW and FSOS.
  • The SSW will not involve the parent in the case planning process if parental rights have been terminated, unless the FSOS or designee determine it is in the child's best interest.
  • While the participation of the child’s parents is important, the review is required within six (6) months of the child’s temporary removal hearing/placement or the last periodic review, even when the parents do not attend.
  • When the child cannot return home immediately, or be safely maintained in the home, alternative permanency goals will be considered.  The SSW, for example, may choose return to parent as a permanency goal and at the same time, have an alternate permanency objective and tasks in the OOHC section of the case plan. 
  • Children in status cases and those with a goal of planned permanent living arrangement (PPLA) should continue to receive concurrent planning services.  Intensive ongoing efforts to return the child to the home or secure placement with a fit and willing relative, legal guardian, fictive kin, or adoptive parent, including efforts that utilize search technology to find the biological family, should continue. 
  • The SSW may not choose a goal of PPLA for a child less than sixteen (16) years of age.  (Section 475 (5)(C)(i) of the Social Security Act)
  • The permanency goal of PPLA for any child placed in a PCC residential placement or other placement such as supports for community living (SCL) group homes must be approved by the DCBS commissioner or designee.  The Division of Protection and Permanency (DPP) director is the designated approval authority for these requests.  Please see the Permanency Goals in OOHC Case tip sheet for detailed instructions regarding the approval request process. 
  • Careful consideration should be given when requesting the goal of PPLA for children placed in PCC residential and other non-foster home placements.  It is important for children to maintain familial and non-familial connections with caregivers.  The goal of PPLA would be appropriate for children placed in residential settings when the child has established familial and/or non-familial connections with individuals and those individuals, as well as the child, are actively working towards placement with the individuals once treatment goals are met.
  • The SRA approves the goal of PPLA for children placed in DCBS foster homes, PCP foster homes, or other placements such as SCL family home providers where the placement has the same family structure as a foster home.
  • The SSW assesses the progress of the family in meeting the family and individual objectives as part of ongoing assessment and service delivery.
  • Any revisions or updates to the plan must be developed in consultation with the child and up to two (2) members of the case planning team designated by the child. (Section 475 (1) (B) of the Social Security act)
  • Federal language around “compelling reasons” for an Adoption and Safe Families Act (ASFA) exception is broad.  Such reasons may include, but are not limited to, a determination that adoption isn’t an appropriate goal—perhaps due to the parents’ progress, or that there are international legal obligations that preclude termination.  The worker, in consultation with the FSOS as appropriate, may exercise some discretion on whether or not “compelling reasons” exist. 
  • Child-specific recruitment efforts to find a permanent placement may include such efforts as tribal, state, regional, and national adoption exchanges, and electronic exchange systems in order to facilitate orderly and timely in state and interstate placements (when the child’s goal is adoption).
  • Public Law 96-272 (title IV-E) requires the participation of one objective third party in the periodic review, who is not:
    • The case manager;
    • In the line of supervision for the case; or
    • Involved in the delivery of services to either the child or the parents.
  • Examples of acceptable objective third party participants include the following: 
    • Permanency specialist;
    • An SSW or FSOS who is not directly involved with the case; or
    • Regional office staff.
  • It is preferred that the objective third party is a protection and permanency employee.
  • Periodic reviews are scheduled on a day and time when primary participants can attend.
  • Participants are encouraged to attend, in part by convenience of schedule and sufficient notice.
  • The permanency hearing is required no later than twelve (12) months from the date the child entered OOHC by order of temporary custody following the temporary removal hearing or placement as a result of voluntary commitment and every twelve (12) months thereafter if custody and out of home placement continues (Sec 475(5)(c)). 

Procedure

Prior to all periodic reviews the SSW: 

  1. Reviews the case history, circumstances, and investigative information to determine if the case meets concurrent planning criteria for the initial case plan;
  2. Completes the Waiver of Reasonable Efforts Checklist and consults with the FSOS.  Refers to SOP 11.8 Judicial Determination of Reasonable Efforts and Aggravated Circumstances, if the case meets for waiver of reasonable efforts;
  3. Compiles current assessment information from collateral sources, including updated information from the most recent assessment;
  4. Engages the family to solicit and encourage their approval for community partner involvement in developing the case plan;
  5. Makes attempts to identify and include both parents and relatives in the case conference/team meeting; ​1 2​
  6. Includes the child or children, when age appropriate, in case planning efforts;
  7. Includes the child's caregiver in case planning efforts;
  8. Empowers children age fourteen (14) and older in the development of their own case plan and transition planning for successful adulthood;
  9. Permits a child who has attained age fourteen (14) years to designate up to two (2) additional people to participate in the case planning conference, one of whom may be designated as the child’s advisor, and when necessary, to advocate with respect to the application of the reasonable and prudent parent standard, as outlined in SOP 4.30 Normalcy for Children and Youth in Out of Home Care (Section 475 (1) (B) of the Social Security act);  3
  10. Ensures full disclosure by respectful, candid discussion from the outset with all parties involved in the case planning and service provision of the following:
    1. The negative impact of foster care on children;
    2. Clarity about the birth parent’s rights and responsibilities;
    3. Services DCBS will provide;
    4. Permanency options;
    5. Concurrent planning; and
    6. Consequences for not following the case plan.

Six (6) Month Periodic Reviews

The FSOS: 

  1. Chairs the periodic review and provides input into case plan development; and
  2. Reviews and approves the case plan by signature and date prior to distribution.

The SSW:

  1. Holds case planning conference periodic reviews as appropriate or as needed, but is required to hold one within six (6) months of a child’s temporary removal hearing and/or order of temporary custody or placement date of a voluntary commitment;
  2. Holds subsequent periodic reviews within six (6) months of the previous review when the child remains in OOHC;
  3. Assesses the case for concurrent planning at the first periodic review, unless through supervisory consultation, it is determined that the parents are making significant case plan progress towards reunification;
  4. Assesses the case to​ concurrent planning at each subsequent periodic review; 
  5. Determines the permanency goal or goals that are in the best interest of the child;
  6. Establishes a target date for achievement of the permanency goal or goals;
  7. Ensures that the immediate safety needs of the child and the risk of future abuse and/or neglect should guide the selection of goals, objectives, and tasks;
  8. Ensures that there are specific tasks developed related to the individual's high-risk behaviors;
  9. Ensures that the goals, objectives, and tasks outlined in the case plan support the permanency plan;
  10. Specifies the activities or tasks to be undertaken, the person(s) responsible for each task and the time frame for achieving the goals, objectives, and tasks;
  11. Develops the child/youth action plan as described in the Case Planning Objectives-Out of Home Care (OOHC) Tip Sheet;
  12. Ensures that the periodic review includes the following:
    1. A discussion of ASFA guidelines, including the cabinet’s obligation to make reasonable efforts to finalize a permanent placement and the cabinet’s obligation to file for a termination of parental rights (TPR) once the child has been in OOHC for fifteen (15) months under federal law: (475 (5)(E) and 45 CFR 1356.21 (i)(1)(i));
    2. A discussion of the problems that are barriers to the child’s safe return home or other permanent placement, and the progress of the family and child to overcoming each barrier;
    3. A review of the appropriateness of services, including assessment and recommendations from community partners, whether services are being provided according to schedule and whether the parties, including identified fathers as outlined in SOP 4.14 Family Attachment and Involvement with expectations set for them are complying with those expectations;
    4. A review of any plan of safe care developed for a substance affected infant as required by CAPTA 106(b)(2)(B)(ii)and (iii) (referenced in SOP 1.15);
    5. A review of the quality and appropriateness of visits between parents and children, and between siblings;
    6. A review of the child’s health, including mental health, educational history, and current status are reviewed and the plan for meeting the child’s needs is reviewed;
    7. A review of the steps the agency is taking to ensure that the child’s foster family home or child caring institution is following the reasonable and prudent parent standard and to ascertain whether the child has regular, ongoing opportunities to engage in age or developmentally appropriate activities; (Section 475 (5)(B))
    8. A discussion of any goal of PPLA, to ensure documentation of intensive, ongoing, and as of the date of the review, unsuccessful efforts to return the child home or secure a placement for the child with a fit and willing relative or fictive kin (including adult siblings), a legal guardian, or an adoptive parent, including efforts that utilize search technology (including social media) to find biological family members for the children; (Section 475A) and
    9. A decision, based on (a) and (b) above, about whether the child may be returned home immediately and safely maintained in the home (Sec 475(5)(B));
  13. Ensures that the following components are always documented on the case plan documentation (in accordance with provisions of title IV-E of Social Security act):
    1. Permanency goal(s);
    2. Appropriate services to the parents that will constitute reasonable efforts towards reunification;
    3. Services that will be provided to achieve the least restrictive (most family like) placement that is in the closest proximity to the parents’ home (Sec 475 and 42 USC 675);
    4. A schedule for visitation between the child and parents, ensuring that visits are occurring no less than once every two (2) weeks unless there is a documented reason regarding why this is not in the child's best interest.  Visits are designed to enhance and support the relationship (refer to OOHC Visitation Tip Sheet for information regarding frequency and duration of visits);
    5. A schedule for visitation between separated siblings, as appropriate to the case circumstances, designed to enhance and support the relationship;
    6. A schedule for visitation between children in OOHC and significant individuals in their lives, including relatives and fictive kin as case appropriate;
    7. Documentation of the child-specific efforts being taken to finalize a permanent placement for the child, including efforts to identify, recruit, process or approve a qualified family for (475(1)(E) and (5)(E)):
      1. Relative placement;
      2. Adoption; or
      3. Legal guardianship placement;
    8. Documentation of the reasons permitted under law for not initiating a TPR when the child has been in care for fifteen (15) of the last forty-eight (48) months, one of which must be met for an ASFA exception:
      1. The child is being cared for by a relative or fictive kin;
      2. A compelling reason why filing for a TPR would not be in the best interest of the child; or
      3. Failure to provide, consistent with the time period in the case plan, services deemed necessary for the safe return of the child to the home when reasonable efforts are required (45 CFR 1356.21 (i)(2));
    9. Documentation of justification for the selection of “another planned permanent living arrangement,” when selected as the goal for the child (45 CFR 1356.21(h)(3));
    10. A plan for assuring that services are provided to the child and placement provider as necessary to support the placement and meet the needs of the child while in foster care (Sec 475(1)(b)).  Such a plan should incorporate the following documentation pertaining to health and education records (Sec 475(1)(c)):  
      1. The names and addresses of the child's health and educational providers;
      2. The child's grade level performance;
      3. The child's school record; 
      4. A record of the child's immunizations;
      5. The child's known medical problems; and
      6. The child's medications.
    11. Objectives, tasks, or other notes that constitute a plan for the child’s educational stability (reference SOP 4.28 Meeting Educational Needs) as required by Sec 475 (1)(g) and Sec 471 (a)(30) of the Social Security Act, including:
      1. Assurances that each placement takes into account the appropriateness of the child’s current school setting, as well as the proximity of the placement to the child’s current school at the time of placement;
      2. Assurances that the cabinet coordinated with the local education agency to ensure the child is able to attend the same school where enrolled at the time of each placement;
      3. Assurances that, when a change of schools is necessary, the child will be immediately enrolled in an appropriate school, with all of the educational records of the child provided to the new school;
      4. Verification that a child, who has attained the minimum age for compulsory school attendance, is attending school in accordance with state law; or
      5. Regularly updated medical documentation that verifies that a child is incapable of attending school; 4
    12. Information describing the safety and appropriateness of the child’s current placement, and any consideration being given to change in placement is presented to conference participants (U.S. Code 42 USC Section 675 (1)(A); 5
    13. A description of the programs and services which will assist youth in preparing for the transition to adulthood as outlined in SOP 4.29.1 Independent Living Services (Sec 475(5)(C)(i));
    14. A transition plan, for youth age seventeen (17) and over, updated as appropriate during the periodic review (Sec 475(5)(H));
    15. Signatures of the periodic review participants, including an objective third party as required by federal law (Sec 475(6));
  14. Ensures that a child in OOHC who has attained fourteen (14) years of age is provided a copy of their rights included with the DPP-1281 Family Case Plan, and files the child’s signed acknowledgment of receipt with the agency’s copy of the case plan;  (475a of the Social Security act)
  15. Ensures that the parent/guardian is informed of their right and responsibility to make health care decisions about their child, as well as the expectation that they will participate in these decisions;
  16. Ensures that a signed DPP-106A is maintained in the child’s file; 
  17. Enters the case plan information and submits it to the FSOS who approves it within ten (10) days from the case planning conference date;
  18. Submits the case plan to the FSOS with or without the parents’ signatures and documents in the comment section of the DPP-1281 Family Case Plan why the parents did not sign;
  19. Ensures that all required signatures are obtained on the approved case plan including, but not limited to the following:
    1. Parent, guardian or custodian (including non-custodial parent);
    2. Child (if age and developmentally appropriate);
    3. Foster and adoptive parent;
    4. Relative or fictive kin caregiver;
    5. Court-appointed special advocate (CASA);
    6. Guardian ad litem (GAL);
    7. PCC or PCP agency worker;
    8. SSW; and
    9. FSOS;
  20. Dockets a placement court review no later than six (6) months after the child is removed from the home, regardless of placement or custody, when the child is age sixteen (16) or younger at the time of removal in accordance with Family Court Civil Rule 34;
  21. Files, for the purpose of the six (6) month review, a court case review ​report with the court at least three (3) days prior to the hearing (Family Court Civil Rule 28);
  22. Submits a copy of every case plan, visitation agreement, ​​saftey plan, and prevention plan to the court (45 CFR 1356.21 (i)(2) and Family Court Civil Rule 29); 6
  23. Mails or distributes a copy of the family plan portion of the DPP-1281 Family Case Plan to:
    1. Parent, guardian or custodian (including identified fathers);
    2. Any person or agency providing services to the family; and
    3. Administrative Office of the Courts Citizen Foster Care Review Board Program at the following address:

      Dependent Children’s Services
      Administrative Office of the Courts
      100 Millcreek Park
      Frankfort, KY 40601
  24. Distributes the OOHC child/youth portion of the DPP-1281 to the following:
    1. Family, including identified fathers as outlined in SOP 4.14;
    2. Caregiver (foster parents, PCC provider, relative, etc.);
    3. Case planning participants in attendance (with the consent of the parents or court order);
    4. Parent’s attorney, if applicable;
    5. CASA, if applicable (the CASA worker receives all information pertaining to the child’s case plan and may have case plan information pertaining to the parents with their consent or court order);
    6. Administrative Office of the Courts Citizen Foster Care Review Board Program for the ten (10) day initial case planning only;
    7. Any community partners assigned a task at parent’s request in the case plan, (with parent consent); and
    8. Guardian ad litem.
  25. Mails a copy of the approved DPP-1281 Family Case Plan, DPP-154 Protection and Permanency Service Appeal and other approved documents, by certified mail, to all biological and legal parents if the parent or guardian did not attend the case plan meeting;
  26. Documents the following in TWIST:
    1. Efforts to involve both parents, the child’s guardian, or custodian in the case planning process;
    2. Contents of the court report; and
    3. Court hearings and any court orders.

Annual Periodic Reviews and Permanency Hearings

The SSW: 

  1. Prepares for the second periodic review, approximate to the child’s twelfth (12th) month in care; 
  2. Determines, in consultation with the supervisor, staff, and other professionals involved in the case, including but not limited to Office of Legal Services (OLS), whether or not to pursue a TPR or an exemption to ASFA requirements at the next annual permanency hearing when DCBS will be requesting a goal of adoption.
  3. Considers the length of time the child has been in care;
  4. Considers whether or not services provided to the parent have been adequate for reunification, and whether or not additional services are likely to facilitate a safe reunification;
  5. Holds the case conference as required;7
  6. Completes the case plan document as required;
  7. Documents case conference activities;
  8. Requests the annual permanency hearing using the DPP-165 Permanency Hearing Notification within sixty (60) days of the required due date:
    1. No later than twelve (12) months from the date the child entered OOHC, and
    2. Every twelve (12) months thereafter for as long as the child remains in OOHC.
  9. Files a court report, case plan, visitation agreement, safety plan, and any prevention plans at least three (3) days prior to any annual review in accordance with Family Court Rules 28 and 29;  
  10. Ensures the court report includes sufficient documentation of the information discussed and reviewed during the periodic review to include:
    1. The discussion of ASFA guidelines, including the cabinet’s obligation to make reasonable efforts to finalize a permanent placement and the cabinet’s obligation to file for a TPR once the child has been care for fifteen (15) months under federal law: (475 (5)(E) and 45 CFR 1356.21 (i)(1)(i));
    2. The problems that are barriers to the child’s safe return home or other permanent placement and the progress of the family and child to overcoming each barrier;
    3. The appropriateness of services, including assessment and recommendations from community partners, whether services are being provided according to schedule and whether the parties, including identified fathers as outlined in SOP 4.14 Family Attachment and Involvement with expectations set for them are complying with those expectations;
    4. The quality and appropriateness of visits between parents and children, and between siblings;
    5. The child’s health, including mental health, educational history, and the current status is reviewed and the plan for meeting the child’s needs is reviewed;
    6. The steps the agency is taking to ensure that the child’s foster family home or child caring institution is following the reasonable and prudent parent standard, and information about whether the child has regular, ongoing opportunities to engage in age or developmentally appropriate activities (Section 475 (5)(B));
    7. Documentation of (only for a child who has attained age sixteen (16))a compelling reason for the selection of the goal of PPLA (Section 475 (5)(B));
    8. Documentation, for children with a goal of PPLA, of intensive, ongoing, and as of the date of the court hearing, unsuccessful efforts to return the child home or secure a placement for the child with a fit and willing relative or fictive kin (including adult siblings), a legal guardian, or an adoptive parent, including efforts that utilize search technology (including social media) to find biological family members for the children (Section 475A);
    9. Documentation regarding ongoing searches for relatives at a minimum of every six (6) months during case planning conferences;
    10. A decision, based on (a) and (b), about whether the child may be returned home immediately and safely maintained in the home (Sec 475(5)(B));
  11. Ensures the contents of the court report are reflected in TWIST;
  12. Obtains the judicial determination regarding the appropriateness of the permanency goal; 
  13. Obtains a judicial determination regarding the appropriateness of the agency’s efforts to finalize the permanency plan; and
  14. Documents the hearing and any court orders in TWIST, noting the court’s agreement with or deviation from the court report.
​​
 

Footnotes

  1. Absent parent and relative searches must be conducted, on all identified fathers and relatives, within thirty (30) calendar days of the child’s entrance into OOHC and documented in TWIST to generate an Absent Parent Form (TWIST form) and continue at a minimum of every six (6) months during case planning conferences.
  2. In voluntary TPR situations, if the worker has obtained a waiver of efforts based on the parent's intention to voluntary TPR, a case planning meeting is held, but plans to reunite parent and child are not required.
  3. The SSW, in consultation with the FSOS, may at any time reject a person selected by the child if the worker has good cause to believe the individual would not act in the best interests of the child. (Section 475 (1)(B) of the Social Security Act).
  4. If a child is not enrolled in school as required by state law, the child becomes ineligible for title IV-E benefits.  The SSW notifies the CBW accordingly of changes to the child’s enrollment status as they pertain to title IV-E eligibility.  (Sec 471 (a)(30)).
  5. The SSW ensures the correct placement information is entered in TWIST.
  6. This includes both the family and OOHC youth portions of the case plan. 
  7. The case plan goal must match the court's goal.  In situations where the case has been consulted on through a pre-permanency conference with OLS, OLS has certified the case for TPR during the pre-permanency conference, but the court denied the goal change to adoption, the SSW should select adoption as the concurrent planning goal.  The SSW and FSOS should consult with OLS regarding proceeding with the filing of the TPR petition in these cases.
 

Communicate

Sign In (Editor Access Only)
Copyright © 2011 Commonwealth of Kentucky - All Rights Reserved
Kentucky Unbridled Spirit