Effective Date: 3-5-21
This subsection contains the Legal Basis for the Provision of Health Care Services and the following: Definitions, Medical and Behavioral Health Case Management, Informed Consent Medical Service Alternatives/Planning, Identification of Children in the Custody of the Children’s Division Solely for the Purpose of Accessing Mental Health Services, Custody Diversion Protocol, Voluntary Placement Agreement, Pregnancy of Child in Out-of-Home Care, Chemical Dependency Treatment, HIV/AIDS Issues, Life Support, Sustaining Therapies and Death of a Child in the Legal Custody of the Children’s Division.
Legal Basis for the Provision of Health Care Services:
To accept for social services and care, homeless, dependent or neglected children in all counties where legal custody is vested in the Children’s Division by the juvenile court where the juvenile court has acquired jurisdiction pursuant to subdivision (1) or (2) of subsection 1 of section 211.031; provided that prior to legal custody being vested in the Children’s Division, the Children’s Division shall conduct an evaluation of the child, examine the child and investigate all pertinent circumstances of his or her background for the purpose of determining appropriate services and a treatment plan for the child. This evaluation shall involve local division staff and consultation with the juvenile officer or such officer’s designee, appropriate state agencies, including but not limited to the department of mental health and the department of elementary and secondary education, or private practitioners who are knowledgeable of the child or programs or services appropriate to the needs of the child and shall be completed within thirty days. Temporary custody may be placed with the Children’s Division while the evaluation is being conducted. A report of such proceedings and findings shall be submitted in writing to the appropriate court in accordance with section 207.020 (17) RSMo., 2014.
Legal custody, according to Section 211.021 (4), RSMo., means the right to care, custody and control of a child and the duty to provide food, clothing, shelter, ordinary medical care, education, treatment and discipline of a child. Legal custody may be taken from a parent only by court action and if the legal custody is taken from a parent without termination of parental rights, the parent’s duty to provide support continues even though the person having legal custody may provide the necessities of daily living.
Any member of the child’s Family Support Team who has a juvenile court order to serve as the consenting authority for the administration of psychotropic medications to a child.
Assent is permission, by a child twelve (12) – seventeen (17) years of age or a child’s attorney/guardian ad litem (for a child of any age) in Children’s Division legal custody and in foster care who is not legally able to give informed consent, indicating that they agree with the proposed psychotropic medication treatment. Assent is an on-going developmentally and behaviorally appropriate discussion between the child, parents, health care providers and others involved in the child’s care.
The Children’s Service Worker or other designee who is responsible for the child’s health care while the child is in the legal custody of Children’s Division.
The case manager is required to document any and all services provided to the child in the Family and Children Electronic System (FACES) and upload any paper documents to the document imaging system (OnBase) immediately.
Extraordinary Care Treatment
Extraordinary care services include, but are not limited to, extraordinary dental treatment, sterilization, experimental/hormonal drug treatments, invasive or extensive medical testing, any elective body modification requiring general anesthesia i.e., gender reassignment , and any other procedures governed by local court rule or as otherwise directed by the local juvenile court. The case manager will consult with the Division of Legal Services to assist in obtaining a court order for extraordinary care services.
Health Information Specialist
The Health Information Specialist (HIS) is part of the HIS team implemented in January 2019 in advance of the Psychotropic Medication Joint Settlement Agreement (Agreement). The Agreement outlines that CD shall maintain an adequate number of full time staff members statewide for the purpose of gathering and maintaining full and accurate medical information and history for each child in CD custody. The HIS team is responsible to ensure that all elements of the Agreement are monitored, documented and that CD is in compliance with the Agreement requirements.
The HIS team members are under the direction of the Health Specialist Coordinator and two Unit Managers. A HIS team member is located in each region throughout the State.
Informed consent is the agreement to any medical or behavioral health treatment (such as a medical service or procedure) given after the child, parent, and/or legal custodian has had the opportunity to receive sufficient information about its risks and benefits. Consent must be given, after receiving all necessary information, based upon what is in the best interests of the child.
To make an informed decision about behavioral health treatment or medications without undue influence/coercion, which means that the consenter is deciding based on what is best for the child, not because of pressure to consent to the medication or treatment services. For example, a decision must not be made based on a school’s or other entity’s insistence that a child take medication in order to participate or receive services, or continue placement.
The case manager cannot provide informed consent for psychotropic medications until he/she completes the psychotropic medication management and informed consent trainings.
Non-routine treatment includes, but is not limited to: surgery, inpatient hospitalization, behavioral therapy or behavioral health services and psychiatric treatment.
In this section the following classes and medications are considered psychotropic medications:
- Alpha agonists (e.g., clonidine or guanfacine);
- Anxiolytics/hypnotics (e.g., benzodiazepines and nonbenzodiazepines); and
- Anticonvulsants/mood stabilizers.
A psychotropic medication may be any medicine that affects the mind, emotions or behavior. In addition to the categories above, other medicines, including herbal remedies, may be used that affect mind, emotions or behavior. Some of the medications above may be prescribed for physical health reasons. If a case manager or other team member has questions about whether a medication should be considered a psychotropic, even after discussing it with the prescriber, the case manager should consult with a HIS for direction.
Routine (Standard) Treatment
Routine (Standard) Treatment includes, but is not limited to: ordinary illnesses, routine dental care, immunizations, well child visits, preventative health services, on-going treatment for chronic medical health conditions, and necessary routine testing for those chronic conditions, such as asthma, diabetes, and ear infections.
4.3.2 Medical and Behavioral Health Case Management
Children’s Division (CD) shall ensure that children in the agency’s custody receive appropriate medical and behavioral health care. Each child’s care must include:
- Emergency treatment, whenever necessary;
- Timely examination and treatment of nonemergency injuries and illnesses;
- Provision of ongoing allied health services, like physical or occupational therapy, when recommended. Allied health professionals are not doctors, dentists or nurses, but others who aim to prevent, diagnose and treat a range of conditions and illnesses and often work within a multidisciplinary health team to provide the best patient outcomes;
- Proper assessment and care of behavioral health issues; and
- Regular preventive care appropriate to the child’s age and condition, including immunizations
Initial Family Support Team (FST) Meeting: At the first FST meeting following the child’s placement in alternative care, the case manager shall inform the parent(s) that CD will expect them to take an active role in health care decisions about the child, unless the FST determines that would be contrary to the best interests of the child. An active role would include, but is not limited to:
- Attending the child’s appointments;
- Demonstrating an understanding of the child’s health status and recommendations of any providers; and
- Providing necessary care and medication during visitation and trial home placement.
The case manager shall keep the parent(s) informed of the child’s medical and behavioral health decisions. The case manager is responsible for the child’s medical and behavioral health care while the child is in CD custody. The case manager shall partner with the parent(s), the child (to the extent reasonable for the child’s age and understanding), resource providers, and primary health care providers. The case manager will attempt to contact these partners prior to the provision of any treatment. The parent(s) will be asked to return the completed Child/Family Health and Development Assessment (CW-103) within a week of the Initial FST if not returned at the time of the meeting.
If the parent does not return the completed CW-103, the case manager shall engage the parent to obtain the necessary information to complete the CW-103 and share information with resource provider.
All information about the child’s medical or behavioral health care while in alternative care shall be shared with the parent/caregiver on an ongoing basis unless Termination of Parental Rights (TPR) has occurred or the court has issued an order preventing the parent/guardian access to the information.
Ongoing Case Management
Provision of Appropriate Care: The health of a child in alternative care is of paramount importance throughout the child’s placement. The resource provider shall obtain a medical examination for the child immediately following initial placement and at least annually thereafter in cooperation with CD. This requirement is satisfied by completion of Initial Health Examination or the Full Healthy Children and Youth (HCY) Screening.
- Initial Health Examination: An initial health examination should occur when the child enters care. When possible, this should be completed by the current primary care physician as they are already familiar with the child’s medical history. If a provider is not readily accessible, this exam must occur within seventy-two (72) hours of the initial placement. The case manager need not attend these initial examinations; however, they should receive documentation of the results of the examination of the appointment and ensure compliance with any recommended follow-up treatment/interventions.
- Full HCY Screenings: A full HCY screening consists of a physical examination, and other developmental components, including but not limited to vision, hearing, social/emotional and dental screenings. The screenings shall be completed no later than thirty (30) days after the child is placed in (CD) custody. If it is not possible to schedule the appointment within thirty (30) days, the reason for the delay shall be documented in FACES and the screenings completed at the earliest possible date. Staff should promptly follow up on any recommendations from the screening.
An Initial Health Examination may be considered a Full HCY screening if the Initial Health Examination contains a review of all sections within the HCY screening.
Ongoing Medical Assessments: Children’s Division shall maintain best practices in monitoring the child’s health as required by federal and state laws, and as recommended by the American Academy of Pediatrics (AAP) and the Child Welfare League of America (CWLA), which set forth that certain medical appointments occur timely to assess and monitor the child’s health.
All children in the custody of the Children’s Division shall receive medical assessments in accordance with the “Bright Futures /American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care” also known as the “Periodicity Schedule.” The periodicity schedule is based on age and may require some children to have more frequent visits than children in other age groups.
- Some medical care, even though standard or routine, may be controversial in some families. With respect to those issues, the case manager shall follow CD policy as set forth below.
Immediately following placement the resource provider should obtain a dental examination for the child as recommended by the dentist or every six (6) months; but at least annually.
Dental exams are performed by dentists or qualified dental professionals. During a dental exam, the dentist or hygienist will check for cavities and gum disease and may clean the child’s teeth. The exam involves a more comprehensive oral health evaluation and may include dental X-rays or other diagnostic procedures, when indicated. Oral hygiene habits and anticipatory guidance are typical points of discussion during each visit.
- Dental Exam Periodicity Schedule – When and How Often Exams Should Occur
- First Dental Exam: The American Academy of Pediatric Dentistry (AAPD) recommends the first dental examination occur at the time of the child’s first tooth eruption, or no later than 12 months of age.
- A child’s developing primary teeth (or “baby teeth”) are susceptible to decay as soon as they appear. This first visit provides the early opportunity to check existing teeth for decay and to assess any potential problems with the child’s gums, bite, oral tissues, and jaw. The dentist can provide guidance on baby bottle tooth decay, infant feeding practice, teething, pacifier habits, finger-sucking habits, and mouth cleaning.
- Ongoing Dental Exams: Dental exams are recommended every six (6) months, or more frequently if recommended by the dentist based on the child’s risk status.
- Child’s First Dental Exam Following Entry in to Alternative Care
All children entering alternative care must have a full, comprehensive HCY screening within thirty (30) days. Included in this physical health and developmental assessment are vision, hearing, and dental screenings.
The dental screening may be completed by the physician performing the physical exam, or the child can be taken to a dentist to receive this screening. A full dental examination is not required during this thirty (30)-day timeframe solely due to the child’s entry into alternative care. However, if during the HCY dental screening the provider indicates a need for a full dental/oral examination, the physician will make a referral and staff shall ensure this exam occurs. This dental exam must be performed by a dentist or qualifying dental professional.
Because dental exams are recommended every six (6) months, staff should promptly collect the child’s dental records upon entry into alternative care to ascertain when the child last had a dental exam and when he/she should visit the dentist next. These records can be obtained from the child’s dental provider, or by accessing the information via CyberAccess for MO HealthNet recipients.
- If the child has no history of a dental exam, the child’s first dental exam should be scheduled based on the anticipatory guidance given by the physician during the thirty (30)-day HCY screening, but no later than six (6) months from entering CD custody.
Immunizations: The case manager will ensure that children in the agency’s custody are scheduled to be immunized against disease, in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP) under the Centers for Disease Control and Prevention. If a parent has an objection to immunizing a child based upon religious or health reasons, the parent should inform the case manager and the parent may choose to address the issue with the Court. However, unless there is a court order exempting the child from immunizations, the case manager will ensure that immunizations are scheduled pursuant to the appropriate schedule as set for by the Advisory Committee on Immunization Practices (ACIP).
Reproductive Health: Information on sexual health, education, including information on sexually transmitted infections and birth control should be made available to a child, appropriate to their age and physical and emotional maturity. The case manager shall document when and by whom this education was provided. Educational information and prevention resources shall be made available to parent(s) and/or resource providers as requested for discussion with the child.
Birth Control: Children in foster care are afforded the choice to obtain or refuse birth control. Missouri law does not require minors to have parental consent to obtain contraception, although it is the practice of some medical providers. If the medical provider requires signed consent, CD may provide the written consent.
Attendance at Health-Related Appointments: After a child is placed in the custody of CD, parent(s) and resource provider attendance at the child’s health-related appointments is expected and welcomed, in most instances. The case manager should invite the parent(s) and resource provider to attend all health-related appointments at least three days in advance, whenever possible. There may be special circumstances in which it is not in the best interests of the child for the parent(s) to be involved in health care decisions about the child. In these cases, the case manager should speak to their supervisor and may consider a referral to the Division of Legal Services or CD attorney.
If behavioral health therapy is arranged for the child, ideally the case manager will attend the initial appointment with the child. If the case manager is unable to attend the initial appointment, s/he must communicate with the therapist prior to the appointment to discuss the child’s needs and provide consent to begin treatment. If a child is referred for psychiatric assessment or care, the case manager or supervisor must attend all initial appointments.
Communication Regarding Health Care Needs: The case manager should recognize that continued collaboration with the parent(s), child, resource provider, and primary health care providers will lead to clearer communication and provision of services in the child’s best interests, resulting in a smoother transition in the event of any change, including at the time of reunification or, for an older youth, placement in independent living.
Family Support Team (FST) Meetings: FST meetings shall include a discussion of medical and behavioral health updates, unless the case manager has determined that such discussion is contrary to the child’s best interests.
A supervisor should be consulted regarding any such determination and an explanation provided to the FST, with appropriate documentation in FACES. Notice of the right to pursue being designated as an alternative consenter for psychotropic medications is to be provided to all members of the FST at each meeting. See Alternative Consenter in 4.3.3.
- Parent(s): Unless termination of parental rights has occurred or the court has issued an order restricting parent(s) access to information, the case manager will routinely share information about the child’s health with the parent(s) during home visits and will timely respond to requests for information. Additionally, the case manager shall engage the parent(s) promptly about any major change in the child’s health status, including, but not limited to, significant injury, new diagnosis or medication, or any emergency treatment or hospitalization. The parent(s) should be asked to provide updates about any newly acquired knowledge of familial illness which might impact the child and to promptly inform CD of any illness or injury incurred by the child during visitation with the parent(s).
- Child: Children and youth should participate as much as possible in making decisions about their medical care. Children should be encouraged by the team members to communicate information or worries about their health to parent(s), resource providers, the case manager, and to health care providers. Case managers should ask a child’s opinion about proposed medical care and discuss safe use of medication, as developmentally appropriate. Providing a child with information:
- helps the child achieve developmentally appropriate awareness of health status;
- tells the child what to expect about treatment;
- helps to prepare a child for assuming more responsibility for health care decisions as they develop;
- aids the case manager and other adults involved in the child’s care to assess the child’s understanding of the situation; and
- solicits the child’s willingness to accept the proposed care.
Children/youth age twelve (12) or older shall be provided written notice of their rights regarding assent as described in the Informed Assent section. The Guardian Ad Litem (GAL) and any attorney for every child shall also be provided written notice of children’s rights regarding assent. Staff shall document in the case record when and to whom the Learn Your Rights (CD-281) form was provided.
- Resource Provider: The case manager will provide all available medical and behavioral health information to the resource provider as required by law. The case manager and the resource provider will regularly review the child’s health care status throughout the duration of the child’s placement. The resource provider will notify the case manager as soon as possible of any significant injury or illness of the child.
- Court: The case manager shall provide a comprehensive summary regarding the child’s health in regular court reports and shall include any current diagnoses and medications, if any.
Children’s Division Responsibilities: In addition to the historical documentation cited in this chapter and the provision of such documentation to a resource provider upon initial placement of a child, CD has an overarching responsibility to ensure that current medical information is documented throughout a child’s placement in care.
- CD shall exercise reasonable and diligent efforts to compile and maintain the medical records for each child in alternative care. Collection of medical history and updating the child’s medical records are continuing and shared responsibilities.
- The case manager will obtain medical information for each child in their caseload. The case manager will upload any medical and/or behavioral health documents into the document imaging system and maintain a physical paper file. The Health Information Specialists (HIS) are available in each region to assist the case manager with coordination of obtaining the documents.
- All efforts to involve the child and parent(s) in decisions about the health care of the child shall be documented in FACES by the case manager. Documentation should include the child’s response and the parent’s actual involvement or reasons why the parent could not or should not be involved. If the parent(s) cannot be located, the case manager will document any efforts taken to notify them. Available documentation shall be uploaded into document imaging system.
Medical Records – Compilation and Access
- Case Record: The case manager and HIS may collaborate to obtain and upload any historical and current medical and/or behavioral health documents. These documents are maintained in the document imaging system and can be retrieved to compile a medical record for the child. This medical record shall include full and accurate medical information and history, including but not limited to the following: Medical and surgical history, dental history, psychosocial history, past behavioral health and psychiatric history, including medication history and documented benefits and adverse effects; past hospitalization or residential treatment history; allergies; immunizations; current and past medications, including current dosage and directions for administration; family health history; treatment and/or service plans, and results of any clinically indicated lab work.
- Process and Documentation: To the extent applicable, such efforts shall include, but not be limited to, accessing Medicaid claims data, requesting information from current and past medical care providers known to CD, reaching out to the child’s health insurance plan, gathering records from past foster care episodes, and gathering records and information from parents (whose rights have not been terminated) or guardians and other family members involved in the child’s health care.
- Access to Medical Records/Providing Medical Information
When a child is placed in alternative care, the case manager placing the child will request pertinent medical information from the parent(s) or other caregiver, to include information necessary to provide immediate care for the child, including current medications, if any, and complete the Health Care Information Summary (CD-264). Ideally, the CD-264 should be provided to the resource provider at the time of the child’s placement.
The case manager will obtain comprehensive health and developmental information about the child from the parents or other significant adults in the children’s life and/or health care providers, using the Child/Family Health and Development Assessment (CW-103). The case manager should begin the process of completing these forms with the family at the time of initial contact; but should continue to engage the family to gather information during subsequent visits until the form is complete.
The Monthly Medical Log (CD-265) was created to assist the resource provider and residential facilities in documenting health related needs, informed consent decisions for routine care, medications, and appointments regarding the child.
The CD-265 is to be maintained and supplemented by the resource provider throughout the child’s placement and is to be submitted to the case manager monthly, primarily during the case manager’s visit with the child in the child’s placement. The CD-265 also offers an opportunity for the resource provider to provide information about the child’s progress and needs related to the child’s health.
The residential treatment provider must provide the case manager with the completed CD- 265 as well as the Medication Administration Record (MAR) by the 5th day of the following month. The written documentation must contain all medication administered for the month, including the dosage and any new medications prescribed, including the dosage.
Initial Placement: When a child has been placed in any alternative care setting for the first time since coming into the legal custody of CD, the case manager will ensure that the CD-264 and the Child/Family Health and Developmental Assessment (CW-103) are provided to the resource provider or residential care providers within seventy-two (72) hours whenever possible but no later than thirty (30) days following placement. While the parent or legal guardian should be primarily responsible for completing the CW-103, it is the case manager’s duty, even if the parent does not assist in completion of the assessment paperwork, for ensuring that both forms are as accurate and complete as possible, and are given to the resource provider within thirty (30) days.
Case managers shall also document when and to whom the health information (CD-264 and CW-103) was provided.
Subsequent Placements: If a placement change must occur, the case manager will provide to the new resource provider or residential care provider the CW-103, an updated version of CD-264, and a copy of the resource provider or residential care provider’s medical file, including all CD-265s, from the child’s prior foster care placements. This information will be made available at the time of placement, but no later than seventy-two (72) hours following placement. This history shall include all information gathered and provided at the time of initial placement and all additional information maintained by the previous resource provider (including information that has been provided to the case manager). Any medication previously prescribed for the child should be delivered in the original container with written instructions. Case mangers shall document when and to whom the health information (CD-264, CW-103 and CD-265) was provided.
The case manager will provide the names and contact information for all of the child’s current and past behavioral health, dental, and medical providers, and upload all signed forms i.e., CW-103, CD-264, CD-265 and CD-275 into the document imaging system. Efforts to obtain the information described shall be documented in FACES.
The case manager is not required to perform the initial and subsequent placement process for hospital placements.
4.3.3 Informed Consent
While children are in the custody of Children’s Division (CD), the case manager shall be primarily responsible for granting informed consent for their care, unless an alternative consenter has been appointed by the Court. Resource providers may continue to provide informed consent for routine or standard treatment. This policy outlines steps for consultation and communication when managing routine and non-routine treatment decisions. Case managers should refer to this section to determine next steps after a health care provider recommends a specific treatment (e.g. medication, service, or procedure) for a child in CD’s custody.
To ensure that those authorized to give informed consent fully understand the role/responsibilities of granting informed consent, including considering the use of non-pharmacological interventions (options that do not involve medicines), CD has developed training to assist consenters. As described below, resource providers may only consent to routine treatments/services.
Case managers may consent to routine and non-routine treatments/services. Case managers and resource providers must successfully complete Informed Consent and Psychotropic Medication Management Training before becoming consenters.
NOTE: This policy does not apply to cases where the youth is in the legal custody of a third party (LS-3).
To ensure that consent is informed and legally valid, the case manager should collect from the prescriber information about the following factors, and understand and consider their impact upon the child:
- Nature and purpose of recommended treatment; what are the prescriber’s reasons for this particular recommended course of treatment; and
- Diagnosis: what is the specific condition to be treated?
- For medication recommendations, also consider:
- Dosages of any medications and the beneficial effects on the condition expected from the medications;
- Whether recommendation is for “off-label” use. “Off-label” means that if a drug has been approved for one use, dosage or age group, prescribers may choose to use this same drug for other reasons, if they believe it may be helpful;
- Possible side-effects, including probable clinically significant side effects and risks associated with the medications;
- Required follow-up or monitoring;
- Availability of alternatives, including generally accepted alternative medications and/or non-pharmacological interventions, if any; and
- Prognosis without an intervention, including the probable physical and/or behavioral health consequences of not consenting to the recommended treatment, including medication.
The case manager must always complete the CD-275 Informed Consent for Psychotropic Medication and document the informed consent decision in the medical information screen in FACES. The case manager will complete the date informed consent was given for psychotropic medication, by whom informed consent was provided, and the comments field listed under medication. This field should be utilized to document overall comments regarding medical care for the child and information about a secondary or mandatory review that was completed. Child assent can be documented in this field as well.
Guidelines for Informed Consent Decisions
Health care treatment decisions for children, including the use of medication, are always important and should be made thoughtfully, considering relevant information available. Just as non-pharmacological interventions should be considered for any condition, pharmaceutical intervention for behavioral health issues should never be the first nor sole intervention for children in CD custody.
When a case manager is deciding whether to consent to routine or non-routine treatment, in addition to the factors listed above, they should also consider:
- Child and Family medical history, as documented in the CD-264, CW-103 and CD-265;
- Age of the child;
- Child’s and parent(s)’ expressed preference;
- Assessment by the health care provider;
- Whether a consultation with the statewide clinical consultant would be helpful or otherwise required by policy; and
- Plan for safe storage of medications.
Informed Consent for Routine Treatment
As defined above, routine (standard) medical treatment includes treatment for ordinary illnesses and on-going treatment for chronic conditions. Per Missouri law, a minor may consent to administration of birth control.
- The case manager or the resource provider (consenter) may consent to any routine (standard) medical treatment for a youth in Children’s Division’s custody. As noted in this chapter, the case manager or resource provider should attempt to involve the parent in routine treatment by offering invitations to appointments and providing updates about the child’s health status.
Documentation of the informed consent decision for routine treatment is always required and shall be in FACES and the medical record within the child’s file. The resource providers’ documentation should be contained in the Monthly Medical Log (CD-265) and the event shared with the case manager. The consenter may be asked by the health care provider to document their consent or refusal of treatment on a form offered by the provider. If this occurs, the consenter should request a written copy of the consent documentation from the health care provider to be saved in the child’s medical record.
Informed Consent for Non-Routine Treatment, including Behavioral Health Services and Psychotropic Medication
As defined above, non-routine medical treatment includes any health intervention that is not considered routine (standard) or extraordinary care. Only CD and contracted case management staff may grant informed consent for non-routine treatment; resource providers are not authorized to consent for non-routine treatment, excepted in the limited circumstances described below.
Every informed consent decision shall include engagement with the parent(s). Contact with the parent(s) shall include a conversation about the recommended treatment and/or procedure, such as diagnosis, purpose, names and dosages of any medications, possible side-effects, required follow-up or monitoring, availability of alternatives, and prognosis without an intervention. The informed consent decision process shall be documented in the case record.
Some children may need medication to cope with the trauma of abuse, neglect or separation. Other children may need medication to help treat behavioral health disorders that they inherited or developed, such as Attention Deficit Hyperactivity Disorder (ADHD), severe depression, or psychosis.
Informed consent for a specific psychotropic medication may not be used to imply informed consent for another medication. Thus, the case manager should follow this process each time an additional medication is recommended.
Psychotropic Medication – Initiation and Monitoring
- A case manager shall not consent to the use of psychotropic medications without first having sought alternative interventions to aid the child, resource provider or parents. Those may include, but are not limited to therapy, skills building, parenting assistance or family therapy.
- Every child shall have a behavioral health assessment, with a DSM-based diagnosis, documented in the child’s case record prior to being prescribed a psychotropic medication. In the case of a child who comes into CD legal custody with an existing psychotropic medication prescription, CD may continue to administer such medication until the necessary evaluations have been made.
- Every child prescribed a psychotropic medication shall have medical examinations as indicated by the current “Bright Futures /American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care,” or “periodicity schedule,” or more frequently if recommended by the prescriber.
- Every child prescribed a psychotropic medication for ongoing use (more than a single dose) shall have, documented in the child’s case record, monitoring appointments with a prescriber at least every three (3) months, or more frequently if indicated by the prescriber.
- The informed consent decision-making process for all new recommended psychotropic medications must be documented using form Informed Consent for Psychotropic Medication (CD-275). Dosage increases or decreases for a medication previously authorized do not require completion of this form unless the prescriber states the dose exceeds guidelines at which time, a new CD-275 will need to be completed. Every CD-275 should be retained in the case record; form shall be uploaded to the document imaging system and placed in child’s medical section of the case record.Every child prescribed a psychotropic medication shall receive concurrent non-pharmacological treatment at the frequency and duration recommended by the prescriber.
- Informed consent decisions are valid for one (1) year. Case Managers shall consult with supervisor once every ninety (90) days regarding informed consent decisions. These consultations shall include but are not limited to what, if any, adverse effects the child has experienced and whether the symptoms for which the drug was prescribed have been addressed, and the frequency of non-pharmacological treatment. These consultations shall be documented in FACES. A new Informed Consent for Psychotropic Medication (CD-275) form will be completed annually prior to informed consent decisions expiring. The CD-275 should be retained in case record; form shall be uploaded to document imaging system and placed in child’s medical section of the case record.
Process for Obtaining Informed Consent and Assent for Psychotropic Medication.
No case management staff member is authorized to provide informed consent unless and until she or he successfully completes the Informed Consent training and Psychotropic Medication Management Training referenced above in section 4.3.3. Until such time, an assigned supervisor shall fulfill the informed consent functions.
- Special Circumstances: Except in the emergency circumstances set forth below, informed consent must be obtained voluntarily and without undue influence or coercion prior to:
- The administration of a newly prescribed psychotropic medication, to include the continued administration of a psychotropic medication administered to a child under the emergency circumstances set forth below, or
- The continued administration of a drug prescribed prior to the child entering foster care; in which case, the consent must be obtained prior to the expiration of the child’s current prescription or promptly after the child’s first medical appointment with the prescriber upon entering foster care, whichever occurs first.
- Emergencies: Psychotropic medications may be administered by a qualified prescriber without informed consent in an emergency situation.
An emergency situation occurs when the purpose of the medication is to protect the life, safety or health of the child; to protect the life, safety or health of others; to prevent serious harm to the child or others; or to treat current or imminent substantial suffering.
- In instances of emergency, notification shall be provided to the case manager or authorized consenting party as soon as practicable.
- For a child in a residential program under contract with CD, residential program staff shall provide notice to the case manager or authorized consenting party within 24 business hours after the emergency administration of the medication.
- For a child in a hospital setting, the child’s case manager shall inquire within two (2) business days of the child’s hospital discharge to determine whether any psychotropic medications were administered on an emergency basis.
- The case manager shall document in the child’s case record in FACES any psychotropic medications administered on an emergency basis while in a residential or hospital placement.
- The case manager shall notify the parent within 24 hours of learning of the event.
- Circumstances when a Mandatory Review and Recommendation is Required PRIOR to Giving Informed Consent
- Before informed consent may be given in the following circumstances, CD shall make a referral to the Statewide Clinical Consultant, currently the Center for Excellence in CHILD Well-Being (The Center) and receive a recommendation as to whether consent should be granted:
- Before a child age three (3) or younger is prescribed any psychotropic medication;
- For a child age four (4) or older:
- Before starting a 3rd (or more) psychotropic medication;
- Before starting a 2nd (or more) antipsychotic;
- Before a psychotropic medication is started by a second prescriber; and
- Before starting a psychotropic medication that exceeds dosage guidelines.
- The case manager needs to make contact with the Health Information Specialist (HIS) as soon as possible upon receiving a recommendation for psychotropic medication to notify the HIS to request a referral for a mandatory review.
- The request or referral to The Center for a mandatory informed consent review shall be made by the HIS as soon as practicable in writing or electronically using a standardized form or template, currently the online referral for the Center for Excellence in CHILD Well-Being located on the CD intranet, Behavioral Health webpage.
- CD shall provide to The Center access to the information that The Center determines necessary in order to conduct the secondary review, to the extent that the information is reasonably available to CD.
- This may include the child’s medical history, including clinically relevant records and information.
For Mandatory and Secondary Reviews:
- The recommendation of The Center shall be communicated in writing to the case manager within five (5) business days if the child is outpatient and three (3) business days for inpatient from the day The Center receives the written or electronic request or referral or, if requested by The Center, any other necessary information.
- The individual authorized to provide informed consent shall consider the recommendation and collaborate with the prescriber if necessary prior to providing an informed consent decision.
- Documentation of the request and the recommendation shall be included in FACES.
- The findings and recommendations of The Center shall be provided to the child’s parent or legal guardian; the individual authorized to provide informed consent for the medication (if an alternative consenter has been appointed by the court); child’s resource provider; and any other person or entity authorized to receive the recommendations by order of the court.
- The findings and recommendations of The Center may be provided to other individuals as determined appropriate which could include: Guardian Ad Litem (GAL), Court Appointed Special Advocate (CASA), other members of the Family Support Team (FST), and medical providers.
- In the event that CD declines to share the findings and recommendations of The Center with the child’s parent or legal guardian, CD shall notify in writing any person denied access to the findings of the reason for the denial, using the Denial Notification Letter of Center for Excellence Findings, CD-280. The notice shall also explain an individual’s right to seek a review of the denial by completing a Service Delivery Grievance (CS-131) form or to file an appropriate motion with a juvenile court. Reasons CD may decline to share the findings and recommendations include the following:
- When a court exercising authority over the child has entered an order restricting the individuals access to information pertaining to the child
- Where CD determines that sharing the information may endanger the health, safety and welfare of the child or another person, or is otherwise contrary to the best interests of the child;
- Where CD determines that sharing the information may interfere with a child abuse, child neglect, or criminal investigation involving the Child or another child as a victim;
- Whenever providing the information is otherwise contrary to law.
- Although the authorized consenter is not bound by the recommendation of The Center, consent may not be given until after the mandatory review is completed and such recommendation has been provided and considered.
- Consent for a specific psychotropic medication may not be used to imply consent for a different medication. Consent need not be re-obtained for a dosage change unless the prescriber communicates to CD (through a written form or otherwise) that a dosage exceeds current FDA-approved pediatric dosage guidelines, or if no such guidelines exist, current FDA-approved adult dosage guidelines.
Consenting Authority and Process Prior to Termination of Parental Rights:
- The case manager shall have authority to grant informed consent for the administration of psychotropic medication to a child in CD custody:
- provided that CD consults with one or more of the child’s parents, to the extent the parents are available and willing to participate, see Parent Opposed section below; and
- unless another individual or entity is authorized to make the decision by order of the juvenile or family court exercising authority over the child.
- Parent Engagement: Except as provided below, and emergency circumstances described above, every time a health care provider recommends the administration of a new psychotropic medication, the case manager shall:
- Make at least two (2) attempts, on different days (which in some circumstances may occur within the same 24-hour period, though still occurring on two different days), to contact a parent (both parents if applicable) to provide notice of the recommendation; and
- Attempt to reach the parent(s) by at least two (2) methods (phone, email, in-person, etc.), to the extent two such methods are available for a particular parent. Each attempt by a case manager to contact the parent(s) must be documented in FACES and on the Informed Consent for Psychotropic Medication (CD-275) form.
- Contact with the parent(s) shall include a conversation about the recommended treatment, such as diagnosis, purpose, names and dosages of any medications, possible side-effects, required follow-up or monitoring, availability of alternatives, and prognosis without an intervention.
- If, after two attempts to contact the parent(s), the case manager is not able to reach the parent(s), then the case manager may consent to or refuse the administration of the psychotropic medication at issue. The case manager will document in the FACES and on the Informed Consent for Psychotropic Medication (CD-275) form attempts to reach the parent(s), efforts to provide notice, and the decision regarding consent.
- Except when parent notification is not required as provided below, the parent(s) shall be provided the contact information if requested for the child’s treating health care provider in order to communicate with them directly, if the parent(s) so chooses.
- For every informed consent request, the case manager shall also engage the child’s resource provider, and shall notify the child’s GAL, CASA, and FST of such decisions within ten (10) business days.
- Parent Notification/Consultation Not Required: CD is not required to attempt to notify and/or consult with the parent(s), or give the parent the contact information of the prescribing provider, in the following circumstances:
- If the parent(s) is unknown, or when CD cannot locate the parent(s) after a good faith search in accordance with CD policy;
- If the parent(s) has abandoned the child for a period of ninety (90) days without any meaningful contact (visits, support, participation in court/FSTMs/child’s treatment);
- If a court exercising authority over the child has entered an order restricting parental access to information pertaining to the child;
- If CD determines that sharing the information may endanger the health, safety, or welfare of the child or another person, or is otherwise contrary to the best interests of the child;
- If CD determines that sharing the information may interfere with a child abuse, child neglect, or criminal investigation involving the child or another child as a victim; or
- If providing the information is otherwise contrary to law.The case manager remains the consenter until the child is adopted or until a juvenile court issues an order authorizing an alternate person, such as the pre-adoptive parent, to provide consent. For every informed consent request, the case manager shall engage the child’s resource provider, and shall notify the child’s GAL, CASA, and FST of informed consent decisions within 10 business days.
If the parental rights of both parents have been terminated, or the court has otherwise restricted both parents’ access to medical information about the child, the case manager may provide informed consent for the administration of psychotropic medications without attempting parental notification.
The case manager remains the consenter until the child is adopted or until a juvenile court issues an order authorizing an alternate person, such as the pre-adoptive parent, to provide consent. For every informed consent request, the case manager shall engage the child’s resource provider, and shall notify the child’s GAL, CASA, and FST of informed consent decisions within 10 business days.
- Parent Opposed to Proposed Course of Treatment: If a parent disagrees with a case manager’s informed consent decision, the matter shall be referred to The Center, unless a review from The Center has been completed involving the same proposed course of treatment.
- The case manager shall, after being informed and confirming that such a disagreement exists, shall contact the Health Information Specialist (HIS). The (HIS) shall submit a referral to The Center within five (5) business days. The referral to the Center should be made using The Center’s online referral request form.
- The Center shall, within five (5) business days of receiving the request for consultation, review the pending prescription and provide an opinion and recommendation as to the appropriateness and timing of the prescription (including but not limited to whether the child should begin taking the proposed medication immediately). Documentation of the request and the recommendation shall be included in the child’s case record.
- The individual authorized to provide informed consent shall consider the recommendation and collaborate with the prescriber if necessary prior to providing an informed consent decision.
- Documentation of the request and the recommendation shall be included in the child’s case record.
- The findings and recommendations of The Center shall be provided to the child’s parent or legal guardian; the individual authorized to provide informed consent for the medication (if an alternative consenter has been appointed by the court); Child’s Resource Provider; and any other person or entity authorized to receive the recommendation by order of the court.
- The findings and recommendations of The Center may be provided to other individuals as determined appropriate which could include: GAL, CASA, other members of the FST, and medical providers.
- In the event that CD declines to share the findings and recommendations of The Center to the child’s parent or legal guardian, CD shall notify in writing the reason for the denial using the Denial Notification Letter of Center for Excellence Findings, CD-280. The notice shall also explain an individual’s right to an administrative review of that decision or to file an appropriate motion with a juvenile court. Reasons CD may decline to share the findings and recommendation include the following:
- Whenever providing the information is otherwise contrary to law.
- In the event that CD declines to share the findings and recommendations of The Center to the child’s parent or legal guardian, CD shall notify in writing the reason for the denial using the Denial Notification Letter of Center for Excellence Findings, CD-280. The notice shall also explain an individual’s right to an administrative review of that decision or to file an appropriate motion with a juvenile court. Reasons CD may decline to share the findings and recommendation include the following:
- If a parent does not agree with the recommendation from The Center, the parent may (a) within five (5) business days from the date the parent was informed of the recommendations initiate a service delivery grievance, or (b) at any time, file an appropriate motion with the juvenile court.
- If the case manager does not receive notice of a service delivery grievance or motion filed with the juvenile court within six (6) business days from the date the parent was informed of the recommendations, the case manager may consent to or refuse the course of treatment at issue.
- The case manager will document in FACES attempts to reach the parent(s), efforts to provide notice, and the decision regarding consent.
- If The Center has recommended immediate administration of a psychotropic medication, then the case manager may follow that recommendation, regardless of any pending service delivery grievance or juvenile court motion filed by the parent.
- If The Center recommends that immediate administration of a psychotropic medication is not required, then the case manager will not consent to the medication until any service delivery grievance or juvenile court motion has been resolved.
Alternative Consenters: In the event any member of the FST seeks to serve as the consenting authority for the administration of psychotropic medications to a child, CD will, to the extent permitted by the juvenile court, inform the court and request an opportunity for the proposed alternative consenter to be heard. CD may require that such a request be provided in writing, include the reasons for the request and a statement that the alternative consenter will provide informed consent.
CD’s responsibility will be only to inform the juvenile court and the parties of the request, not to support the request. Notice of the right to pursue this process shall be provided in writing to all members of the FST utilizing the Learn Your Rights flyer (CD-287).
CD staff will provide the CD-287 at the initial FST meeting and again if their child is prescribed a psychotropic medication. Documentation of the distribution of this flyer (date and to whom) shall be recorded in the narrative section in FACES.
In the rare instance that a child is placed in the joint custody of CD and DYS, while the child is in a placement arranged by DYS, DYS shall be the consenting authority. DYS shall keep the CD case manager fully informed regarding all medical and behavioral health care received including any recommended treatment or medication changes as they occur.
- Standardized Form (CD-275) Required When Giving Informed Consent: All informed consent decisions must be documented on the Informed Consent for Psychotropic Medication (CD-275) form. Any authorized consenting party (i.e. case manager, alternative consenter, or youth over 18) must complete and sign the form. If the authorized consenting party is a CD staff member the completed and signed CD-275 must be uploaded to the document imaging system.
- Information Required for Informed Consent: The case manager or other authorized consenting party shall ensure that he or she has the following information before making an informed consent decision:
- The results of the behavioral health/psychiatric evaluation of the child including the child’s diagnosis or diagnoses, along with the target symptoms to be addressed by the medication;
- An explanation of the purpose of the medication, the anticipated duration of treatment, and its expected results;
- Whether medically necessary metabolic and other screenings indicated by the prescriber have been completed at the recommended frequency (e.g. bloodwork, BMI, weight);
- Whether, according to the prescriber, (i) each medication is FDA-approved for pediatric use, or (ii) there are any limitations on FDA-approval related to the age of the child and the diagnosis;
- The short and long-term risks and possible benefits associated with the medication and any combination of medications prescribed, including the nature and possible occurrence of any adverse effects and/or irreversible symptoms;
- Alternative non-pharmacological treatments that have not yet been attempted and their risks and benefits;
- Alternative non-pharmacological treatments that were attempted and not successful;
- The known allergies of the child;
- The current illnesses of the child;
- The psychiatric history and treatments of the child;
- The risks and benefits of not undergoing treatment;
- Any other medications the child has received in the past and the child’s reaction to those drugs; and
- Any other information necessary to provide informed consent relating to the medical treatment of the child.
Secondary Review Requests for Medication or Other Recommended Treatment
- Requesting a Secondary Review
- A referral for a Secondary Review shall be made for any of the following:
- The case manager has concerns about psychotropic medications being prescribed, or any other recommended physical or behavioral health intervention.
- The parent or child disagrees with a case manager’s informed consent decision.
- A request from members of the child’s FST, including the child, child’s parents or legal guardian, the child’s GAL or CASA, the child’s resource provider, and the Juvenile Officer for a secondary review of the child’s psychotropic medications or any other recommended physical or behavioral health intervention.
- A referral for a Secondary Review shall be made for any of the following:
- The case manager needs to make contact with HIS as soon as possible once a decision has been made that a secondary review is necessary based upon the criteria listed above, clearly documenting why the review is being requested.
- The HIS will make a referral to The Center. The referral form is located on the CD intranet Behavioral Health webpage and should be completed and submitted electronically.
- The electronic referral form shall be submitted within five (5) business days.
- The HIS shall provide a fully completed referral form with all the required supporting documentation, and any additional information The Center determines necessary to conduct the secondary review.
- Supporting documentation includes: medical records with current diagnosis, prescriber notes, current medication list including dose and frequency, lab results, psychiatric evaluation, therapy reports and other records related to the child’s behavior or diagnosis. The HIS shall provide supporting documentation to the extent that information is reasonably available to CD.
- The secondary review conducted by The Center shall include an assessment of:
- The child’s diagnosis(es);
- Appropriateness, efficacy, and potential adverse effects or risks of current psychotropic medication(s);
- The child’s medication history as it relates to psychotropic medications prescribed to the child;
- Why the current psychotropic medication(s) is/are being used;
- Whether the medically necessary lab work and/or baseline health screenings have been completed as they relate to psychotropic medications prescribed to the child, and any adjustments indicated by the results of such lab work or screenings;
- A plan to taper off of psychotropic medications where medically appropriate;
- Whether the documentation supports the diagnosis being treated, recognizing that the Qualified Psychiatrist cannot make a diagnosis; and
- Whether other non-pharmacological interventions have been or are currently being provided for the child.
The HIS may, at their discretion, decline to refer the case for more than one review for a particular child within the same sixty (60) day period.
All referrals for secondary review and resulting recommendations must be documented in FACES.
Automatic Quarterly Case Reviews
Each quarter The Center evaluates and analyzes information on children in alternative care who are administered psychotropic medication(s). The Center may request a case review to assess the use of psychotropic medication(s) for a child.
If a child’s case has been selected for a review, The Center will send an electronic notification to the case manager, case manager supervisor and the HIS.
If The Center requests documentation, the HIS will have ten (10) business days from the date of receiving the electronic notification to collect the materials or documents and send to The Center.
When the case review is complete, The Center will send a findings and recommendations letter to the case manager, case manager supervisor and HIS. The letter should be sent within five (5) business days from the date of the notice or the date The Center received the requested documents.
The case manager and case manager’s supervisor will review the findings and recommendations letter to determine how to process the recommendation(s). HIS staff can assist the case manager with processing the recommendation(s).
The Center will send an electronic alert to the case manager and case manager’s supervisor requesting information on how the recommendation(s) was processed.
The criteria for an automatic case review is:
- Use of an antipsychotic or atypical antipsychotic medication in a child age four (4) or younger.
- For a child age five (5) or older:
- Use of five or more concurrent psychotropic medications for 90 days or more;
- Use of two or more concurrent antipsychotic medications for 90 days or more; and
- Multiple prescribers of any psychotropic medication for 90 days or more.
The criteria for an automatic case review after December 5, 2020 is:
- Use of any Psychotropic Medication for a child age three (3) or younger.
- For a child age four (4) or older:
- Use of three or more psychotropic medications for 90 days or more;
- Use of two or more concurrent antipsychotic medications for 90 days or more;
- Multiple prescribers of any Psychotropic Medication for 90 days or more; and
- A Child is prescribed a dose in excess of the guidelines referenced in section”For Mandatory and Secondary Reviews.”
Bodily integrity is the principle that it is the right of each human being, including children, to autonomy and self-determination over their own body. Children who have been abused or neglected often feel little control over what happens to them.
Children should be routinely involved in the process of making routine and non-routine treatment decisions, to the extent appropriate. These communications should occur in a developmentally appropriate, judgment-free manner and in a physical space offering confidentiality to ask questions and share concerns. Children may need multiple opportunities to ask questions and receive information in order to build skills to become capable and confident health care consumers. These interactions also offer the opportunity to assess the child’s level of understanding about what to expect with tests or treatment and to help them develop awareness about their physical and behavioral health. At minimum, children should be offered the opportunity to:
- Know their diagnosis
- Understand all the treatment options
- Ask questions about potential benefits and side effects
- Participate in decision-making to the extent that is developmentally appropriate
- Receive assistance from the family support team to help with decisions
- Obtain or refuse birth control
- Consent to substance abuse treatment when 16 years of age or older
- Refuse psychotropic medication after being offered the opportunity to consult with their health care provider
Informed Assent (under age 18)
During the assent process, the child is engaged and his or her input is sought allowing them to voice their preferences and concerns. It is important to have conversations about prescribed medication or treatment, as age and developmentally appropriate, with all children. For youth ages 12 and above, informed assent shall be obtained in writing.
- Obtain Assent: Before providing informed consent for a psychotropic medication, the case manager or supervisor (in coordination with the alternative consenter, if applicable) must seek to obtain informed assent from the youth, consistent with the following:
- In partnership with the child’s treating health care provider, ensure that the child is informed, in an age and developmentally appropriate manner, of the recommendation for prescribed medication(s) as part of the child’s treatment plan.
- In partnership with the child’s treating health care provider, ensure the child is provided an opportunity to voice his or her reactions or concerns regarding prescribed medication(s).
- Ensure that the child (if over age 12) and the child’s attorney/GAL (for a child of any age), are provided the Learn Your Rights flyer CD-281 to provide notice in writing of:
- All rights set forth above, along with the right to file a service delivery grievance or to file a motion with the juvenile court;
- The right to speak privately with the health care provider regarding any proposed psychotropic medication;
- The right to seek a second opinion from a different health care provider regarding any psychotropic medication; and
- The right for children age 12-17 to request that their refusal to assent to the administration of a psychotropic medication be reviewed by the Center. The request will follow the same timeline and requirements set forth in above in the Parent Opposed to Proposed Course of Treatment section.
- Give the child the opportunity to sign the Informed Consent for Psychotropic Medication (CD-275) and ensure that the signed form is placed in the child’s case record.
The case manager will give the CD-281 in person during first contact with child and/or GAL when providing Family-Centered Out-of-Home services, when a prescriber is recommending administration of a psychotropic medication, when the child turns 12 (twelve), and annually until the child is eighteen (18) years of age.
If the GAL is not present during the FST meeting case manager will contact the GAL and provide the flyer either electronically or mailed to the GAL’s address.
Expiration of Assent: Except in cases of a medically significant change in circumstances, informed assent shall expire and must be re-sought 12 months from the date the assent is provided or withheld.
Youth 18 Years or Older
Once a youth has reached 18 years of age, the ability to give consent or refuse treatment shall transfer from the case manager to the youth. The case manager should be available to answer questions and assist the youth in making an informed decision. The only exception to this is if a court order has been obtained that such a transfer would not be in the youth’s best interest due to lack of capacity or disability that prevents the youth from making medical decisions.
In that event, the case manager should continue as the consenter but involve the youth in the decision-making process to the greatest extent possible.
4.3.4 Medical Service Alternatives/Planning
Medical planning for children in out-of-home care is a necessary service to ensure that children receive the medical care they need. The following includes several medical service alternatives for which planning will be necessary.
Routine Medical/Dental Care
Routine medical/dental care including services available through the Healthy Children and Youth (HCY) Program, also known as Early Periodic Screening, Diagnosis and Treatment (EPSDT):
- Children entering out-of-home care need initial medical examinations, as well as regular medical examinations throughout their out-of-home care placement.
- Resource parents should seek medical providers who are enrolled with MO HealthNet (MH) or MO HealthNet/Managed Care (MH/MHMC).
- Plan with out-of-home care providers and other appropriate team members to ensure that all children in out-of-home care shall receive education on sexual development, appropriate to their age, life experiences, and living conditions. This information should include information on sexuality and venereal diseases.
- Children in out-of-home care are eligible for MM/DSP (MO HealthNet, Title XIX). As a result, they are also eligible for HCY services.
- When a resource parent receives an invoice for medical or mental health services for a foster placement in their home, the invoice must be submitted to the foster youth’s case manager immediately.
Human Immunodeficiency Virus (HIV) Screening
HIV Screening (ELISA test) is available for children entering out-of-home care who are displaying symptoms of Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or at increased risk of AIDS. The Children’s Services Worker may arrange for the ELISA test through the local Health Department or a private physician. The ELISA test is covered by MM/DSP.
Emergency and Extraordinary Medical/Dental Care
When children are in CD custody their birth parents still have certain rights. One of these rights is to give permission for extraordinary medical/dental care. Whenever possible, the worker should seek parental permission for these medical/dental services. If this is not possible, the Children’s Services Worker shall seek approval for the medical/dental services from the juvenile court. Then the Children’s Service Worker shall seek approval through their Area Office.
Children’s Treatment Services
Children in Out-of-home care are eligible for a variety of children’s treatment services, medical and psychiatric services covered by a contract with CD. If a child in out-of-home care is in need of these services, the worker should consult the listing of CD approved contractual treatment providers who offer the service and make the appropriate referral. Payment will be made at MO HealthNet or state contracted rates.
NOTE: For medical examinations, the HCY referral should be done first. CTS would be used if an HCY physician is not available.
Missouri Medical/Dental Services Program (MM/DSP) (Also known as Title XIX or MO HealthNet)
Children in out-of-home care are eligible for MM/DSP if they are in the custody of CD. Guidelines established by the MO HealthNet Division (MHD) determine which medical services are eligible for payment and at what rate. Staff should use this program whenever possible to provide a child with medical care. HCY services are available through this program.
Section 6036 of the Deficit Reduction Act of 2005 section 1903 of the Social Security Act requires that states obtain satisfactory documentation of citizenship in order to receive MO HealthNet benefits. States must obtain documents establishing identity and citizenship for new applicants and recipients for all categories of MO HealthNet.
For all children coming into Division custody after July 1, 2006, and for all eligibility re-determinations, the Children’s Service Workers will provide the Eligibility Specialist with a copy of the court order and if available documentation of identity and citizenship, preferably a copy of the child’s birth certificate. (Original birth certificates will remain in the child’s file.)
If documentation is not available the Children’s Service Worker will begin the process of collecting the appropriate documentation immediately and when obtained forward copies to the Eligibility Specialist. The Children’s Service worker will presume all children coming into care as eligible for MO HealthNet, however if the worker is not able to collect the proper documentation, it will be the responsibility of the Eligibility Specialist to make that determination and put the proper coding on the SS-61. The Eligibility Specialist may request the Children’s Service Worker to collect particular documentation during the certification or re-certification process.
The citizenship and identification verification process is also applicable for children eligible for MO HealthNet who were referred to the Division for adoption subsidy by outside adoption agencies.
Documents Used to Verify both U.S. Citizenship and Identity:
- U.S. Passport. The passport does not have to be currently valid to be accepted as long as it was originally issued without limitation;
- Certificate of Naturalization (N-550 or N-570); or
- Certificate of Citizenship (N-560 or N-561).
Documents Verifying Citizenship Only:
- U.S. Birth Certificate or IBTH.
- IBTH is available for individuals born in the State of Missouri.
- IBTH will display birth records for those born in Missouri back to 1920.
- IBTH can be viewed to verify citizenship. When using this information, document in the case record the date viewed and the information verified. Do not print and file the IBTH in the case record.
- A Certification of Report of Birth (DS-1350).
- Consular Report of Birth Abroad (FS-240).
- Certificate of Birth Abroad (FS-545).
- U.S. Citizen ID card (I-197 or I-179).
- American Indian Card (I-872).
- Northern Mariana Identification Card (I-873).
- Final adoption decree which shows a U.S. place of birth.
- Official Military Record of Service which shows a U.S. place of birth.
- Hospital record that meets the following criteria:
- Created on hospital letterhead;
- Established at the time of the person’s birth;
- Created at least five years before the initial application date; and
- Indicates a U.S. place of birth.
NOTE: For children under 5 years of age, the document must have been created near the time of birth.
- Life or health insurance record, created at least five years before the initial application date, showing a U.S. place of birth.
- U.S. State Vital Statistics official notification of birth registration.
- Statement signed by the physician or midwife who was in attendance at time of birth.
- Institutional admission papers from a nursing home, skilled nursing care facility, or other institution that were created at least five years prior to the initial application date and indicates a U.S. place of birth.
- Medical (clinic, doctor, or hospital) record that was created at least five years before the initial application date and indicates a U.S. place of birth. An immunization record is not considered a medical record for purposes of establishing citizenship.
- For children under 5 years of age, the document must have been created near the time of birth.
NOTE: When using a document from the above to verify citizenship, a second document must be obtained from the following list to verify identity.
When documents verifying both citizenship and identity are not available, a document may be used to verify citizenship accompanied by a second document that verifies identity. Sources of documentation of identity for children under age 16 are as follows:
- School record that shows the date and place of birth and parent(s) name. School records may include nursery or child care records.
- Clinic, doctor, or hospital record showing date of birth.
- Court orders identifying individual.
- Identity may be verified through our database if child received coverage as a Newborn.
- If none of the above documents are available, an affidavit by the parent or guardian may be used.
Verification of Citizenship and Identity for Newborns
Citizenship and identity are not required to be verified to add children as newborns as these children are deemed to have applied for and been found eligible to receive MO HealthNet benefits as a result of their mothers being active recipients at the time of birth.
Obtaining Records from the Bureau of Vital Records
The Bureau of Vital Records, within the Missouri Department of Health and Senior Services, has certificates of Missouri births, deaths and fetal death reports. BVR screens frequently utilized by staff include IBTH and IDTH. In Missouri these records are not open to the public and each screen includes the wording: “Information on this screen is confidential and shall be used for official state purposes only”. This information is for inquiry only and should not be printed, faxed or copied.
Certified copies of Missouri vital records of birth and death on behalf of children in out-of-home care can be obtained by submitting form CD-127 to Central Office as directed on the form.
Amendments to a Missouri vital record on behalf of a child in out-of-home care should be requested through Central Office. The CD-127, as well as a certified court order – with raised seal – clearly describing what changes need to be made to the record should be mailed to Central Office. Central Office will review, log, and send to Vital Records for processing.
Requests for out-of-state birth or death certificates must be made to the holding state’s vital records office. Staff should complete that State’s vital records application form via an on-line search. The application, any other documents (court order, photo id, cover letter, etc) required by that state, and a SAMII Payment Request Form should be forwarded to the DFAS Payments/Accounts Payable Unit. DFAS will process payment for the vital record and send the payment and application to the holding state.
Bureau for Children with Special Health Care Needs (BCSHCN)
This bureau provides some medical services not covered by MO HealthNet. To make a referral for a child, the Children’s Service Worker should make sure that the needed medical services are not covered by MO HealthNet. When it has been determined that the needed medical services are not covered by MO HealthNet, the Children’s Services Worker may make a referral to the appropriate regional bureau office.
Department of Mental Health
The Department of Mental Health (DMH) provides prevention, evaluation, and treatment services to eligible adults and children in out-of-home care who are in need of DMH services may be referred to the appropriate DMH division to meet the needs of the child.
Division of Behavioral Health (DBH): Provides, among others, outpatient community-based services, targeted case management, day treatment, treatment family home programs, and community psychiatric rehabilitation (CPRP). DBH also assures the availability of substance use prevention, treatment, and recovery support services.
Division of Developmental Disabilities (DD): Supportive services for individuals with developmental disabilities such as intellectual disabilities, cerebral palsy, head injuries, autism spectrum disorder, epilepsy, and certain learning disabilities. Such conditions must have occurred before age 22 and be considered lifelong in duration.
More information about DD, including referrals, must be made directly to DMH/DD. For more information on services and referral procedures for DBH, contact the appropriate Community Mental Health Center servicing the county of interest. These DMH affiliates are responsible for determining eligibility and providing the services. Contact information for regional Community Behavioral Health Centers can be found on the DMH website.
Private Psychiatric Hospital Placement
Children in Out-of-home care who are eligible for private psychiatric hospital care. These facilities provide services including medical treatment, psychiatric/psychological counseling and testing, nursing care, educational services, social work services, recreation services and occupational therapy. The Children’s Services Worker should contact the hospital directly to arrange for the child’s admission. Cost for the child’s care is paid by MO HealthNet for a number of days as prescribed by the Professional Activity Study (PAS).
Payment for days beyond the PAS days may be paid with Area Office approval. The psychiatric facility should request prior approval of the extension through the MO HealthNet Division (MHD) for extended MO HealthNet payment of the service. If MHD denies, the psychiatric facility should submit the request for payment to the County Office. Such a request is forwarded through normal supervisory channels to the Program Development System Unit (PDSU). The worker should consult the listing of CD contracted services and use these facilities, if treatment is anticipated to exceed the number of PAS days.
Medical Foster Care
Children in Out-of-home care who require special care directly attributable to a medical/physical/developmental disability may be eligible to receive medical foster care. If a child is in need of such special care, refer the child through local procedure.
Medical Services Authorization Information Letter
The Children’s Division (CD) participates in the development and implementation of coordinated social and health services which includes preventive, maintenance, and long-term medical and mental health care for children placed in the legal custody of the Children’s Division.
Services for foster youth medical and mental health needs should be provided by service providers who are enrolled in the state Medicaid plan, MO HealthNet. If a provider who is not enrolled with MO HealthNet is used for a foster youth, the resource provider may have to pay for the services out-of-pocket and not be reimbursed. If the resource parent is reimbursed, it will be at the Medicaid rate. Any reimbursement to the resource provider will be from Children’s Treatment Services (CTS) funds.
In the event that a resource parent uses a medical or mental health provider who is not enrolled with MO HealthNet or a MO HealthNet Managed Care Plan the CD-27 must be presented prior to the foster youth receiving services.
When a resource parent pays for a medical or mental health service out-of-pocket, the receipt for services must be submitted to the foster youth’s case manager immediately.
When a resource parent receives an invoice for medical or mental health services for a foster placement in their home, the invoice must be submitted to the foster youth’s case manager immediately.
4.3.5 Identification of Children in the Custody of the Children’s Division Solely for the Purpose of Accessing Mental Health Services
Parents should not have to relinquish custody of their child due solely to a need to access clinically indicated mental health services. Children in custody for that reason and absent a probable cause or preponderance of evidence CA/N finding may be eligible for return to the custody of their parents through a protocol established by the passage of Senate Bill 1003 (SB 1003) during the 2004 legislative session:
Supervisory Review of Children Who Are in Division Custody Solely for Mental Health Services per Section 208.204.2 and 208.204.3 RSMo.
Children who have entered Children’s Division custody, absent a probable cause or preponderance of evidence CA/N finding, should be carefully reviewed to determine if they meet the criteria that were contained in SB 1003 signed into law in 2004.
The review of a child in CD custody and determination of meeting SB 1003 criteria must include the following:
- Is the child in the custody of the Division solely because the parents were unable to access or afford mental health needs of the child?
- Is the parent verbalizing a desire for the child’s return to his/her custody if the child could receive the necessary mental health services?
- Would the child’s safety or the safety of others in the home be compromised by such a return of custody?
Should the parent of a child not previously identified as potentially meeting the eligibility criteria contact the CD expressing a belief that his/her child indeed meets these criteria, CD staff will respond to the request and inform the parent that an FST meeting will be convened within two weeks of the parent’s request.
Convening the Family Support Team
Once the review is completed and it appears that the reason for the initial placement may be due solely to a need to access clinically indicated mental health services, a Family Support Team (FST) meeting is to be convened by the CD case manager upon agreement with the child’s parents. This FST meeting should be scheduled and held within 2 weeks in order to begin the process for further assessment and planning. Current policy for FST meetings is to be observed in keeping with the requirements of Section 4, Chapter 7 of the Child Welfare Manual. It is crucial that the child’s family be actively involved in the FST and planning process. The case record should clearly document if the family states they are not yet ready to regain custody.
Additional and crucial FST participants shall include:
- The local representatives of the Department of Mental Health’s (DMH) Community Mental Health Center and/or DMH Regional Office staff; and
- Representatives of current placement and treatment providers.
If the child has developmental disabilities that can best be served by DD within DMH, this agency should be actively involved in the planning process.
The focus of the FST meeting is to jointly determine if the child’s placement in CD was due solely to a need for mental health services and was unrelated to parental abuse, neglect, or abandonment. In addition, the team should determine if the child can be returned safely to the custody of the parent even if he/she continues to need out-of-home care.
If consensus is not reached by the FST on whether the child meets the eligibility criteria, the child shall be considered inappropriate for the Senate Bill 1003 protocol. This, however, should not exclude other efforts toward reunification or further steps to obtain clinically indicated services or supports through DMH.
Development of an Individualized Plan to Return the Child to the Custody of the Parent and Request for a Court Hearing
If the FST agrees that the family meets the criteria for SB 1003 and the parent desires to have the child returned to his/her custody, an individualized plan shall be developed which outlines all services and supports needed by the child and family and identifies who shall be financially responsible for each.
The child, if appropriate and the family shall actively participate in the plan’s design. Identified services shall be provided in the least restrictive and most normalized environment. Treatment services and supports shall include but not be limited to those which are home and community based.
This plan shall be submitted to the court within sixty (60) days of the child having been identified through consensus of the FST. The judge may then return custody of the child to the parent.
Payment for Services Provided to the Child and Family Once Custody Has Been Returned to the Parent
208.204.4: When children are returned to their family’s custody and become the service responsibility of the Department of Mental Health, the appropriate moneys to provide for the care of each child in each particular situation shall be billed to the Department of Social Services by the Department of Mental Health pursuant to a comprehensive financing plan developed by the two departments.
The Children’s Division is committed to assuring that the child and family continue to have access to those services that help them meet the needs of the child. If the Division previously paid for such services, it will continue to do so. It is not necessary for the child to be returned to the home of the parent in order for custody to be transferred. To that end, the Division will continue to fund residential treatment if the child continues to need that service as identified through the individualized treatment plan.
Staff should contact Central Office for assistance in payment to placement providers for any youth in need of continued residential placement but no longer in the Division’s legal custody.
Ongoing Implementation of Sections 208.204
For youth who meet criteria under statute cited above and are not otherwise diverted from CD custody, staff should implement the above protocol as quickly as possible to help expedite the youth’s return to the custody of his/her parents. The issues relating to the child’s placement should be addressed as early as the initial 72-hour FST meeting. The representation of DMH and the current placement provider(s) should be brought into the FST process as soon as possible to assist in the service planning.
Within sixty (60) days of a child being identified as appropriate for the provisions of Section 208.204.2-3 RSMo. an individualized treatment plan shall be developed by the FST, and the Children’s Division shall submit the plan to the juvenile/family court judge for approval. The child may be returned by the judge to the custody of his/her family.
The instructions for Form CS-1 have been revised to better document the needs of the child and family, see CS-1 in E-Forms Index. Issues relating to the child’s mental health needs and the services and supports that may be needed for his/her parents should be addressed in the ongoing FST meetings. Special emphasis should be placed on determining if the child can be safely returned to his/her parents’ custody if the necessary mental health services and supports were in place.
4.3.6 Custody Diversion Protocol
The protocol has been developed to divert youth from entering state custody solely to access mental health services. This protocol is predicated on the belief that no parent should voluntarily have to relinquish custody of their child to access mental health services, if clinically appropriate services and supports, either within or outside the home setting, can be provided to the youth and family.
The current protocol can be found on the Department of Mental Health website here.
The Custody Diversion Protocol Screening and Feedback Form can be found here.
4.3.7 Voluntary Placement Agreement
With the 2004 passage of House Bill 1453, the Voluntary Placement Agreement was introduced and established in statute (210.122 RSMo). The Voluntary Placement Agreement is predicated upon the belief that no parent should have to relinquish custody of a child solely in order to access clinically indicated mental health services.
The Voluntary Placement Agreement (VPA) is a written agreement between the Department of Social Services (DSS)/Children’s Division (CD) and a parent, legal guardian, or custodian of a child under the age of eighteen (18) in need of mental health treatment. The agreement is only used when an out-of-home placement is recommended by DMH and the Custody Diversion Protocol cannot otherwise divert the need for such placement. DMH determines the need for mental health services and administers the placement and care of a child while the parent, legal guardian, or custodian of the child retains legal custody.
The VPA will only be made available to a parent in conjunction with, and only after staff has utilized the Custody Diversion Protocol which serves to link parents with DMH services for their child. The Custody Diversion Protocol reflects the mutual commitment of CD, DMH and its Community Mental Health Centers/Administrative Agents (CMHC/AA), Regional Offices, and/or Adolescent CSTAR providers, and the local Juvenile/Family Courts to assist parents in accessing needed mental health services for their children without a needless transfer of legal custody. The VPA requires the commitment of a parent to be an active participant in his/her child’s treatment. A VPA may not exceed 180 days in duration.
Local CD CDP Designees are responsible for guiding and assisting throughout the CDP process and monitoring the family’s progress through the duration of the VPA. A Family Support Team (FST) meeting must be held within 72 hours of placement to develop permanency and treatment plans. The local CD case worker will ensure FSTs are scheduled as necessary. Designated staff from CD, Community Mental Health Centers, DMH Regional Office, and/or Adolescent CSTAR providers, the child’s family, and children who are able to effectively participate in meetings must be invited to attend all FSTs.
FSTs need to be scheduled to occur around but not later than 100 and 150 days of the date the child is placed. The child and family’s progress will be reviewed to ensure appropriate transition planning occurs prior to the maximum 180 day VPA closure. If the child is unable to return home a determination must be made as to continuous care being provided by other available resources or CD petitioning the court for custody. The local Custody Diversion Protocol designees will be required to attend any hearings and testify in support of the plan to petition the court for custody.
DMH may arrange for a staffing for a youth served through a VPA. The DMH provider will notify the local Custody Diversion Protocol designee of meetings held on the child’s behalf. The local Custody Diversion Protocol designee should maintain consistent communication with the DMH provider on each child served through a VPA.
Children placed in Voluntary Placements are subject to the Adoption and Safe Families Act (ASFA) requirements. Within sixty (60) days of the date the child is removed from the home, a case plan must be developed. To meet the requirements of Section 472 (a) (1) of the Social Security Act a removal from the home must occur pursuant to:
- A VPA entered into by a parent or guardian which leads to removal (i.e. a non-physical or paper removal of custody) of the child from the home; or
- A judicial order for removal of the child from a parent or specified relative.
Funding for treatment services under a VPA will be provided by DMH or the CMHC/AA, Regional Center, and/or Adolescent CSTAR provider up front with Department of Social Services appropriation accessed through an interdepartmental funds transfer. Local CD staff will not authorize payment for residential treatment or any other services for children placed through a VPA. Youth active in a VPA will be eligible for MO HealthNet coverage through the Family Support Division. The youth’s SSI benefits and/or private insurance, as well as other means of financial support, must be explored prior to VPA approval. If the family receives SSI benefits for the youth, it is the family’s responsibility to contact the Social Security Administration and inform them of an out-of-home placement.
- As a part of the CDP, DMH must conduct an assessment and it should establish that out-of-home placement is clinically appropriate and if there are no other means of financial support, the local CD CDP Designee can explore a VPA.
- If it is determined that a VPA is to be requested, the agreement must be reviewed and signed by the parent(s) and the CD-CDP designee. At the time a VPA is presented to a parent, CD staff shall, in conjunction with the parent, complete the Children’s Severity of Psychiatric Illness (CSPI). The CSPI is included as part of the CS-9. Staff do not have to complete the entire CS-9, only the CSPI.
- The signed agreement must then be sent to the CD Central Office designee responsible for the oversight of the VPA program for final approval. VPAs must be signed by the CD Central Office designee before it will be considered officially approved, and a placement made.
- If the VPA is approved, the CD-CDP designee will then send a copy of the agreement to the local DMH CDP Designee responsible for placement.
- The local DMH Administrative Agent, Regional Office or Adolescent CSTAR provider should send a copy of the signed agreement with the identified placement date back to the local CDP designee. This should be completed within 5 days of placement. If the identified placement provider is requesting rates which exceed the standard contract rate for the Division of Behavioral Health, CD Central Office review and prior approval is required.
- If the approved agreement is not returned with a placement date within five (5) days the CD-CDP should contact the DMH Administrative Agent, Regional Office or Adolescent CSTAR provider to request the begin date. A copy of the signed agreement will then be sent to the RCST Coordinator and Central Office designee responsible for the oversight of the VPA program within 10 days from receipt of the signed agreement with the placement date added. The VPA begin date is the date the child is placed in an out-of-home setting for treatment. The RCST Coordinator shall be responsible for entering the VPA begin date and the CSPI rehab date in FACES. For additional instructions see CD09-103.
- VPAs may not exceed one hundred eighty (180) days in duration. In the event the child is in placement less than 180 days, subsequent agreements can only be approved with the authorization of the CD Director. Total period of placement under one or multiple VPAs shall not exceed 180 consecutive days from the first day the child is placed in out-of-home care.
- The DMH provider is to notify the local CD-CDP designee any time a child is returned home. It is the local CD-CDP designee’s responsibility to then notify the RCST Coordinator and the CD Central Office designee. It is the RCST Coordinator’s responsibility to update FACES once a child is returned home. The duration of the VPA may be for as short a period as the parties agree is in the best interests of the child.
- The FACES system will automatically close a youth (in legal status V) the day the length of a VPA reaches 180 days in duration and the day before the child reaches his/her eighteenth (18th) birthday. However, if a youth is returned home prior to the 180 day maximum, the FACES system should be updated with a close date one day following the date the youth returned home.
NOTE: Although the FACES system will automatically close the SS-61 upon the youth’s eighteenth birthday a VPA may extend beyond such. The RCST Coordinator must update the FACES system to reflect one day following the actual date the youth returned home or the day the length of the VPA reaches 180 days in duration.
4.3.8 Pregnancy of Child in Out-of-Home Care
When a child becomes pregnant while in foster care, all efforts should be made to ensure the child receives complete prenatal care. In addition, the court of jurisdiction should be notified of the youth’s pregnancy. The Children’s Service Worker should refer the youth to appropriate persons for information and resources needed to explore her options. The child should make an informed decision without undue influence and/or coercion by the Division, placement provider or parents. If the child elects to give birth and care for the infant, every effort must be made to keep the child and infant together. The Worker must refer the child and infant to the Eligibility Specialist, utilizing form CS-IV-E/FFP1. The Worker shall carefully document the child’s progress and any contact regarding the health of the child and infant in the case record. See later in this chapter for Children of Youth in Alternative Care (CYAC) information.
4.3.9 Chemical Dependency Treatment
Adolescents often experiment with the use of drugs and/or alcohol and should be provided with education regarding the consequences of such behavior and support in stopping the behavior, particularly if the child comes from an alcohol/drug addicted family environment.
Chemical dependency treatment will be explored when a child is motivated and demonstrates a willingness to participate in treatment. The value of chemical dependency treatment must be carefully assessed when the child has a history of repeated failures in treatment, and there is no substantial change in their circumstances or behavior since their dismissal from the previous program. Under these circumstances, the appropriateness of a specific treatment program should be questioned if the program does not offer aftercare services.
To the extent possible, the best possible treatment must be provided in the child’s community of residence, i.e., community C-Star program operated by the Department of Mental Health.
4.3.10 HIV/AIDS Issues
Screening for HIV/AIDS shall occur for children in the following high risk groups:
- Infants born to mothers known to be HIV antibodies positive or who are known to be HIV carriers.
- Hemophiliac youths who received blood or blood products before May 1985.
- Children who have had sexual contact with or who have shared IV needles with persons who are known to be HIV antibodies positive or who are known to be HIV carriers.
- Children whose medical symptoms or sexual histories indicate the possibility of exposure to HIV carriers.
NOTE: Screening results are reliable only for “a moment in time” and do not establish whether a child has been exposed to HIV/AIDS.
The request for HIV/AIDS screening and the results of the screening should be handled in a discreet, confidential manner. The child’s Children’s Service Worker and placement resource should be advised when there is a positive screening result. In order to assure that confidentiality and the child’s right to privacy is protected, other persons involved (Guardian ad Litem, juvenile court, biological parents) will be notified on case-by-case and need-to-know basis. As few people as possible should be notified, depending on the circumstances of the case.
Children who are known to be HIV antibodies positive or HIV carriers and their placement provider should receive specialized counseling services and support to help them deal with the ramifications of the disease and to make plans for the possible deterioration in health.
4.3.11 Life Support/Sustaining Therapies
This section includes guidelines for Life sustaining therapies and Do Not Resuscitate Orders (DNR) or Removal of Life Support for Children in the legal custody of the Division. This decision will be made in consultation with the child (if mentally and physically capable of making the decision), biological parent, guardian, guardian ad litem, juvenile court, the child’s physician, the child’s Children’s Service Worker, care provider, and at least two physicians who have access to the child and the child’s records. The final decision regarding the use of life support and DNR orders or removal of life support for children in the legal custody of the Division shall rest with the court or the family if the court agrees. Children’s Division and the Department of Social Services will not take a partisan position on Life Support/Sustaining Therapies in those cases in which the doctors are recommending a DNR or removal of life support. We will provide unbiased, objective facts to the court, but we will not make any recommendations as to the final outcome. The Department’s position in these situations is that the decision must be made by the court after reasonable notice and an opportunity for a hearing is given to the child’s parents, the Guardian ad litem (GAL), the Juvenile Officer (JO) and any other interested parties to provide input into the case as appropriate. The department will not take the position that the responsibility for making DNR or Removal of Life Support decisions should be vested in a foster parent or (former foster parent) or other third party unless ordered by the court.
The wishes of a child with a life threatening illness may be taken into consideration when making major decisions regarding medical care for the child, especially a DNR decision as to what weight to give to the child’s wishes is a judgment that must be based on the individual facts of each case considering factors such as the ability of the child to understand his/her condition, to make decisions; the maturity of the child, the wishes of the parents and other parties.
NOTE: Life sustaining therapies are defined as tube feeding, respirator, physical therapies to sustain life, intravenous fluids (IV), etc.
When circuit office staff is confronted with situations which require the continued use of life support systems or the removal of life sustaining therapies and those cases in which the doctors are recommending a DNR or removal of life support for children within the care and custody of the Children’s Division, staff shall:
- Immediately gather appropriate identifying and medical information including:
- Condition and prognosis of the child;
- Other pertinent information regarding the child, i.e., age, birth date and location;
- Parent(s) name and address; if there is no parent(s), then the nearest relative
- Most recent court order; and
- Other appropriate medical and identifying information.
- Notify immediately, via telephone, and provide an explanation of the child’s situation and appropriate information based on Step 1.
- Refer such situations to the office of the Children’s Division Director for review.
- CD shall not be the agency to file a motion with the court asking for the court to make a DNR or removal of Life Support decisions. The motion should be filed by the JO or the GAL or parent(s) whose parental rights have not been terminated. If the JO and/or GAL or parent(s) refuses to file such a motion, then Division of Legal Services may file a motion notifying the court that:
- The child is seriously ill and the doctors are recommending DNR or removal of Life Supports. The best practice would include a written statement from the doctor attached to the motion;
- CD does not make DNR or Removal of Life Support decisions and does not have a specific recommendation to make regarding the child; and
- CD requests that the court take evidence on the child’s condition and enter an appropriate order.
- Notify the birth parent(s)/kinship of the hearing. Notice of hearing must be in writing. It is preferable to deliver the notice personally, but if this is not possible then it should be sent by certified mail so there is documentation to show the efforts to notify interested parties. If CD does not know the location of a parent or guardian CD/Division of Legal Services needs to take all reasonable steps to locate that individual and provide them reasonable notice so that they have an opportunity to present information to the court. The steps taken to locate, the absent parent or guardian needs to be documented in the file.
- Notify the juvenile office and/or juvenile court immediately if the medical facility does not provide all appropriate information or there is a concern for the child’s health while a review is being conducted.
- Immediately submit a written report containing the information outlined above to the regional director.
- Before, during, and after the decision has been made to begin or discontinue life support systems, establish open communications with the birth parent(s), foster parent(s) and sibling(s) of the child.
- County office staff will update Regional Director, as necessary, on any changes in the child’s condition during the review process.
- Assist the family by providing or arranging contact with support groups, counseling or any other service necessary to aid the family in the event of the child’s death.
Upon notification the Regional Director will:
- Call and advise the Children’s Division Director of this medical emergency, relaying the information concerning the child as provided in the required staff report.
- Forward immediately, upon receipt, a copy of the written report containing the information outlined above to the Children’s Division Director.
4.3.12 Death of a Child in Out-of-Home Care
The following are special procedures the Family Centered Out of Home (FCOOH) Case Manager will follow whenever a child who is in the care and custody of the Children’s Division residing in an out of home placement dies:
- Notify the Supervisor immediately that a Child in CD custody has died. This will include any sudden or unexpected death, as well as a foreseeable death due to illness.
- Supervisor shall initiate the Fatality/Critical Event Reporting and Review Protocol.
If the child died under suspicious circumstances, or if there is reason to believe the child died from child abuse or neglect, the Children’s Service Worker shall:
- File a report with CANHU right away;
- Assure that no other children are at risk of immediate harm. Assure the safety of other children by:
- Contacting Law Enforcement at once if there is reason to believe any other children are at risk of immediate harm;
- Immediately contacting the Case Manager and/or the Supervisor regarding any other children who are in the home to notify them of any concerns; and
- Advising the Licensing Worker and/or Supervisor of the situation.
- Immediately notify the juvenile office and/or family/juvenile court of jurisdiction and the Guardian Ad Litem and/or CASA of the child’s death
- Immediately make personal contact with the biological parents to notify them of their child’s death. Do not notify the family of the child’s death by phone or by mail.
- If the biological parents reside in another county or out of state, the worker shall request assistance from the worker in the other county or state to make personal notification.
- The worker should coordinate efforts with other persons involved who may be communicating with the family or coordinating services, such as another worker, Contracted Case Manager, OHI Investigator, Law Enforcement Officer, or Juvenile Officer, so that the primary or extended family does not experience multiple or unnecessary contacts which may only add to their grief or despair.
- Provide supportive services and referrals as necessary to assist the family with grieving or other issues.
The child’s death will have a profound impact on the parent and placement provider. The worker should be particularly sensitive to their loss and offer appropriate support.
- Consult with the Supervisor for the need to schedule a Family Support Team meeting to modify the family’s case plan as a result of the child’s death. Allow ample time for the family to grieve and for funeral proceedings when scheduling the FST. Continue to work with the family as directed by the Supervisor.
- Cooperate with the Children’s Division CA/N Investigator assigned to the investigation, including an Investigator from the Out of Home Investigations Unit, if applicable.
- Provide any information available that may assist in the investigation, including access to the case record.
- Inform your supervisor that the fatality is being investigated.
- If the child was less than 18 years of age, the Children’s Service Worker will need to determine if the coroner or medical examiner has been notified under the provisions of Missouri Revised Statutes chapters 58.452 and 58.772. If notification has not been made, the worker will need to notify the coroner or medical examiner of the child’s death.
- Additionally, notify the coroner when there is reasonable ground to believe that the child died as a result of:
- Violence by homicide, suicide or accident;
- Criminal abortions, including those self-induced;
- Some unforeseen sudden occurrence and the deceased had not been attended by a physician during the 36 hour period proceeding the death;
- Any injury or illness while in the custody of the law or while an inmate in a public institution.
- In any unusual or suspicious manner;
- The coroner or medical examiner will, if appropriate, contact the chairman of the Child Fatality Review Panel.
- Contact all other persons who have knowledge of the circumstances of the death. This may include physicians, police, placement providers, school personnel, witnesses, etc.
- The family Children’s Service Worker shall gather and document in the case record, all pertinent facts regarding the child’s death including:
- Cause of death;
- Time of death;
- Location of death; and
- Circumstances surrounding the child’s death and any witnesses.
- Current case status information (date case was opened and reason, summary of court activity, Name, address and phone number of GAL, past and current services received by family);
- List of other children remaining in the household with the alleged perpetrator and how their safety has been assured (attach a safety re-assessment form);
- A summary of progress or lack of progress made recently (attach most recent treatment plan);
- Date(s) of most recent contact(s) made with the family;
- CD history with the family (CA/N, Alternative Care/Adoption; prior FCS history);
- List of other agencies involved; and
- Other pertinent facts of case
- Update/close the FCS and AC Functions in FACES (if applicable), and assure that the information in FACES is updated as soon as possible.
- The Supervisor is to complete and submit a Critical Event Report (CS-23) to the Circuit Manager, or designee to allow enough time for review so that summary can be forwarded to central office.
- Provide the coroner/medical examiner and funeral home information for completion of the death certificate.
- Advise any agency the child was receiving benefits from such as SSI, VA, insurance companies, etc.
- A copy of the child’s death certificate may be provided upon request.
- Inform the eligibility analyst that the child’s KIDS account can be closed.
When the death occurs of a child in CD care and custody, placed in out-of-home care, the family’s worker will work with the biological family regarding burial arrangements and expenses. If the biological family is willing and able to assume responsibility for the burial, they should be encouraged to do so. The family worker shall explore resources such as insurance policies, Social Security and other benefits.
If the biological family is not able to assume responsibility, the worker shall contact a local funeral home to provide a dignified burial within the acceptable standards of the community. To the extent possible, consider the wishes of the biological and foster family in making arrangements for the child’s burial. Payment, not to exceed $1,500.00, will be made through SAMII. An itemized list of expenses will need to be attached to the payment.
Related Practice Points and Memos: