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Title:

Child Welfare Manual

Section 4:

Out of Home Care

Chapter 24:

Medical/Mental Health Planning

Subsection 7:

Pregnancy of Child in Out-of-Home Care

Effective Date:

December 30, 2010

§4 ch24: Medical/Mental Health Planning

• 24.7  Pregnancy of Child in Out-of-Home Care

  Should a child become pregnant while in foster care, all efforts should be made to ensure complete prenatal care is received. 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.

  Related Subject:  Section 4, Chapter 11, Attachment F:  Children of Youth in Alternative Care

• 24.8  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.

• 24.9  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.

• 24.10  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 situation 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:

  1. Immediately gather appropriate identifying and medical information including:
     1. Condition and prognosis of the child;
     2. Other pertinent information regarding the child, i.e., age, birth date and location;
     3. Parent(s) name and address; if there is no parent(s), then the nearest relative
     4. Most recent court order; and
     5. Other appropriate medical and identifying information.
  2. Notify immediately, via telephone, and provide an explanation of the child’s situation and appropriate information based on Step 1.
  3. Refer such situations to the office of the Children’s Division Director for review.
  4. 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 has not been terminated:
     1. 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.
  5. 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.
  6. 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.
  7. Immediately submit a written report containing the information outlined above to the regional director.
  8. 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.
  9. County office staff will update Regional Director, as necessary, on any changes in the child’s condition during the review process.
  10. 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:

  1. 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.
  2. Forward immediately, upon receipt, a copy of the written report containing the information outlined above to the Children’s Division Director.

• 24.11  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.

  The Supervisor shall immediately notify the Regional Director, through supervisory channels, of the circumstances of the death; The Regional Director shall then assure the Children’s Division Director or designee has been made aware of the death pursuant to the Critical Event Reporting and Review Protocol as outlined in Section 2, Chapter 4.3.9.1

  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.

  Make personal contact with the biological parents to notify them of their child’s death. This notification is to occur immediately. If the biological parents reside in another county or out of state, the Children’s Service Worker shall request assistance from the worker in the other county or state to make personal notification. Do Not notify the family of the child’s death by phone or by mail. The CSW should coordinate efforts with other persons involved who may be communicating with the family or coordinating services, such as another CSW, 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.

  NOTE:  The child’s death will have a profound impact on the parent and placement provider. The Children’s Service Worker (CSW) 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 a report was received:

  • 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.

  Update the SS-63, close the SS-61, and assure that the information in the Computer Information System 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 within:
  • Three hours (or by 9 a.m. the following business day for reports alerted after hours).
    • Any case receiving media attention
    • Un-Concluded prior CA/N at time of fatality
    • Open FCS Case
    • Child currently in CD custody (open A/C case)

    This three hour timeframe does not preclude the necessity for immediate notification of the event to the CD Director/Designee.

  • 24 hours for CA/N fatalities
    • Any new CA/N incident in which child abuse/neglect has been alleged as a factor in the critical event, where no prior CD involvement exists
    • Any case with past CD involvement (CA/N, FCS. A/C)
  • The cause of the death, if known;
  • 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

  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 specialist that the child’s KIDS account can be closed.

  • 24.11.1  Burial Arrangements

    When the death occurs of a child in CD care and custody, placed in out-of-home care, the family’s Children’s Service Worker (CSW) 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.

Chapter Memoranda History: (prior to 1/31/07)

• CD04-83,
• CD05-05,
• CD05-48,
• CD05-50,
• CD05-51,
• CD06-76

Memoranda History: