Plans of Safe Care Infants With Prenatal Substance Exposure and Their Families - California

Definitions
Citation: DSS All County Letter No. 17-92

In policy: Under California law, an 'infant born and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a fetal alcohol spectrum disorder (FASD)' is defined as an infant for whom substance exposure is indicated at birth, and subsequent assessment identifies indicators of risk that may affect the infant's health and safety.

Notification/Reporting Requirements
Citation: Penal Code § 11165.13; DSS All County Letter No. 17-92

For the purposes of this article, a positive toxicology screen at the time of the delivery of an infant is not in and of itself a sufficient basis for reporting child abuse or neglect. However, any indication of maternal substance abuse shall lead to an assessment of the needs of the mother and child pursuant to § 123605 of the Health and Safety Code. If other factors are present that indicate risk to a child, then a report shall be made. However, a report based on risk to a child which relates solely to the inability of the parent to provide the child with regular care due to the parent's substance abuse shall be made only to a county welfare or probation department and not to a law enforcement agency.

In policy: A health practitioner or a medical social worker, prior to the infant's release from the hospital, must perform the assessment of needs. The purpose of the assessment is to identify the services needed for the mother, child, or family and the level of risk to the newborn upon release to the home. The assessment will identify the level of services and intervention necessary and may include a referral to the county welfare department for child welfare services.

Upon receipt of a mandated report from a health-care provider, the county child welfare agency must then respond in accordance with the appropriate protocols and assessments required by State regulations set forth in Division 31-100 of the Child Welfare Manual of Policies and Procedures.

When investigating a referral, the county child welfare agency must assess and identify any safety threats to the child, including any safety threat posed by the parent's substance abuse. This includes completion of a risk assessment.

Assessment of the Infant and Family
Citation: Health & Safety Code § 123605; Welf. & Inst. Code § 16604.5; DSS All County Letter No. 17-92

Each county shall establish protocols between county health departments, county welfare departments, and all public and private hospitals in the county regarding the application and use of an assessment of the needs of, and a referral for, a substance-exposed infant to a county welfare department pursuant to § 11165.13 of the Penal Code.

The assessment of the needs shall be performed by a health practitioner or a medical social worker. The needs assessment shall be performed before the infant is released from the hospital.

The purpose of the needs assessment is to do all the following:

• Identify needed services for the mother, child, or family, including, where applicable, services to assist the mother in caring for her child and services to assist in maintaining children in their homes
• Determine the level of risk to the newborn upon release to the home and the corresponding level of services and intervention, if any, necessary to protect the newborn's health and safety, including a referral to the county welfare department for child welfare services
• Gather data for information and planning purposes

When preparing needs assessments and plans, as required by title IV-B, counties shall consider providing an in-home assessment of substance-exposed infants after release from a hospital, as part of the protocols of § 123605 of the Health and Safety Code.

In policy: Prenatal substance exposure may be demonstrated by a positive toxicology screen from the infant or mother at delivery, an infant showing signs of substance withdrawal, an FASD diagnosis, or other credible information that there was prenatal substance abuse by the mother (e.g., self-admission, witnessed drug or alcohol abuse while pregnant). An indication of substance exposure at birth includes exposure to either illegal or legal substances, such as prescription opioids or other drugs. Such an indication will trigger an assessment of needs and indicators of risk to the child's health and safety.

A positive toxicology screen at the time of delivery is not in and of itself a sufficient basis for a mandated report. If, following the assessment, there are other factors present indicating risk to the child, a report shall be made by the health-care provider to the county child welfare agency. Other indicators of risk to the infant's health and safety that may be identified upon further assessment include, but are not limited to, the following:

• Special medical or physical problems of the infant
• Special care needs of the infant
• Infant's experience of withdrawal symptoms
• Parent's lack of prenatal care
• Parent's history of drug or alcohol use
• Parent's history of drug or alcohol treatment
• Parent's awareness of the impact of drug or alcohol use on the child
• Parent's emotional and mental functioning and stability
• Parent's responsiveness to the infant, bonding and attachment, and parenting skills
• Parent's preparedness to care for the infant (e.g., adequate baby supplies)
• Parent's history of abuse or neglect of other children
• Parent's history of family violence
• Parent's involvement in criminal activity or criminal activity in the household
• Lack of a family support system
• Unsafe home environment conditions

Responsibility for Development of the Plan of Safe Care
Citation: DSS All County Letter No. 17-92

When a safety plan or case plan is developed and implemented for an infant born and identified as being affected by substance abuse, that plan shall also act as the plan of safe care.

If the caseworker determines the caregiver has the protective capacity to mitigate safety threats or risks with appropriate services while keeping the child in the home or placement, the caseworker shall develop a safety plan to permit the child to remain in the home with specific, timely actions that mitigate the identified safety threats. If the safety threats are not mitigated during the investigation period, and the referral is promoted to a case, or if the child must be removed from the home, a case plan shall be developed in accordance with Welfare and Institutions Code § 16501.1.

Consistent with the existing requirements of safety plans and case plans, the caseworker shall clearly identify and document the effect(s) of the substance abuse, withdrawal symptoms, or FASD in these plans as well as the specific action steps necessary to assist in maintaining children in their homes or, if appropriate, to promote family reunification.

Services for the Infant
Citation: DSS All County Letter No. 17-92

These action steps must address the immediate safety needs of the affected infant and the ongoing treatment needs of the infant. The action steps shall include referrals to and delivery of services that are appropriate for the infant and the affected family member or caregiver.

Services for the Parents or Other Caregivers
Citation: Health & Safety Code § 11757.59; Code of Regs. Tit. 9, § 10360; DSS All County Letter No. 17-92

In carrying out its responsibilities, the Office of Perinatal Substance Abuse may include in its guidelines the special needs of pregnant women and postpartum women who are chemically dependent and who are in need of treatment services. These special needs include, but are not limited to, the following:

• Provision for medical services, which may include, but are not limited to, the following:
  • Low-risk and high-risk prenatal care
  • Pediatric follow-up care, including preventive infant health care
  • Developmental follow-up care
  • Nutrition counseling
  • Methadone
  • Testing and counseling relating to AIDS
  • Monthly visits with a physician and a surgeon who specialize in treating persons with chemical dependencies
• Provision for nonmedical services, which may include, but are not limited to, the following:
  • Case management
  • Individual or group counseling sessions, which occur at least once a week
  • Family counseling, including, but not limited to, counseling services for partners and children of the women
  • Health education services, including perinatal chemical dependency classes, addressing topics that include, but are not limited to, the effects of drugs on infants, AIDS, addiction in the family, child development, nutrition, self-esteem, and responsible decision-making
  • Parenting classes
  • Adequate child care for participating women
  • Encouragement of active participation and support by spouses, domestic partners, family members, and friends
  • Opportunities for a women-only treatment environment
  • Transportation to outpatient treatment programs
  • Follow-up services, which may include, but are not limited to, assistance with transition into housing in a drug-free environment
  • Child development services
  • Educational and vocational services for women
  • Weekly urine testing
  • Special recruitment, training, and support services for foster parents of substance-exposed infants
  • Outreach that reflects the cultural and ethnic diversity of the population served

In regulation: When the pregnancy of a patient participating in a narcotic treatment program has been confirmed, the patient's treatment plan shall be updated to include instruction on each of the following prenatal topics:

• Risks to the patient and unborn child from continued use of both illicit and legal drugs, including premature birth
• Benefits of replacement narcotic therapy and risks of abrupt withdrawal from opioids, including premature birth
• The importance of attending all prenatal care visits
• The need for evaluation for opioid addiction-related care of both the patient and the newborn following the birth
• Signs and symptoms of opioid withdrawal in the newborn child and warning that the patient should not share take-home medication with the newborn child who appears to be in withdrawal
• Current understanding related to the risks and benefits of breastfeeding while on medications used in replacement narcotic therapy
• The phenomenon of postpartum depression
• Family planning and contraception
• Basic prenatal care for those patients not referred to another health-care provider, including instruction on at least the following:
  • Nutrition and prenatal vitamins
  • Child pediatric care, immunization, handling, health, and safety
• Evidence-based practices for managing neonatal abstinence syndrome

In policy: These action steps must address the health and substance abuse treatment needs of the affected family member or caregiver. The action steps shall include referrals to and delivery of services that are appropriate for the infant and the affected family member or caregiver.

Monitoring Plans of Safe Care
Citation: DSS All County Letter No. 17-92

The caseworker also must monitor the safety plan or case plan to ensure appropriate implementation and that the specific action steps are completed. The monitoring should include all steps necessary to ensure the safety of the infant. This includes ensuring that the family or caregiver receives the treatment and appropriate services required by the plan.