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

Definitions
Citation: Rev. Stat. §§ 432B.0655; 432B.330(4); DCFS Pol. Man. § 0519

'Fetal alcohol spectrum disorder' (FASD) means a continuum of birth defects caused by maternal consumption of alcohol during pregnancy. The term includes, without limitation, fetal alcohol syndrome.

A child may be 'a child in need of protection' if the child is identified as being affected by FASD, prenatal substance use disorder, or as having withdrawal symptoms resulting from prenatal substance exposure.

In policy: CARA plan of care (CARA plan) refers to the plan of care that a State is required to develop by the Federal Comprehensive Addiction and Recovery Act (CARA) of 2016. This plan will address the safety, health, and substance use disorder treatment needs of the infant and affected family members or caregivers through the interdisciplinary coordination of services to enhance the overall well-being of the infant and family/caregiver.

The term 'neonatal abstinence syndrome' (NAS) is used to represent the pattern of effects that are associated with opioid withdrawal in newborns. NAS symptoms are affected by a variety of factors, including the type of opioid the infant was exposed to, the point of gestation when the mother used the opioid, genetic factors, and exposure to multiple substances.

The term 'substance-affected infants' (SAI) refers to a newborn infant that has been affected by prenatal substance abuse (licit or illicit) or has withdrawal symptoms resulting from prenatal drug exposure or FASD. SAI should be identified by a qualified medical professional and may be reported by hospital or medical personnel. Physical signs of infants affected by prenatal drug exposure may include, but are not limited to, crying and tremors, painful facial expression, small size for gestational age, and unusually thin arms and legs. Because substance-affected infants have a delayed response to the care they receive, a baby may continue to cry or tremble for a long time, even after they have been picked up and cared for, thus increasing the risk of child maltreatment.

The term 'substance use disorder' means a complex behavioral disorder characterized by preoccupation with obtaining alcohol or other drugs and by narrowing the behavioral repertoire toward excessive consumption and loss of control over consumption. It is usually also accompanied by the development of tolerance and withdrawal and impairment in social and occupational functioning.

Notification/Reporting Requirements
Citation: Rev. Stat. §§ 432B.220(3); 432B.230(2); 432B.310

Any person who is a mandated reporter who delivers or provides medical services to a newborn infant and who, in their professional or occupational capacity, knows or has reasonable cause to believe that the newborn infant has been affected by FASD, prenatal substance use disorder, or has withdrawal symptoms resulting from prenatal substance exposure shall, as soon as reasonably practicable but no later than 24 hours after the person knows or has reasonable cause to believe that the newborn infant is so affected or has such symptoms, notify an agency that provides child welfare services of the condition of the infant and refer each person who is responsible for the welfare of the infant to an agency for appropriate counseling, training, or other services. A notification and referral to a child welfare agency pursuant to this subsection shall not be construed to require prosecution for any illegal action.

The report must contain the following information, if obtainable:

• The name, address, age, and sex of the child
• The name and address of the child's parents or other person responsible for the care of the child
• The nature and extent of the abuse or neglect of the child, the effect of FASD or prenatal substance use disorder on the newborn infant, or the nature of the withdrawal symptoms resulting from prenatal drug exposure of the newborn infant
• Any evidence of previously known or suspected effects of FASD, prenatal substance abuse, or evidence of withdrawal symptoms resulting from prenatal substance exposure of the newborn infant
• The name, address, and relationship, if known, of the person who is alleged to have abused or neglected the child
• Any other information known to the person making the report that the child welfare agency considers necessary

An agency that provides child welfare services shall not report to the central registry any information concerning a child identified as being affected by FASD or prenatal substance use disorder or as having withdrawal symptoms resulting from prenatal substance exposure unless the agency determines that a person has abused or neglected the child after the child was born.

Assessment of the Infant and Family
Citation: Rev. Stat. § 432B.260; DCFS Pol. Man. § 0519

Upon receipt of a report concerning the possible abuse or neglect of a child, an agency that provides child welfare services shall conduct an evaluation no later than 3 days after the report or notification was received to determine whether an investigation is warranted. For the purposes of this subsection, an investigation is not warranted if the alleged abuse or neglect of the child or the alleged effect of FASD, prenatal substance use disorder, or withdrawal symptoms resulting from any prenatal substance exposure of the newborn infant could be eliminated if the child and the family of the child are referred to or participate in social or health services offered in the community, or both.

If the agency determines that an investigation is not warranted, the agency may, as appropriate, conduct an assessment of the child's family to determine any services or refer the family to a person who has entered into a written agreement with the agency to make such an assessment.

In policy: The hotline or intake screener should explore the following information to support information collection and screening decisions regarding substance-affected infants:

• The nature and extent of the effects of prenatal alcohol or drug exposure on the newborn and the nature of the withdrawal symptoms (NAS), including the medical diagnosis or lab results
• The type of drug exposure
• The infant's medical condition and any current or ongoing health-care needs, including an extended hospital stay prior to discharge
• Special medical or physical problems in the newborn infant
• Medical monitoring or special equipment or medications needed by the newborn infant
• Prenatal care history
• Parent preparations for the care of the infant
• The nature and extent of the mother's current drug use
• The nature and extent of the mother's compliance with medication-assisted treatment or substance treatment, including medication
• Parenting skills demonstrated in the health-care setting that suggest a lack of responsiveness to the newborn infant's needs (e.g., little or no response to infant's crying, poor eye contact, resistance to or difficulties in providing care)
• Limited or no family support
• Anticipated discharge date
• The CARA plan completed or requested

Responsibility for Development of the Plan of Safe Care
Citation: Rev. Stat. § 432B.170; Admin. Regs. § 449.947; DCFS Pol. Man. § 0519

Nothing in the provisions of this chapter prohibits a child welfare agency from sharing information with other State or local agencies if the purpose for sharing the information is for the development of a plan for the care, treatment, or supervision of an infant who is born and has been affected by FASD, prenatal substance use disorder or has withdrawal symptoms resulting from prenatal substance exposure. The other agency must have standards for confidentiality equivalent to those of the child welfare agency. Proper safeguards must be taken to ensure the confidentiality of the information.

In regulation:  A health-care provider who delivers or provides medical services to an infant in a medical facility and who, in their professional capacity, knows or has reasonable cause to believe that the infant was born with FASD, is affected by a prenatal substance use disorder, or is experiencing symptoms of withdrawal from a substance as a result of exposure to the substance in utero shall ensure that a CARA plan of care is established for the infant before the infant is discharged from the medical facility.

A CARA plan of care must be completed using the form prescribed by the Division Public and Behavioral Health and include, without limitation, the following:

• Measures to ensure the immediate safety of the infant
• Measures to address the needs of the infant and the infant's family or caregiver for substance use disorder treatment and health care
• Measures to ensure that the infant and the infant's family or caregiver receive any necessary services, including, without limitation, referrals to appropriate providers of such services
• Any other information necessary to ensure that the needs of the infant are met

When an infant is discharged from a medical facility, the medical facility shall provide a copy of the CARA plan of care to each parent or legal guardian of the infant or both, if applicable; and to the division within 24 hours after the discharge.

In policy: Health-care providers who deliver or provide medical services to an infant in a medical facility and who, in their professional occupational capacity, know or have reasonable cause to believe that the infant has been affected by FASD or prenatal substance abuse or is experiencing withdrawal symptoms resulting from in utero drug exposure shall ensure a CARA plan is in place prior to discharge. CARA plans shall be made available to child welfare agencies upon request.

Services for the Infant
Citation: DCFS Pol. Man. § 0519

The CARA plan should address the needs of the child as well as those of the parent or caregiver to ensure that appropriate services are provided to the parent or caregiver and the infant to ensure the infant's well-being. A CARA plan should include appropriate care for the infant who may be experiencing neurodevelopmental or physical effects or withdrawal symptoms from prenatal substance exposure and services and supports that strengthen the parents' capacity to nurture and care for the infant and to ensure the infant's continued safety and well-being.

At a minimum, the CARA plan should include referrals for the infant's health care and early intervention services. A referral to Nevada Early Intervention Services must be made for infants with a CARA plan. This is applicable to screened-in cases and is required to be completed by the assigned social worker or caseworker within 2 days of the receipt of the CARA plan.

Services for the Parents or Other Caregivers
Citation: DCFS Pol. Man. § 0519

The CARA plan should address the needs of the child as well as those of the parent or caregiver to ensure that appropriate services are provided to the parent or caregiver and the infant to ensure the infant's well-being. There will be instances that a parent will decline to engage in a CARA plan; this in and of itself does not require the child welfare agency to screen in the report for maltreatment.

A CARA plan is not the same as a safety plan but may be one critical component of the safety plan. A safety plan addresses immediate safety concerns, and the CARA plan addresses the affected caretaker's need for substance use or mental health treatment and the health and developmental needs of the affected infant. The CARA plan may provide pertinent information for safety planning.

A CARA plan should address the caregivers' need for treatment for substance use and mental disorders and services and supports that strengthen the caregivers' capacity to nurture and care for the infant and to ensure the infant's continued safety and well-being. At a minimum, the CARA plan should include referrals for the caregiver's health, including, but not limited to, postpartum care, substance abuse treatment, mental health, and parenting support.

Monitoring Plans of Safe Care
Citation: Rev. Stat. § 432B.260(7); Admin. Regs. § 449.948; DCFS Pol. Man. § 0519

If an agency that provides child welfare services enters into an agreement with a person to provide services to a child or the child's family, the agency shall require the person to notify the agency if the child or the family refuses or fails to participate in the services or if the person determines that there is a serious risk to the health or safety of the child.

In regulation: The division shall do the following:

• Monitor the implementation of each CARA plan of care to ensure that the infant to whom the plan pertains and the infant's family or caregiver are receiving appropriate services
• Provide a copy of a CARA plan of care in the possession of the division to an agency that provides child welfare services upon request

In policy: Families with open child welfare cases will have the CARA plan incorporated into the family's case plan to address the infant's and caregiver's ongoing substance use treatment, medical, developmental, social, and emotional needs at the time the initial case plan is completed or within 30 calendar days of receipt when there is an existing case plan in place. The caseworker shall clearly identify and document the effect(s) of the substance abuse, withdrawal symptoms, or fetal alcohol spectrum disorder, as well as the specific action steps necessary to assist in maintaining children in their homes or, if appropriate, to promote family reunification. The infant and caregiver's needs and services should be documented in the case plan outcomes.