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

Definitions
Citation: Cent. Code §§ 27-2.3-01(3), (5); 50-25.1-02(4), (20), (21), (24)

'Aggravated circumstances' means circumstances in which a parent subjects the child to prenatal exposure to chronic or severe use of alcohol or any controlled substance as defined in chapter 19-03.1 in a manner not lawfully prescribed by a practitioner.

'Child in need of protection' means a child who was subjected to prenatal exposure to chronic or severe use of alcohol or any controlled substance in a manner not lawfully prescribed by a practitioner.

'Alternative response assessment' means a child protection response involving substance-exposed infants that is designed to do the following:

• Provide referral services to and monitor support services for a person responsible for the child's welfare and the substance-exposed infant
• Develop a plan of safe care (POSC) for the substance-exposed infant

'Prenatal exposure to a controlled substance' means the use of a controlled substance, as defined in chapter 19-03.1, by a pregnant woman for a nonmedical purpose during pregnancy, as evidenced by withdrawal symptoms in the child at birth, results of a toxicology test performed on the mother at delivery of the child at birth, or medical effects or developmental delays during the child's first year of life that medically indicate prenatal exposure to a controlled substance.

'Substance exposed infant' means an infant younger than 12 months of age at the time of the initial report of child abuse or neglect and who is identified as being affected by substance abuse or withdrawal symptoms or by a fetal alcohol spectrum disorder (FASD).

'Neglected child' means a child who, due to the action or inaction of a person responsible for the child's welfare, was subject to prenatal exposure to alcohol misuse or any controlled substance, as defined in § 19-03.1-01, in a manner not lawfully prescribed by a practitioner.

Notification/Reporting Requirements
Citation: Cent. Code §§ 50-25.1-16; 50-25.1-17; 50-25.1-18

A mandatory reporter who has knowledge of or reasonable cause to suspect that a woman is pregnant and has used a controlled substance for a nonmedical purpose during the pregnancy shall report the circumstances to the Department of Human Services if the knowledge or suspicion is derived from information received by that individual in their official or professional capacity. Any individual may make a voluntary report if they have knowledge of or reasonable cause to suspect that a woman is pregnant and has used a controlled substance for a nonmedical purpose during the pregnancy.

If the woman has obstetrical complications that are a medical indication of possible use of a controlled substance for a nonmedical purpose or alcohol misuse, upon the consent of the pregnant woman, or without consent if a specimen is otherwise available, a physician shall administer a toxicology test to the pregnant woman under the physician's care within 8 hours after delivery to determine whether there is evidence that she has ingested a controlled substance or alcohol. If the test results are positive, the physician shall report the results under § 50-25.1-03.1. A negative test result or the pregnant woman's refusal to consent to a test does not eliminate the obligation to report if other evidence gives the physician reason to believe the patient has used a controlled substance for a nonmedical purpose or has engaged in alcohol misuse.

If a physician has reason to believe based on a medical assessment of the mother or the infant that the mother used a controlled substance for a nonmedical purpose or engaged in alcohol misuse during the pregnancy, the physician shall administer, without the consent of the child's parents or guardian, a toxicology test to the newborn infant born under the physician's care to determine whether there is evidence of prenatal exposure to a controlled substance or alcohol. If the test results are positive, the physician shall report the results as neglect. A negative test result does not eliminate the obligation to report if other medical evidence of prenatal exposure to a controlled substance or alcohol misuse is present.

A mandatory reporter who has knowledge of or reasonable cause to suspect that a woman is pregnant and has engaged in alcohol misuse after the woman knows of the pregnancy shall do either of the following:

• Arrange for an assessment of substance use disorder conducted by a licensed treatment program and confirm that the recommendations indicated by the assessment are followed
• Immediately report the circumstances to the department if the knowledge or suspicion is derived from information received by that individual in that individual's official or professional capacity

If the woman is referred for a substance use disorder assessment and fails to obtain an assessment, continues to engage in alcohol misuse, or refuses to comply with the recommendations of the assessment, a mandatory reporter who has knowledge of the failure to obtain the assessment, continued alcohol misuse, or refusal to comply with recommendations of the assessment shall make a report to the department.

If a report alleges a pregnant woman has engaged in alcohol misuse, the department shall immediately initiate an appropriate assessment that must include a referral for assessment for the presence of a substance use disorder with the expectation to follow any treatment recommendations and a referral for prenatal care. The department may also take any appropriate action under chapter 25-03.1.

Assessment of the Infant and Family
Citation: Cent. Code §§ 50-25.1-16; 50-25.1-18; CPS Pol. Man. § 640-01-10-80-06

If a report alleges a pregnant woman's use of a controlled substance for a nonmedical purpose, the department or authorized agent shall immediately initiate an appropriate assessment that must include a referral for assessment of the presence of a substance use disorder with the expectation to follow any treatment recommendations and a referral for prenatal care. The department or authorized agent may also take any appropriate action under chapter 25-03.1.

A report and assessment are not required if the pregnant woman voluntarily enters treatment in a licensed treatment program. If the pregnant woman does not complete voluntary treatment, continues to use controlled substances for a nonmedical purpose, or fails to follow treatment recommendations, a mandatory reporter who has knowledge of the failure to complete voluntary treatment, continued use controlled substances for a nonmedical purpose, or failure to follow treatment recommendations shall make a report as required by this section. The report must be sufficient to identify the woman, the nature and extent of use if known, the nature and extent of the abuse of alcohol, any health risk associated with the abuse of alcohol, and the name and address of the individual making the report.

In policy: Alternative response is the preferred response to reports of substance-exposed infants and should be offered whenever the following are present:

• There has been a previous pregnant-woman assessment, and the mother engaged in service planning and development of a POSC for the infant.
• The initial report concerns an infant within the first 12 months of life.
• The concerns reported involve only prenatal exposure to misuse of alcohol or use of a controlled substance, and there are no other children involved where there are concerns of abuse or neglect.
• The initial report indicates that this is the first birth to this mother.
• There is no previous child protective services (CPS) history concerning the mother or other caregivers, or there is a history of previous CPS reports involving the mother or other caregivers that were administratively assessed, terminated in progress, determined no services required, or unconfirmed.
• There was a previous services-required or confirmed determination for neglect, and the parent followed through with the required services, working successfully with the case manager.
• The infant, or other siblings or household members, are not currently in the care and custody of a county or the department.
• The parent has no intellectual limitations that may impair the parent's ability to nurture or physically care for the child.
• The parent has no major psychiatric illness not currently controlled with medication.
• There is no current or recent (within 6 months) history of domestic violence in the home with the current partner.

Alternative response shall not be used when the following are true:

• The initial report contains abuse or neglect concerns for the infant or other children in the home, in addition to substance exposure.
• The infant affected by substance exposure is over 12 months old.
• There is a current open assessment involving abuse or neglect concerns other than prenatal substance exposure.
• There is a history of previous CPS assessments with a services-required or confirmed determination related to physical abuse, sexual abuse, or medical neglect.
• There is a history of failure to thrive, death of a child from abuse or neglect, or undetermined injury or death of an infant.
• The infant, other siblings, or household members are currently in the care and custody of a human service zone, Tribal jurisdiction, or out-of-State child welfare jurisdiction.
• The parents or caregivers within the same household refuse.

Responsibility for Development of the Plan of Safe Care
Citation: Cent. Code § 50-25.1-21; CPS Pol. Man. § 640-01-10-80-07

In response to an alternative response assessment, the department shall do the following:

• Provide referral services to and monitor support services for the person responsible for the child's welfare, the substance-exposed newborn, and other children under the same care as may be necessary for their well-being and safety
• Develop a POSC for the substance-exposed newborn

In policy: A POSC is an action plan to address the health and safety needs of the substance-exposed infant and the health and substance use disorder treatment needs of the infant's caregivers. A POSC is intended to provide knowledge, services, and supports to sustain safety and health that begins during the CPS assessment and continues after the CPS intervention ends. The POSC is not a safety plan.

A POSC may be approached using a family team, a family-centered engagement (FCE) meeting, individual contacts, or a combination of these. Use of a team approach that includes service providers, safety support persons, and other informal supports is encouraged but not required.

Development of the POSC should begin at the time of the initial visit and must be in place within 30 calendar days of the initial visit to allow for at least 30 calendar days of monitoring prior to closing the assessment.

Services for the Infant
Citation: CPS Pol. Man. § 640-01-10-80-07

The POSC must include, but is not limited to, services and supports for the infant, including the following:

• Any medical care needed, including acute services for symptoms of neonatal abstinence syndrome and routine medical follow-up
• Safe housing that protects the infant from environmental exposure to substances and individuals under the influence of substances
• A general day-to-day plan for caring for the infant, including the caregiver's understanding of the special care needs of the infant and the ability to provide such care
• Verification that the parent has received the 'Period of Purple Crying' (shaken baby syndrome prevention) materials from the hospital
• Verification that the parent has received infant safe sleep information and has safe sleep arrangements in the home (e.g., a crib) and infant-caring supports
• Referral to Part C Infant Development services

Services for the Parents or Other Caregivers
Citation: CPS Pol. Man. § 640-01-10-80-07

The POSC must include, but is not limited to, services and supports for the caregivers, including the following:

• Referral to necessary substance use disorder treatment evaluation and compliance with recommendations
• A list of phone numbers and contacts to call as a resource during a time of relapse or crisis or for general help with parenting issues
• Referral or follow-up to any needed physical health services
• Inclusion of safe care for the infant in any relapse plan developed for the parent
• Referral to Women, Infant and Children (WIC) (if appropriate)
• Referral for any needed public assistance programs: Medicaid, Supplemental Nutrition Assistance Program, Low-Income Home Energy Assistance Program, Healthy Steps, etc. (if appropriate)
• Referral to lactation consultants if the mother chooses to breastfeed
• A referral for the parent to other behavioral health services, including mental health evaluation for postpartum depression, trauma screening, mental health screening, parental capacity, etc.
• Referral to Early Head Start (where available)
• Referral to Nurturing Parent programs or other attachment-based parenting programs 

Monitoring Plans of Safe Care
Citation: Cent. Code § 50-25.1-20; CPS Pol. Man. § 640-01-10-80-07

If an alternative response assessment is initiated as a result of a report of child abuse or neglect, a decision that a child is confirmed abused or neglected may not be made if the person responsible for the child's welfare complies with the resulting referred services and POSC for the substance-exposed infant. The department shall determine whether a person responsible for the child's welfare has complied with the referred services and POSC for the substance-exposed infant. If the department determines a person responsible for the child's welfare has not complied with the referred services and POSC for the substance-exposed infant, an assessment of the initial report of child abuse or neglect may be completed.

In policy: As required by the Child Abuse Prevention and Treatment Act (CAPTA), when an infant has been identified as a substance-exposed newborn, CPS workers must monitor the POSC. The worker must ensure the implementation of the POSC by following up with service providers and collateral contacts, including the family and other parties involved in the plan.

The POSC shall be monitored through a minimum of the following actions:

• Following hospital discharge, weekly contacts (with face-to-face contact every other week) must be made by CPS workers with the parents or caregivers and the infant.
• Any other children in the home must be assessed for safety throughout the assessment.
• The worker must make at least one face-to-face or via electronic means visit with each safety support person who agrees to act as a resource for emergency care of the infant in the POSC.
• The worker must contact (via email, text, etc.) each participant who is an informal support at least every other week.
• Contacts with service providers or follow-up contacts with safety support persons and other informal supports can be made by phone, email, in writing, text message, etc., to verify follow through with the plan.

All assessments with a POSC must include monitoring documentation. POSCs must be monitored for a minimum of 30 days prior to closing the assessment.