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

Definitions
Citation: Admin. Code Tit. 22, §§ 40-705-10; 40-705-40; Child & Family Serv. Man. § C.10

'Plan of safe care' (POSC) means a guide developed by service providers with their clients to ensure mothers and other caregivers of a substance-exposed infant have the necessary resources to safely care for the infant. The plan should address the needs of the child, mother, and other caregivers, as appropriate.

The term 'affected by substance abuse' refers to a determination by a health-care professional that may be determined by clinical indicators that include maternal and infant presentation at birth, substance use and medical histories and include toxicology study results of the infant that are positive for illegal substances or indicate abuse of controlled substances.

In policy: The term 'assessment' refers to an in-depth look at an individual's past and current substance use and the impact of that use on the overall functioning of that individual. Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.

'Fetal alcohol spectrum disorders' (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, or learning disabilities with possible lifelong implications.

'Neonatal abstinence syndrome' (NAS) is a group of problems that occur in a newborn as a result of sudden discontinuation of addictive opioids or other legal or illegal drugs to which the newborn was exposed while in the mother's womb.

Notification/Reporting Requirements
Citation: Ann. Code §§ 2.2-213; 63.2-1509(B)

To respond to the needs of substance-abusing women and their children, the Department of Health and Human Resources shall develop criteria for the following:

• Enhancing access to publicly funded substance abuse treatment programs in order to effectively serve pregnant substance abusers
• Determining when a drug-exposed child may be referred to the early intervention services
• Determining the appropriate circumstances for contact between hospital discharge planners and local departments of social services for referrals for family-oriented prevention services
• Determining when the parent of a drug-exposed infant, who may be endangering a child's health by failing to follow a discharge plan, may be referred to the child protective services unit of a local department of social services

A report is required when, in their professional or official capacity, a reporter has reason to suspect that a child is abused or neglected. For purposes of this section, 'reason to suspect that a child is abused or neglected' shall, due to the special medical needs of infants affected by substance exposure, include the following:

• A finding made by a health-care provider within 6 weeks of the birth of a child that the child was born affected by substance abuse or experiencing withdrawal symptoms resulting from in-utero drug exposure
• A diagnosis made by a health-care provider within 4 years following a child's birth that the child has an illness, disease, or condition that, to a reasonable degree of medical certainty, is attributable to maternal abuse of a controlled substance during pregnancy
• A diagnosis made by a health-care provider within 4 years following a child's birth that the child has a fetal alcohol spectrum disorder attributable to in utero exposure to alcohol 

When 'reason to suspect' is based upon this subsection, that fact shall be included in the report along with the facts relied upon by the person making the report. Such reports shall not constitute a per se finding of child abuse or neglect. If a health-care provider in a licensed hospital makes any finding or diagnosis as described above, the hospital shall require the development of a written discharge plan under protocols established by the hospital, pursuant to § 32.1-127(B)(6).

Assessment of the Infant and Family
Citation: Ann. Code § 63.2-1506; Child & Family Serv. Man. § C.10

A family assessment requires the collection of information necessary to determine the following:

• The immediate safety needs of the child
• The protective and rehabilitative services needs of the child and family that will deter abuse or neglect
• Risk of future harm to the child
• Whether the mother of a child who was exposed in utero to a controlled substance sought substance abuse counseling or treatment prior to the child's birth
• Alternative plans for the child's safety if protective and rehabilitative services are indicated, and the family is unable or unwilling to participate in services

If a report or complaint is based upon one of the factors specified in § 63.2-1509(B), the local Department of Social Services (LDSS) shall (a) conduct a family assessment unless an investigation is required pursuant to this subsection or other provision of law or is necessary to protect the safety of the child, and (b) develop a plan of safe care in accordance with Federal law, regardless of whether the local department makes a finding of abuse or neglect.

In policy: An essential part of the initial safety assessment is to complete a brief substance use screening to determine if a substance abuse assessment is needed and if so, what services would best meet the needs of the mother. Substance use screening should include questions concerning the following:

• Frequency and amount of alcohol consumption prior to and during pregnancy
• Frequency and amounts of over-the-counter prescriptions and legal or illegal substances prior to and during pregnancy
• Effects of substance use on life areas such as relationships, employment, legal, etc.
• Other parent or partner substance use
• Previous referrals for substance abuse evaluation or treatment
• Previous substance use treatment or efforts to seek treatment

In addition to conditions in the infant, conditions or behaviors in the mother that may indicate risk of harm should be assessed, including, but not limited to, the following: 

• Special medical or physical problems in the infant
• Close medical monitoring or special equipment or medications needed by the infant
• Lack of prenatal care or inconsistent prenatal care
• Previous delivery of a substance-exposed infant (SEI)
• Prior child protective services (CPS) history
• Prior removal of other children by the courts or voluntary placement with relatives
• Lack of preparations for the care of the infant
• Intellectual limitations that may impair the mother's ability to care for the child
• Psychiatric illness
• Home environment that presents safety or health hazards
• Evidence of financial instability that affects the mother's ability to nurture or physically care for the infant
• Limited or no family support
• The young age or immaturity of the parent(s)
• Parenting skills demonstrated in the health-care setting that suggest a lack of responsiveness to the SEI's needs (e.g., little or no response to infant's crying, poor eye contact, resistance to or difficulties in providing care)
• Domestic violence 

Collateral involvement to determine risk and possible services is crucial and may include contacts with the immediate or extended family, birthing hospital, pediatrician, and substance use disorder evaluation and treatment providers. At the minimum, contact should be made with health-care providers to gather the following information:

• To identify how the infant was affected by in-utero substance exposure, including results of laboratory tests or toxicology studies done on the infant
• To identify any medical treatment needed for the child or mother
• To assess the mother's attitude and behavior with the infant
• To determine the expected discharge dates of the mother and infant
• To determine whether there are other children in the home at risk 

Responsibility for Development of the Plan of Safe Care
Citation: Ann. Code § 32.1-127; Child & Family Serv. Man. § C.10

Effective July 1, 2025: The regulations regarding the licensure of hospitals require that each licensed hospital develop and implement a protocol requiring written discharge plans for identified, substance-abusing, postpartum women and their infants. The protocol requires that the discharge plan be discussed with the patient and that appropriate referrals for the mother and the infant be made and documented. 
The discharge planning process shall involve, to the extent possible, the father of the infant and any members of the patient's extended family who may participate in the follow-up care for the mother and the infant. Immediately upon identification of any substance-abusing, postpartum woman, the hospital shall notify, subject to Federal law restrictions, the community services board (CSB) of the jurisdiction in which the woman resides to appoint a discharge plan manager. The CSB shall implement and manage the discharge plan.  

In policy: The POSC should address the needs of the child as well as those of the parent, as appropriate, and ensure that appropriate services are provided to ensure the infant's safety. A POSC should begin when the mother is pregnant and be initiated by her health-care providers. Once the LDSS becomes involved in an SEI referral, the LDSS becomes a part of this POSC. The LDSS is one of many agencies that can provide a POSC for the SEI and the mother.

A POSC should incorporate the mother's (and potentially the other primary caregivers) need for treatment for substance use and mental disorders, 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.

The LDSS must complete an initial safety assessment of the SEI and family. Most reports involving a SEI will require a safety plan due to the infants' vulnerability. A safety plan is not the same as a POSC but is considered one critical component of the POSC. A safety plan addresses immediate safety concerns and needs, while the POSC addresses both short- and long-term needs.

Services for the Infant
Citation: Ann. Code § 32.1-127; Child & Family Serv. Man. § C.10

Effective July 1, 2025: Appropriate referrals may include, but need not be limited to, treatment services, comprehensive early intervention services for infants and toddlers with disabilities and their families pursuant to Part H of the Individuals with Disabilities Education Act (20 U.S.C. § 1471 et seq.), and family-oriented prevention services.

In policy: Regardless of whether a CPS ongoing case is opened for services, the LDSS shall refer any child under age 3 for early prevention services to the local Infant and Toddler Connection of Virginia to whom any of the following apply:

• The child is identified as affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.
• The child is the subject of an investigation with a founded disposition.
• The child has a physical or mental condition that has a high probability of resulting in developmental delay, regardless of track or disposition.

As soon as possible but no later than 7 calendar days after completing the investigation or family assessment, the LDSS should send a referral to the local Part C Early Intervention program using the local referral form.

Services for the Parents or Other Caregivers
Citation: Ann. Code § 32.1-127; Child & Family Serv. Man. § C.10

Appropriate referrals may include, but need not be limited to, treatment services and family-oriented prevention services.

In policy: Services for mothers with substance use disorders and their families may be different than services for other populations. A thorough assessment done by a certified substance abuse counselor will typically be the first step in providing services for SEI referrals. Assessment refers to an in-depth look at an individual's past and current substance use and the impact of that use on the overall functioning of that individual. Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.

Postpartum women with substance use disorders and their newborns may have multiple health care, treatment, safety, and environmental needs. Their hospital discharge plans should include, but are not limited to, the following: 

• A referral of the mother to the local CSB for a substance use assessment and implementation of the discharge plan.
• Information and medical directives regarding potential postpartum complications and, as appropriate, indicators of substance use withdrawal and postpartum depression
• A follow-up appointment for the mother for postpartum gynecological care and family planning 

In addition to substance abuse services, other services may include, but are not limited to, the following: 

• Child care
• Relapse prevention
• Parenting education
• Job skills training or employment
• Mental health assistance
• Safe housing
• Support systems

Home visiting services match parents and caregivers with trained paraprofessionals who can provide information and support during pregnancy and throughout the child's earliest years. Home visiting programs support healthy prenatal behaviors and parenting attitudes, engage infants in meaningful learning activities, build positive parent-child relationships, and promote family self-sufficiency. Project Link is one home visiting program offered in Virginia and is specifically for pregnant and parenting substance-using women.

Monitoring Plans of Safe Care
Citation: Child & Family Serv. Man. § C.10

The POSC should ensure a process for continued monitoring of the family and accountability of responsible agencies, such as substance use disorder treatment, home visiting, public health, and health-care providers for the infant and mother.