Chapter 3 : Section 3

Developing and Reassessing the Family-Centered Case Plan

Procedures

Develop the initial written case plan with the family after completing the Family Functioning Assessment – Ongoing (for families with unsafe children), or after engaging with the family to discuss and update the Protective Factors assessment (for families with safe children). See Family Functioning Assessment – Ongoing and Family Functioning Assessment – Progress Update.

Explain the case planning process to the family during the introduction stage of the Family Functioning Assessment – Ongoing. During the FFA-Ongoing exploration stage, engage the parents, guardians, and/or custodians to identify the diminished protective capacities that have resulted in their inability to protect the child from danger. Address these diminished protective capacities in the initial written case plan.

If a Family Functioning Assessment is not required, meet with the family to explain the case planning process and to discuss and update the Protective Factors Framework (PFF) assessment. Engage the parents, guardians, and/or custodians to identify protective factors to be strengthened to reduce the likelihood of another report of abuse or neglect. Address these protective factors in the initial written case plan.

Arranging and Facilitating Case Plan Staffings

Preparation for the Staffing

Prior to a case plan staffing, the DCS Specialist should discuss the following with the parents, guardians, and/or custodians, and children invited to attend the staffing:

• what a case plan is;

• what a case plan staffing is;

• who DCS invites to the meeting;

• who the family may invite to the meeting;

• what happens at the meeting, including the types of decisions made;

• why attendance at the meeting is important; and

• how to prepare for the meeting.

Based on information gathered and conversations with the family during the exploration stage of the Family Functioning Assessment – Ongoing, develop a draft statement describing the reasons DCS is involved with the family (danger statement) and draft desired behavioral change statements.

Scheduling

Schedule the case plan staffing at a time and location that meets the needs of parents, guardians, and/or custodians, out-of-home care providers, and children. Schedule the case plan staffing with at least two weeks’ notice to allow attendees to make arrangements to attend. Inform service team members who cannot attend the case plan staffing in person that they may provide a written report, a verbal report, or participate by conference call. Arrange interpreter services if necessary.

Invitations

Invite the following service team members to participate in the case plan staffing:

• parents, guardians and/or custodians (see Case Plan Staffing Invitation for Parents, CSO-2860);

• child, if age 12 years or older (see Notice of Rights for Children and Youth in Foster Care, CSO-1141);

• extended family members identified as an active or potential resource/support;

• out-of-home caregiver;

• licensing worker if the out-of-home caregiver is a licensed foster family;

• service providers working with the family;

• tribal social service representative;

• tribal legal representative;

• Court Appointed Special Advocate (CASA);

• child's and/or parent, guardian and/or custodian’s Regional Behavioral Health Authority (RBHA) case manager;

• child's attorney and/or guardian ad-litem;

• parent, guardian and/or custodian's attorney and/or guardian ad-litem; and

• Assistant Attorney General assigned to the case.

Inform youth who are age 14 years or older that they may invite two individuals selected by the child who are not the DCS Specialist or the foster parent to the case plan staffing. It is permissible to reject an individual selected by a youth to be a member of the case planning team at any time if there is good cause to believe that the individual would not act in the best interests of the child. One individual selected by a youth to be a member of the child’s case planning team may be designated to be the child’s advisor and, as necessary, advocate, with respect to the application of the Reasonable and Prudent Parent Standard to the child.

Invitees may also include:

• other significant individuals with whom the child may be placed or who have knowledge of or an interest in the welfare of the child;

• DCS Specialist's supervisor;

• school personnel;

• law enforcement personnel including probation and parole officers; and

• other DCS personnel or contracted staff.

Identify services, strategies, and supports to assist the parent, guardian, and/or custodian(s) and family to achieve the desired behaviors identified in the case plan and remediate safety threats in the home. Tailor services to meet the specific needs of the family to eliminate the need for DCS involvement. See Family Functioning Assessment – Ongoing and Planning for Services and Supports to Achieve Permanency.

Case Plan Content

Reasons for DCS Involvement

If a child has been assessed as unsafe, document the reason for DCS involvement (danger statement) developed during the most recent Family Functioning Assessment (ensure all parents, guardians, and/or custodians are addressed, as applicable to the case).

The danger statement is a behaviorally based statement in very clear, non-judgmental language that states the following:

• What the parent, guardian, and/or custodian’s actions were.

• What the impact was/is on the child(ren).

• What the DCS Specialist is concerned about that could happen in the future without DCS intervention.

If a child has been assessed as safe, document a description of the diminished caregiver protective capacities to be enhanced and/or family protective factors to be strengthened through the provision of services.

Record the danger statement in the box labeled Reason for DCS Involvement.

Permanency

Select a permanency goal for all children, and identify an expected date of achievement. See Selecting the Permanency Goal.

A concurrent permanency goal must be established within six months of actively working with the family on both the reunification plan and concurrent planning activities. This applies to all children placed in out-of-home care with a permanency goal of family reunification when the prognosis of achieving family reunification is assessed as poor (unlikely to occur within 12 months of the child's initial removal). See Concurrent Planning.

When a child has been in care for 10 months and the goal is family reunification, or a permanency goal has not been selected, the Program Manager shall attend the next clinical supervision discussion with the Program Supervisor and Specialist. Discuss and develop a plan together to move forward with reunification transition planning or a change of permanency goal. See Providing Strength Based Supervision.

When a child has a permanency goal or concurrent goal of adoption, specify the actions that will be taken to finalize the goal, including identifying an adoptive family. See Selecting an Adoptive Family.

Living Arrangement

Include the following information for children placed in Out-of-Home Care:

• Living arrangement type:

  • detention;

  • foster home;

  • group home;

  • non-relative;

  • relative;

  • residential treatment; and

  • runaway;

• whether or not the caregiver for the child is the least restrictive (most family-like) setting available;

• whether or not the caregiver is in close proximity to the home of the parent, guardian and/or custodian(s) when the case plan goal is reunification and if not, the reason(s) why;

• whether or not all siblings placed in out-of-home care are residing together; and

• description of how the caregiver is consistent with the best interests and special needs of the child.

Developing Behavioral Change Statements

In collaboration with the parent, guardian or custodian(s), and all service team members, develop behavioral change statements that describe the new desired behaviors. Include the behavior change statements in the case plan.

In families with children assessed as unsafe, the behavioral change statements are based on the diminished caregiver protective capacities identified during the exploration stage of the Family Functioning Assessment – Ongoing and describe the behaviors that will be observed when the diminished caregiver protective capacities have been enhanced. The desired behavioral changes indicate the positive behaviors or conditions that will result from the change.

In families with children assessed as safe, the behavioral change statements are based on the protective factors assessment and describe the behaviors and circumstances that will be observed when the family’s protective factors are strengthened and the likelihood of abuse or neglect is low.

Behavior change statements provide clear direction for change. Written behavioral change statements are:

• Understandable

  • the description of the desired behavior and its relationship to the reason for DCS involvement should be self-evident to the parent, guardian, and/or custodian and other service team members who may review the case plan; and, language should be absent of jargon, straightforward, and consistent with a parent, guardian, and/or custodian’s capacity to read and understand what is stated;

• Behaviorally Stated

  • they describe in positive terms how the parent, guardian and/or custodian would behave in order to demonstrate enhanced caregiver protective capacities that contribute to child safety and permanency;

• Specific

  • they are individualized based on the unique dynamics of the family, how impending danger is manifested, and which caregiver protective capacities are diminished;

• Measurable

  • in the sense of specifically defining what must change and/or exist related to caregiver thinking, feeling, and behaving;

• Achievable

  • they must be reasonable, not far-fetched, and not beyond the capacity and motivation a parent, guardian and/or custodian has or expresses;

• Relevant

  • they reflect how a parent, guardian and/or custodian’s thoughts, feelings, and behavior are interrelated and influence caregiver performance and the ability to behave protectively; and

• Timely

  • they are necessary for achieving progress, a priority related to what must change, and likely to contribute to timely change and additional change.

Record the desired family behaviors that were finalized at the case plan staffing for all parents, guardians, and/or custodians with a case plan goal of remain with family or family reunification.

Identifying Services, Supports, and Tasks to Include in the Case Plan

Using information gained through the completion of the Family Functioning Assessment, protective factors assessment (when applicable), and engagement with the family, the DCS Specialist, parents, guardians and/or custodians, and other service team members decide together what will assist the family in making the necessary change. Explore the available intervention options with the parent, guardian and/or custodian(s) and consider their input to ensure services are culturally relevant and maximize the family’s self-determination and commitment to the process of change.

Services and supports for parents, guardians and/or custodians should be relevant to enhancing the specific diminished caregiver protective capacities or strengthening the family’s protective factors targeted in the behavioral change statements. Services and supports for children should be relevant to the needs identified by rating the Child Well-Being Indicators.

When a family is receiving Family Connections and/or Nurturing Parenting Program services, the DCS Specialist shall discuss with the family and service team the integration of the FC and/or NPP service plan into the case plan. See Parent Skill-Building Services.

A case plan staffing or court order is not required in order to add or change the services or supports provided to meet the needs of the child(ren), parent(s), and/or out-of-home caregiver(s). At any time a service or support is determined to be ineffective or an additional service becomes necessary, the DCS Specialist should discuss the change with the individual receiving the service and discuss the plan to modify the service or support.

List the agreed upon services to help the family for all parents, guardians, and/or custodians, or other adults who have a caregiving role. Services must be tailored to meet the specific needs of the family, and include services for the out-of-home caregivers where appropriate, to prevent removal of the child and/or reunify the family. See Planning for Services and Supports to Achieve Permanency.

Record the child’s needs as well as supports and services for children placed in out-of-home care to ensure that the child's medical, educational, and psychological needs are addressed. Include the most recent information available regarding the child's needs and the identified services to address the needs.

Include for each child, age or developmentally appropriate activities the child is participating or will participate in, and services or tasks to achieve this.

Education Plan & Educational Stability

Every child in out-of-home care shall have an Education Plan as a component of the case plan. For school-aged children placed in out-of-home care, describe the reasonable efforts that will be made to provide educational stability. The DCS Specialist will utilize the Education Plan to document the most recent information available regarding the child’s education status including:

• the name and address of the child’s school;

• the child's educational status including child’s grade level, academic performance, special education services if applicable, attendance and any other relevant education information;

• indication of whether the child is attending school in their home school district; and if not the plans to help the child transition into the new school setting;

• any special needs of the child.

The DCS Specialist will attach the Education Plan to the completed Case Plan.

See Education Services for Children in Out-of-Home Care and Special Education and Early Intervention Services for Children in Out-of-Home Care.

Health Plan

Every child in out-of-home care shall have an individualized Health Plan as a component of the case plan. The DCS Specialist will utilize the Health Plan to document the most recent information available regarding the child’s health status including:

• name and address of the child’s healthcare providers;

• the child’s immunizations;

• the child’s known medical problems;

• the child’s known medication;

• any other relevant health information; and

• actions to assure the child’s health needs are met.

The DCS Specialist will attach the Health Plan to the completed case plan.

Transition Plan

Complete the Transition Plan for all children age 14 and older, and for young adults age 18 and older participating in continued care through a voluntary agreement. See Services and Supports to Prepare Youth for Adulthood for more information on what to include in the Transition Plan. The DCS Specialist must complete the Transition Plan in the Transition to Adulthood tab and attach it to the completed Case Plan.

Family Contact Plan

For children placed in out-of-home care, describe the plan for visitation with parents, siblings, etc. Develop the Family Contact Plan in accordance with guidelines in Parenting Time and Family Contact Plan. The DCS Specialist must complete the Family Contact Plan and attach it to the completed Case Plan.

Case Plan Agreement

Explain to the service team that the case plan agreement signature sheet serves as acknowledgement that the DCS Specialist has reviewed the case plan with the family, other service team members, and participants.

Ask the family and other service team members in attendance at the case plan staffing to sign the case plan agreement, and note whether they agree or disagree with the plan.

Provide a copy of the case plan to all members of the service team, whether or not they attend the case plan staffing, within five days of completing the case plan staffing.

Reassessment of Case Plan

Using information gained through the completion of the Family Functioning Assessment, protective factors assessment (when applicable), and engagement with the family, the DCS Specialist, parents, guardians and/or custodians, and other service team members reassess the case plan together:

• at least every 6 months; and

• at specified key decision points in the life of a case, including when a change in the permanency goal is considered or there is a significant change in case circumstances.

Confirm that services have been initiated as scheduled, and are addressing the needs of the family. Explore the effectiveness of the interventions offered with the parent, guardian and/or custodian(s) and consider their input to ensure services are culturally relevant and maximize the family’s self-determination and commitment to the process of change.

Although the case plan is reassessed and revised at specific intervals, ongoing monitoring of services occurs on a monthly basis. Changes to services may be made at any time it is appropriate to do so.

The reassessment of the case plan should determine whether:

• desired behavioral changes have been achieved, meaning previously diminished caregiver protective capacities have been sufficiently enhanced;

• the same services and supports shall be continued;

• services and supports shall be changed; or

• no available service or intervention will enable the parent, guardian and/or custodian to adequately address the safety threats within a time frame that meets the needs of the child, and a change in permanency goal should be considered.

Provide a copy of the revised case plan to all members of the family and service team within 5 days of the case plan staffing being completed.

Documentation

If applicable, document the proposed case plan in the Preliminary Protective/Initial Court Hearing Report.

Review and update the Health and Education tabs as needed.

Update the Person Demographics tab and Native American Details tab when new/updated information is received.

Document in Notes within 10 days, the case plan invitation and list of service team members invited to the case plan staffing.

Create and document case plans in the Plans tab. Follow the prompts to document all the necessary components of the case plan.

Document the education, living arrangement, and supports and services currently provided and scheduled to be provided to support educational stability in Notes.

For all youth age 14 and older, and for young adults age 18 and older participating in continued care through a voluntary agreement, document anticipated outcomes and tasks related to the preparation for adulthood in the Transition Plan. Ensure the youth’s preparation for foster care discharge is reflected in the Transition Plan.

Document the plan for contact with parents, siblings, etc. in the Family Contact Plan.

Document the supports and services to be provided to the out-of-home caregiver in the Case Plan.

Document in Notes the detail of case plan staffings, including participation and input from parents, children, and other family members.

Document whether the participants agreed or disagreed with the case plan. If a participant is unsure, select "undetermined" and record the service team member(s) reason for disagreeing with the case plan, efforts to reach consensus and the outcome in case notes, Case Conference/Staffing type.

File the hard copy of the case plan in the case record.

If changes in services need to occur between scheduled review dates, document these changes in Notes within 10 days.

Effective Date: January 3, 2023

Revision History: November 30, 2012, February 12, 2016, January 31, 2018, February 1, 2021, July 23, 2021