Case 2:89-cv-00859-AHN
Document 502-5
Filed 11/07/2005
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LINK Extraction Tool for the 2005 Outcome Measure Case Review (Outcome Measures 3-22) Final Version Dated April 28, 2005
Administrative
A.1 Reviewer Name: (check the appropriate box below) 1. Collins, Debra 5. Hofferth, Lisa 2. Corcoran, Mary 6. Kolpinski, Kathie Gonzalez, Janet 7. LaBelle, Janet 3. Hartmann, MaryAnn 8. Marks-Roberts, Susan 4. 9. 10. 11. 12. Roderick, Joni Beth Rothfarb, Eileen Somaroo-Rodriguez, Kim Other
A.2 A.3
Date of LINK Extraction: ________ / ________ / 2005 (MM/DD/YYYY) Is this case selected for the sub-sample interview? 1. Yes 2. No
Demographics
D.1 Treatment Case Assignment Type 1. CPS In-home family (IHF) case CPS Child-in-Placement (CIP) case 2. 3. Associated family case to Child-in-Placement (ACIP or VSACIP) case Voluntary Services In-home family (VSIHF) case 4. Voluntary Services Child-in-Placement (VSCIP) case 5. LINK Case Number: _________________ LINK Family Case or Child's Name: _______________________________ (LAST NAME, FIRST NAME) LINK Person ID Number (Case name or child-in-placement): _____________ Child's Date of Birth: ______/_______/_________ (MM/DD/YYYY) (enter 11/11/9999 if IHF, ACIP, VSACIP, VSIHF) Race (Child's or Family Case Name): American Indian or Alaskan Native 1. Asian 2. 3. Black/African American Native Hawaiian 4. White 5. 6. Unknown Blank (no race selected in LINK) 7. UTD 8. 9. Multiracial Ethnicity (Child's or Family Case Name): 1. Hispanic Non-Hispanic 2. 3. Unknown Blank (no ethnicity selected in LINK) 4. Date the case was most recently opened/reopened: ____/_____/_______(MM/DD/YYYY)
D.2 D.3
D.4 D.5
D.6
D.7
D.8
Case ID __________________________________
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D.9
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Current residence of child on the date of this review: 1. Detention Group Home 2. Home of biological parent, adoptive parent or legal guardian 3. 4. In-state hospital setting In-state DCF foster care setting 5. In-state private provider foster care setting 6. 7. In-state residential setting Out-of state residential setting 8. 9. Out-of-state foster care setting 10. Out-of-state hospital setting Pre-Adoptive Placement 11. 12. Safe Home Shelter 13. TLAP/CHAPS 14. 15. N/A - In-home family case N/A- Associated Family to CIP or VSCIP case 16. Social Worker's Office: 1. Bridgeport Danbury 2. 3. Greater New Haven Hartford 4. Manchester 5. 6. Meriden Middletown 7. New Britain 8. 9. New Haven Metro Norwalk 10. Norwich 11. 12. Stamford Torrington 13. 14. Waterbury Willimantic 15.
D.10.
D.11 What is the child in placement's legal status on May 15, 2005? 1. 96 hour hold Committed 2. Dually Committed 3. 4. Not Committed OTC 5. 6. TPR 7. N/A In-Home Family Case (Voluntary, AFCIP, or CPS) D.12 On May 15, 2005 were any children in this in-home case under protective supervision? 1. Yes No 2. 3. N/A Not an In-Home Case D.13 On May 15, 2005 what is the status of this case? 1. Open/Reopen 2. Closed
Case ID __________________________________
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Case Management Issues
CM.1 What is the assigned Social Worker's name as of the date of the case review (today)? ____________________________________(LAST NAME, FIRST NAME)
CM.2 What is the name of the Social Work Supervisor as of the date of the case review (today)? ______________________________(LAST NAME, FIRST NAME) CM.3 Date of most recent removal from home: _______/________/__________(MM/DD/YYYY) (enter 11/11/9999 if IHF, VSIHF)
CM.4 Has/was this child in out of home care for at least 6 months as of May 15, 2005 (or date of case closure during the quarter ending May 15, 2005)? 1. Yes No 2. 3. N/A In-Home Case (IHF or VSIHF) CM.5 Do supervisory conference notes indicate that the SWS and SW discussed risk factors in the case during the period of February 15, 2005 May 15, 2005? 1. Yes No 2. 3. UTD No SWS narratives in LINK during this period CM.5a How many supervisory conferences are documented during this period? ___________ CM.6 In reference to the supervisory conferences in CM.5 above, did the SWS offer clear directives on how to proceed with the case to minimize the risks identified? 1. Yes No 2. 3. N/A no risks identified UTD no SWS narratives during this period 4. CM.6a In the reviewers opinion were there clear risk factors present within the documentation for the case that were not addressed in SWS conferences? 1. Yes No 2. UTD No SWS narratives in LINK during this period 3. CM.7 Reading all narratives related to the case events during this period does the reviewer feel that the supervision provided was: 1. Negligible Poor 2. Good 3. 4. Exellent Please document your rationale for the rating on the reverse of this page. CM.8 Were the SWS' directives followed by the SW in the prescribed manner and timeframe from the date of supervisory conference documentation? 1. All directives were followed 2. Partial compliance with SWS directives noted 3. No directives were followed N/A no directives issued 4. 5. UTD - No narratives during this period
Case ID __________________________________
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CM.9 What was the child's stated goal on the most recent approved treatment plan in place during the period November 15, 2004 May 15, 2005? 1. Reunification Adoption 2. Transfer of Guardianship 3. 4. Other Permanent Living Arrangement: Long Term Foster Care Other Permanent Living Arrangement: Independent Living 5. In-Home Goals Safety/Well Being Issues 6. 7. Other UTD Plan incomplete, unapproved or missing for this period 8. CM9a. If "Other is indicated in CM9, specify here: ________________________ CM.10 What is the concurrent plan? ______________________ / _______________________ 1st State Goal / 2nd Stated Goal CM.11 Did the social worker actively manage the case so that both goals were concurrently being pursued? 1. Yes 2. No N/A There is not a concurrent plan 3. 4. N/A In-Home case 5. UTD there is no approved treatment plan in place for the period of November 15, 2004 May 15, 2005 CM.12 Was the goal as identified on the most recent approved treatment plan (November 15, 2004 May 15, 2005) changed from the stated goal in the prior approved treatment plan? 1. Yes 2. No N/A there was no prior approved treatment plan with which to compare goals. 3. UTD there is no approved treatment plan in place for the period of November 15, 2004 4. May 15, 2005 5. UTD case closed prior documentation locked down CM.13 Did this stated DCF treatment plan goal coincide with the court approved permanency goal? 1. Yes 2. No No court approved plan required 3. UTD No Legal Narratives in the twelve month period ending May 15, 2005 4. 5. UTD child placed via OTC pending court date no court approved goal of CIP CM.14 What is the target date for goal achievement on the most current DCF 553 (completed November 15, 2004 May 15, 2005)? ________/_________ (MM/YYYY) CM.15 Has TPR been filed for the child in question? 1. Yes No 2. N/A child's goal did not require termination of parental rights 3. 4. N/A In-home case (CPS or Voluntary Services) CM.16 Enter the date of filing here: ________/_________/__________ (11/11/9999 if not applicable) CM.17 Has TPR been granted? 1. Yes No 2. 3. N/A DCF did not file TPR 4. N/A In-home case (CPS or Voluntary Services) CM.18 Enter date that TPR was granted: _________/_________/__________ (11/11/9999 if not applicable)
Case ID __________________________________
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CM.19 What court granted TPR? ______________________________ (enter SKIP if not applicable) CM.20 Is there LINK documentation that the parent(s) appealed the TPR? 1. Yes No 2. 3. N/A TPR not applicable to this case TBD TPR is currently pending 4. UTD Appeal window not yet expired 5. CM.21 For children in placement on May 15, 2005 with a singular or concurrent goal of adoption or transfer of guardianship, has a permanent resource been identified? 1. Yes No 2. 3. N/A child is not in placement on May 15, 2005 N/A child does not have the goal of adoption or TOG on May 15, 2005 4. N/A child achieved goal of adoption during the quarter 5. CM.22 For children in placement on May 15, 2005 with a singular or concurrent goal of adoption or transfer of guardianship, has the child been placed with the identified resource? 1. Yes No 2. N/A child is not in placement on May 15, 2005 3. 4. N/A child does not have the goal of adoption or TOG on May 15, 2005 N/A child achieved goal of adoption during the quarter 5.
CM.23 For children in out of home placement at any point during the period of February 15, 2005 May 15, 2005 with TPR status, does the record indicate that a Life Book has been initiated to identify all familial ties, placement history, and information suitable for the child's level of understanding? 1. Yes 2. No N/A child's legal status is not TPR 3.
Outcome Measure #3 - Treatment Plans
For this section of the data collection instrument, the reviewer should refer to the most recent SWS approved treatment plan and ACR/TPC documentation in LINK. Reminder, if the date of the most recent TPC/ACR entered in question OM3.1 is greater than 7 months old, be sure to select the appropriate N/A responses for the remaining question within this section. OM3.1 What is the date of the last documented TPC/ACR? ________/_________/_______(MM/DD/YYYY) OM3.2 Does LINK document a treatment plan that corresponds to a TPC/ACR held during the period of November 15, 2004 May 15, 2005? 1. Yes No 2. 3. N/A No TPC/ACR conducted in the period of November 15, 2004 May 15, 2005 OM3.3 Is this treatment plan approved in LINK by the SWS? 1. Yes No 2. 3. N/A No TPC/ACR conducted in the period of November 15, 2004 May 15, 2005 OM3.3A What is the date of the SWS approval on this plan? _________/_________/_________(MM/DD/YYYY)
Case ID __________________________________
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OM3.4 Is the most recent SWS approved treatment plan in compliance with the timing requirement set in policy? (Policy = treatment plan within 60 days of the date the case opening in ongoing services/child entered placement or less than 7 months of the prior treatment plan) 1. Yes No 2. 3. N/A-No SWS approved treatment plan documented in the period of Oct 15, 2004 May 15, 2005 OM3.5 Per the reviewers reading of LINK narratives and the Case Maintenance information, were all appropriate parties officially invited to participate in the most recent treatment planning conference/administrative case review via the DCF 556 letter? 1. Yes No 2. 3. UTD LINK information does not provide insight into case participants N/A there is no TPC/ACR documented from November 15, 2004 May 15, 2005 4. OM3.6 If written letters were not issued, were all appropriate parties given advance notice to participate via documented phone contact? Yes 1. 2. No UTD LINK information does not provide insight into case participants 3. N/A there is no TPC/ACR documented from November 15, 2004 May 15, 2005 4. 5. N/A letters were issued to all appropriate parties. OM3.7 If there is any documentation that the family or child requested the meeting be rescheduled at least 24 hours in advance of the meeting, was this request granted? 1. Yes No 2. 3. N/A there is no TPC/ACR documented from November 15, 2004 May 15, 2005 N/A No request recorded in LINK 4. OM3.8 If ACR/TPC was for a child in placement age 12 or older was the conference scheduled at a time that accommodated his educational program so that he/she could participate (either in person or via phone conference)? 1. Yes No 2. UTD No ACR/TPC or child in placement (over age 12) not invited to participate 3. 4. N/A Child is not required to participate due to age (less than 12) or mental health N/A In-Home case 5.
Using the table below indicate via check mark in the appropriate column whether the following individuals were invited by letter to participate in the most recent ACR/TPC documented from November 15, 2004 May 15, 2005?
Yes OM3.9 OM3.10 OM3.11 OM3.12 0M3.13 0M3.14A OM3.14B OM3.15 OM3.16 OM3.17A 0M3.17B 0M3.18 Mother (or Legal Guardian) Father Father 2 Father 3 Child over 12 Child's Caretaker 1 Child's Caretaker 2 All Active Service Providers Child's Attorney Father's Attorney Mother's Attorneys Other DCF Staff No N/A No ACR/TPC Held
Case ID __________________________________
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OM 3.19(a-hh): Who was involved in the development of the treatment plan and who participated in the TPC/ACR? (Check all that apply in the table found on page 8) Note: If there is no plan less than seven months old on May 15, 2005 select "No Plan". If there is no documented TPC/ACR in the period of November 15, 2004 through May 15, 2005 select "No ACR". For the Agency Provider use the Service Provider Type table to choose a category that best fits that type of Agency Provider that the child/family has utilized in the period leading up to the current plan. "Developed in conjunction with" is defined as a documented discussion held between the SW/SWS or with an identified party that indicates that the participant had active knowledge of the service need to be addressed, and what was required to address that service need in the upcoming 6 months. Use your review of the narratives and the case maintenance screens to determine who should have been included and enter those participants in the left column. Select N/A only if the identified party is not applicable to the case. Identify the "other participant" by generic title, such as Guardian, Grandparent, Attorney, GAL, etc. Service Provider Type 6. Housing 10. Substance Abuse 7. Medical 11. Support Out of Home 8. Mental Health 12. Support In Home Services 9. Out-of-Home Care 13. Training
1. Childcare 2. Dental 3. Domestic Violence 4. Education 5. Employment
Plan developed in conjunction with party indicated to the left
Party participated in the TPC/ACR 3.19b. Yes No N/A UTD No ACR
Mother Father Father 2
3.19a. Yes
No
N/A
No Plan
3.19c. Yes
No
N/A
No Plan
3.19d. Yes
No
N/A
UTD
No ACR
3.19e. Yes
No
N/A
No Plan
3.19f. Yes
No
N/A
UTD
No ACR
Father 3 Child (12 and older) (CIP case only) 3.19k Agency Provider ________________ 3.19n Agency provider ________________ 3.19q Agency provider _______________ 3.19t Agency provider ________________
3.19g. Yes
No
N/A
No Plan
3.19h. Yes
No
N/A
UTD
No ACR
3.19i. Yes
No
N/A
No Plan
3.19j. Yes
No
N/A
UTD
No ACR
3.19l. Yes
No
N/A
No Plan
3.19m. Yes
No
N/A
UTD
No ACR
3.19o. Yes
No
N/A
No Plan
3.19p Yes
No
N/A
UTD
No ACR
3.19r. Yes
No
N/A
No Plan
3.19s. Yes
No
N/A
UTD
No ACR
3.19u. Yes
No
N/A
No Plan
3.19v. Yes
No
N/A
UTD
No ACR
Case ID __________________________________
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Plan developed in conjunction with party indicated to the left
Party participated in the TPC/ACR
3.19w. Agency provider ________________ 3.19z. Other case participant ___________________ 3.19cc. Other case participant ___________________ 3.19ff. Other case participant ___________________
3.19x. Yes
No
N/A
No Plan
3.19y. Yes
No
N/A
UTD
No ACR
3.19aa. Yes
No
N/A
No Plan
3.19bb. Yes
No
N/A
UTD
No ACR
3.19dd. Yes
No
N/A
No Plan
3.19ee. Yes
No
N/A
UTD
No ACR
3.19gg. Yes
No
N/A
No Plan
3.19hh. Yes
No
N/A
UTD
No ACR
OM3.20. Did the facilitator in the TPC/ACR require a need for change/amendment or addition to the treatment plan used by participants of the TPC/ACR? 1. Yes 2. No UTD- the DCF-553-F/DCF-553-CIP was not completed 3. OM3.21. Were the required changes/amendments or additions identified for OM3.20 entered into the treatment plan? 1. Yes No 2. 3. N/A no changes were required by the 553 UTD the DCF-553-F/DCF-553-CIP was not completed 4. OM3.22 Was the treatment plan then approved by the SWS on the date of or within 10 days of the TPC/ACR? 1. Yes 2. No N/A treatment plan was approved by the SWS prior to the ACR 3. UTD the DCF-553-F/DCF-553-CIP was not completed 4. There is no treatment plan less than 7 months old at the point of review. 5. OM3.23 3.26: How did the ACR/TPC facilitator rank the level of progress within the case for the period leading up to the most recent ACR/TPC held during the period of November 15, 2004 May 15, 2005? Overall Rating Fully Achieved (100%) Almost Achieved (75% - 99%) Moderately Achieved (50% - 74%) Limited Progress (25% - 49%) No or Almost No Progresss (<25%) Too Soon to Rate (Services in place less than 30 days) 7. Participant N/A to this Case 8. UTD No DCF 553 Documentation 1. 2. 3. 4. 5. 6. Mother OM 3.23 Father OM 3.24 Guardian OM 3.25 Child/Youth OM 3.26
Case ID __________________________________
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OM3.27 Was the SWS approved treatment plan document prepared (or subsequently translated) in the primary language of the family or child selected for this review (D4)? 1. Yes No 2. UTD 3. 4. N/A Child is TPR and under age 12 N/A No approved treatment plan documented 5. OM3.28 Was the TPC/ACR conducted in the primary language of the family or child identified in Question D.4? 1. Yes- no interpreter needed 2. Yes- interpreter participated No 3. 4. UTD N/A Child is TPR and under age 12 5. N/A There is no record of an ACR in the period of November 15, 2004 May 15, 2004 6. OM3.29 A-0. Indicate if the following elements are included in the most recent treatment plan (within the review period November 15, 2004 May 15, 2005). 1. Yes OM3.29 OM3.29 OM3.29 OM3.29 OM3.29 OM3.29 OM3.29 A. A clear description of household members and each identified member (or description of child-in-placement) B. Prior relevant case history C. Reason for most recent case opening D. Presenting issues and problem areas as identified by DCF or provider assessment E. Family issues as perceived by the parent/caretaker/child (if over age 12) F. Family or child's strengths G. Family or child's needs (medical, dental, mental health, educational, other service needs-housing, childcare, employment, transportation, etc.) H. Responsibilities of children, parents, caretakers, service providers and DCF for reaching identified case goals (tasks required during the planning period) I. Clearly stated case/permanency goal J. Identification of the measurement of participants' progress toward and achievement of stated goal (for those adolescents where applicable, this includes the attachment of a completed Independent Living Plan DCF-2091) K. Timelines for completing tasks/expectations related to the case goal/permanency goal L. Proposed services and identified responsible parties M. Legal activity and status during the preceding treatment planning period. N. No elements (A-M) were included in the treatment plan O. No approved treatment plan to review 2. No
OM3.29
OM3.29 OM3.29
OM3.29 OM3.29 OM3.29 OM3.29 OM3.29
OM3.30 Does the treatment plan include reasonable efforts as determined by the court to prevent out of home placement? 1. Yes No 2. 3. N/A IHF, VSIHF, VSCIP or AVSCIP case 4. N/A -No treatment plan during the period of November 15, 2004 May 15, 2005
Case ID __________________________________
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OM3.31 Does the treatment plan include reasonable efforts to reunify the child with their family in a timely manner (including a description of the services that have been offered and provided)? 1. Yes No 2. 3. N/A-Judicial determination that reasonable efforts are no longer appropriate, or goal is not reunification N/A IHF, VSIHF, VSCIP or AVSCIP case 4. 5. UTD Pending Court Decision related to reasonable efforts at point of review. N/A No treatment plan during the period of November 15, 2004 May 15, 2005 6. OM3.32 Does the treatment plan include a synopsis of the current Visitation Plan for the parent(s)/guardian with the child who is placed out of the home? 1. Yes No 2. N/A- Visitation Plan not needed (e.g. child is TPR'd) 3. 4. IHF or VSIHF case N/A No treatment plan during the period of November 15, 2004 May 15, 2005 5. OM3.33 Does the treatment plan include a synopsis of the current Visitation Plan for this child with his/her siblings who are not placed together? 1. Yes 2. No N/A- Visitation Plan not needed (e.g. child does not have siblings or siblings placed 3. together) 4. IHF or VSIHF case N/A No approved treatment plan during the period of November 15, 2004 May 15, 2005 5.
Outcome Measure #4 - Search for Relatives (Proposal Review Question #4)
For this section review information from the date of the child's removal from home through the first six months of placement.
STOP: Answer Question4.1 Question 4.5, only if the case has had an identified child in placement and only if that child entered DCF out of home care on or after January 1, 2004 .If not applicable check here: On May 15, 2005... .
OM4.1A Is Child currently placed with relatives? OM4.1B Is child currently placed in a special study home? OM4.2 Was child reunited home during the period of review? 1. Yes 1. Yes 1. Yes 2. No 2. No 2. No and SKIP the remaining questions in OM4.
Case ID __________________________________
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OM4.3A1 4.3H6: Using the table below, please enter "0" if child was not in care during the identified month within the six months following placement. Enter "1"if the LINK narrative indicates that the Social Worker/Social Work Supervisor (includes Investigation SW/SWS as well as Ongoing Services)addressed the following topics, enter a "2" if there is no documentation of such issues and child still required a resource, enter "99" if not applicable ( placement resource is no longer needed or required actions could not be conducted as no person(s) were identified to act upon): Topic Addressed in SW/SWS Narratives or New LINK Relative Search Narratives:
A. Discussed with Parent/Guardian possible resource for placement, for the child-in-placement Discussed (as appropriate) with child possible resources for placement, respite, visiting resources or other supportive resource Had contact with the person identified as resource for placement, respite, visiting resources or other supportive resource Documented determination of appropriateness or non-appropriateness of the person identified as a resource for placement, respite, visiting resources or other supportive resource Completed criminal record checks on person identified as a resource for placement, respite, visiting resources or other supportive resource
Month following child's removal from home: 1
4.3A1
2
4.3A2
3
4.3A3
4
4.3A4
5
4.3A5
6
4.3A6
B
4.3B1
4.3B2
4.3B3
4.3B4
4.3B5
4.3B6
C
4.3C1
4.3C2
4.3C3
4.3C4
4.3C5
4.3C6
D
4.3D1
4.3D2
4.3D3
4.3D4
4.3D5
4.3D6
E
4.3E1
4.3E2
4.3E3
4.3E4
4.3E5
4.3E6
F Requested a Special Study (or relative study) from FASU regarding the person identified as a resource for placement, respite, visiting resources or other supportive resource G H Exhausted all identified resources for placement Was successful in achieving placement for the child with identified resource
4.3F1
4.3F2
4.3F3
4.3F4
4.3F5
4.3F6
4.3G1
4.3G2
4.3G3
4.3G4
4.3G5
4.3G6
4.3H1
4.3H2
4.3H3
4.3H4
4.3H5
4.3H6
OM4.4. There is documentation in LINK indicating that a search was conducted for possible placement resources during the period of review. 1. Yes 2. No OM4.5. Did the search for relatives or other possible placement resource known to the child begin in the investigatory phase of the case. 1. Yes No 2. N/A Ongoing Services already searching at point of investigation 3. OM4.6 Was use of Locate Plus software documented in the search process? 1. Yes 2. No
Case ID __________________________________
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OM4.7 Did the area office request a waiver from Central Office to grant a relative with a criminal or CPS background a relative license? 1. Yes 2. No OM4.8 If waiver was requested at the Central Office level, was it granted? 1. Yes 2. No 3. N/A OM4.9 Reviewers Opinion: From your review of the record, are there any family or other persons known to this child that have not been given proper consideration ? 1. Yes 2. No OM4.9a-c. If yes, list up to three resources that you feel should be explored that have not been documented by the worker.
a. _____________________
b. _______________________ c. __________________________
Case ID __________________________________
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Outcome Measure 5: Repeat Maltreatment
STOP: Answer Question5.1 Question 5.122, only if the case has had an identified victim of substantiated abuse or neglect in the twelve months ending May 15, 2005. If not applicable, check here and do not answer any questions related to OM5
OM5.1 Has any child been identified as a victim of substantiated maltreatment in the twelve months ending May 15, 2005? 1. Yes No 2. OM5.2-OM5.112: Repeat Maltreatment Essential Data Elements - Directions: ColumnI: Enter Child's Name as Last Name, First Name (may enter up to 5 children in an InHome case). Column II: Enter the total number of substantiations during the 12 month period ending May 15, 2005.
Column III: Enter the substantiation code for any type of substantiation recorded during the twelve month period ending May 15, 2005. Enter any given code only once, separating by "/". 1. Educational Neglect 2. Emotional Abuse/Maltreatment 3. Emotional Neglect 4. Medical Neglect 5. Physical Abuse 6. Physical Neglect 7. Sexual Abuse/Exploitation 8. Moral Neglect Column IV: Enter the relationship code to explain the relationship between the perpetrator and child for any type of substantiation recorded during the twelve month period ending May 15, 2005. Enter any given code only once, separating by "/". 1. Daycare Provider 8. Parent or Guardian's Paramour 2. Father 9. Residential Facility Provider 3. Foster Parent 10. Sibling's Father 4. Grandparent 11. Sibling's Mother 5. Guardian 12. Stepfather 6. Mother 13. Stepmother 7. Other Relative Caretaker 14. Other Enter the total number of Non-substantiated reports involving the child(ren) listed in Column I during the twelve months period ending May 15, 2005.
Column V:
Column VI: Enter the total number of Regulatory Violations cited against any provider in relation to the child(ren) listed in Column I during the twelve months period ending May 15, 2005.
Case ID __________________________________
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I
II
III
IV
V # of Nonsubstantiated Reports
VI
Relationship between child and Perpetrator
# of Substantiated Reports
Child's Name
OM5.2
OM5.3
OM5.4-OM5.9
OM 5.10 OM5.23
OM5.24
OM5.25
OM5.26
OM5.27
OM5.28 OM5.33
OM5.34-OM5.47
OM5.48
OM5.49
OM5.50
OM5.51
OM5.52-OM5.57
OM5.58-OM5.72
OM5.73
OM5.74
OM5.75
OM5.76
OM5.77-OM5.82
OM5.83-OM5.96
OM5.97
OM5.98
OM5.99
OM5.100
OM5.101-OM5.106
OM5.107-OM5.120
OM5.121
OM5.122
OM5.123a-e. If "other was selected as response for any child in Column IV (Relationship between Child and Perpetrator) Please indicate the relationship here: a. ______________________________ b. ______________________________ c. ______________________________ d. ______________________________ e. ______________________________ OM5.124 Were any of the instances of maltreatment (date of incident or acceptance date at Hotline if date is not recorded) separated by less than a six month window of time? 1. Yes No 2. 3. N/A one or no substantiated allegations during this time frame. OM5.125 Was the perpetrator the same in any repeat occurrences of substantiated abuse or neglect in the time period? 1. Yes No 2. 3. N/A one or no substantiated allegations
Case ID __________________________________
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# of Regulatory Violations cited
Type of Substantiations
Case 2:89-cv-00859-AHN
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Filed 11/07/2005
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OM5.126 Were any substantiations in the second (or later) report(s) identical in nature to the first documented substantiation during the 12 month period ending May 15, 2005? 1. Yes No 2. N/A one or no substantiations 3. OM5.127 At the time of the initial substantiation identified for this family during the twelve month period ending May 15, 2005, were services offered to ameliorate the stressors or issues contributing to the episode of abuse or neglect? 1. Yes 2. No 3. N/A - Child was removed for safety reasons N/A Services were already in place 4. OM5.128 Did the investigation worker make the referrals for all services offered? 1. Yes No 2. N/A - Child was removed for safety reasons 3. 4. N/A Services were already in place OM5.129 Did the client(s) participate1 in the referred services? 1. All members participated in all of the referred services All members participated in at least one of the referred services 2. 3. Some members participated in at least one of the referred services No members participated in referred services 4. N/A No services were offered by the SW (but were needed) 5. 6. N/A No services required (i.e. perpetrator is whereabouts unknown or has no further access to child) OM5.130 Was the case transferred to treatment following the initial substantiation during this period? 1. Yes 2. No N/A case already open in treatment 3. OM5.131 Does the social worker's LINK narrative indicate concerns related to the safety of the child specifically does the narrative indicate that the worker (investigation or treatment) conducted an assessment of risk during face to face contact with the child and family in the 6 month period following the family's initial substantiation during the period of 12 months ending May 15, 2005? 1. Yes 2. No 3. UTD LINK indicates no face to face contacts 4. N/A There was no open DCF case (investigation or treatment) during the period between the finding of the initial substantiation and the subsequent report to be substantiated. OM5.132 In the opinion of the reviewer, based on the review of the record the risk assessment activity of this worker was: 1. Adequate (concerns identified by SW who assessed risk and planned accordingly) 2. Inadequate (concerns identified by SW but did little assessment of risk or nothing further with the documented concerns) Inconclusive (SW had little or no documentation of visits upon which reviewer can base 3. determination)
1
Particpate defined as participating in service beyond the introductory or assessment session.
Case ID __________________________________
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OM5.133 In the opinion of the reviewer, did DCF prematurely reunite this child(ren) with his/her family or allow the child(ren) to remain in the family setting in spite of known risk factors (grounds for removal), and as a result, a subsequent substantiation occurred? 1. Yes No 2. 3. N/A no subsequent substantiations occurred N/A Court Ordered Reunification in spite of DCF protest 4. OM5.134 What intervention provided in the year ending May 15, 2005 most increased the likelihood that the family will sustain a level of functioning and avoid repeat maltreatmemt? ______________________________ OM5.135 Which intervention provided in the year ending May 15, 2005 was least helpful to increasing the level of family functioning? ________________________________ Briefly explain your responses to OM5.134 and 5.135 on the reverse side of this page.
Outcome Measure 6 Maltreatment of Children in Out of Home Care
STOP: Answer if child was in placement at any point during the period of February 15, 2005 May 15, 2005. If it does not apply to your case, check here questions in OM6. and SKIP the remaining
Please indicate the number of times during the quarter ending May 15, 2005 that the identified child has been a substantiated victim of abuse/neglect by an out of home care provider (foster parent or residential personnel), or was subject to inappropriate treatment in a placement for which the provider was cited with regulatory violations. OM6.1 Substantiations ____________ OM6.2 Regulatory violations ____________ OM6.3 Looking at the most recent substantiation, were support services provided to the placement resource following the substantiation or regulatory violation? 1. Yes No 2. N/A there were no incidents of substantiation or regulatory violations in child's out of 3. home placement during the quarter ending May 15, 2005
OM6.4 Was the placement overcapacity at the time of any substantiation or regulatory violation during the quarter ending May 15, 2005? 1. Yes 2. No N/A there were no incidents of substantiation or regulatory violations in child's out of 3. home placement during the quarter ending May 15, 2005 OM6.5 If there were substantiations or regulatory violations cited for this foster home, was the violation handled per the requirements of DCF Policy? 1. Yes 2. No 3. N/A there were no incidents of substantiation or regulatory violations in child's out of home placement during the quarter ending May 15, 2005
Case ID __________________________________
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OM6.6 Identify the provider for which the most recent substantiation occurred during the quarter ending May 15, 2005. Does this provider have a pattern of regulatory violations, or substantiated reports? 1. Yes a pattern is documented No there was no pattern discernible 2. 3. N/A there were no incidents of substantiation or regulatory violations in child's out of home placement during the quarter ending May 15, 2005 OM6.7 In reviewing the provider record of the foster care provider most recently substantiated or cited with regulatory violations, has the FASU worker document a quarterly visit to the home and assess training or support needs? 1. Yes No 2. 3. N/A there were no incidents of substantiation in a foster home placement during the quarter ending May 15, 2005 OM6.8 In reviewing the provider record of the foster care provider most recently substantiated or cited with regulatory violations has the FASU worker documented the annual support plan to address the investigations concerns? 1. Yes No 2. N/A there were no incidents of substantiation in a foster home placement during the 3. quarter ending May 15, 2005 OM6.9 At this juncture (upon your review) is the documented support plan (addressing regulatory or investigation concerns) in the process of implementation? 1. Yes No 2. 3. N/A No incidents of substantiation or regulatory violation UTD No Support Plan 4. UTD No FASU narratives followed documentation of the support plan 5.
Outcome Measure 7 - Reunification
STOP: Answer this section only if the child was reunified during the period of February 15, 2005 May 15, 2005. If this is not the case, check this box questions in OM7. and SKIP the remaining
OM7.1 Was this child reunified during the period of February 15, 2005 May 15, 2005? 1. Yes No 2. OM7.2 Did reunification occur within 12 months of the removal from home? 1. Yes No 2. OM7.3 Enter the time frame from the first date of current placement episode to the date of reunification: _______ (round to the nearest month) OM7.4 Does the LINK record indicate a specific therapeutic reason for child's placement exceeding 12 months in care? (e.g. child needed to complete program or service) 1. Yes 2. No 3. N/A Child reunified in 12 months or less
Case ID __________________________________
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OM7.5 Does LINK indicate that parent's treatment needs required child's placement to exceed 12 months in care? (e.g. Parent engaged in service DCF required prior to reunification) 1. Yes No 2. N/A Child reunified in 12 months or less 3. OM7.6 OM7.23. From your review of the LINK record, please indicate (circle 1 for "yes", 2 for" no") if the following could be identified barriers for extending the child's time in DCF custody: Yes OM7.6 DCF Approval/Financing Issues OM7.7 DCF Case Management OM7.8 Client Insurance Issues OM7.9 Parent whereabouts unknown OM7.10 Parent refused all services OM7.11 Parents unable to rehabilitate OM7.12 Parent needs affordable housing OM7.13 Incarceration OM7.14 Child refusing to go home OM7.15 Transportation OM7.16 Provider(s) unwilling to engage client OM7.17 Placed on waiting list OM7.18 No slots were available OM7.19 Hours of operation (Alt. hours needed) OM7.20 Service not available in primary language OM7.21 Court OM7.22 UTD from LINK OM7.23 Other 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 No 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
OM7.24 If other, enter barrier here: _____________________________________ OM7.25 In the 6 months leading up to the reunification occurring during the quarter, did the Department facilitate increased visitation between the child and parent/guardian to whom reunification was the goal as the case progressed? 1. Yes No 2.
Case ID __________________________________
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Outcome Measure 8 Adoption
STOP: Answer this section only if the child was adopted during the period of February 15, 2005 May 15, 2005. If this is not the case, check this box OM8. and SKIP the remaining questions in
OM8.1 Has child been adopted in the period of February 15, 2005 May 15, 2005? 1. Yes 2. No OM8.2 Were there any barriers noted in LINK to timely adoption of this child? 1. Yes No 2. OM8.3 OM8.14: Circle the barriers to the timely adoption of this child: Yes 1 1 1 1 1 1 1 1 1 1 1 1 1 No 2 2 2 2 2 2 2 2 2 2 2 2 2
OM8.3 Approval Process OM8.4 Child Indecision OM8.5 Child's Deterioration higher level of care required OM8.6 Court delays OM8.7 DCF case management OM8.8 Disruption due to Abuse/Neglect OM8.9 Disruption due to child's behaviors OM8.10 ICPC or Private Agency OM8.11 Lack of adoptive resource OM8.12 Lack of community services (i.e PPSP/ in-home services) OM8.13 Pre-Adoptive Parent Indecision OM8.14 Subsidy Rate OM8.15 Adoption Timely (within 24 months) No Barriers
OM8.16 At how many months after most recent entry into DCF custody did the court grant TPR?________ OM8.17 Was child registered on the ARE? 1. Yes No 2. OM8.18 At how many months after most recent entry into DCF custody was the initial pre-adoptive resource identified? ________ OM8.19 Did the child remain in that initially identified pre-adoptive placement? 1. Yes 2. No OM8.20 How many preadoptive placements did this child experience prior to adoption? _____ OM8.21 At how many months after most recent entry into DCF custody was the child placed with the pre-adoptive resource that went on to become the adoptive resource? ________ OM8.22 Was this adoptive resource a Legal Risk home? 1. Yes No 2.
Case ID __________________________________
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OM8.23 If there is LINK documentation that an appeal was filed by the parents, for how long did the appeal process stall the adoption process? __________(round to the nearest month enter 99 if N/A) OM8.24 How many consecutive months was child in DCF custody prior to the date of adoption? ________ OM8.25 What court finalized the adoption? __________________ OM8.26 What was the date of the adoption finalization? ______/_______/_________ (mm/dd/yyyy) OM8.27 How many months after TPR did the finalization occur? _______ OM8.28 Was the adoption a subsidized adoption? 1. Yes No 2. OM8.29 Were Post Adoptive Services planned for the child/family? 1. Yes 2. No N/A Per LINK, family declined services 3. OM8.30 Was child receiving services through the community collaboratives at the point of adoption? 1. Yes 2. No N/A no special needs identified 3. UTD conflicting LINK documentation 4.
Outcome Measure 9 Transfer of Guardianship STOP: Answer this section only if there has been a TRANSFER OF GUARDIANSHIP during the period of February 15, 2005 May 15, 2005. For those cases not applicable check this box and SKIP the remaining questions in OM9. OM9.1 Has child had guardianship transferred in the period of February 15, 2005 May 15, 2005? 1. Yes 2. No OM9.2 Were there any barriers noted in LINK to timely transfer of guardianship for this child? 1. Yes No 2.
Case ID __________________________________
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OM9.3-OM9.15 : Check whether the identified barriers impeded the timely transfer of guardianship of this child: Yes No (1) (2) OM9.3 Approval Process OM9.4 Child Indecision OM9.5 Child's Deterioration higher level of care required OM9.6 Court delays OM9.7 DCF case management OM9.8 Disruption due to Abuse/Neglect OM9.9 Disruption due to child's behaviors OM9.10Guardian Indecision OM9.11 ICPC or Private Agency OM9.12 Identification of family resource OM9.13 Lack of community services (i.e. PPSP/In-home services) OM9.14 Subsidy Rate OM9.15 Statutory Requirement (12 month rule) OM9.16 No Barriers Timely TOG (within 24 months) OM9.17 How many consecutive months was child in DCF custody from the first date of the most recent placement episode to the date of TOG? ________ OM9.18 What court finalized the TOG? __________________________ OM9.19 Was the TOG subsidized? 1. Yes No 2. OM9.20 At how many months after most recent entry into DCF custody was the guardian resource identified? ________ OM9.21 At how many months after most recent entry into DCF custody was the child placed with the guardian resource? ________ OM9.22 How many placements did child have prior to placement with the TOG resource? _______ OM9.23 Does the LINK record indicate that After Care Services were provided for the child/family through the community collaboratives? 1. Yes No 2. N/A family declined services 3. 4. UTD conflicting LINK documentation
Case ID __________________________________
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Outcome Measure #10 Sibling Placement
STOP: Answer OM10.1 OM10.5 only if the case has had an identified child in placement and only if Child entered DCF out of home care on or after January 1, 2004 . If N/A check here: and SKIP the remaining questions in OM10 OM10.1 When the child entered placement, was the child placed together with siblings? 1. Yes, child entered placement and was placed with all siblings. No, siblings entered placement at same time but not placed together. 2. 3. N/A, there are therapeutic documented reasons for sibling separation N/A, there are no siblings. 4. N/A, there are siblings but not removed at the same time. 5. 6. UTD OM10.2 If initial placement did not maintain the sibling group, and barring any documented therapeutic reasons for separation, were siblings reunited into one placement location? 1. Yes 2. No N/A, there are therapeutic documented reasons for sibling separation. 3. N/A, there are no siblings. 4. 5. N/A, there are siblings but not removed at the same time. N/A, initial placement maintained the sibling group 6. OM10.3 As of the date of this review, is the sibling group placed together? 1. Yes No 2. N/A- there are therapeutic documented reasons for sibling separation 3. 4. N/A, there are no siblings N/A, no more than one child remains in placement 5. UTD 6. OM10.4 Does LINK indicate that there is a sibling visitation plan? 1. Yes 2. No N/A- there are therapeutic documented reasons for sibling visitation restrictions 3. 4. N/A, there are no siblings N/A siblings are placed together 5. OM10.5 Is the sibling visitation plan being adhered to/facilitated by DCF so that sibling contact is consistently occurring? 1. Yes No 2. N/A- No plan required 3. 4. UTD- Plan needed but not found in LINK
Case ID __________________________________
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Outcome Measure 11 Re-Entry into DCF Custody
STOP: If child has not re-entered custody during the period of February 15, 2005 May 15, 2005 please check here SKIP the remaining questions in OM11. And go on to OM12.
OM11.1 On what date did child re-enter DCF Custody? ____________/_____________/____________ OM11.2 How soon after reunification did the child re-enter care?________(round to nearest month) OM11.3 For what reasons did child re-enter DCF custody during this quarter? (select all that are applicable) 1. Child's Mental Health (Needs Beyond Caretakers Ability) Parent/Guardian's Death 2. 3. Parent/Guardian's Incarceration 4. Parent/Guardian's Whereabouts Unknown 5. Parent's Mental Health Parent's Substance Abuse 6. Substantiated Abuse/Neglect 7. 8. Other ___________________________________ OM11.4 Is the reason for child's re-entry the same as the prior episode of out of home placement? 1. Yes No 2. OM11.5 Was protective supervision in place at the point of re-entry? 1. Yes No 2. OM11.6 Was case open in treatment at the point of re-entry? 1. Yes 2. No OM11.7 In regard to the prior episode of DCF custody for this child, how many months was DCF involved with the family after the time the child was returned home? _______________ (round to nearest month)
Case ID __________________________________
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OM11.8 OM 11.25 Looking at the prior episode of out of home placement, and most recent return home to parent or guardian, did the DCF follow Policy 36-110.1-1.1 prior to closing the case so that the final entries documented: Yes (1) OM11.8 Date and reason for case opening OM11.9 Reason for case closing OM11.10 Applicable history and legal OM11.11 Protective service issues noted during recent case management OM11.12 Services offered OM11.13 Services engaged OM11.14 Level of compliance and progress of clients OM11.15 Final risk assessment of the home OM11.16 Medical collateral check OM11.17 Therapist collateral check OM11.18 Other Service Provider collateral check OM11.19 School collateral check OM11.20 Police checks OM11.21 AAG or ARG consults as applicable OM11.22 Face to Face contact with all active family members in the home OM11.23 Other collaterals as applicable OM11.24 Supervisory review and approval OM11.25 PS review and approval OM11.26 In the opinion of the reviewer, was this child prematurely reunited with his/her family in spite of known risk factors? 1. Yes No re-entry was not the result of risk factors known to DCF at the time of reunification 2. OM11.27 In the opinion of the reviewer, was the child and family appropriately connected to services and community supports at the time of and following the reunification, so that the likelihood of re-entry was reduced? 1. Yes No 2. N/A re-entry to care was necessary for reasons other than risk factors known to DCF at the 3. time of reunification OM11.28 In the opinion of the reviewer, could the family be better served via voluntary services? 1. Yes No CPS issues are present in addition to mental or medical health needs 2. No (2) N/A to Case (3)
Case ID __________________________________
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Outcome Measure 12 Multiple Placements
STOP: Answer the series of questions related to OM 12, only if there was a child in DCF custody during the 12-month period ending May 15, 2005. If not applicable, check this box and go on to OM13. OM12.1 Has this child experienced more than three placements in the 12 month period ending May 15, 2005? 1. Yes No 2. OM12.2 How many moves has this child experienced in the 12 month period ending May 15, 2005? ________ (enter 0 if no moves) OM12.3 How many placements has this child experienced during this time period? __________ OM12.4 Per Policy 36-55-20 A case conference shall occur if any child has experienced two (2) foster home disruptions within an eighteen (18) month period for reason related to the child's behavior or condition. Was such a conference held? 1. Yes No 2. 3. N/A - not applicable to this child's situation/not warranted. OM12.5 What was the result of the most recent disruption conference? 1. A new foster care placement no evaluation Temporary placement or hospitalization with evaluation of child for higher level of care 2. Respite and supports implemented to maintain placement 3. 4. N/A disruption conference not required UTD required disruption conference not documented 5. OM12.6a-f If supports were put in place to maintain the child in a new placement, or return the child to a home from which he/she disrupted, indicate what those supports were below (if N/A please write SKIP in the first space below) a. _______________________________________ d._________________________________________ b. _______________________________________ e. ________________________________________ c. ________________________________________ f.________________________________________ OM12.7 If moves were not the result of disruption for reasons related to child's behavior or condition, please indicate below all applicable reasons for this child's multiple placements: (select N/A only if there were no moves for causes other than child's behaviors) Yes No N/A (1) (2) (3) OM 12.7a Planned move to higher or lower level of care OM12.7b Foster Family life circumstances OM12.7c Overcapacity/Lack of resources OM12.7d Moved to Pre-Adoptive home OM12.7e Placement in closer proximity to home OM12.7f Relative placement OM12.7g Reunited with siblings OM12.7h Special Study placement OM12.7i Substantiated Abuse Neglect OM12.7j Temporary Placement 12.8 If reason for move not indicated above, write in reason here: _____________________________
Case ID __________________________________
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Outcome Measure 13 Foster Parent Training
STOP: For those cases in which there has been DCF foster parent involvement during the period of February 15, 2005 May 15, 2005 please answer the following questions on the most recent foster care provider identified under the LINK placement icon If there has been no DCF foster parent in the period of February 15, 2005 May 15, 2005 check here , and do not answer any questions related to OM 13.
OM13.1 Rounding to the nearest month, How long has this foster parent been licensed by DCF? __________ (enter as years and months e.g. 1.05 = 1 year and 5 months) OM13.2 Does the provider record indicate that a support plan was developed identifying the training requirements of this foster care provider at any point during the period beginning May 15, 2004 and ending May 15, 2005? 1. Yes 2. No OM13.3 Has this provider attended any foster parent trainings in the year of May 15, 2004 through May 15, 2005? 1. Yes 2. No OM13.4 How many hours of training is documented for this foster parent in the period of May 15, 2004 and ending May 15, 2005? ___________ (enter number documented in the LINK Provider Record) OM13.5 Does LINK document any barriers to foster parent attendance/completion of the required modules? 1. Yes 2. No OM13.6 If yes, indicate barrier(s) below. 1. Day Care 2. Lack of Availability Language 3. Location/Transportation 4. 5. Other UTD no barriers identified 6. N/A training attended 7. OM13.6A If other Specify: ___________________________________ OM13.7 Was this provider relicensed during the period of February 15, 2004 through May 15, 2005 without documentation that they had completed the required number of foster parent training hours? 1. Yes No 2. N/A License has not been renewed during this period. 3. 4. N/A relative license does not require additional hours or training
Case ID __________________________________
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Outcome Measure 14 Placement within Licensed Capacity
Answer the following series of questions for those cases in which there has been foster care placement (DCF or private provider) during the period of February 15, 2005 May 15, 2005 please answer the following questions on the most recent foster care provider identified under the LINK placement icon If there has been no foster parent in the period of February 15, 2005 May 15, 2005 check here do not answer any questions related to OM 14. , and
OM14.1 During the quarter of February 15, 2005 May 15, 2005 was for the identified child in placement in an overcapacity home? 1. Yes 2. No OM14.2 Was this overcapacity the result of a sibling group placement? 1. Yes No 2. 3. N/A No placements in overcapacity homes recorded during this quarter OM14.3 Does the LINK Provider record document the FASU worker's efforts to reduce the overcapacity? 1. Yes No 2. N/A No placements in overcapacity homes recorded during this quarter 3. OM14.4 Did the LINK Provider record contain the required update to the support plan to reflect the overcapacity status and supports necessary to maintain the home until such time that the home returned to capacity (Policy 41-19-2) 1. Yes 2. No N/A No placements in overcapacity homes recorded during this quarter 3. N/A overcapacity was the result of emergency/temporary placement <7 days 4. 5. UTD no support plan documented OM14.5 Were those additional supports implemented? 1. Yes No 2. UTD No additional supports were identified 3. 4. N/A no overcapacity >7 days OM14.6 For how long was the home overcapacity during the quarter of February 15, 2005 May 15, 2005? 1. < 7 Days 7-14 Days 2. 3. 15-21 Days 22-28 Days 4. >28 Days 5. OM14.7 Is there any indication in the treatment worker narratives that the home was/is at risk of disruption due to the overcapacity status? 1. Yes 2. No 3. N/A No placements in overcapacity homes recorded during this quarter
Case ID __________________________________
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Outcome Measure #15 Children & Families' Needs Met
Answer the series of questions related to OM 15 for all cases reviewed. OM15.1 Were there any clearly indicated needs identified in the most recent clinically appropriate treatment plan (November 15, 2004 May 15, 2005) whether approved (in LINK) or not?? 1. Yes No 2. 3. UTD there is no document TPC/ACR OM15.1.a Was this plan accepted at the most recent ACR/TPC(November 15, 2004 May 15, 2005)? 1. Yes No 2. 3. UTD there is no document TPC/ACR OM15.1b In your opinion, are there any service needs that were not identified in this plan, but that are clearly identifiable within the documentation in the case record? (Document on reverse.) 1. Yes No 2. OM15.2 OM 15. Using the Service Need Type Table and Barrier to Services Table below, please answer on page of this document. 1. What was the identified need listed in the most recent clinically appropriate treatment plan, accepted during the ACR/TPC whether approved (in LINK) or not2? (Column 1) 2. Was the need met? (Column II) 3. What was the type of barriers identified that prevented families or children from having their medical, dental, mental health or other service needs met? (Column III) Column 1: Service Need Type3 5. Employment 6. Housing 7. Medical 8. Mental Health
1. Childcare 2. Dental 3. Domestic Violence 4. Education
9. Out-of-Home Care 10. Substance Abuse 11. Support (Out of Home) 12. Support (In-Home-Services) 13. Training
Column III: Barriers to Services
1. Approval process 2. Child hospitalized 3. Client refused service 4. Delay in referral by worker 5. Hours of operation (Alt. hours needed) 6. Insurance Issues 7. Financing unavailable 8. Gender-specific service not available male 9. Gender-specific service not available female 10. Service not available in primary language 11. Service does not exist in the community 12. Services not available for age group 13. Service deferred pending completion of another 14. Referred service is unwilling to engage client 15. Transportation unavailable 16. Placed on waiting list 17. No slots were available 18. No service identified to address this need 66. UTD from treatment plan or narrative 77. Skip No barriers documented 88. N/A client engaged in recommended service 99. Other 100. SKIP only one barrier identified If plan was accepted with stated revisions that were not subsequently incorporated into the plan, the reviewer will use both the treatment plan and the form 553 to determine needs. 3 See crosswalk for listing of services as they fall into these categories.
2
Case ID __________________________________
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Column I What were the identified Service Needs listed in the most recent treatment plan during the period of October 1. 2004 May 15, 2005? EXAMPLE (8) OM15.2.a
Column II Were the needs met as required in Treatment Plan (timeframe as specified or within 6 months from the date of the TPC/ACR) EXAMPLE No TBD
Yes
Column III If need was not met in the specified timeframe, what were the barriers that prevented families or children from having their medical, dental, mental health or other service needs met? EXAMPLE (1) OM15.2c. _____________________
OM15.2.b. Yes No
OM15.2e.
TBD
OM15.2d._____________________
OM15.2.f. Yes No
OM15.2i
OM15.2g. _____________________
TBD
OM15.2h._____________________
OM15.2j. No Yes
OM15.2m.
OM15.2k.______________________
TBD
OM15.2l._____________________
OM15.2n. Yes No
OM15.2q.
OM15.2o. ______________________
TBD
OM15.2p._____________________
OM15.2r. Yes No
OM15.2u.
OM15.2s. ______________________
TBD
OM15.2t._____________________
OM15.2v. No Yes
OM15.2y.
OM15.2w. ______________________
TBD
OM15.2x._____________________
OM15.2z. No Yes
OM15.2cc.
OM15.2aa. ____________________
TBD
OM15.2bb.____________________
OM15.2dd. Yes No
OM15.2gg.
OM15.2ee. ____________________
TBD
OM15.2ff._____________________
OM15.2hh. No Yes
OM15.2ii. ____________________
TBD
OM15.2jj._____________________
OM15.3. Status of Plan used during the ACR/TPC held during the quarter: 1. There is an approved treatment plan at point of review There is no approved treatment plan at point of review 2. OM15.4. There is a need(s) identified on the prior DCF 553 that is not not carried over to the approved treatment plan 1.
Yes 2.
No 3.
UTD No 553
OM15.5. There is a need(s) identified on the most recent DCF 553 that is not carried over to the approved treatment plan
1.
Yes 2.
No 3.
UTD No 553
Case ID __________________________________
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Outcome Measure #16 - Worker-Child Visitation Out-Of-Home STOP: Answer the series of questions related to OutcomeMeasure 16 only if the case has had
an identified child in placement during the period of February 15, 2005 May 15, 2005 . Check this box if not applicable and go on to OM17.
1. Yes 2. No
OM16.1. Were there any documented face-to-face visits by a DCF Social Worker for this child in placement during the quarter of this review? OM16.2. Were there monthly4 face-to-face visits documented for this child in placement during the quarter of this review?
1. Yes
2. No
OM16.3 Did the DCF worker have documented face to face contact with the parent(s) for which reunification is the goal on a monthly basis during the quarter reviewed? 2. No 3. N/A reunification is not the goal 1. Yes OM16.4 Did the DCF worker have documented face to face contact with the parent(s) for which reunification is the goal at least once during the quarter reviewed? 2. No 3. N/A reunification is not the goal 1. Yes Please write the number of visits that occurred during the months below in which the following individual(s) had face-to-face visits with the child-in-placement. Remember to include investigation, ARG, and FASU visits. Caution: You must look at the provider record to ensure that you capture FASU. (Note: Review the instructions carefully enter a number if the visit type is applicable, enter N/A only if case was not open for the full month, or the visit type was not required for this case!) Total number of documented February March 2005 April 2005 May 2005 visits: 2005 OM16.5. DCF Assigned SW OM16.5a. OM16.5b. OM16.5c. OM16.5d. face-to-face visit with the child _____ _____ _____ _____ Total for period February 15, 2005 May 15, 2005: _________ N/A N/A N/A N/A OM16.6. Other DCF SW faceto-face visit with the child Total for period February 15, 2005 May 15, 2005: _________ OM16.7. *ICPC Social Worker face-to-face visit with child Total for period February 15, 2005 May 15, 2005: _________ OM16.8 Private provider faceto-face visit with child Total for period February 15, 2005 May 15, 2005: _________
OM16.6a. _____ N/A
OM16.6b. _____ N/A
OM16.6c. _____ N/A
OM16.6d. _____ N/A
OM16.7a. _____ N/A
OM16.7b. _____ N/A
OM16.7c. _____ N/A
OM16.7d. _____ N/A
OM16.8a. _____ N/A
OM16.8b. _____ N/A
OM16.8c. _____ N/A
OM16.8d. _____ N/A
* ICPC refers to cases in which child is placed out of state and that state has agreed to monitor the child through home visits and report to DCF.
4
At minimum one visit per month during the quarter.
Case ID __________________________________
Page 30
Case 2:89-cv-00859-AHN
Document 502-5
Filed 11/07/2005
Page 31 of 41
OM16.9 Did the DCF Social Worker document any concerns related to the child's placement during the quarter ending May 15, 2005? 1. Yes No 2. UTD no face to face visits during the quarter ending May 15, 2005 3. OM16.10 Did the DCF Social Worker raise these concerns to the SWS for case direction? 1. Yes 2. No N/A No concerns noted in LINK 3. UTD no face to face visits during the quarter ending May 15, 2005 4. OM16.11 Did the DCF Social Worker follow SWS directives as it related to concerns raised by the face to face contacts with this child in placement? 1. Yes No 2. N/A No concerns noted by SW during narratives related to face to face visits 3. 4. N/A no face to face visits by a DCF social worker in the quarter ending May 15, 2005 UTD SWS did not document any directives in the supervisory conference notes 5. UTD -No Supervisory Narratives in LINK during the quarter ending May 15, 2005 6. OM16.12 Did the DCF Social Worker advise FASU or the PREU of any serious concerns arising as a result of the visit at the provider location? 1. Yes No 2. 3. N/A No concerns noted during this quarter UTD no face to face visits by a DCF social worker in the quarter ending May 15, 2005 4. OM16.13 Did the child in placement or provider request assistance with service provision, clothing, or other necessary items? 1. Yes 2. No UTD no face to face visits during the quarter ending May 15, 2005 3. OM16.14 If yes, did the worker document his/her follow through with assistance or information in a timely manner? 1. Yes 2. No N/A No requests noted in narratives related to face to face visits 3. UTD no narratives entered by worker following documented request(s) 4.
Case ID __________________________________
Page 31
Case 2:89-cv-00859-AHN
Document 502-5
Filed 11/07/2005
Page 32 of 41
Outcome Measure #17- Worker-Child Visitation-In-Home
Note: Does not include Interstate (children placed in-state to be monitored by DCF) STOP: Answer series of questions related to OM 17 only if case review was identified as an inhome case at any point during the Quarter of February 15, 2005 through May 15, 2005. If not applicable check here and go on to OM 18.
2. No
OM17.1 Were there any documented face to face visits by a DCF Social 1. Yes Worker for this child(ren) active in this in-home case during the quarter of this review?
OM17.1a How many successful visits5 were recording by a DCF social worker or Supervisor during the period of February 15, 2005 through May 15, 2005? ____________ Document the number of visits the DCF SW made with the in-home family during each month below and then answer the corresponding question for that month as presented below.
Number of Visits per Month
Did the SW visit, twice a month, with all active case participants under the age of 18yrs.6 living in the home? (Note: does not apply to children in DCF placement they will be captured via out of home measure)
OM17.3. 1. 2. 3. OM17.5. 1. 2. 3. OM17.7. 1. 2. 3. OM17.9. 1. 2. 3. Yes No N/A- Case open less than a full calendar month Yes No N/A- Case open less than a full calendar month Yes No N/A- Case open less than a full calendar month Yes No N/A- Case open less than a full calendar month
February 05
OM17.2. ________
March 05
OM17.4. ________
April 05
OM17.6. ________
May 05
OM17.8 _________
OM17.10 How many unsuccessful home visit attempts were documented by the SW during the period of February 15, 2005 through May 15, 2005?7 ____________
"Successful" is defined a face to face visit with one or more family members. Originally identified as age 19 in error corrected with Court Monitor approval on October 5, 2005. 7 "Unsuccessful" is defined as a physical visit to the home in which no case partic
Free Order - District Court of Connecticut - Connecticut
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| Date: | November 7, 2005 |
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