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3200 APS Service Plan

APS IH September 2014

The APS specialist works with the client to develop a service plan in accordance with Human Resource Code §48.203 Voluntary Protective Services. A person who is age 65 or older or is an adult with a disability:

  •   may receive voluntary protective services if the person requests or consents to receive those services;

  •   participates in all decisions regarding his or her welfare, if able to do so;

  •   must be offered the least restrictive alternatives by the APS specialist; and

  •   may withdraw or refuse consent, in which case the APS specialist may not provide services, except in situations as described in Human Resources Code §48.208.

3210 Developing the APS Service Plan

APS-IH November 2016

The specialist develops a service plan when:

  •  there are immediate interventions taken as part of the Safety Assessment, or

  •  there is harm to be addressed related to a validated allegation; and

  •  when a Strengths and Needs Assessment is completed.

Developing a service plan begins in the investigation stage and continues throughout the service delivery stage of a case as needs are identified.

Example: Upon initial face to face with the alleged victim, the APS specialist identifies the alleged victim is without life sustaining medications (immediate intervention). During the investigation, it is revealed the alleged victim is also without food on a regular basis (services related to Valid ANE) as a result of the client’s grandson having access to the checking account. The specialist takes steps to remedy the financial exploitation to alleviate further maltreatment (ICS services).

The APS specialist considers:

  •  the client’s and APS specialist’s perception of the problem, including the conditions that contributed to current dangers or that appear to be the underlying cause of abuse, neglect, or financial exploitation;

  •  the client’s and caretaker’s areas of strength and areas of need;

  •  the client’s motivation and capacity to address the problem; and

  •  the resources available.

If the client is able to participate, the APS specialist involves him or her in developing the action plan.

The APS specialist:

  •  makes all reasonable efforts to resolve each problem; and

  •  respects the right of a client who has the capacity to consent to or refuse protective services, except in cases that are covered in Human Resources Code §48.208.

See also:

3214 Documenting the APS Service Plan

3213 Making a Reasonable Effort

3262 Procedures for Service Contacts

3640 Developing a Service Plan When Using Purchased Client Services

3211 Offering Least Restrictive Alternatives

APS IH September 2014

The APS specialist works with the client to develop a service plan to address identified problems. Safely maintaining clients in the least restrictive environment is a primary goal of APS intervention.

Example

A client has difficulty managing money so that the client’s income lasts through the month. The APS specialist recommends financial counseling as a first step toward resolving the problem, provided this has not been offered and proven ineffective in the past. Representative payee service is an alternative that is a more restrictive option, and is only offered after less restrictive options have proven ineffective.

3212 Using Legal Alternatives

APS IH September 2014

If the action plan includes legal alternatives, the APS specialist refers to 4000 Legal Alternatives and its subitems.

The APS specialist obtains supervisory approval before encouraging, assisting with, or advocating for any legal actions.

Exception: If DFPS is not the applicant for a representative payee or a protective order, supervisory approval is not required.

The APS specialist consults with the regional attorney before taking action on behalf of DFPS, as follows:

  •   proceeding with any court action that is authorized under the Human Resources Code Chapter 48; or

  •   filing for a protective order authorized under the Texas Family Code §82.001 Application for a Protective Order.

3212.1 Documenting Legal Actions in the Service Plan

APS IH September 2014

The APS specialist documents any legal actions taken by:

  •   selecting Legal Action from the Action Category section of the APS Service Plan page;

  •   documenting a description of the legal action taken in the Action Description section of the APS Service Plan page;

  •   completing the Legal Action page; and

  •   completing the Guardianship Detail page, if appropriate.

See also:

3214 Documenting the APS Service Plan

4130 Documentation of Legal Actions

4752 Documentation for Assisting Individuals With Guardianship

3213 Making a Reasonable Effort

APS IH September 2014

The APS specialist makes all reasonable efforts to resolve problems, including root causes, and stabilize the client’s condition. The APS specialist determines what qualifies as reasonable effort and what is stabilized on a case-by-case basis. Full resolution of a client’s problems is always the goal of APS casework, but it is not always achievable. When full resolution is not a practical goal because of inadequate resources, client resistance, or some other impediment, the APS specialist closes the case when a client’s situation is as close to stable as possible.

The phrase "reasonable effort" implicitly recognizes that:

  •   personal choice on the part of the client may limit the effectiveness of APS intervention;

  •   resources available to APS for helping clients are limited; and

  •   APS cannot remedy all situations.

Reasonable efforts include:

  •   searching for a solution among available regional resources, if resources are unavailable;

  •   searching for a solution in other parts of the state, if those services meet the needs of the client;

  •   using Purchased Client Services (PCS), when appropriate, if other resources are unavailable and PCS can meet the needs of the client;

  •   changing the service plan if an intervention fails to solve the problem, and a different action is likely to be more effective;

  •   evaluating services continually to ensure effectiveness;

  •   recognizing that some problems cannot be solved if the resources are not available regionally or in other parts of the state; and

  •   recognizing that some clients are not willing to change their circumstances.

Reasonable efforts do not include:

  •   keeping a case open indefinitely in the eventuality that a resource will become available;

  •   making a positive outcome an absolute condition for closure; or

  •   doing more for one client than DFPS would do for another in the same situation.

See also 3284 Supervisor Review of Case Closure.

3214 Documenting the APS Service Plan

APS IH September 2014

The Service Plan page in IMPACT is for:

  •   indicating all problems that were identified;

  •   documenting a description of each problem identified during the investigation or Strengths and Needs Assessment;

  •   documenting a description of each action to be taken;

  •   checking the category or categories of actions taken and by whom to alleviate identified problems;

  •   indicating the results of each action taken or that services were not available;

  •   indicating the final outcome for each problem; and

  •   documenting in the Contact Standards section the frequency and types of contacts necessary to monitor the progress of the APS Service Plan.

Each problem listed on the APS Service Plan may have multiple actions and individual actions can also address multiple problems.

See:

2232 Documentation of Situations Involving Current Danger Factors

3221 Procedure for Completing a Strengths and Needs Assessment

3262 Procedure for Service Contacts

3263 Documentation of Service Contacts

3214.1 Service Plan Actions, Action Results, and Outcomes

APS-IH November 2016

The following chart provides guidance for the appropriate action, action results, and outcomes to select for problems identified on the service plan.

Type of Action

Description

Action by family members, neighbors, or friends

This refers to applying the family’s own strengths as resources and using extended family members, neighbors, or other individuals to mitigate safety concerns or identified problems.

Examples include, but are not limited to, engaging a family member, neighbor, or friend to provide temporary assistance, shelter, or care to the client.

Action by community or governmental agencies or services (not purchased client services)

This includes involving a community- or faith-based organization, tribal council, or other agency in activities to address safety concerns or identified problems.

Examples when this item would be used to address safety concerns include, but are not limited to:

  •  immediate psychological or medical evaluation;

  •  emergency home health care services;

  •  access to emergency food, shelter, and medication;

  •  utility assistance;

  •  major clean-up and repair services;

  •  public health authority;

  •  housing inspectors;

  •  calling 911; or

  •  animal control.

Examples when this item would be used to address a problem related to a valid allegation of abuse, neglect, or financial exploitation or needs identified during ICS include, but are not limited to:

  •  long-term therapy;

  •  treatment;

  •  referrals; or

  •  being put on a waiting list for services.

APS-direct provision of services (does not include the investigation or assessment itself)

This refers to actions taken by the specialist or other APS staff that specifically address one or more current danger factors or other problems identified.

Examples include, but are not limited to, delivering materials from APS resource rooms or delivering medication or food.

Legal action

This includes actions taken by law enforcement, APS, or another agency to ensure the client’s safety.

Placement

This refers to when a client was removed from the home and placed in a hospital, nursing home, or other alternate care facility.

Purchased client services

This includes any goods or services purchased or pledged using purchased client services (PCS) funds.

Other safety intervention

This refers to unique interventions identified by the client, family, or specialist to address a specific safety concern or problem that does not fit within the other action items.

 

Action Result

Description

Action successful

The action was successful in addressing and mitigating a specific safety concern or identified problem.

Action unsuccessful

The action was not successful at addressing or mitigating a specific safety concern or identified problem.

Client refused services or withdrew

The client was offered services to address a specific safety concern or identified problem but refused services or he or she initially agreed to services, but withdrew before completing services or using them to their fullest intended extent.

Caretaker refused services or withdrew

The caretaker refused services or initially agreed to services, but withdrew before completing services or using them to their fullest extent.

Examples of caretaker refusal of services include when the caretaker:

  •  has been offered services to help him or her mitigate the client’s safety concerns or identified problems; and

  •  has been offered services to address the role he or she may have had in creating the safety concerns or identified problems, including as an alleged perpetrator.

This action result is also selected when the caretaker is refusing to participate in protective actions being offered to the client.

No services available

The APS specialist has made reasonable efforts to address all identified problems but is still unable to secure a long term solution, or the client does not qualify for necessary services.

 

Outcome

Reason

Yes – Problem resolved

The safety concern or problem was resolved by the associated actions.

No – Moved/Unable to Locate

Client has moved to another state, or despite reasonable efforts, APS has been unable to locate the client.

No – Efforts or services exhausted or insufficient

The safety concern or problem was not resolved by the associated actions because available services were insufficient to mitigate it. Mark this item if:

  •  the caretaker has refused services and all other efforts to address the safety concern or problem have been exhausted, or

  •  the client engaged in services, but these services were not successful in addressing the safety concern or problem, and there are no remaining services that could be provided to the client.

No – Client has refused all actions or has withdrawn

Client originally accepted, but has since withdrawn from all actions and services.

N/A – Client died

Client died during the open APS case.

See:

2411 Procedure for Completing the Safety Assessment

3210 Developing the APS Service Plan

3250 Service Plan Outcomes

3215 Documentation of Contacts During Service Delivery

APS IH April 2015

The goal of narrative documentation is to tell the whole story of the case. Narrative documentation has no major gaps and is:

  •  clearly written;

  •  well organized;

  •  easy to read; and

  •  free of all but minor errors in spelling and grammar.

Anyone who reads the case must be able to understand clearly:

  •  the actions taken by APS or others on the client’s behalf and the reasons for taking them;

  •  the actions APS considered, but did not take, and the reasons for not taking them;

  •  the results of actions taken by APS or others;

  •  the client’s situation at the close of the case; and

  •  why remaining problems, if any, could not be resolved.

Contact Detail Page in IMPACT

All case contacts are documented using the Contact Detail page. To document contacts in IMPACT, the APS specialist:

  •  selects the appropriate Contact/Summary Type;

  •  fills in all fields on the Contact Detail page;

  •  clicks the Save button; and

  •  clicks the Narrative button on the Contact Detail page and enters the narrative contact information.

If the APS specialist contacts multiple agencies or service providers in rapid succession for purposes of providing immediate interventions or services, these contacts can be documented in a single contact detail page. All other contacts must be documented in individual contact detail pages.

Purpose of Contacts

The Contact Detail page has four choices in the Purpose dropdown box. The APS specialist chooses the appropriate purpose of the contact.

The four options are defined as follows:

1.   Assessment: The APS specialist assesses the alleged victim’s situation and determines the need for service. The assessment process starts with the intake and continues until all relevant information is obtained from the alleged victim, the alleged perpetrator, and collaterals.

2.   Case Planning: At the completion of the investigation, a case plan, or service plan, is developed which identifies the care, services, and resources required to meet the client’s needs and how they might be most appropriately delivered. The APS Service Plan is developed through a collaborative process involving the client, the caretaker, and other parties as appropriate. Case planning is associated with the completion of the APS Service Plan as services are needed in the investigation stage, Maintenance stage, or Intensive Case Services stage.

3.   Service Coordination and Monitoring: The APS specialist ensures the client’s access to the care, services, and resources identified in the APS Service Plan. This is accomplished by face-to-face visits and telephone contacts to ensure services are implemented and appropriate. The APS specialist’s actions in this category include, but are not limited to:

  •  arranging for resources or services, or both;

  •  purchasing resources or services, or both, with PCS funds; and

  •  safety contacts or service contacts.

4.   Case Plan Re-assessment: The APS specialist continues to assess if services are adequate to meet the identified needs. Re-assessment may lead to alteration of actions in the APS Service Plan if previous actions did not resolve the identified problems.

New allegations discovered during Maintenance or Intensive Case Services will require a new intake and, consequently, a new assessment.

Content of Contacts

Contact narratives, especially those that summarize interviews, are clearly documented, and include a summary of what was said, done, or observed. If the person is not listed on the Person Detail page, the APS specialist includes in the narrative the person’s name and relationship to the alleged victim (brother, friend, home health care provider, and so on).  

Time Frame for Entry of Contacts

The APS specialist is responsible for documenting all contacts made during Intensive Case Services in Contact Detail pages. The APS specialist documents these contacts and attempted contacts as they occur or as soon after they occur as possible, to maximize both the accuracy of documentation and the efficiency of casework. At the latest, all contacts are documented within 24 hours, or the next business day when the next day is a weekend or a holiday.

Timely documentation within 24 hours means documenting the day the contact occurred or by the next business day. For example:

  •  If a contact occurred at 4:00 p.m. on Friday, the APS specialist documents that contact by 11:59 p.m. on Monday in order to be in compliance with policy.

  •  If a contact occurred at 4:00 p.m. on Friday, the APS specialist documents that contact by 11:59 p.m. on Monday in order to be in compliance with policy.

See:

2333 Documentation of Investigation Contacts

3263 Documentation of Service Contacts

3220 Strengths and Needs Assessment

APS IH April 2015

The Strengths and Needs Assessment (SNA) is completed on every case that is progressed to Intensive Case Services. The SNA is used to:

  •  systematically identify critical strengths and needs of the client and the client’s primary caretaker (does not include paid caretakers); and

  •  inform development of an effective service plan.

Human Service Technicians (HSTs), contractors, and student interns may not complete Strengths and Needs Assessments or Re-assessments. Only trained APS staff in the position of APS specialist I or higher may complete Strengths and Needs Assessments or Re-assessments.

3221 Procedure for Completing a Strengths and Needs Assessment

APS IH April 2015

The APS specialist completes a Strengths and Needs Assessment (SNA) as soon as possible, but no later than 14 calendar days after the case is progressed to Intensive Case Services.

All strength and need items are assessed and given one of the following scores:

  •  “a” – This is a strength response. The client or primary caretaker is functioning very well in this area. He or she may experience a typical degree of stress or struggle, but is generally managing well.

  •  “b” – This is a moderate need. The client or primary caretaker is experiencing a definite, but not severe need in this area and would likely benefit from some additional supports and services.

  •  “c” – This is a significant need. The client or primary caretaker is experiencing extraordinary need in this area and requires additional support and services.

Once scored, these items, as well as the current danger factors identified on the Safety Assessment, are listed in the Consideration of Root Causes section of the SNA. The items are grouped based on their scores. All items identified as a significant need (“c”) must be included in the Service Plan.

The APS specialist reviews the items in the Consideration of Root Causes section and considers:

  •  if any items identified as moderate needs (“b”) contribute to current danger factors or root causes of the validated abuse, neglect, or financial exploitation and need to be included on the Service Plan;

  •  how the client’s and caretaker’s areas of strength may support the Service Plan; and

  •  how the identified needs contribute to current danger factors or root causes of the validated abuse, neglect, or financial exploitation.

Once the service plan is created, a Strengths and Needs Re-assessment may be completed to assess any changes in the client’s functioning as well as to evaluate the impact of services being provided. A re-assessment is also completed when a new case on the same alleged victim is validated or a new significant need is identified.

See:

3210 Developing the APS Service Plan

3240 Additional Allegations Discovered and New Reports Received During the Intensive Case Services Stage

3262 Procedures for Service Contacts

Appendix XVII: Assessments Policy and Procedures Overview

3230 Case Outcomes

APS IH September 2014

The phrase “problem resolved” implies that the client is as safe as possible under the circumstances, that the client’s major needs are being met, and that resources exist to keep the situation stable for the foreseeable future or at least three months.

The following chart outlines descriptions of case outcomes that:

  •   met reasonable effort standards and resulted in full resolution; and

  •   met the reasonable effort standards; and resulted in resolution sufficient for closure.

Type of Case

Full Resolution: Case is closed

Client Stabilized: Case is closed if other conditions for full resolution are not practical

Financial Exploitation

The financial exploitation stopped. For example:

  •   measures were taken to prevent future financial exploitation;

  •   law enforcement is pursuing prosecution of the perpetrator; or.

  •   exploited resources were restored.

The exploitation stopped.

  •   Measures were taken to reduce likelihood of future financial exploitation.

  •   The client’s needs are met.

Physical, sexual, emotional, or verbal abuse

The abuse stopped. For example:

  •   the perpetrator no longer has access to the client or factors leading to the abuse are fully remedied; or

  •   law enforcement is pursuing prosecution of the perpetrator.

The abuse stopped.

The perpetrator still has access to the client, but services addressing factors leading to abuse have started and recurrence is less likely.

Medical Neglect

The disease or disorder is cured. For example:

  •   for chronic or terminal medical conditions, the client is receiving all treatment- desired; and

  •   all other major needs are being met.

The disease or disorder is following a normal course. The client is receiving treatment or pain relief appropriate for the stage of illness and deemed adequate by an attending physician.

Self-Neglect (Poverty)

All major needs are met and likely to be met indefinitely. For example:

  •   client is approved for all services and support for which they are eligible; and

  •   services are being managed well.

All major needs are met and are likely to be met for at least three months, and no long-term resources to meet all client needs are available.

  •   The client has applied for all services and support and benefits for which they are eligible.

  •   Financial management issues were addressed.

Self-Neglect (Mental Illness)

Issues causing the self-neglect are addressed. For example:

  •   client receives treatment for mental illness, including taking medication as prescribed;

  •   client has ongoing contact with a mental health case manager; and

  •   all of the client’s needs for food, clothing, shelter and health care are met.

  •   Client receives treatment for the most recent problems stemming from untreated mental illness.

  •   Client is currently compliant with prescribed medications or if not compliant, serious physical or emotional harm is not likely to result.

  •   Client has access to food, clothing, shelter and health care.

  •   Client has been referred for mental health services.

See also 3213 Making a Reasonable Effort.

3240 Additional Allegations Discovered and New Reports Received During the Intensive Case Services Stage

APS IH September 2014

If new allegations are reported to DFPS staff other than SWI or discovered during the Intensive Case Services stage, the APS specialist determines if a new intake is necessary.

Self-Neglect Allegations

Changes in the client’s situation after the completion of the investigation do not require a separate intake report when a change in actions is necessary, but the change does not constitute new allegations of self-neglect.

If the action to be taken relates to an existing problem already in the Service Plan in IMPACT, the APS specialist adds another action to the existing problem.

If the action taken is not related to an existing problem, the APS specialist reports the new allegation to SWI and completes a new investigation.

Allegations Involving Alleged Perpetrators

If the APS specialist learns of new allegations or a new incident involving an alleged perpetrator that is a separate incident from what was investigated during the investigation stage of the current case, regardless of the allegation type, the APS specialist reports the new allegation to SWI and completes a new investigation.

For example, an intake alleges a client is struck by her son and an investigation determines this did not happen, but a self-neglect allegation is validated and the case is progressed to service delivery for follow-up on community referrals. During service delivery, the APS specialist is informed by a neighbor the client’s son pushed the client down. Although these are both physical abuse allegations, they are separate incidents and a new intake would be required.

3241 Procedure for New Intake Reports Received During the Intensive Case Services Stage

APS IH April 2015

When a new intake report is received during an open Intensive Case Services case involving the same alleged victim, including one reported by APS staff, the APS specialist completes a case initiation, a face-to-face contact, and a new Safety Assessment. One or both of these contacts may be the contact in which the APS specialist discovered the new allegations.

These contacts are completed in accordance with the following sections:

1600 Allegation Priorities

2200 Case Initiation

2240 Initial Face-to-Face Contact With the Alleged Victim

2410 Safety Assessment

The APS specialist then:

  •  completes the investigation;

  •  completes a new Risk of Recidivism Assessment, if there are valid findings;

  •  progresses the case to Intensive Case Services, if appropriate;

  •  merges the case with the existing one (both now in Intensive Case Services stage); and

  •  completes a Strengths and Needs Re-assessment.

If the new case will not be progressed and merged with the old case, but the finding is valid, the APS specialist must complete a Strengths and Needs Re-assessment in the old case.

If the new intake report is determined to be a duplicate referral, the APS specialist:

  •  completes a new case initiation contact;

  •  completes Section 1 of the Safety Assessment. The full Safety Assessment is not required; and

  •  closes the case using rapid closure procedures.

See:

2541 Procedure for New Intake Reports Received During the Investigation Stage

2921.15 Duplicate Referral/Already Investigated

3220 Strengths and Needs Assessment

3320 Additional Allegations Discovered and New Reports Received Involving a Maintenance Case

5241 When to Merge Cases

3250 Service Plan Outcomes

APS IH September 2014

Once the actions to complete the service plan are implemented, the APS specialist monitors these actions to determine the result and final outcome.

When an action has been completed, the APS specialist selects an action result on the APS Service Plan. Once an overall outcome for the problem has been determined, the APS specialist selects an outcome on the APS Service Plan page in IMPACT for each problem that best describes the disposition of the problem.

See:

2510 Safety Contacts

3214.1 Service Plan Actions, Action Results, and Outcomes

3261 Service Contacts

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