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11200 Medical and Dental Services

CPS October 2017

DFPS must ensure that children in DFPS conservatorship receive medical care.

Each child's care must include:

  •   emergency treatment, whenever necessary;

  •   timely examination and treatment of nonemergency injuries and illnesses; and

  •   regular preventive care appropriate to the child's age and condition, including immunizations and tuberculin (TB) tests.

DFPS Rules, 40 TAC §700.1329(a)

CPS staff must work with all substitute caregivers and medical consenters to make reasonable efforts to see that youth and children in DFPS conservatorship receive the medical care they need and are entitled to receive.

Obtaining Services

All children and youth in DFPS conservatorship receive medical and dental care through Texas Medicaid.

STAR Health

STAR Health, a comprehensive healthcare system offered statewide, provides Medicaid services for most children and youth in DFPS conservatorship.

For children enrolled in STAR Health, including those in kinship placements, medical consenters must use STAR Health and its network of providers for the medical care described above.

In the Medical Services Resource Guide, see STAR Health.

Traditional Medicaid

If a child or youth in DFPS conservatorship is not eligible for enrollment in STAR Health, then traditional Medicaid or, if applicable, an HHSC Medicaid Managed care health plan, provides medical care.

In the Medical Services Resource Guide, see Traditional Medicaid.

Confirming Eligibility

The caseworker must contact the CPS eligibility worker to resolve issues related to a healthcare provider's inquiry about the Medicaid eligibility of a child or youth in DFPS conservatorship.

Medical and Dental Checkups

The Texas Health Steps program provides medical and dental checkups to children and youth in DFPS conservatorship.

Texas Health Steps is Texas Medicaid's comprehensive and preventive child health service. Texas Health Steps medical and dental checkups are available through both STAR Health and traditional Medicaid.

In the Medical Services Resource Guide, see Texas Health Steps.

11210 Meeting the Requirements for Medical and Dental Services

CPS October 2017

CPS staff must follow the schedule for obtaining initial and routine medical and dental checkups and screenings explained in detail in the following subitems:

11211 Initial Texas Health Steps Medical Checkup

11212 Initial Texas Health Steps Dental Checkup

11213 Subsequent, Ongoing Texas Health Steps Checkups

11214 Immunizations

11320 Psychotropic Medications

The schedule meets the medical care requirements published in:

  •   the Minimum Standards and Guidelines for Child-Placing Agencies, §§749.1151 and 749.1153; and

  •   the Texas Health Steps schedule for medical and dental services checkups.

In the Medical Services Resource Guide, see Texas Health Steps.

Children Who Are Exempt

For details on when children are exempt from the medical and dental requirements, see 11211 Initial Texas Health Steps Medical Checkup.

Children in Special Facilities

For children placed in the following facilities, the applicable facility rules for preventive care apply, as explained in 4231 Facilities Under the Authority of Other State Agencies in General:

  •   A facility regulated by the Texas Juvenile Justice Department (TJJD)

  •   A nursing home

  •   A state supported living center

  •   Intermediate Care Facilities for Individuals with an Intellectual Disability (ICF/IID)

11211 Initial Texas Health Steps Medical Checkup

CPS October 2017

The child's caseworker must ensure that the child receives an initial Texas Health Steps medical checkup within 30 days after the child enters DFPS conservatorship. The checkups are available to all children through both STAR Health and traditional Medicaid.

An initial medical checkup:

  •   must be performed by a licensed health practitioner who is enrolled in Texas Medicaid as a Texas Health Steps provider;

  •   must be completed within 30 days after a child enters DFPS conservatorship; and

  •   is considered overdue 31 days after entering conservatorship.

A child who is being transferred from one licensed agency to another licensed agency (for example, from one child-placing agency, residential treatment center, or general residential operation to another) is exempt from receiving another Initial Texas Health Steps checkup after changing placements, as long as he or she has had a Texas Health Steps medical checkup within the past year, while in DFPS conservatorship.

11212 Initial Texas Health Steps Dental Checkup

CPS October 2017

All children six months of age or older must receive an initial dental exam, known as a Texas Health Steps dental checkup.

The checkup must be performed by:

  •   a licensed dentist who is enrolled in Texas Medicaid as a Texas Health Steps provider; or

  •   a dental hygienist who is working under the supervision of a licensed dentist who is enrolled in Texas Medicaid as a Texas Health Steps provider.

The initial checkup:

  •   must be scheduled within 30 days after placement in DFPS conservatorship; and

  •   is considered overdue after 60 days.

If a child turns six months of age while in care, the initial Texas Health Steps dental checkup:

  •   must be scheduled within 30 days of the date the child reaches six months of age; and

  •   is considered overdue after 60 days.

Care Provided by STAR Health

The child's caseworker must ensure that the child receives an initial Texas Health Steps dental checkup within 60 days after the child enters DFPS conservatorship. STAR Health helps to ensure that children in DFPS conservatorship receive an initial Texas Health Steps dental checkup in a timely manner by requiring the checkup within 60 days of enrollment in STAR Health.

For details, see:

Minimum Standards and Guidelines for Child-Placing Agencies, Child Care Licensing Division, §§749.1153 and §749.1409

Texas Health Steps Schedule

Follow-up appointments and services are scheduled as needed, or as requested by the Texas Health Steps medical or dental provider.

11213 Subsequent, Ongoing Texas Health Steps Checkups

CPS October 2017

Annual Medical Checkups

Following the initial medical checkup through Texas Health Steps, the caseworker must ensure that all children in DFPS conservatorship continue to receive medical checkups in accordance with the Texas Health Steps Periodicity Schedule.

The caseworker must ensure the medical checkups are conducted by a licensed health practitioner who is enrolled in Texas Medicaid as a Texas Health Steps provider.

The caseworker must ensure that subsequent medical checkups are in accordance with the Texas Health Steps Periodicity Schedule. In the Medical Services Resource Guide, see Texas Health Steps.

A child being transferred from one licensed agency to another licensed agency (for example, from one child-placing agency, residential treatment center, or general residential operation to another) is exempt from receiving an additional annual Texas Health Steps checkup after changing placements, as long as he or she has had a Texas Health Steps medical checkup within the past year, while in DFPS conservatorship.

Minimum Standards and Guidelines for Child-Placing Agencies, §§749.1151 and 749.1401

Routine Dental Checkups

The caseworker must ensure that, beginning at the age of 6 months, children in DFPS conservatorship must receive dental checkups through Texas Health Steps, in accordance with the Texas Health Steps Periodicity Schedule.

The caseworker must ensure that the dental checkups are provided by:

  •   a licensed dentist who is enrolled in Texas Medicaid as a Texas Health Steps provider; or

  •   a dental hygienist who is working under the supervision of a licensed dentist who is enrolled in Texas Medicaid as a Texas Health Steps provider.

Subsequent dental checkups:

  •   must be scheduled six months after the month in which the child received the previous checkup; and

  •   are overdue at nine months.

Texas Health Steps Schedule

For licensed foster care placements, Licensing requires compliance with the dentist's recommendations for examinations and treatment.

Minimum Standards and Guidelines for Child-Placing Agencies, §749.1411

Follow-up appointments and services are scheduled as needed, or as requested by the Texas Health Steps medical and dental provider.

11214 Immunizations

CPS October 2017

The caseworker must ensure that children in DFPS conservatorship are immunized against disease and screened for tuberculosis (TB), in accordance with the Periodicity Schedule as recommended by the Texas Department of State Health Services (DSHS).

The caseworker must ensure that children are also tested for TB, if there are additional recommendations by:

  •   the regional DSHS offices; or

  •   local public health authorities in the county in which the child has been living.

Minimum Standards and Guidelines for Child-Placing Agencies, §§749.1417; 749.1421

In the Medical Services Resource Guide, see Immunizations.

Consent for Immunizations by Pregnant or Parenting Foster Youth

A youth may consent to his or her own immunization for a disease if the youth is pregnant or parenting and the Centers for Disease Control recommends the initial dose for the vaccine to be administered before 7 years of age. See:

Texas Family Code 32.1011(a)

Centers for Disease Control and Prevention (CDC) Vaccines and Immunizations

The ability to consent for immunizations does not give the youth the right to refuse a vaccine that the healthcare provider recommends and the youth's medical consenter has agreed upon, unless the youth has been designated his or her own medical consenter.

11220 Reproductive Health

11221 Contraceptive Services

CPS October 2017

A youth may request contraceptive services through his or her physician or other family planning services provider. The decision to provide a minor with contraception and to obtain the appropriate consent, if applicable, is the healthcare provider's responsibility. The caseworker must not attempt to prohibit the youth from seeking contraceptive services.

Restrictions on Sterilization

If a youth in DFPS's conservatorship asks to be sterilized, the youth's primary caseworker must consult with the regional attorney to determine whether to ask the court to make a ruling on the request. Neither DFPS nor the medical consenter have the authority to consent to the request.

Federal Regulation

Medicaid funds must not be used to pay for the sterilization of any individual who:

  •   is less than 21 years old; or

  •   has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction, unless the individual has been declared competent for purposes that include the ability to consent to sterilization.

42 C.F.R. §§441.251, 441.253

In the Medical Services Resource Guide, see Contraceptive Services.

11230 Informing Caregivers and Medical Consenters About Health Services

CPS October 2017

CPS staff must provide caregivers and medical consenters with:

  •   pamphlets and other information about the services provided by STAR Health and traditional Medicaid through the Texas Health Steps program; and

  •   the addresses of the websites for these programs.

In the Medical Services Resource Guide, see Texas Health Steps.

Staff must direct individuals with questions about how to obtain particular medical or dental services to the STAR Health and the Texas Health Steps program, as appropriate.

11240 Using the Health Passport

CPS October 2017

The Health Passport is a Web-based electronic system for storing and retrieving a child's health information. Healthcare providers, caregivers, and authorized CPS staff use the Health Passport to manage a child's healthcare needs.

All CPS staff planning to use the Health Passport must first carefully read and sign a user agreement.

All caseworkers must take the online Health Passport training in the DFPS Learning Station.

Accessing the health information contained in a Health Passport without a business need is a violation that carries penalties up to and including termination.

In the Medical Services Resource Guide, see Using the Health Passport.

11300 Medication

11310 If CPS Staff Administers Medications

CPS October 2017

CPS staff does not routinely administer prescription or over-the-counter medications, but may need to do so if children are in their care temporarily. Such situations include:

  •   after removal;

  •   between placements; or

  •   if a child is being cared for by caseworkers in a CPS office or other location.

If CPS staff administers medications, they must:

  •   be informed about the child's diagnosis and other medications;

  •   be informed about the actions of the medication and side effects;

  •   administer medications ONLY if they are stored in the original pharmacy container;

  •   administer medications according to the instructions on the container or from the prescribing licensed healthcare provider;

  •   ensure the child has taken the medication as prescribed;

  •   document that the medication was administered, in the IMPACT Contact Detail and on either the Prescription Medication Log or Non-Prescription Medication Log;

  •   place the original Prescription Medication Log or Non-Prescription Medication Log in the child's permanent case record; and

  •   provide a copy of the Prescription Medication Log or Non-Prescription Medication Log to the child's next caregiver.

CPS staff must contact the regional CPS nurse consultant with any questions about a medication prescribed to a child.

11311 Route of Administration of Medication

CPS October 2017

Medication route refers to the way the drug is introduced into the body.

Permissible Routes

CPS staff members who are NOT licensed healthcare providers may administer medications and assist older children in taking medications by the following routes:

  •   Capsules, pills, or liquids taken by mouth (for example, swallowed, placed under the tongue, and so on)

  •   Inhalers taken through the nose or mouth

  •   Eye drops

  •   Skin patches

  •   Nebulizers

Non-Permissible Routes

CPS staff members who are NOT licensed healthcare providers may not administer medications by the following routes:

  •   Injection (such as a shot)

  •   Suppositories or creams taken through the rectum or vagina

  •   Indwelling IV

  •   Nasogastric tube (NG-tube)

  •   Gastrostomy tube (G-tube or G-button)

Insulin

CPS staff may supervise older children in administering their own insulin if the children are experienced in doing so. CPS staff members who are not licensed healthcare providers may not supervise insulin administration by children who are still learning to administer their own insulin and need guidance on technique.

Suppositories

If an older child is prescribed and understands how to insert a suppository or cream that is administered through the rectum or vagina, CPS staff may hand the medication to the child for the child to insert. CPS staff members who are the same gender as the child may stand outside the door of the bathroom while the child inserts the medication. However, CPS staff must not directly assist the child in inserting the medication into the child's rectum or vagina.

If a child is prescribed a medication through a route that CPS staff may not give (such as an NG-tube or injection) or staff has any questions, they must contact the CPS nurse consultant, the child's healthcare provider, or STAR Health at 1-866-912-6283 for assistance.

11312 Action If a Child Has Not Taken a Medication in Over 24 Hours

CPS October 2017

Cases may arise in which a child has missed taking a prescribed medication for a period of time because the child ran away, the medication was left at the child's birth home or previous placement, the child refused to take the medication, or other reason.

Some medications should NOT be resumed at all or at the same dose if the child has not taken the medication for a period of time.

If Less Than 24 Hours Have Elapsed

If less than 24 hours have elapsed since the child took the last dose of the medication, the caseworker may administer the medication according to the instructions on the label.

If 24 Hours or More Have Elapsed

If 24 hours or more have lapsed since the child took the last dose of the medication, or if the caseworker is not informed about the child's medications as required in 11310 If CPS Staff Administers Medications, the caseworker must determine whether to give the medication by contacting:

  •   the child's healthcare provider; or

  •   STAR Health Nurse Wise at 1-866-912-6283.

11313 Storing Medications

CPS October 2017

If children are in the temporary care of CPS staff, staff must:

  •   ensure that children's medications are kept in a secure and locked location at all times, such as:

  •   a locked file cabinet in a CPS office, or

  •   the locked glove compartment or trunk of a car, if transporting a child.

  •   immediately turn in medications that the child can no longer use to a staff member designated in the office to receive the medication. Staff may contact their supervisor to determine the designated recipient of the medication. Regions must designate appropriate staff in each office. The person may be a supervisor, program director, CPS nurse consultant, or other suitable staff person.

Safeguarding Controlled Substances

Some children may be prescribed medications considered as controlled substances that have substance abuse potential, such as psycho-stimulants used to treat Attention Deficit/Hyperactivity Disorder (ADHD), tranquilizers, and pain medications. These medications must be kept in a locked area and secure at all times.

11314 Destroying Medications

CPS October 2017

Cases may arise in which medications that children no longer need are left in the possession of CPS staff or in a CPS office, such as when a medication changes, or a child is hospitalized or leaves DFPS care. In these cases, staff designated in each office must take these steps to dispose of the medication:

  •   Maintain security in designated locked cabinets until destruction can be completed.

  •   Complete the Medication Destruction Log.

  •   Ensure that another CPS staff member is available to witness the destruction of medication.

  •   Provide the caseworker and supervisor with documentation that the medications have been destroyed.

  •   File documentation of the medication's destruction in the child's record and make a note in IMPACT that the medication was destroyed.

  •   Adhere to the federal guidelines when disposing of prescription and non-prescription drugs (in the Medical Services Resource Guide, see Destroying Medications).

11320 Psychotropic Medications

CPS October 2017

Psychotropic medication is a medication prescribed to treat symptoms of psychosis or another mental, emotional, or behavioral disorder. It affects the central nervous system to influence and modify behavior, cognition, or affective state. The term includes the following categories:

  •   psychomotor stimulants;

  •   antidepressants;

  •   antipsychotics or neuroleptics;

  •   agents for control of mania or depression;

  •   antianxiety agents; and

  •   sedatives, hypnotics, or other sleep-promoting medications.

Texas Family Code §266.001

11321 Providing Required Information to Medical Consenters

CPS October 2017

Caseworkers must provide copies of the brochure Making Decisions about Psychotropic Medications to all medical consenters for a child in DFPS conservatorship:

  •   at the time of placement, along with Form 2085-B Designation of Medical Consenter;

  •   within seven days following the placement; or

  •   within seven days following the court's authorization of:

  •   a non-CPS person as a child's medical consenter; or

  •   a 16 or 17 year old as his or her own medical consenter.

The caseworker must encourage the medical consenter to read and use the brochure during office visits at which psychotropic medications will be discussed or prescribed.

11322 Informed Consent for Psychotropic Medication

CPS October 2017

Giving informed medical consent means making a decision about whether to agree to a medical test, treatment, procedure, or medication.

To make an informed decision about behavioral health treatment or medications without undue influence means that the medical consenter is deciding based on what is best for the child, not because of pressure to consent to the medication or treatment services. For example, a decision must not be made based on a school's or other entity's insistence that a child take medication in order to participate or receive services.

Consent must be given voluntarily and without undue influence.

To ensure medical consent is informed and legally valid, the medical consenter must receive the following information either verbally or in writing from the prescribing healthcare provider, and understand and consider its impact on the child:

  •   the specific condition to be treated, including the child's symptoms and medical diagnosis;

  •   the beneficial effects on that condition expected from the medication;

  •   the probable health and mental health consequences of not consenting to the medication;

  •   the probable clinically significant side effects and risks associated with the medication;

  •   the generally accepted alternative medications and non-pharmacological interventions to the medication, if any (see 11326 Non-Pharmacological Interventions); and

  •   the healthcare provider's reasons for the proposed course of treatment.

Texas Family Code §266.0042

The medical consenter may refer to the Making Decisions about Psychotropic Medications brochure for guidance on the principals of informed consent.

11323 Deciding Whether to Consent to a Psychotropic Medication

CPS October 2017

Medical consenters decide whether to consent to, or choose not to consent to, psychotropic medication for children in DFPS conservatorship. The medical consenter, including CPS staff medical consenters, must discuss with the prescribing healthcare provider any non-pharmacological interventions that may be helpful to use before trying the medication, or to use along with the medication. See 11326 Non-Pharmacological Interventions.

The medical consenter considers all the elements of informed consent for the individual child described in 11322 Informed Consent for Psychotropic Medication. The medical consenter asks the healthcare provider questions about the medication and appropriate non-pharmacological interventions.

Conservatorship caseworkers must encourage medical consenters to read and use the Making Decisions about Psychotropic Medications brochure during office visits at which psychotropic medications will be discussed or prescribed. DFPS must provide this brochure to the medical consenter within the time frames described in 11321 Providing Required Information to Medical Consenters.

11323.1 Providing Consent to an Initial Psychotropic Medication in an Inpatient Setting

CPS October 2017

If providing medical consent for a child in an inpatient setting, the medical consenter must:

  •   consider all the elements of informed consent for psychotropic medications in policy (11320 Psychotropic Medications);

  •   complete both:

  •   a hospital's required consent forms; and

  •   the DFPS Form 4526 Psychotropic Medication Treatment Consent.

Consent Forms Required by the Hospital

For children admitted to a psychiatric hospital, the medical consenter must provide informed consent for initial psychotropic medications and dosage changes according to the hospital's requirements. This includes completing the hospital's consent form.

If the medical consenter is not the child's primary caseworker, the medical consenter must send a copy of the signed hospital consent form to the caseworker within five business days.

If Face-to-Face Medical Consent is Possible

In addition to following any consent process the hospital requires, the medical consenter must attempt to meet in person with the hospital's prescribing provider and the child to:

  •   provide informed consent for an initial psychotropic medication;

  •   sign DFPS Form 4526 Psychotropic Medication Treatment Consent; and

  •   obtain the signature of the prescribing provider or designee.

If Face-to-Face Medical Consent is Not Possible

If the medical consenter is unable to meet with the provider face to face, the medical consenter must provide by phone verbal informed consent to an initial psychotropic prescription or dosage change. The medical consenter must complete and sign Form 4526 and note on the form:

  •   consent was provided verbally; and

  •   the prescribing provider's name and credentials.

11323.2 Deciding Not to Consent to a Psychotropic Medication

CPS October 2017

If a medical consenter decides not to consent to a psychotropic medication recommended by a child's healthcare provider, the medical consenter must notify the child's caseworker in writing within 24 hours. Notification must include the healthcare provider's recommendation and the reason the medical consenter decided not to consent.

Following a decision not to consent, the caseworker must discuss the elements of informed consent and the decision process with the medical consenter and must document the elements of informed consent in the child's case record. See 11322 Informed Consent for Psychotropic Medications.

11323.3 Withdrawing Consent

CPS October 2017

The medical consenter may withdraw consent to treatment with a psychotropic medication at any time after consulting with the prescribing provider and the child's caseworker. The caseworker must discuss with the medical consenter the reasons for the decision and the consultation with the prescribing healthcare provider.

The caseworker must document this discussion, including any instructions about how to safely discontinue the medication, in the child's record.

11324 Documenting Consent for Psychotropic Medications

11324.1 Documenting Consent to an Initial Psychotropic Medication Prescription

CPS October 2017

The medical consenter and provider must complete and sign Form 4526 Psychotropic Medication Treatment Consent during the appointment. The medical consenter must notify the conservatorship caseworker by the next business day, in writing, of any initial psychotropic medication prescription.

The medical consenter can provide notification by fax, email, other written communication, or by providing the completed Form 4526.

If next day written notification does not include a copy of the completed Form 4526, the medical consenter must provide a copy of the form to the child's caseworker within five business days (see 11323 Deciding Whether to Consent to a Psychotropic Medication).

The conservatorship caseworker must file a copy of the form in the child's section of the case file.

See:

11324.2 Documenting Consent to Psychotropic Medication in an Inpatient Setting

11320 Psychotropic Medications

11324.2 Documenting Consent to Psychotropic Medication in an Inpatient Setting

CPS October 2017

To document either face-to-face or verbal informed consent for an initial psychotropic medication during a child's inpatient stay the caseworker must file:

  •   Form 4526 Psychotropic Medication Treatment Consent; and

  •   a signed copy of any informed consent form required by the hospital.

See 11323.1 Consenting to an Initial Psychotropic Medication in an Inpatient Setting.

11324.3 Documenting the Decision to Consent for Psychotropic Medication

CPS October 2017

The caseworker must obtain information from the medical consenter about the decision process described in 11323 Deciding Whether to Consent to a Psychotropic Medication.

The caseworker must record the information in the child's case record along with the copy of the completed Form 4526 Psychotropic Medication Treatment Consent for the child's case. For more information about documentation requirements see:

11131.4 Psychotropic Medication Appointments

11162 Notifying Parents About Psychotropic Prescriptions and Significant Medical Conditions

11324.4 Documenting Consent for Changes in Psychotropic Medication

CPS October 2017

The medical consenter must inform the child's conservatorship caseworker in writing (fax, email, or text), by the next business day, of any dosage change to a prescription psychotropic medication agreed to by the consenter.

Form 4526 Psychotropic Medication Treatment Consent is not required for changes in dosage or for refills of the same medication.

11325 Psychotropic Medications Follow-Up Visits

CPS October 2017

The caseworker must ensure that each child prescribed a psychotropic medication attends an office follow up visit with the prescribing healthcare provider and medical consenter at least once every 90 days for a review of the child's progress with the medication. The visit allows the healthcare provider to:

  •   monitor the medication's side effects appropriately;

  •   determine if the medication is helping the child achieve the treatment goals; and

  •   determine if it is appropriate to continue using the medication.

Texas Family Code §266.011

The medical consenter must attend the medical appointment with the child and provide the caseworker with documentation of the medical appointment. The caseworker must file a copy of the documentation in the child's case file.

If the caseworker is the medical consenter the caseworker must attend each office visit in person. The caseworker must complete and file the documentation.

Texas Family Code §266.004

11326 Non-Pharmacological Interventions

CPS October 2017

Caseworkers must discuss with medical consenters and other caregivers the fact that psychosocial therapies, behavior strategies and other non-pharmacological (non-medicine) interventions should be considered before or along with psychotropic medications for children in DFPS conservatorship.

The medical consenter or caregiver should seek assistance from the child's healthcare provider, child placing agency, caseworker, and therapist to develop strategies to help the child to manage behaviors.

If the parties agree on non-pharmacological interventions, the medical consenter arranges for the child to receive them. The caseworker must coordinate with the medical consenter, the healthcare provider, and the child placing agency case management staff, if applicable, to help the medical consenter make these arrangements for the child.

If psychotropic medication is necessary, medical consenters should ask the prescribing provider to recommend specific non-pharmacological interventions, tailored to the child's needs, which can be employed at the same time as the treatment with psychotropic medication. See 11320 Psychotropic Medications.

Discussions with medical consenters and caregivers about non-pharmacological interventions may address various issues. In the Medical Consent Resource Guide, see Non-Pharmacological Interventions.

11327 Psychotropic Medication Utilization Review (PMUR)

CPS October 2017

A Psychotropic Medication Utilization Review (PMUR) is the process used to screen and review a child's psychotropic medications if they fall outside of the Psychotropic Medication Utilization Parameters. A medical consenter, caregiver, or CPS staff may request a PMUR any time they have concerns about a child's psychotropic medication regime.

When CPS staff requests a PMUR they must request a written response from STAR Health Behavioral Health.

CPS staff, medical consenters, and caregivers must not stop any child's medications without consulting with the prescribing healthcare provider.

In the Medical Services Resource Guide, see Psychotropic Medication Utilization Review (PMUR).

CPS staff must file the results of a medication review in the child's record.

11400 Special Healthcare Needs

11410 Arranging for Special Healthcare Management Services

CPS October 2017

If a child needs or would benefit from special healthcare management, the caseworker must call STAR Health to request it. Caregivers and medical consenters may also call to request this service.

Special healthcare management may involve care related to:

  •   a condition (such as diabetes or hearing loss);

  •   a transplant (such as a kidney transplant) and follow-up; or

  •   an injury (such as physical therapy following traumatic brain injury or a sports injury).

11411 Referring a Child to Medical Professionals and Health-Related Community Services

CPS October 2017

If a child has or appears to have a disability, the caseworker must:

  •   consult with the regional education specialist and developmental disabilities specialist, as appropriate;

  •   refer the child to the appropriate professionals and community services; and

  •   ensure that the child is assessed and diagnosed.

If the child has already been assessed and diagnosed, the caseworker must ensure that DFPS has the appropriate professional documentation on record. If needed, the caseworker contacts the CPS program specialist for children with disabilities at the CPS regional or state office for further information or resources.

11412 Working With Children in DFPS Conservatorship Who Have Special Healthcare Needs

CPS October 2017

While a child with special healthcare needs is in DFPS conservatorship, the caseworker must:

  •   develop an understanding of the child's medical needs and the services recommended by medical professionals;

  •   ensure that the child is receiving the recommended services; and

  •   maintain contact with healthcare providers to ensure that the child's medical needs are being met.

Throughout the case, the caseworker must assess the caregiver's ability to meet the child's ongoing medical needs, working with the child's family, healthcare providers, and collateral to:

  •   conduct ongoing home visits throughout the case to assess the home environment's appropriateness;

  •   ensure that the caregiver is trained to meet or is proficient in meeting the child's special needs, including being trained to use or being proficient in using medical equipment, administering prescribed medication, and providing needed supplies;

  •   ensure that the caregiver has access to and uses the medical equipment recommended by medical professionals; and

  •   assess the child's care during each contact to ensure that the family continues to comply with the recommended medical care (including administering prescribed medication, attending medical appointments, and completing other tasks to meet the child's needs).

See:

6241 The Child's Service Plan

6242 The Family's Service Plan

11500 HIV Testing and Care for Children in DFPS Conservatorship

CPS October 2017

The caseworker must ensure that a child in DFPS conservatorship is tested for HIV infection in accordance with the Texas Health Steps Medical Checkup Periodicity Schedule, Comprehensive Health Screening, or at any other time the child's healthcare provider determines the test is medically indicated.

The caseworker must request that the healthcare provider test the child for HIV infection if the child has a history of sexual abuse or other risk factors, or if the child requests to be tested.

DFPS Rules, 40 TAC §700.1401

11510 Counseling, Treatment, and Medical Management for a Child With HIV Infection

CPS October 2017

STAR Health provides counseling, treatment, and medical management for a child in DFPS conservatorship with HIV.

Counseling

DFPS must ensure that children with HIV and their caregivers are provided with age-appropriate post-test counseling and information in accordance with the Texas Health and Safety Code, §81.109.

DFPS Rules, 40 TAC §700.1402

The caseworker must secure age-appropriate post-test counseling and information for the child with HIV and their caregivers through STAR Health.

11520 Maintaining Confidentiality of HIV Status

CPS October 2017

Information regarding a child's HIV status is confidential. Staff must not disclose a child's HIV status with any other individual or entity, except those listed in 11521 Required Notification About a Child's HIV Status and 11522 Allowable Releases of HIV Status Information, or under other applicable law or rule.

DFPS Rules, 40 TAC §700.1405

Medical Exception

DFPS may release information about an individual's HIV status to medical personnel in an emergency, if necessary to provide for their protection and to provide for the patient's health and welfare. Other exceptions apply to healthcare providers, who are required by law to report the information to certain governmental entities for purposes of communicable disease tracking.

Public Documents

The caseworker must keep information regarding a child's HIV status out of any documents that will be available to the public, such as removal affidavits or court reports. If the welfare of the child requires the child's status to be documented in a public document, staff must use language such as confidential illness or confidential diagnosis.

Court Testimony

A child's HIV status may be discussed if DFPS is currently the child's managing conservator.

The judge has the discretion and authority to require testimony on any subject that he or she deems appropriate or necessary. In such cases, staff must give testimony as requested.

Removal Affidavit

A person's HIV status must NEVER appear in a removal affidavit. This is true for children coming into DFPS care and for any other adult or child referred to in the affidavit.

Adults

Section 81.103 of the Texas Health and Safety Code protects the confidentiality of an adult's HIV status and HIV test results. Staff must never disclose an adult's HIV status, or HIV test results, without the adult's consent.

11521 Required Notification About a Child's HIV Status

CPS October 2017

If a child in DFPS conservatorship tests positive for HIV infection, the caseworker must notify the following parties of the child's condition:

  •   the child's legal parents (if parental rights have not been terminated and their whereabouts are known);

  •   current and prospective foster parents, 24-hour child-care providers, prospective adoptive parents, or relatives with whom the child has been placed or with whom DFPS plans to place the child; and

  •   the medical consenters.

DFPS Rules, 40 TAC §700.1403

11522 Allowable Releases of HIV Status Information

CPS October 2017

Release of Positive HIV result

If a child in DFPS conservatorship has tested positive for HIV infection, DFPS may notify the following parties of the child's condition:

  •   a physician, nurse, or other professional who has a legitimate need to know the information in order to provide for the child's health and welfare;

  •   a court having jurisdiction of a proceeding involving the child or a proceeding involving a person suspected of abusing the child, if requested;

  •   any person with a legal right to obtain the information pursuant to law or court order; and

  •   the child.

 DFPS Rules 40 TAC §700.1404(a)

Release of Negative HIV result

If a child in DFPS conservatorship has tested negative for HIV infection, DFPS may notify the parties listed in this section and in 11521 Required Notification About a Child's HIV Status if:

  •   the party requests the information; or

  •   DFPS determines the information is needed to provide for the child's health or welfare.

DFPS Rules 40 TAC §700.1404(b)

11600 Behavioral (Mental Health) Services

11610 Mental Health Treatment

CPS October 2017

11611 Admission to a Mental Health Facility

CPS October 2017

11611.1 DFPS Request for Admission to an Inpatient Facility

CPS October 2017

Before requesting that a child in DFPS conservatorship be admitted to an inpatient psychiatric facility, DFPS must obtain the child's consent. If the youth does not consent and DFPS believes inpatient treatment is necessary, DFPS must seek an application for court-ordered mental health services or emergency detention or an order for protective custody. In the Medical Services Resource Guide, see Inpatient Mental Health Treatment.

11611.2 Child or Youth Requests Admission

CPS October 2017

Inpatient Facilities

Youth 16 or Older

A youth in DFPS conservatorship who is at least 16 years old may seek voluntary admission in an inpatient mental health facility and be admitted without the consent of the parent, managing conservator, or guardian. The youth files a request with the administrator of the facility.

Texas Health and Safety Code §572.001

The inpatient mental health facility may be unfamiliar with the DFPS court order that permits a youth age 16 years or older to consent or refuse his or her own mental health or medical treatment. If so, the caseworker must explain and provide a copy of the court order to the facility.

The facility is not required to accept the request for admission.

Children

A child in DFPS conservatorship may be admitted on a voluntary basis to an inpatient mental health facility. The facility must obtain the consent of both the child (regardless of age) and a representative of DFPS as conservator.

A medical consenter who is not a CPS employee may not request or consent to the child's admission to inpatient care.

Outpatient Facilities

A youth in DFPS conservatorship who is at least 16 years or older may request outpatient mental health services by filing a request with the administrator of the facility where the youth is seeking outpatient treatment.

The administrator of an outpatient mental health facility may admit a minor who is 16 years of age or older to an outpatient mental health facility as a voluntary patient without the consent of the parent, managing conservator, or guardian.

The facility is not required to accept the request for admission.

Texas Health and Safety Code §572.001

11611.3 Locating a DFPS Representative to Approve Admission

CPS October 2017

A non-CPS medical consenter does not have authority to give consent to voluntary admission to an inpatient mental health facility. If someone other than a CPS employee brings the child to the facility for voluntary admission, that person must locate a DFPS representative to approve the admission.

  •   The person who brought the child to the facility for admission should contact the child's caseworker or supervisor.

  •   If the caseworker or supervisor cannot be located, the person requesting admission should contact Statewide Intake at 1-800-252-5400 to locate the caseworker.

11611.4. Consent for Healthcare and Medications After Admission

CPS October 2017

Unless the youth has been authorized to consent to his or her own medical care under Texas Family Code §266.010, the designated medical consenter must provide or deny consent for healthcare or the use of psychotropic medications once the youth is admitted.

The caseworker must provide the mental health facility with the name and contact information for the child's medical consenter.

11611.5 Designating a Medical Consenter

CPS October 2017

The caseworker must evaluate the designation of the medical consenter if the child is admitted to a psychiatric facility. If the primary medical consenter is related to the child's previous placement, the caseworker must designate a new medical consenter, if necessary, or the caseworker must be appointed as the backup consenter.

11611.6 Changing Medical Consenters While the Child is Hospitalized

CPS October 2017

Any time a child or youth is not returning to a placement with a non-CPS employee designated by DFPS to consent to medical care, DFPS must change the primary and back-up medical consenter to the caseworker while the child is hospitalized.

If a new placement is located for the child following hospital discharge, the caseworker must determine the most appropriate medical consenter, back-up medical consenter, or both, based on the child's new placement type.

See:

11117 Changing Medical Consenter and Back-Up Consenter

11111 Selecting the Medical Consenter and Back-Up Medical Consenter

11323.1 Consenting to an Initial Psychotropic Medication in an Inpatient Setting

Texas Health and Safety Code §572.001(d)

11612 Emergency Detention Order and Order for Protective Custody

CPS October 2017

A caseworker or the residential child care provider may seek law enforcement assistance if he or she believes that a child needs a temporary involuntary mental health commitment and the child will not willingly be evaluated by mental health professionals.

In the Medical Services Resource Guide, see Emergency Detention and Order for Protective Custody.

Medical Consenter's Role

The medical consenter must provide or deny consent for any healthcare and the administration of psychotropic medication, except in an emergency, during the time that the Emergency Detention Order and the Order for Protective Custody are in effect.

11613 Involuntary Commitment Order for Mental Health Services

CPS October 2017

If CPS staff or a residential childcare provider believes an order for involuntary inpatient mental health services (court commitment) is necessary for a child, staff or the provider contact the regional mental health authority (MHA), also known as regional MHMR, for assistance and assessment.

In the Medical Consent Resource Guide, see Involuntary Commitment Order for Mental Health Services.

11700 Extraordinary Medical Conditions

11710 Enrollment and Participation in Certain Drug Research Programs

CPS October 2017

Texas Family Code §266.0041 requires a court order before a child in DFPS conservatorship may enroll or participate in a drug research program, unless the person enrolling the child is the child's parent and has been authorized by the court to make medical decisions for the child.

In the Medical Services Resource Guide, see Enrollment and Participation in Certain Drug Research Programs.

11720 End of Life Medical Decisions

CPS October 2017

If a child in DFPS conservatorship has been diagnosed with an "irreversible condition" or a "terminal condition" and medical professionals suggest withholding or withdrawing life-sustaining treatment, the regular process for medical consent does not apply.

Withholding life-sustaining treatment means to refrain from administering or applying life support such as CPR, ventilators, defibrillation, and other related treatments.

Withdrawing life-sustaining treatment means to discontinue life support previously administered or applied.

In some cases, decisions to withhold or withdraw treatment may be done in advance of the need, such as with an Advance Directive or Do Not Resuscitate Order. This policy applies to advance directives and orders as well as other end-of-life medical care decisions.

See Texas Health and Safety Code Chapter 166 for Texas law regarding advance medical directives for more information.

The caseworker and supervisor must follow the procedures outlined below. However, any party may seek court intervention at any time if all parties do not agree on a course of action or if any party is concerned about the child's rights.

11721 DFPS has TMC or PMC but Parental Rights Have Not Been Terminated

CPS October 2017

If parental rights have not been terminated and the child's attending physician recommends end-of-life care, the parents have the authority to make the end-of-life decisions even if DFPS has temporary managing conservatorship (TMC) or permanent managing conservatorship (PMC). CPS staff or other medical consenters do not have the legal authority to consent in these circumstances.

The caseworker and supervisor must:

  •   obtain a written statement from the attending physician certifying that the child has a terminal or irreversible condition and that the physician recommends withholding or withdrawing life-sustaining treatment;

  •   request a second opinion or a review by a hospital medical or ethics review board if there are any concerns about the attending physician's recommendation. The hospital decides whether to convene a review committee;

  •   inform the parents of the child's medical condition and the recommendation of the attending physician and any hospital medical or ethics review board (if applicable);

  •   arrange for the parents to discuss any recommendation with the attending physician directly (by phone or in person); and

  •   discuss the recommendation with the program director, regional director, regional attorney, attorney representing DFPS, the child's attorney ad litem, guardian ad litem, CASA (if applicable), and any other legal party to the case.

If the parents…

Then…

consent to the DNR, advance directive, or recommended end-of-life care…

the parents are the party that must execute any order and sign any required documents. CPS staff must not do so.

refuse to consent to the DNR, advance directive, or recommended end-of-life care…

the caseworker and supervisor must not take further action.

cannot be located, or are otherwise unavailable to make a decision…

the caseworker and supervisor must request that the attorney representing DFPS initiate proceedings to seek termination of parental rights (TPR) and PMC of the child and obtain TPR and PMC; and follow procedures in 11722 DFPS has TMC or PMC and Parental Rights Have Been Terminated or Parents are Deceased.

Staff must ensure all parties are informed of the decision once a decision has been made.

11722 DFPS has TMC or PMC and Parental Rights Have Been Terminated or Parents Are Deceased

CPS October 2017

If parental rights have been terminated for both parents, or the parents are deceased, and the attending physician recommends end-of-life care, the caseworker and supervisor must:

  •   obtain a written statement from the attending physician certifying that the child has a terminal or irreversible condition and that the physician recommends withholding or withdrawing life-sustaining treatment;

  •   request a second opinion or a review by a hospital medical or ethics review board if there are any concerns about the attending physician's recommendation. The hospital decides whether to convene a review committee;

  •   confirm that there is no relative, fictive kin, or other individual with possessory or custodial rights. If one is available, that person must be consulted for end-of-life decisions if possible;

  •   notify and discuss the recommendation with the program director, regional director, regional attorney, attorney representing DFPS, the child's attorney ad litem, guardian ad litem, CASA (if applicable), and any other legal party to the case; and

  •   notify and consult with the local court, according to the procedures explained below.

If the court …

The caseworker must…

will rule on the decision…

  •   involve the attorney representing DFPS, the child's attorney ad litem, the child's guardian ad litem, any individual with possessory or custodial rights, and any other involved individuals in developing a recommendation for the court. (If there is no attorney ad litem, the caseworker must recommend that the court appoint one); and

  •   comply with the court's directive or order.

The commissioner must take any action necessary to carry out the court's decision.

declines to rule on the decision…

  •   involve the attorney representing DFPS, the child's attorney ad litem, the child's guardian ad litem, any individual with possessory or custodial rights, and any other involved individuals in developing a recommendation about the child's care;

  •   present the recommendation to the regional director;

  •   the regional director must present the recommendation to the commissioner for the commissioner's decision;

  •   notify the hospital or healthcare provider and the court of the commissioner's decision.

The commissioner must take any action necessary to carry out the decision.

11730 Organ Donation/Anatomical Gifts

CPS October 2017

If the Parents Decide to Donate the Child's Organs

The child's parents are legally authorized to donate the child's organs in the event of death, if the parental rights have not been terminated (Chapter 692A.004, Health and Safety Code).

CPS staff must never sign consent forms for organ donation on behalf of a child's family member who has made a decision to donate the child's organs. If the family members retain their legal rights to the child but are unavailable to consent, DFPS must not give consent for organ donation in the family member's absence.

When DFPS May Decide to Donate the Child's Organs

CPS staff may make the decision to donate an organ of a child if DFPS is managing conservator and:

  •   parental rights have been terminated; or

  •   the parents are deceased.

In some instances, DFPS may decide not to approve organ donation. In the Medical Consent Resource Guide, see Organ Donation/Anatomical Gifts.

11740 Pregnancy and Abortion

11741 If a Youth Is Pregnant

CPS October 2017

If a youth in DFPS conservatorship informs a caseworker that she is or believes she may be pregnant, or the caseworker otherwise becomes aware of the youth's pregnancy or possible pregnancy, the caseworker must ensure that the youth has an appointment with a STAR Health provider as soon as possible.

Within seven days of learning about the youth's pregnancy, the caseworker and supervisor must consult with the program director and must advise the youth that she has the right to be free from pressure when deciding how to deal with her pregnancy.

In addition, the caseworker must:

1.   Interview the youth to assess if she was a victim of incest, sexual abuse, or a criminal offense.

2.   Encourage the youth to discuss options regarding the pregnancy with supportive persons such as the youth's parents, caregivers, therapist, spiritual leaders, guardian ad litem, and attorney ad litem. The caseworker must ensure that the youth is aware of her options and available community resources, including providing the booklet So You're Pregnant, Now What?

3.   Help the youth plan for the alternative she chooses, including providing her with referrals to:

  •   appropriate providers of pre- and postnatal care, including obstetric services provided through STAR Health; and

  •   a family planning clinic, if appropriate.

Authorization for Abortions: A youth who chooses to have an abortion must either obtain her parent's consent or seek a judicial bypass (a court order allowing the youth to have an abortion without receiving consent from or telling her parents or legal guardian). The caseworker and medical consenter must not approve or authorize an abortion or sign abortion-related medical consent forms, or assist the youth in applying for a judicial bypass.

See 5850 Judicial Bypass to Notifying a Parent About Abortion. For questions concerning a youth's request for an abortion, the caseworker may consult with the regional attorney.

4.   Address the youth's plans for the infant in the youth's plan of service, if applicable. If the youth chooses to care for the infant herself and to remain in foster care, and if the caregiver agrees to accept both the mother and her infant, see 6442 When a Youth in Substitute Care is Parenting.

5.   Work with the youth to decide if it is feasible and appropriate to work with the infant's father. If it is feasible, the caseworker may:

  •   encourage the father to participate with the mother in considering alternatives for the infant's care;

  •   help the father participate in planning for the alternative chosen; and

  •   help the father plan for the infant's financial support.

      If the father is in substitute care, the caseworker must also address the plans for the infant in the father's plan of service.

11742 Informing Parents and Caregivers About Pregnancy and Abortion-Related Information

CPS October 2017

Federal statutes and state licensing standards require that DFPS share a youth's medical information with the parents and caregivers, unless there are reasons not to do so.

DFPS must share pregnancy and abortion-related information with a youth's parents or caregivers, unless:

  •   disclosure poses a risk of harm or abuse to the youth;

  •   the youth expresses an interest in obtaining a judicial bypass (a court order allowing the youth to have an abortion without receiving consent from or telling her parents or caregiver); or

  •   the court has ordered a judicial bypass.

DFPS must inform the youth that youth's parents or caregivers will be informed about the pregnancy unless the above conditions are met.

See 5850 Judicial Bypass to Notifying a Parent About Abortion

When pregnancy and abortion-related information is not being disclosed to parents or caregivers, the caseworker must:

  •   obtain approval from the program director; and

  •   document the reasons in the youth's case record.

In the Medical Services Resource Guide, see Counseling a Pregnant Youth About Informing Others.

11743 If DFPS Is Appointed as Guardian Ad Litem for a Youth Who Has Applied for Judicial Bypass

CPS October 2017

If a court authorizes a youth to consent to some or all of her own medical care under Texas Family Code §266.010, the authorization does NOT authorize the youth to consent to an abortion. In order for a youth to consent to an abortion without her parents' involvement, the court must grant a judicial bypass under Texas Family Code Chapter 33.

A court may appoint a CPS staff member to be the guardian ad litem for a youth who has applied for a judicial bypass.

Texas Family Code 33.003(f)(3)

Staff appointed as guardian ad litem must immediately begin to follow the policies in 5851 DFPS Appointment as Guardian Ad Litem.

11744 Documenting Pregnancy and Abortion-Related Information for Youth in Conservatorship

CPS October 2017

In All Cases

CPS staff must document pregnancy and abortion-related information in the case record.

Pregnancy and abortion-related information includes any information about:

  •   the youth's pregnancy;

  •   the youth's pregnancy that is related to the abortion;

  •   the abortion; and

  •   any judicial bypass proceedings related to the abortion.

In the Case of Judicial Bypass

Although DFPS may document pregnancy and abortion-related information in the case record, if the youth is successful in getting a judicial bypass that specifically prohibits DFPS from disclosing the abortion-related information, DFPS must redact that information before disclosing information from the case record to a parent, caregiver, or prospective adoptive parent.

If the caseworker does not disclose the pregnancy and abortion-related information to the parents or caregiver, the caseworker must document the reasons in the case record. For example:

  •   there is risk of harm or abuse to the minor that may result from that information; or

  •   a court has ordered DFPS not to inform the parents or caregiver.

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