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Effective: 5/22/2025

C7.21 SSW's Ongoing Contact with the Child and Family, Including the Medically Complex Child

Legal Authority

Introduction

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​From the moment of the initial contact with the family, the SSW, and the Department for Community Based Services (DCBS) are obligated under federal and state law to make reasonable efforts to keep families intact whenever possible; and in removal situations, to make reasonable efforts to reunify children with their families. As part of this obligation, the SSW is required to maintain personal contact with families and children. Ongoing contact with the family provides information that contributes to a thorough assessment of whether the family has reduced the safety threats and risk factors that initially lead to the involvement of DCBS.

Caseworkers are required to conduct face-to-face visits with children placed in out-of-home care (OOHC) in all placement settings at least one (1) time every calendar month.

Features of an acceptable pattern of visits to parents or other significant family members include:

  • Face-to-face contact frequently enough to evaluate the family’s progress; 
  • Sufficient meaningful discussion of case planning tasks and objectives; 
  • Sufficient opportunity to observe the residence(s) of the parent(s) and child(ren), or other family members significant to the case; Assessment of the current condition within a home or family and considerations of whether there is an immediate safety threat to a child; and 
  • Assessment of risk, which includes the identification of risk factors, which are family behaviors that create an environment or circumstances that increase the chance that parents or caregivers will maltreat their children.

Through the life of the case, the burden is on the SSW to locate and maintain contact with family members.




Practice Guidance

Video Conferencing

Video conferencing is a beneficial tool for staff to contact families and children. Typically, video conferencing cannot be considered as a face-to-face visit with a family or child. However, under specific circumstances, such as a state of emergency, caseworkers can utilize video conferencing to conduct face-to-face visits. When these special circumstances are in place, the Division of Protection and Permanency (DPP) will provide guidance to field staff indicating that video conferencing is an appropriate option for conducting face-to-face visits.

Ongoing Contact with the Child

  • The SSW may utilize the Caseworker Visit Template during the face-to-face contact with the child. 
  • If a child is in a supports for community living (SCL) program, the SSW may use the Support for Community Living Program Visit-Review of Records and Facility Form at each monthly visit to the child’s placement setting, providing a copy to the central office SCL liaison. 
  • The SSW may contact the central office SCL liaison if there are concerns, questions, or a need for a Department for Behavioral Health Developmental and Intellectual Disabilities (DBHDID) case consultation after reviewing the Supports for Community Living Tip Sheet and the Resource Manual for Youth with Disabilities in Foster Care.

Ongoing Contact with the Family

  • The SSW makes face-to-face contact with parents, in their residences, at a minimum of once per calendar month. However, the appropriate frequency of visit is guided by the case specific circumstances. When the overall pattern of face-to-face visits is not monthly (once per calendar month), the SSW enters an explanation for the pattern of contact into the next case plan evaluation/ongoing assessment. 
  • In addition to face-to-face contact, the SSW may utilize telephone, mail, or email; however, the case specific circumstances should guide the overall pattern of contact within the case. 
  • The SSW documents a pattern of visits with the children and parents that will appropriately demonstrate reasonable efforts to reunify children who have been removed from their homes or finalize an appropriate permanency plan for children. ​Workers are not required to execute monthly visits to parents if there is a no contact order prohibiting contact, or if a judge has granted a waiver of efforts on the case. 
  • ​Workers will document the issuance of such orders in their ongoing assessment until the no contact order is lifted, or until case closure. 
  • Case workers are prohibited from documenting that a face-to-face contact occurred unless a face-to-face visit was completed by department personnel. Falsification of documentation is an ethical violation. 

Ongoing Contact with the Medically Complex Child

  • Multidisciplinary care teams, which may consist of physicians, therapists, nurses, managed care organization (MCO) staff, caregivers, and DCBS staff, support youth with medical complexity in OOHC. ​
  • ​The SSW communicates with members of the child's team monthly to obtain updates on the child’s medical conditions, diagnoses, progress, or challenges, changes in treatment or medications, etc. 
  • ​The SSW documents monthly contacts with the child’s care team in the TWIST service recording, including monthly documentation that the MCO uploads into TWIST.​
  • The SSW, medically complex liaison, or caregiver may request consultation at any time with the Medical Support Section, nurse consultant inspector (NCI), or MCO nurse regarding a medically complex child. 
  • The Medical Support Section may: 
    • Upon request, provide consultation and a visit to the medically complex child and/or placement; and 
    • Notify the FSOS responsible for the child if the Medical Support Section determines a condition that warrants additional attention. 
  • The SSW, recruitment and certification (R&C) worker, and MCO nurse reviews and discusses the following, as related to the specific needs of the medically complex child during the home visit (as applicable): 
    • MCO case management; 
    • Transportation arrangements for the child; 
    • Home health referrals and/or durable medical equipment (MCO nurse may assist); 
    • Availability of all medications and medical technology to care for the needs of the child; 
    • Supportive services to the caregiver(s); 
    • Future needs of the caregiver(s); 
    • Respite and/or babysitting issues; 
    • Upcoming service needs; 
    • Child/youth action plan and individual health plan with the caregiver and the child, when appropriate; 
    • Current diet and eating pattern; 
    • Medical passport, including medication logs; 
    • Transition planning; and 
    • Other information including: 
      • The child's weight; 
      • Alertness; 
      • Physical condition; 
      • Current diet and eating patterns;
      • Mental health needs; 
      • Behavioral health needs; 
      • Medication log; 
      • Current medical services; 
      • Any illness or medical change since the last visit; and 
      • Recent or future medical appointments. 
  • The foster/adoptive parent, relative, and/or out-of-state placement provider completes the DPP-104C Medically Complex Monthly Report and submits it to the SSW, who uploads it into the TWIST case record, ensures the child's medical information is up-to-date in TWIST, and forwards the form to the: 
    • ​MCO nurse, if applicable; 
    • Region's medically complex liaison; and 
    • Medical Support Section if issues are identified on the report.​​


Procedure

Ongoing Contact with the Child

Following any placement (initial or move) the SSW:

  1. Contacts the child by phone within five (5) calendar days of placement, if the child’s developmental level permits; if not developmentally appropriate, the SSW assesses the child’s transition to placement and any placement needs through the child’s caretaker; 1
  2. Within ten (10) calendar days after placement, conducts a private face-to-face visit with the child; 2 
  3. Uses face-to-face contact to assess safety threats and risk factors surrounding ​the child's placement and to ensure the child's assessed needs are being served appropriately through referrals for services and supports; 
  4. Conducts a private face-to-face visit with the child​ and a face-to-face visit with their caregiver in their placement at least once every calendar month to assess progress toward case plan goals and objectives and to assess adjustment to the out-of-home care placement; 
  5. During each face-to-face contact with the child, the SSW:
    1. ​​Allows sufficient time alone with the child in a setting that provides an opportunity for the child to speak freely and/or express thoughts and feelings; 
    2. Discusses, in an age and developmentally appropriate manner, any positive or negative feelings the child may have regarding:
      1. The placement (e.g., the foster family members, other people who visit the home, residential treatment program staff, etc.); 
      2. Services currently offered or needed;​
      3. The permanency plan(s);
      4. Visitation (e.g., parents and siblings); and
      5. The child’s interests (e.g., friends, hobbies, and extracurricular activities). 
    3. ​Photographs the child. Please see SOP C7.45 for additional guidance.
  6. Will review/update the child youth action plan and complete a new Partnership Plan with all required individuals as outlined in SOP C7.17 Ongoing Case Planning​; 
  7. Assess for safe sleep practices when the family or household includes any infant(s) up to one (1) year of age..
    1. ​​When speaking with a foster parent, ensures to specifically ask where the child sleeps and request to observe the sleep space.
    2. Provides the What Does a Safe Sleep Environment Look Li​ke ​tip sheet to care providers.
  8. Visits a child designated as medically complex: 
    1. ​Jointly with the MCO nurse within thirty (30) calendar days of the child’s designation as medically complex for the initial visit; then 
    2. At least one (1) time per calendar month, in the placement setting, which includes DCBS foster/adoptive homes, private child placing (PCP) foster homes, private child-caring (PCC) facility, psychiatric or medical hospital, SCL programs, or a relative/fictive kin placement as determined by the child's needs. NCIs, in conjunction with DCBS staff, visit medically complex youth placed in an SCL;  
    3. Face-to-face annually in the placement setting, when the child is placed out-of-state, or as often as needed, based on the child’s needs; and
    4. Monthly by phone contact to receive the child’s medical updates for out-of-state placements; 
  9. Reviews service recordings submitted by the PCC/PCP to document monthly face-to-face contact between the PCC/PCP personnel and the child, but contacts the facility's treatment/clinical staff, by telephone, at least monthly (when no face-to-face contact occurred with PCC/PCP staff during the monthly visit) to assess the child's progress towards case plan goals, objectives, and tasks.

Children Placed Out-of-State

The SSW, at minimum:
  1. ​Conducts private face-to-face contact in the child’s placement setting annually; 
  2. Conducts a video conference with the child monthly to assess the child’s safety and well-being in placement and to ensure the child's assessed needs are being served appropriately. Phone contact may be used if technological barriers prevent video conferencing. If the child’s developmental stage prevents meaningful communication over video or phone, the SSW may communicate with the child’s placement;
  3. Conducts weekly phone contact with the child; contact may be virtual/video if preferred; 
    1. Using phone and video conferencing communication, follows the standards of practice outlined below for ongoing contact with the caregiver. 
      1. ​For youth placed in family settings out-of-state, the SSW: 
        1. ​Uses quarterly progress reports provided through the states’ Interstate Compact on the Placement of Children (ICPC) offices to document monthly face-to-face contact with the youth. See SOP C10.8 Request for Supervision and Services for ICPC Placements, Including Ongoing Contact with Child​ for additional guidance.
      2. ​For youth placed in residential treatment settings out-of-state, the SSW: 
        1. Participates in monthly treatment planning meetings with child’s treatment team to assess the child’s readiness for discharge and prepare for the youth’s return to Kentucky;
        2. Documents all communication and documentation from the provider in the TWIST case record, including photographs of the youth; and
        3. Uses progress reports from the placement provider to document monthly face-to-face contact and assess the child’s progress towards case plan goals, objectives, and tasks. 
        4. Participates in monthly treatment planning meetings with child’s treatment team to assess the child’s readiness for discharge and prepare for the youth’s return to Kentucky;
        5. Documents all communication and documentation from the provider in the TWIST case record, including photographs of the youth; and
        6. Uses progress reports from the placement provider to document monthly face-to-face contact and assess the child’s progress towards case plan goals, objectives, and tasks. 

Ongoing Contact with the Child's Family

The SSW:

  1. Conducts face-to-face visits with parents and other household members frequently enough to: 
    1. Facilitate reasonable efforts; 
    2.  Communicate effectively about case plan objectives; 
    3. Identify and resolve barriers to case objectives; and ​
    4. To assess parental progress in reducing risk. 2
  2. Accomplishes case-specific intervention tasks during the contact, as well as: 
    1. Assesses for safety threats, high-risk behaviors, or risk factors; 
    2. Evaluates the family’s progress at reducing the immediate safety threats and/or reducing the risks that necessitated case action; 
    3. Reviews the family’s progress toward accomplishment of their case planning tasks and those of other service providers; 
    4. Identifies and resolves barriers to case objectives; 
    5. Provides the family with information about their child, especially placement and well-being issues; 
    6. Reviews the family’s options regarding the sharing of personal information, photographs, and recordings of the youth in out-of-home care and updates releases of information documented on the DCBS-1 and DCBS-2 as needed. Please see SOP G1.18 Informed Consent and Release of Information, SOP C7.45 Photography, Video and Audio Recording of a Child in Out-of-Home Care for additional guidance. 3
    7. Prepares for a case planning conference, periodic review,​ or court hearing; and 
    8. When appropriate, prepares an aftercare plan. 
  3. Thoroughly documents: 
    1. Observations regarding the family and the home setting; 
    2. Progress towards each task on the family case plan; 
    3. The family’s response to services they receive to other providers; 
    4. Additional assessment and planning information provided by the family; and 
    5. That the family has been provided information about the child’s: 
      1. Placement; 
      2. Physical and mental health; 
      3. Education; and 
      4. Activities; 
  4. Documents in their ongoing assessments any barriers to their ability to maintain contact with the family including, but not limited to: 
    1. The parent’s whereabouts are unknown; 
    2. Written determination by the FSOS that family members are or may be violent; or 
    3. Family members refuse to participate in ongoing visits.

Ongoing Contact with the Caregiver

The SSW:

  1. ​Conducts face-to-face visits with caregivers and other household members during visit with the child to: ​
    1. Assess for safety threats, high risk behaviors, or risk factors;
    2. Assess progress in the following areas on the child/youth action plan and assist in identifying barriers to meeting the needs of the child:
      1. ​​Physical health; 
      2. Mental health; 
      3. Education/development; 
      4. Attachment/visitation issues; and 
      5. Permanency. 
    3. ​​​Assess needed supports and resources for the caregiver; and 
    4. Provide assistance and prepare caregiver for court hearings, case planning conferences, and appointments. ​​​
  2. Accomplishes case specific intervention tasks during the contact, such as: ​
    1. Assess placement stability; 
    2. Evaluate caregiver's commitment; and 
    3. Implement Partnership Plan, (i.e., working in partnership with the birth family) 
  3. Thoroughly documents: 
    1. Observations regarding the family and the home setting; 
    2. Progress towards each task on the child/youth action plan; 
    3. Caregiver's response to services they receive and their response to meeting the child's needs; 
    4. Additional assessment and planning information needed for the caregiver; and 
    5. That the caregiver has been provided information about the child's: ​
      1. Physical and mental health; 
      2. Education; and 
      3. Activities. ​​​
  4. Documents in the ongoing assessment any barriers to their ability to maintain contact with the caregiver.

​Contingencies and Clarifications​​​

  • ​According to ICPC rules, when a child is placed in a residential treatment facility out-of-state, the placement facility is primarily responsible for the child's supervision and care, meaning that the child welfare agency in the receiving (placement) state does not conduct monthly courtesy face-to-face visits with the child within the facility.

​Footnotes​

  1. This is in addition to the initial visit when the child is taken to the placement for the first time. 
  2. The SSW may also contact the incarcerated parent in between quarterly visits by using mail, telephone, or virtual conferencing technology, if appropriate.
  3. Prior to placement in a PCC residential treatment setting, the SSW reviews the DCBS-2 with the family, explains that consent may be needed for the purpose of supervision and safety in a residential treatment setting as required under 922 KAR 1:300, and discusses the potential advantages and disadvantages to consenting or deferring consent, providing a clear choice to the family. Updates the documentation of the family’s choice regarding consent on the DCBS-2, if applicable. 

Documents

Revisions

​10/4//2023 Addition:  

6.  Will assess for safe sleep practices when the family or household includes any infant(s) up to one (1) year of age.
    1. ​​​​​​​When speaking with a foster parent, ensure to specifically ask where the child sleeps and request to observe the sleep space.
    2. Provide What Does a Safe Sleep Environment Look Lilke for care p​roviders.
  • The managed care organization (MCO) nurse visits a child defined in their complex tier as medically complex at least two (2) times per calendar month in the placement setting, which includes, but is not limited to a DCBS resource foster/adoptive home, a private child placing (PCP) foster home, psychiatric or medical hospital, independent living, or a SCL program, as determined by the child's needs. 
  • The SSW, medically complex liaison, or caregiver may request consultation at any time with the Medical Support Section, nurse consultant inspector (NCI) or MCO nurse regarding a medically complex child.
  • The SSW, recruitment and certification (R&C) worker, and/or SKY MCO nurse reviews and discusses the following, as related to the specific needs of the DCBS determined medically complex/MCO complex tier child during the home visit (as applicable): 
  • ​Behavioral health needs; ​

7/00/23 Deletion: 

  • The Supporting Kentucky Youth (SKY) nurse uploads documentation of the monthly home visits in the TWIST/SKY module and the SSW accesses the documentation from the TWIST/SKY module to enter the contact into TWIST. and files a copy in the hard copy case file. ​

​E. Enters into TWIST that the Office for Children with Special Health Care Needs (OCSHCN) nurse had face-to-face contact with the child as reported on his/her contact note. ​

2. The Department for Medicaid Services (DMS) nurse will visit the child in the placement setting one (1) time every calendar month and provide a contact note to the SSW. 

 2.  The Department for Medicaid Services (DMS) nurse will visit the child in the placement setting one (1) time every calendar month and provide a contact note to the SSW. ​

5/22/2025

  • The MCO Supporting Kentucky Youth (SKY) nurse uploads documentation of the monthly home visits in the TWIST/SKY module and the SSW accesses the documentation from the TWIST/SKY module to enter the contact into TWIST. and files a copy in the hard copy case file. 

Multidisciplinary care teams, which may consist of physicians, therapists, nurses, MCO staff, caregivers, and DCBS staff, support youth with medical complexity in OOHC. 
​The SSW communicates with members of the child's team monthly the assigned MCO nurse regarding the child monthly. This should include To obtain updates on the child’s medical conditions, diagnoses, progress, or challenges, change in treatment or medications, etc. 

The SSW documents monthly contacts with the child’s care team in the TWIST service recording, including monthly documentation that the MCO uploads into TWIST​


  • The MCO nurse uploads documentation of the monthly home visits in the TWIST/SKY module and the SSW accesses the documentation from the TWIST/SKY module to enter the contact into TWIST.
  • The managed care organization (MCO) nurse visits a child defined in their complex tier at least two (2) times per calendar month in the placement setting, which includes, but is not limited to a DCBS resource foster/adoptive home, a private child placing (PCP) foster home, psychiatric or medical hospital, or independent living program, as determined by the child's needs. 
  • The foster/adoptive parent, relative, and/or out-of-state placement provider completes the DPP-104C Medically Complex Monthly Report and submits it to the SSW, who uploads it into the TWIST case record, ensures the child's medical information is up-to-date in TWIST, and forwards the form to the: 
  1. Contacts the child by phone within five (5) calendar days of placement, if the child’s developmental level permits; if not developmentally appropriate, the SSW assesses the child’s transition to placement and any placement needs through the child’s caretaker; 1
  2. Within ten (10) calendar days after placement, conducts a private face-to-face visit with the child; 2 

  4. Conducts a private face-to-face visit with the child​ and a face-to-face visit with their caregiver in their placement at least once every calendar month to assess progress toward case plan goals and objectives and to assess adjustment to the out-of-home care placement; 
  5. During each face-to-face contact with the child, the SSW:
    1. ​​Allows sufficient time alone with the child in a setting that provides an opportunity for the child to speak freely and/or express thoughts and feelings; 
    2. Discusses, in an age and developmentally appropriate manner, any positive or negative feelings the child may have regarding:
      1. The placement (e.g., the foster family members, other people who visit the home, residential treatment program staff, etc.); 
      2. Services currently offered or needed;​
      3. The permanency plan(s);
      4. Visitation (e.g., parents and siblings); and
      5. The child’s interests (e.g., friends, hobbies, and extracurricular activities). 
    3. ​Photographs the child. Please see SOP C7.45​ for additional guidance.
​​7.  Must return within ten (10) calendar days after placement, to have an additional private face-to-face visit with the child; 1 
8.  Has phone contact with the child within five (5) calendar days of placement, if the child is age appropriate to respond by phone; if not age appropriate, the SSW assesses the child’s transition to placement and any placement needs through child’s caretaker; 
9.  Has a private face-to-face visit with the child, and a face-to-face visit with their caregiver in their placement at least once every calendar month in order to assess progress toward case plan goals and objectives and to assess adjustment to the out of home care placement; 
  1. Has private face-to-face contact, at least one (1) time per calendar month, in the child's placement setting; 
  2. Has private face-to-face contact in the child’s placement setting annually if the child is placed out-of-state; 
  1. When a child is placed out-of-state, uses progress reports, collected at least every six (6) months, from a caseworker for the state agency where the placement is located or from the placement provider to document monthly face-to-face contact and assess the child’s progress towards case plan goals, objectives, and tasks; and 
  2. Has monthly phone contact with the child or the child’s placement when a child is placed in an out-of-state setting.

Children Placed Out-of-State

The SSW, at minimum:
  1. ​Conducts private face-to-face contact in the child’s placement setting annually; 
  2. Conducts a video conference with the child monthly to assess the child’s safety and well-being in placement and to ensure the child's assessed needs are being served appropriately. Phone contact may be used if technological barriers prevent video conferencing. If the child’s developmental stage prevents meaningful communication over video or phone, the SSW may communicate with the child’s placement;
  3. Conducts weekly phone contact with the child; contact may be virtual/video if preferred; 
    1. Using phone and video conferencing communication, follows the standards of practice outlined below for ongoing contact with the caregiver. 
      1. ​For youth placed in family settings out-of-state, the SSW: 
        1. ​Uses quarterly progress reports provided through the states’ ICPC offices to document monthly face-to-face contact with the youth. See SOP 10.8 Request for Supervision and Services for ICPC Placements, Including Ongoing Contact with Child for additional guidance.
      2. ​For youth placed in residential treatment settings out-of-state, the SSW: 
        1. Participates in monthly treatment planning meetings with child’s treatment team to assess the child’s readiness for discharge and prepare for the youth’s return to Kentucky;
        2. Documents all communication and documentation from the provider in the TWIST case record, including photographs of the youth; and
        3. Uses progress reports from the placement provider to document monthly face-to-face contact and assess the child’s progress towards case plan goals, objectives, and tasks. 
        4. Participates in monthly treatment planning meetings with child’s treatment team to assess the child’s readiness for discharge and prepare for the youth’s return to Kentucky;
        5. Documents all communication and documentation from the provider in the TWIST case record, including photographs of the youth; and
        6. Uses progress reports from the placement provider to document monthly face-to-face contact and assess the child’s progress towards case plan goals, objectives, and tasks. 

F. Reviews the family’s options regarding the sharing of personal information, photographs, and recordings of the youth in out-of-home care and updates releases of information documented on the DCBS-1 and DCBS-2 as needed. Please see SOP G1.18 Informed Consent and Release of Information, 4.57 Photography, Video and Audio Recording of a Child in Out-of-Home Care for additional guidance. 3

Contingencies and Clarifications​​​

  • ​According to ICPC rules, when a child is placed in a residential treatment facility out-of-state, the placement facility is primarily responsible for the child's supervision and care, meaning that the child welfare agency in the receiving (placement) state does not conduct monthly courtesy face-to-face visits with the child within the facility.

Footnotes

3. Prior to placement in a PCC residential treatment setting, the SSW reviews the DCBS-2 with the family, explains that consent may be needed for the purpose of supervision and safety in a residential treatment setting as required under 922 KAR 1:300, and discusses the potential advantages and disadvantages to consenting or deferring consent, providing a clear choice to the family. Updates documentation of the family’s choice regarding consent on the DCBS-2, if applicable.