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Effective: 7/5/2021

23.1 Ongoing Case Planning

Legal Authority

Introduction

​​​​​​​​​​​​​​The SSW offers the adult the necessary protective or preventive services as identified in the adult assessment. These services are based on the voluntary request for or acceptance of protective services by the adult in need of services, the voluntary request for services by a guardian on behalf of the adult or court ordered protective services, which are specified by the court and defined within the court order.

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In order to provide the most comprehensive services to the adult, the SSW is encouraged to participate in local coordination efforts with community partners including, but not limited to local coordinating councils on domestic violence, local coordinating councils on elder maltreatment, multidisciplinary geriatric crisis response and intervention teams, adult fatality review teams, or TRIAD's. Participation will enhance interagency knowledge and cooperation, thus enhancing the safety and stability of abused and/or neglected adults.

Practice Guidance

Adult Self Determination
  • ​An adult has the right to choose who to involve in their individual case planning and should be encouraged to involve friends or family members who have the potential to assist them. 
  • An adult who voluntarily accepts services has the right to decide which goals and objectives to address in their case plan.
Family Level Objectives (FLO)
  • The case plan must contain at least one FLO based on the adult assessment or case plan evaluation. 
  • The wording of the FLO is tailored to the adult’s view of the problem and reflects their phrasing and terminology. 
  • If the adult refuses to accept an FLO based on the highest risk identified on the adult assessment, but agrees to an FLO which is not identified as the highest risk, the case plan is based on the objectives the adult wishes to address. 
  • Tasks are completed for every FLO established in the case plan to identify what the family, SSW, or other parties involved in the case plan are to complete. ​
    • There must be one task for each objective identified.​
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Individual Level Objectives (ILO) ​
  • Case plans may contain an ILO if the adult agrees or chooses to address such individual issues. 
  • The ILO addresses personal patterns of behavior that are preventing an individual from achieving family developmental tasks; however, it is not required that APS case plans contain an ILO due to the voluntary nature of these cases. 
  • Tasks are completed for every ILO established in the case plan to identify what the family, SSW, or other parties involved in the case plan are to complete. 
    • There must be one task for each objective identified.
Considerations for safety in cases involving perpetrators residing in the home.​
  • Case plans may contact an ILO if the adult agrees or chooses to address such individual issues. 
  • The ILO addressed personal patterns of behavior that are preventing an individual from achieving family developmental tasks; however, it is not required that APS case plans contain an ILO due to the voluntary nature of these cases. 
  • Tasks are completed for every ILO established in the case plan to identify what the family, SSW or other parties involved in the case plan are to complete. ​
    • There must be one task for each objective identified.
Considerations for safety in cases involving perpetrators residing in the home.​
  • The SSW should keep in mind that an adult experiencing ongoing abuse that also fits the definition of domestic violence in KRS 403.720(1) may experience the case planning process differently than an adult that experienced an isolated act of abuse. 
  • If an adult is currently experiencing domestic violence in the home and is requesting ongoing services, the SSW should reassure the adult that it is their right to have services without others being involved. 
  • With permission from the adult, the FLO should focus on physical safety. 
  • If the alleged perpetrator is involved in case planning, the first ILO should address the specific behavior surrounding the abuse, neglect, or exploitation. 
  • The adult may wish to involve the alleged perpetrator in case planning, but may have a desire to keep specific tasks confidential. 
  • The SSW may offer an adult personal development plan (SOP 23.4) to address these tasks.
Ongoing alternate care services provided by the SSW may include: ​
  • Protective services referrals to community mental health centers, home health agencies, and other resources for:
    • ​Counseling to help the resident and family members: 
    • Adjusting to the placement; 
    • Understanding grief and loss issues; 
    • Understanding changes in social economic status; 
    • Adjusting to loss of functional abilities; and 
    • Alleviating conflict. ​
  • Assistance in budgeting the monthly personal allowance; 
  • Explanation of Department for Community Based Services (DCBS) responsibility; 
  • Education on the aging process and methods for dealing with special needs and behaviors; 
  • Assistance in securing information about proper nutrition, medical services, budgeting, and recreational activities;
  • Assistance in arranging special health care services; 
  • Assistance in arranging transportation for medical and social activities; and 
  • Assistance in securing volunteers or community organizations for social activities, outings, or other supportive services in the facility.

Procedure

When providing ongoing case services to an adult, the SSW:
  1. ​​Ensures that the DCBS-1B Application for Services form is completed upon opening the case; 
  2. Develops a case plan with the adult, caretaker and others as appropriate within fifteen (15) working days after the approval of the investigative assessment; 
  3. With consent of the adult may include the following people in case planning:
    1. ​Designated regional cabinet staff; 
    2. Family members; 
    3. Family friends; 
    4. Community partners, (i.e., medical providers, faith-based organization members); or 
    5. Other individuals requested by the adult. 
  4. Develops the case plan only with the client if the adult chooses not to have a family member involved,(i.e., alleged perpetrator); 1 
  5. Documents all identified ongoing services to be provided by the SSW as tasks in the family level objective (FLO) or individual level objective (ILO); 
  6. Establishes with the adult the expectation of monthly contacts and documents such in the case plan; 
    1. Documents preferred method of monthly contact (face to face, telephone, virtual); and 
    2. Documents preferred location of monthly contact. 
  7. Signs the case plan along with the adult and others involved; 
  8. Documents in the case record if the adult agrees to the case plan goals and objectives, but chooses not to sign the plan;
  9. Provides a copy of the DPP-154 Protection and Permanency Service Appeal to the victim; 
  10. Provides a copy of the DPP-154 to the alleged perpetrator if they are requesting or being provided services; 
  11. Must consider confidentiality as a significant concern, since inappropriate access to the case plan might cause risk to the victim. 
  12. Updates the case plan every six (6) months or whenever a significant change occurs.
The FSOS:

Approves all case plans.


Footnotes

  1. In those circumstances, the excluded person is not included as part of the FLO or ILO and should not sign the case plan.​​​​

Documents

Revisions