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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

V

Health Services

Chapter:

A

Health Services

11-4-2013

Subchapter:

1

Health Services

Issuance:

250

Medical Care of Children Receiving Services from CP&P

 

 

General Policy        11-8-2004

 

All children receiving services from CP&P receive preventive medical care and treatment in addition to medical care and treatment required by a present health condition. CP&P is exempt from paying for copies of records needed to complete an investigation of child abuse or neglect or to provide services to an abused or neglected child (N.J.S.A. 9:6-8.40).

 

Also see CP&P-V-A-7-100, Health Considerations for Adolescents.

 

Worker:

 

Arrange, monitor and document the medical care of CP&P children for the following reasons:

 

      To promote and ensure the good health and well-being of the child;

 

      To maintain a medical record and medical history of the child during his or her involvement with CP&P;

 

      To document professional examinations performed to meet CP&P case management requirements;

 

      To document professional examinations performed to determine the presence of abuse and neglect.

 

“The Division representative shall make every reasonable effort to assure that each child in out-of-home placement receives appropriate and necessary health care, including mental/behavioral health services.” (N.J.A.C. 10:122D-2.5(a))

 

See CP&P-V-A-1-1300, Pre-Placement and Re-Placement Assessment (Health).

 

Examinations          12-22-2003

 

PRS medical examinations are required during most abuse and neglect investigations. Preventive medical examinations are given routinely during ongoing case management of children receiving services from CP&P. See CP&P-V-A-3-800, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Schedule of EPSDT Screenings.

 

A medical examination is performed by a licensed physician, or a pediatric nurse practitioner working under the direct supervision of a licensed physician. The examination is documented in writing on the Child's Medical Examination Form, CP&P Form 11-2, by the examining physician or pediatric nurse practitioner.

 

CPS Medical Examination           4-23-2012

 

A medical examination is performed and documented as part of a protective services investigation whenever:

 

      A child has serious injuries, including, but not limited to burns, broken bones, unexplained bruising and/or a skull fracture;

 

      The severity of a child's injuries/condition is unclear;

 

      The allegation indicates that the child may have suffered an internal injury or incapacity due to abuse and neglect;

 

      A child is alleged to have suffered sexual abuse;

 

      The Worker has determined that documentation of the child's medical condition is warranted for casework reasons, particularly if the child's history indicates the possibility of HIV infection.

 

A medical examination and any treatment indicated by the examination should be arranged with the knowledge and consent of the child's parents. If the parent has not consented and removal of the child is not the case plan, a court order for a protective services investigation is requested. The order should include authorization for CP&P to consent to examination and to any treatment indicated as a result of the examination.

 

A medical examination must be performed and documented on CP&P Form 11-3, Pre-Placement/Re-Placement Assessment, whenever a child is removed from his home in emergency circumstances under N.J.S.A. 9:6-8.29. This is a removal by CP&P or any other person without parental consent and/or without a court order. A medical examination must be performed prior to the out-of-home placement. In this emergency removal situation, CP&P can consent to the examination and treatment of a child immediately upon removal or notification of removal and prior to the initiation of any custody action that may be planned.

 

Preventive Medical Examination for Children Receiving Services from CP&P

5-9-2011

 

Timely, preventive medical care is important for maintaining good health. CP&P intervention requires preventive medical examinations to ensure children's medical and dental needs are identified and met. These medical examinations are documented on the CP&P Form 11-2 and in NJS. All children receiving services from CP&P must have consistent medical examinations based on the age and needs of the child. Preventive medical examinations for children and adolescents include immunization. Refer to the National Immunization Program website at www.cdc.gov/vaccines/ to view the current Recommended Immunization Schedules. See CP&P-IX-A-1-100, Hepatitis, for information regarding the treatment and prevention of hepatitis. See CP&P-V-A-1-120, for information about Comprehensive Health Evaluations for Children (CHEC).

 

If there is reason to believe that a child is from a family affected by HIV, then the child requires testing. See CP&P-V-A-1-100, HIV Affected Families. In the case of a child who tests positive for HIV, great care must be used regarding immunizations. The usual immunization schedule for children with HIV infection must be altered. Immunizations containing live viruses, such as polio virus, measles, mumps, rubella, and varicella (chicken pox) may be dangerous for a child with a deficient immune system. See CPP-V-A-1-1400, Children and Adolescent Immunizations. The physician managing the child's well-child care needs to be informed of the child's immunizations, frequency of follow-up visits, and prevention/treatment of various opportunistic infections. The physician determines the child's immunization schedule on a case by case basis.

 

The schedule below lists minimum CP&P medical examination requirements.

 

Living Arrangement

Examination Schedule

In own home

Consistent medical examinations based on the age and needs of the child. See CP&P-V-A-3-800, Schedule of EPSDT Screenings.

 

In CP&P Resource Care

For each child initially entering out-of-home placement, the Division representative shall obtain a pre-placement assessment at the time of placement. The Division representative shall assure that the child receives a medical examination at least annually after the initial medical examination performed at the time of placement and a dental examination at least semi-annually for each child age three years and older. The type and frequency of the examinations shall be based on the child's age and medical needs. The Division representative shall assure that each child with a suspected mental/behavioral health need receives a mental/behavioral health assessment and identified follow-up care. At a minimum, the child's examinations shall comply with the Early and Periodic Screening and Diagnostic Treatment periodicity schedule in accordance with N.J.A.C. 10:54-5.10 through 5.13.” See CP&P-V-A-3-800 (N.J.A.C. 10:122D-2.5(b) and (f)).

 

Private Residential

Within 30 days prior to admission; then at least once a year. (Type and frequency of the exam is Facilities/Group Homes based on the age and medical needs of the child).

 

Children’s Shelters

Within 72 hours after placement, unless the Shelter is given a copy of a medical examination performed within 30 days prior to entry. (Type and frequency of the exam is based on the age and medical needs of the child).

 

Day Care Centers

Within six months prior to admission for children 2 1/2 years old or younger; within one year for those above 2 1/2 years old. (Type and frequency of the exam is based on the age and medical needs of the child).

 

Family Day Care Providers

Six months prior to or within one month following admission for children 2 1/2 years old or younger; or one year prior to or within one month following admission for children above 2 1/2 years old. (Type and frequency of the exam is based on the age and medical needs of the child).

 

 

In accordance with N.J.A.C. 10:122-7.3 and N.J.A.C. 10:126-6.8, day care centers and family day care providers are required to maintain on file a medical record of each child enrolled. The medical record must include:

 

      Name and address of the child's physician;

 

      An up-to-date immunization record appropriate to the child's age; or documentation that the child is under a prescribed medical program to obtain immunizations;

 

      Information on any condition requiring special attention (i.e. handicap, allergy, special diet).

 

It is the responsibility of the Worker/Caregiver to provide the above information (CP&P Form 11-2) to the day care center or family day care provider upon the child's admission or within thirty days of admission.

 

Children Receiving Services in Their Own Homes  11-7-2011

 

Parents/caregivers should be encouraged to provide adequate medical care to their children. Failure to provide such care may be neglectful. See CP&P-II-C-5-700.  Families should be advised that regular examinations and treatment cannot be ignored because of the inability to pay for it. Families with financial problems may be eligible for Medicaid through the County Welfare Agency because of financial need or through the Social Security Administration because of a physical disability. Parents may also be directed to Municipal Welfare for assistance with medical expenses or referred to clinics that provide medical services on a free or sliding scale basis.

 

If a child is living at home and medical examination or treatment is indicated either because of a present health condition or because a preventive medical examination has not been conducted for over 1 year, the cooperation of the parents should always be sought in getting the examination and documentation of this preventive examination. If they are not cooperative and the child has no history of serious, chronic medical problems or does not appear to be ill, that information should be written in the record and no preventive examination need be performed. If the child appears to be ill, developmentally delayed or otherwise in need of medical observation, the Worker shall seek the intervention of the court when there is no parental cooperation. If there are no parental resources or community resources to pay for the services, the child should be enrolled in Code 650. The family's lack of financial resources should be documented in the case record. See CP&P-V-A-4-100.

 

Written Documentation    4-23-2012

 

Keeping a record of the health history, significant developmental history and of medical examinations and treatment given to children receiving services from CP&P is required. Information about the child's health/development history is taken by the Worker either at intake or prior to the child's initial medical examination. The information may be gathered from the child's parents or caregiver, the child's physician, the child's school records and if possible, from the child himself. If parents or caregivers refuse to divulge this information, it should be noted in the record. Particular attention is given to recording any significant health history of the child's immediate family, the child's significant birth history and developmental milestones, the child's immunization history and any noteworthy illnesses, injuries, operations, allergies, etc. that the child may have experienced. This information is documented in full in the case recording in the case record.

 

The information is noted in brief on the CP&P Form 11-2, Child's Medical Examination Form, when it is completed in preparation for the child's initial medical examination.

 

“The Division representative shall establish a health care record for each child and shall provide the out-of-home placement provider with a health care record, which documents health information concerning the child…” N.J.A.C. 10:122D-2.5(b), using CP&P Form 11-10, Health Passport and Placement Assessment.

 

When the child is taken for an examination, the Worker provides the physician with the CP&P Form 11-2 on which to document the examination and the findings. The form must be dated and signed by the physician or pediatric nurse practitioner performing the examination. The form is returned to the Worker for review and inclusion in the case record.

 

The completed, signed CP&P Form 11-3, Pre-Placement/Re-Placement Assessment, may be used as evidence in CP&P child abuse and neglect litigation when submitted with the physician's notarized affidavit. See CP&P-IX-L-1-500  for information related to the use of the Medical Affidavit.

 

Recording and Payment              2-22-88

 

If the child is not eligible for Code 600 or Code 650 Medicaid and there is no parental or community resource, CP&P may pay for a medical examination on a CP&P Form K-100 at prevailing Medicaid rates. Rate information is available from the local Medical Assistance Customer Center or from the Office of Child and Family Health.  See the list of MACCs at http://www.state.nj.us/humanservices/dmahs/info/resources/macc/MACC_Directory.pdf.

 

Consent to Medical Examination and Treatment      2-22-88

 

Medical care professionals often require that formal consent be documented in their records before they are willing to provide health care services. Most frequently written consent is requested as a protection against future litigation.

 

It is good case management practice to contact the child's parents and have them give the provider verbal or written consent for examination and treatment of their child. In instances where the parents are unavailable or uncooperative, CP&P, through the LO Manager, may consent to a medical examination and, if necessary, treatment of a child if:

 

      CP&P has guardianship or legal custody and/or,

 

      there is a signed substitute care agreement and/or,

 

      there is a court order granting CP&P authority to make a protective services investigation and/or,

 

      there has been an emergency removal by CP&P staff or any person with or without the consent of the child's parents.

 

CP&P' written consent is transmitted to the provider using the CP&P Form 11-4, Consent for Operation, Treatment and Examination.

 

Provider Consent Forms             10-22-91

 

When providers require that their own consent forms be used, the form should be completed by the provider and forwarded to the Local Office Manager or designee for signature. If there is not sufficient time for that procedure the Worker may sign the form with the consent of the LO Manager/SPRU Supervisor or designee.

 

Minor's Consent to Own Medical Examination and Treatment     10-22-91

 

Minors who are married/civil union partnered or pregnant may consent to or refuse any medical or surgical care to be provided to themselves.

 

Minors who are not married/civil union partnered or pregnant may only consent to their own medical care and treatment for:

 

      venereal disease, when they are infected, or suspect that they are infected; and/or

 

      drug use or drug dependency when they are suffering from drug use or dependency;

 

      sexual abuse/assault victimization.

 

When a child presents himself for an examination or treatment based on sexual assault, the parent(s) or guardian(s) is to be notified immediately, unless the attending physician believes it is in the best interests of the child not to do so. N.J.S.A. 9:17A-4.

 

Consent for Minors Residing in Institutions  12-15-93

 

The Chief Executive Officer of a state or county institution for the mentally ill, mentally retarded or penal or correctional institution may consent to medical, surgical, psychiatric or dental care of a minor residing in the institution, if the parent is unavailable or unwilling to make a decision. If the medical practitioner certifies that emergency treatment is necessary, the Chief Executive Officer may consent to the treatment without prior notice to the parent.

 

Consent for Medical Examinations and Treatment Outside Normal Working Hours                         2-19-2013

 

See CP&P-II-A-5-200, Medical Consent.

 

Resource Parents' Consent for Medical Examination and Treatment    12-15-93

 

“The out-of-home placement provider shall be responsible for arranging and providing care to meet the child's health needs, including, but not limited to, medical and dental examinations, ongoing care, mental/behavioral health services and follow-up care, as agreed to with the Division representative with information concerning the child's health care, including mental/behavioral health care, and needs.” (N.J.A.C. 10:122D-2.5(g))  See CP&P-IV-B-6-300. Resource parents may not provide written consent to medical examination and treatment of a child receiving services from CP&P when written consent is requested by a provider, such as a doctor or hospital. Appropriate CP&P staff are responsible for giving consent for examination and treatment, Worker, Supervisor, LO Manager, SCR.

 

CP&P staff provide the consent according to CP&P-V-A-1-250. In situations where there is no time to notify CP&P staff without risk to the child, resource parents may give written consent to emergency medical care on behalf of CP&P, notifying CP&P personnel as quickly as time and circumstances permit.

 

Consent for Circumcision           2-11-92

 

Circumcision is the surgical removal of the skin covering the penis. There is no absolute medical indication for circumcision, although there is some evidence that circumcision may reduce the risk of penile cancer or phimosis (a condition in which the foreskin is too tight). However, the circumcision procedure itself results in complications for 4 to 13% of the newborns.

 

Therefore, when a male infant or an older male child is surrendered for adoption prior to circumcision, the Division will not routinely authorize circumcision without first obtaining medical justification for the procedure. Adoptive parents will be advised that the decision whether to circumcise has been reserved for them to make, in consultation with the child's pediatrician. If it is the expressed desire of the adoptive parents to have an infant circumcised prior to finalization, however, and the procedure for this child is not medically contraindicated, consent of the Local Office Manager must be obtained. Use the Special Approval Request, CP&P Form 16-76. Because an older child may be traumatized by this medical procedure, the procedure is inherently irreversible, and statistics suggest that older children may be more likely to change pre-adoptive homes, CP&P will not authorize circumcision for older children prior to adoption unless there is medical or psychological justification.

 

Policy Regarding Do Not Resuscitate (DNR) Orders           11-4-2013

 

As the state child protection agency, CP&P is statutorily mandated to care for children, with an implicit goal of preserving life. Therefore, in order to avoid possible conflicts of interests, CP&P is not permitted to sign a consent form for a DNR order. Also see CP&P-V-A-7-100, Health Considerations for Adolescents.

 

UNDER NO CIRCUMSTANCES MAY CP&P STAFF AND/OR RESOURCE FAMILY PARENTS CONSENT TO A DNR ORDER.

 

In a small number of cases, particularly terminally ill children with AIDS, where CP&P may receive a request from a nurse, a relative, a physician, a resource parent, for example, to seek a Do Not Resuscitate (DNR) Order, the request is handled on a case-by-case basis.

 

When CP&P a CPS court order for care and/or custody, but does not have legal guardianship:

 

      CP&P attempts to locate a parent, legal guardian or other responsible relative of the child in order for that person to make a determination about providing the consent for a DNR Order.

 

      If a parent, legal guardian or other responsible relative is unavailable, deceased or unwilling to consent to a DNR Order, the hospital, health care provider or CP&P may initiate action to obtain a court order.

 

Whenever a request is received for a DNR order for a child under CP&P supervision where the parent or guardian is not available, whether or not CP&P has guardianship, the appropriate DAG must be consulted. CP&P provides the DAG with all of the available and pertinent medical documentation. The DAG may then prepare and file an Order to Show Cause for the DNR order so that the matter may be reviewed by the court. A DAG is available at all times to assist staff in the event of a medical emergency that might require a DNR order and to facilitate the timely filing of an Order to Show Cause. The following conditions must be met in order to pursue an Order to Show Cause for a DNR Order:

 

      the child's treating physician(s) has determined that a DNR order is necessary because the child is in the end stages of an illness or is expected to die as a result of another condition or accident;

 

      cardio-pulmonary resuscitation will either do more harm than good or will do nothing to stabilize or enhance the child's quality of life;

 

      there is no person who can assume responsibility for signing the consent; and

 

      CP&P-V-A-6-100, End of Life Care policy, has been followed to the extent applicable to the child's circumstances.

 

When a child's physician makes it known to CP&P that a DNR order is in the best interests of the child, the DAG is immediately notified. CP&P provides the DAG with all materials relevant to the child and his or her illness, including medical records, case records and Pediatric Nurse Consultant's notes. A case conference is scheduled with the DAG. The CP&P Chief Pediatric Consultant and the Pediatric Nurse Consultant are notified of the request for the DNR order, invited to the case conference, and provided with all the relevant material prior to the conference.

 

If the medical situation of the child is such that there is no time to conduct a case conference, the DAG is notified immediately and is responsible for contacting the court and preparing the Order to Show Cause. At a minimum CP&P provides the DAG with the following information:

 

      child's name and date of birth;

 

      legal status of the child with CP&P;

 

      child's medical condition, cause and prognosis;

 

      name and telephone number of the child's physician; and

 

      names and telephone numbers of the Worker, supervisor and the Local Office Manager.

 

As soon as possible all pertinent medical materials (including physicians' statements) must be made available to the DAG since the court will not hear the case without a review of the records.

 

The staffs of the Offices of Program Operations, Intergovernmental Affairs and Attorney General are available to field staff 24 hours a day through SCR to address case-specific issues.