REFUGE HOUSE, INC.

PURPOSE

This policy establishes Refuge House's commitment to developing and implementing comprehensive, individualized service plans for all children in foster care placement. Service planning at Refuge House integrates T3C System requirements, trauma-informed approaches through Trust-Based Relational Intervention® (TBRI®), and regulatory compliance to ensure each child receives services tailored to their unique needs, strengths, and permanency goals.

POLICY STATEMENT

Refuge House recognizes that effective service planning is the cornerstone of quality foster care. Every child deserves a thoughtful, comprehensive plan that addresses their physical, emotional, educational, developmental, and permanency needs while incorporating the voice of the child and their family. Service plans will be developed collaboratively, implemented consistently, and reviewed regularly to ensure progress toward positive outcomes.

The Living Service Plan. The Service Plan is a living document, continuously maintained: it is updated whenever new information arises — a CANS 3.0 re-rating, a crisis event, a school change, a caregiver observation — not only at scheduled intervals. The periodic Service Plan Review required by 26 TAC §749.1335 (known internally as the "Service Plan Snapshot") therefore does not update the plan; it certifies it: a point-in-time, signed record of the current plan and the child's status is frozen, signed per the package's requirements, filed to the child's permanent record, and submitted to the SSCC/DFPS where required. Between Snapshots, the Monthly Pulse (Provision 7) keeps the plan informed and current. A living plan and a periodic certification are complementary, not contradictory: the plan is the record; the Snapshot is the proof.

Service Plan Review (Snapshot) Timelines by Package

¹ The RCC Contract requires 90-day reviews, which supersedes the 6-month baseline in 26 TAC §749.1335 for as long as that contract term is in effect (decision: June 2026). ² Basic CANS follows the minimum stated requirement of the regulating entities: annual for age 3+ per FC-T3C-01 and the April 2026 T3C Blueprint (pp.50-58). A Basic Snapshot is not deficient for lacking a 90-day CANS.

Service Planning Meeting Cadence: Across all T3C service packages, service planning meetings with the youth, family/caregivers, Case Manager, and relevant clinical/service-delivery staff occur at a minimum every 90 days, or more frequently as required by the specific service package (see package-specific review cycles below). For Short-Term Assessment (30-45 day placements), service planning meetings occur at the 30-day mark and at extension decision points. Per T3C Blueprint (April 2026) and 26 TAC §749.1335.

PROVISIONS

1. T3C SERVICE PACKAGE VERIFICATION AND COMPLIANCE

Refuge House will verify T3C Service Package assignments and ensure compliance by:

• Confirming both Refuge House and foster home credentials match the assigned T3C Service Package
• Assessing capacity to implement package-specific requirements
• Developing implementation plans aligned with package requirements
• Monitoring ongoing compliance throughout placement

2. SERVICE PLAN DEVELOPMENT TIMELINES

All service plans will be developed according to the following mandatory timelines:

• 72-Hour Preliminary Service Plan: Addressing immediate needs within 72 hours of placement
• Initial 30-Day Service Plan: Comprehensive plan completed within 30 days (26 TAC §749.1301 - HIGH WEIGHT STANDARD)
• Service Plan Reviews (Snapshots): At minimum every 90 days per the RCC Contract (which supersedes the 6-month baseline of 26 TAC §749.1335), or more frequently as required by specific T3C packages

3. SERVICE PLAN CONTENT REQUIREMENTS

Every service plan will include:

• Child's identifying information and permanency goal
• Current CANS 3.0 Assessment results and integration
• Medical, dental, and mental health needs with provider information
• Educational status and support plans
• Family connections and visitation plans
• Cultural, religious, and linguistic considerations
• TBRI® implementation strategies specific to the child
• Safety planning when indicated
• Normalcy activities and developmental milestones
• Transition planning for youth 14 and older
• Package-specific interventions and requirements
• Anticipated length of stay (see §3.1)
• Goal types for every plan goal (see Provision 8)

3.1 Anticipated Length of Stay

Each Service Plan documents an anticipated length of stay that is:

1. Individualized to the youth — reflecting the youth's specific clinical, permanency, and developmental needs, per CANS 3.0 findings and admission assessment.
2. Stated in concrete time units — expressed in weeks, months, or years (e.g., "6-9 months," "12-18 months"). "Indefinite" or "TBD" is not an acceptable entry.

Anticipated length of stay is reviewed at each Service Plan Snapshot (per package cadence) and updated as clinical circumstances evolve. Per T3C Blueprint (April 2026) and 26 TAC §749.1335.

4. COLLABORATIVE PLANNING PROCESS

Service planning will be a collaborative process involving:

• The child/youth (as age and developmentally appropriate)
• Foster parents as primary caregivers
• DFPS/SSCC caseworker
• Biological family members when appropriate
• Educational representatives
• Medical and mental health providers
• Other identified supportive persons

5. TBRI® INTEGRATION

As our Evidence-informed Treatment Model, TBRI® principles will be integrated throughout each service plan:

• Connecting Strategies: Building trust through relationship and attachment
• Empowering Strategies: Meeting physical and environmental needs
• Correcting Strategies: Shaping behaviors through teaching and nurturing

6. MONITORING AND QUALITY ASSURANCE

Refuge House will ensure service plan quality through:

• Treatment Director review for clinical appropriateness
• Program Director review for regulatory compliance
• Regular monitoring of goal progress
• Documentation of all plan modifications
• Quality assurance audits and continuous improvement

7. MONTHLY PULSE

Each month, between Snapshots, the assigned Case Manager conducts the Monthly Pulse — the structured instrument that keeps the living plan current:

1. Instrument generation. A questionnaire is generated for the specific child from the current Service Plan, the child's needs/goals assessments (including CANS 3.0), and any new documents in the record. Generative AI may be used to assemble this tailored instrument.
2. Fallback instrument. If a tailored questionnaire cannot be generated for any reason (system unavailability, insufficient record, new placement), the Pulse proceeds using the General Pulse Questionnaire, a standing standard form covering the universal domains (safety, placement stability, school, health/medication, family contact, normalcy, emerging needs, caregiver supports). The Pulse is never skipped for lack of a tailored instrument; the Case Manager documents the use of the general form and the reason.
3. Interviews. The questionnaire drives an interview with the foster parents and a separate, age- and developmentally-appropriate interview with the child. Interviews may be recorded with documented consent per FC-REC-01.
4. Summary and integration. A summary with recommendations is drafted (AI-assisted drafting is permitted); a staff member reviews, edits, and signs it. AI-assisted documents are identified as such; professional judgment is not delegated to any automated system. Accepted findings are entered into the living Service Plan as updates.

8. GOAL TYPES

Every Service Plan goal carries a goal type that determines how it is measured and dispositioned at review:

• Maintenance — a steady state held continuously (safety, placement stability, normalcy, medication adherence). Evaluated as sustained / at-risk / lapsed, never on a progress scale; maintenance goals are never closed while the child is in care.
• Achievement — a measurable trajectory toward a defined target, evaluated on the progress scale; at target, the goal closes, steps down, or converts to maintenance.
• Hybrid — an achievement phase that converts to maintenance at target rather than closing.

CANS 3.0 rating trajectory informs the type (actionable ratings 2–3 → achievement; 0–1 → maintenance). This typing is what gives effect to 26 TAC §749.1335(1)'s requirement to evaluate "progress and the effectiveness of strategies": a sustained maintenance goal is succeeding, not stalled. Operational detail: Service Plan Snapshot — Definition of Done (cookbook: t3c-service-plan-review-matrix) and the T3C Goal Types reference.

PACKAGE-SPECIFIC REQUIREMENTS:

☒ MENTAL & BEHAVIORAL HEALTH SUPPORT SERVICES

For children receiving Mental & Behavioral Health Support Services, service plans will include enhanced components:

Review Cycle: Service Plans shall be reviewed every 90 days in conjunction with the Continued Stay confirmation (the attestation layer of the Snapshot). Service planning meetings — attended by the youth (age-appropriate), Foster Family Home Caregiver, Case Manager, Treatment Director (as applicable), and family/permanency connections — occur at each 90-day review and at any ad hoc point triggered by clinical need, placement stability concerns, or significant CANS 3.0 change.

1. Clinical Integration Requirements:

   • Integration of psychiatric evaluations and psychological assessments
   • Coordination with assigned therapist for treatment planning
   • Documentation of therapeutic modalities and frequency (individual, family, group)
   • Medication management plans with prescriber coordination
   • Crisis response protocols integrated with 24/7 crisis team

2. Behavioral Support Planning:

   • Functional behavior assessments informing intervention strategies
   • Specific de-escalation techniques tailored to the child
   • Environmental modifications to support emotional regulation
   • Daily mood and behavior tracking systems
   • Foster parent training plans for therapeutic interventions

3. Enhanced Review Frequency:

   • Service plan reviews aligned with treatment team meetings (per Treatment Model)
   • Minimum quarterly reviews or more frequently based on clinical need
   • Integration of therapy progress notes and psychiatric recommendations
   • Adjustment of interventions based on treatment response

4. Aftercare Planning Integration:

   • Begin aftercare planning at admission for 6-month mandatory aftercare
   • Include transition planning for therapeutic services
   • Document referral processes for continued mental health support
   • Plan for medication continuity post-discharge

☒ INTELLECTUAL OR DEVELOPMENTAL DISABILITY (IDD)/AUTISM SPECTRUM DISORDER SUPPORT SERVICES

For children receiving IDD/Autism Support Services, service plans will include specialized components:

1. Developmental Support Planning:

   • Integration of developmental evaluations and adaptive functioning assessments
   • Communication plans including AAC devices and visual supports
   • Sensory profiles with environmental accommodation plans
   • Daily living skills goals with step-by-step teaching strategies
   • Registered Nurse consultation integration for medical needs

2. Educational Advocacy Requirements:

   • Detailed special education coordination plans
   • ARD/IEP participation and advocacy strategies
   • Related services coordination (speech, OT, PT, etc.)
   • Transition planning for educational settings
   • Home-school collaboration protocols

3. Behavioral Support Components:

   • Positive behavior support plans based on functional analysis
   • Environmental structure and predictability planning
   • Visual schedules and routine maintenance strategies
   • Crisis prevention through proactive supports
   • Data collection systems for behavior tracking

4. Medical Coordination Elements:

   • Medication administration protocols with RN oversight
   • Medical appointment coordination and support
   • Emergency medical response planning
   • Equipment and supply management
   • Health status monitoring systems

☒ SUBSTANCE USE SUPPORT SERVICES

Service planning for children receiving Substance Use Support Services follows Mental & Behavioral Health patterns with recovery-focused enhancements.

Review Cycle: Service Plans shall be reviewed every 90 days in conjunction with the Continued Stay confirmation (dual signature — Program Director and Treatment Director — per FC-CSR-01 §3.1).

Package-Specific Service Plan Components:

• Recovery goals and objectives
• Weekly therapy minimum documentation with clinical justification
• Drug screening protocol (when clinically indicated per FC-SU-01 §14)
• Relapse prevention planning

Cross-Reference: Detailed procedures in FC-SU-01 Substance Use Support Services Policy §13-14.

☒ SHORT-TERM ASSESSMENT SUPPORT SERVICES

For Short-Term Assessment placements, assessment IS the primary purpose. Service planning focuses on assessment coordination and Service Package determination.

Review Cycle: Service Plans shall be reviewed every 30 days per T3C Blueprint pp.70-78 (April 2026).

CRITICAL DISTINCTIONS:

• Time-limited placement (30/45 days + 15-day extension)
• NO Continued Stay Review required
• NO Add-On Services eligible

Package-Specific Service Plan Components:

• Assessment coordination goals (primary focus)
• CANS 3.0 completion within 21 days (≤5 years) or 30 days (6+ years)
• Service Package recommendation as primary outcome goal
• Transition planning to receiving placement

Cross-Reference: Detailed procedures in FC-STASS-01 Short-Term Assessment Support Services Policy §13-14.

☒ T3C TREATMENT FOSTER FAMILY CARE SUPPORT SERVICES

Service planning for T3C Treatment Foster Family Care reflects the highest level of clinical intervention with accelerated review cycles and time-limited structure.

Review Cycle: Service Plans shall be reviewed every 60 days per T3C Blueprint pp.137-148 (April 2026).

Legal Framework: Texas Family Code §264.1073; TAC §700.1335

CRITICAL REQUIREMENTS:

• Dual Signature: Both Program Director AND Treatment Director written confirmation required at each 60-day review per T3C Blueprint pp.137-148 (April 2026)
• Step-Down Planning from Day 1: Initial Service Plan shall include step-down goals
• 365-Day Maximum: Track placement days (274 standard + 91 extension)

Package-Specific Service Plan Components:

• Intensive therapeutic services with written clinical justification
• Step-down goals and treatment milestones
• Anticipated length of service
• Crisis safety planning

Cross-Reference: Detailed procedures in FC-TFFC-01 T3C Treatment Foster Family Care Support Services Policy §12-16.

DEFINITIONS

CANS 3.0 Assessment: Child and Adolescent Needs and Strengths assessment tool required by T3C for comprehensive evaluation of children's needs across multiple domains.

Living Service Plan: The always-current Service Plan, continuously maintained as new information arises. It is the only editable plan object; it is never "due" because it is never out of date.

Monthly Pulse: The monthly questionnaire-and-interview instrument (Provision 7) that keeps the living plan current. The Pulse informs the plan; it certifies nothing.

Service Plan: A comprehensive, written document that guides the provision of services to meet a child's individual needs and achieve permanency goals.

Service Plan Review ("Service Plan Snapshot"): The certification event required by 26 TAC §749.1335: a point-in-time, frozen, signed image of the living Service Plan, including the continued-stay confirmation where applicable, filed to the child's permanent record and submitted to SSCC/DFPS where required. In internal documents this event is titled "Service Plan Snapshot" with "Service Plan Review · 26 TAC §749.1335" as subtitle; in external and regulatory documents the titles swap. The 26 TAC citation appears in both orientations.

Goal Type: The classification (maintenance, achievement, or hybrid) that determines a goal's status scale and disposition rules at review (Provision 8).

T3C Service Package: The specific level and type of foster care services credentialed and provided based on the child's assessed needs.

TBRI® (Trust-Based Relational Intervention): An evidence-informed approach designed for children who have experienced relationship-based traumas, focusing on building trust and secure attachments.

Dual Signature Confirmation: Requirement that both Program Director and Treatment Director provide written confirmation of continued need at the applicable Snapshot cadence (every 90 days for MBH, IDD/Autism, and Substance Use; every 60 days for T3C Treatment Foster Family Care per T3C Blueprint pp.137-148, April 2026).

Recovery Goals: Service Plan goals specific to substance use recovery per FC-SU-01.

Service Package Recommendation: Clinical determination of appropriate ongoing T3C Service Package based on assessment findings, required for Short-Term Assessment discharge per FC-STASS-01.

Step-Down Planning: Process of identifying goals for transitioning from Treatment Foster Family Care to less-intensive placement per FC-TFFC-01.

REFERENCES:

T3C Blueprint (April 2026 edition — authoritative; see regulatory-references/markdown/T3C-BLUEPRINT-INDEX.md):

• Pages 50-58 (T3C Basic Foster Family Home)
• Pages 59-69 (Substance Use Support Services)
• Pages 70-78 (Short-Term Assessment Support Services)
• Pages 79-89 (Mental & Behavioral Health)
• Pages 125-136 (IDD/Autism)
• Pages 137-148 (T3C Treatment Foster Family Care Support Services)
• Pages 149-164 (Add-On Services)

26 TAC Chapter 749 (Minimum Standards):

• 26 TAC §749.1301: 30-Day Service Plan Timeline (HIGH WEIGHT STANDARD)
• 26 TAC §749.1309: Service Plan Content Requirements
• 26 TAC §749.1317: Signature and Distribution Requirements
• 26 TAC §749.1335: Service Plan Review Requirements (TAC baseline every 6 months; superseded in practice by the RCC Contract 90-day requirement — see Provision 2)
• 26 TAC §749.665: Program Director Responsibilities
• 26 TAC §749.673: Treatment Director Responsibilities

RCC Contract:

• DFPS 24-Hour RCC Requirements (FY26) §§4200–4230 (service planning participants and content; Form 3300 documentation; 10-day submission to CPS); 90-day review cadence per T3C Blueprint package requirements
• 15 business days submission deadline for Continued Stay Reviews (enhanced packages)

Other:

• Texas Family Code §264.1073
• TAC §700.1335
• TBRI® Pocket Guide
• FC-CONV-01.1 Legacy-to-T3C Conversion Procedure §6
• Service Plan Snapshot — Definition of Done (cookbook slug: t3c-service-plan-review-matrix)
• Service Plan Lexicon (cookbook slug: t3c-service-plan-lexicon)

RELATED PROCEDURES:

• FC3-01.1 Individual Service Planning Procedure
• FC2-01.1 Admission Assessment Procedure
• FC7-01.1 Family Connections and Engagement Procedure
• FC14-01.1 Discharge and Permanency Planning Procedure
• FC-CSR-01 / FC-CSR-01.1 Continued Stay Review Policy and Procedure
• FC-REC-01 / FC-REC-01.1 Recorded Interview & Transcript Management Policy and Procedure
• Mental & Behavioral Health Support Services Procedure
• IDD/Autism Spectrum Disorder Support Services Procedure
• FC-SU-01 Substance Use Support Services Policy
• FC-STASS-01 Short-Term Assessment Support Services Policy
• FC-TFFC-01 T3C Treatment Foster Family Care Support Services Policy

FORMS/ATTACHMENTS:

Core Forms:

• 72-Hour Preliminary Service Plan
• Initial 30-Day Individual Service Plan
• Service Plan Review Form
• Service Plan T3C Supplement and Continued Stay Evaluation Form (FC3-03)
• Service Plan Snapshot Contents Checklist (source of truth: t3c-service-plan-review-matrix)
• Monthly Pulse Questionnaire (tailored, AI-assisted)
• General Pulse Questionnaire (standing fallback form)
• Pulse Summary & Recommendations Form
• Service Planning Developmental Worksheet
• Service Planning TBRI Integration Guide
• Casey Life Skills Assessment (CLSA)
• Enhanced Continued Stay Confirmation Forms (Mental Health and IDD/Autism versions)

Substance Use Forms:

• Enhanced Continued Stay Confirmation Form - Substance Use Version (dual signature)

Short-Term Assessment Forms:

• Service Plan - Short-Term Assessment Supplement
• Service Package Recommendation Form

Treatment Foster Family Care Forms:

• Enhanced Continued Stay Confirmation Form - Treatment Foster Care Version (dual signature)
• Step-Down Planning Worksheet

This policy document establishes the governing principles for Individual Service Planning. The corresponding procedure document (FC3-01.1) operationalizes these principles by providing specific implementation details (who, when, where, and how). While policies require Board approval and remain relatively stable, procedures may be updated by the Executive Director to adapt to regulatory changes, technological advancements, or operational improvements without requiring Board approval, provided such changes maintain alignment with the policy's intent.