# REFUGE HOUSE, INC.

| Policy Information | Details |
| :---- | :---- |
| **POLICY NAME** | On-Call Policy |
| **POLICY NUMBER** | FC-OC-01 |
| **ORIGINATED** | 6/04 |
| **APPROVED BY** | Board of Directors |
| **EFFECTIVE DATE** | 5/15/25 |
| **REVISION DATE** | 6/15/26 |
| **LAST UPDATED** | 5/15/2026 |
| **LAST APPROVED** | 5/22/2026 |
| **RELATED PROCEDURE** | FC-OC-01.1 On-Call Procedure |

| APPLICABLE T3C PACKAGES: | APPLICABLE T3C ADD-ON SERVICES: |
| :---- | :---- |
| ☒ T3C Basic Foster Family Home | ☒ Transition Support Services for Youth & Young Adults |
| ☒ Substance Use Support Services | ☒ Kinship Caregiver Support Services |
| ☒ Short-Term Assessment | ☒ Pregnant & Parenting Youth or Young Adult |
| ☒ Mental & Behavioral Health |  |
| ☒ Sexual Aggression/Sex Offender |  |
| ☒ Complex Medical Needs or Medically Fragile |  |
| ☒ Human Trafficking Victim/Survivor |  |
| ☒ Intellectual or Developmental Disability (IDD)/Autism Spectrum Disorder |  |
| ☒ T3C Treatment Foster Family Care |  |

## PURPOSE:

To establish the governing principles by which Refuge House provides continuous crisis response, placement acceptance, and foster-family support outside of normal business hours — ensuring a qualified responder is always available to protect the safety, well-being, and placement stability of every child in care.

## POLICY:

Refuge House actively supports its foster families and the children they serve through 24-hour crisis intervention **24 hours per day, 7 days per week, 365 days per year (24/7/365)**. This policy applies the **strictest** requirement cross-referenced across 26 TAC Chapter 749, the DFPS 24-Hour Residential Child Care Contract (§§1111 and 1115), the T3C System Blueprint, and every applicable SSCC Provider Manual (OCOK, Belong/SJRC, Saint Francis, 2INgage, EMPOWER, 4Kids4Families). This policy applies to all foster care and adoption programs and departments within the organization.

## 24/7/365 COVERAGE:

Refuge House maintains **case-manager-level-or-above** staff available 24/7/365 to respond — in person, by phone, or by video conference — to any crisis, and ensures an **on-call Licensed Therapist is always available** to provide consultation and to respond in person when needed for mental, emotional, or behavioral crises (T3C System Blueprint). On-call responsibilities rotate among eligible case managers under a published schedule maintained at least quarterly.

## DESIGNATED EMERGENCY ON-CALL CONTACT:

Refuge House provides and maintains a current designated **Emergency On-Call Contact** (name, phone, email) to DFPS, each contracting SSCC, supervision staff, and every foster parent. The Emergency On-Call Contact must be readily accessible and able to implement an immediate plan for compliance (24-Hour RCC Contract §1115; Addendum #5).

## PLACEMENT-REQUEST AVAILABILITY:

Refuge House is available for placement referrals **and** for the physical placement of children 24/7/365, and responds to every placement request within the strictest applicable timeframe (24-Hour RCC Contract §1111; SSCC provider manuals). The on-call worker or designee and the caregiver must be present to receive the child at the time of placement. Specific response timeframes are maintained in FC-OC-01.1.

## CRISIS, SUICIDE, AND TRAFFICKING RESPONSE:

On-call response to mental-health, suicide-related, and missing-child/trafficking situations follows the agency's suicide prevention, intervention, and postvention policy (**TAC §§749.136 and 749.137**) and **FC-04 Crisis Management** — including consultation with the on-call Licensed Therapist, use of mobile crisis resources prior to hospitalization when clinically appropriate, high-risk suicide safeguards, and immediate (no later than 8-hour) law-enforcement/NCMEC/DFPS notification for suspected trafficking or missing children.

## INCIDENT REPORTING:

All incidents occurring while on call are reported under **FC-SIR-01 Serious Incident Reporting Policy** at the strictest applicable timeframe (**TAC §§749.501–749.513**; verbal report within 12 hours for critical incidents per Saint Francis §4.7.3; TPG submission within 24 hours). The responding on-call worker remains responsible for the corresponding documentation and for keeping the Treatment Manager and assigned case manager informed.

## 24-HOUR AWAKE SUPERVISION AND DFPS MONITORING:

Where 24-Hour Awake Supervision applies, Refuge House self-reports any instance of non-compliance to DFPS through the 24-Hour Awake Check Portal **within 24 hours** (24-Hour RCC Contract §1115). During an unannounced DFPS monitoring visit, the Emergency On-Call Contact provides access within 10 minutes of arrival, implements an immediate supervision plan, cooperates with the Certification of Awake Night Supervision documentation, and submits any required written response, cause analysis, and corrective plan within 3 business days.

Refuge House timely forwards records and reports of non-compliance to its SSCC as required by the Provider Services Agreement, and provides the SSCC its routine case-status reporting on the contracted cadence **(2INgage Provider Manual, Rev. 1.2026, §11 Risk Management & Reporting, p.47 — timely forwarding of records and the 2INgage Monthly Case Status Report by the 10th of each month; EMPOWER Provider Manual, Rev. 1.2026, §11 Risk Management & Reporting, p.49 — Monthly Case Status Report by the 10th; 4Kids4Families Joint Operations Manual, Dec 2025 — Daily Notifications by 9:00 am / 5:00 pm and Significant Events/Issues reporting, pp.34–36)**. Serious incidents are reported per FC-SIR-01 (TPG within 24 hours; Contract §1411).

## QUALITY ASSURANCE:

On-call response times, placement-request timeliness, incident follow-up, and end-of-rotation reporting are monitored through Treatment Manager review and the agency's PQI process, with patterns and trends reviewed at least quarterly.

## REGULATORY ALIGNMENT:

- **26 TAC §§749.136, 749.137** — Suicide Prevention, Intervention, and Postvention (policy requirement; model policy and safety planning)
- **26 TAC §§749.501–749.513** — Reporting Serious Incidents
- 24-Hour Residential Child Care Contract **§1111** (responding to placement requests) and **§1115** (Emergency On-Call Contact; continuous 24-Hour Awake Supervision; Addendum #5)
- T3C System Blueprint (April 2026) — case-manager-level-or-above 24/7/365; on-call Licensed Therapist
- SSCC Provider Manuals: OCOK (Rev. 7-1-2025) §4 (24/7/365 crisis response; Turning Point mobile crisis 817-909-1171); Saint Francis (May 2025) §§2, 4.7; Belong/SJRC (Aug 2025); 2INgage (Rev. 1.2026) §20 (15-min emergency / 1-hr non-emergency); EMPOWER (Rev. 1.2026); 4Kids4Families (8-hour trafficking/missing-child notification)

**SSCC alignment (FY-26):** Reviewed against the 2INgage Provider Manual Rev. 1.2026; aligned — 2INgage provider-specific provisions were captured in the prior reconciliation pass; no further changes required. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC coverage tracker (`temporary-reference/fy26-sscc-joint-monitoring/sscc-alignment/`).

**SSCC alignment (FY-26) — EMPOWER:** EMPOWER Provider Manual Rev. 1.2026 — aligned (parallel template to 2INgage); EMPOWER provider-specific provisions captured in the EMPOWER pass; no additional changes required. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — OCOK:** OCOK Network Management Operations Manual Rev. 7-1-2025 — reviewed; OCOK provider-specific provisions are carried in the companion procedure/policy (see the FY-26 SSCC variance matrix). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — 4Kids:** 4Kids4Families Joint Operations Manual (Dec 2025) / Subcontractor Agreement — reviewed; 4Kids provider-specific provisions carried in the companion procedure/policy (see the FY-26 SSCC variance matrix). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — Belong:** Belong Stage I & II Provider Manual (Aug 2025) / Provider Services Agreement — reviewed; Belong provider-specific provisions carried in the companion procedure/policy (see the FY-26 SSCC variance matrix). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — SFCS:** SFCS Placement Provider Manual (July 2020, publicly-sourced) / 2019 Affiliate Provider Agreement — reviewed; SFCS provider-specific provisions carried in the companion procedure/policy (see the FY-26 SSCC variance matrix). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

## RELATED POLICIES AND PROCEDURES:

- FC-OC-01.1 On-Call Procedure
- FC-04 Crisis Management Policy (crisis response; suicide; missing child/trafficking)
- FC-WCM-01 Worker Contact and Monitoring Policy (new-placement contact; ongoing support)
- FC-SIR-01 Serious Incident Reporting Policy (incident reporting and timeframes)

## DEFINITIONS:

**On-Call Worker:** A Refuge House case-manager-level-or-above staff member scheduled to provide 24/7/365 crisis response, placement acceptance, and foster-parent support outside of normal business hours.

**Emergency On-Call Contact:** A current designated contact (name, phone, email) provided to DFPS, each SSCC, supervision staff, and each foster parent, who is readily accessible and able to implement an immediate plan for compliance (24-Hour RCC Contract §1115).

**24/7/365:** 24 hours per day, 7 days per week, 365 days per year — the required availability standard for crisis response and placement.

**Urgent Placement Request:** A placement request identified as urgent by the SSCC Placement Team, requiring a response within 4 hours (24-Hour RCC Contract §1111).

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*This policy document establishes the governing principles for On-Call services. The corresponding procedure document (FC-OC-01.1) operationalizes these principles. While policies require Board approval and remain relatively stable, procedures may be updated by the Executive Director to adapt to regulatory changes or operational improvements without requiring Board approval, provided such changes maintain alignment with the policy's intent.*