REFUGE HOUSE, INC.

Procedure Information	Details
PROCEDURE NAME	On-Call Procedure
PROCEDURE NUMBER	FC-OC-01.1
RELATED POLICY	FC-OC-01 On-Call Policy
EFFECTIVE DATE	5/15/25
REVISION DATE	6/15/26
LAST UPDATED	5/15/2026
LAST APPROVED	5/22/2026

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 operationalize the On-Call Policy (FC-OC-01) by detailing coverage and designation, equipment and readiness, response requirements, placement-request timeframes, documentation, end-of-rotation handoff, and DFPS monitoring compliance. The strictest applicable timeframe always controls.

24/7/365 COVERAGE AND DESIGNATION:

#	Who	Action
1	Treatment Manager	Complete and publish an on-call schedule at least quarterly (more frequently or for shorter periods if staffing requires). On-call responsibilities rotate among eligible case managers, scheduled to the needs of the office and the caseload.
2	Treatment Manager / Administrator	Ensure case-manager-level-or-above staff is always available — in person, by phone, or by video conference — to respond to any crisis (T3C Blueprint: TFFC, STASS, MBH, Complex Medical Needs).
3	Treatment Director	Ensure 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 Blueprint).
4	Administrator	Provide and maintain a current designated Emergency On-Call Contact (name, phone, email) to DFPS, each contracting SSCC, supervision staff, and every foster parent; the contact must be readily accessible and able to implement an immediate plan for compliance (24-Hour RCC Contract §1115; Addendum #5).

ON-CALL EQUIPMENT AND READINESS:

#	Who	Action
5	Case Manager	Obtain on-call equipment before end of business the day you take over: on-call cell phone + charger from the previous worker; on-call computer, signature pad, wireless card, etc., from the Office Manager; confirm the computer bag holds paper placement packets as a backup.
6	Case Manager	Readiness: cell phone fully charged; ringer audible (especially overnight); carry the current Foster Family Directory and SSCC/CPS contact list; do not schedule evening appointments unless they can be readily rescheduled if you are called away.

WHILE ON CALL — RESPONSE REQUIREMENTS:

#	Who	Action
7	Case Manager	Carry the cell phone at all times; return all missed calls within five (5) minutes.
8	Case Manager	For all incidents while on call, contact the Treatment Manager immediately (see FC-SIR-01 Serious Incident Reporting and FC-04 Crisis Management for required notifications and timeframes).
9	Case Manager	Crisis response: respond promptly to all crisis situations 24/7/365; de-escalate and advance to an action plan that stabilizes the placement (OCOK; Saint Francis; Belong).
10	Case Manager + Treatment Manager	If more than one situation requires support simultaneously, the Treatment Manager provides support until the on-call worker is available, or as the Treatment Manager otherwise determines.

RESPONDING TO PLACEMENT REQUESTS (STRICTEST):

#	Who	Action
11	Case Manager (on call)	Respond to every placement request by email or phone within the strictest applicable timeframe (see table below). If declining, include the denial reason — insufficient capacity, child characteristic, cannot meet the child's needs, child does not meet admission criteria, etc. (24-Hour RCC Contract §1111).
12	Case Manager (on call)	Be available for placement referrals and physical placement 24/7/365; the on-call worker (or designee) and caregiver must be present to receive the child at placement (2INgage §20).

Request Type	Response Timeframe	Source
2INgage / EMPOWER emergency placement	within 15 minutes of notification	2INgage §20 (strictest)
2INgage / EMPOWER non-emergency placement	within 1 hour of notification	2INgage / EMPOWER
CPA urgent request (all SSCCs)	within 4 hours	24-Hour RCC Contract §1111
CPA standard request	within 24 hours	24-Hour RCC Contract §1111

ON-CALL DOCUMENTATION AND FOLLOW-UP:

#	Who	Action
13	Responding On-Call Worker	Complete required paperwork/follow-up for incidents while on call — treat each event as if you are that child's/family's case manager (e.g., a non-reportable incident is yours to report).
14	Responding On-Call Worker	Handle non-reportable and reportable incidents per FC-SIR-01, applying the strictest timeframes — including verbal report within 12 hours for critical incidents (Saint Francis §4.7.3) and TPG submission within 24 hours.
15	Responding On-Call Worker	Email the current case manager about any incident so they stay apprised; you remain responsible for completing the corresponding paperwork.
16	Responding On-Call Worker	For mental-health and suicide-related calls, follow FC-04 Crisis Management (§§749.136/.137): deploy trauma-informed de-escalation; consult the on-call Licensed Therapist; use mobile crisis/MHMR resources before any hospitalization when clinically appropriate (OCOK: Turning Point 817-909-1171); if high risk for suicide — do not leave the child alone until a mental-health professional completes a risk assessment, remove harmful objects, alert all responsible persons, and refer immediately.
17	Responding On-Call Worker	For suspected/confirmed trafficking or missing children, notify law enforcement, NCMEC (1-800-THE-LOST), and DFPS Special Investigations immediately, no later than 8 hours after identifying or suspecting victimization (4Kids4Families).

END OF ON-CALL ROTATION:

#	Who	Action
18	Case Manager	At rotation completion: email all case managers, treatment managers, the Administrator, and the Treatment Director a summary of events; hand the cell phone + charger to the next worker; return the on-call bag to the Office Manager first thing in the morning for inventory.
19	Office Manager	Have the outgoing worker sign for inventory; verify the bag contains the on-call laptop, wireless card, and all applicable items (signature pad, paper placement packets, chargers).

DFPS UNANNOUNCED MONITORING — ON-CALL COMPLIANCE:

#	Who	Action
20	Emergency On-Call Contact	On an unannounced (overnight) DFPS monitoring visit identifying supervision non-compliance: provide access within 10 minutes of arrival (timely access is a contract requirement); implement an immediate supervision plan for the night; cooperate with the Certification of Awake Night Supervision documentation; submit a written response, cause analysis, and corrective plan within 3 business days if DFPS determines non-compliance.
21	Administrator	Self-report any 24-Hour Awake Supervision non-compliance (when applicable) within 24 hours to DFPS via the 24-Hour Awake Check Portal (24-Hour RCC Contract §1115).

NEW-PLACEMENT CONTACT AND CRISIS SUPPORT:

#	Who	Action
22	On-Call Worker / Assigned Case Manager	After any new placement during on-call hours, ensure contact with the child and the caregiver within one (1) business day, not to exceed 72 hours (OCOK §4; Saint Francis); verify immediate needs (medical/dental, clothing, school enrollment, medications, psychiatric, CPS contact, biological-family visits) and open the crisis-support line. (See FC-WCM-01.)

ONGOING FOSTER-PARENT SUPPORT / AFTER-HOURS CONSULTATION:

#	Who	Action
23	Case Manager (on call)	Provide support and consultation for any after-hours issue affecting child safety, well-being, or placement stability: de-escalate conflicts, coordinate respite, document interventions, and escalate to the Treatment Manager as needed.
24	Case Manager (on call)	Notify the SSCC Intake/Placement Department and Permanency Case Manager of any potential placement disruption and participate in a staffing with all parties before any disruption occurs (2INgage). (See FC-WCM-01; FC6-01 disruption mitigation.)

REFERENCES:

Same as Policy FC-OC-01 — principally TAC §§749.136/.137 (suicide prevention/intervention/postvention), §§749.501–749.513 (serious-incident reporting); 24-Hour RCC Contract §§1111/1115 (Addendum #5); the T3C System Blueprint; and the SSCC provider manuals (OCOK, Belong/SJRC, Saint Francis, 2INgage, EMPOWER, 4Kids4Families).

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.

FORMS/ATTACHMENTS:

On-Call Schedule (Quarterly)
On-Call Bag Inventory Checklist
End-of-Rotation Summary Email Template
Placement Packet (paper backup)
DFPS Certification of Awake Night Supervision Form (when applicable)
SSCC Contact Directory (OCOK, Belong, Saint Francis, 2INgage, EMPOWER, 4Kids4Families)

This procedure operationalizes the principles established in FC-OC-01 On-Call Policy. 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.

On-Call Procedure