A taxonomy of states' approaches to plans of safe care.

BACKGROUND: The 2016 Comprehensive Addiction and Recovery Act amended the Child Abuse Prevention and Treatment Act (CAPTA), expanding requirements for the development of state-specific Plans of Safe Care (POSC) for prenatal substance exposure. POSCs were intended to amplify existing efforts to include maternal referral to treatment and services in addition to infant safety planning. States were left to re-operationalize their own POSC procedures, including the extent to which the POSC process involved the child welfare system. We reviewed state statutes, regulations, and reports to create a taxonomy of state POSC approaches based on their relationship with child protective services (CPS) and healthcare systems. METHODS: We evaluated state POSC-related statutes, regulations, and federally mandated child welfare state reports (Annual Progress & Services Reports, Child & Family Services Plans, & CAPTA plans) for all 50 states and Washington, D.C. from 2012 to 2024. Using artificial intelligence-assisted text extraction and subject matter expert textual interpretation, we reviewed 634 documents and more than 123,000 pages of text. Through iterative categorization, we developed a five-domain POSC taxonomy, organizing POSC policies by their proximity to and engagement with CPS and healthcare systems. We then identified the number of states with POSC policies in each domain and the timing of implementation. RESULTS: Nearly all states had implemented their POSC by 2024. Our final taxonomy consisted of the following domains: (a) All CPS Referrals (26%), (b) Open Case Only (28%), (c) Alternative Response (26%), (d) Hospital-initiated (16%), and (e) Dual Pathways, that uses type of substance exposure to determine receipt of a Hospital-initiated POSC or traditional CPS response (14%). Eighty percent (80%) of states restrict POSC access to families already subject to CPS reporting or investigation. CONCLUSIONS: Despite federal intent to broaden public health supports, state POSC policies largely reinforce existing CPS practices rather than offering proactive, non-punitive interventions. The proposed taxonomy offers a framework for future comparative research, policy evaluation, and reform efforts.