Title: In re Child of Barni A.

State: maine

Issuer: Maine Supreme Court

Document:

MAINE SUPREME JUDICIAL COURT 
Reporter of Decisions
Decision: 
2024 ME 16 
Docket: 
And-23-100 
Argued: 
September 13, 2023 
Decided: 
January 31, 2024 
Revised: 
March 7, 2024 
Panel: 
STANFILL, C.J., and MEAD, JABAR, HORTON, CONNORS, LAWRENCE, and DOUGLAS, JJ.* 
IN RE CHILD OF BARNI A. 
JABAR, J. 
[¶1] Barni A. appeals from an order of the District Court (Lewiston,
S. Driscoll, J.) terminating her parental rights to her younger child.  She contends 
that the State of Maine’s failure to provide her child with 24/7 private nursing 
care that he is legally entitled to receive under Maine’s Medicaid Program,
MaineCare, resulted in the trial court erroneously finding that she is unfit
because she could not address her child’s complicated medical needs.1  
[¶2]  Because the trial court’s findings do not address important issues
that must be answered before we can determine whether the record supports 
* Although Justice Jabar participated in the appeal and authored the original decision, he retired 
before the opinion was revised. 
1  Briefs of amici curiae were submitted by Disability Rights Maine, the American Civil Liberties 
Union, and the American Civil Liberties Union of Maine; the Maine Parental Rights Attorneys 
Association; and the Civil Rights Corps.   
 
2 
a finding by clear and convincing evidence that the mother is unfit, we vacate 
the judgment and remand the matter to the trial court. 
I.  BACKGROUND 
A. 
Procedural History 
[¶3]  On July 16, 2019, the Department of Health and Human Services 
filed a petition for a child protection order and a request for a preliminary child 
protection order as to the child at issue here and the child’s older brother.  The 
District Court (Oram, C.J.) granted an order of preliminary child protection the 
same day.  The petition involved both parents, but the father of the children
died unexpectedly only days later.  On July 31, 2019, the court (Martin, J.) held 
a summary preliminary hearing at which the mother appeared and waived her 
right to a hearing.   
[¶4]  Jeopardy was found against the mother as to both children on 
October 9, 2019, due to the threat of serious physical harm and deprivation of 
adequate care and shelter.  The court (Dow, J.) found that the mother had failed 
to ensure that she consistently met the children’s medical needs, had not been 
able to parent the children in a consistent and predictable manner, and did not 
have safe and appropriate housing.  The court ordered the mother to, inter alia, 
engage in a court ordered diagnostic evaluation (CODE), engage in a mental 
3 
health assessment, consistently attend the children’s medical appointments, 
maintain stable housing, and participate actively and consistently in mental 
health services.   
[¶5]  Following the jeopardy order, the court held regular judicial review 
hearings.  On June 22, 2021, the court (S. Driscoll, J.) entered a judicial review 
and permanency planning order finding that the mother had engaged in the
mental health treatment required by the jeopardy order and had made 
progress in her treatment.  The court also found that the mother had 
demonstrated, over the course of a trial home placement that had begun in 
March 2021, an ability to meet the older brother’s needs.  Based on those 
findings, the Department moved to dismiss the older brother from the child 
protection proceeding, and on September 28, 2021, the court granted the 
motion.  The mother has retained custody of the older brother since that time.   
[¶6]  A week after the older brother was dismissed, the Department filed 
a petition to terminate the mother’s parental rights as to the younger child.  The 
court held a three-day hearing on the petition that concluded on February 1, 
2023.  On March 1, 2023, the court entered its judgment terminating the 
mother’s parental rights to the child.  The court found that the mother is unfit
because (1) she is unable to protect the child from jeopardy and these 
 
4 
circumstances are unlikely to change within a time reasonably calculated to 
meet the child’s needs and (2) she is unable to take responsibility for the child 
within a time reasonably calculated to meet the child’s needs.  See 22 M.R.S.
§ 4055(1)(B)(2)(b)(i)-(ii) (2023).2  The court further found that terminating 
the mother’s parental rights was in the best interest of the child.  See id. § 
4055(1)(B)(2)(a). The mother timely appealed. See M.R. App. P. 2B(c).
B. 
Facts 
[¶7]  The mother is the biological mother of both children.  The younger
child was born premature and with a genetic abnormality that causes a range 
of medical challenges.  Tumors on his brain cause seizures and affect his 
executive functioning, vision, and visual processing.  The tumors will likely 
grow and change over time and, if they grow aggressively, could become 
malignant or impact brain function.  The child is predisposed to neurological, 
cognitive, kidney, feeding, skin, and breathing issues, as well as learning and
intellectual disabilities.  He is unable to chew or swallow due to impaired 
neurological functioning.  His food must be mixed and administered in 
measured doses through a gastronomy tube (g-tube) into his stomach, after 
2  Under 22 M.R.S. § 4055(1)(B)(2)(b), a court may find that a parent is unfit when the parent is 
either unable or unwilling to eliminate jeopardy or to take responsibility for the child.  Here, the court 
expressly found that the mother is unfit based on her lack of ability and not on her lack of will.   
5 
which he must be vented, a process that manipulates his stomach to push up 
air to minimize painful abdominal distension and vomiting.  The child receives 
numerous medications through both the g-tube and, at times, a nebulizer.  He 
receives speech, occupational, and physical therapy to assist with sitting, 
standing, and muscle development.   
[¶8] To manage his condition, the child has a cohort of care providers, 
including a neurologist; a primary care physician; a nutritionist; a nephrologist;
a pulmonologist; a urologist; an oncologist; an ear, nose, and throat specialist;
a gastroenterologist; an eye specialist; an occupational therapist; a physical 
therapist; a speech therapist; a teacher for the visually impaired; and a 
developmental pediatrician.  The child has significant long-term medical needs, 
and it is not known whether his condition will improve or worsen over time.   
[¶9]  Although his condition is not acutely life threatening, the child must 
be monitored constantly and vigilantly for behavioral cues due to his inability 
to communicate verbally, lest otherwise-treatable issues be missed.  He must 
be surveilled for subtle seizure activity, visual disturbances, twitching, 
urination and defecation, changes in breathing, and changes to his skin—all
symptoms that could necessitate medical attention.   
 
6 
[¶10]  According to his many caregivers, the child qualifies for 
24/7 private nursing care under Maine’s Medicaid program, MaineCare.  See 
22 M.R.S. §§ 3172-3196 (2023); 10-144 C.M.R. ch. 101, ch. II §§ 94 (effective 
May 1, 2010); 10-144 C.M.R. ch. 101, ch. II § 96 (effective Feb. 11, 2019); 
42 U.S.C.A. §§ 1396 to 1396w-7 (Westlaw through Pub. L. No. 118-30).  He 
receives skilled nursing care in his resource home only on weekdays and never
overnight.  He has never received the 24/7 private nursing care that he legally 
qualifies for, either in the resource home or in the mother’s home.   
[¶11]  The mother has made great progress since the commencement of 
this child protection proceeding and has alleviated the jeopardy caused by her
housing and mental health issues to such an extent that she successfully 
reunified with the child’s older brother.   
[¶12]  Under the care of his resource family, the child has progressed.  
The resource mother has provided him extraordinary care.  She is extremely 
knowledgeable about his condition, capably coordinates his care and providers, 
and can provide emergency response including transportation.  The resource 
family can also care for and attend to the child at all hours.  The child has been 
in this placement for most of his life, and he has bonded with his resource 
family.   
7 
II.  DISCUSSION 
A. 
Legal Standard 
[¶13]  “To terminate parental rights, a trial court must first find one of 
the four statutory bases of parental unfitness in 22 M.R.S. § 4055(1)(B)(2)(b), 
and then it must consider the best interest of the child.”  In re Child of 
Christine M., 2018 ME 133, ¶ 6, 194 A.3d 390. Unfitness may be based on any
one of the following: 
(i) 
The parent is unwilling or unable to protect the child from 
jeopardy and these circumstances are unlikely to change 
within a time which is reasonably calculated to meet the 
child’s needs; 
(ii) 
The parent has been unwilling or unable to take 
responsibility for the child within a time which is reasonably 
calculated to meet the child’s needs;  
(iii) The child has been abandoned; or 
(iv)
The parent has failed to make a good faith effort to 
rehabilitate and reunify with the child pursuant to section 
4041. 
22 M.R.S. § 4055(1)(B)(2)(b).  Unless the court first finds by clear and 
convincing evidence that the parent is unfit, it cannot reach the issue of whether 
termination of parental rights is in the child’s best interest.  See Adoption by 
Stefan S., 2020 ME 5, ¶ 8, 223 A.3d 468.   
 
8 
[¶14]  We review a court’s factual findings of parental unfitness and best 
interest of the child for clear error and its ultimate decision on termination for 
an abuse of discretion.  Id. ¶ 10.  “When the burden of proof at trial is clear and 
convincing evidence, our review is to determine whether the fact-finder could 
reasonably have been persuaded that the required findings were proved to be 
highly probable.” Id. (quotation marks omitted).
[¶15]  On appeal, the mother and amici contend that we must examine 
this case in the context of the mother’s constitutional right to provide for her 
child.  See generally Santosky v. Kramer, 455 U.S. 745 (1982).  They urge us to 
go beyond the clear-and-convincing-evidence standard and determine whether 
termination of the mother’s parental rights, based on a finding that she is unfit 
due to her inability to resolve jeopardy and take responsibility for the child and 
his complicated medical needs, was the least restrictive means to achieve a 
compelling government interest, see Hiller v. Fausey, 904 A.2d 875, 885-86 
(Pa. 2006), given that the State has failed to provide 24/7 private nursing care 
to the child that could enable the mother to care for him.   
[¶16]  We agree that we must review this case with regard to the mother’s
constitutional right to parent her child.  We note, however, that Maine’s statute 
9 
regarding the termination of parental rights presently contains sufficient 
safeguards to protect a parent’s constitutional rights.  We have stated that  
[t]he Supreme Court of the United States has concluded that 
requiring proof by clear and convincing evidence in termination of 
parental rights proceedings satisfies the Constitution because it
“adequately conveys to the factfinder the level of subjective 
certainty about [the] factual conclusions necessary to satisfy due 
process.” 
In re Child of Shayla S., 2019 ME 68, ¶ 7, 207 A.3d 1207 (second alteration in 
original) (quoting Santosky, 455 U.S. at 769).  We have repeatedly asserted that 
the standard of proof of clear and convincing evidence is constitutionally 
sufficient in termination of parental rights cases.  E.g., In re Crystal S., 483 A.2d 
1210, 1213 (Me. 1984); Guardianship of Chamberlain, 2015 ME 76, ¶ 23, 118 
A.3d 229.  We therefore review the trial court’s judgment to determine whether 
clear and convincing evidence supports the court’s finding that the mother is 
unfit and its decision to terminate the parental rights of the mother. 
B. 
Parental Unfitness 
[¶17]  The trial court found the mother unfit under two statutory criteria: 
inability to protect the child from jeopardy and inability to take responsibility 
for the child in a time reasonably calculated to meet the child’s needs.  22 M.R.S. 
§ 4055(1)(B)(2)(b)(i)-(ii).  These findings were based on the trial court’s 
observations that the mother “is unable to consistently meet [the child’s] 
 
10 
heightened medical needs” and “has not yet demonstrated an ability to care for 
[him] full time in her home even with the available nursing assistance.”   
[¶18]  The mother now challenges the trial court’s conclusion that, 
because she is unable to address the child’s complicated medical problems 
without assistance, she is an unfit parent for him.  She contends that if the State 
provided the nursing care and other services that she and the child are legally
entitled to receive, she would be able to meet his medical needs.  The mother 
asserts that because the unavailability of adequate private nursing care and her 
inability to care for the child on her own were the primary reasons for the 
court’s unfitness finding, the court erred when it concluded by clear and 
convincing evidence that she is unfit under 22 M.R.S. § 4055(1)(B)(2)(b)(i)-(ii).   
[¶19]  We agree.  The child has severe medical needs that entitle him to 
full-time private nursing care under federal and state law.  The Department 
never provided that care, and its reunification and rehabilitation plan did not 
afford the mother any opportunity to demonstrate that, with the medical 
services the child is entitled to receive, she is able to care for the child.  Absent 
evidence that the mother—not on her own but with the benefit of 24/7 private 
nursing care—is unable to alleviate jeopardy or take responsibility for the 
child, the record was not sufficient to find by clear and convincing evidence that 
11 
the mother is unfit.  Furthermore, although the court noted that the mother’s 
personal challenges impeded reunification, her significant progress dealing 
with those challenges throughout this child protection proceeding undermines
the court’s unfitness finding. 
1. 
Full-Time Nursing Care and Reunification Efforts 
[¶20] We have held that the extraordinary medical needs of a child,
coupled with a parent’s failure to meet those needs, is sufficient to support a
finding that the parent is unable to protect the child from jeopardy or take 
responsibility for the child within a time reasonably calculated to meet the 
child’s needs.  See In re Jesse B., 2017 ME 90, ¶¶ 3-5, 10, 160 A.3d 1187; In re
A.H., 2013 ME 85, ¶¶ 2-7, 15, 77 A.3d 1012.  In In re Jesse B., we affirmed the 
termination of the parents’ parental rights where the child had substantial 
medical needs and the parents failed to engage in services that would allow 
them to meet their child’s needs.  2017 ME 90, ¶¶ 3-5, 10, 160 A.3d 1187.  Also,
in In re A.H., we held that, “[g]iven the evidence that the[] parents, however 
loving, [would] never have the capacity to adequately care for th[e] child with 
her significant medical needs, the court could reasonably have been persuaded 
that it was highly probable that the parents were unable to protect the child 
from jeopardy to her health or welfare and were unable to take responsibility 
 
12 
for her within a time reasonably calculated to meet her needs.”  2013 ME 85, 
¶ 15, 77 A.3d 1012. 
[¶21]  Those cases do not compel terminating the mother’s parental 
rights here.  Unlike the present matter, neither case involved a situation in
which the child was legally entitled to 24/7 private nursing services to manage 
his medical needs and the State failed to facilitate that care. The case before us
is unique because the child qualifies for around-the-clock private nursing care 
under the federal Medicaid Act and MaineCare.  See 42 U.S.C.A.
§§ 1396 to 1396w-7; 22 M.R.S. §§ 3172-3196; 10-144 C.M.R. ch. 101, ch. II §§ 94 
(effective May 1, 2010); 10-144 C.M.R. ch. 101, ch. II, § 96 (effective Feb. 11, 
2019).  Medicaid requires states to promptly provide or arrange for treatment 
necessary to correct or ameliorate a medical condition once screening and 
assessment have occurred and the child’s medically necessary services have 
been identified.3  42 U.S.C.A. §§ 1396a(a)(10)(A), (43)(C), 1396d(a)(4)(B), (8), 
3  Although the federal Medicaid Act often requires states only to pay for medical services, when 
the Act was amended in 2010, states became responsible for providing the services themselves in 
some instances.  O.B. v. Norwood, 838 F.3d 837, 843 (7th Cir. 2016) (“[W]here the Medicaid Act refers 
to the provision of services, a participating State is required to provide (or ensure the provision of) 
services, not merely to pay for them.” (quotation marks omitted)); Patient Protection & Affordable 
Care Act, Pub. L. No. 111-148, § 2304, 124 Stat. 119, 296 (2010).  The Seventh and the Ninth Circuit 
Courts of Appeals have held that the obligation to provide, or arrange for the provision of, medical 
services extends to private duty nursing services for children under the early and periodic screening, 
diagnostic, and treatment provisions of the Medicaid Act.  O.B., 838 F.3d at 841-43 (holding that state
was required to arrange for provision of home nursing services for qualified children when state
13 
(r)(5).  These services include private-duty nursing services.  Id. § 1396d(a)(8); 
supra n.3.  Under MaineCare, the child is eligible for Level IV Private Duty 
Nursing, which includes residential care.  10-144 C.M.R. ch. 101 § 96.01-3, 
96.02-4(D) (effective Feb. 11, 2019).4   
[¶22]  The Department, which administers MaineCare, has never 
provided the child with this level of care.5 The record contains vague references
to nursing shortages and problems surrounding the COVID-19 pandemic, but
there is nothing indicating that the Department made any attempt to secure 
24/7 nursing care, or anything close to it, for the child.  Nor did the mother’s 
failed to argue that nursing shortage may interfere with Medicaid obligations); Katie A. ex rel. Ludin 
v. Los Angeles Cnty., 481 F.3d 1150, 1154 (9th Cir. 2007); 42 U.S.C.A. § 1396d(r)(5).  
Even if the Department here is required only to provide reimbursement for the child’s necessary 
medical services, it is still the Department that sets the rates that directly impact service capacity, 
and it is still the Department that manages the system and arranges the provision of these services 
by other entities.  The record does not address the Department’s unique role to provide reunification
services under the child protection statute on one hand and its role as the gatekeeper of Title 42 
benefits to provide services to qualified individuals on the other. 
4  Alternatively, the child is eligible for all medically necessary treatment services covered by 42 
U.S.C. § 1396(a) and (r) under the early and periodic screening, diagnostic, and treatment regulations 
of MaineCare.  10-144 C.M.R. § 94.02, 94.05-2 (effective May 1, 2010). 
5  Relatedly, the U.S. Department of Justice has documented in detail the Department’s failure to 
provide sufficient community-based services to children with long-term behavioral and 
developmental disabilities.  See Letter from Kristen Clarke, Assistant Att’y Gen., C.R. Div., U.S. Dep’t of 
Just., to Gov. Janet Mills & Att’y Gen. Aaron Frey (June 22, 2022), https://www.justice.gov/opa/press-
release/file/1514326/download [https://perma.cc/9AGG-LDXE].  This failure violates Subpart A of 
Title II of the Americans with Disabilities Act, which prohibits states from discriminating based on 
disability.  See id.; 42 U.S.C.A. §§ 12131-12134 (Westlaw through Pub. L. No. 118-30); Olmstead v. L.C. 
ex rel. Zimring, 527 U.S. 581, 597 (1999). 
 
14 
attorney or the guardian ad litem (GAL) seek to compel the provision of 
adequate care.  Rather, the most the child received was sixty hours per week of 
nursing care, provided only on weekdays.  Because of this failure, the mother
has never been afforded the assistance necessary to care for her child.   
[¶23]  Moreover, the Department’s reunification and rehabilitation 
efforts failed to adequately address the child’s medical needs and provide the 
services that would create any possibility of the mother reunifying with the 
child.  In a child protection proceeding, the Department must develop a 
reunification plan that includes “changes . . . necessary to eliminate jeopardy to
the child while in the care of a parent” and must “[m]ake good faith efforts to 
cooperate with the parent in the pursuit of the plan.”  22 M.R.S. 
§ 4041(1-A)(A)(1)(c)(ii), (3) (2023).  “The rehabilitation and reunification plan 
is the roadmap by which the Department and a parent are expected to 
cooperatively seek to rehabilitate the conditions that resulted in jeopardy to 
the child.”  In re Child of Rebecca J., 2019 ME 119, ¶ 6, 213 A.3d 108 (quotation 
marks omitted).  The Department and the parent share the obligation to 
reunify.  In re Thomas D., 2004 ME 104, ¶ 23, 854 A.2d 195. 
[¶24]  Although the Department filed rehabilitation and reunification 
plans pursuant to section 4041(1-A), the plans failed to afford the mother 
15 
opportunities for home visits with sufficient nursing care or resources in place 
to assist her in alleviating jeopardy.  
[¶25]  After the jeopardy order was entered and the Department 
prepared its first reunification plan in March 2020, the court held regular 
judicial review hearings addressing reunification efforts, but the mother’s 
visitation time with the child was substantially limited throughout the case.  
A judicial review order dated June 22, 2021, indicated that visits between the 
mother and her child had been suspended prior to the COVID-19 pandemic,
because of the mother’s difficulty early in the proceeding meeting the child’s 
needs, and were never restarted because of the pandemic.  Then, a judicial 
review order dated October 28, 2021—after the Department filed the petition 
to terminate the mother’s parental rights—indicated that although supervised 
visits between the mother and child had resumed on June 25, 2021, they were 
again suspended only a month later due to a lack of nursing staff.  A judicial 
review order dated March 17, 2022, indicated that there was “inconsistency in 
visitation due to the lack of available nursing staff.”  And a judicial review order 
dated August 11, 2022, again indicated that between late March 2020 and 
May 2022, a period of over two years, visitation between the mother and the 
child had been limited due to lack of available nursing staff.  The Department’s 
 
16 
second reunification plan, filed on September 8, 2022, stated that supervised 
visitation was occurring only on Monday afternoons and Thursday mornings
for one and a half hours each.   
[¶26]  Since the child has been in the custody of the resource parents and 
visitation was severely curtailed due to the COVID-19 pandemic, the mother 
has never had the opportunity to demonstrate her ability to care for the child 
with increased nursing care.  The GAL testified that she has never observed the 
child with the mother in the mother’s home, therefore precluding any 
opportunity to comment on the mother’s ability to care for the child, with or 
without the requisite nursing care.  And, as noted above, although the child 
qualifies for full-time nursing care, the most he ever received was sixty hours 
per week on weekdays.   
[¶27]  The September 8, 2022, reunification plan indicated that the 
mother “would most likely require full-time or nearly full-time support to 
provide adequate, safe care-taking to [the child].”  But the plan failed to mention
that the child legally qualifies for 24/7 nursing care under MaineCare.  Further, 
in discussing how to measure the mother’s progress toward eliminating 
jeopardy, the plan indicated that reunification would “include an ability [for the 
mother] to care for [her child] by herself and recognize when and with whom
17 
to seek professional medical care.”  In light of the medical needs of the child that 
are part of the record, the Department’s benchmark of “an ability [for the 
mother] to care for [her child] by herself” was virtually impossible for the 
mother to meet.6   
[¶28]  It was repeatedly stated throughout the child protection 
proceeding that, although the child was entitled to 24/7 private nursing care,
there were inadequate resources to meet his needs.  Inadequate resources do 
not excuse a state’s obligation to provide benefits under Medicaid.  See, e.g., Ala.
Nursing Home Ass’n v. Harris, 617 F.2d 388, 396 (5th Cir. 1980) (holding that 
state health department’s failure to obtain sufficient funds to cover Medicaid 
expenditures did not preclude eligible providers from receiving reasonable 
cost reimbursement); Doe v. Chiles, 136 F.3d 709, 721-722 (11th Cir. 1998).   
[¶29]  In this case, there is nothing on the record explaining why there 
were inadequate resources for this child, nor is there evidence of any advocacy 
on behalf of the child or the mother by the Department, the GAL, or the mother’s 
6  The September 8, 2022, reunification plan, filed only three months before the scheduled hearing
on the Department’s petition for termination of parental rights, was totally unrealistic given the 
child’s extensive medical needs and was not a good faith effort to effectuate reunification.  See
22 M.R.S. § 4041(1-A)(A) (2023).  We acknowledge, however, that the mother has not challenged the 
sufficiency of the Department’s reunification efforts.  Nonetheless, whether the record contains 
sufficient evidence to find that the mother is unfit to care for her medically needy child is squarely 
before us, and that question requires us to determine whether the mother was afforded adequate 
opportunities under appropriate circumstances to demonstrate her ability to care for her child. 
 
18 
attorney.  In its pursuit of reunification, the Department never provided the 
child with the services that he is entitled to receive, even though sufficient 
nursing care for the child may have enabled the mother to eliminate jeopardy 
and take responsibility for him.  
[¶30]  The trial court concluded that the mother’s inability to meet the 
child’s significant medical needs was why she had not alleviated jeopardy, and 
that, although she had made progress in developing the skills necessary to care 
for the child, she had not demonstrated the ability to do so full-time with the 
available nursing assistance.  The trial court did not, however, make any
findings as to whether she would have been able to alleviate jeopardy had the 
Department met its obligation under federal and state law to provide the 
full-time medical care to which the child is entitled.  In contrast to our prior 
caselaw concerning the termination of parental rights of parents with medically
compromised children, the trial court’s findings in this case indicate that it was 
the mother’s inability, without legally mandated assistance, to provide the
necessary medical care for her child’s complicated health problems that led to 
the trial court’s conclusion that she is unfit.   
[¶31]  The mother’s inability to care for the child full-time with the 
assistance presently available may not be a problem if the mother is provided 
19 
the nursing care her child is legally entitled to receive.  The court did not 
address the mother’s fitness if the requisite nursing care were available.  The
need for her to acquire the skills necessary to care for the child would have been 
greatly diminished had she had the nursing support to which the child was 
legally entitled.  Furthermore, the record clearly shows that the mother was not 
afforded a realistic opportunity to meet the child’s medical needs because the
mother’s visits with the child were severely limited due to the COVID-19
pandemic and lack of nursing resources.  Therefore, we cannot conclude on this 
record that a reasonable fact finder could be persuaded that it was highly 
probable that the mother is unfit. 
2. 
Mother’s Personal Challenges 
[¶32]  The evidence presented at the termination hearing further 
demonstrates that the unfitness finding was based only on the mother’s 
difficulty managing the child’s complex medical condition and that, in all other 
respects, the mother made significant progress following the initial jeopardy 
determination.  The trial court found that the mother’s own behavioral 
challenges and difficulties learning how to administer the child’s medical care 
“impede her ability to work with the constellation of providers who must rely 
on [the child’s] primary caregiver to monitor and report symptoms and seek 
 
20 
appropriate care, including emergency care if necessary.”  The court also found 
that the mother’s intellectual and mental health challenges have “impeded her 
progress towards reunification.”  
[¶33]  The evidence does not support this finding by clear and convincing 
evidence.  The mother has made significant progress in dealing with her 
behavioral challenges and, because of the limited, understaffed visitation time
she was afforded, she never had the opportunity to demonstrate that she had 
resolved any personal impediments to her ability to care for the child.   
[¶34]  A Department caseworker acknowledged that the mother had 
alleviated many of the original bases for jeopardy and had done everything that 
the Department had asked her to do in pursuit of reunification.  The caseworker
testified that the only remaining basis for jeopardy was the inability to meet the 
child’s medical needs.  Moreover, in her reports, the GAL focused on the child’s 
medical needs, stating that there were “significant concerns about [the 
mother’s] ability to manage his fragile medical condition” and that the mother 
“has not demonstrated the ability to effectively care for her significant 
medically compromised child.”  This opinion by the GAL was given even though 
she never observed the mother and child together at the mother’s home.   
21 
[¶35]  One of the child’s nurses testified that the mother is “very attentive 
to [the child], very loving, and tries to be interactive with him” as much as 
possible.  A nurse who attended visits between the mother and the child 
testified that, after training, the mother was able to independently feed the 
child and mix and administer his medications.  It is clear that the mother made 
progress despite the limited number of visitations with the child and a nurse.
[¶36]  A licensed clinical professional counselor who began counseling 
the mother nearly three years prior to the termination hearing acknowledged
that any parent would be overwhelmed by the situation the mother faced—a 
sick child, the death of her husband, and an ongoing pandemic crisis—and that 
because of those circumstances the mother never had a full opportunity to learn 
the child’s medical needs and meet them.  He believed that the mother was 
doing well and testified that he had seen a significant improvement in her 
behavior over time.  He commented on the mother’s February 2020 CODE 
evaluation, which indicated that the mother had some intellectual difficulties.  
He stated that during the two years and nine months that he counselled her
following the CODE evaluation he did not see any actual intellectual disability.7   
7  The CODE evaluation raised the question of whether the mother is disabled and entitled to 
receive resources to assist her in caring for her child.  The CODE report flagged concerns about the 
mother’s cognitive function and raised a possible diagnosis of intellectual disability.  Despite these 
 
22 
[¶37]  The counselor’s observation that the mother’s behavior had 
improved since the removal of her children and death of her husband is 
consistent with the Department’s observations as the proceedings progressed.  
The Department acknowledged in its September 2022 reunification plan that 
the mother had secured stable housing with space for both of her children and 
the medical equipment for the younger child, expanded her network of support 
for transportation to appointments and visitations, attended every visitation 
and appointment after they resumed in May 2022, and “put[] forth full effort to 
learn how to care for” the child and “maintain[] her personal health.”  Most 
significantly, the Department believed that the mother had alleviated any 
jeopardy regarding the child’s older brother and withdrew its petition to 
terminate the mother’s parental rights regarding him.   
[¶38]  It is clear that the court’s conclusion regarding the mother’s 
unfitness focused on the mother’s inability to deal with her child’s complicated 
results, the Department never followed up to determine whether the mother has an intellectual 
disability. Had the Department inquired further and obtained a diagnosis of intellectual disability, 
the Department might have owed obligations not only to provide medical services to the child, supra
§§ 20-31, but also to provide services to the mother to manage the child’s needs in pursuit of 
rehabilitation and reunification.  See 22 M.R.S. § 4041(1-A)(A)(1)(c)(iv).  So, regardless of whether 
the mother has an intellectual disability, the record does not support the unfitness finding.  On one 
hand, if the mother has an intellectual disability, the Department did not meet its reunification 
obligation to provide rehabilitative services that would have allowed the mother to care for the child.  
On the other hand, if the mother does not have an intellectual disability, the Department still failed 
to provide sufficient opportunities after the mother had made progress in her personal challenges to 
determine whether she is an unfit parent when the services that the child needs are in place. 
23 
medical condition on her own.  Given the mother’s significant progress in 
overcoming her personal challenges, and the fact that the mother was 
permitted only limited opportunities to demonstrate her ability to care for the 
child with adequate nursing care in place after making that progress, we 
question whether the court’s finding of unfitness meets the “clear and 
convincing” standard.
[¶39]  We must review this case within the constitutional framework 
imposing a heightened burden to prove parental unfitness by clear and 
convincing evidence.  To conclude that the record establishes a high probability 
that the mother is unable to take responsibility for her child or alleviate 
jeopardy because she cannot manage the child’s extraordinary medical needs
without support, when the Department has a legal duty to provide that support, 
would undermine the mother’s fundamental constitutional right to the care, 
custody, and control of her child and render meaningless the procedural 
safeguards, including the heightened evidentiary burden, erected to protect 
that interest.  See generally In re Guardianship of Chamberlain, 2015 ME 76, 
¶¶ 20-24, 118 A.3d 229 (noting the constitutional significance of the 
heightened standard of proof required to terminate parental rights); 22 M.R.S. 
§ 4041 (imposing reunification duties upon both the Department and the 
 
24 
parent); 22 M.R.S. § 4005 (2023) (providing a right to legal representation in 
proceedings for termination of parental rights); 22 M.R.S. § 4038(1) (2023)
(mandating judicial review of jeopardy findings).  
[¶40]  The Department should have offered 24/7 skilled nursing care for 
the child as part of its reunification plan, and its failure to do so is a violation of 
its reunification responsibility as well as its MaineCare obligation. See 22 M.R.S.
§ 4041(1-A).  The Department’s “rehabilitation and reunification plan is the 
centerpiece 
of 
child 
protective 
proceedings 
following 
a 
jeopardy 
determination.”  In re Thomas D., 2004 ME 104, ¶ 26, 854 A.2d 195.  Although 
the Department’s failure to “provide adequate rehabilitation and reunification 
services” or “complete a rehabilitation and reunification plan” is not alone a 
“basis to deny a petition to terminate parental rights,” it is an “important factor 
that must be carefully evaluated” when determining parental unfitness based 
on a parent’s failure to achieve benchmarks for reunification set by the 
Department.  Id ¶ 28.  Even if the Department has failed to meet its reunification 
responsibility, a parent may still be deemed unfit.  See In re Doris G., 2006 ME 
142, ¶¶ 15-16, 912 A.2d 572.   
[¶41]  But this case is different.  We cannot assume that the mother would 
have been found unfit if the Department had met its legal obligations.  The 
25 
significance of the Department’s failure to provide the services that the child 
needs is elevated by the fact that the services are mandated by law.  In fact, the 
record demonstrates that the Department’s failure to meet its MaineCare 
obligations actually impeded the mother’s visitations for extensive periods of 
time.   
[¶42] The record does not, in the absence of a finding that the mother
would be unfit even if the Department had met its legal duty, establish by clear 
and convincing evidence that the mother is unfit.   
C. 
Best Interest of the Child 
[¶43]  Because we cannot conclude that there was sufficient evidence in 
the record to find the mother unfit by clear and convincing evidence, we do not
reach the issue of whether termination of the mother’s parental rights was in 
the child’s best interest.  Nonetheless, we take the opportunity to reiterate the 
trial court’s alternatives when conducting a best interest analysis. 
[¶44]  Although not before us, it is important to note that in determining 
the best interest of the child and providing permanency for the child, 
termination of parental rights and adoption is not the only alternative.  As we 
recently stated, 
[t]he Legislature has provided five different permanency options 
including adoption and permanency guardianship.  A permanency 
 
26 
guardianship may be ordered to establish safe, long-term care for 
a child, but it is not appropriate when the child needs the certainty 
and stability of adoption and the parties otherwise need clarity in 
their respective roles.  Unlike adoption, a permanency 
guardianship allows for a court to order that a parent have 
reasonable contact with the child where it is in the best interest[] 
of the child. If a trial court finds that a child needs permanency,
then the trial court should not automatically conclude that 
terminating the parents’ parental rights and adoption is the best 
way to effectuate permanency.  The Legislature has determined 
that both adoption and permanency guardianships are equally 
available to further the goal of permanency for children, and courts 
should consider the particularities of what kind of permanency and 
stability a child needs before determining that adoption, rather 
than one of the other equally available options, is the best course.  
A finding that a child needs permanency cannot, without more, be 
enough to conclude that termination is in the best interest of the 
child because this would never allow a court to conclude that any 
other permanency option, including a permanency guardianship, 
would be in the best interest of the child.  
. . . . 
In sum, to ensure that terminating a parent’s parental rights 
is in the best interest of the child, there must be some reason 
besides a general need for permanency that adoption is the best 
permanency option for that child.  The risk of a generalized finding 
that permanency always requires adoption, and therefore 
termination of a parent’s parental rights, is that a court might 
terminate a parent’s parental rights when it is not in the best 
interest of a child and another, better permanency option exists. 
In re Children of Quincy A., 2023 ME 49, ¶¶ 22, 24, 300 A.3d 832 (cleaned up). 
[¶45]  The caseworker for the Department testified that she considered 
a permanency guardianship, but there is nothing in the record regarding any 
27 
follow up or advocacy for this option by the Department, the GAL, or the 
mother’s attorney.  Permanency guardianship in this case might have been a 
viable option and in the best interest of the child, without the need to terminate
the mother’s parental rights. 
[¶46]  The trial court found that it was in the child’s best interest to 
remain with the resource family and that the child needed permanency and
concluded that the permanency plan should be adoption.  In this case, the 
mother’s attorney did not appeal the trial court’s conclusion regarding the 
child’s best interest, nor did the mother’s attorney file a motion for further 
findings on the issue of permanency, and therefore the issue of the best 
permanency plan for the child is not before us.  See M.R. Civ. P. 52(b); cf. In re 
Children of Quincy A., 2023 ME 49, ¶ 26, 300 A.3d 832.  Still, because we vacate 
the judgment and remand the matter to the trial court, we note that a 
permanency guardianship may be an appropriate permanency plan under 
these circumstances. 
III.  CONCLUSION 
[¶47]  We fully recognize that vacating the termination judgment does 
nothing by itself to rectify the Department’s failure to fulfill its obligation to 
provide services, so we encourage the court, the mother, and the Department 
 
28 
to explore alternatives to termination that do not put the child at risk but that 
recognize the Department’s obligation. 
[¶48]  We remand the case to the trial court for further proceedings to 
consider the following: (1) whether the mother has an intellectual disability 
and, if she does, how it bears on both parental fitness and the Department’s 
reunification obligation; (2) whether the mother is, or would be, unfit
regardless of the Department’s failure to meet its MaineCare obligation 
regarding skilled nursing care; and (3) whether there is an alternative to 
termination of the mother’s parental rights that meets the best interest of the 
child.  On remand, the District Court may take further evidence.  
The entry is: 
Judgment vacated.  Remanded to the District 
Court for further proceedings consistent with 
this opinion. 
Rory A. McNamara, Esq. (orally), Drake Law LLC, York, for appellant mother 
Aaron M. Frey, Attorney General, and Hunter C. Umphrey, Asst. Atty. Gen. 
(orally), Office of the Attorney General, Bangor, for appellee Department of 
Health and Human Services 
Jeremy Pratt, Esq., Pratt & Simmons, P.A., Camden, and Sumayya Saleh, Esq., 
Civil Rights Corps, Washington D.C., for amicus curiae Civil Rights Corps 
29 
Julian Richter, Esq., Bath, for amicus curiae Maine Parental Rights Attorneys 
Association 
Lauren Wille, Esq., Disability Rights Maine, Augusta, for amicus curiae Disability 
Rights Maine 
Carol Garvan, Esq., and Zachary L. Heiden, Esq., American Civil Liberties Union
of Maine Foundation, Portland, and Zoe Brennan-Krohn, Esq., American Civil 
Liberties Union Foundation, San Francisco, California, for amici curiae 
American Civil Liberties Union and American Civil Liberties Union of Maine 
Lewiston District Court docket number PC-2019-76 
FOR CLERK REFERENCE ONLY