[Senate Prints 115-18]
[From the U.S. Government Publishing Office]
115th Congress } { S. Prt
COMMITTEE PRINT
1st Session } { 115-18
_______________________________________________________________________
AN EXAMINATION OF FOSTER CARE
IN THE UNITED STATES
AND THE USE OF PRIVATIZATION
----------
Prepared by the Staff of the
COMMITTEE ON FINANCE
UNITED STATES SENATE
Orrin G. Hatch, Chairman
Ron Wyden, Ranking Member
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
OCTOBER 2017
Printed for the use of the Committee on Finance
AN EXAMINATION OF FOSTER CARE IN THE UNITED STATES
AND THE USE OF PRIVATIZATION
115th Congress } { S. Prt
1st Session } COMMITTEE PRINT { 115-18
_______________________________________________________________________
AN EXAMINATION OF FOSTER CARE
IN THE UNITED STATES
AND THE USE OF PRIVATIZATION
----------
Prepared by the Staff of the
COMMITTEE ON FINANCE
UNITED STATES SENATE
Orrin G. Hatch, Chairman
Ron Wyden, Ranking Member
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
OCTOBER 2017
Printed for the use of the Committee on Finance
_________
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COMMITTEE ON FINANCE
ORRIN G. HATCH, Utah, Chairman
CHARLES E. GRASSLEY, Iowa RON WYDEN, Oregon
MIKE CRAPO, Idaho DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming BILL NELSON, Florida
JOHN CORNYN, Texas ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia SHERROD BROWN, Ohio
ROB PORTMAN, Ohio MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada MARK R. WARNER, Virginia
TIM SCOTT, South Carolina CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana
A. Jay Khosla, Staff Director
Joshua Sheinkman, Democratic Staff Director
INVESTIGATIVE STAFF
Senate Finance Committee Majority Senate Finance Committee Minority
Staff Staff
KIMBERLY BRANDT, Chief Oversight IAN M. NICHOLSON, Investigator
Counsel EMILY DOUGLAS, SRCD/AAAS
DONALD ABBOTT, U.S. Secret Service Congressional Fellow
Detailee DAVID M. BERICK, Chief
BECKY SHIPP, Health and Human Investigator
Services Policy Advisor LAURA BERNTSEN, Chief Human
JOHN A. CARLO, Senior Oversight Services Advisor
Counsel DOUGLASS V. CALIDAS, Legislative
Fellow
(ii)
C O N T E N T S
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Page
Executive Summary................................................ 1
I. Introduction.................................................. 2
II. Overview of the Problem and Justification for the Committee
Investigation.................................................. 3
A. Child Abuse and Neglect and Foster Care................... 3
B. Federal Financing of Foster Care Services................. 3
C. Recent Committee History on Foster Care and Related Issues 4
D. Initial Media Reports About For-Profit Foster Care and
Children's Deaths.......................................... 5
E. MENTOR and Private Foster Care Agencies................... 6
F. Therapeutic Foster Care................................... 8
III. The Committee's Investigation and Surveys of the States:
Foster Care Services and Performance........................... 8
A. The 50-State Overview Letter and Request.................. 8
B. The 5-State In-Depth Letter and Request................... 9
C. U.S. HHS Child and Family Services Reviews................ 10
D. The MENTOR Letter and Request............................. 10
IV. Findings From the Committee's Investigations and Surveys..... 11
A. Use of Private Child Welfare Services..................... 11
B. Background Checks......................................... 13
C. Child Welfare Workforce Operations and Concerns........... 14
D. Physical and Mental Well-Being of Children in Foster Care. 16
E. Failure to Identify and Respond to Risk to Children....... 17
F. Actions When Maltreatment Is Substantiated in Foster Homes 18
G. MENTOR Incident Reports................................... 20
H. MENTOR Mortality Report................................... 23
I. Financial Settlements From MENTOR......................... 26
V. Oversight of Child Welfare Services and Protecting Vulnerable
Children....................................................... 27
VI. Conclusions.................................................. 29
VII. Recommendations............................................. 31
Recommendations for States and Tribes........................ 31
Recommendations for the Department of Health and Human
Services (HHS)............................................. 31
Recommendations for Congress................................. 32
Appendix A--50-State Overview Letter............................. 35
Appendix B--Responses to 50-State Overview Letter................ 38
Exhibit 1--Response From Alabama, Department of Human
Resources.................................................. 39
Exhibit 2--Response From Alaska, Department of Health and
Social Services............................................ 47
Exhibit 3--Response From Arkansas, Office of the Governor.... 51
Exhibit 4--Response From California, Health and Human
Services Agency, Department of Social Services............. 55
Exhibit 5--Response From Colorado, Office of the Governor.... 62
Exhibit 6--Response From Connecticut, Department of Children
and Families............................................... 66
Exhibit 7--Response From Delaware, Department of Services for
Children, Youth, and Their Families........................ 69
Exhibit 8--Response From Guam, Department of Public Health
and Social Services........................................ 74
Exhibit 9--Response From Hawaii, Office of the Governor...... 79
Exhibit 10--Response From Illinois, Department of Children
and Family Services........................................ 82
Exhibit 11--Response From Indiana, Department of Child
Services................................................... 88
Exhibit 12--Response From Iowa, Department of Human Services. 93
Exhibit 13--Response From Kansas, Department for Children and
Families................................................... 97
Exhibit 14--Response From Kentucky, Cabinet for Health and
Family Services............................................ 101
Exhibit 15--Response From Maryland, Department of Human
Resources.................................................. 107
Exhibit 16--Response From Massachusetts, Office of the
Governor................................................... 114
Exhibit 17--Response From Minnesota, Department of Human
Services................................................... 120
Exhibit 18--Response From Nebraska, Office of the Governor... 126
Exhibit 19--Response From New Hampshire, Department of Health
and Human Services......................................... 130
Exhibit 20--Response From New Jersey, Department of Children
and Families............................................... 134
Exhibit 21--Response From New Mexico......................... 139
Exhibit 22--Response From New York, Office of Children and
Family Services............................................ 153
Exhibit 23--Response From North Dakota....................... 158
Exhibit 24--Response From Oklahoma, Department of Human
Services................................................... 162
Exhibit 25--Response From Oregon, Office of the Governor..... 166
Exhibit 26--Response From Pennsylvania, Department of Human
Services................................................... 172
Exhibit 27--Response From South Dakota, Office of the
Governor and the Department of Social Services............. 179
Exhibit 28--Response From Tennessee, Department of Children's
Services................................................... 184
Exhibit 29--Response From Texas, Department of Family and
Protective Services........................................ 189
Exhibit 30--Response From Utah, Department of Human Services. 201
Exhibit 31--Response From Washington, Department of Social
and Health Services........................................ 206
Exhibit 32--Response From West Virginia, Department of Health
and Human Resources........................................ 209
Exhibit 33--Response From Wisconsin, Department of Children
and Families............................................... 213
Exhibit 34--Response From Wyoming, Department of Family
Services................................................... 219
Appendix C--5-State In-Depth Letters............................. 222
Exhibit 1--Letter to Georgia, Department of Community Health. 223
Exhibit 2--Letter to Illinois, Department of Children and
Family Services............................................ 228
Exhibit 3--Letter to Massachusetts, Department of Children
and Families............................................... 233
Exhibit 4--Letter to Maryland, Department of Human Resources. 238
Exhibit 5--Letter to Texas, Department of Family and
Protective Services........................................ 243
Appendix D--Congressional Research Service Memorandum on the U.S.
HHS Children and Family Services Reviews....................... 248
Appendix E--Letter to The MENTOR Network......................... 275
Appendix F--MENTOR Level 4 Incident Reports...................... 282
Appendix G--MENTOR Mortality Report and Backup Data.............. 606
Exhibit 1--Foster Care Mortality Analysis.................... 607
Exhibit 2--Backup Data and Explanation of Mortality Analysis. 613
AN EXAMINATION OF FOSTER CARE
IN THE UNITED STATES
AND THE USE OF PRIVATIZATION
EXECUTIVE SUMMARY
Foster care placements for children who are victims of
abuse and neglect have historically been managed by a
combination of private and public resources. However, the need
for specialized foster care services and a shortage of foster
care homes in recent years has led to the privatization of many
core foster care services. Today, both non-profit and for-
profit private agencies contract with and provide foster care
services on behalf of State agencies. In 2015, 671,000 children
in the United States were provided out-of-home foster care
services. There are no official statistics on what proportion
of these children received contracted foster care, case
management, or other services. State child welfare agencies
report they have procedures in place to monitor child welfare
providers' performance and outcomes. But this investigation
conducted by the bipartisan staff of the U.S. Senate Finance
Committee shows that these policies are not always followed;
exceptions are made, waivers are granted, profits are
prioritized over children's well-being, and sometimes those
charged with keeping children safe look the other way. High
turnover among staff sometimes makes it impossible to develop
case plans to ensure that children are ``on-track.'' Foster
parents with questionable backgrounds, who lack the skills to
provide care to vulnerable children, are given licenses to
parent challenging children, and these children are then
inadequately monitored. The outcome of this investigation shows
that the child welfare system does not always protect children.
The data collection and oversight structures at both the State
and Federal levels make it difficult and sometimes impossible
to monitor the operations of the child welfare system, as well
as its private contractors.
A recent bout of national media attention concerning
questionable behavior by private for-profit agencies, abuse and
neglect by foster parents working for those providers, and in
some instances abuse and neglect which caused children's
deaths, led the Finance Committee to investigate this issue. As
the Finance Committee has primary jurisdiction over Federal
child welfare and foster care funding and policy (largely
through the Social Security Act), the Committee launched an
investigation in April 2015 to examine the privatization of
foster care services. One specific private company, The MENTOR
Network, one of the largest for-profit providers of foster care
services in the United States, was used as a case study to
highlight the problems that exist with the privatization of
human services. This report documents the findings of this
investigation and reveals problems with child welfare
contracting practices as well as public agency oversight of
such contracts and services.
The investigation was conducted by collecting information
from public child welfare agencies across the Nation concerning
their general policies and practices, including how they
contract with and monitor private agencies. The Committee also
gathered information from The MENTOR Network, specifically, by
reviewing incident reports about the deaths of children in the
company's care, an internal ``mortality report,'' legal
settlements, case notes, foster parent applications, and other
related documentation.
The Committee staff concluded that children who are under
the legal authority of their State, yet receive services from
private for-profit agencies, have been abused, neglected, and
denied services. The very agencies charged with and paid to
keep foster children safe too often failed to provide even the
most basic protections, or to take steps to prevent the
occurrence of tragedies. In MENTOR's case in particular,
investigations into fatalities were never followed up after the
fact; autopsy reports which were pending years ago were
excluded from files; and the vast majority of children who died
were not the subject of internal investigations, even when
their deaths were unexpected. The MENTOR Network issued a
report which falsely claimed that its death rates are in line
with national death rates and the rates of death among all
children in the foster care system. Moreover, families of these
and other victims of inadequate care have received millions of
dollars in financial settlements, significant enough for The
MENTOR Network to receive less favorable terms from its
insurer.
As the role of private for-profit and non-profit providers
of foster care services has grown, oversight of these entities
by State agencies--as well as Federal oversight of the States--
has been inadequate. The Finance Committee staff has made
recommendations to HHS, the States, and to Congress addressing
these shortcomings.
I. INTRODUCTION
The privatization of foster care, and specifically for-
profit foster care, has been a growing trend in the delivery of
child welfare services over the past few decades.\1\ Recent
national media attention concerning questionable performance by
these private agencies, including abuse and neglect by foster
parents working for these agencies, and in some instances abuse
and neglect which led to children's deaths, led the Senate
Finance Committee (hereinafter, the ``Committee'' or ``SFC'')
to investigate these issues.
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\1\ Flaherty, C., Collins-Camargo, C. and Lee, E., ``Privatization
of child welfare services: Lessons learned from experienced states
regarding site readiness assessment and planning.'' Children and Youth
Services Review, Vol. 30, No. 7, pp. 809-820, http://
www.sciencedirect.com/science/article/pii/S0190740907002538.
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The Committee has jurisdiction over Federal child welfare
and foster care funding and policy in the United States, and
thus has a responsibility in ensuring children receive the most
suitable placements to appropriately support their healthy
development. Chairman Hatch and Ranking Member Wyden launched
an investigation in April 2015 to examine the privatization of
foster care services within the context of the larger child
welfare system. One specific private company, The MENTOR
Network (hereinafter, ``MENTOR''), was used as a case study in
order to highlight some of the problems that exist with the
privatization of human services in general. At the time the
Committee initiated the investigation, MENTOR reported it was
the ``leading provider of home- and community-based health and
human services to must-serve individuals and families.'' \2\
MENTOR continues to make this claim today.\3\ This report
documents the findings of this investigation and reveals
problems with child welfare contracting practices as well as
public agency oversight of such contracts and services.
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\2\ Civitas Solutions, Inc., U.S. Securities and Exchange
Commission, 2014 10-K filing for the fiscal year ending September 30,
2014, https://www.sec.gov/Archives/edgar/data/1608638/
000119312514445499/d798786d10k.htm.
\3\ Civitas Solutions, Inc., U.S. Securities and Exchange
Commission, 2017 10-Q filing for the quarterly period ending March 31,
2017, https://www.sec.gov/Archives/edgar/data/1608638/
000160863817000017/civi3311710q.htm.
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II. OVERVIEW OF THE PROBLEM AND JUSTIFICATION FOR THE COMMITTEE
INVESTIGATION
A. Child Abuse and Neglect and Foster Care
According to the National Child Abuse and Neglect Data
System (NCANDS), in 2015 there were 683,000 children who were
victims of abuse or neglect in the United States, representing
a rate of 9.2 victims per 1,000 U.S. children.\4\ In instances
where children are abused or neglected and cannot safely remain
at home or with relatives, they are placed in foster care.
According to the Adoption and Foster Care Analysis and
Reporting System (AFCARS), 671,000 children were served by the
foster care system in 2015 either because they were already in
foster care, or because they newly entered foster care that
year.\5\ When children are placed in foster care, they are most
often placed in one of three settings:
nonrelative foster care (45%), relative/kinship care (30%), or
institutions/group homes (14%).\6\ Foster care placements can
occur either through a child's State or public child welfare
agency, or through private entities that contract with public
child welfare agencies to find placements for children. These
private organizations can be non-profit or for-profit agencies.
The private agencies that were the focus of this report
(specifically MENTOR) provide non-relative foster care for
children outside of institutional settings.
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\4\ U.S. Department of Health and Human Services, Administration
for Children and Families, Children's Bureau, ``Child Maltreatment
2015,'' Report, January 2017, https://www.acf.hhs.gov/sites/default/
files/cb/cm2015.pdf.
\5\ U.S. Department of Health and Human Services, Administration
for Children and Families, Children's Bureau, ``Trends in Foster Care
and Adoption,'' Published: June 30, 2016, last reviewed: March 13,
2017, https://www.acf.hhs.gov/cb/resource/trends-in-foster-care-and-
adoption-fy15.
\6\ U.S. Department of Health and Human Services, Administration
for Children and Families, Children's Bureau, ``Foster Care Statistics
2015,'' Report, pp. 2-4, March 2017, https://www.childwelfare.gov/
pubpdfs/foster.pdf.
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B. Federal Financing of Foster Care Services
The Committee has jurisdiction over many areas of public
finance including the Internal Revenue Code, major health-care
programs such as Medicare and Medicaid, and Social Security.
Federal child welfare policy is largely guided by the Social
Security Act, originally established in 1935.\7\ Foster care
services are partly funded through titles IV-B and IV-E of the
Social Security Act. In addition, services and supports for
children and their families, including foster care, can be
funded through title XX and title IV-A of the Social Security
Act. Federal assessment and monitoring of State child welfare
systems are also covered by title IV-E. Thus, potential misuse
or mismanagement of these funds to place children in foster
homes where they may potentially be unsafe is of keen interest
to the Committee.
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\7\ U.S. Social Security Administration, Social Security Act of
1935, https://www.ssa.gov/history/35act.html.
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C. Recent Committee History on Foster Care
and Related Issues
The Committee and its members have a long history of
working to improve the State and Federal child welfare systems.
For decades, the child welfare advocacy and provider
communities, as well as families and children impacted by the
system, have recognized that the government is no substitute
for a family when it comes to raising children. Frequent news
stories highlighting traumatic experiences children in foster
care sometimes face have led Congress to take steps to improve
the system in two key ways: first, to do more to ensure that
foster care is an intervention used only when in the best
interest of the child; and second, to ensure that when foster
care is necessary, it is of the highest possible quality and
promotes normalcy.
In the 114th Congress, the Committee held several hearings
and roundtable discussions related to the child welfare system,
its incentives, and its funding structure. Specifically, in May
2015, the Committee held a hearing entitled ``No Place to Grow
Up: How to Safely Reduce Reliance on Foster Care Group Homes.''
\8\ The purpose of the hearing was to examine how Congress can
best address the challenges facing foster children and protect
them from the unfit environment and risk of sex trafficking
found in group homes. In August 2015, the Committee held a
hearing entitled, ``A Way Back Home: Preserving Families and
Reducing the Need for Foster Care.'' \9\ Its purpose was to
explore safe alternatives to foster care and better understand
the interventions, services, and funding mechanisms States and
Tribes are using--or would like to use--to help keep families
and children safely together. And in February 2016, the
Committee held a hearing entitled ``Examining the Opioid
Epidemic: Challenges and Opportunities.'' \10\ The purpose of
this hearing was to examine the opioid abuse epidemic and its
effect on the health and child welfare systems, as well as to
consider solutions. Committee members heard testimony detailing
the links between rising opioid use and fatalities and the
corresponding strain on State foster care systems.
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\8\ U.S. Senate Finance Committee, ``No Place to Grow Up: How to
Safely Reduce Reliance on Foster Care Group Homes,'' Committee Hearing,
114th Congress, May 19, 2015, https://www.finance.senate.gov/imo/media/
doc/20209.pdf.
\9\ U.S. Senate Finance Committee, ``A Way Back Home: Preserving
Families and Reducing the Need for Foster Care,'' Committee Hearing,
114th Congress, August 4, 2015, https://www.
finance.senate.gov/imo/media/doc/20779.pdf.
\10\ U.S. Senate Finance Committee, ``Examining the Opioid
Epidemic: Challenges and Opportunities,'' Committee Hearing, 114th
Congress, February 23, 2016, https://www.finance.
senate.gov/imo/media/doc/23291.pdf.
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As a result of these hearings and working closely with
stakeholders from the foster care provider community, State
groups, advocates, and current and former foster youth, the
chairman and ranking member developed a bipartisan proposal,
``The Family First Act.'' Working with House Ways and Means
Committee Chairman Brady and Ranking Member Levin, Chairman
Hatch and Ranking Member Wyden introduced the bipartisan/
bicameral ``Family First Prevention Services Act of 2016''
(H.R. 5456/S. 3065).\11\ The House of Representatives passed
H.R. 5456 by voice vote on June 21, 2016.\12\ The goal of this
legislation was to increase the availability of prevention
services so that more children can stay at home with their
families and avoid the trauma associated with foster care when
safely possible. The legislation also aimed to reduce the
unnecessary use of congregate care and group homes.
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\11\ S. 3065: ``Family First Prevention Services Act of 2016,''
114th Congress, https://www.congress.gov/bill/114th-congress/senate-
bill/3065; see also: Kelly, John, ``Massive child welfare Finance bill
planned for 2016,'' The Chronicle of Social Change, December 18, 2015,
https://chronicleofsocialchange.org/child-welfare-2/massive-child-
welfare-finance-bill-planned-for-2016/14890.
\12\ H.R. 5456: ``Family First Prevention Services Act of 2016,
Actions/Overview,'' 114th Congress, https://www.congress.gov/bill/
114th-congress/house-bill/5456/actions.
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While the legislation ultimately was not enacted into law,
the Committee continues to work to advance the goals of the
legislation. The findings of this investigation underscore the
importance of holding States accountable for their child
welfare system management and outcomes, as well as providing
States with the tools necessary to improve their capacity to
both prevent foster care (when it is possible to do so without
jeopardizing the safety of children) and to ensure that
children who enter foster care are safe from harm.
D. Initial Media Reports About For-Profit Foster Care and
Children's Deaths
In 2015, BuzzFeed News \13\ and Mother Jones \14\ reported
similar stories concerning the private, for-profit foster care
company, MENTOR. The reports provided evidence of a company
that prioritizes profits over children's well-being; a company
that skirted corners when screening foster parents, that
increased social workers' caseloads, that hired unlicensed
workers, and whose primary mission was to ``fill beds'' in
order to increase company profits. According to these reports,
children were placed in homes with individuals who had been
convicted of kidnapping and other serious crimes, with parents
who had substance abuse problems, and in homes where caretakers
had previous ``failed'' foster care placements. Some children
were deprived of emotional care, were sexually abused, and even
beaten to death in their foster homes. The news articles
included both allegations of wrong-doing and information that
was substantiated through criminal trials and lawsuit
settlements to families of the children who had been harmed.
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\13\ Roston, Aram and Singer-Vine, Jeremy, ``Fostering Profits,''
BuzzFeed News, February 20, 2015, https://www.buzzfeed.com/aramroston/
fostering-profits?utm_term=.xwMQrm3yR#.qfOw
1kDqO.
\14\ Joseph, Brian, ``The Brief Life and Private Death of
Alexandria Hill,'' Mother Jones, October 26, 2015, http://
www.motherjones.com/politics/2015/02/privatized-foster-care-mentor/.
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The Committee received numerous questions and expressions
of concern from the public as a result of these news accounts.
The chairman and ranking member also felt strongly that the
allegations in the press accounts deserved a more thorough
examination. As a result, the chairman and ranking member
directed the majority and minority oversight teams to
investigate the issue of privatization within the foster care
system using MENTOR as a case study, as it is among the largest
providers of private foster care services in the United
States.\15\, \16\ Because the Committee did not
conduct an in-depth investigation of other providers, direct
comparisons cannot be made with other private providers.
However, it did collect State-level data on the performance of
other for-profit and non-profit providers, and it is also
notable that MENTOR is by no means alone when it comes to
negative attention and questionable practices. For example, the
following headlines demonstrate that contracting practices,
provider quality, and inadequate oversight issues are rampant
across States and providers:
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\15\ McBeath, Bowen, Collins-Camargo, Crystal, and Chuang,
Emmeline, ``Portrait of Private Agencies in the Child Welfare System:
Principal Results From the National Survey of Private Child and Family
Serving Agencies,'' National Quality Improvement Center on the
Privatization of Child Welfare Services, September 2011, http://
muskie.usm.maine.edu/helpkids/public
privateresources/nspcfsareportfinal.pdf.
\16\ Civitas Solutions, Inc., 2014 10-K filing (September 30,
2014). See Footnote 2.
L``Foster care scandal deepens: `Every single staff
person has a criminal record' '' (The Oregonian,
January 9, 2016).\17\
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\17\ Theriault, Dennis C., ``Foster care scandal deepens: `Every
single staff person has a criminal record,' '' The Oregonian, January
9, 2016, http://www.oregonlive.com/politics/index.ssf/2016/01/
foster_care_scandal_deepens.html.
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L``Federal Judge: Texas Foster Care System Violates
Children's Rights'' (The Texas Tribune, December 17,
2015).\18\
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\18\ Walters, Edgar and Ramshaw, Emily, ``Federal Judge: Texas
Foster Care System Violates Children's Rights,'' The Texas Tribune,
December 17, 2015, https://www.texastribune.org/2015/12/17/judge-
foster-care-system-violates-childrens-rights/.
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L``Suit Alleges Widespread Deficiencies in South
Carolina Foster Care'' (The New York Times, January 12,
2015).\19\
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\19\ Blinder, Alan, ``Suit Alleges Widespread Deficiencies in South
Carolina Foster Care,'' The New York Times, January 12, 2015, https://
www.nytimes.com/2015/01/13/us/suit-alleges-widespread-deficiencies-in-
south-carolina-foster-care.html?_r=2.
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L``Report Finds `Blatant Lack of Oversight By DCF' In
Licensing of Foster Home Where Toddler Died'' (WBUR
News, October 1, 2015).\20\
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\20\ Conway, Abby Elizabeth, ``Report Finds `Blatant Lack of
Oversight by DCF' in Licensing of Foster Home Where Toddler Died,''
WBUR News, October 1, 2015, http://www.wbur.org/news/2015/10/01/auburn-
foster-child-death-investigation.
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L``State Must Step up on Foster Care Deaths'' (The
Courier, June 11, 2017).\21\
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\21\ Hines, Doug, ``State Must Step up on Foster Care Deaths,'' The
Courier, June 11, 2017, http://wcfcourier.com/opinion/editorial/state-
must-step-up-on-foster-care-deaths/article_b4d69f
95-4402-54ac-a294-83ce38eb1625.html.
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L``Minnesota Faces Penalties for Failed Placements of
Foster Children'' (The Star Tribune, February 10,
2014).\22\
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\22\ Serres, Chris, ``Minnesota faces penalties for failed
placements of foster children,'' The Star Tribune, February 10, 2014,
http://www.startribune.com/state-faces-penalties-for-failed-placements-
of-foster-children/244571021/.
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E. MENTOR and Private Foster Care Agencies
MENTOR, headquartered in Boston, Massachusetts, is a for-
profit service agency that describes itself as a ``national
network of local health and human services providers in 35
States offering an array of quality, community-based services
to adults and children[. . .].'' \23\ It is owned by Civitas
Solutions, Inc., a publicly traded company. Civitas is majority
owned (approximately 68%) by Vestar Capital Partners and
management investors.\24\ Public investors hold roughly 32% of
the company according to the company's filings with the
Securities and Exchange Commission (SEC).\25\ The group
emphasizes its work with higher-risk youth in foster care,
particularly those with intellectual or developmental
disabilities, or who are medically fragile.
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\23\ ``The MENTOR Network.'' Available on the company's website,
http://thementornetwork
.com/.
\24\ On its own, Vestar owns 53% of the company's shares according
to the Civitas Solutions, Inc. U.S. Securities and Exchange Commission
2016 10-K filing for the fiscal year ending September 30, 2016, https:/
/www.sec.gov/Archives/edgar/data/1608638/000162828016022032/civi-
930201610xk.htm.
\25\ Civitas Solutions, Inc., 2014 10-K filing (September 30,
2014). See Footnote 2.
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According to information reported in MENTOR's SEC filings
for 2014, it was the leading provider of human services to
29,100 clients in 36 States during that year--12,600 in
residential settings and 16,500 in non-residential
settings.\26\ With regard to the foster care population, which
is the focus of the Committee's investigation, MENTOR served
10,300 at-risk children, adolescents, and their families in 18
different States in 2014. By way of comparison, according to a
2011 national survey of non-profit and for-profit private child
welfare agencies conducted by the National Quality Improvement
Center on the Privatization of Child Welfare Services, only 13
child and family-serving agencies, or 3%, provided services in
more than one State.\27\ This survey also showed that
nationally the largest private agency budgets range from $17
million to $140 million. Again, for comparison, in 2014 MENTOR
reported to the SEC that its gross revenue for serving at-risk
youth was $203 million and that its net revenue for this same
population was about $198 million.\28\ Private child welfare
agencies across the country largely rely on public government
contracts in order to provide services to children and
families. In 2011, half of the surveyed child and family-
serving agencies reported that almost 100% of their revenue
came from public contracts.\29\ This is also the case for
MENTOR.\30\
---------------------------------------------------------------------------
\26\ The Committee began its investigation in 2015, which is why
2014 SEC information is reported here. See Footnote 2.
\27\ McBeath, B., Collins-Camargo, C., and Chuang, E. See Footnote
15.
\28\ Civitas Solutions, Inc., 2014 10-K filing (September 30,
2014). See Footnote 2.
\29\ McBeath, B., Collins-Camargo, C., and Chuang, E. See Footnote
15.
\30\ Statement by Civitas Solutions: ``We derive approximately 90%
of our revenue from contracts with state and local government agencies,
and a substantial portion of this revenue is state-funded with federal
Medicaid matching dollars,'' 2014 10-K filing, p. 16. See Footnote 2.
---------------------------------------------------------------------------
The Committee focused on MENTOR's work as a provider of
foster care services, since it was one of the largest providers
of those services nationally. At the time the Committee began
its investigation, MENTOR provided foster care services to
thousands of children who are involved with their State's child
welfare system. As recently as 2015, MENTOR provided foster
care services to children in 15 different States.\31\ Since the
Committee launched its investigation, MENTOR has withdrawn from
a number of States. During FY 2015, MENTOR discontinued at-risk
youth services in the States of Florida, Louisiana, Indiana,
North Carolina, and Texas.\32\
---------------------------------------------------------------------------
\31\ Roston, A. and Singer-Vine, J. See Footnote 13.
\32\ Civitas Solutions, Inc., 10-Q filing for the period ending
March 31, 2017, p. 20. See Footnote 3. (Note: Illinois terminated its
contract with AHS/MENTOR on July 1, 2015.)
---------------------------------------------------------------------------
F. Therapeutic Foster Care
In representations to the Committee, MENTOR claims to
largely serve high-risk children classified as in need of
therapeutic foster care (TFC) because they are medically
complex or fragile. There is no uniform definition of TFC in
the field or in statute, but the Foster Family-based Treatment
Association describes it as ``a clinical intervention, which
includes placement in specifically trained foster parent homes,
for youth in foster care with severe mental, emotional, or
behavioral health needs. This includes medically fragile or
developmentally delayed youth whose physical and emotional
health needs require more intensive clinical and medical
intervention than can be accommodated in traditional foster
care.'' \33\
---------------------------------------------------------------------------
\33\ Boyd, Laura W., ``Therapeutic Foster Care: Exceptional Care
for Complex, Trauma-Impacted Youth in Foster Care,'' State Policy
Advocacy and Reform Center, Report, July 2013, https://
childwelfaresparc.files.wordpress.com/2013/07/therapeutic-foster-care-
exceptional-care-for-complex-trauma-impacted-youth-in-foster-care.pdf.
---------------------------------------------------------------------------
Many States claim reimbursements from Medicaid for
components of TFC services. A 2015 report by the Medicaid and
CHIP Payment and Access Commission noted that 3% of child
Medicaid enrollees receive TFC services.\34\ States may also
claim reimbursement under title IV-E for some of the costs
associated with TFC. There is significant variation across
States and providers both with regard to eligibility for and
the provision of services related to TFC. A study that was
commissioned and funded by MENTOR showed that 17.3% of U.S.
children in foster care were in TFC-level placements.\35\
MENTOR reports that 75% of its caseload is comprised of TFC-
level placements.\36\ In its 2014 SEC filings, MENTOR reported
billing Medicaid for the provision of at-risk youth
services.\37\
---------------------------------------------------------------------------
\34\ Medicaid and CHIP Payment and Access Commission (MACPAC),
``Report to Congress on Medicaid and CHIP,'' Report, June 2015, https:/
/www.macpac.gov/wp-content/uploads/2015/06/June-2015-Report-to-
Congress-on-Medicaid-and-CHIP.pdf.
\35\ Gonyea, J.G., Bachman, S.S., Rajabiun, S., Springwater, J.S.,
Tobias, C.R., Hirschi, M. and Little, F., ``The 50 State Chartbook on
Foster Care.'' Retrieved March 28, 2017. As originally cited on p. 5 of
the MENTOR Mortality Report in Appendix G, Exhibit 1, http://
www.bu.edu/ssw/research/usfostercare/.
\36\ The MENTOR Network, ``Backup Data and Explanation of Mortality
Analysis Final,'' March 2016. Supplied by MENTOR to the Finance
Committee. See Appendix G, Exhibit 2.
\37\ Statements by Civitas Solutions: ``We derive approximately 90%
of our revenue from contracts with state and local government agencies,
and a substantial portion of this revenue is state-funded with federal
Medicaid matching dollars,'' p. 16; ``We derive revenues for our I/DD
and ARY services and a significant portion of our SRS services from
Medicaid programs,'' p. 9. See Footnote 2.
---------------------------------------------------------------------------
III. THE COMMITTEE'S INVESTIGATION AND SURVEYS OF THE STATES: FOSTER
CARE SERVICES AND PERFORMANCE
A. The 50-State Overview Letter and Request
In April 2015, the Committee requested information from all
50 governors regarding their States' privatization of child
welfare and/or foster care services.\38\ For example, the
Committee asked each State to describe its process used to
select and contract with private agencies providing child
welfare services as well as the process used to inspect the
safety of foster care settings in which children are placed.
The Committee also asked States to outline how they investigate
and respond to allegations and substantiations of maltreatment
when a child is in out-of-home care. Thirty-three (33) States
responded to that request with information prepared by their
child welfare administrators (see Appendix B for State
responses to the 50-State Overview Letter).\39\
---------------------------------------------------------------------------
\38\ See Appendix A for the complete 50-State Overview Letter.
\39\ The States that responded: Alabama, Alaska, Arkansas,
California, Colorado, Connecticut, Delaware, Guam, Hawaii, Illinois,
Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Minnesota,
Nebraska, New Hampshire, New Jersey, New Mexico, New York, North
Dakota, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas,
Utah, Washington, West Virginia, Wisconsin, and Wyoming.
---------------------------------------------------------------------------
B. The 5-State In-Depth Letter and Request
In March 2016, the Committee sent in-depth inquiries to
five States regarding their child welfare operations in order
to obtain more information about MENTOR and its affiliates as
well as other for-profit and non-profit providers in each
State.\40\ The request for additional information was sent to
the directors of the State child welfare agencies in Georgia,
Illinois, Maryland, Massachusetts, and Texas. These States were
selected because they were served by MENTOR and highlighted in
news accounts that documented serious allegations of
mismanagement of services and mistreatment of children served
by private foster care agencies. As of today, MENTOR still
provides foster care services in Georgia, Maryland, and
Massachusetts; it no longer provides those services in Illinois
or Texas. The primary goal of the request for additional
information was to compare performance indicators of the public
agencies and private agencies providing foster care services.
The Committee sought information related to standard
performance measures for foster care using the Child and Family
Services Reviews' (CFSRs) performance metrics as a basis (see
subsection C below). Among the many questions directed to the
State agencies, SFC staff focused on the following information
from these select States:
---------------------------------------------------------------------------
\40\ See Appendix C for copies of the 5-State In-Depth letters.
LPhysical and behavioral subgroups (special needs,
physically disabled, infants, etc.);
LMaltreatment during a foster care episode;
LRate of maltreatment in foster care;
LPermanency outcomes (reunification, adoption,
guardianship);
LPhysical and mental health screenings of children in
foster care;
LChildren receiving monthly caseworker visits;
LAverage caseload for each caseworker employed by the
contractor; and
LTotal cost to the State under the contract.
Four out of five States complied with the Committee's
request for this detailed information. Despite repeated contact
with the Commonwealth of Massachusetts, its public child
welfare agency never complied with official requests from the
Committee to provide the requested in-depth information.\41\
---------------------------------------------------------------------------
\41\ For purposes of clarification, Massachusetts did respond to
the initial 50-State Letter to provide overview information about their
State, but did not submit any documentation to the Committee in
response to the 5-State In-Depth Letter.
---------------------------------------------------------------------------
In addition to the performance metrics, the Committee also
asked these five States for copies of any rankings or reviews
of contractors, as well as performance and investigative
reports of MENTOR, particularly in the case of reports relating
to the death, sexual abuse, or injury to a child while in the
care or custody of foster parents recruited or employed by
MENTOR. Each of the four responding States complied with this
request. In addition, Illinois provided Committee staff an
extensive ``Statewide Specialized Foster Care Review'' focused
on Alliance Human Services/Illinois MENTOR, which was conducted
prior to the State terminating services with the company.\42\
(The Committee's initial official requests for information from
State child welfare agencies are in Appendices A and C.)
---------------------------------------------------------------------------
\42\ Illinois Department of Children and Family Services, Division
of Quality Assurance and Research. ``Alliance/Illinois MENTOR Statewide
Specialized Foster Care Review,'' Report, August 8, 2014, Print.
---------------------------------------------------------------------------
C. U.S. HHS Child and Family Services Reviews
The Children's Bureau in U.S. Department of Health and
Human Services (HHS) conducts Child and Family Services Reviews
(CFSRs), which are periodic reviews of State child welfare
systems, to achieve three goals: (1) ensure conformity with
Federal child welfare requirements; (2) determine what is
actually happening to children and families as they are engaged
in child welfare services; and (3) assist States in helping
children and families achieve positive outcomes. The first CFSR
round began in 2001. HHS is currently conducting the third
round of CFSRs between 2015 and 2018. In October 2016, SFC
staff asked the Congressional Research Service (CRS) to provide
a compilation and ranking of State-level data and indicators
from AFCARS that are used in the CFSR assessments (see Appendix
D).\43\ The CRS analysis provided the Committee with national
data concerning the performance of all States in the country,
including those States that did not respond directly to the
Committee's requests.
---------------------------------------------------------------------------
\43\ Stoltzfus, Emilie, Memorandum prepared by the Congressional
Research Service: ``Statewide data indicators used in the Child and
Family Services Review (CFSR),'' October 27, 2016. Available in
Appendix D.
---------------------------------------------------------------------------
D. The MENTOR Letter and Request
The Committee sent its first letter to Bruce Nardella, the
President and CEO of MENTOR, in June 2015. This initial letter
and correspondence requested information about the company's
structure, performance, and standards. Specifically, the
Committee requested the total number of children served
nationwide; copies of assessments and performance reviews
conducted on MENTOR; average caseloads of MENTOR caseworkers;
processes for investigating, vetting, and training potential
foster parents; details surrounding the use of bonuses for
placing children; processes for handling allegations of
misconduct against foster caregivers; copies of settlement
agreements entered into by MENTOR since 2005; total funding
received from States; nondisclosure/confidentiality clauses;
and critical incident reports. Additionally, because MENTOR
operates under different names in different States, questions
regarding its corporate structure, affiliates, and related
organizations were asked as well.\44\ (The Committee's official
request for information from MENTOR is available in Appendix
E.)
---------------------------------------------------------------------------
\44\ In Illinois, for example, MENTOR operated under the name
Alliance Human Services.
---------------------------------------------------------------------------
IV. FINDINGS FROM THE COMMITTEE'S INVESTIGATIONS AND SURVEYS
A. Use of Private Child Welfare Services
One of the first goals of the Finance Committee's
investigation was to determine the extent to which States use
or rely on contracted child welfare services. Information
obtained by the Committee from the initial 50-State Letter
shows that of the 33 States that responded, 31 use private
agencies to provide services to children in foster care and 16
of these States contract with for-profit and non-profit
providers. The nature of contracted services provided by the
entities described in responses to the 50-State Letter varied
considerably. Twenty States volunteered that services from
private providers are targeted toward the specialized
population of youth needing TFC. With the exception of two
States, administrators were adamant that they were obligated to
provide oversight--and that they provided this oversight--of
all foster care placements. According to the responses, private
agencies might recruit, screen, train, and provide case
management services to foster families, but the public agencies
were responsible for approving all placements and for ensuring
that children were living in safe conditions. For example,
Texas wrote that children are placed in homes that are
``directly overseen by child protective services.'' \45\
Delaware wrote that the State ``retain[s] . . . legal and case
management responsibilities for meeting the needs of all
children in foster care, whether they are placed in a [public]
foster home or private provider home. . . .'' \46\
---------------------------------------------------------------------------
\45\ Response from Texas to the 50-State Overview Letter, Appendix
B, Exhibit 29.
\46\ Response from Delaware to the 50-State Overview Letter.
---------------------------------------------------------------------------
Other States reported inconsistent information. For
example, Massachusetts reported that the public agency handles
96% of placements for the almost 11,000 children in the State
who are in out-of-home care. Cases that involve a conflict of
interest with the child welfare agency (for example, employees
who are the subject of maltreatment allegations), adoptions, or
unaccompanied refugees who are minors are handled by private
contract agencies. Nevertheless, in that same response,
Massachusetts also reported statistics showing that roughly 35%
of its foster care caseload is managed by a contracted
agency.\47\ Similarly, Maryland reported ``we contract with
private providers for placement services only,'' but then went
on to say ``100% of Maryland foster youth are placed by the
public agency.'' \48\ Oregon listed two county-run shelters and
a Youth Villages facility as ``for-profit'' entities when other
sources identified these entities as non-profits.\49\ News
reports out of Oregon also show how the non-profit/for-profit
distinction can be abused, and even non-profit entities can be
used for financial gain. For example, the director of the now-
shuttered Oregon foster care provider ``Give Us This Day'' was
accused of using three non-profit organizations to buy property
for personal use ($100,000), remodel and furnish her home
($213,000), and pay for trips, meals, clothes, and beauty
expenses including cosmetic surgery ($249,800).\50\
---------------------------------------------------------------------------
\47\ Massachusetts, Department of Children and Families, Letter to
SFC, June 10, 2015, p. 1. The full response is listed in Appendix B,
Exhibit 16.
\48\ Maryland, Department of Human Resources, Letter to SFC, July
20, 2015, p. 1. See full response listed in Appendix B, Exhibit 15.
\49\ United States District Court, District of Oregon, Portland
Division, United States of America v. Mary Holden Ayala, 3:16-CR-00495-
HZ; https://www.justice.gov/usao-or/press-release/file/965436/download;
Lincoln County, Oregon Juvenile Shelter website; http://
www.co.lincoln.or.
us/juvenile/page/shelter; Douglas County, Oregon Juvenile services
website, http://www.co.
douglas.or.us/departments.asp#Juvenile.
\50\ Theriault, Dennis C., ``Oregon accuses foster care provider of
`plundering' $2 million in state funds,'' The Oregonian, October 15,
2015. Updated: October 16, 2015, http://www.oregonlive.
com/politics/index.ssf/2015/10/oregon_accuses_foster_care_pro.html.
---------------------------------------------------------------------------
When asked what types of services private agencies provide,
21 States indicated they were used for case management, even if
this task was shared or duplicative of services provided by the
public agency. Twenty-eight States indicated that private
agencies provide support, services, or training to foster
families. All States have licensing standards, but only six
(California, Kansas, Kentucky, Illinois, Tennessee, and Texas)
reported that they require all of the agencies that contract
with the State to be accredited. In addition, some States, such
as Illinois, use benchmarks that private agencies are expected
to meet, such as an annual permanency rate of 40%. The business
model is to reward top-performing agencies with ``a greater
share of new, incoming foster cases.'' \51\
---------------------------------------------------------------------------
\51\ Illinois DCFS Letter to SFC, December 15, 2015, pp. 2-3. Full
response is listed in Appendix B, Exhibit 10.
---------------------------------------------------------------------------
MENTOR is one of the largest contractors providing foster
care services in many of the States the Committee staff
examined. Information provided by Texas in response to the 5-
State In-Depth Letter showed that when combining the number of
children served from all MENTOR jurisdictions, it ranked either
5th or 6th in total size among all Texas private child welfare
agencies from 2010-2013, before Texas stopped contracting with
the company. It was always the largest for-profit provider. In
Maryland, for each of the years the Committee staff reviewed
in-depth information, MENTOR always had the highest number of
children receiving contracted services among all providers.
With regard to the financing of private child welfare
services, information from the four States that responded to
the 5-State In-Depth Letter shows that between 2010 and 2015,
these States spent between $63 million and $291 million
annually on private child welfare services. Roughly 20% of
these expenditures went to pay for-profit agencies for
services. This means these States paid between $18 million and
$50 million annually to companies that profited from children
and families involved with the foster care system. Using MENTOR
as an example, in 2015 MENTOR Maryland was paid an average of
$47,542 per foster child, for a total approaching $16 million.
The contractor with the highest annual rate per child in 2015
in this one State was paid an average of $69,242 per child.
B. Background Checks
All of the States that responded to the Committee's 50-
State Overview Letter described, in various levels of detail,
how they assess children's safety in out-of-home placements and
specifically among potential or current foster parents.
Sometimes there were variations in public versus private
settings, but all described a process that involves some
version of a State criminal background check, a national or
Federal background check, and a check into their own State's
child abuse and neglect registry--and sometimes in registries
of other States where potential foster parents have recently
lived. Some States volunteered information showing or
suggesting that positive findings of criminal activity or a
history of maltreating children do not automatically close a
door to family foster care. For example, California wrote:
``For persons with criminal convictions, the Department of
Justice provides the county child welfare agency with the
record information report [which is reviewed], to determine
whether the crimes are those for which an exemption may be
granted.'' \52\ These kinds of exemptions and waivers turned up
in the materials reviewed by Committee staff concerning
MENTOR's operations in other States.
---------------------------------------------------------------------------
\52\ Response from California to 50-State Overview Letter. See
Appendix B, Exhibit 4.
---------------------------------------------------------------------------
In response to inquiries from the Committee, MENTOR wrote:
``as a part of our commitment to quality, MENTOR entities
conduct criminal and non-criminal background checks on
prospective foster parents in accordance with local/State
requirements and regulations. This has always been part of our
practices. Not only do background checks support our rigorous
vetting efforts to find the most qualified, caring foster
parents, they are also a requirement of the States and
referring agencies with whom we partner.'' Yet, several news
accounts tell a different story.\53\, \54\ Most
notably is one media account which notes that MENTOR placed
children in a home with a household member who had previously
been convicted of aggravated kidnapping and robbery when she
kidnapped a pregnant convenience store employee.\55\ Similarly,
the Committee staff determined that MENTOR is often out of
compliance with its own guidelines, as well as State
guidelines, with respect to conducting background checks of
those who care for foster children or those who are routinely
in homes where foster children are placed. In the State of
Texas, case records showed that on four separate occasions in
an 8-month period, MENTOR was instructed to conduct background
checks on a frequent visitor to a foster home. That check was
never completed.\56\
---------------------------------------------------------------------------
\53\ Joseph, Brian. See Footnote 14.
\54\ Ansari, Talal, and Roston, Aram, ``Parent at Nation's Leading
For-profit Foster Care Firm Facing Murder Charges,'' BuzzFeed News,
February 23, 2016, https://www.buzzfeed.com/talalansari/parent-at-
nations-leading-for-profit-foster-care-firm-
facing?utm_term=.nkGzyWJJD#.
od1APe11V.
\55\ Roston, A. and Singer-Vine, J. See Footnote 13.
\56\ MENTOR bates numbers 0001822-1823.
---------------------------------------------------------------------------
Even when MENTOR met background screening guidelines, it
sometimes waived the outcomes of the findings. For example, in
the Committee staff's investigation of documents from MENTOR
Maryland, the Committee staff found that the husband of a
foster parent, who was later convicted of sexually abusing
foster children in their home, had been the subject of four
previous abuse allegations. The MENTOR worker marked in
handwriting on the criminal background search results, ``Not
Mentor [sic] parent,'' presumably indicating that the husband's
criminal history was irrelevant because the foster mother was
the primary caretaker. Similarly, MENTOR Texas noted in
documentation provided to the Committee that in one case
potential foster parents reported that they or family members
had been convicted of a crime, but no further information was
provided. The exact quote is: ``Yes, no description given.''
\57\ These individuals went on to become MENTOR foster parents,
and the foster mother killed a 3-year-old foster child by blunt
force trauma to the head.\58\
---------------------------------------------------------------------------
\57\ Notes from MENTOR Texas Documents: Clemon and Sherill Small
Case.
\58\ Joseph, Brian. See Footnote 14.
---------------------------------------------------------------------------
In another case reviewed by Committee staff, during the
vetting process for one particular set of MENTOR foster parents
in Maryland, the foster father indicated that he had a
preference for ``white, male children.'' This was not seen as a
red flag to the agency. Male children who were subsequently
placed with this MENTOR foster parent were sexually abused. In
fact, media accounts report that children who disclosed abuse
were not believed at first and were instead sent back to live
with their abusive foster father. Eventually a foster child was
believed and the case moved through the legal system.\59\
---------------------------------------------------------------------------
\59\ Roston, A. and Singer-Vine, J. See Footnote 13.
---------------------------------------------------------------------------
C. Child Welfare Workforce Operations
and Concerns
Caseworker Turnover. The child welfare field consistently
has high rates of turnover among its workforce. The national
range of turnover among child welfare workers is 30-40%
annually.\60\ When there is movement among staff, children are
often served by many different caseworkers, which can make it
difficult for children to form relationships with their
caseworkers, for caseworkers to put together a treatment plan
for children, and for cases to be adequately
monitored.\61\, \62\ Many records and news accounts
referenced the high turnover rate among staff at MENTOR; it was
of keen interest to the Committee staff to examine this at the
State and provider level.
---------------------------------------------------------------------------
\60\ U.S. General Accounting Office, ``Child Welfare: HHS Could
Play a Greater Role in Helping Child Welfare Agencies Recruit and
Retain Staff,'' Report to Congressional Requesters, No. GAO-03-357,
March 2003, http://www.gao.gov/new.items/d03357.pdf.
\61\ Illinois DCFS Report. See Footnote 42.
\62\ Garner, Bryan R., Hunter, Brooke D., Modisette, Kathryn D.,
Ihnes, Pamela C., and Godley, Susan H., ``Treatment staff turnover in
organizations implementing evidence-based practices: turnover rates and
their association with client outcomes,'' Journal of Substance Abuse
Treatment, March 2012, pp. 134-142, https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3268938/. See also U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration,
``Report to Congress on the Nation's Substance Abuse and Mental Health
Workforce Issues,'' January 24, 2013, https://www.google.com/
url?sa=t&rct=j&q=&esrc=
s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiZ_avJka_VAhWG5yYKHajECAMQFg
go
MAA&url=https%3A%2F%2Fstore.samhsa.gov%2Fshin%2Fcontent%2FPEP13-RTC-
BHWORK%
2FPEP13-RTC-BHWORK.pdf&usg=AFQjCNGxewm3bHzmpsqu5zeWfUdqYhVpiw.
---------------------------------------------------------------------------
Illinois reported that MENTOR had trouble maintaining
qualified staff. Its overall turnover rate for caseworkers was
actually consistent with national norms, but the turnover rate
for therapists working with MENTOR children was 44% in 2012. At
one Illinois site, the turnover rate for therapists was 80% in
2013. In this same year, the turnover rate for MENTOR child
welfare program directors in Illinois was an astounding 82%. In
its own periodic reviews of MENTOR, the State of Georgia also
noted concerns about staff turnover. In the Macon, Georgia
jurisdiction, MENTOR staff turnover reached 83%.
Caseload Size. Another workforce issue is the size of
caseloads that child welfare professionals carry. Despite the
field's attention to caseload size in the child welfare
profession, Committee staff found it difficult to obtain this
information from the States that were investigated. Three
States that responded to the 5-State In-Depth Letter do not
maintain information on the average caseload per caseworker
employed by each private contractor. Georgia indicated that it
tracks this information, but it was not easily accessible to
the State or the Committee, stating, ``There is no
comprehensive database that collects average caseload
numbers.'' Apparently caseload size is one of many indicators
that is recorded on paper files during periodic onsite reviews
of private foster homes and other similar agencies. This
information is never transmitted into an electronic database.
To further complicate matters, Georgia also insisted that it
does not use ``caseworkers,'' per se. Instead, the State uses
the term ``case support workers,'' a distinction which almost
prevented SFC staff from obtaining any information about the
caseload sizes in that State.
National standards for special needs children or children
requiring TFC services indicate that workers should not have
more than 10-12 cases per worker.\63\ Illinois contracted with
MENTOR to provide TFC services at the ratio of 10 cases per
worker. The State learned that MENTOR was not in compliance
with this standard. In some instances the ratio was as high as
14.5 to 1.\64\ Even though Illinois required specific levels of
case management, it did not maintain a data reporting system
that would ensure these levels were met and monitored. Maryland
indicated that, should caseloads exceed what is contracted, a
corrective action plan would be put in place.
---------------------------------------------------------------------------
\63\ Hughes, Sean and Lay, Suzanne, ``Direct Service Workers'
Recommendation for Child Welfare Financing and System Reform,'' Child
Welfare League of America, January 2012.
\64\ Illinois DCFS Report. See Footnote 42.
---------------------------------------------------------------------------
Communication. Communication within the company was also
noted to be a problem. When the State of Illinois was
conducting its own annual review and subsequent comprehensive
investigation of MENTOR, the Illinois team had to provide
copies of the two previous reports from the Illinois Office of
the Inspector General to MENTOR company officials, as they were
not aware of the prior investigations completed by the State
about their company. Nor were company officials aware of
commitments made by previous MENTOR officers as a result of
these reports. In these reports, Illinois child welfare
administrators noted that ``interagency communication issues
were evident at the onset of the review.''
Multiple Violations. Maryland conducted periodic reviews of
MENTOR from 2010-2015. Each review noted any specific violation
of regulations. Committee staff examined 22 quarterly reviews
that were conducted of MENTOR Maryland. In only two of those
quarters were no violations noted. Common and repeated
violations included missing documentation from employee hiring,
missing foster parent case files and child client case files,
concerns around board management and oversight of MENTOR
operations, and licensing and staffing issues. In many cases,
foster parents did not document the required hours of annual
training, nor did children's case files document all medical
and psychiatric exams. FBI clearance checks were also
incomplete in some cases. These reviews, over a period of 6
years, also noted frequent changes in the MENTOR Maryland
Board's composition and a high rate of staff turnover at
MENTOR.
Recruitment Bonuses. MENTOR provides incentives for
recruiting new foster parents to the company. Specifically, the
company provides financial incentives for employees who recruit
new foster parents that result in the placement of a child
through MENTOR. Employees who oversee recruitment efforts in
each State are called ``recruitment managers.'' Between 2012
and 2014, MENTOR reported paying an average of $92,000 each
year in bonuses to employees for foster parent recruitment,
which is about what a State would pay annually to take care of
two children who were placed with MENTOR families. According to
MENTOR, this is an average of $3,800 per recipient. In
addition, MENTOR also provides incentive payments to foster
parents who recruit other foster parents to have a child placed
in their home through MENTOR. The financial bonus for this
action is $250 for each new foster parent/foster home.
According to MENTOR records, in 2014 and the first 8 months of
2015, foster parents received bonuses totaling $126,000 for the
recruitment of new foster parents, which, using MENTOR's own
numbers, would represent about 500 new foster parents. There is
evidence that similar bonuses or incentives are used by State
and other private foster care agencies as well.\65\ While
Committee staff were unable to document a direct impact on
child care resulting from these bonuses, further investigation
regarding the use of bonuses and incentives may be warranted.
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\65\ For example, in Kentucky State foster parents receive bonuses
ranging from $100-$250 for each ``resource home'' that is successfully
recruited. State of Kentucky, Department for Community Based Services,
``Chapter 12.2.3: Recruitment bonus,'' Standards of Practice Online
Manual; http://manuals.sp.chfs.ky.gov/chapter12/22/Pages/
1223RecruitmentBonus.aspx. Also, AdoptUSKids, which is a project of the
Children's Bureau within HHS, recommends using recruitment incentives
for both staff and existing foster/adoptive parents to increase the
pool of potential placements for children. See McKenzie Consulting,
Inc., ``Practitioner's guide: Getting more parents for children from
your recruitment efforts,'' AdoptUSKids, https://www.
adoptuskids.org/_assets/files/NRCRRFAP/resources/practitioners-guide-
getting-more-parents-from-your-recruitment-efforts.pdf.
---------------------------------------------------------------------------
D. Physical and Mental Well-Being of
Children in Foster Care
SFC staff sought to determine the physical and mental well-
being of children in foster care and if this varied by provider
type. According to Federal policy, all States must develop a
plan for the oversight and coordination of health-care services
for children who are in foster care. This plan must involve the
State's Medicaid agency and input from health-care and child
welfare experts. One of the most basic elements of this plan is
to determine the timeline under which children will have an
initial health-care screening upon entering foster care. The
American Academy of Pediatrics recommends that children and
youth receive comprehensive health-care screenings within 30
days of entering foster care.\66\ States vary considerably in
their own timelines, ranging from requiring health screenings
within 24 hours to 30 days after a child enters foster care.
Health-care screenings are one of the items on which States are
assessed in the periodic CFSRs, but a 2015 review of children's
health-care needs and services by the Inspector General of HHS
showed that one-third of children in foster care did not
receive one of their health-care screenings. Further, one-
quarter of the children received their health-care screening
late.\67\
---------------------------------------------------------------------------
\66\ American Academy of Pediatrics, ``Fostering health: Health
care for children and adolescents in foster care, 2nd edition,'' 2005,
Report, p. 22, https://www.aap.org/en-us/advocacy-and-policy/aap-
health-initiatives/healthy-foster-care-america/documents/
fosteringhealthbook.
pdf.
\67\ U.S. Department of Health and Human Services, Office of
Inspector General, ``Not all children in foster care who were enrolled
in Medicaid received required health screenings,'' Report, OEI-07-13-
00460, March 2015, https://oig.hhs.gov/oei/reports/oei-07-13-00460.pdf.
---------------------------------------------------------------------------
In the 5-State In-Depth Letter, States were asked to
determine what portion of children in public State agencies and
private agencies had a full physical and mental health
assessment within 60 days of entering foster care. According to
the Illinois DCFS review of MENTOR, children being served by
Illinois MENTOR did not have their physical or mental health
needs met in a timely manner. Mental health assessments in
Illinois are to be completed within 30 days of contact with a
therapist, a standard that MENTOR met for only 60% of cases
reviewed by the State. Foster children served by MENTOR in
Illinois waited an average of 122 days before having contact
with a psychotherapist. A treatment plan is to be established
within 45 days of a mental health assessment, a standard that
was met for only 73% of MENTOR cases reviewed by the State.
Finally, treatment plans are to be updated every 5 months, a
standard which MENTOR met only 52% of the time. By way of
comparison, Georgia transmitted data on physical and mental
health assessments reporting compliance rates for assessments
within 60 days of placement. The performance in this area was
very poor for both MENTOR and the entire State, at 12% and 11%,
respectively.
In other instances, MENTOR ranked better than the State
averages in its compliance with the 60-day mark. In Texas, the
overall rate for the State was 73%, but for MENTOR it was 84%.
A similar situation was true in Maryland, where overall only
60% of children in the State were seen by a health provider for
a physical and mental health exam within 60 days of entering
foster care, but MENTOR met this mark 69% of the time.
E. Failure to Identify and Respond to
Risk to Children
The documents that were provided by MENTOR and in responses
to the 5-State In-Depth Letter showed that public agencies and
MENTOR repeatedly failed to identify and respond to the risk
that was presented to children in out-of-home care.
During the 2015-2016 reviews that Georgia conducted with
its contracted service providers, the MENTOR jurisdiction in
Athens reported 41 ``significant events,'' which included four
child protection investigations (each unsubstantiated), two
suicidal/homicidal threats, one ``child-on-child sexual
event,'' and two ``child-to-child physical confrontations.''
Despite these reports, the State gave this particular MENTOR
jurisdiction an overall qualitative safety score of 93%. Yet,
of the two caregiver homes randomly selected for the
jurisdiction's annual review, the second home presented
environmental risks to the foster children. The case notes
reviewed by Committee staff read: ``the provider stored the
garden tools, rake, lawn mower and the bottom of a water cooler
in the living room.''
In this same review, one of the ``well-being strengths''
listed is the ``documentation of the younger children's
academic needs being met,'' despite the fact the review also
noted the following:
LThe caregiver reported the two youth have no
ambition, motivation, or life goals;
LThe youth refuse to attend school. . . .
Similarly, under the category of ``Well-being Areas Needing
Improvement,'' the review noted two youth failing in school,
not making adequate progress, and not receiving tutoring or
academic support, in addition to a lack of documentation
explaining more than five unexcused absences.
A MENTOR foster parent in Texas killed one of her foster
children.\68\ Case notes reviewed by Committee staff indicate
there were clear warning signs that the safety and well-being
of children in her care were compromised before the fatal
abuse, but Texas MENTOR failed to see the risk to the children
placed with her and ultimately did not protect the children
being served. MENTOR described the foster mother and her
partner as ``mature, responsible, healthy individuals capable
of meeting the needs of a child placed in their care.'' Yet the
records also show that the foster mother reported being
overwhelmed and uncertain if she could care for foster
children. Children placed in her care were removed with
``negative outcomes,'' placements in the home ``failed,'' and
Early Childhood Intervention staff felt that children should
not be in this particular foster home. Further, the foster
parents were investigated by the Texas Department of Family and
Protective Services for concerns about children in their foster
home. Records from MENTOR report that the children in this home
had bruises and the foster mother reported that the children
would make false allegations against her and her partner. Texas
MENTOR did not terminate their license, but instead reinforced
its commitment to working with this family with case records
stating that MENTOR staff ``agree that this family should
continue to work as foster parents. . . . We will be decreasing
the number of children the family is licensed to care [for] in
efforts to ensure the family remains a Mentor [sic] family.''
---------------------------------------------------------------------------
\68\ Joseph, Brian. See Footnote 14.
---------------------------------------------------------------------------
F. Actions When Maltreatment Is
Substantiated in Foster Homes
All of the MENTOR children who were highlighted in media
accounts and were maltreated by their foster parents were
living in very high-risk situations. (As previously noted, in
one MENTOR home, children had disclosed their maltreatment, but
their disclosures were dismissed by those in a position to take
action. The preceding section noted the presence of bruises on
children and the investigation of maltreatment in one MENTOR
home where a child was killed.\69\) As a result, in the 50-
State Letter, SFC asked States about their procedures for when
maltreatment is substantiated in a foster home. In such a
situation, this would mean it was confirmed, founded, or
substantiated that a foster child was being abused or neglected
in his or her foster placement. According to data presented in
a report to Congress by the U.S. Department of Health and Human
Services, the State median of maltreatment among children who
were in foster care from 2010-2013 was 0.35%.\70\ Missouri,
Wyoming, and Virginia had the lowest rates, as determined by
the 2015 NCANDS and AFCARS datasets; the highest rates were in
New York, Iowa, and Massachusetts.\71\
---------------------------------------------------------------------------
\69\ Roston, A. and Singer-Vine, J. See Footnote 13.
\70\ U.S. Department of Health and Human Services, Administration
for Children and Families, Children's Bureau, ``Child Welfare Outcomes
2010-2013--Report to Congress,'' Report, February 1, 2016, https://
www.acf.hhs.gov/cb/resource/cwo-10-13.
\71\ Stoltzfus, Emilie, Memorandum prepared by the Congressional
Research Service. See Footnote 43.
---------------------------------------------------------------------------
Of the 33 States that responded to the 50-State Letter,
only 9 indicated that substantiation for abuse or neglect in a
foster home would unequivocally result in the revocation of a
foster home license: Arkansas, Delaware, Indiana, Kansas,
Nebraska, New Hampshire, South Dakota, Tennessee, and
Wisconsin. All of the other responding States report that
license revocation is one possible outcome when maltreatment is
substantiated.
Many of the States compared the rates of re-victimization
of children in foster care based on their foster home setting:
public, private non-profit, or private for-profit. There was no
evidence that children who were in privatized foster care
settings were more likely to be re-victimized than children in
publicly run foster homes.
Some of the information provided by the States about
maltreatment in foster care raised serious concerns.
Massachusetts reported the number and percentage of
substantiated child maltreatment episodes as a share of the
total foster care population. Of the 44,240 children in
substitute care during Federal fiscal years 2010-2014,
Massachusetts reported 739 instances of maltreatment in foster
care, which is 1.67% of all children in care. \72\ At face
value, this might appear to be a relatively low rate, but as
previously noted, it is well above the State median of 0.35%.
Further, data used in the third round of the CFSRs shows that
Massachusetts had the highest rate of child re-victimization in
the Nation \73\ and it steadily climbed between 2010 and
2013.\74\
---------------------------------------------------------------------------
\72\ See Appendix B, Exhibit 16--Response From Massachusetts,
Office of the Governor.
\73\ Stoltzfus, Emilie, Memorandum prepared by the Congressional
Research Service. See Footnote 43.
\74\ ``Child Welfare Outcomes 2010-2013--Report to Congress.'' See
Footnote 70.
---------------------------------------------------------------------------
In response to the 5-State In-Depth Letter, Maryland
reported that it does not track the occurrence of maltreatment
in foster care by provider or by type of provider, which means
that the performance of individual contractors and type of
contractor is not monitored in this way. Texas reported that
``serious instances of confirmed abuse and neglect cases result
in licensure revocation.'' But, it only reported one instance
of that happening between 2010 and 2014, despite the fact that
the State also provided the Committee with data showing there
were 295 instances of confirmed maltreatment among children in
foster care in that same time period. \75\ Further
documentation provided by Texas shows that between 2010 and
2015 about 7% of youth in foster care had an episode of
maltreatment against them substantiated; the rate was 8% for
Texas MENTOR.\76\
---------------------------------------------------------------------------
\75\ See Appendix B, Exhibit 29--Response From Texas, Department of
Family and Protective Services.
\76\ Maltreatment in foster care was for many years measured as a
percentage of children in foster care who had a substantiated or
indicated report of maltreatment where the perpetrator was coded as the
child's foster care provider (i.e., the perpetrator was the child's
foster parent or a staff member at a group home or institution where
the foster child was placed). The State median data cited above, for
example, uses that metric. Further, the data provided by Massachusetts
and Texas on the number of children maltreated while in foster care
from FY2010-FY2014 appears to use a similar if not identical metric. By
contrast, when it separately reported a percentage of children in Texas
foster care who were maltreated, the State appears to have made this
calculation based on all reports of maltreatment of children in foster
care, without regard to the perpetrator of the abuse or neglect. HHS
has begun to move its measurement of maltreatment of children in foster
care to include maltreatment without regard to who is the perpetrator.
However, the new HHS calculation, which measures incidents of
maltreatment for every 100,000 days of foster care provided by the
State, also takes certain steps to ensure that reports of maltreatment
for children in foster care do not unintentionally capture those
reports that were responsible for bringing a child in to foster care.
---------------------------------------------------------------------------
There is also a troubling example from Massachusetts that
was captured by investigative journalists where the State
changed its determination of whether an infant died from child
abuse or neglect.\77\ A 2-month-old infant died in a
Massachusetts foster home that was run by MENTOR. Initially the
case was ruled by the State as a death related to neglect
because of unsafe sleeping conditions. There is a provision in
Federal law which requires States to release information about
abuse and neglect-related deaths to the public.\78\ When
journalists used this provision to press the Massachusetts
Department of Children and Families to release information
about the infant's death, the substantiation of neglect was
reversed by the State--2.5 years after the death. Instead, the
State ruled that the death was not related to neglect. This
meant that Massachusetts was no longer required to release
information about the circumstances relating to and causes of
the infant's death. Accordingly, this information and the
record can remain sealed from the public.
---------------------------------------------------------------------------
\77\ Roston, Aram, ``In an unmarked grave, a baby's untold story,''
BuzzFeed News, June 18, 2015, https://www.buzzfeed.com/aramroston/in-
an-unmarked-grave-a-baby-who-died-on-for-profit-foster-
co?utm_term=.wt0VkV8zl#.aqARDROwG.
\78\ Child Abuse Prevention and Treatment Act, ``2.1A.4, Assurances
and requirements, Access to child abuse and neglect information, Public
disclosures.'' The full statute can be found at https://
www.acf.hhs.gov/cwpm/programs/cb/laws_policies/laws/cwpm/
policy_dsp.jsp?citID=
68.
---------------------------------------------------------------------------
G. MENTOR Incident Reports
The Committee staff requested that MENTOR submit all of its
highest-level incident reports from FY 2005 to FY 2014 for
review. This would allow SFC staff to investigate the most
serious cases where children died or were seriously harmed.
MENTOR submitted a total of 98 ``level 4'' incident reports
which capture the agency's most serious incidents of injury,
assault, abuse, or other similar events; 86 involved the death
of a child.\79\ The other cases involved psychiatric
admissions, allegations of sexual assault perpetrated against
foster children, allegations of sexual assault committed by
foster children, and accidents or injuries that happened to
foster children. Table 1 shows that about half of the reports
(45%) involved a child with a behavioral health concern and 40%
involved a child who was medically complex. Of the cases that
involved a death, almost three-quarters (73%, or 62 cases) of
the deaths were listed as ``unexpected,'' which is a check box
on MENTOR's incident report form.
---------------------------------------------------------------------------
\79\ See Appendix F for a sample of the level IV incident reports
provided by MENTOR. The company provided Committee staff all death-
related level IV incident reports for children in foster care under
MENTOR for FY2005-FY2014, with the exception of one incident report
that could not be located by the company. In addition, Committee staff
reviewed non-death-related level IV incident reports provided to the
Committee for those years, in addition to death-related and non-death-
related incident reports for FY2015. The Committee staff considered all
of these reports in its analysis. Committee staff cannot draw
conclusions about this full time frame given that the most recent
reports were provided after the Committee staff's analysis and have not
been fully reviewed.
Table 1. Summary of Incident Reports Reviewed
------------------------------------------------------------------------
Area of Assessment No. Percent
------------------------------------------------------------------------
Service Category (Indicated by MENTOR)
------------------------------------------------------------------------
Behavioral health 44 45%
------------------------------------------------------------------------
Blank 2 2%
------------------------------------------------------------------------
Juvenile Justice 3 3%
------------------------------------------------------------------------
Medically Complex 39 40%
------------------------------------------------------------------------
Missing Incident Report 1 1%
------------------------------------------------------------------------
Mentally Retarded/Dev. Delay 3 3%
------------------------------------------------------------------------
Other 6 6%
------------------------------------------------------------------------
Total 98 100%
------------------------------------------------------------------------
Death Was Expected? *
------------------------------------------------------------------------
Yes 23 27%
------------------------------------------------------------------------
No 62 73%
------------------------------------------------------------------------
Total ** 85 100%
------------------------------------------------------------------------
Was an Internal Investigation Launched?
------------------------------------------------------------------------
Yes 13 13%
------------------------------------------------------------------------
No 84 87%
------------------------------------------------------------------------
Total 97 100%
------------------------------------------------------------------------
* Calculation only includes death cases.
** One incident report for a death was not provided to the Senate
Finance Committee.
Table 2 shows that of the deaths that were unexpected, an
internal investigation was launched only 21% of the time (13
cases--set bold in Table 2), which suggests MENTOR does not
seek opportunities to learn from unexpected critical incidents.
The child welfare profession,\80\ along with many other
professions including law enforcement,\81\ health care,\82\ and
transportation,\83\ is moving in the direction of increasing
transparency and trying to learn from crises. In many cases and
jurisdictions, this includes systematic reviews of incidents
that result in unexpected deaths. The Committee staff also
determined that in at least nine of the incidents, there were
financial settlements paid to families of the victims.
---------------------------------------------------------------------------
\80\ See the National Center for the Review and Prevention of Child
Deaths, https://www.ncfrp.org/. See also: Hochstadt, N.J., ``Child
death review teams: a vital component of child protection,'' Child
Welfare, 2006 July-August, 85(4): 653-70, https://www.ncbi.nlm.nih.gov/
pubmed/17039823.
\81\ See ``Critical Incident Review Library'' at The Police
Foundation, https://www.
policefoundation.org/critical-incident-review-library/.
\82\ Wald, Heidi and Shojania, Kaveh G., U.S. Department of Health
and Human Services, ``Chapter 4: Incident reporting,'' Agency for
Healthcare Research Quality--Archive. Retrieved March 28, 2017, https:/
/archive.ahrq.gov/clinic/ptsafety/chap4.htm.
\83\ National Transportation Safety Board, ``History of the
National Transportation Safety Board.'' Retrieved March 28, 2017,
https://www.ntsb.gov/Pages/default.aspx.
Table 2. Internal Investigations and Death Expected/Unexpected
------------------------------------------------------------------------
Death Expected?
Internal Investigation? ---------------------------- Total
No Yes
------------------------------------------------------------------------
No 49 (79%) 23 (100%) 72
------------------------------------------------------------------------
Yes 13 (21%) 0 (0%) 13
------------------------------------------------------------------------
Total 62 (100%) 23 (100%) 85
------------------------------------------------------------------------
At the most basic level, MENTOR's incident reports have
typos, errors, inconsistencies, and missing information. More
concerning instances include inaccurate information and
diagnostically implausible conditions. For example:
LMENTOR's incident reports are incomplete. For
example, several reports mention that an internal
investigation is underway, but the outcome is never
indicated. Similarly, other reports note that an
investigation by law enforcement is underway, but there
was never any follow-up information available from the
incident reports to indicate the outcomes of these
investigations.
LOne MENTOR incident report was missing. In the list
of incident reports that was presented to Committee
staff, one incident report was not provided. In fact,
the company was unable to locate the document. Yet,
documentation attached to that case ID indicated that
the outcome of the case was serious enough to warrant a
settlement from MENTOR with the family.
LMENTOR's incident reports include information that
is diagnostically inaccurate. For example, one report
documenting the death of a 2 month-old infant described
the deceased as being ``oppositional.'' At best, this
was an error. At worst, it was an actual (although
implausible) diagnosis, since the conditions leading to
a diagnosis of ``oppositional defiant disorder'' need
to persist for a minimum of 6 months before a diagnosis
can be made.\84\ Even then, it is developmentally
inappropriate to give an infant this kind of diagnosis.
The average age of onset for oppositional defiant
disorders is between ages 5-15.\85\ Similarly, in
another case, a 4-month-old infant who also died was
described as having ``behavioral health'' problems when
the field widely recognizes that most serious mental/
behavioral health conditions are not diagnosed until
adolescence or early adulthood. Even when more
childhood-based conditions are treated (such as
attention deficit/hyper-activity disorders) the average
age of onset is 4-11 years old.\86\
---------------------------------------------------------------------------
\84\ American Academy of Child and Adolescent Psychiatry,
``Oppositional defiant disorder: A guide for families by the American
Academy of Child and Adolescent Psychiatry,'' Report, 2009, https://
www.aacap.org/App_Themes/AACAP/docs/resource_centers/odd/
odd_resource_center_
odd_guide.pdf.
\85\ Kessler, Ronald C., Amminger, G. Paul, Aguilar-Gaxiola,
Sergio, Alonso, Jordi, Lee, Sing, and Ustun, T. Bedirhan, ``Age of
onset of mental disorders: A review of recent literature,'' Current
Opinion in Psychiatry, Vol. 20, No. 4, 2007, https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC1925038/.
\86\ Ibid.
---------------------------------------------------------------------------
LMENTOR's incident reports contain information that
conflicts with media accounts of incident. One incident
report documents the death of a 4-year-old child and
states that the child died from cardiac arrest. Media
accounts of that incident (which were discovered by the
Committee staff based on the State and age of the
deceased, as well as the date of death) indicate that
the foster mother of the child was convicted of second
degree manslaughter in the death of the child. MENTOR
also reached a legal settlement with this family.
H. MENTOR Mortality Report
In response to the national attention concerning children
who died on MENTOR's watch and the investigation by SFC staff,
MENTOR conducted its own analysis of children who died in the
company's care. This MENTOR ``mortality report'' was completed
through a contract held with a research center at a public
university in the company's home State (see Appendix G,
Exhibits 1 and 2).\87\ In this analysis, MENTOR concludes that
its child death rates are in keeping with the rates of deaths
among foster children and among the youth population (in
general) at the national level. As discussed further in this
section, these conclusions are inaccurate and they appear to
misrepresent the experiences of children who are served by
MENTOR. The company did not have the report independently
validated. When SFC staff inquired about having the report
``peer reviewed'' by independent researchers with expertise in
child maltreatment, MENTOR indicated that this would only be
possible with the company's approval.
---------------------------------------------------------------------------
\87\ Note: On October 5, 2017, MENTOR provided Committee staff with
an updated mortality analysis, which reflected data through August
2017. To the extent Committee staff feels this data meaningfully
changes the analysis in the Committee Print, Committee staff will make
this information available on the Committee website in the future.
---------------------------------------------------------------------------
Committee staff found this report to be inaccurate and
misleading. The report used unequal points of comparison
between deaths that occurred under MENTOR's watch and national
rates of the deaths of foster children, according to AFCARS.
MENTOR's report included a comparison of its own annual death
rate based on the total number of children in its care each
year, with the national, annual death rate of foster children.
This national rate is based on the number of children who were
in care on the single date of September 30th, which is when
annual counts are taken. The result is the appearance of the
national death rate being much higher than MENTOR's death rate,
when in fact the opposite is true, as explained below.
In addition to these false conclusions, MENTOR's methods
and standards of analysis are not consistent with the field,
nor are they employed by HHS or the Centers for Disease Control
and Prevention (CDC). For example, the report stated the rate
of child deaths per 100 live children, as opposed to 100,000
live children, which is what is used by HHS \88\ and the
CDC.\89\
---------------------------------------------------------------------------
\88\ U.S. Department of Health and Human Services, Administration
for Children and Families, Administration on Children, Youth, and
Families, Children's Bureau, ``Child Maltreatment 2015,'' Report,
January 19, 2017, https://www.acf.hhs.gov/sites/default/files/cb/
cm2015.pdf.
\89\ Kochanek, K.D., Murphy, S.L., Xu, J., and Tejada-Vera, B.,
U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Health Statistics, National
Vital Statistics System, ``Deaths: Final Data for 2014.'' National
Vital Statistics Reports, Vol. 65, No. 4. June 30, 2016, https://
www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf.
---------------------------------------------------------------------------
Using the numbers provided in its own report, MENTOR's
average rate of death for 2010-2014 is .074 per 100 foster
children served (or as the field would express it, 74 per
100,000 children served), as compared with national rates of
.052 per 100 foster children served (or 52 per 100,000 children
served). Yet, MENTOR concludes: ``The MENTOR Network serves
significantly more children and youth with heightened risk
factors relative to others in foster care, and sustains child
mortality rates that are comparable with national norms'' (bold
emphasis in the original document). In fact, MENTOR's death
rate among foster children is 42% higher than the national
average.
Figure 1 demonstrates MENTOR's misleading display of
information. The red comment box points to MENTOR's inclusion
of a national death rate that is based on point-in-time counts
of the number of children in foster care on a single day. Using
this number in the denominator makes it look like the death
rate among children in foster care is higher than is actually
the case. The Committee staff concluded that this information
is not a valid comparison. The black comment box points to the
national death rate that is based on the total numbers of
children served annually in foster care, which provides a more
accurate estimate of the death rate among foster children. The
blue comment box points to the death rate among foster children
who are being served by MENTOR. This is also based on the
number of children served annually by MENTOR. This chart
clearly shows that the blue bar and rate, which captures
MENTOR's death rate, is higher than the black bar and rate,
which captures the comparable national death rate of children
who are in foster care.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Further, in its mortality report, MENTOR also states:
``Mortality rate in TMN [The MENTOR Network] foster care
programs has been very similar to, and more recently equal to
or better than, national norms.'' To substantiate this, MENTOR
provided a line chart of death rates for 2009-2014, with data
points that are too small to decipher and no numbers. The chart
appears intended to capture the national death rate among those
aged 0-22. Regardless, this chart is also misleading. Mortality
information collected by Committee staff from the CDC Wide-
ranging Online Data for Epidemiologic Research (WONDER)
database shows that the national death rate in the United
States between 2009 and 2014 among those aged 0-22 is 54.7 per
100,000 in the population.\90\ That means that the MENTOR death
rate (74 per 100,000) among youth aged 0-22 is 35% higher than
the national average.
---------------------------------------------------------------------------
\90\ For more information about the WONDER database, visit its
website https://wonder.cdc.gov/.
---------------------------------------------------------------------------
Furthermore, MENTOR's graphical analyses only focused on 5
years of data, 2009-2014, but in its report, MENTOR included 10
years of data. Figure 2 displays the full 10 years of rates of
children's deaths per 100,000 for 2005-2014. There are only 2
years during which MENTOR's death rates were at or below the
foster care population and national averages.\91\
---------------------------------------------------------------------------
\91\ The national data in Figure 2 is for youth ages 0-22, which is
the same age range that MENTOR used in their mortality report.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Finally, in the MENTOR conclusion cited above in this
section, the company highlights its contention that it serves
``significantly more children and youth with heightened risk
factors'' and therefore a higher death rate should be expected
among its served population. However, as noted earlier in the
report, when the Committee staff examined MENTOR's incident
reports, it found that of the cases involving a death, nearly
three-quarters of those cases (73%) indicated that MENTOR
itself concluded the death was ``unexpected.'' In short,
MENTOR's own incident reports do not support the conclusion
that MENTOR's fatality rate is attributable to these heightened
risk factors.
I. Financial Settlements From MENTOR
The documentation provided by MENTOR allowed Committee
staff to review over 20 financial settlement agreements
resulting from alleged negligence and/or damages. However, this
did not capture the full range of such settlements. According
to documents reviewed by Committee staff in reference to
Maryland dated between 2005 and 2015, there were 22 settlements
of claims against MENTOR. Illinois submitted materials to the
Committee indicating that there had been nine similar
settlements in the State. In almost all of the MENTOR legal
documents the plaintiffs and settlement amounts are redacted.
However, the documents from Illinois cite a total of $19.5
million in payouts. Given the numerous settlements made between
MENTOR and dozens of parties, MENTOR has likely paid many
millions of dollars in wrongful suit settlements. In fact, in
its 2014 SEC filings, MENTOR wrote: ``Several years ago, we
experienced a spike in claims filed against the Company, and we
could face an increase in claims in the future. As a result of
the prior increase in claims, we received less favorable
insurance terms and have expensed greater amounts to fund
potential claims.'' \92\
---------------------------------------------------------------------------
\92\ Civitas Solutions, Inc., 2014 10-K Filing (September 30,
2014), p. 13. See Footnote 2.
---------------------------------------------------------------------------
V. OVERSIGHT OF CHILD WELFARE SERVICES AND PROTECTING VULNERABLE
CHILDREN
The States that responded to the 50-State Letter were
adamant about their oversight of children in their foster care
systems, regardless of the nature of the children's placement.
That said, the information provided to and reviewed by SFC
staff describes systems that do not always keep children safe
or allow their performance to be readily evaluated. In fact,
one State--Massachusetts--failed to comply with a request from
the Committee to submit more detailed information about its
child welfare services. To further complicate matters, the
complex and fragmented nature of the child welfare system makes
it difficult for the Federal Government, and others, to monitor
the operations and outcomes of children who are involved in the
system. Some of the problems SFC staff encountered in trying to
evaluate and compare the performance of States and providers
through this review are as follows:
LGeorgia does not specifically record data about
children needing TFC services, which means the State is
likely unable to track the well-being of this
subpopulation (and likely many others).
LData from Illinois provided point-in-time
measurements for a single date on two key measures
(siblings placed in same living arrangement and average
caseload per caseworker), as opposed to over a period,
such as a fiscal year or multiple fiscal years. SFC
staff repeatedly raised this issue with Illinois staff
and requested a State average across all providers
which would have given the Committee at least some
benchmark for comparison purposes. The State was unable
to provide this information.
LMaryland only provided the Committee with data on
private TFC placements, as opposed to data about their
entire child welfare population with subpopulations
that might have included those needing TFC placements.
LNot all child welfare indicators are available
electronically. Some States collect information,
perform reviews, and maintain data in paper files that
are never entered into an electronic database or that
are never synthesized into a single report or review.
Without more systematic procedures in place, it is
almost impossible for States to have any meaningful
oversight over their own systems or the agencies that
provide contracted services for them.
LThe field lacks a consistent language about child
welfare services, clients, and operations, which makes
it difficult to make comparisons between States and
between providers. For example:
LThere is no uniform definition of
what constitutes TFC. Some States use the term
``treatment foster care,'' instead of
``therapeutic foster care,'' although the
spirit of the definition, the needs of the
children, and the services provided would be
similar. Other common terms used include
``special needs'' children or ``medically
fragile'' children.
LOne State does not use the term
``caseworkers'' and would not provide client-
to-caseworker ratios until SFC staff
established that this State called these
employees ``case support workers.'' MENTOR
calls its caseworkers ``child welfare
specialists.''
LThe terms that States use to
refer to the private agencies with which they
contract to provide foster care services vary
as well. Some States refer to these agencies as
``child placement agencies.'' Another common
term is ``contract agencies'' or ``foster care
agencies.''
LStates have varying definitions and
conceptualizations of what it is that private child
welfare agencies do in their States. Some States do not
use the term ``child placement agencies'' to refer to
contract agencies, while others do. This is because the
State has control over and responsibility for placing
children in foster homes. So when the Committee asked
States, ``What proportion of the children in foster
care in your State is placed by the public agency, not-
for-profit providers, and for-profit providers,'' many
States indicated ``zero'' for anything outside of the
public agency because they maintain that all children
are placed by the State. Other States (which maintained
that the public agency places all children) still
provided rates of children placed by contracted
agencies. This meant it was impossible for SFC staff to
determine the proportion of children living in homes
that for all intents and purposes are run by private
agencies.
LWith regard to substantiations of maltreatment in
foster care, the Committee asked States to indicate in
``how many of these instances . . . were children
placed by: not-for-profit providers, for-profit
providers, and public providers?'' Some States
indicated ``zero'' for the first two categories, again
because they maintain that children in their State are
not placed by contracted agencies, they are only placed
by public agencies, even if the foster parents work for
and are managed by a contracted agency. Thus, the
information obtained from different States was not
always comparable.
LOther States maintain that public employees provide
full case management services for the children in their
care, yet private agency workers set up appointments
for the clients, make arrangements for services,
provide transportation, provide support for foster
parents, and visit the children in their foster care
placements. According to the National Association for
Social Workers, the definition of case management
services is: ``A process to plan, seek, advocate for,
and monitor services from different social services or
health care organizations and staff on behalf of a
client.'' \93\ This seems consistent with the services
private agencies provide children who are in the
protective care and custody of their State, even if the
public agencies call it otherwise.
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\93\ National Association of Social Workers, ``NASW Standards for
Social Work Case Management,'' Report, 2013, https://
www.socialworkers.org/practice/naswstandards/CaseManagement
Standards2013.pdf.
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LThe Committee staff noted the various ways and
outcomes by which child welfare agencies and government
documents discuss the maltreatment of children involved
with child welfare agencies. CFSRs, which are
implemented by HHS and monitor State-level child
welfare outcomes, track the percentage of any
recurrence of maltreatment among all children in the
State. The standard: States should not be above 9.1%.
In 2013, 19 States failed to meet this benchmark.
LMaltreatment of children in foster care is measured
as the number of children who were victims of
substantiated maltreatment per 100,000 days spent in
foster care. The national standard is set at 8.5 per
100,000 days. In 2013, 22 States exceeded this
standard. A document prepared by HHS for Congress
showed that the State median of maltreatment of
children in foster care is 0.35%. Meanwhile, individual
States submitted rates to SFC that ranged from 2% to
20%. These varying ways for measuring and reporting the
same construct make it difficult for regulators to
monitor outcomes and the well-being of children
involved with their State's child welfare system.
LThe third round of CFSRs is being conducted between
2015 and 2018. In late 2016, HHS discovered an error in
the syntax the Department used to electronically gather
information from the States regarding their program
performance. Information is still being gathered, but
States that submitted data before the error was
discovered will not be assessed in the areas that were
affected by the syntax error. Thus, a major Federal
mechanism that is in place for monitoring child welfare
performance in the States is not fully functional and
means that for some States, there will be approximately
a 10-year gap on the Federal assessment of some child
welfare performance indicators.
LNot all of the States responded to inquiries from
the Committee.
LSeventeen States failed to
respond to the 50-State Letter. Those States
were: Arizona, Florida, Georgia, Idaho,
Louisiana, Maine, Michigan, Mississippi,
Missouri, Montana, Nevada, North Carolina,
Ohio, Rhode Island, South Carolina, Vermont,
and Virginia.
LMassachusetts failed to respond
to the 5-State In-Depth Letter. Despite
repeated assurances from the Massachusetts
Department of Children and Family Services that
``continuing efforts are being made to collect
and prepare the information'' with ``the full
intention to send a response to the
Committee,'' a response to the Committee's
questions was never received.
VI. CONCLUSIONS
Despite the limitations on information supplied to the
Committee, there is sufficient information from this single
private agency and the States to show that children who are
under the legal authority of their State are often ill-served.
Some children served by MENTOR were abused, neglected, and
denied services, and the very State agencies that have been
charged with and paid to keep them safe have likely contributed
to their suffering and deaths. As documented by MENTOR's
incident reports, investigations about fatalities were never
followed up, autopsy reports which were pending years ago are
not part of case files, and the vast majority of children who
died were not the subject of an internal investigation--even
when their deaths were unexpected. MENTOR issued a report to
the Committee which falsely claimed that its death rates are in
keeping with national death rates and the rates of death among
children in the foster care system. Add to this complicated
narrative the fact that the families of MENTOR victims have
received millions of dollars in financial settlements,
significant enough for MENTOR to have received less favorable
terms from its insurer in 2014. The Committee staff recognizes
that a case study of one provider does not allow for direct
comparisons with other individual providers, and thus, cannot
draw conclusions regarding MENTOR's operations in relation to
other contracted agencies, for-profit or otherwise. Regardless,
information collected for this report shows that MENTOR
repeatedly placed the health and well-being of children at
risk.
State agencies would likely counter concerns about their
performance by noting the procedures they have in place to
monitor private agencies. For example, Illinois notes that all
licensed foster homes are physically inspected at least twice
each year, with licenses valid for 4 years. Maryland states
that it assesses all private TFC providers quarterly. This same
State noted that providers can find themselves on the agency's
``hotlist'' by not complying with contractual obligations or by
committing license violations. In such situations, providers
would not be able to take in new clients until a corrective
action plan is generated and subsequently completed. Even
though MENTOR repeatedly failed to meet all State licensing
criteria in 20 of the 22 quarters reviewed that the Committee
examined, MENTOR continues to operate in Maryland. Illinois
described a similar regulatory approach, but MENTOR no longer
operates in that State.
State oversight guidelines are in place in almost every
State in the Nation, either written into State statute or as
part of agency policy. This investigation and precipitating
media reports show that these policies are not always followed,
exceptions are made, waivers are granted, and sometimes
professionals serving children look the other way.
The documents reviewed in this investigation show a system
that does not always protect children. Profits are sometimes
prioritized over children's safety and well-being. Turnover
among staff sometimes makes it impossible to develop case plans
to ensure that children are ``on-track'' and being monitored.
Foster parents with questionable backgrounds who seemingly lack
the skills to provide care to vulnerable children are given
licenses to parent challenging children and then are often
inadequately monitored. Further, the data and oversight
structures at both the State and Federal level make it
difficult and sometimes impossible to monitor the operations of
the child welfare system itself, as well as its private
contractors. Thus, the bipartisan Committee staff sets forth
the following recommendations.
VII. RECOMMENDATIONS
Recommendations for States and Tribes
LImprove outreach, customer service, and support
services for those interested in becoming foster
parents to attract and retain high-quality foster
families.
LSupport enhanced oversight of foster families to
ensure robust background checks, home study
assessments, and ongoing placement oversight.
LFrequently review performance of child welfare
service providers/contractors to ensure child safety,
permanency, and well-being standards are being met.
LTrack child safety and well-being related outcomes
at the individual provider level, including whether
children served by specific providers have higher than
average needs (e.g., medically fragile, special needs,
or therapeutic foster care placement, etc.).
LSet standards for maximum caseload size for child
welfare workers, which may include differentiated
standards based on variations in case type (e.g.,
medically fragile children, children in therapeutic
foster care placements, etc.) or activity (e.g.,
investigations of abuse or neglect, case planning for
children in foster care).
LProvide greater funding for the training of front-
end staff charged with making removal and placement
setting decisions for children entering foster care or
at risk of entry.
LRevoke contracts from child welfare service
providers who are unable to demonstrate the capacity to
provide safe foster care placements for children.
LProvide subsidized guardianship payments to
relatives willing and able to provide safe placements
for children who can no longer remain at home.
LEnsure child death review teams are transparent,
timely, and well-staffed. Require the timely
publication of the results of child death reviews while
ensuring appropriate and robust privacy protection of
sensitive data.
LMake placement setting decisions based on the
assessed strengths and needs of children entering
foster care using an age-appropriate, evidence-based,
validated, functional assessment tool to ensure
children receive the appropriate level of care in the
least restrictive, most family-like environment.
LEstablish child welfare ombudsman offices through
which children in care, family members, child welfare
workers, foster parents, whistleblowers, and members of
the public at large can submit comments and concerns
about misconduct within the child welfare system.
Recommendations for the Department of Health
and Human Services (HHS)
LWork to engage States, Congress, and the broader
child welfare community in understanding the purpose
and State-
specific relevance of the CFSRs and ensure this process
contributes to meaningful improvement and reform.
LSeek and provide clarification on how States and
Tribes are defining, using, and overseeing the delivery
of Therapeutic Foster Care (TFC) and establish a common
definition of TFC for the purposes of Medicaid and
title IV-E.
LDevelop a uniform definition of ``child abuse and
neglect fatality'' and provide guidance related to
determining and reporting such fatalities and ensure
States and Tribes are using this new definition when
reporting data via the National Child Abuse and Neglect
Data System (NCANDS).
LAid States in developing the means and mechanisms to
accurately collect provider-specific outcomes data,
consistent with the metrics and definitions associated
with AFCARS, NCANDS, and the CFSRs.
LEstablish maximum caseload guidelines to promote
manageable caseload sizes for the child welfare
workforce.
Recommendations for Congress
LSupport both funding and oversight for States and
Tribes to enhance foster parent recruitment and
retention activities to ensure robust background
checks, home studies, ongoing placement oversight, and
strong support services for foster parents.
LSupport both funding and oversight for States and
Tribes to enhance caseworker recruitment and retention
activities to ensure child welfare caseworkers are both
prepared to enter the field and given the support
services necessary to carry out their jobs effectively.
LAllow States and Tribes to use title IV-E funds to
support evidence-based services aimed at safely
preventing foster care entries.
LConsider de-linking subsidized guardianship payments
from the Aid to Families with Dependent Children (AFDC)
income standard so that States and Tribes can receive a
Federal match on behalf of all children placed in
subsidized guardianship placements and promote equity
in the payment rate for kinship placements.
LRequire all States to report to the National Child
Abuse and Neglect Data System (NCANDS) using standard
definitions and provide support for this data
collection and reporting.
LConsider legislation creating an explicit private
right of action for children and youth in foster care
tied to components of the case plan and case review
requirements defined under section 475 of the Social
Security Act.\94\
---------------------------------------------------------------------------
\94\ ``Compilation of the Social Security Laws,'' Social Security
Act, section 475, https://www.ssa.gov/OP_Home/ssact/title04/0475.htm.
---------------------------------------------------------------------------
LConsider statutory changes requiring HHS to assess
fiscal penalties on States for failing to meet CFSR
outcomes or system requirements and develop a penalty
reinvestment structure under which assessed penalties
must be used by the State to address the key identified
deficiencies (rather than be deposited into the Federal
Treasury).
LConsider amending section 479A of the Social
Security Act to require States to collect, and HHS to
audit, provider-
specific child outcomes data in addition to State-
specific data on outcomes such as: child fatalities,
maltreatment in care, recurrence of maltreatment within
6 months, exits from foster care by reason for the exit
(adoption or guardianship, reunification,
emancipation), time to reunification, re-entry rates,
and the average number of placements. Ensure this
performance data is available to the public and
considered by States or Tribes before making or
renewing a contract with the provider.
LConsider prohibiting Federal title IV-E
reimbursements for providers who consistently perform
poorly on key safety, permanency, and well-being
indicators. Charge HHS with auditing States and
providers to determine which providers shall be
excluded from Federal title IV-E reimbursement.
LRequire States to make their contracts with private
child welfare service providers publicly available and
include details on whether such providers are private
not-for-profit or private for-profit.
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Appendix A
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Appendix B
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