Foster Care: HHS Should Ensure That Juvenile Justice Placements Are
Reviewed (Letter Report, 06/09/2000, GAO/HEHS-00-42).

Pursuant to a congressional request, GAO provided information on the
Department of Health and Human Services' (HHS) approval of the Social
Security Act's title IV-E reimbursements for foster care placements,
focusing on: (1) the number of title IV-E foster care placements made by
juvenile justice agencies in fiscal year (FY) 1998 and the amount of
federal care funding expended for these placements; (2) how selected
states ensure that title IV-E funds are not used for placements in
detention facilities and ensure that procedural requirements to protect
the welfare of children in title IV-E funded juvenile cases are met; and
(3) HHS' processes for ensuring the appropriate use of funds and
compliance with these procedural requirements in title IV-E funded
juvenile justice placements.

GAO noted that: (1) in FY 1998, about $300 million in title IV-E funds
was used to support foster care placements of children in the juvenile
justice system; (2) almost half of the states used some portion of their
title IV-E funds in this way; (3) nearly 60 percent of the total amount
of title IV-E funding used for juvenile justice placements was used by
California; (4) the $300 million used for children in the juvenile
justice system is 10 percent of all FY 1998 title IV-E expenditures; (5)
to ensure that title IV-E funds are not being used for placements in
detention facilities, the 10 states that used the largest amount of such
funding in FY 1998 rely primarily on the requirements that a facility
must meet in order to be licensed as a child care institution; (6)
licensing regulations in those states establish standards designed
primarily to ensure a healthy and safe physical environment for the
children; (7) in some states, these regulations allow a facility to
engage in some restrictive practices that have been associated with
detention; (8) state licensing regulations also play a role with regard
to meeting title IV-E procedural requirements intended to protect the
welfare of children in foster care cases--namely, that case plans be
developed, administrative case reviews be conducted, and procedural
safeguards be in place; (9) states enforce their licensing regulations
through periodic on-site visits and facility inspections; (10) in
addition to their licensing regulations, the two states whose procedures
GAO examined more closely have administrative regulations for protecting
children in foster care, which address in detail the title IV-E
procedural requirements; (11) HHS has acknowledged that states have
sometimes encountered difficulty in determining whether the facilities
in which juvenile justice system children are placed qualify to receive
title IV-E funding and in meeting procedural requirements in these
cases; (12) HHS conducts two broad oversight reviews in each state, a
title IV-E eligibility review and a child and family services (CFS)
review; (13) title IV-E eligibility reviews primarily verify children's
and foster care providers' eligibility for title IV-E funding in random
sample of title IV-E funded foster care placements in each state; and
(14) CFS reviews assess systems states use to determine the eligibility
of foster care providers for title IV-E funding and systems states use
to ensure that procedural requirements are met in title IV-E funded
placements.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-00-42
     TITLE:  Foster Care: HHS Should Ensure That Juvenile Justice
	     Placements Are Reviewed
      DATE:  06/09/2000
   SUBJECT:  Foster children
	     Federal/state relations
	     State-administered programs
	     Juvenile delinquency
	     Eligibility determinations
	     Federal funds
	     Detention facilities
	     Entitlement programs
IDENTIFIER:  California
	     Texas
	     Title IV-E Foster Care Program
	     Illinois
	     Maryland
	     Michigan
	     Missouri
	     New York
	     North Carolina
	     Ohio
	     Pennsylvania

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GAO/HEHS-00-42

Appendix I: Scope and Methodology

24

Appendix II: Fiscal Year 1998 Title IV-E Funding Claimed and
Number of Placements, by State

27

Appendix III: Provisions of State Licensing Regulations for Child
Care Institutions Related to Physical Restriction of Residents

29

Appendix IV: Provisions in State Licensing Regulations That Relate
to Procedural Requirements in Title
IV-E Funded Foster Care Cases

32

Appendix V: Comments From the Department of Health and Human Services

42

46

Table 1: Number of Title IV-E Funded Juvenile Justice and Child Welfare
Placements in California and Cost per Day, by Setting and Level of Care
Received, Fiscal Year 1998 13

Table 2: Number of Title IV-E Funded Juvenile Justice and Child Welfare
Placements in Texas and Cost per Day, by Setting and Level of Care Received,
Fiscal Year 1998 14

CFS child and family services

DSS Department of Social Services

HHS Department of Health and Human Services

ISP individual services plan

JPC Juvenile Probation Commission

PRS Department of Protective and Regulatory Services

TYC Texas Youth Commission

Health, Education, and
Human Services Division

B-281545

June 9, 2000

The Honorable George Miller
Ranking Minority Member
Committee on Resources
House of Representatives

The Honorable Charles Rangel
Ranking Minority Member
Committee on Ways and Means
House of Representatives

The Honorable Henry A. Waxman
Ranking Minority Member
Committee on Government Reform
House of Representatives

The Honorable Pete Stark
Ranking Minority Member
Subcommittee on Health
Committee on Ways and Means
House of Representatives

The Honorable David R. Obey
Ranking Minority Member
Committee on Appropriations
House of Representatives

The Honorable John Conyers
Ranking Minority Member
Committee on the Judiciary
House of Representatives

The Honorable Barbara Lee
House of Representatives

Each year, the federal government spends over $3 billion to finance foster
care placements for about half a million children. Under title IV-E of the
Social Security Act, which authorizes federal foster care funding, foster
care placements may be based on a judicial determination that remaining in
the home would be contrary to the welfare of the child. These determinations
are made in both dependency (child welfare) and delinquency (juvenile
justice) cases. Although most foster care funds support child welfare
placements, they may also be used to support juvenile justice placements.

Since the early 1980s, the Department of Health and Human Services (HHS) has
been approving title IV-E reimbursements for foster care placements made by
juvenile justice agencies for children in the juvenile justice system.
However, the Social Security Act prohibits using foster care funds for
placements in facilities operated primarily for detention. In addition, the
act stipulates specific procedural requirements intended to protect the
welfare of all children in foster care placements supported by title IV-E
funds. These include developing a written case plan for each placement, a
court or administrative case review at least every 6 months, a permanency
hearing within 12 months of placement, and "procedural safeguards" to
protect parents' rights when a child is removed from the home. Concerned
that compliance with provisions of the law may be more difficult in juvenile
justice placements, you asked us to (1) determine the number of title IV-E
foster care placements made by juvenile justice agencies in fiscal year 1998
and the amount of federal care funding expended for these placements, (2)
describe how selected states ensure that title IV-E funds are not used for
placements in detention facilities and ensure that procedural requirements
to protect the welfare of children in title IV-E funded juvenile justice
cases are met, and (3) assess HHS' processes for ensuring the appropriate
use of funds and compliance with these procedural requirements in title IV-E
funded juvenile justice placements.

To conduct our work, we reviewed state licensing regulations for child care
institutions in the 10 states that HHS data showed had claimed the most
fiscal year 1998 title IV-E funding for all foster care maintenance
expenses--primarily food, shelter, and clothing: California, Illinois,
Maryland, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania,
and Texas. To estimate the number of title IV-E funded juvenile justice
placements in fiscal year 1998 and the federal dollars expended for both
maintenance and administrative costs, we surveyed all 50 states and the
District of Columbia. We also did fieldwork at state and county child
welfare and juvenile justice agencies in California and Texas to determine
how they attempt to ensure that title IV-E procedural requirements are met.
However, we did not independently verify the effectiveness of these
activities. We reviewed a total of 18 cases during our fieldwork to obtain
some indication of how the systems that are in place to ensure facility
eligibility and procedural requirements operate and what issues arise
related to placement eligibility for title IV-E funds and compliance with
title IV-E procedural requirements in cases involving juvenile justice
placements. We did not determine, in these cases, if facilities in which
children were placed were eligible for title IV-E funding, if procedural
requirements were met, or if children received the services they required.
We also interviewed HHS officials and reviewed pertinent laws, regulations,
and documents, including regulations issued in January 2000 revising the
objective, scope, and methodology for HHS title IV-E eligibility and child
and family services review systems. (For a detailed description of our scope
and methodology, see app. I.) We conducted our work between January 1999 and
May 2000 in accordance with generally accepted government auditing
standards.

In fiscal year 1998, about $300 million in title IV-E funds was used to
support foster care placements of children in the juvenile justice system.
Almost half of the states used some portion of their title IV-E funds in
this way. Nearly 60 percent of the total amount of title IV-E funding used
for juvenile justice placements was used by California. The $300 million
used for children in the juvenile justice system is 10 percent of all fiscal
year 1998 title IV-E expenditures; however, the 15,000 juvenile justice
system children supported by those funds constituted only about 4 percent of
all children supported by foster care funds. The disproportionate spending
on juvenile justice system foster care children may be attributable, in
part, to the greater levels of--and thus more costly--supervision that,
according to juvenile justice officials, many children in the juvenile
justice system need.

To ensure that title IV-E funds are not being used for placements in
detention facilities, the 10 states that used the largest amount of such
funding in fiscal year 1998 rely primarily on the requirements that a
facility must meet in order to be licensed as a child care institution.
Licensing regulations in those states establish standards designed primarily
to ensure a healthy and safe physical environment for the children. In some
states, these regulations allow a facility to engage in some restrictive
practices that have been associated with detention; however, the regulations
permit such practices only under certain circumstances, such as when
children pose a threat to themselves or others or when such practices are
necessary in order to manage inappropriate behaviors. State licensing
regulations also play a role with regard to meeting title IV-E procedural
requirements intended to protect the welfare of children in foster care
cases--namely, that case plans be developed, administrative case reviews be
conducted, and procedural safeguards be in place. States enforce their
licensing regulations through periodic on-site visits and facility
inspections. In addition to their licensing regulations, the two states
whose procedures we examined more closely, California and Texas, have
administrative regulations for protecting children in foster care, which
address in detail the title IV-E procedural requirements.

HHS has acknowledged that states have sometimes encountered difficulty in
determining whether the facilities in which juvenile justice system children
are placed qualify to receive title IV-E funding and in meeting procedural
requirements in these cases. Consequently, HHS has provided guidance to
states on what constitutes detention and is currently in the process of
developing additional guidance on that subject. In addition, HHS conducts
two broad oversight reviews in each state, a title IV-E eligibility review
and a child and family services (CFS) review. Title IV-E eligibility reviews
primarily verify children's and foster care providers' eligibility for title
IV-E funding in a random sample of title IV-E funded foster care placements
in each state. CFS reviews, in part, assess systems states use to determine
the eligibility of foster care providers for title IV-E funding and systems
states use to ensure that procedural requirements are met in title IV-E
funded placements. CFS reviews collect information for this assessment
through interviews with state and community representatives and a review of
a random sample of title IV-E funded cases in each state. It is not clear
based on new regulations for eligibility and CFS reviews whether the results
of these reviews will enable HHS to determine if title IV-E funding is being
used for placement in appropriate facilities or if procedural requirements
are being met in juvenile justice cases--and, thus, whether these reviews,
as designed, constitute adequate oversight of the use of title IV-E funds in
these cases. Therefore, we are recommending that HHS review a sufficient
number of title IV-E funded juvenile justice placements in child care
institutions in those states having such placements to determine with a
reasonable degree of assurance whether facility eligibility and procedural
requirements are being met for such cases. In its comments on a draft of
this report, HHS agreed that more information is needed to understand and
address issues surrounding the use of title IV-E funding in juvenile justice
cases and suggested other means than those we recommended for collecting
this information. Therefore, we modified the language of our recommendations
to accommodate the use of alternative means of accomplishing their intended
effect.

Federal funds for foster care are authorized under title IV-E of the Social
Security Act. The foster care entitlement program provides matching funds to
states to cover the cost of maintaining neglected and abused children in
foster care placements, such as foster family homes or child care
institutions, also referred to as group homes.1 To receive title IV-E funds,
a state must submit to HHS for approval a plan that protects the rights of
foster care children and families and defines a statewide service delivery
system for the foster care maintenance program authorized by the act. These
state plans must include, in part, how agencies will ensure that (1) the
children and the foster homes or child care institutions in which the
children are placed meet title IV-E eligibility criteria and (2) procedural
requirements in the act are met in title IV-E funded placements.

Children qualify if they have been removed from the home pursuant to a
voluntary agreement entered into by their legal guardian or as the result of
a judicial determination that continuation in the home would be contrary to
their welfare, and their families meet eligibility criteria related to
income level.2 Title IV-E funded placements are typically for children in
the child welfare system. However, HHS has issued several policy statements
specifically allowing eligibility claims for title IV-E funding for foster
care placements for juveniles who are wards of the court.

Foster homes and child care institutions qualify for title IV-E funding if
they are licensed by the state and not operated primarily to detain children
who have been determined to be delinquent. In a policy statement issued in
1982, HHS stated that the term "child care institution" may not include
"detention facilities, forestry camps, training schools, or any other
facility operated primarily for the detention of children determined to be
delinquent." The statement also noted that "primarily" refers to the use of
the facility for detention purposes and that determining whether a facility
operates primarily for detention depends on who operates it, for what
purposes it exists, from whom it receives its major financial resources, the
circumstances of the children who reside there, and its economic viability
if it did not house children adjudicated delinquent. In 1988, HHS issued a
policy statement emphasizing that "the two factors that will be
determinative in identifying such a facility are (1) it must be a physically
restricting facility and (2) it would not be operational without a
population of children who have been adjudicated delinquent."

The nature and purpose of facilities' restrictive practices were addressed
in a 1988 Departmental Grant Appeals Board decision in which California
appealed HHS' decision to disallow IV-E payments for placements in a Rite of
Passage facility. HHS' Departmental Grant Appeals Board cited a number of
physically restrictive practices as indications that a facility's primary
purpose may be detention. These practices include location in a remote area,
confiscation of personal belongings, pursuit of runaways, constant
supervision of residents, and use of isolation as punishment. The board,
while drawing a distinction between restrictive practices for the purpose of
detention and restrictive practices for the purpose of treatment, recognized
that treatment is an integral part of a juvenile justice placement even when
the treatment's primary purpose is detention. According to current HHS
regulations, a detention facility, "in the context of the definition of
child care institution in section 472(c)(2) of the [Social Security] Act
means a physically restricting facility for the care of children who require
secure custody pending court adjudication, court disposition, execution of a
court order or after commitment."3

According to federal requirements related to state foster care plans, states
are responsible for establishing and maintaining licensing regulations for
facilities. These regulations must represent minimum standards related to
admission policies, safety, sanitation, and protection of the civil rights
of children placed in foster family homes and child care institutions and,
to a reasonable extent, be in accord with the standards recommended by
national organizations concerned with standards for such institutions or
homes. The Child Welfare League of America recommends that licensing
standards for child care institutions cover facility administration,
personnel qualifications, the personal rights of residents, services and
activities provided to residents, and provisions to ensure a healthy and
safe physical environment.

State child welfare agencies are also responsible for ensuring that
procedural requirements are met in title IV-E funded foster care placements.
The Social Security Act4 requires that there be a written case plan for each
title IV-E funded foster care placement and specifies that this plan address
such concerns as the appropriateness of the placement, the treatment and
services the child needs, meeting the child's health and educational needs,
and services needed to improve the conditions in the home. The act also
requires a court or administrative review in these cases at least every 6
months to monitor compliance with the case plan, the necessity for and
appropriateness of the placement, the progress made in improving the home,
and when the child is likely to return home or when an action to terminate
parental rights is likely to be initiated. A permanency hearing is also
required within 12 months of the child's entrance into foster care to decide
what the child's permanency goal should be--to return home, remain in foster
care, or be adopted. Finally, the act requires that "procedural safeguards"
be applied to protect a parent's rights when a child is removed from the
home, when there is a change in the child's placement, and when decisions
are made concerning the parent's right to visit the child.

States are responsible for carrying out specific monitoring and evaluation
activities; HHS has oversight responsibility for the title IV-E program in
general. Federal law requires states to monitor and periodically evaluate
their own activities to ensure that children and placements qualify for
title IV-E funding and that procedural requirements are met in IV-E funded
cases. States must also submit statistics to HHS on the legal status of
children in title IV-E funded placements and their demographic
characteristics, location, and length of stay in foster care. In addition to
reviewing state foster care plans and approving those that meet federal
requirements, HHS is required by the Social Security Act to evaluate and
periodically monitor states' compliance with these plans and to collect and
publish state data pertaining to the incidence and characteristics of foster
care in this country. In addition, according to its strategic plan, HHS has
identified the importance of supporting the state-administered title IV-E
program by ensuring that (1) procedures for monitoring the program allow for
a realistic examination of the experiences of families and children, (2)
best practices related to the program are disseminated, and (3) HHS'
technical assistance and training are relevant and useful to states and
localities in administering their title IV-E programs.

Title IV-E funds are meant to cover a portion of states' costs for food,
shelter, clothing, daily supervision, school supplies, general incidentals,
liability insurance for the child, and travel to the child's home for
visits. States set the basic rates they pay foster parents and child care
institutions for these maintenance costs.5 States set higher payment rates
for foster care placements that provide higher levels of care needed by
children with, for example, psychological or behavioral problems or
exceptional physical care needs. The higher rates correspond to the higher
levels of supervision that are needed. To determine the amount of
reimbursement states receive for a placement under title IV-E, a state's
payment rate for that placement (minus the costs not allowable under title
IV-E) is multiplied by its title IV-E matching rate, which is the same as
its Medicaid matching rate and based on per capita income. These matching
rates vary from 50 to 83 percent, averaging about 57 percent across all
states.

Placements, but These Placements Are More Costly

Of the more than $3 billion in title IV-E funding claimed in 1998, 10
percent was used to finance foster care placements for children in the
juvenile justice system. Nearly half of the states indicated they had used
title IV-E funds to finance juvenile justice placements in 1998, with three
states accounting for about 80 percent of total title IV-E funds expended
for juvenile justice placements. While title IV-E juvenile justice
placements consumed 10 percent of all title IV-E funds claimed nationwide,
they account for only about 4 percent of all title IV-E foster care
placements. One reason for this disproportion is that compared to child
welfare children, juvenile justice children were more often placed in
facilities that provided a higher level of supervision, which costs more.6

Justice Placements

We estimate that, in fiscal year 1998, about $318 million, or 10 percent, of
total title IV-E funds was used to finance placements for children in the
juvenile justice system.7 Of the 41 respondents to our survey, 23 states
indicated they had used title IV-E funds to finance juvenile justice
placements in fiscal year 1998.8 About 60 percent of the total amount of
title IV-E funding for juvenile justice placements by these states went to
California. New York and Pennsylvania combined accounted for another 24
percent. (See app. II for a state-by-state breakdown of title IV-E funds
used to finance juvenile justice placements and the number of these
placements in fiscal year 1998.)

Amount of Total Title IV-E Expenditures

While the juvenile justice placements reported nationwide consumed 10
percent of total title IV-E expenditures in fiscal year 1998, they accounted
for only about 15,000--or 4 percent--of all children placed in foster care.
Such disproportions occurred, to varying degrees, across the states that
used these funds--including California and Texas, which together accounted
for about 35 percent of all title IV-E funded juvenile justice placements
nationwide. For juvenile justice placements in California--where the
disproportion was most dramatic--24 percent of the fiscal year 1998 title
IV-E funds claimed was used for just 6 percent of all the state's title IV-E
funded placements. In Texas, 12 percent of the year's title IV-E funds was
used for juvenile justice placements, which represented about 8 percent of
the state's placements.

According to California and Texas officials, juvenile justice children
require higher levels of care or supervision than do children in the child
welfare system and, consequently, are placed in homes and child care
institutions in which care is more costly. In California, 69 percent of
juvenile justice placements--compared to 6 percent of child welfare
placements--were in child care institutions, which receive higher payment
rates than do foster homes. In addition, a greater percentage of juvenile
justice children were placed in child care institutions that provide higher
levels of care. (See table 1.) As the level of care (determined primarily by
staff-to-child ratios) increases, the state payment rate and, thus, the
title IV-E allowable amount increases. For example, the title IV-E allowable
amount for child care institutions with care levels 1 and 2 averages $44 per
day per child. At care levels 9 and 10--which may entail as many as four
full-time workers supervising six children (a two-to-three staff-to-child
ratio)--the title IV-E allowable amount averages $122 per child per day. In
fiscal year 1998, 54 percent of juvenile justice children in institutions
received care at levels 9 through 14, compared to 42 percent of child
welfare children. The levels of care in part explain why California's title
IV-E funded juvenile justice placements averaged about $120 a day per
child--five times the per diem cost for the state's child welfare placements
in that year.9

                      Juvenile     Child welfare        Cost per daya
                      justice
                                                     State
                                                               Title IV-E
                   Number Percent  Number  Percent  payment     allowable
                                                     rateb      amountc
 Foster family
 homes            428     13%      47,301 72%      $15       d
 Foster family
 agenciese        565     17       13,012 20       14f       d
 Child care
 institutionsg
 Care levels 1
 and 2            650h    20       1,929h 3        47i       $44j
 Care levels 3
 and 4            12      0        21     0        68i       66j
 Care levels 5
 and 6            78      2        66     0        89i       82j
 Care levels 7
 and 8            318     10       183    0        109i      101j
 Care levels 9
 and 10           788     24       470    1        133i      122j
 Care levels 11
 and 12           383     12       719    1        151i      134j
 Care levels 13
 and 14           60      2        423    1        172i      155j
 Otherk           23      1        1,177  2        d         d
 Total            3,305   100% l   65,301 100% l   m         m

aThe monthly amount divided by 30 days, rounded to the nearest dollar.

bState payment rates include maintenance costs and the administrative costs
associated with maintenance as well as the cost of treatment and other
services. Rates vary by age of child. Amount represents the average of the
base rate for each age range.

cTitle IV-E funds cover only maintenance costs and the administrative costs
associated with maintenance.

dData not available.

eFoster family agencies provide homes or other living arrangements for
children who alternatively would be placed in a child care institution.

fAgencies can receive more--up to $51 per day for a child from 15 to 19
years of age--if they provide additional care and services.

gReferred to in California as group homes.

hThe data California provided to us placed these children in the child care
institution category. State officials, however, noted that for children
receiving levels of care 1 or 2, it could not be determined with certainty
whether the care was provided in child care institutions or through foster
family agencies.

iAmount represents the average of the rates for the two levels of care
indicated.

jIn California, there is a different IV-E allowable rate for each group
home; consequently, the allowable amount shown is the average of the
individual amounts for which the state could seek title IV-E reimbursement
for all placements in the two levels of care.

kOther placements include medical facilities and shelters.

lDue to rounding, total percentages do not add to 100.

mNot applicable.

Source: GAO analysis of statewide data provided by California.

Texas also bases its payment rates on the level of care provided in foster
family homes and child care institutions (see table 2). At care levels 5 and
6, for example, children have 24-hour supervision and staff-to-child ratios
are greater than those at care levels 3 and 4. In Texas, almost 70 percent
of the children in the juvenile justice system were placed in foster family
homes and child care institutions at care level 4, 5, or 6, compared to less
than 20 percent of child welfare placements. The levels of care in part
explain why Texas' cost per juvenile justice placement averaged $30 a day in
fiscal year 1998 while its cost per child welfare placement averaged $18 a
day.

           Juvenile justice  Child welfare           Cost per daya
                                                State
           Number  Percent   Number Percent    payment       Title IV-E
                                                          allowable amountc
                                                rateb
 Foster family homes
 Care
 level 1   0       0%        2,967  45%      $16          $13
 Care
 level 2   1       0         704    11       34           30
 Care
 level 3   3       1         669    10       58           52
 Care
 level 4   34      12        443    7        83           68
 Care
 level 5   0       0         1      0        100          85
 Care
 level 6   0       0         0      0        187          161
 Foster group homes and child care institutions
 Care
 level 1   0       0         112    2        16           13
 Care
 level 2   11      4         106    2        34           30
 Care
 level 3   74      25        417    6        58           52
 Care
 level 4   95      32        457    7        83           68
 Care
 level 5   70      24        261    4        100          85
 Care
 level 6   4       1         89     1        188          161
 Otherd    3       1         392    6        e            e
 Total     295     100% f    6,618  100% f   e            e

aThe daily rate rounded to the nearest dollar.

bState payment rates include maintenance costs and the administrative costs
associated with maintenance as well as the cost of treatment and other
services. Unlike rates in California, rates in Texas do not vary by age of
child.

cTitle IV-E funds cover only maintenance costs and the administrative costs
associated with maintenance.

dOther placements include medical facilities and shelters.

eNot applicable.

fDue to rounding, total percentages do not add to 100.

Source: GAO analysis of statewide data provided by Texas.

Title IV-E Funds and Compliance With Procedural Requirements

To ensure that title IV-E funds are used appropriately and that title IV-E
procedural requirements are met, the 10 states claiming the most fiscal year
1998 title IV-E funding rely on licensing regulations and other
administrative regulations. The states' licensing regulations establish
minimum standards for child care institutions, where many juvenile justice
children in title IV-E funded foster care are placed, to ensure the safety
and well-being of children. To qualify for title IV-E funds, facilities need
to be licensed or approved as child care institutions. Although title IV-E
prohibits the use of funds to finance placements for detention purposes,
some states' licensing regulations allow, under certain circumstances,
restrictive practices that could be associated with detention. States'
licensing regulations also address title IV-E procedural requirements
intended to protect the welfare of children, including requirements to
develop a case plan, conduct periodic administrative reviews, and follow
procedural safeguards. Each of these 10 states uses several monitoring
mechanisms to ensure child care institutions comply with licensing
regulations. California and Texas also have administrative regulations that
establish standard procedures--which mirror title IV-E procedural
requirements--as well as monitoring procedures to ensure these procedures
are followed in individual cases.

Detention and Address Most Title IV-E Procedural Requirements

Each of the 10 states' licensing regulations for child care institutions
establishes minimum standards regarding facility administration and
personnel qualifications, intake procedures and children's personal rights,
services and activities to be provided, and practices to ensure a healthy
and safe physical environment for children. Several provisions in these
regulations specifically address restrictive practices. Others establish
procedures that mirror title IV-E procedural requirements intended to
protect the welfare of children.

Child care institutions are eligible to receive title IV-E funds if they
meet the licensing standards set for these institutions by the state. While
facilities operating primarily for the detention of children determined to
be delinquent are ineligible to receive title IV-E funds, some provisions
governing the practices of licensed child care institutions allow for
certain restrictive practices. For example, although none of the 10 states
allow facilities to isolate or restrain a child as a form of punishment,
some allow facilities to use short-term isolation and physical restraint to
prevent children from posing a risk or threat to themselves, others, or
physical property, and to manage inappropriate behaviors.10 Maryland and
Michigan also allow locks to be used for reasons other than security.
Specifically, licensed child care institutions in Maryland are allowed to
lock doors as part of "secure care programs" for children who are deemed
delinquent, and licensed child care institutions in Michigan are permitted
to lock the doors of "behavior management rooms." Similarly, when we asked
staff in county probation departments in California and Texas about the
restrictive practices in 18 title IV-E funded juvenile justice cases we
reviewed in their states, we learned that in 7 of these cases the facility
served primarily children in the juvenile justice system. While this
information alone does not constitute sufficient evidence to disqualify
these facilities for title IV-E funding, it illustrates how difficult it may
be to distinguish between juvenile justice placements in detention and
nondetention facilities without more knowledge about the facilities in these
cases and the nature of the treatment they provide. This information also
emphasizes the importance of adequate oversight of the use of title IV-E
funds for juvenile justice placements.

Licensing standards for child care institutions in the 10 states also
contain provisions that address three procedural requirements under title
IV-E: (1) development and updating of case plans; (2) review by a court or
an administrative body of children's status at least every 6 months; and (3)
procedural safeguards for notifying parents about their child's placement,
any changes in the placement, and about reviews and hearings that take
place.11 None of the state licensing regulations we reviewed addressed
permanency hearings. All 10 states' licensing regulations require a case
plan for each child that includes an educational program and provides for
health care. All also require reviews of case plans on a regular basis,
ranging from once a month to once a year. Some states' regulations for case
plans require child care institutions to specify steps and time frames for
tracking progress toward long-range goals. Michigan's licensing regulations,
for example, require that case plan reviews evaluate progress toward family
reunification. All states' licensing regulations also contain procedural
safeguards regarding admission, visitation, and services to families.

All of the 10 states have systems in place to ensure licensed child care
institutions continue to comply with all provisions in licensing
regulations, including those covering restrictive practices and title IV-E
procedural requirements. For example, California and Texas officials told us
that, to enforce their licensing regulations, they conduct annual on-site
visits, which include reviews of case records and files to ensure that the
facility is providing required services, interviews with children and staff,
and a visual inspection of the facility.12 They also stated that they
investigate complaints and have procedures for levying penalties for
noncompliance, including denying renewal of, temporarily suspending, or
revoking a license.

Address Procedural Requirements in Title IV-E Funded Cases

When we looked more closely at how California and Texas ensure that title
IV-E procedural requirements are met, we found that in addition to their
licensing regulations, their child welfare agencies also have administrative
regulations that address title IV-E procedural requirements and contain
processes for enforcing these requirements. In California, the Department of
Social Services (DSS) is responsible for enforcing compliance with these
procedural requirements; in Texas, the Department of Protective and
Regulatory Services (PRS) has this responsibility.

DSS regulations require children in foster care in California to be visited
at least monthly; the child welfare agency in each county is responsible for
conducting these visits with children in its jurisdiction. For title IV-E
funded juvenile justice cases, the juvenile probation department in each
California county, through formal agreements with the county child welfare
agency, is required to conduct monthly visits with children in these cases,
monitor the services they receive, and ensure that title IV-E procedural
requirements are met. According to DSS officials, California has recognized
that juvenile justice agencies and the courts play key roles in ensuring
that title IV-E funded juvenile justice cases are managed in accordance with
the law. As a result, California is developing special training for
probation officers on procedural requirements that accompany title IV-E
funding. To address concerns related to the courts' role in ensuring that
procedural requirements are met in title IV-E funded juvenile justice cases,
California recently passed legislation placing into state law many of the
federal procedural requirements in the Social Security Act. According to DSS
officials, this legislation will better ensure that the procedural
requirements are met, particularly in title IV-E funded juvenile justice
cases. These officials stated that, as regulatory rather than legislative
requirements, courts that usually handle juvenile justice cases involving
title IV-E funded placements were not legally bound to follow them. As a
result of title IV-E requirements being placed into state law, the courts
must see to it that, in juvenile justice cases, procedural requirements are
met.

In Texas, PRS is responsible for ensuring that procedural requirements are
met in all title IV-E placements and that children receive the services they
require. To ensure that these requirements are met in juvenile justice
placements, PRS contracts with two state-level juvenile justice agencies:
(1) the Juvenile Probation Commission (JPC), which oversees county juvenile
probation agencies in the state, and (2) the Texas Youth Commission (TYC),
which handles juvenile justice cases statewide that require more resources
than local probation departments can provide. According to PRS officials, to
monitor compliance with these contracts, PRS annually reviews the case files
for a sample of title IV-E funded juvenile justice cases from each agency.
PRS officials also stated that the department contracts with a private
agency, Youth for Tomorrow, to monitor licensed child care institutions in
Texas in order to ensure that they are providing the types and level of
services that the children in their care require.

JPC and TYC each have a system in place to comply with the title IV-E
procedural requirements in their contracts with PRS. JPC officials told us
that the agency, through contracts with county probation departments,
requires probation department staff to review cases on a quarterly basis and
to contact on a monthly basis every child in title IV-E funded placements,
the parent or guardian, and the caregiver in each placement. Officials also
noted that JPC staff audit the caseload of title IV-E funded juvenile
justice placements twice per year. Similarly, TYC officials told us that the
agency contracts with placement service providers and requires them to
follow the agency's policies regarding procedural requirements, which mirror
title IV-E requirements. To monitor these contracts, TYC officials told us
that they regularly review each provider's service delivery processes and
periodically review provider performance in each case, relative to the needs
of the youth in the placement. TYC officials also noted that, for each case,
the agency reviews the case record and case plan every month for the
duration of a placement and conducts a 6-month administrative review and a
permanency hearing.

on Juvenile Justice Placements

According to HHS, some states have claimed title IV-E funds for children
placed in facilities not eligible for title IV-E reimbursement. HHS has
recognized that states might encounter difficulty in determining whether a
specific facility would qualify to receive title IV-E funding for the
placement of juvenile justice children. HHS has also found that states face
unique challenges in meeting title IV-E procedural requirements within a
juvenile justice framework. HHS is in the process of developing additional
guidance on what constitutes detention and on meeting procedural
requirements in juvenile justice placements. It began this initiative by
issuing in December 1998 a request for public comment on these issues.13 A
total of 17 states and 5 facilities responded along with several advocacy
and professional groups. The comments provided examples of the issues states
face in determining facility eligibility and meeting procedural requirements
in juvenile justice placements. Our review of the comments shows that states
differ on how they believe detention should be defined, and some have
explicitly asked HHS to clarify the definition. To address these facility
eligibility issues, HHS is continuing to review these comments and is
considering its options for creating more comprehensive guidance related to
title IV-E eligibility of facilities in juvenile justice placements. HHS
also addressed comments related to satisfying procedural requirements in
title IV-E juvenile justice cases in its new regulations for title IV-E
eligibility and CFS reviews.

HHS carries out its title IV-E oversight responsibilities primarily through
its title IV-E eligibility and CFS reviews. HHS recently revised the
regulations for these two reviews, in part, to respond to federal
legislation requiring the department to modify its approach to monitoring
state compliance with federal child welfare requirements, including title
IV-E eligibility and procedural requirements. The new regulations, which
went into effect on March 27, 2000, specify a new objective, scope, and
methodology for these reviews. Through statewide and on-site assessments,
CFS reviews are intended to ensure that individual states "substantially
conform" to their foster care requirements and other program requirements
under title IV-E, as well as title IV-B, of the Social Security Act.14 Title
IV-E eligibility reviews focus on verifying eligibility for title IV-E
funding by reviewing records for a random sample of title IV-E funded
placements in each state. The purpose of these reviews is to validate the
accuracy of a state's claims to ensure that payments are appropriate--that
is, they are made on behalf of eligible children, to eligible homes and
institutions, and at allowable rates. CFS reviews, as designed, focus
primarily on results or outcomes and, according to HHS, do not cover
eligibility requirements for children or facilities. They examine, state by
state, (1) indicators of safety, permanency, and child and family well-being
and (2) systems affecting a state's capacity to deliver services leading to
these outcomes. To obtain information for these assessments, HHS relies on
statewide data on outcome indicators, interviews with state and local
community representatives, and reviews of case records.

As part of its title IV-E eligibility reviews, HHS intends to randomly
sample in each state 80 cases from a sample of 88 cases in the primary
review from all title IV-E funded placements in the state; during the
on-site component of its CFS reviews, HHS intends to review a sample of 30
to 50 cases selected from a sample of 150 individual cases drawn from all
cases of children served by the state in foster care and in their own
homes.15 The remaining cases would be reviewed only in the event of a
discrepancy between the on-site findings and the statewide assessment. While
HHS looks at a sample of individual cases as part of each of its reviews,
the sample sizes are small, so relatively few juvenile justice cases will be
selected for review. Moreover, protocols for its title IV-E eligibility and
CFS reviews have not been finalized, and at this point it is not clear what
specific information related to eligibility and procedural issues in
juvenile justice cases will be collected.

Juvenile justice placements constitute a small proportion of all title IV-E
placements. However, states have on occasion claimed reimbursement for
juvenile justice placements at facilities that were not eligible for such
reimbursement and, in many of the title IV-E funded cases we reviewed, the
facility served primarily children in the juvenile justice system.
Furthermore, according to HHS, states find it particularly difficult in
juvenile justice cases to meet title IV-E procedural requirements intended
to protect the welfare of children. In light of these findings, we believe
it is important for HHS to exercise adequate oversight of title IV-E funded
juvenile justice placements to determine the extent to which title IV-E
funding is appropriately used and procedural requirements are met in these
cases. To do this, HHS needs sufficient information about

ï¿½ facility eligibility and compliance with procedural requirements in
individual title IV-E funded juvenile justice cases and

ï¿½ the state and county systems used to determine if the facilities in title
IV-E funded juvenile justice cases are eligible for title IV-E funding, as
well as systems used to ensure that procedural requirements are met in these
cases.

Although states have primary responsibility for making title IV-E facility
eligibility decisions and meeting procedural requirements in juvenile
justice placements, we believe that as the ultimate steward of title IV-E
funds, HHS has responsibility to exercise close oversight of the use of
those funds. Collection of such information will allow HHS to identify the
nature and magnitude of any problems that may exist in these cases.

We recommend that the Secretary of HHS direct the Assistant Secretary,
Administration for Children and Families, to review title IV-E funded
juvenile justice placements in child care institutions in states that have
such placements in order to collect information needed to determine whether
or not the facility in which the child was placed was a detention facility.

We also recommend that, in each state having title IV-E funded juvenile
justice placements in child care institutions, HHS review a sufficient
number of such placements to provide a reasonable degree of assurance that
detention facilities are not receiving title IV-E funds and that procedural
requirements intended to protect the welfare of children are being met in
juvenile justice placements. Depending on the results of the initial review
in a given state, HHS could decide whether it would be necessary to review
the same number of juvenile justice cases in that state in the future.

Finally, we recommend that for those states having title IV-E funded
juvenile justice cases, HHS ensure that the adequacy and effectiveness of
state and county systems used to (1) determine if the facilities in which
juvenile justice children are placed are licensed and otherwise eligible for
title IV-E funding and (2) ensure that procedural requirements are met in
title IV-E funded juvenile justice cases are examined.

We gave HHS an opportunity to review a draft of this report; its written
comments are reproduced in app. V. While HHS agreed that more information is
needed to understand and address issues related to placing juvenile justice
children under foster care, it did not agree with our suggestions on how to
obtain such information. HHS said that the disproportion we found--10
percent of title IV-E funds spent on juvenile justice placements that
constitute 4 percent of all title IV-E funded foster care placements--was
insufficient to justify revising its review systems for the foster care
program. We did not, however, base our recommendations on the disproportion
HHS cites. Rather, they were based on concern for the welfare of the
children involved, given that title IV-E funds have been claimed for
juvenile justice placements in ineligible facilities and that meeting
procedural requirements intended to protect the welfare of children can be
difficult in juvenile justice cases. Although the magnitude of federal
expenditures involved is certainly an important consideration, we believe
that ensuring the appropriateness of placements for and the welfare of
15,000 juvenile justice children is important as well. While there have been
inappropriate placements in the past, and difficulties have been encountered
in meeting procedural requirements, the extent to which these situations
exist now is unknown and needs to be determined.

HHS' comments to our draft report also indicated to us that the department
believed that our proposal to modify its title IV-E eligibility and CFS
reviews to sample enough juvenile justice cases to provide reasonable
assurance that the extent of problems with these cases was measured would
involve more work than necessary. HHS said that it had two mechanisms--the
partial CFS review and the partial review for state plan requirements
outside the scope of a CFS review--that could be used as an issue-specific,
targeted approach to identify and respond to problems with juvenile justice
placements. The intent of our proposed recommendation was to have HHS
determine the extent of problems with juvenile justice foster care
placements and to correct problems that may exist. HHS believes it can
adequately accomplish these objectives through alternative means, which we
found satisfactory. Therefore, we modified the language of our
recommendations to allow for the use of alternative means to accomplish
their intended effect.

California and Texas also commented on a draft of the report; HHS also
provided technical comments. These comments were incorporated where
appropriate.

We will send copies of this report to the Honorable Donna E. Shalala,
Secretary of HHS, and program officials in California and Texas. We will
also send copies to child welfare program directors in all other states and
make copies available to others on request.

If you have any questions concerning this report, please contact me at (202)
512-7215 or Clarita Mrena at (415) 904-2245. Susan Riggio, Cornelius
Williams, May Lee, Patrick DiBattista, and Traci Gleason Wright also made
important contributions to this report.

Cynthia M. Fagnoni
Director, Education, Workforce, and
Income Security Issues

Scope and Methodology

To determine the number of title IV-E funded juvenile justice and child
welfare placements nationwide, the amount of title IV-E funds used by each
state for juvenile justice and child welfare placements, and the ages of
children in title IV-E funded juvenile justice placements, we conducted a
survey of all 50 states and the District of Columbia. We asked each state to
provide this information statewide for their fiscal year 1998. We conducted
follow-up calls to encourage states to complete the survey and to clarify
responses when necessary.

In response to our survey, 23 states indicated that they had claimed title
IV-E funding for juvenile justice placements during fiscal year 1998; 16 17
states and the District of Columbia indicated they had not. The remaining 10
states did not respond to our survey.

While all of the 23 states that indicated they had financed juvenile justice
placements with title IV-E funding could provide the total amount claimed
that year, only 17 could provide the amount claimed for juvenile justice
placements alone. To determine what proportion of all title IV-E funding
nationwide during fiscal year 1998 was used for juvenile justice placements,
we used estimates of the amount each of the other five states claimed for
these placements.17 We estimated this amount in these states by multiplying
the total title IV-E funding each state indicated they claimed by 14.5
percent. We used this percentage because, across the 17 states that could
provide the amount claimed for juvenile justice placements, 14.5 percent of
the total title IV-E funding claimed was for juvenile justice placements.
For example, in Alabama we estimated that $991,543 in title IV-E funding, or
14.5 percent of the total $6,833,512 claimed, was for juvenile justice
placements.

Similarly, only 18 of the 23 states that indicated they had claimed title
IV-E funding for juvenile justice placements could provide the number of
juvenile justice placements for which these funds were claimed. To determine
what proportion of all title IV-E funded placements nationwide were juvenile
justice placements, we used estimates of the number of juvenile justice
placements in two of the four states that could not provide this number.18
We multiplied the total number of title IV-E funded placements in each state
by 6.4 percent because 6.4 percent of all title IV-E funded placements
across the 18 states that could provide this number were juvenile justice
placements. For example, in Alabama we estimated that 79 title IV-E funded
placements, or 6.4 percent of the total 1,235 placements for which the state
claimed title IV-E funding, were juvenile justice placements.

To determine what systems are in place in states to ensure title IV-E funds
are not used for placements in detention facilities and that procedural
requirements are met in title IV-E funded cases, we conducted in-depth
fieldwork in California and Texas. We visited state-level agencies in both
states and met with officials from county agencies in Los Angeles and San
Bernardino counties in California and Dallas and Harris counties in Texas.
As part of this fieldwork, we reviewed the case files of a total of 18
children in title IV-E funded juvenile justice placements. These reviews
examined case planning, administrative reviews, permanency planning, and
efforts to reunify the children in these cases with their parents. We also
obtained information on selected features of most of the facilities in these
cases from probation officers and title IV-E program staff in county
probation departments in Texas and county probation officers in
California.19 We did not independently determine in these cases if the
facilities in which children were placed were eligible for title IV-E
funding, if procedural requirements were met, or if children received the
services they required. We also obtained state administrative data relevant
to IV-E funded placements in 1998. These data included breakdowns of the
title IV-E funded juvenile justice and child welfare populations in these
states by level of care received, type of foster care placement or placement
setting, and the state payment rate and the title IV-E allowable amount paid
for such care. Finally, we conducted extensive interviews with officials in
the state and county agencies responsible for administering title IV-E
funding.

To determine how provisions in state licensing regulations for child care
institutions reflect eligibility criteria for title IV-E funding and address
title IV-E procedural requirements, we reviewed licensing regulations in the
10 states claiming the most federal foster care funding during 1998. In
addition to California and Texas, we reviewed licensing regulations in
Maryland, Ohio, North Carolina, Missouri, Illinois, New York, Michigan, and
Pennsylvania.

To identify the processes HHS has in place to ensure that title IV-E funds
are only used for placements that qualify for this funding and that title
IV-E procedural requirements are met in juvenile justice cases, we reviewed
pertinent laws, regulations, and other documents and interviewed program
officials from the department. We conducted our work between December 1998
and May 2000 in accordance with generally accepted government auditing
standards. We did not independently verify the data states provided to us.

Fiscal Year 1998 Title IV-E Funding Claimed and Number of Placements, by
State

                                                   Number of placements for
                    Amount of title IV-E funding   which title IV-E funding
                              claimed
                                                         was claimed
                                    For juvenile
      State           Total           justice        Total      Juvenile
                                    placements                  justice
 Alabama          $6,833,512      $991,543a        1,235     79b
 Alaska           8,630,748       917,789          489       52
 Arizona          39,781,393      0                4,224     0
 Arkansas         20,167,765      0                c         0
 Californiad      779,431,192     188,900,670      70,696    4,317
 Colorado         27,760,609      3,419,368        4,432     416
 Connecticutc     --              --               --        --
 Delaware         6,476,120       140,078          405       5
 Washington, D.C. 31,141,626      0                2,350     0
 Florida          111,048,387     0                10,130    0
 Georgia          26,265,132      0                7,410     0
 Hawaii           10,294,557      0                1,920     0
 Idaho            3,830,200       0                497       0
 Illinois         470,708,348     0                43,061    0
 Indiana          28,454,479      4,128,745a       5,346     341b
 Iowac            --              --               --        --
 Kansas           12,061,336      0                1,725     0
 Kentucky         34,061,773      915,654          5,071     66
 Louisiana        52,170,448      5,337,890        3,561     481
 Maine            44,315,875      0                3,109     0
 Maryland         74,320,191      1,361,650        1,941     327
 Massachusettsc   --              --               --        --
 Michigan         185,380,873     0                9,080     0
 Minnesota        27,657,424      4,013,093a       c         c
 Mississippi      10,443,760      0                1,009     0
 Missouri         61,145,850      0                10,507    0
 Montanac         --              --               --        --
 Nebraskac        --              --               --        --
 Nevadac          --              --               --        --
 New Hampshire    9,604,538       960,454          1,002     225
 New Jersey       43,100,000      0                c         0
 New Mexico       3,699,023       0                1,100     0
 New York         380,423,754     36,000,000e      58,655    2,456
 North Carolina   35,825,085      0                7,726     0
 North Dakota     8,618,741       1,356,542        1,121     83
 Ohio             295,000,000     1,338,872        28,000    344
 Oklahomac        --              --               --        --
 Oregonc          --              --               --        --
 Pennsylvania     269,864,495     39,157,339a      31,223    3,910
 Rhode Island     15,837,832      160,416          2,115     41
 South Carolina   17,424,000      0                2,160     0
 South Dakota     2,851,781       40,642           564       2
 Tennessee        28,856,741      12,737,366e      5,874     673
 Texas            79,944,180      9,901,770        11,545    889
 Utah             16,075,312      584,096          2,019     276
 Vermontf         --              --               --        --
 Virginia         36,199,110      5,252,491a       c         c
 Washington       20,974,310      0                4,882     0
 West Virginiac   --              --               --        --
 Wisconsinc       --              --               --        --
 Wyoming          224,372         29,075           303       19
 Total            $3,336,904,872  $317,645,543     346,487   15,002

aState used title IV-E funds for juvenile justice placements but could not
provide statewide data on the amount claimed for juvenile justice
placements. Entry is our estimate of the amount based on the percentage of
title IV-E funds other states, in general, claimed for juvenile justice
placements.

bState used title IV-E funds for juvenile justice placements but could not
provide data on the number of these placements statewide. Entry is our
estimate of the number based on the percentage of all title IV-E funded
placements in other states, in general, for juvenile justice placements.

cState did not respond to our survey or could not provide the data we
requested.

d It should be noted that, in 1999, California no longer authorized
placements in (that is, decertified) three out-of-state facilities that
received title IV-E funds during 1998. The state has not determined whether
these decertifications should be retroactive to 1998, which would require
these facilities to return title IV-E funds they received for placements in
that year.

e State provided an approximate amount.

fState indicated that it claimed title IV-E funding for juvenile justice
placements but did not provide the data we requested.

Provisions of State Licensing Regulations for Child Care Institutions
Related to Physical Restriction of Residents

    Discipline         Isolation            Locks            Restraints
 California
 Any form of
 discipline that
 violates a
 child's personal
 rights is
 prohibited.
 Acceptable forms
 of discipline                        Resident children  (See discipline
 include exclusion                    cannot be locked   column.) Physical
 in an unlocked                       in any room,       restraining
 living, sleeping,                    building, or       devices may be
 or play area;                        facility premises  used for the
 institution of                       by day or night.   protection of a
 fines under                          Facility is        child with special
 certain           (See discipline    permitted to use   health care needs
 conditions;       column.)           any other means    during treatment
 prohibition                          for securing       and diagnostic
 against                              exterior doors and procedures such
 attendance at or                     windows or for     as, but not
 participation in                     protection of      limited to,
 planned                              residents provided intravenous
 activities; and                      residents are able therapy or
 prohibition                          to exit the        catheterization
 against use of                       facility.          procedures.
 entertainment
 devices, such as
 telephones,
 televisions,
 radios, and
 phonographs.
 Illinois
 Discipline may
 only be used to
 help children     Confinement is                        Physical restraint
 develop           limited to                            may be used only
 self-control and  children who pose                     as a therapeutic
 learn to assume   a threat of                           measure when a
 responsibility    physical harm to                      child presents a
 for their         themselves or                         threat of physical
 actions.          others. A child                       harm or dangerous
 Acceptable        may not be kept in                    behavior
 discipline        confinement more                      reasonably
 includes          than 30 minutes    Key locks may not  expected to lead
 assigning special beyond the point   be used on locked  to physical harm
 or additional     at which the child confinement room   to self or others.
 tasks and/or      ceases presenting  doors. Automatic   Physical
 removing          the specific       mechanisms are to  restraints are not
 privileges for    behavior for which release the child  to be used until
 periods not to    the confinement    from confinement   after other less
 exceed 1 month,   was ordered or any in the event of a  restrictive
 restriction to    other behavior for fire or other      procedures or
 the child's       which confinement  disaster.          measures have been
 sleeping quarters is an appropriate                     explored and found
 or room for       intervention.                         to be
 periods not to    Confinement may be                    inappropriate. No
 exceed 3 hours    used to prevent                       child is to be
 per day, or       runaway only when                     subjected to
 restriction to    the child presents                    mechanical
 the premises or   a threat of                           restraints unless
 specified areas   physical harm to                      prescribed by a
 of the premises   self or others.                       licensed
 for periods not                                         physician.
 to exceed 3 days.
 Maryland
 Prohibited
 disciplinary
 measures include  A child may not be                    Restraints can
 assigning         kept in a locked                      only be used when
 physically        room away from the Facility with      (1) failure to do
 strenuous         general population "secure care       so would result in
 exercise or work  unless it is       program" may       harm to self or
 and the           clearly necessary  employ locked      others or would
 withholding of    to prevent         doors or other     result in property
 meals, sleep,     imminent physical  means to care for  damage, (2)
 mail, family      harm to the child  alleged or         ordered by a
 visits, or        or other           adjudicated        physician or court
 program           individuals or to  delinquent         of competent
 participation     prevent imminent   children.          jurisdiction, and
 other than        and substantial                       (3) permitted by
 recreation or     destruction of                        state law.
 leisure           property.
 activities.
 Michigan
 A child care
 facility may                         The door to the
 receive approval                     behavior
 to use a                             management room
 "behavior                            may be equipped
 management" room                     with a
 for a child who                      security-locking
 is out of control                    device that
 and is in danger  (See discipline    operates by means  (See discipline
 of harming self   column.)           of a key or is     column.)
 or others. The                       electrically
 rooms are to be                      operated and has a
 used only for the                    key override and
 time needed to                       emergency
 change the                           electrical backup
 behavior                             in case of a power
 compelling its                       failure.
 use.
 Missouri
                   Locked isolation
                   for the purpose of
                   discipline is not
                   to be used. A
 Facilities are to facility with a
 have written      residential
 policies and      treatment program                     Restraints are to
 procedures        may use locked                        be used only to
 prohibiting       isolation when a                      end disturbances
 discipline that   child presents a   (See isolation     that threaten
 may adversely     danger to self or  column.)           physical injury to
 affect a child's  others or poses a                     the child or
 health or         threat of serious                     others or do
 physical or       property damage                       serious property
 psychological     and in the                            damage.
 well-being.       shortest intervals
                   possible until the
                   child regains
                   reasonable
                   self-control.
 New York
                                                         Restraints are to
                                                         be used without
                                                         purposely
 Discipline is to                                        inflicting pain or
 be prescribed,                                          harm and only when
 administered, and                                       other forms of
 supervised only                                         intervention are
 by adults.        Room isolation as  No child is to be  either
 Deprivation of    a method of        confined to a      inappropriate or
 meals, snacks,    discipline is      locked room for    have been tried
 mail, or visits   prohibited.        any reason.        and proven
 by family as                                            unsuccessful.
 methods of                                              Restraint,
 discipline are                                          including room
 prohibited.                                             isolation, will
                                                         never be used for
                                                         punishment or for
                                                         the convenience of
                                                         staff.
 North Carolina
 Isolation or
 locked custody is
 to not be used as
 punishment.
 Appropriate work                     No locks are to be
 tasks or denials                     installed on exits
 of privileges are                    and on room doors
 acceptable        (See discipline    that would prevent (Not specifically
 methods of        column.)           occupants from     addressed in state
 discipline.                          getting out by the regulations.)
 Corporal                             simple operation
 punishment or                        of a single knob
 denials of meals                     or lever.
 are not to be
 used as
 punishment.
 Ohio
                                      All locks on doors
 Facilities must                      to any room or
 have disciplinary Isolation can be   storage area in    Isolation,
 policy and        used exclusively   which a child      physical,
 procedures to     for the behavior   could be confined  chemical, or
 prohibit all      management of a    are to be of the   mechanical
 cruel, unusual    child who is out   type that permit   restraint may not
 practices and     of control.        the door to be     be used as a means
 punishments.                         unlocked from      of punishment.
                                      either side of the
                                      door.
 Pennsylvania
                                                         Use of mechanical
                                                         restraint is
                                                         prohibited. No
 A licensed        Placing a child in                    child is to be
 facility may not  a locked                              restrained for
 use a method of   room--including                       purposes of
 physical          rooms with any     Locks may be used  punishment or for
 restraint,        type of door       as a means of      the convenience of
 isolation,        locking device,    external security  others. Restraint
 security, or      such as a key      to keep persons    may be used only
 physical barriers lock, spring lock, out or deny access in cases of
 that would        bolt lock, foot    to an area but not emergency where
 prevent a child   pressure lock, or  to exit.           there is the
 from leaving the  physically holding                    occurrence or
 facility.         the door shut--is                     serious threat of
                   prohibited.
                                                         violence to self,
                                                         others, or
                                                         property.
 Texas
 Any discipline or
 control must fit
 the needs of each
 child. Children
 must not be
 punished by
 shaking or
 striking; denied
 food, mail, or
 family visits as
 punishment; or
 subjected to
 cruel, harsh,
 unusual, or
 unnecessary
 punishment.
 Physical
 punishment (that  A child must not
 is, spanking) is  be placed alone in
 permitted only in a locked room.
 basic care        Children must not
 facilities, not   be placed in a
 in facilities     dark room.
 serving mentally  Children in a
 retarded or       behavior therapy                      Physical holding
 emotionally       program and                           for restraint or
 disturbed         required to be                        mechanical
 children. If the  placed in a locked                    restraints must be
 facility has a    time-out must not                     used only when
 behavior therapy  be placed in a                        necessary to
 program, it must  locked time-out                       protect the child
 have clearly      room for more than                    from injury to
 written policies  15-minute                             self or others. If
 and procedures    intervals.                            physical restraint
 for the program   Children in a                         is to be used
 and be approved   locked time-out    (See isolation     other than in an
 by the state's    room must be       column.)           emergency, it can
 Department of     watched or                            be used only upon
 Protective and    visually monitored                    the orders of a
 Regulatory        on a continuous                       licensed
 Service. If a     basis by the                          physician. An
 facility's policy foster parent or                      order for physical
 permits physical  child care worker.                    restraint must
 punishment, a     If a child in an                      designate the type
 complete          individual                            of restraint, the
 description of    behavior                              circumstances, and
 any physical      management program                    the duration of
 punishment        is restricted to                      its use.
 administered must the facility for
 be recorded. The  more than 24
 punishment must   hours, the
 be administered   restriction must
 by a staff member be recorded in the
 and witnessed by  child's record.
 another staff
 member. If a
 child is
 restricted to the
 facility for more
 than 24 hours,
 the restriction
 must be recorded
 in the child's
 record. Denial of
 "edible treats"
 may be used as
 part of an
 individual
 behavior
 management
 program.

Source: State child care licensing regulations in each state cited.

Provisions in State Licensing Regulations That Relate to Procedural
Requirements in Title
IV-E Funded Foster Care Cases

   Case/service plan     Case reviews/program     Procedural safeguards
                           progress reports
 California
 -- Plan development:
 Needs and services
 plans are to include
 (1) reason for
 placement; (2)
 education and training
 history; (3) ability to
 care for and groom
 oneself and to manage
 money; (4) on- and
 off-site visitation
 privileges with family                        -- Resident visitation:
 members and friends;                          Needs and services plans are
 and (5) other specific                        to identify the child's
 services, including                           needs regarding visitation,
 those required by the                         including the frequency of
 child's parent or                             and any other limitations on
 guardian.                                     visits to the family
                        Licensees must have    residence and other visits
 -- Services to family: procedures for         inside and outside the
 Licensees must have a  reviewing and          facility.
 policy regarding       evaluating needs and
 participation of the   services plans, which  -- Services to family:
 child and authorized   are to be updated at   Licensees must have a policy
 representative in the  least every 6 months   regarding participation of
 development of the     to determine (1) the   the child and authorized
 needs and services     child's need for       representative in the
 plan.                  continuing services    development of the needs and
                        and (2) the facility's services plan.
 -- Education: Licenseesrecommendation
 are to ensure each     regarding the          -- Admission/intake
 child's attendance at  feasibility of the     procedures and practices:
 an educational program child's return home,   Licensees are to develop,
 in accordance with     placement in another   maintain, and implement
 state law.             facility, or move to   intake procedures that will
                        independent living.    specify (1) needs and
 -- Health services:                           services plan requirements
 Licensees are to obtain                       and (2) signature of child
 and maintain in each                          and authorized
 child's record medical                        representative that they (a)
 and dental insurance                          were offered the opportunity
 coverage information                          to participate in plan
 and consent forms                             development and (b) approved
 completed by the                              the plan.
 child's authorized
 representative.
 Licensees are not to
 accept any child with
 special health care
 needs unless the
 licensee has obtained
 an individualized
 health care plan for
 the child.
 Illinois
 -- Plan development:
 Plans for services for
 each child and family
 must be in writing,
 reviewed at least every
 6 months, and signed by
 all the parties
 involved. Plans are to
 describe the services
 to be provided and how
 these services (1) will
 meet the needs of the
 child and family and
 (2) are directed toward
 resolution of the need
 for placement. Plans
 also must establish a                         -- Resident visitation:
 time frame for                                Children are not to be
 termination of services                       deprived, as discipline, of
 and care in the                               visits or weekly telephone
 facility.                                     contacts with family,
                                               attorneys or legal
 -- Education: Each                            assistants, assigned
 child is to have the                          caseworkers, or other
 opportunity and be                            persons who have established
 encouraged to complete                        a parenting bond with the
 high school or                                child. Children are to be
 vocational training in                        allowed to visit families
 accordance with                               other than their own and
 aptitude. Those                               friends in the community
 excluded from school or                       when the living conditions
 unable to benefit from                        of the family to be visited
 usual school attendanceLicensees are to       are known and the visits are
 are to be provided     assess with the        approved by the child care
 education, training, orreferring agency,      facility. The facility is to
 work experience        child, and/or family   ensure that visits with the
 consistent with their  the child's need for   child, on or off the
 needs and abilities.   placement, the purpose facility's premises, are in
 Each child is to be    for referral to the    the child's best interests.
 permitted and          specific institution,
 encouraged to          and the institution's  -- Services to family:
 participate in         ability to serve the   Families are involved in
 extracurricular        child. Each child's    developing and improving
 activities. The group  plan for services must service plans for the child
 home must ensure that  be reviewed at least   and family.
 each child has         every 6 months and
 available necessary    signed by all parties  -- Admission/intake
 school supplies,       involved.              procedures and practices:
 materials, and                                Children are to be admitted
 equipment and must                            only upon written consent or
 maintain contact with                         application of parent or
 and seek cooperation of                       guardian; upon court order;
 those serving the                             or, in emergency situations,
 educational needs of                          upon authorization of an
 its children.                                 officer of the law or a
                                               department child protective
 -- Health services:                           services worker. No person
 Each child is to be                           who has attained age 18 is
 examined by a physician                       to be admitted unless
 within 30 days before                         referred by a parent or a
 placement and screened                        guardian, including an
 for communicable                              agency having legal
 diseases within 72                            responsibility for the
 hours. If an emergency,                       person under Illinois
 the physical                                  statute.
 examination is to be
 scheduled within 5 days
 after placement and
 completed within 15
 days after placement.
 Children must also be
 examined annually, or
 more frequently if
 findings and medical
 opinion indicate need,
 and given a dental
 examination at least
 annually with diagnosed
 dental defects treated
 promptly.
 Maryland
 -- Plan development:
 Licensees are to have
 and follow written
 policies regarding
 individual service
 planning. Service plans
 are to be developed
 within 30 days after
 admission and are to
 identify the child's
 needs with respect to
 (1) counseling and drug
 and alcohol abuse, (2)
 education, (3) family
 relationships, (4)
 health care, (5) life
 skills development, (6)
 recreation, (7) social
 work, (8) program
 goals, and (9) the time
 planned to achieve                            -- Resident visitation:
 goals.                                        Licensees are to have and
                                               follow a written policy
 -- Services to family:                        regarding
 Licensees are to invite                       communications--which
 to participate in the                         include visitations,
 admission process and                         telephone contacts,
 in the development of                         correspondences, and
 the individual service                        reports--between the child
 plan and the discharge                        and others. When consistent
 plan the (1)                                  with the child's service
 representative                                plan, family members are to
 designated by the                             be encouraged to participate
 placing agency and (2)                        in the program.
 child's parent if
 consistent with the                           -- Services to family:
 child's permanency                            Licensees are to give the
 plan.                                         child's parent and, as
                                               appropriate, the child a
 -- Education: Licensees                       written description of the
 are to (1) ensure that                        program that includes (1)
 each child who is of                          the program mission and
 mandatory school                              admission and discharge
 attendance age and who Licensees are to       policies, (2) daily
 has not earned a       review and update      routines, (3) treatment
 secondary school       individual service     strategies and disciplinary
 diploma or a           plans at least every   practices, (4) visiting
 certificate of         90 days.               hours and other procedures
 completion, and each                          related to communications
 child who is eligible                         with the child, and (5)
 for special education                         procedures for registering
 services attends school                       grievances regarding the
 or is provided with                           child's care.
 appropriate education
 services; (2) work                            -- Admission/intake
 cooperatively with the                        procedures and practices:
 local school system to                        Licensees are to have and
 ensure that the                               follow written policies
 children attend the                           regarding admission,
 local school whenever                         individual service planning,
 possible; and (3) when                        and discharge, and invite to
 applicable, obtain a                          participate in the admission
 certificate of approval                       process and in developing
 for educational                               the individual service plan
 programs in nonpublic                         and the discharge plan the
 schools and child care                        representative designated by
 and treatment                                 the placing agency and the
 facilities.                                   child's parent if consistent
                                               with the child's permanency
 -- Health services:                           plan.
 Licensees are to (1)
 have and follow a
 written plan for the
 provision of
 preventive, routine,
 and emergency medical,
 dental, and mental
 health care for
 children; (2) obtain
 written authorization
 from a parent or other
 authorized individual
 for nonemergency
 medical, dental, or
 mental health care; (3)
 authorize emergency
 medical, dental, or
 mental health care if a
 parent cannot be
 reached.
 Michigan
 -- Plan development:
 Service plans are to be
 developed within 30
 days of admission and
 with resident, parents,
 and the referral
 source. Plans are to
 include (1) an
 assessment of the
 resident's and family's
 strengths and
 weaknesses in the areas
 of education,
 economics, psychology,
 society, and health as
 they relate to the
 resident's needs; (2)
 parent and child                              -- Resident visitation:
 visitation plans; (3)                         Facilities are to make
 treatment goals to                            provisions for visits
 remedy problems of the                        between each resident and
 resident and family and                       the resident's parents,
 time frames for        Services plans are to  except where parental rights
 achieving the goals;   be updated and         have been terminated or the
 (4) indicators of goal recorded by the social resident's record contains
 achievement; (5)       services worker for    documentation that
 persons responsible foreach child at least    visitation is detrimental to
 coordinating and       once every 3 months    the resident.
 implementing the       following the initial
 resident and family    plan. Updated service  -- Services to family:
 treatment goals; (6)   plans are to be        Facilities are to have a
 staff techniques for   developed with the     program statement that
 achieving the          resident, the          specifically addresses the
 resident's treatment   resident's parents,    services that will be
 goals; and (7) the     and the referral       provided to residents and
 projected length of    source, unless         parents directly by the
 stay and next          documented as          institution and the services
 placement.             inappropriate. Updated provided by outside
                        service plans are to   resources.
 -- Education: Licenseesinclude (1) progress
 are not to admit a     made toward achieving  -- Admission/intake
 child for care unless  the goals established  procedures and practices:
 an appropriate         in the previous plan;  Service plans developed for
 educational program can(2) any changes in the each child within 30 days of
 be provided in         plan, including new    admission include (1) an
 accordance with Act No.problems and new goals assessment of the child's
 451 of the Public Acts to remedy the          immediate and specific
 of 1976, as amended    problems; and (3)      needs, (2) the specific
 (sect.380.1 et seq of the  indicators of goals    services to be provided by
 Michigan Compiled Laws,and time frames for    the institution and other
 known as the School    achievement.           resources to meet the
 Code of 1976) not later                       child's needs, and (3) a
 than 5 school days                            description of the child's
 after admission and                           placement circumstances and
 continuously thereafter                       general physical and
 for each resident of                          emotional state at the time
 school age.                                   of admission.

 -- Health services:
 Licensees are to
 establish and follow
 written health service
 policies and procedures
 for (1) routine and
 emergency medical and
 dental care, (2) health
 screening procedures,
 (3) maintenance of
 health records, and (4)
 storage and dispensing
 of medications and
 personnel authorized to
 dispense medications.
 Missouri
 -- Plan development:
 From the time a child
 is admitted, a
 preliminary written
 service plan must be
 developed and
 documented in the
 child's record within                         -- Resident visitation:
 15 days for each child                        agencies are to develop
 admitted by plan for                          written visitation policies.
 placement or within 72                        An agency is to encourage
 hours for emergency                           and support contacts between
 placement admissions.                         a child and the family while
 The service plan must                         the child is in care, unless
 identify and include                          the rights of the parent to
 (1) the child's                               contact the child have been
 individual needs in                           terminated or restricted by
 addition to basic needsThe service plan       court order.
 for food, shelter,     review with the date
 clothing, routine care,and signature of the   -- Services to family: The
 and supervision; (2)   treatment team         admission assessment must be
 specific strategies andcoordinator and a      in writing and include
 their frequency to meetsigned and dated       specific information on (1)
 the child's needs,     attendance sheet of    the circumstances that led
 including instructions all other participants to the child's referral; (2)
 to staff; (3) specific in the review must be  the immediate and long-range
 strategies and         documented in the      goals of placement; and (3)
 frequencies for family child's record.        the parent's or legal
 involvement, including Reports of the         guardian's expectations for
 a defined plan for     evaluations in         placement, family
 visitation and engagingsummarized form are to involvement, and duration of
 the family in services be included in the     the child's stay in care.
 for the child; (4)     child's record and
 specific strategies to shared with the        -- Admission/intake
 meet the recreational  parent, guardian, or   procedures and practices:
 and developmental needslegal custodian. The   Intake policies are to be in
 of the child; (5) the  service plan review    writing and are to identify
 estimated length of    must include (1) an    services and programs
 stay; and (6) the date evaluation of progress offered. Whenever possible,
 and signature of the   toward meeting the     an agency is to arrange for
 treatment team         child's needs; (2) an  one or more preplacement
 coordinator and a      evaluation of progress visits by the child (except
 signed and dated       toward family          in emergency placements)
 attendance sheet of allreunification; (3) any and, when appropriate,
 other participants.    needs identified since arrange for at least one or
                        the plan was developed more preplacement visits by
 -- Services to family: or last reviewed and   the child's parent,
 The service plan must  strategies to meet the guardian, or legal
 also identify and      needs, including       custodian. When a child is
 include time-limited   instructions to staff; self-referred, efforts are
 goals and preliminary  and (4) an update of   to be made to contact the
 plans for discharge,   the estimated length   child's parent, guardian, or
 including plans for    of stay and discharge  legal custodian within 24
 reintegration into     plans, if changed.     hours. If the parent,
 family and community.                         guardian, or legal custodian
                                               cannot be contacted, the
 -- Education: The                             agencies are to notify the
 facility administrator                        appropriate public agency.
 is responsible for                            All efforts to notify the
 ensuring compliance                           appropriate public agency,
 with Missouri statutes                        parent, guardian, or legal
 pertaining to a child's                       custodian are to be
 education.                                    documented in the child's
                                               case record.
 -- Health services: The
 facility is to have a
 written health care
 program plan that
 addresses preventive
 medical eye, hearing,
 and dental care.
 New York
 -- Plan development: A
 case planner is
 assigned to each child
 and is responsible for
 assessing the need for,
 providing or arranging
 for, and coordinating
 and evaluating the
 provision of services
 to children in foster
 care and services to
 parents of children in
 foster care.

 -- Services to family:
 Casework contacts are
 defined as individual
 or group face-to-face
 contacts between the   During the first month
 case planner and a     of placement, casework
 child's parents or     contacts are to be
 relatives for the      held with the child's
 purpose of guiding     parents or relatives   -- Resident visitation: For
 parents and relatives  as often as is         children with a permanency
 toward a course of     necessary to implement planning goal of returning
 action aimed at        the tasks in the       to parents or relatives,
 resolving problems or  family and children's  contacts between the
 needs of a social,     services plan but, at  caseworker and the child's
 emotional,             a minimum, are to      parents or relatives are to
 developmental, or      occur at least twice,  be scheduled to occur in the
 economic nature that   unless compelling      home of the parents or
 are contributing to thereasons are documented relatives to whom the child
 need for foster care.  why such contacts are  will be discharged as often
                        not possible. After    as is necessary to implement
 -- Education: Licenseesthe first month of     the tasks in the family and
 are to take such steps placement, casework    children's services plan.
 as may be necessary to contacts are to be
 make certain that all  held with the child's  -- Services to family:
 children receive       parents or relatives   Social service officials
 education appropriate  at least once every    must provide care and
 to their needs and in  month if the permanent services as directed by the
 accordance with the    planning goal for the  family court judge to
 requirements of the    child is to return to  encourage and strengthen the
 state's Education Law  the parents or         parental relationship when
 and are to make certainrelatives and          the court finds that such
 that each child        quarterly if the       efforts will not be
 receives appropriate   child's permanent      detrimental to the best
 educational and        planning goal is for   interests of the child.
 vocational guidance.   adult residential care
                        or to prepare for      -- Admission/intake
 -- Health services:    independent living.    procedures and practices
 Each child must have   Casework contacts may  (see case reviews).
 complete medical       include either
 examinations and is to face-to-face contacts
 be provided, when      or telephone
 necessary, with        consultations.
 eyeglasses, hearing
 aids, and prosthetic or
 other adaptive devices.
 Food is to be of good
 quality, properly
 prepared, served at
 regular hours,
 sufficient in quantity,
 and meet nutritional
 standards recommended
 by the National
 Research Council. To
 the extent possible,
 nutritional
 requirements based on a
 child's religious
 beliefs are to be met.
 North Carolina
 -- Plan development: A
 written plan of care
 for each child is to be
 developed at the time
 of admission and
 reviewed at least
 semiannually by                               -- Resident visitation:
 facility staff; parents                       Resident visitation and
 and legal custodians;                         telephone calls are to be
 and the child, where                          planned on an individual
 appropriate. This plan                        basis. Visitation policies
 of care is to include                         are to be developed through
 (1) the expectations                          consultation with and the
 and goals for the child                       approval of the legal
 and (2) the tasks and                         custodian of the child.
 activities of facility
 staff, parents, and                           -- Services to family: Each
 legal custodian to meet                       facility is to provide
 the needs of the child                        services that it stated it
 while in care.                                will provide in children's
                                               written plans of care. In
 -- Services to family:                        reviews of each child's
 Each facility is to                           placement needs, licensees
 provide those services                        are to include the parents,
 to children and their                         relatives, and the agency
 families that it has                          with legal responsibility
 stated it will provide                        for the child.
 in each child's plan of
 care. Licensees are to                        -- Admission/intake
 evaluate each child's                         procedures and practices:
 placement needs on a   Each child's plan of   Admission policies are to be
 regular basis and are  care is to be reviewed clearly defined in writing
 to include in this     at least semiannually  and are to be reviewed
 review the parents,    by facility staff,     annually and changed as
 relatives, and the     parents, legal         needs and conditions in the
 agency with legal      custodian, and, when   community change. A written
 responsibility for the appropriate, the       plan of care for each child
 child.                 child.                 is to be developed at the
                                               time of admission and
 -- Education: Children                        reviewed at least
 are to attend the                             semiannually by the group
 public school to which                        home staff, parents, legal
 they are assigned,                            custodian, and, when
 unless an alternative                         appropriate, the child.
 education plan is                             Written placement
 agreed upon by the                            agreements, signed by
 child, the facility,                          authorized persons, are to
 and the responsible                           include the services to be
 person or placement                           provided by the facility and
 agency.                                       the responsibilities of
                                               parents and legal
 -- Health services:                           custodians, indicating
 Facilities are to have                        responsibility for (1) the
 a planned program of                          child's financial and
 medical care. No child                        medical needs and fees to be
 is to be accepted into                        paid; (2) consent for
 a program without                             emergency medical treatment;
 having had a physical                         and (3) determining length
 examination within 90                         of stay, visitation
 days prior to                                 expectations and
 admission, which is to                        limitations, and the
 include a signed                              schedule of review
 statement by a licensed                       conferences.
 medical provider
 specifying the child's
 current medical
 condition and
 prescribed medications.
 Ohio
 -- Plan development:
 Service plans are to be
 in writing and contain,
 at a minimum, (1) goals
 and objectives; (2) the
 time frame projected
 for meeting placement
 goals and objectives
 and projected placement
 plans upon discharge;
 (3) the educational,
 counseling,
 recreational,
 vocational, and medical                       -- Resident visitation:
 activities or services                        Service plans are to contain
 that will be provided                         specifications for
 by facility; (4) any                          visitations between the
 specialized services                          child and family or friends.
 that will be provided                         Facilities are to develop a
 or arranged; (5)                              handbook for residents and
 frequency of progress  At least every 90 days their families, which
 reports; and (6)       after the initial      contains visiting hours and
 specifications for     review of a child's    communication policies.
 visitation between     service plan, all
 child and family or    individuals involved   -- Services to family: The
 friends.               in the development and facilities' handbooks must
                        implementation of the  also describe the roles and
 -- Services to family: plan are to review and responsibilities of the
 The facility is to (1) make any necessary     family in the care and
 develop and review a   amendments. Such       treatment of the child.
 service plan for each  reviews are to be
 child with authorized  documented in case     -- Admission/intake
 representative, parent,records and are to     procedures and practices:
 or guardian and (2)    include an assessment  Facilities are to have
 keep the parent,       of the current         written individual child
 guardian, or custodian adjustment of the      care agreements for each
 informed of health carechild and a            child with the person or
 provided to the child  determination of       agency holding custody of
 while at the facility. whether the child      the child. Facilities are to
                        should remain in the   document, at the time of
 -- Education: The childfacility.              admission, a physical
 has the right to                              description of each child or
 participate in an                             teenage mother, any
 appropriate educational                       available medical
 program.                                      information, the name and
                                               authority or relationship of
 -- Health services:                           the person placing the
 Within 5 working days                         child, and the reason for
 of admission, the                             placement.
 facility is to secure a
 placement medical
 screening of the child
 conducted by a licensed
 physician, registered
 nurse, licensed
 practical nurse, or
 physician's assistant.
 Health care is to
 include dental and
 optical examinations by
 licensed practitioners.
 Pennsylvania
 -- Plan development:
 Licensees are to
 develop and begin
 implementing an
 individual service plan
 (ISP) for each child
 within 30 days of
 admission. The plan is
 to include (1) service
 goals; (2) time-limited
 objectives to be used
 for evaluating progress
 toward these goals; (3)
 specialized activities
 or services that the
 facility will provide,
 arrange for, or
 coordinate, and methods
 for measuring
 accomplishment; (4) a
 schedule of the child's
 visits by or with a                           -- Resident visitation:
 parent or guardian; (5)                       Licensees are to arrange
 anticipated duration of                       family visitations that are
 stay; and (6) the                             convenient for the family
 persons responsible forLicensees are to       and the facility.
 and their role in      review each child's    Visitations and
 implementing the plan, ISP at least once      communications between a
 and methods of         every 6 months to      child and the child's
 assessing progress.    determine progress in  parents, attorney, clergy,
                        achieving the plan's   or placing agency may not be
 -- Education: Children goals and objectives.  restricted or terminated
 of compulsory school   The first ISP review   without a written court
 age are to be enrolled is to occur no later   order.
 in or have access to a than 6 months from the
 basic education.       date the child was     -- Services to family:
 Children beyond the ageplaced in the facility Licensees are to provide the
 of compulsory school   or, for certain        child's parents or guardian
 age are to have an     children, no later     (1) an opportunity to
 opportunity to access  than 6 months from the participate in the ISP
 career counseling and  initiation date of the development and reviews and
 continuing education.  ISP. Subsequent        to sign the initial or
 Academic and vocationalreviews are to be held revised or modified ISP and
 programs operated on   no later than 6 months (2) a copy of the initial
 facility grounds are tofrom the date of the   and each amended ISP.
 meet applicable        previous review. If
 requirements of the    appropriate, ISPs are  -- Admission/intake
 state's Department of  to be modified or      procedures and practices:
 Education.             revised as a result of Licensees may accept a child
                        these reviews. ISP     for care if it receives in
 -- Health services:    review results are to  writing (1) a description of
 Licensees are to ensurebe recorded in the     the circumstances that make
 each child receives a  child's record.        placement necessary, (2) the
 health screening within                       needs of the child that the
 24 hours of admission.                        facility must address, and
 The screening may be                          (3) the child's legal
 conducted by a licensed                       status.
 physician, nurse
 practitioner,
 registered nurse,
 licensed practical
 nurse, physician's
 assistant, or a
 specially trained
 direct care staff
 person. Licensees are
 to establish written
 policies and procedures
 governing the provision
 of health care,
 including preventive,
 routine, and emergency
 medical and dental
 care; the
 administration of
 medication; and staff
 training.
 Texas
 -- Plan development:
 Licensees are to
 complete an intake
 study for each child
 accepted for placement                        -- Resident visitation:
 (see admission/intake                         Contacts between the child
 procedures and                                and family are to be allowed
 practices) and, within                        unless the rights of the
 30 days of admission,                         parents have been terminated
 develop an initial plan                       by court order or family
 of service after                              contact is not in the
 conferring with the                           child's best interest. If
 child and the child's                         limits are put on
 parents or managing                           communication or visits for
 conservator. The plan                         practical reasons (such as
 of service is to                              expense), such limitations
 specify the objectives                        are to be determined with
 of placement, how the                         the participation of the
 child's needs will be                         child and family. Children
 met, and the estimated                        may not be denied visits
 length of stay.                               with their families as
                                               punishment.
 -- Services to family:
 The parents or guardian                       -- Services to family: A
 cooperate with the                            written plan of service must
 child-placing agency in                       be developed and documented
 developing and carrying                       in the child's record within
 out the plan of servicePlans of service are   30 days of admission for
 for each child.        to be reviewed and     each child in care. The plan
                        updated by conference  must be based on the
 -- Education: Licenseesevery 6 months.        admission assessment. A copy
 are to arrange an      Conferences are to     or summary of the plan must
 education appropriate  include a              be given to the child, when
 for each child. The    representative from    appropriate, and the child's
 facility is to provide the group home who     parents. Staff who work with
 for the social and     meets the same         the child must implement and
 educational needs of   qualifications as the  follow the plan.
 each child; each child person doing the
 is to be permitted to  intake study, the      -- Admission/intake
 attend the public free child's parents, and   procedures and practices:
 schools in the districtthe child. Updated     Facilities may not accept a
 in which the foster    plans are to note      child for care until an
 parents reside free of achieved or changed    intake study has been made
 charge to the foster   objectives. The        and a determination that the
 parents.               child's parents are    placement meets the needs
                        provided copies of     and best interests of the
 -- Health services All updated plan           child and family. In
 children are to be     summaries.             addition to the parents' or
 examined each year by a                       managing conservator's
 licensed physician and                        expectations of placement,
 at least once a year by                       the intake study is to
 a licensed dentist or a                       describe the child's (1)
 dental hygienist                              family circumstances and
 working under the                             relationships that make
 supervision of a                              placement necessary; (2)
 licensed dentist.                             developmental and medical
 Provisions are to be                          history; (3) understanding
 made for emergency                            of placement; (4)
 medical and dental                            personality, behavior, and
 care. All medications                         interests; (5) school
 are to be given by                            history; (6) previous
 foster parents or an                          placements; (7) legal
 adult staff member,                           status; and (8) needs. The
 except when a child is                        study is also to describe
 participating in a                            the immediate and long-range
 medically approved                            goals of the placement and
 self-medication                               the family member or
 program. Prescription                         managing conservator who
 medications are to be                         will be responsible for the
 in the original                               relationship between the
 container, labeled with                       home and the child.
 the child's name, a
 date, instructions, and
 the prescribing
 physician's name.

Source: State child care licensing regulations in each state cited.

Comments From the Department of Health and Human Services

Related GAO Products

Foster Care: States' Early Experiences Implementing the Adoption and Safe
Families Act (GAO/HEHS-00-1 , Dec. 22, 1999).

Federal Reimbursement for Foster Care (GAO/HEHS-95-197R , Aug. 11, 1995).

Residential Care: Some High-Risk Youth Benefit, but More Study Needed
(GAO/HEHS-94-56 , Jan. 28, 1994).

Foster Care: State Agencies Other Than Child Welfare Can Access Title IV-E
Funds (GAO/HRD-93-6 , Feb. 9, 1993).

Child Welfare: Monitoring Out-of-State Placements (GAO/HRD-91-107BR , Sept.
3, 1991).

Youth Camps: Nationwide and State Data on Safety and Health Lacking
(GAO/HRD-89-140 , Sept. 20, 1989).

Foster Care: Use of Funds for Youths Placed in the Rite of Passage Program
(HRD-87-23BR , Dec. 9, 1986).

Review of Certain Aspects of Group Home Care for Children in California
(GAO/HRD-85-62 , July 19, 1985).

(116025)

Table 1: Number of Title IV-E Funded Juvenile Justice and Child Welfare
Placements in California and Cost per Day, by Setting and Level of Care
Received, Fiscal Year 1998 13

Table 2: Number of Title IV-E Funded Juvenile Justice and Child Welfare
Placements in Texas and Cost per Day, by Setting and Level of Care Received,
Fiscal Year 1998 14

  

1. These include private nonprofit or for-profit child care institutions and
public child care institutions housing up to 25 residents.

2. Specifically, the criteria in effect are those in the Aid to Families
with Dependent Children program--precursor to the Temporary Assistance to
Needy Families program--on July 16, 1996.

3. 45 C.F.R.

4. Sections 471(a)(16) of the Social Security Act require states to develop
case plans for title IV-E eligible children. Section 475(1) of the act sets
forth the requirements regarding the content of such plans.

5. According to the American Public Human Services Association, the basic
rate for foster care varies across states because the expenses states factor
into their basic rate vary by state. In addition to the cost of room and
board, clothing, supervision, and child care, for example, a state's rate
can include the costs of school supplies, liability insurance for the child,
reasonable travel to the child's home for visits, personal allowances,
recreational activities, and other general incidentals.

6. It should be noted that, according to HHS, many juvenile justice children
in title IV-E placements are placed in out-of-state facilities, which
increases cost. Because we did not obtain data from states that
distinguished between in- and out-of-state placements, we could not
determine what effect out-of-state placements have on the disproportion of
title IV-E funds expended on child welfare versus juvenile justice children.
According to California officials, 15 percent of their title IV-E funded
juvenile justice placements in November 1998 were in out-of-state
facilities.

7. Not all states could provide both the dollars claimed and the number of
juvenile justice placements made. We estimated these numbers for those
states.

8. Eighteen states could provide the amount claimed for and/or the number of
juvenile justice placements funded under title IV-E. For a few additional
states, we were able to develop estimates.

9. Children in juvenile justice placements in California also tend to be
older than those in the state's child welfare placements, and the IV-E
allowable amount increases as the age of the child increases.

10. See app. III for a description of the specific provisions related to
each of these restrictive practices in the licensing regulations for child
care institutions in each of these 10 states.

11. See app. IV for a description of the specific provisions related to
title IV-E procedural requirements in the licensing regulations for child
care institutions in each of these 10 states.

12. California and Texas also conduct prelicensing inspections.

13. 63 Fed. Reg. 67484-67485 (Dec. 7, 1998).

14. Title IV-B of the Social Security Act authorizes funds to states for a
broad range of child welfare services, including family preservation and
family support services.

15. For CFS reviews, case samples will be drawn from all title IV-E funded
foster care placements and cases that receive services funded under title
IV-B of the Social Security Act.

16. See app. II for state-by-state information on the amount of title IV-E
funding claimed for juvenile justice placements and the number of these
placements.

17. These states include Alabama, Indiana, Minnesota, Pennsylvania, and
Virginia.

18. We estimated this number for Alabama and Indiana. Minnesota and Virginia
could provide neither the number of juvenile justice placements nor the
total number of placements for which title IV-E funding was claimed, so
there was no basis for estimating the number of juvenile justice placements
in these states.

19. Features included whether the facility was located in an isolated or
remote area, whether the facility was locked, facility policies regarding
visitation and telephone calls and pursuit of runaways, and whether the
facility primarily serves youth in the juvenile justice system.
*** End of document. ***