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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF SOUTH CAROLINA
CHARLESTON DIVISION

MICHELLE H., by her next friend Tamara

)

Coppinger, AVA R., by her next friend Tamara )

Coppinger, ZAHARA L., by her next friend

)

Deborah Wilson, SAMMY V., by his next friend )

Aleksandra Chauhan, ANDREW R., by his next )

friend Cheryl Kreider, MARCUS, ANNIE,

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CAMERON, SARA, and ROGER B., by their )

next friend Margaret Wilson, and KYLE S., by his )

next friend Tamara Coppinger,

)

)

individually and on behalf of all other similarly )

situated children.

)

)

Plaintiffs,

)

) C/A No. __2_:_1_5_-c_v_-_1_3_4_-R__M__G______

v.

)

)

NIKKI HALEY, in her official capacity as

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Governor of the State of South Carolina, )

)

SUSAN ALFORD, in her official capacity as

)

Acting State Director of the South Carolina )

Department of Social Services.

)

)

Defendants.

)

)

_________________________________________ )

PLAINTIFFS’ ORIGINAL COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF AS A CLASS ACTION

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TABLE OF CONTENTS
I. INTRODUCTION .............................................................................................................. 1 II. JURISDICTION AND VENUE ......................................................................................... 6 III. PARTIES ............................................................................................................................ 6
A. PLAINTIFFS .......................................................................................................... 6 Named Plaintiffs, Collectively................................................................................ 6 Michelle H. ............................................................................................................. 6 Ava R. ................................................................................................................... 10 Zahara L. ............................................................................................................... 14 Sammy V. ............................................................................................................. 18 Andrew R. ............................................................................................................. 21 Marcus B., Annie B., Cameron B., Sara B., and Roger B. ................................... 24 Kyle S.................................................................................................................... 26
B. DEFENDANTS .................................................................................................... 29 IV. CLASS ACTION ALLEGATIONS ................................................................................. 30 V. FAILURES IN THE SOUTH CAROLINA FOSTER CARE SYSTEM
HAVE BEEN WELL-KNOWN BUT UNADDRESSED FOR ALMOST THREE DECADES .......................................................................................................... 35 VI. SPECIFIC FAILURES IN DEFENDANTS’ OPERATION OF THE SOUTH CAROLINA FOSTER CARE SYSTEM ........................................................... 39 A. DEFENDANTS’ DANGEROUS PLACEMENT PRACTICES
STEMMING FROM AN EXTREME SHORTAGE OF FOSTER HOMES AND OTHER APPROPRIATE PLACEMENTS VIOLATE THE LAW .......................................................................................... 39

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1. Defendants Maintain A Dangerous Shortage Of Safe And Appropriate Foster Homes And Other Living Situations For Children in Foster Care.............................. 39
2. Defendants Unnecessarily Institutionalize Children in Foster Care, Especially Young Children, For Extended Periods Of Time............................................................ 41
3. Defendants Deny Community-Based Placements and Necessary Treatment Services For Children in Foster Care Who Have Emotional, Behavioral, or Mental Health Disabilities ............................................................ 44
4. Defendants Repeatedly Move Children From One Inappropriate Foster Home Or Facility To Another ..................... 47
5. Defendants’ Known Placement Practices Significantly Interfere With Critical Family Ties For Children In Foster Care .......................................................... 49
6. Defendants’ Placement Shortage Causes Children in Foster Care to be Housed Unnecessarily in Juvenile Justice Facilities ............................................................................ 53
B. DEFENDANTS’ EXCESSIVE CASELOADS AND SAFETY MONITORING FAILURES VIOLATE THE LAW ........................................... 54
C. DEFENDANTS VIOLATE THE LAW BY FAILING TO PROVIDE CHILDREN IN FOSTER CARE WITH REQUIRED MEDICAL, DENTAL AND MENTAL HEALTH ASSESSMENTS, SCREENINGS AND TREATMENT ..................................... 60
VII. CAUSES OF ACTION ..................................................................................................... 64
VIII. PRAYER FOR RELIEF ................................................................................................... 71

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I. INTRODUCTION 1. This civil rights class action seeks injunctive relief compelling the Honorable
Nikki Haley, Governor of the State of South Carolina (“Governor Haley”), and Susan Alford, Acting State Director of the South Carolina Department of Social Services (“Director Alford”), in their official capacities (collectively, the “Defendants”), to remedy specific deficiencies in the South Carolina Department of Social Services (“DSS”) in order to safeguard and prevent harm to foster children in DSS custody.
2. Governor Haley and Director Alford directly and indirectly control the actions, inactions, policies, patterns, customs and practices of DSS alleged in this Complaint.
3. This civil rights class action is brought pursuant to 42 U.S.C. § 1983 on behalf of a Class and Subclasses of children who are or will be in the legal custody of DSS in foster care (“Plaintiff Children”).
4. Plaintiff Children seek only systemic declarative and injunctive relief to stop DSS from continuing to violate the federal constitutional and statutory rights of the putative Class and Subclasses.
5. Plaintiffs are children who are removed from their homes due to extreme family circumstances and placed in the legal custody of DSS at the direction and control of DSS. As wards of the State, Plaintiff Children are wholly dependent on the State, and in particular on DSS, for their safety, well-being and required services.
6. As a direct result of longstanding, well-documented failures by DSS, Plaintiff Children have been and continue to be harmed physically, psychologically and emotionally and continue to be placed at ongoing risk of such harms while in DSS custody. DSS is re-victimizing the very children it is charged to protect.
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7. DSS has long operated, and continues to operate, a system in which Plaintiff
Children are the victims, or remain at risk of becoming victims, of three specific unaddressed
deficiencies:
 A drastic shortage of foster homes. DSS fails to maintain an adequate number and kind of foster homes and other appropriate living situations for children. According to the June 2014 DSS Child and Family Services Plan for FFY 20152019 (the “2014 DSS Plan”), DSS “did not regularly put the child in placement settings appropriate for the child – examples include[] group home settings and shelters.” A 2008 report of the Governor’s Task Force on Children in Foster Care and Adoption Services (the “2008 Governor’s Task Force”) found that DSS’s “insufficient number of foster homes” leads to “the inability to match children’s needs to available foster homes.”
 Excessive caseworker caseloads and an unstable foster care workforce that cannot provide basic monitoring of children’s safety. The caseloads of foster care caseworkers and child protective services investigators frequently exceed two times and often three or four times national standards and DSS’s own policy standards. As found by the South Carolina General Assembly Legislative Audit Council in its October 2014 report (the “2014 LAC Report”), DSS child welfare caseloads are “excessive, reducing the amount of attention that can be given to each child” and “reducing the ability of caseworkers to investigate and prevent child abuse and neglect.” These high caseloads (many as high as 50, 60 or even 75 children per worker), combined with persistent high turnover, result in an unstable workforce that does not and cannot provide basic monitoring of children’s safety.
 The failure to provide basic health care services. DSS fails to ensure timely medical, dental and mental health assessments, periodic screens and required treatment for children in DSS custody. The 2014 DSS Plan documents a “lack of medical assessments, medical or dental records on file or collateral contacts made with medical providers to obtain assessments or documentation of appointments, make referrals to address medical issues” as well as a lack of “medications and contacts with service providers.” The 2014 DSS Plan also found that “appropriate referrals… were not made,” including “psychological evaluations” and “mental health screenings.” The 2010 DSS Annual Progress and Services Report (the “2010 DSS Annual Report”) similarly found that many foster children’s medical needs are not monitored and children frequently do not receive needed follow up treatment.
8. As a result of these three deficiencies, the Plaintiff Children are harmed and
subjected to ongoing risks of harm by DSS in specific ways.
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9. As a direct result of the drastic shortage of foster homes, children in foster care, including very young children, are unnecessarily institutionalized. As admitted in the 2014 DSS Plan, DSS “did not regularly” place children in appropriate settings. Similarly, DSS admitted in its own press release in 2010 that it “overrelies on congregate care facilities for our children, when research shows that children have better outcomes when placed in families.” The most recent federal data, comparing state performance in 2012, shows that South Carolina DSS had the single highest rate of institutionalizing young children age 12 and under in the United States. Absent rare circumstances when children require highly specialized restrictive settings, DSS’s use of facilities and institutions, particularly for younger children, is grossly inappropriate and harmful, unnecessarily wastes taxpayer dollars, and leads to damaging effects on children’s developmental, social and emotional functioning.
10. Also as a direct result of the lack of foster homes, children with emotional, behavioral or psychological disabilities who require intensive foster care services are denied placements and services that meet their treatment needs while in DSS custody. According to DSS data, over the past five years, DSS has identified thousands of children in foster care who have disabilities, particularly children with intensive emotional, behavioral or psychological needs who require therapeutic community-based, home-like placements and mental health services, but for whom no such placements and services were available. As a result, these disabled children are often either denied treatment or unnecessarily segregated from the general population and housed in grossly inappropriate institutions and group facilities in order to access mental health treatment.
11. In another harmful direct result of the foster home shortage, children in foster care are frequently moved unnecessarily among multiple homes and facilities, when professional
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standards and DSS’s own policy recognize that multiple moves inflict severe emotional and psychological harm to children and damage their ability to form trusting relationships with adults. According to 2013 DSS data, over 600 children had three different placements just in their first year of custody, and for 2012, over 900 children experienced six or more placements during their current stay in DSS custody. The 2014 DSS Plan admits that the “stability of placements” for children in foster care “seemed to be affected by capacity, matching of children with families and identifying causes of acting out and intervening before a disruption was imminent.”
12. The shortage of homes even causes some children in foster care to be unnecessarily housed in juvenile justice detention facilities. When children in DSS custody are placed in detention or other juvenile justice facilities, DSS has a pattern or practice of recommending that they remain there, without a pending charge or awaiting a hearing or determination on their charge or beyond the term of their plea or adjudicated sentence specifically because DSS has nowhere else to house them. This practice is unnecessarily punitive and extremely harmful to children’s physical, emotional and psychological well-being.
13. As a direct result of the excessive caseworker caseloads and failure to monitor child safety, foster children frequently suffer maltreatment while in DSS custody. In its 2010 review of DSS, the U.S. Department of Health and Human Services (HHS), Administration for Children and Families (ACF) raised concerns about “inaccurate data” reporting with respect to foster children maltreated in DSS custody. This problem continues today and the DSS data regarding the rate of abuse and neglect is unreliable and masks a much higher rate of maltreatment actually suffered by Plaintiff Children.
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14. Also in terms of safety, according to the 2014 DSS Plan, DSS has failed to meet its own “Wildly Important Goal” to “[i]mprove child safety by increasing the quality of the decisions that control safety and manage risk,” with safety adequately assessed in only 62% of cases as of December 2013. Specific ongoing DSS failings include the failure to conduct any investigation at all when dangerous conditions or possible maltreatment in homes or facilities arise, and, when investigations are conducted, the failure to follow mandated investigation requirements.
15. As a direct result of the lack of basic health care, children in foster care are denied necessary assessments and treatment and suffer physical, emotional and psychological deterioration while in DSS custody.
16. As a direct result of both the overburdened workforce and the shortage of placements for foster children, children in foster care are often denied opportunities to maintain critical family relationships. The 2014 DSS Plan admits that the agency “was often unable to place siblings together in the foster system” and was failing “to identify and address barriers that were preventing siblings from being placed together.” For siblings that are separated, DSS often fails to facilitate visits or other contact to preserve those crucial relationships. The 2014 DSS Plan further admits that the “agency did not regularly make concerted efforts to promote, support, and/or maintain positive relationships between children and their parents.”
17. Defendants have failed to remedy the three overarching deficiencies of workload, placement array and health care and the resulting harms and risks of harm to children that directly flow from those deficiencies. Defendants’ violations of Plaintiff Children’s legal rights continue despite longstanding notice and knowledge of agency-wide dangers.
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18. Plaintiff Children in this action have waited far too long for DSS to meet its federal constitutional and statutory obligations to children in foster care. These children now respectfully seek specific targeted equitable relief from this Court that is addressed to the failures at DSS, as the executive agency responsible for their safety and care. II. JURISDICTION AND VENUE
19. This action is brought pursuant to 42 U.S.C. § 1983 to redress violations of the Constitution and laws of the United States. This Court has jurisdiction pursuant to 28 U.S.C. §§ 1331 and 1343(a)(3).
20. Venue is proper in this District pursuant to 28 U.S.C. § 1391(b) because the Defendants reside in this District and a substantial part of the events or omissions giving rise to the Plaintiffs’ claims occurred in this District.
21. Assignment to the Charleston Division is proper pursuant to District of South Carolina Local Civil Rule 3.01(A)(1) because the Defendants do business in this Division relating to the events or omissions alleged herein. III. PARTIES
A. PLAINTIFFS Named Plaintiffs, Collectively
22. Defendants’ actions and inactions with respect to the Named Plaintiffs are part of a systemic pattern of conduct that has played a role and caused, and continues to cause, irreparable harm. Michelle H.
23. Michelle H. is a 16-year-old girl in the legal custody of DSS in foster care. Michelle is currently placed at a group facility in Summerville (Dorchester County). Michelle’s case is brought by her adult Next Friend, Tamara Coppinger, who lives in Charleston County.
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Ms. Coppinger is sufficiently familiar with the facts of Michelle’s situation and dedicated to Michelle’s best interests to fairly and adequately represent the child’s best interests in this litigation.
24. Michelle first entered DSS custody in Charleston (Charleston County) in November 2007 when she was 8 years old as a result of physical abuse and neglect by her mother. Michelle later disclosed sexual abuse by a family friend while she lived with her mother. Michelle’s parents’ parental rights were terminated in 2009.
25. Michelle entered DSS custody with severe hearing loss in one ear. Throughout her entire time in DSS custody in foster care, Michelle has not received medically necessary services to address her medical condition.
26. DSS first placed Michelle in a foster home in Beaufort (Beaufort County), an hour and a half from her home community. Michelle had been receiving mental health services before DSS removed her; however, after being placed in DSS custody, her services abruptly stopped because DSS placed her far from her home community. After only several weeks in her first foster home, DSS moved Michelle to an in-patient stay at the Medical University of South Carolina. After eleven days at MUSC, Michelle was returned to the same foster home in Beaufort, where she remained for three years.
27. During her three years in the Beaufort foster home, between the ages of 8 and 11, Michelle was repeatedly physically abused by her foster mother, including being beaten with a belt on her arms, legs, back and buttocks. Another foster sibling in the home was also physically aggressive toward Michelle which Michelle’s foster mother knew about and encouraged by saying that Michelle “needed it.”
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28. In 2010, DSS next moved Michelle to a foster home in St. Helena (Beaufort County). After only one week, DSS moved Michelle again, this time to a foster home in Charleston (Charleston County) in February 2010.
29. In the spring of 2010, Michelle was referred for mental health assessment, after which she was referred for counseling. The counseling services stopped in January 2011.
30. On or about February 2011, DSS next moved Michelle to a foster home in Ladson (Berkeley County) where she remained for about one year. During this time, Michelle was again referred for mental health therapy, but services stopped after only a few sessions. In August 2011, Michelle was given yet another clinical assessment, but she received extremely limited mental health services for the rest of 2011.
31. After being charged with a juvenile delinquency offense, from November 2011 – January 2012 Michelle was given a community psychological evaluation through the Department of Juvenile Justice (DJJ). During the evaluation, Michelle disclosed that her foster mother at the Ladson foster home had physically abused her, including choking her once, and that the foster mother threatened to “return” her to DSS if she misbehaved. Desperate and scared, Michelle threatened self-harm during this time.
32. DSS was alerted to Michelle’s abuse in the Ladson foster home, but failed to investigate the allegations and ensure Michelle’s safety. Instead, the abuse was eventually reported to DSS’s Out of Home Abuse and Neglect Unit by the Department of Juvenile Justice’s psychological evaluator. In response, DSS made a single visit in February to the foster home, concluded Michelle was “in no danger” and took no further action in investigating the abuse. The day after that visit the foster parent requested that Michelle be removed from her home. DSS moved Michelle to a foster home in St. Stephens (Berkeley County).
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33. Michelle’s DJJ community psychological evaluation again recommended therapy for Michelle. The evaluation noted that “changes in foster home placements may present additional losses” for Michelle.
34. DSS next moved Michelle to a foster home in Pineville (Berkeley County) in the spring of 2012. After one week DSS moved Michelle to a foster home in Charleston (Charleston County).
35. Despite feeling rejected by all the different placements she had been shuffled between, Michelle began to form a relationship with her foster mother in Charleston. However, after five months, DSS moved Michelle to the Pinelands Group Home in Summerville (Dorchester County) in October 2012. Michelle’s limited mental health services were again discontinued. Michelle was housed for 15 months at Pinelands, a highly restrictive group care facility for about 40 boys and girls ages 11-18.
36. After being discharged from Pinelands in April 2014, Michelle was placed back at the same prior Charleston foster home. In May 2014, a mental health assessment concluded that Michelle needed individual counseling once a week and family counseling twice a month. Before any services began, Michelle was sent to the Coastal Regional Evaluation Center (CEC) in Ridgeville (Dorchester County) in June 2014 after she skipped school, which was considered a violation of her probation. CEC provides court ordered evaluations for male and female adjudicated delinquent juveniles ages 11-17. At CEC, Michelle was given a psychological and psychiatric evaluation and again the assessment concluded that Michelle needed mental health therapy.
37. At a hearing on her probation violation, although Michelle remained in DSS custody, DSS stated that Michelle’s former foster mother no longer was considering adopting her
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and DSS had no available placements for Michelle and therefore recommended her continued placement with DJJ for this reason. Michelle was moved back to Pinelands group home through the Department of Justice for 90 days in July 2014.
38. Although Michelle’s 90 day court ordered time at Pinelands expired in October 2014, Michelle is still languishing at the facility today. At Pinelands, abused and neglected children, along with children serving time on pleas or adjudicated delinquency charges with DJJ, are placed in solitary confinement if they misbehave. They are placed in a bare room where they must stay without any contact with others.
39. While at Pinelands, Michelle is not provided with adequate hygiene products, including soap appropriate for Michelle’s eczema. After being slammed on her back in an earlier incident, Michelle suffers from back pain. She submitted a medical complaint but has yet to be evaluated by a doctor.
40. Since being placed back at Pinelands, Michelle has lost weight and is not receiving adequate mental health treatment services. After 12 placements in 8 years in DSS custody, Michelle desperately wants to live with a foster family. However, Michelle’s social worker – her third since entering DSS custody – has told her there are not enough foster homes and there is no other place for her. Ava R.
41. Ava R. is a 15-year-old girl in the legal custody of DSS in foster care. Ava is currently placed in a therapeutic foster home in Summerville (Dorchester County). Ava’s case is brought by her adult Next Friend, Tamara Coppinger, who lives in Charleston County. Ms. Coppinger is sufficiently familiar with the facts of Ava’s situation and dedicated to Ava’s best interests to fairly and adequately represent the child’s best interests in this litigation.
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42. Ava entered DSS custody in Charleston County in December 2013 when she was 14 years old, due to physical abuse and neglect by her mother. DSS first placed Ava at Jenkins Institute for Children (“Jenkins Facility”) in Charleston County, where she was housed for ten months.
43. Jenkins Facility is a group facility that provides “low management residential group care” for approximately 32 girls age 11 – 21 years old. There is no indication that DSS assessed Ava’s needs and made a determination that her needs could not be addressed in a foster home before placing her in this group facility.
44. Ava has been denied basic medical screens and treatment while in DSS custody. While Ava has been in DSS custody for over a year, she has never seen a dentist.
45. Despite multiple evaluations indicating that Ava required mental health treatment, and despite DSS’s knowledge of her need for mental health treatment, Ava did not receive a single therapy session until ten months after she entered DSS custody. During those ten months Ava suffered repeated maltreatment at the Jenkins Facility.
46. While housed at the Jenkins Facility, Ava was frequently deprived of sufficient food and she and other residents would hoard food supplies when possible. The food that was actually available was often expired or moldy. While Ava was at the Jenkins Facility, at least one resident became ill after eating moldy bread.
47. While housed at the Jenkins Facility, Ava and other girls were deprived of basic feminine hygiene products, and Ava did not always have enough clothes to wear. The physical conditions were unsanitary and in disrepair. There was feces on the floor of the shower for over a month during Ava’s placement. Ava’s room did not have curtains for privacy and had holes in the walls.
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48. While housed at the Jenkins Facility, staff withheld Ava’s depression medication as punishment. When Ava finally got her medication back, staff laughed and told her not to “overdose” on it. Ava reported this incident to both the President of Jenkins and her DSS caseworker. No action was taken.
49. While housed at the Jenkins Facility, staff would frequently curse at residents and threaten “beat down[s]” for misbehavior. Fighting among residents was also a regular occurrence, and often was not interrupted until the police were called. Ava witnessed a brawl break out among several residents at Jenkins Facility, including two pregnant teens, while staff watched and did not intervene. The brawl did not end until another resident called the police.
50. Ava suffered inappropriate touching and sexual advances while housed at the Jenkins Facility. Staff would pat her buttocks to wake her up in the morning and a maintenance worker asked Ava to take nude pictures of herself and provide them to him. Ava reported this to Jenkins staff but no action was taken. The maintenance worker continued to come to the facility.
51. Ava felt so much in danger at the Jenkins Facility that she ran away to her physically abusive mother’s home, but she was found and returned to the Jenkins Facility. This was the only time she saw her mother since DSS removed her and her mother relinquished her parental rights. Still Ava felt that it was her only option and she would rather risk further abuse by her mother than stay at the Jenkins Facility.
52. The Jenkins Facility was frequently short staffed while Ava was housed there, which prevented adequate supervision of residents. Residents often left the facility and when staff went to find them, the other residents would be left alone. Similarly, because there were often so few staff present, there was limited transportation to school, and as a result Ava often missed school. Supervision at night was poor, and consequently, young men in the
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neighborhood would regularly sneak into the facility. One night a young man came in through Ava’s window and tried to inappropriately touch her. She got away from him and she later reported the incident to staff. No action was taken and several young men returned two nights later.
53. Ava attempted to report her maltreatment at Jenkins Facility to her DSS social worker but could often not reach her. When she did report the maltreatment to her DSS caseworker, Ava was told by her caseworker that she had a lot of children on her caseload and so was limited in what she could do to help her.
54. Ava was also a victim of bullying by other residents, including trashing her room and stealing her belongings. At one point, another resident put an abrasive cleaning product in Ava’s makeup. When she applied the makeup to her face, it burned and her face bled. Ava reported the incident to staff, but staff did not intervene and DSS took no action.
55. Feeling rejected by residents and frustrated by the absence of help from staff or DSS, Ava resorted to self-harm. One incident in August 2014 resulted in Ava being hospitalized after she cut her wrists. While hospitalized, Ava continued to report trauma and depressive symptoms that required intensive mental health treatment. The hospital noted in a letter to DSS that Ava – who had been evaluated as needing therapeutic services in February 2014 - had yet to receive any services because “her current placement has not ever provided her transportation for those services” (emphasis in original). Staff at the hospital agreed to release her to DSS on the condition that Ava receive counseling services three days a week. DSS returned her to the Jenkins Facility but she was still denied counseling services for another three months.
56. In September 2014, DSS finally determined that Ava was severely emotionally disturbed and required Level 3 Therapeutic Foster Care and that at Jenkins Facility – one of the
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many “low management” group facilities that DSS contracts with to house children in foster care in DSS custody – “her needs are not being met.” Yet Ava languished at the Jenkins Facility for almost two more months.
57. In late October 2014, Ava was moved to a therapeutic foster home in Moncks Corner (Berkeley County). Ava finally began therapy sessions, however after a few weeks DSS advised that Ava would be moved again, and the foster parents stopped taking her to counseling.
58. DSS moved Ava again, this time to a foster home in Summerville (Dorchester County) in late December, right before Christmas. Meanwhile, since Ava’s DSS caseworker left DSS in November, Ava does not know who her new caseworker is – this will be her third caseworker since entering DSS custody almost a year ago – and has yet to meet her. Zahara L.
59. Zahara L. is a 9-year-old girl in the legal custody of DSS in foster care. Zahara is currently placed in a therapeutic foster home in Florence County. DSS has moved Zahara through 13 placements in her four years in DSS custody. Zahara’s case is brought by her adult Next Friend, Deborah Wilson, who lives in Lee County. Ms. Wilson is sufficiently familiar with the facts of Zahara’s situation and dedicated to Zahara’s best interests to fairly and adequately represent the child’s best interests in this litigation.
60. DSS initially removed Zahara from her biological home in late 2010 when she was five years old. Zahara was involuntarily removed, along with her 3-year-old brother, while living in Lee County after DSS received reports of physical abuse in her family’s home. After entering foster care, Zahara also disclosed that she was a victim of sexual abuse by a relative.
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61. DSS first placed Zahara in a Lee County foster home with her brother for 3-4 weeks, after which DSS placed Zahara’s brother with paternal grandparents and Zahara, after being identified as needing Intensive Foster Care, in a therapeutic foster home.
62. After only a few days, DSS moved Zahara again, at the age of 5, to be one of the youngest children placed at Seacoast Academy, a secure, locked level III institutional facility in Myrtle Beach (Horry County) that houses 25-38 children ranging from age 5–21 years old placed through both DSS and the juvenile justice system.
63. While at Seacoast, devastated at the loss of her family connections, Zahara acted out at school and at the facility. Her therapist informed DSS that Seacoast was not an appropriate placement for Zahara. Only age 5, Zahara could not possibly understand, let alone function within, the Seacoast institutional system of levels of privileges and points. Because Zahara’s parents did not have the means to travel 90 miles to Seacoast and DSS did not provide transportation support, Zahara had only one visit with her family in her six months there.
64. In the spring of 2011, rather than find a less restrictive setting for Zahara, DSS placed her at Three Rivers Behavioral Health facility, in an even more restrictive, high security Psychiatric Residential Treatment Facility designed for older youth in West Columbia (Lexington County). Five year old Zahara was one of the youngest children placed at Three Rivers, which is designed to treat children with severe mental health needs.
65. While at Three Rivers, Zahara was placed on several powerful psychotropic medications. Zahara described her placement at Three Rivers as the “worst time in [her] life.” At age 5 in a grossly inappropriate institutional placement, Zahara threatened to commit suicide. For several months while at Three Rivers, Zahara had no visits with any family members, including
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her brother. Only after Zahara talked about wanting to die were her grandparents and brother able to visit her and she had two visits with her biological parents.
66. After approximately six months in Three Rivers, DSS moved Zahara and placed her with her grandparents in September 2011. While there, Zahara briefly received local mental health services, although her mental health treatment providers had been constantly changing due to her multiple moves.
67. DSS moved Zahara from her grandparents after two months and placed her in a therapeutic foster home in Williamsburg County, her sixth placement. DSS moved her yet again only two days later.
68. DSS then placed Zahara in a therapeutic foster home in Nesmith (Williamsburg County), approximately 80 miles from her biological family. While in this foster placement, DSS changed Zahara’s therapist again, severing another important relationship in her life. Zahara missed several of her therapy sessions because her foster mother complained that the distance was too far to take her. After about 5-6 months in this home, Zahara revealed maltreatment by the foster parents, and disclosed to a DSS worker that her foster mother tried to “get the devil out of [her]” during a religious service. Zahara revealed that she was forced to go up to the church altar against her will for an extremely long period in a ceremony that would remove the devil from the then 6-year-old’s soul.
69. DSS moved Zahara again, in the late spring of 2012, to her eighth placement, this time to the foster home of a disabled elderly minister in Marion (Marion County), over an hour from her biological family. Zahara had no visits or contact with her brother during the three months she was in this home. However, DSS was allowing Zahara and her biological mother to have unsupervised visits, although DSS had changed her permanency goal to termination of
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parental rights and adoption. While visiting with her mother, Zahara was encouraged to talk by phone with a man that claimed to be her father and was led to believe she would be returning to her biological home. Zahara’s primary DSS caseworker was unaware of this and only after the caseworker was informed by Zahara’s guardian ad litem, after 2-3 months of unsupervised visits, DSS required all visits to be supervised going forward.
70. Desperate, Zahara exhibited suicidal behavior while in the Marion foster home, including trying to stab herself and running into oncoming traffic. DSS moved Zahara yet again, this time to a therapeutic foster home in Dillon (Dillon County), ninety miles from her home community. At this placement, Zahara continued to talk about suicide, and despite several reports to the police by the foster parent out of concern for Zahara’s safety, DSS did not intervene or provide more intensive supports.
71. Instead, after approximately 5-6 weeks, DSS moved Zahara back to the Three Rivers institution in Columbia. This time DSS kept her there, now age 7, for almost a year and a half. While at Three Rivers, Zahara’s treating psychiatrist recommended that Zahara be carefully transitioned out of this level of care because her mental health treatment needs did not require sustained extreme institutional segregation. However, DSS failed to implement a transition plan and decided to remove Zahara without consulting Three Rivers’ staff.
72. In August 2014, the day Zahara was to be removed from Three Rivers, the staff at the facility held a meeting with DSS. At the conclusion of the meeting, DSS changed course and agreed that Zahara should not be moved without a transition plan that included Zahara visiting and having family therapy with her new foster mother over at least a two week period. That same day, however, at 5pm, DSS returned to Three Rivers and removed Zahara without any transition or notification of the deviation from their own transition plan. DSS did not take any of Zahara’s
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medication with her when she was abruptly moved and the removal was declared by the Three Rivers staff to be against medical advice.
73. That evening, a DSS psychiatrist wrote Zahara multiple prescriptions for psychotropic medications; however, there is no record that this psychiatrist saw Zahara any time within the prior year, let alone that evening.
74. DSS next placed Zahara in a therapeutic foster home in Florence (Florence County), her eleventh placement. She remained there for two days before she was moved again, back to Three Rivers. After yet another institutional placement at Three Rivers, in October 2014, Zahara was moved again, this time to a therapeutic foster home, where she currently lives.
75. During her four years in DSS custody, Zahara has had at least 6 different DSS caseworkers assigned to her, which has further traumatized her and compounded her profound sense of loss and lack of attachment to stable adults in her life. Sammy V.
76. Sammy V. is a 13-year-old boy in the legal custody of DSS in foster care. Sammy is currently placed at Midlands Evaluation Center in Richland County. Sammy’s case is brought by his adult Next Friend, Aleksandra Chauhan, who lives in Richland County. Ms. Chauhan is sufficiently familiar with the facts of Sammy’s situation and dedicated to Sammy’s best interests to fairly and adequately represent the child’s best interests in this litigation.
77. In September 2014, DSS removed Sammy, then 12, from his mother’s home in Columbia (Richland County) for neglect and placed him with a family friend. The next day Sammy was sent to the Midlands Evaluation Center in Richland County for an evaluation stemming from juvenile justice charges that were pending when Sammy was removed. Midlands
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is a juvenile justice evaluation facility. While Sammy was at the Midlands, his mother was arrested and detained.
78. In October 2014, Sammy was placed in DSS Emergency Protective Custody and immediately placed in the Miracle Hill Boys Shelter, a temporary, emergency shelter housing boys 11-21 and homeless adults in Greenville (Greenville County), over an hour from his home community and his biological family. After two weeks, DSS moved Sammy to Lancaster Children’s Home (Lancaster County), another group facility over an hour away from his biological family. There is no indication that DSS placed him in this facility after a determination that his needs could not be addressed in a foster home.
79. After only seven days, Sammy was removed from the Lancaster facility because it was determined that his “continued placement would [] become an issue for his safety.” Staff at Lancaster Children’s Home observed that Sammy was easily agitated, lacked consistency with making good decisions and required close monitoring and frequent redirection. His “Plan of Care and Recommendations and Outcomes” recommended Sammy have access to community services including family counseling, behavioral modification and mental health assessment and be placed with increased supervision and structure. Despite these recommendations, Sammy has not been provided with any mental health assessment or treatment services.
80. Sammy’s behavior and disruption from the Lancaster facility instead was treated as a probation violation, and Sammy was sent to the Alvin S. Glenn Detention Center (ASG) in Columbia (Richland County), a detention facility housing older juvenile delinquents, where he was confined alone for seven days because of his young age, with no peers or contact with anyone other than his attorney and phone access with his DSS caseworker. In addition, Sammy was not provided with any mental health services while at ASG.
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81. While Sammy should have next been placed in a DSS foster placement, Sammy was moved back to ASG because DSS had no available placement for him.
82. DSS then placed Sammy at New Beginnings of Charleston (Charleston County), a level II/III group home facility almost two hours from his home community and biological family. New Beginnings provides group care intensive services for children ages 10 to 16 in a highly structured setting for both children involved in the juvenile justice system and those who have been abused or neglected. While at New Beginnings, Sammy suffered physical and verbal abuse by staff, including being grabbed by the arms, slammed on the ground or dragged across the floor. Sammy was also a victim of child-on-child maltreatment when he was inappropriately touched by another resident. None of these maltreatment incidents at New Beginnings were investigated by DSS.
83. After less than two weeks at New Beginnings, Sammy was moved back to the jail at ASG. Sammy again was held in effectively solitary confinement, this time for four days, without contact with peers, without mental health treatment or contact with a DSS caseworker.
84. Sammy was then moved back to the Midlands Evaluation Center because, DSS admitted, it had nowhere in foster care to place him despite his being in DSS legal custody. While at Midlands, Sammy was assaulted by a juvenile corrections officer, leaving him with bruising and scratches. Reflecting the grossly inappropriate placements he had experienced, Sammy was still relieved to be back at Midlands because to him “at least the food is better” than the jail at ASG. Sammy remains at Midlands today while he is on a waitlist for an appropriate DSS placement.
85. Although Sammy’s permanency goal is reunification, he has had limited visits with his biological parents since entering DSS custody. Because DSS has not added Sammy’s
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mother’s name to the visitor’s list at Midlands Evaluation Center, she has not been able to visit him since his placement there. Sammy has also had no contact with his siblings, ages 14, 17, 18 and 20, at least two of whom are also currently in DSS custody. Andrew R.
86. Andrew R. is a 16-year-old boy in the legal custody of DSS in foster care. Andrew is currently placed in a therapeutic foster home in Lancaster County. Andrew’s case is brought by his adult Next Friend, Cheryl Kreider, who lives in Aiken County. Ms. Kreider is sufficiently familiar with the facts of Andrew’s situation and dedicated to Andrew’s best interests to fairly and adequately represent the child’s best interests in this litigation.
87. Andrew first entered DSS custody in Aiken County in September 2013 when he was 14 years old. After being neglected by his mother in Jackson (Aiken County), often spending nights sleeping in a public park, Andrew had been living with relatives in Easely (Anderson County). DSS took custody of Andrew and involuntarily placed him in foster care after he ran away from their home and was found on the street by police.
88. DSS first placed Andrew in the Epworth Children’s Home, a group home facility in Richland County, over an hour from both his parents and almost two hours from the relatives with whom he had been living. There is no indication that DSS assessed Andrew’s needs and made a determination that his needs could not be addressed in a regular foster family home before placing him in this group facility. The Epworth Children’s Home housed an average of 76 children between the ages of 4 and 18 at any given time.
89. Staff at Epworth described Andrew as impulsive, restless and constantly agitated, and he struggled with behavior problems. Despite multiple requests by his guardian ad litem that Andrew receive a psychological assessment, during his two month placement at Epworth,
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Andrew did not receive any mental health assessments or therapy despite showing signs of emotional duress. Yet at Epworth, Andrew was prescribed a powerful psychotropic medication for the first time in his life. The medication is commonly prescribed to treat bipolar disorder; yet Andrew had never been (and has never been) diagnosed with bipolar disorder.
90. Andrew was so addicted to cigarettes that he often combed the grounds at the Epworth facility for used cigarette butts. Despite knowing that Andrew had a severe smoking problem, a habit he acquired at age six, other than providing Andrew with a nicotine patch, DSS failed to provide Andrew with any support. Instead, Epworth staff complained to DSS about Andrew’s smoking habit, and in November of 2013 DSS moved Andrew from Epworth and placed him in a foster home in Elgin (Kershaw County), almost two hours from Andrew’s biological home.
91. After three weeks, in December of 2013, DSS moved Andrew yet again, this time identifying Andrew as eligible for Intensive Foster Care and Clinical Services (“Intensive Foster Care”). DSS placed him in another “therapeutic” foster home in Hartsville (Darlington County), two and a half hours from his biological home.
92. After four weeks, in January of 2014, DSS moved Andrew yet again. DSS placed Andrew in a “therapeutic” foster home in Lancaster (Lancaster County), with a single elderly foster parent with serious health needs. He remains there today. As a means to control Andrew’s behavior, DSS advised his current foster parent not to let Andrew out of the house and instructed that he have no contact with his peers.
93. During summer 2014, Andrew revealed to a DSS private contractor that he had been sexually abused at the age of six by the son of his father’s live-in girlfriend. The social
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worker did not report this to Andrew’s caseworker; rather, Andrew’s guardian ad litem notified DSS of the revelation.
94. After a forensic interview, specific therapy was recommended to address the sexual abuse, but Andrew did not feel comfortable with the therapist with whom he had the initial session. Despite the urging of Andrew’s guardian ad litem to assign him a new therapist and schedule more therapeutic sessions, DSS failed to act and only made new therapy appointments for Andrew six months later after the court ordered DSS to provide a comprehensive mental health evaluation.
95. Between October 2013 and January 2014, Andrew had been moved among four placements in three months and had not been enrolled in a new school, thereby missing months of school during a critical time of the year. Feeling rejected by three different homes that failed to meet his needs, Andrew described feeling like “trash” and unwanted.
96. More recently, in September of 2014, after being bullied by other students, Andrew’s attendance declined. When contacted by the school, rather than support the school or Andrew’s foster parent, the DSS Intensive Foster Care caseworker advised that the school should contact the Department of Juvenile Justice. In October of 2014, Andrew was charged with truancy.
97. Andrew has had at least four different DSS caseworkers since entering DSS custody a little over a year ago. The changes in caseworkers have further prevented Andrew from forming a trusting adult relationship.
98. Andrew’s permanency plan remains reunification. However, since entering care there has been a question as to the identity of Andrew’s biological father, which DSS has not resolved. Andrew has only seen his mother once since entering DSS custody.
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Marcus B., Annie B., Cameron B., Sara B., and Roger B. 99. Marcus, Annie, Cameron, Sara and Roger B., ages 10, 8, 5, 3, and 2, respectively,
are siblings currently in the legal custody of DSS in foster care. Marcus B. and Annie B. are currently placed with their maternal grandparents in Virginia. Cameron B. and Sara B. are currently placed with their paternal grandparents in Georgia. Roger B. is currently placed in a foster home in Aiken County. The B. siblings’ case is brought by their adult Next Friend, Margaret Wilson, who lives in Aiken County. Ms. Wilson is sufficiently familiar with the facts of the B. siblings’ situation and dedicated to their best interests to fairly and adequately represent the children’s best interests in this litigation.
100. In September 2014, DSS involuntarily removed these five siblings from their mother’s home in Aiken, South Carolina (Aiken County) due to neglect and the failure to complete a DSS safety plan. At the time DSS removed the children, their mother’s home did not have water and electricity and DSS had concerns about supervision of the children. Immediately upon entry into foster care, due to the shortage of foster care placements, DSS separated all of the siblings from each other and placed them in different placements across the state. For their first week in DSS custody, the children did not have a DSS caseworker assigned to them.
101. DSS initially placed 9-year-old Marcus in a foster home in Salley, South Carolina (Aiken County). However, after only three days in that placement, DSS removed Marcus and placed him in Helping Hands, a group home that houses up to 58 children from infancy to 21 years old in Aiken County. There is no indication that DSS assessed Marcus’s needs and made a determination that his needs could not be addressed in a regular foster home before placing him in this group facility, rather DSS was just trying to find an available bed for him.
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102. In October, three weeks into his placement at the Helping Hands facility, someone put feces on Marcus’s toothbrush and Marcus witnessed an assault by several children in the home. Traumatized, Marcus learned to kick out the window in his room if he was scared and the police would come. In November, in reaction to an incident where another child resident at the facility was trying to take Marcus’s teddy bear, staff at Helping Hands took Marcus’s teddy bear and he later saw it in the trash.
103. DSS failed to provide Marcus B. with his required medical assessment when he entered foster care in September.
104. DSS initially placed 8-year-old Annie in the Bowers-Rodgers Home in Greenwood (Greenwood County), a group facility over an hour from her home community that accepts children from infancy to age 17. As with her brother, there is no indication that DSS assessed Annie’s needs and made a determination that her needs could not be addressed in a regular foster home, before placing her in this group facility.
105. Within only weeks of her placement in the group home, 8-year-old Annie B. was assaulted by her 12-year-old roommate. Staff at Bowers-Rodgers moved the roommate to another room; however, when new foster children were admitted to Bowers-Rodgers, the roommate was moved back into Annie’s room. DSS did not investigate the incident. Additionally, Annie reported to her DSS caseworker that staff at Bowers-Rodgers had kicked her. Staff denied the incident and no further action was taken.
106. In December, while Annie was still at Bowers-Rodgers, a bed became available at the facility in her brother Marcus’s age group. However, DSS failed to move or consider moving Marcus so he or Annie could be placed with one of their siblings.
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107. DSS initially placed Cameron and Sara, 4 and 3 years old respectively, in a foster home in North Augusta (Aiken County), a half hour from their brother Marcus in Aiken and over an hour from their sister Annie in Greenwood. Cameron and Sara did not receive an initial medical assessment when they entered foster care.
108. DSS initially placed the youngest child, 2 year old Roger B., in a foster home in Aiken County, forty minutes to over an hour from his siblings. Upon entry into DSS custody in early September, DSS had notice or knowledge that Roger had a bead or other object lodged on his eardrum. Despite the urgency of the situation, DSS did not take the child to a medical professional until the end of October 2014, a month and a half after Roger was placed in DSS’s care.
109. The B. siblings did not have any initial visit or any contact with each other, or with their mother, for three weeks after DSS placed them in foster care and separated them all from each other. Even that initial visit was cut short because several of the siblings were late arriving due to various distances they had to travel, and their mother missed a visit because she did not have transportation and DSS did not provide any assistance.
110. In late December, DSS placed Marcus B. and Annie B. with their maternal grandparents in Virginia, and DSS is evaluating them to be licensed as foster parents. Also in late December, DSS placed Cameron B. and Sara B. with their paternal grandparents in Georgia, and DSS is evaluating them to be licensed as foster parents. Roger B. remains in a foster home in Aiken County. Kyle S.
111. Kyle S. is a 17-year-old boy in the legal custody of DSS in foster care. Kyle is currently placed in the Pickens County Detention Center. DSS has kept Kyle in DSS custody
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since approximately the age of 3, and since then DSS has moved him through 28 placements. Kyle’s case is brought by his adult Next Friend, Tamara Coppinger, who lives in Charleston County. Ms. Coppinger is sufficiently familiar with the facts of Kyle’s situation and dedicated to Kyle’s best interests to fairly and adequately represent the child’s best interests in this litigation.
112. DSS initially removed Kyle and his brother from a relative’s home in Beaufort (Beaufort County), when he was 3 years old, due to reports of severe physical abuse. Since being in DSS custody, Kyle was only placed once with his older brother and has had inconsistent visitation and contact with him. DSS has terminated Kyle’s parents’ parental rights and changed his permanency goal to adoption.
113. In the course of his 28 placements, DSS has moved Kyle virtually throughout the entire state of South Carolina. Despite moving Kyle through so many different placements, DSS has not evaluated Kyle to assess whether he ever needed a higher level of care or to provide him with any additional mental health support services.
114. Kyle suffered physical abuse or neglect while in DSS custody. In February 2014, Kyle’s foster parent called him the devil and choked and assaulted him in front of the private agency staff that provided the home under contract with DSS. DSS did not investigate this incident.
115. After this incident, DSS admitted that it had no available placement for Kyle and refused to provide a higher level of care for him. As such, DSS recommended that Kyle be detained in a juvenile justice facility. In May 2014, Kyle was moved to a juvenile justice detention facility for 90 days.
116. After Kyle was released from the juvenile justice facility, DSS placed him in the Pinelands group home in Summerville (Dorchester County), a group care facility for
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approximately 50 boys and girls ages 11-18. While Kyle was housed there, Pinelands often did not have enough food and he did not receive adequate mental health services. Kyle was also placed at a group home in Ridgeland (Jasper County) in 2014.
117. In the fall of 2014, DSS placed Kyle at Hampton Psychiatric Residential Treatment Facility, a 55 bed highly restrictive institutional facility in Pickens (Pickens County) for boys ages 5 -21, because a bed was available and DSS had no other available placement for him. This level of placement is reserved for children with the highest level mental health treatment needs. While housed at the Hampton facility, Kyle was initially denied contact with anyone outside the facility.
118. Cut off from the outside world and frustrated at being moved to yet another placement, Kyle acted out and kicked in a door at the facility. As a Psychiatric Residential Treatment Facility, Hampton was required to have on site behavioral and mental health intervention services, but instead DSS reported the incident to police and Kyle was arrested and placed in jail in Pickens County.
119. Although Kyle was able to obtain a personal recognizance bond and remains ready to be released from jail and housed in an appropriate foster care placement, DSS has refused to move him. Because he can only be released to DSS personnel, Kyle has been languishing at the jail for over three weeks solely because DSS has admitted they have no placement for him and that he will likely remain in jail until “mid-January or longer.”
120. After literally growing up in DSS custody, Kyle remains in jail awaiting a foster care placement and at risk of aging out of DSS foster care without any meaningful adult connections in his life, without any support services and without a permanent safe home.
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B. DEFENDANTS 121. Governor Haley is the Governor of the State of South Carolina and is sued solely in her official capacity. Under Article IV, Section 15 of the South Carolina Constitution, the Governor is constitutionally-required to “take care that the laws be faithfully executed” and, therefore, is responsible for ensuring that all South Carolina executive departments and agencies, including DSS, comply with all applicable laws. Governor Haley has controlling authority over DSS, and, as the supreme executive authority, she is ultimately responsible for appointing, and has the power to remove, the Director of DSS. Governor Haley also appoints members of the board of the Division for Review of the Foster Care of Children (the “Foster Care Review Board”), which is part of the Office of the Governor and is statutorily mandated to make recommendations to the Governor “with regard to foster care policies, procedures, and deficiencies of public and private agencies which arrange for foster care of children. . . .” Governor Haley also appoints members of local Foster Care Review Boards located throughout the state. 122. Governor Haley currently maintains her principal office at the State House, 1100 Gervais Street, Columbia, S.C. 29201; but has authority and acts throughout the State of South Carolina. 123. Director Alford is the Acting State Director of DSS and is sued solely in her official capacity. DSS is the executive agency responsible for supervising and administering the public welfare activities and functions of the State, including activities and functions for the Plaintiff Class and Subclasses as defined herein. Director Alford is “vested with the duty and authority to oversee, manage, and control the operation, administration, and organization” of DSS. Director Alford reports directly to Governor Haley. Director Alford currently maintains
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her principal office at 1535 Confederate Avenue Extension, Columbia, S.C. 29202; but has authority and acts throughout the State of South Carolina. IV. CLASS ACTION ALLEGATIONS
124. This action is properly maintained as a class action pursuant to Rules 23(a) and (b)(2) of the Federal Rules of Civil Procedure.
125. The general Class is defined as all children who are or will be involuntarily placed in foster care in the legal custody of DSS as a result of emergency protective custody (EPC) and/or a referral, report, suspicion, allegation and/or adjudication of abuse or neglect. The “Disability Subclass” includes all Class members whom DSS has identified or will identify as eligible for Intensive Foster Care and Clinical Services, which is defined as children “who have emotional/behavioral/psychiatric needs of such intensity that they require a specialized out of home placement” (“Intensive Foster Care”). The “Sibling Subclass” includes all Class members who have or will have sibling(s) in DSS custody. The “Juvenile Justice Subclass” includes all Class members who are “taken” or will be “taken into custody” by the Department of Juvenile Justice pursuant to S.C. Code §63-19-810.
126. The Class and each Subclass are sufficiently numerous to make joinder impracticable. As of June 2014, according to DSS data, an estimated 3,372 children under 18 years old were in the legal custody of DSS in foster care. A similar number of children currently comprise, and will continue to comprise, the Class. In terms of the Disability Subclass, according to DSS data, in fiscal year 2013 there were 1,600 children in DSS custody who were determined by DSS to be in need of Intensive Foster Care. A similar number of children currently comprise, and will continue to comprise, the Disability Subclass. In terms of the Sibling Subclass, according to federal data, two-thirds of children in foster care nationally have
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siblings in care. Upon information and belief, there is approximately the same proportion of children in DSS custody who had one or more siblings while in DSS custody, which equals over 2,200 children based on the total DSS population as of June 2014. A similar number of children currently comprise, and will continue to comprise, the Sibling Subclass. In terms of the Juvenile Justice Subclass, according to DSS data, in January 2012 there were 198 children receiving services from both DSS and the Department of Juvenile Justice. A similar number of children currently comprise, and will continue to comprise, the Juvenile Justice Subclass.
127. The questions of fact and law raised by Named Plaintiffs’ claims are common to and typical of those of each putative member of the Class and the respective Subclasses whom they seek to represent, because each Named Plaintiff and putative Class member is in the legal custody of DSS in foster care and relies on Defendants for his or her safety, health and wellbeing, and has been subjected to significant known harms and/or the imminent risk of known harms as a direct result of the continuous and systematic legal deficiencies of South Carolina’s child welfare system alleged in this Complaint on behalf of the Class and the Subclasses.
128. Defendants have acted or failed to act on grounds generally applicable to all members of the Class and Subclasses, necessitating class-wide declaratory and injunctive relief.
129. Questions of fact common to the Class include: a. Whether Defendants, through their actions and inactions, have a pattern, custom and/or practice of failing to maintain an adequate number and kind of foster homes and other appropriate living situations for children, that results in the unnecessary institutionalization of children in foster care, the repeated movement of children from one placement to another, and the deprivation of meaningful contact with family members of Plaintiff Children. b. Whether Defendants, through their actions and inactions, have a pattern, custom and/or practice of excessive caseworker caseloads and an unstable foster care workforce that cannot provide basic monitoring of children’s safety, that results in maltreatment and the risk of maltreatment while in
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DSS custody, the failure to investigate maltreatment, the failure to follow DSS protocols when maltreatment is investigated, the failure to correct dangerous conditions in homes and facilities, and the deprivation of meaningful contact with family members of Plaintiff Children.
c. Whether Defendants, through their actions and inactions, have a pattern, custom and/or practice of failing to provide initial and periodic medical, dental and mental health assessments, screens and necessary medical, dental and mental health treatment, that results in the harm and risk of harm and children’s physical, emotional and psychological deterioration while in DSS custody.
130. Questions of law common to the Class include:
a. Whether Defendants’ actions, inactions, patterns, customs and/or practices in paragraph 129 (a) – (c) violate Plaintiff Children’s substantive due process rights to personal safety and security and/or their right to be reasonably free from known harms and imminent risks of known harms while in state custody, guaranteed by the Fourteenth Amendment to the United States Constitution; and
b. Whether Defendants’ actions, inactions, patterns, customs and/or practices in paragraph 129 (a) – (c) violate Plaintiff Children’s rights to family association and integrity, guaranteed by the Fourteenth Amendment to the United States Constitution;
c. Whether Defendants’ actions, inactions, patterns, customs and/or practices violate Plaintiff Children’s rights established by the Medicaid Act under the Early and Periodic Screening, Diagnosis and Treatment program (“EPSDT”), 42 U.S.C. §§ 1396a(a)(10)(A), 1396a(43)(B), 1396a(43)(C), 1396d(a), 1396d(r).
131. Additional questions of fact common to the Disability Subclass include:
a. Whether Defendants, through their actions and inactions, have a pattern, custom and/or practice of failing to provide children in the Disability Subclass with intensive emotional, behavioral or psychological needs who require community-based placements and mental health treatment, with medically necessary mental health services; and
b. Whether Defendants, through their actions and inactions, have a pattern, custom and/or practice of failing to place children in the Disability Subclass in the most integrated setting appropriate to their needs in order to access mental health treatment.
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132. Questions of law common to the Disability Subclass include:
a. Whether Defendants’ actions, inactions, patterns, customs and/or practices violate Plaintiff Children’s rights established by Title II of the Americans with Disabilities Act (“ADA”) of 1990, 42 U.S.C. § 12131 et seq.;
b. Whether Defendants’ actions, inactions, patterns, customs and/or practices violate Plaintiff Children’s rights established by the federal Medicaid Act under the Early and Periodic Screening, Diagnosis and Treatment program (“EPSDT”), 42 U.S.C. §§ 1396a(a)(10)(A), 1396a(43)(B), 1396a(43)(C), 1396d(a), 1396d(r).
133. Additional questions of fact common to the Sibling Subclass include:
a. Whether Defendants, through their actions and inactions, have a pattern, custom and/or practice of knowingly failing to place siblings in DSS custody together, and if separated, failing to facilitate visits or other contacts between such siblings; and
b. Whether Defendants, through their actions and inactions, have a pattern, custom and/or practice of depriving the Sibling Subclass of meaningful contact with family members.
134. Questions of law common to the Sibling Subclass include:
a. Whether Defendants’ actions, inactions, patterns, customs and/or practices violate the Sibling Subclass’ rights to family association and integrity, guaranteed by the Fourteenth Amendment to the United States Constitution.
135. Additional questions of fact common to the Juvenile Justice Subclass include:
a. Whether Defendants, through their actions and inactions, have a pattern, custom and/or practice such that when children in DSS custody are placed in detention or another juvenile justice facility, DSS leaves them and/or recommends that they remain there, without a charge or awaiting a hearing or determination on their charge or beyond their pleas or adjudicated sentence, specifically because DSS has nowhere else to house them.
136. Questions of law common to the Juvenile Justice Subclass include:
a. Whether Defendants’ actions, inactions, patterns, customs and/or practices violate the Juvenile Justice Subclass’ substantive due process rights to personal safety and security and/or to be reasonably free from known harms and imminent risks of known harms while in state custody,
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guaranteed by the Fourteenth Amendment to the United States Constitution. 137. Named Plaintiffs will fairly and adequately protect the interests of the Class and Subclasses that they seek to represent. 138. The violations of law and resulting harms averred by Named Plaintiffs are typical of the legal violations and harms and/or imminent risks of harms experienced by all Plaintiff Children in the Class, the Disability Subclass, Sibling Subclass, and Juvenile Justice Subclass, respectively. 139. Each Named Plaintiff appears by a Next Friend pursuant to Federal Rule of Civil Procedure 17(c), and each Next Friend is sufficiently familiar with the facts of the child’s situation and dedicated to the child’s best interests to fairly and adequately represent the child’s best interests in this litigation. 140. Named Plaintiffs and Plaintiff Children in the Class and Subclasses are represented by the undersigned attorneys who are competent and experienced in class action litigation, child welfare litigation and complex civil litigation. These include attorneys employed by the South Carolina Appleseed Legal Justice Center, a non-profit legal organization, who have substantial expertise and experience in state and federal civil rights litigation on behalf of underserved populations in South Carolina; attorney Matthew T. Richardson, a partner at the Wyche P.A. law firm in South Carolina, who has significant experience in complex litigation in state and federal court in South Carolina; and attorneys employed by Children’s Rights, Inc., a non-profit legal advocacy organization, who have substantial experience and expertise in federal child welfare class actions nationally.
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141. Plaintiffs have identified and thoroughly investigated all claims in this action and have committed sufficient resources to represent the Class and Subclasses through trial and any appeals.
142. Plaintiff Children’s counsel knows of no conflict among Class members or among members of the Disability Subclass, the Sibling Subclass, or the Juvenile Justice Subclass. V. FAILURES IN THE SOUTH CAROLINA FOSTER CARE SYSTEM HAVE
BEEN WELL-KNOWN BUT UNADDRESSED FOR ALMOST THREE DECADES 143. For almost 30 years, Defendants have been aware of the numerous systemic failures at DSS and the resultant harms and risks of harm to vulnerable children such as Plaintiff Children, yet have failed to fix these systemic failures or implement reforms to address them. 144. In a 1985 report, “Management and Performance Review of the South Carolina Department of Social Services,” the South Carolina Legislative Audit Council (“LAC”) found that DSS had failed to adopt adequate policies and standards for caseworkers to sufficiently ensure the safety of and provide basic services to foster children. 145. Six years later, in a 1991 report, “A Limited-Scope Review of the Department of Social Services,” the LAC found that DSS failed to take adequate measures to ensure that foster homes were safe for foster children in DSS custody, including the failure to do proper background checks and the failure to train foster parents. 146. In a follow-up 1993 report, the Compliance Review Committee for the Department of Social Services found that DSS failed to sufficiently remedy the deficiencies detailed in the 1991 LAC report and that many foster homes remained inappropriate and unsafe for children.
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147. In 2003, the same problems at DSS remained. In the 2003 Child and Family Service Review (a limited periodic federal review conducted by the Administration for Children and Families (ACF), a division of the U.S. Department of Health and Human Services (HHS)), DSS failed six of the seven safety, permanency and well-being outcomes tracked by the federal review, including safely maintaining children at home when possible and appropriate; providing permanency and stability in children’s living situations; preserving continuity of family relationships and connections; and ensuring that children receive services to meet their physical and mental health needs.
148. According to the 2003 CFSR, foster children were “kept in shelters for extensive periods of time because of a lack of appropriate placement resources,” DSS had not made concerted efforts to address the mental health needs of children, and “DSS is not consistently effective in promoting visitation between children in foster care with their parents or with their siblings in foster care.”
149. Another state-level review was conducted in 2007 when then-Governor Mark Sanford issued an Executive Order establishing the Task Force on Children in Foster Care and Adoption Services (“Governor’s Task Force”), which identified significant agency-wide problems at DSS and submitted recommendations to the Governor in February 2008.
150. DSS failed to implement most of those recommendations. For example, upon finding that DSS maintains an overburdened and inexperienced workforce, the Governor’s Task Force recommended that DSS “[m]aintain a sufficient work force” of child welfare workers who “directly impact child welfare and protection,” in order “to meet the caseload standards established by the Child Welfare League of America.” That same year, rather than implement that recommendation, DSS instituted a hiring freeze resulting in the loss of hundreds of
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additional workers and even more dangerously high caseloads and preventing caseworkers from doing their jobs of ensuring the safety, health and well-being of foster children.
151. As of October 2014, caseloads of child welfare workers continue to be dangerously high. As found in the 2014 LAC Report, the caseloads of foster care caseworkers and child protective services investigators frequently exceed two times and often exceed three or four times national standards and far exceed DSS’s own policy standards.
152. Finding that DSS maintains a grossly insufficient number of foster homes, the 2008 Governor’s Task Force also recommended that DSS “increase the number of foster homes to equal the number of children in foster care.” To date, there is still a severe shortage of foster homes. For example, according to DSS data, in 2013 there were over 3,000 children in foster care, yet there were only 2,565 licensed foster homes.
153. In DSS’s 2009 “South Carolina Statewide Assessment,” published in advance of the 2010 CFSR (“2009 Statewide Assessment”), DSS recognized that it had failed to maintain a sufficient array of family foster homes and admitted that this lack of placements “lead[s] to children being placed in institutional settings,” the state’s inability to keep siblings together, and the high rate of placement moves experienced by foster children.
154. In 2010, in the second round CFSR, South Carolina failed all seven safety, permanency and well-being outcomes measured by the CFSR. The 2010 CFSR again identified the shortage of foster homes as a “key factor” leading to South Carolina’s “low performance.” The 2010 CFSR also determined that in only 58 percent of cases the agency “had made diligent efforts to assess and address the risk of harm” and nearly half of children in foster care were not achieving stability in their placements.
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155. The 2010 CFSR also identified the DSS failure to “clearly define[]” its policy and practice standards for new reports [of abuse or neglect] on open cases, which “results in inaccurate data on maltreatment recurrence and maltreatment in foster care and affects the State’s ability to make effective case decisions based on child and family history with SCDSS.” DSS announced in a press release posted to its website in March 2010 that it was expecting the poor results of the 2010 CFSR and admitted that South Carolina’s child welfare system “is falling short of what [DSS] believe[s] it needs to do.”
156. In late 2013, after news of several child deaths involving children who had contact with DSS, the South Carolina Senate created a DSS Oversight Committee to examine DSS policies and practices, and charged it with investigating questions raised regarding over 300 children harmed while involved with DSS since 2009. The Oversight Committee uncovered that nearly a third of DSS workers were shouldering larger than recommended caseloads.
157. The Legislative Audit Council was also asked by Senate members to investigate DSS policies and practices. The 2014 LAC Report found that DSS child welfare caseloads are “excessive and inequitable from county to county,” “[t]here is not an adequate system for screening, investigation, treatment, and placement of children in safe homes when abuse and neglect are reported,” and “[d]ata regarding child maltreatment deaths … is not reliable and should not be used as a measure of agency performance.”
158. Despite nearly three decades of repeated notice of dangers to children in DSS custody and multiple opportunities to improve the foster care system, Defendants have continued to ignore those dangers and operate DSS in a manner contrary to law and reasonable professional judgment in deliberate indifference to known harms and imminent risk of known harms to Plaintiff Children, so as to shock the conscience.
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VI. SPECIFIC FAILURES IN DEFENDANTS’ OPERATION OF THE SOUTH CAROLINA FOSTER CARE SYSTEM A. DEFENDANTS’ DANGEROUS PLACEMENT PRACTICES STEMMING FROM AN EXTREME SHORTAGE OF FOSTER HOMES AND OTHER APPROPRIATE PLACEMENTS VIOLATE THE LAW 1. Defendants Maintain A Dangerous Shortage Of Safe And Appropriate Foster Homes And Other Living Situations For Children in Foster Care 159. Defendants have a pattern, custom and/or practice of failing to develop and
sustain a sufficient number and array of foster family homes and other safe and appropriate placements for Plaintiff Children.
160. A foster care system must maintain a sufficient number of foster homes to safely accommodate the number of children currently in custody and additional children as they are reasonably anticipated to enter the system on an ongoing basis. Widely accepted professional child welfare practices and federal law and policy require that a sufficient array of placement types be available, so that a child’s placement is the least restrictive, most family-like placement that can meet the child’s needs. Further, children who are in more restrictive placements should be “stepped down” to less restrictive ones when they are safely able to do so.
161. Despite these recognized standards, the consistent shortage of foster family homes and other placements maintained by DSS results in children being placed wherever a bed or slot is available and without being matched with placements that can meet their needs, in gross violation of accepted professional practices, federal law and even DSS policies.
162. In its 2009 Statewide Assessment, DSS recognized that the number of licensed foster homes was not adequate for its foster care population, “limit[ing] the choices of placement” and posing risk of harms of institutionalization and placement instability to Plaintiff Children.
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163. In contrast to the 2008 Governor’s Task Force recommendation that DSS maintain at least the same number of foster homes as the number of children in foster care, in June 2013, the number of licensed regular foster homes per child needing regular foster care placement in South Carolina was 0.8 – a shortage that only continued to grow. In November 2014, the number of licensed foster homes per child was 0.4.
164. Due to DSS’s drastic shortage of foster care placements, especially foster homes, DSS exposes Plaintiff Children to specific harms, including: unnecessarily institutionalizing children in foster care, especially young children, for extended periods of time; denying community-based placements and services that meet the treatment needs of children in foster care with emotional, behavioral or psychological disabilities; repeatedly moving children from one inappropriate home or facility to another; separating children in foster care from their siblings and interfering with those family relationships; placing children on a reunification track at great distances from their biological parents and interfering with those family relationships; and unnecessarily housing children in foster care in juvenile justice detention facilities awaiting a hearing or determination on their charge or beyond their sentence or plea specifically because DSS has nowhere else to house them.
165. According to the 2010 CFSR, DSS’s shortage of adequate foster homes, in part, is a direct result of its failure to take sufficient steps to diligently recruit and retain foster families, including families who reflect the racial and ethnic diversity of the children in DSS custody.
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2. Defendants Unnecessarily Institutionalize Children in Foster Care, Especially Young Children, For Extended Periods Of Time
166. Defendants have a pattern and/or practice of relying on overly restrictive nonfamily group care facilities, and unnecessarily institutionalizing Plaintiff Children – including children aged 12 and under – for extended periods of time.
167. Federal law, DSS policy and accepted professional standards all mandate that foster children be placed in the least restrictive, most family-like setting that is clinically appropriate to meet their needs. For example, according to the South Carolina Child Welfare Services Practice Model, “[p]lacements in non-family settings should be temporary, should focus on individual children’s needs, and should prepare them for return to family and community life.”
168. Defendants grossly fail to meet federal law, accepted professional standards and their own standards. In its 2014 DSS Plan, DSS admits that it does “not regularly put the child in placement settings appropriate for the child – examples included group home settings and shelters.”
169. According to federal data, in 2011 and 2012, more than 20% of all children in DSS custody were placed in group homes and institutions, when many of these children’s needs could have been met in less restrictive placements. In its 2011-2012 Accountability Report, DSS admitted that while the in-custody population has declined since 2007, the “market share” of group home providers has remained the same at 24%.
170. The unnecessary institutionalization of children in foster care by DSS, and the harms caused to Plaintiff Children, are well-known to Defendants. The 2008 Governor’s Task Force report found that the insufficient number of foster homes in South Carolina led to children
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being unnecessarily placed in institutional settings. In a 2010 publication, DSS admitted that it “overrelies on congregate care facilities for our children, when research shows that children have better outcomes when placed in families.” In the 2010 CFSR, the federal government found that the shortage of foster homes in South Carolina leads to DSS’s “overuse of institutional placements, such as emergency shelters and group homes.”
171. According to the Adoption and Foster Care Analysis and Reporting System, DSS also places children in group homes and institutions as their first or second placement at more than double the rate of such placements in the national foster care population.1 Over 32% of children who entered DSS custody during that year and had one placement were placed in a group home or institution as their first placement, compared to just 14% of such children in the national foster care population.
172. Additionally, many of the DSS group homes and institutions house mixed populations of children without adequate safeguards. This dangerous practice places children who have been victims of abuse or neglect at risk of further victimization by children with known histories of violence.
173. The harm to children from the unnecessary use of institutional placement settings is well established. Numerous social science studies, such as the 2002 report by Dr. Richard Barth, “Institutions vs. Foster Homes: The Empirical Base for a Century of Action,” consistently confirm that unnecessary institutionalization has a powerful negative impact on all aspects of children’s development, especially for young children.
1 AFCARS is one of the U.S. Department of Health and Human Services’ child welfare-related data systems. It collects case-level information from states and jurisdictions on all children in foster care. All states and jurisdictions that receive Title IV-E money are required to submit AFCARS data twice a year.
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174. Social science studies, such as the 2005 study entitled “SAFE Homes: Is it worth the cost? An evaluation of a group home permanency planning program for children who first enter out-of-home care,” have repeatedly shown that children placed in group homes, compared to children placed in family foster homes, spend more time in government custody in foster care, have decreased placement with siblings over time, are less likely to be placed in or near their home community, are more likely to be re-abused, and are less likely to have the chance to develop a close relationship with an adult.
175. Another predictable consequence of unnecessary institutionalization is that children who are not placed in family foster homes are far less likely to be adopted because they are deprived of relationships with foster parents. The highest portion of children adopted out of foster care – approximately 60 percent, according to the 2008 report by the Governor’s Task Force – are adopted by their foster parents. According to DSS data, in 2012, approximately 30% of children placed in foster family home settings exited foster care to adoption, while 0% of children placed in group homes or institutions exited to adoption.
176. Defendants’ unnecessary institutionalization of Plaintiff Children is particularly severe and harmful with respect to young children, who, according to social science studies such as Dr. Barth’s 2002 report and a 2002 report by Dr. Brenda Jones Harden, “Congregate Care for Infants and Toddlers: Shedding New Light on an Old Question,” are especially subject to negative effects on their development and social-emotional functioning, delayed language development and poor mental development and adaptive skills.
177. According to 2012 data from the federal Administration for Children and Families – the most recent year for which comparative national data is available -- South Carolina DSS had the single highest rate in the United States for institutionalizing its foster children aged 12
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and younger. According to the same federal data, in 2012 and throughout the past decade, approximately 20% of all children 12 and younger in DSS custody were placed in group homes or institutions, when many of these children could and should have been served in less restrictive placements. DSS has had the highest rate for at least the previous three years; yet, Defendants have failed to address this known problem and the harms and risks of harm it imposes on Plaintiff Children.
178. Defendants’ unnecessary institutionalization of Plaintiff Children also wastes state funds because institutional placements are far more expensive than supporting foster family homes. For example, the rate DSS pays for placement services at Level 3 group homes – which are often used because DSS lacks enough therapeutic foster homes – is double the rate for Level 3 therapeutic foster homes. The cost of psychiatric residential treatment centers is six times the rate for Level 3 therapeutic foster homes.
3. Defendants Deny Community-Based Placements and Necessary Treatment Services For Children in Foster Care Who Have Emotional, Behavioral, or Mental Health Disabilities
179. Defendants have a pattern and/or practice of failing to provide placements and services that can meet the treatment needs of children in the Disability Subclass.
180. Children in DSS custody with intensive emotional, behavioral or psychological needs are disabled within the meaning of Title II of the federal Americans with Disabilities Act (ADA).
181. DSS maintains an inadequate array of therapeutic family foster homes that can provide community based intensive mental health services for children with intensive emotional, behavioral or psychological needs. As a result, disabled children are often denied the treatment
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services to meet their needs, or are unnecessarily segregated and institutionalized in overrestrictive institutions and group facilities in order to receive necessary mental health services.
182. DSS identifies children eligible for Intensive Foster Care, which is the unit within DSS that serves children “who have emotional/behavioral/psychiatric needs of such intensity that they require a specialized out of home placement” and ensures they “are provided appropriate out-of-home therapeutic placement and other services designed to enhance their emotional and social functioning and well-being.”
183. However, according to a 2011 Joint Citizens and Legislative Committee Annual Report, DSS failed to provide sufficient placements to serve the number of children identified as eligible for Intensive Foster Care. Although 2,268 such children were identified, “due to limited resources, Intensive Foster Care could provide intense case management and support services for only 1,401 of these children in therapeutic placements.” In other words, as a direct result of DSS’s placement shortage, DSS failed to provide appropriate placements and supportive mental health treatment services to meet the needs of over 850 disabled children whom DSS deemed to have emotional, behavioral or psychological needs such that “they require a specialized out of home placement.”
184. From 2007 to 2012, instead of increasing the number of therapeutic placements available to foster children who need them, DSS in fact reduced the number of therapeutic placements by over 500, according to DSS data.
185. When assessing a child to determine eligibility for Intensive Foster Care, regional and area DSS offices also determine whether the child is eligible for Interagency System for Care of Emotionally Disturbed Children (“ISCEDC”) or other funding streams. ISCEDC creates a “pooled services fund” to “prescribe an interagency service planning process for addressing the
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needs of emotionally-disturbed children in DSS custody.” ISCEDC funding eligibility is not available for all children assessed as needing Intensive Foster Care placements; however, some DSS reports identify available placements by ISCEDC funding eligibility.
186. According to DSS data, there were 1,759 children in foster care who were ISCEDC eligible in FY 2012, but there were only 1,079 Intensive Foster Care placements, leaving 680 children with disabilities whom DSS failed to provide placements to meet their treatment needs. DSS’s data reveals that, from fiscal year 2007-2008 to 2011-2012, DSS has denied therapeutic placements to over 3,648 ISCEDC eligible children whom DSS itself identified as in need of such placements and mental health services.
187. For severely emotionally disturbed children who are not placed in ISCEDC/IFCCS placements, they often do not get the intensive mental health treatment they require. In the June 2014 DSS Health Care Oversight and Coordination Plan 2015-2019 (“2014 DSS Health Care Plan”), DSS admitted that “[a]t the current time South Carolina has a very limited pool of private practice Child Psychiatrists not contracted to congregate care facilities open to taking new Medicaid patients.”
188. DSS’s failure to place Plaintiff Children eligible for ISCEDC/IFCCS placements in such placements results in only two choices—basic level foster homes or “low management” group facilities, neither of which are structured to provide for their intensive mental health treatment needs. Such placements predictably and frequently disrupt because they are ill equipped to meet children’s needs. This causes children to suffer the severe and known emotional trauma of being shuffled among multiple inappropriate placements.
189. Other children in the Disability Subclass are inappropriately placed in segregated institutional settings in order to at least ostensibly obtain mental health treatment services. DSS’s
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drastic placement shortage results in the failure to provide disabled children in foster care with the integrated community based placements that they require. Children in the Disability Subclass are often institutionalized unnecessarily in psychiatric residential treatment facilities (“PRTF”), South Carolina’s most restrictive type of institutional placement, and in “Level 3” group facilities, which are also highly restrictive, both of which are segregated from nondisabled persons, because these institutions are the only placements DSS has that can provide the services that these disabled children need. As such, DSS fails to place these children in the most integrated setting appropriate to their needs. According to DSS data for state fiscal year 20122013, 19% of children identified as needing therapeutic placements were housed in PRTFs or Level 3 facilities.
190. Notably, DSS’s ability to maintain a small, insufficient array of therapeutic foster families for Intensive Foster Care/ISCEDC eligible children, indicates that this placement option could be expanded to meet the community based needs of children in the Disability Subclass.
4. Defendants Repeatedly Move Children From One Inappropriate Foster Home Or Facility To Another
191. Defendants have a pattern and/or practice of frequently moving Plaintiff Children from one inappropriate home or facility to another, repeatedly disrupting their lives and decreasing stability.
192. Frequent placement moves are widely recognized as harmful to children in foster care. The DSS Foster Care Policy and Procedure Manual specifically states that placement “[c]hanges can be traumatic to children and adults and special efforts should be extended to reduce stress to the extent possible.”
193. DSS admitted in its 2014 DSS Plan that “[t]he stability of placements seemed to be affected by capacity, matching of children with families and identifying underlying causes of
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acting out and intervening before a disruption was imminent.” The 2008 Governor’s Task Force found that DSS’s “insufficient number of foster homes” leads to “the inability to match children’s needs to available foster homes, and an inevitably high number of disrupted placements.”
194. In 2012 alone, 26.5% of all children in DSS custody had four or more placements and 14.3% - 929 children - experienced six or more placement settings during their current stay in foster care.
195. According to the National Data Archive on Child Abuse and Neglect, in 2012 almost half of children in foster care in DSS custody for at least one year but less than two years had three or more placements. Seventy-six percent of children in care for 24 months or longer had three or more placements.
196. Instability in foster care placement is a well-known, longstanding practice that harms children in DSS custody. Over ten years ago, in DSS’s 2003 Statewide Assessment, DSS reported to the U.S. Administration of Children and Families that “as of November 2002, almost 40% of all children in foster care (regardless of their length of stay) had had four or more placements.” In 2009 DSS reported that over one-fifth of foster children in DSS custody had experienced six or more placement settings during their current stay in foster care.
197. In the 2010 CFSR, the federal government reported that DSS’s constant and traumatic movement of abused and neglected children from one placement to another is directly caused by DSS’s lack of sufficient foster homes and its placement of children is “based on the availability of a bed rather than on the skills and training of foster parents.” As a direct result of Defendants’ gross failure to provide placement stability, Plaintiff Children suffer significant
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known harms or imminent risk of harms from frequent placement changes, including attachment disorders and behavioral and mental health problems.
198. According to social science studies, Defendants’ failure to provide Plaintiff Children with placement stability is particularly harmful. Children with a higher number of placement changes are known to experience a decreased likelihood of reunification, greater severity of behavior problems and more time in residential care.
199. The South Carolina Foster Care Review Board recognized the harm caused by frequent placement moves in its 2010 annual report, stating that “[f]or children who have been abused and neglected, the trauma of even one placement into a foster home or group home can have a negative impact on their overall development and jeopardize their ability to become healthy and well-adjusted adults.”
200. Additionally, DSS’s pattern and/or practice of frequently and disruptively moving children from one placement to another harmfully disrupts any consistent mental health treatment Plaintiff Children may be receiving (see also Section VI.C, infra). As noted in the 2014 DSS Health Care Plan, “[providers] express concerns that when Foster Children are moved from one placement to another, it may take a period of time before they see their new [primary care provider], and authorizations to continue treatment may be held up, creating a loss of momentum in the therapy setting to a point of threatening previously-achieved gains.”
5. Defendants’ Known Placement Practices Significantly Interfere With Critical Family Ties For Children In Foster Care
201. Defendants have a pattern and/or practice of unnecessarily and significantly interfering with foster children’s meaningful contact with family members.
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202. Federal law, South Carolina state law and accepted professional standards and DSS policies all require the child welfare agency to make reasonable efforts to preserve families and family relationships whenever possible. The DSS Foster Care Policy and Procedure Manual emphasizes the importance of “maintaining continuity of the child’s relationship with his/her parents and siblings” and making “every effort” to place the siblings with the same foster care provider.
203. The 2014 DSS Plan found that “the agency did not fully utilize resources … to maintain connections, nor was there documentation as to the reasons connections should not/could not be preserved, and whether this was reassessed each year in situations where dynamics may have changed allowing contact.” Further, the “agency did not regularly make concerted efforts to promote, support, and/or maintain positive relationships between children and their parents” and there is a “general lack of understanding of the importance of promoting connections in addition to the monthly visitations” among staff.
204. According to the 2010 CFSR, DSS made concerted efforts to support parent/child relationships in only 30 percent of applicable cases, drastically short of the 90 percent standard set by the federal government.
205. DSS routinely fails to facilitate visitation for Plaintiff Children in DSS custody with their parents, including when the child’s goal is reunification with their parent(s), resulting in the children’s loss of critical family ties and relationships. The 2010 CFSR found that Defendants made concerted efforts to ensure that parent-child visitation was of sufficient frequency and/or quality to meet the needs of the family in only 45 percent of cases, again far from the 90 percent standard set by the federal government.
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206. DSS’s failure to facilitate visitation between children and parents occurs in part because too often caseworkers are not available to supervise visits, due to DSS’s excessive caseworker caseloads and an unstable foster care workforce.
207. Although placing children near their home communities minimizes the trauma children have suffered from removal, helps children maintain ties with siblings and parents, and avoids unnecessary separation from school, family relationships, friends and other local support networks, due to the drastic shortage of foster homes and other appropriate placements for children, DSS frequently places children outside of their home county, often at great distances from their biological parents’ home. Moreover, DSS routinely fails to provide the parents of children in foster care with transportation assistance, further interfering with parent-child relationships and possible reunification, especially when parents frequently lack the means to travel long distances and/or live where there is no access to public transportation.
208. The 2014 DSS Plan admitted that “[p]roximity of placement was often too far from child’s biological family for easy visiting access with the child” which was “often caused by a lack of availability of appropriate foster homes within the child’s home community.” This problem is not new -- according to DSS data, in fiscal year 2011-2012, 33% of children in foster care were placed outside of their home county. DSS’s 2009 Statewide Assessment documents that as of December 31, 2008, approximately one third of children in non-therapeutic foster care placements were placed outside their home county, while DSS’s 2003 Statewide Assessment documented that more than a quarter of children in foster care in calendar year 2002 were placed outside of their home county for at least one placement.
209. Additionally, as admitted in the 2014 DSS Plan, the agency “was often unable to place siblings [in DSS custody] together” and “frequently there was not documented, concerted
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effort to identify and address barriers that were preventing siblings from being placed together.” This pattern and/or practice denies children the opportunity to maintain critical family relationships, causing them severe emotional and psychological harm.
210. It is widely recognized that, for the great majority of children, separating siblings in foster care is harmful to emotional and psychological well-being, increases separation trauma from being brought into foster care in the first place, and can also impede adaptation to new living environments.
211. Social science research has found that separated siblings in foster care are at higher risk for a number of negative outcomes, including placement disruption; running away; and failure to exit the system to reunification, adoption, or guardianship. Girls separated from all of their siblings are at the greatest risk for poor mental health and socialization.
212. Compounding the significant interference with family relationships caused by DSS unnecessarily separating siblings, DSS often fails to ensure that siblings in DSS custody who are separated have frequent visits and other contact with each other. DSS acknowledged this failure in June 2014 and reported that developing visitation plans with siblings “to preserve connections continued to be an Area Needing Improvement.” In 2009, DSS admitted that additional barriers to sibling visitation include DSS’s “lack of coordination” and high caseloads. As a result, siblings who are separated while in DSS custody routinely go months and sometimes years without any contact, causing significant emotional harm and profound damage to this family relationship.
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6. Defendants’ Placement Shortage Causes Children in Foster Care to be Housed Unnecessarily in Juvenile Justice Facilities
213. Defendants’ placement shortage is so severe that they have developed a pattern and/or practice of leaving children or recommending that children in the Juvenile Justice Subclass be left in detention and other Juvenile Justice facilities, without a pending charge, awaiting a hearing or determination on their charge or beyond the term of a plea or adjudicated sentence. This is specifically because DSS does not have any available appropriate placements in foster care for the child.
214. When children in foster care in DSS custody are subject to a charge or plea or adjudicated sentence for a juvenile delinquency offense, DSS maintains legal custody of Plaintiff Children while they are in the physical custody of the Department of Juvenile Justice.
215. Once these children have completed their term with the Department of Juvenile Justice, they must be returned to the physical custody of DSS. However, as a direct result of DSS’s drastic shortage in the number and type of foster care placements for children in DSS custody, DSS has a pattern and/or practice of failing to immediately take physical custody of a child exiting the juvenile justice system, and recommending that the child be left in a juvenile detention or other juvenile justice facility when that child could and should be served in a foster care facility if one were available.
216. As described in Section III, in the case of three of the Named Plaintiffs – Michelle H., Sammy V. and Kyle S. – DSS openly admitted that they did not have an available appropriate placement even though these children completed a DJJ term, and DSS thus refused to immediately provide them with a placement in foster care despite there being no pending
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charge, unfinished plea or adjudicated sentence. As a result, these children were left in punitive juvenile justice detention placements solely because of DSS’s severe placement shortage.
217. This pattern and/or practice flagrantly violates DSS’s own policy that requires DSS to place children in the least restrictive appropriate placement that matches a child’s needs with the skills and training of foster parents or other caregivers that can meet those needs.
218. Leaving children in restrictive detention facilities solely because there is no available foster care placement is also extremely harmful to children’s physical, emotional and psychological well-being, is unnecessarily punitive and inflicts further emotional harm on children who have already suffered abuse and neglect in their homes and have fully served a sentence pursuant to a plea or adjudication on a charge of a delinquency or status offense.
B. DEFENDANTS’ EXCESSIVE CASELOADS AND SAFETY MONITORING FAILURES VIOLATE THE LAW
219. Defendants have a pattern, custom and/or practice of maintaining an overburdened, inadequately staffed, inexperienced, and constantly changing workforce that does not and cannot adequately monitor the safety, health and well-being of Plaintiff Children or ensure that the homes and facilities caring for them are reasonably free from harm, and that their service needs are being met.
220. The Child Welfare League of America, a national coalition of private and public agencies that develops child welfare policies and promotes sound child welfare practice, limits caseloads to between 12 and 15 foster children per caseworker and 12 active reports per caseworker performing protective service investigations. The Council on Accreditation (“COA”), a national accrediting body that partners with human service organizations to improve child welfare service delivery outcomes, also publishes widely recognized professional standards and recommends that caseloads for foster care caseworkers be limited to 8 to 15 children per
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worker, depending on the needs of the children, and 15 children per caseworker performing protective service investigations.
221. By contrast, DSS caseworkers, who routinely have mixed caseloads of investigations (both pre-custodial and those involving children in DSS custody), family cases receiving ongoing services and foster care cases, carry total caseloads that grossly exceed any of the CWLA and COA caseload standards by a wide margin. These excessive caseloads overburden caseworkers and prevent them from performing basic casework in conformance with DSS policy and generally accepted standards of professional child welfare case practice.
222. The proposed DSS standard for foster care caseworkers is now 14-20 children, with a maximum not to exceed 26 children, 54% higher than professional standards. The maximum proposed DSS standard for investigation/assessment caseworkers is 24 children. However, according to the 2014 LAC Report, DSS has failed by a wide margin to meet even its own excessive maximum caseload standards because of “limited resources.”
223. The 2014 LAC Report found that 57.8% of the 611 caseworkers statewide had caseloads that exceeded DSS standards, 38.5% of caseworkers had caseloads that exceeded the standards by 50% or more, 21.9% of caseworkers had caseloads that exceeded the standards by 100% or more, and 11.3% of caseworkers had caseloads that exceeded the standards by 150% or more. The 2014 LAC Report also found that 19% of caseworkers statewide were assigned more than 50 children, 11% were assigned more than 60 children and 2.8% were assigned more than 75 children at one time.
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224. According to DSS data from September 15, 2014, 63% of Investigation/Assessment caseworkers across South Carolina have more than DSS’s recommended caseload standards.2
225. These excessive caseloads prevent caseworkers from adequately monitoring the safety of foster children and from performing casework in conformance with South Carolina’s state law and DSS’s policies and within reasonable standards of professional child welfare practice. As found by the 2014 LAC Report, DSS child welfare caseloads are “excessive, reducing the amount of attention that can be given to each child” and “reducing the ability of caseworkers to investigate and prevent child abuse and neglect.”
226. DSS’s failure to maintain an adequately staffed workforce is made even worse by the high rate of turnover among caseworkers. According to DSS data, from 2011 to 2013, the annual turnover rate among child welfare workers in foster care increased by more than 12 percentage points, from 16.1% to 28.8% of child welfare caseworkers leaving their jobs. Twenty-seven of the forty-six county directors also left their positions from 2011 through August 2014.
227. High caseworker turnover at DSS has been an unaddressed, longstanding problem. In 2008, for example, the Governor’s Task Force recognized that “high employee turnover rates” have contributed to “a largely inexperienced workforce” and that 45 percent of DSS frontline staff have less than one year of experience as a child welfare worker. In its 2010 Annual Accountability Report, DSS recognized that high turnover among its caseworkers
2 For purposes of this calculation, Investigation/Assessment caseworker was defined as a caseworker who either carried at least 3 Investigation/Assessment cases or had less than 2 cases in each type of service category including Investigation/Assessment.
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continues to be a systemic problem, leading to “the loss of years of experience, knowledge, and expertise, and substantial cost in training of new workers.”
228. As found by the 2014 LAC Report, “DSS has not analyzed turnover and has no standard for determining whether its turnover rate is within acceptable limits.” Morever, “DSS reported inaccurate turnover rates among child welfare workers in the agency’s final report on the federal fiscal year 2010-2014 child and family services plan” to federal reviewers. DSS improperly included employees in functional areas that were not child welfare and did not include workers who left a job in child welfare for another position at DSS or another state agency. As a result, the data provided to the federal government “gives a false impression of the number of full-time child welfare workers on staff” and leaves the agency “unable to diagnose its problems in this area.”
229. The high turnover of DSS caseworkers causes children to repeatedly suffer the trauma of having relationships with caseworkers severed and to endure a lack of much-needed continuity and stability. Social science studies, such as the 2010 “Listening to the Voices of Children in Foster Care: Youths Speak Out about Child Welfare Workforce Turnover and Selection,” repeatedly show that “[t]he effect of workforce turnover is to once again disrupt the development of healthy nurturing relationships with a caring adult…it needs to be acknowledged that youths form bonds with their caseworkers … [and] severing those bonds may harm the wellbeing of children in care.”
230. Additionally, the excessive turnover of DSS caseworkers compromises the ability of DSS to ensure child safety. The 2014 DSS Plan states: “Due to the high turnover rate trend, there is a considerable impact on the Agency’s ability to sustain the skill sets that caseworkers receive through training” including the agency’s core “Signs of Safety (SOS)” training, which is
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the agency’s core “practice model” for “equip[ping] leadership, supervisors, and frontline workers with a specific set of tools designed to assess risk and manage safety.” The 2014 DSS Plan specifically lists as an example, “due to the ongoing high turnover rate, the implementation of the SOS statewide is somewhat inconsistent. As new workers are hired to replace former workers trained in the SOS, there are areas of the state where the SOS is not being imbedded into the practice and there may be a lack of confidence with implementing SOS.”
231. DSS’s excessive caseloads, high turnover and inexperienced caseworkers often prevent assigned DSS foster care caseworkers from identifying possible maltreatment of children and safety risks in their placements, harming Plaintiff children and leaving Plaintiff children at imminent risk of harm.
232. Additionally, these same pervasive problems often prevent DSS caseworkers who perform investigations of reported child abuse or neglect from following mandatory investigation protocols as required by law and DSS policy, harming Plaintiff children and leaving Plaintiff children at imminent risk of harm.
233. According to the June 2014 DSS Child and Family Services Plan for FFY 20152019 (the “2014 DSS Plan”), DSS has failed to meet its own “Wildly Important Goal” to “[i]mprove child safety by increasing the quality of the decisions that control safety and manage risk,” with safety adequately assessed in only 62% of cases as of December 2013.
234. The 2014 DSS Plan found that in reviews of DSS cases, “[m]aintaining monthly visits to assess risk and safety relating to children, safety concerns of parents, assessing all individuals residing in the home including . . . the foster parents and residential provider settings were cited issues.”
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235. Policies set forth in the DSS Child Protective Services Policy and Procedure Manual (“DSS Policy Manual”) require that DSS direct reports of suspected abuse or neglect of children in DSS custody by a facility/institutional staff member to its Out of Home Abuse and Neglect unit (“OHAN”). According to the FY 2011-2012 DSS Annual Accountability Report, in January 2010, DSS reduced the number of staff at OHAN and transferred the responsibility of investigating possible maltreatment in foster homes to the already overburdened county offices.
236. Instead of referring allegations of suspected abuse or neglect to OHAN or to a DSS area office investigator when OHAN is not part of the process, as required by DSS policy, if DSS responds at all to indications of child maltreatment of which it has notice or knowledge, DSS has a pattern and/or practice of moving a child out of the facility or home where the child was placed, without assessing or investigating the suspected abuse or neglect, without taking corrective actions concerning the child’s placement, and without safeguarding the other children in the placement.
237. When reports of suspected abuse or neglect of children in foster care are actually directed to OHAN or DSS county office investigators, DSS has a pattern and/or practice of routinely failing to take mandatory steps to investigate the allegations.
238. According to DSS data reported in 2014, in 25 of 46 counties the investigations of alleged child abuse and neglect were more likely than not to be closed in violation of DSS’s own policy. In some instances, DSS found that cases were so poorly documented that it was unclear whether the alleged abuse happened; other cases included documented evidence of abuse but the cases were closed anyway.
239. According to the 2014 LAC report, in 2013 “nearly one in four children whose abuse or neglect reports were accepted for investigation were not seen by a caseworker within 24
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hours, as required by DSS policy.” In some counties, 39% of child victims were not seen within 24 hours. The 2014 LAC Report concluded “[a]s a result, there is reduced assurance that abused and neglected children are being adequately protected.” Compounding this issue, DSS allows employees to delay decisions on whether to investigate reports for up to 24 hours after they are received. From July 1, 2013 to May 31, 2014, DSS delayed decisions for 866 reports for up to 24 hours and 281 were delayed for more than 24 hours.
240. As a result of the safety monitoring and oversight failures listed above, the DSS data regarding the occurrence and rate of abuse and neglect suffered by Plaintiff Children in foster care is unreliable and masks a much higher rate of abuse and neglect actually suffered by Plaintiff Children.
241. The federal government has raised concerns regarding the accuracy of South Carolina’s reported data regarding abuse and neglect suffered by foster children. In the 2010 CFSR, the federal reviewers found that DSS’s investigation policies and procedures result in “inaccurate data” with respect to the incidence of “maltreatment in foster care and affects the State’s ability to make effective case decisions based on child and family history with SCDSS.” This dangerous problem continues today.
C. DEFENDANTS VIOLATE THE LAW BY FAILING TO PROVIDE CHILDREN IN FOSTER CARE WITH REQUIRED MEDICAL, DENTAL AND MENTAL HEALTH ASSESSMENTS, SCREENINGS AND TREATMENT
242. Defendants have a pattern and/or practice of failing to provide basic medical, dental and mental health assessments, screens and treatment to foster children in DSS legal custody, subjecting them to known harms or the imminent risks of known harms.
243. Under federal law, state law and DSS policy, DSS must provide medical and dental assessments, periodic medical/physical and dental health screenings, and follow-up
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treatment to Plaintiff Children as required under the “Early, Periodic Screening, Diagnosis and Treatment” (“EPSDT”) provisions of the Medicaid Act. The DSS Foster Care Policy and Procedure Manual expressly provides that it is the responsibility of the DSS foster care caseworker to arrange for “completion of on-going medical assessments” for foster children according to federally-approved EPSDT standards, which include medical and dental assessments and periodic screenings to determine the existence of illnesses, as well as diagnostic and treatment services to correct or ameliorate any illnesses or conditions known or discovered by such assessments and screenings.
244. According to the 2014 DSS Health Care Plan, under current DSS practice “[a]n initial assessment by a physician is arranged and completed within five working days of a child’s entry into foster care,” and the “Comprehensive Medical Assessment (current SCDSS Form 3057) is obtained from the physician,” and “[a]ll follow up services are arranged and coordinated with medical providers as indicated by the health professional.” Also, “[a]n additional appointment will be scheduled (at the time of the first visit) no later than 30 days from the date of the first appointment [within five days of the child’s entry into foster care] to complete a comprehensive assessment and follow Early, Periodic Screening, Diagnosis, and Treatment (EPSDT) protocols.”
245. The 2014 DSS Health Care Plan further provides that “[c]urrently, children in foster care are provided on-going medical, dental and vision screenings according to the federally-approved standards (EPSDT Guidelines – Physician’s Provider Manual, Section 2., pp 62-63)” and specified by the EPSDT Periodicity Schedule for children in DSS custody.
246. However, DSS routinely fails to ensure that Plaintiff Children receive EPSDTmandated medical and dental assessments, screens and treatment. In its 2014 DSS Plan, in
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regard to children’s physical health, DSS admitted it “lack(s) [] medical assessments, medical or dental records on file or collateral contacts made with medical providers to obtain assessments or documentation of appointments, make referrals to address medical issues [], medications, and contacts with service providers.” In addition, in the 2010 DSS Annual Progress and Services Report (the “2010 APSR”), DSS admitted that “[o]ften dental and eye care is neglected for foster children.”
247. In its 2010 Annual Progress and Services Report, DSS reported that it was not monitoring the medical needs of children in its custody, that those children often did not receive appropriate follow up and treatment, and that these failures usually occur when the child changes placements or is assigned a new caseworker. This failure is especially harmful because placement changes and changes of assigned caseworkers occur with great frequency at DSS (see Section VI.A.4, VI.B, supra).
248. DSS’s failure to provide consistently and timely required medical and dental health assessments, screenings and follow-up treatment to children in DSS custody directly causes harm to and deterioration of Plaintiff Children’s physical health.
249. In addition to the failure to provide medical/physical health services to children, while federal law, state law and DSS policy require DSS to provide assessments, screenings and treatment for mental illnesses and to ensure that Plaintiff Children’s mental health treatment needs are met, DSS routinely denies these basic mental health services to Plaintiff Children.
250. According to the 2014 DSS Health Care Plan, under current DSS practice, DSS must ensure that every “[c]hild will be taken to the Department of Mental Health (SCDMH) or a Licensed Practitioner to complete a mental health assessment to include screening for trauma within 24-28 hours and no later than 72 hours” of a child entering DSS custody. Further, “the
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initial clinical appointment to complete the trauma-focused assessment will be scheduled within 7 business days of the initial DSS request for the assessment.” The completed mental health assessment is part of the initial EPSDT Comprehensive Assessment for every child in DSS custody.
251. Additionally, under DSS’s EPSDT obligations, “[i]f during the mental health assessment, mental health services and counseling for trauma-related issues are identified, [DSS must ensure that] services are to be provided by the appropriate providers, either through a Licensed Practitioner or the SCDMH.” Periodic psychosocial/behavioral assessments are mandated in the DSS EPSDT periodicity schedule, and DSS must ensure that any ongoing medically necessary mental health treatment for Plaintiff Children is provided, under EPSDT.
252. In its 2014 DSS Plan, DSS admits to a “lack of current mental health and behavioral health assessments or evidence of recommended services noted in the case file, as well as the failure to follow up and monitor mental health services.” The 2014 DSS Plan also indicates that substantial delays in obtaining mental health services and the absence of communication with mental health service providers results in the failure to keep up with recommended mental health services and assessments, and untimely referrals for counseling.
253. These deficiencies in the delivery of essential and legally required mental health care services at DSS are well-known, longstanding problems. For example, according to DSS’s 2009 Statewide Assessment reported to the federal government, DSS admitted to a “lack of documentation to indicate that assessment of mental health needs occurred, and a lack of documented follow up for determining that mental health needs were met when such issues were identified.”
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254. In the 2010 CFSR, the federal government identified a scarcity of key mental health services for foster children in South Carolina’s child welfare system, such as psychological evaluations and mental health and substance abuse treatment services, which results in waiting lists for these services.
255. DSS’s denial of timely mental health screens and treatment also often results in disruptions of foster children’s placements, such as when a child’s untreated condition causes the child’s behavior to deteriorate and the foster parents are not equipped to address the child’s needs. VII. CAUSES OF ACTION
First Cause of Action (Substantive Due Process Under the Fourteenth Amendment to the United States Constitution)
(Addressed to Allegations of Deficiencies in Placement Array and Excessive Workload and Safety Monitoring
(Asserted by the general Class; all Named Plaintiffs) 256. The allegations in paragraphs 1-11, 13, 14, 16-22, Section III, 124-130, 137-142, Section V., Section VI.A.1, Section VI.A.2, Section VI.A.4, Section VI.A.5, and Section VI.B of the Complaint are incorporated herein as if fully set forth. 257. South Carolina assumes an affirmative duty under the Fourteenth Amendment to the United States Constitution to protect a child from harm and to keep a child reasonably free from harm and risks of harm when it takes that child into its foster care custody. 258. The foregoing policies and practices of the Defendants, in their official capacities, who directly and indirectly control and are responsible for the policies and practices of DSS, constitute a failure to meet their affirmative duty to protect from harm and keep reasonably free from harm and risks of harm all Named Plaintiffs and Plaintiff Children in the Class, which is a
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substantial factor leading to, and proximate cause of, the violation of the constitutionallyprotected liberty and privacy interests of all Named Plaintiffs and Plaintiff Children.
259. The foregoing actions and inactions of the Defendants, in their official capacities, constitute policies, patterns, practices and/or customs that are contrary to law and any reasonable professional standards, are substantial departures from any accepted professional judgment such that they are outside of that judgment, and are in deliberate indifference to known harms and imminent risk of known harms and to the constitutionally protected rights and liberty interests of, all Named Plaintiffs and Plaintiff Children in the Class, such that Defendants were plainly placed on notice of dangers and chose to ignore the dangers notwithstanding the notice, and shock the conscience. As a result, all Named Plaintiffs and Plaintiff Children have been harmed or are at continuing and imminent risk of harm, and have been deprived of their substantive due process rights guaranteed by the Fourteenth Amendment to the United States Constitution.
260. These substantive due process rights include, but are not limited to: the right to protection from unnecessary physical, emotional or psychological harm and to be reasonably free from harm while in state custody; the right not to be unnecessarily confined in an institutional setting; the right to care, treatment and services necessary to prevent Plaintiff Children from deteriorating or being harmed physically, psychologically or otherwise while in state custody; the right to minimally adequate safety monitoring of foster care homes and facilities; the right to minimally adequate and timely investigations of allegations and indications of abuse or neglect suffered by Plaintiff Children; and right not to be deprived of meaningful contact with family members.
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Second Cause of Action (Early and Periodic Screening, Diagnosis and Treatment program of the Federal Medicaid Act,
42 U.S.C. §§ 1396a(a)(10)(A), 1396a(43)(B), 1396a(43)(C), 1396d(a), 1396d(r)) (Asserted by the general Class; all Named Plaintiffs)
261. The allegations in paragraphs 1-8, 15, 17-22, Section III, 124-130, 137-142, Section V., and Section VI.C of the Complaint are incorporated herein as if fully set forth.
262. As a result of the foregoing actions and inactions by Defendants, in their official capacities, Defendants are engaging in a policy, pattern, practice, and/or custom of depriving Named Plaintiffs and the Class members of the enforceable rights conferred on them by the Early and Periodic Screening, Diagnosis and Treatment Program of the federal Medicaid Act (42 U.S.C. §§ 1396a(a)(10)(A), 1396a(43)(B), 1396a(43)(C), 1396d(a), 1396d(r)), to the payment of and/or to receive initial and periodic health assessments, screens and treatment, specifically physical health, dental health and mental health assessments, screens and treatment.
Third Cause of Action (Title II of the Americans with Disabilities Act, 42 U.S.C. § 12131 et seq.) (Asserted by Named Plaintiffs Michelle H., Ava R., Zahara L., Sammy V., Andrew R.)
and the Disability Subclass) 263. The allegations in paragraphs 1-8, 10, 15, 17-98, 124-128, 131-132, 137-142, Section V., Section VI.A.1, and Section VI.A.3 of the Complaint are incorporated herein as if fully set forth. 264. As a result of the foregoing actions and inactions of Defendants, in their official capacities, Defendants are engaging in a policy, pattern, practice, and/or custom of depriving Named Plaintiffs Michelle H., Ava R., Zahara L., Sammy V., Andrew R., and the Disability Subclass members of the enforceable rights conferred on them by Title II of the Americans with Disabilities Act of 1990 and subsequent Americans with Disabilities Amendments Act of 2008,
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to placements and services that meet their needs in the most integrated setting appropriate to their needs.
265. The children in the Disability Subclass are qualified individuals with disability within the meaning of the ADA, 42 U.S.C. § 12131(2).
266. Defendants are public entities subject to the provisions of the ADA under 42 U.S.C. § 12131(1)(A).
267. Defendants have failed to administer services, programs, and activities in the most integrated setting appropriate to the needs of children in the Disability Subclass. Defendants have placed children in restrictive, segregated institutional settings.
268. Defendants have discriminated against the Disability Subclass by denying them the opportunity to participate in and benefit from therapeutic community-based placements and supportive mental health services and affording them an unequal opportunity to participate in foster care programs and services. Defendants have further discriminated against the Disability Subclass in violation of the ADA by utilizing criteria or methods of administration that have the effect of subjecting the Disability Subclass to discrimination on the basis of disability.
269. Defendants have discriminated against the Disability Subclass on the basis of their disabilities by failing to make reasonable modifications in their policies, practices, or procedures. Reasonable modification of Defendants’ polices, practices, or procedures would not fundamentally alter the nature of their services, programs, or activities, but rather would further Defendants’ stated goals.
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Fourth Cause of Action (Early and Periodic Screening, Diagnosis and Treatment program of the Federal Medicaid Act,
42 U.S.C. §§ 1396a(a)(10)(A), 1396a(43)(B), 1396a(43)(C), 1396d(a), 1396d(r)) (Asserted by Named Plaintiffs Michelle H., Ava R., Zahara L., Sammy V., Andrew R. and the
Disability Subclass) 270. The allegations in paragraphs 1-8, 10, 15, 17-98, 124-128, 131-132, 137-142, Section V., and Section VI.A.3 of the Complaint are incorporated herein as if fully set forth. 271. As a result of the foregoing actions and inactions by Defendants, in their official capacities, Defendants are engaging in a policy, pattern, practice, and/or custom of depriving Named Plaintiffs and the Disability Subclass of the enforceable rights conferred on them by the Early and Periodic Screening, Diagnosis and Treatment Program of the federal Medicaid Act (42 U.S.C. §§ 1396a(a)(10)(A), 1396a(43)(B), 1396a(43)(C), 1396d(a), 1396d(r)) to the payment of and/or to receive initial and periodic mental health assessments, screens and treatment.
Fifth Cause of Action (Substantive Due Process Right to Family Association With Siblings in Placement Under
the Fourteenth Amendment to the United States Constitution) (Asserted by Named Plaintiffs Zahara L., Sammy V., Marcus B., Annie B., Cameron B.,
Sara B., Roger B., Kyle S., and the Sibling Subclass) 272. The allegations in paragraphs 1-8, 16, 17-22, 59-85, 99-120, 124-128, 133-134, 137-142, Section V., Section VI.A.1, Section VI.A.5, and Section VI.B of the Complaint are incorporated herein as if fully set forth. 273. South Carolina assumes an affirmative duty under the Fourteenth Amendment to the United States Constitution to protect a child from harm and to keep a child reasonably free from harm and risks of harm when it takes that child into its foster care custody. 274. The foregoing policies and practices of the Defendants, in their official capacities, who directly and indirectly control and are responsible for the policies and practices of DSS, constitute a failure to meet their affirmative duty to protect from harm and keep reasonably free
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from harm and risks of harm Named Plaintiffs Zahara L., Sammy V., Marcus B., Annie B., Cameron B., Sara B., Roger B., Kyle S. and the Sibling Subclass, which is a substantial factor leading to, and proximate cause of, the violation of the constitutionally-protected liberty and privacy interests of Named Plaintiffs Zahara L., Sammy V., Marcus B., Annie B., Cameron B., Sara B., Roger B., Kyle S. and the Sibling Subclass.
275. The foregoing actions and inactions of the Defendants, in their official capacities, constitute policies, patterns, practices and/or customs that are contrary to law and any reasonable professional standards, are substantial departures from any accepted professional judgment such that they are outside of that judgment, and are in deliberate indifference to known harms and imminent risk of known harms to, and to the constitutionally protected rights and liberty and privacy interests of, Named Plaintiffs Zahara L., Sammy V., Marcus B., Annie B., Cameron B., Sara B., Roger B., Kyle S. and the Sibling Subclass such that Defendants were plainly placed on notice of dangers and chose to ignore the dangers notwithstanding the notice, and shock the conscience. As a result, Named Plaintiffs Zahara L., Sammy V., Marcus B., Annie B., Cameron B., Sara B., Roger B., Kyle S. and the Sibling Subclass have been harmed or are at continuing and imminent risk of harm, and have been deprived of the substantive due process rights guaranteed by the Fourteenth Amendment to the United States Constitution.
276. These substantive due process rights include the right not to be deprived of meaningful contact with family members.
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Sixth Cause of Action (Substantive Due Process Right Under the Fourteenth Amendment to the United States
Constitution) (Asserted by Named Plaintiffs Michelle H., Ava R., Sammy V., Andrew R., Kyle S. and
the Juvenile Justice Subclass) 277. The allegations in paragraphs 1-8, 12, 17-58, 76-98, 111-120, 124-128, 135-142, Section V., Section VI.A.1, and Section VI.A.6 of the Complaint are incorporated herein as if fully set forth. 278. South Carolina assumes an affirmative duty under the Fourteenth Amendment to the United States Constitution to protect a child from harm and to keep a child reasonably free from harm and risks of harm when it takes that child into its foster care custody. 279. The foregoing policies and practices of the Defendants, in their official capacities, who directly and indirectly control and are responsible for the policies and practices of DSS, constitute a failure to meet their affirmative duty to protect from harm and keep reasonably free from harm or risks of harm Named Plaintiffs Michelle H., Ava R., Sammy V., Andrew R., Kyle S. and the Juvenile Justice Subclass, which is a substantial factor leading to, and proximate cause of, the violation of the constitutionally-protected liberty interests of Named Plaintiffs Michelle H., Ava R., Sammy V., Andrew R., Kyle S. and the Juvenile Justice Subclass. 280. The foregoing actions and inactions of the Defendants, in their official capacities, constitute policies, patterns, practices and/or customs that are contrary to law and any reasonable professional standards, are substantial departures from any accepted professional judgment such that they are outside of that judgment, and are in deliberate indifference to known harms and imminent risk of known harms to, and to the constitutionally protected rights and liberty interests of, Named Plaintiffs Michelle H., Ava R., Sammy V., Andrew R., Kyle S. and the Juvenile Justice Subclass such that Defendants were plainly placed on notice of dangers and chose to
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ignore the dangers notwithstanding the notice, and shock the conscience. As a result, Named
Plaintiffs Michelle H., Ava R., Sammy V., Andrew R., Kyle S. and Juvenile Justice Subclass
have been harmed or are at continuing and imminent risk of harm, and have been deprived of the
substantive due process rights guaranteed by the Fourteenth Amendment to the United States
Constitution.
281. These substantive due process rights include the right not to be subjected to DSS
practices under which DSS leaves and/or recommends that Plaintiff Children remain in a
juvenile detention facility or other juvenile justice facility without a pending charge, awaiting a
hearing or determination on their charge, or beyond the term of their plea or adjudicated term to
authorize such confinement, because DSS has no available placements.
VIII. PRAYER FOR RELIEF
WHEREFORE, the Plaintiff Children respectfully request that this Honorable Court:
a. Assert jurisdiction over this action; b. Order that Plaintiff Children may maintain this action as a class action
pursuant to Rule 23(b)(2) of the Federal Rules of Civil Procedure; c. Pursuant to Rule 57 of the Federal Rules of Civil Procedure, declare
unconstitutional Defendants’ failure to provide for Plaintiffs’ safety and freedom from harm under the Fourteenth Amendment to the U.S. Constitution, and declare unlawful Defendants’ failure to comply with the federal Americans with Disabilities Act and failure to comply with the Early and Periodic Screening, Diagnosis and Treatment program of the Federal Medicaid Act. d. Permanently enjoin Defendants from subjecting Plaintiff Children to practices that violate their rights and order appropriately tailored remedies directed at Defendants to ensure Defendants’ future compliance with their legal obligations to Plaintiff Children, including, but not limited to, the following: RELIEF FOR THE GENERAL CLASS
i. Availability of Necessary Placements for Children. Defendants shall develop the minimally adequate
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capacity and array of placements for meeting the placement needs of the Class, including foster homes and other appropriate placements.
ii. Foster Care and Investigation Caseloads. DSS shall establish and implement limits on the caseloads and workloads of all case-carrying workers for children in DSS custody, as well as all case-carrying workers performing child protection investigations for children in DSS custody, beyond which such workers cannot ensure reasonable safety and protection to Class members.
iii. Initial and Periodic Medical, Dental and Mental Health Screens and Treatment. DSS shall ensure the services and periodicity of initial and periodic medical, dental and mental health screens and treatment for foster children in DSS custody.
RELIEF FOR THE DISABILITY SUBCLASS
iv. Availability of appropriate, community based treatment and placements to meet the needs of children with disabilities, specifically children with intensive emotional, behavioral or psychological needs. DSS shall build the capacity to ensure that children in the Disability Subclass receive emotional, behavioral and mental health treatment that meets their needs and that they are placed in the least restrictive, integrated community based settings.
v. Initial and Periodic Medical, Dental and Mental Health Screens and Treatment. DSS shall build the capacity to ensure that children in the Disability Subclass receive services and periodicity of initial and periodic mental health screens and treatment.
RELIEF FOR THE SIBLING SUBCLASS
vi. Availability of Necessary Placements for the Sibling Subclass. Defendants shall develop the minimally adequate capacity and array of placements and services needed to meet the placement needs of the Sibling Subclass.
vii. Sibling Visitation. DSS shall develop and implement policies providing for minimally adequate visitation and other contact among children in the Sibling Subclass when they cannot be placed together.
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RELIEF FOR THE JUVENILE JUSTICE SUBCLASS viii. Ending the practice, when children in DSS custody are placed in detention or another juvenile justice facility, of leaving and/or DSS recommending that they remain there, without a charge or awaiting a hearing or determination on their charge or beyond the term of their plea or adjudicated sentence, specifically because DSS has nowhere else to house them.
e. Monitoring / Enforcement. The provisions of the Court order entered pursuant to Fed. R. Civ. P. 65(d) shall be monitored by a neutral expert monitor appointed by the Court. In addition, the Court shall have continuing jurisdiction to oversee compliance with that Order.
f. Award to Plaintiff Children the reasonable costs and expenses incurred in the prosecutions of this action, including reasonable attorneys’ fees, pursuant to 28 U.S.C. § 1920 and 42 U.S.C. § 1988, and Federal Rules of Civil Procedure 23(e) and (h); and
g. Grant such other and further equitable relief as the Court deems just, necessary and proper to protect Plaintiff Children from further harm while in Defendants’ custody in foster care.
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Dated: January 12, 2015

/s/ Stephen Suggs______ SUSAN BERKOWITZ, Federal Bar #1305 STEPHEN SUGGS, Federal Bar #7525 SOUTH CAROLINA APPLESEED LEGAL JUSTICE CENTER P.O. Box 7187 Columbia, S.C. 29202 Telephone: (803) 779-1113 Facsimile: (803) 779-5951 Email: sberk@scjustice.org
IRA LUSTBADER (pro hac vice application to be filed) KATHRYN A. WOOD (pro hac vice application to be filed) CHILDREN’S RIGHTS 330 Seventh Avenue, Fourth Floor New York, New York 10001 Telephone: 212-683-2210 Facsimile: 212-683-4015 Email: ilustbader@childrensrights.org
MATTHEW T. RICHARDSON, Federal Bar #7791 WYCHE P.A. 801 Gervais Street, Suite B Columbia, SC 29201 Telephone: (803) 254-6542 Facsimile: (803) 254-6544 Email: mrichardson@wyche.com

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 2:15-cv-00134-RMG Date Filed 09/28/15 Entry Number 29 Page 1 of 6

UNITED STATES DISTRICT COURT 
 DISTRICT OF SOUTH CAROLINA 

CHARLESTON DIVISION 


MICHELLE H., by her next friend,

)

Tamara Coppinger, et al., individually and

)

on behalf of all others similarly situated, Plaintiffs,

)

99

) )

.s= ""

-D
CIA No. 2: 15-cv-00134-RMG

~

)

v.

)

)

NIKKI HALEY, in her official capacity as

)

Governor of the State of South Carolina,

)

)

SUSAN ALFORD, in her official capacity as

)

State Director of the South Carolina

)

Department of Social Services,

)

)

Defendants.

)

)

)

CONSENT IMMEDIATE INTERIM RELIEF

WHEREAS, the parties in this action are currently engaged in mediation under the direction of Senior U.S. District Judge P. Michael Duffy with the objective of seeking a resolution of the legal dispute through a negotiated settlement (Dkt. No. 21), and
WHEREAS, the parties in this action consent to the specific immediate interim relief as set forth herein:
I. Definitions:
I. Class Certification: Pursuant to the terms of this Settlement Agreement, this case shall be certified as a class action under Fed. R. Civ. P. 23(a) and (b)(2). The "Certified Class" shall be defined as follows: all children who are or will be involuntarily placed in DSS foster care in the physical or legal custody ofDSS.
2. "Class Members" shall mean a child or children in the Certified Class.
3. "Juvenile Justice Placement" shall mean a placement made by the South Carolina Department of Juvenile Justice.
4. "Referral ofInstitutional Abuse and Neglect" as defined in S.C. Code Ann. § 63-7-20(12), means

2:15-cv-00134-RMG Date Filed 09/28/15 Entry Number 29 Page 2 of 6
a possible incident of abuse or neglect of a Class Member.
5. "Accepted Report of Abuse or Neglect" means a Referral ofInstitutional Abuse or Neglect that DSS has accepted for investigation as defined in S.C. Code Ann. § 63-7-20(12).
6. "Worker" means any employee of DSS that provides direct case management, supervision, or 
 provides permanency services, or investigates one or more Accepted Reports of Abuse or 
 Neglect about a Class Member. 

II. Immediate Interim Relief
The parties agree that Immediate Interim Relief shall include:
1. Workloads: Workload Study and Workload Limits as to Foster Care: (a) DSS shall design, conduct, and complete a workload study ("Workload Study") and adopt one or more workload limits ("Workload Limits") for foster care within one hundred and eighty (180) days. (FRCP 6 Time Computation). (b) In designing, conducting, and completing the Workload Study, DSS shall consider: (i) caseload and workload provisions published by organizations including, but not limited to, the Council on Accreditation and the Child Welfare League of America; (ii) the time needed and the time available for Workers to manage and complete their work; and (iii) accepted best practices for workload studies. (c) The Workload Study must be approved by the Co-Monitors before it is conducted. The results of the Workload Study must also be approved by the Co-Monitors before they are adopted by DSS. (d) A Workload Limit must apply to every Worker and to every Worker's supervisor. DSS may identify categories of Worker or supervisor or both and set a different Workload Limit for each category. Each Workload Limit must be approved by the Co-Monitors before it is adopted.
2. Placement Needs Assessment: Within one hundred twenty (120) days, DSS, with prior input from and subject to approval by the Co-Monitors, shall perform a statewide and regional foster care placement needs assessment in order to determine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members. The needs assessment shall include specific recommendations addressing all the assessment's findings, including but not limited to recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that
can meet their needs.

2:15-cv-00134-RMG Date Filed 09/28/15 Entry Number 29 Page 3 of 6
(a) Within sixty (60) days of the completion of the needs assessment, DSS shall develop an Implementation Plan to implement the recommendations of the needs assessment within eighteen (18) months. The Implementation Plan shall have enforceable benchmarks with specific timelines, subject to approval by the Co-Monitors, to measure progress in executing the recommendations of the needs assessment.
(b) DSS shall achieve substantial compliance with the recommendations in the Implementation Plan.
3. Placements: (a) Family Placements for Children Ages 6 and Under. Within sixty (60) days, DSS shall create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the Co-Monitors, the placement of any Class Member age six and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers). The plan shall include full implementation within sixty (60) days following approval of the Co-Monitors. (b) Phasing-Out Use ofDSS Offices and Hotels. Within sixty (60) days, DSS shall cease using DSS offices as an overnight placement for Class Members, and shall cease placing or housing any Class Members in hotels, motels and other commercial non-foster care establishments. For any Class Members moved out of such DSS Offices or Hotels, DSS shall provide for their appropriate placement. (c) When Class Members are placed in juvenile justice detention or another Juvenile Justice Placement, DSS shall not recommend to the family court or Department of Juvenile Justice that a youth remain in a Juvenile Justice Placement without a juvenile justice charge pending or beyond the term of their plea or adjudicated sentence for the reason that DSS does not have a foster care placement for the Class Member. DSS shall take immediate legal and physical custody of any Class Member upon the completion of their sentence or plea. DSS shall provide for their appropriate placement.
4. Limited Co-Monitors: Paul Vincent and Judith Meltzer shall be appointed as independent and equal Co-Monitors, whose authority is specifically limited to evaluating and validating DSS performance under items 1-3 above, including authority to provide required approvals and periodic reporting as directed by the Court. A six-month budget shall be proposed by the Co­
Monitors within thirty (30) days, paid by Defendants, and agreed to by the Court. Ex parte
communications between and among Co-Monitors or any of their agents, the Mediator, and the parties are allowed. The Monitors may meet privately with the Court concerning issues related to this Interim Relief agreement, provided the parties are made aware of the subject of such meetings. In the event that either Paul Vincent or Judith Meltzer is unable to fulfill his or her duties under this Settlement Agreement, the party who originally selected the departing Monitor will propose a replacement with the consent of the remaining Monitor and other parties, and submit the replacement to the Court for approval. After one hundred and eighty (180) days, the limited authority of the Co-Monitors under this Interim Relief agreement ends if the mediation process does not result in a negotiated settlement.
AND IT IS SO ORDERED.

2:15-cv-00134-RMG Date Filed 09/28/15 Entry Number 29 Page 4 of 6
THE NORABLE RIC U.S. DISTRICT JUDGE
September ~ 2015
Charleston, South Carolina

2:15-cv-00134-RMG Date Filed 09/28/15 Entry Number 29 Page 5 of 6

Dated: September 17,2015

s/Monteith P. Todd- - - - - Monteith P. Todd (lD No. 3125) Rebecca Laffitte (lD No.1 036) J. Michael Montgomery (lD No. 
 10290) 
 Alex E. Davis (lD No. 11323) 
 SOWELL GRAY, LLP 
 Post Office Box 11449 
 Columbia, SC 29211 
 (803) 929-1400 

Attorneys for Defendant Susan Alford, in her official capacity as State Director of the South Carolina Department of Social Services
s/Karl S. Bowers- - - - - - - Karl S. Bowers, Jr. (lD No. 7716) BOWERS LAW FIRM Post Office Box 50549 Columbia, SC 29250 (803) 753-1099
Attorney for Defendant Nikki Haley, in her official capacity as Governor of the State of South Carolina

2:15-cv-00134-RMG Date Filed 09/28/15 Entry Number 29 Page 6 of 6
s/Matthew T. Richardson- - - Matthew T. Richardson, (ID No.7791) WYCHEP.A. 801 Gervais Street, Suite B Columbia, SC 29201 (803) 254-6542
Ira Lustbader (pro hac vice) 
 Christina Wilson Remlin (pro hac vice) 
 Kathryn A. Wood (pro hac vice) 
 Sarah T. Russo (pro hac vice) 
 Aaron H. Finch (pro hac vice) 
 CHILDREN'S RIGHTS 
 330 Seventh Avenue, Fourth Floor 
 New York, NY 10001 
 212-683-2210 

Susan Berkowitz (ID No. 1305) 
 Stephen Suggs (ID. No. 7525) 
 SOUTH CAROLINA APPLESEED 
 LEGAL JUSTICE CENTER 
 P.O. Box 7187 Columbia, SC 29202 (803) 779-1113
Attorneys for Plaintiffs

 
 2:15-cv-00134-RMG Date Filed 06/03/16 Entry Number 32-1 Page 1 of 25
Exhibit A Final Settlement Agreement

2:15-cv-00134-RMG Date Filed 06/03/16 Entry Number 32-1 Page 2 of 25

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF SOUTH CAROLINA
CHARLESTON DIVISION

MICHELLE H., by her next friend Tamara )

Coppinger, AVA R., by her next friend

)

Tamara Coppinger, ZAHARA L., by her next )

friend Deborah Wilson, SAMMY V., by his )

next friend Aleksandra Chauhan, ANDREW )

R., by his next friend Cheryl Kreider,

)

MARCUS, ANNIE, CAMERON, SARA, )

and ROGER B., by their next friend

)

Margaret Wilson, and KYLE S., by his next )

friend Tamara Coppinger,

)

)

Individually, and on behalf of all other

)

similarly situated children.

)

)

Plaintiffs,

)

v.

)

)

NIKKI HALEY, in her official capacity as )

Governor of the State of South Carolina, and )

)

SUSAN ALFORD, in her official capacity as )

Acting State Director of the South Carolina )

Department of Social Services.

)

)

Defendants.

)

)

C/A No. 2:15-cv-00134-RMG

FINAL SETTLEMENT AGREEMENT I. Preamble

A. This Court has subject matter jurisdiction and personal jurisdiction over this action and therefore the authority to enter this settlement agreement ("Settlement Agreement").

B. This Court shall have continuing jurisdiction of this action to ensure compliance with the terms of this Settlement Agreement.

C. The provisions of this Settlement Agreement shall resolve the federal statutory and constitutional claims of the Named Plaintiffs and the Class for injunctive and declaratory relief in the Complaint.

2:15-cv-00134-RMG Date Filed 06/03/16 Entry Number 32-1 Page 3 of 25
Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: 15-cv-00134-RMG
D. For as long as this Settlement Agreement remains in effect, all provisions referring to the "Department," the "Department of Social Services" or "DSS,'' shall apply with full force and effect to the State of South Carolina and to any subsequent agency or agencies with any of the responsibilities that apply to the current DSS as of the date of this Settlement Agreement regardless of any subsequent changes to the governmental organizational structure of the South Carolina DSS. This Settlement Agreement shall be binding on all successors, assignees, employees, agents and all those working for or on behalf of Defendants. Any state agency responsible for the care, protection, or supervision of plaintiff Class Members shall be bound by the provisions of this Settlement Agreement.
E. "Contractors" include agents.
F. This Settlement Agreement, and any of its provisions, are not, and shall not be construed to be, an admission of any liability on the part of any of the Defendants concerning any of the claims and allegations in the Complaint.
G. The parties agree that controlling federal or state laws, rules, or regulations will govern.
H. The undertaking of any obligation by the Defendants under this Settlement Agreement shall not be construed as an admission of liability or as an admission of a violation of a federal or constitutional right of a Class Member.
I. The Defendants shall make all reasonable efforts to provide funding and other resources necessary to the implementation and achievement of the obligations under the Settlement Agreement. Defendants' failure to provide or Defendants' efforts to provide such adequate funding and resources shall not excuse and shall not limit remedies to address the failure to implement or achieve any of the obligations set forth in the Settlement Agreement.
J. If the Court does not grant final approval of the Settlement Agreement, or if appellate review of the approval of the Settlement Agreement reverses approval, then the Settlement Agreement shall become null and void.
K. Without limiting the obligations of Defendants under this Agreement in any way, it is understood and acknowledged between the parties that compliance with the Agreement and achievement of the targets set by the Agreement involves a process of performance improvement that will occur over time and multiple reporting periods.
2

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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: 15-cv-OO134-RMG
II. Class Definition, other Definitions
A. Class Certification and Definition: Pursuant to the terms of this Settlement Agreement, this case shall be certified as a class action under Fed. R. Civ. P. 23(a) and (b)(2). The "Certified Class" shall be defined as follows: all children who are involuntarily placed in DSS foster care in the physical or legal custody of DSS either now or in the future.
B. "Class Members" shall mean a child or children in the Certified Class.
C. "Complaint" and the "Litigation" means the initial pleading filed in this case, 2: l 5cv-00134-RMG, on January 12, 2015, setting forth Plaintiffs' claims and causes of action (Dkt. No. 1).
D. "Assessment and Evaluation Process" is an assessment of the Class Member's strengths and needs, designed to inform decision-making about placement and services, including the level and type of appropriate care within the therapeutic placement and services array.
E. "Day" or "days" mean calendar days.
F. "Defendants" means Defendant Nikki Haley (in her official capacity as Governor of South Carolina) and Defendant Susan Alford (in her official capacity as State Director of the South Carolina DSS).
G. "DJJ" .is the South Carolina Department of Juvenile Justice.
H. "Emergency or Temporary Placement" means an emergency shelter or other placement used as an emergency or temporary facility to house children as described by Human Services Policy and Procedure Manual§ 817.
I. "Exiting the Juvenile Justice System" is when (a) the youth has completed the term of their plea or adjudicated sentence; (b) the youth's charge is dismissed and/or the youth no longer has a pending charge; or (c) there is otherwise no statutory requirement to detain the youth in a Juvenile Justice facility and the youth could be served in a foster care facility.
J. "Congregate Care Facility" means a facility that includes those organizations which provide temporary or long term, full time residential care for children on a year round basis such as child caring institutions, emergency shelters, group homes and organizations with supervised individual living facilities.
K. "Improvement Plan" means the requirements defined in Section IV of this Settlement Agreement.
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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: 15-cv-00134-RMG

L. "Including" means including, but not limited to.

M. "Juvenile Justice Placement" shall mean a placement made by the South Carolina Department of Juvenile Justice.

N. "Placement Moves" means changes in foster care placements. Temporary absence from an ongoing placement setting such as trial home visit, visit to siblings, hospitalization, respite, summer camp, and runaway shall be excluded from the placement setting count, provided the child returns to the ongoing placement setting. The removal to foster care and moves occurring after a Class Member's 18th birthday shall be excluded from the placement setting count.

0. "Placement Instability" means the rate of Placement Moves per one thousand (1,000) days of foster care among Class Members, shown by the following formula:

Among Class Members included in the denominator,

the total number of Placement Moves during the 12 month period Among Class Members in foster care for 8 days or more during the 12 month

x 1000

=

Placement Instability

period, the total number of days spent infaster care during the 12 month period

P. "Referral of Institutional Abuse or Neglect" as defined in S.C. Code Ann. § 63-720(12), means a possible incident of abuse or neglect of a Class Member.

Q. "Reporting Periods" are the sequential six-month intervals beginning when the Settlement Agreement is entered by the Court; however, the first Reporting Period shall end on March 31, 2017. Thereafter, the sequential six-month reporting periods shall run from April 1 through September 30 and October 1 through March 31.

R. "Accepted Report of Abuse or Neglect" means a Referral of Institutional Abuse or Neglect as defined in S.C. Code Ann. § 63-7-20(12) that DSS has accepted for investigation.

S. "Therapeutic Level of Care" means the leveling system used by DSS within the therapeutic placement and services array, including but not limited to Level 1, 2, 3 foster care placements and Psychiatric Residential Treatment Facilities, as described in the Human Services Policy and Procedures Manual and The State of South Carolina, Fixed Price Bid No. 5400002885.

T. "Worker" means any employee of DSS that provides direct case management, supervision, or provides permanency services to a Class Member, or investigates one or more Accepted Reports of Abuse or Neglect about a Class Member.

U. "DSS Monitoring Team" means the individuals designated by DSS as primary contacts for the Co-Monitors.

4

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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: 15-cv-00134-RMG
III. Monitoring
A. Paul Vincent and Judith Meltzer shall be appointed and shall serve jointly as independent and equal Co-Monitors, whose role shall be to issue periodic public reports on performance on the Settlement Agreement to be filed with the Court. At the conclusion of a Reporting Period, or after the Defendants produce the necessary data to the Co-Monitors, the Co-Monitors shall have one hundred and twenty (120) days to produce a confidential draft report to the parties. After receipt of the draft report, the parties shall have twenty-one (21) days to submit comments to the CoMonitors on their findings. The parties shall have ten (10) days to file a written motion to the Court requesting a hearing after the final report is filed.
B. The Co-Monitors may employ Contractors to assist them in their duties under this Settlement Agreement. If the Co-Monitors employ outside consultants, the CoMonitors will notify counsel of the retention. The Co-Monitors may not delegate decision-making authority to one another or any other individual(s) without prior approval of the parties. Any contractors recommended by the Co-Monitors for assistance in this area will be proposed by the Co-Monitors to the parties and final selection will be made by the Co-Monitors in consultation with the parties.
C. In the event that either Paul Vincent or Judith Meltzer or a replacement Monitor is unable to fulfill his or her duties under this Settlement Agreement, the party who originally selected the departing Monitor will propose a replacement with the consent of the remaining Monitor and other parties, and submit the replacement to the Court for approval.
D. The Co-Monitors shall conduct the factual investigation and verification of data and documentation necessary to compile and issue public record reports on progress and performance on the terms of the Settlement Agreement, including but not limited to specific numerical indicators of each measurable target dating back to the first report and each consecutive report thereafter. These reports shall be issued directly to the Court and to the parties. These reports shall be issued approximately one hundred twenty (120) days after the close of each Reporting Period, or after the State and/or DSS produces the necessary data to the Co-Monitors. The Co-Monitors will have an additional thirty (30) days to review parties' comments and produce a final report to the Court. The Co-Monitors' final reports shall be public documents upon final submission to and filing with the Court, except that any individually-identifying information and any other confidential information protected from disclosure shall be filed under seal and redacted or otherwise removed from any public report.
E. No party, nor any employee or agent of a party, shall have any supervisory authority over the independent Co-Monitors' activities, reports or responsibilities under this Settlement Agreement.
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Final Settlement Agreement in Michelle H, et al. v. Haley and Alford, 2: 15-cv-00134-RMG
F. The parties shall have access from the Co-Monitors to all information made available to the Co-Monitors.
G. Within one hundred twenty (120) days from the date of Court approval of this Settlement Agreement, the Co-Monitors shall provide the parties and the Court with a written initial monitoring plan setting forth the methodologies by which the CoMonitors shall measure DSS's progress in implementing the terms of this Settlement Agreement. Specifically, the Co-Monitors' methodologies may include, but are not limited to, analyses of information collected: (1) by DSS's management and information systems as determined to be valid and reliable by the Co-Monitors; (2) from a review of relevant case records; (3) from the production and review of data aggregated by DSS, the Co-Monitors or third parties; and (4) from interviews with DSS staff, resource families, Class Members or prior Class Members and their families, contract agency staff, service providers, and other child welfare stakeholders. The monitoring plan may be revised by the Co-Monitors, after consultation with the parties.
H. DSS ·shall cooperate with the Co-Monitors in providing access to personnel, documents and other information necessary to monitor the progress and performance on the terms of the Settlement Agreement. The DSS Monitoring Team shall be the Co-Monitors' primary point of contact, and prior to contacting DSS personnel to obtain data or other information, the Co-Monitors must notify a member of the DSS Monitoring Team and give reasonable notice if the Co-Monitors want to talk to any employee not on the DSS Monitoring Team.
I. DSS shall provide the Co-Monitors with the necessary resources to perform their duties, including payment of their reasonable fees and expenses. The Co-Monitors will prepare an initial budget proposal and provide it to the parties and the Court within thirty (30) days of court approval of the Settlement Agreement. The budget is subject to review and written objections by the parties prior to court approval and shall be updated or revised and subject to court approval annually on or about the anniversary date of entry of the Settlement Agreement.
J. While the cost of the independent Co-Monitors will be borne by the Defendants, the parties will explore ways to limit the cost of monitoring.
K. The Co-Monitors shall not express any conclusion as to whether Defendants have reached legal compliance on any provision(s).
L. The Co-Monitors may communicate privately with the parties.
M. The Co-Monitors may meet privately with the Court concerning issues related to this case, provided the parties are made aware of the occurrence and subject of such
6

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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: l 5-cv-00134-RMG
meetings. Unless scheduling prevents, both Co-Monitors should be present for such meetings with the Court.
IV. Improvement Plan
A. Workloads.
A.1. The Workload Study for Foster Care.
The dates and obligations set forth in IV.A. I became operative as of September 28, 2015, when the Consent Immediate Interim Relief was entered (Dkt. No. 29).
(a) DSS shall design, conduct, and complete a foster care workload study ("Workload Study") that applies to every Worker and to every Worker's supervisor and adopt one or more workload limits ("Workload Limits") for foster care within one hundred and eighty (180) days. (Fed. R. Civ. P. 6 - Time Computation).
(b) In designing, conducting, and completing the foster care Workload Study, DSS shall consider: (i) caseload and workload provisions published by organizations including, but not limited to, the Council on Accreditation and the Child Welfare League of America; (ii) the time needed and the time available for Workers to manage and complete their work; and (iii) accepted best practices for workload studies.
(c) The foster care Workload Study must be approved by the Co-Monitors before it is conducted. The results of the Workload Study must also be approved by the Co-Monitors before they are adopted by DSS.
(d) A foster care Workload Limit must apply to every Worker and to every Worker's supervisor. DSS may identify categories of Worker or supervisor or both and set a different Workload Limit for each category. Each Workload Limit must be approved by the Co-Monitors before it is adopted.
A.2. Implementing the Workload Limits for Foster Care.
(a) Within sixty (60) days of the entry of the Order approving the Settlement Agreement, Defendants shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by the Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the
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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: 15-cv-00134-RMG
Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.
(b) At least 90% of Workers and Worker supervisors shall have a workload within the applicable Workload Limit.
(c) No Worker or Worker's supervisor shall have more than 125% of the applicable Workload Limit.
B. Worker-Child Visitation. B.1 Within sixty (60) days of the entry of the Order approving the Settlement Agreement, Defendants shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by the Plaintiffs and approval by the Co-Monitors, to measure the progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.
B.2 At least 90% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place.
B.3 At least 50% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place in the residence of the child.
C. Investigations.
C.1. Within sixty (60) days of the entry of the Order approving the Settlement Agreement, Defendants shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by the Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.
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Final Settlement Agreement in Michelle H, et al. v. Haley and Alford, 2: l 5-cv-00134-RMG
C.2. Intake - No Investigation. At least 95% of decisions not to investigate a Referral of Institutional Abuse or Neglect about a Class Member must be made in accordance with South Carolina law and DSS policy.
C.3 Case Decisions of Investigations. At least 95% of decisions to "unfound" investigations of a Referral of Institutional Abuse or Neglect must be based upon DSS ruling out abuse or neglect or DSS determining that an investigation did not produce a preponderance of evidence that a Class Member was abused or neglected.
C.4 Timely Initiation and Completion.
(a) The investigation of a Referral of Institutional Abuse or Neglect must be initiated within twenty-four (24) hours in accordance with South Carolina law in at least 95% of the investigations.
(b) The investigation of a Referral of Institutional Abuse or Neglect must include face-to-face contact with the alleged victim within twenty-four hours in at least 95% of investigations, with exceptions for good faith efforts approved by the Co-Monitors.
(c) Contact with core witnesses must be made in at least 90% of the investigations of a Referral of Institutional Abuse or Neglect, with exceptions approved by the Co-Monitors. Core witnesses will vary from case to case and may or may not include the victim(s), Class Members, alleged perpetrators, reporter (if identified), identified eyewitness(es), other children in the placement, facility staff, treating professionals, and foster parents or caregivers as deemed to be relevant to the investigation.
(d) Timely Completion of Investigations Within Forty-Five (45) Days. At least 60% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within forty-five (45) days of initiation of an investigation, unless the DSS Director or DSS Director's designee authorizes an extension of no more than fifteen (15) days upon a showing of good cause. For the purposes of this section, an i:tivestigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.
(e) Timely Completion of Investigations Within Sixty (60) Days. At least 80% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within sixty (60) days of initiation of the investigation, and all investigations not completed within sixty (60) days shall have authorization of the DSS Director or DSS Director's designee of an extension of no more than thirty (30) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS
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Final Settlement Agreement in Michelle H, et al. v. Haley and Alford, 2: 15-cv-00134-RMG
determines' the Report is unfounded because the deadline to complete the investigation has passed.
(f) Timely Completion of All Investigations Within Ninety (90) Days. At least 95% of all investigations of a Referral of Institutional Abuse or Neglect not completed within sixty (60) days shall be completed within ninety (90) days. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.
D. Placement Resources.
The dates and obligations set forth in IV.D became operative as of September 28, 2015, when the Consent Immediate Interim Relief was entered (Dkt. No. 29).
D.1 Placement Needs Assessment. Within one hundred twenty (120) days, DSS, with prior input from and subject to approval by the Co-Monitors, shall perform a statewide and regional foster care placement needs assessment in order to detennine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members. The needs assessment shall include specific recommendations addressing all the assessment's findings, including but not limited to recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that can meet their needs.
(a) Within sixty (60) days of the completion of the needs assessment, DSS shall develop an Implementation Plan to implement the recommendations of the needs assessment within eighteen (18) months. The Implementation Plan shall have enforceable benchmarks with specific timelines, subject to approval by the Co-Monitors, to measure progress in executing the recommendations of the needs assessment.
(b) DSS shall achieve substantial compliance with the recommendations in the Implementation Plan.
D.2 Family Placements for Children Ages Six (6) and Under. Within sixty (60) days, DSS shall create a plan, subject to the approval of the CoMonitors, for preventing, with exceptions approved by the Co-Monitors, the placement of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers). The plan shall include full implementation within sixty (60) days following approval of the Co-Monitors.
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Final Settlement Agreement in Michelle H, et al. v. Haley and Alford, 2:15-cv-00134-RMG
D.3 Phasing-Out Use of DSS Offices and Hotels. Within sixty (60) days, DSS shall cease using DSS offices as an overnight placement for Class Members, and shall cease placing or housing any Class Members in hotels, motels and other commercial non-foster care establishments. For any Class Members moved out of such DSS Offices or Hotels, DSS shall provide for their appropriate placement. In the extraordinary event that a child stays overnight in a DSS office, Defendants shall immediately notify the CoMonitors, who shall provide a report to the parties as appropriate, including whether or not, in their view, the incident should be reported to the court as a violation which would preclude Defendants' ability to achieve compliance on this provision.
E. Congregate Care Placements and Emergency or Temporary Placements.
E.1. As part of the Implementation Plan required in connection with the needs assessment in IV.D.1.a above, that Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by the Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.
E.2. At least 86% of the Class Members shall be placed outside of Congregate Care Placements on the last day of the Reporting Period.
E.3 At least 98% of the Class Members twelve (12) years old and under shall be placed outside of Congregate Care Placements on the last day of the Reporting Period unless an exception pre-approved or approved afterwards by the Co-Monitors is documented in the Class Member's case file.
E.4 Class Members shall not remain in any Emergency or Temporary Placement for more than thirty (30) days. Under exceptions subject to the Co-Monitors' approval, if a child is initially placed in an Emergency or Temporary Placement that is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long term foster home or therapeutic foster home, then the child's stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move under Section IV.F.1 below.
E.5 Class Members experiencing more than one Emergency or Temporary Placement within twelve (12) months shall not remain in the Emergency or Temporary Placement for more than seven (7) days. Under exceptions subject to the Co-Monitors' approval, if a child's subsequent placement within twelve (12) months in an Emergency or Temporary Placement is not
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a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long term foster home or therapeutic foster home, then the child's stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move under Section IV.F.l below.
F. Placement Instability.
F.1 For all Class Members in foster care for eight (8) days or more during the 12-month period, Placement Instability shall be less than or equal to 3.37.
G. Sibling Placement.
G.1 As part of the Implementation Plan required in connection with the needs assessment in Section IV.D.1.a above, that Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by the Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.
G.2 At least 85% of Class Members entering foster care during the Reporting Period with their siblings or within thirty (30) days of their siblings shall be placed with at least one of their siblings unless one or more of the following exceptions apply: (1) there is a court order prohibiting placing all siblings together; (2) placement is not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) additional exceptions as approved by the Co-Monitors.
G.3 At least 80% of Class Members entering foster care during the Reporting Period with their siblings or within thirty (30) days of their siblings shall be placed with all their siblings, unless one or more of the following exceptions apply: (1) there is a court order prohibiting placing all siblings together; (2) placement is not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) additional exceptions as approved by the Co-Monitors.
H. Youth Exiting the Juvenile Justice System.
The dates and obligations set forth in N.H became operative as of September 28, 2015, when the Consent Immediate Interim Relief was entered (Dkt. No. 29).
ll.1 When Class Members are placed in juvenile justice detention or another Juvenile Justice Placement, DSS shall not recommend to the family court or Department of Juvenile Justice that a youth remain in a Juvenile Justice
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Placement without a juvenile justice charge pending or beyond the term of their plea or adjudicated sentence for the reason that DSS does not have a foster care placement for the Class Member. DSS shall take immediate legal and physical custody of any Class Member upon the completion of their sentence or plea. DSS shall provide for their appropriate placement.
I. Therapeutic Foster Care Placements.
1.1 As part of the Implementation Plan required in connection with the needs assessment in Section IV.DJ.a above, that Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by the Plaintiffs and approval by the Co-Monitors, to measure progress achieving the targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.
1.2 All Class Members that are identified by a Worker as in need of interagency staffing and/or in need of diagnostic assessments shall be referred for such staffing and/or assessment to determine eligibility for therapeutic foster care placement and/or services within thirty (30) days of the need being identified. This requirement shall not apply if the Worker withdraws the identified need in good faith and in the best interests of the Class Member within thirty (30) days.
1.3 All Class Members that are referred for interagency staffing and/or needed diagnostic assessments shall receive recommendations for specific therapeutic foster care placement and/or services within forty-five (45) days of receipt of the completed referral. The recommendation(s) may include diagnostic assessment, community support services, rehabilitative behavioral health services, therapeutic foster care, group care, and psychiatric residential treatment facility. Level of Care Placement recommendations shall utilize the least restrictive care philosophy suitable to the child's needs and seek to place a Class Member in a family setting with a community support system. DSS shall update the assessment at least annually thereafter, upon a placement disruption or upon a material change in the Class Member's needs. In making that determination, DSS may consider the full array of appropriate placement alternatives to meet the needs of the Class Members.
1.4 At least 90% of children assessed as in need of therapeutic foster care placement shall be in the Therapeutic Level of Care and specific placement type that matches the Level of Care for which the child was assessed within sixty (60) days following the date of the first Level of Care Placement recommendation.
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1.5 At least 95% of children assessed as in need of therapeutic foster care placement shall be in the Therapeutic Level of Care and specific placement type that matches the Level of Care for which the child was assessed within ninety (90) days following the date of the first Level of Care Placement recommendation.
J. Family Visitation
J.1 Within sixty (60) days of the entry of the Order approving the Settlement Agreement, Defendants shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.
J.2 At least 85% of the total minimum number of monthly sibling visits for all siblings not living together shall be completed, with exceptions when (1) there is a court order prohibiting visitation or limiting visitation to less frequently than once every month; (2) visits are not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) with exceptions approved by the CoMonitors.
J.3 At least 85% of Class Members with the goal of reunification will have inperson visitation twice each month with the parent(s) with whom reunification is sought, unless (1) there is a court order prohibiting visitation or limiting visitation to less frequently than twice every month; or (2) based on exceptions approved by the Co-Monitors.
K. Health Care Improvement Plan.
K.l Within one hundred eighty (180) days, Defendants, with prior input from and subject to approval by the Co-Monitors, shall develop a Health Care Improvement Plan with enforceable dates and targets for phased implementation and concerning initial screening services, periodic screening services, documentation, and health care treatment services for Class Members in the areas of physical health, immunizations and laboratory tests, mental health, developmental and behavioral health, vision and hearing, and dental health. The Plan shall address:
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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: l 5-cv-00134-RMG
(a) Developing the capacity to track screening and treatment services for individual children and aggregate tracking data, including but not limited to screens that are due and past due;
(b) Assessing the accessibility of health care screening and treatment services throughout the state, including the capacity of the existing health care providers to meet the screening and treatment needs of Class Members; and
(c) Identifying baselines and interim percentage targets for performance improvement in coordinating screens and treatment services.
K.2 With approval of the Co-Monitors and based on evidence of progress toward the development of the Health Care Improvement Plan, Defendants may request an extension of an additional sixty (60) days to complete the Plan.
K.3 The Co-Monitors shall have the ability to engage, as needed, contractors
with specific expertise in the area of child welfare health care reform fo
assist in the development and monitoring of the Health Care Improvement Plan. Any consultants recommended by the Co-Monitors for assistance in this area will be proposed by the Co-Monitors to Defendants and final selection will be made in consultation with the parties.
t.'
K.4 (a) By the end of sixty (60) days following final court approval of the Final Settlement Agreement (identification period), DSS shall identify Class Members who have been in DSS custody for more than sixty (60) days as of the date of final court approval of the Final Settlement Agreement, and who have not had initial health assessments (physical/medical, dental or mental health). Within thirty (30) days after the identification period, Defendants shall schedule the initial health assessment for at least 85% of the identified Class Members.
(b) By the end of ninety (90) days following final court approval of the Final Settlement Agreement (identification period), DSS shall identify Class Members with Immediate Treatment Needs (physical/medical, dental or mental health) for which treatment is overdue. Within forty-five (45) days of the identification period, DSS shall schedule the necessary treatment for at least 90% of the identified Class Members. (Immediate Treatment Needs means immediate non-elective physical/medical, dental or mental health treatment needs and documented assessment needs, excluding routine periodic assessments.)
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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: 15-cv-00134-RMG
(c) With approval of the Co-Monitors and based on evidence of progress toward the goals set forth in K.4 (a) and (b), Defendants may request an extension of up to an additional forty-five (45) days to complete the requirements of this section.
K.5 Within one hundred twenty (120) days of the completion of the Health Care Improvement Plan, the Co-Monitors, with input from the parties, shall identify the final health care outcome measures related to initial screening services, periodic screening services, documentation, treatment and q.ther corrective services, which the parties agree will be final and binding.
V. Enforcement, Dispute Resolution, Termination and Exit
A. All of the provisions in this Settlement Agreement are separately and independently enforceable.
B. The Settlement Agreement delineates the specific compliance targets whose achievements are prerequisite for requesting the Court to issue an order of dismissal and termination ofjurisdiction over the Settlement Agreement and the Litigation.
C. Unless otherwise specifically stated, all provisions of this Settlement Agreement shall apply to all Class Members, regardless of whether they are in a placement under the direct supervision of DSS or of a contract provider, or being provided a service directly by DSS, other state governmental agency or through a private provider.
D. Dispute Resolution. If any party alleges non-compliance with this Settlement Agreement, the following dispute resolution process shall apply:
1. Prior to seeking judicial remedies for non-compliance, the party alleging noncompliance shall notify the other party in writing if they believe the other party is out of compliance with any provisions of this Settlement Agreement.
2. The parties shall engage in good faith negotiations for at least thirty (30) days, which may be extended with consent of the parties, in an effort to resolve the noncompliance issues. The parties may also request that the Co-Monitors and/or Senior U.S. District Judge P. Michael Duffy assist, facilitate or mediate this dispute resolution process.
3. If a matter is not resolved through negotiations, it may be presented to the Court for resolution. If a matter is presented to the Court, the Court may refer such matters to Senior U.S. District Judge P. Michael Duffy for mediation or for a report and recommendations.
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4. A party may bypass the dispute resolution provisions in subsections V.D.1-3 above and seek immediate relief from the Court if the party can clearly demonstrate that the action or inaction in contravention of this Settlement Agreement caused or is likely to cause an immediate and substantial risk of serious harm to Class Members.
5. Any allegation of non-compliance with the Settlement Agreement and the dispute resolution process contained in subsections V.D.1-2 shall remain confidential as settlement negotiations to the fullest extent permitted by law.
E. Identification of Maintenance of Effort Provisions
1. Any of the specific obligations in the Improvement Plan ip Section IV may be designated by the Court for "Maintenance of Effort" status, which means that Defendants have achieved compliance for the specific obligation as reflected in the monitoring report. Under Maintenance of Effort status, if the Defendants continue to maintain substantial compliance with the level of performance reflected in the monitoring report that caused such designation (or if such performance exceeded or was better than a numerical requirement in the Settlement Agreement and the Defendants continue to maintain at least performance at the level of the numerical remedy identified in the Settlement Agreement), then substantial compliance with that level of performance for a year for that specific remedy shall be considered sufficient compliance for purposes of exit, subject to Section V.F.3 below.
2. A designation of Maintenance of Effort further means that, for each such remedy, the independent Co-Monitors shall reduce the level of monitoring over that item to a level sufficient to identify any significant deterioration of performance and not continue at the level of monitoring prior to a designation of "Maintenance of Effort."
3. The Co-Monitors will identify in their monitoring report Defendants' performance on compliance targets in the Improvement Plan, and will identify which provisions may be eligible for the Maintenance of Effort designation.
4. After each monitoring report is filed with the Court, for a period of sixty (60) days the parties will meet and confer in good faith to agree on which items the parties will jointly request the Court designate for Maintenance of Effort monitoring; provided that this does not limit any party from seeking a ruling from the Court regarding a designation of Maintenance of Effort after a reasonable time and after all parties make good faith efforts to agree.
5. The parties may file joint petitions for a modified Settlement Agreement that identifies the obligations that have achieved a Maintenance of Effort status so that the Court and the public can track progress towards exit and dismissal.
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Final Settlement Agreement in Michelle H, et al. v. Haley and Alford, 2: l 5-cv-00134-RMG
F. Termination and Exit
1. This Settlement Agreement shall remain in full force and effect until the Court issues an order of dismissal terminating jurisdiction over this action.
2. This Settlement Agreement does not limit any rights of any party to seek any relief from the Court under applicable federal law.
3. Once a compliance target falls into Maintenance of Effort status and substantial compliance on that target is sustained for a year, Defendants may seek the termination of the Court's jurisdiction over that specific provision of the Settlement Agreement. If Plaintiffs do not agree that the Court should terminate jurisdiction over the particular provision, Defendants may seek a ruling from the Court terminating jurisdiction over the provision. The Court shall terminate its jurisdiction over the provision only if Defendants can demonstrate both achievement of the specific compliance target and sustained substantial compliance for one year; unless in response to such a petition by Defendants, Plaintiffs can establish either: (1) that Defendants have failed to carry this burden; or (2) that the specific provision is directly related to Defendants achieving compliance and sustaining substantial compliance with another term of the Settlement Agreement, and then the Court shall retain jurisdiction over the provision at issue.
4. This Settlement Agreement shall remain in effect until a motion to terminate jurisdiction over this Settlement Agreement is approved by the Court based on achieving Maintenance of Effort status and sustaining substantial compliance for one year on all remaining provisions of the Implementation Plan.
VI. Confidentiality
The Confidentiality Order entered by this Court (Dkt. No. 12) shall remain in full force and effect during the implementation and monitoring of the Settlement Agreement. All communications concerning the Settlement Agreement's negotiation shall be confidential to the fullest extent permitted by law.
VII. Attorneys' Fees and Expenses
A. For Plaintiffs' attorneys' fees and expenses through the date of final approval by the Court of this Final Settlement Agreement, the parties agree to submit the amount and terms of fees and expenses to final and binding arbitration by the Mediator, Senior U.S. District Judge P. Michael Duffy, as the sole Arbitrator. The amount of reasonable fees and expenses awarded by the Arbitrator will be issued in a public Arbitration Award, which will be incorporated into this Final
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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2:15-cv-00134-RMG
Settlement Agreement and which may also be entered by the Court as a judgment ifnecessary.
B. For Plaintiffs' attorneys' fees and expenses after the date of final approval by the Court of this Final Settlement Agreement, the parties agree to negotiate and mediate through the Court-appointed Mediator for at least thirty (30) days the amount of fees and expenses since the last payment of fees and expenses by Defendants to Plaintiffs; and only after that time and if the Mediator declares an impasse 'Yill Plaintiffs file any petition for fees and expenses with the Court.
VIII. Miscellaneous
A. The Settlement Agreement may be modified upon the consent of the parties and approval of the Court.
B. DSS shall bear all costs of notice prescribed by the Court pursuant to Fed. R. Civ. P. 23 in connection with the process for final Court approval of this Settlement Agreement.
C. The Settlement Agreement constitutes the entire agreement between the parties with regard to the subject matters contained therein, and hereby supersedes all prior agreements, representations, statements, negotiations, and undertakings.
D. All parties to the Settlement Agreement have participated in its drafting and, consequently, any ambiguity shall not be construed either for or against any party.
AND IT IS SO ORDERED:

Dated:

THE HONORABLE RICHARD M. GERGEL U.S. DISTRICT JUDGE

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2:15-cv-00134-RMG Date Filed 06/03/16 Entry Number 32-1 Page 21 of 25 Final'Settlement Agreement in Michelle H., el al. v. Haley and Alford, 2: 15-cv-OO 134-RMG Respectfully Agreed to and Submitted by:
THE HONORABLE St: SAN ALFORD DIRECTOR OF THE SOUTll CAROLINA DEPARTMENT OF SOCIAL SERVICES
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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2:15-cv-00134-RMG Respectfully Agreed to and Submitted by:
THE HONORABLE NIKKI HALEY GOVERNOR OF THE STATE OF SOUTH CAROLINA
DIRECTOR OF THE SOUTH AROLINA DEPARTMENT OF SOCIAL ERYICES
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Final Settlement Agreement in Mich elle H. , et al. v. Haley and Alford, 2: 15-cv-00134-RMG
P. Tod (ID No. 312 ) (ID No. 1036)
J. Michael Montgomery (ID No. 10290) Alex E. Davis (ID No. 11323) SOWELL GRAY STEPP & LAFFITTE, LLC Post Office Box 11449 Columbia, South Carolina 29211 (803) 929-1400 Attorneys for Defendant Susan Alford, in her official capacity as State Director of the South Carolina Depai1ment of Social Services
Karl S. Bowers, Jr. (ID No. 7716) BOWERS LAW FIRM Post Office Box 50549 Columbia, South Carolina 29250 (803) 753-1099 Attorney for Defendant Nikki Haley, in her official capacity as Governor of the State of South Carolina
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Monteith P. Todd (ID No. 3125) Rebecca Laffitte (ID No. 1036) J. Michael Montgomery (ID No. 10290) Alex E. Davis (ID No. 11323) SOWELL ORA Y STEPP & LAFFITTE, LLC Post Office Box I 1449 Columbia, South Carolina 29211 (803) 929-1400 Attorneys for Defendant Susan Alford, in her official capacity as State Director of the South Carolina Department of Social Services
~~~~~P Karl S. Bowers, Jr. (ID No. 7716 BOWERS LAW FIRM Post Office Box 50549 Columbia, South Carolina 29250 (803) 753-1099 Attorney for Defendant Nikki Haley, in her official capacity as Governor of the State of South Carolina
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Final Settlement Agreement in Michelle H., et al. v. Haley and Alford, 2: 15-cv-00134-RMG
801 Gervais Street, Suite B Columbia, SC 29201 Telephone: (803) 254-6542 Facsimile: (803) 254-6544
Ira Lustbader Christina Wilson Remlin Kathryn A. Wood Sarah T. Russo Aaron H. Finch CHILDREN'S RIGHTS 88 Pine Street, Suite 800 New York, New York 10005 Telephone: 212-683-2210 Facsimile: 212-683-4015
Susan Berkowitz (ID No. 1305) Stephen Suggs (ID. No. 7525) SOUTH CAROLINA APPLESEED LEGAL JUSTICE CENTER P.O. Box 7187 Columbia, S.C. 29202 Telephone: (803) 779-1113 Facsimile: (803) 779-5951
Attorneys for Plaintiffs
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 2:15-cv-00134-RMG Date Filed 09/13/17 Entry Number 63-1 Page 1 of 86
Michelle H., et al. v. McMaster and Alford
Monitoring Period I (October 1, 2016 – March 31, 2017)
Progress of the South Carolina Department of Social Services
Co-Monitors: Judy Meltzer & Paul Vincent
Co-Monitor Staff: Rachel Paletta Elissa Gelber Gayle Samuels
September 13, 2017

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Michelle H., et al. v. McMaster and Alford Progress Report for the Period October 1, 2016 – March 31, 2017
TABLE OF CONTENTS
I. INTRODUCTION .........................................................................................................1 II. SUMMARY OF PERFORMANCE .............................................................................1 III. MONITORING ACTIVITIES ......................................................................................6 IV. SUMMARY TABLE OF MICHELLE H., et al. v. MCMASTER and ALFORD
FINAL SETTLEMENT AGREEMENT PERFORMANCE.........................................8 V. CASELOADS ............................................................................................................34 VI. CASEWORKER-CHILD VISITATION.....................................................................37 VII. INVESTIGATIONS ....................................................................................................40 VIII. PLACEMENTS ...........................................................................................................53 IX. FAMILY VISITATION...............................................................................................63 X. HEALTH CARE ..........................................................................................................66
APPENDICES A. Glossary of Acronyms…………………………………………………………...70 B. Co-Monitors Initial Monitoring Plan (February 1, 2017)………………………..71 C. Workload Estimation Study Methodology (February 22, 2016)………………...74 D. Placement Needs Assessment Methodology (December 27, 2016)……………..75

2:15-cv-00134-RMG Date Filed 09/13/17 Entry Number 63-1 Page 3 of 86
LIST OF TABLES
TABLE 1. Summary Performance on Settlement Agreement Requirements…………………………….8 2. Status of Implementation Plans and Assessments…………………………………………...24 3. Caseworker Caseload Limits and Supervisor Limits………………………………………...35 4. Good Faith Efforts to Contact Alleged Victim Children…………………………………….45 5. Extraordinary Circumstance Exceptions to Contact with Alleged Victim Children………...46 6. Exceptions to Contact with Core Witnesses…………………………………………………47 7. Examples of Good Cause Reasons to Extend Investigation Timeframes……………………50 8. Types of Placement for Children in Foster Care (March 2017)……………………………..57 9. Types of Placement for Children Age 12 and Under in Foster Care (March 2017)…………57 10. Exceptions for Placement of Children Age Six and Under
in Non-Family-Based Placements…………………………………………………………...58 11. Children Placed with their Siblings (January 1, 2017)………………………………………63 12. Approved Exceptions to Sibling Visitation Requirement…………………………………...65 13. Approved Exceptions to Parent and Child Visitation Requirement…………………………66 14. Completion of Initial Medical, Dental and Mental Health Assessments for Children
(October 5, 2016 – January 5, 2017)………………………………………………………...69

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LIST OF FIGURES
FIGURE 1. Monthly Face-to-Face Caseworker Visits with Children
(October 2016 – March 2017)…..............................................................................................38 2. Monthly Face-to-Face Caseworker Visits With Children in Their Residence
(October 2016 – March 2017)………………………………………………………………..39 3. Appropriateness of Decision Not to Investigate Referral (Alleging) Institutional Abuse
(and/)or Neglect (August 1, 2016 – January 31, 2017)………………………………………43 4. Reason for Reviewer Disagreement with Decision Not to Investigate Referral (August 1,
2016 – January 31, 2017)…………………………………………………………………….44 5. Timely Initiation of Investigations (June – November 2016)………………………………..46 6. Contact with All Necessary Core Witnesses during the Investigation
(June – November 2016)…………………………………………………………………..…48 7. Decision to Unfound Investigation Deemed Appropriate
(June – November 2016)…………………………………………………………………......49 8. Timely Completion of Investigations (June – November 2016)…………………………….51 9. Children Ages Six and Under in Congregate Care (October 2016 – March 2017)………….59 10. Visits Between Siblings Not Placed Together (March 2017)………………………………..65

2:15-cv-00134-RMG Date Filed 09/13/17 Entry Number 63-1 Page 5 of 86

Michelle H. et al. v. McMaster and Alford Progress Report for the Period October 1, 2016 – March 31, 2017

I. INTRODUCTION

This is the first report on the progress of the South Carolina Department of Social Services (DSS) in meeting the requirements of the Final Settlement Agreement (FSA), entered in Michelle H., et al. v. McMaster and Alford. Approved by the United States District Court on October 4, 2016, the FSA includes requirements governing the care and treatment of the more than 4,000 children in foster care in South Carolina1 and incorporates provisions that had been ordered in the previous year in a Consent Immediate Interim Relief Order (the Interim Order)2. The report has been prepared by court-appointed independent Co-Monitors Paul Vincent and Judith Meltzer, with assistance from monitoring staff Rachel Paletta, Elissa Gelber and Gayle Samuels, and is presented to The Honorable Richard Gergel, U.S. District Court Judge, Parties to the lawsuit (Governor McMaster, DSS and Plaintiffs) and the public.

The result of a long negotiating process, the FSA outlines DSS’s obligations to significantly improve experiences and outcomes for the children in its care. Conceived to guide a multi-year reform effort, the FSA reflects DSS’s commitment to remediating long-standing problems in the operation of South Carolina’s child welfare system and includes a broad range of provisions governing: caseworker caseloads; visits between children and their caseworkers and family members; investigations of allegations of abuse and neglect of children in foster care; appropriate and timely foster care and therapeutic placements; and access to physical and mental health care. What follows is a discussion of the Co-Monitors’ general findings and themes, as well as detailed discussion of each FSA requirement and progress made during this monitoring period. As required by the FSA, the Co-Monitors will release reports addressing ongoing progress reports on the FSA requirements on a twice-annual basis.3

II. SUMMARY OF PERFORMANCE
DSS and its staff have demonstrated a commitment to reforming its foster care system in the two years since entry of the Interim Order. They have worked closely with the Co-Monitors, as well as others within and outside of DSS, to understand the infrastructure, operational and practice issues that underlie the problems identified in the FSA, and have made deliberate efforts to comply with the FSA requirements. DSS quickly appointed a new internal monitoring team and has been
1 The class of children covered by the FSA includes “all children who are involuntarily placed in DSS foster care in the physical or legal custody of DSS now or in the future” (FSA II.A.). 2 Consent Immediate Interim Relief Order, (September 28, 2015). 3 FSA III.D. Pursuant to FSA III.K., “The Co-Monitors shall not express any conclusion as to whether the Defendants have reached legal compliance on any provision(s).”

Michelle H., et al. v. McMaster and Alford Progress Report for the Period October 2016 – March 2017

September 13, 2017 Page 1

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consistently responsive to all Co-Monitor feedback and requests. DSS took early action to reduce the number of children ages six and under placed in congregate care facilities and to prohibit overnight stays in offices and hotels as part of initial work to implement a significant shift in practice. In addition, according to data reviewed to date on the frequency and location of caseworker visits with children in the class, DSS also appears to be meeting the FSA requirements for caseworker visitation, highlighting the commitment of its caseworkers to make efforts to maintain monthly contact with children even in the face of unmanageable caseloads.
In the vast majority of areas covered by the FSA, however, a lot of work needs to be done. Current assessments and performance data indicate that there is not a sufficient array of appropriate placement resources in most areas of the state to allow children to be placed close to their families and communities; lapses exist in the provision of diagnostic, preventative and ongoing health care to children; quality issues are present in the screening and investigation of reports of abuse or neglect of foster children; and there are a lack of reliable child welfare data. In addition, though data integrity and methodology issues have made it impossible for DSS and the Co-Monitors to calculate worker caseloads this reporting period, DSS acknowledges that caseworker caseloads throughout the state far exceed agreed upon standards.
All Parties recognize that achieving compliance with the FSA will require a major shift in DSS’s operations, a significant investment of resources and a deepening of system capacity in multiple areas. It is for this reason that the FSA incorporates staged implementation over several years. Much of the early work required in this first monitoring period is in the form of baseline assessments, establishment of benchmarks, strategy planning and capacity development. Parties understand that these are foundational steps that will structure progressive improvements towards court-ordered final outcomes.
The Co-Monitors have identified some themes in its initial work with DSS and have discussed with DSS the importance of addressing them expediently for progress to take hold. Included below is a summary of these themes, along with Co-Monitor recommendations for actions DSS can take to address them.
Additional internal capacity and resources are needed to meet the requirements of the FSA
DSS has formed a team to implement the FSA through the addition of an Internal Monitoring Team, compromised of an Internal Class Action Lawsuit Monitor and a Data Coordinator. They will move forward this fall with hiring a third member of the team with child welfare practice experience. In addition, DSS is currently reorganizing the child welfare division so that responsibilities for core areas of child welfare reform can be spread across a broader leadership base. In the Co-Monitors view, however, DSS has not mustered the resources and the internal capacity needed to intensively drive reform. With very few exceptions, the individuals responsible for the significant planning and capacity-building aspects of the reform are also responsible for day-to-day child welfare operations and have roles that are already complex, demanding and time consuming. Reforming a foster care system with more than 4,000 children in care at any given

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moment is not an easy task, especially if that system has been under-resourced for many years, as is true in South Carolina.
This challenge has been evidenced in the process that DSS has gone through during the first and second monitoring period to develop the many Implementation Plans required by the FSA. Although DSS has tried valiantly to comply with applicable timeframes by submitting initial proposed drafts on time, it was unable to produce plans in any content area with benchmarks and outcomes that could be approved by the Co-Monitors and are acceptable to Plaintiffs.4 The CoMonitors continue to be concerned about a lack of baseline data and enforceable benchmarks, as well as some of the proposed timelines for implementation, many of which reflect DSS’s legitimate concerns about the limited human and financial resources they have available to do this work.
Co-Monitor Recommendations:
 There must be an infusion of resources to drive reform. As the FSA states, “The Defendants shall make all reasonable efforts to provide funding and other resources necessary to implementation and achievement of the obligations under the Settlement Agreement. Defendants’ failure to provide or Defendants’ efforts to provide such adequate funding and resources shall not excuse and shall not limit remedies to address the failure to implement or achieve any of the obligations set forth in the Settlement Agreement” (FSA I.I.). DSS has estimated in its May 31 and August 9, 2017 draft Implementation Plans that it will need to hire an additional 670 caseworkers to meet caseload standards. This cannot be done without significant additional resources both to recruit and hire quality staff, but also—and just as importantly—to house, equip, properly train, supervise and support caseworkers so that they remain over the long term. Further, education and experience requirements and salaries for caseworkers need to be recalibrated to compete with those in neighboring states to ensure an adequate pool of candidates willing and able to do this very difficult job. DSS recognizes these as necessary and has included some action related to them in its draft Implementation Plans, but has proposed delayed timelines based on its expectations for funding availability.
 DSS needs to augment the internal leadership team charged with developing, managing and coordinating the reform work required by the FSA. While the CoMonitors recognize and support DSS’s interest in involving mid-managers and line staff in the reform planning process, this work cannot be successfully driven by those also charged with the complex and challenging task of managing the day-to-day operations.

4 After multiple re-drafts in response to Co-Monitor comments and discussions, on September 11, 2017, the Co-Monitors approved the Implementation Plan for Out-of-Home Abuse and Neglect (OHAN) investigative practice. The remaining step for a fully approved plan is to request and receive consent from Plaintiffs.

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 DSS should invest in developing and supporting new partnerships with private providers to create and implement a strategic plan to redeploy resources. Funding currently devoted to more restrictive congregate care placements can be directed to a full array of community-based, family placement resources. Private providers have indicated a willingness to work closely with DSS to find new ways to provide safe and stable placements for children close to their families and communities but they need to be engaged as partners and supported by DSS in planning for and managing this important transition.
The FSA requirements must be nested within a broader vision for reform
At the FSA Fairness Hearing, Director Alford testified about the importance of understanding the FSA commitments within the context of DSS’s broader effort to make South Carolina’s child welfare system more effective for children, youth, families and communities. While the FSA contains specific requirements that can be identified, quantified and measured, successful reform requires a broader vision that is driven by the values, goals and principles of DSS. These need to be consistently understood, enunciated and recognized by DSS staff at all levels, as well as by external partners, including parents, private providers, community-based resource providers, judges, attorneys and guardian ad litems (GALs), all of whom will together drive the reform.
Co-Monitor Recommendations:
 DSS needs to thoroughly and rapidly develop and begin implementation of a consistent model of case practice. This model should rely heavily on a set of practice principles which relate to the goals and principles of DSS, and, for example, set expectations for meaningful engagement with children and families, including involvement in assessment of underlying needs, case planning and decision-making. The model should also inform the design of staff training, agency policies and an array of development and performance management processes.
 DSS should ensure that its training curricula and practices and its management, supervision and quality assurance processes are aligned with and designed to measure fidelity of practice to its case practice model.
DSS needs to focus on fundamentals
The need for focus on fundamentals is consistently apparent in the Co-Monitors’ work with DSS this monitoring period. As DSS understands, this means not only the development of a case practice model as described above, but shoring up and, in some cases, creating a functional infrastructure for the work. This includes systems for collecting and utilizing reliable data; human resources and administrative capacity to recruit, hire, train and retain new caseworkers and supervisors; and a Continuous Quality Improvement (CQI) process that is closely tied to agency management and that can provide quantitative and qualitative information for managers, supervisors and direct practice caseworkers on the effectiveness of their work.

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In its work with DSS to extract baseline data needed to move forward with the FSA requirements, the Co-Monitors have had a close look at DSS data systems and capacity. DSS’s automated data system, Child and Adult Protective Services System (CAPSS), is the repository for information on case details, status and progress and is used for internal management reports, as well as reports to the Co-Monitors and the federal government. Despite consistent efforts by a small, dedicated staff, issues with the quality of documentation and the integrity of CAPSS data are pervasive, and the Co-Monitors have significant concerns with the way in which some data are entered by caseworkers or, in some cases, not entered at all. Additionally, DSS lacks mechanisms for ongoing oversight and accountability for data entry and consistency in definitions utilized in CAPSS. As discussed throughout this report, these issues have presented significant challenges in attempting to collect baseline data for the FSA requirements, including in such areas as supervisor workloads, visitation standards, placement type and stability and healthcare. Most recently, DSS and the CoMonitors discovered that data regarding children’s permanency goals—essential for any child welfare system and required for reporting to the federal government—were not accurate in a significant percentage of cases. Problems such as these need to be corrected immediately. Data integrity issues are not uncommon for child welfare systems, but fixing them can be difficult and requires that management, program and data staff work together in a focused way.
In terms of workforce capacity, DSS leaders have committed to hiring, training and supporting a sufficient number of caseworkers to meet FSA caseload standards over a four-year period. This is a significant undertaking, even if DSS had the necessary resources. It also requires a coordinated strategy that includes training, policy and practice changes needed to support caseworkers and supervisors in carrying out their work consistent with DSS’s reform vision.
Co-Monitor Recommendations
 There needs to be a comprehensive external audit of DSS’s CAPSS system, including an assessment of its architecture and the processes in place to ensure accurate and reliable data. The Co-Monitors believe this will require the engagement of an outside consultant who will work with DSS to assess for and implement recommended changes so that DSS has a system on which it can rely on to easily and routinely provide accurate data for both management and operations. The Co-Monitors spent significant time during the first monitoring period validating data necessary for reporting and are still not fully confident that what is being produced is reliable.
 DSS needs to build a robust CQI process that utilizes both quantitative and qualitative data for measuring performance and quality of service provision, providing accountability and promoting learning and improvement. The CQI processes should specifically seek information about DSS fidelity to key practice principles and include face-to-face interviews with children, families, DSS staff and external stakeholders about their experiences with DSS. Further, increasing the reliability and use of CAPSS data as part of CQI processes will also be critical.

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 DSS needs to more fully develop an operational plan for the recruiting, onboarding, training and provision of ongoing support for the caseworkers and supervisors it anticipates hiring between now and 2020. This will require close coordination with human resources and facility staff, the University of South Carolina Center for Children and Family Studies (USC CCFS) and county and regional leadership, among others.
III. MONITORING ACTIVITIES
Pursuant to the FSA, the Co-Monitors are responsible for factual investigation and verification of data and documentation to compile and issue public reports on performance with respect to the terms of the FSA. In carrying out this responsibility, the Co-Monitors and their staff have worked closely with DSS leadership and staff. The Co-Monitors used multiple methodologies to conduct their work, including verification and analysis of information available through CAPSS; independent review of individual case records; review and validation of data aggregated by DSS; and conversations with DSS leaders and staff. The Co-Monitors conducted site visits to three local DSS offices, where they met with managers, frontline staff, GALs and providers; and to four congregate care facilities. The Co- Monitors also met and spoke with a range of other child welfare stakeholders in an effort to fully understand issues relevant to DSS reform. Attached as Appendix B is the preliminary monitoring plan developed by the Co-Monitors and submitted to Parties and the Court on February 1, 2017.
The FSA gives the Co-Monitors the responsibility to review and approve plans and to approve or set performance benchmarks and outcomes in multiple areas. As a result, the Co-Monitors have worked with DSS and USC CCFS5 to establish review protocols to assess current practice and performance and to gather baseline data. In so doing, the Co-Monitors and their staff have assumed a technical assistance role in addition to a strict monitoring function, helping to build capacity in DSS and USC CCFS staff and connect its leaders and managers with people and resources from across the country. The Co-Monitors strongly believe that this type of collaboration and use of external technical assistance is critical to DSS’s ability to successfully reform its child welfare system.
Finally, the Co-Monitors have been engaged with Plaintiffs’ counsel to both understand their views of the problems the FSA is designed to address and to keep them informed of DSS’s progress in meeting deliverables. Where required by the FSA, the Co-Monitors have elicited feedback from Plaintiffs – most recently with respect to DSS’s draft Implementation Plans – and have worked with them to build consensus, particularly with respect to commitments that require consent by all Parties. In general, the Co-Monitors believe that open communication with Plaintiffs and between

5 DSS contracts with USC CCFS to complete all required and necessary case reviews and quality assurance activities.

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Plaintiffs, DSS and the Co-Monitors will be an important element of constructive planning and implementation under the FSA.

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IV. SUMMARY TABLES OF MICHELLE H., et al. v. MCMASTER and ALFORD FINAL SETTLEMENT AGREEMENT REQUIREMENTS

Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Workload Limits for Foster Care:
A foster care Workload Limit must apply to every Caseworker and to every Caseworker’s supervisor. DSS may identify categories of Caseworker or Supervisor or both and set a different Workload Limit for each category.
(FSA IV.A.2.(b)&(c))

1a. At least 90% of caseworkers shall have a workload within the applicable Workload Limit.
1b. No caseworker shall have more than 125% of the applicable Workload Limit.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Approved Caseworker Limits:7  OHAN investigator: 1 caseworker: 8 investigations  Foster Care caseworker: 1 caseworker: 15 children  IFCCS caseworker: 1 caseworker: 9 children  Adoptions caseworker: 1 caseworker: 17 children  New worker: ½ of the applicable standard for
his/her first 6 months after completion of Child Welfare Basic
Approved Supervisor Limits:  For Foster Care, IFCCS and Adoptions supervisors:
1 supervisor: 5 caseworkers  OHAN supervisors: 1 supervisor: 6 investigators

2a. At least 90% of supervisors shall have a workload within the applicable Workload Limit.
2b. No supervisor shall have more than 125% of the applicable Workload Limit.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved

Data are not available for this period.8
DSS caseworkers may have more than one type of case on their caseloads, including Class Members and non-Class Members9. The methodology for assessing caseloads has not been approved by the Co-Monitors.
DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.
Data are not available for this period.10

6 The obligations for the workload study (FSA IV.A.1.), placement needs assessment (FSA IV.D.1.) and select placement limitations (FSA IV.D.2., 3. & H.1.) became operative as
of September 28, 2015, when the Consent Immediate Interim Relief Order was entered. Therefore, the Interim Relief Order requirements are incorporated into the FSA. 7 These limits were approved by the Co-Monitors on December 6, 2016 after completion of the Workload Study. 8 See discussion in Section V of this report. 9 Non-Class Members include children receiving family preservation services while remaining in the home with their parent or caregiver and Adult Protective Services cases. 10 DSS has informed the Co-Monitors that data for this measure are not currently available. Data clean-up in CAPSS is necessary to accurately reflect all supervisors who are
managing caseworkers with Class Members on their caseload. DSS has represented to the Co-Monitors that the clean-up process will be completed by September 30, 2017.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Caseworker-Child Visitation: (FSA IV.B.2.&3.)

3. At least 90% of the total minimum number of face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place.

Based on CAPSS data, monthly performance for caseworker visits to Class Members are below.11
October 2016: 98% November 2016: 97% December 2016: 97% January 2017: 98% February 2017: 97% March 2017: 98%

4. At least 50% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place in the residence of the child.

Based on a CAPSS data, monthly performance for caseworker visits to Class Members in their placement are below.12
October 2016: 71% November 2016: 68% December 2016: 69% January 2017: 69% February 2017: 67% March 2017: 70%

11 Co-Monitor staff completed a limited validation of these data, assessing only for frequency and location of visits, as described in Section VI of this Report. DSS appears to be meeting the caseworker visitation measures with respect to the frequency and location of worker-child visits. Plaintiffs have requested that the Co-Monitors perform a more in-depth review of visitation data and documentation in the future to assess the content of caseworker visits with children, based on their reading of the applicable FSA provisions. 12 Ibid.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Investigations – Intake: (FSA IV.C.2.)

5. At least 95% of decisions not to investigate a Referral of Institutional Abuse or Neglect about a Class Member must be made in accordance with South Carolina law and DSS policy.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Between August 1, 2016 and January 31, 2017, there were 128 referrals with decisions not to investigate involving a Class Member; 44% (56) of the screening decisions were determined to be appropriate.13

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

Investigations – Case Decisions: (FSA IV.C.3.)

6. At least 95% of decisions to “unfound” investigations of a Referral of Institutional Abuse or Neglect must be based upon DSS ruling out abuse or neglect or DSS determining that an investigation did not produce a preponderance of evidence that a Class Member was abused or neglected.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Between June and November 2016, there were 94 investigations with decisions to unfound; 47% (44) of these decisions were determined to be appropriate.14
DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

13 Data were collected during a review conducted by USC CCFS and Co-Monitor staff in March 2017 of all applicable referrals made to OHAN for which there was a decision not to investigate. The total number of referrals that were not accepted for investigation during the period under review was larger than 128, however, some referrals were determined not to be applicable for review because the alleged victim child was not a Class Member (i.e., the child was voluntarily placed by the legal guardian or through ICPC from another state or was the biological child of the caregiver). DSS has represented to the Co-Monitors that all referrals of abuse and neglect in licensed foster homes, residential facilities and group homes across the state involving Class Members are received by or forwarded to OHAN for screening and investigation, as appropriate, and that screening decisions are not made by local office or Intake HUB staff. 14 Data were collected during a review conducted by USC CCFS and Co-Monitor staff between March and June 2017 of all applicable investigations completed by OHAN with decisions to unfound the allegations.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Investigations – Timely Initiation: (FSA IV.C.4.(a))

7. The investigation of a Referral of Institutional Abuse or Neglect must be initiated within twenty-four (24) hours in accordance with South Carolina law in at least 95% of the investigations.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Between June and November 2016, of 107 applicable investigations, 78% (83) were timely initiated or had documentation supporting completion of all applicable good faith efforts.15
DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

Investigations – Contact with Alleged Child Victim (FSA IV.C.4.(b))

8. The investigation of a Referral of Institutional Abuse or Neglect must include face-to-face contact with the alleged victim within twenty-four hours in at least 95% of investigations, with exceptions for good faith efforts approved by the Co-Monitors.
Dates to reach final target and benchmarks to be added once Implementation Plan is approved.

Between June and November 2016, of 107 applicable investigations, 78% (83) were timely initiated or had documentation supporting completion of all applicable good faith efforts.16, 17
DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

15 Data were collected during a review conducted by USC CCFS and Co-Monitor staff between March and June 2017 of all applicable investigations completed by OHAN during the period under review. Contact was made with the alleged victim child(ren) within 24 hours in 81 investigations and in an additional two investigations, documentation supported completion of all applicable good faith efforts. 16 Ibid. 17 The Co-Monitors interpretation of the FSA requires that investigations be initiated within 24 hours of receipt of the referral by DSS, not within 24 hours of the decision to accept the referral, and that initiation is completed by making face-to-face contact with the alleged victim child(ren). As a result, the performance for both FSA measures IV.C.4.(a) and (b) are measured using the same methodology and timeframes – the time between receipt of referral and face-to-face contact with alleged child(ren) victim must be within 24 hours.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Investigations – Contact with Core Witnesses (FSA IV.C.4.(c))

9. Contact with core witnesses must be made in at least 90% of the investigations of a Referral of Institutional Abuse or Neglect, with exceptions approved by the Co-Monitors. Core witnesses will vary from case to case and may or may not include the victim(s), Class Members, alleged perpetrators, reporter (if identified), identified eyewitness(es), other children in the placement, facility staff, treating professionals, and foster parents or caregivers as deemed to be relevant to the investigation.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Between June and November 2016, of 107 applicable investigations, contact was made with all necessary core witnesses for whom there was no approved exception in 27% (29) of cases.18
DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

Investigations – Timely Completion: (FSA IV.C.4.(d-f))

10.a. At least 60% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within forty-five (45) days of initiation of an investigation, unless the DSS Director or DSS Director’s designee authorizes an extension of no more than fifteen (15) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

95% of applicable investigations received
between June and November 2016 were appropriately closed within 45 days.19

18 Data were collected during a review conducted by USC CCFS and Co-Monitor staff between March and June 2017 of all applicable investigations completed by OHAN during the period under review. 19 Of the 107 investigations received between June and November 2016, two investigations are excluded from the 45 day compliance measure as extension requests for 15 days were submitted and approved by the OHAN Director. Of the remaining 105 investigations, 104 investigations were completed within 45 days, however, reviewers determined that four of the investigations closed within 45 days were closed as unfounded prematurely in an effort to meet the 45 day requirement. Therefore, the review determined that 100 of the 105 applicable investigations met the FSA standard.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

10.b. At least 80% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within sixty (60) days of initiation of the investigation, and all investigations not completed within sixty (60) days shall have authorization of the DSS Director or DSS Director’s designee of an extension of no more than thirty (30) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

96% of applicable investigations received
between June and November 2016 were appropriately closed within 60 days.20

10.c. At least 95% of all investigations of a Referral of Institutional Abuse or Neglect not completed within sixty (60) days shall be completed within ninety (90) days. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

All investigations received between June and November 2016 were completed within 60 days; therefore, this measure was not applicable this period.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

20 Although all 107 investigations were closed within 60 days of initiation, four investigations were determined to be closed prematurely in an effort to meet the deadline and are not considered as compliant.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Family Placements for Children Ages 6 and Under:
Within sixty (60) days, DSS shall create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the Co-Monitors, the placement of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers). The plan shall include full implementation within sixty (60) days following approval of the Co-Monitors.

11. No child age 6 and under shall be placed in a congregate care setting except with approved exceptions.

There were 142 children ages six and under in congregate care in November 2015. Since that time, this number has continuously declined. By October 2016, there were 17 children ages six and under in congregate care and in March 2017, only six children. The circumstances of five of those six children met an agreed upon exception for placement in congregate care.21

(FSA IV.D.2.)

21 Data about the number of children ages six and under age in a congregate setting and their circumstances was submitted by DSS but have not been validated by the Co-Monitors.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Phasing-Out Use of DSS Offices and Hotels:
Within sixty (60) days, DSS shall cease using DSS offices as an overnight placement for Class Members, and shall cease placing or housing any Class Members in hotels, motels and other commercial non-foster care establishments. For any Class Members moved out of such DSS Offices or Hotels, DSS shall provide for their appropriate placement. In the extraordinary event that a child stays overnight in a DSS office, Defendants shall immediately notify the Co-Monitors, who shall provide a report to Parties as appropriate, including whether or not, in their view, the incident should be reported to the Court as a violation which would preclude Defendants’ ability to achieve compliance on this provision.

12. No child shall be placed or housed in a DSS office, hotel, motel, or other commercial non-foster care establishment.

As of November 28, 2015, DSS was prohibited by the Interim Order from placing or housing children in DSS offices or hotels. Between November 28, 2015 and March 31, 2017, three children were reportedly22 housed overnight in a DSS office.23

(FSA IV.D.3.)

Congregate Care Placements: (FSA IV.E.2.)

13. At least 86% of the Class Members shall be placed outside of Congregate Care Placements on the last day of the Reporting Period.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

In March 2017, 78% (3,223 of 4,124) of all children in foster care were placed outside of a congregate care setting.24
Interim Benchmarks and timelines to meet final target are not yet set.

22 Data are based on self-report by DSS local offices and have not been validated by the Co-Monitors. 23 As reported by DSS, the first two of these placements took place on January 6, 2016, and involved two children, ages 12 and 13. Both children presented with challenging behaviors, one child had specific placement requirements, and despite efforts, placements were not obtained for them on that day. The third placement occurred on October 20, 2016. The child,
who was 14-years old, was ordered into DSS custody at his Department of Juvenile Justice (DJJ) court proceeding earlier that day. Numerous efforts were made throughout the day by DSS staff at all levels to find an appropriate placement for this child, however, placement was not secured and the child stayed overnight at the office. 24 Data about the number of children in a congregate setting was provided by DSS but have not been validated by the Co-Monitors.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Congregate Care Placements – Children Ages 12 and Under:
(FSA IV.E.3.)

14. At least 98% of the Class Members twelve (12) years old and under shall be placed outside of Congregate Care Placements on the last day of the Reporting period unless an exception pre-approved or approved afterwards by the Co-Monitors is documented in the Class Member’s case file.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

In March 2017, 91% (2,630 of 2,905) of children age 12 and under in foster care were placed outside of a congregate care setting. 25, 26
Interim Benchmarks and timelines to meet final target are not yet set.

Emergency or Temporary Placements for More than 30 Days:
(FSA IV.E.4.)

15. Class Members shall not remain in any Emergency or Temporary Placement for more than thirty (30) days. Under exceptions subject to the Co-Monitors’ approval, if a child is initially placed in an Emergency or Temporary Placement that is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the redesignation shall not be considered a placement move under Section IV.F.1 below.

Data are not available for this period. 27
Interim Benchmarks and timelines to meet final target are not yet set.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved

25 Ibid. 26 Exceptions to this standard have not yet been approved by the Co-Monitors; therefore, performance analysis does not consider any exceptions. 27 The Co-Monitors have not been provided with data for this measure. The Co-Monitors anticipate that more information regarding methods to develop and implement data collection for analysis and monitoring will be included in the Placement Implementation Plan due to be complete by October 31, 2017 (60 days from delivery of the Placement Needs Assessment
on August 31, 2017).

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Emergency or Temporary Placements for More than 7 Days:
(FSA IV.E.5.)

16. Class Members experiencing more than one Emergency or Temporary Placement within twelve (12) months shall not remain in the Emergency or Temporary Placement for more than seven (7) days. Under exceptions subject to the Co-Monitors’ approval, if a child’s subsequent placement within twelve (12) months in an Emergency or Temporary Placement is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move under Section IV.F.1 below.

Data are not available for this period. 28
Interim Benchmarks and timelines to meet final target are not yet set.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Placement Instability: (FSA IV.F.1.)

17. For all Class Members in foster care for eight (8) days or more during the 12-month period, Placement Instability shall be less than or equal to 3.37.

Data are not available for this period.

28 Ibid.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Sibling Placements: (FSA IV.G.2.&3.)

18. At least 85% of Class Members entering foster care during the Reporting Period with their siblings or within thirty (30) days of their siblings shall be placed with at least one of their siblings unless one or more of the following exceptions apply: (1) there is a court order prohibiting placing all siblings together; (2) placement is not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) additional exceptions as approved by the Co-Monitors.

As of January 1, 2017, 70% of children in care 30 days or longer were placed with at least one of their siblings. 29, 30
Interim Benchmarks and timelines to meet final target are not yet set.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

19. At least 80% of Class Members entering foster care during the Reporting Period with their siblings or within thirty (30) days of their siblings shall be placed with all their siblings, unless one or more of the following exceptions apply: (1) there is a court order prohibiting placing all siblings together; (2) placement is not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) additional exceptions as approved by the Co-Monitors.

As of January 1, 2017, 37% of children in care 30 days or longer were placed with all of their siblings. 31, 32
Interim Benchmarks and timelines to meet final target are not yet set.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

29 Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier. 30 Exceptions to this standard have not yet been approved by the Co-Monitors and data were not provided to indicate instances in which a court order prohibited placement or in
which the placement was determined not to be in the best interest of one or more siblings. Therefore, performance analysis does not consider any exceptions. 31 Ibid. 32 Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Youth Exiting the Juvenile Justice System: (FSA IV.H.1.)

20. When Class Members are placed in juvenile justice detention or another Juvenile Justice Placement, DSS shall not recommend to the family court or Department of Juvenile Justice that a youth remain in a Juvenile Justice Placement without a juvenile justice charge pending or beyond the term of their plea or adjudicated sentence for the reason that DSS does not have a foster care placement for the Class Member.
DSS shall take immediate legal and physical custody of any Class Member upon the completion of their sentence or plea. DSS shall provide for their appropriate placement.

The Interim Order requirement that prohibited the maintenance of youth in Juvenile Justice Placements took effect on September 28, 2015. Between September 28, 2015 and March 31, 2017, DSS has reported that it is aware of two youth who were held in detention awaiting an available DSS placement.33 DSS has acknowledged, however, that it does not yet have a reliable system in place for tracking compliance with this provision so this may be an underrepresentation of actual incidences.

Therapeutic Foster Care Placements –Referral for Staffing and/or Assessment:
(FSA IV.I.2.)

21. All Class Members that are identified by a Caseworker as in need of interagency staffing and/or in need of diagnostic assessments shall be referred for such staffing and/or assessment to determine eligibility for therapeutic foster care placement and/or services within thirty (30) days of the need being identified. This requirement shall not apply if the Caseworker withdraws the identified need in good faith and in the best interests of the Class Member within thirty (30) days.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Data are not available for this period.34
Interim Benchmarks and timelines to meet final target are not yet set.

33 In December 2015, a youth remained in detention, at the order of a judge, because DSS was unable to find a placement for him. After more than a month, he was placed in an outof-state facility. In September 2016, a youth remained at a detention center for seven days awaiting placement in a group home, upon judicial order. 34 DSS has informed the Co-Monitors that data for this measure are not currently available as fields need to be added to CAPSS to capture and collect necessary information. The Co-Monitors anticipate that more information regarding methods to develop and implement data collection for analysis and monitoring will be included in the Placement Implementation Plan.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Therapeutic Foster Care Placements –Receipt of Recommendations for Services or Placement:
(FSA IV.I.3.)

22. All Class Members that are referred for interagency staffing and/or needed diagnostic assessments shall receive recommendations for specific therapeutic foster care placement and/or services within fortyfive (45) days of receipt of the completed referral. The recommendation(s) may include diagnostic assessment, community support services, rehabilitative behavioral health services, therapeutic foster care, group care, and psychiatric residential treatment facility. Level of Care Placement recommendations shall utilize the least restrictive care philosophy suitable to the child’s needs and seek to place a Class Member in a family setting with a community support system. DSS shall update the assessment at least annually thereafter, upon a placement disruption or upon a material change in the Class Member’s needs. In making that determination, DSS may consider the full array of appropriate placement alternatives to meet the needs of the Class Members.

Data are not available for this period.35
Interim Benchmarks and timelines to meet final target are not yet set.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

35 Ibid.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Therapeutic Foster Care Placements – Level of Care Placement:
(FSA IV.I.4.&5.)

23.a. Within 60 Days: At least 90% of children assessed as in need of therapeutic foster care placement shall be in the Therapeutic Level of Care and specific placement type that matches the Level of Care for which the child was assessed within sixty (60) days following the date of the first Level of Care Placement recommendation.

Data are not available to for this period.36
Interim Benchmarks and timelines to meet final target are not yet set.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

23.b. At least 95% of children assessed as in need of therapeutic foster care placement shall be in the Therapeutic Level of Care and specific placement type that matches the Level of Care for which the child was assessed within ninety (90) days following the date of the first Level of Care Placement recommendation.

Data are not available for this period.37
Interim Benchmarks and timelines to meet final target are not yet set.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

36 Ibid. 37 Ibid.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Family Visitation – Siblings and Parents : (FSA IV.J.2.&3.)

24. At least 85% of the total minimum number of monthly sibling visits for all siblings not living together shall be completed, with exceptions when (1) there is a court order prohibiting visitation or limiting visitation to less frequently than once every month; (2) visits are not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) with exceptions approved by the Co-Monitors.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

As of March 31, 2017, 47% of children in foster care as of March 31, 2017 visited with all siblings with whom they were not placed in the month of March.38
DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

25. At least 85% of Class Members with the goal of reunification will have in-person visitation twice each month with the parent(s) with whom reunification is sought, unless (1) there is a court order prohibiting visitation or limiting visitation to less frequently than twice every month; or (2) based on exceptions approved by the Co-Monitors.

Data are not available for this period.39
Interim Benchmarks and timelines to meet final target are not yet set.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

38 Data were collected during a review conducted by USC CCFS and Co-Monitor staff of a statistically significant random sample based on a 95% confidence level and +/- 5% margin of error. Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier. 39 DSS and the Co-Monitors have determined that data for this measure are not currently available as fields need to be updated in CAPSS to capture and collect necessary information. The Co-Monitors anticipate that more information regarding efforts to update CAPSS and to develop and implement more reliable data collection practices will be available in the next monitoring period.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA)

Requirements6

Final Target

MP1 or Baseline Performance

Health Care Improvement Plan – Initial Health Assessment:
By the end of sixty (60) days following final court approval of the Final Settlement Agreement (identification period), DSS shall identify Class Members who have been in DSS custody for more than sixty (60) days as of the date of final court approval of the Final Settlement Agreement, and who have not had initial health assessments (physical/medical, dental or mental health).

26. Within thirty (30) days after the identification period, Defendants shall schedule the initial health assessment for at least 85% of the identified Class Members.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

(FSA IV.K.4.(a))

Physical/medical assessment: Of the 168 children identified as needing an assessment, 10% (16 children) received the necessary assessment by January 5, 2017.
Dental assessment: Of the 690 children identified as needing an assessment, 15% (102 children) received the necessary assessment by January 5, 2017.
Mental Health assessment: Of the 740 children identified as needing an assessment, 6% (42 children) received the necessary assessment by January 5, 2017.40

Health Care Improvement Plan – Immediate Treatment Needs:
By the end of ninety (90) days following final court approval of the Final Settlement Agreement (identification period), DSS shall identify Class Members with Immediate Treatment Needs (physical/medical, dental or mental health) for which treatment is overdue. (Immediate Treatment Needs means immediate non-elective physical/medical, dental or mental health treatment needs and documented assessment needs, excluding routine periodic assessments.) (FSA IV.K.4.(b))

27. Within forty-five (45) days of the identification period, DSS shall schedule the necessary treatment for at least 90% of the identified Class Members.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Data are not available for this period. 41
Interim Benchmarks and timelines to meet final target are not yet set.

40 Calculation of performance data for this measure required numerous rounds of data clean-up and validation by DSS, USC CCFS and Co-Monitor staff. Reported performance reflects final analysis by DSS which was provided to the Co-Monitors on September 4, 2017. 41 DSS has informed the Co-Monitors that data for this measure are not currently available. The Healthcare Workgroup has been assigned the task of defining “immediate treatment needs” and enhancements will then need to be made within CAPSS to capture and collect the necessary data.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Workload Study for Foster Care
DSS shall design, conduct and complete a foster care Workload Study that applies to every Caseworker and to every Caseworker’s supervisor and adopt one or more Workload Limits for foster care within 180 days (dates and obligations became operative as of September 28, 2015). The foster care Workload Study must be approved by the Co-Monitors before it is conducted. The results of the Workload Study must also be approved by the Co-Monitors before they are adopted by DSS. Each Workload Limit must be approved by the Co-Monitors before it is adopted.
(FSA IV.A.1.)

Completion of Workload Study by March 28, 2016.
Adoption of Workload Limits for Foster Care by March 28, 2016.

DSS began work in August 2015 to address concerns with caseloads. A Workload Estimation Workgroup was chartered to research best practice and develop recommendations for reducing caseloads. DSS collaborated with Casey Family Programs43 to develop and conduct a workload estimation study which was approved by the Co-Monitors on February 22, 2016.44 The study examined best practices and caseload limits in other states and conducted a time study. Based upon caseworker type, the study estimated time needed for specific activities and the amount of time caseworkers have available. An initial workload study report was submitted to the Co-Monitors on March 28, 2016 and a more complete copy of the study findings and recommendations on October 21, 2016.
On December 6, 2016, the Co-Monitors approved workload limits by establishing the following caseload standards for caseworkers and supervisors:
Caseworker Limits:  OHAN investigator – 1 caseworker: 8 investigations  Foster Care caseworker – 1 caseworker: 15 children  IFCCS caseworker – 1 caseworker: 9 children

42 In a few instances, information in this Table reflects the status of actions as of the date of this report. 43 Casey Family Programs is an operating foundation, working nation-wide to influence long-lasting improvements to the safety and success of children, families and the communities
where they live, focused on safely reducing the need for foster care with a mission to provide and improve — and ultimately prevent the need for — foster care.
https://www.casey.org/about/ 44 See Appendix C.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

 Adoption caseworker – 1 caseworker: 17 children45

 New caseworker – ½ of the applicable standard for first six months after

completion of Child Welfare Basic training.

The caseload standard for caseworkers carrying mixed caseloads has not yet been established.

Supervisor Limits:  Foster Care, IFCCS and Adoption supervisors – 1 supervisor: 5 caseworkers  OHAN supervisors – 1 supervisor: 6 investigators46

Although the caseload limits have been approved by the Co-Monitors, the methodologies to calculate performance for these limits have not. In addition to calculating performance for caseworkers servicing a single type of case, a standard and methodology is needed for caseworkers who have Class and NonClass Members47 on their caseload. To address these “mixed caseloads”, DSS proposed a methodology to weight cases in accordance with the individual caseload limits and estimate of time available to caseworkers. The Co-Monitors have not approved the methodology or the mixed caseload standard. In an effort to bring additional data to the discussion, in February 2017, DSS proposed to pilot a methodology in one or more local offices. To date, DSS has not shared details of this pilot or any specific findings with the Co-Monitors.

45 In approving these caseload limits, the Co-Monitors noted that although a caseload of 17 children for adoption caseworkers is not within the standard proffered by the Council on
Accreditation, as DSS is currently structured, case management responsibilities remain with the foster care caseworker, even when an adoption caseworker is assigned, until parental rights have been terminated. Given that DSS adoption caseworkers may therefore have less direct casework responsibilities than in some other jurisdictions, the Co-Monitors accepted the proposed caseload limit for adoption caseworkers. If DSS’s structure were to change so that adoption caseworkers have more case management responsibility for assigned children, the Co-Monitors would expect a proposed modification to the caseload standard. 46 The Co-Monitors approved the higher caseload standard for OHAN supervisors in recognition that those caseworkers will have lower caseloads than other direct service caseworkers. 47 Non-Class Members include children receiving family preservation services while remaining in the home with their parent or caregiver and Adult Protective Services cases.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Implementing the Workload Limits for Foster Care:
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the CoMonitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.
(FSA IV.A.2.(a))

Completion of Workload Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

DSS submitted a draft of the Workload Implementation Plan on November 30, 2016. Since that time, the Co-Monitors and Plaintiffs’ counsel have provided feedback on several drafts and DSS has submitted revisions and modifications several times in response to comments. The Implementation Plan has not yet been finalized or approved by the Co-Monitors.
DSS recognizes that much of the system reform and resulting improvements in outcomes depends upon ensuring caseworkers have manageable caseloads. The draft plans submitted to the Co-Monitors includes strategies for recruitment, hiring and training, among others. The Co-Monitors have discussed with DSS the importance of procuring resources needed to build the infrastructure and support necessary for the addition of caseworkers in the short and long-term, beginning this year.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Caseworker-Child Visitation
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure the progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the CoMonitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Caseworker and Child Visitation Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

DSS reported at the time of entry into the FSA that it was already achieving the
final targets related to caseworker-child visitation, thus DSS did not develop an Implementation Plan for this measure.48

(FSA IV.B.1.)

48 As indicated above, DSS appears to be meeting the caseworker visitation measures with respect to the frequency and location of worker-child visits. Plaintiffs have requested that the Co-Monitors perform a more in-depth review of visitation data and documentation in the future to assess the content of caseworker visits with children, based on their reading of the applicable FSA provisions. Should Co-Monitors conclude at any point that practice in this area is not, in fact, sufficient to meet the FSA requirements, an Implementation Plan may be required in accordance with FSA IV.B.1.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Investigation Implementation Plan
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the CoMonitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Investigations Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

DSS’s OHAN Workgroup has been developing a plan for improving OHAN practice and DSS submitted a draft of the Investigation Implementation Plan on November 30, 2016. Since that time, there have been revisions and modifications based upon feedback from the Co-Monitors and Plaintiffs. On August 9, 2017, DSS submitted a version of the plan which the Co-Monitors approved on September 11, 2017. The remaining step for a fully approved plan is to request and receive consent from Plaintiffs. 49
Case record reviews conducted between March and June 2017 by USC CCFS and Co-Monitor staff have identified significant OHAN policy and practice issues. DSS has already begun to address some and these issues have been areas of focus in DSS’s development of the Investigations Implementation Plan.

(FSA IV.C.1.)

49 FSA IV.C.1.
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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Placement Needs Assessment
Within one hundred twenty (120) days, DSS, with prior input from and subject to approval by the CoMonitors, shall perform a statewide and regional foster care Placement Needs Assessment in order to determine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members. The needs assessment shall include specific recommendations addressing all the assessment’s findings, including but not limited to recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that can meet their needs .

Completion of Placement Needs Assessment, which includes findings and specific recommendations by June 30, 2017.50

The methodology for the Placement Needs Assessment was approved by the CoMonitors on December 27, 2016. The Placement Needs Assessment was to be carried out by USC CCFS under its contract with DSS. The assessment began in February 2017 and involved an analysis of CAPSS quantitative data in addition to qualitative data collection. A core component was a strategic review of 90 cases selected for in-depth interviews using a protocol developed in consultation with the Co-Monitors. Focus group interviews and county surveys to assess the availability of home-based, mental health services were also conducted. The assessment findings and recommendations were forwarded to the Co-Monitors on August 31, 2017 and are being reviewed for discussion with DSS in a meeting in late September 2017.

(FSA IV.D.1.)

50 On December 27, 2016, the Co-Monitors granted an extension for completion of the Placement Needs Assessment to June 30, 2017 from the original expected completed date of January 28, 2017. On June 30, 2017, DSS notified the Co-Monitors that the assessment would be completed and a report would be submitted by August 31, 2017.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Placement Implementation Plan
Within sixty (60) days of the completion of the needs assessment, DSS shall develop an Implementation Plan to implement the recommendations of the needs assessment within eighteen (18) months. The Implementation Plan shall have enforceable benchmarks with specific timelines, subject to approval by the Co-Monitors, to measure progress in executing the recommendations of the needs assessment.
(FSA IV.D.1.(a))

Completion of Placement Implementation Plan, which includes interim benchmarks with specific timelines. Originally, the Interim Order required the Placement Implementation Plan to be completed by March 28, 2016 (60 days from January 28, 2016). The IO then required implementation of the recommendations in the Plan by September 28, 2017.51

The Placement Implementation Plan is not due until 60 days after the Placement
Needs Assessment has been completed. The needs assessment was completed on August 31, 2017, the Implementation Plan is due by October 31, 2017. The CoMonitors’ next report will provide updates on the plan.

Placement Implementation Plan shall include strategies to address the following areas, with accompanying interim benchmarks and specific timelines:

 Congregate Care Placements (FSA IV.E.1.)  Sibling Placement (FSA IV.G.1.)  Therapeutic Foster Care Placements (FSA
IV.I.1)

51 The Co-Monitors approved extensions to these deadlines as they worked with DSS and USC CCFS staff to design a more comprehensive Placement Needs Assessment.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Plan for Family Placements for Children Ages 6 and Under:
Within sixty (60) days, DSS shall create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the CoMonitors, the placement of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers). The plan shall include full implementation within sixty (60) days following approval of the Co-Monitors.

Completion of Plan to prevent placement of Class Members age six (6) and under in any non-family group placement by November 28, 2015.

(FSA IV.D.2.)

On October 31, 2015, DSS provided the Co-Monitors with a draft plan to prevent the use of congregate care for children ages six and under. The plan included immediate actions to review and conduct staffings on cases of applicable children and DSS actions to amend contracts with existing therapeutic foster care providers who had or could develop family placements for these children via Change Orders. DSS had already been taking steps to improve recruitment, training and licensure of foster family placements through Regional Resource Teams. The draft plan also included proposed exceptions to the placement of young children in congregate care settings for review and approval by the Co-Monitors. The CoMonitors provided feedback on these plans in January 2016, after conducting site visits to local county offices and speaking with caseworkers, service providers (including congregate care providers) and legal staff. In that feedback, the CoMonitors suggested modifications to DSS’s proposed exceptions. In March 2016, DSS and the Co-Monitors reached agreement on acceptable exceptions to this requirement and approved the Department’s plan to prevent the placement of any Class Member age six and under in any non-family, group placement.

DSS data demonstrate this plan has been largely successful, resulting in substantial reductions in the number of children ages six and under in congregate care.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Family Visitation – Siblings and Parent Implementation Plan:
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the CoMonitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Family Visitation Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

DSS convened a Visitation Workgroup in October 2016 to assess systemic barriers to family visitation and develop and assist with the implementation of the Visitation Implementation Plan. DSS submitted a draft of the Visitation Implementation Plan on November 30, 2016 and upon receipt of feedback from the Co-Monitors and Plaintiffs’ counsel, has completed several rounds of revisions and modifications. Many of the draft strategies center around increasing supervisory skills, revising policy and procedures, educating caseworkers, increasing foster parent participation and developing plans to reduce logistical barriers. The plan has not yet been approved by the Co-Monitors.

(FSA IV.J.1.)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of July 31, 2017)42

Health Care Improvement Plan:

Completion of Health Care

DSS has requested two extensions to the deadline for completion of the Health

Within one hundred eighty (180) days, Defendants, Improvement Plan by March with prior input from and subject to approval by the 31, 2017. On April 19, 2017,

Care Improvement Plan and the Implementation Plan is now due on September 30, 2017. In developing this plan, DSS has created a Healthcare Work Group;

Co-Monitors, shall develop a Health Care

the Co-Monitors approved a 60 made efforts to effectively track health assessments; conducted county surveys to

Improvement Plan with enforceable dates and targets day extension, with an expected identify providers being utilized for assessments and follow up care; held

for phased implementation and concerning initial

completion date of June 2,

discussions with other states and two model assessment centers within SC; and

screening services, periodic screening services,

2017. On June 1, 2017, DSS planned discussions with the Department of Health and Human Services (DHHS),

documentation, and health care treatment services for filed a Motion for Extension of SC’s Medicaid agency and representatives from Select Health, the Medicaid

Class Members in the areas of physical health,

Time, which was approved and MCO. As of August 2017, DSS, with support from Casey Family Programs,

immunizations and laboratory tests, mental health, extended the deadline to

engaged an external consultant to assist with plan development.

developmental and behavioral health, vision and

September 30, 2017.

hearing, and dental health. The Plan shall address:

(a) Developing the capacity to track screening and treatment services for individual children and aggregate tracking data, including but not limited to screens that are due and past due;

(b) Assessing the accessibility of health care screening and treatment services throughout the State, including the capacity of the existing health care providers to meet the screening and treatment needs of Class Members; and

(c) Identifying baselines and interim percentage targets for performance improvement in coordinating screens and treatment services. With approval of the Co-Monitors and based on evidence of progress toward the development of the Health Care Improvement Plan, Defendants may request an extension of an additional sixty (60) days to complete the Plan. (FSA IV.K.1.)

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V. CASELOADS
A sufficient, qualified and well-trained workforce with manageable workloads is foundational to a well-functioning child welfare system. DSS recognizes that it is critically important that caseloads be lowered across the State and that meeting many other FSA requirements will not be possible until this happens. The FSA required DSS to take immediate action with respect to caseworker and supervisor caseloads. As discussed below, this is an issue DSS has been working to address in the months since the Interim Order went into effect –– convening a workgroup, performing a workload study, requesting additional caseworkers in the FY2018 budget and proposing caseload limits. The Co-Monitors have encouraged and DSS has represented that they have vigorously advocated for the resources needed to hire, train and retain high quality caseworkers who will be able to do the challenging work required by the FSA over the coming years to improve outcomes for South Carolina’s children and families. Although DSS acknowledges that caseloads throughout the State are in excess of agreed upon limits, there is currently no system in place for reliably measuring caseloads for the purpose of assessing FSA compliance. The lack of reliable caseload data is a significant barrier for DSS and it is critical that it be addressed immediately.
A. Workload Study
Pursuant to the FSA, DSS was ordered to design and complete a workload study and develop workload limits for DSS caseworkers by January 28, 2016 (FSA IV.A.1.(a)). The limits apply to caseworkers who provide direct service to children in foster care (foster care caseworkers); caseworkers who are responsible for adoption activities for children in foster care (adoption caseworkers); caseworkers who provide direct service to children categorized as in need of Intensive Foster Care and Clinical Services (IFCCS caseworkers); caseworkers who investigate reports of abuse or neglect against Class Members (Out-of-Home Abuse and Neglect (OHAN) caseworkers); and supervisors who provide direct supervision to caseworkers who service Class Members. The Co-Monitors were required to approve both the workload study methodology and DSS’s proposed caseload limits.
Beginning in August 2015, DSS chartered a Workload Estimation Workgroup to research best practice recommendations for caseload standards and develop recommendations for equalizing caseloads throughout the State. Guided by a methodology developed by Casey Family Programs and approved by the Co-Monitors on February 22, 2016, the workgroup outlined essential caseworker tasks and estimated time required to complete each task. Co-Monitor staff observed workgroup meetings and reviewed the information supporting the recommended Caseloads.

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B. Approved Workload Limits
On December 6, 2016, the Co-Monitors approved the following caseload limits for caseworkers and supervisors as shown in Table 3 below. These standards are in line with national practice standards adopted in other states.

Table 3: Caseworker Caseload Limits and Supervisor Limits

Caseworker Limits

Supervisor Limits

 OHAN investigator – 1 caseworker: 8

 Foster Care, IFCCS and Adoptions supervisors – 1

investigations

supervisor: 5 caseworkers

 Foster Care caseworker – 1 caseworker: 15

 OHAN supervisors – 1 supervisor: 6

children

investigators53

 IFCCS caseworker – 1 caseworker: 9 children

 Adoptions caseworker – 1 caseworker: 17 children52

 New caseworker – ½ of the applicable standard for

first 6 months after completion of Child Welfare

Basic training.

DSS has agreed that it will apply these caseload limits to any caseworker or supervisor with at least one Class Member on their caseload. Recognizing that caseworkers in some counties, especially less populated ones, can, at times, have a mix of Class and Non-Class Members (mixed caseload)54, DSS proposed a methodology to weight cases in accordance with the individual caseload limits. The Co-Monitors have not approved this methodology or the mixed caseload standard. In an effort to bring additional data to the discussion, in February 2017, DSS proposed a plan to pilot test the methodology in one or more local offices. The pilot was eventually limited to Lexington County. To date, DSS has not shared details of this pilot or any specific findings with the Co-Monitors.

Further, many of DSS’s frontline supervisors currently are assigned cases with casework responsibility, in addition to their supervisory responsibilities. The Co-Monitors have communicated to DSS that, once fully implemented, the FSA and its new caseload limits will prohibit supervisors from being assigned cases except in temporary or emergency situations.

52 In approving these caseload limits, the Co-Monitors noted that although a caseload of 17 children for adoption caseworkers is not within the standard proffered by the Council on Accreditation, as DSS is currently structured, case management responsibilities remain with the foster care caseworker, even when an adoption caseworker is assigned, until parental rights have been terminated. Given that DSS adoption caseworkers may therefore have less direct casework responsibilities than in some other jurisdictions, the Co-Monitors accepted the proposed caseload limit for adoption caseworkers. If DSS’s structure were to change so that adoption caseworkers have more case management responsibility for assigned children, the Co-Monitors would expect a proposed modification to the caseload standard. 53 The Co-Monitors approved the higher workload standard for OHAN supervisors in recognition of the fact that those caseworkers will have lower caseloads than other direct service caseworkers. 54 Non-Class Members include children receiving family preservation services while remaining in the home with their parent or caregiver and Adult Protective Services cases.

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C. Workload Implementation Plan
The FSA requires that by December 5, 2016, DSS develop an Implementation Plan to implement the final FSA workload requirements. The Implementation Plan must include “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approved (sic) by the CoMonitors, to measure progress in achieving the final targets…” (FSA IV.A.2 (a)).
In the months since Co-Monitor approval of the caseload limits, the Workload Estimation Workgroup has continued to meet with the goal of developing a plan for staged implementation of the caseload limits. DSS submitted an initial draft of the Workload Implementation Plan on November 30, 2016. Since that time, the Co-Monitors and Plaintiffs have provided feedback on several drafts of the plan and DSS has completed multiple rounds of revisions and modifications. The Implementation Plan has not yet been finalized or approved by the Co-Monitors. DSS has proposed interim benchmarks and targets but they have not yet been approved.
DSS recognizes that the achievement of many, if not all, of the FSA requirements depends upon meeting caseload limits for foster care, adoption, IFCCS and OHAN workers, and has expressed a commitment to onboarding new caseworkers to begin relieving high caseloads, with an initial focus on hiring new IFCCS caseworkers across the State and in counties in which caseworkers are particularly overburdened. DSS also recognizes that in order to hire, onboard and maintain these new caseworkers, it must address human resource and recruitment systems, develop and adopt improved initial and ongoing training to reflect changes in case practice and implement retention strategies.
The Co-Monitors have discussed with DSS the importance of procuring the resources to support the necessary addition of caseworkers in the short and long term, beginning this year. For FY2018, DSS requested and received 163 new caseworkers for assessment, family preservation and foster care, though it has not yet been determined how many of these positions will be dedicated to services for Class Members. DSS anticipates needing funding for and hiring an additional 507 new caseworkers over the next three years.
DSS’s ability to finalize the Workload Implementation Plan has been limited by the fact that data are not yet available to allow for the reliable measurement of baseline performance or for tracking progress. DSS generates a number of caseload reports for managers on a regular basis through CAPSS, however due to current data limitations within the system, there are barriers to collecting and analyzing caseload data for the FSA at this time. For example, DSS has identified the need to develop a more precise method to identify children needing IFCCS services in CAPSS before

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IFCCS caseworker caseloads can be accurately measured,55 and has yet to develop a system for identifying supervisors who are managing caseworkers with Class Members on their caseloads56, or for tracking the hiring and completion of basic training by new caseworkers57. In addition, the finalization of the mixed caseload standard and methodology for measuring performance is essential to DSS’s ability to establish reliable baseline measures. DSS has represented that as of January 2017, there were 383 caseworkers carrying at least one Class Member on their caseload. Of those, 139 had caseloads with only Class Members (non-mixed) – 73 adoption caseworkers58, 52 IFCCS caseworkers59, eight OHAN investigators60 and six foster care caseworkers. The majority of foster care caseworkers – 97 percent (198 of 204 caseworkers) – carried mixed caseloads. These issues will need to be addressed before interim benchmarks can be developed and the Workload Implementation Plan can be approved by the Co-Monitors.

VI. CASEWORKER-CHILD VISITATION
Visits between caseworkers and children in foster care, preferably where the children are residing, are an important way in which DSS supports the safety and well-being and progress of the children in its care. Caseworker visits with children in foster care are a core element of DSS practice and DSS has maintained that caseworkers throughout the State visit with children on a monthly basis in nearly all cases. An initial review of CAPSS documentation on caseworker visits by the CoMonitors indicates that monthly visits are, in fact, occurring.
A. FSA Visitation Requirements

The FSA requires “[a]t least 90% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place” (FSA IV.B.2.) and that “[a]t least 50% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place in the residence of the child” (FSA IV.B.3.). The FSA further required that by December 5, 2016, DSS was to develop an Implementation Plan with “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors” (FSA IV.B.1.) to achieve the final targets related to caseworker visitation with children. Based on review of its data, DSS determined at the

55Currently, IFCCS children are identified by the office of the caseworker who manages them and possible siblings of children
needing IFCCS services may be incorrectly assumed to be categorized as IFCCS. DSS has indicated that a plan to appropriately
identify children needing IFCCS services in CAPSS will be complete by December 2017. As a result, data on caseloads of IFCCS
caseworkers will not be available until that time. 56DSS has indicated that a plan to appropriately identify and track supervisors will be completed by September 2017. DSS has
proposed in its Implementation Plan that the new system will be implemented by August 2018. 57 DSS has indicated that a plan to appropriately identify completion of Child Welfare Basic training by new caseworkers in CAPSS
will be complete by September 2017. 58 There were a total of 75 adoption workers in January 2017; therefore, 97 percent had non-mixed caseloads. 59 There were a total of 95 IFCCS workers in January 2017; therefore, 55 percent had non-mixed caseloads. 60 There were a total of eight OHAN investigators in January 2017; all (100%) had non-mixed caseloads.

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time of entry into the FSA that it was already achieving the final targets related to caseworkerchild visitation, and thus DSS informed the Co-Monitors that it believed it did not need to develop an Implementation Plan for the worker-child visitation measures.61

B. Performance Data

Monthly Face-to-Face Caseworker Visits with Children

Caseworkers are required to record information in CAPSS about monthly visits with children. CAPSS data indicate for each of the six months in the monitoring period that DSS exceeded the requirement that at least 90 percent of Class Members have at minimum a monthly visit by a caseworker.62 For example, in March 2017, there is documentation in CAPSS that caseworkers made 3,714 (98%) of the required 3,804 monthly visits with children. Figure 1 below shows the data from CAPSS for monthly visits during October 2016 and March 2017.

Figure 1: Monthly Face-to-Face Caseworker Visits With Children October 2016 – March 2017

100%

90%

98%

97%

97%

98%

97%

98%

80%

70%

60%

50%

40% 30%

20%

10%

0% Oct-16 Nov-16 Dec-16

Jan-17

Feb-17 Mar-17

Source: CAPSS Data Provided by DSS

FSA Final Target 90%

61 As discussed below, the Co-Monitors conducted a limited validation of CAPSS visitation data and DSS appears to be meeting the caseworker visitation measures with respect to the frequency and location of worker-child visits. Plaintiffs have requested that the Co-Monitors perform a more in-depth review of visitation data and documentation in the future to assess the content of caseworker visits with children, based on their reading of the applicable FSA provisions. Should the Co-Monitors conclude at any point that practice in this area is not, in fact, sufficient to meet the FSA requirements, an Implementation Plan may be required in accordance with FSA IV.B.1. 62 It is important to note that the FSA requires monthly visits to children by a caseworker and not necessarily the caseworker assigned to the child or family.

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Face-to-Face Caseworker Visits with Children in Residence

CAPSS data indicate that DSS exceeded the requirement that at least 50 percent of the monthly caseworker visits take place in the child’s residence for each of the six months in the monitoring period. For example, in March 2017, CAPSS documentation indicates that 2,672 (70%) of the required 3,804 monthly visits were made in the child’s residence. Figure 2 provides the data for each of the six months in the monitoring period.

Figure 2: Monthly Face-to-Face Caseworker Visits With Children in Their Residence October 2016 – March 2017
100%
90%

80%

70%

71%

60%

68%

69%

69%

67%

70%

50%

40%

30%

FSA Final Target 50%

20% 10%

0% Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Source: CAPSS Data Provided by DSS

DSS and Plaintiffs hold different views of the type of validation required to determine compliance with the FSA visitation requirements. DSS’s interpretation of the requirements is that they are explicitly focused only on whether visits occurred and where they were held. Plaintiffs believe that that validation requires a review of visit content to ensure not only that caseworkers visited with children, but that they did so in a way that accords with the core purpose of visitation and includes necessary elements as defined by practice standards and DSS policy. In order to validate DSS’s data with respect to caseworker visits with children, Co-Monitor staff reviewed documentation in the CAPSS case files of a statistically significant sample of children who were reported to have visited with a caseworker in the month of February 2017.63 Because CAPSS documentation was not sufficient to allow for a fuller review of visit content, the review was limited and done solely

63 In February 2017, there were 3,798 children reported by DSS to have visited with a caseworker. A statistically valid random sample of 349 cases was pulled based on a 95% confidence level and +/- 5% margin of error.

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for the purpose of measuring the percentage of cases in which documentation indicated that a caseworker had visited the child in that month, and where the visit occurred.64 The Co-Monitors did not assess the content of the visits nor the extent to which visits were done in accordance with DSS policy.
Based on its review, Co-Monitor staff found that there was documentation that a caseworker visit had occurred in 95 percent of cases reviewed. As a result, the Co-Monitors determined that CAPSS data could be used to calculate performance with respect to the FSA caseworker visitation requirements for this reporting period.
VII. INVESTIGATIONS
For children who have been removed from their homes due to concerns of abuse or neglect, it is imperative that allegations of abuse or neglect in their foster care placement be managed in a sensitive, appropriate manner. DSS is aware that this is an area in need of improvement, particularly in light of the historically high caseloads of investigation caseworkers and the CoMonitors’ baseline findings from record reviews. DSS has committed to addressing its OHAN practice expeditiously.
A. Investigation Implementation Plan
The FSA requires that by December 5, 2016, DSS develop an Implementation Plan for the provisions related to intake and investigations. The Implementation Plan must have “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets…” (FSA IV.C.1.). DSS’s OHAN Workgroup has been developing a plan for improving OHAN practice, adapted in response to the Co-Monitors’ baseline review findings, discussed below. DSS submitted a draft of the Investigation Implementation Plan on November 30, 2016. Since that time, the Co-Monitors and Plaintiffs have provided feedback on several drafts of the plan and DSS has completed multiple rounds of revisions and modifications. A revised Implementation Plan with interim benchmarks and targets was submitted on August 9, 2017. On September 11, 2017, the Co-Monitors approved this plan. The remaining step for full approval is review and consent by Plaintiffs, as required in Section IV.C.1. of the FSA.

64 In the course of their review, Co-Monitor staff found that documentation of caseworker visits was often either sparse or substantially duplicative of documentation entered in prior months. Though CAPSS documentation consistently included references to key domains based on a template, it was often not possible to reliably discern the extent to which those domains had been addressed during the visit or whether the visit supported ongoing assessment of the child’s needs or planning.

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B. Baseline Data

In February 2017, DSS, USC CCFS and Co-Monitor staff began to develop a methodology to collect baseline data for the FSA measures related to intake and investigations. Two review instruments were developed – the first (intake instrument) to assess appropriateness of decisions not to investigate a referral of institutional abuse or neglect about a Class Member and the second (investigation instrument) to assess specific components within an investigation of a referral of institutional abuse and neglect (specifically, timely initiation, timely completion, contact with core witnesses and decisions to “unfound”). These instruments were finalized in March 2017. Reviewers looked at hardcopy records, CAPSS data and videos, when applicable. SurveyMonkey, a web-based survey tool, was used for collecting and analyzing data.

USC CCFS and Co-Monitor staff conducted training prior to each review, which included a discussion of the instrument and purpose of each question and completion of a test case to promote interrater reliability. A Child Welfare Basic trainer from USC CCFS participated in the training for the investigation review and presented information on practice for appropriate assessments of safety and risk. Sixteen first level reviewers participated in the intake review and 22 first level reviewers participated in the investigation review. There were five second level reviewers who reviewed all (100%) instruments from both reviews to ensure completeness and consistency in decision-making; some instruments also received a third level review. Any disagreements between first and second level reviewers were discussed and edits were made accordingly.

All applicable abuse and neglect referrals65 received and screened out by DSS’s OHAN unit between August 1, 2016 and January 31, 2017, a total of 128, were reviewed during the intake review. The investigation review assessed 107 applicable investigations66 received between June and November 2016.

Intake

Pursuant to SC state statute and DSS protocol, all allegations of abuse or neglect of a child in outof-home settings, including licensed foster homes, residential facilities and group homes, that are received by local county offices or regional intake hubs must be forwarded to OHAN for screening and, if accepted, for investigation. 67, 68 OHAN staff make decisions to either accept a referral for

65 Some referrals were found not to be applicable for review because the alleged victim child was not a Class Member (i.e. the child was voluntarily placed by the legal guardian or through ICPC from another state, or was the biological child of the caregiver). DSS has represented to the Co-Monitors that all referrals of abuse and neglect in licensed foster homes, residential facilities and group homes across the state involving Class Members are received by or forwarded to OHAN for screening and investigation, as appropriate, and screening decisions are not made by local office or Intake HUB staff. 66 Some investigations were deemed not applicable for the same reasons as the intake review. 67 SC Code § 63-7-1210; Human Services Policy and Procedural Manual, Chapter 7-721. p.3 (effective date 11/29/2012); SC DSS Directive Memo, April 26, 2016. 68 Allegations of abuse or neglect by a foster parent against their biological or adopted child are investigated by local county offices.

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investigation or take no further action on the referral based upon information collected from reporters to determine if the allegations meet the state’s statutory definition of abuse or neglect69. DSS policy establishes three main screening criteria for investigations of abuse or neglect of children in out-of-home care: (1) the alleged victim child is younger than 18 years of age; (2) there is an allegation of actual harm that has occurred or is occurring to a child or the caregiver’s acts or omissions present a significant risk of harm; and (3) the alleged perpetrator is a person responsible for the child’s welfare.70 OHAN staff are also directed to accept for investigation referrals which identify safety and risk factors to the child in care. All screening decisions are reviewed and approved by a supervisor prior to being finalized.
The FSA requires, “[a]t least 95% of decisions not to investigate a Referral of Institutional Abuse or Neglect about a Class Member must be made in accordance with South Carolina law and DSS policy” (FSA IV.C.2.). When assessing performance for this measure, reviewers considered three main criteria: (1) the allegation, if true, meets the legal definition of maltreatment; (2) the OHAN caseworker did not collect all information necessary to make an appropriate screening decision; and (3) safety or risk factors were identified within the information shared. If any of these questions were answered in the affirmative, the decision not to investigate was determined to be inappropriate.
Of the 128 referrals that were not accepted for investigation by OHAN between August 1, 2016 and January 31, 2017, reviewers determined 56 (44%) of the screening decisions were appropriate (see Figure 3). These baseline data will be utilized to establish interim benchmarks and timelines to move toward the final target of 95 percent.

69 SC Code § 63-7-20. 70 This includes a foster parent; an employee or caregiver in a public or private residential home, institution or agency; or an adult who has assumed the role and responsibility of a parent or guardian for the child, but who does not necessarily have legal custody of the child. Human Services Policy and Procedural Manual, Chapter 7-721. p.3 (effective date 11/29/2012).

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Figure 3: Appropriateness of Decision Not to Investigate Referral (Alleging) Institutional Abuse (and/)or Neglect
August 1, 2016 – January 31, 2017 N=128
44% 56%
Appropriate Not Appropriate
Source: March 2017 Case Record Review, USC CCFS and Co-Monitor staff
The reason for reviewer determinations that the decision not to investigate a referral was incorrect varied, and in some cases, more than one reason was given71. The most common reason, cited in 78 percent (56 of 72) of referrals, was that the allegation met the legal definition of maltreatment as defined by state statute and should have been accepted for investigation. This finding supports the need for additional guidance, training and supervisory support to staff who are making intake decisions. In 44 percent (32) of the 72 referrals, the reviewer identified safety factors which made the decision not to accept the referral inappropriate and in 28 percent (20) of the referrals, the reviewer determined that the OHAN caseworker did not collect all information necessary to make an appropriate screening decision.

71 Of the 72 screen out decisions that were not appropriate, reviewers in 47% (34) cited one reason for determining the screen out was not appropriate, reviewers in 38% (27) cited two reasons and reviewers in 15% (11) cited three reasons.

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Figure 4: Reason for Reviewer Disagreement with Decision Not to Investigate Referral August 1, 2016 – January 31, 2017 N=72

100%

90%

80%

70%

78%

60%

50%

40%

44%

30%

20%

28%

10%

18%

0% Allegation met Reviewer identified Adequeate Agency identified legal definition safety factor(s) information not safety factor(s) gathered during the intake process

Source: April 2017 Case Record Review, USC CCFS and Co-Monitor Totals do not equal 100 percent as reviewers could select all that apply.

Investigations

If a referral is accepted for investigation, the FSA and OHAN policy require face-to-face contact with the alleged victim child(ren) within 24 hours to assess safety and risk and the investigation is to be completed within 45 days.72 OHAN policy also requires that throughout the course of the investigation, the investigator must conduct a safety assessment of the alleged victim child, including a private interview with that child; work with the child’s caseworker or law enforcement to make arrangements for medical treatment or examinations, as needed; interview core witnesses to inform the investigation; review documents and records related to the incident; and assess the risk of further maltreatment to all children within that setting.73 All of these activities are critical components of a quality investigation which results in accurate assessments and findings.

There are seven FSA measures pertaining to investigations – timely initiation (two measures), contact with core witnesses (one measure), investigation determination decisions (one measure) and timely completion (three measures). Baseline data collected during the recent case record review are discussed below. The data demonstrate that current practice in most instances accords

72 Human Service Policy and Procedural Manual, Chapter 7-721. p. 6, 12 (effective date 11/29/2012). 73 Human Services Policy and Procedural Manual, Chapter 7-721. p. 7 (effective date 11/29/2012).

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with the timelines established for investigations, however, the quality of practice is in need of improvement.

Timely Initiation

The FSA requires, “[t]he investigation of a Referral of Institutional Abuse or Neglect must be initiated within twenty-four (24) hours in accordance with South Carolina law in at least 95% of the investigations” (FSA IV.C.4.(a)). Additionally, FSA Section IV.C.4.(b) requires, “[t]he investigation of a Referral of Institutional Abuse or Neglect must include face-to-face contact with the alleged victim within twenty-four hours in at least 95% of investigations, with exceptions for good faith efforts approved by the Co-Monitors.” The Co-Monitors interpretation of the FSA treats both of these requirements in the same manner – investigations must be initiated within 24 hours of receipt of the referral by DSS, not within 24 hours of the decision to accept the referral, and that initiation is completed by making face-to-face contact with the alleged victim child. With these considerations, the performance for both FSA IV.C.4.(a) and (b) are measured using the same methodology and timeframes – the time between receipt of referral and face-to-face contact with the alleged child victim must be within 24 hours.

The Co-Monitors approved the following as “good faith efforts” for timely initiation which must be completed and documented, as applicable, for exceptions to contact with an alleged victim child(ren) within 24 hours:

Table 4: Good Faith Efforts to Contact Alleged Victim Children

 Investigator attempted to see child(ren) at school  Investigator attempted to see child(ren) at doctor’s
visit or hospital  For child(ren) moved to an out-of-state location in
order to receive specialized treatment, investigator attempted to interview by Skype or other electronic means  Investigator attempted to see child(ren) at the police department  Investigator attempted to attend forensic/CAC interview

 Investigator attempted to see child(ren) at therapist’s office
 Investigator contacted the assigned foster care caseworker(s) and/or supervisor(s)
 Investigator attempted to contact the parent/guardian of the victim child(ren) if the child(ren) has gone home
 Investigator attempted to see child(ren) at child care facility
 Investigator attempted to contact the child at all foster

care placements where the child may temporarily be

placed in the first 24 hours

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Additionally, the following extraordinary circumstances were also approved by the Co-Monitors as exceptions to timely initiation:

Table 5: Extraordinary Circumstance Exceptions to Contact with Alleged Victim Children

 Child was returned to biological family prior to  Facility restrictions due to child’s medical

report and family refuses contact

requirements

 Child is deceased

 Natural disaster

 Law enforcement prohibited contact with child

 Child missing despite efforts to locate (efforts

should include all applicable good faith efforts

listed above)

Of the 107 applicable investigations74 conducted between June and November 2016, contact was made with the alleged victim child(ren) within 24 hours in 81 (76%) investigations and in an additional two (2%) investigations, documentation supported completion of all applicable good faith efforts. Therefore, baseline performance for FSA IV.C.4.(a) and (b) is 78 percent (see Figure 5).

Figure 5: Timely Initiation of Investigations June – November 2016 N=107

100%

90%

80%

70%

78%

60%

50%

40%

30%

20%

10%

0% Timely Initiated (within 24 hours)

Source: March – June 2017 Case Record Review, USC CCFS and Co-Monitor staff

FSA Final Target 95%

74 Some investigations were found not to be applicable for review because the alleged victim child was not a Class Member (i.e. the child was voluntarily placed by the legal guardian or through ICPC from another state, or was the biological child of the caregiver).

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Contact with Core Witnesses

The FSA requires, “[c]ontact with core witnesses must be made in at least 90% of the investigations of a Referral of Institutional Abuse or Neglect, with exceptions approved by the CoMonitors. Core witnesses will vary from case to case and may or may not include the victim(s), Class Members, alleged perpetrators, reporter (if identified), identified eyewitness(es), other children in the placement, facility staff, treating professionals, and foster parents or caregivers as deemed to be relevant to the investigation” (FSA IV.C.4.(c)).

A core witness is defined as an individual who is pertinent to the investigation because they witnessed or have knowledge of the alleged actions and can shed light on the allegations and the actions of the alleged perpetrators. Core witnesses may differ in any individual investigation to investigation, but in all cases include: reporter(s), alleged perpetrator(s), alleged child victim(s), child’s DSS caseworker, other child(ren) and/or adult(s) in the home and, when involved, law enforcement. If the allegations involve an institutional setting, all other adults and children relevant to the investigation are also considered core witnesses.

The following are exceptions to the requirement that the investigator make contact with a core witness during an investigation, approved by the Co-Monitors. In all instances, the exception must be supported by documentation of the exception reason and best efforts to engage:

Table 6: Exceptions to Contact with Core Witnesses

 Witness refused to cooperate

 Unable to locate or identify witness

 Witness advised by counsel or law enforcement  Medical conditions prevented witness from

that interview could not occur (e.g. pending charges, lawsuit)

cooperating

 Witness is deceased

Of the 107 applicable investigations received between June and November 2016, reviewers determined that the investigator made contact with all necessary core witnesses for whom there was no approved exception in 29 (27%) investigations (see Figure 6).

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Figure 6: Contact with All Necessary Core Witnesses during the Investigation June – November 2016 N=107

100% 90% 80%

FSA Final Target 90%

70%

60%

50%

40%

30%

20%

27%

10%

0% Contact with Necessary Core Witnesses Completed

Source: March – June 2017 Case Record Review, USC CCFS and Co-Monitor staff

In the 78 investigations in which contact was not made with all necessary core witnesses, the reporter was the most frequent missing core witness and was only interviewed in 45 percent (35) of the investigations. Of these 78 investigations, the alleged child victim was interviewed in all (78) and the alleged perpetrator(s) was interviewed in 86 percent (67) of investigations.75

Case Decisions

At the conclusion of the investigation, a case decision is made based upon the totality of the information collected, with the preponderance of the evidence as standard of proof of the facts.76 The allegations are either founded (indicated) or unfounded.

Section IV.C.3. of the FSA requires, “[a]t least 95% of decisions to ‘unfound’ investigations of a Referral of Institutional Abuse or Neglect must be based upon DSS ruling out abuse or neglect or DSS determining that an investigation did not produce a preponderance of evidence that a Class Member was abused or neglected.”

The investigations received between June and November 2016 included 94 investigations with a case decision to unfound the allegations. Reviewers agreed that the case decision to unfound the

75 In some investigations, more than one core witness was not contacted. 76 SC DSS Human Services Policy and Procedural Manual, Chapter 7-721. p. 3 (effective date 11/29/2012).

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investigation was appropriate in 44 (47%) of the 94 applicable investigations (see Figure 7). Case decisions to unfound the investigation were inappropriate in 50 (53%) investigations.

Figure 7: Decision to Unfound Investigation Deemed Appropriate June – November 2016 N=94

100% 90%

80%

70%

60%

50%

40%

47%

30%

20%

10%

0% Unfounded Decisions Deemed Appropriate

Source: March – June 2017 Case Record Review, USC CCFS and Co-Monitor staff

FSA Final Target 95%

Reviewers selected one of two reasons for their disagreement with the unfounded decision – in 36 (72%) investigations, the investigator did not collect all information critical to make an accurate finding and in the remaining 14 investigations, all necessary information was collected, but the decision to unfound was not supported by the information.

Timely Completion

The FSA includes the following three measures for timely completion of investigations, recognizing that some investigations may take longer than 45 days as policy requires:
 “At least 60% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within forty-five (45) days of initiation of an investigation, unless the DSS Director or DSS Director’s designee authorizes an extension of no more than fifteen (15) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(d)).
 “At least 80% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within sixty (60) days of initiation of the investigation, and all investigations not completed within sixty (60) days shall have authorization of the DSS Director or DSS

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Director’s designee of an extension of no more than thirty (30) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(e)).  “At least 95% of all investigations of a Referral of Institutional Abuse or Neglect not completed within sixty (60) days shall be completed within ninety (90) days. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(f)).

The FSA and OHAN policy provide that the DSS Director or Director’s Designee may authorize an extension of up to 15 days for “good cause” or compelling reasons.77 Good cause means that, through no fault of the investigator, sufficient reason exists for delaying the case decision. Examples of good cause may be one of the following:

Table 7: Examples of Good Cause Reasons to Extend Investigation Timeframes

 Awaiting critical collateral information (e.g. medical report, x-rays, toxicology, video)

 Critical new information was received from witness that requires follow up

 Awaiting forensic interview/findings

 Awaiting action by law enforcement

 Awaiting critical information from another

 Child has been too ill or traumatized to speak with

jurisdiction (e.g. central registry check)

investigator

Of the 107 investigations received between June and November 2016, two investigations are excluded from the 45 day compliance measure as an extension request for 15 days was submitted and approved by the OHAN Director.78 Of the remaining 105 investigations, 104 investigations were completed within 45 days, however, reviewers determined that four of these investigations were closed as unfounded prematurely in an effort to meet the 45 day requirement which is not considered compliant by the FSA. Therefore, the review determined that 100 (95%) of the 105 applicable investigations were appropriately closed within 45 days. The remaining three investigations (two with an approved extension request and one without) were all closed within 60 days; performance for timely completion within 60 days is 96 percent (103 of 107).

77 SC DSS Human Services Policy and Procedural Manual, Chapter 7-721. p. 12 (effective date 11/29/2012). 78 In one investigation, the investigator was awaiting findings from a forensic interview and in the other investigation, the
investigator was awaiting action by law enforcement.

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Figure 8: Timely Completion of Investigation June – November 2016
N=105 within 45 days; N=107 within 60 days

100%

90%

95%

96%

80%

70%

60%

50%

40%

30%

20%

10%
0% 45 Day Compliance

60 Day Compliance

Source: March – June 2017 Case Record Review, USC CCFS and Co-Monitor staff

60 Day Compliance Final Target - 80%
45 Day Compliance Final Target - 60%

All investigations were completed within 60 days; therefore, the FSA measure which requires that investigations be completed within 90 days, if they are not completed within 60 days is not applicable this period.

As these data reflect, both the intake and investigation baseline reviews highlight significant OHAN policy and practice issues. The Co-Monitors identified a number of themes throughout the reviews, some of which DSS has already begun to address, and that became areas of focus in the development of the Investigations Implementation Plan. These are bulleted below:

 OHAN intake and investigation staff had incomplete access to providers’ entire history of prior abuse or neglect referrals and investigations in CAPSS. During the review, OHAN began development of a comprehensive report, available to caseworkers and supervisors within CAPSS, which will address this issue.
 There were inconsistencies in intake screening decisions due to a lack of standardized instruments or tools. Since the review, DSS has adopted an interim intake tool which more clearly delineates which referrals should be accepted for investigation based upon safety and risk concerns and the factors to look for within each typology. OHAN is working with a national consultant to develop a new risk and safety assessment tool which should be finalized later this year.
 Information collected from the reporter by OHAN staff was limited and impacted a caseworker’s ability to thoroughly assess the allegations and level of safety and risk. DSS

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has begun the process of developing a formal training specifically for intake and investigation practice, something that was lacking before, which is scheduled to begin in September 2017.  Interviews with alleged victim children were not consistently conducted in a manner that was likely to elicit reliable information, and many of the interactions with adult core witnesses occurred only via email and/or involved a brief set of questions that were too narrow to gather all necessary information relevant to the unique circumstances of each investigation. The Co-Monitors have discussed this concern with DSS and staff are currently working with USC CCFS to ensure interviewing techniques are included in the OHAN caseworker training.  Some unfounded case decisions appear to have been based upon a facility or institution’s decision to make changes in personnel. Though personnel changes may be appropriate actions by the institution, the decision by OHAN to indicate or unfound allegations should be unrelated and based upon a thorough investigation of facts and circumstances as they occurred at the time of the alleged incident. This specific feedback was provided to OHAN after completion of the review. DSS acknowledges and directs staff that decision-making in an investigation should be independent of personnel decisions or other findings by the institution.  OHAN investigators sometimes used statements and findings collected during a congregate care facility’s own internal investigation without independently interviewing those witnesses or verifying the information. This is a troublesome practice given that facilities have their own interest in investigation findings, and does not constitute thorough, unbiased investigative practice, which should always be undertaken directly by OHAN. The CoMonitors have shared this feedback with OHAN and DSS represents that interviewing techniques will be included in the newly developed OHAN caseworker training.  Some investigators make the decision to unfound allegations that might otherwise have been indicated because there was an expectation that an indicated finding would be reversed on appeal. Though there is always a risk that a finding will change based upon the appeal process, the role for OHAN investigators in all cases should be to conduct a thorough investigation and make the determination that is most supported by the evidence in front of them.
Though the Co-Monitors applaud DSS’s efforts to begin addressing some of the issues identified with respect to OHAN policy and practice, reducing the incidence of abuse and neglect of children in foster care must involve changes that go beyond OHAN. It is imperative that, among other things, DSS work to ensure that caregivers for children in foster care are provided with the necessary training and support to reduce risk of harm, that DSS licensing staff thoroughly collaborate with OHAN and consistently vet foster and groups homes, that caseworkers closely

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monitor children’s safety and experience in placement and that data systems support easy, reliable access to historical information about prior reports and investigations.

VIII. PLACEMENTS A. Placement Needs Assessment

The FSA requires that by February 1, 2017, with prior input from and subject to approval by the Co-Monitors, DSS perform a statewide and regional foster care Placement Needs Assessment “in order to determine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members...” (FSA IV.D.1.). The needs assessment must include “specific recommendations addressing all the assessment’s findings, including but not limited to recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that can meet their needs” (FSA IV.D.1.).

In January 2016, DSS began work with the Co-Monitors to develop a methodology for conducting the placement needs assessment. DSS early on decided to engage USC CCFS, its training, research and QA partner, to conduct the assessment. After engagement of USC CCFS staff to conduct the assessment, discussion with the Co-Monitors about expectations and multiple iterations of the methodology, the Co-Monitors approved DSS’s methodology on December 27, 2016. The methodology incorporates an analysis of CAPSS data and a qualitative data collection process, with the goals of understanding where children from each region are placed in proximity to their biological homes, the underlying needs that drive placement decisions, the available licensed placement resources in each county and the movement of children to higher levels of care. USC CCFS’s analysis would also be informed by case-based data previously collected between March 2015 and October 2016 as part of DSS’s annual Quality Assurance (QA) reviews79, using the federal Child and Family Services Review (CFSR)80 On-Site Review Instrument81. USC CCFS began its statewide placement needs assessment in February 2017, with an original completion date of June 30, 2017. On June 30, 2017, DSS notified the Co-Monitors that the assessment could not be completed and that a report would be completed and submitted by August 31, 2017. DSS submitted a report with data and findings from the placement needs assessment to the Co-Monitors

79 DSS uses QA reviews to ensure services rendered to children and families by the child welfare system are of sufficient intensity, scope and quality to meet their needs. For more information see http://ccfs.sc.edu/looking-closely/qa-reviews.html 80 CFSR’s are periodic reviews of state child welfare systems conducted by the Children’s Bureau. For more information see
https://www.acf.hhs.gov/cb/monitoring/child-family-services-reviews 81 For the on-site instrument and instructions, see https://www.acf.hhs.gov/cb/monitoring/child-family-servicesreviews/instruments-tools-guides

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on that date. The Co-Monitors expect to discuss the report with DSS in a meeting scheduled in late September 2017.
A core component of the placement needs assessment process was a qualitative review of 90 cases. The review consisted of in-depth interviews using a protocol developed in consultation with the Co-Monitors. The cases represent a stratified (for gender, race, age and ethnicity), random sample of children from 14 counties and five regions, including children who were: placed in congregate care or group care within the three months prior to the review (20 cases); placed in therapeutic foster care within the three months prior to the review (20 cases); placed in family foster care placements and experienced more than three placement moves (changes) in the past year (20 cases); or placed in other stable family foster or kinship home settings (30 cases). The review sample also included a mix of children residing with one or more of their siblings in foster care, children placed in and outside of their home county, children with a range of permanency goals and children placed with 20 distinct providers.
Between February and May 2017, USC CCFS teams consisting of trained reviewers reviewed one case per week. Team members read the case record and interviewed relevant persons including the child, parents, caregivers, assigned caseworker and, as applicable, therapist, school personnel and significant others. Where possible, children were interviewed in their placement setting and family and caregivers were interviewed in their own homes. At the end of each week, a meeting was held with each review team to discuss findings. Each review team also provided a written report.
Following the analysis of data from these qualitative case reviews, focus group interviews with DSS employees and external stakeholders were held to clarify issues identified through the quantitative data analysis and the case review process and to answer any questions which had not been answered through other avenues of data collection. The availability, quality and responsiveness of local intensive home-based mental health services to meet the individual needs of children and youth was assessed through surveys to each county. Data matching with Medicaid mental health claims was also completed as part of the placement needs assessment. The methodology for the placement needs assessment is attached to this report as Appendix D.
Although the Placement Needs Assessment was not fully completed by the time of drafting of this report, the Co-Monitors read summaries of the 90 cases reviewed and found common themes which should inform improvements in placement processes and experiences and outcomes for children, youth, families, caregivers, caseworkers and providers, including:
 The current placement process is primarily driven by the availability of beds, rather than by the needs of children. It is common for staff looking for placements to use a Universal Application that is sent out to multiple providers. Placement is frequently based on where there is a willingness to accept the child, with frequent separation of siblings.

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 The needs of many of the children in congregate care and some in Therapeutic Foster Care (TFC) could have been met in a family foster care setting if a placement had been available.
 Many of the children had considerable trauma histories, with exposure during both their time in their biological homes and after placement in foster care. Separation from parents, separation from siblings, multiple placement moves and a lack of permanency all contributed to trauma responses that required skilled clinical therapeutic intervention and trained and competent caregivers.
 The limited availability of intensive home-based mental health services to address behavior related to trauma meant that some children were placed in congregate settings so that they could access more intensive services. Few emotional and behavioral challenges were noted that could not have been met in a less restrictive setting if such intensive home-based services were available.
 In-depth assessments of children were infrequent and those completed by DSS staff and providers did not adequately assess the needs underlying children’s behavior.
 Responsive mental health services, especially trauma responsive supports, were insufficient. It was not unusual for children to receive some form of counseling, but not the type of trauma-focused engagement that would have been appropriate to their needs. Assessment and therapy for some children was delayed by lack of resources, placing them on waitlists.
 Many of the TFC placements appeared to be responsive to most of children’s needs, though there was not a consistent focus on permanency. Some TFC providers did make a commitment to adoption.
 Generally, if the child was in a higher level of care, permanency efforts seemed less urgent, if important at all. In a few cases where adoption was an active consideration, there appeared to be limited coordination with adoption staff. For children in group care, facility staff had little involvement in permanency planning.
 Older children and youth reported having little input into the plans being made for them. For a number of youth and their biological parents, DSS staff were often described as developing the plans without their active involvement. Case plans were not consistently found in children’s files.
 In some cases, the caseworker role was compliance driven, with a focus on meeting court requirements, rather than on actively engaging families to address underlying challenges. This impeded reunification decision-making.

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 The use of a child and family team meetings for planning and coordination was mentioned infrequently, even where placement changes were being considered.

The Co-Monitors shared these themes with DSS and USC CCFS and they are being considered as DSS works to develop the Placement Implementation Plan that is required to follow the completion of the Needs Assessment.

B. Placement Implementation Plan

The FSA requires that “[w]ithin sixty (60) days of the completion of the needs assessment, DSS shall develop an Implementation Plan to implement the recommendations of the needs assessment within eighteen (18) months. The Implementation Plan shall have enforceable benchmarks with specific timelines, subject to approval by the Co-Monitors, to measure progress in executing the recommendations of the needs assessment” (FSA IV.D.1.(a)).

As presented above, DSS completed the placement needs assessment on August 31, 2017. Therefore, the Placement Implementation Plan is due by October 31, 2017. Pursuant to the FSA, the Co-Monitors will report on DSS’s progress towards achieving Implementation Plan benchmarks in subsequent reports (FSA IV.D.1(b)).

C. Performance Data

1. Specific Placement Settings

Placement of Children in Congregate Care

The overwhelming majority of children in foster care do best when they are placed in stable, family-like settings. Placement in group settings and multiple moves for children can result in numerous disruptions in a child’s life including with their caregiver, school and community that are damaging to a child’s well-being. It is for these reasons that the FSA has multiple requirements related to placing children in the most family-like, least restrictive environments and, where possible, with their siblings.

The FSA requires that at least 86 percent of Class Members be placed outside of congregate care placements on the last day of the reporting period (FSA IV.E.2.). DSS data indicate that in March 2017, 78 percent (3,223 of 4,124) of the children in foster care were placed outside of a congregate care placement (to include residential treatment and emergency shelters) as indicated below in Table 8. 82
82 Data about the number of children in a congregate setting was submitted by DSS but have not been validated by the Co-Monitors.

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Table 8: Types of Placement for Children in Foster Care March 2017

All children Family-based

in foster

Setting

care

# of children

4,124

3,223

% of

children

100%

78%

Source: CAPSS Data Provided by DSS

Congregate Care, Emergency Shelter or Residential Treatment
Facility
901
22%

Congregate Care
780 19%

Emergency Shelter
41 1%

Residential Treatment
Facility
80
2%

Children 12 and Under The FSA also includes placement standards specific to certain age groups of children, and requires that “[a]t least 98% of the Class Members twelve (12) years old and under shall be placed outside of Congregate Care Placements on the last day of the Reporting Period unless an exception preapproved or approved afterwards by the Co-Monitors is documented in the Class Member’s case file” (IV.E.3.).

DSS data indicate that 91 percent (2,630 of 2,905) of children ages 12 and under in foster care were residing in a family-based setting as of March 2017.83

Table 9: Types of Placement for Children Age 12 and Under in Foster Care March 2017

All children in foster
care age 12 and under

Family-based Setting

Congregate Care, Emergency Shelter or Residential Treatment
Facility

Congregate Care

# of

children

2,905

2,630

275

234

% of

children 100%

91%

9%

8%

Source: CAPSS Data Provided by DSS

Emergency Shelter
22 <1%

Residential Treatment
Facility
19
<1%

Children Six and Under Placement in a family setting is especially important for young children. The Interim Order put provisions in place to immediately address the placement of children ages six and under in congregate care, requiring that by November 28, 2015, DSS “create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the Co-Monitors, the placement

83 Ibid.
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of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers)” (IO II.3.(a) & FSA IV.D.2.). The plan was to include “full implementation within sixty (60) days following approval of the CoMonitors.”
On October 31, 2015, DSS provided the Co-Monitors with a draft plan for meeting this FSA requirement. The plan included immediate actions to review and hold staffings for children ages six and under in congregate placements; amend contracts with existing therapeutic foster care providers who had or could develop family placements for these children; and improve recruitment, training and licensure of family foster placements through Regional Resource Teams. DSS also proposed exceptions to the placement requirement. On January 22, 2016, after conducting site visits to local county offices and speaking with caseworkers, service providers (including congregate care providers) and legal staff, the Co-Monitors provided feedback on these plans, including modifications to DSS’s proposed exceptions. On March 15, 2016, the CoMonitors approved DSS’s plan, including acceptable exceptions (listed in Table 10 below), and DSS issued a directive outlining the procedure to be used by local and regional office staff to ensure the appropriate placement of children ages six and under in family placements.
Table 10: Exceptions for Placement of Children Ages Six and Under in Non-Family-Based Placements
Any group care placement for a child that is age 6 and under requires prior approval from the Deputy Director of Child Welfare Services upon the advice of the agency clinical staff that the child meets the following criteria:  The child requires a degree of clinical and/or medical support that can only be provided in a group care setting
and cannot be provided in a family like setting, and the placement is a facility that has the capacity and specialized treatment to meet those needs.  The child is the son or daughter of another child placed in a group care setting.  The child coming into care is in a sibling group of four or larger and all efforts to secure foster home and Therapeutic Foster home placements have been completed and have not produced a home. In that instance, placement in a facility that can accommodate the sibling group together and maintain daily contact between siblings is an allowable exception. This exception is time-limited for up to 90 days and can be extended for time-limited increments after considering and documenting the best interests of the children and pursuing and documenting intensive efforts to identify and support an appropriate placement or placements.  The child comes into care and is placed in congregate care with his or/her biological parent who is not in DSS care but who is receiving treatment at a facility.84  Children who are voluntarily placed by their parent or caregiver are not subject to this requirement.

The Co-Monitors have requested and received monthly data from DSS on all children ages six and under who have been in congregate care since entry of the Interim Order and continuing with the entry of the FSA. These data include child-specific information regarding approved exceptions each month, with the reasons for the approval. DSS reports that on November, 1, 2015, there were 142 children ages six and under in a congregate care setting. By February 2016, the number of

84 This exception was requested and approved by the Co-Monitors in May 2017, after the initial list of exceptions was approved.

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children ages six and under in congregate care had been reduced to 108, and by August 2016 DSS has reported that the number fell to 34 children.

As illustrated in Figure 9 below, during this monitoring period, the number of children reported by DSS to be in a congregate care placement greatly decreased from 17 in October 2016 to six in March 2017. The circumstances of five of the six children ages six and under placed in a congregate care setting in March 2017 met an agreed upon exception. Data from DSS, which has not been further validated by the Co-Monitors during this review period, shows that from October 2016 to March 2017, children ages six and under in congregate care have ranged in age from 2months old to just under 7-years old. Throughout this monitoring period, for the majority of children, their circumstance met one of the agreed upon exceptions for a congregate care placement – either the child was part of a sibling group of four children who were placed together or the child is residing with an adolescent parent in a program designed for teen mothers (for whom a familybased placement where they could be placed together could not be located). DSS has reported that approval was sought from the Deputy Director of Child Welfare prior to placement in only two instances during this monitoring period. Though the Co-Monitors have agreed that during this monitoring period these instances of placements prior to approval still meet the approved FSA exceptions, the expectation is that the Co-Monitors will recognize exceptions as such in future monitoring periods only if appropriate approval is sought from the Deputy Director of Child Welfare Services in advance of the child’s placement.

Figure 9: Children Ages Six and Under in Congregate Care October 2016 – March 2017

18 16 14 12 10
8 6 4 2 0
Total Met an exception

17 17
Oct-16 Oct-16
17 17

15 15

13 13

Nov-16
Nov-16 15 15

Dec-16
Dec-16 13 13

12 12
Jan-17 Jan-17
12 12

12 12
Feb-17 Feb-17
12 12

6 5
Mar-17 Mar-17
6 5

Total Source: CAPSS Data Provided by DSS

Met an exception

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Placement in DSS Offices and Hotels
Children experience instability and uncertainty when they are removed from their homes and placed in foster care. Ideally, the transition should be eased by having a consistent and appropriate placement available for each child at any time during the day and night, with caregivers equipped to provide care and support, regardless of the needs with which the child presents. Due to limited availability of appropriate placements, including a continuum of placements to meet child-specific needs, there have been instances in which DSS offices or hotels have been utilized as overnight placements for children in foster care.
The FSA requires that by November 28, 2015, “DSS shall cease using DSS offices as an overnight placement for Class Members, and shall cease placing or housing any Class Members in hotels, motels and other commercial non-foster care establishments. For any Class Members moved out of such DSS Offices or Hotels, DSS shall provide for their appropriate placement. In the extraordinary event that a child stays overnight in a DSS office, Defendants shall immediately notify the Co-Monitors, who shall provide a report to Parties as appropriate, including whether or not, in their view, the incident should be reported to the court as a violation which would preclude Defendants’ ability to achieve compliance on this provision” (FSA IV.D.3.).
The Co-Monitors have been notified of three instances in which a child has stayed overnight at a DSS office or hotel in violation of this provision. The first two incidents were on January 6, 2016 and involved two children, ages 12 and 13. Both children presented with challenging placement requirements and placements were not secured until the following day. The third incident occurred on October 20, 2016. The child was age 14 and ordered into DSS custody during his Department of Juvenile Justice (DJJ) proceeding earlier that day. Numerous efforts were made throughout the day by DSS staff to find an appropriate placement for this child, however, placement was not secured and the child stayed overnight at the office. The Co-Monitors notified Plaintiffs’ counsel of these occurrences and have determined they are violations of the FSA. Given that DSS has not yet developed a formal system for tracking overnight stays but relies on after the fact self-report by local county offices, the Co-Monitors were not able to independently validate these data to ensure they reflect all relevant violations of this provision.
The Co-Monitors will continue to review reports of overnight stays in DSS offices and hotel to better understand placement challenges across the state over time and will look closely at each instance to understand the circumstances and follow-up actions.

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Emergency or Temporary Placements

The FSA requires that “Class Members shall not remain in any Emergency or Temporary Placement for more than thirty (30) days. Under exceptions approved by the Co-Monitors, if a child is initially placed in an Emergency or Temporary Placement that is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move…” (FSA IV.E.4.). Exceptions to this standard have not been approved by the Co-Monitors.

DSS has been unable to provide data on the number of children in emergency and temporary placements and has not yet been able to determine if these placements are re-designated as longterm or therapeutic foster homes; baseline data utilizing the methodology defined in the FSA are not available.

The FSA also requires that “Class Members experiencing more than one Emergency or Temporary Placement within twelve (12) months shall not remain in the Emergency or Temporary Placement for more than seven (7) days. Under exceptions subject to the Co-Monitors’ approval, if a child’s subsequent placement within twelve (12) months in an Emergency or Temporary Placement is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a longterm foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move…” (FSA IV.E.5.).

Exceptions to this standard have not been approved by the Co-Monitors and DSS has not been able to produce data for this measure.

Juvenile Justice Placements

The FSA, incorporating an Interim Order provision, requires “[w]hen Class Members are placed in juvenile justice detention or another Juvenile Justice Placement, DSS shall not recommend to the family court or Department of Juvenile Justice that a youth remain in a Juvenile Justice Placement without a juvenile justice charge pending or beyond the term of their please or adjudicated sentence for the reason that DSS does not have a foster care placement for the Class Member…” (FSA IV.H.1.).

DSS represents that youth are immediately taken into the physical custody of DSS upon exit from juvenile justice placement in almost all instances, but has acknowledged that there is no system in place for routinely tracking youth moving between the juvenile justice and child welfare systems. DSS has reported that it is aware of only two instances of violation of this provision since entry of

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the Interim Order in September 2015. The first instance was in December 2015 when a youth remained in detention, at the order of a judge, because DSS was unable to find a placement for him. After more than a month, the youth was placed in an out-of-state facility. The second instance was in September 2016 when a youth remained in a detention center for seven days awaiting placement in a group home, upon judicial order.
Given the lack of a reliable mechanism for tracking compliance with this measure, occurrence may be understated. The Co-Monitors are committed to working with DSS and other stakeholders in future monitoring periods to both find alternative ways to monitor compliance with this measure and support the development of processes that will capture these important information about a child’s status in a timely and reliable way.
2. Placement Stability
The FSA (IV.F.1.) requires that for all Class Members in foster care for eight days or more during the 12 month period, placement instability shall be less than or equal to 3.37.85 DSS has not produced data to enable the Co-Monitors to assess performance for this measure for this period.
3. Sibling Placement
When children enter foster care they need to be placed with their siblings unless there are prohibitive reasons related to a child’s safety or well-being. The FSA requires children who enter care with or within 30 days of their siblings to be placed with their siblings (FSA.IV.G.2. & 3.). The FSA sets two targets – one for placement with at least one of their siblings and the other placement with all siblings. The FSA allows for exceptions to this requirement, including when there is a court order prohibiting such placement or if the placement is determined not to be in the best interest of one or more siblings. Additional exceptions to this standard have not yet been approved by the Co-Monitors.
As of January 1, 2017, there were 2,459 children who had siblings in foster care.86 Over one-third (37%/911 children) of these children were placed with all of their siblings.87 In addition to the 911 children who were placed with all of their siblings, 812 (33%) children who had siblings in foster care were placed with at least one of their siblings. Thus, a total of 70 percent of children were placed with at least one of their siblings; the remaining 736 children (30%) were placed without a sibling.

85 The formula used to calculate performance is provided in Section II.O. of the FSA. 86 Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS
case identifier. 87 The majority of sibling groups in which all children were placed together were sibling groups with two children (652
children/72%). 183 (20%) of the children placed with all of their siblings were in sibling groups of three.

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Table 11: Children Placed with their Siblings January 1, 2017 N=2,459

Number

Placed with all siblings

911

Placed with at least one sibling

1,723

Not placed with any siblings

736

Source: CAPSS Data Provided by DSS

Percent 37% 70% 30%

Final Target 80% 85% --

IX. FAMILY VISITATION
Visitation is critical to maintaining family connections for children in foster care. The FSA includes measures specific to visits between children in foster care and their siblings and, where there is a goal of reunification, with the parent(s) with whom reunification is sought. The majority of children in DSS care did not visit with their siblings in care on a monthly basis this monitoring period. This information has been reviewed by DSS, which has reported using it to inform an ongoing plan to improve practice in this area. As discussed in more detail below, the Co-Monitors were not able to assess performance with respect to visitation between parents and children this monitoring period due to a lack of reliable data about children’s permanency goals.
A. Visitation Implementation Plan
The FSA requires “[w]ithin 60 days of the entry of the Order approving the Settlement Agreement, Defendants shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent” (FSA IV.J.1.).
DSS convened a Visitation Workgroup in October 2016 to assess systemic barriers to family visitation, and develop and assist with the implementation of the Visitation Implementation Plan. DSS submitted a draft of the Visitation Implementation Plan on November 30, 2016, and upon receipt of feedback from the Co-Monitors and Plaintiffs’ counsel, has completed several rounds of revisions and modifications. The Implementation Plan for visitation has not yet been approved by

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the Co-Monitors, and the data required to set all interim benchmarks and final targets are not available.
B. Methodology, Data Collection and Validation
Although documentation of sibling visits is entered into CAPSS, the fields that capture this information were recently built, and have not yet been used to extract data or in management reporting. In order to ensure completeness and accuracy, in March 2017, DSS, USC CCFS and Co-Monitor staff began work to develop a methodology to collect baseline data for the FSA measures IV.J.2 and IV.J.3 related to family visitation. With the support of the DSS Visitation Workgroup, two review instruments were developed – the first to assess the frequency of visitation between siblings (IV.J.2.) and the second to assess visitation with parents for children with a reunification goal (IV.J.3.). These instruments were finalized in May 2017 utilizing Survey Monkey, a web-based survey tool used for collecting and analyzing data. An orientation for reviewers was conducted by Co-Monitor staff, and included training on review of a case file, appropriate documentation and instrument completion. A test case was completed to promote interrater reliability. Second level reviewers oversaw reviewers’ completion of the instruments and any disparities in findings were conferenced and resolved accordingly.
Though reviewers were able to complete the review of cases with respect to sibling visitation and extract data as described below, a determination was made to halt the parent visitation review when concerns arose about the validity of the sample. DSS and the Co-Monitors agreed that DSS data with respect to cases of children statewide with a permanency goal of reunification was not accurate and needs to be verified before the review can proceed. This finding raised heightened concerns by the Co-Monitors about the accuracy of CAPSS data generally, as discussed more fully earlier in Section II of this report.
C. Performance Data
1. Sibling Visits
Section IV.J.2 of the FSA requires, “[a]t least 85% of the total minimum number of monthly sibling visits for all sibling visits shall be completed.” The FSA also allows for exceptions if there is a court order prohibiting or limiting visitation, if “visits are not in the best interest of one or more of the siblings and the facts supporting the determination are documented in the case file,” or with exceptions approved by the Co-Monitors. The Co-Monitors have approved the following exceptions to this visitation requirement:

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Table 12: Approved Exceptions to Sibling Visitation Requirement
 Court order prohibits or limits sibling visitation  Child or sibling is on runaway during a calendar month with best efforts to locate  Child or sibling is incarcerated or in a facility that does not allow visitation despite efforts  Child or sibling refuses to participate in the visit where age appropriate  Sibling visit is infeasible due to geographic distance with efforts to provide alternative forms of contact.
Geographic distance will only be allowed as an exception upon individual review of the applicable case by the Co-Monitors.  County Director approval with legal consultation for determination that a visit poses immediate safety concerns for the child or sibling. If an immediate safety incident or concern occurs prior to or during a visit, the caseworker is to remove the child from the visit and notify the County Director afterward.
 Supervisory approval for determination that visitation would be psychologically harmful to the child 88
In order to establish baseline performance, reviewers looked at a sample of 311 cases for which sibling visits were required in March 2017.89 Reviewers determined that 143 children had visited with each of their siblings in the month and that there were nine cases to which a valid exception applied90, resulting in a baseline of 47 percent. Of the 159 children who did not visit with all of their siblings, only 20 visited with any of their siblings. DSS will use this baseline to establish interim benchmarks and timelines to move toward the final target of 85 percent.
Figure 10: Visits Between Siblings Not Placed Together March 2017 N=302

47% 53%

Visited Did Not Visit
Source: June 2017 Case Record Review, USC CCFS and Co-Monitor staff
88 A DSS supervisor must confirm the determination that visitation would be psychologically harmful to the child based upon written documentation of a clinical decision issued by a Licensed Practitioner of the Healing Arts (LPHA) within the scope of their practice under SC State Law and who is not an employee of DSS. The LPHA’s name, professional title, signature and date must be listed on the document to confirm the clinical decision. 89 As of March 31, 2017, there were 1,609 children who had been in foster care for at least one month, with siblings in foster care with whom they were not placed. A statistically valid random sample of 311 cases was pulled based on a 95% confidence level and +/- 5% margin of error. Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier. 90 One case was excluded because the child’s adolescent sibling refused visitation and eight cases were excluded based on documentation that sibling visitation would be psychologically harmful to the child or sibling.

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2. Parent Visits
The FSA requires, “[a]t least 85% of Class Members with the goal of reunification will have inperson visitation twice each month with the parent(s) with whom reunification is sought…” (FSA IV.J.3.). The FSA also allows for exceptions if there is a court order prohibiting or limiting visitation, or with exceptions approved by the Co-Monitors.
Table 13: Approved Exceptions to Parent and Child Visitation Requirement
 Court order prohibits or limits parent visitation.  Parent is missing or child is on runaway during a calendar month with best efforts to locate.  Parent or child is incarcerated or in a facility that does not allow visitation in the calendar month despite best
efforts.  Parent refused to participate.  Parent did not show up to visit despite attempts to successfully arrange and conduct the visit  Parental rights were terminated in that month.  Parent visit is infeasible due to geographic distance, with efforts to provide alternative forms of contact.
Geographic distance will only be allowed as an exception upon individual review of the applicable case by the Co-Monitors.  County Director approval with legal consultation for determination that a visit poses immediate safety concerns for the child. In addition, if an immediate safety incident or concern occurs prior to or during a visit, the caseworker is to remove the child from the visit and notify the county director afterward.
 Supervisory approval for determination that visitation would be psychologically harmful to the child.91
As discussed, data for this measure are not currently available. The Co-Monitors are deeply concerned about the lack of reliable data with respect to such a fundamental aspect of child welfare practice. DSS has informed the Co-Monitors of its plan to immediately update and validate these data within the second monitoring period.
X. HEALTH CARE
The provision of health care services to children in foster care is a fundamental obligation of child welfare systems. In order to fulfill this obligation, there must be reliable systems in place to determine when children are due for screenings and assessments, and, if treatment needs are identified, follow up to ensure the receipt of care. Though DSS has made significant efforts to update health information so that the needs of children in foster care can be appropriately tracked and addressed, there have been delays in the data collection and production, and DSS has struggled with planning for broader system and practice reform in this area. The Co-Monitors have

91 A DSS supervisor must confirm the determination that visitation would be psychologically harmful to the child based upon written documentation of clinical decision issued by a Licensed Practitioner of the Healing Arts (LPHA) within the scope of their practice under SC State Law and who is not an employee of DSS. The LPHA’s name, professional title, signature and date must be listed on the document to confirm the clinical decision.

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continuously encouraged DSS to advocate for and engage all resources needed to move this essential work forward.

A. Health Care Improvement Plan

The FSA requires that by April 3, 2017, DSS, “with prior input and subject to approval by the CoMonitors, shall develop a Health Care Improvement Plan with enforceable dates and targets for phased implementation and concerning initial screening services, periodic screening services, documentation, and health care treatment services for Class Members in the areas of physical health, immunizations and laboratory tests, mental health, developmental and behavioral health, vision and hearing, and dental health. The Plan shall address:

(a) Developing the capacity to track screening and treatment services for individual children and aggregate tracking data, including but not limited to screens that are due and past due;
(b) Assessing the accessibility of health care screening and treatment services throughout the State, including the capacity of the existing health care providers to meet the screening and treatment needs of Class Members; and
(c) Identifying baselines and interim percentage targets for performance improvement in coordinating screens and treatment services” (FSA IV.K.1.(a-c)).

The FSA provides that DSS may request an additional 60 days to complete the Improvement Plan if there is evidence of progress toward development of the Improvement Plan and approval by the Co-Monitors (FSA IV.K.2.). On March 31, 2017, DSS requested a 60 day extension until May 31, 2017, which the Co-Monitors approved with certain conditions, including that DSS engage an external health care consultant. The extension approval was based upon the work that DSS had completed in preparing the Improvement Plan, including creation of a Healthcare Work Group; improvements in the ability to track health assessments; completion of county surveys to identify providers being utilized for assessments and follow-up care; discussions with other states and two model assessment centers within South Carolina; and planned discussions with the Department of Health and Human Services (DHHS), South Carolina’s Medicaid agency and representatives from Select Health, the Medicaid Managed Care Organization (MCO).

On June 1, 2017, DSS filed a Motion for Extension of Time for submission of the Improvement Plan, requesting an additional 120 days to submit the Improvement Plan. The Court approved this request and the new deadline for the Improvement Plan is on or before September 30, 2017. The Co-Monitors engage in frequent conversations with DSS around work to complete the Plan.

In addition to the Improvement Plan requirement, the FSA includes two compliance measures with deadlines set shortly after entry of the Agreement (FSA IV.K.4.(a)&(b)), both of which are

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discussed below. All final health care outcome measures related to initial screening services, periodic screening services, documentation, treatment and other corrective services, will be identified by the Co-Monitors, with input from Parties, within 120 days after completion of the Health Care Improvement Plan (FSA IV.K.5.).
B. Performance Data
1. Initial Health Assessments
The FSA requires that by December 5, 2016, DSS “identify Class Members who have been in DSS custody for more than sixty (60) days as of the date of final court approval of the Final Settlement Agreement, and who have not had initial health assessments (physical/medical, dental or mental health). Within thirty (30) days after the identification period, Defendants shall schedule the initial health assessment for at least 85% of the identified Class Members” (FSA IV.K.4.(a)).
In May 2016, DSS began an effort to document, track and produce data reports for both health and educational outcomes for children in foster care, primarily through use of an Education and Health Passport. A Directive Memo issued on May 6, 2016 required a passport for every child in care be entered into CAPSS by July 1, 2016. In August 2016, a CAPSS redesign was implemented, providing discrete fields in CAPSS to capture physical and mental health screenings and followup and to produce data reports to track compliance, among other things. DSS has been responsive to Co-Monitor feedback about ongoing data issues in this area and the process to improve CAPSS functionality is ongoing.
On December 5, 2016, DSS provided reports to the Co-Monitors of children who were in DSS custody for more than 60 days on October 4, 2016 and had not had an initial health/medical, dental or mental health screening date entered into CAPSS. DSS acknowledged that the report was not fully accurate, as healthcare data for many children still needed to be entered. On January 9, 2017, DSS provided updates on the children initially identified in the December 5, 2016 cohort as requiring an assessment. These data subsequently required numerous rounds of data clean-up and validation by DSS, USC CCFS and Co-Monitor staff. For the majority of cases, between December 2016 and January 2017, information was entered into CAPSS that demonstrated that the child had the required health assessment (medical, dental or mental health) prior to October 4, 2016 but the data had not been timely entered. Performance data reported below reflects final analysis by DSS provided to the Co-Monitors on September 4, 2017.
Data analysis produced concerning results (Table 14). Performance for initial medical assessments was 10 percent, initial dental assessment was 15 percent and initial mental health assessment was

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six percent92. For those children who did not have the necessary assessment completed by January 5, 2017, as of August 28, 2017, 54 percent had an initial medical assessment, 62 percent had an initial dental assessment and 59 percent had an initial mental health assessment. Further action to meet the health care needs of children in foster care continues to be a high priority for DSS.

Table 14: Completion of Initial Medical, Dental and Mental Health Assessments for Children
October 5, 2016 – January 5, 2017

Total Applicable Children

Assessment Completed
prior to 10/4/2016

Children requiring assessment after 10/4/2016

Assessment completed between 10/4/16 – 1/5/2017

Assessment Not Completed as of 1/5/2017

Compliance with FSA
K.4.a. – Target 85%

Medical

2,918

2,750

168

16

152

10%

Dental

2,77393

2,083

690

102

588

15%

Mental Health

2,918

2,178

740

42

698

6%

Source: CAPSS Data Provided by DSS

2. Immediate Treatment Needs

The FSA requires that by January 2. 2017, DSS “identify Class Members with Immediate Treatment Needs (physical/medical, dental or mental health) for which treatment is overdue. Within forty-five (45) days of the identification period, DSS shall schedule the necessary treatment for at least 90% of the identified Class Members. (Immediate Treatment Needs means immediate non-elective physical/medical, dental or mental health treatment needs and documented assessment needs, excluding routine periodic assessments.)” (FSA IV.K.4.(b)).

This performance measure has not been met. DSS has informed the Co-Monitors that data for this measure are not currently available. The Healthcare Workgroup has been assigned the task of defining “immediate treatment needs” and DSS represents that enhancements are underway within CAPSS to capture and collect the necessary data. In the Co-Monitors and DSS’s view, this is an area that demands urgent attention.

92 For children under the age of three, completion of an initial medical assessment was considered compliant for the mental health assessment measure as a developmental assessment and screening is a component of their examination with a primary health care provider. 93 For purposes of this analysis, children under the age of one were not considered applicable for an initial dental assessment. An oral examine is a component of their examination with a primary health care provider.

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APPENDIX A
Glossary of Acronyms
CAPSS: Child and Adult Protective Services System CFSR: Child and Family Services Review CQI: Continuous Quality Improvement DHHS: Department of Health and Human Services DSS: Department of Social Services FSA: Final Settlement Agreement GAL: Guardian ad litem IFCCS: Intensive Foster Care and Clinical Services IO: Interim Order MCO: Managed Care Organization OHAN: Out-of-Home Abuse and Neglect Unit QA: Quality Assurance SC: South Carolina TFC: Therapeutic Foster Care USC CCFS: University of Southern Carolina’s Center for Child and Family Studies

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APPENDIX B
Co-Monitors Initial Monitoring Plan (February 1, 2017)
February 1, 2017
The Honorable Richard M. Gergel United States District Judge Post Office Box 835 Charleston, SC 29402
Via electronic mail
Re: Michelle H. v. Haley, et al. 2:15-cv-00134-RMG Initial Monitoring Plan
Dear Judge Gergel,
As court-appointed Co-Monitors pursuant to the Final Settlement Agreement (“FSA”) in the above-referenced matter, Paul Vincent and Judith Meltzer are responsible for conducting a factual investigation and verifying documentation necessary for the issuance of public record reports on the state’s performance with respect to the FSA performance requirements. FSA, III.D. The FSA requires that the Co-Monitors prepare an initial monitoring plan within 120 days of Court approval of the FSA. Since entry of the Consent Interim Relief Order (“Interim Order”) entered on September 28, 2015, the Co-Monitors and Co-Monitor staff, Rachel Paletta and Elissa Gelber, have been working consistently and in collaboration with the Department of Social Services (“DSS”) to implement the Interim Order and early FSA requirements, and gain a thorough understanding of the DSS child welfare system and related data. The attached table includes our preliminary decisions with respect to a monitoring plan.
As indicated in the attached table, there are a number of areas in which precise methodology has not yet been determined because decisions regarding relevant practice or measurement issues or interim benchmarks still need to be made and/or because of the absence of reliable baseline data. As such, we anticipate modifying the monitoring plan as needed over the next several months. The monitoring plan submitted to the Court today has been shared with both Plaintiffs and Defendants in draft form and incorporates their feedback. We will continue to involve both Parties as the plan evolves.
In addition to the specific monitoring activities described in the attached table, the following is a list of general monitoring responsibilities and functions that have been identified by the CoMonitors after consultation with Parties. They reflect the interests of both Parties and the Court in regular, open communication and information sharing, and are integral to the Co-Monitors ability to assess progress and positively support DSS as it moves forward with the changes contemplated by the FSA.

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Monitoring Functions and Responsibilities
 Meet regularly with DSS monitoring team and DSS leadership to discuss implementation progress and challenges: During the early phases of implementation, the Co-Monitors and key DSS staff charged with managing the implementation of the FSA reforms are meeting every two weeks by telephone or in person.
 Meet regularly with Plaintiffs’ counsel to share information on FSA implementation progress and challenges, and to obtain their input on those areas requiring consultation and consent: Plaintiffs have requested, and the Co-Monitors have agreed to, quarterly meetings to keep them apprised of progress and discuss any issues related to FSA implementation and monitoring. We will also be sharing data and information related to implementation progress.
 Convene joint meetings with Parties: We expect to convene and facilitate joint meetings with Plaintiffs and Defendants three to four times a year. The first of such meetings will be focused on discussing Plaintiffs’ feedback in regard to the Court ordered Implementation Plans.
 Continue to work with DSS to reach agreement on the definitions and appropriate application of exceptions to certain FSA requirements: Once these exceptions are agreed upon, data validation will be necessary to verify appropriate use.
 Support DSS in establishing and analyzing baseline data for those measures for which data are not currently available: Some measures will require a qualitative review or case record level analysis and validation.
 Consult with Judge Gergel and Judge Duffy: The Co-Monitors will inform the Court of FSA implementation progress and, if necessary, engage assistance in mediating disputes among Parties.
 Provide technical assistance and support to DSS as requested: The Co-Monitors have been working closely with DSS staff to establish the relationships necessary for effective monitoring and to support technical assistance. We have and will continue to facilitate peer learning with other states and localities that have approached similar issues and to connect DSS, where possible, with national and philanthropic resources. We also expect to support implementation through direct technical assistance by the Co-Monitors and their staff, in consultation with DSS.
 Meet with interested Parties and stakeholders throughout the state: The Co-Monitors have begun and will continue, in consultation with DSS staff and Plaintiffs, to meet with providers, including congregate care providers, and other relevant partners and stakeholders involved in child welfare system services and supports to Class Members.

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 Conduct local office site visits as needed for monitoring: Monitoring activities with respect to many of the FSA requirements will include local office site visits to learn firsthand about implementation progress, barriers and challenges impacting Class Members.
 Participate/observe work group and other kinds of implementation meetings related to FSA implementation progress: The Co-Monitors and staff have already begun and will continue, in consultation with DSS staff, to participate in DSS led workgroups charged with developing Implementation Plans and strategies required under the FSA.
 Respond to inquiries: The Co-Monitors will respond to phone calls, letters and other inquiries from the public related to lawsuit progress and Class Members.
 Prepare required written monitoring reports to the Court and Parties.
 Engage in required dispute resolution functions as a result of findings.
 Participate in Court status conferences as needed.
We are available to discuss any questions you may have related to what is outlined above or in the attached document.
Sincerely,

Judith Meltzer Deputy Director Center for the Study of Social Policy

Paul Vincent Director Child Welfare Policy and Practice Group

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APPENDIX C
Workload Estimation Study Methodology (February 22, 2016)
METHOD FOR FOSTER CARE WORK LOAD STUDY
A. DSS seeks the approval by the Co-Monitors of the proposed Workload Study method. This method would include review and consideration of:
1. Caseload and workload provisions, standards and best practices from organizational publications including the Council on Accreditation and Child Welfare League of America
2. Data concerning current South Carolina Department of Social Services workloads and placement locations and other factors affecting workloads and time to conduct work in South Carolina
3. Data and case load limits in other areas, specifically including Tennessee, New Jersey, Washington, D.C. and Mississippi.
4. Workload study completed by Casey Family Programs in 2015 5. The workload study will include focus on the time needed and time available for
workers to manage and complete current work and work anticipated as a result of the Michelle H. v. Haley Settlement Agreement but will not be a “time study.” Rather, the time needed and time available portions will be considered based upon data regarding caseloads, current system performance, out-of-county placements and other trends; conclusions from other time studies and best practices; ancillary data from the placement study; input from workers, supervisors and administrators; comparison of worker tasks from other states; and specific conclusions concerning time needed/time available for South Carolina Department of Social Services as analyzed by Casey Family Programs 6. Casey Family Programs to conduct evaluation and enhanced analysis of information and data of sections 1-5 above specific to South Carolina.
B. The caseload study proposed would be followed with submission to the co-monitors of specific caseload/workload limits based upon the findings of the study to be completed by Casey Family Programs.

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APPENDIX D
Placement Needs Assessment Methodology (December 27, 2016)
South Carolina Department of Social Services (DSS) Placement Needs Assessment
The Center for Child and Family Studies
February 1, 201794
As part of its contract with the SC DSS, the Center for Child and Family Studies (CCFS) will conduct the Placement Needs Assessment following a plan approved by the SC DSS Internal Monitoring Team and the Co-Monitors. The needs assessment will be conducted to assist DSS in meeting its obligations under the Final Settlement Agreement in Michelle H et al. v. Haley and Alford, specifically determining the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members. The Final Settlement Agreement requires the following:
D. Placement Resources D.1 Placement Needs Assessment. Within one hundred twenty (120) days, DSS, with prior input from and subject to approval by the Co-Monitors, shall perform a statewide and regional foster care placement needs assessment in order to determine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members. The needs assessment shall include specific recommendations addressing all the assessment's findings, including but not limited to recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that can meet their needs.
Class Certification and Definition: Pursuant to the terms of this Settlement Agreement, this case shall be certified as a class action under Fed. R. Civ. P. 23(a) and (b)(2). The "Certified Class" shall be defined as follows: all children who are involuntarily placed in DSS foster care in the physical or legal custody of DSS either now or in the future.

Both quantitative and qualitative strategies will be used in conducting the needs assessment. An in depth analysis of data on foster care placements from the DSS Child and Adult Protectives Services system (CAPSS) data system will lay the foundation for the assessment by providing information as to where SC DSS places its children in foster care. This quantitative data analysis and review will be followed by a qualitative data collection effort to assess the decision-making process, how

94 The Placement Needs Assessment was approved on December 27, 2016 and was updated on February 1, 2017.

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children are faring in foster care, and the impacts on children receiving higher levels of care. Findings will be reported to the agency and federal monitors on a monthly basis.
Quantitative Review of Foster Care Placements (Complete by January 31, 2017)
Analysis of Data from the DSS Child and Adult Protectives Services System (CAPSS) Data System
In order to determine where foster children are currently being placed, CCFS will conduct an depth analysis of placement data in CAPSS. CCFS statisticians will use SAS software to conduct an in depth analysis of CAPSS data to explore where children are placed by region and county and by various characteristics such as race, sibling group, age, level of care, type of placement, etc. DSS identified the following questions to be answered through the placement assessment process. Data analysis will be provided to the team on Excel spreadsheets. Each spreadsheet will be consistently documented as to the variables used, type of analysis conducted, sources and dates that the data represents. In addition, a booklet will be developed to document all of this information for all data analyses.
The in depth analysis will attempt to answer these questions as the data permits.
 Where are our children placed geographically? o Where children from each region are placed o The number of children placed out-of-home county/region o For out of county placements, location by county and region of placement and approximate distance from the home county o The types of placements in which children are currently residing o The number of placement resources, by type in each county o The licensed capacity of foster care providers in each county/region compared to the current census in the county/region
 How many children are placed with some or all of their siblings?  What are the demographic trends for children placed in higher level of care as a whole?  What percentage of children in foster care are discharged to a higher level of care?  What are the trends around which children are placed in higher levels of care? All quantitative data will be provided to the team on Excel Spreadsheets. Each spreadsheet will be consistently documented as to the items used, type of analysis conducted, sources and dates that the data represents.
Analysis of Available Data from the SC Quality Assurance (QA) Annual County Review Process (January 31, 2017)
In South Carolina, each county receives an annual QA review. Reviewers use the federal 18-item Onsite Review Instrument to rate cases. Where available 10 foster care and 10 family preservation cases are reviewed in each county. Results of these annual county reviews are compiled annually into a summative report. This report includes quantitative and qualitative data from the review process. SC began using the new 18-item federal onsite review instrument in March 2015; therefore, summative reports from March 2015 through October 2016 will be reviewed to glean

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some preliminary information regarding the following questions relevant to the placement needs assessment study. A summary of item ratings for 2016 county QA reviews indicate:
System Strengths:
 Item 1 (Timeliness of Initiating Investigation) - 80% strengths  Item 21 (Educational Needs of the Child) - 74% strengths  Item 17 (Physical Health of Child) - 65% strengths  Item 7 (Placement with siblings) - 65% strengths
Areas in Need of Improvement:
 Item 12 (Needs and Services to Child, Parents, and Caregivers) - 20% strengths  Item 15 (Caseworker Visits with Parents) - 24% strengths  Item 13 (Child and Family Involvement in Case Planning) - 31% strengths
Qualitative data from the 2016 QA reports will be analyzed and provided to DSS. DSS will examine the review findings for answers to the following questions:
 Why are children placed in level 2 or level 3 congregate care? Is it because of behaviors or a shortage of resources?
 If children are not placed with their siblings, why not?  Why are children placed out of the county/region? Is it simply a lack of placement options?
Is it because children from other regions are taking those beds? Are there resource or support shortages in certain areas? If yes, then what areas?
Qualitative Assessment of Foster Care Placements
Individual Interviews
A qualitative case study approach is proposed as the method of study to facilitate a better understanding of the experiences of those most directly involved in foster care as consumers, care providers, services providers, and agency staff. These cases studies tied with the broader statistical analysis will capture not only what is occurring in placement decision-making but also why it is occurring. The primary data collection method used in the case study approach will be individual interviews of the consumers, care providers, services providers, and agency staff involved in each case.
Qualitative case reviews of 90 children/youth will be conducted to assist the agency in learning more about the placement decision-making process and its impact on children in foster care across the state. Interviews will be designed to identify practice influences on placement decisions as well as an effort to reveal the effects of placement selection on children’s current status. In addition, it

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is anticipated that interviewers will learn how caregivers are sustaining stability as well as what caregivers need in external supports. As described in greater detail below, in January 2017, the study team will finalize the interview protocol, sampling and training plan in consultation with the Co-Monitor. The interview protocol and case study analysis will be designed to answer the following questions:
 What are the child’s underlying needs  Does the child’s current placement and placement history reflect a good understanding of
the child’s needs  To what extent does the child’s current placement provide the services and support needed
to insure the child’s, safety, well-being and permanency?  What if any, additional supports/services are needed to stabilize the child’s placement?  If children are not placed with their siblings, why not?  Why are children placed out of the county/region? Is it simply a lack of placement options?
Is it because children from other regions are taking those beds? Are there resource or support shortages in certain areas? If yes, then what areas?  What can we learn about the transition of children from placement to placement regarding group homes and foster homes? For example, from all placement moves? From group care placements to post-group care placements? Are there specific behaviors or characteristics present in these children?  What is the decision-making process for placing children in a higher level of care?  What are the resources needed and what shortages of resources exist that keep children from being placed in lower levels of care? At the outset when the placement is first being considered? After a child has been initially placed and a step-down to birth family or another less restrictive placement is being considered?  Why are children placed in level 2 or level 3 congregate care? Is it because of behaviors or a shortage of resources? If it is because of the behavior of the child, what kinds of behaviors? Externalizing? Internalizing? Or an equal mixture of both? What supports are needed and, if those supports were available, how many of these children could be maintained in a therapeutic foster home placement?  Why are children who are approved for therapeutic foster homes placed in congregate care instead? How often does this happen?  Why would a child who is ISCDEC-approved for therapeutic foster care be placed in a congregate care placement instead?  What are the permanency outcomes for children in therapeutic foster care compared with children in conventional family foster homes?
Sample selection. Ninety foster children from 10 counties will be selected for participation in the case study interview process. Two counties will be selected from each of the five regions across the state. This will facilitate a broad geographic representation of the state in the sample. Three steps are involved in the sampling process.

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1. Extract the universe of children in foster care by county and by: o #/% of out of county placements o # of placements experienced by foster care children o #/% of siblings in care o #/% of placements in congregate care facilities o #/% of children in therapeutic foster care o # of licensed foster care families in the county by the length of time the foster home has been licensed o #/% of children in licensed kinship care
2. In collaboration with DSS staff, CCFS will select ten counties representing those with the high and low percentages of the variables listed above. This will allow a broad representation of these key variables in the sample.
3. Once the 10 counties have been selected, the universe of all children in foster care in these 10 counties will be extracted. These data will be stratified by placements in congregate care, therapeutic foster care, foster care homes, and relative foster care homes, and number of placements while in care. The sample will be chosen within each strata as follows: o 20 children who are placed in congregate care (other than short-term emergency shelter) or who were in group care within the past three months of the review o 20 children in therapeutic foster care or who were in therapeutic foster care within the past three months of the review o 20 children in family foster care placements who have experienced more than three moves in the past year o 30 children from other stable family foster home settings (including kinship care providers and foster parents who are caring for children with health and developmental issues)
At this third step, a purposeful selection process will occur in an attempt to achieve a sample that includes children from each of the 10 counties of various ages, genders, races, and in and out of county placements. It is anticipated that foster parents who are known to provide long periods of stability for children in their care as well as foster parents who have recently experienced a child moving to a higher level of care or placement disruption will be interviewed as part of our sample. If not, these types of foster parents will be identified (possibly from counties other than those in the sample) and interviewed.
Development and Training of Review Teams. (February 2017) USC CCFS will identify sufficient review staff to conduct the case reviews in February and March 2017 in pairs of two reviewers per case. Co-Monitors will support USC CCFS in this process by providing resources (people and curricula) for training reviewers. DSS wants to build capacity of DSS staff and partners by conducting the interviews with resources available in South Carolina.
Conduct qualitative case reviews (February through May 2017) QA Review staff will conduct a Strategic Review of all 90 cases selected for interviews using the review protocol developed in consultation with Co-Monitor. Data collection for each case review

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is expected take 2 days. Prior to the on-site review, USC CCFS will coordinate the process by identifying persons to be interviewed for each case and working with the assigned workers to obtain consents and schedule interviews. Review teams will begin review by reading the child’s case record and then proceed to interview relevant persons in including child, parent, caregiver, assigned worker, and as relevant, therapist, school personnel and significant others. Priority will be given to interviewing the child in their placement setting and family/parents/caregiver in their own homes.

Interview teams. A team will be selected to interview those associated with each of the 90 targeted cases. CCFS staff will be recruited as available to serve on teams and conduct interviews. If possible, additional interviewers may be recruited in specific areas of the state to assist with completing the qualitative case reviews. All interview teams will be trained in interview protocol as to how to ask questions and what prompts to use in soliciting needed details. The interview teams will first review the child’s case record to help them better understand the circumstances of the child coming into care and current assessment results. Having this background information will help them focus their questions. Interview appointments for each person involved in the case (foster parents, clinicians, etc.) will be made and team members assigned to conduct the interviews. Teams will complete the interview protocols and narrative case summaries immediately following the case interviews. Each interview team will send the entire package of interview responses to the Needs Assessment Coordinator within five days of completing the interviews.

Data Collection. The entire interview process will be piloted with two cases to ensure processes are effective and efficient and produce the information needed for the placement needs assessment. After the pilot, interviews will be scheduled and conducted by county as much as possible.

Qualitative case review development process. Information collected from qualitative case reviews for each of the 90 cases will be reported using a case narrative format to include demographic information, a description of each child’s issues, the manner in which placements were selected, and the child’s current status (permanency, emotional well-being, educational progress, etc.). The case narrative form will be developed as part of the protocol development in consultation with the Co-Monitor. It will include a recommendations section to suggest whether the current placement option is appropriate to the child’s needs identifying better options to the current placement. At the end of each review week, each interview team will present their case to the QA Director, research facility and other CCFS staff and reviewers to discuss information gathered to include the child and family history, case planning, caregiver supports and needs and to identify themes and trends. It is anticipated that the development of each qualitative case review narrative could take up to five days to complete including travel, case file review, interviews, development of the narrative, and debriefing.
Qualitative data analysis. The narratives will be summarized monthly answering questions posed in this proposal and describing trends regarding placement decision-making, child needs, services needed, placement settings needs and system effectiveness. A final summary report will be developed after the conclusion of the interview process.

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Focus Group Interviews (Complete by May 31, 2017)
Focus group interviews with DSS employees and external stakeholders will be held at or near the end of the data collection process to bring together DSS staff or others who can help clarify questions identified through the case study process and to answer any of the questions posed in this needs assessment proposal that have not been answered through other avenues of data collection. All data collected through focus group interviews will be confidential except as otherwise required by law. Data from the focus group interviews will be analyzed and included in the final report.
Identification of the At-risk Population (Completed by June 30, 2017)
In addition, review of Medicaid data on the recent use of mental health services by Class Members will provide information on the approximate number/percentage of children in different counties who may be at risk for needing higher level placements or placement supports.
Service Array Surveys (Complete by May 31, 2017)
In order to assist the agency in determining the role insufficient clinical supports have on placements of children in distant, temporary, and non-family-based settings, the availability of intensive home-based mental health services in each county will be assessed. Each county will be surveyed about the local availability of such services, their quality and their responsiveness to individual needs. The service array survey will assist in answering the following question relevant to the placement needs assessment study as data permits.
 What resources exist across the state?
The service array survey developed in coordination with the SC DSS in 2009 will be adapted to assess the service array pertinent to placement. This online survey will rate services (grouped into categories) on their availability, quantity, quality, and importance. The online codebook will be adapted as needed to provide specific definitions and examples for each category of services. The code book will be shared with county staff completing the survey. Each DSS county office will be asked to form a team composed of up to five human service caseworkers, program coordinators, and/or supervisors to respond to the survey. Regional Adoption and Intensive Foster Care and Clinical Services staff will be included in various county office teams as directed by the State DSS Leader in charge of these areas. This will result in a unified survey response for each county. A summary report will be developed to document all of this information.

Report Findings (ongoing with final product due June 30, 2017)
The CCFS Team will provide monthly updates through phone conferences or face-to-face meetings with the Deputy Director of Child Welfare, the Director of Child Welfare Operations,

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the DSS Internal Monitoring Team and the Co-Monitors. Summary reports of findings including trends will be shared monthly.
This process will provide the data needed for DSS staff to develop the Implementation Plans. CCFS staff will provide the findings and Recommendations will be developed through a discussion of findings with the DSS Internal Monitoring Team and the Co-Monitors.
Findings from all data sources will be compiled and discussed with the Deputy Director of Child Welfare, the Director of Child Welfare Operations, the DSS Internal Monitoring Team and the CoMonitors at least quarterly. Recommendations will be developed jointly by CCFS project staff, the Deputy Director of Child Welfare, the Director of Child Welfare Operations, the DSS Internal Monitoring Team, and Co-Monitors. These recommendations will be included as part of the final report.
The final report will include recommendations in the following areas:
 the capacity to place Class Members close to their home community,  placing Class Members in the least restrictive, most family-like placement,  the number and array of therapeutic foster care placements,  a system of tracking availability of beds in family foster homes, and  matching of Class Members to placements that can meet their needs.

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Michelle H., et al. v. McMaster and Alford
Monitoring Period II (April 1, 2017 – September 30, 2017)
Progress of the South Carolina Department of Social Services
Co-Monitors: Judith Meltzer & Paul Vincent
Co-Monitor Staff: Rachel Paletta Elissa Gelber Gayle Samuels
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Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 1, 2017 – September 30, 2017
TABLE OF CONTENTS

I. INTRODUCTION ................................................................................................................... 1

II. SUMMARY OF PERFORMANCE .................................................................................... 2

III. MONITORING ACTIVITIES............................................................................................. 7

IV. SUMMARY TABLE OF MICHELLE H., et al. v. McMASTER and ALFORD FINAL SETTLEMENT AGREEMENT PERFORMANCE....................................................................... 8

V. CASELOADS .................................................................................................................... 46

VI. CASEWORKER-CHILD VISITATION........................................................................... 60

VII. INVESTIGATIONS .......................................................................................................... 61

VIII. PLACEMENTS.............................................................................................................. 81

IX. FAMILY VISITATION..................................................................................................... 94

X. HEALTH CARE .............................................................................................................. 100

XI. BUDGET ......................................................................................................................... 104

APPENDICES

A.

Glossary of Acronyms……………………………………...……………..……106

B.

OHAN Implementation Plan Strategy Updates………………………………...107

C.

Health Care Consultants’ Findings and Recommendations……………………113

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LIST OF TABLES
TABLE
Table 1: Summary Performance on Settlement Agreement Requirements .................................... 8 Table 2: Status of Implementation Plans and Assessments .......................................................... 36 Table 3: Baseline, Timeline and Interim Benchmarks for Appropriateness of Decision Not to Investigate Referral (Alleging) Institutional Abuse (and/)or Neglect .......................................... 64 Table 4: Good Faith Efforts to Contact Alleged Victim Children within 24 Hours..................... 68 Table 5: Extraordinary Circumstance Exceptions to Contact with Alleged Victim Children within 24 Hours........................................................................................................................................ 68 Table 6: Baseline, Timeline and Interim Benchmarks for Timely Initiation of Investigations .... 69 Table 7: Exceptions to Contact with Core Witnesses During Investigations ............................... 71 Table 8: Baseline, Timeline and Interim Benchmarks for Contact with All Necessary Core Witnesses during the Investigation ............................................................................................... 72 Table 9: Contact with Necessary Core Witnesses During Investigations by Type of Core Witness.......................................................................................................................................... 74 Table 10: Baseline, Timeline and Interim Benchmarks for Appropriate Case Decisions during Investigations ................................................................................................................................ 76 Table 11: Examples of Good Cause Reasons to Extend Investigation Timeframes..................... 78 Table 12: Baseline, Timeline and Interim Benchmarks for Timely Completion of Investigations ....................................................................................................................................................... 79 Table 13: Types of Placements for Children as of September 30, 2017....................................... 86 Table 14: Types of Placements for Children Ages 12 and Under as of September 30, 2017....... 87 Table 15: Exceptions for Placement of Children Ages Six and Under in Non-Family-Based Placements .................................................................................................................................... 88 Table 16: Sibling Placements for Children Entering Placement between April and September 2017 as of September 30, 2017..................................................................................................... 93 Table 17: Exceptions to Sibling Visitation Requirement ............................................................. 95 Table 18: Exceptions to Parent and Child Visitation Requirement .............................................. 98

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LIST OF FIGURES

FIGURE
Figure 1: Foster Care Caseworkers within the Required Caseload Limits as of September 25, 2017............................................................................................................................................... 50
Figure 2: Caseloads of Foster Care Caseworkers Employed Six Months or Longer that were Over Limit as of September 25, 2017.................................................................................................... 51
Figure 3: Caseloads of Newly Hired Foster Care Caseworkers that were Over Limit as of September 25, 2017 ...................................................................................................................... 52
Figure 4: IFCCS Caseworkers within the Required Caseload Limits as of September 25, 2017. 53
Figure 5: Caseloads of IFCCS Caseworkers Employed Six Months or Longer that were Over Limit as of September 25, 2017.................................................................................................... 54
Figure 6: Caseloads of Newly Hired IFCCS Caseworkers that were Over Limit as of September 25, 2017......................................................................................................................................... 55
Figure 7: Adoption Caseworkers within the Required Caseload Limits as of September 25, 2017 ....................................................................................................................................................... 56
Figure 8: Caseloads of Adoption Caseworkers Employed Six Months or Longer that were Over Limit as of September 25, 2017.................................................................................................... 57
Figure 9: Caseloads of Newly Hired Adoption Caseworkers that were Over Limit as of September 25, 2017 ...................................................................................................................... 58
Figure 10: Foster Care, IFCCS, Adoption and OHAN Caseworkers that were Above and Within the Required Caseload Limits as of September 25, 2017 ............................................................. 59
Figure 11: Appropriateness of Decision Not to Investigate Referral (Alleging) Institutional Abuse (and/)or Neglect ................................................................................................................. 66
Figure 12: Timely Initiation of Investigations .............................................................................. 70
Figure 13: Contact with All Necessary Core Witnesses during Investigations ............................ 73
Figure 14: Decision to Unfound Investigations Deemed Appropriate ......................................... 77
Figure 15: Timely Completion of Investigations.......................................................................... 80
Figure 16: Children Ages Six and Under in Congregate Care...................................................... 89
Figure 17: Children Who Visited With All Siblings .................................................................... 96

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Figure 18: Visits that Occurred between Siblings ........................................................................ 97 Figure 19: Children with Twice Monthly Visits with their Parents.............................................. 99

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Michelle H., et al. v. McMaster and Alford
Progress Report for the Period April 1 – September 30, 2017
I. INTRODUCTION
This is the second report on the progress of the South Carolina Department of Social Services (DSS) in meeting the requirements of the Final Settlement Agreement (FSA) entered in Michelle H., et al. v. McMaster and Alford. Approved by the United States District Court on October 4, 2016, the FSA includes requirements governing the care and treatment of the more than 4,000 children in foster care in South Carolina1 and incorporates provisions that had been ordered in the previous year in a Consent Immediate Interim Relief Order (the Interim Order)2. This report has been prepared by court-appointed independent Co-Monitors Paul Vincent and Judith Meltzer, with assistance from monitoring staff Rachel Paletta, Elissa Gelber, Gayle Samuels and Erika Feinman, and is presented to The Honorable Richard Gergel, U.S. District Court Judge, Parties to the lawsuit (Governor McMaster, DSS and Plaintiffs) and the public.
The FSA outlines DSS’s obligations to significantly improve experiences and outcomes for the children in its care. It was crafted by state leaders and Plaintiffs, who conceived it to include commitments that would guide a multi-year reform effort. The FSA reflects DSS’s agreement to address long-standing problems experienced by children in foster care custody and in the operation of South Carolina’s child welfare system. It includes a broad range of provisions governing: caseworker caseloads; visits between children in foster care and their caseworkers and family members; investigations of allegations of abuse and neglect of children in foster care; appropriate and timely foster care and therapeutic placements; and access to physical and mental health care for children in DSS custody.
While the FSA includes many specific agreements around policy and practice changes and outcomes to be met, some FSA provisions were crafted to be more open-ended, as the Parties agreed to add greater specificity regarding outcomes, benchmarks and timelines in collaboration with the Co-Monitors following DSS diagnostic work (including specified assessments and review of baseline information). The FSA thus established a structure in which the Co-Monitors would work closely with DSS leaders to identify phased implementation plans to guide much of the work ahead.

1 The class of children covered by the FSA includes “all children who are involuntarily placed in DSS foster care in the physical or legal custody of DSS now or in the future” (FSA II.A.). 2 Consent Immediate Interim Relief Order (September 28, 2015).

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Included in this report is a summary of the Co-Monitors’ general findings, followed by a detailed discussion of the progress made during this monitoring period with respect to each of the FSA requirements.3
II. SUMMARY OF PERFORMANCE
In this second six-month monitoring period, covering April 1 to September 30, 2017,4 DSS has made ongoing efforts in the context of its existing capacity and operational framework to comply with FSA requirements. DSS continued to manage the work required by the FSA through statewide workgroups focused on specific areas of practice, with workgroup chairs and state leadership coming together on a regular basis. There is also a small but dedicated Internal Monitoring Team that is a conduit for the work of the Co-Monitors and their staff and is responsive to Co-Monitor requests for information. DSS also has plans to broaden its overall leadership team by adding two new senior positions to its Child Welfare Division; it recently hired a new Director of Permanency and is in the process of hiring a Director for its new Office of Health and Wellbeing.
During this monitoring period, DSS maintained its early success in reducing the number of children ages six and under residing in congregate care facilities, placing them instead in family foster homes. DSS performance improved in some other areas measured by the FSA as well. A greater percentage of children visited with their siblings in foster care this period, and DSS practice related to screening decisions and investigation findings of referrals alleging abuse and/or neglect in out-of-home care has improved.
Nevertheless, as the data and information included in this report show, too little has changed for the children, youth and families served by South Carolina’s child welfare system in the two and half years since entry of the Interim Order. DSS has urgent work ahead to improve its performance with respect to nearly all of the FSA measures. In many areas in which reform work should be underway, there remains a need for decisive actions and for additional capacity to plan and carry out reforms. The lack of accessible and nurturing placement resources throughout the state has meant that many children who have already endured the trauma of being removed from their homes are often placed far from their families, schools and communities in settings that are neither stable nor appropriate to their needs. Persistently high caseloads, well above acceptable standards, have left children in the care of caseworkers without the time, training and resources to ensure their safety, well-being and permanency. As exemplified in DSS’s Out of Home Abuse

3 Pursuant to FSA III.K., “The Co-Monitors shall not express any conclusion as to whether the Defendants have reached legal compliance on any provision(s).” 4 The first monitoring report covered the period October 1, 2016 to March 31, 2017. See Michelle H. et al. v. McMaster and Alford, Progress of the South Carolina Department of Social Services, October 1, 2016 – March 31, 2017.

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and Neglect unit (OHAN), such high caseloads make it exceedingly difficult, if not impossible, for DSS to follow through on improving the quality of practice. And for the vast majority of children, entry into foster care means that they have limited or no contact with their parents, even when the goal is for them to return home.
DSS staff have devoted considerable time and effort to working on the Implementation Plans required by the FSA, but frequently with inadequate results due to capacity issues. In response to the concerns and recommendations included in the Co-Monitors’ first monitoring report, DSS began work with two external consultant groups. By agreeing to the Co-Monitors’ retention of outside health care consultants (Kathleen Noonan and Gail Nayowith) and an audit of Child and Adult Protective Services System (CAPSS)5 data system by national experts, DSS leadership has demonstrated an awareness of the need for additional support in building an understanding of and addressing two key issues (health care delivery and data quality) that underlie the problems identified in the FSA. There is currently positive momentum toward finalizing a Health Care Improvement Plan based on the consultants’ recommendations. Constructive work is also just beginning with Chapin Hall at the University of Chicago on a data audit, which will hopefully result in changes to CAPSS and to data entry processes within DSS to allow for the production of accurate data for management and accountability purposes.
In many critical areas, however, DSS Implementation Plans are long outstanding. DSS’s Workload Implementation Plan, required to be completed by December 5, 2016, has not been fully approved due to barriers in data collection, as well as a continued lack of specificity about the content of budget requests, sequencing and strategies for resource development. The Placement Needs Implementation Plan is now estimated to be completed at the end of March 2018, two years past the original FSA deadline. This delay has left the severe inadequacies in DSS’s placement capacity and placement processes largely unaddressed and has left private providers – many of whom are willing and eager to work with DSS on the transformation of the placement array – without direction or appropriate contracts. Too many children remain placed in congregate care facilities that do not offer the treatment services they need. In some cases, children remain in juvenile justice detention because there is an inadequate array of placements and services to support them in the community. In addition, DSS has not been able to finalize its Visitation Implementation Plan, to be completed under the FSA by December 5, 2016, because of data validity issues that prevented clear identification of which children in its care currently have permanency goals of reunification. Finally, though DSS has demonstrated a commitment to moving its Health Care Improvement Plan forward at an increased pace due to the technical assistance and support provided by the health care consultants, significant work remains to produce a plan and move it to implementation. Most urgently, DSS needs to partner with the

5 CAPSS is DSS’s State Automated Child Welfare Information System (SACWIS).
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South Carolina Department of Health and Human Services (DHHS) and its Managed Care Organization (MCO), Select Health, to find a way to comply with the FSA provision for identifying children in need of medical care, originally intended as a short-term emergency measure to be completed immediately after the entry of the FSA.
In the Co-Monitors’ view, DSS’s response to children and families reflects a system driven by crisis and that fails to offer many children the stability and supports they need to promote and sustain their well-being. The deep-seeded problems that led to the entry of the FSA remain, profoundly impacting the lives of children, youth and families throughout South Carolina. As reported in the last monitoring period, these are problems that cannot be resolved without a major shift in operations, an influx of significant resources and an expansion of system capacity. The Co-Monitors are increasingly concerned that, despite what they believe to be good intentions and earnest efforts of leadership, DSS still must solidify a vision and overall strategy for the type of broad-scale reform that will move it forward in a meaningful way.
In the last monitoring report, the Co-Monitors identified some themes that emerged in their initial work with DSS, as well as recommendations for actions DSS could immediately take to address them. These themes remain relevant and outlined below is an update on DSS’s progress in each of these areas.
The Need for a Broader Reform Vision
As reported previously, and consistently discussed with DSS, the work to improve performance with respect to specific FSA measures will ultimately not be successful unless it is guided by and embedded within an overarching reform vision, and framed by a model of practice that reflects DSS’s values, goals and principles. This vision needs to be consistently understood, enunciated and reflected in the operations and practices of DSS staff at all levels, as well as by external partners, including parents, private providers, community-based resource providers, judges, attorneys and guardian ad litems, who need to be brought together to plan for and drive system transformation.
The Co-Monitors have previously emphasized the foundational importance of a case practice model. In the Co-Monitors’ view, DSS is still very much in need of a fully developed model of case practice, and the work to create and implement one must be accelerated. In discussions with stakeholders, DSS caseworkers and facility staff throughout the state, the Co-Monitors have seen little evidence of a shared vision for what is expected in order to meet the permanency, wellbeing and, in some instances, even the safety needs of the children and families served by DSS. DSS has taken some initial steps and has reported for over a year now that a model is under development, but implementation of a practice model seems to be one of many discrete tasks to

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which DSS’s already overburdened state and mid-level managers have been assigned and cannot decisively pursue. Despite initial efforts, DSS’s work has just scratched the surface and represents very beginning steps; there is not yet a robust and well-articulated model that structures how caseworkers understand and carry out their roles and that forms the foundation of ongoing reform work. Once developed, leadership at all levels must demonstrate commitment to the case practice model’s tenets and to disciplined implementation that builds caseworker and system capacity, ensures fidelity and ultimately achieves better outcomes for children, youth and families.
DSS Capacity and Resources
DSS’s Internal Monitoring Team are the primary DSS staff driving the work to meet the requirements of the FSA which often seems disconnected from a vision for overall reform in the field. The dedicated staff includes an Internal Class Action Lawsuit Monitor and a Data Coordinator, and was expanded to include a Program Improvement Consultant with extensive child welfare experience in February 2018. Recognizing the need to develop more resources focused on reform, DSS took additional steps this period to reorganize its child welfare division so that responsibilities for core areas of practice can be spread across a broader leadership base. A Director for the newly created Office of Permanency has already begun in the role, and DSS is in the process of hiring a Director for a new Office of Health and Wellbeing. The Co-Monitors are supportive of this plan.
There is still a long way to go before DSS will have the resources and internal capacity needed to intensively drive reform. With very few exceptions, the practice staff responsible for implementation of reform efforts are still also responsible for day-to-day child welfare operations and have roles that are already complex, demanding and time consuming. DSS needs to move expeditiously to define the roles and responsibilities for its new positions and to hire appropriately qualified staff. But, also – and most critically – it must be able to articulate how these new offices and positions will support a broader reform vision in the field and with external partners.
Over the past two years, DSS has received additional funding from the Governor and legislature for hiring new workers and has moved forward on a salary study to support improved salaries and ultimately staff retention. However, due to increased reports of alleged child abuse and neglect and expanded intake following statewide implementation of DSS Intake Hubs, and continued high turnover among frontline staff, caseloads that had begun to decline in late 2016 and early 2017 are now back to 2015 levels. Though DSS recognizes the need to move swiftly to hire and train additional qualified staff, the Co-Monitors have not seen a clear operational plan for recruiting, onboarding, training, supporting and retaining these caseworkers. In addition,

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despite repeated requests by the Co-Monitors, and a directive by the Court, DSS reports working on but has not yet completed a detailed, cohesive overall budget plan to support the type of multi-year, broad-scale reform it needs to undertake.

Creating a Functional Data and CQI Infrastructure

DSS remains in need of a functional infrastructure to support its child welfare work. This includes systems for collecting and utilizing reliable data for management and operations. Despite the efforts by a small group of hard-working data staff, issues with the quality of documentation and the integrity of CAPSS data remain pervasive. After months of work, and although some improvement has been made, DSS still cannot accurately track health care delivery or needed follow up for the children in its care, reliably identify children’s permanency goals or readily access the full history of abuse or neglect investigations by provider. Even its documentation of caseworker visits with children – an area of practice DSS has long held out as a bright spot – is tentative at best.

Though DSS has spent time and resources addressing identified issues with respect to particular data elements, progress has been limited and unsustainable given the lack of mechanisms for ongoing oversight and accountability for data entry. The Co-Monitors are pleased that DSS was receptive to its recommendation that it engage an external consultant to perform a data audit, including an assessment of CAPSS architecture and data reliability. As of late February 2018, DSS has entered into a contract with Chapin Hall at the University of Chicago (one of the two external groups recommended by the Co-Monitors) with partial support from Casey Family Programs, a national foundation that focuses on child welfare outcomes. DSS reports that it has requested additional resources in its FY2018-2019 budget request, which was approved by the Governor, including funds for information technology resources and staff to monitor data integrity.

As recommended in the prior monitoring report, it will also be essential that DSS develop a robust Continuous Quality Improvement (CQI) process that is closely tied to agency management, and that can provide quantitative and qualitative information for managers, supervisors and frontline caseworkers on the effectiveness of their work. Although DSS has long reported that work in this area is under development, its entire CQI function rests now with one DSS staff member and the University of South Carolina Center for Child and Family Studies (USC CCFS)6, both of whom are largely disconnected from other equally siloed data accountability and quality assurance functions, and without linkage to a broader vison for reform.
6 DSS contracts with the University of South Carolina Center for Child and Family Studies to complete all required and necessary case reviews and quality assurance activities, most not related to the FSA.

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III. MONITORING ACTIVITIES
The Co-Monitors are responsible for factual investigation and verification of data and documentation to compile and issue public reports on performance with respect to the terms of the FSA. In carrying out this responsibility, the Co-Monitors and their staff have worked closely with DSS leadership and staff. The Co-Monitors used multiple methodologies to conduct their work, including verification and analysis of information available through CAPSS; independent review of individual electronic and hardcopy case records; review and validation of data aggregated by DSS; interviews and conversations with DSS leaders and staff; and conversations with external stakeholders, including youth, foster parents and community organizations. For this period, the Co-Monitors conducted site visits to five local DSS offices, where they met with managers and frontline staff, and to six congregate care facilities throughout the state where they met with staff and some youth.
The FSA gives the Co-Monitors the responsibility to review and approve plans and to set or approve interim benchmarks and outcomes in multiple areas. The Co-Monitors have worked with DSS and USC CCFS to establish review protocols to gather baseline data and assess current practice and performance. In so doing, the Co-Monitors and their staff have assumed a technical assistance role in addition to a strict monitoring function, helping to build capacity in DSS and USC CCFS staff and connect its leaders and managers with people and resources from across the country. The Co-Monitors strongly believe that this type of ongoing collaboration will be critical to DSS’s ability to successfully reform its child welfare system.
Finally, the Co-Monitors have been engaged with Plaintiffs to both understand their views of the problems the FSA is designed to address and to keep them informed of DSS’s progress in meeting deliverables. Where required by the FSA, the Co-Monitors have elicited feedback from Plaintiffs and have worked with them to build consensus around the commitments that require consent by all Parties. As the Co-Monitors have discussed many times with the Parties, the CoMonitors believe that open communication between Plaintiffs, DSS and the Co-Monitors is an important element of constructive planning and implementation under the FSA. A first informal meeting between the Parties occurred in February 2018. Going forward, the Co-Monitors have offered to structure subsequent meetings with the Parties to address emergent and unresolved issues related to FSA implementation.

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IV. SUMMARY TABLE OF MICHELLE H., et al. v. McMASTER and ALFORD FINAL SETTLEMENT AGREEMENT PERFORMANCE
Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

Workload Limits for Foster Care: A foster care Workload Limit must apply to every Caseworker and to every Caseworker’s supervisor. DSS may identify categories of Caseworker or Supervisor or both and set a different Workload Limit for each category. (FSA IV.A.2.(b)&(c))
Approved Caseworker Limits:8, 9  OHAN investigator: 1 caseworker: 8 investigations  Foster Care caseworker: 1 caseworker: 15 children  IFCCS caseworker: 1 caseworker: 9 children  Adoption caseworker: 1 caseworker: 17 children  New worker: ½ of the applicable standard for their first 6
months after completion of Child Welfare Basic

1a. At least 90% of caseworkers shall have a workload within the applicable Workload Limit.
1b. No caseworker shall have more than 125% of the applicable Workload Limit.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Data are not available for this period.

OHAN caseworkers: As of September 25, 2017, no (0%) OHAN worker had a caseload within the required limit and all (100%) caseworkers had caseloads more than 125% over the limit.
Foster Care caseworkers: As of September 25, 2017, 28% of foster care caseworkers had a caseload within the required limit and 59% of caseworkers had caseloads more than 125% over the limit.10

Approved Supervisor Limits:  For Foster Care, IFCCS and Adoption supervisors:
1 supervisor: 5 caseworkers  OHAN supervisors: 1 supervisor: 6 investigators

IFCCS caseworkers: As of September 25, 2017, 10% of IFCCS caseworkers had a caseload within the required limit and 77% of

7 The obligations for the workload study (FSA IV.A.1.), placement needs assessment (FSA IV.D.1.) and select placement limitations (FSA IV.D.2., 3. & H.1.) became operative as of September 28, 2015, when the Consent Immediate Interim Relief Order was entered. Therefore, the Interim Relief Order requirements are incorporated into the FSA. 8 These limits were approved by the Co-Monitors on December 6, 2016, after completion of the Workload Study. 9 Caseload limits and methodologies to calculate performance for caseworkers with mixed caseloads, both Class and Non-Class Members, were approved in December 2017. NonClass Members include children receiving family preservation services while remaining in the home with their parent or caregiver, Adult Protective Services cases, families involved in child protective service assessments and children placed by ICPC. Performance for foster care caseworkers with mixed caseloads is calculated by adding the total number of foster care children (Class Members) they serve to the total number of families (cases) of Non-Class Members they also serve. The total number should not exceed 15 children and cases. 10 Performance includes both newly hired (completed Child Welfare Basic training within six months) foster care caseworkers and foster care caseworkers who had been employed for six months or longer. A standard of seven cases is applied to newly hired foster care caseworkers. Additionally, performance is calculated by applying the mixed caseload standard to applicable staff.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance
caseworkers had caseloads more than 125% over the limit.11

Adoption caseworkers: As of September 25, 2017, 23% of adoption caseworkers had a caseload within the required limit and 62% of caseworkers had caseloads more than 125% over the limit.12

Newly hired caseworker caseloads: As of September 25, 2017:

9% of newly hired foster care
caseworkers had a caseload within the required limit.13

8% of newly hired IFCCS caseworkers had a caseload within the required limit.14

None (0%) of the newly hired
adoption caseworkers had a caseload within the required limit.15

11 Performance includes both newly hired IFCCS caseworkers and IFCCS caseworkers who had been employed for six months or longer. A standard of five children is applied to
newly hired IFCCS caseworkers. 12 Performance includes both newly hired adoption caseworkers and adoption caseworkers who had been employed for six months or longer. A standard of nine children is applied
to newly hired adoption workers. 13 Performance assesses 44 newly hired foster care caseworkers who had completed Child Welfare Basic training less than six months before September 25, 2017. 14 Performance assesses 12 newly hired IFCCS caseworkers who had completed Child Welfare Basic training less than six months before September 25, 2017. 15 Performance assesses five newly hired adoption caseworkers who had completed Child Welfare Basic training less than six months before September 25, 2017.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target
2a. At least 90% of supervisors shall have a workload within the applicable Workload Limit.

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

Data are not available for this period. Data are not available for this period.16

2b. No supervisor shall have more than 125% of the applicable Workload Limit.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved

16 Data for this measure were not available during the previous period as DSS indicated data clean-up in CAPSS was necessary to accurately reflect all supervisors who are managing caseworkers with Class Members on their caseload. After months of effort, DSS was finally able to produce relevant data to the Co-Monitors on March 8, 2018. Given the late production date, the Co-Monitors were unable to review and validate the data for inclusion in this report. The Co-Monitors anticipate reporting data for this measure in the next monitoring report.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Caseworker-Child Visitation:
(FSA IV.B.2.&3.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

3. At least 90% of the total minimum number of face-to-face visits with Class Members by caseworkers during a 12month period shall have taken place.

Based on CAPSS data, monthly performance for caseworker visits to Class Members are below.17
October 2016: 98% November 2016: 97% December 2016: 97% January 2017: 98% February 2017: 97% March 2017: 98%

Unable to determine current performance.18

4. At least 50% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place in the residence of the child.

Based on a CAPSS data, monthly performance for caseworker visits to Class Members in their placement are below.

Unable to determine current performance.19

October 2016: 71% November 2016: 68% December 2016: 69% January 2017: 69% February 2017: 67% March 2017: 70%

17 Co-Monitor staff completed a limited validation of these data, assessing only for frequency and location of visits, as described in Section VI of this Report. DSS appears to be meeting the caseworker visitation measures with respect to the frequency and location of caseworker-child visits. Plaintiffs have requested that the Co-Monitors perform a more indepth review of visitation data and documentation in the future to assess the content of caseworker visits with children, based on their reading of the applicable FSA provisions. 18 As discussed in Section VI, the Co-Monitors reviewed a sample of cases in which caseworker visits were required in September 2017. The Co-Monitors found that documentation was often inadequate, and it was not possible to discern in some cases whether a visit had occurred. Given these findings, the Co-Monitors were not able to validate CAPSS data produced by DSS with respect to these measures this reporting period. 19 Ibid.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Investigations – Intake:
(FSA IV.C.2.)

Final Target
5. At least 95% of decisions not to investigate a Referral of Institutional Abuse or Neglect about a Class Member must be made in accordance with South Carolina law and DSS policy.
Interim benchmark requirement – By September 2017, 75%

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

Between August 1, 2016 and January 31, 2017, there were 128 referrals with decisions not to investigate involving a Class Member; 44% (56) of the screening decisions were determined to be appropriate.20

Monthly performance for screening decisions not to investigate determined to be appropriate:
May 2017: 67% June 2017: 83% July 2017: 59% August 2017: 62% September 2017: 88%

Investigations – Case Decisions: (FSA IV.C.3.)

6. At least 95% of decisions to “unfound” investigations of a Referral of Institutional Abuse or Neglect must be based upon DSS ruling out abuse or neglect or DSS determining that an investigation did not produce a preponderance of evidence that a Class Member was abused or neglected.

Between June and November 2016, there were 94 investigations with decisions to unfound; 47% (44) of these decisions were determined to be appropriate.

Interim benchmark requirement – By September 2017, 48%

In September 2017, there were 38 investigations with decisions to unfound; 58% (22) of these decisions were determined to be appropriate.

20 Performance data reflects screening decisions made by DSS’s OHAN unit. DSS has represented to the Co-Monitors that all referrals of abuse and/or neglect in licensed foster homes, residential facilities and group homes across the state involving Class Members are received by or forwarded to OHAN for screening and investigation, as appropriate, and that screening decisions are not made by local office or Intake Hub staff. Additionally, performance data do not include those referrals determined not to be applicable for review because the alleged victim child was not a Class Member (i.e., the child was voluntarily placed by the legal guardian or through ICPC from another state or was the biological child of the caregiver).

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Investigations – Timely Initiation:
(FSA IV.C.4.(a)) Investigations – Contact with Alleged Child Victim
(FSA IV.C.4.(b))

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

7. The investigation of a Referral of Institutional Abuse or Neglect must be initiated within twenty-four (24) hours in accordance with South Carolina law in at least 95% of the investigations.
8. The investigation of a Referral of Institutional Abuse or Neglect must include face-to-face contact with the alleged victim within twenty-four hours in at least 95% of investigations, with exceptions for good faith efforts approved by the Co-Monitors.

Between June and November 2016, of 107 applicable investigations, 78% (83) were timely initiated or had documentation supporting completion of all applicable good faith efforts.

In September 2017, of the 40 applicable investigations, 80% (32) were timely initiated or had documentation supporting completion of all applicable good faith efforts.21,
22

Interim benchmark requirement – By September 2017, 78%

21 Contact was made with the alleged victim child(ren) within 24 hours in 31 investigations and in one additional investigation, documentation supported completion of all applicable good faith efforts. 22 The Co-Monitors’ interpretation of the FSA requires that investigations be initiated within 24 hours of receipt of the referral by DSS, not within 24 hours of the decision to accept the referral, and that initiation is completed by making face-to-face contact with the alleged victim child(ren). As a result, the performance for both FSA measures IV.C.4.(a) and (b) are measured using the same methodology and timeframes – the time between receipt of referral and face-to-face contact with alleged child(ren) victim must be within 24 hours.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Investigations – Contact with Core Witnesses
(FSA IV.C.4.(c))

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

9. Contact with core witnesses must be made in at least 90% of the investigations of a Referral of Institutional Abuse or Neglect, with exceptions approved by the CoMonitors. Core witnesses will vary from case to case and may or may not include the victim(s), Class Members, alleged perpetrators, reporter (if identified), identified eyewitness(es), other children in the placement, facility staff, treating professionals, and foster parents or caregivers as deemed to be relevant to the investigation.

Between June and November 2016, of 107 applicable investigations, contact was made with all necessary core witnesses for whom there was no approved exception in 27% (29) of cases.

In September 2017, none (0%) of the 40 applicable investigations included contact with all necessary core witnesses during the investigation.

Interim benchmark requirement – By September 2017, 35%

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Investigations – Timely Completion:
(FSA IV.C.4.(d-f))

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

10.a. At least 60% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within forty-five (45) days of initiation of an investigation, unless the DSS Director or DSS Director’s designee authorizes an extension of no more than fifteen (15) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

95% of applicable investigations received between June and November 2016 were appropriately closed within 45 days.

79% of applicable investigations
received in September 2017 were appropriately closed within 45 days.23

Interim benchmark requirement – By September 2017, 75%

23 Of the 40 investigations received in September 2017, one investigation was excluded from the 45 day compliance measure as an extension request for 15 days was submitted and approved by the OHAN Director. Of the remaining 39 investigations, 34 investigations were completed within 45 days, however, reviewers determined that three of the investigations closed within 45 days were closed as unfounded prematurely in an effort to meet the 45 day requirement. Therefore, 31 of the 39 applicable investigations met the FSA standard.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

10.b. At least 80% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within sixty (60) days of initiation of the investigation, and all investigations not completed within sixty (60) days shall have authorization of the DSS Director or DSS Director’s designee of an extension of no more than thirty (30) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

96% of applicable investigations received between June and November 2016 were appropriately closed within 60 days.

88% of applicable investigations
received in September 2017 were appropriately closed within 60 days.24

Interim benchmark requirement – By September 2017, 80%

24 Three investigations were determined to be closed prematurely in an effort to meet the deadline and are not considered compliant.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

10.c. At least 95% of all investigations of a Referral of Institutional Abuse or Neglect not completed within sixty (60) days shall be completed within ninety (90) days. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

All investigations received between June and November 2016 were completed within 60 days; therefore, this measure was not applicable this period.

93% of applicable investigations
received in September 2017 were appropriately closed within 90 days.25

Interim benchmark requirement – By September 2017, 95%

25 Ibid.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

Family Placements for Children Ages 6 and Under:
Within sixty (60) days, DSS shall create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the Co-Monitors, the placement of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers). The plan shall include full implementation within sixty (60) days following approval of the Co-Monitors.

11. No child age 6 and under shall be placed in a congregate care setting except with approved exceptions.

(FSA IV.D.2.)

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

In March 2017, there were six children ages six and under in DSS custody and residing in a congregate care facility. The circumstances of five of those six children met an agreed upon exception for placement in congregate care.

In September 2017, there were four Class Members ages six and under in DSS custody and residing in a congregate care facility. The circumstances of one of those children met an agreed upon exception for placement in congregate care and approval was sought prior to the child’s placement as per DSS directive.26

Between April and September 2017, a total of nine Class Members ages six and under were placed in congregate care. The circumstances of five of these young children met an agreed upon exception.27

26 Two of the children who did not meet an agreed upon exception were placed in a congregate care facility prior to entering DSS custody and the family court, when issuing the emergency removal (from the parents’) custody order, also ordered that the children remain where they were. 27 One of these placements was made in accordance with the process DSS put into place, requiring prior approval by the Child Welfare Director.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

Phasing-Out Use of DSS Offices and Hotels:
Within sixty (60) days, DSS shall cease using DSS offices as an overnight placement for Class Members, and shall cease placing or housing any Class Members in hotels, motels and other commercial non-foster care establishments. For any Class Members moved out of such DSS Offices or Hotels, DSS shall provide for their appropriate placement. In the extraordinary event that a child stays overnight in a DSS office, Defendants shall immediately notify the Co-Monitors, who shall provide a report to Parties as appropriate, including whether or not, in their view, the incident should be reported to the Court as a violation which would preclude Defendants’ ability to achieve compliance on this provision.

12. No child shall be placed or housed in a DSS office, hotel, motel, or other commercial non-foster care establishment.

Between November 28, 2015 and March 31, 2017, DSS reports three children remained overnight in a DSS office.

Between April 1, 2017 and September
30, 2017, DSS reports three children remained overnight in a DSS office.28

(FSA IV.D.3.)

28 Although reports of children sleeping in DSS offices and hotels is limited to these instances, the Co-Monitors are concerned about reports that children are being placed on an emergency, short-term basis in foster homes as a way of avoiding these overnight stays, cycling at times through a series of one-night stays in foster homes until an appropriate placement can be located.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Congregate Care Placements:
(FSA IV.E.2.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

13. At least 86% of the Class Members shall be placed outside of Congregate Care Placements on the last day of the Reporting Period.

In March 2017, 78% (3,223 of 4,124) of all children in foster care were placed outside of a congregate care setting.

As of September 30, 2017, 79% (3,225 of 4,079) of children in foster care were placed outside of a congregate care setting.29, 30

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the Co-Monitors.

29 DSS data reports do not indicate whether a child’s placement in custody is voluntary or involuntary. Although the Co-Monitors have worked with DSS to manually correct for this coding issue with respect to a number of measures, it is possible that, in some instances, such as here and other placement measures discussed in this report, a small number of Non-Class Members are included in aggregate data. The Co-Monitors hope to be able to fully distinguish between Class and Non-Class Members in the future, as DSS develops its data capacity in this area. 30 Thirty-six children who were hospitalized (16) or in a correctional/DJJ facility (20) were removed from the universe for this measure.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Congregate Care Placements – Children Ages 12 and Under:
(FSA IV.E.3.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

14. At least 98% of the Class Members twelve (12) years old and under shall be placed outside of Congregate Care Placements on the last day of the Reporting period unless an exception pre-approved or approved afterwards by the Co-Monitors is documented in the Class Member’s case file.

In March 2017, 91% (2,630 of 2,905) of children ages 12 and under in foster care were placed outside of a congregate care setting.31

As of September 30, 2017, 93% (2,655 of 2,866) of children ages 12 and under in foster care were placed outside of a congregate care setting.32

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the Co-Monitors.

31 Exceptions to this standard have not yet been approved by the Co-Monitors; therefore, analysis of performance does not consider any exceptions. 32 Exceptions were recently approved, though not applied during this monitoring period. DSS will develop a process for review and approval.
Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Emergency or Temporary Placements for More than 30 Days:
(FSA IV.E.4.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

15. Class Members shall not remain in any Emergency or Temporary Placement for more than thirty (30) days. Under exceptions subject to the Co-Monitors’ approval, if a child is initially placed in an Emergency or Temporary Placement that is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the redesignation shall not be considered a placement move under Section IV.F.1 below.

Data are not available for this period.

Data are not available for this period.33

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the Co-Monitors.

33 The Co-Monitors have not been provided with data for this measure. DSS has indicated that creation of a code book of definitions describing each level of foster care is needed to collect accurate data for this measure and anticipates completion of this code book by December 1, 2019.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Emergency or Temporary Placements for More than 7 Days:
(FSA IV.E.5.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

16. Class Members experiencing more than one Emergency or Temporary Placement within twelve (12) months shall not remain in the Emergency or Temporary Placement for more than seven (7) days. Under exceptions subject to the Co-Monitors’ approval, if a child’s subsequent placement within twelve (12) months in an Emergency or Temporary Placement is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the redesignation shall not be considered a placement move under Section IV.F.1 below.

Data are not available for this period.

Data are not available for this period.34

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the Co-Monitors.

34 Ibid.
Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Placement Instability:
(FSA IV.F.1.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

17. For all Class Members in foster care for eight (8) days or more during the 12-month period, Placement Instability shall be less than or equal to 3.37.

Data are not available for this period.

Children in foster care for eight (8) days or more from October 1, 2016 to September 30, 2017, experienced instability at a rate of 3.55.35, 36

35 Specifically, there were a total of 5,186 moves and 1,459,138 total applicable days. 36 It should be noted that performance based on the FSA placement instability measure is not comparable to performance with respect to the federal Round 3 Child and Family
Services Review (CFSR) permanency outcome that measures stability of foster care placement. The CFSR outcome is based on the rate of placement per day of all children who enter foster care in a 12-month period, which is likely to be significantly higher than the rate of placement for all children in foster care during that period of time. See Data Indicators for the Child and Family Services Review, available at https://www.acf.hhs.gov/sites/default/files/cb/data_indicators.pdf.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Sibling Placements:
(FSA IV.G.2.&3.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

18. At least 85% of Class Members entering foster care during the Reporting Period with their siblings or within thirty (30) days of their siblings shall be placed with at least one of their siblings unless one or more of the following exceptions apply: (1) there is a court order prohibiting placing all siblings together; (2) placement is not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) additional exceptions as approved by the CoMonitors.

As of January 1, 2017, 70% of children in care 30 days or longer were placed with at least one of their siblings.

64% (484 of 754) of children entering foster care with their siblings or within 30 days of their siblings from April 1 to September 30, 2017 were placed with at least one of their siblings.37

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

37 Currently, the reported universe of children in foster care includes both Class Members and Non-Class Members. DSS would have to manually remove children placed voluntarily from the universe. The Co-Monitors anticipate being able to report on this measure for Class Members only in the future.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

19. At least 80% of Class Members entering foster care during the Reporting Period with their siblings or within thirty (30) days of their siblings shall be placed with all their siblings, unless one or more of the following exceptions apply: (1) there is a court order prohibiting placing all siblings together; (2) placement is not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) additional exceptions as approved by the Co-Monitors.

As of January 1, 2017, 37% of children in care 30 days or longer were placed with all of their siblings.

As of September 30, 2017, 41% (310 of 754) of children entering foster care with their siblings or within thirty (30) days of their siblings from April 1 to September 30, 2017, were placed with all of their siblings.

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Youth Exiting the Juvenile Justice System:
(FSA IV.H.1.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

20. When Class Members are placed in juvenile justice detention or another Juvenile Justice Placement, DSS shall not recommend to the family court or Department of Juvenile Justice that a youth remain in a Juvenile Justice Placement without a juvenile justice charge pending or beyond the term of their plea or adjudicated sentence for the reason that DSS does not have a foster care placement for the Class Member.
DSS shall take immediate legal and physical custody of any Class Member upon the completion of their sentence or plea. DSS shall provide for their appropriate placement.

The Interim Order requirement that prohibited the maintenance of youth in Juvenile Justice Placements took effect on September 28, 2015. Between September 28, 2015 and March 31, 2017, DSS has reported that it is aware of two youth who were held in detention awaiting an available DSS placement. DSS has acknowledged, however, that it does not yet have a reliable system in place for tracking compliance with this provision so this may be an underrepresentation of actual incidences.

Unable to determine current performance.38

38 DSS has continued to represent that youth are immediately taken into the physical custody of DSS upon exit from juvenile justice placement in almost all instances, and reports no violations of the FSA provision during this monitoring period. It has, however, continued to acknowledge that there is no system in place for tracking youth moving between the juvenile justice and child welfare systems. In the absence of available data, the Co-Monitors have connected with stakeholders throughout the state who work with DSS youth who are also engaged with the Department of Juvenile Justice (DJJ). Many have described serious concerns about the lack of available placements for these youth, and the ways in which this impacts time spent in DJJ facilities. The Co-Monitors have received numerous reports of dually involved youth who have been maintained in DJJ placement after DSS represented to either DJJ or the court that it could not find them an appropriate placement, and many stakeholders describe attempts by DSS to transfer to DJJ the responsibility for youth with significant behavioral needs or youth who require a higher level of care. As a result, the Co-Monitors continue to have very serious concerns in this area and suspect that violations of the applicable FSA provision did, in fact, occur in this monitoring period.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

Therapeutic Foster Care Placements –Referral for Staffing and/or Assessment:
(FSA IV.I.2.)

21. All Class Members that are identified by a Caseworker as in need of interagency staffing and/or in need of diagnostic assessments shall be referred for such staffing and/or assessment to determine eligibility for therapeutic foster care placement and/or services within thirty (30) days of the need being identified. This requirement shall not apply if the Caseworker withdraws the identified need in good faith and in the best interests of the Class Member within thirty (30) days.

Data are not available for this period. Data are not available for this period.39

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

39 DSS has informed the Co-Monitors that data for this measure are not currently available as fields need to be added to CAPSS to capture and collect necessary information. The Co-Monitors anticipate that sufficient information regarding methods to develop and implement data collection for analysis and monitoring will be included in the final Placement Implementation Plan.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Therapeutic Foster Care Placements –Receipt of Recommendations for Services or Placement:
(FSA IV.I.3.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

22. All Class Members that are referred for interagency staffing and/or needed diagnostic assessments shall receive recommendations for specific therapeutic foster care placement and/or services within forty-five (45) days of receipt of the completed referral. The recommendation(s) may include diagnostic assessment, community support services, rehabilitative behavioral health services, therapeutic foster care, group care, and psychiatric residential treatment facility. Level of Care Placement recommendations shall utilize the least restrictive care philosophy suitable to the child’s needs and seek to place a Class Member in a family setting with a community support system. DSS shall update the assessment at least annually thereafter, upon a placement disruption or upon a material change in the Class Member’s needs. In making that determination, DSS may consider the full array of appropriate placement alternatives to meet the needs of the Class Members.

Data are not available for this period.

Data are not available for this period.40

40 Ibid.
Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

April – September 2017 Performance

Therapeutic Foster Care Placements – Level of Care Placement:
(FSA IV.I.4.&5.)

23.a. Within 60 Days: At least 90% of children assessed as in need of therapeutic foster care placement shall be in the Therapeutic Level of Care and specific placement type that matches the Level of Care for which the child was assessed within sixty (60) days following the date of the first Level of Care Placement recommendation.

Data are not available for this period.

Data are not available for this period.41

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

41 Ibid.
Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

23.b. At least 95% of children assessed as in need of therapeutic foster care placement shall be in the Therapeutic Level of Care and specific placement type that matches the Level of Care for which the child was assessed within ninety (90) days following the date of the first Level of Care Placement recommendation.

Data are not available for this period.

Data are not available for this period.42

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

42 Ibid.
Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7
Family Visitation – Siblings and Parents :
(FSA IV.J.2.&3.)

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

24. At least 85% of the total minimum number of monthly sibling visits for all siblings not living together shall be completed, with exceptions when (1) there is a court order prohibiting visitation or limiting visitation to less frequently than once every month; (2) visits are not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) with exceptions approved by the CoMonitors.

47% of children in foster care as of March 31, 2017, visited with all siblings with whom they were not placed in the month of March.
In March 2017, 55% of all required visits between siblings occurred for siblings who were not placed together.

60% of children in foster care as of September 30, 2017, visited with all siblings with whom they were not placed in the month of September.43
In September 2017, 66% of all required visits between siblings occurred for siblings who were not placed together.44

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the Co-Monitors.

43 Data were collected during a review conducted by USC CCFS and Co-Monitor staff of a statistically valid random sample based on a 95% confidence level and +/- 5% margin of error. Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier. 44 In an effort to match measurement with the FSA methodology for this measure, data collected during the case record review referenced above were utilized for the first time this period to reflect the percentage of required visits between siblings that occurred in the month reviewed. Since the data sample identified for review was calculated based on the number of applicable children, these data do not have the same level of statistical validity as the data discussed above. The Co-Monitors will work with DSS and USC CCFS in the next monitoring period to determine whether a sample pull based on applicable visits is possible. For comparison purposes, performance utilizing this methodology was also calculated for the prior period (October 2016 – March 2017) and is included herein.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

25. At least 85% of Class Members with the goal of reunification will have in-person visitation twice each month with the parent(s) with whom reunification is sought, unless (1) there is a court order prohibiting visitation or limiting visitation to less frequently than twice every month; or (2) based on exceptions approved by the CoMonitors.

Data are not available for this period.

12% of children in foster care as of November 30, 2017 with a goal of reunification visited twice with the parent(s) with whom reunification was sought in the month of November.45

Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

45 Data were collected during a review conducted by USC CCFS and Co-Monitor staff of a statistically valid random sample based on a 95% confidence level and +/- 5% margin of error. Permanency goals were identified utilizing data in the CAPSS field in which caseworkers are expected to update case goals in accordance with the most current determination in legal proceedings. Although outside of this monitoring period, November 2017 data were selected for review to allow time for data clean-up efforts to occur.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

Health Care Improvement Plan – Initial Health Assessment:
By the end of sixty (60) days following final court approval of the Final Settlement Agreement (identification period), DSS shall identify Class Members who have been in DSS custody for more than sixty (60) days as of the date of final court approval of the Final Settlement Agreement, and who have not had initial health assessments (physical/medical, dental or mental health).

26. Within thirty (30) days after the identification period, Defendants shall schedule the initial health assessment for at least 85% of the identified Class Members.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Physical/medical assessment: Of the 168 children identified as needing an assessment, 10% (16 children) received the necessary assessment by January 5, 2017.
Dental assessment: Of the 690 children identified as needing an assessment, 15% (102 children) received the necessary assessment by January 5, 2017.

Data for this measure are not available.47

(FSA IV.K.4.(a))

Mental Health assessment: Of the 740 children identified as needing an assessment, 6% (42 children) received the necessary assessment by January 5, 2017.46

46 Calculation of performance data for this measure required numerous rounds of data clean-up and validation by DSS, USC CCFS and Co-Monitor staff. Reported performance reflects final analysis by DSS which was provided to the Co-Monitors on September 4, 2017. 47 As part of their review, and in response to the Co-Monitors’ ongoing concerns about the inaccuracy of DSS health care data, the health care consultants retained by the CoMonitors evaluated DSS’s systems for the collection of data relevant to this measure and concluded that the data are unlikely to be accurate. The consultants made a number of recommendations to DSS in their Findings and Recommendations Report (Appendix C), including immediate steps it believed DSS should take to access health care data already collected by DHHS and Select Health, the MCO that manages the health care of all children in foster care in South Carolina. DSS quickly began to follow up on these recommendations and has recently received an initial data production from DHHS, which captures some basic screening and assessment data for all children who were in foster care in CY2017. The consultants are working with DSS to analyze these data and to determine how this type of reporting can be used to measure progress in this area going forward.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements7

Final Target

October 2016 – March 2017 or Baseline Performance

April – September 2017 Performance

Health Care Improvement Plan – Immediate Treatment Needs:
By the end of ninety (90) days following final court approval of the Final Settlement Agreement (identification period), DSS shall identify Class Members with Immediate Treatment Needs (physical/medical, dental or mental health) for which treatment is overdue. (Immediate Treatment Needs means immediate non-elective physical/medical, dental or mental health treatment needs and documented assessment needs, excluding routine periodic assessments.)

27. Within forty-five (45) days of the identification period, DSS shall schedule the necessary treatment for at least 90% of the identified Class Members.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Data are not available for this period.

Data are not available for this period.48

(FSA IV.K.4.(b))

48 DSS does not yet have a process for accurately tracking the immediate treatment needs of the children in its care. In their Findings and Recommendation Report (Appendix C), the Co-Monitors’ health care consultants concluded that, as with data related to initial screenings and assessments, the process DSS has developed for tracking immediate treatment needs data is not likely to produce reliable data. The consultants have made recommendations for the use of data already collected by DHHS and Select Health to identify and track progress with respect to immediate treatment needs. DSS is in the process of integrating this feedback into its Healthcare Improvement Plan, and the Co-Monitors and consultants will closely monitor progress.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Workload Study for Foster Care
DSS shall design, conduct and complete a foster care Workload Study that applies to every Caseworker and to every Caseworker’s supervisor and adopt one or more Workload Limits for foster care within 180 days (dates and obligations became operative as of September 28, 2015). The foster care Workload Study must be approved by the Co-Monitors before it is conducted. The results of the Workload Study must also be approved by the Co-Monitors before they are adopted by DSS. Each Workload Limit must be approved by the Co-Monitors before it is adopted.

Completion of Workload Study by March 28, 2016.

DSS began work in August 2015 to address concerns with caseloads. A Workload Estimation Workgroup was chartered to research best practice and develop recommendations for reducing caseloads. DSS collaborated with Casey Family Programs50 to develop and conduct a workload estimation study which was approved by the Co-Monitors on February 22, 2016. The study examined best practices and caseload limits in other states and conducted a time study. Based upon caseworker type, the study estimated time needed for specific activities and the amount of time caseworkers have available. An initial workload study report was submitted to the Co-Monitors on March 28, 2016 and a more complete copy of the study findings and recommendations on October 21, 2016.

(FSA IV.A.1.)

49 In some instances, information in this Table reflects the status of actions as of the date of this report. 50 Casey Family Programs is an operating foundation, working nation-wide to influence long-lasting improvements to the safety and success of children, families and the communities where they live, focused on safely reducing the need for foster care with a mission to provide and improve – and ultimately prevent the need for – foster care. https://www.casey.org/about/

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Adoption of Workload Limits for Foster Care by March 28, 2016.

On December 6, 2016, the Co-Monitors approved workload limits by establishing the following caseload standards for caseworkers and supervisors:
Caseworker Limits:  OHAN investigator – 1 caseworker: 8 investigations  Foster Care caseworker – 1 caseworker: 15 children  IFCCS caseworker – 1 caseworker: 9 children  Adoption caseworker – 1 caseworker: 17 children51  New caseworker – ½ of the applicable standard for first six months after
completion of Child Welfare Basic training.

Supervisor Limits:  Foster Care, IFCCS and Adoption supervisors – 1 supervisor: 5 caseworkers  OHAN supervisors – 1 supervisor: 6 investigators52

Although the caseload limits have been approved by the Co-Monitors for over a year, the methodologies to calculate performance for these limits were not provisionally approved until December 2017. In addition to calculating performance for caseworkers servicing a single type of case, a standard and methodology was needed for caseworkers who have Class and Non-Class Members53 on their caseload. See Section V of this report for a more detailed discussion of the approved mixed caseload standard and methodology.

51 In approving these caseload limits, the Co-Monitors noted that although a caseload of 17 children for adoption caseworkers is not within the standard proffered by the Council on Accreditation, as DSS is currently structured, case management responsibilities remain with the foster care caseworker, even when an adoption caseworker is assigned, until parental rights have been terminated. Given that DSS adoption caseworkers may therefore have less direct casework responsibilities than in some other jurisdictions, the CoMonitors accepted the proposed caseload limit for adoption caseworkers. If DSS’s structure were to change so that adoption caseworkers have more case management responsibility for assigned children, the Co-Monitors would expect a proposed modification to the caseload standard. 52 The Co-Monitors approved the higher caseload standard for OHAN supervisors in recognition that those caseworkers will have lower caseloads than other direct service caseworkers. 53 Non-Class Members include children receiving family preservation services while remaining in the home with their parent or caregiver, Adult Protective Services cases, families involved in child protective service assessments and children placed by ICPC.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period April 2017 – September 2017

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Implementing the Workload Limits for Foster Care:
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the CoMonitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Workload Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

DSS submitted a draft of the Workload Implementation Plan on November 30, 2016. Since that time, the Co-Monitors and Plaintiffs have provided feedback on several drafts and DSS has submitted revisions and modifications several times in response to comments. On December 21, 2017, in provisionally approving the mixed caseload methodology, the Co-Monitors informed DSS that they are prepared to approve the Workload Implementation Plan once the following are completed: (1) DSS provides reliable data on supervisory caseloads in order to set interim benchmarks and targets and (2) DSS includes more specificity in the Workload Implementation Plan on budget sequencing, requests and strategies to develop the resources needed to meet the caseload standards within four years. DSS has proposed interim benchmarks and targets in the draft Plan but these have not yet been approved.

(FSA IV.A.2.(a))

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Caseworker-Child Visitation
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure the progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the CoMonitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Caseworker and Child Visitation Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

Given their findings regarding the inadequacy of documentation of caseworker visits, the Co-Monitors were not able to utilize CAPSS data produced by DSS with respect to these measures this reporting period. The Co-Monitors have provided feedback to DSS on data clean-up that will be required and plan to rereview relevant data in the next monitoring period, at which time a determination about the need for an Implementation Plan in accordance with FSA IV.B.1 can be made.

(FSA IV.B.1.)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Investigation Implementation Plan
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the CoMonitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Investigations Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

DSS’s OHAN Workgroup developed a plan for improving OHAN practice and DSS submitted a draft of the Investigation Implementation Plan on November 30, 2016. Since that time, there have been revisions and modifications based upon feedback from the Co-Monitors and Plaintiffs. On August 9, 2017, DSS submitted a version of the plan which the Co-Monitors approved on September 11, 2017 and Plaintiffs provided their consent to the plan on November 7, 2017. An update on implementation of the strategies within the Plan is attached as Appendix B.

(FSA IV.C.1.)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Placement Needs Assessment
Within one hundred twenty (120) days, DSS, with prior input from and subject to approval by the CoMonitors, shall perform a statewide and regional foster care Placement Needs Assessment in order to determine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members. The needs assessment shall include specific recommendations addressing all the assessment’s findings, including but not limited to recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that can meet their needs.

Completion of Placement Needs Assessment, which includes findings and specific recommendations by June 30, 2017.

(FSA IV.D.1.)

DSS submitted a report with data and findings from the Placement Needs Assessment to the Co-Monitors on August, 31, 2017. In late September 2017, the Co-Monitors requested that additional work be completed on placement projections, including adding an assessment of county needs versus regional needs so as to understand what will be needed to place children close to their home community and avoid school changes. In October 2017, written feedback from both the Co-Monitors and Plaintiffs were provided to DSS. In December 2017, the Co-Monitors provided additional written feedback to DSS. DSS reports that county level data will be provided by March 31, 2018, as part of the updated Placement Implementation Plan.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Placement Implementation Plan
Within sixty (60) days of the completion of the needs assessment, DSS shall develop an Implementation Plan to implement the recommendations of the needs assessment within eighteen (18) months. The Implementation Plan shall have enforceable benchmarks with specific timelines, subject to approval by the Co-Monitors, to measure progress in executing the recommendations of the needs assessment.
(FSA IV.D.1.(a))

Completion of Placement Implementation Plan, which includes interim benchmarks with specific timelines. Originally, the Interim Order required the Placement Implementation Plan to be completed by March 28, 2016 (60 days from January 28, 2016). The IO then required implementation of the recommendations in the Plan by September 28, 2017.

Placement Implementation Plan shall include strategies to address the following areas, with accompanying interim benchmarks and specific timelines:

As presented above, DSS completed the Placement Needs Assessment on August 31, 2017. A draft Placement Implementation Plan was completed on October 31, 2017.
The Co-Monitors have not yet approved a Plan and interim benchmarks and timelines. After reviewing the Plan and visiting congregate facilities, Co-Monitors provided verbal feedback, followed by written feedback to DSS on December 20, 2017. In order to incorporate the feedback, DSS informed the Co-Monitors that the next draft of the Plan will be submitted on March 30, 2018.
Concurrent with the work to finalize an approved Placement Implementation Plan, there are a number of tasks that DSS should be aggressively moving forward, such as increasing recruitment of foster homes, improving the process in which foster parents apply and licenses are processed, streamlining processes for placement matching and decisions to improve efficiency, closely reviewing poor performing and inadequate or unsafe congregate care facilities, ensuring timely and appropriate contracts and collaborating with private providers to make the reform successful.

 Congregate Care Placements (FSA IV.E.1.)  Sibling Placement (FSA IV.G.1.)  Therapeutic Foster Care Placements (FSA
IV.I.1)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Plan for Family Placements for Children Ages 6 and Under:
Within sixty (60) days, DSS shall create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the CoMonitors, the placement of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers). The plan shall include full implementation within sixty (60) days following approval of the Co-Monitors.

Completion of Plan to prevent placement of Class Members age six (6) and under in any non-family group placement by November 28, 2015.

Data indicate that DSS’s processes to prevent the placement of any Class Member ages six and under in any non-family, group placement continue to work well. There has been a substantial reduction in the number of children ages six and under in congregate care.
The circumstances of slightly over half of the young children (5 of 9) in congregate care this period met an agreed upon exception; one of these placements was made in accordance with the process DSS put into place, requiring prior approval by the Child Welfare Director.

(FSA IV.D.2.)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Family Visitation – Siblings and Parent Implementation Plan:
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the CoMonitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Family Visitation Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

DSS convened a Visitation Workgroup in October 2016 to assess systemic barriers to family visitation and develop and assist with the implementation of the Visitation Implementation Plan. DSS submitted a draft of the Visitation Implementation Plan on November 30, 2016 and upon receipt of feedback from the Co-Monitors and Plaintiffs, has completed several rounds of revisions and modifications. Many of the draft strategies center around increasing supervisory skills, revising policy and procedures, educating caseworkers, increasing foster parent participation and developing plans to reduce logistical barriers. The plan has not yet been approved by the Co-Monitors.

(FSA IV.J.1.)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of September 31, 2017)49

Health Care Improvement Plan: Within one hundred eighty (180) days, Defendants, with prior input from and subject to approval by the Co-Monitors, shall develop a Health Care Improvement Plan with enforceable dates and targets for phased implementation and concerning initial screening services, periodic screening services, documentation, and health care treatment services for Class Members in the areas of physical health, immunizations and laboratory tests, mental health, developmental and behavioral health, vision and hearing, and dental health. The Plan shall address:
(a) Developing the capacity to track screening and treatment services for individual children and aggregate tracking data, including but not limited to screens that are due and past due;

Completion of Health Care Improvement Plan by March 31, 2017. On April 19, 2017, the Co-Monitors approved a 60 day extension, with an expected completion date of June 2, 2017. On June 1, 2017, DSS filed a Motion for Extension of Time, which was approved and extended the deadline to September 30, 2017.

After receiving an extension for preparation of its Health Care Improvement Plan pursuant to FSA IV.K.2., DSS submitted a draft report to the Co-Monitors on September 29, 2017. The Co-Monitors provided initial feedback, and in November 2017, engaged consultants with specific expertise in child welfare health care reform to assess the sufficiency of the Plan pursuant to FSA IV.K.3. The consultants’ recommendations based on the results of validation activities and extensive interviews with key DSS, DMH, DHHS, MCO and community provider staff, were submitted in a Findings and Recommendations Report on February 12, 2018, attached as Appendix C. DSS is working closely with the consultants to make recommended changes to their Plan and expect to submit an updated version to the Co-Monitors by April 13, 2018. The consultants will also assist the CoMonitors in identifying all final health care outcome measures related to initial screening services, periodic screening services, documentation, treatment and other corrective services once the Plan is complete, as per Section IV.K.5. of the FSA, and progress will be reported in a later monitoring period.

(b) Assessing the accessibility of health care screening and treatment services throughout the State, including the capacity of the existing health care providers to meet the screening and treatment needs of Class Members; and

(c) Identifying baselines and interim percentage targets for performance improvement in coordinating screens and treatment services. With approval of the Co-Monitors and based on evidence of progress toward the development of the Health Care Improvement Plan, Defendants may request an extension of an additional sixty (60) days to complete the Plan. (FSA IV.K.1.)

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V. CASELOADS
A sufficient, qualified and trained workforce with manageable caseloads is foundational to a well-functioning child welfare system. Caseworkers must be given resources and support to allow them to conduct meaningful visits with children and families, assess for safety and risk and monitor progress towards individualized case goals, among many other important tasks. As discussed in performance data below, only about one-quarter of foster care and adoption caseworkers have caseloads within the required limits, and IFCCS and OHAN caseloads are substantially higher than the standards allow.
In January 2018, the DSS Director reported to the legislature that the turnover rate among DSS workers in 2016 was 30.3 percent. In an effort to improve retention, in October 2017, DSS announced incentive pay for employees who remain with the agency for a specific number of years, including one year, three years, five years, ten years, etc. The General Assembly has also approved tuition reimbursement for designated DSS staff who need assistance with educational degrees.
In Fiscal Year (FY) 2018, DSS requested and received funding for 163 new staff positions. Data provided to the Co-Monitors reflect that between July 1 and September 25, 2017, the following number of new caseworkers were hired and began accepting cases: 18 foster care caseworkers, two IFCCS caseworkers and three adoption caseworkers. The Co-Monitors are unable to determine the net addition of new caseworkers for Class and Non-Class Members; more information is required regarding vacancies, the rate at which vacancies are filled and posting and hiring for newly created positions. In addition, DSS has reported that the anticipated decline in caseloads from the hiring of new caseworkers in prior years has been offset by increased reports alleging child abuse and neglect and expanded intake staffing assignments following statewide implementation of DSS Intake Hubs. In combination with continued high turnover among frontline staff, this has meant that caseloads that had begun to decline in late 2016 and early 2017 are now back to 2015 levels.
A. Workload Implementation Plan
The FSA requires that by December 5, 2016, DSS develop an Implementation Plan to achieve the final FSA workload requirements. The Implementation Plan must include “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approved (sic) by the Co-Monitors, to measure progress in achieving the final targets…” (FSA IV.A.2 (a)).
Over a year later, DSS still does not have a final, approved Workload Implementation Plan. DSS submitted an initial draft on November 30, 2016. Since that time, DSS has completed multiple

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rounds of revisions and modifications in response to feedback by the Co-Monitors and Plaintiffs, but has been unable to produce a final Plan due to difficulties in establishing baseline data. The Co-Monitors approved workload limits for caseworkers and supervisors with single type caseloads on December 6, 2016. In current DSS practice, there are also caseworkers who carry mixed caseloads with more than one type of case on their caseload (for instance, a case involving a family with children in the home and a case involving a family with children in placement); a caseload standard and methodology for measuring compliance for these caseworkers was only recently provisionally approved by the Co-Monitors on December 21, 2017. Baseline data for establishing interim benchmarks are still not fully available, and as mentioned in the prior monitoring report, DSS needs to develop a more precise method to identify children needing Intensive Foster Care and Clinical Services (IFCCS) services54,55 as well as supervisors managing IFCSS caseworkers with Class Members on their caseload.
In November 2017, DSS assembled an IFCCS Data Integration and Level of Care Workgroup. The workgroup has been charged with integrating current IFCCS databases into the CAPSS system to allow all client, placement and related services information to be centrally maintained; standardizing all forms, policies and procedures across regions; converting IFCCS specific “administrative directives” into child welfare policy; developing a mechanism to capture and track both funding eligibility and level of care determination criteria within CAPSS; and discussing “IFCCS on-boarding training” to allow for transfer of children on Interagency System for Caring for Emotionally Disturbed Children (ISCEDC) “other lead” list56 to IFCCS workers.
In provisionally approving the mixed caseload methodology, the Co-Monitors informed DSS that they are prepared to approve the Workload Implementation Plan once DSS completes the following: provides reliable data on supervisory caseloads in order to set interim benchmarks and targets; and includes more specificity on budget sequencing, requests and strategies to develop the resources needed to meet the caseload standards within four years. In their draft Plan, DSS estimated that they will need to hire 670 workers over a four year period to meet caseload standards. DSS has proposed interim benchmarks and targets in the draft Plan but due to delays discussed above, these have not yet been approved.

54 Eligibility for IFCCS services is determined following a review of a child’s mental health assessment(s) and diagnosis; frequency, intensity and duration of symptoms; multi-system involvement; and exhaustion of alternative services. IFCCS services utilize funding through SC’s Interagency System for Caring for Emotionally Disturbed Children (ISCEDC) to pay for treatment costs. ISCEDC funding are pooled dollars from multiple state agencies, including DSS, the Department of Mental Health, the Department of Disabilities and Special Needs, the Department of Juvenile Justice and the Department of Education. 55 Currently, IFCCS children are identified by the office of the caseworker who manages them and possible siblings of children needing IFCCS services may be incorrectly assumed to be categorized as IFCCS. DSS committed to developing a method to identify therapeutic children (non-regular foster care) after an assessment to be managed by IFCCS. DSS had indicated that a plan to appropriately identify children needing IFCCS services in CAPSS would be complete by December 2017. 56 The “other lead” list include children who are ISCEDC eligible and may be receiving ISCEDC services, however, they are not currently case managed by an IFCCS worker due to high IFCCS caseload levels.

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B. Performance Data
The FSA requires “[a]t least 90% of Workers and Worker supervisors shall have a workload within the applicable Workload Limit” (FSA IV.A.2.(b)) and that “ [n]o Worker or Worker’s supervisor shall have more than 125% of the applicable Workload Limit” (FSA IV.A.2.(c)). There are different caseload standards dependent upon the types of cases a caseworker manages – foster care, IFCCS, adoption, investigations of allegations of abuse and/or neglect of a child in foster care. There are also reduced workload standards specific to newly hired caseworkers within their first six months of completing Child Welfare Basic training.
The calculation of the baseline performance for this measure was only recently possible due to complications in measuring compliance for caseworkers who have mixed caseloads. Ultimately, DSS plans to move as many caseworkers as possible to caseloads that include only one type of case, but there will continue to be caseworkers who have mixed caseloads because it makes sense from a practice or clinical perspective. For example, it may be appropriate for a caseworker to be assigned to the case of a family in which one or more children are in foster care and other children remain at home with family preservation (treatment) services, or where nonmixed caseloads are not feasible given staffing and the number of families served in some smaller counties.
On December 21, 2017, the Co-Monitors provisionally approved DSS’s November 3, 2017 proposal to calculate caseloads for caseworkers with mixed caseloads by adding the total number of foster care children (Class Members) they serve to the total number of families (cases) of Non-Class Members they also serve. The following types of cases will be counted by family (case): Child Protective Services (CPS) assessment; family preservation; other child welfare services and those involving a child subject to the Interstate Compact on the Placement of Children (ICPC). This methodology will only be applied to foster care caseworkers with mixed caseloads and will not be applied to caseloads for IFCCS and adoption caseworkers. In approving this mixed caseload methodology, the Co-Monitors relied upon DSS’s commitments to: (1) move forward with plans to move caseworkers to single type caseloads as feasible and appropriate; (2) change its internal metrics for family preservation cases to use a “family” as opposed to an individual child count; and (3) assess and find a way to address the Co-Monitors’ concerns about the potential for unreasonable caseloads that could result from caseworker assignment to multiple family preservation cases involving families with multiple children. DSS has indicated that managers will continually assess assignments to caseworkers with mixed caseloads to ensure balanced and manageable workloads. Because approval of this methodology is “provisional,” DSS and the Co-Monitors will continually assess it in practice as it is implemented, reserving the right to modify the standard at any time if it is determined that the best interests of children are not being served.

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The performance data on caseloads discussed below were provided by DSS and have not been independently validated by the Co-Monitors. The Co-Monitors plan to work with DSS and the data audit consultants over the next monitoring period to ensure the accuracy of these data.
Foster Care Caseworkers
The caseload standard for caseworkers who are responsible for providing case management for foster care cases is one caseworker to 15 children (1:15). As of September 25, 2017, there were 230 foster care caseworkers with at least one foster care child on their caseload.57 Of these 230 caseworkers, 65 (28%) foster care caseworkers had caseloads within the required limit (see Figure 1).58 Additionally, 136 (59%) caseworkers’ caseloads were more than 125 percent of the caseload limit.
Forty-four of the foster care caseworkers were newly hired workers, who had completed Child Welfare Basic training within the past six months. The caseload standard for newly hired foster care caseworkers is half of the foster care caseworker standard; therefore, newly hired foster care caseworkers should have no more seven foster care children or Non-Class families on their caseload. Of the 44 newly hired foster care caseworkers, nine percent (4 caseworkers) had seven or fewer cases as of September 25, 2017 (see Figure 1).

57 This includes eight caseworkers designated as Adult Protective Services (APS) caseworkers who were case managing foster care children in addition to their adult clients, and 44 newly hired foster care caseworkers. 58 In calculating performance, a standard of seven foster care children or Non-Class families is applied to newly hired caseworkers (half of the applicable caseload standard) and 15 foster care children or Non-Class families is applied to foster care or APS caseworkers.

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Figure 1: Foster Care Caseworkers within the Required Caseload Limits as of September 25, 2017
Newly hired caseworkers N=44 Caseworkers employed six months or longer N=186
All caseworkers N=230
Source: CAPSS Data Provided by DSS
As of September 25, 2017, the highest caseload for a foster care caseworker employed six months or longer was 44 cases. Figure 2 shows the range of caseloads for those foster care caseworkers who were over the required limit of 15 cases on that date.

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Figure 2: Caseloads of Foster Care Caseworkers Employed Six Months or Longer that were Over Limit as of September 25, 2017 N=125
Source: CAPSS Data Provided by DSS
The highest number of cases a newly hired foster care caseworker had on September 25, 2017 was 29 cases. The majority (68%) of newly hired foster care caseworkers had 15 or more cases. Figure 3 shows the caseload range for newly hired foster care caseworkers who were over the required limit of seven cases on that date.

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Figure 3: Caseloads of Newly Hired Foster Care Caseworkers that were Over Limit as of September 25, 2017 N=40

Source: CAPSS Data Provided by DSS
IFCCS Caseworkers
The caseload standard for caseworkers who are responsible for providing case management to children designated as needing Intensive Foster Care and Clinical Services (IFCCS) services is one caseworker to nine children (1:9). Newly hired IFCCS workers should not have more than five children on their caseload for six months after they complete Child Welfare Basic training.
As of September 25, 2017, there were 82 IFCCS caseworkers59 serving at least one Class Member and eight (10%) of these caseworkers were within the required caseload limit (see Figure 4). Sixty-three (77%) caseworkers had caseloads more than 125 percent of the caseload limit.
Twelve of the IFCCS caseworkers were newly hired, and should have no more than five children on their caseload for six months following completion of Child Welfare Basic training. As of September 25, 2017, only one (8%) of the newly hired IFCCS caseworkers had five or fewer cases (see Figure 4).

59 Total includes 12 newly hired IFCCS caseworkers; their caseload standard is five children.
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Figure 4: IFCCS Caseworkers within the Required Caseload Limits as of September 25, 2017
Newly hired IFCCS caseworkers N=12 IFCCS caseworkers employed six months or longer N=70
All IFCCS caseworkers N=82
Source: CAPSS Data Provided by DSS
As of September 25, 2017, the highest caseload for an IFCCS caseworker employed six months or longer was 29 cases. Figure 5 shows the range of caseloads for those IFCCS caseworkers who were over the required limit of nine cases on that date.

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Figure 5: Caseloads of IFCCS Caseworkers Employed Six Months or Longer that were Over Limit as of September 25, 2017 N=63
Source: CAPSS Data Provided by DSS
The highest number of cases a newly hired IFCCS caseworker had on September 25, 2017, was 13 cases. The majority (92%) of newly hired IFCCS caseworkers had six or more cases. Figure 6 shows the caseload range for new IFCCS caseworkers who were over the required limit of five cases on that date.

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Figure 6: Caseloads of Newly Hired IFCCS Caseworkers that were Over Limit as of September 25, 2017 N=11

Source: CAPSS Data Provided by DSS
Adoption Caseworkers
The caseload standard for caseworkers providing adoption support to children with a goal of adoption is one caseworker to 17 children (1:17).60
As of September 25, 2017, there were 73 adoption caseworkers61 serving at least one Class Member. Of these 73 caseworkers, 17 (23%) caseworkers were within the caseload requirement and 45 (62%) caseworkers had caseloads more than 125 percent of the limit.
Five of the adoption caseworkers were newly hired, and should have no more than nine children on their caseload for six months following completion of Child Welfare Basic training. As of

60 In approving these caseload limits, the Co-Monitors noted that although a caseload of 17 children for adoption caseworkers is not within the standard proffered by the Council on Accreditation, as DSS is currently structured, case management responsibilities remain with the foster care caseworker, even when an adoption caseworker is assigned, until parental rights have been terminated. For example, as of September 18, 2017, of the 1,751 children who were on an adoption caseworkers’ caseload, only 47 children (3%) were receiving primary case management from their adoption caseworker. Given that DSS adoption caseworkers may therefore have less direct casework responsibilities than in some other jurisdictions, the Co-Monitors accepted the proposed caseload limit for adoption caseworkers. If DSS’s structure were to change so that adoption caseworkers have more case management responsibility for assigned children, the Co-Monitors would expect a proposed modification to the caseload standard. 61 Total includes five newly hired adoption caseworkers; their caseload standard is nine children.

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September 25, 2017, none (0%) of the newly hired adoption caseworkers had nine or fewer cases (see Figure 7).
Figure 7: Adoption Caseworkers within the Required Caseload Limits as of September 25, 2017
Newly hired adoption caseworkers N=5 Caseworkers employed six months or longer N=68
All adoption caseworkers N=73

Source: CAPSS Data Provided by DSS
As of September 25, 2017, the highest caseload for an adoption caseworker employed six months or longer was 51 cases. Figure 8 shows the range of caseloads for those adoption caseworkers who were over the required limit of 17 cases on that date.

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Source: CAPSS Data Provided by DSS

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The highest number of cases a newly hired adoption caseworker had on September 25, 2017, was 28 cases. All five caseworkers had at least double the required limit. Figure 9 shows the range of caseloads for those newly hired adoption caseworkers who were over the required limit of nine cases on that date.
Figure 9: Caseloads of Newly Hired Adoption Caseworkers that were Over Limit as of September 25, 2017 N=5

Source: CAPSS Data Provided by DSS

OHAN Caseworkers

The caseload standard for caseworkers conducting investigations involving allegations of abuse and/or neglect of a child in foster care is one caseworker per eight investigations (1:8).

As of September 25, 2017, there were seven OHAN caseworkers investigating allegations of abuse and/or neglect. None (0%) of these caseworkers had eight or fewer investigations. As of that date, caseloads ranged from 14 to 27 investigations per worker.62 All OHAN caseworkers’ caseloads exceeded the standard by 25 percent or more. As discussed later in this report, although the data reflect that caseworkers of all types are currently overwhelmed, the CoMonitors are particularly concerned about current OHAN caseloads given that its workers are

62 One worker had 14 investigations, two caseworkers had 20 investigations, one worker had 21 investigations, one worker had 22 investigations, one worker had 24 investigations and one worker had 27 investigations.

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responsible for ensuring the safety of children who are alleged to have been abused and/or neglected while in foster care. In summary, Figure 10 reflects the percentage of foster care, IFCCS, adoption and OHAN caseworkers within and above the required caseload limits as of September 25, 2017.
Figure 10: Foster Care, IFCCS, Adoption and OHAN Caseworkers that were Above and Within the Required Caseload Limits as of September 25, 2017

Source: CAPSS Data Provided by DSS
Supervisors
The caseload standard for supervisors providing supervision to foster care, IFCCS and adoption caseworkers is one supervisor to five caseworkers (1:5). The standard for supervisors providing supervision to caseworkers conducting OHAN investigations is one supervisor to six investigators (1:6).63

63 The Co-Monitors approved the higher caseload standard for OHAN supervisors in recognition of the fact that the OHAN caseworkers they supervise will have lower caseloads than other direct service caseworkers.

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Data for this measure were not available during the previous period as DSS indicated data cleanup in CAPSS was necessary to accurately reflect all supervisors who are managing caseworkers with Class Members on their caseload. After months of effort, DSS was finally able to produce relevant data to the Co-Monitors on March 8, 2018. Given the late production date, the CoMonitors were unable to review and validate the data for inclusion in this report. The CoMonitors anticipate reporting data for this measure in the next monitoring report.

VI. CASEWORKER-CHILD VISITATION

Visits between caseworkers and children in foster care are critical to a child welfare agency’s ability to monitor the safety, well-being and progress of the children in its care. DSS understands these visits to be a core element of its practice and has maintained that caseworkers throughout the state visit with children on a monthly basis in nearly all cases. Although CAPSS data indicate that the visits are, in fact, occurring in accordance with the FSA requirements, the Co-Monitors were unable to validate these data this period due to significant issues with the quality of documentation.

The FSA requires “[a]t least 90% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place” (FSA IV.B.2.) and that “[a]t least 50% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place in the residence of the child” (FSA IV.B.3.). The FSA further required that by December 5, 2016, DSS was to develop an Implementation Plan with “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors” (FSA IV.B.1.) to achieve the final targets related to caseworker visitation with children.
Based on review of its data, DSS reported at the time of entry into the FSA that it was already achieving the final targets related to caseworker-child visitation and therefore did not need to develop an Implementation Plan for the caseworker-child visitation measures. In the last monitoring period, it became clear to the Co-Monitors that DSS and Plaintiffs hold vastly different views of the FSA visitation requirements. DSS’s interpretation of the requirements is that they are explicitly focused only on whether visits occurred and where they were held. Plaintiffs believe that the content of visits must also be examined to ensure not only that caseworkers saw children, but that they did so in a way that accords with the core purpose of visitation and that includes necessary elements as defined by practice standards and DSS policy.

Although the Co-Monitors performed a validation of CAPSS data in the first monitoring period, the review was limited. Because CAPSS documentation was not sufficient to allow for a fuller review of visit content – many notes were either sparse or substantially duplicative of those

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entered in prior month – the review was done solely for the purpose of measuring the percentage of cases in which documentation indicated that a caseworker had visited the child in that month, and the location of the visit. The Co-Monitors did not assess the content of the visits nor the extent to which visits were done in accordance with DSS policy. Based on its findings, the CoMonitors utilized CAPSS data to report performance on both FSA IV.B.2 and FSA IV.B.3, with the understanding that further validation would be necessary to assess performance on these measures in later periods.
In an effort to better understand DSS practice with respect to caseworker visits with children, the Co-Monitors again reviewed a sample of cases this reporting period.64 Once again, documentation was inadequate in many cases, and, to a greater degree than in the last reporting period, it was not possible to discern in some cases whether a visit had even occurred.65 Given these findings, the Co-Monitors were not able to validate CAPSS data produced by DSS with respect to these measures this reporting period. The Co-Monitors have provided feedback to DSS on data clean-up that will be required and plan to re-review relevant data in the next monitoring period, at which time a determination about the need for an Implementation Plan in accordance with FSA IV.B.1 can be made. The Co-Monitors also believe that DSS and Plaintiffs need to discuss and attempt to resolve their differences on the meaning of the FSA requirement on caseworker visitation.
Given the importance of caseworker visits in monitoring the safety, well-being and permanency of children in foster care, and how critical these visits will be to DSS’s ability to meet many of the FSA measures, the Co-Monitors are increasingly concerned about the lack of reliable documentation in this area and will be closely monitoring progress over the coming months.
VII. INVESTIGATIONS

The work of investigating allegations of abuse and/or neglect of children in foster care – completed by DSS’s Out of Home Abuse and Neglect (OHAN) unit – is one of the most critical functions for any child welfare system. This unit must be prepared 24 hours a day, seven days a week to receive reports, appropriately decide which reports should be screened in for investigation and, for those reports that require an investigation, make contact with the alleged victim child(ren) within 24 hours of the report to assess their safety and the allegations. Children are in foster care as a result of abuse or neglect by their caregivers, and ensuring their safety and well-being while in state custody is a primary obligation.

64 The Co-Monitors reviewed a sample of 200 cases in which caseworker visits with children were required in September 2017. 65 The Co-Monitors found a significant percentage of CAPSS notes reviewed were exact or near-exact replications of notes from prior or subsequent months, described other visits or activities attended by a caseworker with no evidence of interaction with the child, were cursory and non-descriptive or, in some cases, entered in error.

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During the current period, data reflect improved performance in appropriateness of decisions to investigate, timely initiation of investigations and appropriate investigation decisions. However, the Co-Monitors’ case review of investigations from September 2017 was not able to identify any investigation in which contact was made with all necessary core witnesses in carrying out the investigation. As referenced earlier, all OHAN workers during that month had caseloads which far exceeded the required limit, clearly impacting their ability to conduct comprehensive, quality investigations.
Following case reviews in the prior monitoring period, the Co-Monitors provided specific feedback to DSS on intake screening decisions with a focus on themes identified in decisions to inappropriately screen some referrals out. In response to this feedback, as well as other factors, DSS began screening more referrals in for investigation. The average number of referrals accepted each month for investigation between October 2016 and March 2017 was 27 investigations, and between April and September 2017 the average practically doubled to 52 investigations accepted a month with no increase in assigned staff. DSS and OHAN staff continue to be provided with specific feedback following each monthly review of intake screenout decisions so adjustments can be made.

A. Investigation Implementation Plan
The FSA requires that by December 5, 2016, DSS develop an Implementation Plan for the provisions related to intake and investigations. The Implementation Plan must have “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets…” (FSA IV.C.1.). On September 11, 2017, the Co-Monitors approved DSS’s OHAN Implementation Plan and Plaintiffs provided their consent to the Plan on November 7, 2017.
In addition to setting interim benchmarks and timelines, the OHAN Implementation Plan includes strategies developed to improve OHAN practice and achieve the targets required by the FSA. These strategies include: improvement in worker time management; implementation of processes to track and monitor timely initiation of investigations and contact with core witnesses; development of check lists and other forms; development and completion of new OHAN trainings for caseworkers; coordination between OHAN and licensing; and improvements in supervision within OHAN. Attached as Appendix B are implementation status updates on these strategies as of September 30, 2017.

Through ongoing validation and data collection activities, Co-Monitor staff have been able to follow the implementation of several OHAN Implementation Plan strategies. Reviews of

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monthly intakes have shown an increase in the use of standardized forms to assess for safety and risk during intake calls, although consistency in their application still requires improvement. In October 2017, OHAN staff participated in an intake training which was developed and conducted by staff from USC CCFS. Co-Monitor staff also participated in this training and found it to be comprehensive and beneficial. With appropriate follow-up and oversight by OHAN supervisors and management, exposure to the content and conversations during classroom sessions should improve consistency and quality of screening decisions at intake. DSS reports collaboration is underway with USC’s Children’s Law Center to develop a curriculum for an investigation training. Dates for completion of the curriculum and schedule for training workers have not yet been determined.
In December 2017, Co-Monitor staff conducted a group interview with OHAN caseworkers and several themes emerged. The group of experienced staff expressed dedication to their job and care for the children, foster parents and facility staff they encounter. However, as reflected in caseload data discussed earlier in this report, OHAN is significantly understaffed and caseworkers are overworked. Caseworkers reported receiving six new investigations per week, each of which require visits with children throughout the state within the required 24-hour timeframe. Due to high caseload demands, caseworkers reported that they are unable to complete all investigative tasks, and those tasks completed lack thoroughness and quality. Caseworkers also expressed that there is not sufficient time to document the work that they are able to do. The Co-Monitors have repeatedly expressed to DSS leadership their concern that this setup is untenable and unsustainable, that it is directly impacting caseworker morale and retention and that it requires immediate attention, particularly given the critical nature of OHAN’s work.
B. Performance Data
Intake
Pursuant to South Carolina state statute and DSS protocol, all allegations of abuse or neglect of children in out-of-home settings – including licensed foster homes, residential facilities and group homes – received by local county offices or regional Intake Hubs must be forwarded to OHAN for screening and, if accepted, for investigation.66, 67 OHAN staff make decisions to either accept a referral for investigation or take no further action on the referral screen-out based upon information collected from reporters to determine if the allegations meet the state’s

66 SC Code § 63-7-1210; Human Services Policy and Procedural Manual, Chapter 7-721. p.3 (effective date 11/29/2012); SC DSS Directive Memo, April 26, 2016. 67 Allegations of abuse or neglect by a foster parent of their biological or adopted child are investigated by child protective service caseworkers in local county offices.

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statutory definition of abuse or neglect.68 DSS policy establishes three main screening criteria for investigations of abuse or neglect of children in out-of-home care: (1) the alleged victim child is younger than 18 years of age; (2) there is an allegation of actual harm that has occurred or is occurring to a child or the caregiver’s acts or omissions present a significant risk of harm; and (3) the alleged perpetrator is a person responsible for the child’s welfare.69 OHAN staff are also directed to accept for investigation referrals which identify safety and risk factors to the child in care. All screening decisions are reviewed and approved by a supervisor prior to being finalized.

The FSA requires, “[a]t least 95% of decisions not to investigate a Referral of Institutional Abuse or Neglect about a Class Member must be made in accordance with South Carolina law and DSS policy” (FSA IV.C.2.). Baseline performance for this measure collected during a review of 128 referral decisions not to conduct an investigation between August 2016 and January 2017 indicated that 44 percent of the decisions were appropriate. The Table below includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure:

Table 3: Baseline, Timeline and Interim Benchmarks for Appropriateness of Decision Not to Investigate
Referral (Alleging) Institutional Abuse (and/)or Neglect
Baseline

August 2016 – January 2017

44%

Timeline

Interim Benchmark

September 2017

75%

March 2018

90%

September 2018

95%

Final Target Source: OHAN Implementation Plan

95%

In April 2017, a new safety and risk factor assessment tool was introduced to OHAN staff. This tool does not outline all considerations needed to structure consistent decision making, but instead assists workers by defining circumstances which require immediate acceptance, such as the current abuse is severe and suggests there may be present or impending danger to the child,

68 SC Code § 63-7-20. 69 This includes a foster parent; an employee or caregiver in a public or private residential home, institution or agency; or an adult who has assumed the role and responsibility of a parent or guardian for the child, but who does not necessarily have legal custody of the child. Human Services Policy and Procedural Manual, Chapter 7-721. p.3 (effective date 11/29/2012).

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or the child’s physical living conditions are hazardous and present a situation of present or impending danger. Due to changes in practice and transitions that occurred during the month, the Co-Monitors did not review screening decisions in April 2017 and began data collection for the monitoring period in May 2017. All applicable referrals70 of abuse and/or neglect received and not investigated by DSS’s OHAN unit between May and September 2017 were reviewed.71 Performance data were collected separately for each month.
Between May and September 2017, the Co-Monitors determined a monthly range of 59 to 88 percent of decisions not to investigate a referral of abuse and/or neglect to be appropriate (see Figure 11). Specifically, in September 2017, 15 (88%) of the 17 applicable screening decisions were appropriate.72 Performance has improved since the baseline review and exceeded the 75 percent interim benchmark target for September 2017. However, over the five months assessed, there were fluctuations in performance, demonstrating a need for more consistency in decision making to meet the next interim benchmark of 90 percent by March 2018. As discussed above, improved and consistent decision making were goals of the intake training provided to staff in October 2017.

70 Some referrals were found not to be applicable for review because the alleged victim child was not a Class Member (i.e. the child was voluntarily placed by the legal guardian or through ICPC from another state, or was the biological child of the caregiver). DSS has represented to the Co-Monitors that all referrals of abuse and/or neglect in licensed foster homes, residential facilities and group homes across the state involving Class Members are received by or forwarded to OHAN for screening and investigation, as appropriate, and screening decisions are not made by local office or Intake Hub staff. 71 When assessing performance for this measure, reviewers considered three main criteria: (1) the allegation, if true, meets the legal definition of maltreatment; (2) the OHAN caseworker did not collect all information necessary to make an appropriate screening decision; and (3) safety or risk factors were identified within the information shared. If any of these questions were answered in the affirmative, the decision not to investigate the referral was determined to be inappropriate. 72 Of note, of the 40 referrals that were accepted for investigation in September 2017, Co-Monitor staff assessed that 15 of the referrals should not have been accepted for investigation as there were no allegations of abuse or neglect by a caretaker.

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Figure 11: Appropriateness of Decision Not to Investigate Referral (Alleging) Institutional Abuse (and/)or Neglect
May – September 2017

Interim Benchmark – 75%

Source: Monthly review data, USC CCFS and Co-Monitor staff
Investigations
If a referral is accepted for investigation, the FSA and OHAN policy require face-to-face contact with the alleged victim child(ren) within 24 hours to assess for safety and risk, and the investigation is to be completed within 45 days.73 OHAN policy also requires that throughout the course of the investigation, the investigator must conduct a safety assessment of the alleged victim child, including a private interview with that child; work with the child’s caseworker or law enforcement to make arrangements for medical treatment or examinations, as needed; interview core witnesses to inform the investigation; review documents and records related to the incident; and assess the risk of further maltreatment to all children within that setting.74 All of these activities are critical components of a quality investigation that results in accurate assessments and findings.
There are seven FSA measures pertaining to investigations – timely initiation (two measures),75 contact with core witnesses (one measure), investigation determination decisions (one measure)

73 Human Service Policy and Procedural Manual, Chapter 7-721. p. 6, 12 (effective date 11/29/2012). 74 Human Services Policy and Procedural Manual, Chapter 7-721. p. 7 (effective date 11/29/2012). 75 The Co-Monitors’ interpretation of the FSA requires that investigations be initiated within 24 hours of receipt of the referral by DSS, not within 24 hours of the decision to accept the referral, and that initiation is completed by making face-to-face contact with the alleged victim child(ren). As a result, the performance for both FSA measures IV.C.4.(a) and (b) are measured using the

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and timely completion (three measures). The most recent performance data detailed below were collected during a case record review conducted in January 2018 which examined 40 applicable investigations76 that were accepted and initiated in September 2017. Most of the investigations involved allegations of physical neglect (20 investigations/50%) and/or physical abuse (15 investigations/38%). Twenty-three (58%) of the investigations involved allegations of abuse and/or neglect in a facility or institution and the remaining 17 (43%) investigations alleged abuse and/or neglect in a foster home. Investigations involved placements throughout the state, with 30 percent from either Charleston (5 investigations) or Richland (7 investigations) counties. The most frequent reporters alleging abuse and/or neglect were the DSS caseworker or supervisor (13 investigations) or provider/facility staff (13 investigations).
Timely Initiation
The FSA requires, “[t]he investigation of a Referral of Institutional Abuse or Neglect must be initiated within twenty-four (24) hours in accordance with South Carolina law in at least 95% of the investigations” (FSA IV.C.4.(a)). Additionally, FSA Section IV.C.4.(b) requires, “[t]he investigation of a Referral of Institutional Abuse or Neglect must include face-to-face contact with the alleged victim within twenty-four hours in at least 95% of investigations, with exceptions for good faith efforts approved by the Co-Monitors.” The Co-Monitors measure performance for both FSA IV.C.4.(a) and (b) using the same methodology and timeframes – the time between receipt of referral by OHAN and face-to-face contact with the alleged child victim must be within 24 hours.
The Co-Monitors approved the following efforts listed in Table 4 as “good faith efforts” for timely initiation which must be completed and documented, as applicable, for exceptions to contact with an alleged victim child(ren) within 24 hours:

same methodology and timeframes – the time between receipt of referral and face-to-face contact with alleged child(ren) victim must be within 24 hours. 76 A total of 43 reports were accepted in September 2017, however, three were found not to be applicable for this review because the alleged victim child was not a Class Member (i.e. the child was voluntarily placed by the legal guardian or through ICPC from another state) or, in one instance, the investigation involved a child fatality that was predicted, the result of severe and complicated congenital conditions.

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Table 4: Good Faith Efforts to Contact Alleged Victim Children within 24 Hours

 Investigator attempted to see child(ren) at school or  Investigator attempted to see child(ren) at therapist’s

child care facility

office

 Investigator attempted to see child(ren) at doctor’s  Investigator contacted the assigned foster care

visit or hospital

caseworker(s) and/or supervisor(s)

 For child(ren) moved to an out-of-state location in  Investigator attempted to contact the parent/guardian

order to receive specialized treatment, investigator

of the victim child(ren) if the child(ren) has returned

attempted to interview by Skype or other electronic

home

means

 Investigator attempted to contact the child at all

 Investigator attempted to see child(ren) at the police

foster care placements where the child may

department

temporarily be placed in the first 24 hours

 Investigator attempted to attend forensic/CAC

interview

Additionally, the following extraordinary circumstance exceptions to timely initiation (listed in Table 5) were also approved by the Co-Monitors:

Table 5: Extraordinary Circumstance Exceptions

to Contact with Alleged Victim Children within 24 Hours

 Child was returned to biological family prior to  Facility restrictions due to child’s medical

report and family refuses contact

requirements

 Child is deceased

 Natural disaster

 Law enforcement prohibited contact with child

 Child missing despite efforts to locate (efforts

should include all applicable good faith efforts

listed above)

Baseline data for this measure were based on review of 107 applicable investigations77 conducted between June and November 2016, that determined that either contact was made with the alleged victim child(ren) within 24 hours or all applicable good faith efforts to make contact were made and documented, in 78 percent of investigations. Table 6 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure:

77 Some investigations were found not to be applicable for review because the alleged victim child was not a Class Member (i.e. the child was voluntarily placed by the legal guardian or through ICPC from another state, or was the biological child of the caregiver).

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Table 6: Baseline, Timeline and Interim Benchmarks for Timely Initiation of Investigations

Baseline

June – November 2016

78%

Implementation Plan Timeline

Interim Benchmark

September 2017 March 2018
September 2018 March 2019
September 2019 March 2020
September 2020 March 2021 Final Target
Source: OHAN Implementation Plan

78% 80% 80% 85% 85% 90% 90% 95% 95%

Performance data for this period were collected during a case record review of investigations which were received and accepted in September 2017. Of the 40 applicable investigations, contact was made with the alleged victim child(ren) within 24 hours in 31 (77.5%) investigations and in one (2.5%) additional investigation, documentation supported completion of all applicable good faith efforts; total performance for September 2017 is 80 percent, which exceeds the September 2017 interim benchmark of 78 percent (see Figure 12).

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Figure 12: Timely Initiation of Investigations September 2017 N=40

Sept. 2017 Interim Benchmark – 78%

Source: January 2018 Case Record Review, USC CCFS and Co-Monitor staff
Although data for this measure are collected in CAPSS and monthly reports are provided to the Co-Monitors by DSS, the Co-Monitors have determined these data cannot currently be used for reporting for two reasons. First, the CAPSS report for this measure does not distinguish between investigations involving Class and Non-Class Members which is required for reporting performance. As previously mentioned, the case record review of September 2017 investigations determined that three of the 43 investigations did not involve Class Members and should be excluded from this measure for reporting. Second, data collected during the September 2017 investigation case record review determined that all alleged victim children were not seen within 24 hours in nine of the 40 investigations reviewed. However, CAPSS data reflect that four of those nine investigations were timely initiated, indicating that the worker incorrectly entered the data. The Co-Monitors will work with DSS to improve the accuracy and reliability of these data for future reporting.
Contact with Core Witnesses
The FSA requires, “[c]ontact with core witnesses must be made in at least 90% of the investigations of a Referral of Institutional Abuse or Neglect, with exceptions approved by the Co-Monitors” (FSA IV.C.4.(c)).

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A core witness is defined as an individual who is pertinent to the investigation because they witnessed or have knowledge of the alleged actions and can shed light on the allegations and the actions of the alleged perpetrators. Core witnesses may differ investigation to investigation, but in all cases include: reporter(s), alleged perpetrator(s), alleged child victim(s), child’s DSS caseworker, other child(ren) and/or adult(s) in the home and, when involved, law enforcement. If the allegations involve an institutional setting, all other adults and children relevant to the investigation are also considered core witnesses.78

Listed in Table 7 are exceptions, approved by the Co-Monitors, to the requirement that the investigator make contact with a core witness during an investigation. In all instances, the exception must be supported by documentation of the exception reason and best efforts to engage:

Table 7: Exceptions to Contact with Core Witnesses During Investigations

 Witness refused to cooperate

 Unable to locate or identify witness

 Witness advised by counsel or law enforcement  Medical conditions prevented witness from

that interview could not occur (e.g. pending

cooperating

charges, lawsuit)

 Witness is deceased

Baseline data for this measure assessed 107 applicable investigations conducted between June and November 2016 and determined that the investigator made contact with all necessary core witnesses for whom there was no approved exception in 29 (27%) investigations. Table 8 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure.

78 This definition of core witnesses was proposed in DSS’s OHAN Implementation Plan which was approved by the Co-Monitors and consented to by Plaintiffs.

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Table 8: Baseline, Timeline and Interim Benchmarks for Contact with All Necessary Core Witnesses during the Investigation

Baseline

June – November 2016

27%

Implementation Plan Timeline

Interim Benchmark

September 2017 March 2018
September 2018 March 2019
September 2019 March 2020
September 2020 March 2021 Final Target
Source: OHAN Implementation Plan

35% 40% 45% 55% 60% 70% 80% 90% 90%

Performance data for this period were collected during a case record review of investigations which were received and accepted in September 2017. None (0%) of the 40 applicable investigations reflected contact with all necessary core contacts during the investigation (see Figure 13). While OHAN performance has improved with respect to other measures (i.e., intake screening decisions and timely initiation), the lack of quality with respect to contact with core witnesses is of concern and is reflective of the high workload and under-resourcing of OHAN staff and unit.

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Figure 13: Contact with All Necessary Core Witnesses during Investigations September 2017 N=40
Sept. 2017 Interim Benchmark – 35%
Source: January 2018 Case Record Review, USC CCFS and Co-Monitor staff
The following data, presented in Table 9, reflects the frequency of OHAN investigator contact with each type of core witness in the 40 investigations reviewed.

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Core Witness

Table 9: Contact with Necessary Core Witnesses during Investigations by Type of Core Witness
September 2017 N=40
Number of Applicable Contact with All Contact with Some Investigations

Alleged Victim Child(ren)

40

40 (100%)

-

Reporter

3779

12 (32%)

-

Alleged Perpetrator(s)

40

23 (58%)

9 (23%)

Law Enforcement

10

3 (30%)

-

Alleged Victim Child(ren)’s

40

Caseworker(s)

Other Adults in Home or 22
Facility80

Other Children in Home or 31
Facility82

8 (20%) 7 (32%) 5 (16%)

3 (8%) 6 (27%) 3 (10%)

Additional Core Witnesses

1384

1 (8%)

2 (15%)

Source: January 2018 Case Record Review, USC CCFS and Co-Monitor staff *Totals may not equal 100% due to rounding

Contact with None
25 (68%) 8 (20%) 7 (70%) 29 (73%)
9 (41%)81
23 (74%)83 10 (77%)

The interview with the alleged victim child(ren) is one of the most vital components of any quality investigation. Of note, although reviewers determined that the investigator met with the alleged victim child(ren) in all 40 investigations, in two investigations documentation of the interview with the child was poor and insufficient to assess the allegations and child’s safety. Additionally, in nine investigations, the alleged victim child(ren) was not interviewed or observed apart from the alleged perpetrator as age and developmentally appropriate.

79 In two investigations, the reporter was anonymous and could not be interviewed by the investigator and in one investigation, the investigator was unable to locate the reporter despite efforts. 80 For investigations involving foster homes, in addition to speaking with the alleged perpetrator(s), the investigator should speak with all other adults in the household. For investigations involving institutions, the investigator should speak with all other adults who were involved in or who have knowledge of the allegations. 81 All investigations in which only some or none of the other adults were interviewed involved institutions. 82 For children who are placed in foster homes, in addition to speaking with all alleged victim children, the investigator should speak with all non-victim children in the home to inform the investigation, including other foster children and biological or adopted children in the home. For investigations involving institutions, as most facilities have many children placed there, investigators should speak with all other children who were involved in or who have knowledge of the allegations. 83 In the 23 investigations in which none of the other children in the home or facility were interviewed, seven involved foster homes and 16 involved institutions. 84 Additional core witnesses identified by reviewers in 13 investigations included guardian ad litems, daycare staff, staff who supervise parent-child visitation, therapists and caseworker supervisors.

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An alleged victim child’s DSS caseworker is also a key informant during investigations of abuse and/or neglect by a caretaker while in care. The caseworker has regular contact with the child, both in their placement and in the community, and should be frequently assessing the child’s safety and well-being throughout the month. For the 29 investigations in which the investigator did not interview the alleged victim child’s caseworker, there was documentation in 15 investigations that some form of contact with the caseworker had occurred, but there was not documentation that information sufficient to assess the allegations and the child’s safety had been shared.85
Case Decisions
At the conclusion of the investigation, a decision is made based upon the totality of the information collected, with the preponderance of the evidence as standard of proof of the facts.86 The allegations are either founded (indicated) or unfounded.
Section IV.C.3. of the FSA requires, “[a]t least 95% of decisions to ‘unfound’ investigations of a Referral of Institutional Abuse or Neglect must be based upon DSS ruling out abuse or neglect or DSS determining that an investigation did not produce a preponderance of evidence that a Class Member was abused or neglected.”
Baseline data for this measure was collected through an assessment of 94 investigations conducted between June and November 2016 in which a decision was made to unfound the allegations. Reviewers agreed that the case decision to unfound the investigation was appropriate in 44 (47%) of the 94 investigations. Table 10 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure:

85 Specifically, in seven investigations, there was email correspondence between the investigator and caseworker, however, the allegations and child’s safety were not sufficiently discussed – for example, an email exchange may have requested additional information and no response was received or the response did not pertain to the allegations and child’s safety and no follow up occurred or the email only pertained to verifying the child’s address. In five investigations, there was documentation referencing “consulting”, “notifying” or “sharing information” with the caseworker, however, the documentation did not specify when and how contact occurred and if there was sufficient information shared to assess the allegations and child’s safety. In three investigations, the investigator only reviewed the caseworker’s CAPSS dictation and did not make independent contact with the caseworker. 86 SC DSS Human Services Policy and Procedural Manual, Chapter 7-721. p. 3 (effective date 11/29/2012).

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Table 10: Baseline, Timeline and Interim Benchmarks for Appropriate Case Decisions during Investigations

Baseline

June – November 2016

47%

Implementation Plan Timeline

Interim Benchmark

September 2017 March 2018
September 2018 March 2019
September 2019 March 2020
September 2020 March 2021 Final Target
Source: OHAN Implementation Plan

48% 50% 55% 60% 65% 75% 85% 95% 95%

Performance data for this period were collected during the previously referenced case record review of investigations received and accepted in September 2017. Of the 40 applicable investigations, 38 investigations included a case decision to unfound the allegations. Reviewers agreed that the case decision to unfound the investigation was appropriate in 22 (58%) of the 38 investigations (see Figure 14). DSS’s September 2017 performance exceeds the interim benchmark of 48 percent.

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Figure 14: Decision to Unfound Investigations Deemed Appropriate September 2017 N=38

Sept. 2017 Interim Benchmark – 48%

Source: January 2018 Case Record Review, USC CCFS and Co-Monitor staff
For those investigations in which reviewers disagreed with the unfounded decision, in most (14 investigations) the investigator did not collect all information critical to make an accurate finding and in the remaining two investigations, all necessary information was collected, but the decision to unfound was not supported by the information.
Timely Completion
The FSA includes the following three measures for timely completion of investigations, recognizing that some investigations may take longer than 45 days as policy requires:
 “At least 60% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within forty-five (45) days of initiation of an investigation, unless the DSS Director or DSS Director’s designee authorizes an extension of no more than fifteen (15) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(d)).

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 “At least 80% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within sixty (60) days of initiation of the investigation, and all investigations not completed within sixty (60) days shall have authorization of the DSS Director or DSS Director’s designee of an extension of no more than thirty (30) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(e)).
 “At least 95% of all investigations of a Referral of Institutional Abuse or Neglect not completed within sixty (60) days shall be completed within ninety (90) days. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(f)).

The FSA and OHAN policy provide that the DSS Director or Director’s Designee may authorize an extension of up to 15 days for “good cause” or compelling reasons.87 Good cause means that, through no fault of the investigator, sufficient reason exists for delaying the case decision. Examples of good cause may be one of the following listed in Table 11:

Table 11: Examples of Good Cause Reasons to Extend Investigation Timeframes

 Awaiting critical collateral information (e.g. medical  Critical new information was received from witness

report, x-rays, toxicology, video)

that requires follow up

 Awaiting forensic interview/findings

 Awaiting action by law enforcement

 Awaiting critical information from another  Child has been too ill or traumatized to speak with

jurisdiction (e.g. central registry check)

investigator

Baseline performance collected during a prior review of investigations conducted between June and November 2016 determined timely closure within 45 days occurred in 95 percent of investigations and timely closure within 60 days occurred in 96 percent. Table 12 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure.

87 SC DSS Human Services Policy and Procedural Manual, Chapter 7-721. p. 12 (effective date 11/29/2012).

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Table 12: Baseline, Timeline and Interim Benchmarks for Timely Completion of Investigations

Baseline

June – November 2016

45 days – 95% 60 days – 96% 90 days – N/A

Implementation Plan Timeline

Interim Benchmark

September 2017 March 2018
September 2018 March 2019
September 2019 March 2020
September 2020 March 2021 Final Target
Source: OHAN Implementation Plan

45 days – 75% 60 days – 80% 90 days – 95% 45 days – 75% 60 days – 80% 90 days – 95% 45 days – 75% 60 days – 80% 90 days – 95% 45 days – 80% 60 days – 80% 90 days – 95% 45 days – 80% 60 days – 80% 90 days – 95% 45 days – 90% 60 days – 90% 90 days – 95% 45 days – 90% 60 days – 90% 90 days – 95% 45 days – 95% 60 days – 95% 90 days – 95%
95%

Of the 40 investigations received and initiated in September 2017, one investigation was excluded from the 45 day compliance measure.88 Of the remaining 39 investigations, 34 investigations were completed within 45 days, however, reviewers determined that three of these investigations were closed as unfounded prematurely in an effort to meet the 45 day requirement,

88 The extension was requested and granted as the investigator was awaiting information from law enforcement.

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which is not considered compliant under the FSA. Therefore, the review determined that 31 (79%) of the 39 applicable investigations were timely and appropriately closed within 45 days. Thirty-five investigations (one with an approved extension request and three without) were all closed within 60 days (this does not include those three investigations that were closed prematurely to meet required timeframes), resulting in performance of 88 percent (35 of 40) on timely completion within 60 days. The remaining two investigations were closed between 61 and 90 days, resulting in 93 percent performance for closure within 90 days. Current performance exceeds the interim benchmark level for both the 45 and 60 day requirement but not the 90 day requirement (see Figure 15).

Figure 15: Timely Completion of Investigations September 2017
N=39 within 45 days; N=40 within 60 days; N=40 within 90 days

FSA Final Target – 75%

FSA Final Target – 80%

FSA Final Target – 95%

Source: January 2018 Case Record Review, USC CCFS and Co-Monitor staff
Although data for this measure are collected in CAPSS and monthly reports are provided to the Co-Monitors by DSS, the logic within these reports does not reflect the requirements of the FSA measure so a case record review is required to collect data for reporting. Specifically, CAPSS data do not distinguish between investigations involving Class and Non-Class (i.e. the child was voluntarily placed by the legal guardian or through ICPC from another state) members which is required for reporting performance.89 Additionally, a case record review is required to determine if an investigation is closed prematurely to meet required timeframes.

89 The case record review of September 2017 investigations determined that three of the 43 investigations did not involve Class Members and should be excluded.

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VIII. PLACEMENTS

A. Placement Needs Assessment

The FSA requires that by February 1, 2017, with prior input from and subject to approval by the Co-Monitors, DSS perform a statewide and regional foster care Placement Needs Assessment “in order to determine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members...” (FSA IV.D.1.). The Needs Assessment must include “specific recommendations addressing all the assessment’s findings, including but not limited to recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that can meet their needs” (FSA IV.D.1.).

In January 2016, DSS began work with the Co-Monitors to develop an approved methodology for conducting the Placement Needs Assessment. On December 27, 2016, the Co-Monitors approved DSS’s methodology which identified USC CCFS as the entity to conduct the assessment. USC CCFS began the statewide Placement Needs Assessment in February 2017, with an original completion date of June 30, 2017. On June 30, 2017, DSS notified the CoMonitors that the assessment could not be completed and that a report would be submitted instead by August 31, 2017. DSS submitted a report with data and findings to the Co-Monitors on that date and in late September 2017, the Co-Monitors requested that additional work be completed on placement projections, including adding an assessment of county needs versus regional needs so as to understand what will be needed to place children close to their home community and avoid school changes. In December 2017, the Co-Monitors provided additional written feedback to DSS. DSS reports that county level data will be provided by March 31, 2018, as part of the updated Placement Implementation Plan.

Overall, the Placement Needs Assessment identified that extensive work is necessary to expand placements, community-based services and other resources that could stabilize placements and strengthen practices that promote permanency for children in foster care. At the same time, placement processes must be streamlined, with strategic sequencing of targeted and flexible approaches to create and sustain stable placement capacity. These approaches must be manageable for all involved, especially caseworkers and supervisors.

The Co-Monitors shared with DSS that it would be important to include relevant strategies in the Placement Implementation Plan to address several themes identified through the assessment, including:

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 There needs to be a major expansion of family foster care resources in every area of the state, including kinship placement. Children and youth need a caretaker(s) with the skills and willingness to provide care for older adolescents, large sibling groups and for children who have experienced the level of trauma, abuse and neglect reflected in the foster care population. More foster parents should be supported in understanding child development and how to manage developmentally appropriate behaviors.
 There is a need for foster parents who can support legal permanency for children and youth. Foster parents are needed who are willing to work with biological parents to assist them in reunifying with their children and, on the other end of the spectrum, foster parents who are dually licensed and willing to adopt when necessary.
 There are very serious consequences for children, families and the workforce that stem from the placement of so many children far from their homes and communities. The Placement Needs Assessment identified school disruptions; difficulties maintaining parent, sibling and community connections; and significant transportations issues among these consequences, as reported in focus groups, cases reviewed and interviews with caseworkers.
 The placement process needs improvement. The current process does not allow for a matching of children’s needs to the skills of foster parents. The Placement Needs Assessment identified that many placements were made based solely on bed availability.
 The current system seems to require children to change placements, often through a move from traditional to therapeutic foster care, to access more intensive services. Onethird of the children with multiple placements whose cases were reviewed for the Placement Needs Assessment, were age six or under, and almost half of the children reviewed had placement moves that were attributed to their behaviors. Also, the criteria for levels of placement are not clear. As the Placement Needs Assessment suggests, there needs to be a reevaluation of definitions of regular and therapeutic foster care and the development of concrete, understandable criteria.
 The placement process seems too remote from the local offices and may lack useful input from local staff about their in-county foster homes.
 Serious practice challenges are evident, including finding that there is no unifying vision of what foster care is aimed at achieving for children and families. Specific

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practice issues noted were related to: family and child engagement, family and child assessment, concurrent planning and permanency for older youth.
 There is a lack of mental health services for children in all levels of care. Mental health services were most commonly identified as a necessary support in the Placement Needs Assessment. Few children reviewed received follow-up mental health services after entering care and the lack of mental health services often led to preventable placement changes.
 Foster care providers are in need of more DSS support and a role in case planning activities for the children in their care.
 There are a range of placement data issues with respect to CAPSS that need to be addressed.
B. Placement Implementation Plan
The FSA requires that “[w]ithin sixty (60) days of the completion of the needs assessment, DSS shall develop an Implementation Plan to implement the recommendations of the needs assessment within eighteen (18) months. The Implementation Plan shall have enforceable benchmarks with specific timelines, subject to approval by the Co-Monitors, to measure progress in executing the recommendations of the needs assessment” (FSA IV.D.1.(a)).
As presented above, DSS completed the Placement Needs Assessment on August 31, 2017. A draft of the Placement Implementation Plan was shared with the Co-Monitors on October 31, 2017, but there is not yet an approved Placement Implementation Plan. The proposed Plan highlights seven strategies:
1. Develop a comprehensive foster care recruitment and retention strategy – expand kinship care program.
2. Provide additional support for foster parents through education, training, communication and services.
3. Develop a more robust system of in-home supports for foster care children.
4. Include youth and families in service and case planning, strengthen reunification planning and supports for families, and improve permanency planning.

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5. Streamline the process for assessing and documenting the needs of children, services provided, and placements.
6. Develop and implement a system of tracking availability of beds in family and therapeutic foster homes and group care providers.
7. Improve the placement process to ensure that caseworkers and youth are key partners in placement selection, processes are clear and well-coordinated and matching is based on the child’s strengths and needs.
A theme from the Placement Needs Assessment, related to these strategies, is the importance of building positive working relationships with children, youth and families on an ongoing basis, not just in planning meetings to address particular tasks. This core practice function serves as the foundation for effective assessment, planning and permanency, but is not addressed in the Placement Implementation Plan.
On December 6, 2017, the Co-Monitors met with DSS leadership and provided preliminary feedback on the proposed Placement Implementation Plan. This meeting followed visits to and conversations with leadership of psychiatric residential treatment facilities and group homes designated as Levels 1, 2 and 3, as well as a group interview with OHAN staff, as discussed earlier in this report. These meetings helped to support and inform the written feedback presented to DSS on December 20, 2017.
Overall, the Co-Monitors expressed concern about the lack of clarity and concrete strategies in DSS’s draft Placement Implementation Plan. Much of the Placement Implementation Plan reflects intentions to plan. For example, while there is clearly a need for restructuring the current “level of care” system – a process that will require deep work to understand current inadequacies and address a myriad of factors including child assessment processes, standards, payment structures, contracting, training and community supports and more – the Plan references only a general strategy to “streamline” the process for assessing the needs of children.
Even some of the very basic assumptions on which the Plan depend seem flawed. For example, in anticipating the number of placements, DSS assumes that an entire sibling group will be characterized as needing therapeutic foster care placement if one sibling needs such a placement. This is not the case and greatly affects the number of therapeutic beds projected by DSS. Additionally, in several areas, training is listed as something that will need to be addressed, without any more specific detail about how DSS anticipates that a transfer of learning will occur. Finally, many of the timeframes within the draft Plan are too ambitious, while others are too far out. Concurrent with the work to finalize an approved Placement Implementation Plan, there are a number of tasks that DSS should be aggressively moving forward, such as increasing

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recruitment of foster homes, improving the process in which foster parents apply and licenses are processed, streamlining processes for placement matching and decisions to improve efficiency, closely reviewing poor performing and inadequate or unsafe congregate care facilities and collaborating with private providers to make the reform successful. DSS has reported that it is in the process of reviewing the feedback the Co-Monitors provided, in consultation with USC CCFS, and that it anticipates sharing an updated draft Placement Implementation Plan at the end of March 2018.
C. Performance Data
Specific Placement Settings
Placement of Children in Congregate Care
When children cannot safely live with a parent, an alternative living arrangement with a relative or another caring adult that is stable, home and community-based, and appropriate to their needs is essential. The FSA has multiple requirements related to placing children in the most familylike, least restrictive environments and, where possible, with their siblings.
The FSA requires that at least 86 percent of Class Members be placed outside of congregate care placements on the last day of the reporting period (FSA IV.E.2.). DSS data show that as of September 30, 2017, 79 percent (3,225 of 4,079) of children in foster care were placed outside of a congregate care placement (to include residential treatment and emergency shelters) as indicated in Table 13.90, 91

90 Thirty-six children who were hospitalized (N=16) or in a correctional/DJJ facility (N=20) were removed from the universe for this measure. 91 DSS data reports do not indicate whether a child’s placement in custody is voluntary or involuntary. Although the Co-Monitors have worked with DSS to manually correct for this coding issue with respect to a number of measures, it is possible that, in some instances, such as here and other placement measures discussed throughout this section, a small number of Non-Class Members are included in aggregate data. The Co-Monitors hope to be able to fully distinguish between Class and Non-Class Members in the future, as DSS develops its data capacity in this area.

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Table 13: Types of Placements for Children as of September 30, 2017
Children in Foster Care

4,079 (100%)

Types of Placement for Children in Foster Care

Number of Children

Family-Based Setting

3,225 (79%)

Congregate Care, Emergency Shelter or Residential Treatment Facility

854 (21%)

Breakdown by Type of Group Care Facility

Congregate Care

770 (19%)

Emergency Shelter

15 (<1%)

Residential Treatment Facility Source: CAPSS Data Provided by DSS *Totals may not equal 100% due to rounding
Children Ages 12 and Under

69 (2%)

The FSA also includes placement standards specific to certain age groups of children, and requires that “[a]t least 98% of the Class Members twelve (12) years old and under shall be placed outside of Congregate Care Placements on the last day of the Reporting Period unless an exception pre-approved or approved afterwards by the Co-Monitors is documented in the Class Member’s case file” (FSA IV.E.3.).

DSS data in Table 14 indicate that as of September 30, 2017, 93 percent (2,655 of 2,866) of children ages 12 and under in foster care were residing in a family-based setting.

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Table 14: Types of Placements for Children Ages 12 and Under as of September 30, 2017
All Children in Foster Care Ages 12 and Under

2,866 (100%)

Types of Placement for Children Age 12 and Under in Foster Care

Number (Percentage) of Children

Family-Based Setting

2,655 (93%)

Congregate Care, Emergency Shelter or Residential Treatment Facility

211 (7%)

Breakdown of Type of Facility

Congregate Care

187 (7%)

Emergency Shelter

7 (<1%)

Residential Treatment Facility Source: CAPSS Data Provided by DSS *Totals may not equal 100% due to rounding
Children Ages Six and Under

17 (<1%)

The Interim Order, entered September 28, 2015, put provisions in place to immediately address the placement of children ages six and under in congregate care, requiring that by November 28, 2015, DSS “create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the Co-Monitors, the placement of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers)” (IO II.3.(a) & FSA IV.D.2.). The plan was to include “full implementation within sixty (60) days following approval of the Co-Monitors.”

On March 15, 2016, the Co-Monitors approved DSS’s plan, including acceptable exceptions (listed in Table 15), and DSS issued a directive outlining the procedure to be used by local and regional office staff to ensure the appropriate placement of children ages six and under in family placements. The procedure currently requires prior approval from the Deputy Director of Child

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Welfare Services before any child ages six or under can be placed within a non-family-based placement.
Table 15: Exceptions for Placement of Children Ages Six and Under in Non-Family-Based Placements
 The child requires a degree of clinical and/or medical support that can only be provided in a group care setting and cannot be provided in a family like setting, and the placement is a facility that has the capacity and specialized treatment to meet those needs.
 The child is the son or daughter of another child placed in a group care setting.  The child coming into care is in a sibling group of four or larger and all efforts to secure foster home and
Therapeutic Foster home placements have been completed and have not produced a home. In that instance, placement in a facility that can accommodate the sibling group together and maintain daily contact between siblings is an allowable exception. This exception is time-limited for up to 90 days and can be extended for time-limited increments after considering and documenting the best interests of the children and pursuing and documenting intensive efforts to identify and support an appropriate placement or placements.  The child comes into care and is placed in congregate care with his or/her biological parent who is not in DSS care but who is receiving treatment at a facility.92  Children who are voluntarily placed by their parent or caregiver are not subject to this requirement.
The Co-Monitors receive monthly data from DSS on all children ages six and under who were placed in congregate care during this monitoring period. These data include child-specific information regarding approved exceptions each month, with the reasons for the approval.
DSS’ efforts to reduce the number of young children in congregate care, placing them instead in family-based settings, have been very successful. As illustrated in Figure 16, DSS reported that each month during this monitoring period there were four children ages six and under in congregate care placement, except for April and June 2017, when, respectively, there were five and three young children in a congregate care placement. In total, there were reportedly nine Class Members ages six and under in a congregate care facility at some point during this monitoring period. The circumstances of five of the nine children met an agreed upon exception. 93 In two of the remaining four cases, the children were in a congregate care facility and the family court, when issuing the emergency removal (from the parents’) custody order, also ordered that the children remain where they were. The situations for the remaining two children did not reflect an agreed upon exception.

92 This exception was requested and approved by the Co-Monitors in May 2017 after the initial list of exceptions was approved. 93 The most frequent exceptions used are the child is residing with an adolescent parent in a program designed for teen mothers (for whom a family-based placement where they could be placed together could not be located) or the child is placed in congregate care with his or her/biological parent who is receiving treatment in a facility.

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Figure 16: Children Ages Six and Under in Congregate Care October 2016 - September 201794

Source: CAPSS Data Provided by DSS
Placement in DSS Offices and Hotels
The FSA requires that by November 28, 2015, “DSS shall cease using DSS offices as an overnight placement for Class Members, and shall cease placing or housing any Class Members in hotels, motels and other commercial non-foster care establishments. For any Class Members moved out of such DSS Offices or Hotels, DSS shall provide for their appropriate placement. In the extraordinary event that a child stays overnight in a DSS office, Defendants shall immediately notify the Co-Monitors, who shall provide a report to Parties as appropriate, including whether or not, in their view, the incident should be reported to the court as a violation which would preclude Defendants’ ability to achieve compliance on this provision” (FSA IV.D.3.).
Although DSS has sustained its efforts to avoid overnight stays in DSS offices and hotels during this monitoring period, the Co-Monitors were notified of two instances, involving three children, in which children stayed overnight at a DSS office in violation of this provision. DSS reports that in May 2017, two children spent the night in a DSS office while staff were seeking placement and in June 2017, another youth spent time in a DSS office overnight while transitioning from an acute visit to an emergency room. In both instances, documentation sent to the Co-Monitors and

94 Monthly totals are not discrete, one child may be represented across several months.
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reviewed in CAPSS outlined the circumstances that precipitated placement searches and how those situations were handled and resolved.
Although reports of children sleeping in DSS offices and hotels during this monitoring period is limited to these instances, the Co-Monitors are concerned about reports that children are being placed on an emergency, short-term basis in foster homes as a way of avoiding these overnight stays, cycling at times through a series of one night stays in foster homes until an appropriate placement can be located. The Co-Monitors will continue to review reports of overnight stays in DSS offices and hotels to better understand placement challenges across the state over time and will look closely at each instance to understand the circumstances and follow-up actions.
Emergency or Temporary Placements
The FSA requires that “Class Members shall not remain in any Emergency or Temporary Placement for more than thirty (30) days. Under exceptions approved by the Co-Monitors, if a child is initially placed in an Emergency or Temporary Placement that is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move…” (FSA IV.E.4.). Exceptions to this standard have not been approved by the Co-Monitors.
The FSA also requires that “Class Members experiencing more than one Emergency or Temporary Placement within twelve (12) months shall not remain in the Emergency or Temporary Placement for more than seven (7) days. Under exceptions subject to the CoMonitors’ approval, if a child’s subsequent placement within twelve (12) months in an Emergency or Temporary Placement is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move…” (FSA IV.E.5.).
DSS has been unable to provide data on the number of children in emergency and temporary placements and has not yet been able to determine if these placements are re-designated as longterm or therapeutic foster homes. DSS has indicated that creation of a code book of definitions describing each level of foster care is needed to collect accurate data for this measure and anticipates completion of this code book by December 1, 2019. Baseline data utilizing the methodology defined in the FSA are not available.

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Juvenile Justice Placements

The FSA, incorporating an Interim Order provision, requires “[w]hen Class Members are placed in juvenile justice detention or another Juvenile Justice Placement, DSS shall not recommend to the family court or Department of Juvenile Justice that a youth remain in a Juvenile Justice Placement without a juvenile justice charge pending or beyond the term of their pleas or adjudicated sentence for the reason that DSS does not have a foster care placement for the Class Member…” (FSA IV.H.1.).

DSS has acknowledged that there is no system in place for tracking youth moving between the juvenile justice and child welfare systems. After repeated requests by the Co-Monitors for a meeting with the South Carolina Department of Juvenile Justice (DJJ), a phone meeting was held with DJJ, DSS and the Co-Monitors in November 2017 during which these concerns were discussed. Although DJJ indicated during the call that information about the identities of dually involved youth might be captured in the Juvenile Justice Management System (JJMS) – its digital case database – it was not aware of any mechanisms for tracking circumstances in which youth may be put or held in juvenile justice detention or placement because of the unavailability of an appropriate DSS foster care placement. DSS has since reported that it has begun working with DJJ to develop processes to capture information related to dually-involved youth, and has shared with the Co-Monitors a recently executed Memorandum of Understanding (MOU) between the agencies that allows for basic information sharing. The MOU also provides for the designation of DSS liaisons in each county to help facilitate interagency case planning. DSS anticipates, however, that, in most counties, already overburdened county directors will serve in this role.

DSS has continued to represent that youth are immediately taken into the physical custody of DSS upon exit from juvenile justice placement in almost all instances, and reports no violations of the FSA provision during this monitoring period. In the absence of available data, the CoMonitors have connected with stakeholders throughout the state who work with DSS youth who are also engaged with DJJ. Many have described serious concerns about the lack of available placements for these youth, and the ways in which this impacts time spent in DJJ facilities. The Co-Monitors have received numerous recent reports of dually involved youth who have been maintained in DJJ placement after DSS represented that it could not find an appropriate placement, and many stakeholders describe attempts by DSS to transfer to DJJ responsibility for youth with significant behavioral needs or who require a higher level of care. 95 As a result, the Co-Monitors continue to have very serious concerns in this area and suspect that violations of the applicable FSA provision did, in fact, occur in this monitoring period.
95 Although some of these instances may constitute violations of the FSA, they occurred outside of the timeframe covered by this report and will therefore be considered for inclusion in the report for performance between October 2017 and March 2018.

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The lack of data tracking and what seems to be a lack of understanding by DSS and DJJ about the scope and root causes of the problems in this area are particularly problematic in light of the known inadequacies of DSS’s current placement array and processes. It is well understood that youth who are engaged in both the foster care and juvenile justice systems are often among the most difficult to place and support. In the absence of an infrastructure for readily identifying these youth, and purposeful steps to improve outcomes, the prospects of a smooth transition from DJJ placement to a DSS foster care placement capable of meeting youth’s underlying needs become even dimmer.
Placement Stability
The FSA requires that for all Class Members in foster care for eight days or more during the 12 month period, placement instability shall be less than or equal to 3.37 (IV.F.1.). Placement instability is defined as the rate of placement moves per 1,000 days of foster care among Class Members (FSA II.O.) and placement moves are changes in foster care placements.
DSS utilized an external data consultant to complete analysis for this measure. DSS is planning to build capacity within DSS for future reporting. The Co-Monitors have had several conversations with DSS staff, their external data consultant and members of the external data audit team to discuss the source and coding of the underlying data for this analysis. Some potential issues have been identified, including foster care and congregate care providers with multiple provider IDs and addresses and timely data entry, which may impact the accuracy of this analysis. These issues are being explored further over the next monitoring period and will be discussed in the next progress report.
Nonetheless, utilizing the data currently available, for the period October 1, 2016 to September 30, 2017, children meeting the criteria for this measure experienced instability at a rate of 3.55, above the rate required by the FSA.96, 97

96 Specifically, there were a total of 5,186 moves and 1,459,138 total applicable days. 97 It should be noted that performance based on the FSA placement instability measure is not comparable to performance with respect to the Round 3 Child and Family Services Review (CFSR) permanency outcome that measures stability of foster care placement. The CFSR outcome is based on the rate of placement per day of all children who enter foster care in a 12-month period, which is likely to be significantly higher than the rate of placement for all children in foster care during that period of time. See Data Indicators for the Child and Family Services Review, available at https://www.acf.hhs.gov/sites/default/files/cb/data_indicators.pdf.

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Sibling Placement

When children enter foster care, unless there are prohibitive reasons related to a child’s safety or well-being, they should be placed with their siblings. Recognizing the importance of maintaining sibling connections, the FSA requires at least 80 percent of children who enter care with or within 30 days of their siblings to be placed with their siblings (FSA.IV.G.2. & 3.). The FSA allows for exceptions to this requirement, including when there is a court order prohibiting such placement or if the placement is determined not to be in the best interest of one or more siblings. Additional exceptions to this standard can be identified and approved by the Co-Monitors as an element of the Placement Implementation Plan, yet to be approved. The FSA sets two targets – one for placement with at least one of a child’s siblings and the other for placement with all siblings. Interim benchmarks and timelines were proposed in the Placement Implementation Plan and have not been approved by the Co-Monitors.

DSS provided data for 1,288 children who entered placement between April and September 2017 who had a sibling who entered placement with or within 30 days of their entry.98 As of September 30, 2017, 754 of those 1,288 children were still in placement. For this cohort of children, as reflected in Table 16, 41 percent (310 of 754) of children were placed with all of their siblings and 64 percent (484 of 754) of children were placed with at least one of their siblings as of September 30, 2017.

Table 16: Sibling Placements for Children Entering Placement between April and September 2017 as of September 30, 2017 N=754

Sibling Placement Status

Number

FSA Final Target

Total Number of Children Entering

Placement from April 1 to September 30, 2017 Who Have a Sibling Entering

754

--

Placement With or Within 30 Days

Children placed with All Siblings

310 (41%)

80%

Children placed with At Least One Sibling

484 (64%)

85%

Children Not Placed With Any Sibling

270 (36%)

--

Source: CAPSS Data Provided by DSS

98 Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier.

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IX. FAMILY VISITATION

Frequent and regular visits between children in foster care and their families are essential to maintaining family connections for children removed from their homes. The FSA includes measures specific to visits between children in foster care and their siblings and, where there is a goal of reunification, with the parent(s) with whom reunification is sought. In the last monitoring period, the Co-Monitors were unable to measure visits between children and their parents due to data issues, but were able to provide baseline data with respect to sibling visits. A second review this monitoring period reflects improved DSS performance in this area. As discussed in more detail in this section, the Co-Monitors were also able to assess baseline performance with respect to visitation between parents and children this monitoring period, finding that this is an area requiring significant work as the vast majority of children in DSS custody with a reunification goal did not visit with the parent(s) with whom reunification was sought.

A. Visitation Implementation Plan

The FSA requires “[w]ithin 60 days of the entry of the Order approving the Settlement Agreement, Defendants shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent” (FSA IV.J.1.).

As reported in the prior monitoring period, DSS convened staff in a Visitation Workgroup in October 2016 to assess systemic barriers to family visitation and develop and assist with the implementation of the Visitation Implementation Plan. DSS submitted a draft of the Visitation Implementation Plan on November 30, 2016, and upon receipt of feedback from the CoMonitors and Plaintiffs, has completed several rounds of revisions and modifications. The Implementation Plan for visitation has not yet been approved by the Co-Monitors because data required to set all interim benchmarks and final targets have only recently become available.

B. Performance Data

Sibling Visits

Section IV.J.2 of the FSA requires, “[a]t least 85% of the total minimum number of monthly sibling visits for all sibling visits shall be completed.” The FSA also allows for exceptions if

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there is a court order prohibiting or limiting visitation, if “visits are not in the best interest of one or more of the siblings and the facts supporting the determination are documented in the case file,” or with exceptions approved by the Co-Monitors (FSA IV.J.2.). The Co-Monitors have approved the appropriate exceptions to sibling visits as listed in Table 17:
Table 17: Exceptions to Sibling Visitation Requirement
 Court order prohibits or limits sibling visitation.  Child or sibling is on runaway during a calendar month with best efforts to locate.  Child or sibling is incarcerated or in a facility that does not allow visitation despite efforts.  Child or sibling refuses to participate in the visit where age appropriate.  Sibling visit is infeasible due to geographic distance with efforts to provide alternative forms of contact.
Geographic distance will only be allowed as an exception upon individual review of the applicable case by the Co-Monitors.  County Director approval with legal consultation for determination that a visit poses immediate safety concerns for the child or sibling. If an immediate safety incident or concern occurs prior to or during a visit, the caseworker is to remove the child from the visit and notify the County Director afterward.
 Supervisory approval for determination that visitation would be psychologically harmful to the child.99
Although documentation of sibling visits is expected to be entered by caseworkers into CAPSS, the fields that capture this information were recently built and have not yet been used to extract aggregate data or in management reporting. In order to assess changes in performance for this measure, in January 2018, USC CCFS and Co-Monitor staff utilized the instrument developed in the previous monitoring period to collect data on the occurrence of visits between siblings in foster care. Reviewers looked at a sample of 310 cases for which sibling visits were required in September 2017.100 Reviewers determined that 178 children had visited with all of their siblings during the month and that there were 15 cases to which a valid exception applied,101 resulting in performance of 60 percent (see Figure 17). Of the 117 children who did not visit with all of their siblings, eight children visited with at least one of their siblings. Although below the FSA performance target, performance has improved since March 2017, when 47 percent of children visited with all of their siblings.

99 A DSS supervisor must confirm the determination that visitation would be psychologically harmful to the child based upon written documentation of a clinical decision issued by a Licensed Practitioner of the Healing Arts (LPHA) within the scope of their practice under SC State Law and who is not an employee of DSS. The LPHA’s name, professional title, signature and date must be listed on the document to confirm the clinical decision. 100 As of September 30, 2017, there were 1,587 children who had been in foster care for at least one month, with siblings in foster care with whom they were not placed. A statistically valid random sample of 310 cases was pulled based on a 95% confidence level and +/- 5% margin of error. Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier. 101 Three cases were excluded because the child’s adolescent sibling refused visitation; one case was excluded based on documentation that sibling visitation would be psychologically harmful to the child or sibling; one case was excluded because visitation was prohibited by court order; five cases were excluded because the child or sibling were residing in a medical facility in which visitation was not possible; four cases were excluded because the child or sibling was on runaway status; and one case was excluded because visits were infeasible due to geographic distance.

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Figure 17: Children Who Visited With All Siblings September 2017 N=295

Interim Benchmark – 85%

Source: January 2018 Case Record Review, USC CCFS and Co-Monitor staff
Data collected during the case record review referenced above reflect the percentage of children who had visits with all their siblings in the month under review. In an effort to align data collection and analysis methodology with the specific FSA definitions for this measure, performance was also calculated as a percentage of all required visits that occurred in the month reviewed. Reviewers determined that 310 of 472 required visits102 between children and the siblings with whom they were not placed occurred in September 2017, resulting in performance of 66 percent (see Figure 18).103 This is an improvement in performance over the last monitoring period, when 55 percent of required visits between children and siblings occurred.

102 Data reflect the exclusion of 18 visits for which it was determined that a valid exception applied for one of the reasons discussed above. See, supra., fn 101. 103 Because the universe of applicable visits is substantially greater than the universe of applicable children, and the data sample identified for review was calculated based on the number of applicable children, these performance data do not have the same level of statistical validity as the data discussed earlier. The Co-Monitors will work with DSS and USC CCFS in the next monitoring period to determine whether a sample pull based on applicable visits is possible.

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Figure 18: Visits that Occurred between Siblings September 2017 N=472

Interim Benchmark – 85%

Source: January 2018 Case Record Review, USC CCFS and Co-Monitor staff
Parent Visits
The FSA requires, “[a]t least 85% of Class Members with the goal of reunification will have inperson visitation twice each month with the parent(s) with whom reunification is sought…” (FSA IV.J.3.). The FSA also allows for exceptions if there is a court order prohibiting or limiting visitation or with exceptions approved by the Co-Monitors listed in Table 18.

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Table 18: Exceptions to Parent and Child Visitation Requirement
 Court order prohibits or limits parent visitation.  Parent is missing or child is on runaway during a calendar month with best efforts to locate.  Parent or child is incarcerated or in a facility that does not allow visitation in the calendar month despite best
efforts.  Parent refused to participate.  Parent did not show up to visit despite attempts to successfully arrange and conduct the visit.  Parental rights were terminated in that month.  Parent visit is infeasible due to geographic distance, with efforts to provide alternative forms of contact.
Geographic distance will only be allowed as an exception upon individual review of the applicable case by the Co-Monitors.  County Director approval with legal consultation for determination that a visit poses immediate safety concerns for the child. In addition, if an immediate safety incident or concern occurs prior to or during a visit, the caseworker is to remove the child from the visit and notify the county director afterward.
 Supervisory approval for determination that visitation would be psychologically harmful to the child.104
Due to the Co-Monitors’ concerns about the accuracy of permanency goals in CAPSS (discussed in the last monitoring report), the Co-Monitors were unable to assess baseline performance for this measure in the prior reporting period. In August 2017, DSS issued a directive to county offices regarding updated processes for capturing children’s current permanency goals in CAPSS, and between September and December 2017 it tracked case-level edits to relevant CAPSS fields and reviewed a sample of cases for accuracy of data input. Although DSS has identified that there continue to be challenges with the accuracy of these data, Co-Monitor staff worked with USC CCFS to undertake a baseline record review with the understanding that there may still have been children in the sample for whom parent visits were deemed to be expected whose permanency goal may have changed from reunification. That is, in some instances, children who did not have visits with their parent(s) may actually have not done so because their permanency goal had changed from reunification to adoption or guardianship, for example, without a timely update to the goal in the relevant CAPSS field.
In January 2018, USC CCFS and Co-Monitor staff utilized a structured instrument to collect data on the occurrence of visits between children in foster care and their parents with whom reunification is sought. By policy and in accordance with the FSA, children are expected to visit with their parents at least twice per month. In order to assess performance, reviewers looked at a sample of 326 cases for which visits with parents were required in November 2017.105, 106

104 A DSS supervisor must confirm the determination that visitation would be psychologically harmful to the child based upon written documentation of clinical decision issued by a Licensed Practitioner of the Healing Arts (LPHA) within the scope of their practice under SC State Law and who is not an employee of DSS. The LPHA’s name, professional title, signature and date must be listed on the document to confirm the clinical decision. 105 As of November 30, 2017, there were 2,124 children who had been in foster care for at least one month with a goal of “return to home,” or “not yet established.” A statistically valid random sample of 326 cases was pulled based on a 95% confidence level and +/- 5% margin of error.

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Performance was very poor. Reviewers determined that only 39 of the 326 children visited twice during the month with all parent(s) with whom reunification was sought and that there were seven cases to which a valid exception applied,107 resulting in performance of 12 percent, as shown in Figure 19. Almost half, 142 (45%) of the applicable children had no contact at all with any parent in the month of November.
Figure 19: Children with Twice Monthly Visits with their Parents November 2017 N=319
12%
88% Children who had two visits with all parents with whom reunification was sought Children who did not have two visits with all parents with whom reunification was sought Source: January 2018 Case Record Review, USC CCFS and Co-Monitor staff

106 Although outside of this monitoring period, November 2017 data were selected for review to allow time for data clean-up efforts to occur. 107 One case was excluded because visitation was prohibited by a court order; two cases were excluded because the parent was missing; two cases were excluded because the parent resided in a facility in which visitation was not possible; and one case was
excluded because the parent refused visitation despite efforts by the caseworker.

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X. HEALTH CARE
The provision of health care services to children in foster care is a fundamental obligation of child welfare systems. The ability to meet this obligation depends upon not only timely access to and follow up with high quality health care providers, but the capacity to reliably track the delivery of initial and ongoing care to children. Though DSS has made significant efforts to update case level health information so that the needs of children in foster care can be appropriately addressed, it has struggled with a plan for broader reform in this area. With the support of both DSS and Plaintiffs, the Co-Monitors engaged external health care consultants this monitoring period in hopes of moving this essential work forward with clear direction and at a faster pace. As of this report, this has been a helpful strategy. DSS has demonstrated a commitment to working closely with the Co-Monitors’ consultants, and their engagement has brought new knowledge, capacity and momentum to DSS’s work in this area.
A. Health Care Improvement Plan
The FSA requires that by April 3, 2017, DSS, “with prior input and subject to approval by the Co-Monitors, shall develop a Health Care Improvement Plan with enforceable dates and targets for phased implementation concerning initial screening services, periodic screening services, documentation, and health care treatment services for Class Members in the areas of physical health, immunizations and laboratory tests, mental health, developmental and behavioral health, vision and hearing, and dental health. The Plan shall address:
(a) Developing the capacity to track screening and treatment services for individual children and aggregate tracking data, including but not limited to screens that are due and past due;
(b) Assessing the accessibility of health care screening and treatment services throughout the State, including the capacity of the existing health care providers to meet the screening and treatment needs of Class Members; and
(c) Identifying baselines and interim percentage targets for performance improvement in coordinating screens and treatment services” (FSA IV.K.1.(a-c)).
After receiving an extension for preparation of its Health Care Improvement Plan (pursuant to the FSA), DSS submitted a draft Plan to the Co-Monitors on September 29, 2017. The draft Plan describes work that DSS has undertaken – both over the past several years and more recently – to improve access to and the quality of health care for the children and youth in its care. This includes steps to develop an improved capacity to track health care delivery in CAPSS; infrastructure development through partnership with a Managed Care Organization (MCO); the appointment of a part-time child and adolescent psychiatrist for DSS; planning for a new DSS Office of Health and Wellbeing; and the reconvening of the Foster Care Advisory Committee, a

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cross-agency and provider workgroup, to address issues related to the provision of health and mental health services to children in foster care statewide.
Though DSS set out a general vision for the delivery of health, mental health and dental care to children in foster care in its draft Health Care Improvement Plan, it was lacking specifics and was more a “plan to plan.” The Co-Monitors strongly believe that the success of the Plan will ultimately depend upon DSS’s ability to operationalize it. This will require the development of detailed timeframes, determinations regarding MCO capacity, changes to policy and practice and training of staff at all levels – including foster care, IFCCS and group home staff – as well as of foster parents and providers. It will also require that payment rates and funding structures be reexamined and that data systems and worker capacity be developed to accurately capture realtime data.
In light of these complexities and given the importance of this work, in November 2017, the CoMonitors engaged consultants with specific expertise in child welfare health care reform (Kathleen Noonan and Gail Nayowith) to assess the sufficiency of DSS’s Health Care Improvement Plan, pursuant to FSA IV.K.3. The consultants’ recommendations, based on the results of validation activities and extensive interviews with key DSS, DMH, DHHS (Department of Health and Human Services), MCO and community provider staff, were submitted in a Findings and Recommendations Report on February 12, 2018 (Appendix C). In the Findings and Recommendation Report, the consultants concluded that DSS’s Health Care Implementation Plan includes important conceptual and structural elements on which to build a robust health care system for children in foster care, but that it does not yet include the operational framework needed for implementation. The consultants requested that DSS develop a revised plan that includes implementation timeframes, task leads and staffing and needed resources, including a multi-year budget. They also identified five other priority action items, which they recommended DSS undertake right away. These included:
 Identify an Interim Director of the DSS Office of Health and Wellbeing: The consultants suggested that DSS prioritize hiring a permanent candidate to oversee this new office and that it draw on internal staff at partner agencies to fill the role temporarily.
 Identify and Convene a SWAT Team: The consultants suggested that DSS should quickly name a cross-agency leadership team with management authority that can meet weekly to develop a work plan and monitor Plan implementation, troubleshoot issues and provide bi-weekly progress reports to DSS and DHHS leadership, and monthly reports to the CoMonitors.

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 Obtain Gap-in-Care Reports from DHHS and its MCO: The consultants recommended that DSS immediately work with DHHS, its MCO (Select Health), and other relevant state agencies to develop a data sharing agreement that will allow DSS to access all data necessary to monitor the health care needs of the children in its care. In the interim, the consultants recommended that DSS obtain gap-in-care reports that identify children in foster care who have not received required screenings, assessments and follow up, and that the newly convened SWAT team utilize this information to monitor the procurement of this care for children who need it. They also recommended that DSS develop a protocol for notifying caseworkers about children who are missing required screening, assessment or follow up.

 Initiate Short-Term Data Workaround to Mitigate the 30-day Enrollment Gap: The consultants directed DSS to develop and implement a data workaround until DSS can create a structural solution to the 30-day enrollment lag for enrollment in the MCO, Select Health (See Appendix C).

DSS welcomed the analysis and report of the consultants and is now working closely with them to make recommended changes to their Plan and expects to submit an updated version to the CoMonitors by April 13, 2018. They are also utilizing the consultants to guide some early actions necessary to full implementation. The Co-Monitors believe that continued engagement of the consultants will be particularly important over the next year, as DSS works to implement its Plan and believes that DSS will welcome this help. The consultants will also assist the Co-Monitors in identifying all final health care outcome measures related to initial screening services, periodic screening services, documentation, treatment and other corrective services, as per Section IV.K.5 of the FSA.

In addition to the Health Care Improvement Plan requirement, the FSA includes two compliance measures to address unmet health care needs of children currently in care with deadlines set shortly after initial entry into the Agreement (FSA IV.K.4.(a)&(b)), both of which are discussed below.

B. Performance Data

Initial Health Assessments

The FSA required that by December 5, 2016, DSS “identify Class Members who have been in DSS custody for more than sixty (60) days as of the date of final court approval of the Final Settlement Agreement, and who have not had initial health assessments (physical/medical, dental or mental health). Within thirty (30) days after the identification period, Defendants shall

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schedule the initial health assessment for at least 85% of the identified Class Members” (FSA IV.K.4.(a)).
In the prior reporting period, the Co-Monitors reported data on children who had been in DSS custody for more than 60 days on October 4, 2016, who had not yet received initial health/medical, dental or mental health screenings entered into CAPSS. Because DSS acknowledged that the data provided were not fully accurate, the Co-Monitors worked with DSS and USC CCFS to clean-up and validate the data. In the end, the data analysis produced concerning results, and both DSS and the Co-Monitors identified actions to meet the health care needs of children in foster care as an area of high priority.

In the months since the rollout of its electronic Education and Health Passport in the last reporting period, DSS has continued to engage with the Co-Monitors about the implementation of these changes, and has made ongoing efforts to improve the reliability of its health care data. Nevertheless, the Co-Monitors have ongoing concerns about the accuracy of health care data captured in both CAPSS and paper files. As part of their review, the health care consultants retained by the Co-Monitors evaluated DSS’s systems for the collection of data relevant to this measure and concluded that the data are unlikely to be accurate. The consultants made a number of recommendations to DSS in its Findings and Recommendations Report (Appendix C), including immediate steps it believes DSS should take to access health care data already collected by DHHS, and Select Health, the MCO that manages the health care of all children in foster care in South Carolina. DSS quickly began to follow up on these recommendations and has received an initial data production from DHHS, which captures some basic screening and assessment data for all children who were in foster care in CY2017. The consultants are working with DSS to analyze these data and to determine how this type of reporting can be used to identify children with unmet immediate health care needs and to measure progress in this area going forward.

Immediate Treatment Needs
The FSA requires that by January 2, 2017, DSS “identify Class Members with Immediate Treatment Needs (physical/medical, dental or mental health) for which treatment is overdue. Within forty-five (45) days of the identification period, DSS shall schedule the necessary treatment for at least 90% of the identified Class Members. (Immediate Treatment Needs means immediate non-elective physical/medical, dental or mental health treatment needs and documented assessment needs, excluding routine periodic assessments.)” (FSA IV.K.4.(b)).

Since the last reporting period, DSS’s Healthcare Workgroup has spent significant time working to define “immediate treatment needs” and make CAPSS enhancements in an effort to build

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capacity to capture and collect data necessary to track the provision of follow-up care to children in DSS custody. In November 2017, DSS issued a directive memo communicating the definition and importance of “immediate treatment needs” to county administrators, and requiring that all relevant medical information be entered into CAPSS by December 15, 2017. DSS reports that this process has had the benefit of focusing leadership and caseworkers on the importance of monitoring children’s need for follow up health care, but does not yet have confidence in the reliability of the data it has produced.
In its Findings and Recommendation Report (Appendix C), the Co-Monitors’ health care consultants concluded that, as with data related to initial screens and assessments, the process DSS has developed for tracking immediate treatment needs data is very burdensome for workers and is not likely to produce robust, reliable data. The consultants have made recommendations for the use of data already collected by DHHS and Select Health to identify and track progress with respect to immediate treatment needs. DSS is in the process of integrating this feedback into its Healthcare Improvement Plan, and the Co-Monitors and consultants will closely monitor progress.
XI. BUDGET
Reforming a foster care system with more than 4,000 children in care is not an easy task, especially if that system has been under-resourced for many years, as is true in South Carolina, and it certainly cannot be done without a significant influx of resources. The Co-Monitors have consistently discussed with DSS the need for it to muster the funding and internal capacity that will be needed to intensively drive reform of a magnitude sufficient to meet the requirements of the FSA. Throughout the Implementation Plan review process, the Co-Monitors requested that DSS provide more detailed information with respect to its plan for requesting and utilizing resources over the coming years. In the November 14, 2017 status hearing, Judge Gergel asked DSS to include in this monitoring report a specific, overarching budget that sets out the anticipated cost of the comprehensive reform called for by the FSA. DSS has not yet produced this information to the Co-Monitors, but has reported that it is in the process of compiling relevant data.
Based on a review of materials presented by Director Alford in her testimony to the House Ways and Means Healthcare Subcommittee on January 24, 2018, DSS has requested a total FY2019 budget of $20,281,214 to meet requirements that have come out of both the FSA and South Carolina’s recent federal Child and Family Services Review (CFSR). The majority ($16,934,820) of this funding will be utilized to hire additional caseworkers (186), supervisors (37), trainers (6) and quality assurance (QA) staff (5); some ($1,238,064) will be used for

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updates to DSS’s data reporting system and make necessary modifications to CAPSS; and some ($508,330) will be dedicated to additional training, coaching, mentoring, and QA. Without information that puts these requests in the context of a multi-year budget plan – accounting also for the status of hiring of the 163 workers that were approved in the FY2018 budget – it is impossible to assess the adequacy of the requests vis-à-vis a broader reform effort. Further, when viewed without the benefit of a detailed budget plan, it is not possible to know the extent to which DSS has appropriately accounted for the myriad of factors (and expenditures) that underlie its requests. For example, the question of whether DSS will have the resources needed to meet caseload standards within four years (as it has represented it plans to do), requires a close assessment of costs related to training, office space, technology and infrastructure, and supports to retain these workers, including a boost in salaries, as well as consideration of how these expenditures will be offset by vacancies and turnover.

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APPENDIX A
Glossary of Acronyms
APS: Adult Protective Services CAPSS: Child and Adult Protective Services System CFSR: Child and Family Services Review CQI: Continuous Quality Improvement DHHS: Department of Health and Human Services DJJ: Department of Juvenile Justice DMH: Department of Mental Health DSS: Department of Social Services FSA: Final Settlement Agreement GAL: Guardian ad litem ICPC: Interstate Compact on the Placement of Children IFCCS: Intensive Foster Care and Clinical Services IO: Interim Order JJMS: Juvenile Justice Management System MCO: Managed Care Organization MOU: Memorandum of Understanding OHAN: Out-of-Home Abuse and Neglect Unit QA: Quality Assurance SC: South Carolina TFC: Therapeutic Foster Care USC CCFS: University of Southern Carolina’s Center for Child and Family Studies

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Appendix B – OHAN Implementation Plan Strategy Updates

Strategies towards Achieving Targets:

The Department identified a number of strategies to achieving the OHAN targets:

DSS Proposed Strategies to Achieve Targets

DSS Reported Timeline

Resources Identified as Needed in Plan

Intake and Investigations

DSS Implementation Update as of September 30, 2017

a. Institute investigative worker office day for Complete by September

case management activities

2017

Plan identified that action could be completed with existing internal resources

DSS has not implemented this strategy and has indicated that it cannot be implemented with the current number of workers on the unit. No new target completion date has been set.

b. Develop a user-friendly report to track and monitor face-to-face contact and case initiation within 24 hours

To be determined after Data Workgroup prioritizes CAPSS and data work (See Core Foundational and Capacity Building Section Above – 3.b). Some development has already occurred.

Plan identified that action could be completed with existing internal resources

DSS has not implemented this strategy. OHAN staff and management continue to use existing reports that track initial contact with children.

c. Revise the intake referral sheet to gather updated placement and caseworker information

Complete by March 2017

Plan identified that action could be completed with existing internal resources

The intake referral sheet has been updated. Co-Monitor staff have found that data input by workers is inconsistent.

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DSS Proposed Strategies to Achieve Targets
d. Revise existing checklist to expand core witness list

DSS Reported Timeline

Resources Identified as Needed in Plan

Complete by April 2017

Plan identified that action could be completed with existing internal resources

DSS Implementation Update as of September 30, 2017
There have been revisions to the list of core witnesses on OHAN forms. Co-Monitor staff have found that workers and supervisors use this list inconsistently.

e. Develop tracking system for documenting core witness contacts and provide additional guidance and training to caseworkers on identifying core witnesses

Complete by December 2017

Plan identified that action could be completed with existing internal resources

DSS reports that this strategy is partially completed. The OHAN workgroup identified CAPSS updates needed to track contact with core witnesses, however, these updates have not been made. DSS has not provided an update on provision of additional guidance and training to caseworkers on identifying core witnesses.

f. Research and adopt a screening and assessment tool to help guide decision making for OHAN intake

Complete by May 2017

Plan identified that action could be completed with existing internal resources

This strategy has been partially implemented. In April 2017, OHAN began using an Intake and Investigative Safety Factors tool which provides guidance on situations that present safety and risk to a child in care to guide decisions to be accept referrals for investigation. For example, severe physical abuse, physical living conditions that are hazardous and present a situation of present or impending danger, or situations in which a child is fearful of being harmed by people living in or frequenting the home all support the acceptance of a referral for investigation.
This tool was developed as a place holder until a more structured Risk and Safety Assessment tool is developed for use with both CPS and OHAN. DSS anticipated completion of the new tool in 2017.

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DSS Proposed Strategies to Achieve Targets

DSS Reported Timeline

Resources Identified as Needed in Plan

g. Develop and conduct specialized OHAN training to include findings from OHAN baseline reviews (including clarifying practice standards around “collateral” contact prior to making a hotline decision), CAPSS documentation training, interview and investigative techniques, restraint training, assessing for safety and risk, and critical decision making

OHAN basic intake training to occur for existing workers and supervisors beginning September 2017. OHAN basic investigative training to occur for existing workers and supervisors by December 2017. All new workers and supervisors will be required to complete training going forward

Plan identified that action could be completed with existing internal resources and USC Training Staff

DSS Implementation Update as of September 30, 2017
This strategy is partially complete. An intake training curriculum was developed by USC and trainings were conducted between September and November 2017.
DSS reports that the investigation training curriculum has not yet been developed, and a revised timeline is not available.

h. Develop a Provider History report in CAPSS to provide an easy to access and consistent history on providers for use by OHAN workers, supervisors, and reviewers
- Preliminary report is currently being tested - Once finalized, report will be automated in
CAPSS. - OHAN intake Workers will be trained to
access, read, and summarize the previous allegations for the past 2 years and consider the previous history as a factor in determining preponderance of evidence for case

Work has begun. Preliminary report has been created and is being pretested with staff, supervisors, and reviewers. Based on feedback, report will be finalized and automated in CAPSS. Until automation, adhoc reports will continue to be extracted. Work complete by September 2017.

Plan identified that action could be completed with existing internal resources

DSS reports a provider history report has been developed and was incorporated into standard practice in September 2017. The Co-Monitors are concerned that due to instances in which providers may have multiple provider IDs within CAPSS, these reports may not always be accurate.

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DSS Proposed Strategies to Achieve Targets

DSS Reported Timeline

Resources Identified as Needed in Plan

i. Develop a coordinated process with Licensing that may include the following:
- Create a new policy to establish clear guidelines for revocation of foster home and facility licenses for multiple allegations of policy violations that do not constitute abuse or neglect but that are detrimental to child well-being

Development of policies to be completed by July 2017. Implementation of policies and training of existing staff on new policies completed by November 2017 by Licensing and OHAN

Plan identified that action could be completed with existing internal resources

DSS Implementation Update as of September 30, 2017
DSS reports a draft policy has been developed by the OHAN Workgroup. This policy has not been finalized.

a. Determine ways to increase guided supervision staffing, critical thinking, monitoring-accountability system by supervisor

Supervisor Review

- Revise the Guided Supervision Tool to be Complete by May 2017 specific to OHAN performance measures and for case reviews and system for utilization in practice. After implementation, this tool will be used at every supervisory review to guide the critical thinking of staff in investigatory work.

Plan identified that action could be completed with existing internal resources

This strategy has been partially implemented. DSS reports the Guided Supervision Tool was finalized in May 2017 and is only in partial use as supervisors have insufficient time to work with investigators.

- Train OHAN Supervisors on use of the Guided Supervision tool (See above for additional training of supervisors on information from OHAN baseline reviews)

Complete by June 2017

Plan identified that action could be completed with existing internal resources

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DSS reports OHAN supervisors were trained on the Guided Supervision Tool in the summer of 2017.
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DSS Proposed Strategies to Achieve Targets

DSS Reported Timeline

- Implement Guided Supervision in OHAN Complete by June 2017 by training staff on the expectations and begin use of the Guided Supervision process

Resources Identified as Needed in Plan
Plan identified that action could be completed with existing internal resources

DSS Implementation Update as of September 30, 2017
As referenced above, DSS reports that training was completed in the summer of 2017 and that the Guided Supervision Tool is in partial use by supervisors.

b. Implement standardized supervisory case review prior to case decision

Complete by April 2017

Plan identified that action could be completed with existing internal resources

DSS reports that this strategy was underway, however, due to the increase in OHAN caseworker caseload size, reviews are currently being completed too late to request an extension.

c. Refine case closure supervisory review to include CAPSS and paper file (thorough review)

Complete by April 2017

Plan identified that action could be completed with existing internal resources

OHAN supervisors are documenting case closure supervisory reviews, however, they may be completed after an investigation has been closed.

d. Develop methodology for caseload distribution

Complete by September 2017

Plan identified that action could be completed with existing internal resources

DSS reports that a regional assignment process was developed and implementation began, however, due to vacancies in the two regions with the highest caseloads, the new assignment process was ceased. DSS reports there are processes ongoing to fill current vacancies.

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Appendix C – Health Care Consultants’ Findings and Recommendations
Summary of Priority Actions Submitted by Gail Nayowith and Kathleen Noonan February 12, 2018
The Experts’ full report begins on page three of this document. This summary identifies six priority actions from the full report that DSS should commence immediately.
Recognizing that full implementation of the Health Plan will roll out over a period of several years, we offer a short list of actions to help DSS jumpstart the work ahead. Work on these actions should start before a revised Health Plan is completed. We see these near-term actions as necessary in light of the scale of this effort and because the terms of the settlement require attention to the health needs of children in foster care today.
We recommend six priority actions, outlined below, to be undertaken right away:
1. Produce a Revised Health Plan 2. Identify an Interim Director of the DSS Office of Health and Well-Being 3. Identify and Convene a SWAT Team 4. Obtain Gap in Care Reports from HHS and SH 5. Initiate Short-Term Data Work-Around to Mitigate the 30-Day Enrollment Gap 6. Initiate Short-Term Plan to Address Immediate Needs
1. Produce a Revised Health Plan
As outlined in the report, SCDSS should develop a revised Health Plan that includes implementation timeframes, task leads and staffing, technology and other resource need, including a multi-year budget.
2. Identify an Interim Director of the DSS Office of Health and Well-Being
Name an Interim Director to fill this essential position drawing on internal staff or by detailing a staff person from another state agency, preferably SCDHHS, to take on this critical leadership role. If the job posting has not produced a sufficient candidate pool, retain a search firm to source candidates.
3. Identify and Convene a SWAT Team
Convene a SWAT Team comprised of SCDSS and SCDHHS leads, and SH staff as needed to begin meeting weekly to develop a work plan and implementation tracker and begin to monitor: progress made to implement these recommendations and other elements in the revised Health Plan, troubleshoot and resolve issues or conflicts that arise; and, provide bi-weekly progress reports to the SCDSS and SCDHHS Commissioners and monthly reports to the Co-Monitors.

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4. Obtain Gap-in-Care Reports from HHS and SH
SCDSS will work with SCDHHS and other relevant state agencies, and SH if needed, to develop a datasharing agreement to be completed in six months, as outlined earlier in the report. In the interim, SCDSS, SCDHHS, and SH as needed, can produce a Gap-in-Care Report that identifies foster children who have not received required screenings, assessments or follow up. The roster produced should be used by the SWAT Team to monitor completion of these activities for all children listed on the roster. The SCDSS can develop a protocol for notifying caseworkers about children who have missed required screening, assessment or follow-up visits and for tracking completion of all required activities.
5. Initiate Short-Term Data Work-Around to Mitigate the 30-Day Enrollment Gap
Develop and implement a data work-around until SCDSS and SCDHHS create a structural solution to the 30-day enrollment lag into SH, as described in the report. The idea is to create a 1st 30 Days Report to avoid children getting lost in the first 30 days after entry into care. To accomplish this, SCDSS can create a weekly roster of all new entrants into foster care and with assistance from SCDHHS match the roster to the child or family’s Medicaid ID. The Medicaid ID can be used to pull relevant claims and encounter data for children on the roster. This information can be fed to caseworkers for follow-up. The roster will flag children who have entered foster care in the last 30 days who have not received screening, assessment or follow up. The SWAT Team can create a protocol to share this report with caseworkers and SH to promote continuity of care and monitor completion of required activities in the first month of placement.
6. Initiate Short-Term Plan to Address Immediate Needs
The new First 30 Days and Gap-in-Care Reports can be used to identify children with immediate needs. A case-specific Immediate Needs Tracker Report can be developed to capture for any given period of time a roster of children who have not received screenings, assessments or follow-up. The protocol described above can include guidance for caseworkers on how to engage SH to expedite required screenings, assessments and follow-up needed. The SWAT Team can monitor completion of required screening, assessment and follow-up.

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Findings and Recommendations – Full Report Submitted by Gail Nayowith and Kathleen Noonan February 12, 2018
I. Introduction
The Final Settlement Agreement (FSA) in Michelle H. v. Haley requires the South Carolina Department of Social Services (SCDSS) to develop a Health Care Improvement Plan (the “Plan”) for all children involuntarily placed in DSS foster care in the physical or legal custody of DSS. The Plan is subject to the approval of Co-Monitors Judith Meltzer and Paul Vincent, who under the FSA, have the ability to engage expert contractors “to assist in the development and monitoring of the” Plan. (See Section IV.K). Pursuant to that authority, the co-monitors retained Gail B. Nayowith and Kathleen Noonan to “validate” the Health Plan submitted by DSS on September 29th, 2017.
Specifically, the experts agreed to validate the “infrastructure components,” “innovations” and targets as described in the proposed Plan, and identify gaps, if any, in a Findings and Recommendation report.
This Findings and Recommendations report proceeds in four parts: Part I offers an overview of the report. Part II is the methodology including the sources of information used in this discovery and assessment phase of work. Part III includes our findings and assessment of whether the plan element as presented is fine as is = Concur, whether it should remain in the Health Plan but needs revision = Concur with Revisions, or whether the element should be removed from the Plan = Do Not Concur.
As an overall finding, the SCDSS Health Plan submitted to the Court includes important conceptual and structural elements on which to build a robust health system for children in foster care. It does not yet include the operational framework needed for implementation.
In Part IV we propose a reorganization and rethinking of the key building blocks of the SCDSS Health Plan. We offer amendments or alternatives to some core features of the Plan (Concur with Revisions). We also note the need to establish implementation timeframes, identify task leads and describe the staffing, technology, financial or other resources necessary to operationalize the Plan. Further, the Department’s efforts to recruit and hire a senior person with the skills and authority to lead the work to modify, operationalize and implement the health plan is an imperative. The revised Plan should include a multiyear phase-in calendar and an estimated budget.
We also include some short-term actions that DSS should take immediately to move the planning and implementation process along. Most urgent, is the need to establish a new cross-agency project management team with high level representatives with decision-making authority from SCDSS, SCDHHS and Select Health (SH). In the short-term, we recommend convening this as a weekly “SWAT Team” leading up to the production of a revised Health Plan to be submitted to the Co-Monitors and the Court. The SWAT Team could work through the most critical elements of the Plan including: developing a data sharing agreement and framework for data use and reporting; articulating the differentiated roles and responsibilities for DSS and IFCCS caseworkers, SH care coordinators and case managers; solving the 30day enrollment gap to expedite enrollment of children entering foster care into SH, and refining the timelines and targets for key screenings, assessments and services built on AAP guidelines. We also

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recommend moving quickly to generate a gaps-in-care data report to identify children who may need prompt attention.
For the revised Plan, we suggest a focus on six core functions that build on and add to original Plan elements:
1. Governance 2. Data Sharing and Reporting 3. Enrollment 4. Care Coordination and Care Management 5. Network Adequacy, Access to Services and Immediate Needs 6. Targets
II. Methodology
We reviewed and considered the elements of the SCDSS Health plan, including its nine infrastructure components, seven innovation areas and select targets, and developed a validation framework to guide our assessment. We sought to examine reports, data, policies and practices already in place. We did not ask SCDSS to create new tools or reports and instead worked from data that is already collected and documents already in use to better understand the operating environment in which the SCDSS Health Plan will be implemented.
The methods used to verify the various plan elements included phone interviews (Appendix), in-person meetings (Appendix), a focus group with foster parents, extensive documentation and data review (Appendix), a hands-on review of the SCDSS CAPSS system and reports, a review of the Medicaid encounter (services provided) and claims data and the SCDHHS MMIS data system, and observation. We considered a case record review. We spent three days on the ground with SCDSS in early January 2018.
III. Validation Findings
Infrastructure
1. Select Health
The choice of a single MCO for children and youth in foster care is a solid strategy for the delivery of health and mental health services. This element is central to South Carolina’s Health Plan. The contract between SCDHHS and Select Health (SH) specifies the essential elements, core requirements and necessary practices as relates to the provision of health care to children in foster care. All children in foster care in SC (approximately 4200) are immediately eligible for Medicaid upon entry into foster care placement. All children in foster care are enrolled in the SH health plan within 30 days. This lag creates significant complications that are discussed later in the report.
The SCDHHS/SH contract does not yet acknowledge a role for, or accountability to, the SCDSS. We recommend a reset in the governance relationship between SCDSS, SCDHHS and SH, which is described in detail in the Part IV.
Concur with Revisions

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2. The Foster Care Advisory Committee
The re-activated Foster Care Advisory Committee (FCAC) is an important opportunity to bring the SC child serving community together, including both internal and external stakeholders. The FCAC should serve in an advisory capacity, bringing expertise to DSS that informs practice, program and policy development, offering feedback from the field and community, and otherwise offering expertise and guidance on relevant issues like caseworker training, casework practice or clinical quality and the like. The structure of the FCAC should remain flexible so that work groups and members can change as work is completed or new needs emerge. The schedule of quarterly meetings with as-needed work group meetings in between should continue. The FCAC may benefit from an updated charter or statement of purpose to orient members as to their roles and responsibilities.
However, the FCAC – an advisory body that meets on a quarterly basis – cannot be responsible to design or implement the new Health Plan. Instead, as described in our Recommendations, DSS needs a new approach to governance, staff assigned full-time to lead this effort and a reset in its relationship to SCDHHS and SH.
Concur with Revisions
3. Child and Adolescent Psychiatrist
This position now held by Dr. Khetpal serves, in effect, as a Chief Medical Officer (CMO) for DSS. The CMO’s responsibilities are detailed in the Plan. Dr. Khetpal is highly regarded by SCDSS staff, by SCDMH and SCDHHS. Her part-time position brings new clinical, health care and psychopharmacology expertise and depth to DSS. Consideration should be given to building out this function.
However, this position is not properly called “Infrastructure” as labeled in the Plan. This essential position is more accurately described as an enhanced clinical staffing resource to DSS operating under the aegis of the new Office of Health and Well-Being. Consideration should be given to making this a full-time position or bringing on additional part-time capacity to support the clinical work. Our understanding is that Dr. Khetpal serves as a clinical consultant, not as a manager lead for DSS. Dr. Khetpal is in a good position to identify clinical staffing resources that would be needed for the new Office.
Concur with Revisions
4. CAPSS Health Screens and the Electronic Health and Education Passport
The electronic record, called CAPSS has the potential to improve both individual child and system-level outcomes, and should replace any paper health records in SCDSS files as soon as is practicable. The time and effort that SCDSS has invested in developing CAPSS will be helpful for the significant work ahead to develop data sharing capacity with HHS and SH.
At this time, caseworkers are hand entering essential health data and trying to piece together health histories on the approximately 4200 children in care from data reported by foster parents or health care providers. This data is already collected by SCDHHS and the contracted MCO - Select Health. The SCDHHS Medicaid Management Information System (MMIS) and SH data system already tracks services provided

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(encounter data), claims paid and so forth. We do not believe it is a good use of caseworker time to recreate health care data that is collected with more accuracy and in less time by HHS and SH. Whenever possible, the source of CAPSS data and the E&H Passport entries should be generated to the fullest extent from HHS and SH data feeds. The state’s MMIS data, along with contractual reporting requirements for SH, allows for continuous tracking of enrollment, services provided (encounters), gaps in care and other utilization and quality metrics. Because it is a system of record, it can generate timely data that is more reliable than data collected now by hand by SCDSS caseworkers. It should become the basis for populating CAPSS, thereby creating an electronic health record for all children in DSS custody.
DSS and DHHS have begun to sync up their data to create a synchronized roster of eligible children, and are working now to move any remaining children who are not coded as “foster care” into that status. Medicaid claims, service and utilization data from the SCDHHS system of record and SH should populate, along with other ancillary information, the official CAPSS health record for all children in foster care. This is not only important for children while they are in foster care, but will be critical medical history that can follow children once they transition out of foster care. While we understand that setting up a data-sharing exchange will take time and the patience of all involved, it presents an opportunity for SC to be a national model with respect to the health of children in foster care. While we were on site, HHS, SH and DSS verbally agreed to develop a data sharing agreement and protocols for regular data feeds. Protocols will have to be developed around data access and a set of reports to be created. See our Recommendations for more detail on data sharing.
Concur with Revisions
5. Data Gathering and Initial Health Assessment Data
Pursuant to our observation in the previous section, we recommend that DSS focus its efforts on securing a data-sharing agreement with HHS and SH, engage in the development of a Medicaid data capture report on initial screenings and health assessments and secure a gaps-in-care report from SH and/or the SCDHHS MMIS. We address the 30-day enrollment gap in our Recommendations.
As a general rule, we do not support the creation or use of ad hoc data or reports pulled from handentered health care records. From what we have reviewed, it appears that already stretched caseworkers are being diverted from critical casework tasks to chase health information because there is no data link between DSS, HHS and SH. The result – very likely – is the collection of highly inaccurate information. For the time being, caseworkers are patching together health histories and services needed, but it is not a good long-term solution. We understand that SCDSS developed this approach as a work-around in the absence of critically needed information. Delays in securing information on initial health screenings and assessments is complicated by the fact that children in foster care are not enrolled in SH the day they enter care. This means that the caseworkers and foster parents who must meet SCDSS timeframes for screenings, assessments, and care for immediate needs are in a position of having to juggle appointment scheduling, follow-up visits and also chase down essential screening, assessment and referral information from a child’s prior provider. Given the opportunities afforded by having SH as the single MCO for all children in foster care, it seems to run counter to intent to rely on screenings, assessments or treatment plans developed by other plans and providers. In addition to accessing SCDHHS and SH data and tracking, it will also be necessary to address the 30-day enrollment lag.
Do Not Concur

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6. Immediate Treatment Needs Identification
This plan element was created in direct response to the lawsuit. Per the discussion above, to meet the conditions of the settlement agreement, a caseworker-dependent workaround was developed in the absence of other sources of data. We recommend against this work-around because we believe DSS should be working with the Medicaid health data (MMIS) through HHS and SH to identify the treatment needs, services rendered or gaps in care for children in custody. Caseworker and supervisory staff resources should, in the short run, be devoted to making sure that children get to medical appointments and receive the care they currently need, not to tracking down historical data. There could be a way to generate a look-back report for a specified time period for a defined cohort of children in foster care to determine whether immediate needs were met. We have requested data from SH to begin the process of identifying children who have screening, assessment and service needs. This should be happening concurrent with the development of a data sharing agreement.
In addition, while we understand that “immediate treatment needs” is defined in the settlement agreement, we think it may be overbroad and poorly understood in the health care sector. DSS could develop a robust “treatment needs” framework that categorizes needs in language that is consistent with how they are captured in the health care world. For example, in our meeting with DMH, they framed MH needs as “routine, urgent or emergent.” Our Recommendations include more a more detailed discussion of this issue.
Concur with Revisions
7. Healthcare Needs Assessment Survey
The survey findings are extensive and point to significant service, access and availability gaps in the counties. A companion study is needed to follow-up on this work and to ascertain network adequacy and timely availability of services. This capacity analysis would use administrative data and a set of proxy measures to answer the questions of adequacy and availability. Further, the MCO contract between SCDHHS and SH is conditioned on having an adequate provider network and timely access to services and there are penalties associated with failure to do so. As it stands, we consider this survey to be enhanced context to inform the Health Plan. We do not consider this survey an “infrastructure” component as described in the Plan. We address the issue of network adequacy and access to services in the Recommendations.
Concur with Revisions
8. Training
We have not seen a training plan or training calendar for caseworkers or supervisors. This is a critical infrastructure element that should be elaborated upon in the revised Plan. We spoke to a number of stakeholders who verified that training related to psychotropic medications and case record review had taken place. This training is focused narrowly on psychotropic medication issues or federal compliance

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activities. It is unclear whether other health, behavioral health and other health-related training is made available to caseworkers and supervisors. The training plan and calendar should be generated by the new Office of Child Health and Well-Being. However, it is our opinion that there may be other critical building blocks that need to be put in place first, before DSS embarks on creating, purchasing or offering other health-related trainings or bringing a learning management system on line.
Concur with Revisions
9. Office of Health and Wellbeing
The new Office of Health and Wellbeing should play a central role in the development, implementation and monitoring of the DSS Health Plan. By creating this office, DSS can centralize and direct agency activities related to child health, as well as coordinate the extensive inter-agency and community engagement work that is envisioned by the Plan. We discuss the role of this Office in greater detail in our Recommendations. The role, scope of work and leadership authority of the office needs to be more clearly defined, including identifying specifically its role in Plan implementation. Work is underway to recruit a Director for the new Office of Health and Well-Being and the position has been posted. This is a critical position and essential role in the SCDSS Plan.
Concur with Revisions
Health Care Plan Innovations
1. Case Managers to coordinate care for all children and youth in foster care. SCDSS will work with SCDHHS and Select Health to agree to an appropriate caseload for CMs.
DSS, HHS and SH are in agreement that they need to work together to develop a tiered (health) care coordination function. This is a critical component of the Health Plan, and needs significant attention, which we discuss in the Recommendations. This includes defining and describing the SH care coordination role, and defining the DSS case worker role. Both functions are necessary and DSS and SH will have to develop guidelines, training, work flows and protocols.
Concur
2. Assign all SC foster care children to a QTIP1 or other medical home practice of similar quality
The QTIP program was developed with CHIPRA demonstration funds, but is now an ongoing program of HHS. A process and recruitment plan is needed to identify additional providers who could be certified as “QTIP-like” preferred providers in terms of the quality of practice (proficiency in AAP - Bright Futures approach among other things), and specialized knowledge/training/expertise in working with children in foster care. We discuss this in the Recommendations.
Concur

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3. Leverage the SCDHHS Palmetto Coordinated System of Care 1915(c) waiver
The 1915(c) waiver promises to be a very important service for children and youth with SED in South Carolina. To date, SCDHHS has not submitted its waiver request to CMS and the waiver has not been approved. Consequently, it is too early to include this resource in the SCDSS Health Plan waiver. Work is underway to establish the basic infrastructure for the program which will have capacity to serve a limited number of children (our understanding is approximately, 200 in year 1 growing to 600 at full implementation). Eligibility for the program will include SED and a history of hospitalization. Children will be enrolled on a first-come, first-serve basis, with no guaranteed availability for children in foster care. The absence of slot guarantees for children in foster care and the nascent stage of program development, limit our ability to credit this as a Health Plan resource or “innovation” at this time. This said, we strongly encourage SCDSS and SCDHHS to continue planning for the roll-out of these necessary services to eligible foster children.
Do Not Concur
4. Monitor Health Outcomes Using Data
The importance of this element of the Plan cannot be overstated. It is our strong recommendation that quality, utilization, tracking and other reports must be generated from SCDHHS or SH data systems of record. There should be little need for DSS to create its own health data. If the health, dental and behavioral health data feeds from MMIS or SH into CAPSS, the CAPSS records could also be mined for data reports. We elaborate on this earlier in our report. In addition, we have requested that DSS obtain data from SH in the short-term that should answer some basic questions on level of need and services currently provided to children in foster care. It will be important for DSS, as part of its Health Plan, to identify opportunities for health data to be used at the state and local level to actively track the health care needs of children in care. See our Recommendations for more detail.
Concur
5. Enhanced Case Practice
Enhanced case practice is complicated by two competing approaches to case management in the Department. Another layer of complexity is caused by misunderstanding SH’s care coordination role. Clarity is needed to differentiate the roles, responsibilities, practices and caseload sizes of SCDSS caseworkers and IFCCS case workers. The development of a new health-informed practice model needs to be incorporated into a broader discussion about care coordination.
Currently, there is substantial role uncertainly around the case management and care coordination functions, which needs attention. This relates to the roles of DSS, HHS, SH as well as foster parents. Care coordination must be a central plan element, but it is not currently well-defined or clearly understood. This is addressed in more detail in the Recommendations.
Concur with Revisions

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6. Enhanced Training and Partnerships with Foster Parents and Group Care Providers
DSS has some core foundational work to do with HHS and SH before it can train foster parents or group care providers on its new health care practices and requirements. However, this training is necessary and viewed as infrastructure for the Plan. A health and behavioral health training curriculum for foster parents could be developed by the foster care support organizations or a local university or by DSS in partnership with SH. It would be useful to resolve an ongoing question about whether foster parents should choose the child’s health care provider or whether the child should be assigned by SH to a Q-TIP or Q-TIP lookalike provider. We think this could be done by creating a presumption that children will be assigned by SH, but that foster parents have the option to use their own provider (or choice of provider) so long as they notify SH of this designation. In other words, we would not recommend a strict rule, but rather a presumption that allows for flexibility on the ground.
Concur
7. Engagement with the South Carolina Department of Mental Health
At this point, DMH’s electronic records are not coded to identify children in foster care. It is not clear to us that doing so would be necessary since SH captures encounter data and would be the payer for BH services rendered by DMH. It would certainly be worth looking into, but secondary to obtaining accessing to the SH data.
What DMH offers to DSS is a network of clinics and providers around the state, including in remote/rural areas, which could be offered as a walk-in service and for scheduled visits as needed. DMH seemed open to more formal arrangements perhaps as a preferred provider for children in foster care. This preferred provider status could be discussed with DSS, DHHS and SH.
Concur with Revisions
Health Care Targets
See our earlier discussion of initial health screens above and immediate treatment needs, and the need for alignment of SCDSS and SCDHHS/SH timeframes. It seems premature to set these targets before further discussions among DSS, HHS and SH about sharing data, and about protocols and timeframes related to initial screenings and assessments. DSS will need to work with the Co-Monitors, as set forth in the Settlement Agreement, on the development of targets.
1. Initial Health Screens
Achieving a standard of initial health screens with 14 days of a child entering care cannot be met without addressing the 30-day enrollment lag, discontinuity of providers, and poor sources of data. These targets should be reviewed with DHHS and SH as part of the discussion around aligning timeframes and moving to standardized screening and assessment tool(s).

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2. Immediate Treatment Needs

Per our comments above, we recommend setting targets related to this as part of discussions with DHHS and SH on data, treatment approach, etc. The next steps to do this would be through discussions among DSS, DHHS and SH. These discussions would include some agreement on the “look back” parameters defining immediate needs as promised in the Settlement Agreement, as well as an agreement on how regular tracking of immediate needs will be handled going forward. At this point, weekly SWAT Team meetings are needed to move urgent items forward. We recommend that DHHS data be used to generate a gaps in care report. This report will identify children needing attention. SCDSS can use the gaps in care report to do the follow-up promised in the Plan.
IV. Recommendations
The DSS Health Plan includes many of the components needed to build a strong health care system for children in foster care. That said, we believe the Plan needs to be refined and built out, as noted in the early part of the report and again, in more detail below.
Our recommendations are organized around six pillars needed to support a robust health care plan for children in foster care. Relevant elements found in the original Plan can be dropped into this reorganized framework. In addition to reframing, the next version of the Health Plan should specify implementation timeframes, task owners, multi-year resource needs (staffing, technology, other) and identify where changed protocols and staff training will be needed.
In the short term, as noted earlier in the report, and most immediately, DSS should convene a group of high-level decision makers on a weekly basis to begin discussion and expedite action on the foundational components of the Plan. There is no need for to wait for Plan finalization and in fact, getting started on these activities now, will inform and strengthen the next version of the Plan. Acting promptly will offer SCDSS an opportunity to identify operational challenges early and incorporate mitigation strategies into the Plan.
We have organized our recommendations into six pillars:
1. Governance 2. Data Sharing and Reporting 3. Enrollment 4. Care Coordination and Care Management 5. Network Adequacy, Access to Services and Immediate Needs 6. Targets
1. Governance
• The SCDSS Health Plan builds on a model of shared services and differentiated capabilities across relevant state agencies and affiliated organizations. Successful Plan implementation will require a governance entity for coordination, troubleshooting and accountability. A governance structure including DSS, HHS and other relevant state agencies is needed for accountability and to identify and resolve operational challenges through the course of the implementation of this plan. At this stage in the reform effort, an internal state agency-only governance group will need to meet monthly, at minimum, to plan, track progress, resolve disputes, design policies and reports, build

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out the specifications for the care coordination function and otherwise share responsibility for operationalizing relevant components of the Health Care Plan.
• To date, the Director of the Office of Child Health and Well-Being position has been posted but remains unfilled. This is a time-critical hire and recruitment of a highly qualified person is essential to securing dedicated, consistent and skilled leadership in a role that has been historically absent in South Carolina. In considering the responsibilities of the Director, it will be important to identify a person who is knowledgeable about the substance and mechanics of Medicaid, health care data, and care management models as well as someone who has a health-related background. A good candidate will also have strong project management skills as these are essential to implement the Health Plan, as well as the capacity to understand and engage within a broader reform strategy/context. We’ve submitted suggestions for the posting via email.
• Given the importance of data to the Plan, DSS will need to develop a clinically-oriented data team in this office tasked to work with HHS and SH, related departments at SCDSS and other affiliated entities. As well, this office would house the Medical Director, staff the Foster Care Advisory Committee (FCAC), run point for SCDSS on cross-system service coordination and collaboration with the SCDMH and its service continuum and SCDHHS on the development of the 1915(c) waiver protocols, develop policies and procedures and the health and behavioral health training protocols. This team would work with other SCDSS departments to develop dashboards, report templates, inform the QI process and assist with implementation of the SCDSS CSFR PIP.
• DSS needs to work immediately to develop a shared Governance agreement between SCDSS and SCDHHS with a defined role for SH, including a timeline for implementation and projection of resource needs. See the next section for more details on this.
2. Data Sharing and Reporting
• We suggest a reset in the relationship between DSS, DHHS and SH. The contract with SH is held by HHS but the customer is DSS on behalf of children in foster care. While DSS is ultimately accountable for meeting the health needs of children in their care, it depends on a strong partnership with HHS and SH to meet its obligations to children. A key component of the reset must be built upon a data-sharing agreement to be developed between the three parties to 1) facilitate completion of CAPSS records for each child; 2) flag, track and follow-up on youngsters identified with immediate needs; 3) insure timely screening and assessment by SH; 4) identify children in need of Intensive Care Coordination from SH; 5) allow for a targeted focus on the health and behavioral health care needs of children in foster care; 6) formalize channels of reporting and accountability.
• DSS needs to put in place the data sharing agreement ASAP. A very aggressive timeline for this would be six months to get the data sharing agreement completed and executed, test and adjust a live data feed and data exchange and begin to generate administrative reports. The data sharing agreement should cover data needed to populate CAPSS, data access permissions and restrictions and include a list of monthly, quarterly, annually or more frequent administrative reports (more than one medication, immediate needs, etc.).

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• Synchronize DSS, HHS and SH Timelines. DSS must synchronize its screening and service timelines with HHS and SH. Different standards related to appointment availability on the part of SH need to be reconciled with DSS requirements. Children in foster care will need some prioritization for screening and treatment services, especially upon initial entry into care based on the American Academy of Pediatrics standards, as noted above.
• Generate Data reports from HHS and SH. As an MCO, SH is already required to produce dozens of reports, and is subject to federal and state reporting requirements. In addition, SH told us that they themselves generate “gaps in service” reports for children in foster care. HHS also generates routine data reports, and has additional data on children in foster care (e.g., dental records). DSS needs to determine what can be gleaned from the HHS and SH reports to identify children who have not been screened, and/or are not receiving needed services, or who had adverse reactions to medication or treatment. In the long-term, administrative data reports could be generated by DSS based on the HHS/SH data used to populate CAPSS. Work with SCDHHS and SH to develop a set of templates and special reports and timetable for distribution and build out a monthly and quarterly performance review process. As part of our due diligence, we have requested that DSS obtain data reports from HHS and SH both to begin the process of identifying which children are in need of screenings and services, and to verify that the data is available and can be used to meet its obligations under the settlement agreement.
• In the short-term, we recommend that DSS request immediately from SCDHHS/SH a copy of the “gap in service” reports for children currently in care. In addition, while there are a number of descriptive aggregate data reports from SH that DSS and HHS will want to review over time (e.g., routine psychotropic medication reports; population with two or more chronic conditions; population with asthma diagnosis; etc.), at this point DSS should be requesting data to identify any outlier children or children who are missing screenings or needed services. Accordingly, we recommend that DSS request and review the gaps in service reports ASAP, as well as a report from SH that is focused on children from the original cohort in the case (approximately 2,000) to determine which of those children, based on the encounter and claims data, have not received required screening, assessments and follow up care.
• Consider time-limited staff sharing. DSS should consider embedding a staff person familiar with the MMIS from HHS and/or SH to DSS. This staff person(s) could also, as an interim fix to the problem of the 30-day enrollment lag, identify and record in CAPSS, for all new children who enter care (approximately 40 per month), their prior medical history as per HHS data, and ensure a smooth transition to SH for initial care coordination. This will accelerate the transition to the use of MMIS and SH data to populate CAPSS health records, track gaps in care and the development of reports and protocols and serve as a temporary bridge while enrollment lag issues are corrected.
• The revised Plan should include a timeframe, task owner(s) and resources needed for the development of a data-sharing agreement; a preliminary list of reports to be produced; a protocol and trainings developed for data management, data sharing, report distribution and other activities related to use of SCDHHS Medicaid and/or SH data for CAPSS and production of management reports including a timeline for implementation and projection of resource needs. See the next section for more details on this.

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3. Enrollment
• DSS and HHS must address the 30-day time lag between entry into foster care placement and enrollment into SH as a high immediate priority. The vast majority of children coming into the foster care system are Medicaid eligible and already enrolled in one of the state’s MCOs. Children entering foster care are automatically eligible for Medicaid but enrollment in the state’s foster care MCO plan does not start the day the child enters care. One consequence of this lag is that the child may remain the responsibility of a non-foster care MCO making it difficult to ensure that 7-day, 72-hour and 30-day timeframes for assessment are completed, that immediate needs are identified and addressed and that follow-up is scheduled for all identified health and behavioral health needs. In South Carolina, children are assigned to a Medicaid MCO on a monthly basis. MCOs are paid a per member/per month rate. This means that, depending on the time of the month, for a child that enters foster care, there may be a time lag for them to be picked up as a SH member. Approximately 281 children enter foster care each month and it appears that lifting this administrative barrier would go a long way to satisfying several outstanding issues in the litigation.
• Ensure that all children coming into care have a Medicaid ID that includes a designation - - called a paycat - - that recognizes their foster care eligibility status to expedite enrollment in SH. (Although the majority of children enter foster care with an active Medicaid ID#, SCDSS and SCDHHS believe that 400 children have not been coded as eligible based on their foster care status.)
• The Plan should include the development of a new enrollment protocol that will eliminate or mitigate the 30-day enrollment lag for an estimated 512 children entering care each month, including a timeline for development and implementation of the protocol and identifying any resource needs in the revised Plan.
4. Care Coordination and Case Management
• Develop a shared and tiered approach to Care Coordination and Case Management between SCDSS and SCDHHS and SH including definitions, workflow protocols for DSS county case workers, regional IFCCS caseworkers, SH care coordinators and care managers and a timeline for implementation and the clarification and delineation of case management and care coordination responsibilities for both DSS and SH. SCDSS and SCDHHS should identify implementation resource needs.
• Implement SH Care Coordination. All children who enter foster care (approximately 281 children per month) need an early and basic level of care coordination to ensure that their initial screening and assessment is completed, and that any follow up services are put in place. In addition, DSS and SH should identify other routine milestone points for the review of all children by SH care
2 DSS reported that 82% of children who entered care were enrolled in Medicaid already at time of entry. Based on 281 children entering care each month, this means approximately 51 are not enrolled in Medicaid already at time of entry.

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coordination. (DSS must ensure that SH follows the American Academy of Pediatrics Bright Futures recommended screenings, health promotion, anticipatory guidance and health supervision). Finally, the data reports described above should identify children that are already in care who have unmet screening and service needs, and therefore need immediate attention from SH care coordination (and possibly, per below, SH Intensive Care Coordination).
• Define and Implement SH Intensive Care Coordination. DSS and SH must agree on a validated level of need assessment tool to identify DSS children who require “Intensive Care Coordination” (ICC), a function already developed at SH. Currently, SH identifies --using its own criteria-children in foster care in need of ICC. DSS, HHS and SH need to work together to develop agreed upon criteria for children who qualify for ICC (e.g., children with a certain chronic health care condition). Finally, it will be important to develop a plan to identify how children already in care will be identified for ICC (in our focus group in South Carolina, we met two TFC foster parents who are receiving – and very happy about – ICC from SH).
• Define DSS Case Management and Revisit Tiered Design. DSS case workers are ultimately responsible to ensure that children in foster care receive the health care they need. A detailed scope of work, roles and responsibilities, work flows and relationship of DSS and IFCCS caseworkers and their relationship to SH care coordinators needs clarification and further definition. Moreover, we think the tiered design of DSS case management warrants a review. Currently, there are two types of caseworkers at DSS. SCDSS county-based caseworkers and regionally-based IFCCS workers. Our understanding is that the IFCCS is a vestige of the state’s coordinated system of care project that required staff to have behavioral health expertise. IFCCS workers are assigned to children with SED - the highest level of need, but can also be assigned to medically fragile children or children with other special needs. IFCCS workers also carry cases of foster children (1:9) whose care is cross-subsidized by multiple state agencies: special education placements, dual diagnosed. Children placed in residential schools may be served out of state or in remote counties so IFCCS workers’ smaller caseloads and duties around case planning and consultation are intended to leave time for traveling long distances that the workload of DSS county caseworkers cannot support.
Children are referred to IFCCS based on the county worker and supervisor’s assessment of their level of need, but typically do not get transferred from a county worker to an IFCCS worker, which is regional, until at least 35 days after they have entered care. There are expectations that the IFCCS worker will have additional care management responsibilities, including more frequent contacts, case consultation with schools and service coordination activities, though they are flexible by case.
There are several reasons for concern about any bifurcation of casework resources, including that it can create case assignment inefficiencies and accountability challenges with a transfer from county to regional case management. Also, IFCCS eligibility is open to interpretation with a potential for creating long waiting lists or over/underserving serving children in care. It appears that county caseworker shortages and the poorly articulated residential continuum may have created a workaround centered on IFCCS.
Building on the above, we note a gap in care filled by the IFCCS workers as relates to what appears to be an insufficiently differentiated continuum of clinically-oriented residential programs, very limited access to PRTF beds and group and congregate care settings which are prohibited from offering on-site health or

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behavioral health services or staffing with clinically expert treatment teams. Exploration of the rationale for this prohibition is beyond the scope of this study. This also raises concerns about the adequacy of the health and behavioral health services and supports offered to children in group 2 and 3 congregate care beds. A starting point for review might be a data request from DSS to HHS/SH asking for a report on key health/behavioral health indicators for children in residential care group homes 2-3. While this goes beyond our scope of review, we note that frequently during the validation work, children in group care were described as higher need than can be handled presently in either Therapeutic Foster Care or Level 1 group care. Typically, children in congregate care require some on-site medical/clinical support. This is an issue that warrants further review and consideration.
There is a complex interdependency between DSS and SH that warrants careful attention because of an important goal of Least Restrictive Environment (LRE). Work is needed to develop a plan that ties together the child’s need for a therapeutically-oriented placement and the assignment of a DSS county or IFCCS case worker and a SH care coordinator/care manager to accomplish the following: 1) complete timely level of need/level of care assessments, 2) assign county or IFCCS caseworkers, 3) assign SH care coordinators and determine appropriateness of SH utilization reviews, prior authorization and other LOC/LON determinations, 4) clarify workflows differentiating the roles and duties of IFCCS caseworkers, DSS caseworkers and SH care coordination for children placed into group care 2-3, residential schools, PRTF, and therapeutic foster family care, 5) determine eligibility for ICEDEC funding where state funds are pooled to cover the placement, tuition, treatment or other costs of placement. These are multifaceted issues, but because the IFCCS is an important resource and because IFCCS workers may, down the road, play a role in LRE placement, these issues warrant consideration and resolution.
As an immediate starting point, it would be useful to align timeframes for IFCCS eligibility with other health, behavioral health and dental assessments happening within the first 30 days of placement in foster care that are conducted by SH or other providers and consider the use of a standardized assessment tool like CALOCUS or CAFUS or CANS. This will necessitate resolution of the 30-day enrollment lag into SH, resolution of level of need assessments and determinations and level of care approvals by SH as discussed in other sections of the report.
5. Network Adequacy, Access to Services, Screening and Immediate Treatment Needs
• Standardize health and behavioral health care screenings and assessments offered through SH providers (Q-TIP and other designated preferred providers who are committed to and proficient in the American Academy of Pediatrics Bright Futures framework for health supervision) through use of validated screening and assessment tools (trauma, CALOCUS, CANS, CAFUS, depression, etc.). This should include an assessment and possible augmentation of reimbursement rates paid for screenings and assessments.
• Include in the revised Plan, a timeframe for developing and implementing an approach to identifying additional Q-TIP or Q-TIP-like providers and an estimate of resources needed to do so. The Plan should also speak to the issue of provider assignment to enable SCDSS and SH to assign more foster children to a preferred provider and address logistical challenges associated with QTIP provider assignment: travel and transportation access, current practice by foster parents who now choose the child’s health care provider – that will need further attention. We suggest that DSS include in the Plan a mechanism for engaging foster parents and the FCSC to inform the

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resolution of these issues.
• Develop a process with SCDSS, SCDHHS and SH for an annual review of network capacity and access to services including a projection of resources needed for implementation activities. Include a timeline for the implementation and development of a protocol and monthly report to track, flag and prompt timely completion of health, dental and behavioral health screenings and assessments, referrals and follow-up needed and to identify immediate needs and gaps in care.
Note: The question about additional training, quarterly/semi-annual convenings (Grand Rounds, meet and greet, etc.) and increased rates for providers that serve children in foster care is one that HHS seemed open to discussing. We raised an issue about a rate that was quoted to us by one provider that seemed low, and they told us they were aware of the issue and were working on it. From our perspective, DSS will be a better position to advocate with respect to provider rates once it has access to Medicaid data, which will show more reliably the types of screenings and services happening for children in custody.
6. Targets As noted previously, there is an urgent need to align and synchronize DSS, HHS and SH timelines for screenings, assessments, and immediate treatment needs. Jointly with the co-monitors, DSS needs to engage with DHHS and SH to arrive at proposed target dates and benchmarks for completion of screenings, assessments, referral for follow-up and immediate treatment needs.

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Appendix I. Interviews

Advocates: • • •

Erin Hall, CEO, Palmetto Association for Children & Families John Shackelford, Director of Government Relations, SC Youth Advocate Program (SC YAP) Advocate, Protection & Advocacy for People with Disabilities, Inc.

Foster Parents: • John Shackelford, Director of Government Relations, SC Youth Advocate Program (SC YAP) • TFC parents from SCYAP

Medical Professionals: • Dr. Libby Ralston, Co-Director, Project BEST • Dr. Elizabeth Wallis, Medical Director, MUSC Foster Care Clinic • Dr. Olga Rosa, Pediatrician, Palmetto Health Richland

Plaintiffs: • • • • • • •

Stephen Suggs, Appleseed Dione Brabham, Appleseed Sue Berkowitz, Appleseed Erin McGuinness, Children’s Rights Ira Lustbader, Children’s Rights Stephanie Persson, Children’s Rights Matthew Richardson, Wyche

SCDSS:

• Susan Alford, Director, SCDSS • Taron Davis, Deputy State Director of Child Welfare, SCDSS • Tammy Bagwell, QA Director, SCDSS • Holly Pisarik, Internal Monitor, SCDSS • Diana Tester, Data Coordinator, SCDSS • Malik Whitaker, Director of Continuous Quality Improvement, SCDSS • Paulette Salley, IT Director, SCDSS • Dr. Anita Khetpal, Consultant Psychiatrist, SCDSS • Jonnieka K. Farr, CAPSS IT SCDSS • Brad Leake, Data and Accountability Director, SCDSS • Tim Nix, Lead Clinical Specialist, SCDSS • Robert Linares, Contract Administrator, SCDSS

SCDHHS: • • •

Andrea Bickley, Director of Health Informatics & Analytics, SCDSS Peter Liggett Deputy Director, Behavioral Health & Long Term Care SCDHHS Brian Amick, Deputy Director for Health Programs, SCDHHS

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SCDMH: • Mark Binkley, Medical Director, SCDMH • Debbie Blalock, Executive Director, SCDMH • Louise Johnson, Director of Children’s Services, SCDMH
SelectHealth: • Rebecca Engelman, Market President, SelectHealth • James King, Contract Account Manager, SelectHealth
USC: • Dr. Cynthia Flynn, USC Center for Child and Family Studies, USC • Suzanne Sutphin, USC CCFS

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Appendix II. Documents Reviewed
• Group Homes with Levels as of 1/10/2018 • Directive Memo – Immediate Implementation of the Education and Health Passport
May, 2016 • South Carolina Department of Social Services Health Care Oversight and
Coordination Plan 2015- 2019 • 2018 PAFCAF Legislative Priorities • AAP Periodicity Schedule (Recommendations for Preventative Pediatric Health Care) • Chapter 7 of the Child Protective and Preventative Services Policy Manual on
Babynet Referrals • Child and Adolescent Level of Care Utilization System (CALOCUS) manual
(10/17/2010) • CAPSS Immediate Treatment Needs screen • CAPSS screen of Healthcare Passport 10/21/2016 from test site • County Service Array Survey, Appendix to the Placement Needs Study • Director of Wellbeing job announcement • Chapter 8 of the DSS Foster Care Policy Manual on Foster Care and on the Education
and Health Passport • Foster Care Health Advisory Committee Meeting Minutes from 10/04/2017 • South Carolina Department of Health and Human Services Medicaid Policy and
Procedures Manual Chapter 204 on MAGI Eligibility Categories • South Carolina Department of Health and Human Services Medicaid Policy and
Procedures Manual Chapter 502 on Foster Care and Adoption • Healthcare Needs Assessment Analysis from the South Carolina Department of
Social Services Healthcare Workgroup, 04/2017 • Immediate Treatment Needs (List of Definitions from Michelle H., Medicaid and an
operational definition) • Directive Memo – South Carolina Department of Social Services Immediate
Treatment Needs Practice Directive and Policy Change Announcement 11/15/2017 • Initial Healthcare Screening Reports Summary • Medicaid Guidelines for Dental Care • Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children
and Adolescents 09/2013 • Medicaid Spending on Children in Foster Care by County – Per Child Per Month,
Aggregate Data, 12/28/2017 • Michelle H. Initial Complaint • South Carolina Department of Social Services organizational/staff chart • South Carolina Department of Social Services Education and Health Passport • Section 2 of the Physicians Provider Manual • Service Array Codebook • South Carolina Department of Social Services Human Services – Foster Care Children
Immediate Treatment Needs Summary Report as of 12/11/2017 • South Carolina Department of Social Services Human Services – Foster Care Children
Immediate Treatment Needs Summary Report as of 12/18/2017 • South Carolina Department of Social Services Human Services – Foster Care Initial
Screening Summary Report as of 09/24/2017 • South Carolina Department of Social Services Human Services – Foster Care Initial
Screening Summary Report as of 10/02/2017

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• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 10/09/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 10/15/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 10/22/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 10/29/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 11/06/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 11/12/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 11/19/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 11/26/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 12/04/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 12/11/2017
• South Carolina Department of Social Services Human Services – Foster Care Initial Screening Summary Report as of 12/18/2017
• Initial Health Assessments Used for Monitoring Purposes/Initial Health Screenings as of 05/01/2017
• Initial Health Assessments Used for Monitoring Purposes/Initial Health Screenings as of 06/05/2017
• Initial Health Assessments Used for Monitoring Purposes/Initial Health Screenings as of 07/03/2017
• Initial Health Assessments Used for Monitoring Purposes/Initial Health Screenings as of 07/31/2017
• Initial Health Assessments Used for Monitoring Purposes/Initial Health Screenings as of 08/07/2017
• Initial Health Assessments Used for Monitoring Purposes/Initial Health Screenings as of 09/24/2017
• Initial Health Assessments Used for Monitoring Purposes/Initial Health Screenings as of 10/03/2017
• Placement Needs Assessment Baseline Study Final Report, 08/31/2017 • Placement Needs Assessment Report; Appendix B, Appendix C, Appendix D,
Appendix E, Appendix F, Appendix G and Appendix H • South Carolina Department of Social Services Child Welfare Quality Assurance
Review Report: Greenwood County, 05/2016 • Greenwood County Comparison Chart • Greenwood County Quality Assurance Review Summary Case Notes • CAPSS Health Care and Well-Being User’s Manual • Immediate Entry of Initial Medical, Dental, and Behavioral Health Information • Michelle H. Settlement Healthcare FAQ’s • Foster Care Children Psychotropics Medications CAPSS extract, 12/2017

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Michelle H., et al. v. McMaster and Alford
Monitoring Period III (October 1, 2017 – March 31, 2018)
Progress of the South Carolina Department of Social Services
Co-Monitors: Judith Meltzer & Paul Vincent
Co-Monitor Staff: Rachel Paletta Elissa Gelber Gayle Samuels
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Michelle H., et al. v. McMaster and Alford Progress Report for the Period October 1, 2017 – March 31, 2018
TABLE OF CONTENTS

I. INTRODUCTION .............................................................................................................. 1

II. SUMMARY OF PERFORMANCE ................................................................................... 2

III. MONITORING ACTIVITIES.......................................................................................... 10

IV. SUMMARY TABLE OF MICHELLE H., et al. v. McMASTER and ALFORD FINAL SETTLEMENT AGREEMENT PERFORMANCE..................................................................... 13

V. CASELOADS ................................................................................................................... 56

VI. CASEWORKER-CHILD VISITATION.......................................................................... 74

VII. INVESTIGATIONS ......................................................................................................... 76

VIII. PLACEMENTS ................................................................................................................ 93

IX. FAMILY VISITATION.................................................................................................. 109

X. HEALTH CARE ............................................................................................................. 113

APPENDICES

A.

Glossary of Acronyms

B.

OHAN Implementation Plan Strategy Updates

C.

DSS Health Care Improvement Plan (without attachments), Approved

August 23, 2018

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LIST OF TABLES

TABLE
Table 1: Summary Performance on Settlement Agreement Requirements .................................. 13 Table 2: Status of Implementation Plans and Assessments .......................................................... 45 Table 3: Caseloads for OHAN Caseworkers as of March 13, 2018 ............................................. 68
Table 4: Baseline, Timeline and Interim Benchmark for Appropriateness of Decision Not to Investigate Referral Alleging Institutional Abuse and/or Neglect............................................ 79 Table 5: Good Faith Efforts to Contact Alleged Victim Children within 24 Hours ..................... 82 Table 6: Extraordinary Circumstance Exceptions to Contact with Alleged Victim Children within 24 Hour .............................................................................................................................. 82 Table 7: Baseline, Timeline and Interim Benchmarks Timely Initiation of Investigations.......... 83 Table 8: Exceptions to Contact with Core Witnesses during Investigations ................................ 85
Table 9: Baseline, Timeline and Interim Benchmarks for Contact with All Necessary Core Witnesses during the Investigation ............................................................................................... 85
Table 10: Contact with Necessary Core Witnesses during Investigations by Type of Core Witness as of March 2018............................................................................................................. 87
Table 11: Baseline, Timeline and Interim Benchmarks for Appropriate Case Decisions during Investigations..................................................................................................................... 88 Table 12: Examples of Good Cause Reasons to Extend Investigation Timeframes..................... 90
Table 13: Baseline, Timeline and Interim Benchmarks for Timely Completion of Investigations ................................................................................................................................ 91 Table 14: Types of Placements for Children as of March 31, 2018 ............................................. 99
Table 15: Exceptions for Placement of Children Ages 12 and Under in Non-Family-Based Placements .................................................................................................................................. 100 Table 16: Types of Placements for Children Ages 12 and Under as of March 31, 2018 ........... 101 Table 17: Exceptions for Placement of Children Ages Six and Under in Non-Family-Based Placements .................................................................................................................................. 102
Table 18: Sibling Placements for Children Entering Placement between October 2017 and March 2018 as of March 31, 2018 .............................................................................................. 108

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Table 19: Exceptions to Sibling Visitation Requirement ........................................................... 110 Table 20: Exceptions to Parent and Child Visitation Requirement ............................................ 112 Table 21: Children who Received Initial Health Assessments For Children who Entered Care between October 1, 2017 and March 31, 2018................................................................... 118

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LIST OF FIGURES

FIGURE
Figure 1: Foster Care Caseworkers within the Required Caseload Limits for October 2017 March 2018 ................................................................................................................................... 59
Figure 2: Foster Care Caseworkers over 125% of Required Caseload Limits for October 2017 March 2018 ................................................................................................................................... 59
Figure 3: Caseloads for Foster Care Caseworkers that were Over the Limit on March 13, 2018............................................................................................................................................... 60
Figure 4: Caseloads for Newly Hired Foster Care Caseworkers that were Over the Limit as of March 13, 2018 ............................................................................................................................. 61
Figure 5: IFCCS Caseworkers within the Required Caseload Limits for October 2017 - March 2018............................................................................................................................................... 62
Figure 6: IFCCS Caseworkers over 125% of Required Caseload Limits for October 2017 March 2018 ................................................................................................................................... 62
Figure 7: Caseloads for IFCCS Caseworkers that were Over the Limit on March 13, 2018 ....... 63
Figure 8: Adoption Caseworkers within the Required Caseload Limits for October 2017 - March 2018............................................................................................................................................... 64
Figure 9: Adoption Caseworkers over 125% of Required Caseload Limits for October 2017 March 2018 ................................................................................................................................... 65
Figure 10: Caseloads for Adoption Caseworkers that were Over the Limit on March 13, 2018 . 66
Figure 11: Caseloads of Newly Hired Adoption Caseworkers that were Over the Limit on March 13, 2018......................................................................................................................................... 66
Figure 12: OHAN Investigators within the Required Caseload Limits for October 2017 - March 2018............................................................................................................................................... 67
Figure 13: OHAN Investigators over 125% of Required Caseload Limits for October 2017 March 2018 ................................................................................................................................... 68
Figure 14: Foster Care, IFCCS, Adoption and OHAN Caseworkers that were Over and Within the Required Caseload Limits on March 13, 2018 ....................................................................... 69
Figure 15: Foster Care Supervisors within the Required Limits for October 2017 - March 2018 ....................................................................................................................................................... 70

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Figure 16: Foster Care Supervisors with Workloads More Than 125% Over the Required Limit for October 2017 - March 2018 .................................................................................................... 70 Figure 17: IFCCS Supervisors within the Required Limits for October 2017 - March 2018 ...... 71 Figure 18: IFCCS Supervisors with Workloads More Than 125% Over the Required Limit for October 2017 - March 2018 .......................................................................................................... 72 Figure 19: Adoption Supervisors within the Required Limits for October 2017 - March 2018 .. 73 Figure 20: Adoption Supervisors with Workloads More Than 125% Over the Required Limit for October 2017 - March 2018 .......................................................................................................... 73 Figure 21: OHAN Supervisors within the Required Limits for October 2017 - March 2018 ...... 74 Figure 22: Appropriateness of Decision Not to Investigate Referral Alleging Institutional Abuse and/or Neglect for October 2017 - March 2018............................................................................ 80 Figure 23: Timely Initiation of Investigations for June 2016 - March 2018 ................................ 84 Figure 24: Contact with All Necessary Core Witnesses during Investigations for June 2016 March 2018 ................................................................................................................................... 86 Figure 25: Decision to Unfound Investigations Deemed Appropriate for June 2016 - March 2018 ....................................................................................................................................................... 89 Figure 26: Timely Completion of Investigations for March 2018................................................ 93 Figure 27: Children Ages Six and Under in Congregate Care for April 2017 - March 2018..... 103 Figure 28: Visits that Occurred between Siblings for March 2017 - March 2018 ..................... 111 Figure 29: Children with Twice Monthly Visits with their Parents for September 2017 - March 2018............................................................................................................................................. 113

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Michelle H., et al. v. McMaster and Alford Progress Report for the Period October 1, 2017 – March 31, 2018
I. INTRODUCTION
This is the third report on the progress of the South Carolina Department of Social Services (DSS) in meeting the requirements of the Final Settlement Agreement (FSA) entered in Michelle H., et al. v. McMaster and Alford. Approved by the United States District Court on October 4, 2016, the FSA includes requirements governing the care and treatment of the more than 4,500 children in foster care in South Carolina1 and incorporates provisions that had been ordered in the previous year in a Consent Immediate Interim Relief Order (the Interim Order)2. This report has been prepared by court-appointed independent Co-Monitors Paul Vincent and Judith Meltzer, with assistance from monitoring staff Rachel Paletta, Elissa Gelber, Gayle Samuels and Erika Feinman, and is presented to The Honorable Richard Gergel, U.S. District Court Judge, Parties to the lawsuit (Governor McMaster, DSS and Plaintiffs) and the public.
The FSA outlines DSS’s obligations to significantly improve experiences and outcomes for the children in its care. It was crafted by state leaders and Plaintiffs, who conceived it to include commitments that would guide a multi-year reform effort. The FSA reflects DSS’s agreement to address long-standing problems experienced by children in foster care custody and in the operation of South Carolina’s child welfare system. It includes a broad range of provisions governing: caseworker caseloads; visits between children in foster care and their caseworkers and family members; investigations of allegations of abuse and neglect of children in foster care; appropriate and timely foster care and therapeutic placements; and access to physical and mental health care for children in DSS custody.
While the FSA includes many specific agreements on policy and practice changes and outcomes to be met, some provisions are more open ended, with agreement by Parties to add greater specificity regarding outcomes, benchmarks and timelines in collaboration with the Co-Monitors following DSS diagnostic work (including specified assessments and review of baseline information). The FSA thus establishes a structure in which the Co-Monitors work closely with DSS leaders to identify phased implementation plans to guide much of the work ahead.

1 The class of children covered by the FSA includes “all children who are involuntarily placed in DSS foster care in the physical or legal custody of DSS now or in the future” (FSA II.A.). 2 Consent Immediate Interim Relief Order (September 28, 2015).

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Included in this report is a summary of the Co-Monitors’ general findings, followed by a detailed discussion of the progress made during this monitoring period with respect to each of the FSA requirements.3
II. SUMMARY OF PERFORMANCE
Leadership Changes and Internal Restructuring
During the period under review, there have been multiple changes to strengthen the infrastructure and leadership of South Carolina’s Department of Social Services Child Welfare Division. DSS restructured its leadership team and created new positions to provide a more tailored focus on critical functions of the child welfare agency and its reform. Specifically, DSS has created:
 Director of Permanency Management, which oversees Foster Family Licensing and Support, Adoptions, Interstate Compact for the Protection of Children (ICPC) and Independent Living;
 Director of Child Health and Well-Being, which manages Intensive Foster Care and Clinical Services (IFCCS) and Clinical and Behavioral Health Services;
 Director of Safety Management, which administers the State Central Registry of Child Abuse and Neglect, Child Fatality and Near Fatality Review and Out of Home Abuse and Neglect (OHAN) investigations; and
 Director of Family and Community Partnerships, which includes Family Group Conferencing and Kinship Care.
As of the writing of this report, most of these positions have been filled with the exception of the Director of Family and Community Partnerships, which is currently vacant.
On July 16, 2018, Susan Alford resigned as State Director of DSS. On August 9, 2018, Governor Henry McMaster announced the formation of an advisory panel to assist in the search for a new Director. The panel – comprised of state representatives and senators, directors of other state agencies and numerous representatives from community agencies and organizations – is charged with developing a list of qualifications, skills and experience necessary for the next Director. An executive search firm will utilize this information to identify possible candidates for the Governor to interview. Joan Meacham, who was Chief of Staff, is serving as Acting Director while a search for a permanent Director is conducted.

3 Pursuant to FSA III.K., “The Co-Monitors shall not express any conclusion as to whether Defendants have reached legal compliance on any provision(s).”

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Analysis of Five-Year Budget
On April 19, 2018, the Court ordered DSS to develop and submit a comprehensive five-year budget plan that provides year-to-year funding allocations and information about the staff and resources necessary to meet each of the performance requirements in the FSA. On May 22, 2018, DSS submitted the required budget to the Court and during a subsequent status hearing, the Court directed the Co-Monitors to meet with DSS to review the submitted budget. This meeting took place in July 2018, and included the Co-Monitors, DSS staff and their consultant, Public Consulting Group (PCG).
With the assistance of PCG, DSS developed the budget plan by examining spending in previous years; projecting new costs associated with hiring, training and retaining new caseworkers; estimating cost savings by moving children from costly congregate care settings to family-based care; and estimating new costs from implementation of other components of the reform. The budget shared with the Court and the Co-Monitors projects only new dollars needed to supplement existing resources and assumes that current state and federal funding to DSS will remain consistent from prior years. Importantly, the budget document does not include anticipated costs to the Department of Health and Human Services (DHHS), which will likely be necessary expenditures as part of the Health Care Improvement Plan.
DSS recognizes, and the Co-Monitors agree, that the budget submitted in May is an evolving document that will need to be routinely amended as more information is gathered and the required FSA Implementation Plans are finalized. Overall, the Co-Monitors believe that while the five-year budget plan does not yet include every resource need anticipated, the budget represents a good baseline assessment. It clearly identifies that DSS will continue to need significant budget increases over the next four years. It also reflects the important need for the state to move forward aggressively with actions planned to maximize federal revenue potentially available from Title IV-E and Medicaid (Title XIX). Data within the budget also demonstrate the ultimate cost efficiencies of moving children from congregate care to family-based settings. Specifically, the current daily rate of a traditional foster home setting ranges between $13.47 and $17.84, while the daily rate of a group home setting ranges between $101.03 and $176.82.4 The proposed budget anticipates some redeployment of these funds as the state moves to develop more family foster homes.
Over the next several months, PCG plans to work with DSS on four additional projects including: cost allocation plan review, eligibility rates review, Title IV-E training claiming

4 See DSS 5-Year Budget, filed 5/22/18, p. 14.
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review and a comprehensive federal funding review and assessment. Recommendations will be developed and provided to DSS regarding steps that will need to be taken to increase federal revenue and claiming. As FSA Implementation Plans are completed, the Co-Monitors will continue to review the budget plan to ensure it is amended as needed to include the resources identified as necessary for execution of those Plans.
Areas of Accomplishment
Building the Infrastructure to Meet Children’s Health Care Needs
Over the past eight months, with the assistance of consultants hired by the Co-Monitors, DSS developed a Health Care Improvement Plan that will redesign the way health care services are organized and delivered to children in foster care and is intended to create the foundation necessary to meet the requirements of the FSA. Through significant partnership with SC’s DHHS and Select Health, the managed care organization (MCO) that serves children in foster care, DSS made significant progress with respect to each of the areas identified as immediate health care reform priorities in the prior monitoring period. In addition to its work to revise the Health Care Improvement Plan – approved by the Co-Monitors in August – DSS identified a Director of its new Office of Child Health and Well-Being; convened a cross-agency leadership team to manage the work of health care improvement; obtained critical health care data; addressed administrative barriers to MCO enrollment; and initiated a process for identifying, tracking and addressing children’s immediate health care needs.
Data Audit, Training Plan and Case Practice Model
In response to concerns raised by the Co-Monitors about the validity of data in the DSS’s Child and Adult Protective Services System (CAPSS) for measuring performance on a number of FSA measures, DSS began work in January 2018 with Chapin Hall at the University of Chicago to conduct a data audit. There are two primary goals for this project: (1) the validation of data, specifically, review of the data DSS collects for its accuracy and completeness; and (2) the provision of guidance to DSS on how to streamline its processes for data analysis, reporting and evidence use. Since the beginning of the year, Chapin Hall has worked with DSS to identify the analytic questions that need to be answered for either FSA reporting or general management activities (e.g., how many investigations were opened during the month?, what is the average caseload?), the variables relevant to answering these questions (e.g., number of investigations, size of caseloads) and the extent to which there are suspected or observed problems with the validity of these data within CAPSS. As of the writing of this report, most of the groundwork needed to identify priorities and data quality problems has been completed. Chapin Hall staff are working with various DSS workgroups to develop solutions to data quality problems, which

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include enhancements to existing CAPSS architecture and/or updates to policies and procedures to provide clarifications on caseworker responsibilities for data input. Through its work thus far, Chapin Hall has identified several strengths within DSS that have been advantageous to the data improvement work, including that: the assembled workgroup has been extremely responsive, recognizes the importance of data to operations and practice and remains open to change as it relates to current ways of performance reporting and management; and the IT team that supports CAPSS is highly flexible and collaborative in its efforts to develop new system architecture and explore opportunities to pull data from other administrative systems. Several challenges have also been identified: primarily, several vacancies in important leadership positions over the course of their work has slowed progress in developing the policy, procedures and related communication with staff that are the precursors to making any changes in caseworker practice or related CAPSS development. Chapin Hall also has recommended an increased investment in DSS’s Accountability, Data and Research (ADR) team. Although existing staff have demonstrated exceptional effort in working to meet the reporting needs of DSS, the team includes only four staff. Chapin Hall has urged DSS to consider additional statistician positions, as well as a position dedicated to work with partner agencies with whom DSS needs to share data, such as DHHS.

As discussed later in this report, there remain a number of FSA measures for which performance data cannot currently be reported either because the data are not available or cannot be validated, or because the necessary policy definitions and practice expectations have not been clearly outlined.5 However, the Co-Monitors have observed the significant time and effort both DSS and Chapin Hall have invested in the data audit and are hopeful that when the work concludes at the end of September 2018, Parties and the Co-Monitors can have confidence in the data being collected and utilized.

Chapin Hall has also begun working with DSS on two other projects. The first, which began earlier this spring, is a comprehensive assessment of DSS staff training and professional development to ensure it meets the needs of DSS’s workforce, followed by the development of a revised training and workforce development plan. The second scope of work, initiated in June 2018, is aimed at developing a strategy for DSS to operationalize and implement its draft Case Practice Model. For nearly two years, DSS has made efforts to develop and define elements of a model of case practice to include a vision of the child and family outcomes it seeks to produce and of the agency’s practice elements, such as family engagement, child and family teaming, assessment and planning. During this period, the Co-Monitors urged quicker action and DSS recognized the need for external expertise in this area as well. Chapin Hall anticipates that its

5 These include caseworker and child visits (FSA IV.B.2. & 3.), emergency of temporary placements (FSA IV.E.4. & 5.), referral for staffing and/or assessment for therapeutic foster care placements (FSA IV.I.2.), receipt of recommendations for services or placement (FSA IV.I.3.), level of care placement (FSA IV.I.4.&5.) and health measures (FSA IV.K.4(a) & (b)).

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work with DSS on the Case Practice Model will continue into CY2019, which means that the development of staff skills to implement the Case Practice Model is many months away. The CoMonitors continue to emphasize that the Case Practice Model is fundamental to the success of all other reform efforts underway and that work to complete it must occur simultaneously with planning for caseworker retention and training, quality visitation and improved placement processes.
Areas in Need of Focus and Improvement
Performance data for the current monitoring period – from October 2017 to March 2018 – demonstrate how much improvement is needed to meet the goals and expectations of the FSA. The Co-Monitors had hoped to see more improvement in practice and outcomes by this period. Instead, performance to date demonstrates the systemic problems that prompted the Michelle H. lawsuit, and the scope and depth of the necessary reforms. In some areas, performance has declined from baseline levels. And although DSS has worked to produce multiple drafts of Implementation Plans that were due in December 2016, the majority of these Plans have not yet been finalized. Almost all are yet to be approved by the Co-Monitors and remain works in progress. 6
Practice within DSS’s Out-of-Home Abuse and Neglect Investigations
One of the most significant areas of concern is practice within DSS’s Out-of-Home Abuse and Neglect (OHAN) unit, which has the responsibility to receive and investigate reports of alleged abuse and neglect of children placed by DSS in out-of-home settings. This is an area in which the Co-Monitors initially thought that DSS could demonstrate early progress. However, although current performance reflects improvements in the validity of screening decisions to investigate or not investigate a referral, investigative practice remains inadequate. This is primarily due to a continued lack of resources so that staff have the time, direction and tools to satisfactorily complete their work. The caseloads of OHAN caseworkers far exceed the required limit and the quality of the work is suffering. Between October 2017 and March 2018, a monthly range of 74 to 91 percent of OHAN caseworkers were responsible for more than eight investigations, the established standard. In March 2018, five of the six OHAN caseworkers had caseloads ranging from 10 to 36 investigations.

6 The OHAN Implementation Plan was approved on September 11, 2017 and Plaintiffs provided consent on November 7, 2017. The Healthcare Improvement Plan was developed with significant assistance from external consultants and was approved on August 23, 2018. The Visitation Implementation Plan has not yet been finalized and approved. External consultants were engaged by the Co-Monitors in June 2018 to assist in developing the Workforce Implementation Plan and Placement Implementation Plan in order to ensure they include the necessary analysis and strategies.

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While five new OHAN investigator positions were recently allocated, as of June 2018, there were three investigator vacancies and one supervisor vacancy within current OHAN staff, further compounding the workload strain. DSS reports that until these vacancies and new positions can be filled, staff from other regions of the state will assist the OHAN unit in conducting staffings and supervisory reviews of open investigations, and in expediting hiring for the new and vacant positions. The Co-Monitors think that reducing caseloads and staff turnover must remain an immediate and high priority to address the ongoing concerns about the ability of workers to carry out their responsibilities with quality.
The quality of OHAN practice remains an area of significant concern. As discussed later in this report, a review by the Co-Monitors and USC staff of 32 investigations involving Class Members accepted by OHAN and initiated in March 2018 identified continued poor performance or significant declines in performance since the previous review in September 2017. Reviewers determined that less than one-quarter (21%) of decisions to unfound an investigation were appropriate, mostly due to insufficient information being collected during the investigation, and only one investigation (3%) included contact with all necessary core witnesses. One of the most concerning findings from this review was that only 22 (69%) investigations included contact with all alleged victim children prior to closure of the investigation, meaning that in almost onethird of the investigations reviewed (10), the investigator did not interview and assess all alleged victim children prior to making a decision and closing the investigation. One of the strategies in the OHAN Implementation Plan is development of an investigation practice training curriculum to provide workers with the structure and guidance they need to critically assess children’s safety. DSS’s reported date for providing this training to staff was December 2017, however, it did not occur. As of the writing of this report, DSS reports that the curriculum is near completion and that training will be provided to current OHAN staff in October 2018 and to newly hired staff in January 2019. This strategy, if implemented with quality and reinforced through appropriate supervision, is an important component to improving the investigative practice reflected in the recent review.
Placement Array and Processes
Improvements to DSS’s placement array and processes are a significant focus of the FSA. As required by the September 2015 Interim Order, DSS has significantly reduced the number of children ages six and under placed in congregate care7 and the number of children staying overnight at a DSS office8. Yet, data on the percentage of children placed in congregate care this

7 During the period under review, 16 Class Members ages six and under were placed in congregate care; 12 of these children met an agreed upon exception either because the child was residing in a treatment facility with their mother or the child was part of a sibling group of four or more children for whom DSS reports a single, family-based placement could not be located. 8 Between October 2017 and March 2018, DSS reports two children stayed overnight in a DSS office.

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monitoring period (22 percent as of March 31, 2018) has not shown progress since the prior period (21 percent as of September 30, 2017). This is likely due to delays in adequately completing both the Placement Needs Assessment and the Placement Implementation Plan, which were to guide a comprehensive and cohesive process for ensuring appropriate placements and services for children throughout the state. DSS submitted a draft Placement Implementation Plan on October 31, 2017, and a revised draft on March 30, 2018, and after review, the CoMonitors determined that the Plan required substantial revision. Consequently, given the urgency and fundamental importance of placement issues, in June 2018 the Co-Monitors engaged consultants to provide technical assistance in this area. The primary purpose of the consultants’ work is to assess and identify gaps in the recommendations, feasibility, resource needs, strategies and timelines outlined in the draft Placement Implementation Plan; to assist DSS in developing an acceptable Plan; and, if needed, support DSS with Plan implementation.
In an effort to build a deeper understanding of placement issues and processes as part of their monitoring work, the Co-Monitors visited several group care facilities in December 2017 where they observed a number of concerning practices and conditions. Although these observations have been shared with DSS, the Co-Monitors determined that additional in-depth review of children’s experiences in group care placements was needed. In April 2018, the Co-Monitors informed DSS of their plan to augment their monitoring capacity through the engagement of additional consultants to perform a special review of the quality of congregate care facilities throughout the state, focusing on the capacity to meet the needs of Class Members, and the extent to which these needs could be met in family-based settings. Consultants have been engaged and this assessment is expected to be completed in October 2018 and to include findings and recommendations that will inform the development of the Placement Implementation Plan.
Workforce Recruitment and Retention
All parties, as well as all child welfare practitioners agree that manageable caseloads for caseworkers and adequate supervisory supports are foundational components of a productive and effective workforce. Although having an adequate number of staff is critical, it is equally important that the right kind of staff are recruited, hired, trained and retained by DSS. This is another area of reform where progress has been insufficient. In most months during the monitoring period, fewer than 25 percent of caseworkers had caseloads within the required limit; specifically, in March 2018, only 25 percent of foster care caseworkers, 22 percent of IFCCS caseworkers and 15 percent of adoption caseworkers had caseloads within the required limits. Further, with the exception of OHAN supervisors9, all categories of supervisors were not within the 90 percent requirement of their workload limit. For example, in March 2018, only 42 percent

9 All three OHAN supervisors met the required limit of six or fewer investigators assigned each month during the period.

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of foster care supervisors, 57 percent of IFCCS supervisors and 38 percent of adoption supervisors supervised five or fewer caseworkers, the established standard. DSS’s FY2017/2018 budget provided funds for 163 new full time employee positions to support reform efforts in reducing caseload size. As of April 30, 2018, DSS reports only 33 percent of these positions had been filled. Vacancies within existing caseworker and supervisor positions also continue to be a challenge.

The FSA requires DSS to develop a Workload Implementation Plan which includes strategies to meet workload requirements. Several drafts of the Plan have been produced by DSS and the CoMonitors have provided feedback, consistently asking that DSS include more specificity on budget sequencing, requests and strategies to develop the resources needed to meet the caseload requirements within four years. On May 29, 2018, DSS provided an updated draft of the Workload Implementation Plan with budgeting and resource information. In June 2018, the CoMonitors hired a consultant with expertise in hiring and recruitment to assess DSS’s draft Plan, identify where DSS planning can be strengthened and suggest actionable strategies to enable DSS to meet their workload obligations. This consultant will complete the assessment and provide recommendations by the end of September 2018.

Federal Child and Family Services Review Results

In April 2018, the Children’s Bureau released findings from Round 3 of its Child and Family Service Reviews (CFSR) in South Carolina. The CFSR occurred between April and September 2017, and included reviews of 100 randomly selected cases10 from 10 counties11 across the state and stakeholder interviews. The CFSR includes a total of 36 items which are organized as child and family outcomes (safety, permanency and well-being) and systemic factors (statewide information system; case review system; quality assurance system; staff and provider training; service array and resource development; agency responsiveness to the community; and foster and adoptive parent licensing, recruitment and retention). DSS was not found to be in substantial conformity with any of the safety, permanency or well-being outcomes. DSS was in substantial conformity with one of the seven systemic factors – agency responsiveness to the community.

Practice trends identified by the Children’s Bureau based upon CFSR case reviews are consistent with many of the observations of the Co-Monitors. These include lack of quality assessments; the need to focus on engaging parents, youth and caregivers; unstable and multiple placements for children; and lack of access to services. These practices directly impact DSS’s ability to meet many FSA measures and highlight the importance of including strategies to improve practice in the required Implementation Plans. For example, it is difficult to find an appropriate and stable
10 These included 51 in-home cases, 40 foster care cases and nine community-based prevention services cases. 11 The counties include Aiken, Berkeley, Chesterfield, Fairfield, Greenville, Horry, Jasper, Newberry, Pickens and York.

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placement for a child without a quality assessment and access to appropriate supportive and community-based services. And caseworkers must engage with parents and children to ensure that visits occur. DSS is required by the Children’s Bureau to develop a Program Improvement Plan (PIP) to address the areas in which it was not found to be in substantial conformity, with priority given to safety interventions. The first draft of the PIP was due on June 4, 2018, and the plan must be implemented over two years. DSS is working to insure the integration of the PIP strategies with those required by the FSA.
Summary
In conclusion, since the beginning of the reform, DSS has not had sufficient capacity to adequately assess challenges, develop corresponding strategies or appropriately effectuate positive change, and steps to build this capacity have taken longer than everyone anticipated. Commentary among providers and within the legislature about the lack of demonstrable progress in areas such as caseloads, health care and placement are reflective of this frustration. DSS has recently developed additional capacity and structure in its central office to lead this work. Its constructive engagement with the health care consultants, DHHS and Select Health on health care planning has offered a model of work in partnership that can accelerate and focus other key areas of work. These very recent developments, plus the additional support now available through external consultants, will hopefully lead to much-needed progress and some positive results for children and families in the next year. This will be a real test of commitments from leadership to manage a multi-year, complex reform.
III. MONITORING ACTIVITIES
The Co-Monitors are responsible for factual investigation and verification of data and documentation to compile and issue public reports on performance with respect to the terms of the FSA. In carrying out this responsibility, the Co-Monitors and their staff have worked closely with DSS leadership and staff. The Co-Monitors used multiple methodologies to conduct their work, including verification and analysis of information available through CAPSS12; independent review of individual electronic and hardcopy case records; review and validation of data aggregated by DSS; interviews and conversations with DSS leaders and staff; and conversations with external stakeholders, including providers, advocacy and community organizations. The Co-Monitors have worked with DSS and USC’s Center for Child and Family Studies (CCFS) to establish review protocols to gather performance data and assess current practice. Specific data collection and/or validation activities conducted by the Co-Monitors for the current period include the following:

12 CAPSS is DSS’s State Automated Child Welfare Information System (SACWIS).
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 Monthly review of all referrals involving allegations of abuse and/or neglect of Class Members not accepted for investigation by DSS’s OHAN (FSA IV.C.2.);
 Review of all OHAN investigations involving Class Members that were accepted and initiated in March 2018 to assess for timely initiation, contact with core witnesses, timely completion and appropriateness of unfounded decisions (FSA IV.C.3.&4.);
 Review of case files of a statistically valid sample of Class Members with siblings in foster care in March 2018 to assess whether sibling visits had occurred (FSA IV.J.2.);
 Review of case files of a statistically valid sample of Class Members with a goal of reunification in March 2018 to assess whether visits with parents had occurred (FSA IV.J.3.);
 Review of case files of Class Members identified by stakeholders as involved with the South Carolina Department of Juvenile Justice (DJJ) to assess appropriateness of DJJ placement (FSA IV.H.1.);
 Review of case files of children ages six and under who are placed in a congregate care setting (FSA IV.D.2.); and
 Review of all case files of children reported to have remained in a DSS office overnight (FSA IV.D.3.).
In addition to these data collection and reporting functions, the FSA gives the Co-Monitors the responsibility to review and approve Implementation Plans and to set or approve interim benchmarks and outcomes in multiple areas of practice. This has meant that the Co-Monitors and their staff have assumed a technical assistance role in addition to a monitoring function, helping to build capacity, connect DSS leadership with resources from across the country and engage consultants, when needed. The Co-Monitors have also acted in an intermediary role, working at times to bridge differences between DSS and Plaintiffs, and encouraging communication and problem solving among Parties. The Co-Monitors strongly believe that this type of ongoing collaboration will be critical to DSS’s ability to successfully reform its child welfare system.

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IV. SUMMARY TABLE OF MICHELLE H., et al. v. McMASTER and ALFORD FINAL SETTLEMENT AGREEMENT PERFORMANCE
Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Workload Limits for Foster Care: A foster care Workload Limit must apply to every Caseworker and to every Caseworker’s supervisor. DSS may identify categories of Caseworker or Supervisor or both and set a different Workload Limit for each category. (FSA IV.A.2.(b)&(c))

1a. At least 90% of caseworkers shall have a workload within the applicable Workload Limit.
1b. No caseworker shall have more than 125% of the applicable Workload Limit.

OHAN caseworkers: As of September 25, 2017, no (0%) OHAN caseworker had a caseload within the required limit and all (100%) caseworkers had caseloads more than 125% over the limit.

OHAN caseworkers:16,17 As of March 2018, 17% of OHAN caseworkers had a caseload within the required limit and 67% of caseworkers had caseloads more than 125% of the limit.

Dates to reach final target and interim benchmarks to be added once Workload Implementation Plan is approved.

Monthly range of performance for caseworkers within the required limit: 14 – 17%18. Monthly range of performance for caseworkers with caseloads more than 125% of the limit: 67 – 83%19

13 The obligations for the workload study (FSA IV.A.1.), placement needs assessment (FSA IV.D.1.) and select placement limitations (FSA IV.D.2., 3. & H.1.) became operative as of September 28, 2015, when the Consent Immediate Interim Relief Order was entered. Therefore, the Interim Relief Order requirements are incorporated into the FSA. 16 The Co-Monitors selected a random day in each month this period to measure caseload compliance for each type of caseworker. These random dates are as follows: October 24, 2017; November 6, 2017; December 14, 2017; January 29, 2018; February 8, 2018; March 13, 2018. Performance on this date is compared to other randomly selected dates during the month to ensure limited variability and reported performance is not an anomaly.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Approved Caseworker Limits:14, 15  OHAN investigator: 1 caseworker: 8 investigations  Foster Care caseworker: 1 caseworker: 15 children  IFCCS caseworker: 1 caseworker: 9 children  Adoption caseworker: 1 caseworker: 17 children  New caseworker: ½ of the applicable standard for their first
6 months after completion of Child Welfare Basic
Approved Supervisor Limits:  For Foster Care, IFCCS and Adoption supervisors:
1 supervisor: 5 caseworkers  OHAN supervisors: 1 supervisor: 6 investigators

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Foster Care caseworkers: As of September 25, 2017, 28% of foster care caseworkers had a caseload within the required limit and 59% of caseworkers had caseloads more than 125% over the limit.

Foster Care caseworkers: As of March 2018, 25% of foster care caseworkers had a caseload within the required limit and 62% of caseworkers had caseloads more than 125% of the limit.

17 The data audit work being conducted by Chapin Hall has identified potential issues with the quality and accuracy of these data. Specifically, some caseworker profiles still need to be updated, cleaned and/or validated to track case assignments properly. DSS and Chapin Hall plan to engage a small group of counties to test the accuracy of current CAPSS caseload reporting methodology. Additionally, DSS will consider changing policy to dictate that caseworker CAPSS profiles can only be completed by county Human Resources staff or other administrative level personnel instead of caseworker self-identification. 18 Monthly performance for OHAN caseworker caseloads within the required limit are as follows: October 2017, 14%%; November 2017, 14%; December 2017, 14%; January 2018, 17%; February 2018, 17%; March 2018, 17%. 19 Monthly performance for OHAN caseworker caseloads more than 125% over the limit are as follows: October 2017, 71%; November 2017, 86%; December 2017, 71%; January 2018, 83%; February 2018, 83%; March 2018, 67%. 14 These limits were approved by the Co-Monitors on December 6, 2016, after completion of the Workload Study. 15 Caseload limits and methodologies to calculate performance for caseworkers with mixed caseloads, both Class and Non-Class Members, were approved in December 2017. Non-Class Members include children receiving family preservation services while remaining in the home with their parent or caregiver, Adult Protective Services cases, families involved in child protective service assessments and children placed by ICPC. Performance for foster care caseworkers with mixed caseloads is calculated by adding the total number of foster care children (Class Members) the caseworker serves to the total number of families (cases) of Non-Class Members the caseworker also serves. The total number should not exceed 15 children and cases.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Monthly range of performance for caseworkers within the required limit: 25 – 28%.20,21 Monthly range of performance for caseworkers with caseloads more than 125% of the limit: 57 – 63%22

IFCCS caseworkers: As of September 25, 2017, 10% of IFCCS caseworkers had a caseload within the required limit and 77% of caseworkers had caseloads more than 125% over the limit.

IFCCS caseworkers: As of March 2018, 22% of IFCCS caseworkers had a caseload within the required limit and 50% of caseworkers had caseloads more than 125% of the limit.

20 Monthly performance for foster care caseworker caseloads (which includes newly hired caseworkers, supervisors carrying foster care cases and county foster care caseworkers) within the required limit are as follows: October 2017, 27%; November 2017, 26%; December 2017, 25%; January 2018, 28%; February 2018, 27%; March 2018, 25%. 21 Monthly caseload performance for only newly hired foster care caseworkers are as follows: October 2017, 14%; November 2017, 13%; December 2017, 12%; January 2018,
22%; February 2018, 21%; March 2018, 28%. 22 Monthly performance for foster care caseworker caseloads more than 125% over the limit are as follows: October 2017, 62%; November 2017, 62%; December 2017, 63%; January 2018, 57%; February 2018, 59%; March 2018, 62%.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Monthly range of performance for caseworkers within the required limit: 9 - 26%.23,24 Monthly range of performance for caseworkers with caseloads more than 125% of the limit: 50 - 78%25

Adoption caseworkers: As of September 25, 2017, 23% of adoption caseworkers had a caseload within the required limit and 62% of caseworkers had caseloads more than 125% over the limit.

Adoption caseworkers: As of March 2018, 15% of adoption caseworkers had a caseload within the required limit and 67% of caseworkers had caseloads more than 125% of the limit.

23 Monthly performance for IFCCS caseworker caseloads (which includes newly hired caseworkers and supervisors carrying cases) within the required limit are as follows: October 2017, 9%; November 2017, 14%; December 2017, 16%; January 2018, 26%; February 2018, 23%; March 2018, 22%. 24 Monthly caseload performance for only newly hired IFCCS caseworkers are as follows: October 2017, 0%; November 2017, 33%; December 2017, 50%; January 2018, 83%;
February 2018, 67%; March 2018, 78%. 25 Monthly performance for IFCCS caseworker caseloads more than 125% over the limit are as follows: October 2017, 72%; November 2017, 78%; December 2017, 76%; January 2018, 56%; February 2018, 50%; March 2018, 50%.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance
Monthly range of performance for caseworkers within the required limit: 15 - 21%.26,27 Monthly range of performance for caseworkers with caseloads more than 125% of the limit: 64 - 69%28

2a. At least 90% of supervisors shall have a workload within the applicable Workload Limit.
2b. No supervisor shall have more than 125% of the applicable Workload Limit.
Dates to reach final target and interim benchmarks to be added once Implementation Plan is approved.

Data are not available for this period.

OHAN Supervisors: As of March 2018, 100% of OHAN supervisors were within the required limit.
Monthly range of performance for supervisors within the required limit:100%

26 Monthly performance for adoption caseworker caseloads (which includes newly hired caseworkers and supervisors carrying cases) within the required limit are as follows: October 2017, 20%; November 2017, 20%; December 2017, 18%; January 2018, 19%; February 2018, 21%; March 2018, 15%. 27 Monthly caseload performance for only newly hired adoption caseworkers are as follows: October 2017, 14%; November 2017, 14%; December 2017, 0%; January 2018, 14%;
February 2018, 14%; March 2018, 14%. 28 Monthly performance for adoption caseworker caseloads more than 125% over the limit are as follows: October 2017, 65%; November 2017, 66%; December 2017, 68%; January 2018, 64%; February 2018, 69%; March 2018, 67%.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance
Foster Care Supervisors: As of March 2018, 42% of foster care supervisors were within the required limit and 36% of supervisors were more than 125% of the limit.

Monthly range of performance for foster care supervisors within the required limit: 42 – 45%.29 Monthly range of performance for supervisors more than 125% of the limit: 35 – 38%.30

IFCCS Supervisors: As of March 2018, 57% of IFCCS supervisors were within the required limit and 29% of supervisors were more than 125% of the limit.

29 Monthly performance for foster care supervisors within the required limit are as follows: October 2017, 45%; November 2017, 43%; December 2017, 43%; January 2018, 43%; February 2018, 42%; March 2018, 42%. 30 Monthly performance for foster care supervisors more than 125% over the limit are as follows: October 2017, 35%; November 2017, 38%; December 2017, 38%; January 2018, 35%; February 2018, 36%; March 2018, 36%.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance
Monthly range of performance for IFCCS supervisors within the required limit: 47 – 57%.31 Monthly range of performance for supervisors more than 125% of the limit: 29 – 32%.32

Adoption Supervisors: As of March 2018, 38% of adoption supervisors were within the required limit and 19% of supervisors were more than 125% of the limit.

Monthly range of performance for adoption supervisors within the required limit: 38 – 61%.33 Monthly range of performance for supervisors more than 125% of the limit: 11 – 19%.34

31 Monthly performance for IFCCS supervisors within the required limit are as follows: October 2017, 47%; November 2017, 47%; December 2017, 57%; January 2018, 57%;
February 2018, 57%; March 2018, 57%. 32 Monthly performance for IFCCS supervisors more than 125% over the limit are as follows: October 2017, 32%; November 2017, 32%; December 2017, 29%; January 2018, 29%; February 2018, 29%; March 2018, 29%. 33 Monthly performance for adoption supervisors within the required limit are as follows: October 2017, 58%; November 2017, 58%; December 2017, 61%; January 2018, 38%;
February 2018, 38%; March 2018, 38%. 34 Monthly performance for adoption supervisors more than 125% over the limit are as follows: October 2017, 11%; November 2017, 11%; December 2017, 11%; January 2018, 19%; February 2018, 19%; March 2018, 19%.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Caseworker-Child Visitation:
(FSA IV.B.2.&3.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

3. At least 90% of the total minimum number of face-to-face visits with Class Members by caseworkers during a 12month period shall have taken place.

Unable to determine current performance.

Unable to determine current performance.35

4. At least 50% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place in the residence of the child.

Unable to determine current performance.

Unable to determine current performance.36

Investigations – Intake: (FSA IV.C.2.)

5. At least 95% of decisions not to investigate a Referral of Institutional Abuse or Neglect about a Class Member must be made in accordance with South Carolina law and DSS policy.
Interim benchmark requirement – By March 2018, 90%

Monthly performance for screening decisions not to investigate determined to be appropriate:
May 2017: 67% June 2017: 83% July 2017: 59% August 2017: 62% September 2017: 88%

Monthly performance for screening decisions not to investigate determined to be appropriate:
October 2017: 92% November 2017: 84% December 2017: 93% January 2018: 89% February 2018: 80% March 2018: 81%

35 See Section VI for further discussion. 36 Ibid.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Investigations – Case Decisions:
(FSA IV.C.3.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

6. At least 95% of decisions to “unfound” investigations of a Referral of Institutional Abuse or Neglect must be based upon DSS ruling out abuse or neglect or DSS determining that an investigation did not produce a preponderance of evidence that a Class Member was abused or neglected.

In September 2017, there were 38 investigations with decisions to unfound; 58% (22) of these decisions were determined to be appropriate.

In March 2018, there were 29 investigations with decisions to unfound; 21% (6) of these decisions were determined to be appropriate.

Interim benchmark requirement – By March 2018, 50%

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Investigations – Timely Initiation: (FSA IV.C.4.(a)) Investigations – Contact with Alleged Child Victim: (FSA IV.C.4.(b))

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

7. The investigation of a Referral of Institutional Abuse or Neglect must be initiated within twenty-four (24) hours in accordance with South Carolina law in at least 95% of the investigations.
8. The investigation of a Referral of Institutional Abuse or Neglect must include face-to-face contact with the alleged victim within twenty-four hours in at least 95% of investigations, with exceptions for good faith efforts approved by the Co-Monitors.

In September 2017, of the 40 applicable investigations, 80% (32) were timely initiated or had documentation supporting completion of all applicable good faith efforts.

In March 2018, of the 32 applicable investigations, 66% (21) were timely initiated or had documentation supporting completion of all applicable good faith efforts.37, 38

Interim benchmark requirement – By March 2018, 80%

37 Contact was made with all the alleged victim child(ren) within 24 hours in 19 investigations and in two additional investigations, documentation supported completion of all applicable good faith efforts. 38 The Co-Monitors’ interpretation of the FSA requires that investigations be initiated within 24 hours of receipt of the referral by DSS, not within 24 hours of the decision to accept the referral, and that initiation is completed by making face-to-face contact with the alleged victim child(ren). As a result, the performance for both FSA measures IV.C.4.(a) and (b) are measured using the same methodology and timeframes – the time between receipt of referral and face-to-face contact with alleged child(ren) victim must be within 24 hours.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Investigations – Contact with Core Witnesses:
(FSA IV.C.4.(c))

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

9. Contact with core witnesses must be made in at least 90% of the investigations of a Referral of Institutional Abuse or Neglect, with exceptions approved by the CoMonitors. Core witnesses will vary from case to case and may or may not include the victim(s), Class Members, alleged perpetrators, reporter (if identified), identified eyewitness(es), other children in the placement, facility staff, treating professionals, and foster parents or caregivers as deemed to be relevant to the investigation.

In September 2017, none (0%) of the 40 applicable investigations included contact with all necessary core witnesses during the investigation.

In March 2018, 3% (1) of the 32 applicable investigations included contact with all necessary core witnesses during the investigation.

Interim benchmark requirement – By March 2018, 40%

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Investigations – Timely Completion:
(FSA IV.C.4.(d-f))

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

10.a. At least 60% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within fortyfive (45) days of initiation of an investigation, unless the DSS Director or DSS Director’s designee authorizes an extension of no more than fifteen (15) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

79% of applicable investigations received in September 2017 were appropriately closed within 45 days.

82% of applicable investigations received in March 2018 were appropriately closed within 45 days.39

Interim benchmark requirement – By March 2018, 75%

39 Of the 34 applicable investigations received in March 2018, one investigation was excluded from the 45-day compliance measure as a 15-day extension request was submitted and approved by the OHAN Director. (In one additional investigation, an extension was requested and granted due to the assigned investigator becoming ill; the reviewer determined that this situation did not meet the requirements for a good cause reason to approve an extension and should not be excluded from this measure as another investigator could have been assigned.) Of the remaining 33 investigations, 29 investigations were completed within 45 days, however, reviewers determined that two of the investigations closed within 45 days were closed as unfounded prematurely in an effort to meet the 45-day requirement. Therefore, 27 of the 33 applicable investigations met the FSA standard.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

10.b. At least 80% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within sixty (60) days of initiation of the investigation, and all investigations not completed within sixty (60) days shall have authorization of the DSS Director or DSS Director’s designee of an extension of no more than thirty (30) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

88% of applicable investigations received in September 2017 were appropriately closed within 60 days.

88% of applicable investigations received in March 2018 were appropriately closed within 60 days.40

Interim benchmark requirement – By March 2018, 80%

40 Two investigations were determined to be closed prematurely in an effort to meet the deadline and are not considered compliant. Therefore, 30 of the 34 applicable investigations met the FSA standard.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

10.c. At least 95% of all investigations of a Referral of Institutional Abuse or Neglect not completed within sixty (60) days shall be completed within ninety (90) days. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed.

93% of applicable investigations received in September 2017 were appropriately closed within 90 days.

88% of applicable investigations received in March 2018 were appropriately closed within 90 days.41

Interim benchmark requirement – By March 2018, 95%

41 Two investigations were determined to be closed prematurely in an effort to meet the deadline and are not considered compliant. Additionally, while conducting the case record review, it was determined that two investigations involving Class Members that were received and initiated in March 2018 were still open and were exceeding 90 days. The files for these investigations could not be provided so information on these two investigations could not be collected for other OHAN measures, however, they could be included for this measure. Therefore, 30 of the 34 applicable investigations met the FSA standard.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Family Placements for Children Ages 6 and Under:
Within sixty (60) days, DSS shall create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the Co-Monitors, the placement of any Class Member age six (6) and under in any nonfamily group placement (including but not limited to group homes, shelters or residential treatment centers). The plan shall include full implementation within sixty (60) days following approval of the Co-Monitors.

11. No child age six and under shall be placed in a congregate care setting except with approved exceptions.

In September 2017, there were four Class Members ages six and under in DSS custody and residing in a congregate care facility. The circumstances of one of those children met an agreed upon exception for placement in congregate care and approval was sought prior to the child’s placement as per DSS directive.42

In March 2018, there were eight Class Members ages six and under in DSS custody and residing in a congregate care facility. The circumstances of seven of those children met an agreed upon exception for placement in congregate care and approval was sought prior to the child’s placement as per DSS directive.

(FSA IV.D.2.)

Between April and September 2017, a total of nine Class Members ages six and under were placed in congregate care. The circumstances of five of these young children met an agreed upon exception.

Between October 2017 and March 2018, a total of 16 Class Members ages six and under were placed in congregate care. The circumstances of 12 of these young children met an agreed upon exception43.

42 Two of the children who did not meet an agreed upon exception were placed in a congregate care facility prior to entering DSS custody and the family court, (when issuing the order for emergency removal from the parents’ custody), also ordered that the children remain in the facility placement. 43 Applicable exceptions for the referenced children include the child was residing in a treatment facility with their mother or the child was part of a sibling group of four or more children for whom DSS reports a single, family-based placement could not be located.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Phasing-Out Use of DSS Offices and Hotels:
Within sixty (60) days, DSS shall cease using DSS offices as an overnight placement for Class Members, and shall cease placing or housing any Class Members in hotels, motels and other commercial non-foster care establishments. For any Class Members moved out of such DSS Offices or Hotels, DSS shall provide for their appropriate placement. In the extraordinary event that a child stays overnight in a DSS office, Defendants shall immediately notify the Co-Monitors, who shall provide a report to Parties as appropriate, including whether or not, in their view, the incident should be reported to the Court as a violation which would preclude Defendants’ ability to achieve compliance on this provision.

12. No child shall be placed or housed in a DSS office, hotel, motel, or other commercial non-foster care establishment.

Between April and September 2017, DSS reports three children remained overnight in a DSS office.44

Between October 2017 and March 2018, DSS reports two children remained overnight in a DSS office.45

(FSA IV.D.3.)

44 Although reports of children sleeping in DSS offices and hotels is limited to these instances, the Co-Monitors are concerned about reports that children are being placed on an emergency, short-term basis in foster homes as a way of avoiding these overnight stays, cycling at times through a series of one-night stays in foster homes until an appropriate placement can be located. The Co-Monitors will continue to explore this issue. 45 Ibid.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Congregate Care Placements:
(FSA IV.E.2.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

13. At least 86% of the Class Members shall be placed outside of Congregate Care Placements on the last day of the Reporting Period.

As of September 30, 2017, 79% (3,225 of 4,079) of children in foster care were placed outside of a congregate care setting.

As of March 31, 2018, 78% (3,313 of 4,226) of children in foster care were placed outside of a congregate care setting.46, 47

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

46 Twenty-six children who were hospitalized (11) or in a correctional facility (15) are not included in the universe for this measure. 47 The data audit work being conducted by Chapin Hall has identified potential issues with the quality and accuracy of data related to placement. Specifically, placement type, placement stability and emergency or temporary placements. This may impact the accuracy of data for this measure as well as other placement measures reported herein. DSS and Chapin Hall have a project underway to assess the extent of any issues and will develop a plan for correction as needed. Additionally, DSS data provided for this period do not indicate whether a child’s placement in custody is voluntary or involuntary, which would enable reporting to distinguish between Non-Class Members and Class Members. Although the Co-Monitors have worked with DSS to manually correct for this coding issue with respect to a number of measures, it is possible that for some placement measures, a small number of Non-Class Members are included in aggregate data. DSS recently developed the capacity to distinguish between children who are voluntarily and involuntarily placed in care and data for the next monitoring period will reflect these enhancements.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Congregate Care Placements – Children Ages 12 and Under:
(FSA IV.E.3.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

14. At least 98% of the Class Members twelve (12) years old and under shall be placed outside of Congregate Care Placements on the last day of the Reporting period unless an exception pre-approved or approved afterwards by the Co-Monitors is documented in the Class Member’s case file.

As of September 30, 2017, 93% (2,655 of 2,866) of children ages 12 and under in foster care were placed outside of a congregate care setting.

As of March 31, 2018, 92% (2,727 of 2,966) of children ages 12 and under in foster care were placed outside of a congregate care setting. 48

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

48 Exceptions have been approved, though not applied during this monitoring period; therefore, performance may be higher than reported. DSS will develop a process for review and approval.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Emergency or Temporary Placements for More than 30 Days:
(FSA IV.E.4.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

15. Class Members shall not remain in any Emergency or Temporary Placement for more than thirty (30) days. Under exceptions subject to the Co-Monitors’ approval, if a child is initially placed in an Emergency or Temporary Placement that is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move under Section IV.F.1 below.

Data are not available for this period.

Data are not available for this period.49

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

49 DSS is unable to provide the data needed to report on this requirement. DSS has identified two primary barriers to collecting and providing these data: (1) there is not a standard, operational definition for “emergency” or “temporary” placements, and (2) due to a lack of a clear operational definition, placement data utilizing these categories are inconsistently entered by staff into CAPSS. DSS has informed the Co-Monitors that after a definition is agreed upon, a code book of definitions describing each level of foster care will be developed and fields will be added to CAPSS to capture and collect necessary information. The Co-Monitors anticipate that sufficient information regarding methods to develop and implement data collection for analysis and monitoring will be included in the final Placement Implementation Plan.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Emergency or Temporary Placements for More than 7 Days:
(FSA IV.E.5.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

16. Class Members experiencing more than one Emergency or Temporary Placement within twelve (12) months shall not remain in the Emergency or Temporary Placement for more than seven (7) days. Under exceptions subject to the Co-Monitors’ approval, if a child’s subsequent placement within twelve (12) months in an Emergency or Temporary Placement is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move under Section IV.F.1 below.

Data are not available for this period.

Data are not available for this period.
50

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

50 Ibid.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Placement Instability:
(FSA IV.F.1.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

17. For all Class Members in foster care for eight (8) days or more during the 12month period, Placement Instability shall be less than or equal to 3.37.

Children in foster care for eight (8) days or more from October 1, 2016 to September 30, 2017, experienced instability at a rate of 3.55.51, 52

Data for this measure is reported on an annual basis and will be included in the next monitoring report.53

51 Specifically, there were a total of 5,186 moves and 1,459,138 total applicable days. 52 It should be noted that performance based on the FSA placement instability measure is not comparable to performance with respect to the federal Round 3 Child and Family Services Review (CFSR) permanency outcome that measures stability of foster care placement. The CFSR outcome is based on the rate of placement per day of all children who
enter foster care in a 12-month period, which is likely to be significantly higher than the rate of placement for all children in foster care during that period of time. See Data Indicators for the Child and Family Services Review, available at https://www.acf.hhs.gov/sites/default/files/cb/data_indicators.pdf. 53 Performance is reported by fiscal year. The next monitoring report will include performance for October 1, 2017 through September 30, 2018.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Sibling Placements:
(FSA IV.G.2.&3.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

18. At least 85% of Class Members entering foster care during the Reporting Period with their siblings or within thirty (30) days of their siblings shall be placed with at least one of their siblings unless one or more of the following exceptions apply: (1) there is a court order prohibiting placing all siblings together; (2) placement is not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) additional exceptions as approved by the Co-Monitors.

64% (484 of 754) of children entering foster care with their siblings or within 30 days of their siblings from April to September 2017 were placed with at least one of their siblings.

63% (547 of 863) of children entering foster care with their siblings or within 30 days of their siblings from October 2017 to March 2018 were placed with at least one of their siblings on March 30, 2018. 54

Dates to reach final target and interim benchmarks to be added once Placement Implementation Plan is approved.

54 Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

19. At least 80% of Class Members entering foster care during the Reporting Period with their siblings or within thirty (30) days of their siblings shall be placed with all their siblings, unless one or more of the following exceptions apply: (1) there is a court order prohibiting placing all siblings together; (2) placement is not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) additional exceptions as approved by the Co-Monitors.

As of September 30, 2017, 41% (310 of 754) of children entering foster care with their siblings or within thirty (30) days of their siblings from April to September 2017 were placed with all of their siblings.

As of March 30, 2018, 38% (324 of 863) of children entering foster care with their siblings or within thirty (30) days of their siblings from October 2017 to March 2018 were placed with all of their siblings.

Dates to reach final target and interim benchmarks to be added once Placement Implementation Plan is approved.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Youth Exiting the Juvenile Justice System:
(FSA IV.H.1.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

20. When Class Members are placed in juvenile justice detention or another Juvenile Justice Placement, DSS shall not recommend to the family court or Department of Juvenile Justice that a youth remain in a Juvenile Justice Placement without a juvenile justice charge pending or beyond the term of their plea or adjudicated sentence for the reason that DSS does not have a foster care placement for the Class Member.

Unable to determine performance.

Unable to determine current performance.55

DSS shall take immediate legal and physical custody of any Class Member upon the completion of their sentence or plea. DSS shall provide for their appropriate placement.

55 DSS does not currently have a system in place for tracking youth involved with both the juvenile justice and child welfare systems. As discussed in Section VIII below, the CoMonitors reviewed a number of cases – likely representative of many others – in which youth spent time in DJJ facilities due, in part, to DSS’s failure to meet their needs.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Therapeutic Foster Care Placements –Referral for Staffing and/or Assessment:
(FSA IV.I.2.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

21. All Class Members that are identified by a Caseworker as in need of interagency staffing and/or in need of diagnostic assessments shall be referred for such staffing and/or assessment to determine eligibility for therapeutic foster care placement and/or services within thirty (30) days of the need being identified. This requirement shall not apply if the Caseworker withdraws the identified need in good faith and in the best interests of the Class Member within thirty (30) days.

Data are not available for this period.

Data are not available for this period.56

Dates to reach final target and interim benchmarks to be added once Placement Implementation Plan is approved.

56 DSS has informed the Co-Monitors that data for this measure are not currently available as fields need to be added to CAPSS to capture and collect necessary information. The Co-Monitors anticipate that sufficient information regarding methods to develop and implement data collection for analysis and monitoring will be included in the final Placement Implementation Plan.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period October 2017 – March 2018

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Therapeutic Foster Care Placements –Receipt of Recommendations for Services or Placement:
(FSA IV.I.3.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

22. All Class Members that are referred for interagency staffing and/or needed diagnostic assessments shall receive recommendations for specific therapeutic foster care placement and/or services within forty-five (45) days of receipt of the completed referral. The recommendation(s) may include diagnostic assessment, community support services, rehabilitative behavioral health services, therapeutic foster care, group care, and psychiatric residential treatment facility. Level of Care Placement recommendations shall utilize the least restrictive care philosophy suitable to the child’s needs and seek to place a Class Member in a family setting with a community support system. DSS shall update the assessment at least annually thereafter, upon a placement disruption or upon a material change in the Class Member’s needs. In making that determination, DSS may consider the full array of appropriate placement alternatives to meet the needs

Data are not available for this period.

Data are not available for this period.57

57 Ibid.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target
of the Class Members.
Dates to reach final target and interim benchmarks to be added once Placement Implementation Plan is approved.

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Therapeutic Foster Care Placements – Level of Care Placement:
(FSA IV.I.4.&5.)

23.a. Within 60 Days: At least 90% of children assessed as in need of therapeutic foster care placement shall be in the Therapeutic Level of Care and specific placement type that matches the Level of Care for which the child was assessed within sixty (60) days following the date of the first Level of Care Placement recommendation.

Data are not available for this period.

Data are not available for this period.58

Dates to reach final target and interim benchmarks to be added once Placement Implementation Plan is approved.

58 Ibid.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

23.b. At least 95% of children assessed as in need of therapeutic foster care placement shall be in the Therapeutic Level of Care and specific placement type that matches the Level of Care for which the child was assessed within ninety (90) days following the date of the first Level of Care Placement recommendation.

Data are not available for this period. Data are not available for this period.59

Dates to reach final target and interim benchmarks to be added once Placement Implementation Plan is approved.

59 Ibid.
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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13
Family Visitation – Siblings and Parents:
(FSA IV.J.2.&3.)

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

24. At least 85% of the total minimum number of monthly sibling visits for all siblings not living together shall be completed, with exceptions when (1) there is a court order prohibiting visitation or limiting visitation to less frequently than once every month; (2) visits are not in the best interest of one or more of the siblings and the facts supporting that determination are documented in the case file; or (3) with exceptions approved by the CoMonitors.

In September 2017, 66% of all required visits between siblings occurred for siblings who were not placed together.

In March 2018, 57% of all required visits between siblings occurred for siblings who were not placed together.60

DSS has proposed Interim Benchmarks and timelines to meet final target but they have not been approved by the CoMonitors.

60 Data were collected during a review conducted by USC CCFS and Co-Monitor staff of a statistically valid random sample based on a 95% confidence level and +/- 5% margin of error. As discussed in Section IX below, the data sample identified for review was calculated based on the number of applicable children rather than the applicable number of visits. As a result, reported performance data may not have the same level of statistical significance. As DSS’s capacity to extract aggregate data for this measure improves, calculations will be based on a universe of applicable visits, as required by the FSA.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

25. At least 85% of Class Members with the goal of reunification will have inperson visitation twice each month with the parent(s) with whom reunification is sought, unless (1) there is a court order prohibiting visitation or limiting visitation to less frequently than twice every month; or (2) based on exceptions approved by the Co-Monitors.

In November 2017, 12% of children with a goal of reunification visited twice with the parent(s) with whom reunification was sought.

In March 2018, 17% of children in foster care with a goal of reunification visited twice with the parent(s) with whom reunification was sought.61

Dates to reach final target and interim benchmarks to be added once Visitation Implementation Plan is approved.

61 Data were collected during a review conducted by USC CCFS and Co-Monitor staff of a statistically valid random sample based on a 95% confidence level and +/- 5% margin of error. Permanency goals were identified utilizing data in the CAPSS field in which caseworkers are expected to update case goals in accordance with the most current determination in legal proceedings.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Health Care Improvement Plan – Initial Health Assessment:
By the end of sixty (60) days following final court approval of the Final Settlement Agreement (identification period), DSS shall identify Class Members who have been in DSS custody for more than sixty (60) days as of the date of final court approval of the Final Settlement Agreement, and who have not had initial health assessments (physical/medical, dental or mental health).

26. Within thirty (30) days after the identification period, Defendants shall schedule the initial health assessment for at least 85% of the identified Class Members.
Dates to reach final target and interim benchmarks to be added once Health Care Improvement Plan is approved.

Data for this measure are not available.

(FSA IV.K.4.(a))

73% of Class Members who entered foster care between October 1, 2017 and March 31, 2018 received an initial physical health assessment.62
52% of Class Members who entered foster care between October 1, 2017 and March 31, 2018 received an initial mental health assessment.63
48% of Class Members who entered foster care between October 1, 2017 and March 31, 2018 received an initial dental assessment.64

62 Data on initial assessments is based on Medicaid claims and encounter data and has not been independently validated by the Co-Monitors. Because there is still important work that needs to be done to clarify DSS policy and definitions for assessments and map them to Medicaid claims data, DSS is not yet able to identify details related to these initial assessments. 63 For children under the age of three, completion of an initial medical assessment was considered compliant for the mental health assessment measure as a developmental assessment and screening is a component of their examination with a primary health care provider. 64 For purposes of this analysis, children under the age of one were not considered applicable for an initial dental assessment. An oral examine is a component of their examination with a primary health care provider.

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Table 1: Summary Performance on Settlement Agreement Requirements

Final Settlement Agreement (FSA) Requirements13

Final Target

April 2017 – September 2017 Performance

October 2017 – March 2018 Performance

Health Care Improvement Plan – Immediate Treatment Needs:
By the end of ninety (90) days following final court approval of the Final Settlement Agreement (identification period), DSS shall identify Class Members with Immediate Treatment Needs (physical/medical, dental or mental health) for which treatment is overdue. (Immediate Treatment Needs means immediate nonelective physical/medical, dental or mental health treatment needs and documented assessment needs, excluding routine periodic assessments.)

27. Within forty-five (45) days of the identification period, DSS shall schedule the necessary treatment for at least 90% of the identified Class Members.
Dates to reach final target and interim benchmarks to be added once Health Care Improvement Plan is approved.

Data for this measure are not available.

(FSA IV.K.4.(b))

Data for this measure are not available.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Workload Study for Foster Care
DSS shall design, conduct and complete a foster care Workload Study that applies to every Caseworker and to every Caseworker’s supervisor and adopt one or more Workload Limits for foster care within 180 days (dates and obligations became operative as of September 28, 2015). The foster care Workload Study must be approved by the Co-Monitors before it is conducted. The results of the Workload Study must also be approved by the Co-Monitors before they are adopted by DSS. Each Workload Limit must be approved by the Co-Monitors before it is adopted.

Completion of Workload Study by March 28, 2016.

DSS began work in August 2015 to address concerns with caseloads. A Workload Estimation Workgroup was chartered to research best practice and develop recommendations for reducing caseloads. DSS collaborated with Casey Family Programs66 to develop and conduct a workload estimation study which was approved by the Co-Monitors on February 22, 2016. The study examined best practices and caseload limits in other states and conducted a time study. Based upon caseworker type, the study estimated time needed for specific activities and the amount of time caseworkers have available. An initial workload study report was submitted to the Co-Monitors on March 28, 2016 and a more complete copy of the study findings and recommendations was provided on October 21, 2016.

(FSA IV.A.1.)

65 In some instances, information in this Table reflects the status of actions as of the date of this report. 66 Casey Family Programs is an operating foundation, working nation-wide to influence long-lasting improvements to the safety and success of children, families and the communities where they live, focused on safely reducing the need for foster care with a mission to provide and improve – and ultimately prevent the need for – foster care. For more information, see https://www.casey.org/about/

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Adoption of Workload Limits for Foster Care by March 28, 2016.

On December 6, 2016, the Co-Monitors approved workload limits by establishing the following caseload standards for caseworkers and supervisors:
Caseworker Limits:  OHAN investigator – 1 caseworker: 8 investigations  Foster Care caseworker – 1 caseworker: 15 children  IFCCS caseworker – 1 caseworker: 9 children  Adoption caseworker – 1 caseworker: 17 children67  New caseworker – ½ of the applicable standard for their first six months after
completion of Child Welfare Basic training.
Supervisor Limits:  Foster Care, IFCCS and Adoption supervisors – 1 supervisor: 5 caseworkers  OHAN supervisors – 1 supervisor: 6 investigators68

In addition to calculating performance for caseworkers servicing a single type of case, a standard and methodology for caseworkers who have both Class and Non-Class Members69 (mixed caseloads) on their caseload were provisionally approved in December 2017. See Section V. of this report for detailed discussion of the approved mixed caseload standard and methodology.

67 In approving these caseload limits, the Co-Monitors noted that although a caseload of 17 children for adoption caseworkers is not within the standard proffered by the Council on Accreditation, as DSS is currently structured, DSS reports case management responsibilities remain with the foster care caseworker, even when an adoption caseworker is assigned, until a placement agreement is signed. Given that DSS adoption caseworkers may therefore have less direct casework responsibilities than in some other jurisdictions, the Co-Monitors accepted the proposed caseload limit for adoption caseworkers. If DSS’s structure were to change so that adoption caseworkers have more case management responsibility for assigned children, the Co-Monitors would expect a proposed modification to the caseload standard. 68 The Co-Monitors approved the higher caseload standard for OHAN supervisors in recognition that those caseworkers will have lower caseloads than other direct service caseworkers. 69 Non-Class Members include children receiving family preservation services while remaining in the home with their parent or caregiver, Adult Protective Services cases, families involved in child protective service assessments and children placed by ICPC.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Implementing the Workload Limits for Foster Care:
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Workload Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

(FSA IV.A.2.(a))

DSS submitted a draft of the Workload Implementation Plan on November 30, 2016. Since that time, the Co-Monitors and Plaintiffs have provided feedback on several drafts and DSS has submitted revisions and modifications several times in response to comments. The Co-Monitors have consistently asked that DSS include more specificity in the Plan on budget sequencing, requests and strategies to develop the resources needed to meet the caseload standards within four years.
On May 29, 2018, DSS provided an updated draft of the Workload Implementation Plan with budgeting and resource information. The Co-Monitors have hired a consultant with expertise in hiring and recruitment to assess DSS’s draft Plan, identify where DSS planning can be strengthened and suggest strategies that will enable DSS to meet its workload obligations. This consultant was hired in late June 2018 and plans to complete her assessment and provide recommendations by the end of September 2018.
DSS has proposed interim benchmarks and targets in the draft Plan but these have not yet been approved.

Michelle H., et al. v. McMaster and Alford Progress Report for the Period October 2017 – March 2018

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Caseworker-Child Visitation
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure the progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Caseworker and Child Visitation Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

Given their findings regarding the inadequacy of documentation of caseworker visits, the Co-Monitors were not able to utilize CAPSS data produced by DSS with respect to these measures during the last reporting period. The Co-Monitors provided feedback to DSS on required data clean-up. In June 2018, DSS began work through its visitation workgroup to address issues with the validity of these data, including the development of draft documentation and quality guidelines to guide caseworkers. DSS has also identified this as an area of focus in its work with Chapin Hall and has reported that it is considering a case record review to assess documentation once the necessary changes to policy manuals and CAPSS screens have been made. As an initial step, DSS agreed in August 2018 to perform a limited review of CAPSS records jointly with the Co-Monitors for the purposes of assessing whether there have been any improvements to the accuracy of the data since last reported, and building an understanding of the documentation issues that have been identified by the Co-Monitors. The Co-Monitors will reassess the need for an Implementation Plan in the next monitoring period, once more information is obtained from this review.

(FSA IV.B.1.)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Investigation Implementation Plan
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Investigations Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

The Co-Monitors approved the OHAN Implementation Plan on September 11, 2017 and Plaintiffs provided their consent to the plan on November 7, 2017. A full update on implementation of the strategies within the Plan is attached as Appendix B.
Due to the ongoing vacancies in both supervisor and investigator positions, consistent implementation of many of the Plan’s strategies have not occurred.70

(FSA IV.C.1.)

70 For example, OHAN management reports that institution of a caseworker office day for completion of documentation and other case management activities would be extremely beneficial; however, this is not possible with the current level of staffing as caseworkers are needed in the field to respond to reports and complete investigative activities. Another strategy that is overdue is development of an investigation training curriculum. Originally estimated to be completed by December 2017, DSS currently reports the curriculum is near complete and the training will be delivered to existing OHAN staff in October 2018 and new staff in January 2019.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Placement Needs Assessment
Within one hundred twenty (120) days, DSS, with prior input from and subject to approval by the CoMonitors, shall perform a statewide and regional foster care Placement Needs Assessment in order to determine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members. The needs assessment shall include specific recommendations addressing all the assessment’s findings, including but not limited to recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that can meet their needs.

Completion of Placement Needs Assessment, which includes findings and specific recommendations by June 30, 2017.

(FSA IV.D.1.)

DSS submitted a report with data and findings from the Placement Needs Assessment to the Co-Monitors on August, 31, 2017. In late September 2017, the Co-Monitors requested that additional work be completed on placement projections, including adding the required assessment of county needs versus regional needs so as to understand what will be needed to place children close to their home community and avoid school changes. In October 2017, written feedback from both the Co-Monitors and Plaintiffs were provided to DSS. In December 2017, the Co-Monitors provided additional written feedback to DSS. DSS provided requested county level data on March 30, 2018, as part of the updated Placement Implementation Plan.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Placement Implementation Plan
Within sixty (60) days of the completion of the needs assessment, DSS shall develop an Implementation Plan to implement the recommendations of the needs assessment within eighteen (18) months. The Implementation Plan shall have enforceable benchmarks with specific timelines, subject to approval by the Co-Monitors, to measure progress in executing the recommendations of the needs assessment.
(FSA IV.D.1.(a))

Completion of Placement Implementation Plan, which includes interim benchmarks with specific timelines. Originally, the Interim Order required the Placement Implementation Plan to be completed by March 28, 2016 (60 days from January 28, 2016). The IO then required implementation of the recommendations in the Plan by September 28, 2017.

Placement Implementation Plan shall include strategies to address the following areas, with accompanying interim benchmarks and specific timelines:

 Congregate Care Placements (FSA IV.E.1.)  Sibling Placement (FSA IV.G.1.)  Therapeutic Foster Care Placements (FSA IV.I.1)

The Co-Monitors have not yet approved a Plan and interim benchmarks and timelines. DSS submitted a draft Placement Implementation Plan on October 31, 2017, to which the Co-Monitors provided feedback. On March 30, 2018, DSS submitted a revised draft Plan. After reviewing the draft Plan, the Co-Monitors determined that several areas require revision, including improving data analysis and needs projections; clarifying, expanding and operationalizing strategic approaches; elaborating how and when new policies and casework practices will be implemented; and understanding and articulating the undergirding case practice model.
After consulting with DSS and Plaintiffs, in June 2018, the Co-Monitors hired consultants to provide technical assistance in multiple phases, which include (1) reviewing the Placement Needs Assessment and draft Implementation Plan to assess the recommendations, feasibility, resource needs, strategies and timelines that have been proposed and identify gaps, if any; (2) assisting DSS in incorporating the information collected to develop an acceptable Plan that meets each of the expectations outlined in the FSA, including a clear case practice model that will be reflected in all aspects of the placement process; and, (3) if needed, supporting DSS with Plan implementation. The Co-Monitors expect that this work will be done in collaboration with the DSS placement workgroup, additional stakeholders and regional/local staff to capitalize on the strengths of the existing planning effort.

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Plan for Family Placements for Children Ages 6 and Under:
Within sixty (60) days, DSS shall create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the Co-Monitors, the placement of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers). The plan shall include full implementation within sixty (60) days following approval of the Co-Monitors.

Completion of Plan to prevent placement of Class Members age six and under in any nonfamily group placement by November 28, 2015.

Data indicate that DSS’s processes to prevent the placement of Class Members ages six and under in a non-family, group placement continue to work well. There has been a substantial reduction in the number of children ages six and under in congregate care since entry of the Interim Order.
Each month during this monitoring period, the number of Class Members in a congregate care placement ranged from three to eight children. Most of these children were residing in a treatment facility with their mother or were part of a sibling group of four or more
for whom DSS reports a single, family-based placement could not be located.

(FSA IV.D.2.)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Family Visitation – Siblings and Parent Implementation Plan:
Within sixty (60) days of the entry of the Order approving the Settlement Agreement, DSS shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent.

Completion of Family Visitation Implementation Plan, which includes interim benchmarks with specific timelines by December 5, 2016.

DSS convened a Visitation Workgroup in October 2016 to assess systemic barriers to family visitation and develop and assist with the implementation of the Visitation Implementation Plan. DSS submitted a draft of the Visitation Implementation Plan on November 30, 2016, and upon receipt of feedback from the Co-Monitors and Plaintiffs, completed several rounds of revisions and modifications. The Implementation Plan for visitation could not be approved by the Co-Monitors because reliable baseline data with respect to children with reunification goals were not available. As discussed later in this report, the Co-Monitors and University of South Carolina’s Center for Child and Family Studies (USC CCFS) were able to manually collect relevant data beginning in the last monitoring period. DSS submitted a revised Plan on August 11, 2018. The Co-Monitors provided feedback on August 17, 2018 and DSS is currently working to incorporate that feedback into the Plan.

(FSA IV.J.1.)

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

Health Care Improvement Plan: Within one hundred eighty (180) days, Defendants, with prior input from and subject to approval by the Co-Monitors, shall develop a Health Care Improvement Plan with enforceable dates and targets for phased implementation and concerning initial screening services, periodic screening services, documentation, and health care treatment services for Class Members in the areas of physical health, immunizations and laboratory tests, mental health, developmental and behavioral health, vision and hearing, and dental health. The Plan shall address:
(a) Developing the capacity to track screening and treatment services for individual children and aggregate tracking data, including but not limited to screens that are due and past due;

Completion of Health Care Improvement Plan by March 31, 2017. On April 19, 2017, the Co-Monitors approved a 60 day extension, with an expected completion date of June 2, 2017. On June 1, 2017, DSS filed a Motion for Extension of Time, which was approved and extended the deadline to September 30, 2017.

After receiving an extension for preparation of its Health Care Improvement Plan pursuant to FSA IV.K.2., DSS submitted a draft report to the Co-Monitors on September 29, 2017. The Co-Monitors provided initial feedback, and in November 2017, engaged consultants (Kathleen Noonan and Gail Nayowith) with specific expertise in child welfare health care reform to assess the sufficiency of the Plan pursuant to FSA IV.K.3. The consultants’ recommendations based on the results of validation activities and extensive interviews with key DSS, DMH, DHHS, MCO and community provider staff, were submitted in a Findings and Recommendations Report on February 12, 2018. DSS worked closely with the consultants to make recommended changes to their Plan and submitted an updated version to the Co-Monitors on June 29, 2018. The Co-Monitors provided feedback to DSS and on August 23, 2018, the Plan was approved pursuant to FSA IV.K.1(a-b). The Co-Monitors will now work with DSS and the consultants to identify all final health care outcome measures related to initial screening services, periodic screening services, documentation, treatment and other corrective services, as per Sections IV.K.1(c) and IV.K.5. of the FSA.

(b) Assessing the accessibility of health care screening and treatment services throughout the State, including the capacity of the existing health care providers to meet the screening and treatment needs of Class Members; and

(c) Identifying baselines and interim percentage targets for performance improvement in coordinating screens and treatment services. With approval of the Co-Monitors and based on

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Table 2: Status of Implementation Plans and Assessments

Final Settlement Agreement (FSA) Requirements for Study and Plan Development evidence of progress toward the development of the Health Care Improvement Plan, Defendants may request an extension of an additional sixty (60) days to complete the Plan.

Final Target

Status of Implementation Plans and Assessments (as of March 31, 2018)65

(FSA IV.K.1.)

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V. CASELOADS
A sufficient, qualified and trained workforce with manageable caseloads is foundational to a well-functioning child welfare system. Caseworkers must be given resources and support to allow them to conduct meaningful visits with children and families, assess for safety and risk and monitor progress towards individualized case goals, among many other important tasks. Caseloads overall continue to be well above required limits – with roughly a quarter or less of each type of caseworker within the required limits each month. High caseloads have a significant impact on a caseworker’s ability to complete job functions and contribute to unwanted job turnover.
DSS’s FY 2017/2018 budget provided funds for 163 new full-time employee positions in DSS. DSS anticipated utilizing 67 of these positions for new IFCCS positions71, in order to reduce foster care caseworker responsibility for children on the “other lead” list72. Fifty-nine of the new positions were allocated toward second and third shift intake caseworkers in select counties and the remainder were designated for either new foster care, family preservation or assessment caseworker positions in county offices. As of April 30, 2018, 54 (33%) of the 163 positions had been filled, including 19 IFCCS caseworkers. In addition to these newly allocated positions, DSS reported that as of May 2018, there are 56 foster care, IFCCS and adoption caseworker vacancies73 and eight supervisor vacancies statewide; additional vacancies also exist for staff not directly responsible for Class Members cases.
For the first time since monitoring began, DSS is able to provide caseload data for caseworkers and supervisors for each month in the monitoring period. These data were first available in June and July 2018 and have not been independently validated by the Co-Monitors. However, production of the data is a significant step forward. The Co-Monitors will continue to work with DSS and the data audit consultants to validate the accuracy of the caseload data. 74

71 Eligibility for IFCCS services is determined following a review of a child’s mental health assessment(s) and diagnosis; frequency, intensity and duration of symptoms; multi-system involvement; and exhaustion of alternative services. IFCCS services utilize funding through SC’s Interagency System for Caring for Emotionally Disturbed Children (ISCEDC) to pay for treatment costs. ISCEDC funding are pooled dollars from multiple state agencies, including DSS, the Department of Mental Health, the Department of Disabilities and Special Needs, the Department of Juvenile Justice and the Department of Education. 72 The “other lead” list includes children who are ISCEDC (Interagency System of Caring for Emotionally Disturbed Children) eligible and may be receiving ISCEDC services, however, they are not currently case managed by an IFCCS caseworker due to high IFCCS caseload levels. 73 Thirty-three of the caseworker vacancies were for foster care caseworkers. 74 The data audit work being conducted by Chapin Hall has identified potential issues with the quality and accuracy of these data. Specifically, some caseworker profiles still need to be updated, cleaned and/or validated to track case assignments properly. DSS and Chapin Hall plan to engage a small group of counties to test the accuracy of current CAPSS caseload reporting methodology. Additionally, DSS will consider changing policy to dictate that caseworker CAPSS profiles can only be completed by county Human Resources staff or other administrative level personnel instead of caseworker self-identification.

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A. Workload Implementation Plan
The FSA required that by December 5, 2016, DSS develop an Implementation Plan to achieve the final FSA workload requirements. The Implementation Plan must include “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approved (sic) by the Co-Monitors, to measure progress in achieving the final targets…” (FSA IV.A.2. (a)).
DSS submitted a draft of the Workload Implementation Plan on November 30, 2016. Since that time, the Co-Monitors and Plaintiffs have provided feedback on several drafts and DSS has submitted revisions and modifications several times in response to comments. The Co-Monitors and Plaintiffs have consistently asked that DSS include in the Plan more specificity on budget sequencing, requests and strategies to develop the resources needed to meet the caseload standards within four years.
On May 29, 2018, DSS provided an updated draft of the Workload Implementation Plan with budgeting and resource information. In June 2018, the Co-Monitors hired a consultant with expertise in hiring and recruitment to assess DSS’s draft Plan, identify where DSS planning can be strengthened and suggest strategies that will enable DSS to meet their workload obligations. This consultant plans to complete the assessment and provide recommendations by the end of September 2018.
B. Performance Data
The FSA requires “[a]t least 90% of Workers and Worker supervisors shall have a workload within the applicable Workload Limit” (FSA IV.A.2.(b)) and that “ [n]o Worker or Worker’s supervisor shall have more than 125% of the applicable Workload Limit” (FSA IV.A.2.(c)). There are different caseload standards dependent upon the types of cases a caseworker manages – foster care, IFCCS, adoption and investigations of allegations of abuse and/or neglect of a child in foster care. There are also reduced workload standards specific to newly hired caseworkers within their first six months of completing Child Welfare Basic training.
DSS has many staff with mixed caseloads that include both Class and Non-Class Members. On December 21, 2017, the Co-Monitors provisionally approved DSS’s November 3, 2017 proposal to calculate caseloads for caseworkers with mixed caseloads by adding the total number of foster care children (Class Members) they serve to the total number of families (cases) of Non-Class Members they also serve. The following types of cases will be counted by family (case): Child Protective Services (CPS) assessment; family preservation; other child welfare services and those involving a child subject to ICPC. This methodology will only be applied to foster care

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caseworkers with mixed caseloads and will not be applied to caseloads for IFCCS and adoption caseworkers.
In approving this mixed caseload methodology, the Co-Monitors relied upon DSS’s commitments to: (1) move forward with plans to move caseworkers to single-type caseloads as feasible and appropriate; (2) change their internal metrics for family preservation cases to use a “family” as opposed to an individual child count; and (3) assess and find a way to address the Co-Monitors’ concerns about the potential for unreasonable caseloads that could result from caseworker assignment to several family preservation cases involving families with multiple children. DSS has indicated that managers are continually assessing assignments to caseworkers with mixed caseloads to ensure balanced and manageable workloads. Because approval of this methodology is “provisional,” DSS and the Co-Monitors will assess it in practice as it is implemented, reserving the right to modify the standard at any time if it is determined that the best interests of children are not being served.
Foster Care Caseworkers75
The caseload standard for caseworkers who are responsible for providing case management for foster care cases is one caseworker to 15 children (1:15).76 Between October 2017 and March 2018, a monthly range of 25 to 28 percent of foster care caseworkers had caseloads within the required limit (see Figure 1) and 57 to 63 percent of foster care caseworkers had caseloads more than 125 percent of the caseload limit (see Figure 2). Specifically, on March 13, 2018,77 there were 205 foster care caseworkers with at least one foster care child on their caseload.78 Of these 205 caseworkers, 51 (25%) foster care caseworkers had caseloads within the required limit. Additionally, 128 (62%) caseworkers’ caseloads were more than 125 percent of the caseload limit.

75 The Co-Monitors selected a random day in each month this period to measure caseload compliance for each type of caseworker. These random dates are as follows: October 24, 2017; November 6, 2017; December 14, 2017; January 29, 2018; February 8, 2018; March 13, 2018. Performance on this date is compared to other randomly selected dates during the month to ensure limited variability and ensure reported performance is not an anomaly. 76 In calculating performance, a standard of eight foster care children or Non-Class families is applied to newly hired caseworkers (half of the applicable caseload standard) and 15 foster care children or Non-Class families is applied to foster care or Adult Protective Services (APS) caseworkers. 77 The Co-Monitors selected a random day in each month this period to measure caseload compliance for each type of caseworker. The random date for March is March 13, 2018. 78 This includes two caseworkers designated as APS caseworkers who were case managing foster care children in addition to their adult clients, 18 supervisors who were carrying caseloads and 32 newly hired foster care caseworkers.

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Figure 1: Foster Care Caseworkers within the Required Caseload Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS
Figure 2: Foster Care Caseworkers over 125% of Required Caseload Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS
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As shown in more detail below, the majority of foster care caseworkers who had caseloads above the limit were substantially over the limit. Almost half (48 percent or 62 of 129) of foster care caseworkers who had been employed for at least six months and were over the caseload limit on March 13, 2018, had caseloads of 25 children and families or higher, with seven caseworkers with caseloads of between 37 and 48 children and families (see Figure 3). For newly hired foster care caseworkers, 16 (70%) of the 23 caseworkers who were over the limit had caseloads at least double the standard of eight children and families (see Figure 4)79.
Figure 3: Caseloads for Foster Care Caseworkers that were Over the Limit March 13, 2018 N = 129

Source: CAPSS Data Provided by DSS

79 Monthly caseload performance for newly hired foster care caseworkers are as follows: October 2017, 14%; November 2017, 13%; December 2017, 12%; January 2018, 22%; February 2018, 21%; March 2018, 28%.

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Figure 4: Caseloads for Newly Hired Foster Care Caseworkers that were Over the Limit March 13, 2018 N = 23

Source: CAPSS Data Provided by DSS
IFCCS Caseworkers
The caseload standard for caseworkers who are responsible for providing case management to children designated as needing IFCCS services is one caseworker to nine children (1:9). Newly hired IFCCS caseworkers should have no more than five children on their caseload for six months after they complete Child Welfare Basic training.
Between October 2017 and March 2018, a monthly range of nine to 26 percent of IFCCS caseworkers were within the required limits, with performance improving after December 2017. Specifically, on March 13, 2018, there were 82 IFCCS caseworkers80 serving at least one Class Member and 18 (22%) of these caseworkers were within the required caseload limit (see Figure 5) and 41 (50%) caseworkers had caseloads more than 125 percent of the caseload limit (see Figure 6).

80 Total includes six supervisors who were carrying cases and nine newly hired IFCCS caseworkers with a caseload standard of five children.

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Figure 5: IFCCS Caseworkers within the Required Caseload Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS
Figure 6: IFCCS Caseworkers over 125% of Required Caseload Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS
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Figure 7 shows the caseload range for IFCCS caseworkers who were over the required limit on March 13, 2018.81 The highest number of cases carried by one IFCCS caseworker on that day was 28 children’s cases.
Figure 7: Caseloads for IFCCS Caseworkers that were Over the Limit March 13, 2018 N=62

Source: CAPSS Data Provided by DSS
Adoption Caseworkers
The caseload standard for caseworkers providing adoption support to children with a goal of adoption is one caseworker to 17 children (1:17).82
Between October 2017 and March 2018, a monthly range of 15 to 21 percent of adoption caseworkers had caseloads within the required limit (see Figure 8) and 64 to 69 percent had caseloads that exceeded 125 percent of the required limit (see Figure 9). On March 13, 2018,

81 There were nine newly hired IFCCS caseworkers in March 2018. Two had caseloads over the required limit, with 10 and 11 respectively. These caseworkers caseloads are not reflected in the Figure above as the newly hired standard is different than caseworkers who have been employed for six months or longer. Monthly caseload performance for only newly hired IFCCS caseworkers are as follows: October 2017, 0%; November 2017, 33%; December 2017, 50%; January 2018, 83%; February 2018, 67%; March 2018, 78%. 82 In approving these caseload limits, the Co-Monitors noted that although a caseload of 17 children for adoption caseworkers is not within the standard proffered by the Council on Accreditation, as DSS is currently structured, case management responsibilities remain with the foster care caseworker, even when an adoption caseworker is assigned, until a placement agreement is signed. If DSS’s structure were to change so that adoption caseworkers have more case management responsibility for assigned children, the Co-Monitors would expect a proposed modification to the caseload standard.

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2:15-cv-00134-RMG Date Filed 10/01/18 Entry Number 88-1 Page 72 of 190 there were 79 adoption caseworkers83 serving at least one Class Member. Of these 79 caseworkers, 12 (15%) caseworkers had caseloads within the caseload requirement and 53 (67%) caseworkers had caseloads that were more than 125 percent of the limit.
Figure 8: Adoption Caseworkers within the Required Caseload Limits October 2017 - March 2018
Source: CAPSS Data Provided by DSS

83 Total includes eight supervisors who were carrying cases and six newly hired adoption caseworkers with a caseload standard of nine children.

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Figure 9: Adoption Caseworkers over 125% of Required Caseload Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS
Approximately half (51% or 31 of 61) of caseworkers who had caseloads over the limit on March 13, 2018 and had been employed for six months or longer had caseloads ranging between 25 to 38 children’s cases (see Figure 10). Five of the six newly hired adoption caseworkers who had caseloads over the required limit had over double the required limit, with one new adoption caseworker responsible for 29 children’s cases84 (see Figure 11).

84 Monthly caseload performance for only newly hired adoption caseworkers are as follows: October 2017, 14%; November 2017, 14%; December 2017, 0%; January 2018, 14%; February 2018, 14%; March 2018, 14%.

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Figure 10: Caseloads for Adoption Caseworkers that were Over the Limit March 13, 2018 N= 61

Source: CAPSS Data Provided by DSS
Figure 11: Caseloads of Newly Hired Adoption Caseworkers that were Over the Limit March 13, 2018 N=6

Source: CAPSS Data Provided by DSS
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OHAN Caseworkers
The caseload standard for caseworkers conducting investigations involving allegations of abuse and/or neglect of a child in foster care is one caseworker per eight investigations (1:8).
Between October 2017 and March 2018, a monthly range of 14 to 17 percent of OHAN caseworkers had caseloads within the required limits (see Figure 12) and 67 to 86 percent of caseworkers had caseloads of more than 125 percent of the required limit (see Figure 13). Specifically, on March 13, 2018, of the six OHAN investigators, one (17%) investigator had a caseload of eight investigations. The five remaining OHAN investigators had caseloads ranging from 10 to 36 investigations per worker (see Table 3).
Figure 12: OHAN Investigators within the Required Caseload Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS

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Figure 13: OHAN Investigators over 125% of Required Caseload Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS

Table 3: Caseloads for OHAN Caseworkers March 13, 2018 N=6

Caseworker

Number of Investigations

Caseworker 1

8

Caseworker 2

10

Caseworker 3

15

Caseworker 4

24

Caseworker 5

28

Caseworker 6

36

Total – 6 caseworkers Source: CAPSS Data Provided by DSS

Total – 121 investigations

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In summary, Figure 14 reflects the percentage of foster care, IFCCS, adoption and OHAN caseworkers within and above the required caseload limits on March 13, 2018.
Figure 14: Foster Care, IFCCS, Adoption and OHAN Caseworkers that were Over and Within the Required Caseload Limits March 13, 2018

Source: CAPSS Data Provided by DSS
Foster Care Supervisors
The caseload standard for supervisors providing supervision to foster care caseworkers is one supervisor to five caseworkers (1:5).
Between October 2017 and March 2018, a monthly range of 42 to 45 percent of foster care supervisors supervised five or fewer caseworkers (see Figure 15) and 35 to 38 percent of supervisors had workloads of more than 125 percent of the required limit (see Figure 16). Specifically, on March 13, 2018, of the 72 supervisors supervising foster care caseworkers, 30 (42%) supervisors supervised five or fewer caseworkers and 26 (36%) supervisors had workloads more than 125 percent over the required limit.

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Figure 15: Foster Care Supervisors within the Required Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS
Figure 16: Foster Care Supervisors with Workloads More Than 125% Over the Required Limit October 2017 - March 2018

Source: CAPSS Data Provided by DSS
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IFCCS Supervisors
The caseload standard for supervisors providing supervision to IFCCS caseworkers is one supervisor to five caseworkers (1:5).
Between October 2017 and March 2018, a monthly range of 47 to 57 percent of IFCCS supervisors supervised five or fewer caseworkers (see Figure 17) and 29 to 32 percent of supervisors had workloads of more than 125 percent of the required limit (see Figure 18). Specifically, on March 13, 2018, of the 21 supervisors supervising IFCCS caseworkers, 12 (57%) supervisors supervised five or fewer caseworkers and six (29%) supervisors had workloads more than 125 percent over the required limit.
Figure 17: IFCCS Supervisors within the Required Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS

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Figure 18: IFCCS Supervisors with Workloads More Than 125% Over the Required Limit October 2017 - March 2018

Source: CAPSS Data Provided by DSS
Adoption Supervisors
The caseload standard for supervisors providing supervision to adoption caseworkers is one supervisor to five caseworkers (1:5).
Between October 2017 and March 2018, a monthly range of 38 to 61 percent of adoption supervisors supervised five or fewer caseworkers (see Figure 19) and 11 to 19 percent of supervisors had workloads of more than 125 percent of the required limit (see Figure 20). Specifically, on March 13, 2018, of the 16 supervisors supervising adoption caseworkers, six (38%) supervisors supervised five or fewer caseworkers and three (19%) supervisors had workloads more than 125 percent over the required limit.

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Figure 19: Adoption Supervisors within the Required Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS
Figure 20: Adoption Supervisors with Workloads More Than 125% Over the Required Limit October 2017 - March 2018

Source: CAPSS Data Provided by DSS
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OHAN Supervisors The standard for supervisors providing supervision to caseworkers conducting OHAN investigations is one supervisor to six investigators (1:6).85 Between October 2017 and March 2018, there were three OHAN supervisors and each supervised no more than six caseworkers each month (Figure 21).
Figure 21: OHAN Supervisors within the Required Limits October 2017 - March 2018

Source: CAPSS Data Provided by DSS
VI. CASEWORKER-CHILD VISITS
Visits between caseworkers and children in foster care are critical to a child welfare agency’s ability to monitor the safety and well-being of the children in its care. DSS has consistently reported that these visits are a core element of its practice and that caseworkers throughout the state visit with children on a monthly basis in nearly all cases. Due to documentation issues identified in prior reporting periods, the Co-Monitors have been unable to validate the occurrence of visits. In response to Co-Monitor feedback, DSS identified this as an area of work with Chapin Hall and took steps this monitoring period to improve caseworker documentation.

85 The Co-Monitors approved the higher caseload standard for OHAN supervisors in recognition of the fact that the OHAN caseworkers they supervise will have lower caseloads than other direct service caseworkers.

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The Co-Monitors, however, have determined that DSS remains unable to reliably report on this fundamental aspect of practice.

The FSA requires “[a]t least 90% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place” (FSA IV.B.2.) and that “[a]t least 50% of the total minimum number of monthly face-to-face visits with Class Members by caseworkers during a 12-month period shall have taken place in the residence of the child” (FSA IV.B.3.). The FSA further required that by December 5, 2016, DSS was to develop an Implementation Plan with “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors” (FSA IV.B.1.) to achieve the final targets related to caseworker visits with children.

DSS reported at the time of entry into the FSA that it was already achieving the final targets related to caseworker-child visits and therefore did not need to develop an Implementation Plan for the caseworker-child visits measures. Although the Co-Monitors performed a validation of CAPSS data in the first monitoring period, the review was limited. Because CAPSS documentation was not sufficient to allow for a complete review of visit content – many notes were either sparse or substantially duplicative of those entered in prior month – the review was done solely for the purpose of measuring the percentage of cases in which documentation indicated that a caseworker had visited the child in that month and the location of the visit. The Co-Monitors did not assess the content of the visits to assess whether the visits were done in accordance with DSS policy. Based on their findings, the Co-Monitors utilized CAPSS data to report performance on both FSA IV.B.2 and FSA IV.B.3, with the disclaimer that further validation would be necessary to assess performance on these measures in later periods.
The Co-Monitors determined during the last monitoring period that documentation continued to be insufficient to allow for reporting on this measure. The Co-Monitors provided feedback to DSS at that time with respect to necessary data cleanup, with the goal of re-evaluating performance for this measure in the current reporting period. In June 2018, DSS began work through its visitation workgroup to address issues with the validity of these data, including the development of draft documentation and quality guidelines for caseworkers. DSS has also identified this as an area of focus in its work with Chapin Hall and has reported that it is considering a case record review to assess documentation once the necessary changes to policy manuals and CAPSS screens have been made. As an initial step, DSS agreed in August 2018 to perform a limited review of CAPSS records jointly with the Co-Monitors to assess whether there have been improvements to the accuracy and quality of the data on visits and to build a common understanding of the validity and documentation issues that have been identified by the CoMonitors. The Co-Monitors will reassess the need for an Implementation Plan on caseworkerchild in the next monitoring period, once additional information is obtained from this review.

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It continues to be clear to the Co-Monitors that DSS and Plaintiffs hold vastly different views of what counts as a “visit” under the FSA. DSS’s interpretation of the FSA is that the requirement is explicitly focused only on whether a visit literally and factually occurred and where it was held. Plaintiffs’ position is that the content (what happens during the visit) must also be examined to ensure not only that the caseworker saw the child, but that it was done in a way that accords with the core purpose of visitation and includes necessary elements as defined by practice standards and DSS policy. Otherwise, in Plaintiffs’ interpretation of the FSA, a required “visit” did not occur. As reported in the last monitoring period, the Co-Monitors believe that DSS and Plaintiffs need to discuss and attempt to resolve their differences on the meaning of the FSA requirement on caseworker visits with children in foster care. The Parties have not yet addressed this issue.

Given the importance of caseworker visits in monitoring the safety, well-being and permanency of children in foster care, and how critical these visits will be to DSS’s ability to meet many of the FSA measures, the Co-Monitors remain concerned about the lack of reliable documentation in this area and will continue to closely monitor progress over the coming months.

VII. INVESTIGATIONS
The work of investigating allegations of abuse and/or neglect of children in foster care – completed by DSS’s Out of Home Abuse and Neglect (OHAN) unit – is another critical function of any child welfare system. This unit must be prepared 24 hours a day, seven days a week to receive reports, appropriately decide which reports should be screened in for investigation and, for those reports that require an investigation, make contact with the alleged victim child(ren) within 24 hours of the report to assess the child’s safety and the allegations. Children are in foster care as a result of abuse or neglect by their caregivers, and ensuring their safety and wellbeing while in state custody is a primary obligation.

During the current period, data reflect declined and alarming performance in this area. The CoMonitors think this reflects delays by DSS leadership in responding to OHAN’s staffing and support needs, despite repeated, reasonable requests and specific recommendations from OHAN management and the Co-Monitors. Although five new OHAN investigator positions have been recently allocated, as of June 2018, there were three current investigator and one supervisor vacancies within OHAN. This unit has been understaffed and under-resourced for many years, and sustainable improvements will require filling current vacancies; adding new caseworker, supervisor and administrative support staff; and finalizing the investigation practice training curriculum so that workers have the structure and guidance they need to properly assess allegations and children’s safety.

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As discussed in more detail below, when assessing investigations carried out in March 2018, reviewers determined that less than one-quarter (21%) of decisions to unfound were appropriate, mostly due to insufficient information being collected during the investigation. Additionally, only one (3%) of the 32 applicable investigations reviewed included contact with all necessary core witnesses during the investigation. One of the most concerning findings from this review was that only 22 (69%) investigations included contact with all alleged victim children prior to closure of the investigation, meaning that in 10 investigations, the investigator did not interview and assess the safety of all alleged victim children prior to making an investigation decision on whether or not the alleged abuse or neglect occurred and prior to closing the investigation. This level of practice is unacceptable.
A. Investigation Implementation Plan
The FSA requires that by December 5, 2016, DSS develop an Implementation Plan for the provisions related to intake and investigations. The Implementation Plan must have “enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the Co-Monitors, to measure progress in achieving the final targets…” (FSA IV.C.1.). On September 11, 2017, the Co-Monitors approved DSS’s OHAN Implementation Plan and Plaintiffs provided their consent to the Plan on November 7, 2017.
In addition to setting interim benchmarks and timelines, the OHAN Implementation Plan includes strategies developed to improve OHAN practice and achieve the targets required by the FSA. These strategies include: improvement in caseworker time management; implementation of processes to track and monitor timely initiation of investigations and contact with core witnesses; development of check lists and other forms; development and completion of new OHAN training for caseworkers; coordination between OHAN and licensing; and improvements in supervision within OHAN. Attached as Appendix B are implementation status updates on these strategies as of March 31, 2018.
As discussed above, due to the ongoing vacancies in both supervisor and investigator positions, consistent implementation of many of the strategies included in the OHAN Implementation Plan has not occurred. For example, OHAN management reports that institution of a caseworker office day for completion of documentation and other case management activities would be extremely beneficial; however, this is not possible with the current level of staffing as caseworkers are needed in the field to respond to reports and complete investigative activities. Between January and March 2018, 244 referrals were made to OHAN and 169 of these were

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accepted for investigation86. Data reviewed for investigations conducted in March 2018 show that only four OHAN investigative staff were responsible for all required activities on most investigations. When reviewing documentation for the March 2018 investigations, Co-Monitor staff found that in many instances, dictation notes documenting what occurred during interviews or contacts were not entered until weeks or months after the fact. These delays impact the level of detail and reliability of the information. Another strategy included in the Implementation Plan for which implementation is overdue is development of an investigation training curriculum. Originally estimated to be completed by December 2017, DSS currently reports the curriculum is near complete and the training will be delivered to existing OHAN staff in October 2018 and the new staff who are to be hired in January 2019.
B. Performance Data
Intake
Pursuant to South Carolina state statute and DSS protocol, all allegations of abuse or neglect of children in out-of-home settings – including licensed foster homes, residential facilities and group homes – received by local county offices or regional Intake Hubs must be forwarded to OHAN for screening and, if accepted, for investigation.87, 88 OHAN staff make decisions to either accept a referral for investigation or take no further action on the referral (screen out) based upon information collected from reporters to determine if the allegations meet the state’s statutory definition of abuse or neglect.89 DSS policy establishes three main screening criteria for investigations of abuse or neglect of children in out-of-home care: (1) the alleged victim child is younger than 18 years of age; (2) there is an allegation of actual harm that has occurred or is occurring to a child or the caregiver’s acts or omissions present a significant risk of harm; and (3) the alleged perpetrator is a person responsible for the child’s welfare.90 OHAN staff are also directed to accept for investigation referrals which identify safety and risk factors to the child in care. All screening decisions are reviewed and approved by a supervisor prior to being finalized.
In January 2015, DSS began implementation of a regionalized Intake Hub system which provides central locations for receipt of referrals of abuse and/or neglect against children in the

86 These data do not include allegations of abuse or neglect at child care facilities that involve Non-Class Members. OHAN staff are also responsible for these intakes and investigations. 87 SC Code § 63-7-1210; Human Services Policy and Procedural Manual, Chapter 7-721. p.3 (effective date 11/29/2012); SC
DSS Directive Memo, April 26, 2016. 88 Allegations of abuse or neglect by a foster parent of their biological or adopted child are investigated by child protective service caseworkers in local county offices. 89 SC Code § 63-7-20. 90 This includes a foster parent; an employee or caregiver in a public or private residential home, institution or agency; or an adult who has assumed the role and responsibility of a parent or guardian for the child, but who does not necessarily have legal custody of the child. Human Services Policy and Procedural Manual, Chapter 7-721. p.3 (effective date 11/29/2012).

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state.91 A primary objective of this restructuring is to improve the quality and consistency of decisions at the time of intake. As of November 2017, all counties were linked to an Intake Hub. DSS has been considering directing calls related to allegations of abuse and/or neglect for children in foster care to the Intake Hubs instead of directly to centralized OHAN staff. OHAN staff would still be responsible for conducting investigations of those referrals that are accepted. However, a final decision has not been made about this proposal.

The FSA requires “[a]t least 95% of decisions not to investigate a Referral of Institutional Abuse or Neglect about a Class Member must be made in accordance with South Carolina law and DSS policy” (FSA IV.C.2.). Table 4 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure:

Table 4: Baseline, Timeline and Interim Benchmark for Appropriateness of Decision Not to Investigate Referral
Alleging Institutional Abuse and/or Neglect
Baseline

August 2016 – January 2017

44%

Timeline September 2017
March 2018 September 2018
Final Target Source: OHAN Implementation Plan

Interim Benchmark 75% 90% 95% 95%

All applicable referrals92 of abuse and/or neglect received and not investigated (screened out) by DSS’s OHAN unit between October 2017 and March 2018 were reviewed by Co-Monitor staff.93 Performance data were collected and are reported separately for each month.

91 There are a total of seven Intake Hubs within the five state regions. 92 Some referrals were found not to be applicable for review because the alleged victim child was not a Class Member (i.e. the child was voluntarily placed by the legal guardian or through ICPC from another state, or was the biological child of the caregiver). DSS has represented to the Co-Monitors that all referrals of abuse and/or neglect in licensed foster homes, residential facilities and group homes across the state involving Class Members are received by or forwarded to OHAN for screening and investigation, as appropriate, and screening decisions are not made by local office or Intake Hub staff at this time. 93 When assessing performance for this measure, reviewers considered three main criteria: (1) the allegation, if true, meets the legal definition of maltreatment; (2) the OHAN caseworker did not collect all information necessary to make an appropriate screening decision; and (3) safety or risk factors were identified within the information shared. If any of these questions were answered in the affirmative, the decision not to investigate the referral was determined to be inappropriate.

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Between October 2017 and March 2018, the Co-Monitors determined a monthly range of 80 to 93 percent of decisions not to investigate a referral of abuse and/or neglect to be appropriate (see Figure 22). Specifically, in March 2018, 21 (81%) of the 26 applicable screening decisions were deemed appropriate.94 Although performance during the first several months of the monitoring period appeared to be on track to meet the interim target of 90 percent by March 2018, performance declined in both February and March 2018. In March 2018, the primary reason for disagreement with the screening decision was that insufficient information was collected by the Intake caseworker in order to fully assess the allegations – some referrals only included one to five sentences describing the allegations and did not fully explain the incident, severity or impact on the alleged victim child. Additional guidance and coaching is needed for Intake staff on collecting and documenting necessary information, as well as for mandatory reporters (often the DSS caseworker), who should be prepared to provide this information.
Figure 22: Appropriateness of Decision Not to Investigate Referral Alleging Institutional Abuse and/or Neglect October 2017 - March 2018
March 2018 Interim Benchmark – 90%

Source: Monthly review data, Co-Monitor staff

Investigations

If a referral is accepted for investigation, the FSA and OHAN policy require face-to-face contact with the alleged victim child(ren) within 24 hours to assess for safety and risk, and the
94 Of note, of the 32 referrals that were accepted for investigation in March 2018, Co-Monitor staff assessed that eight of the referrals should not have been accepted for investigation as there were no allegations of abuse or neglect by a caretaker.

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investigation is to be completed within 45 days.95 OHAN policy also requires that throughout the course of the investigation, the investigator must conduct a safety assessment of the alleged victim child, including a private interview with that child; work with the child’s caseworker or law enforcement to make arrangements for medical treatment or examinations, as needed; interview core witnesses to inform the investigation; review documents and records related to the incident; and assess the risk of further maltreatment to all children within that setting.96 All of these activities are critical components of a quality investigation that results in accurate assessments and findings.
There are seven FSA measures pertaining to investigations – timely initiation (two measures)97, contact with core witnesses (one measure), investigation determination decisions (one measure) and timely completion (three measures). The most recent performance data detailed below were collected during a case record review conducted in June 2018 which examined 32 applicable investigations98 that were accepted and initiated in March 2018. Most of the investigations involved allegations of physical abuse (16 investigations/50%) and/or physical neglect (13 investigations/41%). Twenty (63%) of the investigations alleged abuse and/or neglect in a foster home and the remaining 12 (38%)99 investigations alleged abuse and/or neglect in a facility or institution. In approximately half of the investigations (17 investigations/53%), the reporter alleging abuse and/or neglect was a DSS caseworker or supervisor, and in 22 percent (7 investigations), the reporter was a provider or facility staff.
Timely Initiation
The FSA requires “[t]he investigation of a Referral of Institutional Abuse or Neglect must be initiated within twenty-four (24) hours in accordance with South Carolina law in at least 95% of the investigations” (FSA IV.C.4.(a)). Additionally, FSA Section IV.C.4.(b) requires “[t]he investigation of a Referral of Institutional Abuse or Neglect must include face-to-face contact with the alleged victim within twenty-four hours in at least 95% of investigations, with exceptions for good faith efforts approved by the Co-Monitors.” The Co-Monitors measure performance for both FSA IV.C.4.(a) and (b) using the same methodology and timeframes – the

95 Human Service Policy and Procedural Manual, Chapter 7-721. p. 6, 12 (effective date 11/29/2012). 96 Human Services Policy and Procedural Manual, Chapter 7-721. p. 7 (effective date 11/29/2012). 97 The Co-Monitors’ interpretation of the FSA requires that investigations be initiated within 24 hours of receipt of the referral by DSS, not within 24 hours of the decision to accept the referral, and that initiation is completed by making face-to-face contact with the alleged victim child(ren). As a result, the performance for both FSA measures IV.C.4.(a) and (b) are measured using the same methodology and timeframes – the time between receipt of referral and face-to-face contact with alleged child(ren) victim must be within 24 hours. 98 A total of 45 reports were accepted in March 2018, however, 13 were determined not appropriate for review for the following reasons – in 10 investigations, the alleged victim child was not a Class Member (i.e. the child was voluntarily placed by the legal guardian or through ICPC from another state); one investigation was a duplicate report of allegations that had previously been investigated and was closed; and two investigations were still open and the files could not be provided. 99 Percentages total more than 100% due to rounding.

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time between receipt of referral by OHAN and face-to-face contact with the alleged child victim must be within 24 hours.

The Co-Monitors approved the following efforts listed in Table 5 as “good faith efforts” for timely initiation which must be completed and documented, as applicable, for exceptions to contact with an alleged victim child(ren) within 24 hours:

Table 5: Good Faith Efforts to Contact Alleged

Victim Children within 24 Hours

 Investigator attempted to see child(ren) at school or  Investigator attempted to see child(ren) at therapist’s

child care facility

office

 Investigator attempted to see child(ren) at doctor’s  Investigator contacted the assigned foster care

visit or hospital

caseworker(s) and/or supervisor(s)

 For child(ren) moved to an out-of-state location in  Investigator attempted to contact the parent/guardian

order to receive specialized treatment, investigator

of the victim child(ren) if the child(ren) has returned

attempted to interview by Skype or other electronic

home

means

 Investigator attempted to contact the child at all

 Investigator attempted to see child(ren) at the police

foster care placements where the child may

department

temporarily be placed in the first 24 hours

 Investigator attempted to attend forensic/CAC

interview

Additionally, the following extraordinary circumstance exceptions to timely initiation (listed in Table 6) were approved by the Co-Monitors:

Table 6: Extraordinary Circumstance Exceptions to Contact with

Alleged Victim Children within 24 Hours

 Child was returned to biological family prior to  Facility restrictions due to child’s medical

report and family refuses contact

requirements

 Child is deceased

 Natural disaster

 Law enforcement prohibited contact with child

 Child missing despite efforts to locate (efforts

should include all applicable good faith efforts

listed above)

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Table 7 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure.

Table 7: Baseline, Timeline and Interim Benchmarks for Timely Initiation of Investigations

Baseline

June – November 2016

78%

Implementation Plan Timeline

Interim Benchmark

September 2017 March 2018
September 2018 March 2019
September 2019 March 2020
September 2020 March 2021 Final Target
Source: OHAN Implementation Plan

78% 80% 80% 85% 85% 90% 90% 95% 95%

Performance data for this period were collected during a case record review of investigations which were received and accepted in March 2018.100 Of the 32 applicable investigations, contact was made with the all alleged victim child(ren) within 24 hours in 19 (59%) investigations and in two (6%) additional investigations, documentation supported completion of all applicable good faith efforts; total performance for March 2018 is 66 percent, which is below the interim benchmark of 80 percent and a decline from performance during the prior period (see Figure 23).

100 The Co-Monitors have continued to assess that although data for this measure are collected in CAPSS and monthly reports are provided to the Co-Monitors by DSS, the aggregate CAPSS report cannot currently be used for reporting due to the following: the CAPSS report does not distinguish between investigations involving Class and Non-Class Members which is required for reporting performance and the Co-Monitors have found instances in which caseworkers have incorrectly documented the time a child is seen. The Co-Monitors will work with DSS to improve the accuracy and reliability of these data for future reporting.

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Figure 23: Timely Initiation of Investigations June 2016 - March 2018

March 2018 Interim Benchmark – 80%

Source: June 2017, January 2018 and June 2018 Case Record Reviews, USC CCFS and Co-Monitor staff

Contact with Core Witnesses

The FSA requires “[c]ontact with core witnesses must be made in at least 90% of the investigations of a Referral of Institutional Abuse or Neglect, with exceptions approved by the Co-Monitors” (FSA IV.C.4.(c)).

A core witness is defined as an individual who is pertinent to the investigation because they witnessed or have knowledge of the alleged actions and can shed light on the allegations and the actions of the alleged perpetrators. Core witnesses may differ investigation to investigation, but in all cases include: reporter(s), alleged perpetrator(s), alleged child victim(s), child’s DSS caseworker, other child(ren) and/or adult(s) in the home and, when involved, law enforcement. If the allegations involve an institutional setting, all other adults and children relevant to the investigation are also considered core witnesses.101

Listed in Table 8 are exceptions, approved by the Co-Monitors, to the requirement that the investigator make contact with a core witness during an investigation. In all instances, the exception must be supported by documentation of the exception reason and best efforts to engage the person:
101 This definition of core witnesses was proposed in DSS’s OHAN Implementation Plan, which was approved by the CoMonitors and consented to by Plaintiffs.

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Table 8: Exceptions to Contact with Core Witnesses during Investigations

 Witness refused to cooperate

 Unable to locate or identify witness

 Witness advised by counsel or law enforcement  Medical conditions prevented witness from

that interview could not occur (e.g. pending

cooperating

charges, lawsuit)

 Witness is deceased

Table 9 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure:

Table 9: Baseline, Timeline and Interim Benchmarks for Contact with All Necessary Core Witnesses during the Investigation

Baseline

June – November 2016

27%

Implementation Plan Timeline

Interim Benchmark

September 2017 March 2018
September 2018 March 2019
September 2019 March 2020
September 2020 March 2021 Final Target
Source: OHAN Implementation Plan

35% 40% 45% 55% 60% 70% 80% 90% 90%

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Performance data for this period were collected during a case record review of investigations, which were received and accepted in March 2018. Only one (3%) of the 32 applicable investigations reflected contact with all necessary core contacts during the investigation (see Figure 24).
Figure 24: Contact with All Necessary Core Witnesses during Investigations June 2016 - March 2018
March 2018 Interim Benchmark – 40%
Source: June 2017, January 2018 and June 2018 Case Record Reviews, USC CCFS and Co-Monitor staff

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The following data, presented in Table 10, reflects the frequency of OHAN investigator contact with each category of core witness in the 32 investigations reviewed:

Table 10: Contact with Necessary Core Witnesses during

Investigations by Type of Core Witness March 2018

N=32

Core Witness

Number of Applicable Investigations

Contact with All

Contact with Some

Alleged Victim Child(ren)

32

22 (69%)

1 (3%)

Contact with None 9 (28%)

Reporter

32

13 (41%)

-

19 (59%)

Alleged Perpetrator(s)

27

19 (70%)

5 (19%)

3 (11%)

Law Enforcement

7

-

-

0 (100%)

Alleged Victim Child(ren)’s Caseworker(s)
Other Adults in Home or Facility102
Other Children in Home or Facility103
Additional Core Witnesses

32 19 24 11104

6 (19%) 3 (16%) 1 (4%)
-

1 (3%) 3 (16%) 4 (17%) 1 (9%)

25 (78%) 13 (68%) 19 (79%) 10 (91%)

Source: June 2018 Case Record Review, USC CCFS and Co-Monitor staff *Totals may not equal 100% due to rounding

Although performance on this measure for all core witnesses was unacceptable during both the prior period (0%) and this period (3%), there is one significant area of decline that is particularly troubling to the Co-Monitors. During the prior period, all alleged victim children were interviewed or observed (as age or developmentally appropriate) at some point during the course of every investigation. However, of the 32 investigations reviewed in March 2018, only 22 (69%) investigations included contact with all alleged victim children prior to closure of the investigation. In 20 of the investigations in which contact was made, documentation does not indicate that the alleged victim child(ren) was interviewed alone or apart from other adults or the alleged perpetrator as age and developmentally appropriate. The interview with the alleged

102 For investigations involving foster homes, in addition to speaking with the alleged perpetrator(s), the investigator should speak with all other adults in the household. For investigations involving institutions, the investigator should speak with all other adults who were involved in or who have knowledge of the allegations. 103 For children who are placed in foster homes, in addition to speaking with all alleged victim children, the investigator should speak with all non-victim children in the home to inform the investigation, including other foster children and biological or adopted children in the home. For investigations involving institutions, as most facilities have many children placed there, investigators should speak with all other children who were involved in or who have knowledge of the allegations. 104 Additional core witnesses identified by reviewers in 10 investigations included family members, school personnel, mental health providers, medical staff and forensic interviewers.

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victim child(ren) is a core investigative task to assess and ensure the safety of children in foster care. This area of practice requires immediate attention and corrective action.

Case Decisions

At the conclusion of the investigation, a decision to indicate or unfound is made based upon the totality of the information collected, with the preponderance of the evidence as standard of proof of the facts.105

Section IV.C.3. of the FSA requires “[a]t least 95% of decisions to ‘unfound’ investigations of a Referral of Institutional Abuse or Neglect must be based upon DSS ruling out abuse or neglect or DSS determining that an investigation did not produce a preponderance of evidence that a Class Member was abused or neglected.”

Table 11 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure:

Table 11: Baseline, Timeline and Interim Benchmarks for Appropriate Case Decisions during Investigations

Baseline

June – November 2016

47%

Implementation Plan Timeline

Interim Benchmark

September 2017 March 2018
September 2018 March 2019
September 2019 March 2020
September 2020 March 2021 Final Target
Source: OHAN Implementation Plan

48% 50% 55% 60% 65% 75% 85% 95% 95%

Performance data for this period were collected during the previously referenced case record review of investigations received and accepted in March 2018. Of the 32 applicable investigations, 29 investigations included a case decision to unfound the allegations. Reviewers

105 SC DSS Human Services Policy and Procedural Manual, Chapter 7-721. p. 3 (effective date 11/29/2012).

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agreed that the case decision to unfound the investigation was appropriate in six (21%) of the 29 investigations (see Figure 25). Current performance has declined since the prior period and does not meet the interim benchmark of 50 percent.
Figure 25: Decision to Unfound Investigations Deemed Appropriate June 2016 - March 2018
March 2018 Interim Benchmark – 50%

Source: June 2017, January 2018 and June 2018 Case Record Reviews, USC CCFS and Co-Monitor staff
For those investigations in which reviewers disagreed with the unfounded decision, in all (23 investigations) the reviewer assessed that the investigator failed to collect sufficient information necessary to make an accurate finding. This was primarily due to the lack of interviews with the children and information collected from collateral contacts.
Timely Completion
The FSA includes the following three measures for timely completion of investigations, recognizing that some investigations may take longer than 45 days as policy requires:
 “At least 60% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within forty-five (45) days of initiation of an investigation, unless the DSS Director or DSS Director’s designee authorizes an extension of no more than fifteen (15) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(d)).

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 “At least 80% of investigations of a Referral of Institutional Abuse or Neglect shall be completed within sixty (60) days of initiation of the investigation, and all investigations not completed within sixty (60) days shall have authorization of the DSS Director or DSS Director’s designee of an extension of no more than thirty (30) days upon a showing of good cause. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(e)).
 “At least 95% of all investigations of a Referral of Institutional Abuse or Neglect not completed within sixty (60) days shall be completed within ninety (90) days. For the purposes of this section, an investigation is not completed if DSS determines the Report is unfounded because the deadline to complete the investigation has passed” (FSA IV.C.4.(f)).

The FSA and OHAN policy provide that the DSS Director or Director’s Designee may authorize an extension of up to 15 days for “good cause” or compelling reasons.106 Good cause means that, through no fault of the investigator, sufficient reason exists for delaying the case decision. Examples of good cause may be one of the following listed in Table 12:

Table 12: Examples of Good Cause Reasons to

Extend Investigation Timeframes

 Awaiting critical collateral information (e.g. medical  Critical new information was received from witness

report, x-rays, toxicology, video)

that requires follow up

 Awaiting forensic interview/findings

 Awaiting action by law enforcement

 Awaiting critical information from another  Child has been too ill or traumatized to speak with

jurisdiction (e.g. central registry check)

investigator

106 SC DSS Human Services Policy and Procedural Manual, Chapter 7-721. p. 12 (effective date 11/29/2012).

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Table 13 includes the approved OHAN Implementation Plan timeline and interim benchmarks for this measure:

Table 13: Baseline, Timeline and Interim Benchmarks for Timely Completion of Investigations

Baseline

June – November 2016

45 days – 95% 60 days – 96% 90 days – N/A

Implementation Plan Timeline

Interim Benchmark

September 2017 March 2018
September 2018 March 2019
September 2019 March 2020
September 2020 March 2021 Final Target
Source: OHAN Implementation Plan

45 days – 75% 60 days – 80% 90 days – 95% 45 days – 75% 60 days – 80% 90 days – 95% 45 days – 75% 60 days – 80% 90 days – 95% 45 days – 80% 60 days – 80% 90 days – 95% 45 days – 80% 60 days – 80% 90 days – 95% 45 days – 90% 60 days – 90% 90 days – 95% 45 days – 90% 60 days – 90% 90 days – 95% 45 days – 95% 60 days – 95% 90 days – 95%
95%

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Performance data for this section were collected during the case record review of investigations that were received and initiated in March 2018.107
Closure within 45 Days Of the 34 applicable investigations received and initiated in March 2018108, one investigation was excluded from the 45 day compliance measure.109 Of the remaining 33 investigations, 29 investigations were completed within 45 days, however, reviewers determined that two of these investigations were closed as unfounded prematurely in an effort to meet the 45 day requirement, which is not considered compliant under the FSA. Therefore, the review determined that 27 (82%) of the 33 applicable investigations were timely and appropriately closed within 45 days. This meets the interim benchmark for timeliness.
Closure within 60 Days Three additional investigations (including one with an approved extension request) were closed between 45 and 60 days resulting in performance of 88 percent (30 of 34)110, on timely completion within 60 days. This meets the interim benchmark for timeliness.
Closure within 90 Days As previously mentioned, two investigations involving Class Members that were initiated in March 2018 were not yet closed during the time of review and were therefore not assessed on other measures in this section; both were open for longer than 90 days, making performance on timely closure within 90 days also 88 percent.
In sum, current performance exceeds the interim benchmark level for both the 45 and 60 day requirement but does not meet the 90 day requirement. As reflected in Figure 26, current performance represents declines since baseline data were collected in June 2016.

107 The Co-Monitors have continued to assess that although data for this measure are collected in CAPSS and monthly reports are provided to the Co-Monitors by DSS, these data cannot currently be used for reporting due to the following: the CAPSS report does not distinguish between investigations involving Class and Non-Class Members which is required for reporting performance and a case record review is required to determine if an investigation is closed prematurely to meet required timeframes.
108 Other OHAN measures discussed within this section include 32 applicable investigations. While conducting the case record review, it was determined that two investigations involving Class Members that were received and initiated in March 2018 were still open and the files could not be provided. These investigations were able to be assessed for timely closure measures but information could not be collected for other measures within this section. 109 In one investigation, an extension was requested and granted as the investigator had not interviewed the alleged perpetrator and the forensic interview had not yet occurred. In one additional investigation, an extension was requested and granted due to the assigned investigator becoming ill; the reviewer determined that this situation did not meet the requirements for a good cause reason to approve an extension and should not be excluded from this measure as another investigator could have been assigned. 110 Based upon the language in the FSA, the two investigations that were closed as unfounded prematurely to meet required timeframes are not considered compliant for any timely closure measure.

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Figure 26: Timely Completion of Investigations March 2018
N=39 within 45 days; N=40 within 60 days; N=40 within 90 days

Lines represent March 2018 Interim Benchmarks
45 Day Performance: 75%
60 Day Performance: 80%
90 Day Performance: 95%

Source: June 2017, January 2018 and June 2018 Case Record Reviews, USC CCFS and Co-Monitor staff
VIII. PLACEMENTS
The requirements of the FSA reflect well-established child welfare principles that children are placed in the most family-like setting appropriate to meet their needs; children are placed with their siblings, whenever possible, and within their home communities; children experience stability, limiting unnecessary placement moves and transitions; and children are cared for by supportive caretakers and receive services necessary to maintain their safety, health and wellbeing. As the data for the current period reflect, very few children ages six and under currently reside in congregate care, however, too many children ages seven and older continue to live in congregate care settings. Additional progress is also needed to ensure that children are placed with their siblings.
A. Placement Needs Assessment
By February 1, 2017, with prior input from and subject to approval by the Co-Monitors, DSS was to have performed “a statewide and regional foster care Placement Needs Assessment in order to determine the minimally adequate capacity and array of placements for meeting the placement needs of all Class Members” (FSA IV.D.1.). The Needs Assessment was to include “specific recommendations addressing all the assessment’s findings, including but not limited to

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recommendations that address the capacity to place Class Members close to their home community, placing Class Members in the least restrictive, most family-like placement, the number and array of therapeutic foster care placements, a system of tracking availability of beds in family foster homes, and matching of Class Members to placements that can meet their needs” (FSA IV.D.1.).
In January 2016, DSS began work with the Co-Monitors to develop an approved methodology for conducting the Placement Needs Assessment. USC CCFS initiated a statewide Placement Needs Assessment in February 2017, with an original completion date of June 30, 2017. DSS later requested, and the Co-Monitors agreed, that a report would be submitted on August 31, 2017; DSS submitted a report with data and findings to the Co-Monitors on that date. In late September 2017, the Co-Monitors requested that additional work be completed on placement projections, including an assessment of county versus regional needs, to better address the State’s capacity to place Class Members close to their home communities. In December 2017, the Co-Monitors provided additional written feedback to DSS. On March 31, 2018, as part of the updated draft Placement Implementation Plan, DSS provided county-level data related to placement projections, discussed below.
B. Placement Implementation Plan
The FSA requires that “[w]ithin sixty (60) days of the completion of the needs assessment, DSS shall develop an Implementation Plan to implement the recommendations of the needs assessment within eighteen (18) months. The Implementation Plan shall have enforceable benchmarks with specific timelines, subject to approval by the Co-Monitors, to measure progress in executing the recommendations of the needs assessment” (FSA IV.D.1.(a)).
After reviewing DSS’s Placement Needs Assessment, the Co-Monitors shared with DSS that it would be important to include strategies in the Placement Implementation Plan to address several themes identified, including the following:111
 Expansion of family foster care resources in every area of the state, including kinship placement resources;
 Engagement of foster parents who can support legal permanency for children and youth;  Stopping the practice of placing children far from their homes and communities;  Improvement of placement processes;

111 Additional information about each bulleted item may be found in the Michelle H., et al. v. McMaster and Alford Monitoring Period II report, pgs 81-82. This report is available at: https://www.cssp.org/publications/child-welfare/abstract/Michelle-H.-v.McMaster-Monitoring-Report-for-April-2017-Sept-2017.pdf

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 Modifying practice so that children do not have to change placements, often through a move from traditional to therapeutic foster care, to access more intensive services;
 Utilization of local office expertise and input about foster parent resources in their counties;
 Creation and integration of a unifying vision of what foster care is aimed at achieving for children and families;
 Significantly increasing mental health services for children in all levels of care;  Enhancing the role of providers and other supports in case planning activities for the
children in their care; and  Addressing CAPSS placement data issues.
On October 31, 2017, DSS submitted a draft Placement Implementation Plan, to which the CoMonitors provided feedback. On March 30, 2018, DSS submitted a revised draft Plan, acknowledging, with agreement from the Co-Monitors, that the breadth and complexity of the work required to develop placement processes and resources made plan development in this area a particularly difficult task. The Plan submitted reiterated DSS’s commitment to some important principles, such as the development and support of kin placements and the need for respite and other supports for foster families. The Plan also highlighted the need for development of caseworkers’ skills for engaging families and children, assessing child and family strengths and needs and performing individualized case planning and teaming. There was also acknowledgement of the necessity for collaboration with other systems and agencies to support children, parents and kin. As part of its draft Placement Implementation Plan, DSS also reported that it would be engaging Casey Family Programs112 to assist with the development of a provider diversification plan.113
After reviewing the Placement Implementation Plan, the Co-Monitors determined that it required additional work, including improved data analysis and needs projections. Among other things, the Co-Monitors identified a need for more specific county placement projections; clarification and operationalizing of strategies, policies and practices to be implemented; and articulation of an underlying case practice model. Many sections of the draft Plan were disjointed and did not link strategies with identified goals, such as prioritization of practices to sustain children safely in their own homes to avoid the use of foster care placement.114 The draft Plan also did not

112 For more information, see https://www.casey.org/what-we-do/ 113 The Proposed South Carolina Residential Care Redesign Plan consists of six phases to be implemented over a two-year period. These include: Creating a Vision; Data Analysis; Stakeholder Engagement; Resource Analysis/Development (including resources available through the federal Family First and Prevention Services Act); and Strategic Plan Development and Implementation. 114 For example, while there was recognition of the need to support the development of skills for engaging families and children, the Plan did not include any information about how DSS would implement this change, nor does it reference integration of the case practice model. In fact, there is no mention of the practice model as related to placement decision-making. Similarly, Family

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include strategies sufficient to address many of the key themes, outlined above, that the CoMonitors had recommended that DSS integrate into its Plan after reviewing the Placement Needs Assessment.

As a result, the Co-Monitors informed DSS that they would be engaging consultants with expertise in child welfare reform, practice and placement to assist DSS in further development of the Placement Implementation Plan. On July 1, 2018, the Co-Monitors engaged Kent Berkley and Andy Shookhoff to support the Co-Monitors and DSS by: (1) assessing the recommendations, feasibility, resource needs, strategies and timelines that have been proposed and identify gaps; (2) incorporating the information collected to develop an approvable Plan that meets each of the expectations outlined in the FSA, including a clear case practice model that will be reflected in all aspects of the placement process; and, (3) if needed, supporting DSS with Plan implementation. This work will be done in collaboration with DSS’s placement workgroup, key stakeholders and regional and county DSS staff to capitalize on the strengths of the existing planning efforts.

In addition, the health care consultants, engaged earlier by the Co-Monitors, are collaborating with DSS to revisit the intensive foster care structure, assessments, levels of care system and services. This analysis will also inform the Placement Implementation Plan. Placement processes must be streamlined, with strategic sequencing of targeted and flexible approaches to create and sustain stable placement capacity. The placement consultants and DSS will work collaboratively with the health care consultants as they revise and develop the Placement Implementation Plan to incorporate this work.

Prior to DSS’s submission of the Placement Implementation Plan, in early December 2017, the Co-Monitors and staff visited several group care facilities to deepen their understanding of placement issues and processes. Information collected from these visits, as well as discussions with stakeholders, OHAN staff and case file reviews reinforced concerns about the conditions and practices in some of the congregate care facilities throughout the state. The Co-Monitors discussed their concerns with DSS, including their observation that the higher level group home structure seemed more punitive than therapeutic at times. They also identified as a problem that the primary method by which children in DSS foster care receive appropriate therapeutic intervention is through placement in highly restrictive psychiatric residential treatment facilities. The lack of engagement between children, families and staff – often made more difficult by the placement of children very far from their homes – was also highlighted as very problematic, especially in cases in which the stated permanency goal is reunification. The Co-Monitors also questioned whether a rate increase was needed for facilities, as many seemed to be functioning
Team Meetings are included as a tool for gathering information and identifying placement, however, there is no discussion of how these teams will be used to identify needs and craft individualized plans for services and other interventions.

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with insufficient staff and other resources including nutritional food. The Co-Monitors also identified that there were strengths within the congregate provider community, with a willingness on the part of some providers to work more closely with DSS on a diversification strategy.

DSS’s draft Placement Implementation Plan did not set forth a plan for assessing quality of care in these facilities. The Co-Monitors informed DSS in April 2018 of their plan to augment their monitoring capacity through the engagement of consultants, Marci White and George Taylor, affiliated with Co-Monitor Paul Vincent’s Child Welfare Policy and Practice Group. Beginning in early July 2018, these consultants, who have expert knowledge about residential and community-based treatment, are performing a special review of the quality of congregate care facilities throughout the state, focusing on the capacity to meet the needs of Class Members, and the extent to which these needs could be met in less restrictive, primarily family-based settings. This work is expected to be completed by October 31, 2018.

Though DSS has acknowledged its need for additional support in these key areas, it initially expressed apprehension about the engagement of additional consultants, citing concerns about internal ability to manage and coordinate the work of multiple consultants, and the overlapping nature of the work with other initiatives and consultants. Over the course of months, the CoMonitors worked with DSS and clarified and reached agreement on the proposed scopes of work and a plan for coordination.

While working toward an updated Placement Implementation Plan, DSS has reported that it has taken steps to begin addressing some identified concerns, including:

 Development of a partnership with All Pro Dad115, a program of Family First116, with support of Tony Dungy, former National Football League coach and player. The goal of partnering with All Pro Dads is to raise awareness of the need for foster and adoptive parents. Recruitment efforts include a Facebook campaign; over 40 billboards; and public service announcements for churches, sports activities and other events. DSS has also worked with local media to feature stories about county-specific needs, featuring the stories of current foster parents, and developed a partnership with the Department of Motor Vehicles, and other state agencies, so that a video about the need for foster and adoptive parents could be screened in waiting rooms throughout the state. Reportedly, these efforts have had a positive impact on the number of foster parent inquiries and has led to the licensing of 253 foster homes between November 2017 and April 2018.117

115 For more information, see https://www.allprodad.com/ 116 For more information, see https://www.familyfirst.net/ 117 55 of the 253 foster homes licensed were recruited by private Child Placing Agencies.

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 Improvement to multiple placement processes, including merging licensure requirements so that there is one process for foster and pre-adoptive parents.
 In January 2018, DSS reports providers were made aware of opportunities to host family team meetings or train and support staff in becoming leads for the practice of family group conferencing through working with National Youth Advocate Program, which has a statewide contract to implement family group conferencing.
 In September 2017, placement providers were introduced to the Building Bridges Initiative118, which includes a commitment to training on de-escalation approaches to reduce or eliminate the use of restraint or seclusion. Core principles promoted by the Building Bridges Initiative, are in line with best practices in child welfare and include being family-driven; youth-guided; strength-based; culturally and linguistically competent; and individualized; and using eevidence and practice-informed interventions. DSS received feedback from participants in Building Bridges to further inform ongoing placement structures and practices. As of the writing of this report, some providers report beginning to use the model.
C. Performance Data119
Placement of Children in Congregate Care
The FSA has multiple requirements related to placement of children in the most family-like, least restrictive environments and, where possible, with their siblings.
The FSA requires that at least 86 percent of Class Members be placed outside of congregate care placements on the last day of the reporting period (FSA IV.E.2.). DSS data show that on March 31, 2018, 78 percent (3,313 of 4,226) of children in foster care were placed outside of a congregate care placement (to include residential treatment and emergency shelters) (see Table 14). 120

118 For more information, see www.buildingbridges4youth.org 119 The data audit work being conducted by Chapin Hall has identified potential issues with the quality and accuracy of data related to placement. Specifically, placement type, placement stability and emergency or temporary placements. This may impact the accuracy of data on placement measures reported herein. DSS and Chapin Hall have a project underway to assess the extent of any issues and will develop a plan for correction as needed. Additionally, current DSS data reports do not indicate whether a child’s placement in custody is voluntary or involuntary, which would enable reporting to distinguish between Non-Class Members and Class Members. Although the Co-Monitors have worked with DSS to manually correct for this coding issue with respect to a number of measures, it is possible that for some measures discussed throughout this section, a small number of NonClass Members are included in aggregate data. DSS recently developed the capacity to distinguish between children who are voluntarily and involuntarily placed in care and data for the next monitoring period will reflect these enhancements. 120 Twenty-six children who were hospitalized (11) or in a correctional/juvenile justice facility (15) are not included in the universe for this measure.

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Table 14: Types of Placements for Children as of March 31, 2018
Children in Foster Care

4,226 (100%)

Types of Placement for Children in Foster Care

Number (Percentage) of Children

Family-Based Setting

3,313 (78%)

Congregate Care, Emergency Shelter or Residential Treatment Facility

913 (22%)

Breakdown by Type of Group Care Facility

Congregate Care Emergency Shelter Residential Treatment Facility Source: CAPSS Data Provided by DSS
Children Ages 12 and Under

841 (20%) 4 (<1%) 68 (2%)

The FSA also includes placement standards specific to certain age groups of children, and requires that “[a]t least 98% of the Class Members twelve (12) years old and under shall be placed outside of Congregate Care Placements on the last day of the Reporting Period unless an exception pre-approved or approved afterwards by the Co-Monitors is documented in the Class Member’s case file” (FSA IV.E.3.).

The Co-Monitors have approved the following exceptions for placing children ages seven to 12 in a congregate care facility, as outlined in Table 15:

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Table 15: Exceptions for Placement of Children Ages 12 and Under in Non-Family-Based Placements
 The child has clinical and medical needs that can only be met in a congregate care setting and cannot be provided in a family-like setting, and the placement is a facility that has the capacity and specialized treatment to meet those needs. The determination of clinical need must be based upon a decision issued by a Licensed Practitioner of the Healing Arts (LPHA) within the scope of their practice under SC State Law and not an employee of DSS. A determination of medical need must be made by a physician.
 The child is part of a sibling group of four or more.  The child has been removed and is in the legal custody of the SCDSS and is
placed with a parent who is not in SCDSS care, but who is temporarily in a residential group setting for treatment.
DSS reports that internal, child-specific decision-making meetings for children ages seven to 12, or “staffings”, regarding whether to continue a congregate placement for a child are being held across the state. Within the past year, meetings have been held to discuss the placements of 170 children and DSS reports that staffings regarding all children would be complete by August 2018.
DSS reports that for the majority of these staffings, there was no uniform process across the state for these meetings. A tool and protocol were finalized in August 2018 in order to provide for more consistent structure and data collection abilities. As DSS embarks on transitioning children, as appropriate, from congregate care facilities, the Co-Monitors have emphasized facilities must provide specialized services to meet the needs of all children remaining in congregate care.

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As reflected in Table 16, as of March 31, 2018, 92 percent (2,727 of 2,966) of children ages 12 and under in foster care were residing in a family-based setting. This represents a slight decline from the prior period, when performance was 93 percent.

Table 16: Types of Placements for Children Ages 12 and Under as of March 31, 2018
All Children in Foster Care Ages 12 and Under
2,966 (100%)

Types of Placement

Number (Percentage) of Children

Family-Based Setting

2,727 (92%)

Congregate Care, Emergency Shelter or Residential Treatment Facility

239 (8%)

Breakdown of Type of Facility

Congregate Care

218 (7%)

Emergency Shelter

0

Residential Treatment Facility Source: CAPSS Data Provided by DSS

21 (<1%)

Children Ages Six and Under

The Interim Order, entered September 28, 2015, included provisions to immediately address the placement of children ages six and under in congregate care, requiring that by November 28, 2015, DSS “create a plan, subject to the approval of the Co-Monitors, for preventing, with exceptions approved by the Co-Monitors, the placement of any Class Member age six (6) and under in any non-family group placement (including but not limited to group homes, shelters or residential treatment centers)” (IO II.3.(a) & FSA IV.D.2.). The plan was to include “full implementation within sixty (60) days following approval of the Co-Monitors.”

On March 15, 2016, the Co-Monitors approved DSS’s plan, including acceptable exceptions (listed in Table 17), and DSS issued a directive outlining the procedure to be used by local and regional office staff to ensure the appropriate placement of children ages six and under in family placements. The procedure currently requires prior approval from the applicable Regional Director before any child age six or under can be placed in a non-family-based setting.

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Table 17: Exceptions for Placement of Children Ages Six and Under in Non-Family-Based Placements
 The child requires a degree of clinical and/or medical support that can only be provided in a group care setting and cannot be provided in a family like setting, and the placement is a facility that has the capacity and specialized treatment to meet those needs.
 The child is the son or daughter of another child placed in a group care setting.  The child coming into care is in a sibling group of four or larger and all efforts
to secure foster home and Therapeutic Foster home placements have been completed and have not produced a home. In that instance, placement in a facility that can accommodate the sibling group together and maintain daily contact between siblings is an allowable exception. This exception is timelimited for up to 90 days and can be extended for time-limited increments after considering and documenting the best interests of the children and pursuing and documenting intensive efforts to identify and support an appropriate placement or placements.  The child comes into care and is placed in congregate care with his or/her biological parent who is not in DSS care but who is receiving treatment at a facility.121  Children who are voluntarily placed by their parent or caregiver are not subject to this requirement.
DSS has provided monthly data on all children ages six and under who were placed in congregate care during this monitoring period. These data include child-specific information regarding approved exceptions each month, with the reasons for the approval.
As illustrated in Figure 27, DSS reported that the number of Class Members in congregate care placements ranged from three to eight children in each month of the monitoring period. Most of these children were residing in a treatment facility with their mothers or were part of a sibling group of four or more children for whom DSS reports a single, family-based placement could not be located.122 The Co-Monitors recognize that making individual determinations about placements that best meet a child’s current needs are appropriate as long as they are based on sound clinical judgments.

121 This exception was requested and approved by the Co-Monitors in May 2017 after the initial list of exceptions was approved. 122 In validating data for this measure, the Co-Monitors identified several situations that did not meet an agreed-upon exception, but are either due to a circumstance which the agency believes to be outside of its control or were caused by a lack of appropriate, available placements. Specifically, one child was in a congregate care facility with siblings at the time DSS filed with the Court to gain custody of the children and the Court ordered that the child remain in that placement; another child was in need of a respite placement and the only placement available was too far from the child’s school, therefore, the child spent several weeks in a congregate facility before returning to the child’s foster home; and another child entered foster care and stayed in a congregate facility for a short time until a family-based placement was located.

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Figure 27: Children Ages Six and Under in Congregate Care April 2017 - March 2018123

Source: CAPSS Data Provided by DSS
Placement in DSS Offices and Hotels
The FSA requires that by November 28, 2015, “DSS shall cease using DSS offices as an overnight placement for Class Members, and shall cease placing or housing any Class Members in hotels, motels and other commercial non-foster care establishments. For any Class Members moved out of such DSS Offices or Hotels, DSS shall provide for their appropriate placement. In the extraordinary event that a child stays overnight in a DSS office, Defendants shall immediately notify the Co-Monitors, who shall provide a report to Parties as appropriate, including whether or not, in their view, the incident should be reported to the court as a violation which would preclude Defendants’ ability to achieve compliance on this provision” (FSA IV.D.3.).
During this monitoring period, the Co-Monitors were notified of one instance of children staying overnight at a DSS office in violation of this provision. DSS reports that in October 2017, two children, age nine and age 11, spent the night in a DSS office while staff were seeking placement for them. The children were taken into protective custody by law enforcement and arrived at a DSS office just after midnight. Multiple DSS staff worked to locate a placement to no avail. At

123 Monthly totals are not discrete, one child may be represented across several months.
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approximately 9:00 AM, it was determined that the children had previously been involved with DSS and had resided with their paternal grandmother. Law enforcement rescinded the decision to take the children into custody, DSS assessed the children’s grandmother and released them to her custody.
DSS promptly reported the overnight stay to the Co-Monitors and provided supporting documentation. To facilitate the notification process and ensure the prompt provision of important information, DSS and the Co-Monitors have drafted an Overnight Stay reporting form to be used in future reporting periods.
Emergency or Temporary Placements
The FSA requires that “Class Members shall not remain in any Emergency or Temporary Placement for more than thirty (30) days. Under exceptions approved by the Co-Monitors, if a child is initially placed in an Emergency or Temporary Placement that is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move…” (FSA IV.E.4.). Exceptions to this standard have not yet been proposed by DSS.
The FSA also requires that “Class Members experiencing more than one Emergency or Temporary Placement within twelve (12) months shall not remain in the Emergency or Temporary Placement for more than seven (7) days. Under exceptions subject to the CoMonitors’ approval, if a child’s subsequent placement within twelve (12) months in an Emergency or Temporary Placement is not a Congregate Care Placement, and that placement is re-designated within thirty (30) days as a long-term foster home or therapeutic foster home, then the child’s stay shall not be considered a violation of this provision and the re-designation shall not be considered a placement move…” (FSA IV.E.5.).
DSS is unable to provide the data needed to report on this requirement. DSS has identified two primary barriers to collecting and providing these data: (1) there is not a standard, operational definition for “emergency” or “temporary” placements, and (2) due to a lack of a clear operational definition, placement data utilizing these categories are inconsistently entered by staff into CAPSS. DSS has informed the Co-Monitors that after a definition is agreed upon, a code book of definitions describing each level of foster care will be developed and fields will be added to CAPSS to capture and collect necessary information. The Co-Monitors anticipate that

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sufficient information regarding methods to develop and implement data collection for analysis and monitoring will be included in the final Placement Implementation Plan.124

Although DSS does not formally or consistently track the use of emergency or temporary placements, DSS data reflect that between October 2017 and March 2018, there were 320 instances of “incentive payments” (with 27 additional pending claims) made to providers to accept placement of a child overnight.125 Although technically not classified as temporary or emergency placements, the payments are used to support such situations and the Co-Monitors view these as temporary and emergency placements that can contribute to placement instability and exacerbate the trauma of placement.

Pursuant to Change Orders 5 and 7, the following describes situations under which the incentive payments may apply:

1. DSS has 24 to 48 hour notice that a child will be discharged from a resource family home, therapeutic foster home or group care, however, DSS is unable to identify an alternative placement;

2. a child who entered DSS custody on an emergency basis and needs a secure placement that has the staffing, supervision and structural environment to ensure the safety and well-being until an appropriate level of care placement is located and for whom referrals for an appropriate level of care placement have been exhausted; or

3. a child who experiences an unscheduled discharge or release from a resource family home, therapeutic foster home or group care and a search for appropriate level of care placements has been exhausted and a determination made that no placements are immediately available but may be in the near future.

Juvenile Justice Placements

The FSA, incorporating an Interim Order provision, requires “[w]hen Class Members are placed in juvenile justice detention or another Juvenile Justice Placement, DSS shall not recommend to the family court or Department of Juvenile Justice that a youth remain in a Juvenile Justice Placement without a juvenile justice charge pending or beyond the term of their pleas or

124 The data audit work being conducted by Chapin Hall has identified potential issues with the quality and accuracy of data related to placement. Specifically, placement type, placement stability and emergency or temporary placements. 125 Per DSS, as of July 14, 2017, a group care facility may receive an additional daily payment of $75 per day for a child accepted to the facility on an emergency basis for up to two weeks, renewable for an additional two weeks. Similarly, as of September 15, 2015, a foster/resource parent may receive an additional $250 per instance of a child accepted for placement on an emergency basis for up to two weeks, renewable for an additional two weeks.

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adjudicated sentence for the reason that DSS does not have a foster care placement for the Class Member…” (FSA IV.H.1.).

As reported in the last monitoring period, DSS does not have a system in place for tracking youth involved with both the juvenile justice and child welfare systems. In an effort to address the need for interagency coordination, DSS entered into a Memorandum of Understanding (MOU) with the South Carolina DJJ in September 2017. The MOU requires, among other things, the identification of DSS and DJJ liaisons in each county to serve as first points of contact to identify youth involved in each system, provide relevant caseworker contact information and share limited records. The MOU also requires that Interagency Staffings – meetings between DSS and DJJ caseworkers involved with a youth’s case – be held within 30 days of “identification,” as well as anytime a youth is detained, on “runaway,” “offends in placement,” or is otherwise at “risk of reoffending.”

DSS began implementing the MOU during this monitoring period in partnership with regional attorneys and county DJJ and child welfare staff. DSS has reported that regional attorneys from the Office of General Counsel have been meeting with legal staff and solicitors throughout the state to communicate MOU requirements, and that designated DSS county liaisons have been providing DJJ with relevant contact information and participating in monthly interagency staffings. In addition, DSS has reported that some counties and regions have initiated quarterly collaborative sessions attended by DSS, DJJ, and law enforcement to address roles, processes and implementation challenges.
DSS has also reported that it has developed a test version of a DJJ portal, demonstrated to DSS leadership in June 2018, which will allow designated DJJ staff to access the DSS CAPSS records of children in foster care. DSS is in the process of adjusting the portal in response to DSS leadership feedback. Details regarding protocols for access have not yet been established. DSS anticipates that changes to CAPSS will enable identification of dually involved youth in the future, and will allow for the aggregation of information related to required interagency staffings.

Though DSS has acknowledged that it does not have the ability to track the youth in its care who are involved with DJJ, it has continued to represent that youth are immediately taken into the physical custody of DSS upon exit from juvenile justice placement. No violations of the FSA were reported to the Co-Monitors by DSS again this monitoring period. Stakeholders throughout the state have, however, continued to express concerns to the Co-Monitors that youth are sometimes being held in detention or secure evaluation facilities because there are no appropriate DSS placements available and describe attempts by DSS to transfer responsibility to DJJ for youth with significant behavioral needs or who require a higher level of care because of lack of appropriate placements.

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In this monitoring period, the Co-Monitors reviewed a number of cases – likely representative of many others – in which youth spent time in DJJ facilities due, in part, to DSS’s failure to meet their needs. For example, in January 2018, a 15-year old youth in Richland County was sent to a secure evaluation center, despite recommendations by DJJ and the solicitor that a community evaluation would be appropriate, because DSS insisted it did not have an appropriate placement for the youth. In December 2017—four months after DSS advocated that charges not be dropped, and after nearly six months of failed placements—a solicitor informed the family court that a 16year old youth from Williamsburg County was still awaiting a placement appropriate to her severe mental health needs. One month later, in January 2018, the youth was placed at a DJJ secure evaluation center after her behavior escalated, violating the terms of her probation. The Co-Monitors have shared these cases, as well as others, with DSS leadership and requested follow-up be conducted by the agency.
The Co-Monitors remain very concerned that youth continue to spend time in secure facilities because DSS cannot provide the placements and supports likely to keep youth in their communities. This is an urgent need and one that DSS must address immediately in its Placement Implementation Plan work. As a beginning point, it is essential that DSS quickly develop the capability to provide accurate, real-time data that identifies which youth in its care are also involved with DJJ. Until this happens, it will be impossible to ensure that the needs of these youth are being addressed.
Placement Instability
The FSA requires that for all Class Members in foster care for eight days or more during the 12month period, placement instability shall be less than or equal to 3.37 (FSA IV.F.1.). Placement instability is defined as the rate of placement moves per 1,000 days of foster care among Class Members (FSA II.O.) and placement moves are changes in foster care placements.
Data for this measure are reported annually and will be included in the next monitoring report. In the prior reporting period, DSS utilized an external data consultant to complete analysis for this measure. The Co-Monitors have had several conversations with DSS staff and their external data consultant to discuss the source and coding of the underlying data for this analysis. Some potential issues have been identified, which may impact the accuracy of this analysis. DSS is currently working with Chapin Hall, its data consultant, to make adjustments to CAPSS to address these issues, as needed.

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Sibling Placement

Children in foster care should be placed with their siblings whenever possible. The FSA recognizes the importance of this familial connection and requires that at least 80 percent of children who enter care with or within 30 days of their siblings be placed with their siblings (FSA IV.G.2. & 3.). The FSA allows for exceptions to this requirement, including when there is a court order prohibiting such placement or if the placement is determined not to be in the best interest of one or more siblings. Additional exceptions to this standard can be identified and approved by the Co-Monitors as an element of the Placement Implementation Plan, yet to be approved. The FSA sets two targets – one for placement with at least one of a child’s siblings and the other for placement with all siblings. Interim benchmarks and timelines were proposed in the draft Placement Implementation Plan and have not been approved by the Co-Monitors.

DSS provided data for 863 children who entered placement between October 2017 and March 2018 with a sibling126 or within 30 days of their sibling’s entry to placement and were still in care on March 30, 2018. As of March 30, 2018, for this cohort of children, as reflected in Table 18, 38 percent (324 of 863) of children were placed with all of their siblings and 63 percent (547 of 863) of children were placed with at least one of their siblings.

Table 18: Sibling Placements for Children Entering Placement between October 2017 and March 2018 as of March 30, 2018 N=863

Sibling Placement Status

Number (Percentage) of Children*

FSA Final Target

Total Number of Children Entering Placement

from October 2017 to March 2018 Who Have a

Sibling Entering

863

--

Placement With or Within 30 Days

Children placed with

324 (38%)

80%

All Siblings

Children placed with

547 (63%)

85%

At Least One Sibling

Children Not Placed With Any Sibling

316 (37%)

--

Source: CAPSS Data Provided by DSS * Total percentage does not equal 100 as children can be included in both “at least one sibling” and “all sibling” categories

126 Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier.

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IX. FAMILY VISITATION
Children who have been removed from their homes must spend time with family members while in foster care. The FSA includes requirements related to visits between children in foster care and their siblings and parents. DSS performance with respect to sibling visits declined this reporting period. Although a greater percentage of children visited with their parent(s), the vast majority of children in DSS custody continue to spend little or no time with the parent(s) to whom they are supposed to return. This continues to be an area of significant concern for the CoMonitors.
A. Visitation Implementation Plan
The FSA requires “[w]ithin 60 days of the entry of the Order approving the Settlement Agreement, Defendants shall develop an Implementation Plan to implement the achievement of the final targets in this subsection. The Implementation Plan shall have enforceable interim benchmarks with specific timelines, subject to consent by Plaintiffs and approval by the CoMonitors, to measure progress in achieving the final targets in this subsection. Plaintiffs will not unreasonably withhold consent, and if the Co-Monitors approve and Plaintiffs do not consent, Plaintiffs will describe with sufficient detail, rationale, and recommendations that will lead to consent” (FSA IV.J.1.).
As reported in the prior monitoring periods, DSS convened staff in a Visitation Workgroup in October 2016 to assess systemic barriers to family visitation and develop and assist with the implementation of the Visitation Implementation Plan. DSS submitted a draft of the Visitation Implementation Plan on November 30, 2016, and upon receipt of feedback from the CoMonitors and Plaintiffs, completed several rounds of revisions and modifications. The Implementation Plan for visitation could not be approved by the Co-Monitors because reliable baseline data with respect to children with reunification goals were not available. As discussed below, the Co-Monitors and USC CCFS were able to manually collect relevant data beginning in the last monitoring period. DSS submitted an updated draft Visitation Implementation Plan on August 11, 2018. The Co-Monitors provided feedback to the Plan on August 17, 2018, and DSS is in the process of modifying its Plan so that it can be resubmitted.

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B. Performance Data
Sibling Visits
Section IV.J.2 of the FSA requires “[a]t least 85% of the total minimum number of monthly sibling visits for all sibling visits shall be completed.” The FSA also allows for exceptions if there is a court order prohibiting or limiting visitation, if “visits are not in the best interest of one or more of the siblings and the facts supporting the determination are documented in the case file,” or with exceptions approved by the Co-Monitors (FSA IV.J.2.). The Co-Monitors have approved the appropriate exceptions to sibling visits as listed in Table 19:
Table 19: Exceptions to Sibling Visitation Requirement
 Court order prohibits or limits sibling visitation.  Child or sibling is on runaway during a calendar month with best efforts to locate.  Child or sibling is incarcerated or in a facility that does not allow visitation despite efforts.  Child or sibling refuses to participate in the visit where age appropriate.  Sibling visit is infeasible due to geographic distance with efforts to provide alternative forms of contact.
Geographic distance will only be allowed as an exception upon individual review of the applicable case by the Co-Monitors.  County Director approval with legal consultation for determination that a visit poses immediate safety concerns for the child or sibling. If an immediate safety incident or concern occurs prior to or during a visit, the caseworker is to remove the child from the visit and notify the County Director afterward.
 Supervisory approval for determination that visitation would be psychologically harmful to the child.127
Although documentation of sibling visits is expected to be entered by caseworkers into CAPSS, the fields that capture this information cannot yet be used to extract aggregate data. In order to assess performance for this measure, in June 2018, USC CCFS and Co-Monitor staff utilized the instrument developed in the first monitoring period to collect data on the occurrence of visits between siblings in foster care. Reviewers looked at a sample of cases for which sibling visits were required in March 2018.128 Reviewers determined that 157 of the applicable 303 children129 (52%) had visited with all of their siblings during the month. Of the 146 children who did not

127 A DSS supervisor must confirm the determination that visitation would be psychologically harmful to the child based upon written documentation of a clinical decision issued by a Licensed Practitioner of the Healing Arts (LPHA) within the scope of their practice under SC State Law and who is not an employee of DSS. The LPHA’s name, professional title, signature and date must be listed on the document to confirm the clinical decision. 128 As of March 31, 2018, there were 1,533 children who had been in foster care for at least one month, with siblings in foster care with whom they were not placed. A statistically valid random sample of 308 cases was pulled based on a 95% confidence level and +/- 5% margin of error. Sibling groups were identified utilizing data in CAPSS which defines a sibling group as a set of children with the same CAPSS case identifier. 129 Two cases were excluded because the child’s adolescent sibling refused visitation; one case was excluded based on documentation that sibling visitation would be psychologically harmful to the child or sibling; one case was excluded because visitation was prohibited by court order; and one case were excluded because the child or sibling was on runaway status during the month.

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visit with all of their siblings, 131 did not visit with any of their siblings (57 percent of children visited with at least one of their siblings). This is a decline since September 2017, when 60 percent of children visited with all of their siblings and 63 percent visited with at least one sibling.
In an effort to align data collection and analysis methodology with the specific FSA definitions for this measure, data were used to calculate performance as a percentage of required visits that occurred in the month reviewed. Reviewers determined that 293 (57%) of 510 required visits130 between children and the siblings with whom they were not placed occurred in March 2018 (see Figure 28).131 This is a decline in performance since the last monitoring period, when 66 percent of required visits between children and siblings occurred.
Figure 28: Visits that Occurred between Siblings March 2017 - March 2018
FSA Final Target – 85%

Source: June 2017, January 2018 and June 2018 Case Record Reviews, USC CCFS and Co-Monitor staff

130 Data reflect the exclusion of 15 visits for which it was determined that a valid exception applied for one of the reasons discussed above. See, supra., fn 129. 131 Because the universe of applicable visits is substantially greater than the universe of applicable children, and the data sample identified for review was calculated based on the number of applicable children, these performance data do not have the same level of statistical significance as the data discussed earlier. As DSS’s capacity to extract aggregate data for this measure improves, calculations will be based on a universe of applicable visits, as required by the FSA.

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Parent Visits
The FSA requires “[a]t least 85% of Class Members with the goal of reunification will have inperson visitation twice each month with the parent(s) with whom reunification is sought…” (FSA IV.J.3.). The FSA also allows for exceptions if there is a court order prohibiting or limiting visitation or with exceptions approved by the Co-Monitors listed in Table 20.
Table 20: Exceptions to Parent and Child Visitation Requirement
 Court order prohibits or limits parent visitation.  Parent is missing or child is on runaway during a calendar month with best efforts to locate.  Parent or child is incarcerated or in a facility that does not allow visitation in the calendar month despite best
efforts.  Parent refused to participate.  Parent did not show up to visit despite attempts to successfully arrange and conduct the visit.  Parental rights were terminated in that month.  Parent visit is infeasible due to geographic distance, with efforts to provide alternative forms of contact.
Geographic distance will only be allowed as an exception upon individual review of the applicable case by the Co-Monitors.  County Director approval with legal consultation for determination that a visit poses immediate safety concerns for the child. In addition, if an immediate safety incident or concern occurs prior to or during a visit, the caseworker is to remove the child from the visit and notify the county director afterward.
 Supervisory approval for determination that visitation would be psychologically harmful to the child.132
In June 2018, USC CCFS and Co-Monitor staff utilized a structured instrument to collect data on the occurrence of visits between children in foster care and their parents with whom reunification is sought. By policy and in accordance with the FSA, children are expected to visit with their parents at least twice per month. In order to assess performance, reviewers looked at a sample of 326 cases for which visits with parents were required in March 2018.133, 134 Performance remains very low. Reviewers determined that only 55 of the applicable 319 children visited twice during the month with all parent(s) with whom reunification was sought and that there were seven cases to which a valid exception applied,135 resulting in performance of 17 percent, as shown in Figure
132 A DSS supervisor must confirm the determination that visitation would be psychologically harmful to the child based upon written documentation of clinical decision issued by a Licensed Practitioner of the Healing Arts (LPHA) within the scope of their practice under SC State Law and who is not an employee of DSS. The LPHA’s name, professional title, signature and date must be listed on the document to confirm the clinical decision. 133 As of March 31, 2018, there were 2,119 children who had been in foster care for at least one month with a goal of “return to home,” or “not yet established.” A statistically valid random sample of 326 cases was pulled based on a 95% confidence level and +/- 5% margin of error. 134 Permanency goals were identified utilizing data in the CAPSS field in which caseworkers are expected to update case goals in accordance with the most current determination in legal proceedings. 135 Two cases were excluded because visitation was prohibited by a court order; two cases were excluded because the parent was missing; two cases were excluded because the parent resided in a facility in which visitation was not possible; one case was excluded because the parent was missing; one case was excluded because visitation was deemed psychologically harmful to the child; and one case was excluded because the parent refused visitation despite efforts by the caseworker.

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29. Almost half, 135 (42%) of the applicable children had no contact at all with any parent in the month of March 2018.
Figure 29: Children with Twice Monthly Visits with their Parents September 2017 - March 2018
FSA Final Target – 85%

Source: January 2018 and June 2018 Case Record Reviews, USC CCFS and Co-Monitor staff
X. HEALTH CARE

It is essential that child welfare systems provide children in foster care with the supports and services they need to be healthy. This requires the ability to quickly identify children’s health and behavioral health needs, to provide high quality preventative and acute care and to maintain a system for tracking care delivery and communicating key health care information. With the assistance of health care consultants, DSS continued to make progress in this area during this monitoring period. Most significantly, DSS obtained Co-Monitor approval for its Health Care Improvement Plan in August. This is an important accomplishment that establishes a strong foundation for meeting the heath care needs of children and youth.
A. Health Care Improvement Plan
The FSA required that by April 3, 2017, DSS, “with prior input and subject to approval by the Co-Monitors, shall develop a Health Care Improvement Plan with enforceable dates and targets for phased implementation concerning initial screening services, periodic screening services, documentation, and health care treatment services for Class Members in the areas of physical

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health, immunizations and laboratory tests, mental health, developmental and behavioral health, vision and hearing, and dental health. The Plan shall address:
(a) Developing the capacity to track screening and treatment services for individual children and aggregate tracking data, including but not limited to screens that are due and past due;
(b) Assessing the accessibility of health care screening and treatment services throughout the State, including the capacity of the existing health care providers to meet the screening and treatment needs of Class Members; and
(c) Identifying baselines and interim percentage targets for performance improvement in coordinating screens and treatment services” (FSA IV.K.1.(a-c)).
After receiving an extension for preparation of the Health Care Improvement Plan (pursuant to the FSA), DSS submitted a draft Plan to the Co-Monitors on September 29, 2017. The draft Plan described work that DSS had undertaken to improve access to and the quality of health care for the children in its care, including the appointment of a Child and Adolescent Psychiatrist; planning for a new DSS Office of Health and Well-Being; and the reconvening of the Foster Care Advisory Committee, a cross-agency and provider workgroup, to address issues related to the provision of health and mental health services to children in foster care statewide.
Though DSS set out a general vision for the delivery of health care services to children in foster care, the draft Plan did not address many of the complexities that the Co-Monitors believed to be essential to effective implementation. In light of this, and given the importance of the work, in November 2017, the Co-Monitors engaged consultants with specific expertise in child welfare health care reform to assess the sufficiency of DSS’s Health Care Improvement Plan, pursuant to FSA IV.K.3. The consultants’ recommendations, based on the results of validation activities and extensive interviews with key DSS, Department of Mental Health (DMH), Department of Health and Human Services (DHHS), Managed Care Organization (MCO) and community provider staff, were submitted in a Findings and Recommendations Report on February 12, 2018. The report concludes that DSS’s draft Health Care Improvement Plan contained important conceptual and structural elements on which to build a robust health care system for children in foster care, but that it did not yet include the operational framework needed for implementation. The consultants identified six priority action items, which they recommended DSS undertake right away, the first of which was the development of a revised plan that includes implementation timeframes, task leads and needed resources, including a multi-year budget.
In the months since the release of the Findings and Recommendations Report, DSS has demonstrated a sustained commitment to improving health care delivery to children in foster

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care. It has continued to effectively utilize the consultants’ expertise and has made great strides with respect to each of the recommended priority action items as outlined below:

Priority Action Item 1 - Produce a Revised Health Care Improvement Plan: DSS has worked intensively with the health care consultants and key partners since the submission of the Findings and Recommendations Report, with the goal of refining its Health Care Improvement Plan. On June 29, 2018, DSS submitted a revised Plan to the Co-Monitors. After providing feedback, the Co-Monitors approved the Plan on August 23, 2018. The Health Care Improvement Plan is broad in scope and includes a comprehensive vision for the delivery of health care to children in foster care through collaboration with DHHS and its MCO, Select Health, including mechanisms for sharing and utilizing critical health care data. If well implemented, the Plan has the potential to improve the physical, mental and dental health care of children in foster care throughout the state.

Priority Action Item 2 - Identify an Interim Director of the DSS Office of Health and WellBeing: The consultants recommended that DSS prioritize hiring a permanent Director to oversee its newly established Office of Health and Well-Being, and that it draw on internal staff at partner agencies to fill the role temporarily. On April 27, 2018, after an extensive search, DSS hired Gwynne Goodlett as the Director of the Office of Child Health and Well-Being. She became immediately involved in the development of a revised Health Care Improvement Plan and has been a much-needed project lead in moving the work forward.

Priority Action Item 3 - Identify and Convene a Leadership Team: The consultants recommended that DSS quickly name a cross-agency leadership team with management authority to develop a work plan and monitor Plan implementation, troubleshoot issues and provide bi-weekly progress reports to DSS and DHHS leadership, and monthly reports to the CoMonitors (a “SWAT team”). DSS immediately acted upon this recommendation. Key representatives from DSS, DHHS and Select Health (MCO) have been meeting weekly since March 2018 to discuss issues related to the development and implementation of the Health Care Improvement Plan, including protocols for data sharing, the production of management reports and coordination of health care case management. This team approach has proven essential to Plan development and will continue to play a critical role as implementation begins.

Priority Action Item 4 - Obtain Gap-in-Care Reports from DHHS and its MCO: The consultants recommended that DSS immediately work with DHHS, its MCO (Select Health) and other relevant state agencies to develop a data sharing agreement to enable DSS access to data necessary to monitor the health care needs of the children in their care. In the interim, the consultants recommended that DSS obtain reports from Select Health that identify children in foster care who have not received required screenings, assessments and follow-up (“gap-in-care

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reports”), and that the newly convened SWAT team utilize this information to monitor the procurement of this care for children who need it. They also recommended that DSS develop a protocol for notifying caseworkers about children on their caseloads with identified unmet needs. DSS immediately began work with DHHS and Select Health to initiate data sharing processes, and obtained all data requested from DHHS. In the months ahead, DSS must act expeditiously to sort and understand the data produced so that it can be used to improve health outcomes for children. This must include a system for regular data transfer, reporting and validation that is efficient and reliable, and a well-tested process for rapidly communicating relevant health information to caseworkers in the field.
Priority Action Item 5: Initiate Short-Term Data Workaround to Mitigate the 30-day Enrollment Gap: Although nearly all children in foster care in South Carolina are enrolled in one MCO, Select Health, enrollment is not immediate. The monthly contracting arrangement DHHS has with Select Health has meant that there can be up to a 30-day enrollment lag. In acknowledgement of the challenges this poses to DSS in its efforts to track health claims data for children from the time they enter DSS custody, the consultants recommended that DSS develop and implement a data workaround until DSS puts a longer term solution in place. DSS and DHHS have been working to resolve this issue, with an expected date of completion in January 2019.

Priority Action Item 6 - Initiate Short-Term Plan to Address Immediate Treatment Needs: Given DSS’s lack of reliable data on follow-up care identified in prior reporting periods, the consultants recommended that DSS quickly develop a process by which DHHS data could be utilized to identify children who did not receive needed screenings, assessments or follow-up care. DSS began work on this recommendation, and has been developing a process for addressing identified gaps in care. This process is addressed in more detail below.

In addition to the Health Care Improvement Plan requirement, the FSA includes two compliance measures to address unmet health care needs of children currently in care with deadlines set shortly after initial entry into the Agreement (FSA IV.K.4.(a)&(b)), both of which are discussed below.

B. Performance Data

Initial Health Assessments
The FSA required that by December 5, 2016, DSS “identify Class Members who have been in DSS custody for more than sixty (60) days as of the date of final court approval of the Final Settlement Agreement, and who have not had initial health assessments (physical/medical, dental

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or mental health). Within thirty (30) days after the identification period, Defendants shall schedule the initial health assessment for at least 85% of the identified Class Members” (FSA IV.K.4.(a)).
In the first monitoring period, the Co-Monitors reported data on children who had been in DSS custody for more than 60 days as of October 4, 2016, who had not yet received initial health/medical, dental or mental health assessments based on information entered into CAPSS. Because DSS acknowledged that the data provided were not accurate, the Co-Monitors worked with DSS and USC CCFS to clean up and validate the data. In the end, the data analysis produced concerning results, and both DSS and the Co-Monitors identified actions to meet the health care needs of children in foster care as an area of high priority.
Although DSS made significant efforts in the last monitoring period to improve the accuracy of its assessment data, its process depended upon caseworkers to manually enter and update appointments into CAPSS, sometimes months after they occurred. As a result, the data continued to be unreliable. With the help of the health care consultants, DSS made significant progress during this monitoring period in building protocols to allow for access to health care data housed at DHHS and Select Health. DSS and the consultants believe that these data are valid because they are extracted directly from Medicaid claims and billing records. Although there is still work to be done to sort and produce the data in a format that can be utilized by management, shared with caseworkers and reported to the Co-Monitors, the ability to access these data has been a breakthrough for DSS.
In an effort to gauge performance with respect to initial health assessments, DSS produced to the Co-Monitors data reflecting the percentage of children who entered DSS foster care in this monitoring period who received initial physical health, mental health and dental assessments of some kind. Because there is still important work that needs to be done to clarify DSS policy and definitions related to assessments and map them to Medicaid claims data, DSS is not yet able to identify details related to these initial assessments (some, for example, may qualify as Early Prevention Screening Diagnosis and Treatment (EPSDT) visits, while others may correspond only with more limited initial screenings or assessments).
According to the data produced, 738 (73%) of the 1,011 children who entered DSS foster care between October 1, 2017 and March 31, 2018 received an initial physical health assessment. Of these 738 children who received an initial assessment, 463 children received an assessment within 14 days of placement, 143 children received an assessment within 15 to 30 days of placement, 91 children received an assessment within 31 to 60 days of placement and 41 children received an assessment within 61 days or more of placement.

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The data also reflect that 525 (52%) of the 1,011 children who entered DSS foster care between October 1, 2017 and March 31, 2018, received an initial mental health assessment.136 Of the 525 children who received an initial assessment, 269 children received an assessment within 14 days of placement, 108 children received an assessment within 15 to 30 days of placement, 93 children received an assessment within 31 to 60 days of placement and 55 children received an assessment within 61 days or more of placement.

Finally, 431 (48%) of 890 children ages one and older137 who entered DSS foster care between October 1, 2017 and March 31, 2018, received an initial dental assessment. For those children who received an assessment, 90 children received an assessment within 14 days of placement, 125 children received an assessment within 15 to 30 days of placement, 95 children received an assessment within 31 to 60 days of placement and 121 children received an assessment within 61 days or more of placement.

Table 21: Children who Received Initial Health Assessments

For Children who Entered Care between October 1, 2017 and March 31, 2018

Total Number

Time to Assessment:

Total Number (Percent) of

of Applicable Children who

Children

Received

1 - 14 Days 15 - 30 Days 31 - 60 Days

61 or More Days

Assessment

Initial

Physical Health

1,011

738 (73%)

463

143

91

41

Assessment

Initial Mental

Health

1,011

525 (52%)

269

108

93

55

Assessment

Initial Dental Assessment

890

431 (48%)

90

125

95

121

Source: DHHS Medicaid claims data

136 For children under the age of three, completion of an initial medical assessment was considered compliant for the mental health assessment measure as a developmental assessment and screening is a component of their examination with a primary health care provider. 137 For purposes of this analysis, children under the age of one were not considered applicable for an initial dental assessment. An oral examine is a component of their examination with a primary health care provider.

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Immediate Treatment Needs
The FSA requires that by January 2, 2017, DSS “identify Class Members with Immediate Treatment Needs (physical/medical, dental or mental health) for which treatment is overdue. Within forty-five (45) days of the identification period, DSS shall schedule the necessary treatment for at least 90% of the identified Class Members. (Immediate Treatment Needs means immediate non-elective physical/medical, dental or mental health treatment needs and documented assessment needs, excluding routine periodic assessments.)” (FSA IV.K.4.(b)).
Since the last reporting period, DSS has worked with DHHS and Select Health to build a health care information system that builds on Medicaid data, collected by DHHS and Select Health, to identify children in DSS custody with immediate treatment needs. As with initial assessment data discussed above, DSS and the health care consultants believe that this approach—which utilizes Healthcare Effectiveness Data Information Set (HEDIS) measures among others, required for Medicaid managed care plans by the federal government—is much more likely to produce robust, reliable data than is now captured in CAPSS or initially conceptualized by DSS. Though a significant amount of data has been made available for use in identifying children in need of follow-up care, called “gap-in-care” reports by DHHS, additional work by DSS is needed with DHHS and Select Health to build an understanding of these data and develop a roster and reports to effectively track and follow-up on unmet health care needs. DSS has begun utilizing its CAPSS data to generate an interim child-specific roster for initial screenings and assessments to guide its new, weekly “cadence calls” with regional staff held by the Office of Child Health and Well-Being.

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APPENDIX A - Glossary of Acronyms
ADR: Accountability, Data and Research APS: Adult Protective Services CAPSS: Child and Adult Protective Services System CFSR: Child and Family Services Review CQI: Continuous Quality Improvement DHHS: Department of Health and Human Services DJJ: Department of Juvenile Justice DMH: Department of Mental Health DSS: Department of Social Services FSA: Final Settlement Agreement GAL: Guardian ad litem ICPC: Interstate Compact on the Placement of Children IFCCS: Intensive Foster Care and Clinical Services IO: Interim Order JJMS: Juvenile Justice Management System MCO: Managed Care Organization MOU: Memorandum of Understanding OHAN: Out of Home Abuse and Neglect Unit PCG: Public Consulting Group PIP: Performance Improvement Plan QA: Quality Assurance SC: South Carolina TFC: Therapeutic Foster Care USC CCFS: University of South Carolina’s Center for Child and Family Studies

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Appendix B - OHAN Implementation Plan Strategy Updates as of March 31, 2018

Strategies towards Achieving Targets:

The Department identified a number of strategies to achieving the OHAN targets:

DSS Proposed Strategies to Achieve Targets

DSS Reported Timeline

Resources Identified as Needed in Plan

Intake and Investigations

DSS Implementation Update as of March 31, 2018 138

a. Institute investigative caseworker office day Complete by September

for case management activities

2017

Plan identified that action could be completed with existing internal resources

DSS has not implemented this strategy and has indicated that it cannot be implemented with the current number of caseworkers within the unit. As of the writing of this report, five new OHAN investigator positions have been allocated; however, as of June 2018, three vacancies existed. There is also a vacancy for one supervisor. As of June 2018, DSS reports that one candidate for an investigator and one supervisor candidate have been selected and recommended to Human Resources staff. No new target completion date has been set.

b. Develop a user-friendly report to track and monitor face-to-face contact and case initiation within 24 hours

To be determined after Data Workgroup prioritizes CAPSS and data work (See Core Foundational and Capacity Building Section Above – 3.b). Some development has already occurred.

Plan identified that action could be completed with existing internal resources

DSS has not implemented this strategy. OHAN staff and management continue to use existing reports that track initial contact with children. As discussed earlier in this report, during review of OHAN investigations in March 2018, Co-Monitor staff identified instances in which CAPSS data for timely initiation were not accurate.

138 In some instances, information in this Table reflects the status of actions after March 31, 2018.
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DSS Proposed Strategies to Achieve Targets
c. Revise the intake referral sheet to gather updated placement and caseworker information

DSS Reported Timeline

Resources Identified as Needed in Plan

Complete by March 2017

Plan identified that action could be completed with existing internal resources

DSS Implementation Update as of March 31, 2018
The intake referral sheet has been updated. DSS plans to hold a training in September 2018 on data collection at intake for all staff to ensure more consistency.

d. Revise existing checklist to expand core witness list

Complete by April 2017

Plan identified that action could be completed with existing internal resources

There have been revisions to the list of core witnesses on OHAN forms. Co-Monitor staff continue to find that caseworkers and supervisors use this list inconsistently. In the June 2018 review of investigations received in March 2018, reviewers found numerous instances in which a core witness was checked off on the check list but documentation does not indicate this witness had been contacted. DSS report that guided supervision is a first priority when the new supervisor is hired.

e. Develop tracking system for documenting core witness contacts and provide additional guidance and training to caseworkers on identifying core witnesses

Complete by December 2017

Plan identified that action could be completed with existing internal resources

DSS reports that this strategy is partially completed. The OHAN workgroup identified CAPSS updates needed to track contact with core witnesses and CAPSS staff are in the process of designing the system change. DSS reports that once completed, the workgroup will test the CAPSS modification for accuracy.

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DSS Proposed Strategies to Achieve Targets
f. Research and adopt a screening and assessment tool to help guide decisionmaking for OHAN intake

DSS Reported Timeline
Complete by May 2017

Resources Identified as Needed in Plan
Plan identified that action could be completed with existing internal resources

DSS Implementation Update as of March 31, 2018
This strategy has been partially implemented. In April 2017, OHAN began using an Intake and Investigative Safety Factors tool which provides guidance on situations that present safety and risk to a child in care to guide decisions regarding screening referrals for investigation.
This tool was developed as a place holder until a more structured Risk and Safety Assessment tool is developed for use with both the state’s general CPS and OHAN. DSS anticipated completion of the new tool in 2017, however, this did not occur.

g. Develop and conduct specialized OHAN training to include findings from OHAN baseline reviews (including clarifying practice standards around “collateral” contact prior to making a hotline decision), CAPSS documentation training, interview and investigative techniques, restraint training, assessing for safety and risk, and critical decision-making

OHAN basic intake training to occur for existing caseworkers and supervisors beginning September 2017. OHAN basic investigative training to occur for existing caseworkers and supervisors by December 2017. All new caseworkers and supervisors will be required to complete training going forward

Plan identified that action could be completed with existing internal resources and USC Training Staff

This strategy is partially complete. An intake training curriculum was developed by USC and trainings were conducted between September and November 2017.
DSS reports that with the assistance of The Children’s Law Center and USC CCFS, the investigation training curriculum is near complete and training will be provided to current OHAN staff in October 2018 and newly hired OHAN staff in January 2019.

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DSS Proposed Strategies to Achieve Targets

DSS Reported Timeline

Resources Identified as Needed in Plan

h. Develop a Provider History report in CAPSS to provide an easy to access and consistent history on providers for use by OHAN caseworkers, supervisors, and reviewers
- Preliminary report is currently being tested - Once finalized, report will be automated in
CAPSS. - OHAN intake caseworkers will be trained to
access, read, and summarize the previous allegations for the past 2 years and consider the previous history as a factor in determining preponderance of evidence for case

Work has begun. Preliminary report has been created and is being pretested with staff, supervisors, and reviewers. Based on feedback, report will be finalized and automated in CAPSS. Until automation, adhoc reports will continue to be extracted. Work complete by September 2017.

Plan identified that action could be completed with existing internal resources

DSS Implementation Update as of March 31, 2018
DSS reports a provider history report has been developed and was incorporated into standard practice in September 2017. DSS has been working with Chapin Hall to develop a process for pulling reports for providers with multiple provider IDs within CAPSS. DSS believes the current process allows them to thoroughly check a provider’s history.

i. Develop a coordinated process with Licensing that may include the following:
- Create a new policy to establish clear guidelines for revocation of foster home and facility licenses for multiple allegations of policy violations that do not constitute abuse or neglect but that are detrimental to child well-being

Development of policies to be completed by July 2017. Implementation of policies and training of existing staff on new policies completed by November 2017 by Licensing and OHAN

Plan identified that action could be completed with existing internal resources

DSS reports a draft policy was developed in November 2017 by the OHAN Workgroup. This policy is awaiting final agency approval.

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DSS Proposed Strategies to Achieve Targets
a. Determine ways to increase guided supervision staffing, critical thinking, monitoring-accountability system by supervisor

DSS Reported Timeline

Resources Identified as Needed in Plan

Supervisor Review

DSS Implementation Update as of March 31, 2018

- Revise the Guided Supervision Tool to be Complete by May 2017 specific to OHAN performance measures and for case reviews and system for utilization in practice. After implementation, this tool will be used at every supervisory review to guide the critical thinking of staff in investigatory work.

Plan identified that action could be completed with existing internal resources

This strategy has been partially implemented. DSS reports the Guided Supervision Tool was finalized in May 2017 and is only in partial use as supervisors have insufficient time to work with investigators. DSS reports more consistent implementation will be concurrent with the hiring of a new supervisor.

- Train OHAN Supervisors on use of the Guided Supervision tool (See above for additional training of supervisors on information from OHAN baseline reviews)

Complete by June 2017

Plan identified that action could be completed with existing internal resources

DSS reports OHAN supervisors were trained on the Guided Supervision Tool in the summer of 2017.

- Implement Guided Supervision in OHAN Complete by June 2017 by training staff on the expectations and begin use of the Guided Supervision process

Plan identified that action could be completed with existing internal resources

As referenced above, DSS reports that training was completed in the summer of 2017 and that the Guided Supervision Tool is in partial use by supervisors.

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DSS Proposed Strategies to Achieve Targets
b. Implement standardized supervisory case review prior to case decision

DSS Reported Timeline

Resources Identified as Needed in Plan

Complete by April 2017

Plan identified that action could be completed with existing internal resources

DSS Implementation Update as of March 31, 2018
DSS reports that this strategy was underway, however, due to the increase in OHAN caseworker caseload size and a vacant supervisor position, reviews are currently being completed too late to request an extension.

c. Refine case closure supervisory review to include CAPSS and paper file (thorough review)

Complete by April 2017

Plan identified that action could be completed with existing internal resources

OHAN supervisors are documenting case closure supervisory reviews, however, they may be completed after an investigation has been closed.

d. Develop methodology for caseload distribution

Complete by September 2017

Plan identified that action could be completed with existing internal resources

DSS reports that a regional assignment process was developed and implementation began, however, due to vacancies in the two regions with the highest caseloads which cover Charleston County, Ononee County and Cherokee County, the new assignment process was ceased. DSS reports a continued commitment to regional assignments but implementation will not begin until hiring is complete.

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APPENDIX C - DSS Health Care Improvement Plan (without attachments), Approved August 23, 2018
SOUTH CAROLINA DEPARTMENT OF SOCIAL SERVICES FOSTER CARE
HEALTH PLAN

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Michelle H. v. Haley – Approved Health Care Improvement Plan August 23, 2018 ___________________________________________________________________
Table of Contents
I. Introduction II. Priority Actions III. Health Care and Related Placement Requirements from Final Settlement Agreement IV. The Proposed Health Care Pilot and Process Review V. Child Health Goals VI. System Component Goals VII. Resource Needs VIII. Appendices

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I. Introduction
The South Carolina Department of Social Services (DSS) is undertaking a comprehensive reform of its child welfare system with a special focus on the heath care needs of children in foster care. In partnership with the South Carolina Department of Health and Human Services (DHHS), DSS is redesigning the way health care services are organized and delivered to children in foster care. Our vision is a fundamentally reformed system that can be a model for other child welfare systems around the country.
The South Carolina Department of Social Services submits this Health Plan to represent and satisfy the commitments it made in the Michelle H. v. McMaster Final Settlement Agreement (FSA). The plan includes the Department’s goals, system components, activities underway and to be undertaken, timeframes for implementation, deliverables, performance targets and process for quality monitoring and performance review.
II. Priority Actions
Given the expansive scope of the reforms envisioned, DSS is working concurrently on both roll out of the Plan, which will take several years, and on “priority actions” that respond to pressing child health issues. Work on these six priority actions started in Winter of 2018, before the final Health Plan was complete. The below identifies the six priority actions, and the status of them at the time of writing this Plan.

Priority Actions
1. Produce a Revised Health Plan

Status as of August 1, 2018
In process. Target for Completion in mid-August, 2018. Working with DHHS and Select Health to accomplish. Other new developments: Child health and system goals have been developed. DSS will move to use a validated assessment tool to determine level of care and level of need. Among other things, the Plan will cover initial assessment, comprehensive assessment and follow-up; immediate needs; care coordination and care management; healthrelated case practice; network adequacy; data and reporting; quality improvement and performance. DSS holds weekly planning meetings with the consultants.

2. Identify an Interim

Completed. Identified a PERMANENT Director139 who began on

Director of DSS Office April 27th. Work is underway to align staffing and new plan

of

functions, reconfigure the FCHAC (Foster Care Health Advisory

Health and Well-Being Committee) and manage all aspects of the revised Health Plan.

139 Position Description in Appendix, Section 5.
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3. Identify and convene a Completed. Consultants140 recommended that DSS meet weekly

Cross-Agency SWAT with DHHS and Select Health. DSS and DHHS now have standing

Team.

weekly meetings. In March, DSS, DHHS and Select Health began

meeting weekly on data sharing; development of a coordinated

health care management model; development of child-specific

rosters and aggregate data tracking reports, etc. The consultants

attend these ongoing weekly meetings as needed.

4. Obtain Gaps in Care Completed & an ongoing process. Consultants found that

Reports from DHHS and retrospective verification of health history, initial and

Select Health

comprehensive assessments by caseworkers were duplicative,

delayed and less reliable than the same information collected and

tracked by Select Health. Data sharing, report development and

testing, a data dictionary and other elements of a data system are

being built now in consultation with consultants. Two reports have

been produced using this new data-sharing approach and they show

that many more children are getting assessed than were originally

identified from third-hand data inputs collected by caseworkers.

Contemporaneous collection of information by caseworkers, which

now occurs, will continue but be verified by administrative reviews

and select case reviews. See no. 6 in this table for more

information.

5. Initiate Short-Term Data Work Around to Mitigate 30-day Enrollment Gap

Ongoing. Resolution by Jan 2019. The DHHS- Select Health contract is negotiated annually in January of each year. DSS and DHHS will collaborate to create a separate administrative contract to include the development of a weekly notification system for new entrants into (and exits from) foster care. DSS currently uploads rosters to DHHS nightly to identify new entrants into and exits from foster care. DHHS will produce monthly a rostered gaps in care/utilization report capturing initial assessments, assessments or follow-up services provided to new entrants. DSS and DHHS are working to resolve the enrollment issue with an expected date of completion in January 2019 and the eligibility gap after the existing process is automated with an expected completion date in June 2019.

140 Consultants Gail Nayowith and Kathleen Noonan were identified by the Co-Monitors under the FSA to work with DSS on health care issues.

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6. Initiate Short-Term Plan Process in development. Once the data reports begin to run

to Address Immediate regularly and the new processes are in place in August 2018, the

Needs

backlog of children on the immediate needs roster will be reduced.

In the short run, to catch up and reach all children on the roster,

DSS developed a new process for addressing immediate needs that

will roll-out beginning in August 2018: DSS caseworkers will

follow up on needed assessments from the DHHS/SH reports and

document into the CAPSS (Child and Adult Protective Services

System, DSS’s Statewide Automated Child Welfare Information

System SACWIS) foster care case record any actions taken. After

implementation of the practice model, caseworkers will also be

expected to enter into case notes, any follow up care needed,

including confirmation with foster parents or other caregivers that

follow-up visits have occurred. Caseworkers will also be expected

to ensure that birth/natural parents are included in health care

planning, and apprised of any/all appointments, etc. To assist with

verification and to see that that care needs are met, DSS will review

the roster of children with high need/risk diagnoses against 30-60-

90-day gaps in care/utilization reports, in collaboration with DHHS

and Select Health. DSS will also undertake a review of select case

records, consistent with CFSR PIP, to ensure that children and

youth are getting services they need. These multiple layers of

tracking and review, at the individual case level and population

level, allow children and youth who might have missed initial

assessments, comprehensive assessment or follow up care to be

identified and staffed until they receive the care they need.

The following sets forth DSS’s health care plan for children and youth in foster care. Section III summarizes the commitments made by DSS related to health care in the Final Settlement Agreement (FSA). Sections IV and V are the core components of the Plan. Section IV identifies the Plan’s four child health goals, and Section V identifies the Plan’s three system goals. Each goal identifies a task Lead; key activities and deliverables; and a timeframe. Additional materials are included in the appendices.
III. Health Care and Related Placement Commitments in the Final Settlement Agreement
In the final Settlement Agreement (FSA) in Michelle H. v. McMaster (FSA), DSS committed to develop and implement a Healthcare Improvement Plan (the “Plan”). In addition, DSS agreed that the Plan would include enforceable dates and targets for phased implementation related to initial assessment services, periodic assessment services, documentation, and health care treatment services for Class Members in the areas of physical health, immunizations and laboratory tests, mental health,

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developmental and behavioral health, vision and hearing, and dental health. Pursuant to the FSA, the Plan will address:
(a) Developing the capacity to track screening and treatment services for individual children and aggregate tracking data, including but not limited to screens that are due and past due;
(b) Assessing the accessibility of health care screening and treatment services throughout the state, including the capacity of the existing health care providers to meet the screening and treatment needs of Class Members; and
(c) Identifying the baselines and interim percentage targets for performance improvement in coordinating screens and treatment services.
DSS understands that the commitments it made to health care in the FSA must work in concert with other commitments, including those related to placements for children in foster care. Under the FSA, DSS envisioned that decision-making about placement and services would be based on assessment of strengths and needs. Moreover, under the FSA, DSS committed to a child welfare system in which family-based placements are the presumption over institutional or congregate placements, especially for young children. Special placement resources like residential treatment or therapeutic foster homes (TFCs) are accessed by referral for interagency staffings. Currently, this process involves assessing for eligibility for the Interagency System of Caring for Emotionally Disturbed Children (ISCEDC).
Given the overlap between the health and placement components of the FSA, synchronizing planning and implementation in these areas is critical to the reform envisioned by DSS. For example, the health and behavioral health care initial assessments and comprehensive assessments used when a child enters foster care should inform decisions about higher level of care placements and services for eligible children. For example, DSS is currently able to verbally authorize a provisional 35-day eligibility for ISCEDC inter-agency staffing in cases where the presumption is that a child needs a higher level of care and where corroborating information can be obtained to substantiate the child’s ISCEDC eligibility. If used, this presumptive eligibility function could prevent multiple placements and reduce the wait time for a “least restrictive, most appropriate” higher level placement or authorize community-based services and supports to stabilize placements. These details are discussed in this Plan.
The Placement Implementation Plan under development by DSS will make explicit the articulation between level of care (LOC) placement decisions and level of need (LON) services, and will further define the process and assessment tools to be used as part of determining appropriate placements and services for children and youth. Among other things, the Placement Implementation Plan will focus on a teaming model, caregiver and youth engagement and other key supports in the assessment and placement process. To the extent possible, DSS would prefer that children in foster care receive their health, behavioral health and dental services in community settings that also serve children who are not in care. This promotes continuity of care when children are in foster care and access to the same services when they leave care.

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In addition to the necessary integration of health care and placement work, DSS’s health plan implementation activities will also be important as DSS begins planning for the implementation of new federal legislation - The Family First Prevention Services Act. Importantly, the new legislation requires states to move away from non-clinical group residential settings to family foster care and community-based preventive services. DSS has asked the health care consultants for assistance in building out the level of need/level of care assessment process design outlined in the Health Plan to best match a child’s service needs with community-based services and a suitable placement. The health assessment features of this process will dovetail with work to strengthen the placement process to be fleshed out in the DSS Placement Implementation Plan. In addition, the new federal law requires child welfare group homes and congregate care to meet new licensing and accreditation standards that were historically more common in PRTFs and other clinically-oriented health care settings and residential treatment programs. The go-live date for certain parts of the federal statute may be as early as October 2019, and DSS wants to be ready for implementation.
DSS began development of the Health Plan in 2017, and submitted a draft to the Co-Monitors on September 29, 2017. The Co-Monitors provided feedback to the draft Plan on October 31, 2017, advising DSS that they would retain consultants to assist the Co-Monitors and staff with validating components identified in the Health Care Plan and identifying additional infrastructure and operational enhancements that may be needed.
The consultants reviewed and considered the elements of the proposed Health Care Plan, including its nine infrastructure components, seven innovation areas and select targets, and developed a validation framework to guide their assessment. They examined reports, data, policies and practices already in place and visited with DSS and its partners for three days in January 2018. The consultants’ review culminated in a report which included identification of six priority actions for immediate implementation and their findings and assessment of whether each Plan element should remain in the plan, remain in the Plan with revisions, or be removed from the Plan. As an overall finding, the consultants found that the draft Health Care Plan included important conceptual and structural elements on which to build a robust health system for children in foster care. Since issuance of their report, DSS and the consultants have worked together through two sets of multi-day onsite meetings and weekly check-in calls on implementation of the six priority action items, framing elements of the Plan and on revisions to the Plan. DSS is committed to plan and implement concurrently and is actively engaged in planning and operational improvement activities simultaneously. To this end, DSS has engaged the health care consultants in both aspects of their work.
IV. The Proposed Health Care Pilot and Process Review
DSS proposes a health care pilot and process review that will test, refine and scale the operational elements of the Health Plan. The Health Care Pilot and Process Review will run from October 2018 through February 2019 with system-wide implementation beginning in March 2019 and continuing through the end of the year. It is the view of the healthcare consultants, that the scope of the system redesign envisioned by the Plan, which includes new external partners and new processes, protocols

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and capacities internal to the Department, warrants careful testing and process refinement before full statewide implementation. The Health Care Pilot and Process Review will identify, follow, and review the health-related processes and care experience of 20 children entering or re-entering foster care. The sample of children will be selected to represent three types of conditions: children who are typically developing with no serious health or behavioral health conditions; children who have a chronic condition that warrants regular follow-up; and, children with complex medical or serious behavioral health care needs. The goals of the Health Care Pilot and Process Review include process review, testing and refinement in the following areas:

1) Assessing and matching child health and/or behavioral health needs and level of care decisions at the point of placement;
2) Assignment of a single DSS caseworker (county-based or regional IFCCS worker), throughout the child’s stay in foster care, informed by the child’s health or behavioral health needs;
3) Alignment of DSS casework and Select Health care management tiering, care coordination responsibilities, practice and protocols;
4) Automation of CAPSS data feeds to reduce the documentation burden on DSS casework and IFCCS staff and to leverage data that is available from Select Health and Medicaid system of record;
5) Red flag or high needs rostering of children whose health or behavioral health condition warrants close monitoring (this will include red flags for events like visits to the emergency room); and
6) Production and use of gaps in care/utilization reports derived from administrative data (Medicaid encounter and claims data) and dissemination to DSS field staff for follow-up;
7) Follow-up tracking of high need, immediate need or other special populations of children based on data and through weekly management meetings at leadership level and “cadencing” to field level. Just as a squad or military formation uses a regular, disciplined practice to march to the same beat, cadencing is a process that tracks a specific data element statewide. On weekly or bi-weekly conference calls missing or unclear data is followed until the information is provided or the issue is resolved. This continual improvement process aligns management and field staff to achieve the same goal and develop a forum for continual improvement;
8) Staff training on new health protocols and use of new health tools and reports; 9) Caregiver education and engagement by Select Health; and 10) Identification of the necessary service array, availability and access.

DSS will lead the Health Care Pilot and Process Review in collaboration with DHHS and Select Health with support from the health care consultants. The Health Care Pilot and Process Review will be coordinated with and build on other DSS work streams and consultant projects to avoid duplication and to leverage other resources (e.g., Chapin Hall retained by DSS for assistance on a data audit, development of the DSS case practice model and training and placement experts retained by Monitoring team). The Health Care Pilot and Process Review is discussed below in the relevant Child Health Goals and the System Components sections.

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V. Health Care Plan: Child Health Goals
DSS translated its commitments in the FSA and the recommendations of the consultants into four child-centered goals and three key system components. The child health goals set forth the key features of DSS’s health care plan for children in foster care.
Child Health Goals

Goal 1. Goal 2.
Goal 3.
Goal 4.

Each child is linked to a care coordinator matched to the child’s needs. Each child in foster care has a primary care provider, preferably a medical home, and receives timely screening, assessment and follow-up.
Each child in foster care has timely access to quality health, behavioral health and dental services.
Each child in foster care has improved health outcomes.

The child-centered goals speak to the ways in which DSS and its partners will plan for, provide and monitor health, behavioral health and dental services to children in foster care. Each goal is expressed as a set of policy, practice or management activities to be undertaken, and each activity is assigned to a task lead.
Child Health Goal 1: Each child in foster care is linked to a care coordinator matched to the child’s needs
This goal speaks to the efforts underway to assign a single DSS caseworker and a Select Health care manager based on each child’s individualized clinical needs. This will involve revisiting and refining DSS caseworker roles and responsibilities and aligning DSS caseworker assignment and Select Health care manager assignment to meet the child’s safety, permanency, well-being and health care needs.
Coordinated and effective care management is foundational to success in improving outcomes for children in foster care. Currently, both DSS and Select Health tier their basic case management and intensive care coordination activities. DSS bases its decision about the level of care management on a combination of diagnostic assessments, treatment needs and placement type (level of care). Select Health bases its decision on the severity or complexity of the child’s health or behavioral health needs (level of need) and other criteria described below. In addition, the Select Health contract requires it to provide a care management system that conforms to the requirements and industry standards stipulated in the National Committee for Quality Assurance (NCQA) requirements for Complex Case Management and by the Standards of Practice of Case Management released by the Case Management Society of America (CMSA). Today, neither DSS nor Select Health use a standardized assessment tool to determine care coordination level. Under this plan, DSS will collaborate with DHHS and Select

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Health to explore the use of single severity assessment tool (MCO Contract 5.3.3) to align care management and case assignment. 141
DSS has two types of child welfare case management: basic county-based case management and regionally-based IFCCS case management. IFCCS workers are expected to have a smaller caseload (9 children) because of the children’s health/behavioral health complexity. While there is agreement that IFCCS workers should focus in greater detail on the health needs of the children on their caseload, the practice requirements for county and regional IFCCS caseworkers are not codified. In other words, heightened case work standards related to a child’s health status do not currently exist.
As described above, beginning in October 2018, DSS plans to launch a Health Care Pilot and Process Review to, among other things, review and test the process for collecting and using health information for case management decisions. This includes adaptations to the current Children’s Services Application (CSA), also called the Uniform Application, assignment to a county or IFCCS/regional caseworker; to understand and make recommendations to improve how case workers obtain health information and services for children on their caseload and document it in CAPSS; to define case management responsibilities for DSS county, IFCCS regional workers and Select Health care management; to consider modifications to the Select Health care management assignment algorithm to include additional health and behavioral health indicators including conditions, prior service use or prior placement in foster care, among others; and, to understand and make recommendations to strengthen DSS’s new practice model.
The Heath Plan Pilot will also assist DSS in determining how to align the CSA with the assessment tools used by Select Health providers and with high quality behavioral health and medical providers. DSS will collaborate with DHHS and Select Health to train providers on the new tool chosen by DSS for its child assessments. Other training will include discussion of preferred brief screening tools like SEEK for social determinants of health for young children, the Edinburgh Postnatal Depression Scale for maternal depression, among other options to improve practice quality. Health and behavioral health training content will be folded into the new DSS Training Plan.
DSS will also use the information gathered during the Health Plan Pilot to inform how information about a child’s health and well-being can be effectively collected and better utilized as part of the placement decision-making process and family teaming work. In collaboration with the work on the Placement Implementation Plan, DSS will obtain advice from experts, and internal and external stakeholders on whether and how to modify the CSA and/or adopt an alternative standardized assessment protocol. The pilot will review the existing systemic health care processes to also help inform thinking about how to enable children with complex medical or serious behavioral health needs to remain in community-based settings with appropriate supports.

141 South Carolina has a history of Medicaid innovations for adults with complex health care needs and piloted a case severity screening tool that uses weighted medical and psycho-social markers to stratify clients into low, moderate and high-risk categories. The severity screen and assessment is administered by a caseworker during an initial home visit, scored to determine level of need and then assignment is made to a registered nurse case manager (for moderate-high severity cases), caseworker (moderate severity cases) or community caseworker (moderatelow severity cases).3 This innovation was awarded the Robert Wood Johnson Culture of Health prize in 2015. This experience offers useful parallels for the changes envisioned for children in foster care.

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In preparation for the Health Plan Pilot process, DSS is collaborating with Select Health to better understand the Select Health risk stratification and care coordination assignment methodology and seeks to align Select Health care management tiering with DSS caseworker assignment protocols to best meet the special case management needs of children in foster care. Weekly calls have been scheduled and are underway to understand Select Health’s three levels of care coordination: 1) integrated health care management, 2) utilization management, and 3) rapid response care management. DSS will collaborate with DHHS and Select Health to introduce additional data elements for consideration in the risk stratification and care coordination assignment methodology and also for use to build out its own caseworker assignment protocols. These criteria include: repeat maltreatment, polypharmacy, dual diagnosis, significant functional limitations, chronic illness and other relevant indicators of health risk. Concurrently, DSS and the healthcare consultants will develop a matrix (following the lead of other states) defining the role of the county DSS or IFCCS caseworker or the care coordinator from Select Health to be completed by the end of the Health Pilot in February 2019.
The Health Pilot will give DSS an opportunity to look closely at its current case management practice and roles, and those of Select Health. The methodology for the DSS Health Pilot will be developed by September 2018 to make it possible to roll-out the Pilot beginning in October 2018. The pilot methodology includes a process review of 20 child-specific “use cases.” The pilot cohort will include both children who are first entering DSS custody, as well as children who are experiencing a placement change, likely to be children who are moving from a lower level of care to a TFC and/or residential placement. These cases will allow DSS to strengthen and develop protocols for case management and Select Health to strengthen care coordination services that can be communicated to all frontline staff. It will also enable a deeper understanding of how this process interacts with the placement process and approach.
DSS intends to define the tiering and caseworker assignment protocols for its own case management practice to best match each child’s needs. The pilot will give DSS an opportunity to do this, and to determine what additional support is available through Select Health care coordination. It is expected that DSS will clarify the responsibilities of county, IFCCS and adoption caseworkers as well as develop new processes for assigning caseworkers to children. Caseload size, deployment and responsibilities of the 110 IFCCS workers will also be reviewed.142 The goal is for each child in foster care to have one DSS case manager who is responsible for their health, well-being, safety and permanency planning.
During the pilot, DSS will work with the Health Care Consultants to test the various roles and functions and develop a case management and care coordination framework for DSS caseworkers (county and IFCCS) and Select Health care managers.

142 This will be coordinated with the workload implementation plan for distributing cases and having a sufficient number of caseworkers that is in development. It’s important to note the explicit intention not to inadvertently increase caseloads for county workers by tightening up the criteria for IFCCS.

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To memorialize and implement improvements in care coordination learned from the pilot, DHHS, Select, and DSS will collaborate to create a policy and procedure manual that governs how children in foster care will receive more robust care coordination. The contract governing the relationship between Select Health and DHHS is a common contract for all five Medicaid managed care entities (MCOs) in South Carolina. The MCO contract cannot be altered for just Select Health, because that contract governs all five MCOs and Select is the exclusive MCO for children in foster care. DHHS has offered to collaborate to create a policy and procedure manual specific to Select Health for children in foster care. DHHS has also agreed to review the rate for children in foster care, if Select Health has additional requirements for children in foster care. Rates are changed in July annually. The Health Care Pilot and Process Review will inform additional requirements for children in foster care and can be incorporated into a rate review prior to new rates being issued in July 2019.
By March 2019, and subject to the approval of the Co-Monitors, DSS will utilize the information gathered from the pilot to produce a care coordination and health care case management framework that details the following:
 Detailed articulation of the differentiated roles of DSS foster care, DSS IFCCS caseworkers, and Select Health care managers, with a delineation of processes for case assignment, care management tiering based on child’s level of need, expectations for communication, and case consultation and coordination between Select Health and SCDSS to meet the health care needs of all children in foster care, including those with complex health needs, disabilities or serious behavioral health needs;
 Development of related policies, and guidance to the field;  Delineation of changes to DHHS-Select Health policies and procedures to operationalize the
care coordination and health care management framework;  Detailed financial projections and budget commitments for resources needed to fully
implement the care management and coordination activities including any new staff, training or resources to support implementation; Timeline for statewide rollout.
Child Health Goal 1: Elements of the Work Plan
Task Lead(s): DSS Office of Child Well-Being
Key Activities and Deliverables:
 Weekly meetings with Select Health on care coordination practice, processes and protocol
 Weekly meetings with DHHS on data-sharing and refining gaps in care prototype and other reports
 Choose validated assessment tool, train DSS staff, roll out standardized assessment tool in accordance with the processes developed in the Placement Implementation Plan

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 Adapt CSA to include health and behavioral clinical and functional assessment questions as recommended by child welfare leadership and the Foster Care Health Advisory Committee.
 Connect health/behavioral health initial assessments and comprehensive assessments to placement decision making processes, informing the Placement Implementation Plan;
 Institute weekly cadence call to staff cases, review progress made and resolve immediate needs beginning August 2018.
 Explore with DHHS, Select Health, QTIP providers and the AAP (American Academy of Pediatrics SC Branch), DSS’s plan to use a standard, system-wide screening and assessment tool and ways to integrate the use of this tool and other best practice guidance on delivering health and behavioral health care to children in foster care.
 Produce a comprehensive care coordination and health care case management framework subject to approval of the Co-Monitors.
Timeframe: Health Care Pilot and Process Review October through February 2019, Implementation March 2019
Child Health Goal 2: Each child in foster care has a primary care provider (preferably, a medical home) and receives timely screening, assessment and follow-up care
This goal is expressed by activities related to eligibility determination, enrollment in a single managed care plan, provider assignment, preferred provider designation, screening, assessment and follow-up and managing the response to immediate needs.
A. A Single Managed Care Organization for all children in foster care: Select Health
In recognition of the fact that children in foster care require a more comprehensive, coordinated healthcare delivery model that promotes better access to health, behavioral health and dental services and improves health outcomes, almost six years ago, in November 2012, DSS and DHHS announced the Foster Care Health Initiative, a collaborative effort to better address healthcare delivery to foster care children. As the legal guardian, DSS determined that it is in the best interest of foster children to be enrolled in coordinated and managed care because these children enter the system at high risk of poor developmental and health outcomes and in need of care related to the effects of the neglect, abuse, and associated trauma that brought them into care. Further, many children entering South Carolina’s foster care system enter already enrolled in managed care. As a result of this initiative, all children and youth placed into foster care, with few exceptions, are enrolled in First Choice by Select Health of South Carolina, a Managed Care Organization to meet their medical and behavioral health needs.
Select Health is required to provide foster care child members “medically necessary” care.

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Specific core benefits and service requirements are set forth in Section 4 of the DHHS and Select Health MCO contract143. Select Health receives a capitation payment of $950.75 per foster child/per month in FY18. This rate incentivizes the expectation that providing health and behavioral health care to children in foster care requires additional time, care coordination and additional specialty services, principally outpatient behavioral health services, over what is needed by the regular Medicaid child population. A comparison of managed care rates for the two populations illustrates this point with a per member/per month rate (PM/PM) for children aged 1-6 set at $134.00, 7-13 at $144.48 and ages 14-18 set at between $156.73-$185.26 as compared to the PM/PM for all children in foster care set at $950.75.144
With this in mind, DSS will collaborate with DHHS and Select Health to identify, plan and implement and care coordination system that works optimally for children in foster care.
Medical Home/QTIP145
While all Medicaid providers are required to meet standards of proficiency and quality, some providers are especially well equipped to provide the highest quality care for foster children. As part of its Plan, DSS, DHHS and Select Health are committed to collaborating so that every child in foster care has a high-quality primary care provider, preferably a “medical home,” which, among other practices, includes providers who adhere to the American Academy of Pediatrics (AAP) “Bright Futures” standards. To achieve this, DSS will build on lessons learned from the Quality through Innovation in Pediatrics (QTIP) program, a DHHS quality improvement initiative in partnership with the AAP that provides direct support to pediatric providers to engage in quality measurement and practice improvement activities and integrates behavioral health and physical health. The QTIP program now includes approximately 30 providers in South Carolina. The graphic below maps the location of QTIP practices and distribution of children in foster care by county.

143 DHHS and Select Health Contract in Appendix, Section 4. 144 All Select Health primary care, specialty care, behavioral health, pharmacies, hospitals and ancillary providers, must be licensed or
credentialed under the NCQA Standards and Guidelines for Accreditation of Medicaid Managed Care Organizations, as described earlier
in the Plan. 145 Improving Outcomes for Children in Child Welfare: A Medicaid Managed Care Toolkit February 2012, Center for Health Care Strategies

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The QTIP project began as a grant-funded CHIPRA Quality Demonstration (authorized by 401 (d) of the Children's Health Insurance Program Reauthorization Act of 2009). This QTIP project was accomplished through encouraging and assisting with use of clinical quality measures and incorporation of mental health services into a medical home. Based on the success of the demonstration project, DHHS continued most aspects of the QTIP program.
QTIP practices engage in quality improvement work in several ways, including a Learning Collaborative in concert with the South Carolina Chapter of the American Academy of Pediatrics; onsite training and technical assistance in general quality improvement principles and topic-specific clinical focus areas during annual on-site visits; monthly conference calls; and specific attention to the quality of the EPSDT visits and the completeness of recommended screenings. Through this work, QTIP practices have repeatedly demonstrated better performance on a range of quality measures, when compared to similar practices.
DSS will explore and develop with DHHS and the AAP new ways to supplement the on-going training of practices with foster care specific training materials and consider enhancing the capacity of the AAP to establish a QTIP-like Learning Collaborative or cohort training model for other pediatric practices who seek preferred provider status.
DSS, DHHS, and Select Health will collaborate on the development of provider assignment protocols to take into account factors such as whether a child is already being seen by a current Select Health provider, unique needs of the child, preferences expressed by the birth parent, geographic access, and provider availability. DSS will implement these assignment protocols through a new policy that considers auto-assignment to a “preferred provider,” with an opt-out to preserve foster parent choice, where appropriate. In addition, DHHS and DSS will collaborate with Select Health, and preferred providers to train caseworkers and foster parents in the standardized and comprehensive health and

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behavioral health assessment tools. One of the significant recommendations of the DSS Foster Care Health Advisory Committee (FCHAC) was to have a standardized protocol for screenings, assessments, and follow-up for all children entering and in foster care. As discussed earlier in the section on Care Coordination, DSS plans include adoption of a validated and standardized assessment protocol for use by its field staff statewide to ensure necessary health and behavioral health information is collected at the time of placement, to inform decisions about placement and services.
Finally, DSS, DHHS and Select Health will collaborate on ways to further incentivize preferred provider participation, increase the number of high quality preferred providers or otherwise enhance QTIP or QTIP-like practices. DHHS is exploring several ways to introduce a special payment for foster child visits, either as a discrete service code or through the use of modifiers. This work will begin 12 months after implementation of the basic reforms outlined in the Health Plan. Currently, Select Health incentivizes its providers for outstanding performance on certain HEDIS measures (HEDIS measures are discussed in detail below) associated with improved health and behavioral health outcomes for members. DSS wants Select Health to benefit from its incentives for outstanding performance on HEDIS measures most relevant to children in foster care. To accomplish this, DHHS, DSS and Select Health will collaborate to develop the preferred provider designation and incentive package for preferred providers beginning in February 2019 so that this work is completed prior to and reflected in the Select Health rate setting process in July 2019.
Of course, not all providers are, or will be QTIP providers. Given this, DSS plans to collaborate with DHHS, Select Health, the AAP South Carolina Branch, and the Foster Care Health Advisory Committee to: 1) review the performance of all health, behavioral health and dental providers currently serving children in foster care, 2) develop criteria and a process for designation of providers as “preferred provider” as well as minimum or baseline criteria for all providers of services to children in foster care, 3) consider designating QTIP, DMH clinics and FQHCs as preferred providers, 4) provide provider training opportunities and other supports, and 5) consider increased or modified rates to incentivize providers to accept and spend sufficient time with foster care children. Taken together, these actions will increase the availability of quality providers and improve health care quality statewide.
B. Eligibility and Covered Services
Children in foster care are eligible for Medicaid the day they enter placement and the vast majority of children in foster care are covered by Medicaid managed care through Select Health146. Select Health provides medical and mental health services and DentaQuest provides dental care. Many children enter foster care already enrolled in Medicaid or Medicaid eligible. The eligibility process for all children in foster care is automatic and each child is assigned a Medicaid number and payment code that allows providers to deliver and bill for services and allows DSS and DHHS to track services rendered, gaps in care/utilization and follow-up needed.

146 Medicaid coverage is provided for all children in foster care through their 18th birthday with the exception of undocumented children whose health care coverage is paid for by the State of South Carolina.

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Enrollment Plan

Unique Children in Foster Care as of 5/4/18

FFS Waiver FFS Non-Waiver Select Health ATC Blue Choice Molina Well Care

65 305 3832 40 50 44 19147

The following services are available to children through the Select Health contract10: services for emergency medical conditions; inpatient services; post-stabilization care services; specialty services; behavioral health and substance use services; vision and audiology services, referral to out-of-network services; pharmacy and a regularly updated pharmacy formulary of generic and brand medication; EPSDT health and developmental screenings that follow the American Academy of Pediatrics periodicity schedule; second opinion; automated 24/7 toll-free line and staffed call center with information on what to do in case of an emergency and option to talk directly to a nurse or other clinician; and care coordination, among other services.

A small number of children in foster care are not covered by Select Health as shown in the table above. Children who are undocumented are ineligible for Medicaid and receive identical physical, mental and dental benefits paid by 100% state dollars until age 18. Children in any of the nine DHHS fee for service waivers are also not covered by Select Health. As of May 4, 2018, 65 children were in those waivers. Children with complex medical or behavioral health needs may also receive services outside of the Select Health network. DSS tracks health care utilization and outcomes for all children, whether they are in Select Health or in one of the groups that falls outside the MCO contract. DSS will track the care and services for all of these children, whether covered by the Select Health program or through another Medicaid coverage vehicle such as a waiver program.

The current contract between DHHS and Select Health does not differentiate between the benefit and service package provided to children who are in foster care and those who are not. In fact, there is a single contract between DHHS and the five MCOs that operate in South Carolina. Since children in foster care are enrolled in Select Health, the contract does not contain any specific requirements related to foster care children. However, moving forward, Select Health will be expected to enhance its model to offer unique plan elements relevant to children in foster care including, but not limited to, in electronic and paper form: foster care member handbook, ID card, provider directory, health education materials, guidance on member rights, communication and coordination between Select Health and DSS caseworkers.148 By March 2019, DSS, DHHS and Select Health will collaborate to determine specific requirements and implement policies and procedures for Select Health that will
147 As of the May 4, 2018 member matched file. 10 SCDHHS-MCO Contract 7/1/2016. 148 Contract Between SCDHHS and << Contractor>> for the Purchase and Provision of Medical Services Under the SC Medicaid Managed Care Program, July 1, 2016 (Section 3)

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include alignment with DSS timeframes and tools for required initial assessments, standardized assessment, follow-up and identification of immediate treatment needs for and data tracking for all foster care children. These will be memorialized in a DHHS-Select Health Foster Care policy and procedure manual.
As noted above, dental services are not provided through the Select Health contract. Rather, all children in foster care receive their dental services through DentaQuest, including regular screenings and annual dental exams, follow-up for dental caries, orthodontia and other oral health needs. By December 2018, DSS will develop a new report to flag, roster and follow-up on gaps in care and introduce this new report into the process for handling all other gaps in care and cadence call process.
C. Enrollment
Although coverage is guaranteed for all children in foster care, the Medicaid system has a builtin enrollment lag of 30 days. DSS, DHHS and Select Health began to address the 30-day time lag as an immediate priority based on the report by the Health consultants to reduce any gaps between entry into foster care placement and enrollment into Select Health.
As noted earlier, the vast majority of children coming into the foster care system are Medicaid eligible and already enrolled in one of the state’s MCOs. Children entering foster care are automatically eligible for Medicaid and there is no interruption in any services that they are already receiving; however, enrollment in Select Health does not start automatically the day the child enters care. One consequence of this lag is that a child may remain the responsibility of a health plan or provider not affiliated with Select Health making more challenging to make sure that 7-day, 72-hour and 30-day timeframes for initial assessment and comprehensive assessment are completed, that immediate needs are identified and met, and that follow-up is scheduled for all identified health and behavioral health needs.
Children are assigned to and enrolled in Select Health on a monthly basis. Approximately 284 children entered foster care each month in 2017. However, from January to April of 2018, the monthly average of children entering foster care each month was 368 children, indicating a rise in the number of children entering foster care. During this 30-day period, initial assessments, comprehensive assessments and follow-up are paid fee-for-service or by the MCO that the child had prior to coming into care. Lifting this administrative barrier will address key gaps in care.
There are several administrative steps that can be taken quickly to address the enrollment lag. All children coming into care have a Medicaid ID that includes a designation - - called a recipient service program (RSP) that allows the Medicaid system of record to recognize their foster care eligibility status. Although the majority of children enter foster care with an active Medicaid ID#, DSS and DHHS found that approximately 300 children were deemed ineligible based on a coding error in third party software. Work is ongoing to permanently resolve the software issue. Until that time, DHHS staff manually remedy the problem.

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The Plan includes the development of a new enrollment and eligibility protocol that will eliminate the 30-day enrollment lag for an estimated 300 children entering foster care each month, which will be in place by January 2019, the annual date under the state’s contractual terms with the MCO by which contractual changes can be made. In the interim, the mitigation plan includes the development and use of existing reporting processes that correct any missing or incorrect enrollment data, matches the current roster of children placed in foster care against CAPSS data and other DSS reports, DHHS Medicaid utilization, claims and other data. These matched files are then used to identify missing health, mental health or dental initial assessments, comprehensive assessments and follow-up. This report, called a “gaps in care/utilization report” will be used to flag unmet need in the first 30 days of foster care placement and throughout the duration of placement. The gaps in care report will be used centrally by the DSS Office of Health and Well-Being and in the field by caseworkers, supervisors and directors. The detail on how DSS will manage to and use the report is described on page 43. DSS received its first gaps in care report in April 2018 and its second report in late May 2018.

Currently, there are two categories or “buckets” of data that DSS is analyzing for the Health Plan: 1) Data collected within the first thirty days of a child entering foster care. This includes initial medical, mental, and dental health assessment data. These data come from CAPSS and are verified through a matching process with DHHS administrative claims data.149 2) Data from Select Health, including data on gaps in care. DSS is working to understand how Select Health categorizes and reports gaps in care. To that end, DSS and Select Health are working to understand and clarify data reporting definitions with sources. This will assist DSS in understanding how best to use data that Select Health has at its disposal for children in foster care.

DSS will begin piloting the gaps in care report with the field in August 2018, described in greater detail later in this report. In addition, the Health Care Pilot and Process Review will use the sample of 20 children to develop statewide policies and practice protocols related to care coordination but also to Medicaid enrollment. The enrollment and payment lag described earlier will be addressed by drafting a standalone DHHS-Select Health administrative contract with a go-live date of January 2019. A timelimited enrollment mitigation work around will be used until then, which involves DSS and DHHS manually ensuring that all children that enter foster care are enrolled in Select Health.

D. Screening and Assessment

DSS wants all children in foster care to be appropriately screened and assessed and receive the followup services they need. Children can come into foster care with little known or documented about their health history or medical, dental, and mental health needs, and these initial assessments and comprehensive assessments are critical to drive early identification of needs and matching services. Early coordination to track these assessments, identify needs, and procure necessary services, will assist DSS in placing and stabilizing children in the least restrictive most family-like setting, hopefully making each child’s first placement, his/her only placement. For those children where a more restrictive setting is necessary, early coordination of these efforts will assist DSS in developing a plan to step the child down to a less restrictive more family-like setting when the child is ready.
149 Initial Assessment Data in Appendix, Section 10.

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Building on the above, DSS plans for all children to receive the appropriate initial assessments and comprehensive assessments in a number of ways, including: tracking children at the time of placement into the level of care coordination that best fits their level of need; and including in the CSA appropriate questions about child health, behavioral health and well-being so that the care coordination, placement and services decisions made at the time of placement are informed by initial health information about the child. As noted earlier, synchronizing any health care initial assessments and assessments with placement decision making, staffing and family teaming is critical.
The term “screening” as typically used by primary care providers involves a brief paper and pencil questionnaire given to a parent or other youth to quickly and easily determine if further assessment is needed. Primary care providers may be able to bill separately for these screenings. Examples include the Modified Checklist for Autism in Toddlers (M-CHAT) or the Ages and Stages Questionnaire (ASQ) which can be completed by a parent in a pediatrician’s office during a well-child visit. Depending on the results of the screening, a provider knows whether to refer a child for more thorough assessment, typically performed by another more specialized provider. DSS policy refers to the first medical, mental health, and dental encounters a child has upon entering foster care as “initial assessments”. These initial medical, mental and dental health assessments are more detailed than screens and are intended to be thorough enough to determine what follow-up care should be addressed in the child’s plan of care.
DSS has previously committed to the following timelines related to collecting health information, initial assessments, and comprehensive assessment and includes the timelines below for reference. Health Plan implementation activities related to initial assessments and comprehensive assessments will be undertaken in collaboration with DHHS, Select Health, DMH and other partners to align and refresh policies, timeframes and practice. The activities and timelines are as follows:
 Within 72 hours of the child's entry into foster care the Foster Care/IFCCS Worker shall gather all necessary, educational and healthcare information for completion of the child's Education and Health Passport (DSS Form 30245), which should be updated at least every three months.
 The Foster Care/IFCCS Worker shall schedule the Initial Medical Assessment and Mental Health Assessment within one business day of a child’s removal to foster care. The worker shall schedule a dental health assessment within 14 days of a child’s removal into foster care.
 The worker shall facilitate completion of a Comprehensive Medical Assessment within 30 days of the child's Initial Medical Assessment, if a Comprehensive Medical Assessment was not completed during the Initial Medical Assessment.
 If the Initial Mental Health Assessment recommends further assessment or the provision of Mental Health Services, the worker shall facilitate the completion of a Comprehensive Mental Health Assessment within 30 days of the Initial Mental Health Assessment.

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 If a child is under the age of three at the time of his or her removal, the worker shall immediately make a referral to BabyNet, South Carolina's interagency Early Intervention System for infants and toddlers.
 If a child is a suspected or known victim of acute physical abuse or sexual abuse, the worker shall schedule a forensic exam within 24 hours.
 The initial dental assessment will occur within thirty calendar days of coming into care. If the child is less than 1 year of age or has not had a tooth emerge or the provider is unwilling to re-exam the child due to previous encounter within six months, an oral exam during the EPSDT/well child visit is acceptable.
As part of the DSS Health Care Pilot and Process Review as discussed earlier in the Health, DHHS, DSS and Select Health will collaborate to determine whether certain children should be targeted for screenings and assessments with preferred providers. For example, children who initially enter care or children who are being moved to a new placement who meet certain health and/or mental health criteria might be referred for screenings and assessments with preferred providers (e.g., QTIP practices, FQHCs or DMH clinics). This will be particularly important for children that DSS has already determined through the CSA to need heightened care coordination. Children needing intensive care coordination include children with certain medically complex or behavioral health conditions or diagnoses such as bipolar disorder or psychotic disorders, or children who are receiving or being prescribed a psychotropic medication(s) and are age six or less, taking an antipsychotic, or are taking four or more psychotropic medications, or who are medically fragile or have an activity-limiting chronic condition. The state’s network of 17 SCDMH community mental health centers, are available and may be better utilized by DSS to do 72-hour trauma assessments and leveraged as preferred providers for children with more complex mental health needs. DSS will collaborate with DMH to assess the timely availability of trauma screenings and CMHC clinic capacity to provide child-focused clinical treatment to children in foster care.
As part of their routine case management responsibilities, DSS caseworkers will verify that all children on their caseload have had required screenings and assessments, and any follow-up care needed. Follow-up care will be tracked through the caseworkers’ monthly visitation requirements. DSS will rely on the CAPSS system to capture this information and as a source to extract data for reporting purposes. CAPSS currently has encounter type fields that are designated to allow caseworkers to enter the type of assessment, date of assessment, and provider. In addition, caseworkers can describe through dictation the visits as well as link appropriate medical documents to the case. DSS caseworkers will record notes in CAPSS based on discussions they have with birth parents, foster parents and the children themselves about medical, mental health or dental care assessments and issues requiring follow-up. Where a child has an Intensive Care Coordinator from Select Health, the DSS caseworker will inquire and solicit information regularly from birth parents, and either the foster parent or contract provider (if the child is placed in congregate care) so that the child’s needs are met. DSS and DHHS will collaborate with Select Health to develop a red flag report to notify the assigned DSS caseworker and supervisor and Select Health care manager, if one is assigned, of children who have not received follow-up care, missed a well-child visit, presented at the

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emergency room, was hospitalized or whose utilization patterns suggest may be the subject of repeat maltreatment in care or need referral to specialty services subject of repeat maltreatment.

DSS recognizes that policies and procedures between DHHS and Select Health and DentaQuest will need revisions to meet the current expectations for casework practice for initial assessments. For instance, based on South Carolina Medicaid MCO access standards, providers are required to make a best effort to do initial assessments within 90 days and have appointment availability within four to six weeks for routine office visits, not within 14 days as DSS policy currently requires. DSS will collaborate with DHHS and Select Health to resolve this discrepancy by June 2019. Once set, DSS will develop a training plan for its caseworkers, supervisors and directors on any new policies developed.

In addition, in conjunction with review and modifications to placement processes, DSS will review its existing "interagency-staffing” process (ISCEDC) for children identified as needing therapeutic family foster care or other higher-levels of care. Where possible, modifications will be made so that the decision around an appropriate placement resource happens more quickly than 45 days, especially for children entering foster care for the first time. The Health Care Pilot and Process Review aims to track how this process currently works to identify the best process for children, and where efficiencies could be gained by better coordination between health care and placement assessment processes. As noted above, DSS will use the Health Care Pilot and Process Review to gather information about these activities between September and February and will finalize recommendations from the Pilot by March 2019.

E. Immediate Needs

Under the FSA, DSS committed to identify “Class Members” (children) with “Immediate Treatment Needs (IN).” DSS has previously established an operational definition for “Immediate Treatment Needs” as a mechanism for focusing case practice. However, there are two issues with the language and intent of this requirement that may need modification: (1) how IN are identified and tracked for the defined cohort of children in foster care; and (2) how immediate treatment needs are defined. DSS is currently undertaking efforts to meet the immediate needs of children using this broad definition. See Appendix for DSS Child Health Fact Sheet which contains categories of immediate treatment needs for children. 150

First, while DSS has had success requiring caseworkers to track whether children on their caseload have had the appropriate initial assessments and comprehensive assessments, tracking immediate treatment needs through the case record is proving to be more difficult. To meet the conditions of the FSA and before development of the DSS Health Plan, the Parties developed a caseworker-dependent workaround to fill in for in the absence of other sources of data to identify immediate treatment needs in the identified cohort of Class members. The health care consultants retained by the co-monitors recommended against this data workaround for any “look back” analysis because the information collected was unreliable and likely to be incomplete. Instead the consultants recommended that DSS
150 DSS Child Health Data Fact Sheet in Appendix, Section 6.

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use Medicaid encounter, claims and other data of record (MMIS) to identify the treatment needs, services rendered or gaps in care for children in custody.
The consultants recommended that DSS caseworker and supervisory staff resources be devoted instead to making sure that children get to medical appointments and receive the care they currently need, not to track down historical data. The consultants recommended that DSS collaborate with DHHS and Select Health to generate the gaps in care/utilization report for a specified time period for a defined cohort of children in foster care to determine whether their immediate treatment needs were met. The gaps in care reports are based on a list of diagnostic conditions and HEDIS health quality measures used nationally and by many state child welfare systems including New Jersey, Utah, New York and others. In February, DSS requested a gaps in care report from DHHS, which was delivered at the end of April 2018. As noted above, weekly calls between DSS and DHHS to refine and build the report have been ongoing during the months of May and June 2018 and will continue.
DSS expects that once these gaps in are data reports, which will be tested in the Health Care Pilot and Process Review and in weekly cadence calls beginning August, begin to run regularly, the immediate treatment needs roster will be reduced. In the short run, to catch up and reach all children on the immediate treatment needs roster, DSS’s new process for addressing immediate needs is as follows: DSS caseworkers will review each child’s file on the immediate treatment needs roster and determine what action is required. If an appointment or staffing is required, Office of Child Health and WellBeing staff will monitor the child through completion of the staffing or appointment, whichever is later. The caseworker will enter initial assessment and comprehensive assessment data from the DHHS/Select Health reports into the CAPSS foster care case record. Going forward, caseworkers will also be expected to enter into case notes, any follow-up care needed and confirm with foster parents or other caregivers that follow-up visits have occurred. To assist with verification and so that care needs are met, DSS in collaboration with DHHS and Select Health will review the roster of children missing screenings, assessments or follow-up services and those with high need/risk diagnoses against 30-6090-day utilization reports. DSS will also use external evaluators to review a random sampling of case records through the Child and Family Services Review (CFSR) case review process. The review will determine whether children and youth receive needed health and behavioral health services. Weekly cadence calls will review all cases on the roster, so that cases are staffed as needed and appropriate services are scheduled, if warranted. These reinforcing layers of tracking and review using qualitative and quantitative data, at the individual case level and aggregated at the population level, allows children and youth who might have missed screening, assessment or follow up to be identified and staffed until they receive the care they need.
DSS has been collaborating with DHHS and Select Health to build reporting and analytic capacity and a format for the development of additional gaps in care/utilization reports that can be reviewed on a rolling basis, every 30-60-90 days at the outset, to track that children are receiving the care they need – tracking is for services covered by Select Health as well as those like dental that are covered outside the Select Health contract and the small number of children in foster care who will still be enrolled in the Medicaid fee for service program. DSS uploads a nightly roster of children who come into care that is be tracked against the DHHS Medicaid enrollment roster for accuracy. In addition, children

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with specific diagnoses, including but not limited to diabetes, asthma, sickle cell, and various behavioral health diagnoses, will be tracked and rostered by DSS and Select Health so that they are receiving high quality care and are assigned to a Select Health integrated health care management, if needed. Currently, this care manager assignment from Select Health is time-limited, typically up to six months. DSS will collaborate with DHHS and Select Health to determine if this time limit is appropriate for children in foster care and will work through a protocol for longer duration care management assignment by March 2019. This information will be used by DSS to produce a tracking and red flag report that caseworkers can use to supplement information collected from caregivers and children. Simultaneously, as noted above, DSS caseworkers will incorporate into their monthly visits questions about follow-up medical, mental health and dental care, and make notes of this in the CAPSS electronic case record. DSS envisions a future technology application, to be developed and tested in 2019, that allows verification using DHHS data that will be automatically uploaded into CAPSS. Once this process is complete, existing functionality in CAPSS that gives caseworkers notification prompts for missed follow-up appointments will be more useful in aligning practice to immediate treatment needs.
Second, the health care consultants found that the definition of “immediate treatment needs” as defined in the settlement agreement was overbroad and inconsistent with how the words are used in the health care sector. As part of its Plan, DSS seeks to develop a revised definition that categorizes treatment needs in language that is consistent with the health care field. For example, DMH categorizes needs as either “routine, urgent or emergent” while DHHS defines it as “urgent, nonemergent, routine, and emergent” care. DSS will consult with DHHS, Select Health, DMH and request approval from Co-Monitors and Plaintiffs, for use of a new definition of immediate treatment needs by November 2018. The goal of this exercise is not to reduce DSS’s obligations to provide needed care timely for children in its custody. Rather, it is to see that its treatment needs framework will be adopted, understood and used consistently by its health provider partners. Once this framework is revised, DSS will track services accordingly using real-time data capture by caseworkers in CAPSS and quarterly retrospective look-backs using administrative data.
F. Follow Up
DSS is developing a two-part solution for follow-up visits and services. This process will include a practice solution and a data solution. For the practice solution, DSS caseworkers will continue to engage birth parents, foster parents and youth in reporting the status of health care follow-up and identification of any outstanding needs at monthly visits. These case notes, referred to as “dictation” by DSS, and any discharge summary provided by the health/behavioral health provider will be uploaded into CAPSS. Children identified as having unmet follow-up care needs will be rostered with staff assigned to complete follow-up activities and tracked on the DSS weekly cadence call. The weekly roster will be transmitted from DSS to the Select Health Care Coordination Department for tracking, verification and follow-up scheduling assistance for needed appointments, medication management or medical equipment, eyeglasses or other assistive devices needed. This practice solution will be tested in the Health Care Pilot and Process Review that will be completed by February 2019 and new drop-down fields will be created in CAPSS to enable CAPSS to generate weekly and

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monthly “needing follow-up” rosters. This process will identify individual children in need, and will also surface counties and regions where community-based services are harder to access or altogether unavailable.
A retrospective review of the 30-60-90-day gaps in care/utilization report for children identified as needing follow-up will provide another level of validation. This data solution will require new fields to be added to the report. DSS will be able to use the “needing follow-up” roster to ascertain whether children received services in the 30-60-90-day period following the identification of unmet follow-up care needs. Again, this will surface access and availability patterns related to health and other community-based supports.
Child Health Goal 2: Elements of the Work Plan
Task Lead(s): DSS Office of Child Well-Being and Office of Data, Research and Accountability
Key Activities and Deliverables:
Medical Home
 DSS will collaborate with DHHS, Select Health and the Foster Care Health Advisory Committee to establish a preferred provider designation based on HEDIS parameters and provider agreement to participate in cohort learning collaboratives that meet two times a year
 DSS will collaborate and explore with DMH the designation of its CMHCs as preferred outpatient behavioral health providers, given their child psychiatry staffing and regional locations around the state
 DSS, DHHS and Select Health will collaborate to establish a protocol to assign children to a patient-centered medical home, QTIP-like or FQHC preferred provider and caregivers will have the opportunity to opt-out and exercise freedom of choice
 DSS will work with DHHS and the AAP to build out a learning cohort of pediatric practices who wish to work with the foster care population
 DSS will collaborate with DHHS and Select Health to create a manual for policies and procedures specific to children in foster care by 2020 to include incentives for medical homes/preferred providers, timeframes for assessments, etc.
Eligibility and Enrollment
 Build out and pilot test the rostering, tracking and follow-up mechanism for initial assessments, comprehensive assessments and timely follow-up.
 Fix 30-day enrollment lag by January 2019, and in interim, use developed administrative workaround so that children in foster care receive necessary initial assessment, comprehensive assessment and follow up, and the data tracks them as such.

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Screening and Assessment

 DSS has already developed aligned timeframes for initial assessments, comprehensive assessments and follow-up that track AAP standards for children in foster care. Those timeframes will be clarified and operationalized for data tracking purposes.
 DSS will develop timeframes that align with FSA requirements, and coordination with placement and re-placement decision-making assessments.
 DSS, DHHS and Select will collaborate on the development of a no-lag enrollment protocol by January 2019.
 DSS and DHHS have already developed and signed a data-sharing agreement.  DSS, DHHS and Select Health will develop an implementation timeframe for producing regular
monthly gaps in care reports.  DSS will field-test the use of gaps in care reports, cadence calls, and monthly tracking and
develop practice guidelines beginning in August 2018 and running through February 2019.  DSS will include a targeted focus on health and behavioral health in its CFSR PIP and will
develop a process for integrating case record review findings into the weekly/monthly cadence calls.  Caseworker training will include new expectations for documentation and follow-up and refresher training on DSS practice standards.

Immediate Needs

 DSS will propose a revised definition of Immediate Needs to more closely match language and conditions that are customarily used in the health care industry by November 2018.
 Use gaps in care and other red flag reports, cadence calls and performance tracking and develop a protocol based on experience beginning in August 2018.

Follow-Up Services

 Develop and pilot practice and data solutions to ensure the regular flow of information to caseworkers and between DSS and DHHS beginning in August 2018.
 DSS will collaborate with DHHS to develop a protocol to identify dental providers and develop a roster of children needing dental care follow-up beginning in August 2018.

Timeframe: Current through February 2019, Draft Select Health Policy and Procedure Manual, May 2019

Child Health Goal 3: Each child in foster care has timely access to quality health, behavioral health and dental services

DSS will accomplish this goal by assessing provider capacity to accept and serve children in foster care, coordinating the annual network adequacy assessments conducted by Select Health and validated by DHHS and use data to develop a process to address capacity gaps. To improve the availability of

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high-quality, community-based health and behavioral health services, DSS will collaborate with DHHS and Select Health to develop a process for an annual review of network capacity and access to services at the local, regional and state level. In addition, DSS has developed a monthly report to track, flag and prompt timely completion of health, dental and behavioral health initial assessments. DSS will also develop a protocol for a monthly report and assessments, referrals and follow-up needed and to identify immediate needs and gaps in care as discussed in detail earlier in the Health Plan.
DSS is actively exploring ways to align its own network adequacy assessments with those required by DHHS for Select Health. The network adequacy features envisioned for the new health system for children in foster care are detailed below.
A. DSS sponsored USC Study
In April 2017, the DSS Healthcare Improvement Workgroup, in partnership with the University of South Carolina’s Center for Child and Family Studies (USC), undertook a healthcare needs assessment specifically focused on the initial and ongoing health assessments for the physical, mental health, dental, and trauma needs of children in care. Members of the Healthcare Improvement Workgroup, along with USC team members, designed and tested an instrument to be deployed through Survey Monkey. Each county director through their Regional leadership was asked to submit one answer that best represented the circumstances of that county. The instrument was deployed with a 100% response rate. Data was unduplicated where necessary and, in some instances, recoded to be easily summarized for patterns. The survey established baseline capacity needs and gaps and provided useful information to inform DSS’s annual discussion of network adequacy with DHHS and Select Health. DSS has a current contract with USC to conduct the needs and capacity survey bi-annually. The survey findings will be used to inform DSS’s resource development.
DHHS’s network adequacy requirements in the Select Health contract also offer DSS another source for actionable information on community-based service and provider capacity. DHHS and Select Health will revisit the need to supplement this analysis and will develop a process for monitoring and addressing issues of local and regional service availability, access and timeliness and reporting back to DSS about plans to fill service gaps.
Some key findings from the USC study related to the availability of services included:
 Generally, counties felt that they did have sufficient providers to meet their medical needs though some have issues with access within their counties. Those counties who appeared to have issues with access were often rural, with Florence one notable exception. Some counties were more specific in their accessibility barriers. These barriers included a lack of providers in some parts of a given county, limited mental health providers who would see children under 6 years of age, dentists who sometimes did not want to see young children, and not all providers being trained in trauma or otherwise qualified to serve the specialized needs of children in care.

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 Over a third of the counties experienced timeliness issues for three or more of the initial assessments.
 Counties experienced a number of barriers to completing their assessments that fell into several “buckets”. The first bucket of barriers was related to the lack of placements within a child’s home county. Because of the lack of placements in a given county, a child may need to be placed in a county far away from their home county. This led to caseworkers who were not familiar with providers in distant counties and caseworkers having to spend time traveling. They also noted the hardships placed on the child who sometimes had to miss school. A second bucket included wait times and a lack of late or alternative times for appointments. Finally, the third bucket was Medicaid data issues such as inaccurate data in the system or missing Medicaid numbers and/or Medicaid eligibility issues.
B. Case Record Reviews
DSS CFSR case reviews will review questions related to health and behavioral health services. Questions and data collection will focus on the identification of gaps in care, timeliness of care and ease of access. Other sources of information such as case notes in CAPSS, gaps in care/utilization reports and Select Health network adequacy data will also provide feedback to DHHS about the need for additional capacity or a different regional service mix. This will include CFSR Item 12 assessing needs of families and children and providing those services; CFSR Item 13 including parents and children in case planning; CFSR Item 14 frequency and quality of visits between caseworkers and child, CFSR Item 15 frequency and quality of visits between caseworkers and mothers and fathers, CFSR Item 16 educational needs, CFSR Item 17 physical health needs, and CFSR Item 18 behavioral health needs. The information in the case record reviews will further inform DHHS and Select Health’s analyses described below so that DSS has a comprehensive view of both community-based services and supports.
C. DHHS and Select Health Network Analyses
DHHS requires Select Health to have a network of providers sufficient to deliver adequate access to services for all children in care, including prevention services, primary and specialty care. The contract also requires Select Health to develop mechanisms to monitor compliance by providers and take corrective action for failure to comply. The DHHS-Select Health contract details minimum provider network adequacy requirements informed by:
 Utilization estimates based on the characteristics and health care needs of the population served
 A geographic service area which in the case of children in foster care requires Select Health to plan for geo-mapped statewide geographic distribution
 Estimates of the number and types of credentialed providers needed who are primary care and specialty care providers, hospitals and other health care providers.
 Estimates of credentialed providers with capacity to accept new patients  Sufficient credentialed providers who can provide a second opinion

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 Distance, travel time, typical means of transportation; physical access  Meet standards for timely access and respond to urgent care needs  Standard hours of operation  24/7 service access for medically necessary services  Routine visits within 4-6 weeks  Wait times that do not exceed 45 minutes for routine schedule appointments  Urgent care within 48 hours  Capacity to handle walk-ins

In addition to the network adequacy requirements covered under contract, Select Health must also manage utilization review and prior authorization for services. The “utilization management (UM) function” as it is known by MCOs is not to be confused with the care coordination function. The UM function monitors the child’s patterns of service use and pays particular attention to overutilization, underutilization, hospitalization and emergency room use, medication adherence, medical necessity and prior authorization of certain in or out of network services. Network adequacy information will be shared annually by Select Health in a performance improvement meeting with DHHS and DSS. UM data will be provided by DHHS to DSS quarterly to inform casework follow-up with the child and family.

D. Out-of-Network Services

DSS will collaborate with DHHS to review the eligibility and enrollment protocols for the nine waiver programs and other specialty services for high needs children currently operating in South Carolina and refresh its referral protocols. DSS will also collaborate with DHHS and Select Health to develop a notification process so DSS caseworkers and Select Health care managers know which children are receiving out-of-network services. DSS will also collaborate with DHHS to track utilization of dental, waiver and other out-of-network services for children who receive services outside of the Select Health provider network. Review of these programs will include the identification of access and availability of community-based services necessary to meet the health care needs of children in care.

Child Health Goal 3: Elements of a Work Plan

Task Lead(s): DSS Office of Child Health and Well-Being

Key Activities/Deliverables:

USC Study

 DSS to plan a behavioral health and dental services capacity study to be conducted every two years by USC using Medicaid administrative data, qualitative surveys from foster parents, birth families and youth in care and DSS regional office staff
 DSS will contract with USC to conduct targeted annual topical studies, with recommendations, as needed

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CFSR Case Record Review and PIP
 DSS will continue its focus on health and behavioral health services in CFSR case record reviews.
 Using the CFSR quality assurance process, which reviews each of the state’s 46 counties every three years, DSS will analyze CFSR review data from the 23 counties in the 2017 cycle. Of the 450 cases for this time period, approximately half were foster care cases. The review included questions from the federal CFSR tool related to physical health including dental (item 17) and mental/behavioral health (item 18).
 DSS will develop corrective action plans and PIPs to address issues that relate wellbeing outcomes 1, 2 and 3 which include CFSR Item 12 assessing needs of families and children and providing those services, CFSR Item 13 including parents and children in case planning, CFSR Item 14 frequency and quality of visits between caseworkers and child, CFSR Item 15 frequency and quality of visits between caseworkers and mothers and fathers, CFSR Item 16 educational needs, CFSR Item 17 physical health needs, and CFSR Item 18 behavioral health needs.
Select Health Network Adequacy Review
 DSS will review the annual External Quality Review Reports for Select Health to determine adequacy of the provider network and quality improvement plans to improve access
 DSS, DHHS and Select Health will meet once a year to review provider and network adequacy and capacity issues
 DSS will collaborate with DHHS and Select Health to determine network sufficiency, and implement mitigation plans for areas where service or provider capacity is limited
Out-of-Network Services
 DSS will collaborate with DHHS to create a report and roster that tracks services delivered to children in foster care who are either ineligible for Medicaid or utilize services that are not covered by Select Health’s per member/per month rate including dental services, Medicaid waiver services and specialty care for medically fragile children among other out-of-network services provided to children in foster care. DSS and DHHS will use the report to recommend changes or improvements needed.
 DSS will identify the appropriate role for DSS caseworker where out-of-network services are necessary and train caseworkers accordingly.
Timeframe: Current through December 2018 to establish basic understanding of methodologies used with annual review thereafter, Network Sufficiency and Topical Studies planned through June 2019

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Child Health Goal 4: Each child in foster care has improved health outcomes

DSS is committed to improving the health outcomes for children in its custody. Under the FSA, DSS committed to targets related to initials assessments, comprehensive assessments, and timely follow-up care. DSS also intends to track the health outcomes of the children and youth in its custody. Specifically, DSS will collaborate with its Foster Care Health Advisory Committee (FCHAC) experts, DHHS and Select Health, to determine key outcomes it should track, including those identified by the Academy of Pediatrics Bright Futures program. The targets will include outcomes such as percent % completed medical, mental health and dental initial assessments within X days, % completed assessments within X days, % follow-up visits completed within X weeks, % completed immunizations, % vision and hearing screenings conducted, etc. DSS and Select Health performance will also be benchmarked against HEDIS targets and compared to children served by Select Health who are not placed in foster care. DSS will refresh its measures and targets, collect baseline data and produce an annual report showing work underway and over time to improve from baseline.

Child Health Goal 4: Elements of a Work Plan

Task Lead(s): DSS Office of Child Health and Well-Being and the Office of Data, Reporting and Accountability

Key Activities/Deliverables:

 Develop proposed set of child health outcome benchmarks and targets similar to those in the Center for Health Care Strategies’ report “Improving Outcomes for Children in Child Welfare: A Medicaid Managed Care Toolkit” (Allen, 2012).
 Convene FCHAC in facilitated working sessions to review proposed benchmarks and targets
 Finalize benchmarks and targets  Review/refine annually  Publish annual report on health status of children and youth in foster care

Timeframe: FCHAC will convene each year in Spring and Fall to review annual performance against benchmarks and targets. The initial review will begin by April 2019.

VI.

Child Health Plan: System Components

DSS also translated its commitments in the FSA and the recommendations of the consultants into three key system components. The key system goals speak to the core operating elements of an effective health care system for children in foster care.

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Component 1.

Establish the Office of Health and Well-Being and define Internal and External Roles and Responsibilities and build into a sustainable governance structure that provides direction and oversight of initial Health Plan implementation and thereafter ongoing review.

Component 2.

Build out the capacity to collect, analyze, disseminate and use administrative data to drive child health outcomes (including central and field-facing quality improvement processes, incident review and adverse event monitoring and monitoring of network adequacy).

Component 3. Develop practice guidance, policies and training for the field, birth families, foster parents and contract, placement and treatment providers.

System Component 1. Establish the Office of Health and Well-Being and define internal and external roles and responsibilities developing a sustainable governance structure that provides direction and oversight of Health Plan implementation and ongoing review.
A. Establish the Office of Health and Well-Being
DSS is principally responsible for implementation and oversight of the Plan through the recently created Office of Health and Well-Being within the Division of Child Welfare. The Office is responsible for child and adolescent health, child and adolescent clinical and behavioral health through the IFCCS, therapeutic foster care, specialized treatment services, oversight and monitoring of psychotropic medication, child and adolescent education services and provide support for the Foster Care Health Advisory Committee (FCHAC). This office will develop health and behavioral health policies, procedures, protocols, and practices designed to achieve safety, permanency, and well-being outcomes for children and families. It is also responsible for developing, with internal and external partners, health, behavioral health and other well-being measures and performance targets. This Office has primary responsibility for implementation of this Plan.
The Office is currently staffed with a Director hired in April 2018151, a Consultant Psychiatrist, Lead Clinical Specialist, and Intensive Foster Care and Clinical Services Administrator. The Director is responsible for building out, refreshing and rolling out all DSS health and behavioral health policies and practice protocols, data reporting and quality assurance and the operation of this new office at DSS. The scope of the reforms underway in foster care will require the Director to provide health and behavioral health leadership and support to related Department activities including guidance on the health and behavioral health components of the case practice model being developed by Chapin Hall, implementation of the CFSR PIP, and the development of the Foster Care Placement Plan. In this capacity, the Director serves as the liaison to DHHS, DMH, Select Health and other external Health Plan implementation partners and stakeholders, is a member of the DSS Foster Care Leadership Team

151 Position Description in Appendix, Section 5.

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and sets strategy, goals and performance targets for health and behavioral health services for children in foster care, attends the Joint Council on Children and Adolescents, leads in the development of department health and behavioral health priorities, policies and practice and leads on the implementation management of the Health Plan. The Director also sets the agenda for the Foster Care Health Advisory Committee, interfaces with USC and internal partners on the bi-annual capacity and network adequacy survey, coordinates the DSS response to the well-being quality improvement components of the CSFR PIP (Program Improvement Plan), which includes physical and behavioral health of children in foster care.
The Child Psychiatrist’s responsibilities include psychotropic medication oversight, clinical consultation for regional clinical specialists and other field staff, tracking and follow-up on high need cases (children receiving psychotropic medication, polypharmacy and children < 6), development of protocols for informed consent, enhanced clinical health care and psychopharmacology and behavioral health basic training for DSS and IFCCS casework staff and supervisors.
The Lead Clinical Specialist’s duties include providing guidance or specialized clinical assistance to field staff serving children with significant behavioral health needs, oversight of the psychotropic medication management process for youth in psychiatric residential treatment facilities, project management for the implementation of the health and education passport, managing the roster of high needs/immediate needs children and cadence calls to staff cases for follow-up, and provision of field training to DSS caseworkers and supervisors on health and behavioral health policy and practice.
IFCCS develops policies procedures and practices to enable the 110 IFCCS caseworkers achieve safety, permanency, and well-being outcomes for children in need of intensive foster care and clinical services, coordinates the rostering, staffing and follow-up for complex behavioral health cases, participates in community, governmental, and educational activities representing the Child Welfare Services Program, provides input on program related issues, and provides content for IFCCS worker Basic Orientation Training.
Given the significant expansion of duties in DSS’s new Office of Health and Well-Being, and the need for deep engagement of other state agencies, stakeholders and partners tied to successful implementation of the Health Plan, DSS will evaluate the need for additional staffing and the phase-in of any additional staff, including additional clinical staff. Detailed information regarding the plan for additional staff will be included in the care coordination and healthcare case management framework discussed above, to be completed by March 2019. One area of consideration will be the addition of up to three Clinical Specialists, including pediatric nurses, who could serve under the supervision of the Lead Clinical Specialist and Chief Medical Officer to enhance training, support and consultation to DSS and IFCCS caseworkers and supervisors, interface with health care providers and support the rostering, tracking and follow-up work needed by high-needs and medically complex children. Another functional consideration will be for up to three staff to build out the team responsible for data analytics, rostering and monitoring and quality and performance improvement, support PIP implementation and quality improvement activities. The preliminary budget model was prepared for submission to the Co-Monitors in May 2018 and is currently under review.

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The DSS Office of Health and Well-Being has a lateral relationship with the DSS Director of County Operations to whom all regional and county foster care operations report and the Director of Data, Accountability and Research who produces and analyzes data for DSS. The Office will have functional authority over all policies and procedures related to healthcare and will also serve as clinical advisor to the entire Division of Child Welfare. County and regional operations will be expected to coordinate efforts with the Office of Health and Well-Being to implement the elements in this Plan.
B. Define External Roles and Responsibilities
For the Health Plan to be successful, DSS must collaborate closely and in partnership with multiple state agencies including DHHS, DMH, and Select Health, the MCO that serves children in foster care. DSS and DHHS are lead agencies for the purpose of Health Plan activities. Weekly planning and implementation meetings began in April 2018. SCDMH serves in both a key provider and partner role. Select Health is central to the provision of health and behavioral health services to children in foster care and DSS has reset its relationship with DHHS and Select Health and the three entities are meeting, planning, problem-solving together.
DHHS
The South Carolina Department of Health and Human Services (DHHS) operates, among other activities, the state’s Medicaid program and is an essential partner with DSS in ensuring that the health care needs of children in foster care are met. DHHS manages Medicaid eligibility and enrollment; determines covered services; pays for covered services; holds the contract with the managed care organization (MCO) that serves these children and provides fee-for-service payment for medical, behavioral or dental care to a small number of children in foster care with complex needs. DHHS is the state agency that is responsible for federal Medicaid requirements, including implementation of the state Medicaid plan, Home and Community-Based (HCBS) waiver services.
SCDMH
The South Carolina Department of Mental Health (SCDMH) has 17 community mental health centers operating over 60 clinics, with at least one clinical location in every County. The agency operates two psychiatric hospitals, Bryan Psychiatric Hospital in Columbia and Harris Psychiatric Hospital in Anderson, as well as a specialty hospital for substance use disorders, Morris Village, in Columbia. The Department’s Bryan Psychiatric Hospital includes the William S. Hall Psychiatric Institute, which consists of three separate hospital units for children and adolescents:
 a latency age hospital unit for patients ages 4 to 12;  an adolescent unit for patients age 13 to 18; and  a substance use disorder unit for adolescents age 13-18.

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DMH Community Mental Health Centers provide outpatient mental health services, including when needed psychiatric services and medication management. Staff are trained and practice traumainformed care, and SCDMH Mental Health Centers offer a number of other evidence-based interventions, such as school mental health services. In the 2017–18 school year, SCDMH Mental Health Center therapists provided clinical services in over 600 schools across South Carolina.
Select Health
In recognition of the fact that foster care children require a more comprehensive, coordinated healthcare delivery model that promotes better access and improves health outcomes, in November 2012, DSS and DHHS announced the Foster Care Health Initiative, a collaborative effort to better address healthcare delivery to foster care children. As the legal custodian of children in foster care, DSS determined that it is in the best interest of foster children to be enrolled in a single MCO that could coordinate their care in both their routine health care needs and the special needs that arise for children who have been abused, neglected and placed in state custody. As a result of this initiative, all foster youth, with few exceptions, are enrolled in First Choice by Select Health of South Carolina, a Managed Care Organization. Specific core benefits and service requirements are set forth in Section 4 of the DHHS and Select Health MCO contract. Select Health is paid through a capitation rate, a “per member/per month” fee of $950.75 for each child in foster care. The rate has been adjusted to meet the special needs of children in foster care. In addition to screening, assessment, treatment and follow up, Select Health is also required to provide care management that meets national standards.152
C. Develop Governance Structures and Routines
Development and implementation of the Plan will require a tiered governance structure led by DSS with DHHS to keep the lines of communication open, to resolve issues that may arise and to establish accountability mechanisms for DSS internal; cross-agency; and external partners. The governance structure being utilized by DSS to develop and implement the FSA and the Plan are described in the table below. The structures include both internal decision-making groups, and external advisory groups. As part of its priority actions, DSS has recently created a cross-agency SWAT team that meets weekly on implementation issues. This group has proven critical to gaining traction on important cross-agency issues, particularly as it relates to DHHS’ role as contract manager to Select Health.
But more than a SWAT team, this plan requires the establishment of, and routine meetings by, a set of new governance bodies, as described below, as well as the continued convening of an outside advisory group. The table below identifies the set of governance groups DSS is convening to implement the Plan. Over time, groups like the SWAT team will be converted to routine governing bodies that meet on a regular basis to oversee and monitor the ongoing health functions described in this Plan.
The table below sets forth the governance structures (including internal “cadence” structure) that DSS will utilize to design, track and implement the Health Plan.

152 Detailed contractual requirements for Select Health in Appendix, Section 4.
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Governance Level/ Group Name Internal/ Cadence Team
Internal/Regional
Internal/ Supervisors Cross-Agency/ SWAT Team

Members*

Responsibilities

• Office of Child Health and Well-Being
• DSS Division of CW (includes program support, IT, etc.)
• Regional and County Operations

Operations group of Executive Team and Regional Directors for day-to-day management, system and operations planning and system-wide health-related oversight.

Meeting Frequency
Weekly

• Regional Directors • County Directors • Performance Coaches
• County supervisors • Caseworkers
• DSS • DHHS • Select Health

Regional directors share data, identify outliers, and gaps.

Weekly

Discuss data, identify outliers in unit cases; flag cases for staffing and follow up.

Weekly

Operations group to coordinate,

Weekly

track and trouble-shoot all aspects of

data and analytics to support health

care for children in foster care.

Develop outlier reports and flags for

higher needs children.

Develop and track system

performance and quality reports.

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External/Foster Care Health Advisory Committee153

• DSS • DHHS • Foster Care Health
Advisory Committee • Select Health • SCDMH • Health and Behavioral
Health providers, practitioners and organizations, including QTIP and Federally Qualified Health Clinic representatives

Advisory group co-Lead by DSS Quarterly and DHHS; provides consultation on issues as needing; for example, Access to Care; trauma-informed Care; Medical Assessment.

*Governance group lead in red
Although successful implementation of this Plan will be a collaborative effort, DSS is principally responsible for its oversight. Three other entities will play a major role in implementation of this Plan: DHHS, Select Health, and the South Carolina Department of Mental Health. Key leads from DSS, DHHS, and Select Health have convened weekly meetings, which will continue throughout the implementation of this Plan. The purpose of these meetings is to develop and revise this Plan, where necessary, monitor implementation, troubleshoot and resolve issues and conflicts that arise.
External partners and stakeholders will serve in an advisory capacity related to implementation issues. The Foster Care Health Advisory Committee (FCHAC) will be instrumental in implementing and monitoring fidelity to the Healthcare Plan. This is an existing committee charged with helping children in foster care have effective and coordinated medical and mental health services and is comprised of a broad representation from the medical and behavioral healthcare fields statewide, including nurses and pediatricians from various clinics, Select Health representatives, Child Advocacy Centers, Department of Mental Health (SCDMH), private community-based Licensed Independent Professionals (LIPs), Palmetto Association for Children and Families, Therapeutic Foster Care agencies, Group Care and Rehabilitative Behavioral Health Services (RBHS) providers, and Foster Parent support agencies. 154 DSS and DHHS will partner together to lead the quarterly FCHAC meetings. DSS expects to reorganize the FCHAC to focus more directly on achieving the healthcare targets set forth in this Plan. The FCHAC has reviewed the draft Plan and discussed it at its June 26, 2018 meeting.

153 The FCHAC is comprised of representatives from the medical and behavioral healthcare fields statewide, including nurses and pediatricians from various clinics, Select Health representatives, Child Advocacy Centers, Department of Mental Health (DMH), private community-based Licensed Independent Professionals (LIPs), Palmetto Association for Children and Families, Therapeutic Foster Care agencies, Group Care and Rehabilitative Behavioral Health Services (RBHS) providers, and Foster Parent support agencies. 154 List of FCHAC Members in Appendix, Section 7.

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System Component 1: Elements of a Work Plan Task Lead(s): DSS Office of Child Health and Well-Being Key Activities and Deliverables

 DSS will develop a working protocol for its internal governance activities including guidance to the field: health data report production and dissemination, cadence calls, follow-up and oversight tracking
 DSS will collaborate with DHHS to develop a data-sharing agreement and schedule for reports
 DSS, DHHS and SH will collaborate to develop a process for data sharing  DSS, DHHS and SH will collaborate to develop a protocol for resolution of child
or provider specific issues  The Office of Health and Well-Being will work with the Office of Data,
Research and Accountability to develop health data management reports and guidance to the field, data analytics, technology solutions through CAPSS
Timeframe: Work has already begun on establishing structures. Governance protocols complete by December 2018; Health Data Management Reports January 2019

System Component 2: Build out the capacity to collect, analyze, disseminate and use administrative data to drive child health outcomes
The Plan’s success rests on DSS capacity to collect, analyze, disseminate and use administrative and case data to improve health care services to children in foster care, improve field operations and see that children in foster care receive quality care. While DSS is ultimately accountable for meeting the health needs of children in their care, it depends on a strong partnership and collaboration with DHHS and Select Health to meet its obligations to children. Key components of the Plan Are built on a data-sharing agreement to be developed between DSS, DHHS and Select Health to:

 Program automatic uploads and facilitate completion of CAPSS records for each child  Flag, roster, track and follow-up on children identified with immediate needs  Provide timely screening and assessment  Identify children in need of IFCCS or Select Health Intensive Care Coordination  Allow for a targeted focus on the health and behavioral health care needs and follow-up of
children in foster care  Formalize channels of reporting and accountability

As described earlier, DSS and DHHS are collaborating to develop a system-wide database and report that captures health and behavioral health measures for each child in foster care and can be aggregated

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by region, county, supervisor and caseworker. Work is also underway to formalize this data-sharing agreement by December 2018. The data agreement will cover sharing data needed to populate CAPSS, data access permissions and restrictions and will include a data dictionary, list of monthly, quarterly, annual or more frequent population health reports (more than one medication, immediate needs, etc.) and other elements.
The Plan contemplates three components of its data and quality improvement system, including a component related to continuous case- and management-level data; immediate need (IN) data as defined in the FSA; and quality improvement. They are described below.
A. Strengthening Use of Case-Level Data and Management-Level Data
DSS and DHHS have begun to link their data to create a synchronized roster of eligible children and are working now to move any remaining children who are not coded as “foster care” into that status. Medicaid claims, service and utilization data from the DHHS system of record and Select Health should populate, along with other ancillary information, the official CAPSS health record for all children in foster care. This is not only important for children while they are in foster care but will provide critical medical history that can follow children once they transition out of foster care. While we understand that setting up a data-sharing exchange will take time and the patience of all involved, it presents an opportunity for South Carolina to be a national model with respect to the health of children in foster care. Given the importance of data to the Plan, DSS is developing a clinically and analytically-oriented data team tasked to work with DHHS and Select Health, related departments at DSS and other affiliated entities. This team will work with other DSS departments to develop dashboards, report templates, inform the quality improvement process and assist with implementation of the DSS CSFR PIP.
Continuous case-level data will mean that a child’s case record will be up-to-date as far as whether a child has received appropriate screening and assessments, and any routine, urgent or emergent followup care. To accomplish this, DSS county and IFCCS workers will continue to populate CAPSS with information on screenings, assessments and follow-up care as they are currently doing. In the shortterm, follow-up care will be documented monthly in case notes. Over the long-term and beginning in March 2019, DSS will collaborate with DHHS and Select Health to determine which data from providers’ electronic health record or Medicaid data can auto-populate the DSS CAPSS record. Additionally, DSS will collaborate with DHHS and Select Health to review utilization data to determine which health episodes, if any, for example a trip to the emergency room, should trigger immediate provider contact with Select Health, followed by immediate notification to DSS. Notification of emergency room visits, or injuries identified during a routine health visit can serve as a proxy for identifying maltreatment in care and so should likely be an important immediate notification flag. Over time and as needed, other immediate notifications or red flag reports will be developed between DSS, DHHS and Select Health.
Continuous management-level data will mean that DSS county, regional and central leaders will have regular data reports on key practice and child health indicators, such as percent of children with timely

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screenings and assessments or utilization of behavioral health services by children placed in congregate care. These reports will identify certain gaps in care reports that DSS, DHHS and Select Health will use to routinely monitor child health outcomes and field-level performance.
Missing Initial Assessment A missed initial medical, dental or behavioral health assessment becomes an immediate treatment need. DSS began tracking these missed initial assessments in June 2017. Immediate need reports are pulled weekly and reviewed with child welfare leadership Fridays and cadenced with regional health care liaisons on Mondays. The process for staffing immediate needs cases, follow-up activities and monitoring completion of follow-up activities are outlined on page 48 of the Plan.
DSS has begun receiving Medicaid claims and encounter data and tests it against CAPSS data for accuracy and reliability. Using the initial cohort defined in the FSA, DSS is testing a process to crossreference the two data sets, identify nuances in the data that may require further clarification (medically fragile children who may be unable to participate in a behavioral health initial assessment, healthcare providers who do not bill Medicaid for services provided or batch claims, and claims that may have a lag time), and where it appears certain that a health, behavioral health or dental initial assessment should have been scheduled and was not, provide instruction to the field to immediately schedule the missed initial assessment. Once DSS has refined and streamlined the new gaps in care/utilization report and cadence process, it will begin using it for the FSA cohort--all children who entered care during CY 2017 and are still in care which is a shift in the definition outlined in the FSA. DSS has developed a standardized reporting formal that will enable the caseworkers to report back to the Regional Health Care Coordination Liaisons and for the regional liaisons to report back to the Office of Health and Well-Being in weekly calls. DSS will use its cadence governance process and the gaps in care report to routinely monitor and follow-up on initial assessments, missing assessments and other immediate needs.
Gaps in Care/Utilization
The definition of immediate treatment needs includes, ‘[a]ny diagnosis that requires follow-up with a medical, mental health, and dental provider outside of the child’s normal routine periodic assessments.’ To better identify and address unmet need, DSS has asked DHHS and Select Health to prepare gaps in care/utilization reports based on HEDIS (Healthcare Effectiveness Data and Information Set) measures. HEDIS measures are a widely used set of performance measures in the managed care industry developed by the National Committee for Quality Assurance (NCQA). Generally, HEDIS measures address a broad range of important health issues and represent nationally agreed upon practices to improve healthcare quality. Select Health routinely distributes these gaps in care reports to its network providers to identify members or providers who failed to meet a particular HEDIS measure.
In April 2018, DSS compiled a list of the most common diagnoses and conditions for children in foster care and sent this list to DHHS. From that list, DHHS and Select Health selected HEDIS measures that aligned most closely with the identified diagnoses and conditions deemed important.

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This list was further refined and expanded with the assistance of a HEDIS expert at DHHS and Select Health’s current and former medical director and corporate quality assurance director. The current list includes the HEDIS measures below.
The gaps in care/utilization reports serve as a roster and based on the HEDIS measures tracked, will identify children who require follow up, as required by the immediate treatment need definition; those who are and those who fall below an established HEDIS parameter. The report will also identify lack of access to more preventative health care services such as immunizations, well-child visits, and weight assessment. The gaps in care data can also be queried and organized to produce focused reports on utilization or access challenges by region, by placement type (TFC or congregate care), by diagnosis and by provider, among others. The data can be queried to identify providers who are not adhering to DSS, DHHS or Select Health prescribing standards. DSS and DHHS anticipate producing the first set of gaps in care reports in August 2018.

HEDIS Measures to be Included in Monthly Gaps in Care Report

Abbreviation/Measure

Measure Description

Notes

CDC—Comprehensive Diabetes Care

Used to determine if patients age 18-75 with Type I or Type II diabetes received proper testing and care for diabetes during the measurement year.

This diabetes measure will be reported for all children in foster care with age restriction removed (blood pressure <140/90, HbA1c<9, dilated eye exam, and nephropathy screening). Note this measure is dependent on record review.

AMR—Asthma Medication Ratio

Paid pharmacy claims are used to determine if the patient is filling more rescue medication compared to total asthma medication. An AMR less than .5 is a strong indicator that a patient may benefit from a discussion about current medication usage.

This will be reported with actual ratio for each child.

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FUH—Follow-Up After Hospitalization for Mental Illness
ADD—Follow-Up Care for Children Prescribed ADHD Medication
AMM—Antidepressant Medication Management
CIS—Child immunization Status: Combo 10

Used to determine if patients age 6 and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, and intensive outpatient encounter, or partial hospitalization with a mental health practitioner. Treatment is measured after a psychiatric hospitalization—7 days, best practice and 30 days to pass the measure.

Pharmacy claims data is used to determine if newly prescribed (or restarted with sufficient break) ADHD for 612-year olds had at least three follow-up care visits within a 10-month period, with the first visit being within 30 days of when first ADHD medication was dispensed. Best practice is to get all three visits.

This will be reported with the age restriction removed.

Used to determine if patients 18 This will be reported with the age years or older with a diagnosis restriction removed. of major depression who were newly treated with an antidepressant remained on the antidepressant medication for 84 days for the acute phase and 180 days for the continuation phase. Uses pharmacy claims data.

Used to determine if children received immunizations. Includes 4 DTAP, 1 MMR, 3 HepB, 4 PCV, 2 or 3RV, 3 IPV, 3 HIB, 1 VZV, 1 HepA, 2 Influenza. PCPs also document vaccines in the SC immunization registry

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APM—Metabolic Monitoring for Children on Antipsychotics

Used to determine whether children 1-17 years old who are on an antipsychotic also had metabolic monitoring.

APP—Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics

Used to determine if children 117 years old have psychosocial treatments prior to being prescribed antipsychotic medication. Antipsychotics are recommended as a second-line treatment option only after psychosocial interventions have been tried and symptoms are severe and persistent.

Measure only focuses on first appointment, not ongoing appointments. Later consider matching to DHHS claims data to determine if other psychosocial interventions being utilized.

APC—Use of Multiple Concurrent Antipsychotics in Children and Adolescents

Used to determine % of patients 1-17 on two or more antipsychotics concurrently in a 90-day period. Lower % is better.

Fine as is

IET—Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

Used to determine % of patients ages 13 and older with a new episode of alcohol or other drug dependence who received initiation of AOD treatment (admission, outpatient visit, intensive outpatient, or partial hospitalization) within 14 days of diagnosis and engagement of AOD treatment after initiation with two or more services within 30 days of initiation visit.

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IMA—Immunizations for Adolescents

Used to determine if males and females turning 13 during the measurement year completed immunizations on or before their 13th birthday: 1 MCV (on or between 11th and 13thbirthday), 1Tdap (on or between 10th and 13thbirthdays), and 3 HPV (on or between 9th and 13thbirthdays) PCPs also document vaccines in the SC immunization registry

W15—Well-Child Visits in the First 15 Months of Life

Used to determine if babies turning 15 months old completed six or more wellchild visits before reaching 15 months of age In order to count, documentation must include evidence of: health history, physical developmental history, mental developmental history, physical exam, and health education/anticipatory guidance

W34—Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life

Used to determine children ages 3-6 who had at least one well-care visit with a PCP during the measurement year. In order to count, documentation must include evidence of: health history, physical developmental history, mental developmental history, physical exam, and health education/anticipatory guidance

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AWC—Adolescent WellCare Visits
WCC—Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Used to determine if patients age 12-21 had at least one comprehensive well-care visit with a PCP or OB/GYN during the measurement year

This will be reported with the age restriction removed.

Used to determine if children age 3-17 completed a body mass index percentile, counseling for nutrition and counseling for physical activity. To pass, BMI percentile, height, and weight must be documented.

Note this measure is dependent on record review.

DSS acknowledges that tracking missed initial assessments in the gaps in care reports are the first step in addressing the FSA issue of immediate needs. It is also clear that tracking missed initial assessments is a first step. This leaves unaddressed the following portion of the agreed upon treatment need definition, “Additionally, should the required initial assessments or any routine periodic assessment identify a diagnosis, symptom, or condition resulting in an additional follow-up referral or treatment need, this is considered an immediate treatment need.”

The immediate treatment needs report will ultimately be a combination of multiple data elements that will be tracked in an enhanced gaps in care report. It will include HEDIS measures, diagnoses, AAP data standards, and other national child welfare health, behavioral health, and dental measures. To this end, DSS will develop additional reports, request additional more specific claims data, and conduct case reviews with some regularity in the first year of Plan implementation. However, no combination of DSS and Medicaid data alone will be sufficient to address this portion of the definition. DSS will develop, pilot, and implement a robust care management and coordination process to distribute the data, follow-up with providers, caseworkers, birth families and foster parents, and to see that followup care is identified and provided. DSS has developed a new protocol internally to identify and address missing initial assessments, comprehensive assessments and follow-up, outlined on page 48.

DSS is collaborating closely with DHHS and Select Health, to build out this data and tracking system, define specific roles and responsibilities for each entity, identify existing resources such as a staff person on loan from DHHS to assist DSS with Medicaid data management and analytics and evaluate the need for additional resources for consideration in a future budget request. Going forward, DSS anticipates producing or receiving, at a minimum the following data from DHHS, Select Health or DMH on a routine basis, every 30-60-90 days:

 Claims and encounter data related to medical, dental, and mental health initial assessments for all Class Members

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 Psychotropic medication red flag data for all Class Members  Gaps in Care/utilization reports for all Class Members; rosters of all Class Members with
Immediate Needs or needing follow-up services (discussed in detail below)  Weekly cadence and completed follow-up notification reports that flag and roster children
with no or partial initial assessments, assessment and follow-up on immediate and other needs
B. Build Data Capacity Related to Immediate Treatment Needs as Defined in the FSA
In the FSA, DSS committed to submit information on the status of initial medical, dental, and mental health assessments for Class Members in an identified cohort. In addition, DSS committed to submitting data related to the immediate treatment needs of Class Members in the same cohort. Accomplishing this required a significant amount of capacity building. Initially, DSS did a significant amount of CAPSS development to build fields for this data, caseworker training to capture this data, and data input. Ultimately, DSS, with the assistance of the healthcare consultants, determined that this method was too burdensome on the caseworkers and not the most reliable method. Instead, DSS began collaborating with DHHS and Select Health to capture this information through claims data.
Recently, DSS received its first initial health assessments report from DHHS for calendar year 2017 for all children in the original FSA cohort and those who entered care in 2017. And, as noted in earlier in Section IV, DSS received its first batch of gaps in care reports in April 2018 which was designed to show the children that need some type of follow-up care. DSS, DHHS, and Select Health continue to refine the methodology for capturing this data, and upon agreement to the best approach, DSS will begin receiving these data on a monthly basis.
Additionally, DSS is developing a protocol for distribution and follow-up on this data as described below. Now, with this new, more reliable method of tracking initial health assessments and other health care utilization, DSS will be better equipped to meet the healthcare needs of children.
The development of management structures and practices is the key to leveraging the value of this data. Building on the governance processes described in the Plan, DSS has built out an Immediate Treatment Need/gaps in care follow-up process to link data reports with follow-up care management. The timing, work flows and management hierarchy will be implemented in August 2018 and is described below:
1) Leadership Cadence Calls--Fridays  DSS Leadership holds “cadence calls” Friday mornings.  Friday calls are with child welfare services leadership: Deputy Director Child Welfare Services, Regional and County Operations Director, Safety Management Director, Permanency Management Director, Child Health and Well-Being Director, Performance Management and Accountability Director, Director of Data, Reporting and Accountability, and Regional Directors.

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 Data is presented at the state and regional level. Staff present percent and number of missed initial assessments by type—medical, mental health, and dental.
2) Individual child level cadence calls--Mondays  Regional Healthcare Liaisons for each region have “cadence calls” each Monday with Child Well-Being Staff. These liaisons may be performance coaches, data coordinators, or other staff chosen by the Regional Director. Two are chosen for each region.  Office of Child Well-Being Staff send spreadsheet lists to liaisons monthly. The liaisons break down the regional list and email individualized lists to each foster care case manager who has a child on the list. The county director, supervisor, and program coordinators are copied on the email.  Foster care case managers review case files and determine if documentation, followup appointments, or case staffing is needed. Foster care case managers report that information back to liaisons.  During the Monday cadence call, questions and common themes are discussed. Office of Child Well-Being staff gather lessons learned and address systemic barriers. The group works together to continually improve the process.  Liaisons report back to Office of Child Well-Being staff on a standard spreadsheet on what was found during the file review: o Appointment occurred, documentation found in case file: If only a date was entered, the case manager reports any documentation located in the case file. This documentation may include an uploaded linked file or dictation. o Appointment occurred, documentation not in case file: If a date was entered, but no documentation is in the case file, foster care case managers can get documentation (such as a discharge summary, patient plan or after visit summary) from the provider. Until documentation is provided, liaisons report on the status of getting documentation in CAPSS. o Appointment needed: If there is no evidence that an appointment occurred, then the foster care case manager schedules an appointment and lets the liaison know the date of the appointment. Once an appointment date is scheduled, the appointment is entered in CAPSS for follow up and monitoring. o Staffing needed: In cases where a decision needs to be made such as a psychotropic red flag issue, a staffing may need to be scheduled. Each child is followed until the staffing has occurred and a decision has been made.  For physical health care issues, each child is tracked until documentation is provided in CAPSS that a staffing or a follow-up appointment occurred, whichever is later.  For psychotropic medication issues, each child is tracked until documentation is provided in CAPSS that a satisfactory staffing occurred with a Regional Clinical Specialist and/or DSS Psychiatrist or a follow up referral appointment occurred with a specialist such as a psychiatrist, whichever is later. For example, a child on multiple psychotropic medications may be staffed and need an appointment with a

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psychiatrist. The child would be followed until the appointment with the psychiatrist was complete.
DSS is hopeful that the above processes will allow it to use the data available on children in its care for the benefit of better health care access and outcomes.
C. Strengthen Continuous System-level Quality and Performance Improvement Capacity
At the same time that DSS caseworkers and managers are creating routine access to health care data and that DSS is meeting its commitments related to immediate treatment needs under the FSA, DSS is also collaborating with DHHS and Select Health to coordinate and enhance its continuous systemlevel quality and performance improvement capacity. This enhanced capacity will track system-wide care quality, investigate adverse events, and review case records among other continuous quality improvement (CQI) activities and use this information to improve policies, practice and staff and foster parent/caregiver/birth family training. The elements of a broad quality improvement system will include several elements:
1. Regular Reporting
A. Quarterly review of DSS/DHHS/Select Health initial assessment and comprehensive assessment data derived from the standard assessment tool that DSS, DHHS and Select Health will identify and use for children and youth in foster care. The use of a standardized tool should allow DSS to develop a comprehensive understanding of the needs of children and youth in its care. These reports will be generated by county and region and will compare quarter-overquarter performance. DSS will establish performance targets and develop and monitor corrective action plans.
B. Annual Child Health Data Measures Review (HEDIS and others) will be conducted annually to monitor statewide, regional and county improvements in child health outcomes and to monitor adverse events. This will roll up into an annual report on the health of children in foster care.
2. Performance Monitoring and Review
A. Ongoing Select Health Data Reports and Processes. Select Health produces a number of daily, weekly, monthly, quarterly, annually and ad hoc reports for DHHS. These reports run the gamut from claims verification, encounters (services provided, by date), member and provider characteristics to claim payments. DHHS uses the data from Select Health to evaluate access to care, availability of services and quality of care. DHHS also uses this data to assess the cost-effectiveness of Select Health and its performance by validating actual service utilization and determining whether federal Medicaid reporting

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requirements have been met. Encounter validation is done by comparing utilization data against health records and reviewing data from other sources. DHHS conducts a minimum of one site visit to Select Health annually and conducts independent audits every three years.
By contract, Select Health must comply with Quality Assessment and Performance Improvement (QAPI) standards established by DHHS and must meet NCQA (National Committee for Quality Assurance) health plan accreditation requirements. In order to meet these robust state and federal mandates, Select Health must have an approved continuous quality improvement program, called a QAPI. Central to the terms of the QAPI, Select Health must operate a Quality Assurance Committee that meets at least quarterly and is comprised of the Chief Medical Officer, quality improvement staff, representative health professionals, network providers with a primary care emphasis and pediatricians. The Select Health QAPI Plan also requires a significant amount of data tracking, health outcomes and performance review and the development of corrective action for any problems identified. Data tracking includes specific statewide and regional utilization and quality and access measures such as over/underutilization, and care quality and appropriateness for all members specifically, members with special health care needs.
The CQI process in place between DHHS and Select Health includes quarterly performance review meetings and the development of Performance Improvement Plans (PIPs) focused on clinical and non-clinical areas of operation when warranted. Progress on PIPs is reported to DHHS annually. In addition to the QAPI Plan and CQI process, Select Health is also subject to a HEDIS compliance audit and regular reporting on Child Core Quality Measures. Select Health is held to a high standard or performance and is subject to fines, established by DHHS if they fail to meet quality and contract requirements.
Select Health also conducts an annual member satisfaction survey of all members using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) from the US Agency for Healthcare research and Quality (AHRQ), CAHPS Health Plan Survey required by NCQA for accreditation annually by July 1st. Significant levels of member dissatisfaction triggers CAPs (corrective action plans). DSS in conjunction with DHHS and Select Health will meet annually to review provider quality and performance.
B. Annual Services Review will review the availability, utilization and types of follow-up or specialty services received by children and youth in foster care, episodes of service for children in foster care compared to other South Carolina children enrolled in the Medicaid or CHIP programs. This report will be informed by the network capacity study conducted DHHS/Select Health and by

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USC, if appropriate. This review will also include a review of grievances and appeals to Select Health and DHHS that reflect adverse incidents or service decisions.
C. Annual Topical Reports will be special reports identified and developed annually by DSS, DHHS and SH to examine key child health issues, such as the use of psychotropics medications by children in foster care; or the prevalence of depression for children in foster care; teen pregnancy; substance misuse or early childhood development. The point of these reports will be for the purposes of developing better system knowledge and capacity related to key child health issues.
3. Case Record Review Beginning in July 2018, as noted above, DSS will use the case record review component of the CFSR to identify strengths and limitations in its practice around the health and behavioral care for children in foster care. The Office of Health and Well-Being will be responsible for implementing the health and behavioral health components of the PIP including ongoing CQI efforts and monitoring the health-related elements of the case record review. The review will be used as a way to verify administrative data but also to identify more qualitative issues that are not as easily discerned from aggregate data sets. The case reviews, done in tandem with family and child satisfaction surveys, and potentially child and family interviews, will provide a comprehensive view of health care for children in foster care.
4. Annual Family and Child Satisfaction Survey Conducted by Select Health, the survey will be anonymized, aggregated and shared with DHHS and DSS to ascertain feedback on service access and effectiveness. Consideration will be given to oversampling foster families and youth in care to ensure a strong response rate and generate more useful data.
5. Development of Workplan, Measures and Targets DSS will develop an implementation workplan with timeframes and task assignments incorporating all Plan implementation activities by late August 2018. The workplan will include the development of a process to select, track and report out performance and quality measures tied to established benchmarks and improvement targets by November 2018.
System Component 2: Elements of a Work Plan
Task Lead(s): DSS Office of Child Health and Well-Being and Office of Data, Reporting and Accountability
Key Activities & Deliverables

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 Include capacity in the DSS budget to increase capacity to manage and analyze data (e.g., Medicaid claims data, CAPSS data; Select Health gap in care reports, etc.) and produce actionable dashboards and reports that can be disseminated to caseworkers, supervisors and Regional Directors. DSS will need analysts who are familiar and comfortable working with large administrative data sets
 Produce new reports and annual studies that highlight emerging capacity, quality, access and coordination issues
 Establish a process for DSS and DHHS to review Select Health quality and performance annually
 Develop a process for DSS to assess the performance of its casework staff in securing necessary health care information for children on their caseloads
 DSS to get aggregate member satisfaction data from Select Health annually and develop corrective action plans and mitigation actions to address issues that arise
Timeframes: Quality and performance improvement data, dashboards and reports to be issued monthly, quarterly and annually beginning November 2018.
System Component 3: Develop practice guidance, policies and training for the field, birth families, foster parents and contract, placement and treatment providers.
Implementation of the Plan will require developing new practice guidance for the field, as well as accompanying policies and training. Although the Plan is focused on the health of children and youth in foster care, the case practice contemplated by the Plan focuses on the state’s responsibilities related to safety and permanency, and also on the state’s capacity to improve child and family well-being. Through a lens of improved child and family well-being, the Plan envisions child welfare case practice that considers the strengths and needs of children, youth and their families from the first-time contact is made with them. In other words, from the moment of contact, caseworkers consider not only what is needed to promote child safety, but how the child welfare system, if it stays involved with the family, can support improved family well-being while simultaneously helping children stay connected to their family and maintain placement stability, if a child is taken into care. With this as a goal, the Plan sets forth below the following approach to the development of system components related to health practice guidance, policies and training.
A. Development of DSS Health Practice Guidance
Under the FSA, DSS committed to a vastly improved child welfare system built on a number of core system and practice components, including focusing on the use and development of family-based placement resources rather than institutions, especially for young children; and on the importance of caseload sizes that allow for family visitation that supports both sibling connections and reunification. DSS is keenly aware that research has shown that children do better growing up with their own families or with substitute, permanent families; and that children and parents that visit more while a child is in foster care are more likely to be reunified.

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The Plan described in this document is built on the promise of these (and other) critical practice system building blocks–better family-based placement resources and caseload sizes that support robust family visitation. The health care practices identified in this Plan will be integrated within the context of these improved core practice components being developed by the Department in conjunction with Chapin Hall. Specifically, to complement the child health goals described earlier, DSS will develop health practice guidance for the field that:
 County caseworkers collect information on child health and well-being from initial contact with a family and include it in the child’s case record; this is especially important for cases where children are not immediately removed but the caseworker believes they will substantiate abuse or neglect (in other words, cases where there is a chance that the child(ren) will be removed to foster care at a later date);
 County caseworkers include information about child health and well-being in the CSA, including use of the standardized assessment that DSS chooses to use to accompany placement resource requests;
 County caseworkers understand and know how to connect with either DHHS or Select Health for children if there is a likelihood that a child will need a higher level of care management from the start of a case (e.g., caseworkers will have practice guidance that helps them connect with DHHS or SH resources if they need help understanding a child’s health at the start of an investigation and/or they need help developing the CSA);
 Regional Placement Units understand and know how to match children to placements that can support their health needs, including seeing that children placed in congregate care settings (group homes and residential facilities) have the health and behavioral health services and treatments that a child needs. This function will be revisited in the DSS Placement Plan and will build on important system practices like family team meetings and other ways to incorporate family voice and choice;
 Regional Placement Units work with county and IFCCS caseworkers to match children to the appropriate level of DSS and Select Health case management and care coordination;
 IFCCS and county caseworkers understand and know how to incorporate their ongoing assessment and monitoring of child health and well-being in visits with children, placement resources (e.g., foster parents, group home child care staff) and birth families, including updating the child’s case record on both routine child health matters (e.g., well visits) and any issues that require follow up;
 IFCCS and county caseworkers understand and know how to coordinate and collaborate with Select Health care coordinators, as well as DHHS for children who remain in the fee-for-service Medicaid program; and

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 Regional and county leaders understand and know how to supervise as related to health care and well-being issues so that initial assessments and comprehensive assessments are completed timely and use data to manage case practice goals.
As discussed above, DSS will detail additional practice guidance and changes in its care coordination and health care case management framework to be prepared upon completion of the DSS Health Care Pilot and Process Review.
B. Development of Health-Related Policies
DSS will develop health-related policies that reflect the new practice guidelines identified above. Given that the Plan anticipates a pilot phase upon which many of the new practices associated with child health goals will be developed, the formalization of new policies will not occur until early to mid-2019. Policies already in place related to initial assessments and assessment requirements, as well as responsibilities of caseworker staff to track and monitor health and well-being will remain in effect as the pilot rolls out. New policies will build on current requirements with a focus of improving collaboration between DSS, DHHS and Select Health, as well as considering a child’s health needs and incorporating them in the context of all placement decisions. DSS will also review, modify and, as needed, develop policies related to consent for treatment and the informed consent process. As discussed above, DSS will detail additional policy changes in the care coordination and health care case management framework to be prepared upon completion of the DSS Health Care Pilot and Process Review.
C. Training and Supervision
Training and supervision are foundational to the effective casework practice and improved operations that lead to improved health for children and youth in foster care. A complete overhaul of DSS’s caseworker and supervisor health-related training, will not happen immediately. Rather, DSS will phase its review and modifications to training focusing initially on what will result in the most immediate results for improved child health. In this regard, collaboration with the Chapin Hall consultants developing the Department’s case practice model and Training Plan and the Foster Care Health Advisory Committee (FCHAC), as well as the American Academy of Pediatrics (AAP), statewide QTIP network and foster parent association will be leveraged for more rapid feedback. In particular, DSS will engage these groups to determine what health-related training is essential for workers, birth families, foster parents and other placement resources and health and behavioral health providers. Because DSS will be simultaneously implementing and building an improved health care practice lead by the Office of Health and Well-Being and contemplated in the Chapin Hall practice model under development, its training will be organized into two buckets: short-term essentials, and longer-term system training components. The short-term health and behavioral essentials for DSS caseworkers and supervisors will focus on what needs to be done for children and youth to be timely initially assessed, assessed, and receive follow-up services so that any gaps in care are staffed and addressed timely. Longer term health training components will consider including additional modifications to new worker child welfare basic training; IFCCS worker Orientation Training;

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supervisory training; foster parent training; working with families; Select Health and DHHS training; and data and monitoring training.
Select Health is required by contract to provide educational information and materials for all enrollees. These materials can be used to inform DSS caseworkers, foster families and other caregivers about how Select Health serves its members and the responsibilities of SH providers and provider networks.
System Component 3: Elements of a Work Plan
Task Lead(s): Office of Child Health and Well-Being
Key Activities and Deliverables
 Develop practice guidance consistent with the Health Care Plan, including clarity for case workers related to their own obligations to meet children’s health care needs; coordination with birth families, foster parents and placement providers on child health; and collaboration with Select Health care coordination on child health;
 Develop policies consistent with Health Care Plan; the policies will be informed by the Health Care Pilot and Process Review
 Develop/adapt training for caseworkers and supervisors related to new case management/care coordination processes and roles based on Health Care Pilot and Process Review (20 prototype cases)
Timeframes: Health training essentials will be identified by December 2018 and incorporated into the newly developed child welfare basic and IFCSS case manager trainings beginning in February 2019. Additional health-related training components will be identified by fall 2018 and rolled out by end of 2020. Health practice guidance and health policies will be developed following the Health Care Pilot and Process Review with initial roll-out to occur March 2019.
VII. Resource Needs
The South Carolina Department of Social Services (SCDSS) submitted a comprehensive, fiveyear budget plan (2019 – 2023) to the Court in May 2018 that includes the financial, staffing and other support the agency anticipates will be necessary to meet the performance targets required by the Settlement Agreement. The budget identifies estimated funding requirements for new positions, training, technology, rates, and services needed to facilitate the Implementation Plans associated with meeting Health Care Improvement requirements of the Settlement Agreement and to address budget requirements for each of the performance targets. It is important to note the budget plan only includes new or increased costs to be incurred each year. It is expected that once costs are appropriated for a specific line item, those appropriations will be recurring in subsequent years.

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To address the performance targets as part of the health plan, SCDSS anticipates the following costs in the fiscal years outlined below. SCDSS anticipates that many of the costs required as part of the healthcare and mental health plan will be absorbed through the South Carolina Department of Health and Human Services (DHHS) budget and DHHS’s managed care contract (MCO) for children in foster care. Determining the appropriate budget for Health Plan activities is an evolving and ongoing process. As specific costs are identified, the following budget will be updated.

Design of an Infrastructure for Tracking and Delivery of Health and Mental Health Services for Children in Foster Care

Purpose

Amount Budget Year

Contracts—Consultants to provide agency with support during plan

implementation

$90,000

2019

Training--Contract for standardized level of care assessment tool

$30,000

2020

Training—Contract for continuing training for new staff on standardized level of care assessment tool

$3,000155

2021

Staff—Office of Well-Being Staff, clinical specialists, and staff to monitor monthly initial assessment reports, psychotropic medication reports and gaps in care. Staff will also identify service array issues, and communicate those gaps to Select Health, develop standards for preferred providers, educate providers on best practices for children in foster care, identify paid and unpaid resources for families and children, and recruit providers when those providers are outside of Select Health’s network development goals.

$2,360,582

2020

Staff—Salary increase for staff hired in 2020

$73,031

2021

Staff—Salary increase for all recurring staff

$76,757

2023

155 These costs will be adjusted to reflect actual costs of implementation, training and fidelity monitoring of a new assessment tool once the pilot is complete and a full care coordination plan has been developed.

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VIII.

Appendix 1. FSA Michelle H. Settlement Agreement—See attachment 2. Consultant Validation Report—See attachment 3. Placement Needs Assessment Baseline Study Final Report—See attachment 4. Select Health Scope of Work and DHHS Managed Care Contract—Selections below
and full contract found here https://msp.scdhhs.gov/managedcare/sites/default/files/2016%20MCO%20Amendment% 205%20%20Risk%20and%20Minor%20Changes.pdf 5. Position Description for Director of Child Health and Well-Being—See attachment 6. DSS Child Health Fact Sheet—See Attachment 7. South Carolina DSS Five-Year Comprehensive Budget Narrative—See attachment 8. Foster Care Health Advisory Committee Members—See attachment 9. DHHS and DSS Data Sharing Memorandum of Agreement 10. Initial Assessment Data—See attachment

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 Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 1 of 29

U.S. District Court District of South Carolina (Charleston) CIVIL DOCKET FOR CASE #: 2:15−cv−00134−RMG

CLOSED

Michelle H et al v. McMaster et al Assigned to: Honorable Richard M Gergel Cause: 42:1983 Civil Rights Act
Plaintiff Michelle H by her next friend Tamara Coppinger

Date Filed: 01/12/2015 Date Terminated: 10/04/2016 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: Federal Question
represented by Aaron Hirsh Finch Children's Rights 88 Pine Street Suite 800 New York, NY 10005 212−683−2210 Fax: 212−683−4015 Email: afinch@childrensrights.org LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe SC Appleseed Legal Justice Center PO Box 7187 Columbia, SC 29202 803−779−1113 Fax: 803−779−5951 Email: adam@scjustice.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin Children's Rights 88 Pine Street Suite 800 New York, NY 10005 212−638−2210 Fax: 212−683−4015 Email: cremlin@childrensrights.org LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Ira P Lustbader Children's Rights 330 7th Avenue 4th Floor New York, NY 10001 212−683−2210 Fax: 212−683−4015 Email: ilustbader@childrensrights.org LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Kathryn Anne Wood Children's Rights 330 7th Avenue 4th Floor New York, NY 10001

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 2 of 29
212−683−2210 Fax: 212−683−4015 Email: kwood@childrensrights.org LEAD ATTORNEY PRO HAC VICE
Matthew T Richardson Wyche PA 807 Gervais Street Suite 301 Columbia, SC 29201 803−254−6542 Fax: 803−254−6544 Email: mrichardson@wyche.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sarah Teresa Russo Children's Rights 330 7th Avenue 4th Floor New York, NY 10001 212−683−2210 Fax: 212−683−4015 Email: srusso@childrensrights.org LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White Children's Rights 88 Pine Street Suite 800 New York, NY 10005 212−683−2210 Fax: 212−683−4015 Email: swhite@childrensrights.org LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson Children's Rights 88 Pine Street Suite 800 New York, NY 10005 202−683−2210 Fax: 212−683−4015 Email: spersson@childrensrights.org LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs SC Appleseed Legal Justice Center PO Box 7187 Columbia, SC 29202 803−779−1113 Fax: 803−779−5951 Email: ssuggs@scjustice.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz SC Appleseed Legal Justice Center PO Box 7187

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 3 of 29

Plaintiff
AR by her next friend Tamara Coppinger

Columbia, SC 29202 803−779−1113 Fax: 803−779−5951 Email: sberk@scjustice.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Ira P Lustbader (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Kathryn Anne Wood (See above for address) LEAD ATTORNEY PRO HAC VICE
Matthew T Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
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Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 4 of 29

Plaintiff
ZL by her next friend Deborah Wilson

(See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Ira P Lustbader (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
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Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
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Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 5 of 29

Plaintiff SV by his next friend Aleksandra Chauhan
Plaintiff

represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
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Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 6 of 29

AR by his next friend Cheryl Kreider
Plaintiff MB by their next friend Margaret Wilson

Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
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Kathryn Anne Wood (See above for address) LEAD ATTORNEY PRO HAC VICE
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Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 7 of 29

Plaintiff
AB by their next friend Margaret Wilson

PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Ira P Lustbader (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Kathryn Anne Wood (See above for address) LEAD ATTORNEY PRO HAC VICE
Matthew T Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 8 of 29

Plaintiff
CB by their next friend Margaret Wilson

Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Ira P Lustbader (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Kathryn Anne Wood (See above for address) LEAD ATTORNEY PRO HAC VICE
Matthew T Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 9 of 29

Plaintiff
SB by their next friend Margaret Wilson

ATTORNEY TO BE NOTICED
Christina Wilson Remlin (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Ira P Lustbader (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Kathryn Anne Wood (See above for address) LEAD ATTORNEY PRO HAC VICE
Matthew T Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 10 of 29

Plaintiff
RB by their next friend Margaret Wilson

(See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Ira P Lustbader (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Kathryn Anne Wood (See above for address) LEAD ATTORNEY PRO HAC VICE
Matthew T Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin (See above for address) LEAD ATTORNEY PRO HAC VICE

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 11 of 29

Plaintiff
KS by his next friend Tamara Coppinger, individually and on behalf of all other similarly situated children

ATTORNEY TO BE NOTICED
Ira P Lustbader (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Kathryn Anne Wood (See above for address) LEAD ATTORNEY PRO HAC VICE
Matthew T Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Aaron Hirsh Finch (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Adam Protheroe (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Christina Wilson Remlin (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Ira P Lustbader

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 12 of 29

V. Defendant Henry Dargan McMaster

(See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Kathryn Anne Wood (See above for address) LEAD ATTORNEY PRO HAC VICE
Matthew T Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sarah Teresa Russo (See above for address) LEAD ATTORNEY PRO HAC VICE
Shereen Arthur White (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Stephanie Marie Persson (See above for address) LEAD ATTORNEY PRO HAC VICE ATTORNEY TO BE NOTICED
Steve Suggs (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Susan Beth Berkowitz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Karl S Bowers , Jr Bowers Law Office PO Box 50549 Columbia, SC 29250 803−753−1099 Fax: 803−250−3985 Email: butch@butchbowers.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Thomas Ashley Limehouse , Jr Office of the Governor State of South Carolina South Carolina State House 1100 Gervais Street Columbia, SC 29201 803−734−6023 Fax: 803−734−5167 Email: tlimehouse@governor.sc.gov

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 13 of 29

Defendant Michael Leach in his official capacity as State Director of the South Carolina Department of Social Services
V. Interested Party Judith Meltzer Co−Monitor Interested Party Paul Vincent Co−Monitor Interested Party Rachel Paletta Co−Monitor Staff Interested Party

LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Alexander Erwin Davis Copeland Stair Kingma and Lovell LLP 40 Calhoun Street Suite 400 Charleston, SC 29401 843−266−8203 Fax: 843−727−2995 Email: adavis@carlockcopeland.com TERMINATED: 07/26/2016 LEAD ATTORNEY
John M Montgomery Robinson Gray Stepp and Laffitte LLC 1310 Gadsden Street Columbia, SC 29201 803−929−1400 Fax: 803−929−0300 Email: mmontgomery@robinsongray.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Monteith Powell Todd Robinson Gray Stepp and Laffitte LLC 1310 Gadsden Street Columbia, SC 29201 803−929−1400 Fax: 803−929−0300 Email: mtodd@robinsongray.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Rebecca Laffitte Robinson Gray Stepp and Laffitte LLC 1310 Gadsden Street Columbia, SC 29201 803−929−1400 Fax: 803−929−0300 Email: rlaffitte@robinsongray.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 14 of 29

Elissa Gelber Co−Monitor Staff

Date Filed 01/12/2015 01/12/2015 01/12/2015 01/14/2015
01/15/2015
01/15/2015
01/15/2015
01/16/2015 01/16/2015 02/11/2015 02/12/2015 02/20/2015

# Docket Text
1 COMPLAINT against Susan Alford, Nikki Haley ( Filing fee $ 400 receipt number 0420−5729224.), filed by A B, S B, M B, Z L, K S, A R(by his next friend Cheryl Kreider), M H, R B, S V, C B, A R(by her next friend Tamara Coppinger). Service due by 5/15/2015(sshe, ) (Entered: 01/12/2015)
2 Local Rule 26.01 Answers to Interrogatories by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V.(sshe, ) (Entered: 01/12/2015)
3 Summons Issued as to Susan Alford, Nikki Haley. (sshe, ) (Entered: 01/12/2015)
5 ACCEPTANCE OF SERVICE OF COMPLAINT by A B, S B, M B, Z L, K S, A R(by his next friend Cheryl Kreider), M H, R B, S V, C B, A R(by her next friend Tamara Coppinger). Susan Alford served on 1/14/2015, answer due 2/4/2015. (Attachments: # 1 Acceptance of Personal Service of the Summons on Defendant Susan Alford in her official capacity as Acting Director of the South Carolina Department of Social Services)(Richardson, Matthew) (Entered: 01/14/2015)
6 MOTION to Appear Pro Hac Vice by Ira Lustbader ( Filing fee $ 250 receipt number 0420−5736975) by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 2/2/2015. (Attachments: # 1 Affidavit Application, # 2 Supporting Documents Certificate of Good Standing, # 3 Proposed Order PDF of Order)Proposed order is being emailed to chambers with copy to opposing counsel.(Suggs, Steve) (Entered: 01/15/2015)
7 MOTION to Appear Pro Hac Vice by Kathryn Wood ( Filing fee $ 250 receipt number 0420−5737030) by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 2/2/2015. (Attachments: # 1 Affidavit Application, # 2 Supporting Documents Certificate of Good Standing, # 3 Proposed Order pdf copy)Proposed order is being emailed to chambers with copy to opposing counsel.(Suggs, Steve) (Entered: 01/15/2015)
8 ACCEPTANCE OF SERVICE OF COMPLAINT by A B, S B, M B, Z L, K S, A R(by his next friend Cheryl Kreider), M H, R B, S V, C B, A R(by her next friend Tamara Coppinger). Nikki Haley served on 1/14/2015, answer due 2/4/2015. (Attachments: # 1 Acceptance of Personal Service of the Summons on Defendant Nikki Haley in her official capacity as Governor of the State of South Carolina)(Richardson, Matthew) (Entered: 01/15/2015)
9 ORDER granting 6 Motion of Ira Lustbader to Appear Pro Hac Vice for Plaintiffs. Signed by Honorable Richard M Gergel on 1/15/2015.(sshe, ) (Entered: 01/16/2015)
10 ORDER granting 7 Motion of Kathryn A. Wood to Appear Pro Hac Vice for Plaintiffs. Signed by Honorable Richard M Gergel on 1/15/2015.(sshe, ) (Entered: 01/16/2015)
11 MOTION for Confidentiality Order by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 3/2/2015. (Attachments: # 1 Proposed Order)Proposed order is being emailed to chambers with copy to opposing counsel.(Richardson, Matthew) (Entered: 02/11/2015)
12 CONFIDENTIALITY ORDER granting 11 Motion for Confidentiality Order Signed by Honorable Richard M Gergel on 2/12/2015.(sshe, ) (Entered: 02/12/2015)
13 Consent MOTION for Extension of Time to Answer, Move, or Otherwise Plead in Response to Plaintiffs' Complaint by Susan Alford. Response to Motion due by 3/9/2015. No proposed order.(Laffitte, Rebecca) (Entered: 02/20/2015)

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 15 of 29

02/23/2015 03/16/2015 03/16/2015 03/16/2015 03/16/2015 03/20/2015 03/25/2015 03/30/2015
04/03/2015 04/03/2015 04/08/2015 04/28/2015

14 TEXT ORDER granting 13 Motion for Extension of Time to Answer, Move, or Otherwise Plead in Response to Plaintiff's Complaint. Defendants' Answers now due by March 15, 2015. Entered at the Direction of Honorable Richard M Gergel on 2/23/2015.(sshe, ) (Entered: 02/23/2015)
15 NOTICE of Appearance by Karl S Bowers, Jr on behalf of Nikki Haley (Bowers, Karl) (Entered: 03/16/2015)
16 First MOTION to Dismiss by Nikki Haley. Response to Motion due by 4/2/2015. (Attachments: # 1 Memo in Support)No proposed order.(Bowers, Karl) (Entered: 03/16/2015)
17 MOTION TO DISMISS FOR FAILURE TO STATE A CLAIM by Susan Alford. Response to Motion due by 4/2/2015. (Attachments: # 1 Memo in Support)No proposed order.(Todd, Monteith) (Entered: 03/16/2015)
18 Local Rule 26.01 Answers to Interrogatories by Susan Alford.(Todd, Monteith) (Entered: 03/16/2015)
19 Consent MOTION for Extension of Time to File Response/Reply as to 16 First MOTION to Dismiss , 17 MOTION TO DISMISS FOR FAILURE TO STATE A CLAIM by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 4/6/2015. No proposed order.(Richardson, Matthew) (Entered: 03/20/2015)
20 TEXT ORDER: Plaintiffs have moved, with the consent of Defendants, for an extension of time to respond to Defendants' motions to dismiss. (Dkt. No. 19). The motion is granted. The time to respond to Defendants' motions to dismiss (Dkt. Nos. 16, 17) is extended to 5/4/15. AND IT IS SO ORDERED. Entered at the direction of the Honorable Richard M Gergel on 3/25/15.(ltap, ) (Entered: 03/25/2015)
21 TEXT ORDER: The Court has had considerable success in recent years promoting early mediation in complex litigation, which has allowed the parties to focus their energies on seeking common solutions rather than engaging in protracted litigation. The most notable of these successful mediations involved the litigation over the deepening of the Savannah Harbor, which involved environmental groups, the Georgia Ports Authority and the Army Corps of Engineers. The mediators in that matter were former Congressman John Spratt and then Magistrate Judge (now District Judge) Bruce Hendricks. In light of that experience, the Court has asked Senior United States District Judge Michael Duffy whether he would be willing to serve as a mediator in this matter and he has graciously agreed to do so. Mediation, of course, requires willing participants who enter into the process with the objective of seeking a resolution of a legal dispute through a negotiated settlement. The Court directs the parties to consult their clients and to advise the Court within 10 days of this order whether they are willing to participate in early mediation. To the extent there is an interest in early mediation, the parties should further advise the Court whether they would like the entry of a brief stay while negotiations are pursued. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 3/30/2015. (erav, ) (Entered: 03/30/2015)
22 REPLY by Susan Alford, Nikki Haley to 21 Order,,,,, . (Laffitte, Rebecca) (Entered: 04/03/2015)
23 REPLY by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V to 21 Order,,,,, . (Richardson, Matthew) (Entered: 04/03/2015)
24 AMENDED NOTICE of Hearing: Status Conference set for 4/15/2015 at 02:00 PM in Charleston Courtroom #1, Hollings Judicial Center, 83 Meeting St, Charleston before Honorable Patrick Michael Duffy. **PLEASE NOTE: Out of state attorneys may participate by telephone and are not required to appear in person at the hearing (chub, ) Modified text on 4/8/2015 (erav, ). (Entered: 04/08/2015)
25 First MOTION to Appear Pro Hac Vice by Christina Wilson Remlin ( Filing fee $ 250 receipt number 0420−5918751) by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V.

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 16 of 29

04/28/2015 04/28/2015 04/29/2015 09/28/2015 02/03/2016 03/17/2016 06/03/2016 06/14/2016 06/24/2016 06/28/2016

Response to Motion due by 5/15/2015. (Attachments: # 1 Exhibit Application for Admission, # 2 Exhibit Certificate of Good Standing, # 3 Proposed Order Proposed Order of Admission)Proposed order is being emailed to chambers with copy to opposing counsel.(Suggs, Steve) (Entered: 04/28/2015)
26 First MOTION to Appear Pro Hac Vice by Aaron Hirsh Finch ( Filing fee $ 250 receipt number 0420−5918808) by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 5/15/2015. (Attachments: # 1 Exhibit Application for Admission, # 2 Exhibit Certificate of Good Standing, # 3 Proposed Order Proposed Order of Admission)Proposed order is being emailed to chambers with copy to opposing counsel.(Suggs, Steve) (Entered: 04/28/2015)
27 First MOTION to Appear Pro Hac Vice by Sarah Teresa Russo ( Filing fee $ 250 receipt number 0420−5918843) by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 5/15/2015. (Attachments: # 1 Exhibit Application for Admission, # 2 Exhibit Certificate of Good Standing, # 3 Proposed Order Proposed Order of Admission)Proposed order is being emailed to chambers with copy to opposing counsel.(Suggs, Steve) (Entered: 04/28/2015)
28 ORDER granting 25 Motion for Christina Wilson Remlin to Appear Pro Hac Vice; granting 26 Motion for Aaron Hirsh Finch to Appear Pro Hac Vice; granting 27 Motion for Sarah Teresa Russo to Appear Pro Hac Vice; for A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V Signed by Honorable Richard M Gergel on 4/29/2015.(sshe, ) (Entered: 04/29/2015)
29 CONSENT IMMEDIATE INTERIM RELIEF ORDER Signed by Honorable Richard M Gergel on 9/28/2015. (sshe, ) (Entered: 09/28/2015)
30 TEXT ORDER: The Court has pending on its docket two motions to dismiss. (Dkt. Nos. 16, 17). In light of the progress made by the parties in mediation, the Court denies these motions to dismiss without prejudice and with leave to restore to the docket if the parties wish to do so. AND IT IS SO ORDERED. Entered at the direction of the Honorable Richard M Gergel on 2/3/16.(ltap, ) (Entered: 02/03/2016)
31 ORDER re 29 Consent Immediate Interim Relief Order. The parties consent and agree to the extension of the Co−Monitors' authority under Section II.4 of Dkt. No. 29 until final approval and entry of a full negotiated settlement agreement or until the mediator reports to the court that mediation was ultimately unsuccessful, to allow the parties to complete negotiations and file a proposed full settlement agreement. Signed by Honorable Richard M Gergel on 3/17/2016. (sshe, ) (Entered: 03/17/2016)
32 Joint MOTION for Settlement Approval of the Class Action by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 6/20/2016. (Attachments: # 1 Exhibit A − Final Settlement Agreement, # 2 Exhibit B − Proposed Order Granting Preliminary Approval, # 3 Exhibit C − Notice of Class Action Settlement, # 4 Exhibit D − Resumes of Co−Monitors)Proposed order is being emailed to chambers with copy to opposing counsel.(Richardson, Matthew) (Entered: 06/03/2016)
33 NOTICE of Hearing on 32 Joint MOTION for Settlement Approval of the Class Action : Motion Hearing set for 6/24/2016 at 10:00 AM in Hon. Sol Blatt, Jr., Courtroom, J. Waties Waring Judicial Cntr, 83 Meeting St, Charleston before Honorable Richard M Gergel. (ltap, ) (Entered: 06/14/2016)
34 Minute Entry. Proceedings held before Honorable Richard M Gergel: Motion Hearing held on 6/24/2016 re 32 Joint MOTION for Settlement Approval of the Class Action. Court to issue an order approving settlement. Parties submit to court final Notice of Class. Hearing to be set for final approval. Court Reporter Debbie Potocki. (erav, ) (Entered: 06/24/2016)
35 ORDER GRANTING PRELIMINARY APPROVAL OF CLASS ACTION SETTLEMENT AGREEMENT, SETTING HEARING FOR FINAL

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 17 of 29

06/28/2016 07/15/2016 07/21/2016 07/26/2016 08/22/2016 08/24/2016
09/19/2016
09/22/2016
09/22/2016
09/29/2016 10/04/2016 10/04/2016 10/21/2016

APPROVAL, AND DIRECTING NOTICE TO THE CLASS granting 32 Motion for Settlement. Details set forth in Order. Signed by Honorable Richard M Gergel on 6/28/2016.(sshe, ) (Entered: 06/28/2016)
36 NOTICE of Hearing: Settlement Conference set for 10/4/2016 10:00 AM in Courtroom To Be Determined, J. Waties Waring Judicial Cntr, Meeting St and Broad, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 06/28/2016)
37 AFFIDAVIT of Anthony Catone by Susan Alford. (Attachments: # 1 Affidavit Affidavit of Compliance with Notice Requirements)(Laffitte, Rebecca) (Entered: 07/15/2016)
38 MOTION to Withdraw as Attorney − Alex E. Davis by Susan Alford. Response to Motion due by 8/8/2016. No proposed order.(Laffitte, Rebecca) (Entered: 07/21/2016)
39 ORDER granting 38 Motion of Alex E. Davis to Withdraw as counsel of record for defendant Susan Alford. Signed by Honorable Richard M Gergel on 7/26/2016.(sshe, ) (Entered: 07/26/2016)
41 AFFIDAVIT (Supplemental Affidavit of Compliance with Notice Requirements) by Susan Alford. (Attachments: # 1 Affidavit)(Laffitte, Rebecca) (Entered: 08/22/2016)
42 NOTICE OF RESCHEDULED HEARING *NOTE TIME CHANGE ONLY* Settlement Conference set for 10/4/2016 10:00 AM cancelled and rescheduled to: Settlement Conference set for 10/4/2016 09:00 AM in Courtroom To Be Determined, J. Waties Waring Judicial Cntr, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 08/24/2016)
43 MOTION to Withdraw as Attorney Sarah T. Russo by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 10/6/2016. Proposed order is being emailed to chambers with copy to opposing counsel.(Richardson, Matthew) (Entered: 09/19/2016)
44 NOTICE OF RESCHEDULED HEARING *NOTE TIME CHANGE ONLY: In light of the Order and Notice to Class at Dkt. #35 the Settlement Conference will be held on 10/4/2016 at 10:00 AM as per the ORDER. The hearing will be held in the Hon. Sol Blatt, Jr., Courtroom, J. Waties Waring Judicial Cntr, 83 Meeting St, Charleston before Honorable Richard M Gergel. (ltap, ) (Entered: 09/22/2016)
45 Joint MOTION for Settlement Approval by A B, C B, M B, R B, S B, M H, Z L, A R(by his next friend Cheryl Kreider), A R(by her next friend Tamara Coppinger), K S, S V. Response to Motion due by 10/11/2016. (Attachments: # 1 Exhibit Award, # 2 Exhibit Letter, # 3 Exhibit Letters, # 4 Exhibit Letters, # 5 Exhibit Letter, # 6 Exhibit Letter, # 7 Exhibit Letter, # 8 Exhibit Letter, # 9 Exhibit Letter, # 10 Exhibit Letter, # 11 Exhibit Letter, # 12 Exhibit Letter, # 13 Exhibit Letters from Group Homes, # 14 Exhibit Number of Group Homes, # 15 Exhibit Letter)No proposed order.(Suggs, Steve) (Entered: 09/22/2016)
46 ORDER GRANTING MOTION FOR WITHDRAWAL OF APPEARANCE OF SARAH T RUSSO granting 43 Motion to Withdraw as Attorney. Signed by Honorable Richard M Gergel on 9/29/2016.(sshe, ) (Entered: 09/29/2016)
47 Minute Entry. Proceedings held before Honorable Richard M Gergel: Settlement Conference (Fairness Hearing) held on 10/4/2016. Court to issue an order approving settlement. Court Reporter Debbie Potocki. (erav, ) (Entered: 10/04/2016)
48 FINAL JUDGMENT AND ORDER APPROVING CLASS ACTION SETTLEMENT granting 45 Motion for Settlement Signed by Honorable Richard M Gergel on 10/4/2016.(sshe, ) (Entered: 10/04/2016)
51 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of fairness hearing held on 10−4−16, before Judge Richard M. Gergel. Court Reporter/Transcriber Debra Potocki, Telephone number/E−mail 843−723−2208/potockidebra@bellsouth.net. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 18 of 29

02/08/2017 02/08/2017 02/08/2017 02/08/2017
02/13/2017 02/13/2017 02/14/2017 02/14/2017
02/21/2017 06/01/2017
06/05/2017 09/13/2017 10/11/2017

filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 11/14/2016. Redacted Transcript Deadline set for 11/21/2016. Release of Transcript Restriction set for 1/19/2017. (dpotocki, ) (Entered: 10/21/2016)
52 Letter dated 1/23/2017 from Co−Monitors. (sshe, ) Modified docket text on 2/8/2017 (sshe, ). (Entered: 02/08/2017)
53 Letter dated 1/24/2017 from DSS General Counsel. (sshe, ) Modified docket text on 2/8/2017 (sshe, ). (Entered: 02/08/2017)
54 Letter dated 2/7/2017 from Co−Monitors. (sshe, ) Modified docket text on 2/8/2017 (sshe, ). (Entered: 02/08/2017)
55 ORDER The Court has reviewed the Co−Monitors letters of January 23, 2017 52 and February 7, 2017 54 , and a letter from the DSS General Counsel of January 24, 2017 53 . If any party to this action desires to provide any additional information on this issue before the Court reaches a determination concerning this dispute over data access under the Final Settlement Agreement, such response shall be filed with the Court on or before February 13, 2017. The Court further directs that DSS General Counsel provide to the Court under seal on or before February 13, 2017 a sample of the data and records from the child protective services portion of the CAPSS system that the agency seeks to prevent access to by the Co−Monitors. The Court intends to review such data and records in camera to determine the relevancy and necessity of the requested disclosure. S.C. Code § 63−7−690(11). AND IT IS SO ORDERED. (Further details provided in Order) Signed by Honorable Richard M Gergel on 2/8/2017. (sshe, ) (Entered: 02/08/2017)
56 Letter from Matthew Richardson pursuant to Order, Dkt # 55. (Richardson, Matthew) (Entered: 02/13/2017)
57 Letter from DSS. (Attachments: # 1 Exhibit A − E−mail from CSSP 2/3/17, # 2 Exhibit B − E−mail to CSSP from SCDSS 2/6/17, # 3 Exhibit C − E−mail from CSSP to SCDSS 2/6/17, # 4 Exhibit D − Email CSSP to Jude Duffy 2/6/17, # 5 Exhibit E − Email from SCDSS to CSSP 2/7/17)(Laffitte, Rebecca) (Entered: 02/13/2017)
58 Sealed Documents. Filed per Direction of Honorable Richard M Gergel on 2/14/2017. (sshe, ) (Entered: 02/14/2017)
59 ORDER that the Court hereby orders and directs, pursuant to the terms of the Settlement Agreement and the Court's injunctive powers, that the Defendants, without delay, provide direct access to the Co−Monitors to the child protective portion of the CAPSS. The parties are directed to file a joint certification with the Court on or before February 21, 2017 that there has been full compliance with this order. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 2/14/2017. (sshe, ) (Entered: 02/14/2017)
60 REPLY by Susan Alford to 59 Order,, (Joint Certification). (Laffitte, Rebecca) (Entered: 02/21/2017)
61 MOTION for Extension of Time for Submission of Health Care Improvement Plan by Susan Alford. Response to Motion due by 6/15/2017. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. Proposed order is being emailed to chambers with copy to opposing counsel.(Todd, Monteith) (Entered: 06/01/2017)
62 ORDER EXTENDING TIME granting 61 Defendant's Motion for Extension of Time. The Health Care Improvement Plan shall be submitted by September 30, 2017. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 6/5/2017.(sshe, ) (Entered: 06/05/2017)
63 Letter from Co−Monitors Judith Meltzer and Paul Vincent. (Attachments: # 1 Exhibit Co−Monitors Monitoring Report)(sshe, ) (Entered: 09/13/2017)
64 NOTICE of Hearing: Status Conference set for 11/17/2017 10:00 AM in Courtroom To Be Determined, J. Waties Waring Judicial Cntr, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 10/11/2017)

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 19 of 29

11/13/2017
11/14/2017 11/17/2017 11/27/2017
01/24/2018 04/06/2018 04/19/2018
05/22/2018 06/01/2018 06/04/2018

65 First MOTION to Appear Pro Hac Vice by Stephen Suggs for Stephanie Persson ( Filing fee $ 250 receipt number 0420−7460161) by AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, MH, RB, SB, SV, ZL. Response to Motion due by 11/27/2017. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. (Attachments: # 1 Affidavit Application/Affidavit, # 2 Supporting Documents Certificate of Good Standing, # 3 Proposed Order Proposed Order)Proposed order is being emailed to chambers with copy to opposing counsel.(Suggs, Steve) Modified on 11/14/2017 to add filer as listed on document(sshe, ). (Entered: 11/13/2017)
66 ORDER granting 65 Motion for Stephanie Persson to Appear Pro Hac Vice for AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, MH, RB, SB, SV, ZL. Signed by Honorable Richard M Gergel on 11/14/2017.(sshe, ) Modified on 11/14/2017 to edit docket text to add represented party(sshe, ). (Entered: 11/14/2017)
67 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 11/17/2017. Court Reporter Debbie Potocki. (erav, ) (Entered: 11/17/2017)
68 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of status conference held on 11−17−17, before Judge Richard M. Gergel. Court Reporter/Transcriber Debra Potocki, Telephone number/E−mail potockidebra@bellsouth.net. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 12/18/2017. Redacted Transcript Deadline set for 12/28/2017. Release of Transcript Restriction set for 2/26/2018. (dpotocki, ) (Entered: 11/27/2017)
69 NOTICE of Appearance by Thomas Ashley Limehouse, Jr on behalf of Henry Dargan McMaster (Limehouse, Thomas) (Entered: 01/24/2018)
70 Letter from Co−Monitors Judith Meltzer and Paul Vincent. (Attachments: # 1 Exhibit Co−Monitors Monitoring Report)(sshe, ) (Entered: 04/06/2018)
71 ORDER The Court hereby orders and directs Defendants to submit to the Court on or before May 21, 2018 a comprehensive five year budget plan that provides year to year budgets for each year and sets forth in detail the additional funding, staff, and other resources necessary to meet each of the performance requirements set forth in IV(A) − (K) of the Settlement Agreement. Further, the Court sets the next status conference with the parties on June 1, 2018 at 10:00 a.m. at the J. Waties Waring Judicial Center. The Court at that time will address in detail the Co−Monitors' report filed on April 6, 2018, any compliance concerns of the Plaintiffs, the Defendants' five year budget plan, and other issues which any of the parties desire to bring to the attention of the Court. See Order for all details. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 4/19/2018. (sshe, ) (Entered: 04/19/2018)
72 RESPONSE by Susan Alford and Henry Dargan McMaster to 71 Order to Submit. (Attachments: # 1 5−Year Budget Plan)(ltap, ) (Entered: 05/22/2018)
73 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 6/1/2018. Status reports from Co−monitors. Court Reporter Debbie Potocki. (erav, ) (Entered: 06/01/2018)
74 TEXT ORDER The co−monitors have proposed the use of consultants to assist in certain areas where critical work in meeting the goals of the Settlement Agreement needs to be accomplished. Pursuant to Paragraph III(B) of the Settlement Agreement, the co−monitors have a duty to consult with the parties on these proposed hires, with the ultimate decision left to the discretion of the co−monitors. The Court directs the parties to promptly complete that consultation process and a final decision be made by the co−monitors regarding the consultants on or before June 30, 2018. The co−monitors have also provided the parties their proposed annual budget for their services, pursuant to Paragraph III(I) of the Settlement Agreement. The parties are to advise the co−monitors and the Court in writing on or before June 15, 2018 of any

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 20 of 29

06/15/2018 06/21/2018 06/26/2018
06/26/2018 07/02/2018
07/02/2018 07/02/2018 07/02/2018 07/02/2018
08/02/2018

objections to the proposed budget. The co−monitors are to submit to the Court a written response to any written objections by June 22, 2018, and the Court will thereafter approve a budget for the co−monitors for the next 12 months. AND IT IS SO ORDERED. Entered at the Direction of Honorable Richard M Gergel on 6/4/2018. (sshe, ) (Entered: 06/04/2018)
75 REPLY Letter from Monteith Todd Providing DSS' Objections to Co−Monitors' Budget by Susan Alford to 74 Order.(Todd, Monteith) Filing corrected for event type (sshe, ) (Entered: 06/18/2018)
76 MOTION for Hearing by Susan Alford. Response to Motion due by 7/5/2018. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. No proposed order.(Laffitte, Rebecca) (Entered: 06/21/2018)
77 TEXT ORDER: Defendants have moved for a hearing on their objections to the Co−Monitors' budget. (Dkt. No. 76). The Court will set a hearing via telephone conference on July 3, 2018. Details will be provided by the Clerk in the entry of the hearing notice. The parties should appreciate that the Court remains deeply concerned about the lack of meaningful progress in many critical areas addressed in the Settlement Agreement and is aware that the consultants previously retained by the Co−Monitors have contributed to much of the progress that has been made. The Court directs that the Co−Monitors and Ms. Alford participate in the hearing. The Court further directs that the Co−Monitors and Ms. Alford directly communicate between now and the July 3, 2018 hearing in an effort to resolve areas of disagreement. If the matter is not resolved by the parties, the Court will rule promptly on the issues still in dispute. AND IT IS SO ORDERED. Entered at the direction of the Honorable Richard M Gergel on 6/26/2018. (ltap, ) (Entered: 06/26/2018)
78 NOTICE of Hearing: Telephone Conference on 76 MOTION for Hearing set for 7/3/2018 10:30 AM before Honorable Richard M Gergel. Court staff needed. Defense must provide all parties and the Court conference call−in information for the same no later than July 2nd. AND IT IS SO ORDERED.(ltap, ) (Entered: 06/26/2018)
79 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Status Conference held on 6−1−18, before Judge Richard M. Gergel. Court Reporter/Transcriber Debra Potocki, Telephone number/E−mail potockidebra@bellsouth.net. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 7/23/2018. Redacted Transcript Deadline set for 8/2/2018. Release of Transcript Restriction set for 10/1/2018. (dpotocki, ) (Entered: 07/02/2018)
80 Withdrawal of Motions: 76 MOTION for Hearing filed by Susan Alford.. (Laffitte, Rebecca) (Entered: 07/02/2018)
82 NOTICE of Cancellation of Hearing: Telephone Conference 7/3/2018 10:30 AM is CANCELED per 80 Withdrawal of Motion requesting Hearing (sshe, ) (Entered: 07/02/2018)
83 Co−Monitors proposed budget for 2018 from Co−Monitors. (sshe, ) (Entered: 07/02/2018)
84 TEXT ORDER The Court has before it the Co−Monitors' proposed budget for 2018. (Dkt. No. 83 ) Defendants initially filed an objection to one aspect of the proposed budget but have since reached an amicable resolution of the matter with the Co−Monitors. (Dkt. Nos. 75, 80). Consequently, the Court hereby approves the Co−Monitors' budget for the calendar year 2018. AND IT IS SO ORDERED. Entered at the Direction of Honorable Richard M Gergel on 7/2/2018. (sshe, ) (Entered: 07/02/2018)
87 NOTICE of Appearance by Adam Protheroe on behalf of AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, MH, RB, SB, SV, ZL (Protheroe, Adam) (Entered: 08/02/2018)

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 21 of 29

10/01/2018 11/06/2018 11/26/2018
11/28/2018
11/30/2018 12/03/2018 12/04/2018 12/05/2018 12/05/2018 12/05/2018 12/10/2018 12/17/2018

88 Letter from Co−Monitors Judith Meltzer and Paul Vincent. (Attachments: # 1 Exhibit Co−Monitors Monitoring Report)(sshe, ) (Entered: 10/01/2018)
89 NOTICE of Hearing: Status Conference set for 12/4/2018 10:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 11/06/2018)
90 MOTION for Contempt and Enforcement of Final Settlement Agreement by AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, MH, RB, SB, SV, ZL. Response to Motion due by 12/10/2018. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. (Attachments: # 1 Memo in Support, # 2 Exhibit A − Workforce Report, # 3 Exhibit B − Co−Monitor Letters)No proposed order.(Protheroe, Adam) Modified on 11/29/2018 to reference 91 Supplement filed 11/28/18(sshe, ). (Entered: 11/26/2018)
91 SUPPLEMENT to 90 MOTION by AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), KS, MB, MH, RB, SB, SV, ZL . (Attachments: # 1 Exhibit A − Co−Monitor Letter re Facility Visits, # 2 Exhibit B − Co−Monitor Letter re Additional Consultants, # 3 Exhibit C − Co−Monitor Response to DSS, # 4 Exhibit D − Co−Monitor Response re DSS Budget Objections, # 5 Exhibit E − Co−Monitor Letter re Children in Facility)(Protheroe, Adam) Modified on 11/29/2018 to link correct event to associated event(sshe, ). (Entered: 11/28/2018)
92 RESPONSE in Opposition re 90 MOTION for Contempt and Enforcement of Final Settlement Agreement Response filed by Susan Alford, Henry Dargan McMaster.Reply to Response to Motion due by 12/7/2018 Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6. (Montgomery, John) (Entered: 11/30/2018)
93 REPLY to Response to Motion re 90 MOTION for Contempt and Enforcement of Final Settlement Agreement Response filed by AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, MH, RB, SB, SV, ZL. (Protheroe, Adam) (Entered: 12/03/2018)
94 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 12/4/2018. Status conferences to be held every 30 days. Court to issue order regarding new implementations. Court Reporter Debbie Potocki. (cper, ) (Entered: 12/04/2018)
95 Report from Judith Meltzer. Workforce Assessment by Sue Steib. (sshe, ) (Entered: 12/05/2018)
97 DELETION OF DOCKET ENTRY NUMBER 96 Reason: per Chambers. Filing date of original filing: 12/5/18 (sshe, ) (Entered: 12/05/2018)
98 ORDER See Order for All Details. Status Conference set for 1/11/2019 09:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. Signed by Honorable Richard M Gergel on 12/5/2018. (sshe, ) (Entered: 12/05/2018)
99 TEXT ORDER re: 90 Plaintiffs' Motion for contempt and enforcement of final settlement agreement. In light of the Court's December 5, 2018 Order (Dkt. No. 98), Plaintiffs' motion for contempt and enforcement is denied without prejudice. AND IT IS SO ORDERED. Entered at the direction of the Honorable Richard M Gergel on 12/10/2018.(ltap, ) (Entered: 12/10/2018)
100 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of status conference held on 12−4−18, before Judge Richard M. Gergel. Court Reporter/Transcriber Debra Potocki, Telephone number/E−mail potockidebra@bellsouth.net. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 1/7/2019. Redacted Transcript Deadline set for 1/17/2019. Release of Transcript Restriction set for 3/18/2019. (dpotocki, ) (Entered: 12/17/2018)

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 22 of 29

12/18/2018 12/21/2018 01/11/2019 01/15/2019
02/11/2019
02/20/2019 02/26/2019
02/27/2019 03/15/2019

102 NOTICE of Hearing: Mediation Hearing set for 1/8/2019 at 10:00 AM in Charleston Courthouse, J. Waties Waring Judicial Center, 83 Meeting St, Charleston (Room Location To Be Determined) before Retired Judge Patrick Michael Duffy. (ltap, ) (Entered: 12/18/2018)
103 ORDER The Court makes the following modification to Paragraph 5 of the Court's order of December 5, 2018 (Dkt. No. 98 ). See ORDER for details. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 12/21/2018. (sshe, ) (Entered: 12/21/2018)
104 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 1/11/2019. Order is forthcoming. (Status Conference set for 2/26/2019 10:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel). Court Reporter Tana Hess. (cper, ) (Entered: 01/11/2019)
105 ORDER The Court conducted a status conference on January 11, 2019 to discuss the continued work of the South Carolina Department of Social Services ("DSS") with the Co−Monitors to make the meaningful reforms necessary to meet the benchmarks and standards of the October 4, 2016 Settlement Agreement. See Order for All Details re implementation of these reforms. NOTICE of Hearing The next monthly Status Conference is set for 2/26/2019 at 10:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. Signed by Honorable Richard M Gergel on 1/15/2019. (sshe, ) (Entered: 01/15/2019)
106 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Status Conference held on January 11, 2019, before Judge Richard M. Gergel. Court Reporter/Transcriber Tana J. Hess, Telephone number/E−mail 843.779.0837 tana_hess@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 3/4/2019. Redacted Transcript Deadline set for 3/14/2019. Release of Transcript Restriction set for 5/13/2019. (thes, ) (Entered: 02/11/2019)
107 MOTION for Extension of Time Regarding Health Care Implementation Plan by Susan Alford. Response to Motion due by 3/6/2019. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. No proposed order.(Laffitte, Rebecca) (Entered: 02/20/2019)
108 Minute Entry. Proceedings held before Honorable Richard M Gergel: finding as moot 107 Motion for Extension of Time; Status Conference held on 2/26/2019. Budget staff is to be present at the April Status conference. Before the April status conference, the foster care rate number is to be established, the placement plan's undetermined numbers are to be determined, the family visitation plan is to be resolved and what constitutes a visit is to be defined. (Status Conference set for 4/2/2019 10:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel.) Court Reporter Debbie Potocki. (cper, ) (Entered: 02/26/2019)
109 ORDER The Court conducted a status conference on February 26, 2019 to discuss the continued work of the South Carolina Department of Social Services ("DSS") with the Co−Monitors to comply with the provisions of the benchmarks and standards of the October 4, 2016 Settlement Agreement. See Order for All Details re continued implementation of the mandates of the Settlement Agreement. The next monthly Status Conference is set for 4/2/2019 at 10:00 AM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 2/27/2019. (sshe, ) (Entered: 02/27/2019)
110 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of status conference held on 2−26−19, before Judge Richard M. Gergel. Court Reporter/Transcriber Debra Potocki, Telephone number/E−mail potockidebra@bellsouth.net. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 23 of 29

03/27/2019 03/28/2019 04/01/2019
04/02/2019
04/03/2019
04/03/2019 04/03/2019 04/03/2019 04/03/2019 04/03/2019
04/04/2019

with the court a Notice of Intent to Request Redaction.. Redaction Request due 4/5/2019. Redacted Transcript Deadline set for 4/15/2019. Release of Transcript Restriction set for 6/13/2019. (dpotocki, ) (Entered: 03/15/2019)
111 MOTION for Extension of Time Regarding Foster Parent Board Rates by Susan Alford. Response to Motion due by 4/10/2019. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. (Attachments: # 1 Exhibit A − PCG Proposal for Foster Parent Board Rates−March 2019)No proposed order.(Laffitte, Rebecca) (Entered: 03/27/2019)
112 TEXT ORDER re 111 Motion by DSS for an extension of time. Plaintiffs are directed to file a response to the motion by 12:00 PM on 4/1/2019. AND IT IS SO ORDERED. Entered at the Direction of Honorable Richard M Gergel on 3/28/2019. (sshe, ) (Entered: 03/28/2019)
113 RESPONSE in Opposition re 111 MOTION for Extension of Time Regarding Foster Parent Board Rates Response filed by AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, Michelle H, RB, SB, SV, ZL.Reply to Response to Motion due by 4/8/2019 Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6. (Attachments: # 1 Exhibit A − Approved DSS Placement Implementation Plan, # 2 Exhibit B − Governors Task Force Report Findings, # 3 Exhibit C − USDA Report, # 4 Exhibit D − Ahn et al Report, # 5 Exhibit E − MARC Report)(Protheroe, Adam) (Entered: 04/01/2019)
114 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 4/2/2019; denying 111 Motion for Extension of Time. The foster care rate number is to be approved by the monitors 3 business days before May 14th. (Status Conference set for 5/14/2019 10:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel.) Court Reporter Tana Hess. (cper, ) (Entered: 04/02/2019)
115 ORDER The Court conducted a status conference on April 2, 2019 to discuss the continued work of the South Carolina Department of Social Services ("DSS") with the Co−Monitors to comply with the provisions of the benchmarks and standards of the October 4, 2016 Settlement Agreement. See Order for All Details re continued implementation of the mandates of the Settlement Agreement. The next monthly Status Conference is set for 5/14/2019 at 10:00 AM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 4/2/2019. (sshe, ) (Entered: 04/03/2019)
116 DSS OHAN Implementation Plan re 115 Order (sshe, ) (Entered: 04/03/2019)
117 DSS Placement Implementation Plan re 115 Order (Attachments: # 1 DSS Placement Implementation Plan Fiscal Impact Analysis)(sshe, ) (Entered: 04/03/2019)
118 DSS Visitation Implementation Plan re 115 Order (sshe, ) (Entered: 04/03/2019)
119 DSS Workload Implementation Plan re 115 Order (Attachments: # 1 DSS Workload Implementation Plan Appendix)(sshe, ) (Entered: 04/03/2019)
120 DSS Health Care Implementation Plan re 115 Order (Attachments: # 1 DSS Health Care Plan Addendum, # 2 DSS Health Care Addendum Appendix B Health Care Targets, # 3 DSS Health Care Addendum Appendix C Process Map, # 4 DSS Health Care Addendum Appendix D Care Coordination Model, # 5 DSS Health Care Addendum Appendix E Request for Additional Information, # 6 DSS Health Care Plan Appendices Combined)(sshe, ) (Entered: 04/03/2019)
121 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Status Conference held on April 2, 2019, before Judge Richard M. Gergel. Court Reporter/Transcriber Tana J. Hess, Telephone number/E−mail 843.779.0837 tana_hess@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 4/25/2019. Redacted Transcript Deadline set for 5/6/2019. Release of Transcript Restriction set for 7/3/2019. (thes, )

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 24 of 29

04/08/2019 05/07/2019 05/09/2019 05/14/2019
05/15/2019
06/04/2019
06/05/2019 06/12/2019 06/18/2019
06/18/2019

(Entered: 04/04/2019)
122 NOTICE OF RESCHEDULED HEARING Status Conference previously set for 5/14/2019 10:00 AM rescheduled for ***TIME CHANGE ONLY*** to: Status Conference set for 5/14/2019 09:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. ***PLEASE NOTE TIME CHANGE ONLY. (sshe, ) (Entered: 04/08/2019)
123 Letter from Co−Monitors Judith Meltzer and Paul Vincent. (Attachments: # 1 Exhibit Co−Monitors Monitoring Report)(sshe, ) (Entered: 05/07/2019)
124 MOTION for Extension of Time Regarding Foster Parent Board Rates by Susan Alford. Response to Motion due by 5/23/2019. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. No proposed order.(Laffitte, Rebecca) (Entered: 05/09/2019)
125 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 5/14/2019. MOTION 124 for Extension of Time Regarding Foster Parent Board Rates Denied as moot in light of the May 14, 2019 conference. Court to issue written order. (Status Conference set for 6/24/2019 11:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel) Court Reporter Tana Hess. (cper, ) Modified text on 5/14/2019 (cper, ). (Entered: 05/14/2019)
126 ORDER The Court conducted a status conference on May 14, 2019 to discuss the continued work of the South Carolina Department of Social Services ("DSS") to comply with the provisions of the Settlement Agreement between the parties to this action. See Order for All Details re continued implementation of the Settlement Agreement. The next monthly Status Conference is set for 6/24/2019 at 11:00 AM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 5/15/2019. (sshe, ) (Entered: 05/15/2019)
127 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Monthly Status Conference held on May 14, 2019, before Judge Richard M. Gergel. Court Reporter/Transcriber Tana J. Hess, Telephone number/E−mail 843.779.0837 tana_hess@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 6/25/2019. Redacted Transcript Deadline set for 7/5/2019. Release of Transcript Restriction set for 9/3/2019. (thes, ) (Entered: 06/04/2019)
128 Letter from Matthew T. Richardson. (Richardson, Matthew) (Entered: 06/05/2019)
129 MOTION to Amend/Correct 126 Order,, Regarding Visitation Data by Susan Alford. Response to Motion due by 6/26/2019. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. (Attachments: # 1 Exhibit − June 5, 2019 letter)No proposed order.(Laffitte, Rebecca) (Entered: 06/12/2019)
130 MOTION to Appear Pro Hac Vice by Shereen Arthur White ( Filing fee $ 250 receipt number 0420−8510876) by AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, Michelle H, RB, SB, SV, ZL. Response to Motion due by 7/2/2019. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. (Attachments: # 1 Affidavit for Pro Hac Vice Admission, # 2 Exhibit Certificate of Good Standing, # 3 Proposed Order)Proposed order is being emailed to chambers with copy to opposing counsel.(Protheroe, Adam) (Entered: 06/18/2019)
131 MOTION Submit Plaintiffs' Request for Attorneys' Fees and Expenses to Arbitration by AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, Michelle H, RB, SB, SV, ZL. Response to Motion due by 7/2/2019. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. (Attachments: # 1 Proposed Order)Proposed order is being emailed to chambers with copy to opposing counsel.(Protheroe, Adam) (Entered: 06/18/2019)

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 25 of 29

06/19/2019 06/19/2019 06/24/2019 06/24/2019 06/24/2019
06/24/2019 06/24/2019 06/25/2019
06/25/2019
07/01/2019
07/02/2019 07/02/2019

132 ORDER granting 130 Motion for Shereen Arthur White to Appear Pro Hac Vice for AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, Michelle H, RB, SB, SV, ZL. Signed by Honorable Richard M Gergel on 6/19/2019.(sshe, ) (Entered: 06/19/2019)
134 MOTION for Extension of Time Regarding Difficulty of Care Board Rates by Michael Leach. Response to Motion due by 7/3/2019. Add an additional 3 days only if served by mail or otherwise allowed under Fed. R. Civ. P. 6 or Fed. R. Crim. P. 45. (Attachments: # 1 Exhibit − DCBR Comparison Chart)No proposed order.(Montgomery, John) (Entered: 06/19/2019)
135 Letter from DSS re 126 Order regarding sibling visits, parent visits, congregate care, and class member statistics. (ltap, ) (Entered: 06/24/2019)
136 Letter from DSS re 126 Order regarding investigation statistics. (ltap, ) (Entered: 06/24/2019)
137 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 6/24/2019. Joint report re: list of implementations for the July 1, 2020 order is due July 12, 2019. Court to issue written order. (Status Conference set for 7/29/2019 (Time to be determined) in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. Court Reporter Karen Martin. (cper, ) (Entered: 06/24/2019)
138 Letter from DSS regarding budget request. (ltap, ) (Entered: 06/24/2019)
139 NOTICE of Hearing: Status Conference set for 7/29/2019 10:00 AM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. (cper, ) (Entered: 06/24/2019)
140 ORDER The Plaintiffs' motion (Dkt. No. 131 ) is granted. The matter of Plaintiffs' request for post−settlement fees and expenses for the period ending December 31, 2018 is submitted to Judge Duffy for binding arbitration. The parties shall file a joint status report on the status of this arbitration on or before August 15, 2019. Please See Order for All Details and Deadlines re arbitration. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 6/25/2019.(sshe, ) (Entered: 06/25/2019)
141 ORDER The Court conducted a status conference on June 24, 2019 to discuss the continued work of the South Carolina Department of Social Services ("DSS") to comply with the provisions of the Settlement Agreement between the parties to this action. The Court approves the motion of DSS regarding extending the time for setting the "difficulty of care" foster parent rates (granting Dkt. No. 134 ). See Order for All Details re continued implementation of the Settlement Agreement. The next monthly Status Conference is set for 7/29/2019 at 11:00 AM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 6/25/2019.(sshe, ) (Entered: 06/25/2019)
142 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Status Conference held on 6/24/19, before Judge Richard M. Gergel. Court Reporter/Transcriber Karen E. Martin, Telephone number/E−mail Karen_E_Martin@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction. Redaction Request due 7/22/2019. Redacted Transcript Deadline set for 8/1/2019. Release of Transcript Restriction set for 9/30/2019. Associated Cases: 2:15−cv−00134−RMG, 3:19−cv−01693−RMG(kmartin, ) (Entered: 07/01/2019)
143 Letter from Rebecca Laffitte for Director Leach. (sshe, ) (Entered: 07/02/2019)
144 NOTICE OF RESCHEDULED HEARING Status Conference set for 7/29/2019 10:00 AM cancelled and rescheduled to: Status Conference set for 7/30/2019 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 07/02/2019)

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 26 of 29

07/22/2019 07/24/2019 07/30/2019 07/31/2019 07/31/2019
07/31/2019 08/15/2019 08/15/2019
08/20/2019
08/28/2019
09/09/2019

145 Letter from Rebecca Lafitte re: implementation activities between July 19, 2019 and July 1, 2020. (ltap, ) (Main Document 145 replaced on 7/24/2019) (sshe, ). Modified on 7/24/2019 to replace document per chambers(sshe, ). (Entered: 07/22/2019)
146 Sealed Document (filed per chambers). (sshe, ) (Entered: 07/24/2019)
147 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 7/30/2019. Court sets deadline for areas in dispute for August 31st. Court to issue an order. Court will also set a hearing for another status conference in early September. Court Reporter: Tana Hess. (ssam, ) (Entered: 07/30/2019)
148 Response of Defendants to Order # 141 . (ltap, ) (Entered: 07/31/2019)
149 ORDER The Court conducted a status conference on July 30, 2019 to discuss the continued work of the South Carolina Department of Social Services ("DSS") to comply with the provisions of the Settlement Agreement between the parties to this action. Please See Order for All Details and Deadlines re continued implementation of the Settlement Agreement. The next monthly Status Conference is set for 9/9/2019 01:00 PM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 7/31/2019. (sshe, ) (Entered: 07/31/2019)
150 NOTICE of Hearing: Status Conference set for 9/9/2019 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 07/31/2019)
151 STATUS REPORT Concerning Status of Fee Arbitration by AB, AR(by his next friend Cheryl Kreider), AR(by her next friend Tamara Coppinger), CB, KS, MB, Michelle H, RB, SB, SV, ZL. (Protheroe, Adam) (Entered: 08/15/2019)
152 ORDER Many critical provisions of the parties' settlement are due for implementation on July 1, 2020, and the Court thought it important at this time to state with clarity and specificity the State's binding obligations under the Settlement Agreement that come due on July 1, 2020. The Court hereby adopts the parties' Joint Report (Dkt. No. 145 ) as the binding obligations of the Defendants due for performance on or before July 1, 2020. Please See Order for All Details. The Court expects, and will insist upon, the full and timely performance of the State's obligations under the Settlement Agreement. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 8/15/2019. (sshe, ) (Entered: 08/15/2019)
153 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Status Conference held on July 30, 2019, before Judge Richard M. Gergel. Court Reporter/Transcriber Tana J. Hess, Telephone number/E−mail 843.779.0837 tana_hess@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 9/10/2019. Redacted Transcript Deadline set for 9/20/2019. Release of Transcript Restriction set for 11/18/2019. (thes, ) (Entered: 08/20/2019)
154 AMENDED ORDER re 149 . The Court conducted a status conference on July 30, 2019 to discuss the continued work of the South Carolina Department of Social Services ("DSS") to comply with the provisions of the Settlement Agreement between the parties to this action. Please See AMENDED Order for All Details and Deadlines re continued implementation of the Settlement Agreement. The next monthly Status Conference is set for 9/9/2019 01:00 PM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 8/28/2019. (sshe, ) (Entered: 08/28/2019)
155 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 9/9/2019. Court to issue written order. (Status Conference set for 11/4/2019 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel.) Court Reporter Tana Hess. (cper, ) (Entered: 09/09/2019)

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09/09/2019 09/09/2019 09/19/2019 09/29/2019
10/10/2019 11/04/2019 11/04/2019 11/04/2019
11/04/2019 11/26/2019
01/09/2020 01/09/2020

156 NOTICE of Hearing: Status Conference set for 11/4/2019 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 09/09/2019)
157 ORDER: Next status conference will be held November 4, 2019. See Order for further details related to the status conference. Entered at the direction of the Honorable Richard M Gergel on 9/9/2019. (ltap, ) (Entered: 09/09/2019)
158 Co−Monitors Monitoring Report for Period October 1, 2018 March 31, 2019 from Co−Monitors Judith Meltzer and Paul Vincent. (sshe, ) (Entered: 09/19/2019)
159 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Status Conference held on September 9, 2019, before Judge Richard M. Gergel. Court Reporter/Transcriber Tana J. Hess, Telephone number/E−mail 843.779.0837 tana_hess@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 10/21/2019. Redacted Transcript Deadline set for 10/30/2019. Release of Transcript Restriction set for 12/30/2019. (thes, ) (Entered: 09/29/2019)
160 TEXT ORDER re 129 . DSSs request to amend the May 15, 2019 Order to extend the deadline by which DSS was to provide certain statistical information is DENIED AS MOOT in light of the information subsequently provided at 135 and 136. AND IT IS SO ORDERED. Entered at the Direction of Honorable Richard M Gergel on 10/10/2019.(sshe, ) (Entered: 10/10/2019)
161 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 11/4/2019, Court to issue written order. ( Status Conference set for 1/9/2020 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel.) Court Reporter Tana Hess. (cper, ) (Entered: 11/04/2019)
162 Joint Agreement on Immediate Treatment Needs of Class Members (cper, ) (Entered: 11/04/2019)
163 ORDER The Court conducted a status conference on November 4, 2019 to discuss the continued work of the South Carolina Department of Social Services ("DSS") to comply with the provisions of the Settlement Agreement between the parties to this action. Please See Order for All Details and Deadlines re continued implementation of the Settlement Agreement. The next monthly Status Conference is set for 1/9/2020 at 01:00 PM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 11/4/2019. (sshe, ) (Entered: 11/04/2019)
164 NOTICE of Hearing: Status Conference set for 1/9/2020 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 11/04/2019)
165 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Status Conference held on November 4, 2019, before Judge Richard M. Gergel. Court Reporter/Transcriber Tana J. Hess, Telephone number/E−mail 843.779.0837 tana_hess@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 12/17/2019. Redacted Transcript Deadline set for 12/27/2019. Release of Transcript Restriction set for 2/24/2020. (thes, ) (Entered: 11/26/2019)
166 Letter dated 1/6/2020 from DSS. (sshe, ) (Entered: 01/09/2020)
167 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 1/9/2020, ( Status Conference set for 3/4/2020 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel.) Court Reporter Tana Hess. (cper, ) (Entered: 01/09/2020)

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 28 of 29

01/09/2020
01/09/2020 02/04/2020
03/04/2020 03/04/2020 03/04/2020 03/10/2020
03/10/2020
03/10/2020 03/10/2020 03/10/2020

168 ORDER The Court conducted a status conference on January 9, 2020 to discuss the continued work of the South Carolina Department of Social Services ("DSS") to comply with the provisions of the Settlement Agreement between the parties to this action. Please See Order for All Details and Deadlines re continued implementation of the Settlement Agreement. The next monthly Status Conference is set for 3/4/2020 at 01:00 PM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 1/9/2020. (sshe, ) (Entered: 01/09/2020)
169 NOTICE of Hearing: Next Status Conference set for 3/4/2020 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 01/09/2020)
170 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Monthly Status Conference held on January 9, 2020, before Judge Richard M. Gergel. Court Reporter/Transcriber Tana J. Hess, Telephone number/E−mail 843.779.0837 tana_hess@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 2/25/2020. Redacted Transcript Deadline set for 3/6/2020. Release of Transcript Restriction set for 5/4/2020. (thes, ) (Entered: 02/04/2020)
171 Co−Monitors Monitoring Report for Period April 2019 − September 2019 from Co−Monitors Judith Meltzer and Paul Vincent. (Attachments: # 1 Progress Report)(sshe, ) (Entered: 03/04/2020)
172 Letter dated 2/28/2020 from DSS. (sshe, ) (Entered: 03/04/2020)
173 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 3/4/2020. *Tentative Status Conference set for 4/3/2020 01:00 PM in Charleston pending court's meeting with counsel. Clerk will issue a separate notice of hearing. Court Reporter Tana Hess. (cper, ) (Entered: 03/04/2020)
174 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Monthly Status Conference held on March 4, 2020, before Judge Richard M. Gergel. Court Reporter/Transcriber Tana J. Hess, Telephone number/E−mail 843.779.0837 tana_hess@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction.. Redaction Request due 3/31/2020. Redacted Transcript Deadline set for 4/10/2020. Release of Transcript Restriction set for 6/8/2020. (thes, ) (Entered: 03/10/2020)
175 TEXT ORDER The Court previously advised counsel and the parties that a full status conference in Michelle H would be held on April 3, 2020. After further reflection, the Court has decided to hold a counsel only chambers conference on April 3, 2020 at 2:00 p.m., and the next full Michelle H status conference will be held on April 30, 2020 at 1:00 p.m. AND IT IS SO ORDERED. Entered at the Direction of Honorable Richard M Gergel on 3/10/2020. (sshe, ) (Entered: 03/10/2020)
176 NOTICE of Hearing Chambers Conference: Pursuant to Text Order 175 the Court will conduct a conference with counsel in Chambers on April 3, 2020 at 2:00 p.m. before Honorable Richard M Gergel. Counsel for the parties are required to attend. (sshe, ) (Entered: 03/10/2020)
177 NOTICE of Hearing: Next full Status Conference set for 4/30/2020 01:00 PM in Charleston Courtroom #1, J. Waties Waring Judicial Center, 83 Meeting St, Charleston before Honorable Richard M Gergel. (sshe, ) (Entered: 03/10/2020)
178 ORDER The Court conducted a status conference on March 4, 2020 to discuss the continued work of the South Carolina Department of Social Services ("DSS") to comply with the provisions of the Settlement Agreement between the parties to this action. Please See Order for All Details and Deadlines re continued implementation of the Settlement Agreement. The next monthly Status

Case: 2:15-cv-134 As of: 05/24/2020 05:06 PM EDT 29 of 29

03/10/2020 03/16/2020 03/20/2020 04/24/2020 04/30/2020 05/08/2020
05/21/2020 05/22/2020

Conference has been set for 4/30/2020 at 01:00 PM. AND IT IS SO ORDERED. Signed by Honorable Richard M Gergel on 3/10/2020. (sshe, ) (Entered: 03/10/2020)
179 NOTICE to disregard duplicate filing notification of Official Transcript. Correct Filing Document Number 174 Filing date: 3/10/2020 (sshe, ) (Entered: 03/10/2020)
180 NOTICE OF RESCHEDULED HEARING The In Chambers Conference previously scheduled for April 3, 2020 at 2:00 p.m. will now be conducted via Telephone Conference before Honorable Richard M Gergel. Counsel will be notified by chambers beforehand as to dial−in information. (sshe, ) (Entered: 03/16/2020)
181 NOTICE of Cancellation of Hearing: April Telephone Status Conference set for 4/3/2020 at 2:00 pm is cancelled. (cper, ) (Entered: 03/20/2020)
182 NOTICE of Hearing by TELECONFERENCE: Status Conference scheduled for April 30, 2020 at 1:00 p.m. will be conducted via Telephone before Honorable Richard M Gergel. (Note: The Court will send dial−in instructions to counsel before the hearing.)(cper, ) (Entered: 04/24/2020)
183 Minute Entry. Proceedings held before Honorable Richard M Gergel: Status Conference held on 4/30/2020 by telephone. All parties and monitors represented on the call. Court will contact counsel to schedule the next counsel only telephone status conference. Court Reporter Karen Martin. (cper, ) (Entered: 04/30/2020)
184 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings. Status Conference held on 4/30/2020, before Judge Richard M. Gergel. Court Reporter/Transcriber Karen E. Martin, Telephone number/E−mail Karen_E_Martin@scd.uscourts.gov. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Parties have 7 calendar days from the filing of the transcript to file with the court a Notice of Intent to Request Redaction. Redaction Request due 5/29/2020. Redacted Transcript Deadline set for 6/8/2020. Release of Transcript Restriction set for 8/6/2020. (kmartin, ) (Entered: 05/08/2020)
185 ORDER: As a follow up to our recent telephone conference, this is to advise the parties that retired South Carolina Chief Justice Jean Toal has agreed to assume responsibility as mediator in this matter. AND IT IS SO ORDERED. Entered at the direction of the Honorable Richard M Gergel on 5/21/20. (ltap, ) (Entered: 05/21/2020)
186 NOTICE of Hearing: Telephone Conference with counsel set for 6/2/2020 10:00 AM before Honorable Richard M Gergel. Dial in information will be sent to counsel.(cper, ) (Entered: 05/22/2020)