1 

" ! COMMITTEE PRINT 115TH CONGRESS

1st Session 

S. PRT. 

115–18 

AN EXAMINATION OF FOSTER CARE 

IN THE UNITED STATES 

AND THE USE OF PRIVATIZATION 

PREPARED BY THE STAFF OF THE

COMMITTEE ON FINANCE 

UNITED STATES SENATE 

ORRIN G. HATCH, Chairman 

RON WYDEN, Ranking Member 

OCTOBER 2017 

Printed for the use of the Committee on Finance 


congress.#13
AN EXAMINATION OF FOSTER CARE IN THE UNITED STATES 

AND THE USE OF PRIVATIZATION 

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26–354—PDF 

" ! COMMITTEE PRINT 115TH CONGRESS

1st Session 

S. PRT. 

2017

115–18 

AN EXAMINATION OF FOSTER CARE 

IN THE UNITED STATES 

AND THE USE OF PRIVATIZATION 

PREPARED BY THE STAFF OF THE

COMMITTEE ON FINANCE 

UNITED STATES SENATE 

ORRIN G. HATCH, Chairman 

RON WYDEN, Ranking Member 

OCTOBER 2017 

Printed for the use of the Committee on Finance 


congress.#13
COMMITTEE ON FINANCE 

ORRIN G. HATCH, Utah, Chairman 

CHARLES E. GRASSLEY, Iowa 

MIKE CRAPO, Idaho 

PAT ROBERTS, Kansas 

MICHAEL B. ENZI, Wyoming 

JOHN CORNYN, Texas 

JOHN THUNE, South Dakota 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

ROB PORTMAN, Ohio 

PATRICK J. TOOMEY, Pennsylvania 

DEAN HELLER, Nevada 

TIM SCOTT, South Carolina 

BILL CASSIDY, Louisiana 

RON WYDEN, Oregon 

DEBBIE STABENOW, Michigan 

MARIA CANTWELL, Washington 

BILL NELSON, Florida 

ROBERT MENENDEZ, New Jersey 

THOMAS R. CARPER, Delaware 

BENJAMIN L. CARDIN, Maryland 

SHERROD BROWN, Ohio 

MICHAEL F. BENNET, Colorado 

ROBERT P. CASEY, Jr., Pennsylvania 

MARK R. WARNER, Virginia 

CLAIRE MCCASKILL, Missouri 

A. JAY KHOSLA, Staff Director 

JOSHUA SHEINKMAN, Democratic Staff Director 

INVESTIGATIVE STAFF 

Senate Finance Committee Majority Staff 

KIMBERLY BRANDT, Chief Oversight 

Counsel 

DONALD ABBOTT, U.S. Secret Service 

Detailee 

BECKY SHIPP, Health and Human Services 

Policy Advisor 

JOHN A. CARLO, Senior Oversight Counsel 

Senate Finance Committee Minority Staff 

IAN M. NICHOLSON, Investigator 

EMILY DOUGLAS, SRCD/AAAS 

Congressional Fellow 

DAVID M. BERICK, Chief Investigator 

LAURA BERNTSEN, Chief Human Services 

Advisor 

DOUGLASS V. CALIDAS, Legislative Fellow 

(II) 

(III) 

C O N T E N T S 

Page 

Executive Summary ................................................................................................. 1 

I. Introduction .......................................................................................................... 2 

II. Overview of the Problem and Justification for the Committee Investigation ........................................................................................................................ 3 

A. Child Abuse and Neglect and Foster Care ................................................ 3 

B. Federal Financing of Foster Care Services ................................................ 3 

C. Recent Committee History on Foster Care and Related Issues ............... 4 

D. Initial Media Reports About For-Profit Foster Care and Children’s 

Deaths ............................................................................................................ 5 

E. MENTOR and Private Foster Care Agencies ............................................ 6 

F. Therapeutic Foster Care .............................................................................. 8 

III. The Committee’s Investigation and Surveys of the States: Foster Care 

Services and Performance ................................................................................... 8 

A. The 50-State Overview Letter and Request .............................................. 8 

B. The 5-State In-Depth Letter and Request ................................................. 9 

C. U.S. HHS Child and Family Services Reviews ......................................... 10 

D. The MENTOR Letter and Request ............................................................ 10 

IV. Findings From the Committee’s Investigations and Surveys ........................ 11 

A. Use of Private Child Welfare Services ....................................................... 11 

B. Background Checks ..................................................................................... 13 

C. Child Welfare Workforce Operations and Concerns ................................. 14 

D. Physical and Mental Well-Being of Children in Foster Care .................. 16 

E. Failure to Identify and Respond to Risk to Children ............................... 17 

F. Actions When Maltreatment Is Substantiated in Foster Homes ............. 18 

G. MENTOR Incident Reports ........................................................................ 20 

H. MENTOR Mortality Report ........................................................................ 23 

I. Financial Settlements From MENTOR ....................................................... 26 

V. Oversight of Child Welfare Services and Protecting Vulnerable Children .... 27 

VI. Conclusions ........................................................................................................ 29 

VII. Recommendations ............................................................................................ 31 

Recommendations for States and Tribes ........................................................ 31 

Recommendations for the Department of Health and Human Services 

(HHS) ............................................................................................................. 31 

Recommendations for Congress ....................................................................... 32 

Appendix A—50-State Overview Letter ................................................................. 35 

Appendix B—Responses to 50-State Overview Letter .......................................... 38 

Exhibit 1—Response From Alabama, Department of Human Resources .... 39 

Page

IV 

Appendix B—Responses to 50-State Overview Letter—Continued 

Exhibit 2—Response From Alaska, Department of Health and Social 

Services .......................................................................................................... 47 

Exhibit 3—Response From Arkansas, Office of the Governor ...................... 51 

Exhibit 4—Response From California, Health and Human Services Agency, Department of Social Services ............................................................... 55 

Exhibit 5—Response From Colorado, Office of the Governor ....................... 62 

Exhibit 6—Response From Connecticut, Department of Children and 

Families ......................................................................................................... 66 

Exhibit 7—Response From Delaware, Department of Services for Children, Youth, and Their Families ................................................................. 69 

Exhibit 8—Response From Guam, Department of Public Health and Social Services ................................................................................................... 74 

Exhibit 9—Response From Hawaii, Office of the Governor .......................... 79 

Exhibit 10—Response From Illinois, Department of Children and Family 

Services .......................................................................................................... 82 

Exhibit 11—Response From Indiana, Department of Child Services .......... 88 

Exhibit 12—Response From Iowa, Department of Human Services ............ 93 

Exhibit 13—Response From Kansas, Department for Children and Families .................................................................................................................. 97 

Exhibit 14—Response From Kentucky, Cabinet for Health and Family 

Services .......................................................................................................... 101 

Exhibit 15—Response From Maryland, Department of Human Resources . 107 

Exhibit 16—Response From Massachusetts, Office of the Governor ........... 114 

Exhibit 17—Response From Minnesota, Department of Human Services .. 120 

Exhibit 18—Response From Nebraska, Office of the Governor .................... 126 

Exhibit 19—Response From New Hampshire, Department of Health and 

Human Services ............................................................................................ 130 

Exhibit 20—Response From New Jersey, Department of Children and 

Families ......................................................................................................... 134 

Exhibit 21—Response From New Mexico ....................................................... 139 

Exhibit 22—Response From New York, Office of Children and Family 

Services .......................................................................................................... 153 

Exhibit 23—Response From North Dakota .................................................... 158 

Exhibit 24—Response From Oklahoma, Department of Human Services ... 162 

Exhibit 25—Response From Oregon, Office of the Governor ........................ 166 

Exhibit 26—Response From Pennsylvania, Department of Human Services .................................................................................................................. 172 

Exhibit 27—Response From South Dakota, Office of the Governor and 

the Department of Social Services ............................................................... 179 

Exhibit 28—Response From Tennessee, Department of Children’s Services .................................................................................................................. 184 

Exhibit 29—Response From Texas, Department of Family and Protective 

Services .......................................................................................................... 189 

Exhibit 30—Response From Utah, Department of Human Services ........... 201 

Exhibit 31—Response From Washington, Department of Social and 

Health Services ............................................................................................. 206 

Exhibit 32—Response From West Virginia, Department of Health and 

Human Resources ......................................................................................... 209 

Exhibit 33—Response From Wisconsin, Department of Children and Families ................................................................................................................. 213 

Exhibit 34—Response From Wyoming, Department of Family Services ..... 219 

Appendix C—5-State In-Depth Letters .................................................................. 222 

Exhibit 1—Letter to Georgia, Department of Community Health ............... 223 

Page

V 

Appendix C—5-State In-Depth Letters—Continued 

Exhibit 2—Letter to Illinois, Department of Children and Family Services .................................................................................................................. 228 

Exhibit 3—Letter to Massachusetts, Department of Children and Families .................................................................................................................. 233 

Exhibit 4—Letter to Maryland, Department of Human Resources .............. 238 

Exhibit 5—Letter to Texas, Department of Family and Protective Services .................................................................................................................. 243 

Appendix D—Congressional Research Service Memorandum on the U.S. HHS 

Children and Family Services Reviews .............................................................. 248 

Appendix E—Letter to The MENTOR Network ................................................... 275 

Appendix F—MENTOR Level 4 Incident Reports ................................................ 282 

Appendix G—MENTOR Mortality Report and Backup Data .............................. 606 

Exhibit 1—Foster Care Mortality Analysis .................................................... 607 

Exhibit 2—Backup Data and Explanation of Mortality Analysis ................ 613 

(1) 

AN EXAMINATION OF FOSTER CARE 

IN THE UNITED STATES 

AND THE USE OF PRIVATIZATION 

EXECUTIVE SUMMARY 

Foster care placements for children who are victims of abuse and 

neglect have historically been managed by a combination of private 

and public resources. However, the need for specialized foster care 

services and a shortage of foster care homes in recent years has led 

to the privatization of many core foster care services. Today, both 

non-profit and for-profit private agencies contract with and provide 

foster care services on behalf of State agencies. In 2015, 671,000 

children in the United States were provided out-of-home foster care 

services. There are no official statistics on what proportion of these 

children received contracted foster care, case management, or other 

services. State child welfare agencies report they have procedures 

in place to monitor child welfare providers’ performance and outcomes. But this investigation conducted by the bipartisan staff of 

the U.S. Senate Finance Committee shows that these policies are 

not always followed; exceptions are made, waivers are granted, 

profits are prioritized over children’s well-being, and sometimes 

those charged with keeping children safe look the other way. High 

turnover among staff sometimes makes it impossible to develop 

case plans to ensure that children are ‘‘on-track.’’ Foster parents 

with questionable backgrounds, who lack the skills to provide care 

to vulnerable children, are given licenses to parent challenging 

children, and these children are then inadequately monitored. The 

outcome of this investigation shows that the child welfare system 

does not always protect children. The data collection and oversight 

structures at both the State and Federal levels make it difficult 

and sometimes impossible to monitor the operations of the child 

welfare system, as well as its private contractors. 

A recent bout of national media attention concerning questionable behavior by private for-profit agencies, abuse and neglect by 

foster parents working for those providers, and in some instances 

abuse and neglect which caused children’s deaths, led the Finance 

Committee to investigate this issue. As the Finance Committee has 

primary jurisdiction over Federal child welfare and foster care 

funding and policy (largely through the Social Security Act), the 

Committee launched an investigation in April 2015 to examine the 

privatization of foster care services. One specific private company, 

The MENTOR Network, one of the largest for-profit providers of 

foster care services in the United States, was used as a case study 

to highlight the problems that exist with the privatization of 

human services. This report documents the findings of this invesVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
2 

1Flaherty, C., Collins-Camargo, C. and Lee, E., ‘‘Privatization of child welfare services: Lessons learned from experienced states regarding site readiness assessment and planning.’’ Children and Youth Services Review, Vol. 30, No. 7, pp. 809–820, http://www.sciencedirect.com/ 

science/article/pii/S0190740907002538. 

tigation and reveals problems with child welfare contracting practices as well as public agency oversight of such contracts and services. 

The investigation was conducted by collecting information from 

public child welfare agencies across the Nation concerning their 

general policies and practices, including how they contract with 

and monitor private agencies. The Committee also gathered information from The MENTOR Network, specifically, by reviewing incident reports about the deaths of children in the company’s care, 

an internal ‘‘mortality report,’’ legal settlements, case notes, foster 

parent applications, and other related documentation. 

The Committee staff concluded that children who are under the 

legal authority of their State, yet receive services from private forprofit agencies, have been abused, neglected, and denied services. 

The very agencies charged with and paid to keep foster children 

safe too often failed to provide even the most basic protections, or 

to take steps to prevent the occurrence of tragedies. In MENTOR’s 

case in particular, investigations into fatalities were never followed 

up after the fact; autopsy reports which were pending years ago 

were excluded from files; and the vast majority of children who 

died were not the subject of internal investigations, even when 

their deaths were unexpected. The MENTOR Network issued a report which falsely claimed that its death rates are in line with national death rates and the rates of death among all children in the 

foster care system. Moreover, families of these and other victims of 

inadequate care have received millions of dollars in financial settlements, significant enough for The MENTOR Network to receive 

less favorable terms from its insurer. 

As the role of private for-profit and non-profit providers of foster 

care services has grown, oversight of these entities by State agencies—as well as Federal oversight of the States—has been inadequate. The Finance Committee staff has made recommendations 

to HHS, the States, and to Congress addressing these shortcomings. 

I. INTRODUCTION 

The privatization of foster care, and specifically for-profit foster 

care, has been a growing trend in the delivery of child welfare services over the past few decades.1 Recent national media attention 

concerning questionable performance by these private agencies, including abuse and neglect by foster parents working for these agencies, and in some instances abuse and neglect which led to children’s deaths, led the Senate Finance Committee (hereinafter, the 

‘‘Committee’’ or ‘‘SFC’’) to investigate these issues. 

The Committee has jurisdiction over Federal child welfare and 

foster care funding and policy in the United States, and thus has 

a responsibility in ensuring children receive the most suitable 

placements to appropriately support their healthy development. 

Chairman Hatch and Ranking Member Wyden launched an investigation in April 2015 to examine the privatization of foster care 

3 

2 Civitas Solutions, Inc., U.S. Securities and Exchange Commission, 2014 10–K filing for the 

fiscal year ending September 30, 2014, https://www.sec.gov/Archives/edgar/data/1608638/ 

000119312514445499/d798786d10k.htm. 3 Civitas Solutions, Inc., U.S. Securities and Exchange Commission, 2017 10–Q filing for the 

quarterly period ending March 31, 2017, https://www.sec.gov/Archives/edgar/data/1608638/ 

000160863817000017/civi3311710q.htm. 4 U.S. Department of Health and Human Services, Administration for Children and Families, 

Children’s Bureau, ‘‘Child Maltreatment 2015,’’ Report, January 2017, https://www.acf.hhs.gov/ 

sites/default/files/cb/cm2015.pdf. 5 U.S. Department of Health and Human Services, Administration for Children and Families, 

Children’s Bureau, ‘‘Trends in Foster Care and Adoption,’’ Published: June 30, 2016, last reviewed: March 13, 2017, https://www.acf.hhs.gov/cb/resource/trends-in-foster-care-and-adoption-fy15. 6 U.S. Department of Health and Human Services, Administration for Children and Families, 

Children’s Bureau, ‘‘Foster Care Statistics 2015,’’ Report, pp. 2–4, March 2017, https:// 

www.childwelfare.gov/pubpdfs/foster.pdf. 

services within the context of the larger child welfare system. One 

specific private company, The MENTOR Network (hereinafter, 

‘‘MENTOR’’), was used as a case study in order to highlight some 

of the problems that exist with the privatization of human services 

in general. At the time the Committee initiated the investigation, 

MENTOR reported it was the ‘‘leading provider of home- and community-based health and human services to must-serve individuals 

and families.’’ 2 MENTOR continues to make this claim today.3

This report documents the findings of this investigation and reveals problems with child welfare contracting practices as well as 

public agency oversight of such contracts and services. 

II. OVERVIEW OF THE PROBLEM AND JUSTIFICATION 

FOR THE COMMITTEE INVESTIGATION 

A. CHILD ABUSE AND NEGLECT AND FOSTER CARE

According to the National Child Abuse and Neglect Data System 

(NCANDS), in 2015 there were 683,000 children who were victims 

of abuse or neglect in the United States, representing a rate of 9.2 

victims per 1,000 U.S. children.4 In instances where children are 

abused or neglected and cannot safely remain at home or with relatives, they are placed in foster care. According to the Adoption 

and Foster Care Analysis and Reporting System (AFCARS), 

671,000 children were served by the foster care system in 2015 either because they were already in foster care, or because they 

newly entered foster care that year.5 When children are placed in 

foster care, they are most often placed in one of three settings: 

nonrelative foster care (45%), relative/kinship care (30%), or 

institutions/group homes (14%).6 Foster care placements can occur 

either through a child’s State or public child welfare agency, or 

through private entities that contract with public child welfare 

agencies to find placements for children. These private organizations can be non-profit or for-profit agencies. The private agencies 

that were the focus of this report (specifically MENTOR) provide 

non-relative foster care for children outside of institutional settings. 

B. FEDERAL FINANCING OF FOSTER CARE SERVICES

The Committee has jurisdiction over many areas of public finance including the Internal Revenue Code, major health-care programs such as Medicare and Medicaid, and Social Security. Federal 

4 

7 U.S. Social Security Administration, Social Security Act of 1935, https://www.ssa.gov/history/35act.html. 8 U.S. Senate Finance Committee, ‘‘No Place to Grow Up: How to Safely Reduce Reliance on 

Foster Care Group Homes,’’ Committee Hearing, 114th Congress, May 19, 2015, https:// 

www.finance.senate.gov/imo/media/doc/20209.pdf. 9 U.S. Senate Finance Committee, ‘‘A Way Back Home: Preserving Families and Reducing the 

Need for Foster Care,’’ Committee Hearing, 114th Congress, August 4, 2015, https://www. 

finance.senate.gov/imo/media/doc/20779.pdf. 10 U.S. Senate Finance Committee, ‘‘Examining the Opioid Epidemic: Challenges and Opportunities,’’ Committee Hearing, 114th Congress, February 23, 2016, https://www.finance. 

senate.gov/imo/media/doc/23291.pdf. 

child welfare policy is largely guided by the Social Security Act, 

originally established in 1935.7 Foster care services are partly 

funded through titles IV–B and IV–E of the Social Security Act. In 

addition, services and supports for children and their families, including foster care, can be funded through title XX and title IV– 

A of the Social Security Act. Federal assessment and monitoring of 

State child welfare systems are also covered by title IV–E. Thus, 

potential misuse or mismanagement of these funds to place children in foster homes where they may potentially be unsafe is of 

keen interest to the Committee. 

C. RECENT COMMITTEE HISTORY ON FOSTER CARE

AND RELATED ISSUES

The Committee and its members have a long history of working 

to improve the State and Federal child welfare systems. For decades, the child welfare advocacy and provider communities, as well 

as families and children impacted by the system, have recognized 

that the government is no substitute for a family when it comes to 

raising children. Frequent news stories highlighting traumatic experiences children in foster care sometimes face have led Congress 

to take steps to improve the system in two key ways: first, to do 

more to ensure that foster care is an intervention used only when 

in the best interest of the child; and second, to ensure that when 

foster care is necessary, it is of the highest possible quality and 

promotes normalcy. 

In the 114th Congress, the Committee held several hearings and 

roundtable discussions related to the child welfare system, its incentives, and its funding structure. Specifically, in May 2015, the 

Committee held a hearing entitled ‘‘No Place to Grow Up: How to 

Safely Reduce Reliance on Foster Care Group Homes.’’ 8 The purpose of the hearing was to examine how Congress can best address 

the challenges facing foster children and protect them from the 

unfit environment and risk of sex trafficking found in group homes. 

In August 2015, the Committee held a hearing entitled, ‘‘A Way 

Back Home: Preserving Families and Reducing the Need for Foster 

Care.’’ 9 Its purpose was to explore safe alternatives to foster care 

and better understand the interventions, services, and funding 

mechanisms States and Tribes are using—or would like to use—to 

help keep families and children safely together. And in February 

2016, the Committee held a hearing entitled ‘‘Examining the 

Opioid Epidemic: Challenges and Opportunities.’’ 10 The purpose of 

this hearing was to examine the opioid abuse epidemic and its effect on the health and child welfare systems, as well as to consider 

solutions. Committee members heard testimony detailing the links 

5 

11S. 3065: ‘‘Family First Prevention Services Act of 2016,’’ 114th Congress, https:// 

www.congress.gov/bill/114th-congress/senate-bill/3065; see also: Kelly, John, ‘‘Massive child 

welfare Finance bill planned for 2016,’’ The Chronicle of Social Change, December 18, 2015, 

https://chronicleofsocialchange.org/child-welfare-2/massive-child-welfare-finance-bill-plannedfor-2016/14890. 12 H.R. 5456: ‘‘Family First Prevention Services Act of 2016, Actions/Overview,’’ 114th Congress, https://www.congress.gov/bill/114th-congress/house-bill/5456/actions. 13 Roston, Aram and Singer-Vine, Jeremy, ‘‘Fostering Profits,’’ BuzzFeed News, February 20, 

2015, https://www.buzzfeed.com/aramroston/fostering-profits?utm_term=.xwMQrm3yR#.qfOw 

1kDqO. 14 Joseph, Brian, ‘‘The Brief Life and Private Death of Alexandria Hill,’’ Mother Jones, October 

26, 2015, http://www.motherjones.com/politics/2015/02/privatized-foster-care-mentor/. 

between rising opioid use and fatalities and the corresponding 

strain on State foster care systems. 

As a result of these hearings and working closely with stakeholders from the foster care provider community, State groups, advocates, and current and former foster youth, the chairman and 

ranking member developed a bipartisan proposal, ‘‘The Family 

First Act.’’ Working with House Ways and Means Committee 

Chairman Brady and Ranking Member Levin, Chairman Hatch 

and Ranking Member Wyden introduced the bipartisan/bicameral 

‘‘Family First Prevention Services Act of 2016’’ (H.R. 5456/S. 

3065).11 The House of Representatives passed H.R. 5456 by voice 

vote on June 21, 2016.12 The goal of this legislation was to increase 

the availability of prevention services so that more children can 

stay at home with their families and avoid the trauma associated 

with foster care when safely possible. The legislation also aimed to 

reduce the unnecessary use of congregate care and group homes. 

While the legislation ultimately was not enacted into law, the 

Committee continues to work to advance the goals of the legislation. The findings of this investigation underscore the importance 

of holding States accountable for their child welfare system management and outcomes, as well as providing States with the tools 

necessary to improve their capacity to both prevent foster care 

(when it is possible to do so without jeopardizing the safety of children) and to ensure that children who enter foster care are safe 

from harm. 

D. INITIAL MEDIA REPORTS ABOUT FOR-PROFIT FOSTER

CARE AND CHILDREN’S DEATHS

In 2015, BuzzFeed News 13 and Mother Jones 14 reported similar 

stories concerning the private, for-profit foster care company, MENTOR. The reports provided evidence of a company that prioritizes 

profits over children’s well-being; a company that skirted corners 

when screening foster parents, that increased social workers’ caseloads, that hired unlicensed workers, and whose primary mission 

was to ‘‘fill beds’’ in order to increase company profits. According 

to these reports, children were placed in homes with individuals 

who had been convicted of kidnapping and other serious crimes, 

with parents who had substance abuse problems, and in homes 

where caretakers had previous ‘‘failed’’ foster care placements. 

Some children were deprived of emotional care, were sexually 

abused, and even beaten to death in their foster homes. The news 

articles included both allegations of wrong-doing and information 

that was substantiated through criminal trials and lawsuit settlements to families of the children who had been harmed. 

6 

15McBeath, Bowen, Collins-Camargo, Crystal, and Chuang, Emmeline, ‘‘Portrait of Private 

Agencies in the Child Welfare System: Principal Results From the National Survey of Private 

Child and Family Serving Agencies,’’ National Quality Improvement Center on the Privatization 

of Child Welfare Services, September 2011, http://muskie.usm.maine.edu/helpkids/public 

privateresources/nspcfsareportfinal.pdf. 16 Civitas Solutions, Inc., 2014 10–K filing (September 30, 2014). See Footnote 2. 17Theriault, Dennis C., ‘‘Foster care scandal deepens: ‘Every single staff person has a criminal 

record,’ ’’ The Oregonian, January 9, 2016, http://www.oregonlive.com/politics/index.ssf/2016/ 

01/foster_care_scandal_deepens.html. 18Walters, Edgar and Ramshaw, Emily, ‘‘Federal Judge: Texas Foster Care System Violates 

Children’s Rights,’’ The Texas Tribune, December 17, 2015, https://www.texastribune.org/2015/ 

12/17/judge-foster-care-system-violates-childrens-rights/. 19 Blinder, Alan, ‘‘Suit Alleges Widespread Deficiencies in South Carolina Foster Care,’’ The 

New York Times, January 12, 2015, https://www.nytimes.com/2015/01/13/us/suit-allegeswidespread-deficiencies-in-south-carolina-foster-care.html?_r=2. 20 Conway, Abby Elizabeth, ‘‘Report Finds ‘Blatant Lack of Oversight by DCF’ in Licensing 

of Foster Home Where Toddler Died,’’ WBUR News, October 1, 2015, http://www.wbur.org/ 

news/2015/10/01/auburn-foster-child-death-investigation. 21 Hines, Doug, ‘‘State Must Step up on Foster Care Deaths,’’ The Courier, June 11, 2017, 

http://wcfcourier.com/opinion/editorial/state-must-step-up-on-foster-care-deaths/article_b4d69f 

95-4402-54ac-a294-83ce38eb1625.html. 22Serres, Chris, ‘‘Minnesota faces penalties for failed placements of foster children,’’ The Star 

Tribune, February 10, 2014, http://www.startribune.com/state-faces-penalties-for-failed-placements-of-foster-children/244571021/. 

The Committee received numerous questions and expressions of 

concern from the public as a result of these news accounts. The 

chairman and ranking member also felt strongly that the allegations in the press accounts deserved a more thorough examination. 

As a result, the chairman and ranking member directed the majority and minority oversight teams to investigate the issue of privatization within the foster care system using MENTOR as a case 

study, as it is among the largest providers of private foster care 

services in the United States.15, 16 Because the Committee did not 

conduct an in-depth investigation of other providers, direct comparisons cannot be made with other private providers. However, it 

did collect State-level data on the performance of other for-profit 

and non-profit providers, and it is also notable that MENTOR is by 

no means alone when it comes to negative attention and questionable practices. For example, the following headlines demonstrate 

that contracting practices, provider quality, and inadequate oversight issues are rampant across States and providers: 

• ‘‘Foster care scandal deepens: ‘Every single staff person has 

a criminal record’ ’’ (The Oregonian, January 9, 2016).17

• ‘‘Federal Judge: Texas Foster Care System Violates Children’s Rights’’ (The Texas Tribune, December 17, 2015).18

• ‘‘Suit Alleges Widespread Deficiencies in South Carolina Foster Care’’ (The New York Times, January 12, 2015).19

• ‘‘Report Finds ‘Blatant Lack of Oversight By DCF’ In Licensing of Foster Home Where Toddler Died’’ (WBUR News, October 1, 2015).20

• ‘‘State Must Step up on Foster Care Deaths’’ (The Courier, 

June 11, 2017).21

• ‘‘Minnesota Faces Penalties for Failed Placements of Foster 

Children’’ (The Star Tribune, February 10, 2014).22

E. MENTOR AND PRIVATE FOSTER CARE AGENCIES

MENTOR, headquartered in Boston, Massachusetts, is a for-profit service agency that describes itself as a ‘‘national network of 

local health and human services providers in 35 States offering an 

7 

23 ‘‘The MENTOR Network.’’ Available on the company’s website, http://thementornetwork 

.com/. 24On its own, Vestar owns 53% of the company’s shares according to the Civitas Solutions, 

Inc. U.S. Securities and Exchange Commission 2016 10–K filing for the fiscal year ending September 30, 2016, https://www.sec.gov/Archives/edgar/data/1608638/000162828016022032/ 

civi-930201610xk.htm. 25 Civitas Solutions, Inc., 2014 10–K filing (September 30, 2014). See Footnote 2. 26The Committee began its investigation in 2015, which is why 2014 SEC information is reported here. See Footnote 2. 27McBeath, B., Collins-Camargo, C., and Chuang, E. See Footnote 15. 28 Civitas Solutions, Inc., 2014 10–K filing (September 30, 2014). See Footnote 2. 29McBeath, B., Collins-Camargo, C., and Chuang, E. See Footnote 15. 30Statement by Civitas Solutions: ‘‘We derive approximately 90% of our revenue from contracts with state and local government agencies, and a substantial portion of this revenue is 

state-funded with federal Medicaid matching dollars,’’ 2014 10–K filing, p. 16. See Footnote 2. 31 Roston, A. and Singer-Vine, J. See Footnote 13. 

array of quality, community-based services to adults and 

children[. . .].’’ 23 It is owned by Civitas Solutions, Inc., a publicly 

traded company. Civitas is majority owned (approximately 68%) by 

Vestar Capital Partners and management investors.24 Public investors hold roughly 32% of the company according to the company’s 

filings with the Securities and Exchange Commission (SEC).25 The 

group emphasizes its work with higher-risk youth in foster care, 

particularly those with intellectual or developmental disabilities, or 

who are medically fragile. 

According to information reported in MENTOR’s SEC filings for 

2014, it was the leading provider of human services to 29,100 clients in 36 States during that year—12,600 in residential settings 

and 16,500 in non-residential settings.26 With regard to the foster 

care population, which is the focus of the Committee’s investigation, MENTOR served 10,300 at-risk children, adolescents, and 

their families in 18 different States in 2014. By way of comparison, 

according to a 2011 national survey of non-profit and for-profit private child welfare agencies conducted by the National Quality Improvement Center on the Privatization of Child Welfare Services, 

only 13 child and family-serving agencies, or 3%, provided services 

in more than one State.27 This survey also showed that nationally 

the largest private agency budgets range from $17 million to $140 

million. Again, for comparison, in 2014 MENTOR reported to the 

SEC that its gross revenue for serving at-risk youth was $203 million and that its net revenue for this same population was about 

$198 million.28 Private child welfare agencies across the country 

largely rely on public government contracts in order to provide 

services to children and families. In 2011, half of the surveyed child 

and family-serving agencies reported that almost 100% of their revenue came from public contracts.29 This is also the case for MENTOR.30

The Committee focused on MENTOR’s work as a provider of foster care services, since it was one of the largest providers of those 

services nationally. At the time the Committee began its investigation, MENTOR provided foster care services to thousands of children who are involved with their State’s child welfare system. As 

recently as 2015, MENTOR provided foster care services to children in 15 different States.31 Since the Committee launched its investigation, MENTOR has withdrawn from a number of States. 

During FY 2015, MENTOR discontinued at-risk youth services in 

8 

32 Civitas Solutions, Inc., 10–Q filing for the period ending March 31, 2017, p. 20. See Footnote 

3. (Note: Illinois terminated its contract with AHS/MENTOR on July 1, 2015.) 33 Boyd, Laura W., ‘‘Therapeutic Foster Care: Exceptional Care for Complex, TraumaImpacted Youth in Foster Care,’’ State Policy Advocacy and Reform Center, Report, July 2013, 

https://childwelfaresparc.files.wordpress.com/2013/07/therapeutic-foster-care-exceptional-carefor-complex-trauma-impacted-youth-in-foster-care.pdf. 34Medicaid and CHIP Payment and Access Commission (MACPAC), ‘‘Report to Congress on 

Medicaid and CHIP,’’ Report, June 2015, https://www.macpac.gov/wp-content/uploads/2015/ 

06/June-2015-Report-to-Congress-on-Medicaid-and-CHIP.pdf. 35Gonyea, J.G., Bachman, S.S., Rajabiun, S., Springwater, J.S., Tobias, C.R., Hirschi, M. and 

Little, F., ‘‘The 50 State Chartbook on Foster Care.’’ Retrieved March 28, 2017. As originally 

cited on p. 5 of the MENTOR Mortality Report in Appendix G, Exhibit 1, http://www.bu.edu/ 

ssw/research/usfostercare/. 36The MENTOR Network, ‘‘Backup Data and Explanation of Mortality Analysis Final,’’ March 

2016. Supplied by MENTOR to the Finance Committee. See Appendix G, Exhibit 2. 37Statements by Civitas Solutions: ‘‘We derive approximately 90% of our revenue from contracts with state and local government agencies, and a substantial portion of this revenue is 

state-funded with federal Medicaid matching dollars,’’ p. 16; ‘‘We derive revenues for our I/DD 

and ARY services and a significant portion of our SRS services from Medicaid programs,’’ p. 9. 

See Footnote 2. 38See Appendix A for the complete 50-State Overview Letter. 

the States of Florida, Louisiana, Indiana, North Carolina, and 

Texas.32

F. THERAPEUTIC FOSTER CARE

In representations to the Committee, MENTOR claims to largely 

serve high-risk children classified as in need of therapeutic foster 

care (TFC) because they are medically complex or fragile. There is 

no uniform definition of TFC in the field or in statute, but the Foster Family-based Treatment Association describes it as ‘‘a clinical 

intervention, which includes placement in specifically trained foster 

parent homes, for youth in foster care with severe mental, emotional, or behavioral health needs. This includes medically fragile 

or developmentally delayed youth whose physical and emotional 

health needs require more intensive clinical and medical intervention than can be accommodated in traditional foster care.’’ 33

Many States claim reimbursements from Medicaid for components of TFC services. A 2015 report by the Medicaid and CHIP 

Payment and Access Commission noted that 3% of child Medicaid 

enrollees receive TFC services.34 States may also claim reimbursement under title IV–E for some of the costs associated with TFC. 

There is significant variation across States and providers both with 

regard to eligibility for and the provision of services related to TFC. 

A study that was commissioned and funded by MENTOR showed 

that 17.3% of U.S. children in foster care were in TFC-level placements.35 MENTOR reports that 75% of its caseload is comprised of 

TFC-level placements.36 In its 2014 SEC filings, MENTOR reported 

billing Medicaid for the provision of at-risk youth services.37

III. THE COMMITTEE’S INVESTIGATION AND SURVEYS 

OF THE STATES: FOSTER CARE SERVICES AND PERFORMANCE 

A. THE 50-STATE OVERVIEW LETTER AND REQUEST

In April 2015, the Committee requested information from all 50 

governors regarding their States’ privatization of child welfare and/ 

or foster care services.38 For example, the Committee asked each 

State to describe its process used to select and contract with private agencies providing child welfare services as well as the process 

9 

39The States that responded: Alabama, Alaska, Arkansas, California, Colorado, Connecticut, 

Delaware, Guam, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, 

Minnesota, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Dakota, 

Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Utah, Washington, West 

Virginia, Wisconsin, and Wyoming. 40See Appendix C for copies of the 5-State In-Depth letters. 

used to inspect the safety of foster care settings in which children 

are placed. The Committee also asked States to outline how they 

investigate and respond to allegations and substantiations of maltreatment when a child is in out-of-home care. Thirty-three (33) 

States responded to that request with information prepared by 

their child welfare administrators (see Appendix B for State responses to the 50-State Overview Letter).39

B. THE 5-STATE IN-DEPTH LETTER AND REQUEST

In March 2016, the Committee sent in-depth inquiries to five 

States regarding their child welfare operations in order to obtain 

more information about MENTOR and its affiliates as well as other 

for-profit and non-profit providers in each State.40 The request for 

additional information was sent to the directors of the State child 

welfare agencies in Georgia, Illinois, Maryland, Massachusetts, and 

Texas. These States were selected because they were served by 

MENTOR and highlighted in news accounts that documented serious allegations of mismanagement of services and mistreatment of 

children served by private foster care agencies. As of today, MENTOR still provides foster care services in Georgia, Maryland, and 

Massachusetts; it no longer provides those services in Illinois or 

Texas. The primary goal of the request for additional information 

was to compare performance indicators of the public agencies and 

private agencies providing foster care services. The Committee 

sought information related to standard performance measures for 

foster care using the Child and Family Services Reviews’ (CFSRs) 

performance metrics as a basis (see subsection C below). Among the 

many questions directed to the State agencies, SFC staff focused on 

the following information from these select States: 

• Physical and behavioral subgroups (special needs, physically 

disabled, infants, etc.); 

• Maltreatment during a foster care episode; 

• Rate of maltreatment in foster care; 

• Permanency outcomes (reunification, adoption, guardianship); 

• Physical and mental health screenings of children in foster 

care; 

• Children receiving monthly caseworker visits; 

• Average caseload for each caseworker employed by the contractor; and 

• Total cost to the State under the contract. 

Four out of five States complied with the Committee’s request for 

this detailed information. Despite repeated contact with the Commonwealth of Massachusetts, its public child welfare agency never 

10 

41For purposes of clarification, Massachusetts did respond to the initial 50-State Letter to 

provide overview information about their State, but did not submit any documentation to the 

Committee in response to the 5-State In-Depth Letter. 42 Illinois Department of Children and Family Services, Division of Quality Assurance and Research. ‘‘Alliance/Illinois MENTOR Statewide Specialized Foster Care Review,’’ Report, August 

8, 2014, Print. 43Stoltzfus, Emilie, Memorandum prepared by the Congressional Research Service: ‘‘Statewide data indicators used in the Child and Family Services Review (CFSR),’’ October 27, 2016. 

Available in Appendix D. 

complied with official requests from the Committee to provide the 

requested in-depth information.41

In addition to the performance metrics, the Committee also 

asked these five States for copies of any rankings or reviews of contractors, as well as performance and investigative reports of MENTOR, particularly in the case of reports relating to the death, sexual abuse, or injury to a child while in the care or custody of foster 

parents recruited or employed by MENTOR. Each of the four responding States complied with this request. In addition, Illinois 

provided Committee staff an extensive ‘‘Statewide Specialized Foster Care Review’’ focused on Alliance Human Services/Illinois 

MENTOR, which was conducted prior to the State terminating 

services with the company.42 (The Committee’s initial official requests for information from State child welfare agencies are in Appendices A and C.) 

C. U.S. HHS CHILD AND FAMILY SERVICES REVIEWS

The Children’s Bureau in U.S. Department of Health and Human 

Services (HHS) conducts Child and Family Services Reviews 

(CFSRs), which are periodic reviews of State child welfare systems, 

to achieve three goals: (1) ensure conformity with Federal child 

welfare requirements; (2) determine what is actually happening to 

children and families as they are engaged in child welfare services; 

and (3) assist States in helping children and families achieve positive outcomes. The first CFSR round began in 2001. HHS is currently conducting the third round of CFSRs between 2015 and 

2018. In October 2016, SFC staff asked the Congressional Research 

Service (CRS) to provide a compilation and ranking of State-level 

data and indicators from AFCARS that are used in the CFSR assessments (see Appendix D).43 The CRS analysis provided the Committee with national data concerning the performance of all States 

in the country, including those States that did not respond directly 

to the Committee’s requests. 

D. THE MENTOR LETTER AND REQUEST

The Committee sent its first letter to Bruce Nardella, the President and CEO of MENTOR, in June 2015. This initial letter and 

correspondence requested information about the company’s structure, performance, and standards. Specifically, the Committee requested the total number of children served nationwide; copies of 

assessments and performance reviews conducted on MENTOR; average caseloads of MENTOR caseworkers; processes for investigating, vetting, and training potential foster parents; details surrounding the use of bonuses for placing children; processes for handling allegations of misconduct against foster caregivers; copies of 

settlement agreements entered into by MENTOR since 2005; total 

11 

44 In Illinois, for example, MENTOR operated under the name Alliance Human Services. 45 Response from Texas to the 50-State Overview Letter, Appendix B, Exhibit 29. 46 Response from Delaware to the 50-State Overview Letter. 47Massachusetts, Department of Children and Families, Letter to SFC, June 10, 2015, p. 1. 

The full response is listed in Appendix B, Exhibit 16. 48Maryland, Department of Human Resources, Letter to SFC, July 20, 2015, p. 1. See full 

response listed in Appendix B, Exhibit 15. 

funding received from States; nondisclosure/confidentiality clauses; 

and critical incident reports. Additionally, because MENTOR operates under different names in different States, questions regarding 

its corporate structure, affiliates, and related organizations were 

asked as well.44 (The Committee’s official request for information 

from MENTOR is available in Appendix E.) 

IV. FINDINGS FROM THE COMMITTEE’S 

INVESTIGATIONS AND SURVEYS 

A. USE OF PRIVATE CHILD WELFARE SERVICES

One of the first goals of the Finance Committee’s investigation 

was to determine the extent to which States use or rely on contracted child welfare services. Information obtained by the Committee from the initial 50-State Letter shows that of the 33 States 

that responded, 31 use private agencies to provide services to children in foster care and 16 of these States contract with for-profit 

and non-profit providers. The nature of contracted services provided by the entities described in responses to the 50-State Letter 

varied considerably. Twenty States volunteered that services from 

private providers are targeted toward the specialized population of 

youth needing TFC. With the exception of two States, administrators were adamant that they were obligated to provide oversight— 

and that they provided this oversight—of all foster care placements. According to the responses, private agencies might recruit, 

screen, train, and provide case management services to foster families, but the public agencies were responsible for approving all 

placements and for ensuring that children were living in safe conditions. For example, Texas wrote that children are placed in 

homes that are ‘‘directly overseen by child protective services.’’ 45

Delaware wrote that the State ‘‘retain[s] . . . legal and case management responsibilities for meeting the needs of all children in 

foster care, whether they are placed in a [public] foster home or 

private provider home. . . .’’ 46

Other States reported inconsistent information. For example, 

Massachusetts reported that the public agency handles 96% of 

placements for the almost 11,000 children in the State who are in 

out-of-home care. Cases that involve a conflict of interest with the 

child welfare agency (for example, employees who are the subject 

of maltreatment allegations), adoptions, or unaccompanied refugees 

who are minors are handled by private contract agencies. Nevertheless, in that same response, Massachusetts also reported statistics showing that roughly 35% of its foster care caseload is managed by a contracted agency.47 Similarly, Maryland reported ‘‘we 

contract with private providers for placement services only,’’ but 

then went on to say ‘‘100% of Maryland foster youth are placed by 

the public agency.’’ 48 Oregon listed two county-run shelters and a 

12 

49 United States District Court, District of Oregon, Portland Division, United States of America 

v. Mary Holden Ayala, 3:16–CR–00495–HZ; https://www.justice.gov/usao-or/press-release/file/ 

965436/download; Lincoln County, Oregon Juvenile Shelter website; http://www.co.lincoln.or. 

us/juvenile/page/shelter; Douglas County, Oregon Juvenile services website, http://www.co. 

douglas.or.us/departments.asp#Juvenile. 50Theriault, Dennis C., ‘‘Oregon accuses foster care provider of ‘plundering’ $2 million in state 

funds,’’ The Oregonian, October 15, 2015. Updated: October 16, 2015, http://www.oregonlive. 

com/politics/index.ssf/2015/10/oregon_accuses_foster_care_pro.html. 51 Illinois DCFS Letter to SFC, December 15, 2015, pp. 2–3. Full response is listed in Appendix B, Exhibit 10. 

Youth Villages facility as ‘‘for-profit’’ entities when other sources 

identified these entities as non-profits.49 News reports out of Oregon also show how the non-profit/for-profit distinction can be 

abused, and even non-profit entities can be used for financial gain. 

For example, the director of the now-shuttered Oregon foster care 

provider ‘‘Give Us This Day’’ was accused of using three non-profit 

organizations to buy property for personal use ($100,000), remodel 

and furnish her home ($213,000), and pay for trips, meals, clothes, 

and beauty expenses including cosmetic surgery ($249,800).50

When asked what types of services private agencies provide, 21 

States indicated they were used for case management, even if this 

task was shared or duplicative of services provided by the public 

agency. Twenty-eight States indicated that private agencies provide 

support, services, or training to foster families. All States have licensing standards, but only six (California, Kansas, Kentucky, Illinois, Tennessee, and Texas) reported that they require all of the 

agencies that contract with the State to be accredited. In addition, 

some States, such as Illinois, use benchmarks that private agencies 

are expected to meet, such as an annual permanency rate of 40%. 

The business model is to reward top-performing agencies with ‘‘a 

greater share of new, incoming foster cases.’’ 51

MENTOR is one of the largest contractors providing foster care 

services in many of the States the Committee staff examined. Information provided by Texas in response to the 5-State In-Depth Letter showed that when combining the number of children served 

from all MENTOR jurisdictions, it ranked either 5th or 6th in total 

size among all Texas private child welfare agencies from 2010– 

2013, before Texas stopped contracting with the company. It was 

always the largest for-profit provider. In Maryland, for each of the 

years the Committee staff reviewed in-depth information, MENTOR always had the highest number of children receiving contracted services among all providers. 

With regard to the financing of private child welfare services, information from the four States that responded to the 5-State InDepth Letter shows that between 2010 and 2015, these States 

spent between $63 million and $291 million annually on private 

child welfare services. Roughly 20% of these expenditures went to 

pay for-profit agencies for services. This means these States paid 

between $18 million and $50 million annually to companies that 

profited from children and families involved with the foster care 

system. Using MENTOR as an example, in 2015 MENTOR Maryland was paid an average of $47,542 per foster child, for a total approaching $16 million. The contractor with the highest annual rate 

per child in 2015 in this one State was paid an average of $69,242 

per child. 

13 

52 Response from California to 50-State Overview Letter. See Appendix B, Exhibit 4. 53 Joseph, Brian. See Footnote 14. 54 Ansari, Talal, and Roston, Aram, ‘‘Parent at Nation’s Leading For-profit Foster Care Firm 

Facing Murder Charges,’’ BuzzFeed News, February 23, 2016, https://www.buzzfeed.com/ 

talalansari/parent-at-nations-leading-for-profit-foster-care-firm-facing?utm_term=.nkGzyWJJD#. 

od1APe11V. 55 Roston, A. and Singer-Vine, J. See Footnote 13. 56MENTOR bates numbers 0001822–1823. 

B. BACKGROUND CHECKS

All of the States that responded to the Committee’s 50-State 

Overview Letter described, in various levels of detail, how they assess children’s safety in out-of-home placements and specifically 

among potential or current foster parents. Sometimes there were 

variations in public versus private settings, but all described a 

process that involves some version of a State criminal background 

check, a national or Federal background check, and a check into 

their own State’s child abuse and neglect registry—and sometimes 

in registries of other States where potential foster parents have recently lived. Some States volunteered information showing or suggesting that positive findings of criminal activity or a history of 

maltreating children do not automatically close a door to family 

foster care. For example, California wrote: ‘‘For persons with criminal convictions, the Department of Justice provides the county 

child welfare agency with the record information report [which is 

reviewed], to determine whether the crimes are those for which an 

exemption may be granted.’’ 52 These kinds of exemptions and 

waivers turned up in the materials reviewed by Committee staff 

concerning MENTOR’s operations in other States. 

In response to inquiries from the Committee, MENTOR wrote: 

‘‘as a part of our commitment to quality, MENTOR entities conduct 

criminal and non-criminal background checks on prospective foster 

parents in accordance with local/State requirements and regulations. This has always been part of our practices. Not only do background checks support our rigorous vetting efforts to find the most 

qualified, caring foster parents, they are also a requirement of the 

States and referring agencies with whom we partner.’’ Yet, several 

news accounts tell a different story.53, 54 Most notably is one media 

account which notes that MENTOR placed children in a home with 

a household member who had previously been convicted of aggravated kidnapping and robbery when she kidnapped a pregnant convenience store employee.55 Similarly, the Committee staff determined that MENTOR is often out of compliance with its own guidelines, as well as State guidelines, with respect to conducting background checks of those who care for foster children or those who 

are routinely in homes where foster children are placed. In the 

State of Texas, case records showed that on four separate occasions 

in an 8-month period, MENTOR was instructed to conduct background checks on a frequent visitor to a foster home. That check 

was never completed.56

Even when MENTOR met background screening guidelines, it 

sometimes waived the outcomes of the findings. For example, in 

the Committee staff’s investigation of documents from MENTOR 

Maryland, the Committee staff found that the husband of a foster 

parent, who was later convicted of sexually abusing foster children 

in their home, had been the subject of four previous abuse allegaVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
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57 Notes from MENTOR Texas Documents: Clemon and Sherill Small Case. 58 Joseph, Brian. See Footnote 14. 59 Roston, A. and Singer-Vine, J. See Footnote 13. 60 U.S. General Accounting Office, ‘‘Child Welfare: HHS Could Play a Greater Role in Helping 

Child Welfare Agencies Recruit and Retain Staff,’’ Report to Congressional Requesters, No. 

GAO–03–357, March 2003, http://www.gao.gov/new.items/d03357.pdf. 61 Illinois DCFS Report. See Footnote 42. 62Garner, Bryan R., Hunter, Brooke D., Modisette, Kathryn D., Ihnes, Pamela C., and Godley, 

Susan H., ‘‘Treatment staff turnover in organizations implementing evidence-based practices: 

turnover rates and their association with client outcomes,’’ Journal of Substance Abuse Treatment, March 2012, pp. 134–142, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3268938/. 

See also U.S. Department of Health and Human Services, Substance Abuse and Mental Health 

Services Administration, ‘‘Report to Congress on the Nation’s Substance Abuse and Mental 

Health Workforce Issues,’’ January 24, 2013, https://www.google.com/url?sa=t&rct=j&q=&esrc= 

s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiZ_avJka_VAhWG5yYKHajECAMQFggo 

MAA&url=https%3A%2F%2Fstore.samhsa.gov%2Fshin%2Fcontent%2FPEP13-RTC-BHWORK% 

2FPEP13-RTC-BHWORK.pdf&usg=AFQjCNGxewm3bHzmpsqu5zeWfUdqYhVpiw. 

tions. The MENTOR worker marked in handwriting on the criminal background search results, ‘‘Not Mentor [sic] parent,’’ presumably indicating that the husband’s criminal history was irrelevant 

because the foster mother was the primary caretaker. Similarly, 

MENTOR Texas noted in documentation provided to the Committee that in one case potential foster parents reported that they 

or family members had been convicted of a crime, but no further 

information was provided. The exact quote is: ‘‘Yes, no description 

given.’’ 57 These individuals went on to become MENTOR foster 

parents, and the foster mother killed a 3-year-old foster child by 

blunt force trauma to the head.58

In another case reviewed by Committee staff, during the vetting 

process for one particular set of MENTOR foster parents in Maryland, the foster father indicated that he had a preference for 

‘‘white, male children.’’ This was not seen as a red flag to the agency. Male children who were subsequently placed with this MENTOR foster parent were sexually abused. In fact, media accounts 

report that children who disclosed abuse were not believed at first 

and were instead sent back to live with their abusive foster father. 

Eventually a foster child was believed and the case moved through 

the legal system.59

C. CHILD WELFARE WORKFORCE OPERATIONS

AND CONCERNS

Caseworker Turnover. The child welfare field consistently has 

high rates of turnover among its workforce. The national range of 

turnover among child welfare workers is 30–40% annually.60 When 

there is movement among staff, children are often served by many 

different caseworkers, which can make it difficult for children to 

form relationships with their caseworkers, for caseworkers to put 

together a treatment plan for children, and for cases to be adequately monitored.61, 62 Many records and news accounts referenced the high turnover rate among staff at MENTOR; it was of 

keen interest to the Committee staff to examine this at the State 

and provider level. 

Illinois reported that MENTOR had trouble maintaining qualified staff. Its overall turnover rate for caseworkers was actually 

consistent with national norms, but the turnover rate for therapists 

working with MENTOR children was 44% in 2012. At one Illinois 

site, the turnover rate for therapists was 80% in 2013. In this same 

year, the turnover rate for MENTOR child welfare program direcVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00022 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
15 

63 Hughes, Sean and Lay, Suzanne, ‘‘Direct Service Workers’ Recommendation for Child Welfare Financing and System Reform,’’ Child Welfare League of America, January 2012. 64 Illinois DCFS Report. See Footnote 42. 

tors in Illinois was an astounding 82%. In its own periodic reviews 

of MENTOR, the State of Georgia also noted concerns about staff 

turnover. In the Macon, Georgia jurisdiction, MENTOR staff turnover reached 83%. 

Caseload Size. Another workforce issue is the size of caseloads 

that child welfare professionals carry. Despite the field’s attention 

to caseload size in the child welfare profession, Committee staff 

found it difficult to obtain this information from the States that 

were investigated. Three States that responded to the 5-State InDepth Letter do not maintain information on the average caseload 

per caseworker employed by each private contractor. Georgia indicated that it tracks this information, but it was not easily accessible to the State or the Committee, stating, ‘‘There is no comprehensive database that collects average caseload numbers.’’ Apparently caseload size is one of many indicators that is recorded on 

paper files during periodic onsite reviews of private foster homes 

and other similar agencies. This information is never transmitted 

into an electronic database. To further complicate matters, Georgia 

also insisted that it does not use ‘‘caseworkers,’’ per se. Instead, the 

State uses the term ‘‘case support workers,’’ a distinction which almost prevented SFC staff from obtaining any information about the 

caseload sizes in that State. 

National standards for special needs children or children requiring TFC services indicate that workers should not have more than 

10–12 cases per worker.63 Illinois contracted with MENTOR to provide TFC services at the ratio of 10 cases per worker. The State 

learned that MENTOR was not in compliance with this standard. 

In some instances the ratio was as high as 14.5 to 1.64 Even though 

Illinois required specific levels of case management, it did not 

maintain a data reporting system that would ensure these levels 

were met and monitored. Maryland indicated that, should caseloads exceed what is contracted, a corrective action plan would be 

put in place. 

Communication. Communication within the company was also 

noted to be a problem. When the State of Illinois was conducting 

its own annual review and subsequent comprehensive investigation 

of MENTOR, the Illinois team had to provide copies of the two previous reports from the Illinois Office of the Inspector General to 

MENTOR company officials, as they were not aware of the prior investigations completed by the State about their company. Nor were 

company officials aware of commitments made by previous MENTOR officers as a result of these reports. In these reports, Illinois 

child welfare administrators noted that ‘‘interagency communication issues were evident at the onset of the review.’’ 

Multiple Violations. Maryland conducted periodic reviews of 

MENTOR from 2010–2015. Each review noted any specific violation of regulations. Committee staff examined 22 quarterly reviews 

that were conducted of MENTOR Maryland. In only two of those 

quarters were no violations noted. Common and repeated violations 

included missing documentation from employee hiring, missing foster parent case files and child client case files, concerns around 

16 

65For example, in Kentucky State foster parents receive bonuses ranging from $100–$250 for 

each ‘‘resource home’’ that is successfully recruited. State of Kentucky, Department for Community Based Services, ‘‘Chapter 12.2.3: Recruitment bonus,’’ Standards of Practice Online Manual; 

http://manuals.sp.chfs.ky.gov/chapter12/22/Pages/1223RecruitmentBonus.aspx. Also, 

AdoptUSKids, which is a project of the Children’s Bureau within HHS, recommends using recruitment incentives for both staff and existing foster/adoptive parents to increase the pool of 

potential placements for children. See McKenzie Consulting, Inc., ‘‘Practitioner’s guide: Getting 

more parents for children from your recruitment efforts,’’ AdoptUSKids, https://www. 

adoptuskids.org/_assets/files/NRCRRFAP/resources/practitioners-guide-getting-more-parentsfrom-your-recruitment-efforts.pdf. 

board management and oversight of MENTOR operations, and licensing and staffing issues. In many cases, foster parents did not 

document the required hours of annual training, nor did children’s 

case files document all medical and psychiatric exams. FBI clearance checks were also incomplete in some cases. These reviews, 

over a period of 6 years, also noted frequent changes in the MENTOR Maryland Board’s composition and a high rate of staff turnover at MENTOR. 

Recruitment Bonuses. MENTOR provides incentives for recruiting new foster parents to the company. Specifically, the company provides financial incentives for employees who recruit new 

foster parents that result in the placement of a child through 

MENTOR. Employees who oversee recruitment efforts in each 

State are called ‘‘recruitment managers.’’ Between 2012 and 2014, 

MENTOR reported paying an average of $92,000 each year in bonuses to employees for foster parent recruitment, which is about 

what a State would pay annually to take care of two children who 

were placed with MENTOR families. According to MENTOR, this 

is an average of $3,800 per recipient. In addition, MENTOR also 

provides incentive payments to foster parents who recruit other foster parents to have a child placed in their home through MENTOR. 

The financial bonus for this action is $250 for each new foster 

parent/foster home. According to MENTOR records, in 2014 and 

the first 8 months of 2015, foster parents received bonuses totaling 

$126,000 for the recruitment of new foster parents, which, using 

MENTOR’s own numbers, would represent about 500 new foster 

parents. There is evidence that similar bonuses or incentives are 

used by State and other private foster care agencies as well.65

While Committee staff were unable to document a direct impact on 

child care resulting from these bonuses, further investigation regarding the use of bonuses and incentives may be warranted. 

D. PHYSICAL AND MENTAL WELL-BEING OF

CHILDREN IN FOSTER CARE

SFC staff sought to determine the physical and mental wellbeing of children in foster care and if this varied by provider type. 

According to Federal policy, all States must develop a plan for the 

oversight and coordination of health-care services for children who 

are in foster care. This plan must involve the State’s Medicaid 

agency and input from health-care and child welfare experts. One 

of the most basic elements of this plan is to determine the timeline 

under which children will have an initial health-care screening 

upon entering foster care. The American Academy of Pediatrics recommends that children and youth receive comprehensive healthVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
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66 American Academy of Pediatrics, ‘‘Fostering health: Health care for children and adolescents in foster care, 2nd edition,’’ 2005, Report, p. 22, https://www.aap.org/en-us/advocacyand-policy/aap-health-initiatives/healthy-foster-care-america/documents/fosteringhealthbook. 

pdf. 

67 U.S. Department of Health and Human Services, Office of Inspector General, ‘‘Not all children in foster care who were enrolled in Medicaid received required health screenings,’’ Report, 

OEI–07–13–00460, March 2015, https://oig.hhs.gov/oei/reports/oei-07-13-00460.pdf. 

care screenings within 30 days of entering foster care.66 States 

vary considerably in their own timelines, ranging from requiring 

health screenings within 24 hours to 30 days after a child enters 

foster care. Health-care screenings are one of the items on which 

States are assessed in the periodic CFSRs, but a 2015 review of 

children’s health-care needs and services by the Inspector General 

of HHS showed that one-third of children in foster care did not receive one of their health-care screenings. Further, one-quarter of 

the children received their health-care screening late.67

In the 5-State In-Depth Letter, States were asked to determine 

what portion of children in public State agencies and private agencies had a full physical and mental health assessment within 60 

days of entering foster care. According to the Illinois DCFS review 

of MENTOR, children being served by Illinois MENTOR did not 

have their physical or mental health needs met in a timely manner. Mental health assessments in Illinois are to be completed 

within 30 days of contact with a therapist, a standard that MENTOR met for only 60% of cases reviewed by the State. Foster children served by MENTOR in Illinois waited an average of 122 days 

before having contact with a psychotherapist. A treatment plan is 

to be established within 45 days of a mental health assessment, a 

standard that was met for only 73% of MENTOR cases reviewed 

by the State. Finally, treatment plans are to be updated every 5 

months, a standard which MENTOR met only 52% of the time. By 

way of comparison, Georgia transmitted data on physical and mental health assessments reporting compliance rates for assessments 

within 60 days of placement. The performance in this area was 

very poor for both MENTOR and the entire State, at 12% and 11%, 

respectively. 

In other instances, MENTOR ranked better than the State averages in its compliance with the 60-day mark. In Texas, the overall 

rate for the State was 73%, but for MENTOR it was 84%. A similar 

situation was true in Maryland, where overall only 60% of children 

in the State were seen by a health provider for a physical and mental health exam within 60 days of entering foster care, but MENTOR met this mark 69% of the time. 

E. FAILURE TO IDENTIFY AND RESPOND TO

RISK TO CHILDREN

The documents that were provided by MENTOR and in responses to the 5-State In-Depth Letter showed that public agencies 

and MENTOR repeatedly failed to identify and respond to the risk 

that was presented to children in out-of-home care. 

During the 2015–2016 reviews that Georgia conducted with its 

contracted service providers, the MENTOR jurisdiction in Athens 

reported 41 ‘‘significant events,’’ which included four child protection investigations (each unsubstantiated), two suicidal/homicidal 

threats, one ‘‘child-on-child sexual event,’’ and two ‘‘child-to-child 

18 

68 Joseph, Brian. See Footnote 14. 

physical confrontations.’’ Despite these reports, the State gave this 

particular MENTOR jurisdiction an overall qualitative safety score 

of 93%. Yet, of the two caregiver homes randomly selected for the 

jurisdiction’s annual review, the second home presented environmental risks to the foster children. The case notes reviewed by 

Committee staff read: ‘‘the provider stored the garden tools, rake, 

lawn mower and the bottom of a water cooler in the living room.’’ 

In this same review, one of the ‘‘well-being strengths’’ listed is 

the ‘‘documentation of the younger children’s academic needs being 

met,’’ despite the fact the review also noted the following: 

• The caregiver reported the two youth have no ambition, motivation, or life goals; • The youth refuse to attend school. . . . 

Similarly, under the category of ‘‘Well-being Areas Needing Improvement,’’ the review noted two youth failing in school, not making adequate progress, and not receiving tutoring or academic support, in addition to a lack of documentation explaining more than 

five unexcused absences. 

A MENTOR foster parent in Texas killed one of her foster children.68 Case notes reviewed by Committee staff indicate there were 

clear warning signs that the safety and well-being of children in 

her care were compromised before the fatal abuse, but Texas MENTOR failed to see the risk to the children placed with her and ultimately did not protect the children being served. MENTOR described the foster mother and her partner as ‘‘mature, responsible, 

healthy individuals capable of meeting the needs of a child placed 

in their care.’’ Yet the records also show that the foster mother reported being overwhelmed and uncertain if she could care for foster 

children. Children placed in her care were removed with ‘‘negative 

outcomes,’’ placements in the home ‘‘failed,’’ and Early Childhood 

Intervention staff felt that children should not be in this particular 

foster home. Further, the foster parents were investigated by the 

Texas Department of Family and Protective Services for concerns 

about children in their foster home. Records from MENTOR report 

that the children in this home had bruises and the foster mother 

reported that the children would make false allegations against her 

and her partner. Texas MENTOR did not terminate their license, 

but instead reinforced its commitment to working with this family 

with case records stating that MENTOR staff ‘‘agree that this family should continue to work as foster parents. . . . We will be decreasing the number of children the family is licensed to care [for] 

in efforts to ensure the family remains a Mentor [sic] family.’’ 

F. ACTIONS WHEN MALTREATMENT IS

SUBSTANTIATED IN FOSTER HOMES

All of the MENTOR children who were highlighted in media accounts and were maltreated by their foster parents were living in 

very high-risk situations. (As previously noted, in one MENTOR 

home, children had disclosed their maltreatment, but their disclosures were dismissed by those in a position to take action. The preceding section noted the presence of bruises on children and the inVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
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69 Roston, A. and Singer-Vine, J. See Footnote 13. 70 U.S. Department of Health and Human Services, Administration for Children and Families, 

Children’s Bureau, ‘‘Child Welfare Outcomes 2010–2013—Report to Congress,’’ Report, February 

1, 2016, https://www.acf.hhs.gov/cb/resource/cwo-10-13. 71Stoltzfus, Emilie, Memorandum prepared by the Congressional Research Service. See Footnote 43. 72See Appendix B, Exhibit 16—Response From Massachusetts, Office of the Governor. 73Stoltzfus, Emilie, Memorandum prepared by the Congressional Research Service. See Footnote 43. 74 ‘‘Child Welfare Outcomes 2010–2013—Report to Congress.’’ See Footnote 70. 

vestigation of maltreatment in one MENTOR home where a child 

was killed.69) As a result, in the 50-State Letter, SFC asked States 

about their procedures for when maltreatment is substantiated in 

a foster home. In such a situation, this would mean it was confirmed, founded, or substantiated that a foster child was being 

abused or neglected in his or her foster placement. According to 

data presented in a report to Congress by the U.S. Department of 

Health and Human Services, the State median of maltreatment 

among children who were in foster care from 2010–2013 was 

0.35%.70 Missouri, Wyoming, and Virginia had the lowest rates, as 

determined by the 2015 NCANDS and AFCARS datasets; the highest rates were in New York, Iowa, and Massachusetts.71

Of the 33 States that responded to the 50-State Letter, only 9 indicated that substantiation for abuse or neglect in a foster home 

would unequivocally result in the revocation of a foster home license: Arkansas, Delaware, Indiana, Kansas, Nebraska, New 

Hampshire, South Dakota, Tennessee, and Wisconsin. All of the 

other responding States report that license revocation is one possible outcome when maltreatment is substantiated. 

Many of the States compared the rates of re-victimization of children in foster care based on their foster home setting: public, private non-profit, or private for-profit. There was no evidence that 

children who were in privatized foster care settings were more likely to be re-victimized than children in publicly run foster homes. 

Some of the information provided by the States about maltreatment in foster care raised serious concerns. Massachusetts reported 

the number and percentage of substantiated child maltreatment 

episodes as a share of the total foster care population. Of the 

44,240 children in substitute care during Federal fiscal years 2010– 

2014, Massachusetts reported 739 instances of maltreatment in foster care, which is 1.67% of all children in care. 72 At face value, this 

might appear to be a relatively low rate, but as previously noted, 

it is well above the State median of 0.35%. Further, data used in 

the third round of the CFSRs shows that Massachusetts had the 

highest rate of child re-victimization in the Nation 73 and it steadily 

climbed between 2010 and 2013.74

In response to the 5-State In-Depth Letter, Maryland reported 

that it does not track the occurrence of maltreatment in foster care 

by provider or by type of provider, which means that the performance of individual contractors and type of contractor is not monitored in this way. Texas reported that ‘‘serious instances of confirmed abuse and neglect cases result in licensure revocation.’’ But, 

it only reported one instance of that happening between 2010 and 

2014, despite the fact that the State also provided the Committee 

with data showing there were 295 instances of confirmed maltreatVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
20 

75See Appendix B, Exhibit 29—Response From Texas, Department of Family and Protective 

Services. 76Maltreatment in foster care was for many years measured as a percentage of children in 

foster care who had a substantiated or indicated report of maltreatment where the perpetrator 

was coded as the child’s foster care provider (i.e., the perpetrator was the child’s foster parent 

or a staff member at a group home or institution where the foster child was placed). The State 

median data cited above, for example, uses that metric. Further, the data provided by Massachusetts and Texas on the number of children maltreated while in foster care from FY2010– 

FY2014 appears to use a similar if not identical metric. By contrast, when it separately reported a percentage of children in Texas foster care who were maltreated, the State appears to have 

made this calculation based on all reports of maltreatment of children in foster care, without 

regard to the perpetrator of the abuse or neglect. HHS has begun to move its measurement of 

maltreatment of children in foster care to include maltreatment without regard to who is the 

perpetrator. However, the new HHS calculation, which measures incidents of maltreatment for 

every 100,000 days of foster care provided by the State, also takes certain steps to ensure that 

reports of maltreatment for children in foster care do not unintentionally capture those reports 

that were responsible for bringing a child in to foster care. 77 Roston, Aram, ‘‘In an unmarked grave, a baby’s untold story,’’ BuzzFeed News, June 18, 

2015, https://www.buzzfeed.com/aramroston/in-an-unmarked-grave-a-baby-who-died-on-forprofit-foster-co?utm_term=.wt0VkV8zl#.aqARDROwG. 78 Child Abuse Prevention and Treatment Act, ‘‘2.1A.4, Assurances and requirements, Access 

to child abuse and neglect information, Public disclosures.’’ The full statute can be found at 

https://www.acf.hhs.gov/cwpm/programs/cb/laws_policies/laws/cwpm/policy_dsp.jsp?citID= 

68. 

79See Appendix F for a sample of the level IV incident reports provided by MENTOR. The 

company provided Committee staff all death-related level IV incident reports for children in foster care under MENTOR for FY2005–FY2014, with the exception of one incident report that 

could not be located by the company. In addition, Committee staff reviewed non-death-related 

level IV incident reports provided to the Committee for those years, in addition to death-related 

and non-death-related incident reports for FY2015. The Committee staff considered all of these 

reports in its analysis. Committee staff cannot draw conclusions about this full time frame given 

ment among children in foster care in that same time period. 75

Further documentation provided by Texas shows that between 

2010 and 2015 about 7% of youth in foster care had an episode of 

maltreatment against them substantiated; the rate was 8% for 

Texas MENTOR.76

There is also a troubling example from Massachusetts that was 

captured by investigative journalists where the State changed its 

determination of whether an infant died from child abuse or neglect.77 A 2-month-old infant died in a Massachusetts foster home 

that was run by MENTOR. Initially the case was ruled by the 

State as a death related to neglect because of unsafe sleeping conditions. There is a provision in Federal law which requires States 

to release information about abuse and neglect-related deaths to 

the public.78 When journalists used this provision to press the Massachusetts Department of Children and Families to release information about the infant’s death, the substantiation of neglect was 

reversed by the State—2.5 years after the death. Instead, the State 

ruled that the death was not related to neglect. This meant that 

Massachusetts was no longer required to release information about 

the circumstances relating to and causes of the infant’s death. Accordingly, this information and the record can remain sealed from 

the public. 

G. MENTOR INCIDENT REPORTS

The Committee staff requested that MENTOR submit all of its 

highest-level incident reports from FY 2005 to FY 2014 for review. 

This would allow SFC staff to investigate the most serious cases 

where children died or were seriously harmed. MENTOR submitted 

a total of 98 ‘‘level 4’’ incident reports which capture the agency’s 

most serious incidents of injury, assault, abuse, or other similar 

events; 86 involved the death of a child.79 The other cases involved 

21 

that the most recent reports were provided after the Committee staff ’s analysis and have not 

been fully reviewed. 80See the National Center for the Review and Prevention of Child Deaths, https:// 

www.ncfrp.org/. See also: Hochstadt, N.J., ‘‘Child death review teams: a vital component of child 

protection,’’ Child Welfare, 2006 July–August, 85(4): 653–70, https://www.ncbi.nlm.nih.gov/ 

pubmed/17039823. 

psychiatric admissions, allegations of sexual assault perpetrated 

against foster children, allegations of sexual assault committed by 

foster children, and accidents or injuries that happened to foster 

children. Table 1 shows that about half of the reports (45%) involved a child with a behavioral health concern and 40% involved 

a child who was medically complex. Of the cases that involved a 

death, almost three-quarters (73%, or 62 cases) of the deaths were 

listed as ‘‘unexpected,’’ which is a check box on MENTOR’s incident 

report form. 

Table 1. Summary of Incident Reports Reviewed 

Area of Assessment No. Percent 

Service Category (Indicated by MENTOR) 

Behavioral health 44 45% 

Blank 2 2% 

Juvenile Justice 3 3% 

Medically Complex 39 40% 

Missing Incident Report 1 1% 

Mentally Retarded/Dev. Delay 3 3% 

Other 6 6% 

Total 98 100% 

Death Was Expected? * 

Yes 23 27% 

No 62 73% 

Total ** 85 100% 

Was an Internal Investigation Launched? 

Yes 13 13% 

No 84 87% 

Total 97 100% 

* Calculation only includes death cases. 

** One incident report for a death was not provided to the Senate Finance Committee. 

Table 2 shows that of the deaths that were unexpected, an internal investigation was launched only 21% of the time (13 cases—set 

bold in Table 2), which suggests MENTOR does not seek opportunities to learn from unexpected critical incidents. The child welfare 

profession,80 along with many other professions including law enVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00029 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
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81See ‘‘Critical Incident Review Library’’ at The Police Foundation, https://www. 

policefoundation.org/critical-incident-review-library/. 82Wald, Heidi and Shojania, Kaveh G., U.S. Department of Health and Human Services, 

‘‘Chapter 4: Incident reporting,’’ Agency for Healthcare Research Quality—Archive. Retrieved 

March 28, 2017, https://archive.ahrq.gov/clinic/ptsafety/chap4.htm. 83 National Transportation Safety Board, ‘‘History of the National Transportation Safety 

Board.’’ Retrieved March 28, 2017, https://www.ntsb.gov/Pages/default.aspx. 84 American Academy of Child and Adolescent Psychiatry, ‘‘Oppositional defiant disorder: A 

guide for families by the American Academy of Child and Adolescent Psychiatry,’’ Report, 2009, 

https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/odd/odd_resource_center_ odd_ guide.pdf. 

forcement,81 health care,82 and transportation,83 is moving in the 

direction of increasing transparency and trying to learn from crises. 

In many cases and jurisdictions, this includes systematic reviews 

of incidents that result in unexpected deaths. The Committee staff 

also determined that in at least nine of the incidents, there were 

financial settlements paid to families of the victims. 

Table 2. Internal Investigations and Death Expected/Unexpected 

Internal Investigation? 

Death Expected? 

Total 

No Yes 

No 49 (79%) 23 (100%) 72 

Yes 13 (21%) 0 (0%) 13 

Total 62 (100%) 23 (100%) 85 

At the most basic level, MENTOR’s incident reports have typos, 

errors, inconsistencies, and missing information. More concerning 

instances include inaccurate information and diagnostically implausible conditions. For example: 

• MENTOR’s incident reports are incomplete. For example, 

several reports mention that an internal investigation is underway, but the outcome is never indicated. Similarly, other 

reports note that an investigation by law enforcement is underway, but there was never any follow-up information available from the incident reports to indicate the outcomes of 

these investigations. 

• One MENTOR incident report was missing. In the list of incident reports that was presented to Committee staff, one incident report was not provided. In fact, the company was unable to locate the document. Yet, documentation attached to 

that case ID indicated that the outcome of the case was serious enough to warrant a settlement from MENTOR with the 

family. 

• MENTOR’s incident reports include information that is diagnostically inaccurate. For example, one report documenting 

the death of a 2 month-old infant described the deceased as 

being ‘‘oppositional.’’ At best, this was an error. At worst, it 

was an actual (although implausible) diagnosis, since the 

conditions leading to a diagnosis of ‘‘oppositional defiant disorder’’ need to persist for a minimum of 6 months before a 

diagnosis can be made.84 Even then, it is developmentally inappropriate to give an infant this kind of diagnosis. The average age of onset for oppositional defiant disorders is beVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
23 

85Kessler, Ronald C., Amminger, G. Paul, Aguilar-Gaxiola, Sergio, Alonso, Jordi, Lee, Sing, 

and Ustun, T. Bedirhan, ‘‘Age of onset of mental disorders: A review of recent literature,’’ Current Opinion in Psychiatry, Vol. 20, No. 4, 2007, https://www.ncbi.nlm.nih.gov/pmc/articles/ 

PMC1925038/. 86 Ibid. 87 Note: On October 5, 2017, MENTOR provided Committee staff with an updated mortality 

analysis, which reflected data through August 2017. To the extent Committee staff feels this 

data meaningfully changes the analysis in the Committee Print, Committee staff will make this 

information available on the Committee website in the future. 

tween ages 5–15.85 Similarly, in another case, a 4-month-old 

infant who also died was described as having ‘‘behavioral 

health’’ problems when the field widely recognizes that most 

serious mental/behavioral health conditions are not diagnosed until adolescence or early adulthood. Even when more 

childhood-based conditions are treated (such as attention 

deficit/hyper-activity disorders) the average age of onset is 

4–11 years old.86

• MENTOR’s incident reports contain information that conflicts with media accounts of incident. One incident report 

documents the death of a 4-year-old child and states that the 

child died from cardiac arrest. Media accounts of that incident (which were discovered by the Committee staff based on 

the State and age of the deceased, as well as the date of 

death) indicate that the foster mother of the child was convicted of second degree manslaughter in the death of the 

child. MENTOR also reached a legal settlement with this 

family. 

H. MENTOR MORTALITY REPORT

In response to the national attention concerning children who 

died on MENTOR’s watch and the investigation by SFC staff, 

MENTOR conducted its own analysis of children who died in the 

company’s care. This MENTOR ‘‘mortality report’’ was completed 

through a contract held with a research center at a public university in the company’s home State (see Appendix G, Exhibits 1 and 

2).87 In this analysis, MENTOR concludes that its child death rates 

are in keeping with the rates of deaths among foster children and 

among the youth population (in general) at the national level. As 

discussed further in this section, these conclusions are inaccurate 

and they appear to misrepresent the experiences of children who 

are served by MENTOR. The company did not have the report 

independently validated. When SFC staff inquired about having 

the report ‘‘peer reviewed’’ by independent researchers with expertise in child maltreatment, MENTOR indicated that this would 

only be possible with the company’s approval. 

Committee staff found this report to be inaccurate and misleading. The report used unequal points of comparison between 

deaths that occurred under MENTOR’s watch and national rates of 

the deaths of foster children, according to AFCARS. MENTOR’s report included a comparison of its own annual death rate based on 

the total number of children in its care each year, with the national, annual death rate of foster children. This national rate is 

based on the number of children who were in care on the single 

date of September 30th, which is when annual counts are taken. 

The result is the appearance of the national death rate being much 

24 

88 U.S. Department of Health and Human Services, Administration for Children and Families, 

Administration on Children, Youth, and Families, Children’s Bureau, ‘‘Child Maltreatment 

2015,’’ Report, January 19, 2017, https://www.acf.hhs.gov/sites/default/files/cb/cm2015.pdf. 89Kochanek, K.D., Murphy, S.L., Xu, J., and Tejada-Vera, B., U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, ‘‘Deaths: Final Data for 2014.’’ National Vital Statistics 

Reports, Vol. 65, No. 4. June 30, 2016, https://www.cdc.gov/nchs/data/nvsr/nvsr65/ 

nvsr65_04.pdf. 

higher than MENTOR’s death rate, when in fact the opposite is 

true, as explained below. 

In addition to these false conclusions, MENTOR’s methods and 

standards of analysis are not consistent with the field, nor are they 

employed by HHS or the Centers for Disease Control and Prevention (CDC). For example, the report stated the rate of child deaths 

per 100 live children, as opposed to 100,000 live children, which is 

what is used by HHS 88 and the CDC.89

Using the numbers provided in its own report, MENTOR’s average rate of death for 2010–2014 is .074 per 100 foster children 

served (or as the field would express it, 74 per 100,000 children 

served), as compared with national rates of .052 per 100 foster children served (or 52 per 100,000 children served). Yet, MENTOR 

concludes: ‘‘The MENTOR Network serves significantly more 

children and youth with heightened risk factors relative to 

others in foster care, and sustains child mortality rates that are 

comparable with national norms’’ (bold emphasis in the original 

document). In fact, MENTOR’s death rate among foster children is 

42% higher than the national average. 

Figure 1 demonstrates MENTOR’s misleading display of information. The red comment box points to MENTOR’s inclusion of a national death rate that is based on point-in-time counts of the number of children in foster care on a single day. Using this number 

in the denominator makes it look like the death rate among children in foster care is higher than is actually the case. The Committee staff concluded that this information is not a valid comparison. The black comment box points to the national death rate that 

is based on the total numbers of children served annually in foster 

care, which provides a more accurate estimate of the death rate 

among foster children. The blue comment box points to the death 

rate among foster children who are being served by MENTOR. This 

is also based on the number of children served annually by MENTOR. This chart clearly shows that the blue bar and rate, which 

captures MENTOR’s death rate, is higher than the black bar and 

rate, which captures the comparable national death rate of children 

who are in foster care. 

25 

90For more information about the WONDER database, visit its website https://wonder.cdc.gov/. 91The national data in Figure 2 is for youth ages 0–22, which is the same age range that 

MENTOR used in their mortality report. 

Further, in its mortality report, MENTOR also states: ‘‘Mortality 

rate in TMN [The MENTOR Network] foster care programs has 

been very similar to, and more recently equal to or better than, national norms.’’ To substantiate this, MENTOR provided a line chart 

of death rates for 2009–2014, with data points that are too small 

to decipher and no numbers. The chart appears intended to capture 

the national death rate among those aged 0–22. Regardless, this 

chart is also misleading. Mortality information collected by Committee staff from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) database shows that the national death 

rate in the United States between 2009 and 2014 among those 

aged 0–22 is 54.7 per 100,000 in the population.90 That means that 

the MENTOR death rate (74 per 100,000) among youth aged 0–22 

is 35% higher than the national average. 

Furthermore, MENTOR’s graphical analyses only focused on 5 

years of data, 2009–2014, but in its report, MENTOR included 10 

years of data. Figure 2 displays the full 10 years of rates of children’s deaths per 100,000 for 2005–2014. There are only 2 years 

during which MENTOR’s death rates were at or below the foster 

care population and national averages.91


26354.CP1
26 

92 Civitas Solutions, Inc., 2014 10–K Filing (September 30, 2014), p. 13. See Footnote 2. 

Finally, in the MENTOR conclusion cited above in this section, 

the company highlights its contention that it serves ‘‘significantly 

more children and youth with heightened risk factors’’ and therefore a higher death rate should be expected among its served population. However, as noted earlier in the report, when the Committee staff examined MENTOR’s incident reports, it found that of 

the cases involving a death, nearly three-quarters of those cases 

(73%) indicated that MENTOR itself concluded the death was ‘‘unexpected.’’ In short, MENTOR’s own incident reports do not support 

the conclusion that MENTOR’s fatality rate is attributable to these 

heightened risk factors. 

I. FINANCIAL SETTLEMENTS FROM MENTOR 

The documentation provided by MENTOR allowed Committee 

staff to review over 20 financial settlement agreements resulting 

from alleged negligence and/or damages. However, this did not capture the full range of such settlements. According to documents reviewed by Committee staff in reference to Maryland dated between 

2005 and 2015, there were 22 settlements of claims against MENTOR. Illinois submitted materials to the Committee indicating that 

there had been nine similar settlements in the State. In almost all 

of the MENTOR legal documents the plaintiffs and settlement 

amounts are redacted. However, the documents from Illinois cite a 

total of $19.5 million in payouts. Given the numerous settlements 

made between MENTOR and dozens of parties, MENTOR has likely paid many millions of dollars in wrongful suit settlements. In 

fact, in its 2014 SEC filings, MENTOR wrote: ‘‘Several years ago, 

we experienced a spike in claims filed against the Company, and 

we could face an increase in claims in the future. As a result of the 

prior increase in claims, we received less favorable insurance terms 

and have expensed greater amounts to fund potential claims.’’ 92


26354.CP2
27 

V. OVERSIGHT OF CHILD WELFARE SERVICES AND 

PROTECTING VULNERABLE CHILDREN 

The States that responded to the 50-State Letter were adamant 

about their oversight of children in their foster care systems, regardless of the nature of the children’s placement. That said, the 

information provided to and reviewed by SFC staff describes systems that do not always keep children safe or allow their performance to be readily evaluated. In fact, one State—Massachusetts— 

failed to comply with a request from the Committee to submit more 

detailed information about its child welfare services. To further 

complicate matters, the complex and fragmented nature of the 

child welfare system makes it difficult for the Federal Government, 

and others, to monitor the operations and outcomes of children who 

are involved in the system. Some of the problems SFC staff encountered in trying to evaluate and compare the performance of States 

and providers through this review are as follows: 

• Georgia does not specifically record data about children 

needing TFC services, which means the State is likely unable to track the well-being of this subpopulation (and likely 

many others). 

• Data from Illinois provided point-in-time measurements for 

a single date on two key measures (siblings placed in same 

living arrangement and average caseload per caseworker), as 

opposed to over a period, such as a fiscal year or multiple fiscal years. SFC staff repeatedly raised this issue with Illinois 

staff and requested a State average across all providers 

which would have given the Committee at least some benchmark for comparison purposes. The State was unable to provide this information. 

• Maryland only provided the Committee with data on private 

TFC placements, as opposed to data about their entire child 

welfare population with subpopulations that might have included those needing TFC placements. 

• Not all child welfare indicators are available electronically. 

Some States collect information, perform reviews, and maintain data in paper files that are never entered into an electronic database or that are never synthesized into a single 

report or review. Without more systematic procedures in 

place, it is almost impossible for States to have any meaningful oversight over their own systems or the agencies that 

provide contracted services for them. 

• The field lacks a consistent language about child welfare 

services, clients, and operations, which makes it difficult to 

make comparisons between States and between providers. 

For example: 

» There is no uniform definition of what constitutes TFC. 

Some States use the term ‘‘treatment foster care,’’ instead of ‘‘therapeutic foster care,’’ although the spirit of 

the definition, the needs of the children, and the services provided would be similar. Other common terms 

used include ‘‘special needs’’ children or ‘‘medically fragile’’ children. 

28 

93 National Association of Social Workers, ‘‘NASW Standards for Social Work Case Management,’’ Report, 2013, https://www.socialworkers.org/practice/naswstandards/CaseManagement 

Standards2013.pdf. 

» One State does not use the term ‘‘caseworkers’’ and 

would not provide client-to-caseworker ratios until SFC 

staff established that this State called these employees 

‘‘case support workers.’’ MENTOR calls its caseworkers 

‘‘child welfare specialists.’’ 

» The terms that States use to refer to the private agencies with which they contract to provide foster care services vary as well. Some States refer to these agencies as 

‘‘child placement agencies.’’ Another common term is 

‘‘contract agencies’’ or ‘‘foster care agencies.’’ 

• States have varying definitions and conceptualizations of 

what it is that private child welfare agencies do in their 

States. Some States do not use the term ‘‘child placement 

agencies’’ to refer to contract agencies, while others do. This 

is because the State has control over and responsibility for 

placing children in foster homes. So when the Committee 

asked States, ‘‘What proportion of the children in foster care 

in your State is placed by the public agency, not-for-profit 

providers, and for-profit providers,’’ many States indicated 

‘‘zero’’ for anything outside of the public agency because they 

maintain that all children are placed by the State. Other 

States (which maintained that the public agency places all 

children) still provided rates of children placed by contracted 

agencies. This meant it was impossible for SFC staff to determine the proportion of children living in homes that for 

all intents and purposes are run by private agencies. 

• With regard to substantiations of maltreatment in foster 

care, the Committee asked States to indicate in ‘‘how many 

of these instances . . . were children placed by: not-for-profit 

providers, for-profit providers, and public providers?’’ Some 

States indicated ‘‘zero’’ for the first two categories, again because they maintain that children in their State are not 

placed by contracted agencies, they are only placed by public 

agencies, even if the foster parents work for and are managed by a contracted agency. Thus, the information obtained 

from different States was not always comparable. 

• Other States maintain that public employees provide full 

case management services for the children in their care, yet 

private agency workers set up appointments for the clients, 

make arrangements for services, provide transportation, provide support for foster parents, and visit the children in their 

foster care placements. According to the National Association 

for Social Workers, the definition of case management services is: ‘‘A process to plan, seek, advocate for, and monitor 

services from different social services or health care organizations and staff on behalf of a client.’’ 93 This seems consistent with the services private agencies provide children 

who are in the protective care and custody of their State, 

even if the public agencies call it otherwise. 

29 

• The Committee staff noted the various ways and outcomes 

by which child welfare agencies and government documents 

discuss the maltreatment of children involved with child welfare agencies. CFSRs, which are implemented by HHS and 

monitor State-level child welfare outcomes, track the percentage of any recurrence of maltreatment among all children in the State. The standard: States should not be above 

9.1%. In 2013, 19 States failed to meet this benchmark. 

• Maltreatment of children in foster care is measured as the 

number of children who were victims of substantiated maltreatment per 100,000 days spent in foster care. The national standard is set at 8.5 per 100,000 days. In 2013, 22 

States exceeded this standard. A document prepared by HHS 

for Congress showed that the State median of maltreatment 

of children in foster care is 0.35%. Meanwhile, individual 

States submitted rates to SFC that ranged from 2% to 20%. 

These varying ways for measuring and reporting the same 

construct make it difficult for regulators to monitor outcomes 

and the well-being of children involved with their State’s 

child welfare system. 

• The third round of CFSRs is being conducted between 2015 

and 2018. In late 2016, HHS discovered an error in the syntax the Department used to electronically gather information 

from the States regarding their program performance. Information is still being gathered, but States that submitted 

data before the error was discovered will not be assessed in 

the areas that were affected by the syntax error. Thus, a 

major Federal mechanism that is in place for monitoring 

child welfare performance in the States is not fully functional and means that for some States, there will be approximately a 10-year gap on the Federal assessment of some 

child welfare performance indicators. 

• Not all of the States responded to inquiries from the Committee. 

» Seventeen States failed to respond to the 50-State Letter. Those States were: Arizona, Florida, Georgia, Idaho, 

Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nevada, North Carolina, Ohio, Rhode Island, 

South Carolina, Vermont, and Virginia. 

» Massachusetts failed to respond to the 5-State In-Depth 

Letter. Despite repeated assurances from the Massachusetts Department of Children and Family Services that 

‘‘continuing efforts are being made to collect and prepare the information’’ with ‘‘the full intention to send a 

response to the Committee,’’ a response to the Committee’s questions was never received. 

VI. CONCLUSIONS 

Despite the limitations on information supplied to the Committee, there is sufficient information from this single private agency and the States to show that children who are under the legal 

authority of their State are often ill-served. Some children served 

by MENTOR were abused, neglected, and denied services, and the 

30 

very State agencies that have been charged with and paid to keep 

them safe have likely contributed to their suffering and deaths. As 

documented by MENTOR’s incident reports, investigations about 

fatalities were never followed up, autopsy reports which were pending years ago are not part of case files, and the vast majority of 

children who died were not the subject of an internal investigation—even when their deaths were unexpected. MENTOR issued a 

report to the Committee which falsely claimed that its death rates 

are in keeping with national death rates and the rates of death 

among children in the foster care system. Add to this complicated 

narrative the fact that the families of MENTOR victims have received millions of dollars in financial settlements, significant 

enough for MENTOR to have received less favorable terms from its 

insurer in 2014. The Committee staff recognizes that a case study 

of one provider does not allow for direct comparisons with other individual providers, and thus, cannot draw conclusions regarding 

MENTOR’s operations in relation to other contracted agencies, forprofit or otherwise. Regardless, information collected for this report 

shows that MENTOR repeatedly placed the health and well-being 

of children at risk. 

State agencies would likely counter concerns about their performance by noting the procedures they have in place to monitor private 

agencies. For example, Illinois notes that all licensed foster homes 

are physically inspected at least twice each year, with licenses 

valid for 4 years. Maryland states that it assesses all private TFC 

providers quarterly. This same State noted that providers can find 

themselves on the agency’s ‘‘hotlist’’ by not complying with contractual obligations or by committing license violations. In such situations, providers would not be able to take in new clients until a corrective action plan is generated and subsequently completed. Even 

though MENTOR repeatedly failed to meet all State licensing criteria in 20 of the 22 quarters reviewed that the Committee examined, MENTOR continues to operate in Maryland. Illinois described 

a similar regulatory approach, but MENTOR no longer operates in 

that State. 

State oversight guidelines are in place in almost every State in 

the Nation, either written into State statute or as part of agency 

policy. This investigation and precipitating media reports show 

that these policies are not always followed, exceptions are made, 

waivers are granted, and sometimes professionals serving children 

look the other way. 

The documents reviewed in this investigation show a system that 

does not always protect children. Profits are sometimes prioritized 

over children’s safety and well-being. Turnover among staff sometimes makes it impossible to develop case plans to ensure that children are ‘‘on-track’’ and being monitored. Foster parents with questionable backgrounds who seemingly lack the skills to provide care 

to vulnerable children are given licenses to parent challenging children and then are often inadequately monitored. Further, the data 

and oversight structures at both the State and Federal level make 

it difficult and sometimes impossible to monitor the operations of 

the child welfare system itself, as well as its private contractors. 

Thus, the bipartisan Committee staff sets forth the following recommendations. 

31 

VII. RECOMMENDATIONS 

Recommendations for States and Tribes 

• Improve outreach, customer service, and support services for 

those interested in becoming foster parents to attract and retain high-quality foster families. 

• Support enhanced oversight of foster families to ensure robust background checks, home study assessments, and ongoing placement oversight. 

• Frequently review performance of child welfare service 

providers/contractors to ensure child safety, permanency, 

and well-being standards are being met. 

• Track child safety and well-being related outcomes at the individual provider level, including whether children served by 

specific providers have higher than average needs (e.g., 

medically fragile, special needs, or therapeutic foster care 

placement, etc.). 

• Set standards for maximum caseload size for child welfare 

workers, which may include differentiated standards based 

on variations in case type (e.g., medically fragile children, 

children in therapeutic foster care placements, etc.) or activity (e.g., investigations of abuse or neglect, case planning for 

children in foster care). 

• Provide greater funding for the training of front-end staff 

charged with making removal and placement setting decisions for children entering foster care or at risk of entry. 

• Revoke contracts from child welfare service providers who 

are unable to demonstrate the capacity to provide safe foster 

care placements for children. 

• Provide subsidized guardianship payments to relatives willing and able to provide safe placements for children who can 

no longer remain at home. 

• Ensure child death review teams are transparent, timely, 

and well-staffed. Require the timely publication of the results of child death reviews while ensuring appropriate and 

robust privacy protection of sensitive data. 

• Make placement setting decisions based on the assessed 

strengths and needs of children entering foster care using an 

age-appropriate, evidence-based, validated, functional assessment tool to ensure children receive the appropriate level of 

care in the least restrictive, most family-like environment. 

• Establish child welfare ombudsman offices through which 

children in care, family members, child welfare workers, foster parents, whistleblowers, and members of the public at 

large can submit comments and concerns about misconduct 

within the child welfare system. 

Recommendations for the Department of Health 

and Human Services (HHS) 

• Work to engage States, Congress, and the broader child welfare community in understanding the purpose and Statespecific relevance of the CFSRs and ensure this process contributes to meaningful improvement and reform. 

32 

94 ‘‘Compilation of the Social Security Laws,’’ Social Security Act, section 475, https:// 

www.ssa.gov/OP_Home/ssact/title04/0475.htm. 

• Seek and provide clarification on how States and Tribes are 

defining, using, and overseeing the delivery of Therapeutic 

Foster Care (TFC) and establish a common definition of TFC 

for the purposes of Medicaid and title IV–E. • Develop a uniform definition of ‘‘child abuse and neglect fatality’’ and provide guidance related to determining and reporting such fatalities and ensure States and Tribes are 

using this new definition when reporting data via the National Child Abuse and Neglect Data System (NCANDS). • Aid States in developing the means and mechanisms to accurately collect provider-specific outcomes data, consistent 

with the metrics and definitions associated with AFCARS, 

NCANDS, and the CFSRs. • Establish maximum caseload guidelines to promote manageable caseload sizes for the child welfare workforce. 

Recommendations for Congress 

• Support both funding and oversight for States and Tribes to 

enhance foster parent recruitment and retention activities to 

ensure robust background checks, home studies, ongoing 

placement oversight, and strong support services for foster 

parents. 

• Support both funding and oversight for States and Tribes to 

enhance caseworker recruitment and retention activities to 

ensure child welfare caseworkers are both prepared to enter 

the field and given the support services necessary to carry 

out their jobs effectively. 

• Allow States and Tribes to use title IV–E funds to support 

evidence-based services aimed at safely preventing foster 

care entries. 

• Consider de-linking subsidized guardianship payments from 

the Aid to Families with Dependent Children (AFDC) income 

standard so that States and Tribes can receive a Federal 

match on behalf of all children placed in subsidized guardianship placements and promote equity in the payment rate 

for kinship placements. 

• Require all States to report to the National Child Abuse and 

Neglect Data System (NCANDS) using standard definitions 

and provide support for this data collection and reporting. 

• Consider legislation creating an explicit private right of action for children and youth in foster care tied to components 

of the case plan and case review requirements defined under 

section 475 of the Social Security Act.94

• Consider statutory changes requiring HHS to assess fiscal 

penalties on States for failing to meet CFSR outcomes or system requirements and develop a penalty reinvestment structure under which assessed penalties must be used by the 

State to address the key identified deficiencies (rather than 

be deposited into the Federal Treasury). 

• Consider amending section 479A of the Social Security Act 

to require States to collect, and HHS to audit, providerVerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD
33 

specific child outcomes data in addition to State-specific data 

on outcomes such as: child fatalities, maltreatment in care, 

recurrence of maltreatment within 6 months, exits from foster care by reason for the exit (adoption or guardianship, reunification, emancipation), time to reunification, re-entry 

rates, and the average number of placements. Ensure this 

performance data is available to the public and considered by 

States or Tribes before making or renewing a contract with 

the provider. • Consider prohibiting Federal title IV–E reimbursements for 

providers who consistently perform poorly on key safety, permanency, and well-being indicators. Charge HHS with auditing States and providers to determine which providers shall 

be excluded from Federal title IV–E reimbursement. • Require States to make their contracts with private child 

welfare service providers publicly available and include details on whether such providers are private not-for-profit or 

private for-profit. 

(35) 

Appendix A 

36 


26354.001

0!1l\i}l (", H!lfCII. UlAh CHt.!HMAN 

CttH!SCAMI'!lELl.STAff t:l11lfC10/1 

IOS>!\J.\ SHf-IW(MML {)~M(JCHt,fiC !;T;;F~ fllmCTOfl 

Dear Governor: 

1llnitcd ~tatcs ~mate COMM!TI~E ON FINANCE 

WASHINGTON, DC 20510-6200 

April24, 2015 

When children are removed f1·om the custody oftheir parents due to abuse or neglect, as 

lawmakers, we have an obligation to ensure their safety and well-being. TI1e reality is that there 

is no clear child wellare "system" but rather a complex structure consisting of overlapping 

Federal, State, County and Tribal laws and practices carried out by a mix of public and private 

entities. At times, this structure leads to tinger pointing and confhsion when it comes to the 

question of who is responsible when something goes wrong. In recent months, a particularly 

troubling series from BuzzFecd News reporting on the practices of a national private foster care 

provider network has raised the salience of this question once again. 

The United States Senate Finance Committee has jurisdiction over Title IV of the Social Security 

Act (SSA), which includes the federal foster care and adoption programs. As Chairman and 

Ranking Member of the Senate Finance Committee, we arc writing for background and 

information on your state's policy and practices relative to privatized foster care. 

We are aware that states are increasingly contracting with private entities or organizations to 

administer some or all of their foster care programs. However, the extent and structure of these 

arrangements are less clear. To help us better understand these public-private partnerships, please 

provide the Senate Finance Committee with the following information no later than May 29, 

2015. 

To the degree applicable, describe your state's utilization of private entities to provide 

case management services (e.g., placement of children with particular foster care 

providers, ongoing casework and oversight of taster c~1re placements). 

• What proportion of the children in foster care in your state is placed by the public agency, 

not-for-protit providers, and tor-protit providers? 

• Please provide the number and names of private entities providing these core services, as 

well as information on whether each provider is a for-pro tit or not-for-protit entity. 

• Does your state require that private foster care entities or organizations operating in your 

state be accredited? If so, by which organization and how often is this accreditation 

renewed? 

Describe in detail the process you use to select and contract with these private entities, as 

well as to review and renew such contracts. 

Describe in detail the process your state uses to inspect the safety of the foster care 

settings in which children are placed and the extent to which this process differs for 

public, not-for-protit, and for-public providers operating in your state. 
37 


26354.002

How many instances of abuse in a foster care placement have been substantiated in the 

last five years in your state? Of those substantiated, how many of these instances related 

to children placed by: not-for-profit providers, for-profit providers, and public providers? 

Describe in detail the actions taken when an abuse claim is substantiated while a child is 

in an out of home placement? Do these actions differ depending on whether the child was 

place by the public agency, a not-for-profit provider, or a for-profit provider? 

We thank you for your prompt attention to this matter. Please submit your response 

electronically to: becky _shipp@finance.senate.gov and laura_bemtsen@finance.senate.gov. 

Any additional inquires may be directed to Becky Shipp, Health and Human Resources Policy 

Advisor, Senate Finance Committee or Laura Berntsen, Senior Human Services Advisor, Senate 

Finance Committee at 202-224-4515. 

Orrin G. Hatch 

Chairman 

Sincerely, 

~~ Ron Wyden 

Ranking Member 
38 

Appendix B 

39 


26354.003

ROBERT BENTLEY 

Govl!rnor 

State of Alabama 

Department of Human Resources 

S, Gordon Persons Building 

50 Ripley Street 

1'. o. BoxJOjQ()O 

Montgomery, Alabama 36130~4000 

(JJ4) 242-1310 

May 29, 2015 

Senator Orin Hatch, Chairman 

Senator Ron Wyden, Ranking Member 

United States Senate 

Committee on Finance 

washington, DC 20510-6200 

Dear Senator Hatch and Senator Wyden: 

Nancy T. Buckner 

Commissioner 

Governor Robert Bentley has forwarded your letter of 04/24/2015 to me for 

response. The Alabama Department of Human Resources is the state agency 

charged with the responsibility for providing services under the auspices 

of Title IV of the Social Security Act (SSA). In your letter you seek 

clarification on Alabama's policy and practices related to privatized 

foster care. I hope that the following information proves helpful to you. 

To the degree applicable, describe your state's utilization of private 

entities to provide case management services (e.g., placement of children 

with particular foster care providers, ongoing casework and oversight of 

foster care placements) . 

From the point of initial investigation/assessment, agency staff of the 

Department of Human Resources (DHR) makes decisions on all children and 

youth removed from their families for abuse and/or neglect. Imminent 

safety of a child in his/her own home is of paramount concern in the 

decision to place a child in foster (out of home) care. To ascertain the 

specific needs of the individual child and family, DHR initiates an 

individualized service planning process that must be done for all children 

in out of home care. Departmental staff convenes a planning group known as 

the Child and Family Planning Team. This team consists of individuals 

involved in planning and/or delivery of services for a child and family. 

It will include the parents, the age-appropriate child, others requested 

by the family or child, the DHR worker, the foster care provider, and 

other service providers if any. The team's work product is known as the 

Individualized Service Plan (ISP). Alabama DHR staff maintains 

responsibility for all case planning and case decisions through the 

An Affirnw.tive Actian/Equal Opportunity Employer 
40 


26354.004

utilization of Individualized Service Plans (ISPs) which bring all parties 

relevant to the case together to craft a plan for the child. These plans 

are facilitated by the Alabama DHR Social Worker and updated regularly. 

Throughout the entire service implementation process, departmental staff 

maintains case management responsibility. Decisions as to foster care 

placements are predicated on a variety of factors including proximity to 

family, schools if applicable, matching of children with foster 

parents/appropriate providers and placement with siblings if possible. 

Exceptions exist for tribal investigation/placement process, but for all 

other placements, departmental staff exclusively provides case management 

and oversight of foster care placements. 

What proportion of children in foster care in your state is placed by the 

public agency, not- for- profit providers, and for-profit providers? 

100 % of the children in foster care to include residential, therapeutic 

foster care and transitional/independent living programs are placed by the 

public agency with the exception of tribal placements noted above. Neither 

not-for-profits nor for-profit providers make foster care placements. 

Please provide the number and names of the private entities providing 

these core services, as well as information on whether each provider is a 

for-profit or not-for-profit entity. 

All of these core services (placement and case management services) are 

provided exclusively by the public agency (DHR). Other services are 

provided externally by contract providers (See attachment A) . 

Does your state require that private foster care entities or organizations 

operating in your state be accredited? If so, by which organization and 

how often is this accreditation renewed? 

Alabama approves most of its foster care providers and all of its child 

placing agencies or entities. These child placing agencies (private foster 

care entities) also approve foster homes. We have no requirements for 

accreditation. Many providers seek accreditation through the Council on 

Accreditation (COA) or Joint Commission. 

Describe in detail the process you use to select and contract with these 

private entities, as well as to review and renew such contracts. 

Alabama goes through a standardized and very thorough Request for Proposal 

(RFP) process when it comes to contracting with foster care providers. 

All RFPs are posted on the state DHR website with sufficient lead time to 

respond if interested. The document specifies timeline for submission, 

format requirements, project overview and instructions, eligible entities 

and any licensing requirements. It offers the opportunities to ask 

2 
41 


26354.005

specific questions about the RFP and review the department's responses. It 

details both mandatory and general requirements in order to respond; 

provides cost proposal information as well as submission deadlines. 

Providers interested in service provision and meeting licensing 

requirements submit their proposals by the stated deadline. These 

proposals are then reviewed and scored internally by departmental staff 

based on the quality of the proposal. Contracts are offered based on 

scores, service proximity to placement needs, and number of slots 

available for contract. Rates will be established based on the parameters 

of the RFP and contracts will be negotiated for the next contract cycle. 

This contract will have a two year cycle, with the state having the 

ability to extend the contract for any combination of two year or single 

year extensions up to three additional years. It is the responsibility of 

our Office of Resource Management to monitor contract compliance. 

Describe in detail the process your state uses to inspect the safety of 

the foster care settings in which children are placed and the extent to 

which this process differs for public, not-for-profit, and for-profit 

providers operating in your state. 

All foster care providers go through a rigorous licensing process that is 

specific for the type of foster care that they wish to provide (group 

homes, institutions, therapeutic foster care (TFC), shelters, etc.). For 

congregate care providers, this process begins with an application that 

incorporates state mandated compliance with minimum standards that are 

service appropriate. These minimum standards address issues such as 

staffing requirements, staff development, social services, 

admissions/discharges, program issues around physical care, child care 

practices including discipline and punishment, the physical facilities 

including compliance with code, living unit accommodations, medicines and 

drugs and safety plans. All employees must have Federal and State Criminal 

History Checks and Clearances by Alabama's Child Abuse Central Registry. 

When the licensing application is received by the department, the 

application is reviewed for completeness, and onsite visits by licensing 

staff are made. If it is determined that the facility is in compliance 

with minimum standards for the service in question, a license/approval 

will be issued by the department. A follow up visit will be made in six 

(6) months to monitor compliance, and a two-year license/approval will be 

issued. The program will be re-visited in the last year of licensing and 

will be visited anytime there are complaints. These visits may be 

announced or unannounced to monitor compliance. Traditional foster care 

home providers may either be approved by DHR staff or licensed/approved by 

an approved Child Placing Agency (which is also licensed by DHR) . The 

process is similar to that completed by congregate care providers. An 

application to foster is submitted to DHR which includes a completed 

physical examination for each adult member of the household as well as a 

statement from a licensed practicing medical doctor that all other 

3 
42 


26354.006

household members are free from infectious and contagious diseases. 

Financial information is obtained, an Alabama and Federal criminal history 

check is obtained, and the state child abuse registry is reviewed. 

References are contacted, and a home study is completed. Continuing 

education requirements are detailed as well as any other specific 

requirements. The DHR staff and/or the child placing agency will make 

supervisory visits to the foster home, either announced or unannounced as 

often as necessary to assure the well- being of the child or children. 

Approval of foster home status shall be for one year. This process is 

duplicated for Therapeutic Foster Care (TFC) . 

How many instances of abuse in a foster care placement have been 

substantiated in the last five years in your state? Of those 

substantiated, how many of those instances related to children placed by: 

not-for-profit providers, for-profit providers, and public providers? 

The details by fiscal year are as follows: 

FY 2010 - 3 

FY 2011 - 15 

FY 2012 - 14 

FY 2013 - 7 

FY 2014 - 13 

For all of the substantiated cases of abuse in a foster care placement, 

the placement decision was made by this agency. 

Describe in detail the actions taken when an abuse claim is substantiated 

while a child is in an out of home placement? Do these actions differ 

depending on whether the child was placed by the public agency, a not-forprofit provider, or a for-profit provider? 

DHR staff investigates all Child Abuse/Neglect reports. The child is our 

main focus during all investigations, with that focus being exclusively on 

maintaining child safety. The protocol for initiating investigations of 

all reports may vary slightly based on the placement setting, (i.e., DHR 

approved foster homes; foster homes approved by private child-placing 

agencies, group homes, and child care institutions). During the 

investigation a child's placement may be changed to ensure child safety. 

Residential providers may suspend or terminate identified employees during 

the investigation. The department can also decide to suspend all 

referrals to the provider until the investigation is completed. At the 

point that an investigation determines that a complaint is indicated 

(substantiated), all individuals I parties are notified. The notification 

is considered a preliminary disposition and must include information on 

due process rights. These notifications may be hand-delivered or mailed 

(both first-class and certified) . Upon completion of the due process 

protocol, child welfare staff shall enter the final disposition into the 

Central Registry for indicated dispositions. 

4 
43 


26354.007

When foster parents have been identified as responsible for the abuse/ 

neglect, the foster parent's right to due process does not preclude DHR's 

right to remove foster children from the foster horne before the hearing. 

Decisions to remove any child from the foster horne will be based on safety 

threats to the child. 

The general process is the same for group homes or institutions. Once the 

complaint has been investigated and has an "indicated" finding, the due 

process protocols apply. If the indicated status is upheld after the due 

process hearing, staff in question are terminated from employment and 

entered into the Central Registry; and the foster home will likely be 

closed. 

Please note that the actions do not differ across agency types as the 

public agency (DHR} is the only agency making placement decisions. 

If you have any further questions regarding Alabama's foster care system, 

please contact me at 334-242-9500. 

Respectfully submitted, 

~~~ Commissioner 

NTB/PJB 

Enclosure: Copy of Providers and Services 

5 
44 


26354.008

Providers and Services 

Attachment A 

Therapeutic Foster care 

1. Brewer-Porch Children's Center (Non-Profit) 

2. SAFY (Non-Profit) 

3. United Methodist Children's Home (Non-Profit) 

4. lee County Youth Development center (Non-Profit) 

5. Alabama Mentor (Profit) 

6. Youth Villages (Non-Profit) 

7. Seraaj Family Homes, Inc:. (Profit) 

B. Gateway ( Non- Profit) 

9. St. Mary's Home (Non-Profit} 

10. Christian Services (Non-Profit) 

11. Growing Homes (Non-Profit) 

12. Alabama Clinical Schools (Non-Profit) 

13. camellia Therapeutic Foster Agency (Profit) 

Basic Residential 

1. United Methodist Children's Home (Non-Profit) 

2. Presbyterian Home for Children (Non-Profit) 

3. Thirteenth Place, Inc. (Non-Profit) 

4. Brantwood Children's Home (Non-Profit) 

5. Childhaven, Inc. (Non-Profit) 

6. Children's Service, Inc. (Non-Profit) 

7. Boys & Girls Ranches of Alabama (Non-Profit) 

B. Grace House Ministries (Non-Profit) 

9. Children's Village, Inc. (Non-Profit) 

10. St. Mary's Home (Non-Profit) 

11. Weldy Home (Non-Profit) 

12. Eagle Rock Boys Ranch (Non-Profit) 

13. King's Home, Inc. (Non-Profit) 

14. Boyd School, Inc. (Profit) 

15. North Alabama Christian Children's Home (Non-Profit) 

16. Atonement, Inc. (Profit) 

17. Tears, Inc. {Non-Profit) 

1B. King's Home, Inc. (Non-Profit) 

19. Harris Home (Non-Profit) 
45 


26354.009

Moderate Residential 

1. Lee County Youth Development Center (Non-Profit) 

2. Chrysalis A Home for Girls (Non-Profit) 

3. St. Mary's Home (Non-Profit) 

4. King's Home, Inc. (Chelsea) (Non-Profit) 

5. Presbyterian Home for Children {Non-Profit) 

6. Tri-Will, Inc. (Profit) 

7. SafetyNet Youth Systems, LLC (Profit) 

8. concerned Citizens for Our Youth, Inc. (Non-Profit) 

9. Boyd School (Profit) 

10. Eagle Rock Boys Ranch (Non-Profit) 

11. Pathway, Inc. (Profit) 

12. New Life Center for Change-Teen University (Non-Profit) 

13. UA Brewer-Porch Children's Center (Non-Profit) 

14. Family Garden, Inc. (Profit) 

Intensive Residential 

1. Lee County Youth Development Center (Non-Profit) 

2. Southeastern Psychiatric Management, Inc. dba Mountain View Hospital (Profit) 

3. Glenwood Mental Health Services (Non-Profit) 

4. UA Brewer-Porch Children's Center (Non-Profit) 

5. Gateway (Non-Profit) 

6. Sequel, TSI (Madison) (Profit) 

7. Sequel, TSI (Owens Cross Roads) (Profit) 

8. Laurel Oaks Behavioral Health Center (Profit) 

9. Hill Crest Behavioral Health Services (Profit) 

10. AltaPolnte Health Systems· BayPolnte (Non-Profit) 

11. SafetyNet Youth Systems, LLC (Profit) 

12. Pathway, Inc. (Profit) 

13. St. Mary's Home (Non-Profit) 

14. Sequel, TSI (Courtland)(Proflt) 

15. Sequel, TSI (Tuskegee) (Profit) 

16. Hill Crest BHS (Bessemer) (Profit) 

17. Hill Crest BHS (Higdon) (Profit) 

18. Alta Pointe (Adolescent Independency Program (Non-Profit) 

Transitional Uvlng Program 

1. Lee COunty Youth Development Center (Non-Profit) 

2. United Methodist Children's Home (Non-Profit) 

3. Brantwood Children's Home (Non-Profit) 

4. Harris Home for Children, Inc. (Non-Profit) 

5. Childhaven, Inc. (Non-Profit) 

6. Chyrsalls A Home for Girls (Non-Profit) 
46 


26354.010

7. SAFV (Non-Profit) 

8. King's Home, Inc. (Chelsea) (Non-Profit) 

9. Aliiibamill Mentor (Profit) 

10. Cillmellla Thefillpeutlc Foster Agency (Profit) 

11. Alta Pointe Health Systems (Non-Profit) 

12. Gfillce House Ministries (Non-Profit) 

13. King's Home, Inc. (Wllsonvllle) (Non-Profit) 

Independent Uvlng Progfillms 

1. Gateway {Birmingham) (Non-Profit) 

2. AltaPointe Health Systems, Inc. (Non-Profit) 

3. Lee County Youth Development Center (Non-Profit) 

4. Brantwood Children's Home (Non-Profit) 

5. SAFY (Non·Profit) 

6. King's Home, Inc. (Non-Profit) 

7. Harris Home for Children, Inc. (Non-Profit) 

8. Chlldhaven, Inc. (Non-Profit) 

9. Eagle Rock Boys Ranch (Non-Profit) 

10. Gateway (Huntsville) (Non-Profit) 

Moms and Babies 

1. United Methodist Children's Home (Non-Profit) 

2. Childhaven, Inc. (Non-Profit) 

3. Sefillaj Family Home, Inc. (Profit) 

4. Alabama Mentor (Profit) 

5. SAFY (Non-Profit) 

Sexual Rehabilitation 

1. Sequel (Profit) 

2. Alabama Clinical School (Non-Profit) 

3. Hill Crest Behavlofilll Health Services (Profit) 
47 


26354.011

THE STATE 

o~LASKA 

GOVERNOR BILl. WALKER 

May29,2015 

Senator Orrin G. Hatch 

Senator Ron Wyden 

United States Senate 

Committee on Finance 

Washington, DC 20510-6200 

Dear Senator Hatch and Senator Wyden: 

Department of 

Health and Social Services 

COMMISSIONER'S OFFICE 

r .o_ l3a)( llOWl 

juneau, Alaska 996i 1-060 I 

Moln: 907.465.1616 

Fax: 907A65.3'J68 

Thank you for the opportunity to respond to your inquiry regarding children removed from the 

custody of their parents due to abuse and neglect, and how Alaska pursues placement of children 

into the out-of-home care settings. Below is Alaska's response to your specific questions: 

1) To the degree applicable, describe your state's utilization of pn'vate entities to provide case 

management services (e.g. placement of children with particular foster care providers, ongoing 

casework and oversight of foster care placements). 

In Alaska, not-for-profit and for-profit providers for foster care do not exist at this time. 

The Office of Children's Services (OCS) does utilize in-state, non-profit agencies, called Child 

Placement Agencies (CPA), to provide therapeutic foster care and intensive supports (including case 

management) to children who require higher levels of support and therapeutic interventions. Child 

Placement Agencies are licensed through OCS, and foster homes that work for the CPA are also 

independently licensed directly through the OCS. Thus, OCS directly licenses both the foster home and 

the Child Placement Agency for which the foster home works. The CPA may recommend a foster home 

placement for a child in custody; however, the placement cannot be made without the approval of the 

child's OCS caseworker. 

In addition, the Division of Behavioral Health reimburses for therapeutic services for intensive supports 

through Medicaid funding. All of these services receive strong oversight by the Division of Behavioral 

Health, through site visits and funding reviews. 
48 


26354.012

Response to United State Senate: Committee on Finance 

May 29,2015 

Page2 

2) What proportion of the children in foster care in your state is placed by the public agency, not1or-profit 

providers, and for-profit providers? 

There are two populations of children who require foster care in Alaska: 1) children and youth who are 

in the custody of the state through either OCS or the Division of Juvenile Justice (DJJ); and 2) children 

who are in the custody of their parents, in which the parents are requesting therapeutic foster care 

services and supports for their children. 

The majority of children placed in foster care are placed by the OCS or DJJ. The total number of 

children currently in the care for state custody children is approximately 2,600. There is a small 

proportion of children (200) who are placed in foster care at Child Placement Agencies by their parents, 

who are not in the custody of the Department of Health and Social Services (DHSS or the Department). 

In these cases, the CP As are required to keep the parents actively involved in the treatment needs of the 

children in private placements. Placement changes cannot be made without the approval or consent of 

the parents. 

3) Please provide the number and names of private entities providing these core services, as well as 

information on whether each provider is a for-profit or not-for-profit entity. 

None. Private entities (for-profit or not-for-profit) do not provide core services to children in out-ofhome care in Alaska. 

4) Does your slate require that private foster care entities or organizations operating in your state be 

accredited? If so, by which organization and how often is the accreditation renewed? 

The Division of Behavioral Health approves provider agencies to operate behavioral health services and 

to bill Medicaid services in our state. Those providers need to be accredited by the Joint Commission, 

Commission on Accreditation of Rehabilitation Facilities (CARF) or Council on Accreditation (COA). 

The frequency of renewal is based on the criteria for each accrediting agent. 

5) Describe in detail the process you use to select and contract with these private entities, as well as to 

review and renew such contracts. 

The Office of Children's Services and the DHSS does not contract directly with these private entities for 

purposes of child placement. The DHSS utilizes Medicaid funding and grant services to support the 
49 


26354.013

Response to United State Senate: Committee on Finance 

May29, 2015 

Page 3 

more intensive level of care for children; however, the placement decisions are made either by the 

Department placement worker or the parents (if the child remains in the parents' legal custody). 

The Alaska DHSS has an extensive grants and contracts process in which performance-based measures 

and outcomes are encouraged for all service contracts. 

6) Describe in detail the process your states uses to inspect the safety of the foster care settings in which 

children are placed and the extent to which this process differs for public, not-for-profit and for-profit 

providers operating in your state. 

Under state statutes AS 47.32 and AS 47.05 and state regulations 7 AAC 50 and 7 AAC 10, the 

Department has a statutory responsibility to inspect all licensed facilities, inclusive of licensed foster 

homes, at least once a year for the first two years of!icensure, and then once every other year under a 

biennial licensing process. All agencies that provide services to children and youth are licensed through 

a DHSS licensing entity. 

7) How many instances of abuse in foster care placement have been substantiated in the last five years in 

your state? Of those substantiated, how many instances related to children placed by: not-for-profit, 

for-profit providers and public providers. 

Between January I, 2010, and December 31,2014, 269 allegations of maltreatment in foster care 

placements have been substantiated in CPS Provider Investigation CPS Reports. Since OCS staff 

members are the only people 'placing' children, there are no numbers for any children placed by 

contracted providers (for profit or not-for-profit). 

8) Describe in detail the actions taken when abuse claim is substantiated while a child is in an out of home 

placement? Do these actions differ depending on whether the child was placed by the public agency, a 

not-for-profit provider, or a for-profit provider? 

When an abuse claim is substantiated while a child is in an out-of-home placement, the case would go 

through two tracks: I) a CPS investigation is conducted to determine if the report is substantiated; and 2) 

a licensing investigation is conducted to determine if there are violations to licensing standards. If the 

abuse is substantiated, the child's placement worker is notified and a decision will be made to either 

leave the child in the foster home or remove the child from the home to another foster home setting. 

Each case is looked at individually and considers the uruque needs of the child when making a decision 

to move the child. Whether or not a child would be removed or remain in the placement would be 
50 


26354.014

Response to United State Senate: Committee on Finance 

May29,2015 

Page4 

determined by the child's caseworker (for children in custody) or by the parents (for children that are 

privately placed). For children in the custody ofDHSS, the courts may be notified of the placement 

change. 

Should a licensing violation be confirmed in the scope of the investigation, the Office of Children's 

Services may impose licensing sanctions, called enforcement actions, up to and including a suspension 

or revocation of the foster care license. Enforcement actions require due process standards for the 

licensee, and as such, the foster parent is able to appeal the decision through the administrative hearing 

processes. 

Thank you for the opportunity to respond to this inquiry. 

Commissioner 

Cc: Christy Lawton, Director, Alaska Office of Children's Services 

Amy Dobson, Office of Alaska Governor Bill Walker 
51 


26354.015

The Honorable Orrin G. Hatch 

Chairman 

Committee on Finance 

United States Senate 

219 Dirksen Senate Office Building 

Washington, DC 20510 

The Honorable Ron Wvden 

United States Senate • 

219 Dirksen Senate Office Building 

Washington, DC 20510 

June 6, 2015 

Dear Chairman Hatch and Senator Wyden, 

Thank you for your continued leadership in the area of child welfare. I agree, as 

do the professionals working in Arkansas's Division of Children and Family Services 

(DCFS), that when children are removed from the custody of their parents due to abuse 

and/ or neglect, we have an obligation, regardless of a specific role, to ensure their safety 

and well-being. I am pleased to respond to your letter of April 24, 2015 requesting 

information about Arkansas's policy and practices relative to privatized foster care. To 

address your specific questions, l offer the below: 

1. To the degree applicable, describe your state's utilization of private 

entities to provide case management services (e.g., placement of 

children with particular foster care providers, ongoing casework and 

oversight of foster care placements). 

In Arkansas, DCFS is the child welfare agency for the state. All in-home and out-ofhome casework practice is pe1formed by staff employed by DCFS. Foster homes are 

licensed and maintained by the State. Placement services are contracted through 

specialized private providers for placement services when need for therapeutic foster 

care, residential group homes, comprehensive residential treatment, emergency 

shelter, developmental disability services and/or respite services are required. 
52 


26354.016

2. \Vltat proportion of the children in foster care in your state is placed by 

the public agency, not-for-profit providers, and for-profit providers? 

All placements for the children in the foster care systems are made by DCFS. 

3· Please provide the number and names of private entities providing these 

core services, as well as information on whether each provider is a forprofit or not-for-profit entity. 

Arkansas will be happy to pro;ide this information however we question if you want 

the listing of all providers in which a contract for placement has been granted. The 

state contracts with 14 providers for therapeutic foster homes (which, in turn, 

contract with indhidual families); 20 providers for residential treatment; 15 

providers for comprehensive residential treatment; 17 providers for emergency 

shelter; and 3 for developmental disability services (which, in turn, contract 'Aith 

individual families). None of these providers are for-profit organizations. 

If you need the detailed information for all contracts, please let us know and we will 

forward this information to you immediately. 

4. Does your state require that private foster care entities or organizations 

operating in your state be accredited? If so, by which organization and 

how often is this accreditation renewed? 

In Arkansas, a child placement agency must be licensed with the state. Arkansas 

Code Annotated 9-28-401 et. seq., "The Child Welfare Licensing Act" (the Act), is 

the legal authority under which Arkansas's Child Welfare Agency Review Board 

prescribes minimum licensing standards for child welfare agencies, as defined under 

the statute. Further information regarding the agencies requiring a license and the 

type oflicense required by each facility can be found in Appendix A. 

5· Describe in detail the process you use to select and contract with these 

private entities, as well as to review and renew such contracts. 

DCFS's process for contracting with a child welfare agency is as follows: 

1. Notices• are posted on the state's website and Request for Proposals (RFP) are 

let for the various services needed; 

2. Pro\iders respond to the RFPs and submit proposals to the agency; 

3. Contracting agency selects a group to review RFPs; 

4. RFP's are scored in accordance to Procurement rules; 

5· Respondents are notified of the state's Intent to Award; and 

1 Notices include the scope of work and performance indicators requested by the agency, location of need for 

services (either specific county, area or statewide), some will include a price per unit that will be paid and some are 

budget based and then rates are negotiated when contracts are awarded. 
53 


26354.017

6. If no opposition, contracts are written and awarded. 

Arkansas's child welfare agency has a strong partnership with its contract provider 

community. Contract language gives the agency the ability to address any areas of 

non-compliance and allows the agency to terminate a contract due to issues related 

to non-performance and professional and ethical issues. 

6. Describe in detail the process your state uses to inspect the safety of 

foster care settings in which children are placed and the extent to which 

this process differs for public, not-for-profit, and for-public providers 

operating in your state. 

Please refer to iYiiDimiJm~:bHrl'vVdfm:t'J,iecll:'ill1fL~t!lndnr.ds U§Il!Jtcd inJ'..Lt\t-_QA as there are specific requirements for each license type including child welfare foster 

home. These inspections are performed by licensing staff employed by the Division 

of Child Care and Early Childhood Education, which is a separate entity than that of 

the child welfare agency. 

The requirements for agency foster homes can be found in E11k±2_, Per DCFS policy, 

child welfare staff is required to visit the foster home on a quarterly basis. 

7• How many instances of abuse in a foster care placement have been 

substantiated in the last five years in your state? Of those substantiated, 

how many of these instances t•elated to children placed by: not-forprofit, for-profit providers and public providers'? 

With reference to state agency approved and licensed foster homes, over the last five 

years there have been 734 reports in which foster parents were identified as the 

alleged offenders. Note that this figure also includes therapeutic foster homes. Of 

those reports, 101 were found to be trcw, and all homes were subsequently closed as a 

result. 

In Arkansas, when an allegation is made on an employee/staff in a treatment facility, 

those allegations are called into the state Child Abuse Hotline and are investigated by 

the Crimes Against Children's Division. There is not a number available for these 

instances as calls are stored by alleged victim versus the type of incident. 

8. Describe in detail the actions taken when an abuse claim is substantiated 

while a child is in an out of home placement? Do these actions differ 

depending on whether the child was placed by the public agency, a notfor-profit provider, or a for-profit provider? 

As stated above, ifthere is a substantiated finding of abuse in a foster home, the 

home is closed. The agency takes a very strong stance on this. There arc also 

instances in \vhich, even though the allegations are not substantiated, homes are 

closed due to concerning information disclosed in the investigation and/or DCFS has 

had other issues related to this home in the past. Those are handled on a case by case 

:;oowiH!llli\Nl S!tnJL:-;t!l! -~>O·L)!lil 1\l!\i,,\!~ 

Tl!ll'l!tl\J {SO!JM{,: .:q:; WWW.gt)V{'fllOL,lrk;l!lS,)S.gt)\r' 
54 


26354.018

basis and are staffed at an executive level before tina! decisions are made regarding 

closure. 

Regarding allegations and substantiated findings on placement facility staff, DCFS 

works with those providers on corrective action plans that are put in place during the 

investigative process. There have been instances in which all foster children have 

been removed from the plac.ement facility due to the allegations pending the 

outcome of the investigation. 

I hope the above information is useful to you and your efforts. If you have 

questions or require further information, please contact Betty Guhman, Senior Advisor 

on my staff at 501-683-6407 or betty.guhman@governor.arkansas.gov. 

Jf·erely,/ L-~-­

~1/~ Hutchinson 
55 


26354.019

[]] 

CDSS 

- STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY 

DEPARTMENT OF SOCIAL SERVICES 744 P Street • Sacramento, CA 95814 • www.cdss.ca.gov WILL UGHTBOURNF: EDMUND G, BROW-N JR. 

DIRECTOR 

August 11, 2015 

The Honorable Orrin G. Hatch 

Chairman 

Committee on Finance 

United States Senate 

219 Dirksen Senate Office Building 

Washington, DC 20510-6200 

The Honorable Ron Wyden 

Ranking Member 

Committee on Finance 

United States Senate 

GOVERNOR 

219 Dirksen Senate Office Building 

Washington, DC 20510-6200 

Dear Chairman Hatch and Ranking Member Wyden: 

Thank you for the opportunity to share information on California's child welfare services 

system for vulnerable children, youth, and families. The focus of your questions is on 

privatized foster care. We do not utilize private for-profit providers; however, as part of 

our network of providers and others engaged in child welfare, we do work with private 

non-profit providers and organizations as explained in our responses to your questions, 

which follow the background below. 

BACKGROUND 

California has a complex child welfare services system, serving the most populous state 

in the country with nearly 9.5 million children, and one of the most linguistlcally diverse 

regions in the world with the largest minority population in the country, including 109 

federally recognized Indian tribes and an estimated 79 tribes that are seeking federal 

recognition. California's state-supervised child welfare system is administered at the 

local level by 58 counties, each governed by a county elected board of supervisors. The 

range of diversity among the counties is immense and there are many challenges 

inherent in the complexity of this system. However, its major strength is the flexibility 

afforded to each county in determining how best to meet the needs of its own children 

and families. The counties, which differ significantly by population and economic base, 

are a wide mixture of urban, rural and suburban settings, thus driving the need to make 

their own decisions on how to coordinate local service delivery to children and families. 

The California Department of Social Services (CDSS) is authorized by statute to 

promulgate regulations, policies, and procedures necessary to implement the state's 

child welfare system and to ensure the safety, permanency, and well-beintJ for 

California's children. The CDSS is responsible for the supervision and coordination of 

programs in California funded under federal Titles IV-8, IV-E, and XX of the Social 

Security Act. Furthermore, CDSS is responsible for developing the state's Child and 

Family Services Plan. These efforts are achieved within a framework of collaboration 

with child welfare stakeholders. Due to its complexity and this high degree of 
56 


26354.020

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

Page 2 

collaboration, California's child welfare services system is ever-changing as we seek to 

improve our ability to improve outcomes for the state's children and families. 

The CDSS has oversight of the state's child welfare services system and plays a vital 

role in the development of policies and programs that implement the goals of CDSS' 

mission. In developing policies and programs, the CDSS collaborates with other state 

and local agencies, tribal representatives, foster/kinship caregivers, foster youth, foster 

care service providers, community-based organizations, the courts, researchers, child 

advocates, the Legislature, and private foundations to maximize families' opportunities 

for success. 

RESPONSES TO QUESTIONS 

1. To the degree applicable, describe your state's utilization of private entities to 

provide case management services (e.g., placement of children with particular 

foster care providers, ongoing casework and oversight of foster care 

placements). 

In California, we do not contract with private entities to provide case 

management services. Case management is conducted by the child placement 

agency at the county level, either by child welfare or probation, and is carried out 

by the social worker. In our state, we do work with public and private non-profit 

providers to provide support and services to the foster parent and the child. 

Social workers support the case planning process in public and private non-profit 

agencies called Foster Family Agencies (FFAs). Please use the link below to 

access regulations pertaining to social work provided by FFAs. 

Community Care Licensing Regulations for Social Work FFAs 

Title 22, Div 6, Chap 1, Art 5-6- General Licensing Requirements 

http://yvww.dss.cahwnet.gov/ord/entreslgetinfo/pdf/Ffaman.pdf 

(Sections 88001, 88065.3, 88065.4, 88065.5, 88070.1) 

2. What proportion of the children in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? 

Please see enclosed "placement types" chart for relative, foster care, FFA, and 

group home placements. 

3. Please provide the number and names of private entities providing these core 

services, as well as information on whether each provider is a for-profit or not-forprofit entity. 

The federal government has provided the state with the option to include in its 

state plan the placement of children in a private facility operated on a for-profit 

basis, and our state statute authorizes for-profit placement as articulated in 
57 


26354.021

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

Page 3 

California Welfare and Institutions Code (WIC) section 11402.6. However, it is 

CDSS's preference to place foster care children in a non-profit group home 

setting. Currently, counties do not place foster children with for-profit providers. 

Counties may place children with for-profit group home facilities after all other 

placement options have been exhausted. Placement into a for-profit group home 

facility may occur only subject to specified conditions. Please use the links below 

to access lists of foster family agencies and group homes in which children and 

youth are placed in California. 

Foster Family Agencies: County placement agencies use licensed private FFAs 

for the placement of children who require more intensive care as an alternative to 

group homes. By statute, FFAs are organized and operated on a non-profit basis 

and are engaged in the following activities: recruiting, certifying, and training 

foster parents, providing professional support to foster parents, and finding 

homes or other temporary or permanent placements for children who require 

more intensive care. 

The CDSS has statutory responsibility for developing, implementing, and 

maintaining a rate setting system for FFAs receiving Aid to Families with 

Dependent Children-Foster Care (AFDC-FC) funds. The AFDC-FC rates vary by 

age group. For the purpose of determining FFA rates, CDSS regulations specify 

the purposes, types and services of FFAs. Currently, CDSS sets AFDC-FC rates 

for approximately 220 FFAs as of January 2015. The rates are organized into 

five age groupings. 

Group Homes (GHs}: Group homes provide the most restrictive out-of-home 

placement option for children in foster care. They provide a placement option for 

children with significant emotional or behavioral problems who require more 

restrictive environments. A licensed group home is defined as a facility of any 

capacity which provides 24-hour nonmedical care and supervision to children in a 

structured environment, with such services provided at least in part by staff 

employed by the licensee. Group homes run the gamut from large institutional 

type environments which provide an intense therapeutic setting, often called 

"residential treatment centers," to small home environments which incorporate a 

"house parent" model. As a result, group home placements provide various 

levels of structure, supervision, and services. 

Group homes may offer specific services targeted to a specific population of 

children or a range of services depending on the design of their program. These 

services include substance abuse, minor-parent (mothers and babies), infant 

programs, mental health treatment, vocational training, mental health day 

treatment, sex offenders, wards only, emancipation and reunification. Many 

programs provide more than one service and list their primary service function as 

reunification of children with the biological family. 
58 


26354.022

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

Page 4 

FFA Provider Lists 

FFAs: bJtQ;L.i';V~,.£llllclsworld.ca.qov/reslpdf/FFAUst.p..Qi 

FFA Regional Centers: http://www.childsworld.ca.gov/res/pdf/FFARC.pdf 

ITFC: b!1J2://WyyW.childsV:LQIIQ,@mYirt~J:Wl1fCP.pdf 

GH Provider Lists 

GHs & Regional Centers: http://www.childsworld.c_£)"gov/res/pdf/GHList.pdf 

GHs RCL 13 & 14: _http://www.childsworld.ca.gov/res/pdf/GH1314.pdf 

4. Does your state require that private foster care entities or organizations operating 

in your state be accredited? If so, by which organization and how often is the 

accreditation renewed? 

Currently we are engaged in foster care reform through our Continuum of Care 

Reform initiative. Among many other important changes to California statutes 

governing foster care, Assembly Bill 403 (authored by California Assembly 

Member Mark Stone) will require all group homes and FFAs to be accredited by 

a national accrediting body, identified by the CDSS, as a condition of receiving a 

foster care rate. We believe that national accreditation brings benefits to an 

organization, such as professionalizing staff, establishing administrative best 

practices, improving service delivery, and promoting a culture of continuous 

quality improvement. 

The Continuum of Care Reform report to the California Legislature, upon which 

this reform proposal is based, can be found here at the following web address: 

';VWW.cdss.ca.gov/cdssweb/entreslpdf/CCR LegislativeReport.pdf 

5. Describe in detail the process you use to select and contract with these private 

entities, as well as to review and renew such contracts. 

The state does not contract with private entities to provide foster care services. 

Contracts occur between local government and individual providers. The state's 

role is to license providers and set rates for their services. Please use the links 

below to access requirements related to licensing and rates. 

Manual of Policies and Procedures, Community Care Licensing Division 

General Licensing Requirements: 

b.l!N/.\:VWW.dss.cgl]';Vnet.gov/ord/entreslgetinf.QLp.c.lfill?l!man1.1?DF 

Manual of Policies and Procedures, Foster Care Rate Regulations 

bl!J?.;llwww._g.b.Jjqswqrld. ca,,_Qov/PG 1343. htm# 
59 


26354.023

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

Page 5 

6. Describe in detail the process your state uses to inspect the safety of the foster 

care settings in which children are placed and the extent to which this process 

differs for public, not-for-profit, and for-profit providers operating in your state. 

California assesses and approves relatives (defined in WIC 361.3(f)) and 

nonrelative extended family members (defined in WIC 362.7) using the same 

standards as those used to license foster family homes. This includes: 1) a 

criminal background check of the caregiver and all adults residing in the home; 

2) an assessment of the caregiver's ability and suitability to provide care and 

supervision; 3) a caregiver orientation/training regarding the standards; and 4) an 

inspection of the home and grounds. 

The criminal background check is accomplished through LiveScan submission of 

fingerprints to the California Department of Justice (DOJ), which returns 

California criminal history and other state convictions held by the Federal Bureau 

of Investigation. Additionally, a check is made of California's Child Abuse Central 

Index to learn whether the caregiver or any adults residing in the home have a 

child abuse history. The criminal background check process also includes a 

check of other states' child abuse indexes (where they exist) when the caregiver 

or any of the resident adults declare they have lived in another state within the 

past five years. If there is no criminal history, the DOJ "clears" the individual. 

For persons with criminal convictions, the DOJ provides the county child welfare 

agency with the individual's criminal offender record information report (also 

known as a "rap sheet"). The county reviews the rap sheet to determine whether 

the crimes are those for which an exemption may be granted through an 

exemption process. Pursuant to state and federal law there are a number of 

crimes which cannot be exempted. Individuals who have non-exemptible 

criminal history are denied a clearance and cannot get an exemption. If a 

caregiver or any adult living in the home cannot obtain an exemption, then no 

child can be placed in that home so long as that individual resides in the home. 

For a caregiver or other adult in the home who has criminal history which is not 

prohibited from exemption, a process is applied which includes gathering 

documentation regarding the crimes and convictions, evidence of good character 

and rehabilitation, and the individual's statement about the crime/conviction. This 

information is evaluated and a determination is made as to whether to provide an 

exemption. To ensure continued safety, at the initial submission of fingerprints, a 

subsequent arrest notification process is established for each fingerprinted 

individual. If an individual is arrested subsequent to the initial fingerprinting, the 

DOJ notifies the county having jurisdiction of the case and the county is required 

to investigate the circumstances of the arrest and crime and take appropriate 

action consistent with statute and regulations. 
60 


26354.024

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

Page 6 

Separately, the county child welfare agency assesses the caregiver's ability to 

provide care and supervision by evaluating if the caregiver can: 1) provide a 

safe, secure and stable environment for the child; 2) exercise proper and 

effective care and control of the child; 3) provide a home and the necessities of 

life for the child; 4) protect the child from his or her parents as appropriate; 5) 

facilitate court-ordered reunification efforts with the parents; 6) facilitate visitation 

with the child's other relatives; 7) facilitate implementation of all elements of the 

case plan; 8) provide legal permanence for the child if reunification fails; and 9) 

arrange for appropriate and safe child care, as necessary. Additionally, the 

county utilizes a state-required assessment document to further evaluate the 

caregiver's suitability consistent with statutes and regulations for the proper care 

and supervision of the foster child. 

The safety of the home is assessed by using a state-required form to evaluate 

the home's compliance with safety standards. Items assessed in the home 

include verifying that there is: telephone service in the home; a safe vehicle for 

transporting children and that only a licensed driver will transport the child; an 

individual bed (or crib) with a clean, comfortable mattress, clean linens, blankets 

and pillows for each child in the home; consideration of bedroom occupancy 

standards, which takes in to account shared rooms with adults, those of the 

opposite gender, and those of different ages; adequate closet and drawer space 

for the child's clothing and personal belongings; protection from bodies of water 

so that they are safe/inaccessible; a safe yard or outdoor activity space that is 

free from hazards that endanger the child's health and safety; and at least one 

toilet, sink and tub or shower in safe, clean operating condition and hot water is 

delivered at a safe temperature. In addition, the home must be in otherwise good 

repair, clean, safe and sanitary; well-lit and maintained at a comfortable 

temperature; and store and dispose of waste in a way that will not permit the 

spread of disease/odor, or attract insects and rodents. The home is also 

assessed to ensure the safe storage of medications, poisons, firearms and other 

dangerous weapons. 

The county child welfare agency also provides an orientation and/or training to 

the caregiver. This includes a copy of the approval standards and regulations. 

Caregivers also are informed about the child's personal rights, the prudent parent 

standard, and a child's participation in age and developmentally appropriate 

extracurricular/enrichment activities. 

7. How many instances of abuse in a foster care placement have been 

substantiated in the last five years in your state? Of those substantiated, how 

many of these instances related to children placed by not-for-profit providers, forprofit providers, and public providers? 

26354.025

--

YOUTH-iN FOSTER CARE BY PLACEMENT TYPE (CHILD WELFARE AND PROBATION AGENCJES) 

YEAR RELATIVE FOSTER CARE FOSTER FAMILY GROUP HOME Guardian Other TOTAL 

PLACEMENT (FOSTER) AGENCY (FFA) (GH) (Dep/Non-Dep} ( n) 

(KIN) 

n % n % n % n % n % n % 

JAN.1, 18,866 33.4% 5,546 9.8% 16,382 I 29.0% 3,795 6.7% 7,575 13.4% 4,364 7.7% 56,52 

2011 8 

JAN.1, 19,130 35.2% 5,253 9.7% 14,783 27.2% 3,681 6.8% 7,110 13.1% 4,461 8.2% 54,41 

2012 8 

JAN.l, 20,200 35.9% 5,180 9.2% 14,460 

25.7% 3,696 6.6% 7,133 12.7% 5,543 9.9% 56,21 

2013 2 

JAN.1, 21,708 35.9% 5,412 8.9% 15,244 25.2% 3,714 6.1% 7,006 11.6% 7,454 12.3% 60,53 

2014 8 

JAN.1, 22,053 35.3% 5,582 8.9% 15,604 25.0% 3,744 6.0% 6,740 10.8% 8,784 14.1% 62,50 

2015 7 

I .. 

Data Source: CWS/CMS 2015 Quarter 1 Extract 

Note: Other category includes shelter. SILP, Runaway, and other non-foster care placements. 
62 


26354.026

OFFICE OF THE GOVERNOR 

1 J6 Stat'' Capitol Building 

Denver, Colorado 80203 

(303)866-2471 

(303) 866-2003 fax 

Orrin G. Hatch, Chairman 

United States Senate 

Committee on Finance 

Dear Senator Hatch. 

STATE OF COLORADO 

,John W. Hickenlooper 

Governor 

This is a response to the letter dated April24, 2015 regarding Colorado's practices and policks 

relative to privatized f()ster care. Colorado is a state supervised and county administered system. 

Child welfare programs, including foster care, are administered by the 64 counties in the state. 

Question 1: To the degree applicable. describe your state's utilization of private entities to provide 

case management services (e.g., placement of children with pm1icular foster care providers, ongoing 

casework and oversight of foster care placements). 

R~spgnse: Placement and case management of children and youth in out-ol~home care is the 

responsibility ofthe 64 C<.ltmty depm1ments of human or social services in Colorado. El Paso County 

Depat1ment of Human Services is the only county department that contracts with a private not-forprofit agency for case management services tor children and youth placed in foster homes. 

On January 1, 2014, as the result of being selected through a Request for Proposal (RFP) process, 

Savio, a not-for-proJit that is accw:lited by the Council on Accreditation (COA), contracted with the 

county department to provide case management services primarily ftl!' children and youth placed in 

foster care homes cc11i!ied and supervised by child placement agencies ( CP As). The CPAs contract 

with the county department for foster care services (see history below). For consistency, Savio 

continues to provide case management services when children or youth on their caseload transition to 

residential or group settings, back to tbster homes, or return home. 

Savio functions like a division in the county department of humatl services and staff are certified case 

workers and supervisors. The county attorney represents Savio staff as it does county staff. Savio is 

responsible for all aspects of case management, including oversight of the children and youth placed 

in foster homes and facilities, documentation, court reports, visitation, family service planning, and 

data entry into the Statewide Automated Child Welfare System (SACWJS). 

The El Paso County Department of Human Services determines the toster care placements tor 

children and youth. Recommendations are made by a placement team in the county department for 

placements into speci fie foster homes and the staff work with Savio to complete the process. The 
63 


26354.027

county department generally provides case management for in-home, kinship, and kinship foster care 

cases, though for consistency, caseworkers provide case management if a child or youth on their 

case load enters foster care or a higher level of care. 

In addition, the county department contracts with Lutheran Family Services-Rocky Mountains 

(LFSRM), a not-for-profit. to provide case management and foster care services for children and 

youth in the Unaccompanied Refugee Minor Program (URMP). This population was carved out of 

the general foster care a number of years ago because of the expertise of LFSRM to meet the needs of 

these children and youth. 

TheEl Paso County Department of Human Services has a team that oversees and measures 

compliance and performance for Savio (case management only) and for the CPAs that provide foster 

care services. Savio is monitored regularly for the number served, the outcomes of the children and 

youth, and is paid at 1112 of the contract each month. 

Historically, from approximately 1999-2014, the county department entered into contracts with nine 

CPAs to provide both foster care and case management services as a way to manage resources This 

was done initially because staffing capacity was capped and there was insufficient staff to manage all 

of the work. Foster care positions in the county department were converted to caseworker positions. 

Some of the disadvantages of the process were: inconsistency in case management practice among the 

CPAs and difficulty for the county department to provide oversight, monitoring, and to manage 

quality and performance measures with nine CPAs of differing sizes (capacity) for both case 

management and foster care. At times the agencies didn't collaborate among themselves when a 

child or youth needed a different foster home and the agencies did not consistently involve the county 

department placement team in making placement changes. Placements were sometimes made within 

the same agency rather than looking at other possible appropriate foster homes among the nine 

agencies. 

Moving to a system with one agency solely responsible for case management also helps to prevent an 

appearance of conflict of interest because there is not an investment to use a specific CPA for 

placement of a child or youth. Or, if a foster parent wants to adopt a child or youth in care versus 

permanency with a relative or kin, a conflict of interest is prevented when the CPA is not responsible 

for case management and advocacy for their foster parent. 

Question 2: What proportion of children in foster care is placed by the public agency, not-for-profit 

providers, and for-profit providers? 

Response: One hundred percent of children and youth in foster care are placed by the county 

department with custody and placement responsibility. Placement and/or casework staff in the 

county departments work with county foster homes and CPAs to place children and youth, based 

upon the appropriateness of the foster parent to meet the needs of each child or youth. 

Question 3: Please provide the number and names of private entities providing these core services, as 

well as information on whether each provider is a for-profit or not-for-profit entity. 

Response: Two private agencies, Savio, a not-for-profit, and Lutheran Family Services-Rocky 

Mountain, a not-for-protlt, provide case management for the El Paso County Department of Human 

Services discussed in Question I. The county department has custody and placement responsibility. 
64 


26354.028

Question 4: Docs your state require private foster care agencies or organizations operating in your 

state be accredited? If so, by which organization and how often is this accreditation renewed? 

Response: Accreditation is not required, although approximately 15 CPAs in the state are accredited 

by the Council on Accreditation (COA). The accredited agencies generally provide more than one 

type of out-of-horne care and provide an array of services, including residential care, foster care, and 

in-horne programs. The number of accredited agencies fluctuates. 

Question 5: Describe in detail, the process you use to select and contract with these private entities, as 

well as review and renew the contracts 

Response: In addition to the contractual arrangements discussed in Question I, the remaining 63 

county departments have the option to contract with private CPAs, regardless of profit status. The 

purpose is to supplement existing county foster home resources so there are a sufficient number of 

foster homes to meet the placement needs of the county. County departments are required by rule to 

monitor and review all contracts. 

Question 6: Describe in detail, the process your state uses to inspect the safety of the foster care 

settings in which children are placed and extent to which this process differs for public, not-for-profit, 

and for-profit providers operating in your state. 

Response: The Colorado Department of Human Services (CDHS) licenses all CPAs, regardless of 

profit status, in compliance with requirements in the Colorado Code of Regulations (12 CCR-2509-

8). County departments are agents of the state (state supervised and county administered system). 

Both CP As and county departments certify foster homes using the same standards. CDHS provides 

oversight of county department certification of foster homes, licensure of CPAs, and of CPA certified 

foster homes. 

Question 7: How many instances of abuse in a foster horne placement have been substantiated in last 

tivc years in your state? Of those substantiated, how many of these instances related to children 

placed by not-for-profit providers, for-profit providers, and public providers? 

Response: All children and youth were placed by the custodial county department of human services 

responsible for placement. Foster homes were certified by either public providers or CPAs. Of 

29,606 placements into foster homes, there were 229 instances of substantiated abuse and neglect in 

the past five years. Of these, 193 occurred in public provider foster homes and 36 occurred in CPAs 

without regard to profit status. 

Question 8: Describe in detail, the actions taken when an abuse claim is substantiated while a child is 

in an out of horne placement? Do these actions differ depending on whether child is placed by the 

public agency, not-for-profit, or a for-profit provider? 

Response: Colorado is a state supervised and county administered system and all child welfare 

activities are the responsibility of the county departments. The public agencies have custody and 

placement responsibility for the children and youth in out-of-horne care. 
65 


26354.029

An assessment for child abuse and/or neglect is conducted by the county department where the foster 

home is located, not the certifying agency. Large and most mid-sized county departments have 

designated staff that conducts an assessment when there is an allegation of abuse and/or neglect in 

out-of~home placement. Small county departments request a courtesy assessment by another county 

to prevent an appearance of a conf1ict of interest. The assessment is conducted in accordance with 

rules promulgated by the State Board of Human Services. 

The assessment begins with face-to-face contact with the alleged victim child or youth, and includes 

but is not limited to face-to-face contact with the primary caregiver, assessing for safety, and taking 

action to secure safety, if indicated, assessing risk, needs, and strengths of children, youth, and foster 

parents. The assessment includes a determination whether there are other victim children or youth 

not named in the referral and immediately assesses the safety of those individuals. In addition, any 

other alleged victim children or youth who no longer reside in the foster home are interviewed, when 

appropriate. The assessment includes interviews with witnesses, including children, youth, or others 

who may have additional infonnation. Child and youth vulnerabilities and strengths, and the foster 

parent's strengths and protective capacities are assessed, along with the living situation and any 

immediate hazard or threat to the health or safety based upon the age or development of the child or 

youth. 

The caseworker determines whether removal is justified, contacts the custodial county, as well as the 

certifying entity (public or CPA). The custodial county decides whether the child or youth for whom 

they are responsible, is removed. The certifying agency determines whether to close the foster home, 

depending on the severity and circumstances of the substantiation in accordance with rules 

promulgated by the State Board of Human Services. A follow-up review is conducted by the state 

Institutional Abuse Review Team (!ART) to review fidelity to the assessment process, and to make 

any additional recommendations for follow-up for the certifying agency. 

If there are additional questions, please contact Dennis Desparrois, Placement Services Manager for 

the Colorado Department of Human Services, at 303-866-7925 or by email to 

Dcnnis.Desparrois@state.co.us. 

Sincerely, 

L72-XAarr 

John W. l!ickenlooper 

Governor 
66 


26354.030

Joette Katz 

Commissioner 

DEPARTMENT of CHILDREN and FAMILIES 

Making a Difference for Children, Families and Communities 

Dannel P. Malloy 

Governor 

May 22, 2015 

The Honorable Orrin Hatch 

Chairman 

Committee on Finance 

United States Senate 

Washington, DC 20510 

The Honorable Ron Wyden 

Ranking Member 

Committee on Finance 

United States Senate 

Washington, DC 20510 

Dear Chairman Hatch and Senator Wyden: 

On behalf of Governor Malloy, I write in response to your letter of April 24, 2015, requesting information 

on Connecticut's policies concerning privatized foster care. 

Working together with families and communities to improve child safety, ensure that more children have 

permanent families, and advance the overall well~being of children is the central focus of the Department 

of Children and Families {DCF}. DCF protects children who are being abused or neglected, strengthens 

fami!les through support and advocacy, and builds on existing family and community strengths to help 

children who are facing emotional and behavioral challenges, including those committed to the 

Department by the juvenile justice system. 

The following respond to the specific questions included in your letter. 

Connecticut contracts wlth 16 Child Placing Agencies (CPAs) statewide to provide Therapeutic 

Foster Care (TFC) to children who meet the criteria for this level of care. This is determined by a 

Therapeutic Eligibility Instrument (TEl). Therapeutic Foster Care provides case-management 

services including but not limited to: development and implementation of care plan; active 

participation on child's permanency team; family search and engagement; referral and linkage to 

communlty~based services; provision of life skills; foster family guidance and supervision; respite 

and emergency care planning and placement; ensure health and educational needs are met; 

home safety assessments <:~nd monitoring; behavioral and crisis planning and man.Qgement; and 

discharge planning/after care support. 

Therapeutic Foster Care makes up 21% (690 placements out of 3232 placements) of the children 

ln foster care in Connecticut. 

The following agencies provide Therapeutic Foster Care: A!l16 agencies are not for profit 

organizations: 

STATE OF CONNECTICUT 

www.ct.govjdcf 

An Equal Opportunity Employer 
67 


26354.031

Joette Katz 

Commissioner 

I 

DEPARTMENT of CHILDREN and FAMILIES 

1. 

2. 

3. 

4. 

5. 

6. 

Making a Difference for Children, Families and Communities 

--- Boys and Girls Village 9. 

Community Health Resources 10. 

The Connection Inc. i 11. 

Family and Children's Agency 12. 

Institute of Professional Practice 13. 

14. 

Dannel P. Malloy 

Governor 

Children's Community Programs of CT 

-- Cor:tmunity Residences!~:: ___ --- Dare Family Services 

Family and Children's Aid 

Jewish Family Service 

North American Family Institute Inc.--

- Klingberg Family Center 

I 

7. New Opportunities Inc. 15. The Village for Families and Children 

8. Waterford Count'}'_~~ool 16. Wheeler Clinic --

Connecticut does not require private foster care entities or organizations to be accredited. 

The Department of Children and Families has a well-established process for procuring and 

contracting with private entities that is regulated by State Statute and the Office of Policy and 

Management. (C.G,S. 4~70b and 4~212.) When a new program is being created or a substantial 

redesign of an existing service is proposed, the Department typically engages in a competitive 

procurement process. A solicitation document, Request for Proposals, is generated articulating 

in detail the desired service, including target population, scope of work, funding sources, and 

term of award. (Please see attached template for State of Connecticut Department of Children 

and Families Request for Proposals.) When a "Sole Source" of the service is proposed rather than 

purchasing through a competitive procurement process, the Department submits "Sole Source 

Justiflcation" materials to the Office of Policy and Management to approve of such request. The 

RFP is posted on the State of Connecticut's Department of Administrative Services website and in 

appropriate newspapers. Interested parties attend a Bidder's Conference {technical assistance), 

submit of Letter of Intent and then submit their Proposal by the established deadline. The 

Department's Contracts and Fiscal Division reviews submissions to ensure that the bids meet 

stated requirements. The Department convenes a review team that reviews a !I bids and scores 

them according to a pre-established scoring system. The recommendations generated by the 

review team are submitted to the Commissioner for final determination. The selected providers 

are notified and negotiations with awardees are held to finalize budgets and service delivery. 

Upon agreement, contracts are executed. Currently, contracts are typically awarded for a 3-year 

period. Changes to the terms of a contract, including funding levels, capadty and modifications 

to the language in the Scope of Service occur through a formal contract amendment. Contract 

renewals are routinely carried out and include feedback from consumers, reviews of appropriate 

expenditures, non-compliance with contract e!ements1 and regulatory corrective actions. 

Connecticut has a plan in place for re~procurement of existing contracted services to ensure that 

these service providers are still able to meet the Department's needs. This is 1 in essence, an 

additional measure to ensure that ineffective programs do not continue to hold contracts and 

receive funding. The Department of Children and Families assigns to each contracted service a 

Program Development and Oversight Coordinator (PDOC). The PDOC supports the delivery of 

high quality, accountab[e services to children and famliies who are DCF involved or part of the 

Department's legislative mandate, through collaboration and partnerships with contracted 

providers. The PDOC, in partnership with other DCF staff, carries responsibility to ensure that 

services under their oversight and influence operate effectively and efficiently; and are producing 

posltive outcomes for Connecticut children and their families. The PDOC's overarching role 

STATE OF CONNECfiCUT 

www.ct.gov/dcf 

An Equal Opportunity Employer 
68 


26354.032

Joette Katz 

Commissioner 

DEPARTMENT of CHILDREN and FAMILIES 

Making a Difference for Children, Families and Communities 

Dannel P. Malloy 

Governor 

includes serving as subject matter experts and monitoring their programs through use of quality 

assurance strategies. 

Connecticut uses the same safety inspection process for non~profit agencies and for-profit 

agencies. On-site visits to the facility/program are conducted on a biennial basis. The physical 

plant is reviewed during the on-site visit. The building should be completely furnished and ready 

to open before an Initial provisional license can be issued. The behavioral, developmental, and 

medica! characterlstks of the children to be served must be taken into account when 

determining the adequacy and safety of the physical plant. The personnel files of all staff listed 

on the DCF Staff Schedule A must be reviewed. Each facility/program must prepare a sample case 

record that Includes the required format as called for in the applicable set of regulations. 

There were 45 foster care substantiations of abuse in the last five years. Thirty three {73%) of 

the abuse substantiations were related to DCF licensed foster homes and 12 (27%) were related 

to private foster care homes (CPAs). 

If an abuse claim is substantiated while a child ls in a foster home, an assessment ls 

conducted to determine whether the child's removal from the foster home is in the child's 

best interest This assessment may consider whether the alleged victim is the foster child or 

whether the alleged perpetrator is a household member. If it is determined that the chi!d 1s 

best interest is to remain in the foster home, a waiver must be generated and approved by 

the Department's Commissioner. This process does not differ for DCF licensed foster homes 

and CPA licensed foster homes. 

!fyou have additional questions, your staff should contact the following of my staff; linda Dixon 

at (860) 550·6383 or linda.dixon@ct.gov or Sarah Gibson (860) 550-6536 or sarah.gibson@ctgov. 

Sincerely, 

)#}ft; 

Katz 

issioner, Connecticut Department of Chlldren and Families 

505 Hudson Street 

Hartford CT 06106 

STATE OF CONNECTICUT 

www.ct.gov/dcf 

An Equal Opportunity Employer 
69 


26354.033

State at Delaware 

Office of the Secretary 

Via Email 

Ms. Laura Berntsen 

Senior Human Services Advisor 

Senate Finance Committee 

U.S. Congress 

Dear Ms. Berntsen: 

• 6JJ- 2500 

May 28, 2015 

This letter is to provide Delaware's response to the letter from Senators Hatch and Wyden of 

April 24'" regarding states' use of private entitles to administer some or all of their foster care programs. 

Utilization of Private Entities to Provide Foster Care 

The DE foster care program has long been a public-private partnership. In DE, foster homes are 

provided by the Division of Family Services {DFS), which is the public child welfare agency and several 

private, not-for-profit providers. Private providers are contract agencies through contracts with DFS for 

Purchase of Care (POC). At any one time, approximately 60% of the foster homes in DE are under the 

direct auspices of DFS and 40% under five contracted providers-all of whom are private, not-for-profit 

agencies. 

DFS retains legal and case management responsibilities for meeting the needs of all children In 

foster care, whether they are placed in a DFS foster home or private provider home under a Purchase of 

Care (POC) contract with a licensed agency. This means that each child placed in a foster home managed 

by a private provider remains on the caseload of a DFS caseworker. This DFS caseworker is then 

responsible for providing direct oversight of the case management provided by the POC agency. This 

oversight is accomplished in several ways: 

1) DFS caseworker receives monthly progress notes from the POC agency and enters these into 

the DFS client information (SACWIS) system; 

2) DFS caseworker typically continues to work directly with the blrthparent(s) on their case 

plans, in collaboration with the caseworker from POC agency; 

3) DFS retains the right to give consents as needed (e.g., medical, school trips); 

4) DFS caseworker Is responsible for personally meeting with and assessing the child separately 

from the POC agency caseworker, at least once every six months; and 

5) DFS provides the primary testimony to the Family Court during all court reviews. The 

caseworker from the POC agency is present and may provide additional testimony as required. 

llrlawan' l'o11th ami Familv Ct'llfn 

n.,·;:~ hwlhland Uowi • fh!mmgltm, IJdawrtrt' JtJ/'1'05 
70 


26354.034

Delaware's Response 

May 28, 2015 

Page 2 

The caseworker for the POC agency provides most of the direct casework with the child and is 

responsible for meeting the federally required minimum monthly contact. Visitation between the 

child(ren) in foster care and their birth parent(s) may be monitored by either DFS or the POC agency 

caseworker depending on the factors specific to the case. 

Proportion of Placements by Type 

As of May 18, 2015, there were 689 children in foster care in DE. Of those, 256 were in homes 

administered by private, not-for-profit agencies. The remaining 433 are in homes directly administered 

by DFS, the public child welfare agency, or in residential treatment or juvenile justice facilities. DE does 

not have any for profit foster care providers licensed in the state. 

Non-public Foster Care Entities 

The current POC provider agencies are all private, not-for-profit agencies: 

A Better Chance for Our Children 

Child, Inc. 

Children & Families First 

Children's Choice 

Pressley Ridge 

Progressive life Center 

Accreditation and licensure 

DE does not currently require that private foster care entities be accredited. However, these 

providers are required to be licensed by DFS under Delacare Regulations for Child Plocing Agencies. 

Licenses are issued for a period of one year. Each agency is inspected annually for license review and 

more frequently if complaints are received. 

Selection and Contracting Process 

The contracting process for private entities to become foster care provider agencies follows the 

State's procurement procedures. DFS develops and publishes a Request for Proposals (RFP), outlining 

the services needed, contractual eKpectations and bidding procedure. Each entity much complete a 

proposal and submit according to the requirements. Proposals are reviewed and scored by a multidisciplinary team from across the Department of Services for Children, Youth and Families. That RFP 
71 


26354.035

Delaware's Response 

May 28, 2015 

Page 3 

review committee then forwards their evaluation of the proposals to the Director of DFS for final 

approval of selected bidders. Once approval is obtained, the DFS Program Manager for Foster Care 

Services and related staff meet with successful bidders to begin contract negotiations. Contracts include 

a number of specifications including that the provider agency be licensed, agree to reporting on 

federally and locally required performance indicators, participate in bi-monthly provider meetings, and 

participate in ongoing program monitoring. 

Process for Inspection of Safety of Foster Care Settings 

DFS Managed Foster Homes 

The first safety precaution is that all agency staff and foster parents must have a criminal 

background check and a check to see if they are on the Child Protection Registry. The Criminal History 

Unit of the Office of Child Care licensing then tracks all staff and foster parents for any subsequent 

arrests and reports those to DFS administration. Subsequent arrests of any staff or foster parent are 

immediately reviewed. The Department of Services for Children, Youth and Families has a policy that 

stipulates criteria according to specific criminal backgrounds for employees and foster parents to be 

deemed as prohibited from working with or caring for minor children, whether as the initial approval or 

ongoing monitoring of their approval. 

Prospective foster parents must also undergo a structured home study process prior to being 

approved. The home study process Includes interviews, reference checks, and a specified inspection of 

the family's home to assess the adequacy of accommodations and the absence of health and safety 

concerns. The foster family Is then reassessed at least annually, which includes additional home 

inspection, coupled with updated health information. 

The federal requirement Is that children in foster care receive an in person contact by a 

caseworker at least monthly. DFS has for several years also required that an average of 95% of such 

contacts occur in the child's foster home, so that the child's safety and well-being in the home can be 

continually reassessed. In DE, all children in foster care are represented by either a Court Appointed 

Special Advocate {CASA) or Guardian ad Litem (GAL). These representatives also see the children they 

represent both in their foster homes, as well as in school or other community settings. This provides an 

additional individual to help monitor the safety and well-being of children in care. Foster homes are also 

regularly monitored by Foster Home Coordinators, who first approved the foster home and are involved 

in ongoing placements. 
72 


26354.036

Delaware's Response 

May 28,2015 

Page 4 

Private Nat-For-Profit Hames 

As stated above, DFS <;ontracts with private foster care agencies through the Request for 

Proposal process. Contracts are awarded for a period of one year. The foster care agencies recruit, train, 

approve and monitor their group of foster parents according to both the contract specifications by DFS 

and the license requirements of the Office of Child Care Licensing. During the year of operation, DFS 

conducts at least one contract monitoring review onslte In the agency. More frequent reviews can 

occur If there are complaints. These reviews are conducted by a multi-disciplinary team from the 

Department of Service for Children, Youth and Families and led by contract staff from DFS. The reviews 

include inspection of the license, personnel files of staff, required files for foster parents, training files, 

and case files for all children and youth In care, coupled with interviews of program staff, foster parents, 

and children/youth. 

Additionally, the Office of Child Care Licensing also conducts an annual license review of all of 

these agencies according to the Delocore Regulations for Child Placing Agencies. 

In all other ways, private foster homes are inspected in the same manner as the public ones. 

Foster parents under the auspices of private agencies must undergo the same background and criminal 

background checks. Any subsequent arrests are reported to DFS administration and handled the same as 

for public foster homes. Federally required contacts by caseworkers are conducted by private agency 

staff at least monthly and 95% of these must occur in the home. The DFS caseworker who retains 

primary responsibility also visits the child separately from the private agency caseworker at least semiannually to do an Independent assessment of the child's safety and well-being. Similarly, all children in 

private foster homes are also represented by either a CASA or GAL, who visits the child in his/her foster 

home regularly. 

Instances of Substantiated Abuse In Foster Care 

#of kids In ! Fos~~~~mes Private 

Foster Care Foster 

during the I 

Period Total Year Period I 

FFY 2010 2 1210 1 1 

FFY 2011 1 1267 1 0 

FFY 2012 3 1306 0 3 

FFY 2013 2 1162 2 0 

FFY 2014 0 991 0 0 
73 


26354.037

Delaware's Response 

May 28,2015 

Page 5 

Actions Taken on Abuse Reports and Substantiations 

All reports of child abuse or neglect, including those involving children In foster care, are 

required to be reported to the statewide Child Abuse and Neglect Report Line. Upon that screening, 

reports involving children in foster care (public or private) or other licensed facilities are then 

investigated by the Institutional Abuse Unit of DFS. The Institutional Abuse Unit is administered through 

the DFS central office. This is a specialized child protection investigation unit that follows standardized 

investigation procedures and makes recommendations about case dispositions, including 

substantiations. The investigations of abuse or neglect within foster care are handled the same for 

public and private foster homes. Typically, the foster children In the home (including the alleged victim 

and other foster children) are removed from the home during the investigation to ensure their safety. 

Reports of abuse and neglect in foster homes are also immediately reported to the child's CASA or GAL. 

If the foster parent is subsequently substantiated for abuse or neglect, the home Is closed. 

If in the course of the investigation concerns are discovered about the oversight of the foster 

home, then additional reviews may follow the Institutional Abuse Unit investigation. For public foster 

homes, the assigned Foster Home Coordinator and Supervisor from the regional office Involved will 

conduct a follow up review of the foster home. For private foster homes, the Office of Child Care 

Licensing will conduct a separate review. Either of these reviews may result in closing the foster home if 

concerns are found that do not rise to the level of substantiation. Additionally, the Department of 

Services for Children, Youth and Families will conduct a multi-disciplinary Root Cause Analysis in cases in 

which a foster child is seriously injured or dies. These reviews focus on systemic factors and are followed 

by corrective action plans as Indicated. 

Delaware hopes that this information will be helpful to Senate Finance Committee in its 

deliberations. If there are questions or additional information is requested, please feel free to contact 

Dr. Vicky Kelly, The Director of the Division of Family Services directly at Victoria.Kelly@state.de.us. 

JBR/ccs 

cc: Or. Victoria Kelly 

Director of Division of Family Services 

Respectfully submitted, 

Cabinet Secretary 

Department of Services for Children, 

Youth and Their Families 
74 


26354.038

GOVERNMENT OF GUAM 

DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES 

DIPATTAMENTON SALUT PUPBLEKO YAN SETBISION SUS/AT 

EDDIE BAZA CALVO 

GOVERNOR 

RAY TENORIO 

liEUTENANT GOVERNOR 

Ms. Laura Bemsten 

Senior Human Services Advisor 

Committee on Finance 

United States Senate 

219 Dirksen Senate Office Building 

Washington, D.C. 20510 

Dear Ms. Bemsten: 

JAMES W. GILLAN 

DIRECTOR 

LEOG. CASIL 

DEPUTY DIRECTOR 

_We are in receipt of a request by the Senate Finance Committee to provide information on 

Guam's foster care program. Guam's foster care program is funded through the federal Title XX, 

Consolidated Block Grants Program and the local Foster Care Program funds. The Governor has 

asked me to respond. 

Question 1: 

• To the degree applicable, describe your state's utilization of private entities to provide 

case management services (e.g., placement of children with particular foster care 

providers, ongoing casework and oversight of foster care placements). 

Answer: 

The Department of Public Health and Social Services (DPHSS) of the Government of Guam is 

the state agency that is responsible for placement of all foster children. All foster children on 

Guam are placed at any of the following: licensed family foster home, therapeutic foster home, 

relative placement, 24-hour emergency shelter, or group home. 

The role of private, non-profit entities, such as the emergency shelter and some of the group 

homes, are limited to just providing temporary foster care placements. The duration for these 

placements range from I hour to several years depending on the severity or complexity of the 

case. These temporary homes are reimbursed with monthly or daily maintenance payments, an 

annual clothing allowance, or a set contract amount in the case of therapeutic foster care, 

emergency shelter, and some group homes. The DPHSS may provide other emergency 

essentials for the children. Children's health care are covered through Medicaid or the Medically 

Indigent Program (MIP), which is 100% funded through the local government. 

123 CHAlAN KAR8"A, MANGILAO. GUAM 96913-0304 

WY.W.dohss.gL:am.gov ~ Ph.: 1.671.735. 7102 <~Fa>~:: LS71.734.5910 
75 


26354.039

Some government agencies provide temporary care for those children who exhibit truancy or 

behavioral problems, such as the Department ofYouth Affairs. The Guam Behavioral Health 

and Wellness Center provides temporary care for those children who have emotional or severe 

behavioral problems, or have other disabilities. 

Regardless of the child's placement in any of the above settings, case management services for 

foster children are provided through Social Workers employed by the state agency, the DPHSS. 

Case management services for foster children are not provided by the above entities. The 

DPHSS Social Workers maintain oversight of these cases up until children are reunified with 

their parents or other caregiver, adopted, provided with other permanency plans, or reach the age 

of majority. The Guam family court provides leverage for the cases. The court may also extend 

jurisdiction to the DPHSS up to age 21. 

Question 2: 

• What proportion of the chUdren in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? 

Answer: 

All children in foster care are placed by the public agency, the DPHSS. 

Question 3: 

• Please provide the number and names of private entities providing these core services, 

as well as information on whether each provider is a for-profit or not-for-profit entity. 

Answer: 

Not applicable. 

Question 4: 

• Does your state require that private foster care entities or organizations operating in 

your state be accredited? If so, by which organization and how often is this 

accreditation renewed? 

Answer: 

Not applicable. 

Question 5: 

• Describe in detail the process you use to select and contract with these private entities, 

as well as to review and renew such contracts. 

Answer: 

Not applicable. 

2 
76 


26354.040

Question 6: 

Describe in detail the process your state uses to inspect the safety ofthe foster care 

settings in which children are placed and the extent to which this process differs for 

public, not-for-profit, and for-profit providers operating in your state. 

Answer: 

The DPHSS administers and licenses family foster homes, group homes, and therapeutic foster 

homes in conjunction with the Guam Behavioral Health and Wellness Center. The DPHSS also 

administers and licenses the 24-emergency shelter in accordance with Guam Public Law 31-73, 

an Act to Establish the Administrative Rules and Regulations of the Department of Public Health 

and Social Services relative to Child Care Facilities and Group Care Homes. 

The DPHSS process used to inspect the safety of the 24-hour emergency shelter for foster 

children is through quarterly site visits to the shelter by the DPHSS licensing Social Worker and 

Program Coordinators. Staff utilize a monitoring checklist that is based on the Scope of Work 

for services, and another monitoring checklist that is based on the standards for child care 

facilities, or Public Law 31-73. The discrepancies discovered during the site visit are addressed 

immediately to the shelter. If the shelter does not address the safety issues within the timelines 

outlined in the standards, the DPHSS will either revoke, suspend or not issue a license. Once the 

discrepancies are addressed, the license is provided. In a recent site visit on January 27,2015 

and where issues of safety were questioned, the emergency shelter took action and removed the 

safety violations within two to three weeks upon notice by DPHSS. 

The DPHSS process used to ensure the safety of children in licensed foster homes is through the 

application packet checklist for family foster home license. The licensing Social Worker ensures 

that all applicants meet the criteria contained in the checklist. This checklist includes the 

application for license, autobiography of foster parent, report of medical history, financial report 

sheet, employment verification, 3 character references, consent for disclosure to conduct a 

background check with Child Protective Services, Guam Police Department clearance, Superior 

Court of Guam clearance, clearance(s) from investigative agency if active military personnel (i.e. 

Navy Criminal Investigative Services, Office of Special Investigation), copy of recent check 

stub, marriage certificate or license, and a home inspection and interview conducted by the 

licensing Social Worker. 

The autobiography of the foster parent shall include information on the following: 

• Reasons for wanting to become a foster parent. 

• Describe your upbringing, relationship with parents, etc ... 

• Describe your contact with your family now. 

• Describe how decisions are made as a couple. 

• Describe strengths and weaknesses as a couple. 

• Describe how you deal with difficult issues. 

• Describe your method of discipline. 

• What behaviors do you expect from children, during meals and playtime? 

3 
77 


26354.041

• What behaviors or expectations do you have with regards to teenagers? 

• What are your feelings on religion or morals? How does it relate to child rearing? 

The family foster home license is granted upon satisfactorily meeting the above requirements. 

Once license is granted, the licensing Social Worker conducts regular inspections of the home 

through a checklist that is based on Public Law 23-143, the Standards for Family Foster Homes. 

The DPHSS process used to ensure the safety of children in relative placements includes a 

preliminary home assessment conducted by the Social Worker. The assessment report is 

provided to the child's Guardian ad Litem, and to the Guam family court for approval. The child 

is not placed in a relative placement until all parties grant approval. However, for those cases 

that warrant immediate removal of the child from the natural home or alleged perpetrator, the 

home assessment becomes secondary if the child needs to be placed immediately in the relative 

home placement in order to ensure the most familial environment and to minimize trauma. The 

routine home assessment is then conducted immediately thereafter. Upon entering the 

placement, the Social Worker will continue to monitor the case, to include an inspection of the 

home on a regular basis until case closure. 

Question 7: 

How many instances of abuse in a foster care placement have been substantiated in the 

last five years in your state? Ofthose substantiated, how many of these instances 

related to children placed by: not-for-profit providers, for-profit providers, and public 

providers? 

Answer: 

ln the last five years, there were about five cases of substantiated abuse or neglect within the 

foster care setting. All five cases were placed by the public provider, or DPHSS. 

Question 8: 

• Describe in detail the actions taken when an abuse claim is substantiated while a child is 

in an out of home placement. Do these actions differ depending on whether the child 

was placed by the public agency, a not-for-profit provider, or a for-profit provider? 

Answer: 

The actions taken when an abuse claim is substantiated while a child is in an out of home 

placement does not differ for any of the types of placements mentioned above as all foster 

children on Guam are placed by the public agency, or DPHSS. 

All reports of abuse or neglect within a foster care setting are reported to the state agency, or 

DPHSS, that also has oversight on the investigation of all allegations of child abuse and neglect 

on Guam. This is outlined in Public Law 20-209, the Guam Child Protective Act. Once the case 

is deemed substantiated by the DPHSS, the agency shall take the following actions: 

4 
78 


26354.042

• If the child was placed in a licensed foster family home, therapeutic foster home, or relative 

placement, the child shall be immediately removed from the home and placed in another 

family foster home, therapeutic foster home, relative placement, or group home. 

• The license of the home shall be revoked if the perpetrator is a foster parent. If the 

perpetrator is an employee of a group home or the 24-hour emergency shelter, the DPHSS 

shall coordinate with the home for the removal or termination of the employee. 

• The severity of the injury or crime, as defined in Guam's Criminal Code, shall warrant 

further action and intervention, and other government agencies such as the Guam Police 

Department, Office ofthe Attorney General, and the Superior Court of Guam shall enforce 

criminal proceedings. 

Should you need further clarification or have any other questions on Guam's foster care 

program, please do not hesitate to contact Ms. Linda B. Rodriguez, Human Services Program 

Administrator for the Bureau of Social Services Administration at (671) 4 75-2653/2672. 

ely, 

Y£(___ 

5 
79 


26354.043

DAVID Y.IGE GOVER. NOR 

EXECUTIVE CHAMBERS 

HONOLULU 

May 26,2015 

Ms. Becky Shipp, Health and Human Resources Policy Advisor and 

Ms. Laura Berntsen, Senior Human Services Advisor 

Committee on Finance 

United States Senate 

Washington, D.C. 20510-6200 

Dear Ms. Shipp and Ms. Berntsen: 

The following is Hawaii's response to the information requested in the Apri124, 2015 

letter from Senators Hatch and Wyden. 

1. Private Case Management 

In the State of Hawaii (SOH), all case management services for children in 

foster care are provided by the SOH, Department of Human Services, Child 

Welfare Services (CWS). No private agencies provide case management 

for children in foster care in Hawaii. 

2. Who Places Foster Children 

All children who come into foster care in Hawaii due to maltreatment are 

placed in foster care by the State CWS. 

3. Private Entities Providing Core Services 

All core services are provided by the State CWS. 

4. Accreditation of Private Entities 

Not applicable. 

5. Selection Process for Private Entities 
80 


26354.044

Not applicable. 

6. Inspecting the Safety of Foster Care Settings 

The licensing processes for Emergency Shelter Homes, Foster Family 

Homes for Children, and Child Caring Institutions are set forth in the Hawaii 

Administrative Rules (HAR). The HAR are available at 

http://humanservices.hawaii.gov/admin-rules-2/admin-rules-for-programs/. In 

summary, prior to licensing a foster care setting, a State CWS worker 

completes a safety inspection of both the foster home or facility and the 

perspective caregivers. To ensure the safety of the physical space, the 

worker evaluates: reports or evidence of illegal activity, reports or evidence 

of substance abuse, TB and other communicable diseases status, sanitation, 

storage of medication and cleaning supplies, location and storage of any 

potentially dangerous objects, and adequate sleeping space. To ensure that 

the potential caregivers can safely care for the child, the worker analyzes 

information from a wide array of sources, including: Hawaii's Child 

Abuse/Neglect Database, Hawaii's Criminal Justice Information System, 

Hawaii's Sex Offender Registry, National Sex Offender Registry, Hawaii 

CWS' Foster Home Licensing Files, reports or evidence of illegal activity, 

reports or evidence of substance abuse, physical and mental health reports 

and evidence, access to reliable child care, and the worker executes an 

agreement to never use physical discipline with the child. 

Additionally, information is gathered from Child Abuse/Neglect databases for all 

states where the caregivers have lived. Potential caregivers are also 

fingerprinted and undergo FBI clearance. 

As to ongoing assessment of the foster home, the State CWS caseworker visits 

with the child on a monthly basis; at least six of those visits must take place in 

the foster care setting. Additionally, the State CWS licensing worker visits the 

child in the foster care placement once every six months and completes a safety 

inspection. 

7. Abuse in Foster Care Placement 

In Hawaii, from State Fiscal Year 2010- State Fiscal Year 2014 (July 1, 2009-

June 30, 2014), a total of 47 children were the subjects of confirmed maltreatment 

in foster care placements. All of these children were placed by the Hawaii CWS. 

For each of these five years, the percentage ranged from a low of 0.23% to a high 

of 0.88% out of all children in foster care for that year. 

8. Substantiated Abuse Actions 
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26354.045

When there is an allegation of abuse in a foster care setting, during the 

investigation, the child is removed from the setting. CWS staff makes an 

assessment about the safety of and risk to any other children in the home and 

decides whether or not to remove them. 

If the allegations are substantiated, the CWS Licensing worker completes an 

assessment, and depending upon the severity of the harm and the placement 

situation for the child (length of stay, permanency plans), all children may be 

removed from the home and the foster care license terminated, or rehabilitative 

efforts may take place. There is only one process, as the State CWS places all 

children in foster care. 

Should you have questions, concerns, or would like more information, please 

contact Kayle Perez, Child Welfare Services Branch Administrator, at (808) 586-

5667 or by email at kperez@dhs.hawaii.gov. 

Sincerely, 

~+ DAVID~ }J Govern~ of Hawai'i 
82 


26354.046

Bruce Rauner 

Governor 

December 15, 2015 

The Honorable Orrin Hatch 

Chairman 

Illinois Oep(lrtment of 

DCFS 

Children & Family Services 

The Honorable Ron Wyden 

Ranking Member 

US Senate Committee on Finance 

Washington, DC 20510 

US Senate Committee on Finance 

Washington, DC 20S10 

Dear Chairman Hatch and Ranking Member Wyden: 

George H. Sheldon 

Acting Director 

Thank you for your letter dated April 24, 201S requesting information on the State of Illinois' foster care 

system. On behalf of the State of Illinois' Department of Children and Family Services, I am grateful for 

the opportunity to share with you our answers to your questions. 

Governor Bruce Rauner and I agree that it is of the utmost importance to ensure that youth in out-ofhome placements are kept safe, healthy, and cared for during their temporary stay. We look forward to 

working with you and your colleagues in the Senate to ensure that federal dollars are spent wisely in the 

shared goal of both providing a safe place to stay when necessary, while preventing the need for out-ofhome placements to the greatest extent possible. 

The following pages and accompanying attachments constitute our answers. Please do not hesitate to 

contact Andrew Flach, my Chief of Staff, at 312-814-6847 should you have additional questions. 

Sincerely, Jo 

George Sheldon 

Acting Director 

Illinois Department of Children and Family Services 

Office of the Director 

100 W. Randolph St., Suite 6-100 • Chicago, Illinois 60601-3249 

312-814-2074 • 312-814-1888 Fax 

www.DCFS.illinois.gov 
83 


26354.047

1. To degree applicable, describe your state's utilization of private entities to provide case 

management services. 

a. Public child welfare agencies have historically relied upon private, nonprofit agencies to 

deliver services to particular client population, Illinois is no different, in this regard. 

The Illinois Department of Children and Family Services (DCFS) currently 

contracts with 48 private agencies providing foster care services statewide. 

ii. Caseload tracking data as of March 31, 2015 shows there were 16,330 children 

in paid foster care living arrangements. Private providers are caring for 12,869 

of those children, or 78%, while DCFS is caring for 3,461 children or 21%. 

2. What proportion of the children in foster care in your state is placed by the public agency, notfor-profit providers, and for-profit providers? 

a. Not-for-profit providers care for 12,059 children, or 74%; for-profit providers care for 

810 children, or 5%; and, the public agency cares for 3,461 children, or 21%. 

3. Please provide the number and names of private entities providing these core services, as well 

as information on whether each provider is a for-profit or not-for-profit entity. 

a. Document is attached. 

4. Does your state require that private foster care entities or organizations operating in your state 

be accredited? If so, by which organization and how often is this accreditation renewed? 

a. Yes, state law requires private agencies and their staff to maintain accreditation from a 

nationally recognized organization. Further, state licensing law allows organizations who 

have obtained full accreditation status from the Council on Accreditation for Children 

and Family Services to benefit from a streamlined licensing renewal procedure as long 

as there are not substantiated licensing violations within the previous 4 years. 

5. Describe in detail the process you use to select and contract with these private entities, as well 

as to review and renew such contracts. 

a. Illinois has been a national leader in performance based contracting with private 

agencies for child welfare services. Since 1998, private foster care agencies in Illinois 

have been subject to performance benchmarks for permanency achievement, 

placement stability, and other key child welfare outcomes. 

i. Private agencies and their caseworkers must be accredited and licensed. All 

private agencies must maintain accreditation from a nationally recognized 

organization (such as the Council on Accreditation). In addition, agencies must 

be licensed Illinois Child Welfare Agencies, and all Illinois caseworkers must 

obtain an individual child welfare license by meeting standards for education, 

experience, child welfare training, and a clean criminal background. 

ii. Both public and private providers are currently expected to achieve annual 

permanency rates of 40%, while keeping all children safe from harm while in 

care. Benchmarks are also established for: placement stability; in-person 

casework contacts; parent-child and sibling visitation; home-of-relative 

licensure; and timely case planning. Top-performing agencies are rewarded with 
84 


26354.048

a greater share of new, incoming foster cases. Low-performing agencies have 

diminished intake goals, and are at risk of intake closure. 

6. Describe in detail the process your state uses to inspect the safety of the foster care settings in 

which children are placed and the extent to which this process differs for public, not-for-profit, 

and for-public providers operating in your state. 

a. All licensed foster homes (public, not-for-profit, and for-profit) are physically inspected 

at least twice a year. During the monitoring visits, standards related to safety are 

reviewed and the findings documented on the CFS 597-FFH form. A foster family home 

license is valid for four (4) years. When a license is issued (initial or renewal licenses) 

the CFS 590 form is completed, which documents compliance with every licensing 

standard for foster family homes. Copies of the CFS 590 and CFS 597-FFH forms are 

included as separate attachments. 

b. Violations of licensing standards, including safety violations, are cited and a corrective 

action plan implemented. Serious violations result in a foster home being placed on 

"Involuntary Hold" meaning no additional placements may be made. Children may be 

moved to another placement if they are assessed to be at risk of harm. When a 

corrective action plan is implemented, it will be monitored until all violations have been 

corrected. 

7. How many instances of abuse in a foster care placement have been substantiated in the last five 

years in your state? Of those substantiated, how many of these instances related to children by: 

not-for-profit providers, for-profit providers, and public providers? 

a. There have been 659 indicated counts of abuse of children in a foster care placement. 

Of those indicated counts, 123 (18.7%) were related to a public provider; 46 (7%) to a 

for-profit provider; and, 490 (74.4%) to a not-for-profit provider. 

8. Describe in detail the actions taken when an abuse claim is substantiated while a child is in an 

out of home placement? Do these actions differ depending on whether the child was placed by 

the public agency, a not-for-profit provider, or a for-profit provider? 

a. DCFS has established rules and procedures for concurrent investigations when a child in 

an out of home setting is the victim of abuse/neglect. The same procedures are 

applicable to all homes, regardless of whether the child was placed in a public agency or 

private agency foster home. 

b. The Illinois State Central Register screens (SCR) all calls to the statewide hotline to 

determine if an incident meets the criteria for an abuse/neglect investigation. If the 

child victim is identified as residing in an out of home setting, SCR also notifies the DCFS 

Licensing Division and the licensing agency for that privately run foster home and a 

concurrent licensing investigation is initiated. Child protection staff and licensing staff 

work concurrently to develop a protective plan to ensure the safety of the child until 

both investigations are complete. Protective plans require removal of the child from the 

foster home, or removal of the offending foster parent, or the addition of another 

caregiving adult into the foster home. Weekly communication between child protection 

and licensing is required and licensing staff are responsible for weekly monitoring of the 
85 


26354.049

protective plan until a final determination is made. Children typically are not returned to 

the home if the child abuse/neglect allegation is substantiated. 

c. Upon conclusion of a substantiated child abuse/neglect investigation, the licensing 

agency must update background checks for the foster parents and re-examine the foster 

home to determine whether licensing standards are being met. Licensing must then 

determine whether to move to revoke the foster home's license or ask for a waiver of 

unsuitability to allow the home to maintain their license. This evaluation and actions are 

completed by purchase of service licensing staff if the home is licensed by purchase of 

service agency and by DCFS licensing staff if the home is licensed by DCFS. Purchase of 

service licensing agencies must report to DCFS Agency and Institution licensing staff on 

status of licensing complaints and corrective/revocation actions completed by their 

agencies. 
86 


26354.050

DCFS Children in Out-of-Home Caret 

by Profit-Status of Case Managing 

Agency as of 3/31/15 

ALLIANCE 

HUMAN 

SERVICES, 

INC:l: 

AOAJ>'f 

CAMELOT CARE COMMUNITY 

ALTERNATIVES 

439604 

tOut-of-Home Care Open child cases, exluding those placed at home or in Adoptive/Guardianship settings, 

T Alliance Human Services, Inc is a not-for-profit agency, but ali case management services are provided by its 

subcontractor, Illinois Mentor, which is a for-profit agency, IL DCFS will no longer contract with either Alliance 

Human Services or Illinois Mentor as of 7/1/2015. 

CYCIS Data as of 3/31/15. 
87 


26354.051

158 

ALLENDALE ASSOCIATION 53 LUTHERAN SOCIAL SERVICES OF IL 1,570 

ARDEN SHORE CHILD AND FAMILY 110 LYDIA HOME ASSOCIATION 84 SERVICES 

ASSOCIATION HOUSE OF CHICAGO 90 MYSI CORPORATION 56 

AUNT MARTHAS YOUTH SVC CTR INC 198 NATIONAL YOUTH ADVOCATE 93 PROGRAM INC 

BABY FOLD 118 NEXUS-ONARGA ACADEMY 11 

BETHANY FOR CHILDREN AND 49 OMNI YOUTH SERVICES 60 FAMILIES INCORPORATED 

CARITAS FAMILY SOLUTIONS 679 ONE HOPE UNITED NORTHERN REGN 437 

CATHOLIC CHARITIES/ARCH OF 44 ONE HOPE UNITED-HUDELSON REG 65 CHICAGO, THE 

CATHOLIC CHILDRENS HOME 15 OUR CHILDREN'S HOMESTEAD 145 

CENTER FOR YOUTH & FAMILY 944 OUTREACH ACADEMY 9 SOLUTIONS, THE 

CENTERSTONE OF ILLINOIS INC 13 PROLOGUE INC. 8 

CHADDOCK 121 RUTLEDGE YOUTH FOUNDATION INC 21 

CHILDLINK 220 RUTLEDGE YOUTH FOUNDATION, INC. 35 

CHILDRENS HOME & AID SOC OF IL 1,227 SHELTER, INC. 88 

CHILDRENS HOME ASSOC OF IL 192 SOS CHILDRENS VILLAGES IL 183 

CHILDRENS PLACE ASSOCIATION, THE 48 THRESHOLDS 17 

CHILDSERV 298 THRESHOLDS, THE 24 

CUNNINGHAM CHILDRENS HOME INC 80 UHLICH CHILDREN'S ADVANTAGE 369 NETWORK 

EASTER SEALS JOLIET REGION INC 73 UNITED CEREBRAL PALSY SEGUIN 159 

ENVISION UNLIMITED CAR. C. 58 UNITED METHODIST CHILDRENS HOM 35 

EVANGELICAL CHILD & FAMILY UNITY PARENTING AND COUNSELING 144 AGENCY 

FAMILY SERVICE CENTER OF 98 UNIVERSAL FAMILY CONNECTION IN 140 SANGAMON COUNTY 

FAMILYCORE 235 VOLUNTEERS OF AMERICA 165 

GENEVA FOUNDATION 15 WEBSTER CANTRELL HALL 109 

GUARDIAN ANGEL COMMUNITY 98 YOUTH NETWORK COUNCIL 59 SERVICES 

HARBOUR INC, THE 21 YOUTH OUTREACH SERVICES 32 

HEPHZIBAH CHILDREN'S ASSOCIATION 64 YOUTH SERVICE BUREAU OF ILLiNOIS 401 VALLEY 

HOYLETON YOUTH AND FAMILY 226 YOUTH SERVICE PROJECT INC 6 SERVICES 

INDIAN OAKS 15 PUBLIC AGENCY (IL DCFS) 3,461 

JEWISH CHILD & FAMILY SERVICES 77 PRIVATE FOR-PROFIT (3 Agencies) 810 

KALEIDOSCOPE, INC. 133 ADAPT COMMUNITY AlTERNATIVES 22 

KEMMERER VILLAGE 43 ALLIANCE HUMAN SERVICES, INC 459 

LAKESIDE COMMUNITY COMM 151 CAMELOT CARE CENTERS INC. 329 

LAWRENCE HALL YOUTH SERVICES 255 OUT-OF-HOME CARE CASES 3131/15 16,330 

LITTLE CITY FOUNDATION 47 
88 


26354.052

Michael R. Pence, Governor 

Mary Beth Bonaventura, Director 

Indiana Department of Child Setvices 

Roorn E3o6 MS47 

302 W. Washington Street 

Indianapolis, Indiana 46204-2738 

317·>31r·KIDS 

FAX: 317·234·4497 

www.in.gov/dcs 

Child Support Hotline: 800-840-8757 

Child Abuse and Neglect Hotline: 800-800-5556 

june 2, 2015 

Becky Shipp, Health and Human Resources Policy Advisor 

Laura Berntsen, Senior Human Services Advisor 

U.S. Senate Finance Committee 

Dear Ms. Shipp and Ms. Berntsen, 

Jn response to the letter dated April 24, 2015, from the U.S, Senate Finance Committee, please see 

information below relating to the delivery of child welfare services in Indiana: 

1. To the degree applicable, describe your state's utilization of private entities to provide 

case management services (e.g. placement of children with particular foster care 

providers, ongoing casework and uversight of foster care placements. 

Core case management in Indiana is the responsibility of the Indiana Department of Child Services 

[DCS), and the delivery of child welfare services, including placement of children with particular 

foster care providers, ongoing casework, and oversight of foster care placements is provided by 

DCS staff in local offices throughout the state. 

DCS is responsible for approving all placements for children who are adjudicated to be a· Child in 

Need of Services (CHINS} or delinquent children. Foster eligible placements include foster family 

homes, groLlp homes, and residential treatment facilities, all of which are state-licensed placement 

options. 

All foster family homes receive a state-issued license based upon consistent state requirements, 

whether licensed directly by DCS or by DCS approval of a recommendation for licensure made by a 

Licensed Child Placing Agency (LCPA). DCS enters into contractual agreements with LCPAs to 

recommend licensure of additional foster family homes. LCPAs provide enhanced supervision of 

the foster family homes licensed by DCS through their agency and provide placement support for 

children placed in homes managed by LCPAs. 

Each child in a foster family home placemen.t. 

throughout the duration of the placement. '·' 

by an assigned DCS family case manager 

re Licensing Unit has licensing oversight 

l'rvtetting o11r chi!dtrn,jaJJ?i!iu, amlji111tre 
89 


26354.053

over all foster family homes and may recommend probation, placement hold, and/or revocation as 

needed. 

Additionally, DCS enters into contracts with cross-system care coordination providers to 

supplement case management and coordination of care for children with high levels of need. This 

cross-system supervision is in addition to the supervision by DCS and, where appropriate, LCPAs. 

A foster family home can apply for licensure either through DCS directly or through an LCPA, and all 

foster family homes follow the same licensing procedures and documentation requirements. DCS is 

solely responsible for licensing all child placing agencies in lndiana. LCPAs are private entities that 

license and monitor foster family homes. LCPAs can recommend foster family homes for licensure, 

but DCS is responsible for making the final licensure decision. 

2. What proportion of the children in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? 

DCS is the agency solely responsible for making placement decisions, which must be approved by a 

court with appropriate jurisdiction, for children under the care and control of DCS. Therefore, all 

placement decisions are made by DCS and are based upon the child's needs and the skill set, 

resources, and location of the foster family. 

3. Please provide the number and names of private entities providing these core services, 

as well as information on whether each provider is a for-profit or not-for-profit entity. 

Core case management in Indiana is the sole responsibility of DCS. However, DCS may supplement 

state case management with enhanced supervision and placement support provided by the 33 

currently licensed child placing agencies in Indiana. A list detailing their for-profit or not-for-profit 

status is attached. 

4. Does your state require that private foster care entities or organizations operating in 

your state be accredited? If so, by which organization and how often is this accreditation 

renewed? 

Child placing agencies are reqttired to be licensed by the state pursuant to Indiana Code§ 31-27-6. 

Accreditation is not required. Prior to the submission of an application to become licensed as a 

foster care LCPA, the applicant must attend a five-hour training session offered by DCS, Residential 

Licensing and Contract Compliance. The focus of the training is to give the applicant an overview of 

the foster care system in Indiana and to acquaint the potential applicant with the requirements to 

be licensed as an LCPA in the state of Indiana. 

As a part of the application, the LCPA must provide detailed information, including policies and 

procedures, that clearly and concisely demonstrates the applicant's knowledge of child welfare, 

foster care in general, and requirements of Indiana's system, including the Indiana administrative 

code and the LCPA contract. The application as to compliance with 

Prote,·ting our chi!dm;,fami!ies a11d{ti!Nre 
90 


26354.054

requirements. Often, additional information is required prior to the applicant being granted a 

license. 

5. Describe in detail the process you use to select and contract with these private entities, 

as well as to review and renew such contracts. 

Once a child placing agency is licensed, the agency is eligible to contract with DCS to provide the 

services requested by the agency. The DCS Residential Licensing and Contract Compliance Unit 

(RLCCLJ) licenses these LCPAs, and then DCS contracts with these agencies to provide foster care 

services, including recruitment, licensing, and support/retention. When the DCS RLCCU licenses an 

LCPA, DCS ensures that the LCPA and the foster homes managed by the LCPA meet Indiana statutes, 

rules, and policies. While LCPA licenses are valid for 4 years, DCS RLCCU conducts annual licensing 

and contract reviews of LCPAs to ensure that Indiana statutes, rules, requirements of the contract, 

and policies continue to be met. DC.S plans to make revisions to the Indiana Administrative Code 

within the next five years related to LCPA regulations. 

When an LCPA is not meeting licensing and/or contract standards, DCS RLCCLJ requires the LCPA to 

submit a Plan of Correction, which specifics how the LCPA will come into compliance. Depending 

on the nature of the non-compliance, DCS RLCCU may also institute a placement hold and/or a 

probationary status on the license. Additionally, if an individual foster home is not meeting 

standards, the same actions can be taken. 

6. Describe in detail the process your state uses to inspect the safety of the foster care 

settings in which children are placed and the extent to which this process differs for 

public, not-for-profit, and for-profit providers operating in your state. 

All foster family homes, whether the application is first submitted through DCS directly or through 

an LCPA, are required to obtain a license from DCS per state statute (Indiana Code§ 31-27-4). 

Licenses are issued for a period of four years. Annual reviews are conducted by the licensing 

worker in order to update the foster family's personal information and determine whether the 

family continues to meet the requirements for licensure. The requirements for licensure include: 

Must be at least 21 years of age 

Passing a criminal history and fingerprint-based national background check 

Demonstrating financial stability 

Owning or renting a home that meets physical safety standards (e.g., fire extinguishers, 

adequate bedroom space, reliable transportation) 

Medical statements from a physician for all household members 

Successful completion of pre-service training requirements, including First Aid, CPR, and 

Universal Precautions training 

Positive personal reference statements 

Home visits and a completed home study assessment from the licensing worker 

Completing all required forms within packet 

Protecti11g ottr d:Jildren..fami!ies a11d.fut11re 
91 


26354.055

A Standard License is issued to foster parents who care for children without special medical, 

developmental, mental, or emotional needs. A Therapeutic Certificate includes additional training 

requirements and allows licensed foster parents to serve as a placement for a child who has either a 

moderate to severe medical, developmental, or behavioral( emotional need, or a high-riskbehavior. 

If a family applies for licensure through DCS directly, then DCS is responsible for conducting a home 

study of the prospective foster family home. If the family applies for licensure through an LCPA, 

then the LCPA is responsible for conducting the home study and will make a recommendation to 

the DCS Central Office Foster Care Licensing Unit regarding the licensure decision for the family. 

DCS or its designee (an LCPA, if the family is applying through the LCPA) will conduct a minimum of 

two visits to the home of the prospective foster family for the purpose of assessing the physical 

environment of the home and engaging in a thoughtful dialogue with all members of the household 

about foster parenting or adoption. DCS or the licensing worker will ensure that the home meets all 

applicable safety requirements, such as ensuring that the interior is free of all safety hazards (e.g. 

exposed wiring or chipping paint), the family has access to a working telephone, the home has a 

functioning bathroom, every sleeping room has two exits, etc. Any safety requirement that is not 

met necessitates either a Plan of Correction or a documented waiver or variance, as appropriate. 

This information is retained in the family's licensing file. 

7. How many instances of abuse in a foster care placement have been substantiated in the 

last five years in your state? Of those substantiated, how many of these instances related 

to children placed by: not-for-profit providers, for-profit providers, and public 

providers? 

The children in the following chart were identified as having at least one substantiated allegation of 

abuse or neglect on an assessment during the time period where the perpetrator is a foster parent 

or institutional (group home or residential placement facility) staff. 

The total number of children includes all CHINS children with an open removal episode at any time 

during the 12 months prior to the month of the report. Also included are probation children (who 

are JV-E eligible J with an open removal episode at any time during the 12 months prior to the 

month of the report. The rate of maltreatment equals the number of substantiated victims divided 

by the number of children in foster care. This data is publicly available on the DCS website 

(www.in.gov/dcs >Reports &Statistics> Practice Indicator Reports). 

Prote<'ting o11r thi!dtM, JamilieJ amljit!Nt~ 
92 


26354.056

- Rate of 

Children lf1 VIctims In Malreatment 

Foster care foster Care In Foster care 

March 20;14 to 

March 2015 27,610 100 0.36% 

March 2013 to 

March 2014 2~,252 60 0.27% 

March 2012 to 

March 20!3 20,256 40 0.20% ··~ 

March 2011 to 

March 2012 19,~~ 22 0.11% -----~-

March 2010 to 

March 2011 21,328 63 0.30% 

DCS is the agency solely responsible for making placement decisions, so this data all relates to 

children placed hy DCS. 

8. Describe in detail the actions taken when an abuse claim is substantiated while a child is 

in an out-of-home placement. Do these actions differ depending on whether the child was 

placed by the public agency, a not-for-profit provider, or a for-profit provider? 

All children are placed by DCS, and there are not differing actions to a substantiated abuse claim 

based upon whether the home is licensed directly through DCS or if the home applied for licensure 

through an LCPA. The DCS Institutional Child Protection Service (!CPS) Unit will conduct an 

assessment of a report of child abuse and for neglect if the allegations state the incident occurred 

while the child was placed out-of-hrJme in <1 residential facility, group home, or juvenile correctional 

facility. If the child is placed outside the home in foster care, the DCS local office will conduct the 

assessment The child may be removed from the foster care placement while the investigation 

takes place, depending on t:he circumstances. 

Additionally, a substantiated ahuse allegation would lead to <1 revocation action and ineligibility for 

licensure of the foster parent( s] involved in the substantiation. When abuse or neglect is 

unsubstantiated, the DCS Central Office Foster Care Licensing Unit reviews the assessment for 

unresolved licensing regulation violations and follows up with the licensing agency (DCS or LCPA) 

to ensure appropriate action is taken to correct or resolve those issnes. 

Please let us know if any additional information is required to satisfy this request 

Respectfully, 

gw.· f5. IS. 

Doris B. B. Tolliver, Esq., M.A. 

Chief of Staff, Indiana Department of Child 

rmd }ittwe 
93 


26354.057

Iowa Department of Human Services 

Terry E. Branstact 

Governor 

The Honorable Orin Hatch 

The Honorable Ron Wyden 

United States Senators 

Committee on Finance 

ATTN: Becky Shipp and Laura Berntsen 

Dear Senators Hatch and Wyden: 

Kim Reynolds 

Lt. Governor 

Charlos M. Palmor 

Director 

I am writing in response to the letter you sent dated April 24, 2015, asking states for 

information about the privatization of foster care services. The responses to your inquiries 

are as follows: 

Question: To the degree applicable, describe your state's utilization of private entities to 

provide case management services (e.g., placement of children with particular foster care 

providers, ongoing casework, and oversight of foster care placements). 

Response: Iowa does not utilize private entities to provide case management services to 

children in foster care. Iowa Department of Human Services (DHS) staff are responsible for 

issuing all foster family home licenses, residential treatment facility licenses and shelter 

facility licenses. DHS staff are responsible for selecting the placement, providing required 

information and documents to the selected foster care home or facility, and providing case 

management and oversight of the child while in out-of-home care. 

Iowa does use privately contracted agencies to provide in-home family centered services to 

children in foster care. These services are to promote reunification by providing assistance 

with transportation and supervision of parent!child interactions, providing services to !he 

family to alleviate the safety concerns that lead to out-of-home placement, and facilitate and 

monitor community-based services for children and families. 

Iowa also has a statewide contractor for the recruitment and retention of foster and adoptive 

homes. Iowa Kids Net is comprised of six agencies with one acting as the lead agency. All 

six agencies are not-for-profit. Iowa Kids Net performs licensing activities that include preservice training, completion of record checks, completion of the home study, and all other 

documentation required by rules and statue. Iowa KidsNet makes a recommendation to DHS 

to approve or not approve a family to be a licensed foster home. DHS makes the final 

licensing decision. Iowa KidsNet provides assistance with matching children with foster 

family homes by providing the names of available homes to DHS staff when a child is in need 

of a foster home placement, but DHS staff are responsible for selecting the placement and 

placing the child. Iowa KidsNet also provides supportive services to all licensed foster 

families. 

1305 E. Walnut Street, Des Moines, lA 50319-0114 
94 


26354.058

The Honorable Orin Hatch 

The Honorable Ron Wyden 

Page 2 

DHS also contracts with residential treatment providers and emergency shelters to provide 

congregate care services to children with behavioral needs. DHS is responsible for the 

selection of the facility, placement of the child, and ongoing case management. 

Question: What proportion of the children in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? 

Response: All children in foster care are placed by the state agency as ordered by the Court. 

Question: Please provide the number and names of private entities providing these core 

services as well as information on whether each provider is a for-profit or not-for-profit entity. 

Response: As stated, DHS provides case management services to children in foster care. 

Question: Does your state require that private foster care entities or organizations operating 

in your state be accredited? If so, by which organization and how often is this accreditation 

renewed? 

Response: Iowa does not have private foster care entities or organizations so accreditation 

is not required. 

Question: Describe in detail the process you use to select and contract with these private 

entities as well as to review and renew such contracts. 

Response: DHS is required to follow all state procurement policies. A request for proposal is 

issued which outlines the purpose of the contract, the scope of work, performance measures 

and payment. Bidders submit proposals which are reviewed by a committee. The committee 

scores each proposal and recommends a bidder. The final selection of a bidder is made by 

designated DHS leadership staff. The bidder is announced and a contract is negotiated. 

Contract compliance is monitored by DHS staff. Contracts are renewed annually and may be 

amended as needed. The maximum length of a contract is six years, but can be terminated 

prior to the last allowable renewal for reasons specified in the contract. The contract is repro cured prior to the expiration of the last renewal year and a new contract is executed. 

Question: Describe in detail the process your state uses to inspect the safety of the foster 

care setting in which children are placed, and the extent to which this process differs for 

public, not-for-profit and for-public providers operating in your state. 

Response: Licensed residential foster care facilities are required to meet all safety and nonsafety regulations as described in administrative code. Facilities must perform criminal and 

child abuse checks on any prospective employees. The Department of Inspections and 

Appeals (DIA), a state agency, completes a minimum of one visit each year to each facility to 

monitor compliance with licensing regulations. DIA reports all deficiencies to the facility and 

to DHS. A plan of correction is developed to correct the deficiencies. If a facility has serious 
95 


26354.059

The Honorable Orin Hatch 

The Honorable Ron Wyden 

Page 3 

deficiencies or repeated deficiencies the license may be moved to a time-limited suspended 

license or provisional license. When there are serious safety deficiencies the license may be 

revoked and the facility closed. 

Foster family homes are also required to meet all safety and non-safety regulations as 

described in administrative code. Iowa Kids Net staff are required to visit each foster family 

three times during the licensing year- one unannounced visit, one relicensing visit, and one 

additional visit. During each visit the safety of the home is assessed as well as compliance 

with licensing regulations. Iowa Kids Net staff discuss any deficiencies that are found with the 

foster parents, and a plan is developed to correct the deficiencies. If at any point a foster 

family home is determined to be unsafe the foster children are removed and action is taken 

on the license. This may be a formal written plan of correction or revocation of the foster 

home license. 

DHS staff are required to regularly visit children on their caseload who are in out-of-home 

placement. Staff make every effort to see children monthly. During the visit staff are required 

to see the child alone to provide the child an opportunity to express any problems or 

concerns the child is having with the placement. If the child expresses feeling unsafe, staff 

assess the concerns, and if warranted, will remove the child and place the child in another 

foster family home or residential facility. If the child is determined to be safe, the child's 

concerns are discussed with the foster family or the facility staff to address the child's 

concerns. 

If there is an allegation of abuse or neglect by a licensed foster parent or household member, 

or an employee of a residential facility, it is called into the DHS child abuse hotline 1-800-362-

2178. Intake information is gathered including the alleged perpetrator and where the incident 

occurred. 

A DHS child protection worker is assigned to assess the child's safety and the validity of the 

allegation. The child protection worker has 20 days in which to determine if the allegation will 

be substantiated or not. Child safety is continuously assessed from the time the allegation is 

received through the course of the 20 day assessment. Regulatory staff are included in the 

assessment to determine if the foster home or facility is in violation of licensing requirements. 

The process is the same for public, not-for-profit and for-profit residential facilities and all 

foster family homes. 

Question: How many instances of abuse in a foster care placement have been substantiated 

in the past five years in your state? Of those substantiated, how many of these instances 

related to children placed by not-for-profit providers, for-profit providers, and public providers? 
96 


26354.060

The Honorable Orin Hatch 

The Honorable Ron Wyden 

Page 4 

Response: The chart below shows the number of children who had substantiated reports of 

abuse in all foster care settings. All of the children were placed by DHS. 

Number of children abused by foster care 

providers by federal fiscal year 

Federal Fiscal Year # 

2010 41 

2011 42 

2012 35 

2013 27 

2014 31 

Question: Describe in detail the actions taken when an abuse claim is substantiated while a 

child is in an out of home placement? Do these actions differ depending on whether the child 

was placed by the public agency, a not-for-profit provider, or a for-profit provider? 

Response: The child is removed from the placement immediately when a determination is 

made that the child is not safe. The child may also be removed if it is determined that it is in 

the best interest of the child not to reside in the foster home or facility during the course of the 

assessment. 

If the abuse allegation is substantiated against a foster family member the abuse report will 

be evaluated by DHS to determine whether the foster home license should be revoked or if a 

formal plan of correction is needed. All foster families are licensed by DHS so the process is 

the same for all substantiated abuse allegations. 

If the allegation is substantiated against an employee of the facility, the report will be 

evaluated by designated DHS staff to determine if the subject is able to continue to work or is 

prohibited from working in the facility. The process is the same regardless of whether the 

facility is a for-profit or not-for-profit agency. 

If you have further questions, please feel free to contact me. 

Sincerely, 

Charles M. Palmer 

Director 

CMP/tp 
97 


26354.061

Kansas 

Department for Children 

and Fmnilie~ 

S.;nmg Famlfws ,\fokr~ u Smmg Kansu> 

Response to Senate Finance Committee Questions 

on Public-Private Partnerships 

May 15, 2015 

To the degree applicable, describe your state's utilization of private entities to 

provide case management services (e.g. placement of children with particular 

foster care providers, ongoing casework and oversight of foster care 

placements). 

The entire case management responsibilities for the Kansas Department for Children 

and Families (DCF) Family Preservation, and Reintegration/Foster Care/Adoption 

Services are performed under competitive bid contracts. There are two providers for the 

Reintegration/Foster Care/Adoption Services contracts, and they are responsible for the 

placement of children who are removed from their homes. Per the contract with DCF, 

the two providers are required to sub-contract with child placing agencies (CPAs) that 

sponsor foster homes. The two providers are CPAs and sponsor foster homes as well. 

The oversight of foster homes is currently regulated by the Kansas Department Health 

and Environment (KDHE). All foster homes are required to be licensed. The CPAs 

provide oversight of the foster homes and are also regulated by KDHE. The oversight of 

the placement of children is monitored by the case management provider and the DCF 

Foster Care Liaison. Oversight of the contracts is done through performance measures, 

DCF case reads and administrative reviews. 

What proportion of the children in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? 

All of the children in foster care are placed by the two case management providers. 

They both are not-for-profit agencies. 

Please provide the number and names of private entities providing these core 

services, as well as information on whether each provider is a for-profit or notfor-profit entity. 

Kansas has two providers of these core services: KVC Health Systems, Inc. and St. 

Francis Community Services. Both are not-for-profit. 

Does your state require that private foster care entities or organizations operating 

in your state be accredited? If so, by which organization and how often is this 

accreditation renewed? 

Yes, DCF requires case management providers to be accredited with a child welfare 

organization. Currently, both providers are accredited by the Joint Commission on 

Accreditation. The certificate and accreditation cycle is valid for up to 39 months. 

Page 1 of 4 
98 


26354.062

Describe in detail the process you use to select and contract with these private 

entities, as well as to review and renew such contracts. 

Procurement Process: 

• The agency submits a letter from the Secretary to the Director of Purchases with 

a request to establish a Procurement Negotiating Committee (PNC); per K.S.A. 

75-37,102 (Attached), the PNC consists of: 

o Director of Purchases, or designee 

o The Director of Purchases' representative will shepherd the project 

through the process. 

o Secretary of Administration, or designee 

o Agency Head, or designee 

o Others may be involved in bid evaluation, negotiations, program planning, but 

the three designated members are ultimately responsible for the final 

decision. 

• A Request for Proposal (RFP) is prepared by agency staff (sections IV and V of 

the RFP template) and posted for advertisement by a Division of Purchases 

Procurement Officer. 

• The RFP information is advertised in the Kansas Register, per statutory 

requirement. 

• The RFP is posted to the internet; notice of RFP is mailed to 

interested/interesting vendors. 

o The RFP document reminds bidders to monitor the Purchases website for 

periodic posting of new information related to the bid document. 

o The RFP will typically involve a pre-bid conference or a pre-bid question and 

answer period that allows potential vendors to request clarification of RFP 

information. 

o The questions and answers are released to all known interested vendors via 

addendum, posted to the internet. 

• Bid closing date (proposal submission deadline) 

o Vendors are instructed to submit their technical proposals in separate sealed 

envelopes (separate from the cost proposals). 

o At bid opening, only names of bidders are announced. 

• Review of proposals begins when technical proposals only. They are forwarded 

to PNC members and other agency participants/evaluators. 

o Cost proposals are retained by the Division of Purchases (the reasoning 

behind this is that technical evaluation should be conducted without the 

prejudice of price). 

o The agency must provide a complete technical evaluation of each proposal 

submitted, with an attempt to list items including (but not limited to): 

Response format as required by the RFP; 

• Adequacy and completeness of proposal; 

Page 2 of4 
99 


26354.063

• Vendors' understanding of the project; 

Compliance with the terms and conditions of the RFP; 

Experience in providing like services; 

Qualified staff; 

Methodology to accomplish tasks; 

Pros/cons; 

Strengths/weaknesses 

Once the technical evaluation has been completed, the evaluation team submits 

a Technical Evaluation Summary to the Division of Purchases. 

• Upon receipt of a complete (quality and substance) Technical Evaluation 

Summary, the cost proposals are released to the PNC/evaluation team for 

review. 

• The PNC/evaluation team reviews the cost proposals in concert with the 

technical evaluations, and selects one or more vendors to invite to negotiations. 

• The List of Vendors to Invite to Negotiations is developed. 

• Negotiation session(s) are scheduled. 

o Preparations for negotiations may include the development of questions and 

answers/discussion points for negotiations, to allow the vendor to be better 

prepared for the meeting. 

o At the end of negotiations, the PNC will request a counter offer/best and final 

offer. Especially important is clarification of the vendor's 

expectations/understanding of the project results in a change of cost. 

• Once counter offers/best and final offers have been submitted, the PNC again 

reviews cost and technical proposals, and works to determine a winner and 

provide documentation of the decision. 

o The PNC/evaluation team prepares a formal recommendation for award. 

o Deadline for documentation of reasons for not awarding to vendors lower 

in cost 

o Contract documents are prepared, and are routed for signatures. 

Once all required signatures have been acquired, work on the project may begin. 

Describe in detail the process your state uses to inspect the safety of the foster 

care settings in which children are placed and the extent to which this process 

differs for public, not-for-profit, and for-profit providers operating in your state. 

o KAR. 28-4-802. License requirements. Each individual shall meet all of the 

following requirements to obtain a license and to maintain a license: 

(a) Submit a complete application for a license on forms provided by the 

department, including requests for the background checks specified in KAR. 

28-4-805; 

(b) be at least 21 years of age; 

(c) have sufficient income or resources to provide for the basic needs and 

financial obligations of the foster family and to maintain compliance with all 

regulations governing family foster homes; 

(d) participate in an initial family assessment, a family assessment for each 

renewal, and any additional family assessments conducted by the sponsoring 

Page 3 of4 
100 


26354.064

child-placing agency. Each family assessment shall include at least one 

individual interview with each household member at least seven years of age 

and at least one visit in the family foster home; 

(e) meet the training requirements in KAR. 28-4-806; and 

(f) obtain and maintain ongoing sponsorship by a public or private child-placing 

agency, including a recommendation by the sponsoring child-placing agency 

that the home be used for placement of children in foster care. 

(Authorized by K.S.A. 65-508; implementing K.S.A. 65-504 and 65-508; effective 

March 28, 2008.) 

How many instances of abuse in a foster care placement have been substantiated 

in your state? Of those substantiated, how many of these instances related to 

children placed by: not-for-profit providers, for-profit providers, and public 

providers? 

• The numbers of children in out-of-home placement who had a substantiated 

abuse neglect, where the perpetrator was a foster parent or placement facility 

employee: 

o SFY 2010 = 12 

o SFY 2011 = 12 

o SFY2012=14 

o SFY2013=16 

o SFY 2014 = 23 

The total is 77 over the five year period. 

Describe in detail the actions taken when an abuse claim is substantiated while a 

child is in an out of home placement? Do these actions differ depending on 

whether the child was placed by the public agency, a not-for-profit provider, or a 

for-profit provider? 

• If the foster parent is substantiated for abuse or neglect, his/her name is placed 

on the Child Abuse and Neglect Registry, and the foster home license is revoked. 

Page 4 of 4 
101 


26354.065

CABINET FOR HEALTH AND FAMILY SERVICES 

OFFICE OF THE SECRETARY 

Steven L. Beshear 

Governor 

May 22,2015 

The Honorable Orin Hatch, Chairman 

The Honorable Ron Wyden, Ranking Member 

United States Senate 

Committee on Finance 

Washington, DC 20510·6200 

Dear Senators Hatch and Wyden: 

275 east Main Street, 5W·A 

Frankfort, KY 40621 

502-564-7042 

502-564-7091 

www.chfs.ky.gov 

Audrey Tayse Haynes 

Secretary 

On behalf of Kentucky Governor Steven L Beshear, I'm pleased to provide background information per your request on 

Kentucky's Implementation of the federal foster care and adoption programs, specifically relating to private contractors 

that assist in our efforts. 

Should you or your committee staff require additional information, do not hesitate to contact us. 

To the degree applicable, describe your state's utlllutlon of private entitles to provide case management services 

(e.g., placement of children with particular foster care providers, ongoing casework and oversight of foster care 

placements). 

The Kentucky Cabinet for Health and Family Services (CHFS), Department for Community Based Services has under Its 

care certain children for whom specialized foster care services are needed. If a child cannot be placed with the public 

agency, CHFS utilizes private providers to provide needed services for children In out of home care. Those services are 

governed under the "Private Child Care Agreement" and are conceptualized as: 

Family centered; 

Youth guided; 

Time limited; 

Intensive; and 

Evidence Informed. 

These practices are designed to promote the child welfare goals of safety, permanency, well-being and stability. 

KentuckyUnbrtdledSplrlt.ccm An Equal Opportunity Employer M/F/0 
102 


26354.066

By accepting children for placement from the Cabinet for Health and Family Services (CHFS), the private agencies agree 

to provide the following services based on the parameters ofthe Individual agency's contract: 

Adoption; 

Therapeutic and Medically Fragile Foster care; 

Independent living; 

Group homes that Include: 

o Treatment; and 

o Crisis intervention; 

Institutions that Include: 

o Treatment; and 

o Crisis intervention; 

Emergency shelter and/or emergency shelter with treatment services. 

As part of the private agency's agreement with CHFS, the agency agrees to provide the child with following ongoing 

case management services: 

Therapy as needed; 

Placement stability; 

Working with family to return child home, if applicable; 

Participation In case planning; 

Appropriate training for foster parents in working with each child's Individual needs; 

Family type environment for a child; 

Baste needs (food, shelter, clothing, etc.); and 

Cultural and religious opportunities. 

What proportion of the children in foster care In your state Is placed by the public agency, not-for-profit providers, and 

for-profit providers? 

All children that are placed in foster care In the state of Kentucky are placed by the public agency. Private agencies are not 

responsible for placing children in the state of Kentucky. 

Please provide the number and names of prlvate entitles providing these core services, as well as Information on whether 

each provider Is a for-profit or not-for-profit entity, 

There are forty-three (43) private agencies that provide the core services listed in question #1 to children placed In out of 

home care in the state of Kentucky. Below is a breakdown of the profit/non-profit status of each private agency. 

For Profit Agencies: 

Community Youth Services; 

Kinder Haven, fnc.; 

Omnl VIsion, Inc.; 

Altemative Youth Services; 

Combs Residential Services; 

Key Assets of Kentucky, LLC; 

New Beginnings Family Services, Inc.; 

New Hope Foster Homes, Inc.; and 

The Balr Foundation. 
103 


26354.067

Not For Profit Agencies: 

All God's Children, Inc.; 

Appalachian Children's Home, Inc.; 

Arbor Youth Services; 

Barnabas Home; 

Benchmark Family Services, Inc.; 

Brighton Center1 Inc.; 

Buckhorn Children and Family Services; 

Children's Home of Northern Kentucky; 

Comprehend, Inc.; 

Diocesan Catholic Children's Home, Inc.; 

ENA, Inc. {dba Neece); 

Family Connection, Inc. (dba Hope Hill Youth Services); 

Father Maloney's Boy's Haven; 

Foothills Academy, Inc.; 

Gateway Juvenile Diversion Project, Inc.; 

Green River Regional MH/MR Board, Inc.; 

Holly Hill Children's Services; 

Kentucky Intensive Family Services, Inc.; 

Kentucky United Methodist Homes for Children and Youth; 

KVC Behavioral Health Care KY; 

Life Connection, Inc.; 

LifeSkills, Inc.; 

Maryhurst, Inc.; 

Mountain Comprehensive Care Foster Care; 

Pennyroyal Regional MH/MR Board, Inc.; 

Ramey Estep Homes1 Inc.; 

REACH of Louisville, Inc.; 

Specialized Alternatives for Families and Youth of Kentucky, Inc.; 

St. Joseph Children's Home; 

St. Joseph's Peace Mission for Children; 

Sunrise Children's Services; 

Uspiritus; 

YMCA Safe Place Services. 

Does your state require that private foster care entitles or organlratlons operating In your state be accredited? If so, by 

which organization and how often Is this accreditation renewed? 

Yes, Kentucky requires that all private foster care entities or organizations operating within the state obtain accreditation by 

a nationally recognized accreditation organization either: 

Within two {2) years of Initial licensure {922 KAR 1:300); or 

Within two (2) years of initial licensure or within two (2) years of acquiring an agreement with the cabinet [(public 

agency)! to provide private child care services, whichever Is later (922 KAR 1:310). 

Accreditation must be maintained utilizing the renewal procedures based on the Individual accrediting body chosen by the 

private agency. 
104 


26354.068

Describe In detail the process you use to select and contract with these private entitles, as well as to review and renew 

such contracts. 

According to Kentucky Revised Statutes (KRS) 45A.690, Definitions for KR5 45A.690 to KRS 45A.725, CHFS does not 

contract with private providers. 

Private entitles provide foster care to children committed to the public agency through the "Private Child Care 

Agreement," which governs private entitles and is similar to a Memorandum of Understanding. Language In the 

agreement specifies services that could be reasonably expected by both parties if a child were to be placed with one of 

the agencies and the expectations or standard of care that would be provided for said child. 

Before a private agency may apply to provide services for the public agency, the entity must be licensed by the public 

agency's Office of Inspector General. After this occurs, an application may be made with the public agency for the 

provisions of foster care/out of home care services. Once the application has been approved, the private agency enters 

Into an agreement with the public agency. 

The following Kentucky Administrative Regulations (KAR) have been promulgated to govern rate methodology, 

standards of care, and licensing and accreditation requirement for private child caring and child placing agencies: 

922 KAR 1:300, Standards for child-caring facilities; 

922 KAR 1:305, Licensure of child-caring facilities and child-placing agencies; 

922 KAR 1:310, Standards for child-placing agencies; 

922 KAR 1:360, Private child care placement, levels of care, and payment; 

922 KAR 1:380, Standards for emergency shelter child-caring facilities; and 

922 KAR 1:390, Standards for residential child-caring facilities. 

These regulations ensure that private providers meet ali state and federal mandates surrounding these matters. 

The private agency undergoes a renewal process every two (2) years for continued approval as a placement resource 

for CHFS. The private agency must submit a new application packet to public agency for review. The public agency 

ensures that all necessary Information Is contained within this application packet, reviews It, and then makes a 

determination of whether or not to renew the private agency's agreement for another two {2) years. 

Describe In detail the process your state uses to Inspect the safety of the foster care settings In which children are placed 

and the extent to which this process differs for public, not-for-profit, and for-public providers operating In your state. 

For Private Agencies: 

The CHFS Office of the Inspector General (OIG) utilizes a survey called the "Child Placing Survey Tool" to inspect the safety of 

private agency foster care settings. This tool contains Items that assist OIG In ensuring that private agencies meet ali 

required state and federal guidelines associated with their approval, as well as provide all necessary safety precautions. This 

process Is the same for both for-profit and not-for-profit agencies. 922 KAR 1:310, Standards for child-placing agencies, 

provides requirements for annual re·evaluations of private agency foster homes. These requirements ensure that the foster 

homes continue to meet standards to remain viable placement options for children In foster care. 

For Public Agencies: 

Foster homes that are approved to receive placements through the public agency are re-evaluated annually. The document 

utilized for these types of placements is the "DPP-1289 Annual Strengths/Needs Assessment for Resource Families." This 

document assesses for continued safety and ongoing training of the placement resource. 922 KAR 1:350, Family 

preparation, provides requirements for annual re-evaluations of public agency foster homes. These requirements ensure 

that the foster homes continue to meet standards to remain viable placement options for children In foster care. 
105 


26354.069

In addition to the completion of the "Child Placing Survey Tool" for private agencies and the "DPP-1289 Annual 

Strengths/Needs Assessment for Resource Families" for public agencies, both private and public agency foster homes agree 

to allow social workers a face to face visit for purposes of completing the annual re-evaluation. The foster parents also 

agree to submit to annual criminal background checks, child abuse/neglect checks, and continue to meet all requirements of 

the Adam Walsh Child Protection and Safety Act of 2006. In addition to the specific requirements of the annual re· 

evaluations, both private and public agency foster homes agree to allow social workers to visit their home each month to 

monitor the continued safety of all children placed In out of home care. 

How many Instances of abuse In a foster care placement have been substantiated In the last five years In your state? Df 

those substantiated, how many of these Instances related to children placed by: not-for profit providers, for-profit 

providers, and public providers? 

The state of Kentucky does not collect Information regarding substantiated claims of abuse In terms of public, private, for· 

profit and not-for-profit statistics. As stated In the answer to question #2, all children In Kentucky who are placed In an out 

of home care situation, are placed by the public agency. All claims of abuse of children are grouped Into the category of 

abuse that occurred while a child was In foster care. The most recent numbers of this occurrence that could be obtained are 

documented in the tables below: 

ACF Data Statistics: Maltreatment In Foster Care· Kentucky 2012 2013 

Children Maltreated While In Foster Care 0.5% 0.54% 

Children Not Maltreated While In Foster Care 99.5% 99.46% 

Total Number In Foster Care 12,085 12,270 

Number Maltreated While In Foster Care 60 66 

Describe In detail the actions taken when an abuse claim Is substantiated while a child Is In an out of home placement. 

Do these actions differ depending on whether the child was placed by the public agency, a not-for-profit provider, or a 

for-profit provider? 

All claims of abuse received by the Cabinet for Health and Family Services on out of home care providers, whether public, 

private, for-profit or not-for-profit, are treated as specialized Investigations. 

Reports on both public foster homes and private providers (for-profit or not-for-profit are treated the same) are tracked by 

the Kentucky CHFS. The private agency Is notified by the public agency regulatory body so that no other children are placed 

In the home. If the referral Is physical abuse, sexual abuse, or otherwise serious In nature, the child Is removed from the 

home during the Investigation. 

For private agencies: 

Information is shared with the licensing agency, Children's Review Program, and OIG. The public agency'regulatory 

body informs the private agency that no children will be placed In their home; and 

A review of the foster home occurs. 
106 


26354.070

922 KAR 1:310, Standards for child-placing agencies, provides requirements for closure when a claim of abuse Is 

substantiated on a private agency foster home. 

For public agencies: 

A review of the foster home Is completed, unless the home is being closed. 

922 KAR 1:350, Family preparation, provides requirements for closure when a claim of abuse Is substantiated on a public 

agency foster home. 

All cases are managed on an Individual basis. The safety and well-being of the child Is of paramount concem In all situations 

and dictates the actions taken as a result of a substantiated claim of abuse. 

As stated In the answer to question #2, all children In Kentucky who are placed in an out of home care situation, are placed by 

the public agency. 

Respectfully, 

Cc: Governor Steven L. Beshear 

Commissioner Teresa James, Department for COmmunity Based Services 
107 


26354.071

Maryland's Human Services Agency 

Department of Human ResourcrJS Larry Hogan. Governor 1 Boyd K Ruttlerfofd, Lt Govornor 1 Sam Malhotra, Secretary 

The Honorable Orrin G. Hatch 

Chairman 

Senate Committee on Finance 

219 Dirksen Senate Building 

Washington, DC 20510 

July 20. 2015 

Dear Chairman Hatch and Ranking Member Wyden: 

The Honorable Ron Wyden 

Ranking Member 

Senate Committee on Finance 

219 Dirksen Senate Building 

Washington, DC 20510 

Thank you so much for your inquiry regarding foster care providers licensed and 

monitored within Maryland. The Department of Human Resources (Department) is 

committed to the health, safety. and welfare of foster youth in the State's care. We take 

this responsibility seriously and work hard to ensure that we, and our partners, strive for 

excellence. 

Please find enclosed the Department's response to this Committee's inquiry. Should you 

have any further questions, please do not hesitate to contact our Office of Government 

Affairs at (410) 767-6586. 

800-332-6347 l TTY 800-925-4434 I 311 West Saratoaa Street l Bal!tmore I Marvland 21201-3500 ! Wlt'VW dht m~rviand oov 
108 


26354.072

To the degree applicable, describe your state's utilization of private entities to provide case 

management services (e.g., placement of children with particular foster care providers, 

ongoing caseworker and oversight of foster care placements). 

Maryland does not contract with private entitiesji1r case manaRement services; we contract 

with private providersfbr placement services only. Case manaRement services are provided by 

Jhe local department ofsocial services sh1j( 

What proportion of the children in foster care in your state is placed by the public agency, 

not-for-profit providers, and for-profit providers? 

100% <~( Mwyland '.\'foster care children are placed hy the puhlic agency 

Please provide the number and names of private entities providing these core services, as 

well as information on whether each proyidcr is a for-profit or not-for-profit entity. 

Maryland does not have private entities for which we contract to provide case manage men/ 

services. Altached is a list ()/private providers wilh whom we contracljor placement services. 

Currenlly Maryland conrracls with 80 (37- Child J'lacemenJ Agency (CPA) and 43- Residential 

Child Care (RCC}) private providers for placement services. 

Docs your state require that pril'8te foster care entities or organizations operating in your 

state be accredited? If so, by which organization and how often is this accreditation 

renewed'! 

No, accreditation is a voluntary' process for Mmyland's private residential child care programs 

and child placementogencies. Maryland residential child care providers and child placement 

agencies are required to adhere to the standardr oft he Code (Jj" Maryland Annotated Regulations 

(CO MAR) to maintain licensure. The licensure and monitoring processes are designed to 

protect the health, safety, and well-being of children placed in residential child care programs 

and with child placement agencies. 

Describe in detail the process you use to select and contract with these private entities, as 

well as to review and renew such contracts. 

Mm}'land does not contract with private entitiesfor case management services. Maryland does 

contract with Residential Child Care (RCC) prowams and Child Placement Agencies (CPAs} 

that provide Treatment Foster Care (TFC) services. In order to be consideredjbr a contract 

with the Department l?ll Iuman Resaurces 'Social Services Administration (SSA), a RCC or CPA 

provider must .first receive a license. RCC licenses are issued by three State agencies including 

the Department 1?/'fiuman Resources' Office of Licensing and Monitoring (OLM), while CPA 

licenses are issued Q!1/.y_ hy 0/,M OLM is a separate entity fram S~<;A within the Department of 

Human Resources to eliminate possible conJlict ol interest hetween the licensing and contracting 
109 


26354.073

units. Ajier receiving a license, the provider must/hen obtain a rate for its RCC or CPA 

placement servicesjrom the interagency Rates Commillee, which is led by the Maryland State 

/)epartmenl ojEducation. Once a rote is obtained, the RCC or CPA may enter into a 

contracting process with SSA, based on .\:''iA ·.,.estimate of bed need across the Slate. In the past 

the R('(' t'fmlracting process has been a competitive process (Request for Proposal), and the 

CI'A contracting process has been a non-competitive process. it should he noted that A1aryland 

only pays a provider ji1r services when a child is actual~y placed at an RCC or CPA home. 

l'er current contract language, theji1llowing performance measures outlined below are being 

used to monitor Con/rae/performance. Pre.ference.hr the continuation and renewal of a 

('on/met is given to those Contractors who meet/he minimum pe~[ormance scorefiJr CPA and 

R< 'C prowams. The perfimnance measures are compiled, moni/Ored and rated fiJUr limes 

during each Contract year. The per[iJrmance measures are related to the following: 

I. Child St!fety 

• Staf(Security-1110% ( 'ompliance with Child Protective Services Clearances (CPS) and 

Criminal Background (CB! checks .for all employees cmd pro~pective employees; 

• Foster Parent Cert!flcation/Recert[fication-100% o.ffiJ.I'/er parents have an initial 

certification and re-cerl[/ication: 

• Maltreatment while in Foster Care- Review ofConlractors serving foster children shall 

have no indicated findings ()(child maltreatment where a Contractor's staff member or 

.f(JSier parent is idemified as the maltrealor. 

2. Licensing and Monitoring 

• Licensing Sanctions- Contractors shall not have any licensing sanctions during each 

quarterly rating period. 

• SSA I lotlist-Contractors shall not he placed on the SSA I lot list anytime during each 

quarterly rarint; period 

• Annual Fiscal Audits-Contractors are required to submit an annual .financial audit timely 

on or before Decem her 2"d (1[ each Contract year. 

3. Child We/1-IJI!ing 

• ( 'hild and Adolescent Needs and Strengths Assessment (CANS) Compliance- C."ANS 

As.l'e.\:rmenls are completed to measure child well-being. Contractors are to ensure 

succes.~[iil provision ofrequired services leading to each child's achievement (1[ case plan 

goals and objectives. 

Describe in detail the process your state uses to inspect the safety of the foster care settings 

in which children are placed and the extent to which this process differs for public, not-forprofit, and for-public providers operating in your state. 

/11 Maryland, the process of inspecting safety and compliance offosrer care settings is different 

./i1r public· and private providers. For public homes, local caseworkers conduct monthly visifs to 

2 
110 


26354.074

ensure safety, permanency, and well-being of all children in foster care. A nnua/ 

redeterminations are conducted with public.fiJster home providers to ensure they are adhering to 

the regulations set.fbrth by Maryland's CO MAR. These requirements include CPS clearances, 

Federal and State criminal background checks.fiJr household members over the age C!( 18, health 

inspect ion of the home. and medical assessments for all members of the family. 

OLM is responsible for ensuring that private providers adhere to Maryland State law as outlined 

and promulgated in Code of Maryland Annotated Regulations (CO MAR) 14.31.05-I4.3I.07 for 

RCCs and .07.05.0I-.07.02.2I for CPAs. The Department of Human Resources, Office of 

Licensing and Monitoring (OLM) licenses and monitors private tesidential child care facilities 

(RCC group homes) and Child Placement Agencies (CPA) which consist ofTreatmenl Foster 

Care (TFC), Independent Living Programs and Adoptions. Through the regulatory process 

OLM strives to ensure that each RCC and CPA program complies with applicable laws and 

regulations designed to ensure the safety and wellbeing of children in care. 

The site visit is the primary activity for monitoring RCC and CPA providers. All private 

residential child care programs are re-/icensed bi-annually. Mid-licensure (one-year) review 

and quarterly visits are conducted to ensure they are administratively and programmatically in 

compliance with COMAR. The OLM's Ucensing Coordinator i.r required to make quarterly 

unannounced visits to the organization and all licensed sites. Announced visits usually occur at 

least annua/~y. 

The OLM Licensing Coordinator may also make an emergenLy visit to complete a complaint and 

incident report investigation. Emergency visits are issues that are related to life, health and 

safety of residents. Complaints or emergency visits are unannounced visits. 

The monitoring visit consists (but is not limited to) the following areas: 

• Entrance Conference - are held with the Program Administrator and!ot Designee and 

consists of a discussion regarding the overview of any programmatic changes, incident 

reports, community complaints, updates on the youth census and staff census, as well ar 

.financial incident reports. 

• Physical Plant inspection of each licensed residential child care site(.v) and child 

placement agency o.ffice(.1). 

• Record reviews (client and personnel) 

• Log and contact notes 

• Interviews (c/ientlsta.fj'on site, foster parent) with children include verbal and nonverbal. The non-verbal child interview is completed by physical observation of the child 

in their placement. 

• Exit Conference ···are held with the Program Administrator and/or designee to 

address the findings from the site visit. OLM will c!ffer technical assistance, as 

necessary. Corrective Action Plan (CAP) is requested if there are CO/I.fAR deficiencies 

observed during the visit. 

3 
111 


26354.075

• ( ll .. lf 11olith•s tll<'l>rii'<!I<'[J/'OI'iclt•r o(lltt• tl<~,tict.:ndes ohsl!rwcl during I he site ••isil and 

,-,·11d.' a wrillt'n summary o(lht• r-.·guluiOIJ' complhmt·t•.fi,/lml'ing 1he ••isil. 

How man)· instan~·rs of 11bu~e In a foster cnre placement have been substantiated in the last 

fh e yean in your st11te'.' Of those substantiated, how many of these instances related to 

children being placed by: not-for-profit providers, for-profit providers, and public: 

pro\·iden? 

I· i1r colt•11dar y,•un :o I 0 1hrough :111-1. rlun· 1rac 39 instances of'ahuse in .faster mre 

f'hl<'<'fll<'lllllua ll't'rL' mhsromimc•,l. O(rlto,,.,. mh.IIWJiiarc•d. 44% were placed wilh not:for-prf!fil 

prnl'idas. 6''" tn•re pluct'd wirh,lilr-pro/irprol'ic/er.,·. ami 50% 1n•re placed wirh puhlk ugerrq 

llft>\'idt•r., 

Ocscribl.' in drtail the 11ction~ taken when :m abuse claim is substantiated while a child is in 

an out of home placcnu:nl'! Do these actions differ depending on whether the child was 

place b~· the public ageney, a not-for-profit provider, or a for-profit provider? 

In .\fury/ami. lht•lwcrl clepcrrlmcnr r!fsodal Sl!l1'k~s inthc_jurisdiclion where rh~fudlity is 

/acor,·d i.~ resprmsihlt>.fi>r rhe im•exrigurion '!(all rC?porrs l!{mu/rrearmcnr and dt•!ermilring where 

<1 child i.1· f'/an•d. nu• process is fill' .1'11/tll' f'('gardh•s.l· l!(lfll! l)'pl! l!f.fitl'fl!r Ctlf(' home reporlec/. 

l -'pon rl!cl'ipl ot a repon olma!llvamwrrr. Ill<• local clt•pm·rmelll will immedlarely aYsess the .vqfel}' 

~~(all childn•n plact•cl in 1/u: /i1s1er·gmup lwm<' ami d,•rermin<' whether or not removal/.v 

lrt/rrclllll!d. 

/(rile childrrcnl is d<•r,·rmint•d ro he sqti• und a hie ro rt:main in I hi! home. lh<•.fimer home (holh 

f>Uhlic unclpril'lll<'l is placed mr hole/ mulno new p/an•menr.•· are al/mn•d whi/erhe inwsllf!Oiion 

ispt•nciing f/llr<· im•c•s1igc11iml resulrs ill a "suh.mmrimecl".flnding.fhr u privure 1'reurmenr 

/·c>.l/<'1' ( 'art• rTP< ') hom<' rcr:rrith•dji~.~·rer pan·m). rile TFC' hum<' musr ht• do.w:d, cmd rhe <'hilt/ 

nmsr h,• lrwlsilimrt•d ro a llc'II'J'Iacem,•nr. 111 a pnh/ic home, illht•.finding is ".mhsrunliarr:d," rhe 

local dt'Jlf.lrlmt'lll II' ill as.ll'.u wht•rlwr or 1101 rile home can remain up.:n ami •·onlinue as a 

l't'.I'!>/1/'<'C' /rCII/11' ll'il// (II(' /ocal tl<'f'<l/'/fnt'f/1. 

l<egcwt/illg a R< '( '. "flrclit·cnwt• ,,/rail illlllll'cliarr(v place rhe t'mt>lr~ye,• 011 tUimini.Hrariw leul'l! 

and 1'<'171<11'1' the ,•mployec.fmm <II'I'<'SS ro rht• chi/drl!ll. 71/i.l' l't'KIIIarion does nor pmll/hit a 

lit't'II.H't'.fi·om suspending wirholll pay or dischtlfRing an emph!J\'1' allt•ged ro hm•e suh_jccred a 

chilt/10 ahus,• or m·glt•cr." ll'rhl' inl't•.wigalion re.mlrs in a ".,uhsranriurrd"finding{ilr u11 

cmplo.n·e t!(ll Rc '( ·. 1111'111111' <'llll'lr\P<!<' is ft•rminur,•J. 

The Department is dedicated to ensuring that appropriate placement services are provided to the 

children who come illlo the c11rc and custody of the state of Maryland but we do not contract for 

case mml111,1.ement services. l'leusc do not heaitute to contact me in the future regordinfL! any 

prn11-rums or llllrvices administered by the Department of Human Resources. 

4 
112 


26354.076

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114 


26354.078

.~ 

' ~{'"_)!.'!~ 

(i!J . 

> 

. 

CHARLES D. BAKER 

GOVERNOR 

June 10,2015 

Orrin G. Hatch, Chairman 

Committee on Finance 

United States Senate 

Washington, D.C. 20510 

OFFICE OF THE GOVERNOR 

COMMONWEALTH OF MASSACHUSETTS 

STATE HousE • BosToN, MA 02133 

(617) 725-4000 

KARYN E. POLITO 

LIEUTENANT GOVERNOR 

c/o Becky Shipp, Health and Human Resources Policy Advisor 

Ron Wyden, Ranking Member 

Committee on Finance 

United States Senate 

Washington, D.C. 20510 

c/o Laura Berntsen, Senior Human Services Advisor 

Dear Chairman Hatch and Ranking Member Wyden: 

In response to your April 24, 2015 letter regarding the Commonwealth's use of privately 

provided foster care related case management for children receiving child welfare 

services in Massachusetts, enclosed please find a detailed set of answers prepared by 

the Massachusetts Department of Children and Families (DCF), the Commonwealth's 

Child Welfare Agency. 

I hope that this information will be helpful to the Senate Finance Committee. DCF is 

available to respond directly to any further questions from the Committee concerning 

the Massachusetts foster care system. 

Charles D. Baker 

Governor 
115 


26354.079

CHARLES D. BAKER 

Governor 

KARYN E. POLITO 

Licutenunt Governor 

The Commonwealth of Massachusetts 

Executive Office of Health and Human Services 

Department of Children and Families 

600 Washington Street, 61h Floor 

Boston, MA 02111 

Tel.: 617-748-2000 Fax: 617-261-7435 W\Hv.mass.~ovjdcf 

June 10,2015 

MARYLOU SUDDERS 

Secretary 

LINDA S. SPEARS 

Commissioner 

Commonwealth of Massachusetts Response to April 24, 2015 Senate Finance Request 

Relative to Privatized Foster Care 

To the degree applicable, describe your state's utilization of private entities to provide case 

management services (e.g., placement of children with particular foster care providers, ongoing 

casework and oversight of foster care placements). 

The Massachusetts Department of Children and Families (DCF) directly provides case mana~ement 

services for nearly all of the DCF total caseload, which as of 313112015, totaled 25,388 cases . DCF 

staff are responsible for full case management services for 25,182 (99.19%) of these cases. DCF 

utilizes private entities to provide case management services for a small percentage (0.81%) of its 

caseload (206 cases) for three specific purposes: conflict of interest, adoption management, and 

Unaccompanied Refugee Minor Program (URMP) cases: 

1. Conflict of Interest: Consistent with national best practices, DCF contracts with private entities 

to provide case management services for children and families where a conflict of interest with 

DCF is indicated. 

2. Adoption Management Services: DCF contracts with a number of private licensed adoption 

agencies to provide case management for children with a goal of adoption. These agencies 

provide all case management required services. 

3. Unaccompanied Refugee Minor Program (URMP): This program provides case management 

to children referred by the Office of Refugee Resettlement. 

it should be noted that even when DCF utilizes private entities to provide case management services, 

children requiring placement services remain in the care/custody of DCF and receive access to the 

same services as children whose cases are managed by DCF. Furthermore, DCF provides contract 

oversight to these case management contract entities. In the case of Adoption Management Services, 

the case management services provided by the contractor are limited to managing decisions related to 

the adopted child- all decisions related to the birth family remain the purview of DCF. 

What proportion of children in foster care in your state is placed by the public agency, not-for· 

profit providers, and for-profit providers? 

Among the 10,714 children in care, 95.58% percent of children are placed by the Department of 

Children and Families into a range of placement services provided directly by DCF or under contract 

with 106 agencies-of which 103 are non-profit agencies, and 3 are for-profit agencies. Among the 

' Case Management services is defined as having responsibility for on-going casework, regardless of the custody 

status of the child and where applicable, determining the type and length of placement as well as oversight of a 

child. 

Suppor tong Chrldr en • Strcngthenrng Famrlres 
116 


26354.080

10,714 children in care, 4.42% percent are placed by agencies responsible for administering services 

in conflict of interest, adoption, and URMP cases. These include 13 not-for-profit, and no for-profit 

agencies. 

Massachusetts DCF Children in Placement as of 3/31/2015 

Agency with Case 

Management 

Non-Profit Agency 

Please provide the number and names of private entities providing these cores services, as 

well as infomnation on whether each provider is a for-profit or not-for-profit entity? 

DCF currently contracts with thirteen not-for profit entities for Case Management Services: 

1. Conflict of Interest Contracts: 

Center for Human Development (CHD) 

Solutions for Living 

2. Adoption Management Support Services: 

Berkshire Children & Family 

Cambridge Family Children Services 

Child & Family Services of Fall River 

Child & Family Services of Merrimack Valley 

Children's Friend 

Children Services of Roxbury 

Justice Resource Institute 

• Ascentria Care Alliance• 

Massachusetts Society for the Prevention of Cruelty to Children (MSPCC) 

RFK Children's Action Corps 

The Home for Little Wanderers 

3. The Unaccompanied Refugee Minor Program (URMP) 

Ascentria Care Alliance• 

"' Ascentria Care Alliance, which provides both Adoption Management Services and Unaccompanied Refugee 

Minor Services, was formally known as Lutheran Social Services of New England. 

Supp01 tmg Children • Su engthening Farni11es 

2 
117 


26354.081

3 

Does your state require that private foster care entities or organizations operating in your state 

be accredited? If so by which organization and how often is this accreditation renewed? 

Massachusetts requires that all residential and foster care programs serving children be licensed. 

The Commonwealth's Department of Early Education and Care (EEC) is the primary entity responsible 

for this activity pursuant to M.G.L. ch. 15D, §§ 2(c), 4A2

, 63 and 84

• 

Residential and Teen Parent Programs under 102 CMR 3.005: 

Standards For The Licensure Or Approval Of Residential Programs Serving Children And Teen 

Parents; and Foster Care and Adoption Services under 102 CMR 5.006

: 

EEC conducts multi-level re-approvals of licenses on a 2 year cycle. 

In addition, Residential Schools must be approved by the Department of Elementary and Secondary 

Education (DESE) pursuant to M.G.L. c. 718 and 603 CMR §§ 187 and 286

• The DESE approval and 

re-evaluation is done on a 6 year cycle with a mid-year cycle at 3 years. Massachusetts does not 

require that residential or foster care programs be accredited. 

Describe in detail the process you use to select and contract with these private entities, as well 

as to review and renew such contracts. 

The Massachusetts Department of Children and Families utilizes an open and competitive bid process 

as required by 801 CMR §21' and 808 CMR §1.0010 in order to contract with, review, and renew 

residential and foster care providers. 

Process elements include information gathering including internal and external stakeholders through a 

variety of methods which could include focus groups, Requests for information (RFI), and surveys; the 

establishment of a Procurement Management Team; the development of models and standards 

(including the specification of staffing requirements); collaboration with the state entity responsible for 

rate setting -the Center for Health Information and Analysis (CHIA); development and release of the 

Request for Response (RFR); submission of proposal responses from bidders; establishment and 

training of proposal review teams; review of proposals; selection and notification of bidders; debriefing 

upon request for unsuccessful bidders; negotiation with successful bidders; establishment of contracts; 

and renewal of contracts at intervals specified in the RFR. 

Describe in detail the process your state uses to inspect the safety of the foster care settings in 

which children are placed and the extent to which this process differs for public, not-for-profit, 

and for-public providers operating in your state. 

Safety is addressed within the EEC licensure and enforcement process as detailed in 102 CMR 3.0011 : 

Standards For The Licensure Or Approval Of Residential Programs Serving Children And Teen 

2 https:l/malegislature.gov/Laws/Generallaws/Parti/Titleii/Chapter15D/Section8 3 https://malegislature.gov/Laws/Generallaws/Parti/Titleii/Chapter15D/Section2 4 https://malegislature.gov/Laws/Generallaws/Parti/Titleii/Chapter15D/Section6 5 http://www.mass.gov/edu/docs/eecllicensing/regulationslresidential-care-regulations.pdf 6 http://www.mass.gov/edu/docs/eec/licensing/regulationsladoption-placement-regulations.pdf 7 http://www.doe.mass.edullawsregs/603cmr18.html?section=all 

' http:llwww.doe.mass.edu/lawsregs/603cmr28.html?section=all 9 http://www.mass.gov/bblregs/801 021. html 10 http://www.mass.govlanfldocslosd/policy/808cmr1.doc 

'' http://www.mass.gov/eduldocsleec/licensing/regulationslresidential-care-requlations.pdf 

Suppo1 nng Ch1ld1 en • Strcngthenmg Fam1hes n 
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Parents; 102 CMR 5.0012: Standards For The Licensure Or Approval Of Agencies Offering Child 

Placement And Adoption Services; and 102 CMR 1.0013: Enforcement Standards and Definitions for 

Licensure or Approval. 

Safety is an essential component of the licensing process (described above), which does not differ 

based on whether the entity is public, not-for-profit or for-profit. EEC licensure requirements include 

provisions addressing safety relative to: 

behavioral supports, including use of restraint procedures and time-out rooms; 

documentation of required permits and inspections; 

physical environment, including the building I grounds I recreation space, recreation and 

exercise equipment, storage and use of power tools, and storage of toxic substances; 

kitchen area including equipment and food storage; 

vehicles and their use; 

use of well water; 

staffing, including ensuring sufficient staffing as well as ensuring that the background of staff is 

free from conduct bearing adversely on safety; 

staff training; 

4 

policies and protocols addressing safety in the environment, treatment and other programming, 

including a safety plan for emergencies, visitation protocols, and internal investigation of 

incidents; 

administration of medications; and 

background record checks. 

For foster homes, background record checks (Criminal History, Child Welfare History, and Sexual 

Offender Registry) are conducted for all household members and frequent visitors age 15 and older. 

This process includes Fingerprint Checks for primary and secondary caregivers; firearms checks and 

adherence to requirements for securing firearms if present in the home; and evaluation of safety of 

pets on the premise. 

How many Instances of abuse in a foster care placement have been substantiated in the last 

five years in your state? Of those substantiated, how many of these instances related to 

children placed by: not-for-profit providers, for-profit providers, and public providers? 

In the last five years (FFY 2010-2014), 44,240 children were in DCF substitute care. During this time 

period, there were 739 instances of substantiated child maltreatment in a foster care placement 

setting: 1.67% of the total number of children in placement. 

During this five year period, of the 739 instances there were: 

• 44 (1.64% of 2,676 children) instances of maltreatment in for-profit settings, 

• 306 (1.98% of 15,452 children) instances of maltreatment in non-profit settings, and 

• 389 (1.49% of 26,112 children) instances of maltreatment in public placement settings. 

12 http:llwww.mass.govleduldocsleecllicensing/regulationsladoption-placement-regulations.pdf 13 http:llwww.mass.govleduidocsleecllicensinglrequlationslenforcement-standards-definitions-licensureapproval.pdf 

Suppot tmg Chtld• en • Strengthenmg Fatmlies 
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26354.083

Agency with Case 

Management Responsibility 

Non-Profit Agency 

PubHc Agency 

Grand Total 

For-Profit 

5 of82 

Non-Profit Public Total 

4 of344 20 of 850 

• Maltreatment counts represent Instances of substantiated maltreatment In foster care settings. 

Children may have experienced one or more instances of supported maltreatment. 

Describe in detail the actions taken when an abuse claim is substantiated while a child is in an 

out of home placement. Do these actions differ depending on whether the child was placed by 

the public agency, a not-for-profit provider, or a for-profit provider? 

In response to concerns regarding abuse and neglect, there are three mechanisms in place designed 

to ensure the protection of the child, provide appropriate oversight of the contracted program, and 

examine any potential licensing violation. Specifically, the response includes: 

• An investigation into the specific allegations of abuse and neglect by the DCF Special 

Investigations Unit (SIU}. Based on the findings of this review decisions are made to address 

any immediate safety concerns, including but not limited to removal of the child from the foster 

home, if necessary. 

5 

The SIU is also responsible to notify DCF contract managers who will review the screening and 

the final decision of the agency in order to determine whether any action is warranted to ensure 

the current and future safety of children placed through the program. 

The SIU is also responsible to notify EEC who reviews the screening and final decision of the 

agency in order to determine what action, if any is warranted. 

These reviews are governed by the following policies and regulations. 

Foster Care: When an abuse claim is supported while a child is in a foster home placement, 

DCF and EEC respond in accordance with their respective regulations. 

Residential Programs: When an abuse claim is supported while a child is residing in a 

residential program, DCF responds in accordance with the "DCF Residential Response 

Guidelines" (copy attached.) As with Foster Care, EEC responds in accordance with its 

regulations. 

These actions are consistent whether the child was placed by the public agency (DCF} or by a private 

entity (not-for-profit or for-profit}. 

Supportmg Children • Su engthentng Fanulles 
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26354.084

LfWJ 

Minnesota Department of Human Services-------------

The Honorable Orrin G. Hatch 

United States Senate 

I 04 Hart Senate Office Building 

Washington, D.C. 20510-4402 

The Honorable Ron Wyden 

United States Senate 

221 Dirksen s~nat~ Office Building 

Washington, D.C. 20510-3703 

Dear Senators Hatch and Wyden, 

May 29, 2015 

On behalf of Governor Mark Dayton, The Minnesota Department of Human Services welcomes 

the opportunity to respond to your letter of April 24, 2015 and your request for information 

regarding Minnesota's policies and practices relative to privatized foster care. Governor Dayton 

shares your concerns about ensuring the safety and well-being of children who are removed from 

the family home due to abuse or neglect. 

Background on Minnesota's Child Foster Care Placement System 

Unlike most states, Minnesota is a state-supervised and county-administered child welfare 

system. Therefore, all child placement activities and case management services rest with local 

county and tribal child welfare agencies, in accordance with Minnesota's approved Title IV-E 

State Plan. The county or tribal social service agencies (with a Title IV-E Agreement), are 

responsible for administering child welfare services, including child placement and services 

activities. (Minn. Stat. 260C.007. 27a) 

Responsibility for performing specific child foster care licensing oversight functions is 

statutorily delegated to county agencies, while issuing licenses and licensing sanctions is the 

responsibility of the Minnesota Department of Human Services (the Depa1tment) through its 

Licensing Division. 

All of Minnesota's county social service agencies conduct child foster care licensing and child 

placement. All children in Minnesota's foster care system are placed by the responsible county 

or tribal social service agency, not by privatized, for-profit or not for-profit enlilies. However, 

private child placing agencies ("private agencies") may be licensed by the Department and 

authorized to perform certain licensing functions. 

There are currently 3,428 licensed child foster care programs in Minnesota. Of these, 2,594 are 

monitored by 87 county licensing agencies, and 834 are monitored by 33 private agencies. 
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Counties are responsible for investigating alleged or suspected maltreatment of a minor in all 

child foster care settings regardless of whether the licensing/monitoring activity is performed by 

the county or a licensed private agency. 

Additional functions performed by counties and private agencies include: 

Accepting and processing child foster care license applications 

• Conducting inspections, studies, and evaluations of child foster care programs 

• Recommending approval or denial of license applications to the Minnesota Department 

of Human Services 

• Monitoring child foster care program compliance with licensing rules 

• Investigating allegations of licensing violations 

• Issuing correction orders for substantiated licensing violations 

Recommending child foster care licensing sanctions to the Depattment when warranted 

by the nature, severity, or chronicity of licensing violations. 

The Department: 

• Issues child foster care licenses and licensing sanctions based on a review of 

recommendations from counties and licensed private agencies 

Provides training and technical assistance to counties and licensed private agencies 

• Conducts background studies on required individuals for child foster care and adoption 

• Oversees county and private agency performance of licensing responsibilities through onsite reviews of their licensing work. (See Minn. Stat., section 245A.l6, Standards for 

County Agencies and Private Agencies) 

Minnesota Responses to Questions in Letter Dated April24, 2015 

To the degree applicable, describe your state's utilization of private entities to provide case 

management services (e.g., placement of children with particular foster care providers, 

ongoing casewot·k and oversight of foster care placements). 

According to Minnesota statutes and rules, county and tribal agencies, as ordered by the court, 

have sole responsibility for the placement, care, custody and control of the foster child. However, 

the Depattment may license and certify private agencies to recruit and provide licensing 

oversight to individuals to provide foster care. 

Counties and tribal agencies have the authority to contract with licensed and certified private 

agencies to assist with recruitment and placement options. These private agencies are responsible 

for licensing activities and ensuring compliance with licensing requirements. County and tribal 

agencies maintain responsibility for supervising, monitoring and managing children's out-ofhome placement plan and corresponding services. (Minn. Stat. 260C.212. subd.l) County and 

tribal agencies work in tandem with the private agencies by identifying potential foster care 

providers and ensuring the safety, well-being and permanency of children. The responsible 

county or tribal social service agencies assume all case management service responsibilities. 

2 
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26354.086

What proportion of the children in foster care in your state is placed by the public agency, 

not-for-profit providers, and for-profit providers? 

In Minnesota, 100 percent of children in foster care are placed by the responsible county or tribal 

social service agency. Minnesota children in the foster care system are not placed by private forprofit or not~for-profit entities. 

Please provide the number and names of private entities providing these core services, as 

well as information ou whether each provider is 11 for-profit or not-for-profit entity. 

Minnesota has 33 licensed private child-placing agencies authorized to perform child foster care 

licensing oversight (see attached list). Minnesota children in the foster care system are not 

placed by private for-profit or notjor-profit entities. 

Does your state require that private foster c11rc entities or organizations operating in your 

state be accredited? If so, by which organization 11nd how often is this 11ccrcditation 

renewed? 

No, accreditation by another entity is not required. 

Describe in detail the process you usc to select and contract with these private entities, as 

well as to review and renew such contracts. 

The Department uses a Request for Proposal (RFP) process to identify and recruit licensed 

private agencies to work with county and tribal social services agencies regarding placement of 

foster children. The Department contracts with licensed private agencies and regularly monitors 

contract compliance through annual site visits and file reviews. Additionally, contracts expire 

after two years, at which time a new RFP process is initiated. 

The Department licenses private agencies under Minn. Stat., Chapters 245A and 245C, and 

Minn. Rules, parts 9545.0755 to 9545.0845 (also known as Rule 4). The Rule 4 license allows an 

agency to receive children for care, supervision, or placement in foster care or adoption, and to 

help plan the placement of children in foster care or adoption. In addition, the Depa1tment 

authorizes pri vatc agencies to provide child foster care licensing oversight according to Minn. 

Rules, parts 9543.0010 to 9543.0150, (also known as Rule 13). The Rule 13 authorization allows 

a licensed agency to perform specific child foster care licensing functions, as described above on 

page one. 

To obtain a license, the agency must submit a license application, pay an application fee, and 

provide additional materials, including: 

• Policies, procedures and program records 

• Information about their legal organization 

• Additional information required if they intend to provide adoption services 
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26354.087

Department staff review the application and inform the agency of missing or incomplete 

infotmation. Upon completing all application requirements, the agency submits the information 

necessary for the Department to complete the required background studies of agency staff. 

Once the Department determines that the agency has met all licensing requirements, Department 

staff meet in-person with agency staff to provide: 

An overview of rules and statutes applicable to child foster care programs 

• Tools for conducting licensing inspections and monitoring compliance 

• A review of the respective roles and responsibilities of the agency and the Depat1ment 

• Answers to questions about licensing responsibilities or about contracting for services 

with the Department. 

Following a successful meeting, the Depat1ment issues a license. One year after the license is 

issued, the Department conducts an on-site licensing review of the agency's compliance with 

both Rule 4 and Rule 13 requirements. The Department conducts subsequent reviews oft!Ie 

agency's Rule 4 licensing compliance every two years, and the agency's performance of 

delegated child foster care licensing functions under Rule 13 every four years. 

Describe in detail the process your state uses to inspect the safety of the foster care settings 

in which children are placed and the extent to which this process differs for public, not-forprofit, and for-public providers operating in your state. 

Child foster care programs are licensed under Minn. Stat., Chapters 24SA and 24SC, and Minn. 

Rules, parts 2960.3000 to 2960.3340. As described above, counties and private agencies are 

primarily responsible for perfotming child foster cme licensing oversight. The licensing process 

includes submitting a license application to the county of residence or private agency of the 

applicant's choosing. The licensing process is the same for all licensed child foster care 

programs, as are requirements; however, the methods used to complete the process may vary, 

depending on the size of the county or private agency. 

Some county and private agencies have regularly scheduled informational meetings to discuss 

the general licensing process for child foster care, while others may provide this information on a 

one-to-one basis when they receive a request for information. In addition, some agencies have 

websites where interested parties may access application materials, while others mail information 

or have it available at the agency. 

Once an application for foster care licensure is received, agencies: 

Submit the information, including the subject's fingerprints, necessmy for the 

Department to complete the Ada!'ll Walsh background study on license applicants, and all 

required household members 

Contact applicants to schedule home visits to complete the home safety checklist 

Ensure safe sleep requirements for infants and sleeping space requirements for foster 

children me understood 

4 
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26354.088

• Determine whether a fire safety inspection is required, based on criteria in the child foster 

care rule. If a fire safety inspection is required, county or private agencies make this 

request to the Minnesota Department of Public Safety. The fire safety inspection must be 

completed and all items corrected prior to recommending licensure. 

Applicants must complete: 

Foster care orientation training, including emergency procedures and a review of state 

statute and rules 

Sudden Unexpected Infant Death and Abusive Head Trauma training if caring for foster 

children through age five 

• Child Passenger Safety training if transportation will be provided for foster children 

under age nine 

Two hours of children's mental health training 

The home study assessment process includes visits to the home to complete these forms: 

• Application 

• Home study assessment 

• Family disaster plan 

• Individual fact sheets for all adults living in the household 

• Home study agency process checklist that documents background study results, 

completed training, variances granted, and other information 

All forms must be completed and all required background studies must be cleared, or there must 

be a set-aside or variance granted if there is a disqualification prior to recommending licensure. 

If applicants meet all requirements, agencies make a recommendation to the Department for a 

one-year license. If an applicant previously held a child foster care license, an agency has the 

discretion to recommend an initial license for up to a two-year period. Prior to the license 

expiring, the county completes the relicensing process which is similar to initial licensing and 

includes completing the five forms of the home study, completing the home safety checklist, and 

reviewing training and placements made, as well as other required documentation. Subsequent 

licenses are issued for up to a two-year period. 

How many instance..~ of abuse in a foster care placement have been substantiated in the last 

five years in your state? Of those substantiated, how many of these instances related to 

children placed by: not-for-profit providers, for-profit providers, and public providers? 

Using data from the Depattment's Social Service Information System (SSIS), there were !50 

determined maltreatment reports in child foster care programs that were completed from 2010 to 

2014. As described earlier, private agencies in Minnesota do not have responsibility for 

placement of children. 
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26354.089

Describe in detail the actions taken when an abuse claim is substantiated while a child is in 

an out of home placement? Do these actions differ depending on whether the child was 

placed by the public agency, a not-for-profit provider, or a for-profit provider? 

County and tribal child welfare agencies are responsible for investigating reports of suspected 

maltreatment of foster children, regardless of whether a county, tribal or private agency performs 

the licensing oversight. 

The Department issues a licensing sanction any time a licensed child foster care provider is 

found responsible for maltreatment. These sanctions are issued by the Department regardless of 

whether a county or a private agency oversees the license. 

The Department notifies county or private agencies of licensing sanctions. The licensing agency 

is required to notify the parents or guardians (i.e., the county or tribal placing agency) of each 

child placed in the sanctioned foster homes about the licensing sanctions. County and tribal 

agencies have the authority to make placement decisions regarding children, and determine the 

significance of a county's determination of maltreatment or Department's issuance of a licensing 

sanction. These decisions include planning for the safety and well-being of children, and 

sometimes the need to remove children from foster homes. 

I hope this was helpful. If you have questions regarding this, do not hesitate to contact me for 

additional information at 651.431.3835 or via email at jim.koppcl(illstate.mn.us. 

Wt\<~ James G. Koppel 

Assistant Commissioner 

Children and Family Services 
126 


26354.090

Senator Orrin Hatch, Chairman 

Senator Ron Wyden, Ranking Member 

United States Senate 

Committee on Finance 

Washington, DC 20510-6200 

Dear Senators: 

May 18,2015 

Thank you for your letter dated April24, 2015, requesting information about Nebraska's policies 

and practices as they relate to privatized foster care. I am happy to share the following 

information in response to your inquiries below: 

I) To the degree applicable, describe your state's utilization of private entities to provide 

case management services (e.g., placement of children with particular foster care 

providers, ongoing casework, and oversight of foster care placements). The Nebraska 

Department of Health and Human Services Division of Children and Family Services 

(DHHS-CFS) entered into a subaward with a private, non-profit agency that provides case 

management duties and responsibilities over the ongoing child welfare cases involving child 

abuse and neglect in Douglas and Sarpy counties. These two counties account for 

approximately 40% of the the state's population. 

This private, non-profit agency, called Nebraska Families Collaborative (NFC), is licensed 

with the state of Nebraska as a Child Placing Agency and is accredited through the Council 

on Accreditation. With regards to foster care, NFC identifies and prepares relative and 

kinship foster parents for placement of foster children. DHHS-CFS reviews and approves all 

relative and kinship foster parents prior to rhe piacemem of children in their· hot1ies. lY'.~..~ 

also subcontracts with other non-profit and for-profit licenced Child Placing Agencies who 

recruit, train, and support licensed foster parents. DHHS-CFS also reviews, approves, and 

issues the foster care license to these foster homes, and approves all placement of foster 

children in these homes. 

In the other areas of the state, DHHS-CFS contracts with private non-profit and for-profit 

agencies to recruit, train, prepare for licensure, and support foster parents. DHHS-CFS 

reviews licensing packets submitted by these agencies and approves each foster home for 

licensure. DHHS-CFS also recruits foster parents directly, prepares them for licensure, and 

provides supports to the foster homes to help stabilize and maintain child placements. 

2) What proportion of the children in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? As of May 11, 2015, 86.3% of 

children in foster care are placed by private agencies; of the 86.3% of children placed by 

An Eqt1ni OpporLun!t.\.' Fmp!r.ly(·~r 
127 


26354.091

private agencies, 5% are placed by for-profit agencies and 95% are placed by not.for-profit 

agencies. 

13.7% of children in foster care are placed by a public agency, either DHHS-CFS or the 

Tribes. Of the 13.7% children placed by a public agency, 93.1% are placed by DHHS-CFS 

and 6.9% are placed by the Tribes. 

3) Please provide the number and names of private entities providing these core services, 

as well as information on whether each provider is a for-profit or not-for-profit entity. 

Please see Attachment-A; 

4) Does your state require that private foster care entities or organizations operating in 

your state be accredited? If so, by which organization and how often is this 

accreditation renewed? No, Nebraska does not require that private foster care entities be 

accredited. Please see Attachment-A for a list of those private foster care entities who have 

chosen to be accredited, and by which accreditating organization. 

5) Describe in detail the process you use to select and contract with these private entities, 

as well as to review and renew such contracts. Nebraska state statute, LB269, requires 

DHHS-CFS to conduct a financial review of private agencies before entering into a child 

welfare contract. Specifically, the statute states that any entity seeking to enter into a 

contract with the Department of Health and Human Services to provide child welfare 

services shall provide evidence of financial stability and liquidity prior to executing such a 

contract. In order to meet this requirement, DHHS-CFS requests the most recently audited 

financial statements from all private foster care agencies, but will accept reviewed financial 

statements, compilation financial statements, internally prepared financial statements, or 

minimally a balance sheet and income statement for the same time periods. This financial 

review is conducted on an annual basis prior to contract renewal. 

All private foster care agencies are required to obtain a Child Placing Agency License 

through Regulation and Licensure with the stare of Nebraska before entering into a foster 

care contract with DHHS-CFS. Licensing standards require the agency to develop a written 

statement of its functions, policies, and programs and submit them for approval by rhe 

licensing unit. Licensed Child Placing Agencies must conduct background on all employees, 

volunteers, and caregivers age 13 or older who have contact with children prior to having 

unsupervised contact with children. Child Placing Agencies are prohibited from employing 

any individual who has been convicted of, admitted to, or has substantial evidence of crimes 

involving intentional bodily harm, crimes against children, or crimes involving moral 

turpitude. The background checks must include: Nebraska Sex Offinder Registry 

maintained by the Nebraska State Patrol; Nebraska Child Abuse and Neglect Central 

Registry; Nebraska Adult Abuse and Neglect Central Registry, Nebraska State Patrol 

Criminal Background Check. and Nebraska Department of Motor Vehicles Check for License 

Points Status. The foster care agency must conduct similar back,ground checks in the state(s) 

of previous residence lfthe employee has resided in Nebraska for less than two years. lfthe 

background checks result in a record of convictions being identified, the foster care agency 

must notifY DHHS-CFS of the convictions lfthey still decide to hire the individual. DHHSCFS reserves the right to prohibit foster care agency staff from having contact with children 
128 


26354.092

upon receipt of this notification of criminal history. 

Personnel File Reviews during the contract period to 

background check requirements. 

DHHS-CFS conducts quarterly 

check for compliance with the 

6) Describe in detail the process your state uses to inspect the safety of the foster care 

settings in which children are placed and the extent to which this process differs for 

public, not-for-profit, and for-profit providers operating in your state. DHHS-CFS case 

managers are required to see each child on their caseload at a minimum of once every• 30 

days. One of these face to face visits must occur in the foster care horne and there must be a 

conversation with the foster youth about their safety in the horne. This information is 

documented each month and if there are any licensing issues, those issues are forwarded to 

resource development workers, who are responsible for working with the foster homes and 

the private agencies who support the foster homes. If there is a safety concern, those are 

called into the Nebraska Child Abuse and Neglect hotline for investigation. The process 

does not differ depending on whether the child was placed by the public agency, a not-forprofit provider, or a for-profit provider. 

7) How many instances of abuse in a foster care placement have been substantiated in the 

last five years in your state? Of those substantiated, how many of these instances 

related to children by: not-for-profit providers, for-profit providers, and public 

provider? 

There have been 140 instances of substantiated abuse in a foster care placement in the last 

five years. Of these 140 instances, 0 instances are related to For-Profit providers; 85 

instances are related to Not-For-Profit providers; and 55 instances are related to the public 

provider (Nebraska). It should be noted that one private for-profit agency, Better Living 

Counseling Services, did not begin providing foster care until Apri/1, 2013. 

8) Describe in detail the actions taken when an abuse claim is substantiated while a child is 

in an out of home placement? Do these actions differ depending on whether the child 

was placed by the public agency, a not-for-profit provider, or a for-profit provider? 

When an abuse claim is substantiated while a child is in an out of home placement, the 

child's placement in the foster horne is terminated and the child is placed into another living 

arrangement. The foster horne is placed on hold from taking any additional placements and 

action is taken to revoke the foster horne's license. The actions do not differ depending on 

whether the child was placed by the public agency, a not-for-profit provider, or a for-profit 

provider. 

Thank you again for this opportujnity to provide information regarding this important foster care 

issue. 

Enclosure 

Sincerely, 

f\/.Jtt~ Pete Ricketts 

Governor 

26354.093 Atta~ ~nt·A Nebraska's Response to the US Senate Committee on Finance Regarding Privatized Foster Care·· May 14, 2015 For Not For Accredited Name of Accrediting Accre

Name of Private Foster Care Agency llome Office Location Profit Profit Organization Renew

1 Apex Foster Care, Inc. Omaha, NE Yes No 2 Behavioral Health Specialists, Inc. Norfolk, NE Yes Yes The Joint Commission Ann

3 Better Living Counseling Services, Inc. South Sioux City, NE Yes No 4 Building Blocks for Community Enrichment O'Neill, NE Yes No 5 Cedars Youth Services lincoln, NE Yes Yes Council on Accreditation Four 

6 Child Saving Institute, Inc. Omaha, NE Yes Yes Council on Accreditation Four 

7 Christian Heritage Children's Home Walton, NE Yes Yes Council on Accreditation Four 

8 Christian Home Association Children's Square USA Omaha, NE Yes Yes No Four 

9 Compass Kearney, NE Yes No 10 Epworth Village, Inc. York, NE Yes In-Process Council on Accreditation Four 

11 Father Flanagan's Boys Home Boys Town, NE Yes Yes Council on Accreditation Four 

12 Grace Children's Home Company Henderson, N E Yes No 13 KVC Behavioral Healthcare Nebraska, Inc. Omaha, NE Yes Yes The Joint Commission Three 

14 Lutheran Family Services of Nebraska Omaha, NE Yes Yes Council on Accreditation Four 

15 Mid-Plains Center for Behavioral Healthcare Services, Inc. Grand Island, NE Yes Yes Council on Accreditation Three 

16 Nebraska Children's Home Society Omaha, NE Yes Yes Council on Accreditation Four 

17 Nebraska Families Collaborative Omaha, NE Yes Yes Council on Accreditation Four 

18 Nova Treatment Community Omaha, NE Yes Yes Commission on Accreditation of Three 

Rehabilitation Facilities 19 Omni Behavioral Health Omaha, NE Yes Yes The Joint Commission Three 

20 South Central Behavioral Services Kearney, NE Yes Yes Commission on Accreditation of Three 

Rehabilitation Facilities 21 St. Francis Community Services of Nebraska, Inc. Salina, KS Yes Yes The Joint Commission Three 

_B ..... TFI Family Service, Inc. Emporia, KS Yes Yes I Council on Accreditation Four 
130 


26354.094

Nicholas A. Toumpas 

Commissioner 

Lorraine Bartlett 

Director 

STATE OF NEW HAMPSHIRE 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

OFFICE OF HUMAN SERVICES 

DIVISION FOR CHILDREN, YOUTH & FAMILIES 

129 PLEASANT STREET, CONCORD, NH 03301-3857 

603-271-4451 1-800-852-3345 Ext. 4451 

FAX: 603-271-4729 TDD Access: 1-800-735-2964 www.dhhs.nh.gov 

The following is our response to your questions from the Senate Finance Committee. It is important to understand 

in the context of the questions below The Department of Health and Human Services, Division for Children 

Youth and Families directly manages the Foster Care Program in New Hampshire. DCYF is the statutorily 

mandated public agency for Child Protection and Juvenile Justice Services per RSA 169-C, D and B. Services and 

Programs under the auspice of the agencies are ordered through the New Hampshire Judicial System. 

Describe your state's utilization of private entities to provide case management services. 

As the Child Protection agency for New Hampshire. DCYF establishes fee for service arrangements with 

private Child Placing Agencies (private entities) that are licensed per RSA 170-E to provide foster care and 

certified per RSA 170-0 to provide a specific level of foster care programming as referenced in chart below. 

Child Placing Agencies are defined in RSA 170-E:25 IV as: any firm, corporation or association which: 

(a) Receives any child for the purpose of providing services related to arranging for the placement of 

children in a foster family home, group home, or child care institution; or 

(b) Receives any child for the purpose of providing services related to arranging for the placement of 

children in adoption. 

Child Placing Agencies recruit and maintain a foster home but ultimately foster care licenses can only be granted 

by the DCYF Director. Those Child Placing Agencies provide a variety of certified court ordered therapeutic 

services to the to the Child who is involved with the Division under petitions of RSA 169-C. 169-B and 169-D. 

The state uses Child Placing Agencies to provide specific levels of treatment based programs to meet the unique 

needs of the child and family. The programs are certified as treatment providers and while the services include 

therapeutic case management as part of the treatment delivery. DCYF maintains all court ordered supervision, 

case management and oversight of the placement. New Hampshire does not contract with any Child Placing 

Agency for foster care placements. Child Placing Agencies are matched, based on therapeutic skiilset, location 

and foster families available to meet the unique needs of the child and family on a fee for service basis. These 

Child Placing Agencies are reimbursed on a fee for service basis for their therapeutic services including Medicaid 

reimbursable services. 

What proportion of the children in foster care in your state is placed by the public agency, not-for-profit 

providers and for-profit providers? 

In New Hampshire, 100% of children requiring foster care placement through child protection or juvenile 

justice are court order placed by DCYF. Children and youth can be placed in foster care following a court order 

on a petition of abuse or neglect RSA 169-C, CHINS (Child in Need of Services) RSA 169-D or delinquency 

RSA 169-B. 

The only other use of foster care services outside of the statutes referenced above, allowed in New Hampshire, is 

in the event of a private adoption which is facilitated by licensed private Adoption agencies when it is required for 

an in-state or interstate private adoption. These Adoption Agencies are licensed by DCYF to recruit, train and 

communi!i<'S and farnilies 

independr>nce. 
131 


26354.095

license homes for this purpose. These children are not involved with the New Hampshire Court System and not 

involved with DCYF case management. 

Please provide the number and names of private entities providing these core services as well as 

information on whether each provider is a for-profit or Not-for-profit entity. 

As stated above, 100% of the children placed in New Hampshire foster care are placed by the Division 

through a court order. The Division maintains all legal authority authorized by the court and ultimately, bears 

responsibility for all case management. There are currently eight providers who are licensed as Child Placing 

Agencies to provide foster care service and eight agencies certified to specifically provide a therapeutic level of 

foster care programming. (Referenced below under column "service provided" as Individual Service Option 

(ISO)). New Hampshire certifies ISO services based on NH Administrative Rule He-C 6339. All of the ISO 

programs are also licensed as a Child Placing Agency with one exception being Crotched Mountain, who 

contracts with another agency for foster homes. The current agencies are as listed: 

t>gercy Remun:e l'erre Oty, State, Zip service provided Profit Status 

ASCBIITRACAREAUJM-a,llll: O:rconJ 1\1-1 a3301 licensirg ard ISO Feser Care seruC€5 Non-Profit 

otLD I>K) FAMLY SB'MCES CF I'l-l rvl3ncrester 1\1-1 03105 licensirg ard ISO Feser Care seruC€5 Non-Profit 

O'IOTCH3::> MOlNTAIN G-eenlield 1\1-1 C0047 ISO foster care seruC€5 ooiy Non-Profit 

EAS'nR SEAL SOCIErY CF I'l-l rvl3nct'ester 1\1-1 03103 licensirg ard ISO Foster Care seruC€5 Non-Profit 

I!IVB'!NJENT SB'MCES IIET\I\IOR( rvl3ncrester 1\1-1 03103 !icensln;J ard 100 Foster care seruces For Profit 

LAKES REGCIII COMVI.NTY SB'MCES l..a:xria. 1\1-103246 licensirg ard general Foster Care Non-Profit 

UASHAFE MANAGEM:NT GRlU' U.C rvl3ncrester 1\1-1 03103 licensirg ard ISO Foster Care seruces Non-Profit 

1'1'1 IIIJRTHIIII: Jefferson 1\1-1 03583 licensirg ard ISO Foster Care seruces Non-Profit 

SPAll.DING 'lOUTH CENTER N:rthlield 1\1-1 03276 licensirg ard ISO Foster Care seruces Non-Profit 

Does your agency require that private foster care entities or organizations operating in your state be 

accredited? If so, by which organization and how orten is this accreditation renewed? 

We require that Private Foster Care agencies operating in New Hampshire be licensed as a Child Placing 

Agency or as a Residential Facility. NH RSA 170-E governs the licensing of such entities with the specifics 

being outlined by Administrative Rules. He-C 6448 is the Rule for Child Placing Agencies and He-C 4001 is the 

Rule for Residential Care Facilities. These NH Rules outline the equivalent of an accreditation process. 

The Department oversees the licensing process and monitors providers for compliance. Child Placing 

Agency licenses are issued by the Director of DCYF and arc valid for four years. Residential Care Licenses are 

issued by the Department's Director of Legal Services and arc valid for three years. In both Rules, the licensed 

agency must submit a renewal application no less than three months prior to license expiration date following the 

process outlined in the respective Rule. 

In addition to licensing requirements above, any Child Placing Agency that wishes to provide services to 

DCYF youth must also apply for certification from DCYF. Certification for the payment of Foster Care Programs 

follows the requirements of Administrative Rule He-C 6355. DCYF oversees the licensing process and monitors 

providers for quality assurance and compliance per RSA l70-G. The certification must be renewed every two 

years. 

2 
132 


26354.096

Describe in detail the process you use to select and contract with these private entities, as well as to review 

and renew such contracts. 

Rather than contract with agencies we certify the private agencies to provide foster care. Agencies 

wishing to provide a foster care program must apply for licensing and certification as outlined above. A 

requirement of the application is to show that there is a need for a new service and service provider per RSA 170-

G. Once an agency has been granted a license and certificate, the decision to utilize the provider is made by 

DCYF through a matching process which reviews the needs of the child with the strengths and services of the 

provider. The renewal process for both licensing and certification requires the provider to participate in site 

reviews of their agency by DCYF to ensure compliance with the rules and appropriate care and service delivery 

to the children and families referred to their programs. 

Describe in detail the process your state uses to inspect the safety of the foster care settings in which 

children are placed and the extent to which this process differs for public, not-for-profit and for-profit 

providers operating in your state, 

All foster care homes in New Hampshire, whether they are with the public or any private agency, are 

licensed following the statutory requirements in NH RSA 170-E and Administrative Rule He-C 6446. All 

potential foster care applicants and household members over age 17 undergo rigorous record checks through FBI 

fingerprinting, a State Criminal record check and a central registry check for child protection complaints. Checks 

are completed in every state in which the applicant or household member has resided in the past seven years. 

Their physical home must pass both a local fire and health inspection. There is no difference in this process by 

the type of agency; however, there is a difference in the detailed requirements of the fire inspection by locality 

primarily because each New Hampshire town or city can set its own building and safety codes based on the Life 

Safety Code edition they have adopted. The minimum standard is the 2003 NFPA (National Fire Prevention 

Association) 101. At a minimum, all foster care homes must be visited annually by either the DCYF foster care 

licensing staff or staff from the Child Placing Agency that maintains the foster home. A foster care license for an 

individual home is valid for two years and verifies that the home has completed health and safety compliance 

requirements. The same process must be completed again for renewal. DCYF is working with the Department to 

add a state registry check for adult and elder abuse to the safety requirements for all licensing as it is seen as best 

practice. 

How many instances of abuse in a foster care placement have been substantiated in the last five years? Of 

those substantiated, how many of these instances related to children placed by: not-for-profit, for-profit 

and public providers'? 

There has been one substantiated instance of abuse to a child in a foster care placement in New 

Hampshire in the past five years. This foster home was licensed by DCYF. 

Describe in detail the actions taken when an abuse claim is substantiated while a child is in an out of home 

placement? Do these actions differ depending on whether the child was placed by the public agency, a not· 

for-profit provider or a for-profit provider? 

All foster care placements in New Hampshire are made by DCYF as ordered by the Court. There has 

only been one instance of a founded abuse claim against a foster parent in the past five years. The child was 

removed immediately and that license was closed after the investigation. Administrative Rule He-C 6446 outlines 

in detail the process to be followed in this situation. This process is the same for all agencies and foster homes. 
133 


26354.097

DCYF has a Special Investigation Unit (SIU) per RSA 169-C:2 XVI and 169-C: 3-a that is assigned to 

assess any report of abuse or neglect in a foster care setting. During the course of the investigation if there are 

founded violations or suspicion of violations of the foster care family licensing requirements He-C 6446 these 

concerns are provided to the foster care licensing manager, and foster care licensing staff in the district office or 

Child Placing Agency. Any violation the foster family care licensing requirements in Hc-C 6446 requires the 

agency to issue a written order to comply to the foster parent. 

He-C 6446.27 Orders to Complv and Immediate Removal of Children In Care. 

(c) Within 14 days of the dare of the order to t:omply, the licensing agency and the foster parent shall jointly develop a 

corrective action plan to correct the violations. 

(d) The foster parent shall not accept any additional children in care, children for respite care, or children in a pre-adoptive 

placement: 

(I) Afier receiving an order to comply as specified in (c) above and prior to the development of a corrective action plan; or 

(2) During an ongoing investigation of alleged child abuse or neslect. 

(i) If any violations ident{fied present a risk to the health, safety, or l"''ell-being of the child in care, the department shall 

immediarely, and with any court approval required by law, remove the child in care from the foster home without issuing an order 

to comply. 

(j) The depanment shall revoke the license or permit of the foster parents without issuing an order to comply if there is a 

founded report of child abuse or neglect for a foster parenl and shall revoke the license or permit of the foster parents without 

issuing an order to comply if there is a judicial finding of abuse or neglect made related to foster parent. 

(k} The dt.'pMtment shall revoke the license or permit of the foster parents without issuing an order lO comply !fa foster 

parent is convicted of a felony or other crimes pursuant to He-C 6446.29(hj. 

Further information on Foster Care Programs in New Hampshire can be found in the Child and Family 

Services Five-Year Plan submitted by DCYF to the Administrative Office for Children and Families, Children's 

Bureau on June 30, 2014. The following are links to the Statute and Rules referenced in the responses to the 

questions posed. 

NH RSA 170-E TITLE XII, PUBLIC SAFETY AND WELFARE, CHAPTER 170-E, CHILD DAY CARE, 

RESIDENTIAL CARE, AND CHILD-PLACING AGENCIES 

lmn:/ /:,v.w_-,~,gt;tlC:.\li!IU!!l1~tlh.,u5Lt:os'!LhJm][x i i/_L7ib;.IJ1.Q~<e.:.mr&Jl1fl1. 

Administrative Rule He-6446 CHILD-PLACING AGENCY LICENSING REQUIREMENTS 

tu~.n.Jh~.Y~~-~~D.~~2.~\ rt:.Jilate .nJJ&.~LnJ!~~~tate 'l£.~D52i&~b~~..6:±.0i)".J:!l!!JJ 

Administrative Rule He-C 6446 FOSTER FAMILY CARE LICENSING REQUIREMENTS 

http:/ /w~ww, gcncou rt. <.;tate. nh. us/rul~.~/st ate agencies/hc-c6400. html 

Administrative Rule He-C 6355 CERTIFICATION FOR PAYMENT OF FOSTER CARE PROGRAMS 

hJ!~J.b.~w. genCQ.!JI!. state. nh. us/rul~5L,:;ta tC-1!£.Q.m;:~.•Jhe-cQ.lQQ1H ml 

Administrative Rule He-C 4001 CHILD CARE LICENSING RULES 

llll!'JLvv_w~W1£.Q.\!_rt.st~nh.us/rule;;{:;!_atc ugencic,;/ll£.c_<;,'!QOO.html 

4 
134 


26354.098

CHRIS CHRISTIE 

Governor 

51\±a:t2 nf ~2fu Wm;ry DEPARTMENT OF CiULDREN AND E\MIL!ES 

PO.Box 729 

KIM Gt:AJ)AGNO 

Lt. Governor 

TRENTO,;, NJ 08625-0729 

United States Senate 

Committee on Finance 

Washington, DC 20510-6200 

Attention: Chairman Orin G. Hatch 

& Ranking Member Ron Wyden 

August 7, 2015 

Dear Chairman Hatch and Ranking Member Wyden, 

ALLISON BLAKE, PH.D., L.S. W. 

Commissioner 

Thank you for your letter inquiring about New Jersey's use of contracted private entities 

to administer foster care. The care of children and youth in foster care is one of the 

States' most critical responsibilities and ! applaud your commitment to this matter. 

New Jersey's use of private entities to administer foster care is different than the trend 

described in the April 24, 2015 letter which identified an increasing reliance on private 

entities. In 2014, New Jersey's Division of Child Protection and Permanency began 

phasing out its reliance on these contracted entities and intends to no longer be utilizing 

private entities in this capacity by the end of 2015. At this time 252 of New Jersey's 

5,346 foster homes are administered by private entities. 

like what is being experienced in other states currently, New Jersey had a critical 

shortage of foster homes prior to our child welfare reform efforts over the past decade. 

This shortage drove a need to contract with private entities to augment the foster homes 

recruited and administered by the public agency. However, we are very pleased that 

currently, due to enhanced recruitment and retention efforts, an intense focus on 

increasing kinship placements, focused efforts on reducing the use of out-of-home 

placement where children can be safely cared for at home, and the dedication of our 

staff and our communities to serving our most vulnerable children, we have a wealth of 

foster homes available. As a result, we made a decision last year to begin to phase out 

the private foster care contracts to allow us to reinvest those funds into other services 

critical to the children and families we serve. This process is scheduled to be 

completed this calendar year. 

Ni!W Je'*"y I< A11 Equal OpporlUnlty Employer • Printed on !?£cycled Paf"'r and Reeve/able 
135 


26354.099

Chairman Orin G. Hatch and Ranking Member Ron Wyden 

August 7, 2015 

Page 2 

As a result of these changes, the answers· to the questions posed by the Senate 

Finance Committee will likely be different from other states and jurisdictions: 

• To the degree applicable, descdbe your state's utilization of pdvate entities to 

provide case management services (e.g., placement of children with particular 

foster care providers, ongoing casework and oversight of foster care 

placements). 

o New Jersey's utilization of private entities to administer foster care does 

not include case management services as described herein. Placements, 

ongoing casework, and placement oversight remain the responsibility of 

public agency caseworkers. The different private entities contracted for 

this purpose perform a combination of the following functions depending 

on their individual contract terms: recruitment; conducting home-studies; 

supporting potential foster homes through the licensing process; training 

foster parents; managing payments to foster parents; providing ongoing 

support to foster parents; assisting public agency caseworkers in 

identifying foster care placements within their network of foster homes; 

and providing specialized support for children in foster care. 

• What proportion of the children in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? 

o All children in foster care are placed by the public agency, though the 

private entities which provide administrative support for foster homes will 

assist the public agency caseworker in identifying foster care placements 

within their managed network of foster homes as needed. 

• Please provide the number and names of pdvate entities providing these core 

services, as well as information on whether each provider is a for-profit or not-forprofit entity. 

o As described above, none of the private entities that provide 

administrative support for foster homes, provide the core child 

placemenVoversight services identified in the previous questions. 

• Does your state require that pdvate foster care entities or organizations operating 

in your state be accredited? If so, by which organization and how often is this 

accreditation renewed? 

o No, the entities providing administrative support of foster homes are not 

required to be accredited. 
136 


26354.100

Chairman Orin G. Hatch and Ranking Member Ron Wyden 

August 7, 2015 

Page 3 

• Describe in detail the process you use to select and contract with these private 

entities, as well as to review and renew such contracts. 

o Because the Division of Child Protection and Permanency is in the 

process of phasing out all contracts with these private entities, there is no 

current process to review and renew such contracts. However, 

historically, these contracts would be reviewed annually to ensure that the 

agency was meeting contractual expectations and an appropriate levels of 

service prior to renewal. Additionally, since public agency staff maintained 

responsibility for the core case management services, they were 

positioned to advise contracting staff of any issues requiring further review 

or corrective action. 

• Describe in detail the process your state uses to inspect the safety of the foster 

care settings in which children are placed and the extent to which this process 

differs for public, not-for-profit, and for-profit providers operating in your state. 

o All foster homes in New Jersey, including kinship homes, public agency 

managed foster homes, and private agency foster homes are required to 

be licensed. Chapter 122C of the New Jersey Administrative Code1 

establishes regulations governing health, safety, and well-being. All foster 

homes are licensed and inspected by state staff. 

o The regulatory requirements are divided into two levels based upon their 

direct impact upon the child in placements safety and well-being. Level 1 

requirements are the most serious, and Level 2 requirements may be 

waived in order to facilitate kinship placements in the best interest of a 

child. 

o Prior to being licensed, all resource homes are subject to an on-site 

inspection and must be found to be in compliance for a license to be 

issued. 

o Once a license is granted, the resource homes are required to have an 

annual inspection to ensure on-going compliance. During these 

inspections, the child's safety is further ensured by requiring that licensing 

staff see each child in placement and conduct an in-person interview with 

each child in placement as age appropriate. 

o Additionally, as all placements are made by public agency staff and as 

monthly visits with children are required to occur in their placement 

locations, the public agency staff have regular and ongoing oversight of all 

foster homes. 

1 

Regulations available at: http://www.nj.gov/dcf/policy_manuals/Regulations_2ABC012C-DlA3-45AE-A25F95EOBDEE5443_10%20-%20Human%20Services_l22C%20-

%20Manual%200f%20Requirements%20For%20Resource%20Family%20Parents.shtml 
137 


26354.101

Chairman Orin G. Hatch and Ranking Member Ron Wyden 

August 7, 2015 

Page4 

• How many instances of abuse in a foster care placement have been 

substantiated in the last five years in your state? Of those substantiated, how 

many of these instances related to children placed by: not-for-profit providers, 

for-profit providers, and public providers? 

o Since all placements are made by public agency staff, there is no 

distinction in the rate of child abuse or neglect between children placed by 

not-for-profit providers, for-profit providers, and public providers. The rate 

and actual number of instances of child abuse or neglect in foster care 

placements over the past five years are as follows: 

• 2014- 20 instances of child abuse or neglect in foster care yielding 

a child victimization rate2 of 0.17% 

• 2013 - 40 instances of child abuse or neglect in foster care yielding 

a child victimization rate of 0.32% 

• 2012-26 instances of child abuse or neglect in foster care yielding 

a child victimization rate of 0.21% 

• 2011 - 26 instances of child abuse or neglect in foster care yielding 

a child victimization rate of 0.22% 

• 2010-27 instances of child abuse or neglect in foster care yielding 

a child victimization rate of 0.22% 

• Describe in details the actions taken when an abuse claim is substantiated while 

a child is in an out of home placement? Do these actions differ depending on 

whether the child was place by the public agency, a not-for-profit provider, or a 

for-profit provider? 

o Since all placements are made by public agency staff, there is no 

distinction in actions taken when child abuse or neglect occurs in an out of 

home placement based on placement by not-for-profit providers, for-profrt 

providers, and pi,Jblic providers. 

o When an allegation of child abuse or neglect is made against a foster 

parent, the Institutional Abuse Investigation Unit, which operates 

independent of the child protection division, investigates the claim. If the 

allegation of child abuse or neglect is substantiated involving the foster 

parent or a member of their household, the Office of Licensing will 

routinely issue a Notice of Revocation. 

2 Child victimi<ation rate is the number of child victims of abuse or neglect in foster care over the calendar year 

divided by the total number of children in foster care over the same period. 
138 


26354.102

Chairman Orin G. Hatch and Ranking Member Ron Wyden 

August 7, 2015 

Page 5 

o There exists, however, an ability to maintain the foster home despite the 

finding of child abuse or neglect where it is in child's best interest to 

remain in placement within the home. This can occur with kinship 

placements where the causes of the instance of child abuse or neglect 

can be remedied to mitigate the risk of reoccurrence and where the 

caregiver bond outweighs the mitigated risk. This is only permitted 

through a waiver process. This waiver process takes into account the 

family/kin connection of the child in placement to the resource parent, the 

best interests of the child, the child's case plan, the current safety of the 

child, and the ability of the resource parent to keep the child in placement 

safe. 

I hope the Senate Finance Committee finds the above information useful and please 

feel free to contact my office with any additional questions or concerns. 

Sin7ely," 

{Jl!!UJlt1 AJ 4 

AlliSOn Blake, Ph.D., L.S.W. 

Commissioner 
139 


26354.103

PUBLIC-PRIVATE PARTNERSHIPS IN NEW MEXICO 

To the degree applicable, describe your state's utilization of private entities to 

provide case management services (e.g. Placement of children with particular 

foster care providers, ongoing casework and oversight of foster care placements) 

o New Mexico requires a casework to be assigned for each child placed in foster 

care. The caseworker retains all decision making, oversight of activities and 

responsibility for that child. 

o All foster care placements, private or public are licensed by the state's Children, 

Youth and Families Department. 

o Most regular foster care placements are directly overseen by CYFD in each 

county. 

o The state as one agency that provides private foster care placements. Their 

capacity is limited. 

o Caseworkers are able to make referrals to community, nonprofit agencies for 

case management type services, however the caseworkers maintain primary 

oversight. The case management services are behavioral health related and 

connected to a DSM IV diagnosis for the parent or child. 

What proportion of the children In foster care in your state is placed by the public 

agency, not for profit providers and for profit providers 

o As of March 2015 New Mexico had 2,146 children in care 

o 14% are in Treatment Foster Care. All Treatment Foster Care Agencies are 

licensed and regulated by CYFD. All Treatment Foster Care agencies are not for 

profit. 

o 3% are placed in Residential Treatment Care. The residential treatment centers 

in New Mexico are for profit centers. 

Please provided the numbers and names of private entities providing these core 

services, as well as information on whether each provider is for profit or not for 

profit: 

o Agave 

o Family Works 

o High Desert 

o La Familia/Namaste 

o La Frontera 

o NM Solutions 

o Open Skies 

o The Peak 

505-639-3038 

505-217-1402 

505-823-4530 

505-766-9361 

505-64 7-2880 

505-286-0701 

505-345-8471 

505-623-6749 

*AI! agencies above are not for profit agencies. 
140 


26354.104

Does your state require that private foster care entities or organizations operating 

in your state be accredited? If so, by which organization and how often is 

accreditation renewed? 

o No, we do not require accreditation for certification or licensure 

Describe in detail the process you use to select and contract with these private 

entities, as well as to review and renew such contracts? 

o The NM Children, Youth and Families Department does not contract for foster 

care or residential treatment services. These are all medically necessary services 

and are contracted by our Human Services Department. 

o CYFD does not have access to this information. HSD might be a resource on 

this. 

o The foster care agency certified by CYFD, requires they meet all the licensing 

standards required by the state for regular foster care. Families are required to 

complete physical forms, a thorough home study (interviews of all household 

members, references forms, and financial history), and training, a safety 

inspection of the home, criminal records and background check by the state and 

Federal Bureau of Investigations, child abuse and neglect checks. 

Describe in detail the process your state uses to inspect the safety of the foster 

care settings in which children are placed and the extent to which this process 

differs for public, not for profit and for public providers in your state. 

o The NM Children, Youth and Families Department certifies our families and all 

families providing any type of foster care, to include the not for profit treatment 

foster care agencies. 

o Below is our Administrative Code which is required for any foster care setting in 

the State of New Mexico : 

8.26.4. 13 SAFETY CHECKLIST FOR FOSTER AND ADOPTIVE HOMES: 

A. Heating, cooling, and ventilation: 

(1) A foster home shall be adequately ventilated. There shall be an effective means of providing 

fresh air to children's sleeping rooms, including at least one window. 

(2) Fuel-burning equipment, including natural gas or liquid propane gas cooking ranges shall be 

vented appropriately and meet applicable safety code requirements. 

(3) Heating equipment shall be adequate to maintain interior temperature of 65 degrees 

Fahrenheit in all rooms. Gas furnaces shall have a cut-off valve. 

(4) The heating systems and associated equipment shall meet all requirements of state and local 

safety codes. 

B. Water: 

(1) A foster home shall have an adequate supply of sanitary water. 

(2) If water is not obtained from a public supply, a well water certificate from the New Mexico 

environment department shall be provided for initial licensure, and at five year intervals. Well 

water testing instructions and an application form are available on the environment department 

website. Bottled water may be used for cooking and drinking if the water source is assessed to be 

unsuitable. 
141 


26354.105

(3) Water supply piping and associated equipment shall be installed and maintained in 

compliance with state and local safety codes. There shall be a pap-off valve on the hot water 

heater. 

C. Sewage, waste and sanitation: 

(1) A foster home shall be kept clean and free of accumulation of dirt, waste, and infestations of 

insects and rodents. 

(2) Toilet and bathing facilities shall be provided and maintained in a sanitary manner. 

Codes. 

(4) Foster homes shall be free of clutter that may cause tripping or falling hazards. 

0. Electrical wiring and communication: 

(1) Electrical wiring shall comply with state and local safety codes. If the licensing agent has 

doubt of the adequacy of electrical wiring, the licensing agent shall request the applicant arrange 

and pay for a local electrical inspector to inspect the wiring and submit a report to the licensing 

agent. 

(2) Electrical extension cords shall not be used for general wiring. 

(3) A readily available telephone in case of emergencies. 

E. Kitchen and food storage: 

(1) A foster home shall have a kitchen with sufficient storage space. Food shall be stored 

separately from cleaning supplies and other household chemicals. 

(2) The kitchen shall be equipped with a refrigerator sufficient to maintain cold food storage in a 

temperature range between 33 degrees and 45 degrees Fahrenheit. 

(3) The kitchen and food preparation equipment and storage shall be maintained in a sanitary 

condition. 

F. First aid and medical supplies: 

(1) Foster parents shall maintain a stock of first aid supplies in the foster home. The minimum 

acceptable stock includes: 

(a) One box of non-medicated adhesive bandages; 

{b) One pair of blunt scissors; 

(c) One rei! of two inch or three inch adhesive roller bandage; 

(d) One roll of one-half inch adhesive tape; 

(e) One box of sterile first aid dressings in sealed envelopes; 

(f) First aid cream or ointment. 

(2) These shall be stored in a single cabinet or kit, separate from food storage or household 

cleaning supplies or other chemicals/poisons, 

(3) Prescription medicines shall be supplied and administered only as prescribed. They shall be 

properly labeled, and stored separately from food, cleaning agents or other household chemicals 

and poisons After the prescribed course of treatment has been completed, leftover medicine 

shall be disposed of in an appropriate manner. 

G. Personal items: 

(1) Each foster child shall be provided an individual comb, toothbrush, night clothes, and under 

garments which shall not be interchanged between children. 

(2) linens and bedding shall be stored and maintained in a manner assuring that they will be 

clean. All linens and bedding shall be laundered before use by another child. 

H. Any animal, birds, and pets shall be in good health with documentation of current 

vaccinations, and have a temperament such that they will not be frightening or hazardous to 

foster children. 

I. Foster home space, furnishing and sleeping arrangement: 

(1) A foster home shall have a separate bedroom for the foster parents and for any other adults 

living in or frequently residing in the home. This shall not preclude a foster child under the age of 

18 months from sleeping in the same room with his or her foster parents provided that the 

bedroom space is available for the foster child when he or she reaches the age of 1 B months. 

(2) There shall be a separate bed provided for each foster child, except that two children of the 

same gender may sleep in the same double bed. 

(3) A foster child over the age of five years shall not share a bedroom with another non-related 

child of the opposite gender. 
142 


26354.106

(4) The licensing agent may allow exceptions to the sleeping arrangement requirements to permit 

placement of siblings together in the same foster home. 

(5) Sleeping quarters for foster children shall be a contiguous part of the main family residential 

building or apartment Exceptions can be made for those children over 16 years of age who are 

preparing for independent living. 

(6) There shall be sufficient closet space or furniture storage space to permit the sanitary storage 

of children's clothes, linens and bedding. 

(7) Furnishings shall be clean and maintained in a sanitary condition at all times. 

J. Doors and locks: 

(1) A foster home shall have at feast two designated exits that meet fire code standards. 

(2) There shaH be no interior door hardware which makes it possible fpr a child to be locked 

inside. All privacy locks shall be provided with emergency unlocking mechanisms. 

K. Yard and play space: 

(1) A foster home shall have access to a safe indoor and outdoor designated play area. 

(2) In areas which have a high density of traffic or other hazards to children, the yard or play 

space shall be adequately fenced for the children's protection. 

(3) All outdoor play space and toys, swings and other outdoor equipment shall be maintained in a 

sound state of repair and free of projecting sharp edges, splinters or other hazards to children. 

L. Other safety issues: 

(1) If the applicant operates an automobile, he or she shall have automobile insurance as 

required by law and a valid driver's license. Motor vehicles shall have safety restraints as required 

by law and shall have properly installed car seats for age appropriate children. 

(2) For age appropriate children, a foster home shall have safety gates and locking mechanisms 

for cabinets that contain cleaning agents or chemicals. 

(3) A foster home shall have at least one fire extinguisher. 

(4) A foster home shall have smoke detectors appropriate for the square footage. 

(5) A foster family shall develop a fire evacuation plan. 

(6) A foster family shall provide to PSD or the agency contact information for at least two 

locations (including one out of town location) where the foster family would go in the event that a 

community evacuation is necessary. 

(7) All weapons owned or acquired by a foster family shall be stored and locked with ammunition 

stored separately as per the PSD approved weapons safety agreement The foster family shall 

provide a signed copy of the PSD approved weapons safety agreement to the licensing agent. 

(8} All pool areas, including hot tubs, shall be adequately fenced or secured in order to prevent 

the access of children when not accompanied by an adult Spas or hot tubs shall be securely 

covered to prevent the access of children when not in use. Outdoor ponds shall not be within the 

immediate play area of children. 

(9) Farm and ranch equipment shall not be easily accessible to foster children as a safety 

precaution. Farm animals shall be properly housed and secured as a safety precaution. 

(10) At initial licensure, the licensing agent will check the list of properties on clandestine drug 

laboratories in New Mexico website located on the New Mexico environment department 

homepage to verify the home has not been listed as a contaminated property. This verification 

shall be documented in the home study. Homes that are listed as contaminated properties shall 

not be licensed. For homes that have been previously licensed, the licensing agent shall check 

the clandestine drug laboratories in New Mexico website at the time of re-licensure. If a home has 

not been listed as a contaminated property, the licensing agent need not check the home again in 

further re-licensure 

8.26.4. 18 UPDATES AND RENEWAL OF FOSTER HOME LICENSE: 

A. The licensing agent shall conduct an annual review of each foster home to include: 

(1) Documentation of completion of the training requirements as described herein at Subsection B 

of 8.26.4.14 NMAC; 

(2) A check of FACTS is conducted on all adults living in the home; 

(3) A check of nmcourts.com shall be conducted on all adults living in the home; 
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(4) a review of the agreement between the foster parent, licensing agency, and PSD or child 

placement agency; the agreement shall be signed again to cover the remainder of the licensing 

period or the new licensing period; 

(5) a review of placements made during the year, identification of strengths and training needs, 

and a review of current policies affecting foster care: and 

(6) A review with the foster parent their duty to disclose any arrests or abuse and neglect 

referrals. 

B. Foster families must meet the following re-licensure requirements every two years. The 

SAFE home study update shall be used for re-assessment for re-licensure. The reassessment 

shall include all requirements listed above in Paragraphs (1)- (5) of Subsection A of 8.26.4.18 

NMAC. 

C. Before the end of the licensure period, both foster parents and PSD or licensed child 

placement agency shall ensure that all requirements are met to qualify the family for a renewed 

license. 

D. PSD or child placement agency foster home licenses shall be issued every two years, if 

they continue to meet requirements 

o How many instance of abuse in foster care placement have been substantiated in 

the last five years in your state? Of those substantiated, how many of these 

instances related to children placed by: not for profit providers, for profit 

providers and public providers? 

o 57 total victims in state foster care, and 9 total victims in private-for-profit 

placements 

o Describe in detail the actions taken when an abuse claim is substantiated while a 

child is in an out of home placement? Do these actions differ depending on 

whether the child was placed by the public agency, a not for profit provider, or for 

a profit provider? 

(Please see below procedures) 

SOCIAL SERVICES- CHILD PROTECTIVE SERVICES 

PROTECTIVE SERVICES INVESTIGATION PROCEDURES (8.10.3 NMAC) 

PR 14: ALLEGATIONS OF ABUSE OR NEGLECT IN FOSTER HOMES, TREATMENT FOSTER 

HOMES, AND PRE-ADOPTIVE HOMES 

INVESTIGATION OF ABUSE OR NEGLECT REPORTS IN FOSTER HOMES, 

TREATMENT FOSTER HOMES AND PRE-ADOPTIVE HOME: PSD investigates reports 

of allegations of abuse or neglect made regarding a child in PSD's custody placed in 

foster care, treatment foster care or pre-adoptive home. This includes reports alleging 

child abuse or neglect in: 

-PSD licensed foster homes, regardless if foster children are currently placed the 

home; 

-Foster homes and treatment foster homes licensed by private agencies, -regardless if 

foster children are currently placed in the home; 

-PSD approved pre-adoptive homes; and 

Pre-adoptive homes approved by private agencies that are licensed by PSD. 
144 


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Allegations of violations of policy or licensing standards that do not Involve abuse or 

neglect allegations or safety of the child In placement are referred to placement for 

resolution. [09-24-01; 11-30-04; 06-30-05; 05-10-1 0; 02-29-12] 

6 NOTIFICATIONS: 

6.1 Law Enforcement: The Investigation worker notifies law enforcement and 

coordinates the investigation with them, if requested, but not at the detriment of the 

investigation initiation time frames. [09-24-01; 11-30-04; 08-20-07; 05-12-1 0] 

6.2 Guardian Ad Litem and Youth Attorney: The investigation worker consults with 

the child's permanency planning worker and the Children's Court Attorney (CCA) to 

determine how and by whom notification will be made to the child's guardian ad litem or 

youth attorney. Notification is made within one-business day of the acceptance of the 

report by SCI. [09-24-01; 06-30-05; 08-20-07; 05-1 0-1 0] 

6.3 Private Child Placement Agency; In those circumstances where the foster home, 

treatment foster home or pre-adoptive home is licensed by a private child placement 

agency, the investigation worker notifies the private child placement agency of the 

investigation and attempts to coordinate the investigation with the private child placement 

agency, if requested, but not at the detriment of the investigation initiation time frames. 

[05-1 0-1 0] 

6.4 Placement and Permanency Planning Workers: In those circumstances where 

the foster home or pre-adoptive home is licensed by a PSD, the investigation worker 

notifies the placement worker and child's permanency planning worker of the 

investigation and attempts to coordinate the investigation with them, if requested, but not 

at the detriment of the investigation initiation time frames. [05-1 0-1 OJ 

7 EFFORTS TO LOCATE: When directions to the home or an address are not 

provided in the report, the investigation worker contacts the placement services worker or 

the licensed placement agency. If the investigation occurs after regular business hours, 

the worker contacts law enforcement or other source, including the emergency after 

hours number of the child placement agency, which may have information for assistance 

in locating a child and family. [09-24-01; 05-12-10] 

8 INFORMATION COLLECTED: 

8.1 Background Questions: The investigation worker gathers the necessary 

information to complete the Safety Assessment and enters all information In FACTS. 

(See PR 10, Investigation Requirements- General, paragraph 8 "Information Collected", 

and paragraph 8.1 "Background Questions.") [09-24-01; 05-1 0-10] 

8.2 Required Interviews and Observations: At a minimum, the investigation worker 

conducts the following interviews and observations In each investigation for: 

1. The alleged victim; 

2. Other children living in the home present at the time of the alleged incident; 

3. All care providers, including the non-offending foster parent, treatment foster 

parent or pre-adoptive parent; 
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26354.109

4. The alleged perpetrator; 

5. The placement worker responsible for the home or treatment coordinators for 

treatment foster homes; 

1. permanency planning worker, when appropriate; and 

7. Necessary collateral contacts. 

Exceptions to the required interviews and home visits are only in those circumstances 

where the foster parent, treatment foster parent, pre-adoptive parent or adult refuses to 

participate in the interview or when law enforcement directs that such an interview not 

occur. The worker consults with his or her supervisor and documents all exceptions in the 

"Investigation Case Narrative" in FACTS. [09-24-01; 05-10-10; 02-29-12] 

8.3 Home Visit: As part of the investigation, the investigation worker visits the foster 

home, treatment foster home or pre-adoptive home. Home visits can be announced or 

unannounced. The worker observes the environmental conditions of the home and of the 

neighborhood and requests to see where any reported incidents occurred. Because the 

home is a licensed or approved entity, the worker may enter the home with or without the 

foster, treatment foster, or pre-adoptive parent's permission. However, if access is 

denied, the worker seeks assistance from the placement worker or child placement 

agency in the case of a privately licensed home. If access continues to be denied, the 

worker consults with his or her supervisor and the Children's Court Attorney to determine 

if law enforcement assistance is required. If law enforcement is contacted, the worker 

waits at the home until assistance arrives. Refusal for the worker to enter the home shall 

be grounds for immediate removal of any child in PSD custody placed based on the 

inability to ensure safety. The requirement for a home visit may not be waived unless the 

licenses is revoked or voluntarily relinquished. Any exceptions for not conducting a rome 

visit must have supervisory approval and be documented in FACTS narrative [09-24-01; 

11-30-04; 05-10-1 0; 02-29-12] 

8.4 Collateral Contacts: The investigation worker makes collateral contacts as 

needed to make a determination about the validity of the abuse or neglect allegations and 

to verify or clarify any inconsistencies obtained from previous interviews. Only those 

collateral contacts that may be beneficial to the determination and disposition of the case 

are interviewed. Collateral contacts are selected on the basis of the relevance of the 

information the contact can offer, which may include: 

1. Persons who witnessed the alleged abuse or neglect; 

2. Professionals who may have first-hand knowledge of the incident, the injury, the 

child's condition and the family circumstances; 

3. Persons or professionals who may be able to verify information provided by the 

alleged victim and members of the provider's family; and 

4. Persons whom the provider identifies as having relevant information about the 

incident, the injury, the child's condition, and the provider family's circumstances. 

The worker discloses only information that is necessary to facilitate the investigation to 

the collateral contact. [09-24-01; 05-10-1 0; 02-29-12] 

9 COORDINATION WITH LAW ENFORCEMENT: The investigation worker 

coordinates and cooperates with law enforcement in joint investigations. The worker 

attempts to coordinate interviews of the involved parties with law enforcement to avoid 
146 


26354.110

multiple interviews of family members, especially children. Law enforcement is 

responsible for collecting physical evidence. The worker: 

1. Does not touch or move any physical evidence; 

2. Contacts the police if he or she believes physical evidence is available; and 

3. Records specific observations of the physical evidence and how it relates to the 

allegations. [09-24-01; 02-29-12] 

10 INTERVIEWING CHILDREN: 

10.1 The Alleged Child Victim: The investigation worker interviews or observes the 

alleged child victim and all other children in the household to obtain the child's perception 

and account of his or her situation. Children who are not able to participate in an 

interview because of age, physical condition or disability are observed by the worker. The 

worker informs the child that his or her participation in the interview is voluntary. Children 

in PSD custody 14 years of age and older must agree to participate in the interview. The 

worker addresses all aspects of the reported abuse or neglect, as well as assesses any 

unreported concerns. The worker develops rapport with the child and is sensitive to: 

1. The child's apprehension about speaking to an authority figure that may be a 

stranger; 

2. The child's developmental stage and its impact on sense of time, vocabulary, and 

distinction between reality and imagination; 

3. The child's hesitancy regarding sharing information about himself or herself and 

the foster or adoptive family; 

4. The child's concern over the repercussions of disclosing; 

5. The child's perception of safety with the family; 

6. Minimizing the number of interviews for the child; 

7. The possible interference with any ongoing criminal investigations; 

8. The alleged victim's responses to the alleged perpetrator or non-offending foster 

or pre-adoptive parent; 

9. Using leading questions with the child; 

10 language differences or first language of the individual; and 

11. Credibility of the child and past history regarding allegations. 

If a child makes the allegation after the child has been removed from the foster, treatment 

foster, or pre-adoptive home, the worker either interviews the child if the child is in the 

same county, or requests a courtesy interview by the county staff where the child is 

currently residing. [09-24-01; 11-30-04; 06-30-05; 05-10-1 0; 02-29-12] 

10.2 Biological or Adoptive Children of Foster, Treatment Foster or Pre-adoptive 

Parents: PR 11, Investigation Requirements- Child Victim and Other Children applies to 

the biological or adoptive children of foster, treatment foster or pre-adoptive parents. [05-

10-10] 
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26354.111

11 RECORDING THE INTERVIEWS: Recording of interviews of children is done, 

whenever possible, to prevent multiple interviews of children. The child being interviewed 

is aware that recording is being done. The recording is filed in the written case record. If 

law enforcement requires the recording, the investigation worker documents the creation 

of the recording and to whom it was given. The worker may coordinate with law 

enforcement and a local safe house provider to facilitate the recording of the child's 

interview. [09-24-01; 05-10-1 0; 02-29-12) 

12 PHYSICAL AND SEXUAL ABUSE EXAMINATIONS: The investigation worker 

provides or arranges for examinations or evaluations of the child to document injuries and 

determine the need and type of intervention required. [09-24-01; 05-10-1 0] 

12.1 Investigation worker Examination: If the allegations are of physical abuse, the 

investigation worker begins by asking the child to identify where on his or her body the 

injury occurred. In the presence of another adult, preferably an adult the child trusts and 

who is not the alleged perpetrator, the worker asks the child (or the adult in the case of 

an infant) if he or she can view the area for indication of injury and observe the child for 

additional bruising, welts, scratches, burns or other injuries. (05-10-10; 02-29-12] 

12.2 Documentation of Bruising or Injury through Photography: The investigation 

worker attempts to document the injury through photographs, if possible, and prepares a 

written description of the injury. The photograph and the written description must have 

the name of the person photographed, the date the photograph was taken, the name of 

the photographer, and who was present at the time the photograph was taken. The 

worker documents in the case activity notes in FACTS the existence of the photograph 

and the child's explanation for the injury or injuries. The photograph is filed in the written 

case record unless requested by law enforcement. The description of photographs taken 

and given to law enforcement or the district attorney's office is documented in the case 

record, including the name of the individual and organization to which any photo is given. 

[09-24-01; 05-10-1 0; 02-29-12) 

12.3 Medical Examination: The investigation worker arranges for a medical 

examination to document visible injuries or when the child requires medical attention. 

Should any questions or concerns arise; the worker and supervisor consult with the 

CYFD-PSD Medical Director. 

Medical personnel are informed of the investigation and consulted on the purpose of the 

examination. Medical personnel are provided with all information necessary to conduct a 

thorough medical examination. Medical personnel are requested to provide 

documentation of the findings and a narrative of any disclosures the child has made at 

the time of the examination. The worker files this information in the written case record 

and documents in the case narrative in FACTS the date of the examination, the location 

of the examination and the identity of the medical professional providing the examination. 

The following are resources for medical examinations: 

I. CART may be contacted during business hours at 505-272-1898 or 505-951· 

2509. After hours contact may be made by calling the Children's Hotline, 1-877· 

866-7543, and asking to speak with the CART doctor on-call. 

2. SANE contact may be made through your local SANE office. 

3. The child's local Primary Care Provider (PCP) may also be contacted. 
148 


26354.112

The cost of medical examinations is applied to the parent's or guardian's insurance first 

or Medicaid. If no other alternatives or resources are available to pay the examination 

expenses, the cost is covered through the use of Title XX funds, which requires Deputy 

Director Approval through a Memorandum for Decision (MFD); once the approval is 

received, then the worker submits a payment request in FACTS. The PSD Director or his 

or her designee must approve cost over $500.00. [12-31-97: 09-24-01; 11-30-04; 05-10-

10; 02-29-12] 

12.4 Sexual Abuse Examination: The investigation worker arranges for a sexual 

abuse examination immediately when there are indications that sexual contact occurred 

within the last 72 hours. The preference is for the examination to be completed by 

medical personnel with specialized training in sexual abuse. 

Para Los Niiios (Child Sexual Abuse Program affiliated with UNM) may be contacted 

during working hours at 505-272-6849. After hours contact may be made through the 

Children's Hotline number 1-877-866-7543. 

If the worker is unable to schedule an appointment with a specialist, the child is evaluated 

in the emergency room. Non-emergency sexual abuse exams are scheduled after the 

child has been interviewed. [09-24-01; 02-29-12] 

13 CONTACT WITH FOSTER PARENTS, TREATMENT FOSTER PARENTS AND 

PRE-ADOPTIVE PARENTS: 

13.1 Notification of Foster Child Interview: When possible, the foster, treatment foster 

or pre-adoptive parents of the foster child who has been interviewed are notified of the 

interview the same day. Notification is face-to-face whenever possible. 

13.2 Adults and Other Care Providers in the Home: Care Providers are defined as 

adults living in the household who have routine responsibility for childcare. This 

responsibility may fall to others besides the child's foster or adoptive parents. Each adult 

household member with childcare responsibilities is considered when assessing safety. 

[09-24-01; 02-29-12] 

13.3 Interview with the Foster, Treatment Foster or Pre-Adoptive Parent: The 

Investigation worker interviews the foster, treatment foster or pre-adoptive parent to 

collect information needed to establish the present safety of the alleged victim and other 

children in the home and appropriateness for future placements in the home. The worker 

assesses the foster, treatment foster or pre-adoptive parent's response to the allegations. 

The worker addresses all aspects of the abuse or neglect allegations. The worker 

attempts to establish rapport and considers the foster, treatment or pre-adoptive parents: 

1. Apprehension about speaking to an authority figure that may be a stranger; 

2. Linguistic ability and use of language; 

3. Hesitancy regarding sharing information about himself or herself and his or her 

family; 

4. Legal concerns regarding disclosing abuse or neglect of the child; 

5. Feelings of inadequacy, failure or anger and his or her responses to these 

feelings; 

6. Language difference or first language of the individual; and 
149 


26354.113

7. Actions or behaviors toward the child. [09-24-01; 0615-04; 11-30-04; 05-10-1 0; 

02-29-12] 

13.4 Information to be provided to the Foster, Treatment Foster or Pre-Adoptive 

Parent by the Investigation worker: At the beginning of the interview, the investigation 

worker informs the foster, treatment foster or pre-adoptive parent that: 

1. In the event of safety concerns, immediate removal of the child may occur; 

2. Any interaction on his or her part is voluntary, but lack of cooperation may raise 

safety concerns; 

3. All information is confidential within PSD, except when it becomes necessary to 

work with law enforcement, the District Attorney and relevant agencies; 

4. All information is confidential within in PSD except in the case of treatment foster 

care the information will be shared with the licensing agency; 

5. Other people may be interviewed to complete the investigation; 

6. Information concerning the report and investigation has been entered into PSD's 

files; 

7. Information gathered could impact their license approval and placement of 

children in the home; 

8. Information is provided to parties to the court proceeding; 

9. If a foster child has been removed, how PSD will determine if the child can be 

returned; 

10. No other placements can be made during the investigation; and 

11. When the foster parent, treatment foster parent or pre-adoptive parent can 

expect information about the results. 

The information is provided to the foster, treatment foster or pre-adoptive parent in 

writing [09-24-01; 11-30-04; 06-30-05; 05-10-1 0; 02-29-12] 

14 SAFETY ASSESSMENT: 

14.1 Safety Assessment: The investigation worker initiates the safety assessment at 

the initiation of the investigation and continues to collect relevant information needed to 

provide for ongoing assessment of safety throughout the investigation. The worker 

obtains the information necessary to complete the Safety Assessment Instrument prior to 

completing the investigation. If at any point during the investigation the worker 

determines that present danger exists, the worker takes action to remove the foster child 

and provides immediate protective services response sufficient to address the safety 

threat for biological or adopted children remaining in the home. 

The worker documents the assessment of safety in FACTS. The worker accesses the 

Safety Assessment in FACTS through the 'Safety" button on the basic tab in the 

investigation by selecting "Casework" then "Risk Assessment" then "Safety Assessment" 

then selects the case and selects "Create." {05-10-10; 02-29-12] 

14.2 Safety Decision: Based on the investigation worker's analysis of safety threats 

and the presence or absence of protective capacities that offset, mitigate or control the 

threat of present or impending danger of serious harm, the worker makes the safety 

decision by indicating whether the child is safe, conditionally safe, or unsafe as follows: 

1. The child is safe: There are no safety threats placing the child in present or 

impending danger of serious harm. Safety threats do not exist or have been 

removed. 

2. The child is conditionally safe: One or more safety threats placing the child in 

present or impending danger of serious harm were identified. However one or 
150 


26354.114

more protective capacities have been identified and documented that offset, 

mitigate or control the threat of present or impending danger of serious harm. 

3. The child is unsafe: One or more safety threats placing the child in present or 

impending danger of serious harm were identified. There are not sufficient 

protective capacities to offset, mitigate or control the threat of present or 

impending danger of serious harm. 

The safety decision may change throughout the investigation as new information is 

gathered and assessed. Prior to closure of the investigation, the worker makes a final 

safety decision that impacts the investigation disposition. The supervisor reviews and 

approves the safety decision. [05-10-10; 02-29-12] 

14.3 The Risk Assessment Instrument: The Risk Assessment instrument is not 

completed as part of the investigation. [05-10-10; 02-29-12] 

15 REMOVAL OF A CHILD FROM AN UNSAFE ENVIRONMENT: Children in PSD 

custody who are assessed to be unsafe must be removed from the foster, treatment 

foster or pre-adoptive home. Removal in such a circumstance constitutes an 

"emergency". The investigation worker notifies the Children's Court Attorney (CCA) of the 

placement change and requests that the required notifications are issued. The assigned 

worker notifies the guardian ad litem or youth attorney within one business day if a 

decision is made to remove the child. [05-1 0-1 0; 02-29-12] 

15.1 Placement: The child's assigned permanency planning worker is involved in 

decisions about placement of a child in a foster home and identifies a home where the 

child can be moved, if the determination is made that the child cannot safely remain in 

the current foster home or pre-adoptive home. [09-24-01, 06-30-05] 

15.2 Safe or Conditionally Safe: Children assessed to be safe or conditionally safe 

may remain in their current placement. In those circumstances where a child is assessed 

to be safe or conditionally safety, the child's permanency planning worker and supervisor 

and the placement worker and supervisor (or child placement agency staff for privately 

licensed or approved families) reviews the investigation results to identify services and 

supports required by the child and the foster parent, treatment foster parent or preadoptive parent. [09-24-01, 06-30-05] 

16 INVESTIGATION COMPLETION: 

16.1 Investigation Decision: The investigation worker completes the investigation 

within 45 days of Statewide Central Intake (SCI) accepting the report unless an extension 

is secured from the supervisor. No extension may be granted unless the reasons for the 

extension are documented in FACTS. Extensions are not to exceed an additional 30 days 

after the original 30 days. (See Completion of an Investigation and Investigation Decision, 

8.10.3.17 NMAC and Investigation Disposition, 8.10.3.18 NMAC) [05-10-10; 02-29-12] 

16.2 Completion of Investigation and Outcome: Following the completion of the 

investigation the foster, treatment foster or pre-adoptive parent and, if applicable, private 

child placement agency are provided the investigation decision in writing. The Safety 

Assessment results are provided upon request. The investigation worker will inform all 

relevant PSD staff (the County Office Manager of the office assigned to the child's case 

and the placement worker and PPW) of the outcome of the investigation through an 

internal staffing. The worker and his or her supervisor offer to meet with the foster, 

treatment foster or pre-adoptive parents at the conclusion of the investigation to explain 

the investigation decision. [09-24-01; 06-30-05; 05-10-1 0; 02-29-12] 
151 


26354.115

17 NOTIFICATIONS: 

17.1 Adoptions and Foster Care Bureau: The investigation worker sends a copy of the 

investigation and disposition to the Adoptions and Foster Care Bureau immediately upon 

completion of the investigation. The Adoptions and Foster Care Bureau notifies the 

licensing and certification unit of CYFD's Youth and Family Services when investigations 

involve treatment foster care homes. [05-10-10; 02-29-12] 

17.2 Guardian ad Litem or Youth Attorney: The permanency planning worker notifies 

the guardian ad litem or youth attorney of any action taken as a result of the report by 

sending the attorney a copy of the results letter sent to the foster, treatment foster or preadoptive parent at the conclusion of the investigation. [09-24-01; 06-30-05; 08-20-07] 

REVOCATION OR NON-RENEWAL OF A LICENSE: A foster home license may be 

revoked or not renewed when, based upon the assessment and professional opinion of 

the placement worker and supervisor, conditions in the foster family home are not 

conducive to the fostering of children. [1 0-29-09] 

9.1 Reasons for Revocation or Non-Renewal: An existing foster home or relative 

foster home license may be revoked or renewed at any time for reasons including but not 

limited to: 

1. Disqualifying criminal records check results as described in PR 10 above; 

2. Disqualifying abuse and neglect check results as described in PR 11 above; 

3. Failure to comply with PSD policies and adoption and foster care regulations, 

including confidentiality provisions; 

4. Failure to comply with safety measures, including those requirements described 

in PR 13 above; 

5. Returning a child to PSD without seeking support services provided by the PSD 

or community service providers in order to preserve the placement; 

6. Refusal to comply with the child's case plan; 

7. Inability to adequately meet the needs the child, including a nutritious diet, 

adequate clothing, etc ... 

8. Failure to include children in family activities; 

9. Overuse or inappropriate use of respite care; 

10. failure to actively preserve connections with foster children and their birth families 

and community of origin, including siblings or other birth relatives, church community; and 

fictive kin, or the child's friends; 

11. Failure to demonstrate the ability to provide emotional support during important 

developmental points in the course of a child's life; 

12. Repeated refusals by the family to accept children who have been identified for 

placement with the family; 

13. Failure to participate in required training; 

14. Failure to comply with PSD decisions regarding the child's safety, permanency, 

and well-being; 

15. Abuse of substances including but not limited to alcohol, illegal drugs; or 

prescription drugs or controlled substances; 

16. Exposure of the child to cigarette smoking and tobacco products; 

17. Fraudulent claims for reimbursement or deliberate falsification of records; 18. 

Neglect or abuse of foster children or other children; 

19. Failure to abide by the foster care agreement; 

20. A documented professional assessment that continued licensure would be 

contrary to the safety, permanency, and well-being of the child, or that conditions in the 

foster home are not conducive to the fostering of children. [1 0-29-09] 
152 


26354.116

9.2 Revocation or Non-Renewal Process: The placement worker documents in 

FACTS the reasons and recommendation to revoke or not renew the license, and 

forwards his/her recommendation to the placement supervisor for approval. The Regional 

Placement Supervisor or designee immediately notifies the Office of General Counsel 

(OGC) after receiving the placement worker's recommendation for revocation or nonrenewal of a license. The Regional Placement Supervisor, placement worker, and others 

as appropriate staff the proposed revocation or non-renewal with the assigned attorney 

from OGC. Upon the approval of the manager and concurrence by OGC, the placement 

worker and supervisor notify the foster parent/relative foster parent in a face-to-face 

meeting and in writing within five days of the decision to revoke or not renew the foster 

care license. The notification includes: 

1. The effective date of the revocation/non-renewal, 

2. Reasons for the revocation/non-renewal, including identification of any policy 

and/or regulation violations, 

3. The right of the foster parent to request an appeal of the decision to revoke or not 

to renew the license, and 

4. The process to request an appeaL [10-29-09] 
153 


26354.117

.--!larK / Office of Children ~ATE and Family Services 

ANDREW M. CUOMO 

Governor 

June 18, 2015 

The United States Senate 

Committee on Finance 

Washington, D.C. 20510-6200 

SHEILA J. POOLE 

Acting Commissioner 

Attn: Rebecca Shipp, Health & Human Resources Policy Advisor 

Laura Berntsen, Senior Human Services Advisor 

VIA ELECTRONIC TRANSMISSION 

becky shipp@senate.finance.qov 

laura berntsen@senate.finance.gov 

Dear Ms. Shipp and Ms. Berntsen: 

I am replying to the April 24, 2015 letter written to the members of the National Governor's 

Association (NGA) and signed by Senators Hatch and Wyden requesting information about public 

and private providers of foster care in the states. I am replying on behalf of New York State (NYS). 

The Office of Children and Family Services (OCFS) serves New York's public by promoting the 

safety, permanency and well-being of our children, families and communities. We achieve results by 

setting and enforcing policies, building partnerships, and funding and providing quality services. 

OCFS is dedicated to improving the integration of services for New York's children, youth, families 

and vulnerable populations; to promoting their development; and to protecting them from violence, 

neglect, abuse and abandonment. The agency supervises the provision of a system of family support, 

juvenile justice, child care and child welfare services that promote the safety and well-being of 

children and adults. Among the operating principles across all program areas are that services should 

be developmentally appropriate, family-centered and family-driven, community-based, locally 

responsive, and evidence and outcome based. 

Among OCFS' responsibilities are programs and services involving foster care, adoption and 

adoption assistance, child protective services including operating the Statewide Central Register of 

Child Abuse and Maltreatment (SCR), preventive services for children and families, and services for 

pregnant adolescents. New York State is one of a few states that has oversight and provides funding 

for such services on a state-supervised, county-administered basis. Foster care in New York State is 

administered by a network of agencies which are empowered by law to temporarily care for and place 

children who are unable to remain in their own homes until a more permanent situation is arranged. 

NYS is comprised of 58 Local Social Services Districts (LOSS). One for each of 57 counties 

outside of New York City and one local district that is made up from the five counties (boroughs) of 

New York City, which is called the Administration for Children's Services (ACS). Foster care may be 

provided directly by a LOSS or through a contract by the LDSS with a voluntary authorized agency (a 

Office of the Comm!SSioner j 52 Washtngton Street, Rensselaer, NY 12144 ! {518) 474-{l666locfs ny gov 
154 


26354.118

not-for-profit corporation with the corporate authority to provide foster care services). Each LOSS has 

the flexibility to contract with providers that will best serve the needs of their individual districts. OCFS 

is responsible for approving, inspecting, supervising and monitoring the LOSS' and voluntary 

authorized agencies that provide care for foster children. We have found this to be the most 

acceptable methodology that best serves the diverse needs of our state. 

The Senators put forth eight questions on behalf of the committee. I am providing you the responses 

for OCFS. 

Q.1. To the degree applicable, describe your state's utilization of private entities to provide case 

management services (e.g. placement of children with particular foster care providers, ongoing 

casework and oversight for foster care placements). 

A.1. The LOSS' contract with over 70 not-for-profit providers statewide. In most of the state, case 

management responsibility is maintained by the LOSS' in regard to children in LOSS custody or 

OCFS in regard to those youth in OCFS custody. In New York City, the role and function of case 

management is with a voluntary authorized agency with final decision making remaining with ACS. 

Q. 2. What proportion of the children in foster care in your state is placed by the public agency, notfor-profit providers and for-profit providers? 

A.2. OCFS does not use for-profit providers. NYS allows the LOSS' the flexibility to contract with the 

not-for-profit providers that are best suited for their needs. All foster children in the legal custody of 

ACS are placed in foster homes or congregate placements through voluntary authorized agencies. 

Q. 3. Please provide the number and names of private entities providing these core services, as well 

as information on whether each provider is a for-profit or not-for-profit entity. 

A.3. A complete list appears at the end of the directive (see link). None of these programs are forprofit. 

http://ocfs.ny.gov/main/policies/externai/OCFS 2014/ADMs/14-0CFS-ADM04%20Maximum%20State%20Aid%20Rates%20for%20Foster%20Care%20Proqrams%20and%20R 

esidentiai%20Programs%20for%20Committee%20on%20Speciai%20Education%20Piacements%20-

%20Effective%20Ju.pdf 

Q. 4. Does your state require private foster care entities or organizations operating in your state to 

be accredited? If so, by which organization and how often is this accreditation renewed? 

A. 4. OCFS does not require that foster care entities receive accreditation from non-governmental 

entities. These entities must receive approval from OCFS to open an agency and obtain an 

operating certificate from OCFS to open a facility. Additional information regarding this can be found 

at the OCFS web site at http://ocfs.ny.gov/main/publications/Pub5032.pdf 

Q. 5. Describe in detail the process you use to select and contract with these private entities, as well 

as to review and renew such contracts. 

A. 5. Annually, OCFS issues Maximum State Aide Rates (MSARs) and Committee on Special 

Education (CSE) Maintenance Rates to LOSS' advising them of the annual rates and methodology 

Office of the CommlssJoner 152 Washington Street, Rensselaer, NY 12144 I (518)474-6666Jocfs ny gov 
155 


26354.119

approved by the state's Division of the Budget MSARs define the State reimbursement limits for 

LDSS' in negotiating contracts with authorized foster care providers, pursuant to Social Services Law 

§398-a and 18 New York State Codes, Rules and Regulations (NYCRR) Part 427. Pursuant to 

Section 398-a (2-a) of the Social Services Law, LOSS' are required to pay no less than 1 DO percent of 

each OCFS-established congregate care rate as well as each administrative/services rate for a 

therapeutic, special needs, or emergency foster home program. We do not contract with for-profit 

agencies. Our grantee provider manual explains the requirements to all applicants. 

Where an LOSS contracts with a voluntary authorized agency, it must use a model contact 

prescribed by OCFS. The model contract addresses the statutory and regulatory standards the 

voluntary authorized agency must satisfy in regard to the care, planning and supervision of the foster 

child. It also addressed the role of the LOSS in the oversight of the operations and services provided 

by of the voluntary authorized agency. The URL below will provide the Model Contract for providers of 

such services. 

http://ocfs. ny.gov/main/policies/externai/OC FS 20 13/ADMs/13-0CFS-ADM08%20%20Revised%20Modei%20Contract%20for%20Purchase%20of%20Foster%20Care%20Servi 

ces.pdf 

Q. 6. Describe in detail the process your state uses to inspect the safety of the foster care settings in 

which children are placed and the extent to which this process differs for public, not-for-profit and forprofit providers operating in your state. 

A 6. Our process is the same for not-for-profit and public agencies. We do not contract with for-profit 

providers. OCFS delineates the safety inspection process in the following publication entitled 

Regulations for Certified and Approved Foster Family Boarding Homes & Regulations for Designated 

Emergency Foster Family Boarding Homes. This publication can be found on our internet site at the 

following URL: 

http://ocfs.ny.gov/MAIN/PUBLICATIONS/Pub5032.pdf 

For residential facilities for children in foster care, OCFS conducts periodic assessments of 

each facility to which an operating certificate has been issued. OCFS inspects such facilities for 

compliance with physical plant standards, safety standards and program standards. Additional 

inspections and reviews occur when complaints are received or when there are allegations of abuse 

or neglect of children in such facilities. 

Q. 7. How many instances of abuse in a foster care placement have been substantiated in the last 

five years in your state? Of the substantiated, how many of these instances related to children placed 

by not-for-profit, for-profit and public providers? 

A. 7. Prior to June 30, 2013, Institutional abuse or neglect (lAB) investigation reports were made to 

the SCR, which is housed within the Office of Children and Family Services (OCFS), and were 

investigated by OCFS or the Commission on Quality Care and Advocacy for Persons with Disabilities 

(CQC). Beginning June 30, 2013, such reports are made to the Justice Center for the Protection of 

People with Special Needs (The Justice Center). Consequently, data reported in the table below are 

based on those reported to OCFS. 

In the period from 2008 to 2013, the a majority of lAB reports involved were on children placed with 

private non-profit or for-profit agencies (voluntary) agencies (table 1 ). These ranged from a high of 65 

Offioo ofthe Commissioner! 52 Washtngton Street, Rensselaer, NY 12144 I (51 B) 474--B666] ocfs ny gov 
156 


26354.120

percent in 2013 (only partial year available), 64 percent in 2009 and 2010 to a lowest of 58 percent in 

2011. The residual were of children placed with New York public agencies. Of the reports that were 

indicated, the highest percent were those on children placed with private not- for-profit agencies 

(voluntary agencies). 

Table 1: Institutional Abuse or Neglect (lAB) Investigations: Distribution of Reports and 

Indicated Reports from 2008 to 2013 

2008 2009 2010 2011 2012 2013 

Total Indicated Total Indicated Total Indicated Total Indicated Total Indicated Total Indicated 

Number 

Private Agencies ~1,092 17~ 11.424 212, ,1.168 15~ I 951 120 I 986 9~ I 516 58 

Public ~gencles 724 97 798 106 649 101 679 81 584 63 275 23 

Total 1.816 270 2.222 318 1.817 260 1,630 201 1,570 158 791 81 

PerHnt(%) Private Agencies I 60% 64o/:l 64% 67'~1 64% 61% 58% 60~1 63% 60o/:l 65% 72% 

Public Agencies 40% 36% 36% 33% 36% 39% 42% 40% 37% 40% 35% 28% 

Total 100% 100% 100% 100°/() 100% 100% 100% 100% 100% 100% 100°/o 100% 

~As of6130J!3, 1/>8 reports were taken by the Jus bee Center and as a result2013 data do notrepresenta complete ~ar 

Source: Data Warehouse {5/1/15) 

In the period from 2008 to 2013 (partial data available for 2013), the percentage of reports that were 

indicated in New York State ranged from a high of 15% in 2008 to a low of 10% in 2012 and 2013 

(Table 2). An "indicated report" is a report for which some credible evidence of abuse or neglect was 

found after investigation. 

Table 2: Institutional abuse or neglect (lAB) investigation Reports and the Percentage 

Indicated from 2008 to 2013 

2008 2009 2010 2011 2012 2013 

% % Total Reports Total Total % Total % Total % Total % 

Reports Indicate Reports l:;i~::~ Reports Indicated Reports Indicated ~eports Indicated Reports Indicated 

d 

Private Agencies 1.092 16% 1,424 15% 1,168 14% 951 13% 986 10% 516 11% 

Public Agencies 724 " 13% 798 .. 13% 649' 16% 679 ' 12% 584 ' 11% 275 8% 

Total 1,816 15% 2.222 14% 1.817 14% 1,630 12% 1,570 10% 791 10% 

~As of6/30113, lAB reports were taken by the Just1ce Center and as a resu!t2013 data do not represent a complete )-eaL 

Source-: Data Warehouse {5!1115) 

Q. 8. Describe in detail the actions taken when an abuse claim is substantiated while a child is in an 

out of home placement? Do these actions differ depending on whether the child was placed by the 

public agency, a not-for-profit or a for-profit provider? 

A. 8. For children in foster homes, reports of alleged abuse or maltreatment are made to the SCR 

and transmated to the appropriate LOSS for investigation. If the report is substantiated, the LOSS 

that placed the child determines the appropriate action take based on the circumstances of the 

individual case. The LOSS has a range of options available, including removal of any or all children 

in care from the foster home and closing the home. In less severe cases, the options could include 

increased supervision of the foster home, or additional training for the foster parents. 

Office of the CommiSsJoner j 52 Washmgton Street, Rensselaer, NY 12144 I (518) 474-6666J ocfs ny gov 
157 


26354.121

In cases of institutional abuse or neglect involving residential facilities that were are reported to 

the SCR, these claims are investigated and an "Institutional Abuse or lAB" hearing is held where 

testimony is given before an administrative law judge who renders a determination based on the 

evidence produced. OCFS is one of the state agencies that is overseen by the Justice Center. Their 

mission is to support and protect the health, safety, and dignity of all people with special needs and 

disabilities through advocacy of their civil rights, prevention of mistreatment, and investigation of all 

allegations of abuse and neglect so that appropriate actions are taken. The Justice Center can and 

has been called when reports of abuse in an out of home placement are placed. OCFS retains its 

oversight role over the foster care facilities subject to the Justice Center's investigations and 

continues to require corrective action from the agency operating the facility when necessary. 

Actions do not differ based on whether the foster care facility is publicly or privately operated. 

I hope that these responses are helpful to the Finance Committee's work. OCFS remains 

committed to serving vulnerable children and families. We hope that you will continue to reach out to 

OCFS through our Governor's Washington D.C. office for information regarding this or other child 

welfare issues. 

Sincerely, 

Sheila J. Poole 

Acting Commissioner 

SPied 

Office of the Commtss!oner! 52 Washmgton Street, Rensselaer, NY 12144 ! (518)474-6666 !octs ny.gov 
158 


26354.122

north dakota 

department of 

human services 

Jack Dalrymple, Governor 

Maggie D. Anderson, Executive Director 

May21,2015 

Senator Orrin G. Hatch, Chairman 

United States Senate 

Committee on Finance 

Washington, DC 20510-6200 

Senator Ron Wyden, Ranking Member 

United States Senate 

Committee on Finance 

Washington, DC 20510-6200 

Executive Office 

(701) 328-2538 

Fax (701) 328-1545 

Toll Free 1-800-472-2622 

ND Relay TTY 1-800-366-6868 

Re: North Dakota's Response to Senate Finance Letter to Governors - Foster Care 

Dear Sen. Hatch and Sen. Wyden: 

In response to your April 24, 2015, letter, The North Dakota Department of Human 

Services is pleased to provide the following information to the Senate Finance 

Committee at the request of Governor Jack Dalrymple. 

• To the degree applicable, describe your state's utilization of private entities to 

provide case management services (e.g., placement of children with particular 

foster care providers, ongoing casework and oversight of foster care 

placements). 

PATH-NO, a private non-profit organization, is utilized as a private provider of 

foster care. PATH recruits and supervises their foster families but the state 

licenses the PATH family foster care providers. The state makes payment 

directly to PATH to cover the costs of foster care. PATH, in turn, pays their foster 

parents and keeps a percentage of the rate for administrative costs. PATH also 

provides case workers to support and oversee the family foster care providers. 

Public agencies with custodial and placement authority provide case 

management services for a child placed in a PATH foster home. Public agencies 

include the counties, the Division of Juvenile Services, and tribes. 

600 East Boulevard Avenue Department 325- Bismarck, NO 58505-0250 

www. nd .gov/dhs 
159 


26354.123

Sen. Orin G. Hatch 

Sen. Ron Wyden 

May 20, 2015 

Page 2 

The state provides much of the training for the PATH foster parents through a 

long standing agreement with PATH. This training is provided by the University 

of North Dakota, Children and Family Training Center. 

• What proportion of the children in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? 

100 percent of the foster children placed into foster care are placed by a public 

agency (counties, Division of Juvenile Services, tribes) because they are the 

custodians of youth in the system. The public agencies make the placements 

into foster care for both public and private provider (PATH) homes. The private 

non profits serve foster youth, but they do not make the placement of youth nor 

do they have placement authority. As of May 7, 2015, PATH was serving 232 

foster children. That accounts for about 17.3 percent of all North Dakota foster 

youth (N=1 ,339). 

• Please provide the number and names of private entities providing these core 

services, as well as information on whether each provider is a for-profit or not-forprofit entity. 

PATH-NO, Inc. 

1202 Westrac Drive, Suite 400 

Fargo, NO 58103 

Phone: 701-551-6341 

PATH is a private not-for-profit entity. 

• Does your state require that private foster care entities or organizations operating 

in your state be accredited? If so, by which organization and how often is this 

accreditation renewed? 

North Dakota does not require private providers be accredited. However, PATH 

is accredited by the Council on Accreditation for Services to Children and 

Families (COA) by choice. Their most recent accreditation was in October 2014 

and is effective for four years. North Dakota does require all private foster care 

providers to be licensed through the North Dakota Department of Human 

Services (NDDHS) according to North Dakota Administrative Code (NDAC) 75-

03-36 Licensed Child Placing Agency. This consists of an annual review and 

licensure by NDDHS to make sure NDAC is being followed. 

• Describe in detail the process you use to select and contract with these private 

entities, as well as to review and renew such contracts. 

NDDHS has had a long standing agreement with PATH (since 1994) to provide 

therapeutic foster care services in North Dakota. As noted above, NDDHS 

reviews and licenses PATH annually per NDAC 75-03-36. This review is 

conducted by a team to ensure compliance with NDAC 75-03-36 relating to the 

children being served, personnel, administrative processes, and provide family 
160 


26354.124

Sen. Orin G. Hatch 

Sen. Ron Wyden 

May 20, 2015 

Page 3 

support and case management. The reviewers also review a representative 

sample of both personnel and children's files to ensure compliance. Any private 

provider wanting to establish services in North Dakota may do so if the provider 

is able to demonstrate the ability to comply with the rules set out in NOAC for a 

licensed child placing agency. 

• Describe in detail the process your state uses to inspect the safety of the foster 

care settings in which children are placed and the extent to which this process 

differs for public, not-for-profit, and for-public providers operating in your state. 

Inspections regarding the safety of the foster care settings are the same for 

public and private providers. All providers, public or private, are required to have 

an annual renewal of their license to ensure ongoing compliance with licensure 

standards. These standards are noted primarily in North Dakota Century Code 

(NDCC) 50-11, NDAC 75-03-14 and foster care service chapter 622-05. They 

relate to the physical structure of the home, on-going training of foster parents, 

make up of people residing in the home, continuing abuse/neglect registry, 

background checks for adults in the home, and a review of foster parent's 

performance/ability to work as team members over the past year. The reviews 

are conducted and information is gathered by the public or private organization 

that has oversight of the home, and presented to the NDDHS at the regional level 

where the information is reviewed. After the review, NODHS determines if the 

license can be renewed for another year or if it should be denied based on the 

information gathered through the annual review. 

• How many instances of abuse in a foster care placement have been 

substantiated in the last five years in your state? Of those substantiated, how 

many of these instances related to children placed by: not-for-profit providers, 

for-profit providers, and public providers? 

There have been 18 instances of abuse by foster parents substantiated in the 

past five years in North Dakota. NDDHS does not track if they were public or 

private providers of foster care. 

• Describe in detail the actions taken when an abuse claim is substantiated while a 

child is in an out of home placement? Do these actions differ depending on 

whether the child was place by the public agency, a not-for-profit provider, or a 

for-profit provider? 

The actions do not differ when dealing with a public versus a private agency 

providing foster care when an allegation of abuse/neglect is substantiated. When 

a report of suspected abuse/neglect is received, the child protection services 

staff in the county in which the provider resides is responsible to complete the 

assessment of the allegation. If there is a conflict of interest (the foster home is 

supervised by the county assigned to do the assessment or the county doing the 

assessment has custodial youth placed in that home), a neighboring county will 
161 


26354.125

Sen. Orin G. Hatch 

Sen. Ron Wyden 

May 20, 2015 

Page 4 

be asked to complete the assessment. A determination is made whether or not it 

is safe to leave the foster child in the home with a strong safety plan in place, or 

to remove the child during the assessment to ensure their safety. If 

abuse/neglect is substantiated in the foster home, NDDHS will revoke that 

family's license to provide foster care as per NDAC 75-03-14 and NDCC 50-11. 

NDDHS does have the ability to determine that the family has been 

''rehabilitated" if they complete all of the recommendations made by the 

assessment team. If this determination is made, the license to provide foster 

care may be reissued. However, once a license is revoked, it usually stays 

revoked. 

If you have further questions, contact me at 701-328-2617 or manderson@nd.gov 

Sincerely, 

~ ~rrh<am-- Mag~ Anderson 

Executive Director 

cc Office of Governor Jack Dalrymple 
162 


26354.126

May 28, 2015 

Sequoyah Memorial Office Building 

PO Box 25352 

Oklahoma City, OK 73125-0352 

(405) 521-3646 • www.okdhs.org 

Dear Ms. Shipp and Ms. Berntsen: 

Please see our answers to the questions posed by Senators Orrin Hatch and Ron 

Wyden in their letter to our Governor dated April24, 2015 regarding foster care. 

To the degree applicable, describe your state's utilization of private entities to 

provide case management services (e.g., placement of children with particular 

foster care providers, ongoing casework and oversight of foster care 

placements). 

Oklahoma uses private entities for management services in traditional foster care, i.e., 

non-kinship, and therapeutic foster care services 

What proportion of the children in foster care in your state is placed by the public 

agency, not-for-profit providers, and for-profit providers? 

See Figure 1 below. 

Please provide the number and names of private entities providing these core 

services, as well as information on whether each provider is a for-profit or not-for 

p refit entity. 

See Figure 2 below. 

Does your state require the private foster care entities or organizations operating 

in your state be accredited? 

No, Oklahoma does not require foster care entities operating in our state to be 

accredited. However, therapeutic foster care contractors are considered health 

providers by the State Medicaid Agency and are required to be accredited by those 

standards. Applicable federal regulations and state laws are followed for approving 

foster care entities. 
163 


26354.127

Describe in detail the process you use to select and contract with these private 

entities, as well as to review and renew such contracts. 

Therapeutic foster care contracts are awarded as "fixed rate" contracts and are not 

required to be open for bidding. The state can enter into a contract with any qualified 

entity for the services of a fixed rate so long as services are needed and funding exists. 

The traditional foster care contracts were competitively bid and first awarded in 2013 for 

a one-year contract with five renewal options. The bids were conducted according the 

Oklahoma Central Purchasing Act. 

Describe in detail the process your state uses to inspect the safety of the foster 

care settings in which children are placed and the extent to which this process 

differs for public, not-for-profit, and for-profit providers operating in your state. 

The process in Oklahoma does not differ based on private/public nor profit/non-profit but 

does differ based on type of setting. While foster care and therapeutic foster care have 

the same requirements, they differ from the requirements for residential facilities. Foster 

care and therapeutic foster care go through a comprehensive family assessment that 

includes a series of background checks, medical assessment of all family members, 

financial assessment and an evaluation of the applicant's residence to assess the 

location, condition and capacity to accommodate the child. For further detail, refer to 

Oklahoma Administrative Code (OAC) 340:75-7 and 340:75-8 found at 

http://www.okdhs.org/library/policy/oac340/075/ 

Furthermore, all private foster care providers are licensed as Child Placing Agency and 

which, among other things, requires background checks on staff and to ensure they are 

not on the restricted registry. Child placing agency requirements are found at 

http ://www.okd hs. org/lib rarv/policy/oac340/11 0/05/ 

Residential facilities are licensed by Child Care Licensing while foster homes are 

licensed by Child Welfare. The requirements for residential facilities are found at 

http://www.okdhs.org/library/policy/oac340/110/03/ 

How many instances of abuse in a foster care placement have been substantiated 

in the fast five years in your state? Of those substantiated, how many of these 

instances related to children placed by: not-for-profit providers, for-profit 

providers, and public providers? 

See Figure 1 below. 
164 


26354.128

Describe in detail the actions taken when an abuse claim is substantiated while a 

child is in an out of home placement. Do these actions differ depending on 

whether the child was placed by the public agency, a not-for-profit provider, or a 

for-profit provider. 

When a report of child abuse or neglect is substantiated in a foster home or therapeutic 

foster home, DHS staff is responsible for making the decision regarding the continued 

use of the home. If deemed appropriate for the home to remain open, a Written Plan of 

Compliance would be initiated. These plans are also initiated when non-compliance 

issues or rule violations in the foster home require remediation for continued use of the 

home to control the safety of and placement stability for the child in DHS custody. 

The Office of Client Advocacy investigates reports of abuse and neglect in residential or 

congregate care settings. When abuse or neglect is substantiated in a congregate care 

setting, a Corrective Action Plan is developed by Child Welfare Services with the 

placement provider and/or other entities responsible for oversight such as Child Care 

Licensing or the Office of Juvenile Affairs. The Corrective Action Plan is monitored by 

members of Child Welfare, and possibly oversight partners, on-site until completion or 

compliance occurs. Monetary consequences and ultimately loss of contract can occur if 

concerns identified in the child abuse and neglect substantiation are not alleviated by 

the Corrective Action Plan. 

Figure 1 ~: 

US Senate Request for FFY 2010 through FFY 2014 

Resource Placement %of MIC* %of %of % ofMIC Type Count Total Type Total ---'-'---·· --

Agency 102563 94.03% 619 0.60% 0.57% 87.5~~ 

Not For 

Profit 6064 5.56% 83 1.37% 0.08% 11.74% 

For Profit 449 0.41% 5 1.11% 0.00% 0.71% 

--

Totals · ······109-~-1 00.00"/~ 707 0.65% 0.65% 100.00% .~-. 

• Maltreatment 1n Care 
165 


26354.129

r---------------·-----· PROFIT 

Choices for Life 

Homebased Services & Resources ~-------- Oklahoma Families First "-·-·~--

r::-:-- . - Shadow Mountain Therapeutic Foster Care t-::-- ---- Southwest Therapeutic Foster Care ~----·---··-- ""-~--

Youthcare of Oklahoma 

~'-- NON PROFIT ·-- r St. Francis Community Youth Emergency Shelter 

1 Servic~s 

Youth Services Creek Tallgrass County 

Bair Foundation Community Children's 

Shelter 1 Ecker<i ____ --r--:-:::- . J. Roy Dunning 

Angels -- Lilyfiel~--

TFl Family services Youth and Family Services r-:---·· 

__ (:~£JtE)_B:idge fanhandle Services 

Specialized Alternatives for A , H se 

Famil and Youth nna s ou 1-:-:-----~------ - . 

WesiE)yan Y()_~!_~_l_~c _______ l_Qklahoma Lions B()y~_l3_anch 

Western Plains Therapeutic c· 1 f c 

Foster Care trc e 0 are 

Oklahoma Association of Youth Eastern OK Youth Services Services 

Northwest Family Services Sunbeam Family Services 

Multi County Youth Services Youth Emergency Shelter 

Youth and Family Services Youth Services Creek 

1----- County 

Logan Community Services Community Children's 

Shelter· 

Northern OK Youth Services J. Roy Dunning ---·-

McClain/Garvin County Payne County Youth Services Youth and Family c-.;;----

Southwest Youth and Family Choctaw/Pushmataha Youth 

Servic~--- Services ---· 

~reat Pl_ains Youth and Family Kiamichi Youth Services 

1 Crossroads Youth and Family 

~ervices _ ------ --

Sincerely, 

f:c(~dt ;~J· 0 ~) fj~ 1 Dtu-t:~t)'rt--......._ Ed Lake, Direct r --
166 


26354.130

May 28. 2015 

Kl\1~ BROWN 

Govcmor 

The Honorable Orrin G. Hatch, Chairman 

The Honorable Ron Wyden. Ranking Member 

United States Senate Committee on Finance 

Washington. DC 20 5 J 0-6200 

Dear Senators Hatch and Wyden. 

Thank you for your inquiry into Oregon ·s policy and practices related to privatized foster care. ln 

an effort to assist you in better understanding the degree to which Oregon has entered into publicprivate partnerships to administer the child welfare program. we have responded to each of your 

questions, in order, below: 

I. To the degree applicable, describe your state's utilization of private entities to provide case 

management services (e.g., placement of children with particular foster care providers, ongoing 

casework and oversight of foster care placements). 

Oregon has a state administered child welfare delivery system run through the Office of Child 

V..'elfare Programs in the Department of Human Services. Local child welfare offices are 

maintained in each of Oregon's 36 counties, with more than one branch location in some of the 

more populated areas. The vast majority of all case management and placement services are 

delivered by state employees of the Department. All foster homes in tbe State not associated 

with Private Child Caring Agencies, including all relative foster placements, are certified by the 

State prior to any placement being made in that home. 

The Department does contract with Private Child Caring Agencies licensed by the State of 

Oregon, through the Department of Human Services' Office of Licensing and Regulatory 

Oversight. 

Oregon Administrative Rules 41 3-215-0001 through 413-215-0131, govern the licensing 

requirements of these private agencies. Those rules and the associated policy can be found at: 

http:/lv.ww.dhs. state.or. uslpolicv/childwelfarelmanual 21ii-c 1 .pdf. 

Vlhat proportion of the children in foster care in your state is placed by the public agency. notfor-profit providers. and for-profit providers? 

In 2014, the distribution between the public system of placement services and the private 

agencies on an average daily basis was approximately: 

254 STATE CAPITOL., SAL.EM OR 97301•4047 (503) 378-31 I I FAX (503) 378·8970 

WWW.GOVI!RNOR.OREGON.GOV 

R/, 
167 


26354.131

The Honorable Orrin G. Hatch, Chairman 

The Honorable Ron Wyden, Ranking Member 

United States Senate Committee on Finance 

May 28,2015 

Page 2 

Type of Placement 

1 

DHS placements in family foster care 

! (public) 

i DHS placements in relative- family 

I foster care (public) 

i Private agency placements 

I Children in Trial Home VisitsI Reunification (public) 

I Totals- Avera.ge daily Population of 

children in care. 

Average Daily Percent of the 

Population (ADP) ADP 

3,078 39% 

I 2,448 31% 

I 

373 5% 

! 1,912 25% 

i 

7,811 100% 

3. Please provide the number and names of private entities providing these core services, as well 

as information on whether each provider is a for-profit or not-for-profit entity. 

PROFIT: FOR PROFIT /NOT FOR 

CONTRACTED PROVIDER: PROFIT 

AI bertina Kerr Centers Not for Proflt 

l Bob Belloni Ranch Inc. Not for Proflt 

I Bo~s and Girls Aid Society of Oregon Not for Profit 

l Christian .fommuE& Placement Center Not for Profit 

Catholic Community Services WW Not for Profit 

PROFIT: FOR PROFIT/NOT FOR 

CONTRACTED PROVIDER, continued ... I PROFIT, continued ... 

Catholic Communitv Services MWV Not for Profit 

Chehalem Youth and Familv Services Not for Profit 

Daniel Moray Corporation For Profit 

Door To Grace Not for Profit 

Douglas Count>' Shelter For Profit 

Eastern Oregon Academy For Profit 

~ily Solutions Not for Profit 

1 Give Us This Dav (GVTD) For Profit 

1 Greater Oregon Behavioral Health Inc. 

! (GOBHI) Not for Profit 

I Not for Profit 

Not for Profit 

Not for Profit 

Not for Proflt 

Not for Profit 
168 


26354.132

Tbe Honorable Orrin G. Hatch. Chairman 

The Honorable Ron Wyden, Ranking Member 

U ru ted States Senate Committee on Finance 

May 28,2015 

Page 3 

Klamath Child and Family Treatment (KBBH) 

Lincoln County Shelter 

Maple Star of Oregon Inc. 

Morrison Child and Family Services 

The Next Door Inc. 

OSLC Community Programs 

1 Professional Therapeutic Community Network 

i CPTCN) 

1 Salvation Amw 

! St. Marv's Home for Bovs 

i Youth Pro£rress Association 

I Youth Villages 

Not for Profit 

For Profit 

For Profit 

Not for Profit 

Not for Profit 

Not for Profit 

For Profit 

Not for Profit 

· Not for Profit 

I Not for Profit 

For Profit 

4. Does your state require that private foster care entities or organizations operating in your state 

be accredited? If so, by which organization and how often is this accreditation renewed? 

No. Oregon Administrative Rules 413-215-0001 through413-215-0131 govern the licensing 

requirements. While several private agencies seek out and become accredited by various 

entities, it is not a requirement in Oregon for agency licensure. Those rules and the associated 

policy can be found at: http://WVI'W.dhs.state.or.us/policv/childwelfare/manual 2/ii-c !.pdf. 

5. Describe in detail the process you use to select and contract with these private entities, as well 

as to review and renew such contracts. 

The Department of Human Services utilizes the State's formal contracting process established 

through various solicitation methods including Invitation to Bid (!TB ), Request for Proposal 

(RFP). and Request for Quotes (RFQ l. Historically the RFP has been re-solicited for new bids 

every five years to ensure fair and competitive processes. More recently the Department has 

created a Request for Applications (RFA) which will allow a more frequent solicitation process 

for contracting. These contracting opportunities are posted online for public review and 

participation through the State's Oregon Procurement Information Network (ORP!N), at: 

http:!/omin.ore!mn.gov/open.dll/welcome. 

In addition, due to the nature of child welfare services, Oregon has a special provision in 

contracting rules to allow for ''client services'· to be solicited on an as needed and individual 

basis. The Department uses this provision to create child specific contracts for children 

requiring specialized care, to add additional resources and supports to a current placement, or to 

extend the contracting capacity of a private agency to take an additional child. 
169 


26354.133

The Honorable Orrin G. Hatch, Chairman 

The Honorable Ron Wyden, Ranking Member 

United States Senate Committee on Finance 

May 28,2015 

Page 4 

6. Describe in detail the process your state uses to inspect the safety of the foster care settings in 

which children are placed and the extent to which this process differs for public, not-for-profit, 

and for-public [profit] providers operating in your state, 

The processes for inspection and certification of private foster homes in Oregon is essentially 

equivalent to the proc.ess for public foster homes in that homes are certified based on the results 

of a comprehensive home study process that includes: assessment of multiple domains, 

including- motivation of the applicants to become foster parents- their life experiences and 

challenges- finances and employment- physical and mental health- marital history- spiritual 

beliefs -cultural background; and safety of the physical environment of the home. 

Jn both public and privately certified homes nationwide background checks are required for all 

household members, in accordance with the requirements of the Adam Walsh Child Safety and 

Protection Act. Private agencies must be licensed by the State in order to certify individual 

foster homes; and private foster care agencies are reviewed and re-licensed every two years. 

Publically certified foster homes differ somewhat in that Oregon's Department of Human 

Services, Office of Child Welfare Programs mandate the use of the Structured Analysis Family 

Evaluation (SAFE) borne study process and for all DHS certified foster homes. Private agencies 

are not required to use the SAFE home study process, however they are required to meet the 

certification requirements of the State. Another difference between plivate and public foster 

homes is the frequency of certification renewal, Publica!ly certified foster homes are reinspected and re-certified once every two years. Privately certified homes must be re-inspected 

and re-certified annually. There is no difference in Oregon between the requirements for private 

non-profit foster care agencies and private for-profit foster care agencies. 

How many instances of abuse in a foster car~ placement have been substantiated in the last five 

years in your statery Of those substantiated, how many of these instances related to children 

placed by: not-for-profit providers, for-profit providers, and public, providers? 

Federal 

Fiscal 

Employee (ward). 

Total % 

Abused 

%NOT 

Abused 
170 


26354.134

The Honorable Orrin G. Hatch, Chairman 

The Honorable Ron Wyden, Ranking Member 

United States Senate Committee on Finance 

May 28, 2015 

Page 5 

7. Describe in detail the actions taken when an abuse claim is substantiated while a child is in an 

out-of-home placement. Do these actions differ depending on whether the child was place[ed) 

by the public agency, a not-for-profit provider, or a for-profit provider~ 

Oregon has two approaches: one for the public certified foster homes and one for the private 

licensed agencies. 

The public certified foster homes are governed by Oregon Administrative Rules 413-200-0404 

through 413-200-0424: Department Responsibilities During Screening and Assessment of a 

Child Abuse or Neglect Reportlnvol1•ing the Home of a Department Certified Foster Parent 

or Relative Caregiver. Those rules and the associated policy can be found at: 

http://\>"Ww.dhs.state.or.us/policy!childwelfare/manual l /i-b223 .pdf. 

TI1e Department's Child Protective Service screener assesses the allegations and makes a 

determ.ination with their supervisor if it constitutes an allegation of abuse or neglect, in which 

case a Child Protective Service worker will be assigned to complete a comprehensive 

assessment. In conjunction with this comprehensive assessment the Department's Foster Home 

Certification staff and the Caseworkers responsible for all children in the foster home are 

notified and jointly make a plan for the children in this home. 

During the assessment process if safety cannot be insured in the home. the Department may 

immediately remove the children from the foster home. The Department may also place the 

foster home on inactive status during the investigation thereby prohibiting additional children 

to be placed into the horne. 

At the conclusion ofthis assessment, the Child Protective Service worker and the Foster Home 

Certification staff meet jointly with the foster fan1ily to share information and the results of the 

CPS assessment. This is also the time in which if there are additional conditions added to the 

foster parent certification they will be discussed and acted upon, such as modification to their 

certificate to operate a foster home by limiting lhe number of children, changing the age range, 

require training, no changes required, or move forward to revoke their certificate and close the 

foster home. 

When an allegation of abuse is made regarding a private agency in Oregon, 1he investigation is 

completed by the Department of Human Services· Office of Adult Abuse Prevention and 

Investigations (OAA..PT) unit. This specialized unit is comprised of staff who focus solely on 

investigating allegations of abuse against private agencies. They are governed by Oregon 

Administrative Rules OAR 407-045-0800 through 407-045-0980 and the basic process follows: 

When the OAAP! Screener receives a Children's Care Provider (CCP) abuse referral, they 

immediately contact the CCP to ensure that any necessary action to protect the alleged 
171 


26354.135

TI1e Honorable Orrin G. Hatch, Chairman 

The Honorable Ron Wyden, Ranking Member 

United States Senate Comminee on Finance 

May 28. 2015 

Page 6 

victim has been taken. This is done whether the case is ultimately assigned for 

investigation, or not 

Depending on the severity of the allegation, OAAPI consults with Child Welfare (CW) and 

Office of Licensing & Regulatory Action (OLRO) to determine if any additional steps need 

to be taken to protect the alleged victim or other involved children. 

lf there is reason to believe that a crime has occurred, OAAPI contacts appropriate law 

enforcement authorities. OAAP!s abuse investigation may be suspended while a criminal 

investigation occurs. 

• lf the case is assigned, the OAAPI Investigator follows up with the CCP to ensure the 

ongoing protective services are adequate to protect the child. 

If. after investigation. the abuse allegation is substantiated, the OAAP!lnvestigator writes a 

report which includes Required Actions (a.ka .. Corrective Actions) to prevent 

abuse/neglect from occurring again. This generally involves recommendations for 

additional training for stafT or changes to policies or procedures. Personnel actions for a 

substarJtiated fmding of abuse are the responsibility of the CCP (the employer). 

The perpetrator is notified of the substantiation in writing, arJd may request a review of the 

fmding within 30 days of receipt of notice. Details of the review process are found in the 

Oregon Administrative Rules referenced above. 

• Additional licensing concerns discovered in the course of the OAAPI investigation are also 

documented in the report which, when completed. is sent to CW and OLRO for review and 

further action as needed. 

If you have any questions related to the above information, please Laurie Price, Well-Being 

Program Manager. is also available at laurie.price@state.or.us or 503-945-6953. 

Sincerely. 

Governor ~ Kate Brown 

K.O/DLtar 
172 


26354.136

COMMONWEALTH OF PENNSYLVANIA 

DEPARTMENT OF HUMAN SERVICES 

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

United States Senate 

Washington, DC 20510 

May 29, 2015 

Dear Chairman Hatch and Ranking Member Wyden: 

Thank you for the opportunity to share information about Pennsylvania's public-private 

partnerships with regard to our child welfare system. The primary focus is always on the 

safety, permanency and well-being of the children we serve. Responses to the questions 

posed in your April24, 20151etter regarding background information on Pennsylvania's policy 

and practices relative to private foster care are below. 

Pennsylvania's Utilization of Private Entities to Provide Case Management Services 

Pennsylvania's child welfare system is state administered and county operated which means 

that state law prescribes the minimum standards for the child welfare system. Child welfare 

and juvenile justice services are delivered by each of the Commonwealth's 67 County 

Children and Youth Agencies and County Juvenile Probation Offices. 

The Department Human Services (DHS) is the agency that administers the state's child 

welfare program. The primary focus of DHS is always on the safety, permanency and wellbeing of the children they serve. Through annual inspections of county children and youth 

agencies, as well as licensed private child serving agencies, DHS reviews the services 

received by Pennsylvania's children and families to ensure the quality of services provided 

and purchased. Additionally, through reviews of annual county needs-based plans and 

budget requests and subsequent expenditure reimbursement, DHS monitors the financial 

commitment and spending of the counties with regard to the children and youth services they 

deliver. The financial review focuses on the reasonableness and necessity of the county 

request and whether the county plan and budget focuses on the state's goals of increasing 

safety; improving permanency; safely reducing reliance on out-of-home care, particularly 

residential institutional programs; and decreasing re-entry into placement. 

Children in Foster Care in Pennsylvania Placed by the Public Agency 

Each county, through its children and youth social service agency, is responsible for 

administering a program of children and youth social services to children and their families. 

Counties may deliver the services themselves or contract with private providers to deliver 

the services. The county children and youth social service program includes: 

OFFICE OF THE SECRETARY 

P.O. BOX 2675, HARRISBURG, PA 17105 I 717.787.2600/3600 FAX:717.772.2062 I www.dhs.state.pa.us 
173 


26354.137

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden -2-

• Services designed to prevent dependency and delinquency of children and 

that help overcome problems that result in dependency and delinquency; 

• Services designed to first and foremost protect children from abuse and 

neglect and that enable children to remain safety in their own homes and 

communities; 

• Services designed to provide permanency and stability for children in their own 

homes or in placement and to preserve relationships and connections for 

children with their families and communities of origin; 

• Services designed to meet the needs of children and families and to enhance 

the family's capacity to provide for their children's needs including services to 

meet the educational, physical and behavioral health needs of children; 

• Services designed for youth alleged and adjudicated delinquent, which are 

consistent with the protection of public interest and which provide balanced 

attention to the protection of the community, the imposition of accountability for 

offenses committed and the development of competencies to enable youth to 

become responsible and productive members of the community; and 

• Services and care ordered by the court for children who have been alleged 

and adjudicated dependent or delinquent. 

Additionally, Commonwealth statute, known as the Juvenile Act, (42 Pa.C.S, Chapter 

63) provides the legal framework for children and youth agencies, juvenile probation 

offices and the courts when children cannot safely stay in their own homes due to 

dependency or are in need of supervision, care and rehabilitation due to delinquency. A 

dependent child can be defined in general terms as a child who is under the age of 18, 

is without proper parent care or control, is in need of supervision, or is under the age of 

10 and has committed a delinquent act. A child who is adjudicated dependent may 

request to remain under the jurisdiction of the court until the age of 21 as long as they 

are engaged in an approved course of instruction or treatment. 

The children and youth agency has the legal mandate to petition the court for 

dependency of a child when the following circumstances exist: 

• The child is without proper parental care or control, basic needs, legally required 

education, other care necessary for the child's physical, mental or emotional health 

or morals; 

The behavior or actions of child's parent or other caregiver places the health, safety 

and welfare of the child at risk; 

• The child has been placed for care or adoption in violation of the law; 

The child is without or has been abandoned by the parents, guardian or other 

custodian; 

The child is born to a parent whose parental rights regarding another child have been 

involuntarily terminated by the court within three years prior to the child's birth and 

the parent presents a risk to the child's health, safety and welfare; 

The child, of compulsory school age, is habitually and without justification, truant 

from school; or 

The child has committed an act or acts of habitual disobedience of the parent or 

other caregiver and is ungovernable and in need of care, treatment and supervision. 

OFFICE OF THE SECRETARY 

P.O. BOX 2675, HARRISBURG, PA 17105 I 717.787.2600/3600 FAX:717.772.2062 I www.dhs.state.pa.us 
174 


26354.138

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden -3-

Therefore, all children who enter child welfare placement are placed by the county 

children and youth agency with court approval. However, children may be placed in the 

care of licensed private agencies. A review of State Fiscal Year 2013-2014 

expenditures for foster family care shows that approximately 87 percent of foster family 

care is purchased at the county level from private foster family care agencies. 

Number and Names of Private Entities Providing Core Services 

Below please find a link to the DHS Human Services Provider Directory. This 

directory provides a list of each program licensed by DHS and provides the 

information requested along with the last licensing inspection summary, which 

provides information resulting from the annual inspection of the agency. To access 

this information using the below link, under the service code category, please select 

"foster family care" and select the submit search button to display the list of licensed 

foster care programs. Selecting the Office of Children, Youth and Families from the 

program office category will result in a complete listing of public and private children 

and youth agencies that provide placement services in the Commonwealth. 

http://www.dhs.state.pa.us/searchforprovider/humanservicesproviderdirectory/index.htm 

Accreditation of Private Foster Care Entities or Organizations 

Private foster care agencies are not required to be accredited, but they are required to 

be licensed annually by DHS. 

Process to Select and Contract with Private Entities 

Contracts for the delivery of child welfare services are executed by each county 

children and youth agency. DHS regulation provides the general parameters for 

entering contracts with private agencies. These requirements are included below: 

55 Pa. Code§ 3170.93. Contracts 

(a) Contracts between Deparlment and counties. The Deparlment may enter into a 

purchase of service agreement annually with counties who wish to provide social 

services under Title XX and the comprehensive annual services program plan. 

(b) Purchase of service requirements. The county shall maintain a written contract or 

purchase of service agreement with providers to which clients are regularly referred, or 

with which the county agency, the juvenile probation office, and the courl have a 

continuing relationship. This includes program-funded facilities. The contract shall 

represent a legally binding agreement between the county and the provider, and shall 

be renewed annually. 

OFFICE OF THE SECRETARY 

P.O. BOX 2675, HARRISBURG, PA 17105 I 717.787.260013600 FAX:717.772.2062 I www.dhs.state.pa.us 
175 


26354.139

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden -4-

(c) Conformity. The contract shall provide for conformity with the regulations or 

procedures promulgated by the Department. The contract shall specify the types of 

services provided by the contracting agency for the county. In the case of unit of 

service agencies, the rate of reimbursement for a service shall be cited. In no case 

shall a provider agency be retroactively awarded an increased rate of reimbursement. 

(d) Suspension or revocation of contract. A county may suspend or revoke a contract if 

the contractor substantially fails to meet the regulations, standards, or terms of the 

contract during the period when the contract is in effect. 

(e) Service contracts or agreements. 

(1) Services purchased by contract or agreement shall bear the signature of the 

chairperson of the county commissioners, or a duly authorized representative, 

and the director or administrator of the service provider. Purchased service 

contracts or agreements shall also include the following: 

(i) Contracting parties and addresses. 

(ii) Effective date and term of the contract. 

(iii) Contracted amount or unit price and payment schedule. 

(iv) Provisions for contract modification, amendments, or termination. 

(v) Prohibition against reassignment of the contract without permission of 

the county. 

(vi) Work statement, including the service provider's location and hours of 

operation. 

(vii) Required reports for the county and the Department. 

(viii) Maintenance and retention of required reports, documents, and 

accounting books. 

(ix) Audit rights on the records in subparagraph (viii) and inspection rights 

of performance by the county and the Department. 

(x) Procurement of liability insurance. 

(xi) Client confidentiality and right of privacy. 

(xii) Units of service to be provided and their definitions. 

OFFICE OF THE SECRETARY 

P.O. BOX 2675, HARRISBURG, PA 17105 I 717.787.260013600 FAX:717.772.2062 I www.dhs.state.pa.us 
176 


26354.140

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden -5-

(xiii) A provision that the parties to the contract shall not discriminate 

against any employe, client, or other persons on account of race, color, 

sex, religious creed, national origin, age, or handicap. 

(2) Contracts or agreements between the county and a program-funded provider 

shall contain the following additional components: 

(i) Provisions for budget modification or amendment. 

(ii) Property title rights for fixed assets purchased or materials, plans or 

procedures developed through the agreement. 

(iii) A budget and fiscal statement of how fees or costs were determined. 

(iv) Provision for the procurement of fixed assets. 

(3) Agreements shall be reviewed by the county solicitor who may require 

additional components beyond the requirements outlined in paragraph (2). 

(4) A narrative description of the services to be covered by the contract shall be 

included in the county's annual services plan. A signed contract becomes the 

authorization for the expenditure of funds for services identified by the 

agreement. Therefore, county agency funds cannot be expended for provider 

expenses until a contract is signed. 

(f) Contracts with providers outside of the county and the county children and youth 

agency. A county or county children and youth agency may purchase services from a 

service provider within the jurisdiction of another county. The services shall be purchased 

via contract or written agreement with the provider. If the provider is a program-funded 

agency, the payments received for the services shall be reported as income and 

subtracted from the gross expenses billed to the county agency of which it is part. 

(g) Conflict of interest. The appropriate county authority shall not make any contract or 

agreement with a person, company, or organization in which a member of the county 

children and youth staff has a financial interest; nor, shall the county authority contract 

with members in its own staff or their immediate families, except with the clear prior 

written approval of the regional office. 

Process Pennsylvania Uses to Inspect the Safety of Foster Care Settings 

Below please find a link to the Safety Assessment and Management Process 

Reference Manual, dated November 27, 2012. Section Ill, entitled Out-ofHome Care Safety Assessment and Management, provides a detailed 

description of the policy and procedures used to assess and monitor the safety 

of children in out-of-home placement. This information is specifically located on 

pages 90-125 of the reference manual. 

http://www. pacwrc. pitt. edu/SafetyAssessmenUSafety%20M anual12. 7. pdf 

OFFICE OF THE SECRETARY 

P.O. BOX 2675, HARRISBURG, PA 17105 I 717.787.2600/3600 FAX:717.772.2062 I www.dhs.state.pa.us 
177 


26354.141

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden -6-

Instances of Abuse in a Foster Care Placement in the Last Five Years 

Below is a chart that outlines the number of residential facility staff and foster parents that 

were identified as perpetrators of child abuse in the corresponding year. We do not have a 

breakdown as to whether they were public or private agency staff or foster parents. 

Year Residential Facility Foster Parents 

Staff 

2013 26 13 

2012 18 28 

2011 10 15 

2010 31 23 

2009 55 38 

Actions Taken When an Abuse Claim is Substantiated 

The county children and youth agency, or DHS (when the alleged perpetrator is an 

agent of the county agency) is responsible for investigating suspected child abuse and 

neglect. The Child Protective Services Law (CPSL) (23 Pa. C.S., Chapter 63) includes 

the parameters for investigation of reports of suspected child abuse. 

At the onset of the investigation, a determination is made if the child or children are safe. If the 

agency is unable to determine if the child is safe based upon the information received, then a 

worker must see the child or children immediately. However, the child or children must be seen 

within 24 hours. This determination includes whether the child must be relocated as a result of 

the alleged abuse or neglect. 

Upon notification that an investigation involves suspected child abuse by a school or child-care 

service employee, including, but not limited to, a service provider, foster parent, independent 

contractor or administrator, the school or child-care service, the entity must immediately 

implement a plan of supervision or alternative arrangement for the individual under investigation 

to ensure the safety of the child and other children who are in the care of the school or childcare service. This plan of supervision or alternative arrangement must be approved by the 

county agency or DHS and is kept on file with the agency until the investigation is completed. 

The investigation is typically completed within 30 days. If the investigation cannot be 

completed within 30 days, the agency must document the reasons and complete the 

investigation within 60 days. During the investigation, the worker must interview the 

child, parents, alleged perpetrator and anyone who may have knowledge of the abuse. 

Visits to the child's home or program where the abuse occurred must take place as part 

of the investigation. In the case of alleged abuse in a child care setting or school, as 

appropriate, other children receiving services from the agency are also interviewed. 

Alleged abuse committed by staff or foster parents from these agencies is also referred 

to law enforcement officials for investigation. Joint investigations are conducted 

between the county agency or DHS and law enforcement officials to minimize trauma to 

the child. Where available, Children's Advocacy Centers are used to conduct medical 

OFFICE OF THE SECRETARY 

P.O. BOX 2675, HARRISBURG, PA 17105 I 717.787.260013600 FAX:717.772.2062 I www.dhs.state.pa.us 
178 


26354.142

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden -7-

exams and forensic interviews. The terms used to describe the results of the 

investigation are listed below: 

Founded -There is a judicial adjudication that the child was abused. 

Indicated -The children and youth agency determines based upon 

substantial evidence that abuse occurred. This conclusion is drawn based on 

medical evidence, the investigation or admission by the perpetrator. 

• Substantiated - Cases that are indicated or founded. 

Unfounded - Cases where there is a lack of evidence that the child was 

abused or it was determined that the child was not abused. (An unfounded 

status does not always mean that the incident did not occur. For example, 

the child may have received an injury from being struck as alleged, but the 

injury did not meet the definition of serious physical injury.) 

If you have further questions regarding this response, please contact Ms. 

Jennifer DeBell, Director, Office of Policy Development, at (717) 772-4141. 

Sincerely, 

~.f!!-- Acting Secretary 

c: Governor Tom Wolf 

OFFICE OF THE SECRETARY 

P.O. BOX 2675, HARRISBURG, PA 17105 I 717.787.2600/3600 FAX:717.772.2062 I www.dhs.state.pa.us 
179 


26354.143

STATE OF SOUTH DAKOTA 

DENNIS DAUGAARD, GOVERNOR 

June 1, 2015 

Senator Orin G. Hatch, Chairman 

United States Senate 

Committee on Finance 

Washington, DC 20510-3200 

Senator Ron Wyden, Ranking Member 

United States Senate 

Committee on Finance 

Washington, DC 20510-3200 

Dear Senator Hatch and Senator Wyden, 

I am responding to your letter of April24, 2015, requesting information about contractual 

partnerships between states and private entities or organizations to administer some or 

all of their foster care programs. In South Dakota, the Department of Social Services 

(DSS) contracts with 6 private not-for-profit child placement agencies for the provision of 

Treatment Foster Care for approximately 114 children which is approximately 20 percent 

of all children in foster care placed by the DSS. The case management of the majority of 

foster care cases in South Dakota is provided by state staff. 

South Dakota's response to the information requested in your letter is enclosed. I hope 

this information provides a better understanding of the partnerships between the state of 

South Dakota and private-not-for-profit child placement agencies in the area of foster 

care in our state. 

Thank you for the opportunity to provide input regarding this topic. Please do not hesitate 

to contact me if additional information or clarification is needed. 

Sincerely, 

DD:ke 

cc: Becky Shipp, Health and Human Resources Policy Advisor 

Laura Berntsen, Senior Human Services Advisor 

STATE CAPITOL o 500 EAST CAPITOL o PIERRE, SOUTH DAKOTA • 57501-5070 • 605-773-3212 
180 


26354.144

SOUTH DAKOTA 

DEPARTMENT OF SOCIAL SERVICES 

DIVISION OF CHILD PROTECTION SERVICES 

1. To the degree applicable, describe your state's utilization of private entities to 

provide case management services (e.g., placement of children with particular 

foster care providers, ongoing casework and oversight of foster care 

placements). 

The Department of Social Services (DSS), Division of Child Protection Serivces 

(DCPS) contracts with six (6) private Child Placement Agencies to provide case 

management services for children in the custody of DSS due to child abuse and 

negelct. 

2. What proportion of the children in foster care in your state is placed by the 

public agency, not-for-profit providers, and for-profit providers? 

As of April 30, 2015, the Department of Social Services had 997 children in in 

placements outside their homes with 570 children or 57% placed in foster care. 

The Department of Social Services has Title IV-E Agreements with four (4) South 

Dakota Tribes who have an additional 49 children placed through the 

agreements with 34 children or 69% placed in foster care. 

The Department of Social Services tracks the the children placed with not-forprofit child placement agencies placed by the Department and children who are 

Title IV-E eligible under State-Tribal Title IV-E Agreements. The Department 

does annual licensing visits at all child placement agencies as mandated by state 

statute and South Dakota Administrative Rules. During licening visits, agency 

personnel files and child case files are reviewed for complaince with licensning 

statutes and rules. There are not any for-profit child placement agencies in 

South Dakota offering foster care services. 

3. Please provide the number and names of private entities providing these 

cores services, as well as information on whether each provider is for-profit or 

not-for-profit entity. 

The not-for-profit child placement agencies providing foster care case 

management services in South Dakota include the following: 

Abbott House 

PO Box 700 

909 Court Merrill 

Mitchell, South Dakota 57301 
181 


26354.145

Capital Area Counseling Services 

PO Box 148 

Pierre, SO 57501 

Children's Home Society 

PO Box 1749 

Sioux Falls, SO 57101 

Northeastern Mental Health Center 

703 3'd Ave SE 

Aberdeen, SO 57401 

Lutheran Social Services 

705 East 41"\ Suite 200 

Sioux Falls, SO 57105 

Black Hills Special Services COOP 

PO Box 218 

Sturgis, SO 57785 

Volunteers of America, Dakotas 

1309 W. 51st St. 

P.O. Box 89306 

Sioux Falls, SD 57109-9306 

All About U Adoptions •• Primary Service is Adoption 

229 E. 2nd Ave., Suite 2 

Milbank, SD 57252-0408 

Mailing Address: 

PO Box 158 

Faulkton, SD 57438-0158 

Bethany Christian Services of Western SO ** Primary Service is Adoption 

508 Columbus St. 

Rapid City, SO 57701 

Bethany Christian Services of Eastern SO •• Primary Service is Adoption 

400 S Sycamore Ave., Suite 103-1 

Sioux Falls, SD 57110 

New Horizons Adoption Agency, Inc. 

2500 W. 49th St., Suite 203E 

PO Box 89532 

Sioux Falls, SO 571 09-9532 

•• Primary Service is Adoption 
182 


26354.146

Catholic Social Services ** Primary Service is Adoption 

9185thSt. 

Rapid City, SO 57701-3798 

Catholic Family Services ** Primary Service is Adoption 

523 N. Duluth 

Sioux Falls, SO 57104-2714 

**Has multiple offices in South Dakota 

NOTE: The private entities the Department of Social Services contracts with are 

balded above. 

There are not any for-profit child placement agencies in South Dakota 

4. Does your state require that private foster care entities or organizations 

operating in your state be accredited? If so, by which organizations and how 

often is accreditation renewed? 

State law requires initial licensure of child placement agencies by the Department 

of Social Services and the license is renewable on a yearly basis providing the 

agency is in compliance with all licensing rules. 

Three of the child placement agencies the Department of Social Services 

contracts with are accredited. Abbott House and Lutheran Social Services are 

accredited through the Council on Accreditation and Children's Home Society is 

accredited through Joint Commission. 

5. Describe in detail the process you use to select and contract with these 

private entities, as well as review and renew such contracts. 

The Department of Social Services contracts annually with the six private entities 

for foster care case management services after ensuring agencies remain in 

compliance with licensing standards. 

6. Describe in detail the process your state uses to inspect the safety of the 

foster care settings in which children are placed and the extent to which this 

process differs for public, not-for-profit, and for-profit providers operating in 

your state. 

The Department of Social Services requires monthly visits in the foster home 

where the child resides by the child's Family Service Specialist. Documentation 

of each home visit is required in the Department's child welfare data system 

describing the care of the child, the assessment of the child's safety and 

discussions with the child and the foster parent. Monthly reports are also 

required to be submitted by the foster parents to the Family Service Specialist 

which provides an overview of monthly activities like school, appointments for 
183 


26354.147

medical, vision, dental or mental health care, contact with the agency, visits with 

family and other information regarding the child's care. Random monthly calls 

are also made by the Family Services Specialist's supervisor to assure staff are 

visiting the child and the foster parents and provide information and supports as 

needed. 

The Department also requires not-for-profit child placement agencies the 

department contracts with for foster care case management to complete monthly 

home visits and document all contacts with the child and foster family. 

7. How many instances of abuse in a foster care placement have been 

substantiated in the last five years in your state? Of those substantiated, how 

many of these instances related to children placed by: not-for-profit providers, 

for-profit providers, and public providers? 

The Department of Social Services substantiated instances of abuse in foster 

care during the following state fiscal years. 

SFY 2015-1 

SFY 2014- 3 (1 case was of a tribally licensed foster home) 

SFY 2013- 1 

SYF 2012-0 

SFY 2011-0 

The Department of Social Services implemented a process to place calls to 

randomly selected foster families and kinship families to ask a set of questions 

about contact by the child's Family Service Specialist, identify areas of need and 

or supports needed from the Department. The calls are made by the 

Department's Constituent Liaison and Child Protection Services management 

staff. The results are documented and identified issues or areas of need are 

addressed. 

8. Describe in detail the actions taken when an abuse claim is substantiated 

while a child is in an out of home placement? Do these actions differ 

depending on whether the child was place by the public agency, a not-forprofit provider, or a for-profit provider? 

Children are removed from the foster home pending the outcome of an out of 

home investigation. When an abuse claim is substantiated against a foster 

parent in South Dakota, the foster care license is closed as state law prevents an 

individual from being licensed as a foster parent if there is a substantiated abuse 

claim, regardless if it is a public of not-for-profit provider. 
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STATE OF TENNESSEE 

DEPARTMENT OF CHILDREN'S SERVICES 

436 5n1 AVJ;:NUJ;: NORTH 

BILL HASLAM 

GOVERNOR 

May28, 2015 

The Honorable Orrin G. Hatch 

Chairman 

U.S. Senate Committee on Finance 

219 Dirksen Senate Office Building 

Washington, DC 20510-6200 

The Honorable Ron Wyden 

Ranking Member 

U.S. Senate Committee on Finance 

219 Dirksen Senate Office Building 

Washington, DC 20510·6200 

CORDELL HULL BLDG,, 7TH FLOOR 

NASHVILLE, TN 37243 

Dear Chairman Hatch and Ranking Member Wyden: 

JAMES M. HENRY COMMISSIONER 

The purpose of this letter is to respond to your questions regarding privatized foster care in Tennessee. On 

behalf of Governor Haslam, I have provided the responses below In answer to your Inquiry. 

SlnGj'ely, 

_ ~J ~~./cfirt-o/ James M. H¢m,Y / 

Commissioner 

In addition to recruiting and retaining its own network of level 1 foster homes, Tennessee's Department of 

Children's Services (DCS) relies on a network of twenty eight {28} direct contracting private providers to 

deliver a wide array of clinical and therapeutic services to chlldren and youth who come into OCS care. 

These providers assist with supports, services, experiences and opportunities that are indiVIdualixed based 

on the strengths and needs of each specific youth. 
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Chairman Hatch and Ranking Member Wyden 

May 28,2015 

Page 2 

DCS uses a number of assessment tools, guidelines and practices to determine the placement needs of all 

children and youth coming into its custody needing out-of-home and therapeutic care. A child/youth may 

be referred to a private provider based upon the match between a provider's clinical program services and 

outcomes and the child/youth's Individual needs. Private providers do not make placement decisions and 

tax status is not a factor in the placement process. 

This out-of-home care includes Levell foster care, Levels 2 & 3 residential and congregate care and Level4 

sub-acute psychiatric care. Several of these agencies also deliver residential specialty services, including 

programs for developmentally delayed children, medically fragile foster care, residential Alcohol & Drug 

treatment and juvenile sex offender programs. 

In the event that a child is placed with a private provider agency, case management and other services are 

delivered not only by the provider but also by a DCS Family Service Worker (FSW) who monitors and 

coordinates the child/youth's care. 

Private Provider Network 

As of May, 2015, DCS' statewide private provider network is comprised of twenty eight (28) agencies. The 

names of those agencies and their tax status are attached hereto as "Exhibit A". 

Data snapshot as of May 18, 2015: 

All children and youth in DCS custody: 

Those being served by private providers {PP): 

Number of those PP youth in foster homes: 

Number of those PP youth In congregate care: 

Children and youth served by private providers: 

Number of those served by for-profit agencies: 

Number of those served by non-profit agencies: 

Direct-contracting private provider agencies: 

Those agencies with for-profit status: 

Those agencies with non-profit status: 

8,064 

4,049 (50.2%)- of ill! youth in custody 

2,549 {63.0%) 

1,310 (32.4%) 

4,049 

1,551 {38.3%) 

2,498 (61.7%) 

28 

8 

20 

DC5 requires that ail providers be accredited by one of the following nationally-recognized accrediting 

bodies: Council on Accreditation (COA); and/or, Commission on Accreditation of Rehabilitation Facilities 

(CARF); and/or, Joint Commission on Accreditation of Healthcare Organizations (JCAHCO). Accreditation 

cycles are typically three (3) years. In addition, all providers are subject to all applicable requirements of the 

Prison Rape Elimination Act (PREA) federal statute. In Tennessee, all primary DCS contractors deliver 

services through "Performance-Based Contracts" (PBC). The development and Implementation of DCS' PBC 

initiative represents an overarching plan to achieve better outcomes for those children served In out-ofhome care by privately contracted providers. 

The PBC model In Tennessee employs an innovative approach stressing timely permanency outcomes for 

children, and utilizes a payment structure that reinforces provider agencies' efforts to offer services that 

improve those outcomes. 
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Chairman Hatch and Ranking MemberWyden 

May 28, 2015 

Page 3 

The outcomes DCS measures as a result of PBC model implementation include: 

improved likelihood of permanency (reunification, adoption or guardianship); 

a reduction in the number of care days used to achieve permanency; and, 

a reduction in instances of re-entry into DCS care. 

Internal quality control systems are used to monitor providers on a scheduled as well as ad hoc 

basis. These quality control systems Include, but are not limited to: 

annual on-site Program Accountability Review (PAR); 

annual on-site licensing reviews; 

monthly monitoring of incident reports; 

weekly Provider Quality Team meetings; 

weekly Foster Care Quality team meetings; 

ad hoc investigations/visits based upon reported concerns; and, 

on-site visits by clinical team members to provide technical program assistance. 

The State of Tennessee utilizes a rigorous and competitive "Request for Qualifications" (RFQ) and "Request 

for Proposal" (RFP) process to select, execute and renew contracts with private providers. In the Spring of 

2014, the RFQ process was used to re-establish uniform qualifications for the network provider pool. In 

addition to meeting mandatory requirements for items such as adequate operating capital, satisfactory 

credit bureau ratings, proof of accreditation, etc., all providers were rated on general qualifications and 

experience. These rated items included the submission of detailed descriptions of program expertise, use of 

evidence-based clinical programming, appropriate staff qualifications, training curricula, etc. Providers 

which received a threshold passing score were awarded a three-year contract. The RFQ process will be 

repeated in 2017. 

The RFP process is similar to the RFQ process except that specific types of services identified by the 

Department are solicited through a competitive procurement process. Any new contracts awarded through 

the RFP process are aligned to fall into the normal RFQ contract cycle. 

Foster Care Settings 

DCS policy In Tennessee is written to provide for the safety, permanency and well-being of all children 

placed in the foster care system. Fostering custodial children and youth is not considered a right of all 

persons in Tennessee, but rather a privilege for well-qualified and well-screened persons making 

application. Tennessee's foster care approval policy and process also applies to ail private providers 

delivering foster care services. 

All applicants must meet a set of pre-established minimum requirements, such as: documentation of 

residence in Tennessee for the past six (6) months; documentation of US citizenship or permanent 

residence, proof of financial stability, verification of being at least 21 years of age and documentation of 

current marital status. Applicants are also pre-screened through Tennessee's child welfare system to assure 

they have not been indicated for child abuse. This and any other concerning history is discussed with each 

applicant prior to allowing that applicant to move further in the approval process. 

The evaluation process, commonly referred to as a "Home Study", begins with a six (6)-week training 

program known as "Parents As Tender Healers" (PATH). This training focuses on providing potential foster 

families with an understanding of the public child welfare system, the impact of the trauma children in 
187 


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Chairman Hatch and Ranking Member Wyden 

May 28,2015 

Page 4 

foster care experience when removed from their familles and subsequently experience if moved while In 

foster care, effective non-corporal discipline techniques and how to understand and respect the individual 

cultures of the families and children who are involved In the system. All adult household members are 

required to complete PATH. Applicants are observed by professional trainers and DCS staff during the 

presentations and discussions. Homework is assigned each week as the training progresses and must be 

submitted in a timely manner. All concerns observed are discussed with the applicant and included in the 

narrative of the Home Study, assuming the applicant is allowed to continue the approval process. PATH 

training concludes with first aid, CPR and medication administration training. Everyone seeking to be an 

approved foster parent must complete this training series. 

A criminal records check is conducted during the training. Any records found are discussed with the 

applicant and Included in the narrative of the "Home Study''. Records reflecting conviction of any crime 

against a child, domestic violence, homicide, rape or sexual assault will not permit an applicant to continue 

in the approval process. Applicants with unresolved felony charges must walt until resolution of those 

charges prior to continuing in the process. Applicants with other felony convictions may be considered after 

further assessment during the Home Study and documentation of a waiver from the appropriate authority 

within DCS. 

At the conclusion of PATH training, visits to the applicant's home begin. All household members are 

Interviewed and assessed on their understanding of the concepts presented in PATH, their personal 

strengths and abilities, and their ability to build and maintain lasting relationships. References are also 

checked, Including a blood relative for each applicant. 

The physical condition of the home is assessed for safety. Included in the assessment for physical safety are: 

adequate and safe water supply; working plumbing and sewage disposal; LAN telephone with 911 service; 

appropriate sleeping space with furnishings; personal space and storage for each child; and adequate 

security for swimming pools or other bodies of water. DCS policy also requires that medications and poisons 

be secure, household pets be vaccinated and weapons be stored In a secured area. 

An escape plan Is posted In every home In the event of a fire. Working smoke detectors, carbon-monoxide 

detectors and fire extinguishers are required. Foster families are expected to hold periodic fire drills. 

Once approved, foster families are reassessed every two (2) years or In the event of a major change within 

the household, whichever occurs first. Following approval, families must maintain in-service training. If a 

family experiences a Child Protective Services (CPS) investigation, the circumstances and outcome of the 

Investigation are reviewed weekly by a team in DCS Central Office. This review is facilitated by the Quality 

Control unit. Homes closed as a result of these reviews may neither reopen without further review by this 

team, nor may they transfer between the state agency and contracted providers. 

Substantiated Abuse Claims in Foster Care 

An allegation of abuse or neglect involving a custodial child is investigated by the Special investigations Unit 

(SIU), which is a specialized team within the Office of Child Safety. Early in the investigative process, if there 

is a concern for the child's safety, actions are taken to remove the child from the foster home until the 
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Chairman Hatch and Ranking Member Wyden 

May 28, 2015 

Page 5 

investigation is completed, whether this is a DCS foster home or a provider foster home. The child is placed 

in another approved foster home. The home Is placed in a "frozen" status, which means there will not be 

any children placed with this family until the Investigation is concluded. Once the investigation is completed, 

the findings are debriefed with the regional staff and family. If the foster parent is substantiated, then the 

foster home is closed and this applies to DCS foster homes as well as private provider foster homes. Another 

placement is made for the children that were moved from that home. 

lfthe child is in a residential placement, the agency works with the private provider to ensure the alleged 

perpetrator does not have access to children until the investigation is completed. If there is a substantiation, 

then it is the expectation that the provider terminate the employee and that there is no more access to the 

children in the facility. 

Following the conclusion of an SIU Investigation, a debriefing occurs with provider agency staff, DCS 

placement staff and foster care staff to share information with everyone to ensure that the safety and 

treatment for the victim and any other children Involved is addressed. 

The actions do not differ for the type of placement. 

Substantiated allegations for children In custody from FFV 2010-2014 

FFV FFV FFV FFY Grand 

FFY 2010 2011 2012 2013 2014 .Total 

Count of 

tNVESTIGATION_ID 517 404 311 292 293 1817 

Note: DCS does not have the ability to break down this data by tax status. 
189 


26354.153

TEXAS DEPARTMENT OF 

FAMILY AND PROTECTIVE 

SERVICES (DFPS) 

~-Jlay 20'15 

INFORMATION RELATED TO FOSTER CARE PROVIDERS 

Overview 

In Texas, the Department of Family and Protective Services (DFPS) is responsible for 

investigating allegations of child abuse and neglect, and if necessary, removing children from 

their home to ensure their safety. DFPS is also responsible for finding the most appropriate 

placement for children who are removed, and for ensuring their safety and well-being while in 

care. 

When Child Protective Services (CPS), a division of DFPS, determines that a child cannot live 

safely at home, the next step is to determine whether or not there is an appropriate relative or 

close family friend who is willing and able to care for them. If not, CPS will petition a state 

district court, and the court can give temporary legal possession of the child( i.e. 

conservatorship), to CPS acting on behalf of the State of Texas. CPS temporarily places these 

children in foster care. Foster care settings include: 

• Foster family homes 

Foster family group homes 

• Residential group care facilities 

For purposes of this paper, "foster care" means contracted and regulated settings, as opposed to 

unregulated relative/kinship settings. 

While most children who are medically fragile or suffer from a severe emotional disturbance are 

placed in least restrictive settings, in very limited circumstances, the child may be placed in a 

state hospital or state supported living center if a child's needs cannot be met by one of the above 

providers. 

CPS, Residential Child Care Licensing, and other programs and divisions within DFPS share 

responsibilities for ensuring that children placed in DFPS conservatorship are safe and receive 

quality services. 
190 


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May 201 S 

Placement 

Once a court has given DFPS conservatorship of a child, CPS oversees the placement of that 

child. CPS is guided by federal and state law to place children in the least restrictive, most 

appropriate foster care setting for that particular child. CPS has the responsibility to maintain 

that criteria for each child as long as that child is in foster care. In an effort to find the best 

possible placement for each child and to ease any transitions in placement while in care, DFPS 

has a Centralized Placement Team in place. This team helps caseworkers make the most 

appropriate choice for placement, as close to the child's home and community as possible. 

Licensing and Regulation 

In Texas, 90 percent of foster children are placed with private, non-profit, and for-profit, 

contracted residential providers. The other I 0 percent of children are placed in foster homes 

directly overseen by CPS as a child placing agency. DFPS oversees the placement of children 

into care, the licensing and regulation of private child placing agencies, and monitors the 

contracts between DFPS and private foster care providers. 

Residential Child Care Licensing (RCCL) is the regulatory division of DFPS responsible for 

protecting children in residential operations through consistent and fair enforcement of licensing 

laws and standards. RCCL investigates reports of abuse and neglect, as well as violations of 

minimum standards, administrative rules, or licensing law. RCCL may impose penalties if an 

operation is deficient, up to and including revocation of a permit or license. RCCL is additionally 

responsible for: 

• Development and monitoring of statewide rules and minimum standards; 

• Processing applications and issuing permits to operations ; 

• Inspecting operations for compliance; 

Overseeing the Licensed Administrator's program; 

• Providing technical assistance to residential child-care operations, to help them improve 

and meet or exceed minimum standards; and 

Random inspections of foster homes and sampling of records kept by child-placing 

agencies. 

Contract monitoring 

The CPS Residential Contracts division awards and manages contracts for 24-hour residential 

childcare facilities that provide substitute care to children in DFPS conservatorship. Through 

these contracts, DFPS establishes the qualifications, standards, services, expectations, and 

outcomes for 24-hour childcare facilities and child-placing agencies across the state. Residential 

contract employees work with CPS staff, RCCL staff, and a third-party service level system 

contractor to ensure compliance and oversight. Residential contract managers are regionally2 
191 


26354.155

May 2015 

based CPS staff and serve as liaisons between CPS field staff and providers. They are 

responsible for assessing, monitoring, and managing residential contracts. 

To the degree applicable, describe your state's utilization of private entities to provide case 

management services (e.g., placement of children with particular foster care providers, 

ongoing casework and oversight of foster care placements). 

In Texas, the state is responsible for and oversees case management services for every child in 

foster care. A CPS Conservatorship caseworker works with the residential provider to develop, 

monitor, and maintain a child's plan of service. The child's plan of service identifies any support 

services that the caregiver must receive to meet the child's needs, and (within the limits of 

available resources) ensure that the caregiver receives those services. The caseworker also 

encourages the caregiver to participate as a team member in planning for, delivering services to, 

and evaluating the progress of the child as well as attend and participate in court hearings and 

permanency planning meetings. 

Texas requires that Conservatorship caseworkers make monthly contact with the child, with the 

majority of the visits taking place in the home where the child is residing. These VISits are 

focused on ensuring the safety and well-being of the child, and to work toward obtaining 

permanency for the child. 

Both during and after a visit with a child or family, the worker must assess: 

• the child's progress and adjustment to substitute care; 

• the child's interaction with the caregiver; 

the safety of the home environment for the child; and 

the child's ability to seek help if necessary. 

During these visits, the caseworker also discusses with the caregiver specific concerns that the 

caregiver may express about the child's care, such as the child's relationship with the caregiver's 

family, changes in the composition or functioning of the caregiver's family, or issues with DFPS 

policies. The caseworker is focused on and responsible for helping the caregiver find ways to 

manage the child's behavior, assess the caregiver's ability to respond to and meet the child's 

needs, assess the caregiver's need for services to support the placement and provide any followup support services that are requested or needed. The caseworker will also identify any follow-up 

support services that may be needed. 

Over the course of a child's placement with a foster care provider, the child's caseworker must 

ensure that the caregiver has up-to-date information about the child, including access to their 

education records, medical and developmental history. The caseworker is also responsible for the 

3 
192 


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May 201~ 

initial permanency court report, subsequent permanency court reports, placement court reports, 

and any other documents that relate to the well-being of the child. 

Foster Care Redesign 

Foster Care Redesign (FCR) is a new way of providing foster care services that relies on a 

community-based, shared-decision making model, by which the state enters into a performancebased contract with one Single Source Continuum Contractor (SSCC). The SSCC must ensure 

the full continuum of foster care services to children in paid foster care and their families in a 

designated geographic area of the state. The guiding principles of foster care redesign are: 

Above all, children and youth are safe from abuse and neglect in foster care; 

Keep children and youth closer to home and connected to their communities and siblings; 

Improve the quality of care and outcomes; and 

Reduce the number of times children move in foster care. 

While the SSCC matches and proposes placements for the child, participates in the joint 

development of a single plan of service, and coordinates services for the children and families, 

DFPS maintains oversight of child's case management and has final approval over all 

recommendations made by the SSCC. 

Currently Texas is piloting FCR through one SSCC contract- ACH Child and Family Services. 

ACH is a not-for-profit agency that has been serving the Fort Worth area since 1915. The FCR 

contract with ACH serves a seven-county contract in north Texas. The initial performance 

measures for ACH are positive and point toward FCR meeting its goals, however these outcomes 

are still early and the state will continue to monitor the progress of Redesign and ACH. DFPS 

will be releasing a Request for Proposal (RFP) for another SSCC in an additional catchment area 

over the next biennium. The RFP will be open to Texas licensed for-profit and non-profit 

entities. Information obtained through evaluation of the first two SSCC's will be used to inform 

model modification as a part of the statewide roll-out of Foster Care Redesign. 

STAR Health 

In 2008, the Texas Health and Human Services Commission (HHSC), the umbrella agency over 

DFPS, worked with the Texas Department of Family and Protective Services (DFPS) to 

implement STAR Health as a medical care delivery system for children in state conservatorship. 

STAR Health serves children as soon as they enter state conservatorship and assists with case 

management decisions for foster children from a health care perspective. , Continuity of care is 

an ongoing challenge for foster children since they are a high-risk population with greater 

medical and behavioral health care needs than most children in Medicaid and continually 

changing circumstances ... 

4 
193 


26354.157

May2015 

HHSC administers the program under a contract with a single statewide managed care 

organization. STAR Health clients receive medical, dental, vision, and behavioral health 

benefits, including unlimited prescriptions. The program includes access to an electronic health 

record called the Health Passport, which contains a history of each child's demographics, doctor 

visits, immunizations, prescriptions, and other pertinent health-related information. The program 

also includes a 7-days-per-week, 24-hours-per-day nurse hotline for caregivers and DFPS 

caseworkers. 

In 2010, the program began trammg and certifying behavioral health providers in Trauma 

Focused Cognitive Behavioral Therapy (TF-CBT) and training in trauma-informed care was 

made available to all caregivers and caseworkers to effectively manage behavior issues that can 

destabilize children's health status and foster family placement and to promote healing from 

trauma associated with abuse or neglect. 

What proportion of the children in foster care in your state is placed by the public agency, notfor-profit providers, and for-profit providers? 

DFPS places I 00 percent of the children in the conservatorship of the state. The chart below 

provides information for child care facilities related to total capacity, broken down by public, 

non-profit, and for-profit. The majority of the State's residential child care operations are 

operated by non-profit organizations. 

Residential Child Care Operations 

Fiscal Number of Non-Profit For-Profit Public fotal Capacity 

Year Operations Organization 

FY12 711 593 107 11 50,140 

l·Y13 697 576 110 11 48,684 

FY!4 711 589 111 11 47,819 

The chart above describes total licensed capacity and does not necessarily equate to "filled" beds. 

Please provide the number and names of private entities providing these core services, as well 

as information on whether each provider is a for-profit or not-for-profit entity. 

Please see attached documents "RCC Operations Fiscal Year 2012-2014" and "CPS-CPA 

Operations Fiscal Year 2012-2014." 

5 
194 


26354.158

May 2015 

Does your state require that private foster care entities or organizations operating in your state 

be accredited? If so, by which organization and how often is this accreditation renewed? 

Texas requires that all foster care providers - non-profit and for-profit - meet state standards. 

The state child care licensing law sets guidelines for what must be included in the standards. The 

standards are comprehensively reviewed through a public process every six years and entities are 

evaluated for compliance at least once per year. Inspections may occur more often depending on 

how well the operation is meeting the required standards. In addition, standards can be updated 

at any time in order to comply with Legislative direction and evolving best practices. For 

example, in 2014 regulation was added to increase the requirements to verify a foster home, 

which increased the number of required, unannounced foster home visits by the Child Placing 

Agency. Regulation was also added to enhance the care of children with primary medical needs. 

In the Foster Care Redesign Model, the Single Source Continuum Contract is awarded through a 

competitive Request for Proposal (RFP) process, which awards a contract based on the merits of 

the proposal. DFPS awards preference in the evaluation of proposals to those that are accredited 

or certify that they will become accredited within 3 6 months of award. Accreditation is 

considered and preferred under the Foster Care Redesign model. Accreditation is preferred 

through the Council of Accreditation (COA) or other relevant accrediting body. COA 

accreditation is renewed every four years following a self-study and an on-site peer review. 

Describe in detail the process you use to select and contract with these private entities, as well 

as to review and renew such contracts. 

Licensing of Residential Providers 

Residential providers in Texas must be licensed by RCCL, which is done through a formal 

screening process. A formal Provider Enrollment solicitation is used to screen private entities 

who apply to serve Texas children who are in foster care. The screening process considers the 

following: 

ability to supply the solicited services and comply with contract requirements; 

licensing history; 

fiscal resources; 

readiness to pay the required pass-through amounts to foster parents; 

• criminal and abuse background checks; 

• facility physical plant review; 

Executive staff interviews ; 

• past business history that includes practices and conduct of the Applicant; 

• organizational history; 

compliance history of governmental contracts; 

6 
195 


26354.159

• history of applying to residential child-care solicitations; 

geographical limitations in serving children in foster care; 

May 2015 

• ability to meet the specific needs of the child population that the Applicant is seeking to 

serve and the Applicant's preparedness to provide the services; 

composition and organizational structure including the Board of Directors depicting lines 

of authority; 

professional staffing plan; 

Executive's experience with federal or state programs; 

Executive's resumes and professional licenses; and 

• Key management staff tum-over rate. 

CPS Residential Contracts also screens the Child Placement Agency. Prior to contract award, 

new residential provider operations and processes are assessed for their ability to monitor foster 

families. 

Foster Home Verification 

While residential providers must be licensed by DFPS, individual foster family homes under the 

umbrella of a provider organization are "verified". This means the child placing agency (CPA) is 

responsible for oversight of individual foster homes verified under the CPA license. RCCL 

monitors and inspects the CPA and conducts investigations on the foster homes when abuse or 

neglect is reported. If issues arc found in a foster home, the CPA is responsible for ensuring the 

necessary corrections arc made to reduce risk to children placed in the individual home. This 

could include additional training for the foster parent; the CPA making more visits to the home; 

the CPA changing the gender, ages, or behaviors of children placed in the home; or the CPA 

could decide to no longer verify the home. 

In September 2014, RCCL amended their rules to strengthen the foster home verification 

process. In addition, RCCL amended rules to increase the CPA's overview of the foster 

homes. These improved rules went into effect in Fall 2014, and require the following: 

• Interview all adult children of prospective foster parents, as well as two new additional 

interviews with neighbors, school personnel, clergy, or other member of the foster 

parents' community who can provide a description of their suitability to provide care for 

children; 

Evaluate prospective foster parents' significant relationships and assessing their financial 

status to strengthen home screenings; 

• Require CPAs to provide additional information regarding law enforcement services 

calls; and 

Educate CP As and prospective foster parents on disciplinary methods. 

7 
196 


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May 201 s 

24-Hour Residential Childcare Contract Monitoring 

In Fiscal Year 2015, DFPS began an initiative to improve contracting and monitoring efforts 

with a focus on provider quality. This effort has resulted in the following milestones thus far: 

• An updated DFPS contract monitoring tool. DFPS overhauled its previous tool, which 

monitored program requirements through a compliance model. Staff is now performing 

qualitative evaluations and analyzing fiscal and programmatic data to better evaluate the 

safety and well-being of children in care and determine the soundness of a residential 

provider's fiscal operations. 

• The creation of a customized training for the contract monitoring tool. Customized 

training was created and provided to DFPS Residential Childcare Contracting staff that 

incorporated findings and recommendations to improve contractor operations. 

Began the first phase of implementation for the tool. The use of predictive analytics to 

monitor residential childcarc contractors will help the agency better focus on safety and 

also analyze a provider's overall operational health. 

DFPS is also collaborating with residential childcare providers to establish a work plan that 

focuses on the second phase of implementing the new contract monitoring tool: continuous 

quality improvement for contracting activities, outcome based performance measure, and a 

provider scorecard to promote transparency. DFPS' approach is to partner with the providers to 

promote the purpose of performance-based contracts and share the results of the scorecards. 

Scorecards will be used to assist DFPS with implementing enhanced targeted monitoring, which 

will allow for a more efficient and effective tiered structure of supports and interventions. 

Scorecards will also be used to help identify high risk providers and to provide an updated 

Continuous Quality Improvement (CQJ) process that will allow all providers to have access to 

data and methods to improve processes. The CQI process for providers who are not deemed 

high-risk will bring with it graduated levels of support from the community of care, such as 

DFPS programs and other high-performing providers. 

Renewal 

Prior to renewing residential contracts, a review of contractor performance is completed that is 

comprised of the following components: 

data from outcome and output measures; 

• licensing standards including incidents of abuse or neglect; 

• history of the enforcement of contract remedies; 

• complaints concerning contractors' performance overall; and 

• compliance with residential child-care contract terms and conditions. 

8 
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May 2015 

Contractors whose performance is Jess than acceptable arc reviewed through a formal written 

and oral process by which risk indicators such as licensing requirements or contracting outcomes 

are presented; contract renewals are based on these indicators. 

DFPS conducts a bi-weekly meeting whereby contractors' performance with licensing and 

contracting requirements are reviewed and examined by a group of interdisciplinary 

professionals comprised of legal, licensing, program and contracts. During these meetings, 

professionals collaborate regarding incidents and the possibility of increased risk to children who 

are placed with private providers. As a result of these meetings, contractors may undergo 

contract remedies including the suspension of future placements and contract termination. 

Foster Care Redesign 

For the Foster Care Redesign Model, the state releases a Request for Proposal (RFP) for a Single 

Source Continuum Contractor in a designated geographic area of the state. Respondents design 

and submit proposals back by the due date. The Texas Health and Human Services Commission 

(HHSC) oversee§. the procurement process. Initially all proposals are reviewed to ensure that 

they meet the minimum qualifications as advertised in the RFP; if they do not, then they are 

screened out prior to evaluation. During the evaluation process, teams of individuals 

independently review and score each proposal based on their particular area of expertise using 

very thorough and objective metrics. HHSC procurement staff processes scores and further 

review outliers , which are reconciled if possible. Once final scores are tabulated, a tentative 

award is made. Negotiations commence and once agreement on the terms and conditions of the 

contract is reached, a final SSCC Contract award is made. 

SSCC contracts are monitored using a team approach and focus on performance, administrative, 

and financial components. The contract is a six year contract and re-procured using the 

competitive RFP process. 

Describe in detail the process your state uses to inspect the safety of the foster care settings in 

which children are placed and the extent to which this process differs for public, not:forprofit, and for-public providers operating in your state. 

Safety of children is the State's first priority and therefore it is the highest priority in inspecting 

foster care settings. Both CPS and RCCL have a role in foster care inspections. 

CPS Conservatorship caseworkers are required to have a face-to-face visit with children at least 

monthly, no matter whether they are placed under non-profit or for-profit arrangements. During 

those visits, caseworkers arc discussing the child's safety, progress towards permanency, and 

visually inspecting the child's placement for any concerns. For those children placed outside of 

9 
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their legal region, there is an additional secondary local caseworker assigned who meets the faceto-face requirement and reports back to the child's assigned caseworker. Any and all concerns 

noted from those visits are reported back to the primary caseworker and/or their chain of 

command. Additionally, any immediate or imminent safety concerns are promptly called in to 

the state's centralized, 24-hour abuse and neglect hotline. A report to the hotline may result in a 

new, formal investigation. Issues are also addressed with the placement at the time of the visit. 

Furthermore, when concerns are noted regarding a facility or the quality of care, then safety 

checks are implemented to ensure the safety and well-being of the children. Safety checks 

consist of one or more caseworkers going out to complete face-to-face interviews with all DFPS 

children placed within that home/operation/facility. During these visits, the worker is ensuring 

that the: 

children are safe, 

facility is safe; 

children's basic needs are met (appropriate clothing, shelter, food, etc.); 

appropriate supervision is being provided; and 

treatment needs are being met. 

Any urgent matter needing immediate attention is addressed promptly prior to the worker leaving 

that visit. If a residential childcare provider or foster family appears to be struggling with 

meeting the ongoing needs of children in conservatorship, an interdisciplinary team consisting of 

Child Protective Services, Residential Contracts, and Residential Child Care Licensing meets to 

discuss possible assistance, action, and/or intervention measures that may need to be 

implemented. 

Public, not-for-profit, and for-profit providers are treated the same in Texas. Once an entity is 

licensed, Texas law requires the operation be inspected by the Residential Child-Care Inspector 

at least once per year based on RCCL rules. The frequency of inspections is based on how the 

operation complies with the minimum rule requirements. In addition, Residential Child-Care 

Licensing conducts~ investigations of any abuse, neglect, or exploitation concerns; investigations 

related to minimum rule requirements; and conducts a sample visit to 25 percent of all foster 

homes each year. Through inspection, investigation, and sampling visits, Residential Child-Care 

Licensing makes determinations on the safety of children in the licensed entity. 

10 
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How many instances of abuse in a foster care placement have been substantiated in the last 

jive years in your state? Of those substantiated, how many of these instances related to 

children placed by: not-for-profit providers ,for profit providers, and public providers? 

There have been 295 instances where abuse or neglect has been substantiated in foster care in the 

last five years. The lowest year was 2010 with 40 cases and the highest year was 2014 with 76 

cases. In a year, there are approximately 31 ,000 children in foster care. CCL investigates 

approximately 2,000 allegations of abuse or neglect in foster care operations. 

Number of Substantiated Cases of Abuse Q! Neglect for Children in Foster Care 

Fiscal Year For-Profits Non-Profit Public ~A.gency Total 

2010 1 32 7 40 

2011 7 44 7 58 

2012 12 55 6 73 

2013 6 37 5 48 

2014 13 55 8 76 

Total for all Fiscal 39 223 33 295 

Years Combined ... 1\ote. CPS as a CPA ( public agency 1n the chart above) takes bas1c level children. ChJidren needmg treatment servtces and a 

higher level of need arc placed in for~profit or non-profit agencies. 

Each and every case where abuse or neglect is substantiated is of particular concern, however, 

many of the substantiated cases are not serious injuries. Examples of substantiated ca~es 

include: over-discipline, corporal punishment, and inadequate supervision. Every substantiated 

case results in a review by RCCL and CPS with appropriate action taken to maintain child safety. 

Describe in detail the actions taken when an abuse claim is substantiated while a child is in an 

out of home placement? Do these actions differ depending on whether the child was placed by 

the public agency, a not-for-profit provider, or a for-profit provider? 

DFPS takes very seriously the oversight and regulation of all contracted residential child care 

providers. Through improved safety rules and regulation, ongoing dialogue with providers, and 

coordination and communication between licensing, contracts and placement - DFPS strives to 

provide the best, highest quality care for all children in foster care. 

For this reason, public, not-for-profit, and for-profit providers are treated the san1e in Texas. 

When an abuse claim is substantiated in a licensed operation or foster home, a finding is made 

against the individual involved in the abuse. If the abuse occurred in a foster home, the children 

placed in the home arc typically removed from the home and/or the child placing agency closes 

the foster home. If the abuse occurs at an operation, then the perpetrator is taken off duty 

pending due process or is terminated. Residential Child-Care Licensing will cite a provider for a 

11 
200 


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May 20lb 

standards violations. To determine what steps should be taken next, RCCL evaluates risks 

related to this incident, the operation's overall compliance history, and overall risks to children. 

DFPS weighs the following options on a case-by-case basis: 

• take no action if the incident seems to be an anomaly and the provider has taken steps to 

ameliorate the issue; 

• increase inspections at the operation; 

• request the operation voluntarily work on making changes based on identified risks; 

place the operation on a corrective action, which involves monthly inspections and the 

operation meeting conditions that are above minimum rule requirements; or 

• take adverse action, which can include revoking an operation's license. 

Note: Serious instances of confirmed abuse and neglect cases resulted in licensure revocation. 

There has been one licensure revocation in the last five years. 

Foster Care Collaboration 

Also of note, DFPS works closely with partner organization such as Court Appointed Special 

Advocates (CASA), Child Advocacy Centers (CACs), Attorneys ad Litem, and multiple faithbased organizations to protect and serve children in the foster care system. Collaboration with 

with these and other child and family focused organizations allows for churches and 

communities to offer a variety of service to enhance safety, permanency and well-being 

outcomes for children. 

DFPS encourages and provides opportunities for contracted providers to collaborate through 

network building and best practice sharing. 

With the child population in Texas currently over 7 million and growing, the State of Texas is 

committed to partnership. transparency and accountability so that the child protection community 

may continue to improve. 

12 
201 


26354.165

State of Utah 

GARY R. HERBERT 

Governor 

SPE~CFR J. COX 

f_JeUfenant Governor 

May 27,2015 

DEPARTMENT OF HUMAN SERVICES 

ANN SILVERBERG WJLLIAMSON 

Executn:e Dtrector 

MARK L BRASHER 

Depury Director 

LANA STOHL 

Deputy D1recwr 

To: United States Senate Finance Committee 

RE: Letter to Governors on Private Foster Care 

In response to the request from the Senate Finance Committee, the State of Utah, Department of 

Human Services (DHS), Division of Child and Family Services (DCFS) issues the following: 

Utah bases its foster care evaluation model on a continuum with seven levels of care. As the 

levels of care progress, they are designed to provide more intensive services and supervision than 

the prior level of care. An assessment is completed for each child in foster care and the result of 

the assessment is a recommendation for a level meeting the child's needs. Services provided by 

direct care staff and/or out-of~home caregivers at each level are defined by the needs of the 

children being served. 

The first three levels of care (Level I, Level II, and Level Ill) are most frequently provided in 

foster family homes licensed by the State of Utah, DHS, Office of Licensing (OL), and 

supervised by DCFS. Children with a need for higher intensity services and/or with a higher 

level of behavioral needs are most often provided care and supervision services through a private 

provider with whom the state contracts (Levels IV, V, or VI). There is some flexibility built into 

the model that permits a higher level of care to be achieved when a child is in a placement that 

would traditionally rate a lower level of care on the continuum, but has additional services in 

place to reach the intensity of services needed tor that child. Utah's Level VII care is provided in 

an institution, such as a psychiatric hospital or the Utah State Hospital. 

For all levels of care, DCFS caseworkers provide oversight and case management services for 

children in their placement. As of May I, 2015 Utah's data shows approximately 25 percent of 

children in care are placed with private providers in Levels IV, V, and VL Utah ctm provide 

further historical or eumulalive data regarding foster care placement levels upon request 

Off~-ee of the F.xecut1v~ Director, 195 North 195-Q West, Sal! La_h City. Utah 841 }6 

t~lephone (8Dl) 5J8-41JOl ~ fa(:s!mile(!l.Oi) $38··1016 "''Nww.hs utah.gov 
202 


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May27, 2015 

Page2 

To the degree applicable, describe your state's utilization of private entities to provide case 

management services (e.g., placement of children with particular foster care providers, 

ongoing casework and oversight of foster care placements). 

Utah docs not utilize private entities to provide case management services. Casework 

activities and oversight of foster care placements are provided through staff employed 

through DCFS, with the exception of a small cohort of high-need mental health cases. For 

these welfare cases, DCFS contracts with a local county mental health authority such as 

Wasatch Mental Health Services. Wasatch Mental Health Services is a public agency, 

and as of May 1, 2015, manages 26 cases, which is 0.9 percent of the total number of 

foster care cases in Utah. Wasatch Mental Health case managers utilize the State 

Automated Child Welfare Information System (SACWIS) for case management and are 

subject to the same performance requirements as DCFS casework staff. 

What proportion of the children in foster care in your state is placed by the public agency, 

not-for-profit providers, and for-profit providers? 

The public agency, DCFS, makes all (I 00 percent) placement decisions of children in 

foster care. Private agencies in Utah may make a placement recommendation to the state; 

however, the placement decision authority ultimately rests with DCFS. 

Please provide the number and names of private entities providing these core services, as 

well as information on whether each provider is a for-profit or not-for-profit entity. 

Requested information is contained in the attached spreadsheet (Attachment 1). Services 

provided by private entities are limited to care, supervision, and treatment of children in 

foster care. None of the entities provide case management services. 

Does your state require that private foster care entities or organizations operating in your 

state be accredited? If so, by which organization and how often is this accreditation 

renewed? 

Utah docs not require accreditation; however, agencies may choose to become accredited 

on their own through an accreditation entity. 

Describe in detail the process you use to select and contract with these private entities, as 

well as to review and renew such contracts. 

DCFS develops a scope of work and a Request for Proposals (RFP) specific to the 

services we require for each level of care (Levels IV, V, and VI). The RFP is issued and 

private agencies have the opportunity to apply. When applications are received through 

the state purchasing process, they are scored according to the criteria in the RFP. 

Proposals from a private entity that meet requirements of the RFP are offered a contract. 

Contracts are issued on a five-year cycle. The process is ongoing and providers must 

apply for a new contract at each contract cycle. The process to apply for a contract is 
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26354.167

May27, 2015 

Page 3 

outlined on the DCFS website located at the following link: 

http://dcfs.utah.gov/pdflllowtocontractwithDCFS.pdf. Attached is a sample of our last 

RFP for Level IV services that contains the scope of work and the criteria and process by 

which a private entity would apply for a contract for foster care services (Attachment 2). 

Describe in detail the process your state uses to inspect the safety of the foster care settings 

in which children are placed and the extent to which this process differs for public, not-forprofit, and for-public providers operating in your state. 

For state licensed and supervised foster homes (Levels I, II, and lll), initial safety 

inspections of foster care homes is completed by the state Office of Licensing (OL) at the 

time of licensure. A copy of the OL Administrative Rule (R501-12) outlining foster home 

requirements can be found at the following link: 1 Iuman Services. Administration. 

Administrative Services, Licensing- Foster Care Services. State licensed and supervised 

homes for Levels I, II, and lii must renew their foster license on an annual basis. In 

addition to the OL initial and renewal processes, DCFS employees are dedicated to 

support and monitor quality care for children placed in foster homes. These staff, known 

as Resource Family Consultants (RFCs), are familiar with the homes they support to 

make informed placement decisions. RFCs are also required to make monthly contact 

with each foster home, as well as site visits to each foster home a minimum of once every 

six months. RFCs are experts in OL rule and DCFS safety requirements, and are therefore 

able to identify and report any problems they observe. RFCs also provide support to 

caseworkers for individual cases and follow up with visits to homes if safety is uncertain. 

Private entities with family-based placements (LevellY) must meet comprehensive OL 

requirements of a child placing agency found in the OL General Provisions (R50 1-1 ), 

Core Rules (RSOI-2), and Foster Care Services (RSOI-12), which can be accessed here: 

Human Services, Administration. Administrative Services, LICENSING. 

However, once the private entity has achieved status with OL as a child placing agency, 

they may oversee and "certify" their own family-based foster homes. The child placing 

agency is required to ensure that their "certified homes" meet OL requirements for foster 

homes. At irregular intervals, OL completes on-site reviews of a random sample of 

homes certified through the child placing agency to ensure they are in compliance with 

OL rules. OL completes a regular audit of the tiles kept by child placing agencies, and if 

discrepancies or errors are noted, OL may require on-site visits to foster homes overseen 

by the agency as a part of the audit as well. 

Homes certified through child placing agencies do not have the direct state oversight and 

training that licensed foster homes have, despite taking on placements requiring higher 

levels of care. This can lead to inconsistency in training and oversight as it becomes 

largely incumbent upon the private entity to create and self-monitor their programs. In 

addition, private child placing agencies may have a financial incentive to certify homes 

that could create a conlliet of interest in their quality assurance. Because of these issues, 

DHS is evaluating if this service delivery method that allows child placing agencies to 

certify their own foster homes should be changed. 
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May27. 2015 

Page 4 

Residential placement settings (Level V and VI) must also meet OL requirements for the 

types of service they are contracting with DCFS to provide. The comprehensive OL 

requirements can also be found at this link under R50 1-19 Residential Treatment 

.!.'rograms and/or R50 1-...,2 Residential Support Programs. OL conducts file audits and site 

visits of these entities as well. 

In addition to the OL process, DCFS has an internal Audit Team that conducts annual 

audits of private entities that provide Level IV, V, and VI foster care services and Level 

V and IV residential treatment programs through contracts with DCFS. The DCFS audit 

team reviews personnel files maintained by the private entity and conducts interviews 

with foster parents and staff to verify they have completed all training requirements 

outlined in their DCFS contract. The audit also ensures that all foster parents and 

individuals over age 18 in the home and all residential treatment staff have the required, 

approved background screenings from OL. Furthermore, the audit team randomly selects 

and interviews children placed in these homes or facilities about issues regarding safety, 

treatment services, and relationships with foster parents and/or other staff. Two to four 

''certified" foster homes are randomly selected for inspection and the audit team inspects 

all residential treatment facilities to ensure they meet health and safety elements outlined 

by OLand in the contract with DCFS. 

In accordance with federal ASFA and CFSR requirements, Utah requires caseworkers to 

complete a minimum monthly face-to-face visit with each child in foster care in their 

placement. The monthly visit must include a private conversation with each child to 

address safety and other issues. The requirement is built into the SACWIS system and an 

"action item" is sent to the caseworker each month for each child they oversee in foster 

care. The caseworker must enter an activity log with details of their visit with the child. 

According to the Utah quantitative review process, the performance rate is more than 96 

percent annually for successful visitation of children in their foster care placements. If 

any safety concerns are identified by the child or caseworker during the caseworker's 

visit, the caseworker reports the safety concerns for investigation to Child Protective 

Services (CPS) Intake. 

How many instances of abuse in a foster care placement have been substantiated in the last 

five years in your state? Of those substantiated, how many of these instances related to 

children placed by: not-for-profit providers, for-profit providers, and public providers? 

Over the past five years, Utah has served 23,196 children in foster care, and has had 89 

substantiated instances of abuse of children in care. Please refer to Attachment 3 for a 

breakdown of instances of abuse, number of perpetrators, and number of victims for each 

level of care. The information was obtained for federal fiscal years 2010. 2011, 2012, 

2013,2014 where the child victim was in foster care and the relationship to the victim 

was recorded as foster mother, foster father, or residential treatment staff. The data also 

includes cases that were substantiated against licensed kinship providers. Some of the 

entities with substantiated cases no longer have existing contracts with DCFS. Utah can 
205 


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May27, 2015 

Page 5 

provide further information regarding substantiated instances of abuse in foster care 

placements if needed. 

Describe in detail the actions taken when an abuse claim is substantiated while a child is in 

an out of home placement? Do these actions differ depending on whether the child was 

place by the public agency, a not-for-profit provider, or a for-profit provider? 

The Office of Services Review (OSR), Related Parties Investigations Team is the state 

agency assigned to investigate claims of abuse or neglect against a child in an out of 

home placement. The agency is housed within DHS, but is distinct from DCFS and is not 

overseen by DCFS. Since DCFS makes all placement decisions for children in out of 

home care, the actions taken to address a substantiated claim do not differ between levels 

of care. 

If an allegation of abuse or neglect is substantiated in an out of home placement, OSR 

notifies the director ofthe ocrs region that oversees the placement of the child. informs 

DCFS of the identity of the perpetrator and relays any ti.uiher safety concerns. Based 

upon the identity of the perpetrator and nature of other case-related details, OSR may also 

notify OL. the DCFS audit team, high-level administrators ofDCFS, or the executive 

director of DHS to follow-up with concerns. recommendations, or a further assessment of 

the provider. 

When OL is notified by OSR of a substantiated allegation of abuse or neglect against a 

provider. OL will assess if the provider still meets the background screening 

requirements as well as conduct an assessment of whether the provider is still in 

compliance with OL rule. OL will determine if action is needed against the license of the 

provider such as corrective action or revocation of the license. 

When the DCFS audit team is made aware of a substantiated allegation of abuse or 

neglect against a private provider, the audit team will discuss the substantiated claim with 

DCFS administration and detennine whether or not DCFS will continue placing children 

in the facility. If DCFS decides to discontinue placing children with the provider, the 

provider is contacted (phone and email) and informed ofDCFS's decision. Each DCFS 

region is also notified (phone and email) of the decision. DCFS is in the process of 

developing a tracking system housed within the SACWIS system to "flag" the provider 

so that DCFS will make no further placements with a provider that has a substantiated 

case of abuse or neglect. This will ensure that if the foster parent attempts to change to 

another provider entity, they will not be able to continue to provide foster care services. 

### 
206 


26354.170

Becky Shipp 

STATE OF WASH!i\GTON 

lll'P,\RTME!';T 01' SOCIAL AND llEALTll SERV!CFS 

CIIII.DREN"S ADMIN lSI RAIION 

PO Box 4)(1cl() o Olympia WA • 93504-5710 

May 27,2015 

Health and Human Resources Policy Advisor 

Senate Finance Committee 

United States Senate 

Washington, D,C. 20510-6200 

Dear Ms. Shipp: 

Governor Ins lee has requested that 1 respond to the request by Senators Ilatch and Wyden in their April 

24, 2015lctter for information regarding Washington State's foster care system. The Senators asked eight 

questions which will be answered in order below. 

1. To the degree applicable, describe your state's utilization o(private entities to provide case 

management services (e.g. placement of children with particular (aster care providers, ongoing 

casework and oversight o((oster care placements). 

Children's Administration (CA) within the Department of Social and Health Services (DSHS)contracts 

with private agencies to provide individual and congregate placement of dependent children in the care 

and custody of the department. These private child placing agencies (CPAs) provide a variety of 

placement services depending on the individual child's need for supervision and services. CPAs certify 

family foster homes licensed by the CPA for children placed into care because their own home is not safe. 

These family foster homes provide supervision, care, and protection. Children placed in these homes 

attend school, participate in normal childhood activities, have visits with their own parents and may 

participate in services, provided through CA, with the goal of reunifying with their parents. CPAs may 

offer foster-to-adopt homes for children with a concurrent plan of reunification and adoption. Children 

placed in these family foster homes receive case management services through Ci\ and do not require any 

additional case management services. Ci\ also serves children with behaviors that pose a threat to 

themselves or others. They often face mental health, developmentally disabling, and other challenges that 

result in behaviors requiring on-site intensive case management. CPAs providing this level of care 

establish child-specific contracts with CA that include agreement to provide a higher level of supervision, 

behavioral management, treatment and other services known through the department as behavioral 

rehabilitation services (BRS). While the CPA provides the on-site intensive case management, CA 

maintains case management of these dependent children, and provides reports to court on the child's 

progress and permanent plan. CA has contracts with CPAs located within Washington State and with 

CPi\s operating out-of-state. 

2. What proportion o{lhe children in foster care in your state is placed bv the public agency, not-forprofit providers, and for-profit providers? 
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Senate Finance Committee 

May 27,2015 

Page 2 

The State of Washington's database only includes children in the care and custody of the Department of 

Social and Health Services, and does not include licensed child-placing agencies who arrange private 

placements not involving dependent children. We do utilize private agencies for placement purposes, but 

the Department maintains case management and other legal responsibilities for these children and 

youth. The State of Washington does not contract for privatized child welfare case management. 

3. Please provide the names and numbers o[private entities providing these core services, as well as 

infiJrmation on whether each provider is a for-profit or not-tor-profit entitv. 

~cJ Copy of CPA Active 

Contracts 5-20-15 no 

4. Does your state req'uire that private foster care entities or organizations operating in your state be 

accredited? ](so. by which organization and how ofien is this accreditation renewed? 

The Department does not require that its child placing agencies be accredited although some of them are. 

5. Describe in detail the process you use to select and contract with these private entities as well as to 

review and rene·w such contracts. 

Children's Administration recruits and licenses most of the foster homes it uses; it contracts with licensed 

Child Placing Agencies to increase the number of placement resources for the children in the state's care 

and custody. Children's Administration does not contract with Child Placing Agencies to perform case 

management for children in our care and custody; however, we do contract with a CPA for the purposes 

of utilizing the foster home placement. Once a CPA is licensed, the decision is made whether or not to 

contract with that agency based on the Department's need for foster homes and placement resources in 

that geographic area. CPAs are monitored on a regular basis and contracts are renewed annually. 

6. Describe in detail the process your state uses to inspect the sa(ety o(/he foster care settings in which 

children are placed and the extent to which the process differs for public, non-profit and for profit 

providers operating in vour state. 

The minimum licensing requirements are identical for all foster homes, whether they are directly licensed 

by the State of Washington, or whether they are a private agency provider, either profit or nonprofit. Families being directly licensed by the Division of Licensed Resources (DLR) in the Children's 

Administration will be assessed by a DLR worker. This assessment includes comprehensive interviews of 

all family members and others living in the household, facility inspections, completion of background 

checks (criminal history, child abuse registry, and other negative actions, such as licensing revocations), 

etc. 

Families seeking licensure by a private agency will be assessed by a licensor employed by the private 

agency, and that agency attests to the department that the family meets the minimum licensing 

requirements. DLR completes the background checks and clears individuals for the private 

agencies. DLR issues a foster family license based on the certification by the private agency. The family 

may only remain licensed under the continued supervision of that private agency, 
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Senate Finance Committee 

May 27, 2015 

Page 3 

After the family is licensed, the CA social worker for the child makes monthly visits with the child to 

assess health and safety. If the child is placed in a private agency home that is contracted as a childplacing agency with the Department, the child-placing agency would be responsible to make visits to the 

home to assess health and safety, in addition to the DSHS worker's visit. 

7. How many instances o(abuse in a {Oster care placement have been substantiated in the last 5 years in 

your state? ()(those substantiated. how many o(these instances related to children placed by public 

providers. for profit providers and nonprofit providers? 

There have been 224 intakes resulting in at least one founded finding between January!, 2010 and 

December 31, 2014. Again, we do not contract for privatized case management of children in the 

Department's placement and care authority. Of these founded findings, 138 of the children were placed 

in foster homes directly licensed by the Department, 70 were placed in private non-profit agencies, and 16 

were placed in private for-profit agencies. 

8. Describe in detail the actions taken when an abuse claim is substantiated while a child is in an out o( 

home placement. Do these actions ditTer depending on whether the child was placed by the public 

agency a nonprofit provider or {Or profit provider? 

The Division of Licensed Resources completes all child abuse or neglect investigations in foster care, 

regardless whether the home is licensed directly by DSHS, or certified through a private agency 

provider. When there is a substantiation of child abuse or neglect, licensing action (revocation of the 

license) is nearly always taken. DLR initiates the action for revocation of the license, regardless of the 

supervising agency or the profit/non-profit status. In addition to following through with the CAPT A 

process, a home is not considered revoked until the 28-day time period for the family to request an 

administrative hearing has passed, or the hearing was held and the Department's actions upheld. If there 

was a child remaining in the home pending the outcome of a revocation, there would typically be a 

recommendation to remove the child from the placement. For the child in the care and custody of the 

Department to remain, shared decision-making with upper management would be required. Because the 

child welfare system is not privatized in the State of Washington, all placements of children in the 

Department's custody are managed by public child welfare. 

Please contact me if you require further information or explanation about the information contained. 

Sincerely, 

dB-· 

Jennifer A. Strus, Assistant Secretary 

Children's Administration 
209 


26354.173

STATE OF WEST VIRGINIA 

DEPARTMENT OF HEALTH AND HUMAN RESOURCES 

Earl Ray TQmblin 

Governor 

Bureau for Children and Families 

Commissioner's Ortice 

350 Capitol Street, Room 730 

Charleston, West Virginia 25301-3711 

Telephone: (304) 558-0628 Fax: (304) 558-4194 

The Honorable Orrin G. Hatch 

Chairman, Committee on Finance 

United States Senate 

Washington, DC 20510-6200 

The Honorable Ron Wyden 

May 22,2015 

Ranking Member, Committee on Finance 

United States Senate 

Washington, DC 20510-6200 

Dear Senators Hatch and Wyden: 

Karen L. BQwling 

Cabinet St:cretary 

Please find the following to be West Virginia's response to your request for 

information in regards to the public-private partnerships within the foster care system. 

Question 1: To the degree applicable, describe your state's utilization of private 

entities to provide case management services (e.g., placement of 

children with particular foster care providers, ongoing casework and 

oversight of foster care placements). 

In West Virginia, the Department of Health and Human Resources (otherwise 

known as DHHR) contracts with private non-profit and for-profit agencies to provide 

certain foster care case management services. As of April30, 2015,1,013 children 

were placed in therapeutic foster care agency foster homes out of a total of 4,522 

children in out-of-home placement. 

These private agencies are responsible for case management; however, the 

DHHR is still required to provide case management services to the children and 

families. The private agencies are required to visit the child in their foster home twice a 

month, whereas the DHHR social worker is required to see the child once every three 

months in the foster home. Both the DHHR social worker and the private agency are 

required members of the Multidisciplinary Treatment Team (MDT) for the cases of the 

children who are placed with them. Additionally, the private agencies are required to 
210 


26354.174

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

May 22, 2015 

Page 2 

provide monthly reports to the DHHR social worker on the status of the child and their 

current placement 

Question 2: What proportion of the children in foster care in your state is placed 

by the public agency, not-for-profit providers, and for-profit 

providers? 

West Virginia does not have private foster care. All placements are made by the 

DHHR, which is the public child welfare agency. We are solely responsible for the 

removal and placement of children who are in State custody. We contract with private 

agencies only to provide foster care and foster care case management services, but all 

of the children are in the custody of the State and the DHHR. The DHHR remains fully 

responsible for the care of the children and oversees the services provided by the 

contracted not-for-profit and for-profit agencies. 

Question 3: Please provide the number and names of private entities providing 

these core services, as well as information on whether each provider 

is a for-profit or not-for-profit entity, 

In West Virginia, there are ten (10) agencies with whom the OHHR contracts to 

provide foster care services to the children in State custody. These agencies are: 

1. National Youth Advocate Program 

2. NECCO 

3. The Potomac Center 

4. Genesis Youth Crisis Center 

5. KVC West Virginia 

6. Press!ey-Ridge 

7. B&T/ResCare 

8. Children's Home Society 

9. Burlington United Methodist Family Services 

10. Try-Again Homes 

(not-for-profit) 

(for-profit) 

(not-for-profit) 

(not-for -profit) 

(not-for -profit) 

(not-for-profit) 

(for-profit) 

(not-for-profit) 

(not-for-profit) 

(not-for-profit) 

Question 4: Does your state require that private foster care entities or 

organizations operating in your state be accredited? If so, by which 

organization and how often is this accreditation renewed? 

West Virginia does not require the foster care agencies to be accredited. Several 

of the agencies are accredited, however, through COA, and Burlington United Methodist 

Family Services is accredited by Eagle Accreditation Commission. 
211 


26354.175

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

May 22, 2015 

Page 3 

Question 5: Describe in detail the process you use to select and contract with 

these private entities, as well as to review and renew such contracts. 

Specialized Foster Care Contracts are limited to those agencies that apply to 

provide specialized foster care services and are granted a child placing license by the 

Bureau's licensing staff. Contracts are reviewed annually and updated as needed. 

Content of the contracts is determined with input from program, field, finance, 

administrative, and provider staff. Contracts are null and void upon the loss of a child 

placing license. 

Question 6: Describe in detail the process your state uses to inspect the safety of 

the foster care settings in which children are placed and the extent to 

which this process differs for public, not-for-profit, and for-profit 

providers operating in your state. 

The licensing process in West Virginia is the same for all providers. All providers 

go through the Certificate of Need (CON) process. This is a very long and detailed 

process. It is outlined and explained in detail on this website: 

http://www. hca. wv. g ov/certificateofneed/Pages/defa ultaspx. 

Depending on the service to be provided, a provider may be able to go through 

the Summary Review Process and would not be required to go through the entire CON 

process. To be eligible for the Summary Review, the provider must meet the 

requirements laid forth in West Virginia Statute 49-7-30 found at: 

http/lwww. legis. state. wv. us!VVVCODE/ChapterEntire. cfm?chap=49&art=7 §ion=30#07. 

Question 7: How many instances of abuse in a foster care placement have been 

substantiated in the last five years in your state? Of those 

substantiated, how many of these instances related to children 

placed by: not-for-profit providers, for-profit providers, and public 

providers? 

In the past five (5) years, there have been 63 cases of substantiated abuse in a 

foster care in placement in West Virginia. Since the DHHR is the only child welfare 

provider in the state, all of these children were placed by the state agency. 

Question 8: Describe in detail the actions taken when an abuse claim is 

substantiated while a child is in an out-of-home placement? Do 

these actions differ depending on whether the child was placed by 

the public agency, a not-for-profit provider, or a for-profit provider? 
212 


26354.176

The Honorable Orrin G. Hatch 

The Honorable Ron Wyden 

May 22, 2015 

Page 4 

Once an investigation on an out-of-home placement is completed, the 

investigating worker will prepare a copy of the Institutional Investigation Unit (IIU) I Child 

Protective Services (CPS) Summary Report, save it within the Statewide Automated 

Child Welfare Information System (SACWIS), and send the report and all pertinent 

information to the IIU Supervisor. The IIU Supervisor will then review and approve the 

investigation and report as indicated. Upon supervisory approval, the investigating 

worker will then provide a copy of the IIUICPS Summary Report to the agency (if the 

home is through one of the specialized foster care agencies) or to the Regional 

Homefinding Supervisor. That worker will also notify the Regional Program Manager for 

Social Services, the Community Services Manager, and the Residential Licensing 

Specialist (if applicable) by e-mail of the findings of the investigation. 

The Regional Homefinding Supervisor or Residential Licensing Specialist will 

then determine policy or licensing violations based on the information provided within 

the "IIUICPS Summary Report." If non-compliance is identified in group residential 

facilities or specialized foster care agencies, the Residential Child Care Licensing 

Specialist will direct the specialized foster care agency or group residential facility to 

develop a time-limited Corrective Action Plan. For West Virginia's DHHR foster family 

homes, the Regional Homefinding Supervisor will direct the Homefinding Specialist to 

develop a time-limited Corrective Action Plan. The development of all Corrective Action 

Plans must not exceed thirty (30) days. 

The investigative worker must notify the foster family home in writing that foster 

care arrangements are being terminated and provide a copy of the "IIU/CPS Summary 

Report" when it is determined that child abuse or neglect occurred in a foster family 

home (per WV Code 49-2-14). For investigations resulting in a Corrective Action Plan, 

the Residential Licensing Unit or Regional Homefinding Unit will ensure that all the 

problems identified in the investigation that contributed to abuse or neglect or noncompliance with regulations or policies are adequately addressed in the Corrective 

Action Plan. 

If you have any additional questions or if we can assist you further regarding 

West Virginia's policy and practices relative to privatized foster care, please let us know. 

/sv 

Sincerely, 

~ Q--Q._,....__) N.E~~ issioner 
213 


26354.177

May 28,2015 

201 East Washington Avenue, Room G200 

P.O. Box 8916 

Madison, Wl53708-8916 

Telephone: 608-266-ll684 

Fax: 608-261-6972 

The Honorable Orrin G. Hatch 

Chairman 

The Honorable Ron Wyden 

Ranking Member 

United States Senate 

Committee on Finance 

Washington, D.C. 20510-6200 

Dear Senators Hatch and Wyden, 

Governor Scott Walker 

Secretary Eloise Anderson 

Secretary's Office 

This letter responds to your April24letter to all Governors requesting information related to the use 

of contractors in the state's child welfare system. Attached is information responding to each 

requested item. 

As noted in the responses, contractors play a limited, but important role, in Wisconsin's child welfare 

system. Wisconsin contracts with providers that are able to provide services more effectively via 

external contractors or services for which there is no state capacity, such as residential treatment 

facilities. The state's contracting and licensing structures provide the necessary protections and 

requirements to ensure that children are served in a safe and effective way and that the state's 

programmatic objectives are met. We consider it important that the state have the flexibility to utilize 

contractors when it is efficient and effective to do so and view our external contractors as constructive 

partners in the child welfare system. 

I trust that you find the enclosed information helpful. 

Sincerely, 

Cc: Govemor Scott Walker 

Becky Shipp, Senate Finance Committee 

Laura Berntsen, Senate Finance Committee 

DCF-F-22-E (R 0812013) www,~ctwisconsin<gov 
214 


26354.178

State of Wisconsin: Response to April 24 letter 

I. Describe your state's utilization of private entities to provide case management services. 

Wisconsin has a state-supervised/county-administered child welfare system with the exception of the largest 

county, Milwaukee County, where the child welfare system is administered directly by the state through the 

Department of Children and Families (DCF). In Milwaukee, state (i.e., public) employees carry out the 

intake and assessment/investigation functions. DCF contracts with external agencies for case management 

of out-of-home care and intensive in-home cases. DCF is currently contracting with the following two 

agencies for case management services in Milwaukee County: Children's Hospital of Wisconsin 

Community Services (also known as Children's Service Society of Wisconsin) and SaintA. Both contracted 

agencies are not-for-profit. 

Contracted case management agencies are required to follow state-issued standards, policies, and procedures 

that are applicable to public county agencies as well. The current contracts with both case management 

agencies require the following major areas of responsibility: 

• To provide for the pennanency, safety, and well-being of each child in care. Planning for these 

services includes goal-directed, time-limited, and measurable activities designed to help children live 

safely in permanent families. This process provides children continuity in their relationships with 

nurturing parents o~ caretakers and the opportunity to establish or maintain life-long family 

relationships. 

• To provide services to address barriers to reunification or permanency and maintain accurate and 

timely documentation in case tiles of all significant case activity. 

• To conduct family-centered assessments and develop case plans that identify and implement essential 

services to enhance parental capacity to provide a safe environment and to provide an environment 

free of current and future incidents of abuse and/or neglect and provide for permanency for the 

child(ren). 

• To ensure that all children in out-of-home care receive medical and dental care in accordance with 

the schedule ofthe Wisconsin Medicaid Health Check program reflecting well-child health 

periodicity. 

• To develop the pennanency plan with the family and to document it within 60 days from the day the 

child was removed from his/her home. 

• To ensure the ongoing case manager will have twice monthly face-to-face contact with all children 

three years of age and younger and other children deemed in need of more frequent contact under as 

outlined in the IlMCW policies and procedures. 

• To ensure permanency consultations occur for every child entering their 5th, lOth, and 15th month in 

out-of-home care. In addition, permanency consultations must occur periodically for any child in 

care longer than IS months with a current legal permanency status below good. 
215 


26354.179

• To provide or purchase and coordinate intense specialized in-horne services to support families in 

alleviating crisis and maintain children safely in their own homes, The majority of services are to be 

provided in the family's horne or other natural setting. ln all cases, the home environment must be 

safe for the child, family, in-home worker, and community to maintain the child within the home. 

The remaining 71 counties in Wisconsin, other than Milwaukee, do not contract with external 

agencies for child welfare case management services. 

2. What proportion of the children in foster care is placed by the public agency, not-for-profit providers, 

andfor-projlt providers? 

As of December 2014, Milwaukee County, which uses non-profit case management contractors, 

accounts for 33% of the state's foster care population. The remaining 67% of children in foster care 

in non-Milwaukee counties use public (i.e., county) child welfare case managers, 

3. Provide the number and name of private entities and information on for-profit/non-profit status. 

Information provided in response to Question I. 

4. Does the state require that private foster care entities or organizations be accredited? 

No. 

5. Describe the process used to select and contract with the case management agencies and the process to 

review and renew these contracts 

DCF used the competitive Request for Proposal (RFP) process specified in state law and policy to 

select the Milwaukee County child welfare case management agencies, Under the RFP process, 

interested proposers were required to respond in a thorough manner to a number of criteria that 

included the agency qualifications to provide ongoing and intensive in-home services and the 

agency's detailed plans to achieve the requirements of the proposaL This RFP included all 

language and obligations required by federal law and state statutes as well as the standard terms 

and conditions of state requirements. Programmatic requirements of the RFP were written by 

Department stafffamiliar with, and expert in, the requirements of the ongoing and intensive inhome programs. 

The evaluation committee to review and score the RFP was composed of members selected 

because of their special expertise and knowledge of the services that were the subject of this RFP. 

Evaluation committee members included individuals outside ofthe Department of Children and 

Families. 

The Milwaukee child welfare case management contracts include outcome-based performance 

measures which are reviewed by DCF staff and shared publicly on a monthly and quarterly basis. 

The proportion of referrals each of the two agencies receives is based on the agencies' annual 

performance on the outcome metrics related to placement stability and achievement of legal 

permanency; with the stronger performing agency receiving relatively more referrals. DCF is able 

to require corrective action plans if a contracted agency has significant variance from the 

benchmarks. The benchmarks that are monitored and evaluated include, primarily, satisfactory 

performance in the areas of placement stability, safe reunification and the achievement of legal 

pe1manency. These benchmarks are in compliance with federal standards as well as with a courtnegotiated settlement regarding child welfare service in Milwaukee County. 

2 
216 


26354.180

The current Milwaukee case management contracts went into effective in January 2012. The initial 

contracts were for a two year period with the opporttmity for an additional three two-year renewals, 

for a maximum total period of eight years. The Department will undertake a competitive RFP 

process, as described above, to select the case management agencies when the current contract is 

no longer in effect. 

6. Describe the process the state uses to inspect the safety of the foster care settings in which 

children are placed and the extent to which this process differs for public, non-profit, and for 

profit providers. 

The process of inspecting and assuring the safety of foster care settings is specified in state statute 

and administrative rules. The same process is applied to public, non-profit, and for profit providers. 

• Group Homes, Residential Care Centers, and Shelters (congregate care settings): Group 

homes, residential care centers (RCCs) and shelters are required to be licensed. Initial 

licenses are granted following the successful completion of an application, which includes 

the background checks required under state statute (s. 48.685(2)(am)), as well as multiple 

background checks on the entity. A physical inspection of the facility, a review of 

environmental hazards by the planning commission the facility is located in, a fire inspection 

by the local fire department, and a review of the agencies policies and procedures also 

occurs. An agency is issued a probationary license and is inspected in accordance with state 

statute (s. 48.69). Upon successful completion of the probationary period, an agency may 

apply for a regular license, at which time all background checks under state statute (s. 

48.685(2)(am)) are redone. Licensees and employees of all agencies are required to submit 

backgrotmd check information to DCF monthly to enter into the state child welfare SACWIS 

information system. In addition, DCF staff ensures compliance with safety checks by 

reviewing staff and child files and conducting monitoring visits to facilities every six 

months, and investigating complaints and serious incident reports. When an issue arises, 

DCF issues corrective action and follows up with the provider to ensure compliance. If 

compliance cannot be ensured, DCF may pursue revocation of the license. 

• Family Foster Care: DCF oversees both public and private child placing agencies that 

license foster homes on behalf of the Department in accordance with state statute (Ch. 48.75 

and 48.62). All State of Wisconsin foster care licenses must be issued by a county agency or 

private child placing agency licensed by DCF. DCF staff licenses private child placing 

agencies and monitors for compliance with state administrative rule and ensures that the 

licensing agency has completed all necessary background checks, physical environment 

inspections, a home study, disaster plan, has home owners/vehicle insurance, etc. to ensure 

child safety. Private child placing agencies are required to submit safety related check 

information to DCF to enter into the child welfare SACWIS infonnation system. DCF staff 

regularly review foster home licenses for compliance with safety checks. When an issue 

arises with a foster home, DCF staff follow up with the appropriate licensing agency 

regardless of whether it is a public or private agency. A private child placing agency may be 

3 
217 


26354.181

subject to regulatory actions for licensing violations. If a county is in violation a corrective 

plan will be implemented. Because the child placing agency is responsible for monitoring 

the individual foster homes, DCF staff do not physically inspect foster homes other than 

Level 5 foster homes or unless an issue requires an inspection of the home as permitted 

under state statute. 

7. How many instances of abuse in a foster care placement have been substantiated in the last five 

years? Of those substantiated, how many related to children placed by not-for-profit,for-profit, 

and public providers? 

As noted above, Milwaukee County uses contracted non-profit case management agencies for all 

children placed in foster care. The chart below shows the number in each ofthe last five years of 

cases of maltreatment of children in out-of-home care. The blue sections ofthe chart represent 

cases in Milwaukee (BMCW stands for Bureau of Milwaukee Child Welfare) which were handled 

by the non-profit case management agencies and the orange sections of the chart represent the 

remaining non-Milwaukee counties (BOS stands for Balance of State) which were handled by 

public case management agencies. 

70 

Substantiated Maltreatment while in OHC 

bO +-------··---

8. Describe the actions taken when an abuse claim is substantiated while a child is in out-ofhome 

placement. Do these actions differ depending on whether the child was placed by the public 

agency, not-for-profit, or for-profit provider? 

All decisions to screen in/out a report regardless of a child's placement is completed in accordance 

with the state Access/Initial Assessment Standards which requires the cotmty child welfare agency 

or DCF (in the case of Milwaukee) to inform DCF or the licensing agency of any alleged 

maltreatment in a licensed facility or foster home, respectively. It is important to note that an 

incident may not meet the standard of child abuse or neglect, but may still violate licensing 

regulations. 

4 
218 


26354.182

When an Initial Assessment is initiated and substantiated for a child in out-of-home care, the 

county child welfare agency or DCF (in the case of Milwaukee) notifies the DCF licensing staff 

and the private child placing agency, if the case involves a foster home licensed by that child 

placing agency. 

For congregate care settings licensed by the DCF, DCF licensing staff review the substantiation 

information and conduct an investigation of the incident to determine any other licensing 

violations. DCF licensing staff deteJmine the appropriate regulatory response, which can include 

revocation of the facility license. 

In the case of a substantiated maltreatment in a licensed foster home, the licensing agency must 

revoke a foster care license as it is a barred offense for foster care licensure to have a substantiated 

finding of abuse/neglect. Additionally, private child placing agencies must inform DCF of the 

licensing revocation. 

If the maltreatment in out-of-home care involves a child death, serious injury, or egregious 

incident, DCF follows the public disclosure and review process established in state statute and 

Department policy for all cases of child death, serious injury, or egregious incident due to 

maltreatment. 

Licensed congregate care and private child placing agencies are required to submit a Serious 

Incident Report regarding any alleged child abuse or neglect to DCF. 

The actions taken in response to substantiation of maltreatment do not differ depending on whether 

the child was placed by the public agency, not-for-profit, or for-profit provider. 

5 
219 


26354.183

WYOMING DEPARTMENT of 

Family Services 

June 12,2015 

Orrin Hatch 

United States Senate 

104 Hart Office Building 

Washington, DC 20Sl0-6200 

REF: SC-15-077 

RE: State Utilization of Private Foster Care Entities 

Department of Family Services 

Dear Chairman Hatch and Ranking Member Wyden, 

2300 Capitol Avenue 

Third Floor Hathaway Bldg 

Cheyenne, WY 82002-0490 

Tel: 307.777.7564 

Fax: 307.777.7747 

dfsweb.wyo.gov 

The State of Wyoming received correspondence from the United States Senate, Committee on 

Finance, dated April24, 2015, requesting information regarding the State's use of foster care 

placements and the use of foster care placing entities in Wyoming. In order to provide concise 

infonnation and answers regarding Wyoming's foster care system and to succinctly address the 

Senate's inquiry, the information provided in this document pertains only to foster care 

placements in a single family home setting with foster parents and does not include information 

regarding con 4, 2015 

gregate care placements. 

The State of Wyoming maintains placement and care responsibility for all children placed in the 

Department of Family Service's (Agency) custody and under no circumstances does the Agency 

contract with private placement providers to act fully on behalf of the Agency to overs"e and 

provide all foster care activities and services. 

The following responses correspond to the bullet-point questions posed by the Senate Committee 

on Finance in the letter dated April24, 2015: 

• The Agency is a service agency and does not have placement authority, however, the 

Agency is the placing agency for children court ordered to Agency custody. All children 

placed in foster care by the Agency are court ordered to foster care and remain in the 

physical and legal custody of the Agency. The Agency does not give private entities legal 

custody or placement and care authority of children placed in the custody of the 

Agency. 

Steve Corsi, Director Matthew H. Mead, Governor 
220 


26354.184

WYOMING DEPARTMENT of FAMILY SERVICES 

Two not-for-profit child placing entities, YES (Youth Emergency Services) House and 

Catholic Charities of Wyoming, and one not-for-profit therapeutic foster care entity, 

Central Wyoming Counseling Center, provide limited foster care services for children in 

the physical and legal custody of the Agency. For example, a child may be placed at YES 

House, and as part of the YES House services, the child is assigned to a family home 

instead of residing in the congregate care building. Additionally, Catholic Charities of 

WY and Central Wyoming Counseling Center may assist in matching children with 

appropriate certified foster homes while the Agency oversees all case management 

services. The YES House, Catholic Charities of WY, and Central Wyoming Counseling 

Center are paid a child placing administration fee and the foster homes are paid a 

standard foster care rate. At all times, the Agency retains physical and legal custody of 

the child and maintains oversight and case management responsibilities, including faceto-face contact with foster children. At no time are the two entities' services used in place 

of the Agency's. Rather, the foster care services are in addition to the Agency's case 

management and oversight. 

• 100% of children placed in foster care in Wyoming are placed through the Agency as the 

Agency has physical and legal custody in addition to care responsibility of all foster care 

children. 

• Three entities provide home-setting foster care services in WY while the Agency retains 

full legal and physical custody of the children. These are: 

YES House (Youth Emergency Services), non-profit; 

Catholic Charities of WY, non-profit; and 

Central Wyoming Counseling Center, non-profit. 

These entities do not replace the Agency but offer services in cooperation with and in 

addition to the Agency. 

• Wyoming does not require private foster care entities to be accredited, however, many 

are. All facilities and homes in which a child will be placed overnight are certified or 

licensed directly through the Agency. 

• All foster care services are selected through a licensing and certification process as 

required by the Certification of Providers of Substitute Care Services rules. 

• Fingerprint based criminal history screens, child abuse and neglect central registry 

screens, and references are required for all adults living in a foster home. Agency 

workers meet face-to-face with all children in the Agency's custody monthly at a 

minimum. All foster care settings in Wyoming are inspected and certified through the 

Agency regardless of whether the Agency's population is placed in such setting or not. 

Wyoming law requires Agency certification for all places where a child will be placed 

over night. Certified foster homes are reviewed annually and certification can be 

Steve Corsi, Director Matthew H. Mead, Governor 
221 


26354.185

WYOMING DEPARTMENT of FAMILY SERVICES 

revoked at any time with Agency Director approval due to, but not limited to failure of 

foster parent to maintain standards as required, refusal to cooperate with an 

investigation, or a substantiated finding of abuse or neglect. The inspection and 

certification process does not differ because of the providers' public, non-profit, or forprofit status. 

• One instance of abuse has been substantiated in a foster care placement in the last five 

years. The foster care placement was through the Agency. 

• Per policy, the Agency investigates or assesses all allegations of child abuse or neglect 

and violations of certification standards made against foster homes. When an allegation 

of abuse is made against a child's out-of-home placement provider, a special 

investigation is initiated and safety precautions are put into place prior to substantiation 

through use of a Safety/Risk Assessment, written Safety Plan, and Family Services Plan, 

and possible removal of children placed in the home. In-person contact is made 

immediately ifthe child in imminent danger as classified by rules, statute, and operating 

policy. The Agency's lead Attorney General and Division Administrator are alerted for all 

special investigations and law enforcement is notified if allegations contain possible 

criminal behavior. When an allegation of abuse is substantiated, the foster care 

certification may be revoked with approval from the Agency Director. 

I am pleased the Senate Committee on Finance has taken an interest in the welfare of foster 

children and youth. As demonstrated by Wyoming's safety record and financial investments, 

Wyoming has been and will continue to remain committed to the safety, well-being, and 

permanency of our foster youth and all children. The state looks forward to the results of the 

Committee on Finance's inquiry and any communication from the Committee regarding 

improvements in the foster care system. 

Sincerely, 

Steve Corsi 

Director 

SC/rc 

Cc: Marty Nelson 

Steve Corsi, Director Matthew H. Mead, Governor 
222 

Appendix C 

223 


26354.186

Oll'!!,U,Ml'H11~ <,IJ\il- iJifllCl!ll\ 

->()SHt!ll'·;Ht"<IKMAl> lJfMOi'H.~ll( C:ll\lf tlHHCfnf< 

Clyde L. Reese III 

'llflitcd ~totes rSmatr COIV·M!TlTF ON fiNAI\!CF 

WNiHINt\!ON, DC 70510., 6?00 

March 3, 2016 

Commissioner, Department of Community Health 

Two Peachtree Street, NW 

40th Floor 

Atlanta, Georgia 30303 

Dear Commissioner Reese: 

Since April of2015, the United States Senate Committee on Finance (Committee) has been 

conducting an investigation into the states' use of private entities, and particularly for-profit 

entities, to serve as child placement agencies in the administration of state foster care programs. 

As you are aware, these state programs are funded under Title IV-E of the Social Security Act 

This letter is a follow-up to the letter we sent your state on April24, 2015, in which we requested 

information about your state's experience in contracting with private entities to administer 

portions of the state's foster care program. 1 

Our interest in the use of private foster care providers is prompted in large part by a number of 

deeply disturbing stories appearing in the media in the recent past. Those stories recount lapses 

in judgment and mistakes by a for-profit child placement entity in the screening, recruitment, 

training and monitoring of foster parents that resulted in the placement of children, who 

represent the most vulnerable segment of our society, into the homes of individuals wholly 

unsuited to discharge the duties of foster parents 2 Tragically, a number of these children died 

while in the care and custody of these foster parents, while other children were abused, neglected 

or physically injured. 

1 We are certain that you share our commitment to protect the wellbeing of the many children whose difficult 

circumstances necessitate their removal from parental control and placement in foster homes. Therefore, please 

provide a response to the letter of April24, 2015 at your earliest convenience so as to assist the Senate Finance 

Committee in its investigation. 

'~ for example: Mother Jones, Brian Joseph: The Brief Life and Private Death of Alexandria Hill (Feb, 26, 

2015); BuzzFeed Ne·ws, Aram Roston and Jeremy Singer: Fostering Profits (Feb. 20, 2015); and BuzzFeed News, 

Aram Roston: In an Unmarked Grave, a Baby's Untold Story (June 18, 2015). 
224 


26354.187

One of the many issues being examined by the Committee is the soundness, from a public policy 

perspective, of permitting for-profit entities to operate as child placement agencies. It is argued 

by some commentators that such entities are ill-suited to discharge the functions of child 

placement agencies, since their pursuit of profit could interfere with their responsibility to 

safeguard the interests of the children under their care. 

The Title IV -E foster care program is a child welfare program under the Social Security Act. 

Consequently, it falls within the oversight jurisdiction of the Committee. As Chairman and 

Ranking Member of the Committee, we are writing to you to secure information necessary to 

advance the Committee's understanding of how well both for-profit and non-profit child 

placement agencies under contract with your state protect the interests of the children who fall 

under their care. 

In accordance with the Committee's oversight responsibility for the Title IV-E program, we 

request that you provide the following information no later than close of business April 1, 2016: 

I. Identify all child placement agencies (both non-profit and for-profit non-public providers that 

carry out responsibilities related to case planning, including permanency planning, and 

review for children in foster care (collectively, "Contractors"), under contract in your State to 

provide foster care services at any time from January 20 I 0 to the present, and the dates when 

those agencies began to provide these services, and when, if applicable, they terminated; 

2. For each individual Contractor, provide the following performance measures,3 for each year 

2010 through 2015: 

a. Total number of children served by such contractor during the year;4 

b. Of this total number of children served by such contractor during each year, identify 

the number and percentage of children in the following subgroups: 5 

i. Special needs children (general category) 

ii. Physically disabled children 

iii. Children with special mental/emotional/behavioral health needs 

3 In the interest of identifying measures for which statewide data should be readily available, several ofthese 

performance measures mirror the Statewide Data Indicators used by the Administration for Children and Families' 

Children's Bureau in conducted the Child and Family Services Reviews (CFSR). The Statewide Data Indicators are 

described in detail in CFSR Technical Bulletin #SA and the Final Notice of Statewide Data Indicators and National 

Standards for Child and Family Services Reviews Executive Summary-Amended (both published May 13, 20 15). 

4 The CFSR literature defines the statewide version of this measure as "all children who were served in foster care 

during the 12-month target period." This measure should include the total number of children served by the 

Contractor at any time during each year in question. 

' This measure is included to account for the fact that particular contractors may be qualified and relied upon to 

serve the needs of particular subgroups of children entering foster care. If necessary for purposes of specificity, 

please provide any working definitions or tests used to classify children within particular subgroups. 
225 


26354.188

iv. Infants 

v. Older youth 

c. Total number and percentage of children served whose placement was moved 

sometime during the year;6 

d. Of all children who entered foster care each year and were discharged within one year 

(to reunification, living with a relative, or guardianship), total number and percentage 

who re-entered foster care within one year of their discharge. 7 

e. Total number and percentage of substantiated or indicated reports of maltreatment (by 

any perpetrator) during a foster care episode;8 

f. Of all children who were victims of a substantiated or indicated maltreatment report 

during each calendar year, total number and percentage of children who had a second 

substantiated or indicated maltreatment report within one year oftheir initial report; 9 

g. Number and percentage of children served who, within one year, achieved the 

following permanency outcomes: 10 

i. Reunification; 

ii. Adoption; 

iii. Guardianship; 

iv. Another planned permanent living arrangement; 

h. Number and percentage of children entering into care who have siblings placed in the 

same living arrangement; 

i. Number and percentage of children entering into care who are placed with relatives; 

j. Number and percentage of children entering foster care who received a full initial 

physical and mental health assessment within 60 days; 

6 CFSR measure: Placement stability 

7 CFSR measure: Re-entry to foster care in 12 months 

s CFSR measure: Maltreatment in foster care 

' CFSR measure: Recurrence of maltreatment 

10 CFSR measures: Permanency in 12 months for children entering foster care 
226 


26354.189

k. Number and percentage of children entering foster care for whom permanency goals 

were established in a timely manner; 11 

l. Number and percentage of children served who received monthly caseworker visits; 

m. The total cost to the state, county, or local government of services provided under the 

contract. 

n. Average caseload for each caseworker employed by the Contractor. 

3. For each measure identified above, please provide the same performance measure for the 

state foster care system as a whole, for each year 2010 through 2015. 

4. Provide a copy of any performance rankings, ratings, or reviews of Contractors prepared by 

your agency for years 2010 through 2015. 

5. Provide any additional information regarding individual Contractor performance that you 

believe may warrant our attention. 12 

6. Provide all performance and investigative reports and evaluations of Contractor placement 

agencies that are subsidiaries or affiliates of National Mentor Holdings, Inc., that have been 

prepared by or issued by the State, or by the contracting entity within the State, from January 

20 I 0 to the present. The term "investigative reports" includes reports relating to the death, 

sexual abuse or injury to a child while in the care/custody of foster parents recruited or 

employed by subsidiaries or affiliates of National Mentor Holdings, Inc. 

7. Provide the name and contact information of a state official with whom Committee staff may 

communicate to resolve any questions regarding the operation of the state's foster care 

program, and in particular, the use by the state offor-profit child placement agencies. 

11 In answering this question, please identity the timeframe in which your agency seeks to establish permanency 

guidelines for each child entering into foster care. 

12 Such information may include observations about individual Contractors' performance in the following areas, 

which may be difficult to quantity in a single measure: thoroughness in conducting criminal background checks of 

potential foster parents; timely reporting of credible claims of abuse and neglect; provision of adequate training to 

caseworkers, etc. 
227 


26354.190

We thank you for your prompt attention to this request. Please submit your response in 

electronic format to Kim Brandt, Chief Oversight Counsel (Majority), 

(hirn_llii!.DQ@inancc.scnills:,J~DY) and to David Berick, Chieflnvestigator (Minority), 

(g;!_yid bcricktaitinanc.<;,'.i;ll<!1C.gov). Any questions may be directed to Ms. Brandt at 

(202) 224-45 I 5 or to Mr. Berick at (202) 224-6399. 

Orrin G. Hatch 

Chairman, Senate Finance Committee 
228 


26354.191

United ,States ,Senate COMMlTTfC Or>.l f!NANC! 

W/\'3H\Nt~10N, DC :?OG10-6?00 

March 3, 2016 

George H. Sheldon 

Acting Director 

Department of Children and Family Services 

406 Monroe Street 

Springfield, Illinois 62701-1498 

Dear Acting Director Sheldon: 

Since April of2015, the United States Senate Committee on Finance (Committee) has been 

conducting an investigation into the states' use of private entities, and particularly for-profit 

entities, to serve as child placement agencies in the administration of state foster care programs. 

As you are aware, these state programs are funded under Title IV -E of the Social Security Act. 

This letter is a follow-up to the letter we sent your state on April24, 2015, in which we requested 

information about your state's experience in contracting with private entities to administer 

portions of the state's foster care program. We thank you for the response provided to the 

Committee by your Department. 

Our interest in the use of private foster care providers is prompted in large part by a number of 

deeply disturbing stories appearing in the media in the recent past. Those stories recount lapses 

in judgment and mistakes by a for-profit child placement entity in the screening, recruitment, 

training and monitoring of foster parents that resulted in the placement of children, who 

represent the most vulnerable segment of our society, into the homes ofindividuals wholly 

unsuited to discharge the duties of foster parents. 1 Tragically, a number of these children died 

while in the care and custody of these foster parents, while other children were abused, neglected 

or physically injured. 

One of the many issues being examined by the Committee is the soundness, from a public policy 

perspective, of permitting for-profit entities to operate as child placement agencies. It is argued 

by some commentators that such entities are ill-suited to discharge the functions of child 

1 See, for example: Mother Jones, Brian Joseph: The Brief Life and Private Death of Alexandria Hill (Feb. 26, 

2015); BuzzFeed News, Aram Roston and Jeremy Singer: Fostering Profits (Feb, 20, 2015); and BuztFeed News, 

Aram Roston: In an Unmarked Grave, a Baby's Untold Story (June !8, 2015), 
229 


26354.192

placement agencies, since their pursuit of profit could interfere with their responsibility to 

safeguard the interests of the children under their care. 

The Title IV -E foster care program is a child welfare program under the Social Security Act. 

Consequently, it falls within the oversight jurisdiction of the Committee. As Chairman and 

Ranking Member of the Committee, we are writing to you to secure information necessary to 

advance the Committee's understanding of how well both for-profit and non-profit child 

placement agencies under contract with your state protect the interests of the children who fall 

under their care. 

In accordance with the Committee's oversight responsibility for the Title IV-E program, we 

request that you provide the following information no later than close of business April!, 2016: 

1. IdentifY all child placement agencies (both non-profit and for-profit non-public providers that 

carry out responsibilities related to case planning, including permanency planning, and 

review for children in foster care (collectively, "Contractors"), under contract in your State to 

provide foster care services at any time from January 2010 to the present, and the dates when 

those agencies began to provide these services, and when, if applicable, they terminated; 

2. For each individual Contractor, provide the following performance measures? for each year 

2010 through 2015: 

a. Total number of children served by such contractor during the year;3 

b. Of this total number of children served by such contractor during each year, identifY 

the number and percentage of children in the following subgroups:4 

i. Special needs children (general category) 

ii. Physically disabled children 

iii. Children with special mentaVemotional/behavioral health needs 

iv. Infants 

v. Older youth 

'In the interest of identifying measures for which statewide data should be readily available, several of these 

perfonnance measures mirror the Statewide Data Indicators used by the Administration for Children and Families' 

Children's Bureau in conducted the Child and Family Services Reviews (CFSR). The Statewide Data Indicators are 

described in detail in CFSR Technical Bulletin #SA and the Final Notice of Statewide Data Indicators and National 

Standards for Child and Family Services Reviews Executive Summary-Amended (both published May 13, 2015). 

3 The CFSR literature defines the statewide version of this measure as "all children who were served in foster care 

during the 12-month target period." This measure should include the total number of children served by the 

Contractor at any time during each year in question. 

4 This measure is included to account for the fact that particular contractors may be qualified and relied upon to 

serve the needs of particular subgroups of children entering foster care. If necessary for purposes of specificity, 

please provide any working definitions or tests used to classifY children within particular subgroups. 
230 


26354.193

c. Total number and percentage of children served whose placement was moved 

sometime during the year; 5 

d. Of all children who entered foster care each year and were discharged within one year 

(to reunification, living with a relative, or guardianship), total number and percentage 

who re-entered foster care within one year of their discharge. 6 

e. Total number and percentage of substantiated or indicated reports of maltreatment (by 

any perpetrator) during a foster care episode/ 

f. Of all children who were victims of a substantiated or indicated maltreatment report 

during each calendar year, total number and percentage of children who had a second 

substantiated or indicated maltreatment report within one year of their initial report; 8 

g. Number and percentage of children served who, within one year, achieved the 

following permanency outcomes:9 

i. Reunification; 

ii. Adoption; 

iii. Guardianship; 

iv. Another planned permanent living arrangement; 

h. Number and percentage of children entering into care who have siblings placed in the 

same living arrangement; 

i. Number and percentage of children entering into care who are placed with relatives; 

j. Number and percentage of children entering foster care who received a full initial 

physical and mental health assessment within 60 days; 

k. Number and percentage of children entering foster care for whom permanency goals 

were established in a timely manner; 10 

' CFSR measure: Placement stability 

6 CFSR measure: Re-entry to foster care in 12 months 

7 CFSR measure: Maltreatment in foster care 

'CFSR measure: Recurrence of maltreatment 

'CFSR measures: Permanency in 12 months for children entering foster care 

10 In answering this question, please identity the timeframe in which your agency seeks to establish permanency 

guidelines for each child entering into foster care. 
231 


26354.194

I. Number and percentage of children served who received monthly caseworker visits; 

m. The total cost to the state, county, or local government of services provided under the 

contract. 

n. Average caseload for each caseworker employed by the Contractor. 

3. For each measure identified above, please provide the same performance measure for the 

state foster care system as a whole, for each year 2010 through 2015. 

4. Provide a copy of any performance rankings, ratings, or reviews of Contractors prepared by 

your agency for years 2010 through 2015. 

5. Provide any additional information regarding individual Contractor performance that you 

believe may warrant our attention. 11 

6. Provide all performance and investigative reports and evaluations of Contractor placement 

agencies that are subsidiaries or affiliates of National Mentor Holdings, Inc., that have been 

prepared by or issued by the State, or by the contracting entity within the State, from January 

20 I 0 to the present. The term "investigative reports" includes reports relating to the death, 

sexual abuse or injury to a child while in the care/custody of a foster parent recruited or 

employed by subsidiaries or affiliates of National Mentor Holdings, Inc. 

7. Provide the name and contact information of a state official with whom Committee staff may 

communicate to resolve any questions regarding the operation of the state's foster care 

program, and in particular, the use by the state of for-profit child placement agencies. 

11 Such infonnation may include observations about individual Contractors' perfonnance in the following areas, 

which may be difficult to quantify in a single measure: thoroughness in conducting criminal background checks of 

potential foster parents; timely reporting of credible claims of abuse and neglect; provision of adequate training to 

caseworkers~ etc. 
232 


26354.195

We thank you for your prompt attention to this request. Please submit your response in 

electronic format to Kim Brandt, Chief Oversight Counsel (Majority), 

(J.;im_bn:Jndt(alfi.!l_:m(,:_~,senatc.uov) and to David Berick, Chiefinvestigator (Minority), 

(fl_<!Yi.Q_b.t;ri.s;_!(rai!!nancc.sqml!c.gov). Any questions may be directed to Ms. Brandt at 

(202) 224-4515 or to Mr. Berick at (202) 224-6399. 

Orrin G. Hatch 

~ Ron Wyden 

Chairman, Senate Finance Committee Ranking Member 
233 


26354.196

COMI'V11T rcr 0.\1 1-INANC!-

WA~>H!Nf-i!ON, nc ?0510 G?oo 

OIHI''C·\MI'tll"l ~. ;~lM'f I'IRli:IOH 

!ilSfi:;A ::;litfNKMIIN lk'.o,Hll RAIIi' '>i.'IJ• IIIH! CJflH 

March 3, 2016 

Linda S. Spears 

Commissioner, Department of Children and Families 

600 Washington Street 

Boston, Massachusetts 021 1 I 

Dear Commissioner Spears: 

Since April of2015, the United States Senate Committee on Finance (Committee) has been 

conducting an investigation into the states' use of private entities, and particularly for-profit 

entities, to serve as child placement agencies in the administration of state foster care programs. 

As you are aware, these state programs are fi.mded under Title IV-E of the Social Security Act. 

This letter is a follow-up to the Jetter we sent your state on April24, 2015, in which we requested 

information about your state's experience in contracting with private entities to administer 

portions of the state's foster care program. We thank you for the response provided to the 

Committee by your Department. 

Our interest in the use of private foster care providers is prompted in large part by a number of 

deeply disturbing stories appearing in the media in the recent past. Those stories recount lapses 

in judgment and mistakes by a for-profit child placement entity in the screening, recruitment, 

training and monitoring of foster parents that resulted in the placement of children, who 

represent the most vulnerable segment of our society, into the homes of individuals wholly 

unsuited to discharge the duties of foster parents. 1 Tragically, a number of these children died 

while in the care and custody of these foster parents, while other children were abused, neglected 

or physically injured. 

One of the many issues being examined by the Committee is the soundness, from a public policy 

perspective, of permitting for-profit entities to operate as child placement agencies. It is argued 

by some commentators that such entities are ill-suited to discharge the fi.mctions of child 

1 ~ for example: Mother Jones, Brian Joseph: The Brief Life and Private Death of Alexandria Hill (Feb. 26, 

2015); BuzzFeed News, Aram Roston and Jeremy Singer: Fostering Profits (Feb. 20, 2015); and BuzzFeed News, 

Aram Roston: In an Unmarked Grave, a Baby" s Untold Story (June 18, 20 15). 
234 


26354.197

placement agencies, since their pursuit of profit could interfere with their responsibility to 

safeguard the interests of the children under their care. 

The Title IV-E foster care program is a child welfare program under the Social Security Act. 

Consequently, it falls within the oversight jurisdiction of the Committee. As Chairman and 

Ranking Member of the Committee, we are writing to you to secure information necessary to 

advance the Committee's understanding of how well both for-profit and non-profit child 

placement agencies under contract with your state protect the interests of the children who fall 

under their care. 

In accordance with the Committee's oversight responsibility for the Title IV-E program, we 

request that you provide the following information no later than close of business April I, 2016: 

!. Identify all child placement agencies (both non-profit and for-profit non-public providers that 

carry out responsibilities related to case planning, including permanency planning, and 

review for children in foster care (collectively, "Contractors"), under contract in your State to 

provide foster care services at any time from January 2010 to the present, and the dates when 

those agencies began to provide these services, and when, if applicable, they terminated; 

2. For each individual Contractor, provide the following performance measures,2 for each year 

2010 through 2015: 

a. Total number of children served by such contractor during the year;3 

b. Of this total number of children served by such contractor during each year, identify 

the number and percentage of children in the following subgroups:4 

i. Special needs children (general category) 

ii. Physically disabled children 

iii. Children with special mental/emotional/behavioral health needs 

iv. Infants 

v. Older youth 

2 ln the interest of identifying measures for which statewide data should be readily available, several of these 

performance measures mirror the Statewide Data Indicators used by the Administration for Children and Families' 

Children's Bureau in conducted the Child and Family Services Reviews (CFSR). The Statewide Data Indicators are 

described in detail in CFSR Technical Bulletin #8A and the Final Notice of Statewide Data Indicators and National 

Standards for Child and Family Services Reviews Executive Summary-Amended (both published May 13, 2015). 

3 The CFSR literature defines the statewide version of this measure as "all children who were served in foster care 

during the !2-month target period." This measure should include the total number of children served by the 

Contractor at any time during each year in question. 

4 This measure is included to account for the fact that particular contractors may be qualified and relied upon to 

serve the needs of particular subgroups of children entering foster care. If necessary for purposes of specificity, 

please provide any working definitions or tests used to classify children within particular subgroups. 
235 


26354.198

c. Total number and percentage of children served whose placement was moved 

sometime during the year;5 

d. Of all children who entered foster care each year and were discharged within one year 

(to reunification, living with a relative, or guardianship), total number and percentage 

who re-entered foster care within one year of their discharge. 6 

e. Total number and percentage of substantiated or indicated reports of maltreatment (by 

any perpetrator) during a foster care episode; 7 

f. Of all children who were victims of a substantiated or indicated maltreatment report 

during each calendar year, total number and percentage of children who had a second 

substantiated or indicated maltreatment report within one year of their initial report; 8 

g. Number and percentage of children served who, within one year, achieved the 

following permanency outcomes:9 

i. Reunification; 

ii. Adoption; 

iii. Guardianship; 

iv. Another plarmed permanent living arrangement; 

h. Number and percentage of children entering into care who have siblings placed in the 

same living arrangement; 

i. Number and percentage of children entering into care who are placed with relatives; 

j. Number and percentage of children entering foster care who received a full initial 

physical and mental health assessment within 60 days; 

k. Number and percentage of children entering foster care for whom permanency goals 

were established in a timely marmer; 10 

'CFSR measure: Placement stability 

6 CFSR measure: Re-entry to foster care in 12 months 

' CFSR measure: Maltreatment in foster care 

8 CFSR measure: Recurrence of maltreatment 

' CFSR measures: Permanency in 12 months for children entering foster care 

10 In answering this question, please identify the timeframe in which your agency seeks to establish permanency 

guidelines for each child entering into foster care. 
236 


26354.199

I. Number and percentage of children served who received monthly caseworker visits; 

m. The total cost to the state, county, or local government of services provided under the 

contract. 

n. Average caseload for each caseworker employed by the Contractor. 

3. For each measure identified above, please provide the same performance measure for the 

state foster care system as a whole, for each year 2010 through 2015. 

4. Provide a copy of any performance rankings, ratings, or reviews of Contractors prepared by 

your agency for years 2010 through 2015. 

5. Provide any additional information regarding individual Contractor performance that you 

believe may warrant our attention. 11 

6. Provide all performance and investigative reports and evaluations of Contractor placement 

agencies that are subsidiaries or affiliates of National Mentor Holdings, Inc., that have been 

prepared by or issued by the State, or by the contracting entity within the State, from January 

20 I 0 to the present. The term "investigative reports" includes reports relating to the death, 

sexual abuse or injury to a child while in the care/custody of a foster parent recruited or 

employed by subsidiaries or affiliates of National Mentor Holdings, Inc. 

7. Provide the name and contact information of a state official with whom Committee staff may 

communicate to resolve any questions regarding the operation of the state's foster care 

program, and in particular, the use by the state of for-profit child placement agencies. 

" Such information may include observations about individual Contractors' performance in the following areas, 

which may be difficult to quantify in a single measure: thoroughness in conducting criminal background checks of 

potential foster parents; timely reporting of credible claims of abuse and neglect; provision of adequate training to 

caseworkers, etc. 
237 


26354.200

We thank you for your prompt attention to this request. Please submit your response in 

electronic format to Kim Brandt, Chief Oversight Counsel (Majority), 

(biP-Lhrandt(il]jinilllff.JiCnat§.gov) and to David Berick, Chieflnvestigator (Minority), 

(~h_tyid bcrick!ldin~mf~.senatc.gov). Any questions may be directed to Ms. Brandt at 

(202) 224-4515 or to Mr. Berick at (202) 224-6399. 

~1Jtk 

Sincerely, 

Orrin G. Hatch 

Chairman, Senate Finance Committee 

Ron Wyden 

Ranking Member 
238 


26354.201

<'l'Hbl'i\MI'Hfl ;,I All >llfUCl~lH 

1\)"-H~'A.~,tlf!N!I:'MAN (1f\,1()Cf1/1h Sl•\1' :lllll\l(lf'l 

Sam Malhotra 

llnitcd ;5tatrs ;5cnatr COMMi f' i l ON f INANCf 

WM-,HINOlUN, DC ?0510 {)/00 

March 3, 2016 

Secretary, Department of Human Resources 

311 West Saratoga Street 

Baltimore, Maryland 21201 

Dear Secretary Malhotra: 

Since April of2015, the United States Senate Committee on Finance (Committee) has been 

conducting an investigation into the states' use of private entities, and particularly for-profit 

entities, to serve as child placement agencies in the administration of state foster care programs. 

As you are aware, these state programs are funded under Title IV -E of the Social Security Act. 

This letter is a follow-up to the letter we sent your state on April 24, 2015, in which we requested 

information about your state's experience in contracting with private entities to administer 

portions of the state's foster care program. We thank you for the response provided to the 

Committee by your Department. 

Our interest in the use of private foster care providers is prompted in large part by a number of 

deeply disturbing stories appearing in the media in the recent past. Those stories recount lapses 

in judgment and mistakes by a for-profit child placement entity in the screening, recruitment, 

training and monitoring of foster parents that resulted in the placement of children, who 

represent the most vulnerable segment of our society, into the homes of individuals wholly 

unsuited to discharge the duties of foster parents. 1 Tragically, a number of these children died 

while in the care and custody of these foster parents, while other children were abused, neglected 

or physically injured. 

One of the many issues being examined by the Committee is the, sotmdness, from a public policy 

perspective, of permitting for-profit entities to operate as child placement agencies. It is argued 

by some commentators that such entities are ill-suited to discharge the functions of child 

placement agencies, since their pursuit of profit could interfere with their responsibility to 

safeguard the interests of the children under their care. 

1 See, for example: Mother Jones, Brian Joseph: The Brief Life and Private Death of Alexandria Hill (Feb. 26, 

20 15); BuzzFeed News, Aram Roston and Jeremy Singer: Fostering Profits (Feb. 20, 2015); and BuzzFeed News, 

Aram Roston: In an Unmarked Grave, a Baby's Untold Story (June 18, 2015), 
239 


26354.202

The Title IV-E foster care program is a child welfare program under the Social Security Act. 

Consequently, it falls within the oversight jurisdiction of the Committee. As Chairman and 

Ranking Member of the Committee, we are writing to you to secure information necessary to 

advance the Committee's understanding of how well both for-profit and non-profit child 

placement agencies under contract with your state protect the interests of the children who fall 

under their care. 

In accordance with the Committee's oversight responsibility for the Title IV-E program, we 

request that you provide the following information no later than close of business April l, 2016: 

l. IdentifY all child placement agencies (both non-profit and for-profit non-public providers that 

carry out responsibilities related to case planning, including permanency planning, and 

review for children in foster care (collectively, "Contractors"), under contract in your State to 

provide foster care services at any time from January 2010 to the present, and the dates when 

those agencies began to provide these services, and when, if applicable, they terminated; 

2. For each individual Contractor, provide the following performance measures,2 for each year 

2010 through 2015: 

a. Total nwnber of children served by such contractor during the year;3 

b. Of this total number of children served by such contractor during each year, identifY 

the number and percentage of children in the following subgroups:4 

i. Special needs children (general category) 

ii. Physically disabled children 

iii. Children with special mental/emotional/behavioral health needs 

1v. Infants 

v. Older youth 

'In the interest of identifying measures for which statewide data should be readily available, several of these 

performance measures mirror the Statewide Data Indicators used by the Administration for Children and Families' 

Children's Bureau in conducted the Child and Family Services Reviews (CFSR). The Statewide Data Indicatcrs are 

described in detail in CFSR Technical Bulletin #SA and the Final Notice of Statewide Data Indicators and National 

Standards for Child and Family Services Reviews Executive Summary-Amended (both published May !3, 2015). 

3 The CFSR literature defines the statewide version of this measure as "all children who were served in foster care 

during the 12-month target period." This measure should include the total number of children served by the 

Contractor at any time during each year in question. 

' This measure is included to account for the fact that particular contractors may be qualified and relied upon to 

serve the needs of particular subgroups of children entering foster care. If necessary for purposes of specificity, 

please provide any working definitions or tests used to classify children within particular subgroups. 
240 


26354.203

c. Total number and percentage of children served whose placement was moved 

sometime during the year;5 

d. Of all children who entered foster care each year and were discharged within one year 

(to reunification, living with a relative, or guardianship), total number and percentage 

who re-entered foster care within one year of their discharge. 6 

e. Total number and percentage of substantiated or indicated reports of maltreatment (by 

any perpetrator) during a foster care episode; 7 

f. Of all children who were victims of a substantiated or indicated maltreatment report 

during each calendar year, total number and percentage of children who had a second 

substantiated or indicated maltreatment report within one year of their initial report;8 

g. Number and percentage of children served who, within one year, achieved the 

following permanency outcomes:9 

i. Reunification; 

ii. Adoption; 

iii. Guardianship; 

iv. Another planned permanent living arrangement; 

h. Number and percentage of children entering into care who have siblings placed in the 

same living arrangement; 

i. Number and percentage of children entering into care who are placed with relatives; 

j. Number and percentage of children entering foster care who received a full initial 

physical and mental health assessment within 60 days; 

k. Number and percentage of children entering foster care for whom permanency goals 

were established in a timely manner; 10 

5 CFSR measure: Placement stability 

6 CFSR measure: Re-entry to foster care in !2 months 

1 CFSR measure: Maltreatment in foster care 

' CFSR measure: Recurrence of maltreatment 

9 CFSR measures: Permanency in !2 months for children entering foster care 

10 In answering this question, please identifY the time frame in which your agency seeks to establish permanency 

guidelines for each child entering into foster care. 
241 


26354.204

I. Number and percentage of children served who received monthly caseworker visits; 

m. The total cost to the state, county, or local government of services provided under the 

contract. 

n. Average caseload for each caseworker employed by the Contractor. 

3. For each measure identified above, please provide the same performance measure for the 

state foster care system as a whole, for each year 2010 through 2015. 

4. Provide a copy of any performance rankings, ratings, or reviews of Contractors prepared by 

your agency for years 2010 through 2015. 

5. Provide any additional information regarding individual Contractor performance that you 

believe may warrant our attention. 11 

6. Provide all performance and investigative reports and evaluations of Contractor placement 

agencies that are subsidiaries or affiliates of National Mentor Holdings, Inc., that have been 

prepared by or issued by the State, or by the contracting entity within the State, from January 

20 I 0 to the present. The term "investigative reports" includes reports relating to the death, 

sexual abuse or injury to a child while in the care/custody of foster parents recruited or 

employed by subsidiaries or affiliates of National Mentor Holdings, Inc. 

7. Provide the name and contact information of a state official with whom Committee staff may 

communicate to resolve any questions regarding the operation of the state's foster care 

program, and in particular, the use by the state of for-profit child placement agencies. 

11 Such information may include observations about individual Contractors' performance in the following areas, 

which may be difficult to quantify in a single measure: thoroughness in conducting criminal background checks of 

potential foster parents; timely reporting of credible claims of abuse and neglect; provision of adequate training to 

caseworkers, etc. 
242 


26354.205

We thank you for your prompt attention to this request. Please submit your response in 

electronic format to Kim Brandt, Chief Oversight Counsel (Majority), 

(kiDJ.J:?Iillili@l.lm!L1f!;.,Ji£!1atc.gov) and to David Berick, Chieflnvestigator (Minority), 

(david ~rLc;_kld'financc.scnatc.gov). Any questions may be directed to Ms. Brandt at 

(202) 224-4515 or to Mr. Berick at (202) 224-6399. 

Orrin G. Hatch 

Chairman, Senate Finance Committee 

Ron Wyden 

Ranking Member 
243 


26354.206

1:.lnitcd ~rates ~cnatr COMMJ I ON FJNANCE 

Wi\SHII>J(ifPN, DC ?0510 0700 

fll/H:oCAMf'fitll ~>fAif IJiftlCH)H 

JOSH! lA Sii!INI(MAI'II l.l[M0Cf1Afh: ~\fAH {)!"'I ( f(lfl 

March 3, 2016 

Jolm J. Specia, Jr. 

Commissioner, Department of Family and Protective Services 

701 West 51st Street 

M.C. E-654 

Austin, Texas 78751 

Dear Commissioner Specia: 

Since April of2015, the United States Senate Committee on Finance (Committee) has been 

conducting an investigation into the states' use of private entities, and particularly for-profit 

entities, to serve as child placement agencies in the administration of state foster care programs. 

As you are aware, these state programs are funded under Title IV-E of the Social Security Act. 

This letter is a follow-up to the letter we sent your state on April24, 2015, in which we requested 

information about your state's experience in contracting with private entities to administer 

portions of the state's foster care program. We thank you for the response provided to the 

Committee by your Department. 

Our interest in the use of private foster care providers is prompted in large part by a number of 

deeply disturbing stories appearing in tbe media in the recent past. Those stories recount lapses 

in judgment and mistakes by a for-profit child placement entity in the screening, recruitment, 

training and monitoring of foster parents that resulted in the placement of children, who 

represent the most vulnerable segment of our society, into the homes of individuals wholly 

unsuited to discharge the duties of foster parents. 1 Tragically, a number of these children died 

while in the care and custody of these foster parents, while otber children were abused, neglected 

or physically injured. 

One of the many issues being examined by the Committee is tbe soundness, from a public policy 

perspective, of permitting for-profit entities to operate as child placement agencies. It is argued 

by some commentators tbat such entities are ill-suited to discharge the functions of child 

1 ~ for example: Mother Jones, Brian Joseph: The Brief Life and Private Death of Alexandria Hill (Feb. 26, 

20 15); BuzzFeed News, Aram Roston and Jeremy Singer: Fostering Profits (Feb. 20, 2015); and Buzz Feed N!?Ws, 

Aram Roston: In an Unmarked Grave, a Baby's Untold Story (June 18, 2015). 
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placement agencies, since their pursuit of profit could interfere with their responsibility to 

safeguard the interests of the children under their care. 

The Title IV-E foster care program is a child welfare program under the Social Security Act. 

Consequently, it falls within the oversight jurisdiction of the Committee. As Chairman and 

Ranking Member of the Committee, we are writing to you to secure information necessary to 

advance the Committee's understanding of how well both for-profit and non-profit child 

placement agencies under contract with your state protect the interests of the children who fall 

under their care. 

In accordance with the Committee's oversight responsibility for the Title IV-E program, we 

request that you provide the following information no later than close of business April I, 2016: 

I. Identify all child placement agencies (both non-profit and for-profit non-public providers that 

carry out responsibilities related to case planning, including permanency planning, and 

review for children in foster care (collectively, "Contractors"), under contract in your State to 

provide foster care services at any time from January 20 I 0 to the present, and the dates when 

those agencies began to provide these services, and when, if applicable, they terminated; 

2. For each individual Contractor, provide the following performance measures,2 for each year 

2010 through 2015: 

a. Total number of children served by such contractor during the year;3 

b. Of this total number of children served by such contractor during each year, identify 

the number and percentage of children in the following subgroups:4 

i. Special needs children (general category) 

u. Physically disabled children 

iii. Children with special mental/emotional/behavioral health needs 

iv. Infants 

v. Older youth 

2 In the interest of identifying measures for which statewide data should be readily available, several of these 

performance measures mirror the Statewide Data Indicators used by the Administration for Children and Families' 

Children's Bureau in conducted the Child and Family Services Reviews (CFSR). The Statewide Data Indicators are 

described in detail in CFSR Technical Bulletin #8A and the Final Notice of Statewide Data Indicators and National 

Standards for Child and Family Services Reviews Executive Summary-Amended (both published May 13, 2015). 

3 The CFSR literature defines the statewide version of this measure as "all children who were served in foster care 

during the 12-month target period." This measure should include the total number of children served by the 

Contractor at any time during each year in question. 

4 This measure is included to account for the fact that particular contractors may be qualified and relied upon to 

serve the needs of particular subgroups of children entering foster care. If necessary for purposes of specificity, 

please provide any working definitions or tests used to classify children within particular subgroups. 
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c. Total number and percentage of children served whose placement was moved 

sometime during the year;5 

d. Of all children who entered foster care each year and were discharged within one year 

(to reunification, living with a relative, or guardianship), total number and percentage 

who re-entered foster care within one year of their discharge.6 

e. Total number and percentage of substantiated or indicated reports of maltreatment (by 

any perpetrator) during a foster care episode;7 

f. Of all children who were victims of a substantiated or indicated maltreatment report 

during each calendar year, total number and percentage of children who had a second 

substantiated or indicated maltreatment report within one year of their initial report; 8 

g. Number and percentage of children served who, within one year, achieved the 

follo\\>ing permanency outcomes:9 

i. Reunification; 

ii. Adoption; 

iii. Guardianship; 

1v. Another planned permanent living arrangement; 

h. Number and percentage of children entering into care who have siblings placed in the 

same living arrangement; 

i. Number and percentage of children entering into care who are placed with relatives; 

j. Number and percentage of children entering foster care who received a full initial 

physical and mental health assessment within 60 days; 

k. Number and percentage of children entering foster care for whom permanency goals 

were established in a timely manner; 10 

' CFSR measure: Placement stability 

6 CFSR measure: Re-entry to foster care in 12 months 

7 CFSR measure: Maltreatment in foster care 

'CFSR measure: Recurrence of maltreatment 

9 CFSR measures: Permanency in 12 months for children entering foster care 

10 In answering this question, please identify the time frame in which your agency seeks to establish permanency 

guidelines for each child entering into foster care. 
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I. Nmnber and percentage of children served who received monthly caseworker visits; 

m. The total cost to the state, county, or local government of services provided under the 

contract. 

n. Average caseload for each caseworker employed by the Contractor. 

3. For each measure identified above, please provide the same performance measure for the 

state foster care system as a whole, for each year 2010 through 2015. 

4. Provide a copy of any performance rankings, ratings, or reviews of Contractors prepared by 

your agency for years 2010 through 2015. 

5. Provide any additional information regarding individual Contractor performance that you 

believe may warrant our attention. 11 

6. Provide all performance and investigative reports and evaluations of Contractor placement 

agencies that are subsidiaries or affiliates of National Mentor Holdings, Inc., that have been 

prepared by or issued by the State, or by the contracting entity within the State, from January 

20 l 0 to the present. The term "investigative reports" includes reports relating to the death, 

sexual abuse or injury to a child while in the care/custody of foster parents recruited or 

employed by subsidiaries or affiliates of National Mentor Holdings, Inc. 

7. Provide the name and contact information of a state official with whom Committee staff may 

communicate to resolve any questions regarding the operation of the state's foster care 

program, and in particular, the use by the state offor-profit child placement agencies. 

11 Such information may include observations about individual Contractors' performance in the following areas, 

which may be difficult to quantify in a single measure: thoroughness in conducting criminal background checks of 

potential foster parents; timely reporting of credible claims of abuse and neglect; provision of adequate training to 

caseworkers, etc. 
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We thank you for your prompt attention to this request. Please submit your response in 

electronic format to Kim Brandt, Chief Oversight Counsel (Majority), 

(kim brandt(a!JinaJ}~"~£ll'o!J.~_,g_~~y) and to David Berick, Chieflnvestigator (Minority), 

(~ht.\'i~L9.£!i<;billinancc"scnatc"gov). Any questions may be directed to Ms. Brandt at 

(202) 224-4515 or to Mr. Berick at (202) 224-6399. 

~1Jt;t;: sm=ly, 

Orrin G. Hatch 

Chairman, Senate Finance Committee 

Ron Wyden 

Ranking Member 
248 

Appendix D 

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~ 

~Congressional ~ Research Service 

Informing the legislative debate since 1914-----------------

MEMORANDUM October 27,2016 

To: Senate Finance Committee 

Attention: Dave Berick and Jan Nicholson 

From: Emilie Stoltzfus, Specialist in Social Policy, 7-2324 

Subject: Statewide data indicators used in the Child and Family Services Review (CFSR) 

This memorandum responds to your questions about national standards established for use in the third 

round of the Child and Family Services Review (CFSR). The CFSR is a comprehensive review done to 

determi ne if a state child welfare agency is achieving positive outcomes for the children and families it 

serves, and, specifically, if the agency is "in substantial conformity" with federal child welfare 

requirements. The national standards are derived from statewide data indicators and have been a pan of 

the CFSR assessment of whether a state is ensuring safety and achieving permanency for children served. 

The majority of the memorandum looks at the seven national standards established for the current CFSR 

(round 3). It discusses data sources used. what the measures look at, why and how the data on state 

performance were risk-standardized, data quality issues, and finally, how states performed compared to 

each other and the national standards. 

The discussion of the standards in this memorandum. including the seven figures ranking state 

perfom1ance on each, is based on the statewide data indicators as they were finalized in May 20 15. 

However, on October II, 2016, the Children's Bureau - the agency within the U.S. Depanment of Health 

and Human Services (HHS), Administration for Children and Families (ACF), Administration on 

Children, Youth and Families (ACYF) that administers federal child welfa re programs and the CFSR -

aooounced that due to " technical errors in syntax and fonnulation of the statewide data indicators" it was 

suspending their use as a "conformity" measure for CFSR round 3. At the same time, the Children's 

Bureau announced it was conducting a thorough re-analysis and testing of each of the seven standards and 

that it plans to revise andre-release the standards. along with revised state perfom1ance on them, before 

the end of20 16. In other words, while the national standards will not play a role in determining any 

potcntialfiseal penalties for states duri ng CFSR round 3, states arc still expected to usc these measures 

(revised) as part of assessing and better understanding their performance going forward. Additionally, 

while the Children's Bureau expects this revision to change, to some degree, the values of each of the 

national standards (and state performance against the standards), it has made clear that the revision will 

not change what it seeks to measure. Instead, the Bureau's goal is to perfect its code to enable state 

perfom1ance on each of the measures to be more accurately reflected. 

Accordingly, while the precise values shown in this memorandum, as well as state perfom1ance against 

the national standards, are subject to change (exact degree of change uncertain at this point), what is being 

measured will remain unchanged. Thus, CRS believes this memorandum will have value in explaining 

what the measures intend to look at and how they seck to capture this infonnation, as well as in showing 

initial values and state performance against the initial values. I trust this information will meet your needs. 

Please don't hesitate to contact me if you have additional questions. 

Congressional Research SerVIce 7-5700 1 www.ers.gov 
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Overview of CFSR 

The Child and Family Services Review (CFSR) is periodically conducted in each state to determine if a 

state is in "substantial conformity" with federal child welfare policies included in Title fV-B and Title IV-

£ of the Social Security Act. ' The reviews focus on whether the state child welfare agency achieved seven 

specific outcomes for children and families served and whether it has in place and is effectively operating 

seven specific systems discussed in federal law and intended to help the agency achieve those outcomes. 

There are two major steps in the process, a state's own assessment of its performance (statewide 

assessment) followed by an onsite review of state performance. After the CFSR, states not found to be in 

'·substantial conformity" with one or more of these outcomes or systems must develop a Program 

Improvement Plan (PIP) or fac.e a fiscal penalty. 

2 

A PIP, developed by the state but with approval of the Children's Bureau required, must describe the steps 

the state will take and progress it will make to address each outcome and/or system for which it was 

found not in conformity; specifically, it must establish benchmarks and indicate the level of progress the 

state must make against those benchmarks in order to be considered to have successfi•lly completed the 

PIP. States typically have two years to implement the PIP and during this time HHS must regularly 

evaluate progress. If the state successfully completes all aspe.cts of its PIP, all penalties assessed based on 

the CFSR are rescinded. If the state successfully completes only some (or none) of its PIP, the amount of 

its fiscal penalty is determined commensurate with its level of success/failure. As further laid out in the 

CFSR regulations, the penalty is taken as a specified share of funding the state receives under the child 

welfare programs included in Title IV-B and Title IV-E of the Social Security Act. 

Through the first two rounds of the CFSR, no state has been found in substantial conformity with a lithe 

outcomes and systems assessed. Every state has entered into a PIP and most states have been successful at 

completing those PIPS. However, HHS assessed varying penalty amounts totaling S9.6 million on 4 

jurisdictions (DC, GA, Rl, and SC) following round one oftbe CFSR3 and it assessed various penalty 

amounts totali ng $13.5 million on 7 j urisdictions (IL, MN, NC, ND, OH, PR, WI) following round two of 

the reviews: 

Outcomes Assessment in the CFSR 

The CFSR looks at whether states achieve seven outcomes related to safety; permanency; and well-being. 

These outcomes arc I) Children are first and foremost protected from abuse and neglect; 2) Children are 

safely mainta ined in their homes whenever possible and appropriate; 3) Children have permanency and 

stability in their living situations; 4) The continuity of family relationships and connections is preserved; 

5) Families have enhanced capacity to provide for their children's needs; 6) Children receive appropriate 

1 Specifically the review is to look at state plan requirements included in the child welfare programs authorized in Title IV .. g and 

Tille IV-E. For a discussion of many oflhOS<! requiremen1s see CRS ReporJ R42794, Chi!</ WettiJre: S/8/e P/011 R<quiremtt~ts 

under the 1itlc rV-E Foster Care. Moption Assistance. and Kinship Guardianship Assistanc:c Program. by Emilie Stoltzfus. 

2 TI1e sta1utory authority lbr these rc,ricws and for .. correetivc action•• {PIPs) is included in Sec. 1123A of the SO<:i(ll Sccurily Acl 

[42 U.S.C. § 1320a- 2a). The CFSR and PIP regulations are at 45 C.F.R. 1355.31 1hrough 45 C.F.R. 1355.37. 

' Initially mtS assessed fines on five additionatjurisdiclions (TX. Fl. IL. MI. and CA) following CFSR round I. However. all of 

lhose Slales successfully appealed (to either HHS ACF or, inCA ·s case lhc HHS Dcpartmcnlal Appeals Boord) and the fines 

were rescinded. 

4 Two ofthosejurisdic1ions (I Land PR) appealed the CFSR round 2 fines. As ofOcJober 21 , 2016, lhe I'R appeal was still 

pending. However, H~IS Depanmental Appeals Board (DAB) denied Illinois's appeal in a decision issued Seplember 20. 2016. 

See HHS. DAB. Appellate Divisions. /1/inois Dcp.utmcm of Children and F:m1ilics. Dockcl No. A· I 5· I 08. De-cision No. 2734. 

lulp://www.hhs.gov/dabldecisionsldabdecisions/20 16/dab2734 .pdf. 
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services to meet their educational needs; a.nd 7) Children receive adequate services to meet their physical 

and mental health needs. 

3 

Each of the seven outcomes is assessed based on an intensive review of a sample of case files (40 children 

served in foster care and 25 children served in the home).5 Intensive case review includes document 

reviews and interviews with all relevant individuals (e.g., child, child's parents, case worker, foster 

parents, and relevant service provider). To be found in "substantial conformity" with a given outcome, the 

review must find the outcome achieved in no less than 95% of the applicable cases assessed. 6 

To determine whether tbe outcome was achieved in an applicable case, the reviewer examines one or 

more specific items associated with each outcome. For example, in assessing whether "children are first 

and foremost protected from abuse and neglect," the case reviewer must determine whether reports of 

child abuse or neglect were investigated on a timely basis and if that investigation included face-to-face 

contact with the child. (For a quick list of"items" associated with each outcome assessment see the text 

box "Outcomes Assessed in the CFSR.") The Children's Bureau has developed a detailed review 

instrument that must be followed as part of conducting a CFSR case review. It provides specific 

instructions on determining when a case is "applicable" for a given item along with detailed guidance on 

how the reviewer should assess and rate tbe state's perl'onnance on individual items' 

For the first two rounds of the CFSR (conducted in 2001-2004 and 2007-201 0), achieving the given 

safety, permanency or well-being outcome in the vast majority of applicable cases reviewed (90% in 

round I and 95% in round 2) was necessary but not sufficie111 to ensure a "substantial conformity" 

determination on two of the seven outc.omes assessed. Specifically, to be found in conformity with 

federal requirements conceming the outcomes: "Children are first and foremost protected from abuse and 

neglect;" and "Children have permanency and stability in their living situations," states were additionally 

required to have statewide data showing they met specific national standards. 

By contrast, for CFSR round 3, and as announced on October II, 2016, achieving the given outcome in 

95% of applicable cases reviewed will be suflicientto show confonnity with the given outcome. The 

Children's Bureau announced that it would suspend the use of the national standards during CFSR round 

3 at the same time it announced it was revising the standards, previously issued in May 20 15, to correct 

technical errors in the syntax and formulation of the computer code. These errors may have inadvertently 

included or excluded data needed to accurately measure state performance on each standard.

8 

s The CFSR case sample is drawn fron'l no fewer than three counties of the state. one of which must be rhe state's most populous 

county. 

6 for tJ1e CfSR round 1 a smaller number of cases were reviewed and states needed to be successful in 9()0/o of applicable cases. 

1 The onsite review instnrment and guide (OSRI) is 93 pages long and provides specific i•lS'Ituctions on dctem1ini•1g whether a 

case is applicable and how co review and rate each case. CFSR RouJJd 3 Onsit'· Rc,?cw ltJSJrumt.'JJl and Instructions available at 

hup1/www acf.hhs gov sites/defauh fileslcblcf.~r r3 osri pdf .. See also "Reviewer Brief: Understanding Federal Expectations for 

Rating Cases." http:.l/www acf.h .gov/sites/de~1.ullffi les/cb/round3 _reviewer_ brici.pdf. 

8 Sec HHS, ACF. ACYF, Children's Bureau. Lcuer to State Child Welfare Administrators. October II , 2016. auached "List of 

round .3 Statewide Data Indicators Issues as of Public-ation." See "transmiualleuer·· for Technic.aJ Bulletin #9 a\•ailabte at 

hups://tmining.cfsrponal.org/rcsources/3 I 05"CFSR%20Technicalo/o20Bulletinso/o20ando/o20Rclatedo/o201nfonnation. 
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Outcomes Assessed in the Child and Family Services Review (CFSR) 

Determination of a state's success (or not) in achieving a given outcome is based solely on case 

reviews for CFSR round 3. A state must achieve the outcome in no less than 95% of the applicable 

cases reviewed. National standards shown are used in CFSR round 3 for context only. 

SAFETY OUTCOMES 

Children are first and foremost protected from abuse and neglect: 

Case review: Was there a timely response to the report alleging maltreatment; did it include 

face-to-face contact with the child or children? 

National standards: Do Statewide data meet recurrence o( maltreatment standard? Do statewide 

data meet maltreatment in foster core standard? 

Children are safely maintained in their homes whenever possible and appropriate. 

Case review: Did the agency make concerted efforts to prevent entry or permit reunification, 

and to assess and address risk and safety for children living at home or in foster care? 

PERMANENCY OUTCOMES 

Children have permanency and stability in their living situations. 

Case review: Was the child in a stable foster core placement! Did the agency establish 

appropriate permanency goals for the child in a timely manner and did it make concerted 

efforts to achieve reunification, guardianship, adoption. or other planned permanent living 

arrangement? 

National Standard: Do statewide data meet the standards related to - I) permanency for children 

entering care within 12 months; 2) re-entry to foster care; 3) placement stability; 4) permanency for 

children in care 12-23 months; and S) permanency for children in care 24 months or more? 

The continuity of family relationships and connections is preserved. 

Case review: Did agency make concerted effort to place siblings together. as appropriate: 

ensure visits with parents or siblings of sufficient frequency and quality, as appropriate: place the 

child with relatives when appropriate; and promote positive relationships between child in 

care and parent(s)lprimary caregiver from whom the child was removed through activities 

other than arranging visits? 

WELL-BEING OUTCOMES 

Families have enhanced capacity to provide for their children's needs. 

Case Review: Did agency make concerted effort to assess needs of, and provide services to, 

children. parents, and foster parents and to involve parents and children (when 

developmentally appropriate) in case planning on an ongoing basis? Were the frequency and 

quality of visits between caseworkers and children and, separately. between caseworkers 

and the mothers and fathers of children, sufficient to achieve positive outcomes and case plan 

goals? 

Children receive appropriate services to meet their educational needs. 

Case Review: Did the agency make concerted efforts to assess children's education needs and 

appropriately address them in case planning and case management activities? 

Children receive adequate services to meet their physical and mental health needs. 

Case Review: Did the agency address the physical health (including dental) and 

mental/behavioral health needs of children? 

Sou"e: Prepared by Congressional Researth Servi'e (CRS) based on "Child and family Servi,es Reviews; Qui'k 

Reference Items Un" and "CFSR Round 3 Statewide Data Indicator ~ries " 
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Systems Assessment in the CFSR 

In addition to successfully achieving safety, permanency, and well-being outcomes for 95% of the cases 

reviewed, a state must demonstrate that it is successfully operating seven "systems" on a statewide basis. 

These systems are- I) statewide information; 2) case review; 3) quality assurance; 4) staff and provider 

training; 5) service array and resource development; 6) agency responsiveness to the community; and 7) 

foster and adoptive parent recruitment and training. 

Federal law spells out specific requirements (some with lar greater detail than others) related to each of 

these "systems" and they arc assumed necessary to enable the state to be successful in achieving positi ve 

outcomes for the children and families it serves. As with outcomes assessed, there are typically multiple 

factors that must be considered as part of determining whether a given system is successfully functioning 

in the state. 9 The Children's Bureau considers a given system factor to be functioning "if it is occurring, 

or is being met, consistently and on an ongoing basis across the state for all relevant populations," and this 

must be demonstrated by more than "mere description of a law, procedure, or process."The Children's 

Bureau encourages states to " use quamified data to show how well each systemic factor functio ns 

statewide, when possible and appropriate." '

0 

For round 3 of the CFSR, determination of whether a state is successfully operating a required child 

welfare system is based on the state's assessment of its work. which must be guided by a Children's 

Bureau supplied assessment instrument. " This may also include relevant information submitted to the 

Children's Bureau (regarding functioning of each of the seven systems), as part of a separate federal ly 

mandated planning and goal-setting process that includes a comprehensive five-year Child and Family 

Services Plan (CFSP) and an annual update of that plan known as the Annual Progress and Services 

Review (APSR).'2 

Following the statewide assessment and prior to the onsite review, the Children's Bureau examines the 

information supplied by the sta te and, to the extent possible, rates each factor associated with one of the 

seven systems as a ·'strength" or as an "area needing improvement."13 If the state does not supply enough 

suitable infonnation to make these determinations prior to the onsite review, the onsite review must 

include stakeholder interviews to gather the needed infom1ation.14 

There is only one system factor associated with each of the statewide information system and the quality 

assurance system; a state must receive a rating of"Strength" on the factor to be determined in "substantial 

conrormity." ror the remaining five systems, there arc mul!iplc ractors assessed regarding how well each 

functions; a state may receive an "area needing improvement" for no more than one of the factors 

associated with a system to be found in "substantial confonnity" with that system. The text box below 

lists each of the systems reviewed. along with the factors (or items) assessed for each system. 

~ Guidance 011 Pou:mi8/ Dtlttt tmd lnfbrm.1rion thllt C.1n be Used 10 Assess S)stcmic FsCJor F~mct;oning, p. I . 

http://www.acf.hhs.gov/cblrcsourcc/round3·guidancc·on·potentia1--data 

10 1bid, p.2 11 Statewide Assessment Instrument, http://www.acf.hhs.gov cb/rcsourcc/round3~cfsr·statewide·assessmcnt 

12 45 CF.R.§ 1357.15 and§ 1357.1 6. as revised by annual program instructions concerning !he CF'SP/AI'SR. See also 

hllp://ww\V,acf.hhs.gov/cblprogramslstate-tribal-<:fsp 

I) CFSR ProcOOures JW.1nual. http://www.acf.hhs.gov cblresou celroundJ~cfsr.procedures~manual 

1

" Ibid. In the firsl two CFSR rounds. stakeholder inlervicws, conducted as pan of the oosite review. were the primary avenue of 

assessment for system factors. See also Slakchofdt:r /n((~rvicwGuidc http://www.acf.hhs.gov/cb/rcsourcc/round3-cfsr· 

stakeholder·inten,iew·guide. Under federal regulations, slakeholder input is required to assess state confom1ity with the system 

"service array.·· 
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Systemic Factors Assessed in the Child and Family Services Review (CFSR) 

Determination that a state is successfully (or not) o perating a given system is determined based on 

Children's Bureau reviews of state assessment or planning documents and, as needed, on-site stakeholder 

interviews. 

Statewide Information System 

Is this system functioning to ensure that the state can. at least. identify the status, demographic 

characteristics, location, and goals for every child in foster core or in care within last 12 months? 

Case Review System 

Is this system functioning to ensure -- each child in foster core has o written case plan; the child's 

status in core is reviewed at least once every 6 months; a permanency hearing occurs every 12 

months (i.e., within 12 months of entry and eve ry 12 months thereafter while child remains in care); 

that filing of termination of parental rights (TPR) proceedings occurs as required; and that foste r 

parents, pre-adoptive parents and relative caregivers of children in care receive notice of and hove o 

right to be heard in any review or hearing with respect to the child? 

Quality Assurance System 

Is this system operating in oil served oreos1 Does it have standards to evaluate quality of servites, 

identify strengths and needs of the service delivery system, provide relevant reports and evaluate 

implemented program improvement measures? 

Staff and Provider Training 

Is system functioning on o statewide basis to ensure initial and ongoing training for staff 

providing services, and training for prospective foster and adoptive parents as well as staff at 

facilities providing foster care? Does training address skills and knowledge needed for each to 

carry out their duties? 

Service Array and Resource Development 

Is system functioning to assure services ore accessible in all relevant areas to assess strengt.hs and 

needs of families, create safe home environments for children, enable children to remain with 

parents and allow children in foster core to achieve permanency? Con these services be individualized 

to meet unique needs of children and families served? 

Agency Responsiveness to the Community 

Is system functioning to ensure state engages in ongoing consultation with relevant entities and 

individuals in planning services and to ensure that the agencies' child welfare services are 

coordinated with other federal or federally assisted programs serving the same children and families? 

Foster and Adoptive Parent Licensing, Recruitment, and Retention 

Is system functioning to ensure - state standards apply to a// licensed foster core homes and 

facilities receiving federal child welfare funds; state complies with criminal background clearance 

requirements; scate meets diligent recruitment requirements to ensure potential foster and 

adoptive families are available that reflect the ethnic and racial diversity of children needing these 

homes and stat e ensures effective use of cross-jurisdictional resources to facilicate timely 

placements? 

Source: Prepared by CRS based on "Child and Family Servkes Reviews; Qt,ick Reference Items s~" 
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National Standards 

In each round of the CFSR, the Children's Bureau has developed •·national standards" and has asked 

states to compare their performance, using stale-reported data, to those national standards. The national 

standards have consistently focused on safety and pcnnanency concerns but the specific measures have 

varied, as the Children's Bureau works to improve how state perfonnance is measured (often in response 

to strong criticism from states or outside child welfare rcscarchers).

11 This memo discusses each of the 

seven national standards developed for this third round of the CFSR. beginning with an overview of the 

child welfare data sysrems used to develop the standards and dctennine state perfonnancc against those 

standards. 

Federal Child Welfare Data Collection and Reporting Systems 

All states collect electronic data as pan of administering tl1eir child welfare programs and as of May 2016, 

36 states claimed federal Tille IV-£ support to operate systems consistent with a federal model known as 

the Statewide Automated Child Welt:1re lnfom1ation System (SACWIS). 16 Developed in the early 1990s 

to support case management and data collection needs related primarily to serving children in foster care, 

the SACWIS model has become increasingly outmoded as technology and child welfare practice have 

undergone significant change. Accordingly, in June 2016, HHS ACF finalized new regulations for the 

Comprehensive Child Welfare In formation System {CCWIS). The new system is expected 10 increase the 

ease with which states can update systems using "off-the-shelf' products and incorporate varying 

practices across the state while maintaining needed statewide data. It also intends 10 place new focus on 

data quality and broader exchange of data (moving outside state health and human services agencies to 

include exchange with education, courts, and other entities important to the work of the child welfare 

agency). States have 24 months (until July 3 1, 2018) to decide whetherto transition their current 

SACWIS to a CCWlS system, to build an entirely new CCWlS, or to opt out of the system." 

A SACWISJCCWIS (or a state's independent model) provides the superstmcture - or fonn for collecting, 

accessing. and shoring data primarily within the state. Funber, although meeting certain federal 

pa.rameters, these state systems vary in how and what infonnation they collect. At the same time. all states 

repon certain child welfare administrative data to the Children's Bureau in standard electronic fonnats. 

The data a.re submincd via rwo reponing systems-- the Adoption and Foster Care Anal)•sis Reponing 

System (AFCARS) and the National Child Abuse and Neglect Data System (NCANDS). 18 State-collected 

u for criticism ofsttmd:uds produced for CFSR Rounds I and/or 2 SI."C Brittany Orlebckc. fred Wulceyn. and St•san Mitchell· 

Herz.ft-ld .• Improving Public Child UH/im· Ag~ncy Pcrli>rm:wcc 1it the Context of Federal Child 1llid Family $efllicc.s Re~itow , 

Chapin I~ all Center for Children. University of Chicago. 2005: Mark Testa. Eun Koh. and John Pocnncr. C.•m AFCARS lx.· 

Rescued: Fh<ing tht' Stmi$ll~al Yard;)tick that Mt:asures Child UN.6uc Perli>rm:mcc. Children and Fa.nily Researc.h Center. 

Uni\'cTSity of Illinois 31 Urbana-Champaign, March 2008~ and John Schucnnan and Barbolr3 N<..'t."<lell. The Child and F.1mi/y 

Services Revien·s CotnpositeScores: AcrouJJWbilityOII't.he Track. Chapin Hall Center fOr Children. Unhrersity of Chicago. 2009. 

16 Once tribc.s were pcnniued to m.akc direct claims for Title IV-E suppOrt (cOCctive with FY2010). the SACWIS was rtnamed 

SACWISifrACWtS. although no tribes op1oo 10 build a TACWtS. 11 Federal Rt•gister. "CCWIS Final Rule." vol. 81. no. 106. June2, 2016. See also chis !ilion overview of the CCWIS system 

http:l/www.acC.hhs.gov/sitcsldcfaultlfilt'Sicblccwis_ovcrvicw.pdfnnd the CCWIS Final Rule Prcscnt:.Uion. 

hup:l/www.ac(hhs.gov/cblresourcc/ccwis-final-rule-overview-presentation. 

11 J-\dditionally. beg.inning with FY20J I, states also report specific data to the 0 1ildren's Bureau via the National Youth in 

Transition J)atabase. For more information about NYTO S\.."C CRS Rcpon R43752. Child Ui'I/Bre: Pro61es oi'Currcm and 

Fornrr Older Foster WHJth &S<.'VI ()II th~ N:uiomtl l'Outh in Transiti011 0.1tab:rst• (NYTV). by Adrienne L. Fe:mandes-Aicantara. 
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data provided via these standardized reporting systems are used to both set national standards and to 

detennine a state's performance against those standards. 19 

AFCARS 

Congress required development of a system for states to collect and report certain data about children in 

foster care in the 1980s. The final regulation for AFCARS was released in 1993 and submission of 

electronic AFCARS data files, consistent with that regulation, are required for a state's participation in the 

Title IV-E program. Beginning with FY 1995 state.s have been required to report data, twice each year, on 

children served in foster care duri ng the preceding six-month period.20 

The data are primarily reported at a child level - not on a summary or "aggregate basis.'' States are 

required to provide data on 66 specific elements for children served in foster care during each six-month 

reporting period and on 33 items for children who were adopted out of foster care during that period. At 

the federal level, these data are used for a variety of policy making and accountability purposes and for 

distribution of certain program funds.

2

' At the basic information level, HHS annually produces summary 

infom1ation on children in foster care and those wbo have lefi foster care, in a given fiscal year, including 

demographic infom1ation. as well as information about their length of stay in foster care, current 

placement seuings, and reasons for leaving foster care.22 

Submitting "child-level" data means a state submits records to the Children's Bureau that show tor each 

child served in foster care, for example, the child's birthdate, date of removal (and placement in foster 

care), race and ethnicity, discharge date and reason (if appli cable) and many more pieces of infonnation. 

With those child level data, the Children's Bureau can detennine many summary statistics: How many 

children were served in foster care. what were their ages, what percentage were of a particular 

race/ethnicity, and how long had they been in foster care during the year. Further, it can "cut" those data 

in many ways allowing it, for example, to examine whether or not children's length of stay in care varied 

by the race of a child, or if children of a particular age were more or less likely to enter foster care. In 

sum, the provision of child level infonnation requ ires data analysis at the federal level but it gives the 

Children's Bureau much greater flexibility in analyzing the data for policy study and performance review. 

In February2015, HHS fonnally proposed revising theAFCARS regulation to •• 1) update the system to 

gather information that incorporates and reflects stallltory changes made since made since the original 

regulations were final ized; 2) institute previously authorized penalties for states submiuing noncompliant 

AFCARS data: and 3) modify and expand data elements reported to promote more accurate understandi ng 

of current data, and that allow for infonnation relevant to new statutory interests (e.g., educational 

outcomes of children served, placement with siblings); and 4) to collect data in a way that will bcner 

enable ana lysis of a single child's whole experience in foster care (longitudina l data).n In April2016, the 

agency released a supplement to the AFCARS proposed rule, related to reporting on Indian children, 

,. As provided for in regulnlion. (45 C.F.R. § 1355. 33(bX2) Slalc'S have been penniucd 10 usc an allcmative data source for 1bc 

child abuse and neglect data used to gauge whether they mel a panicular safety· related standard. The regulation pemtits this 

because NCANOS is considered a volu•Hary reponing system as is diSCllssed in the memornndum (although all States cun'ent1y 

panicipalc in NCANDS). 

:o Sec. 479 of the Social Sccurily Acl. 

" See "Aboul AFCARS" hup://www.acf.hhs.gov/cb/rcsourcc/aboul-afcars. 

z: Basic summary informal ion is included in the annuaJ AFCARS Report, available http://www.acf.hhs.gov/cblresearch .. data· 

•echnology/slaliSiics-research/afcars(scroll 10 bonom of page). 

" Federal Rcgislcr vol. 80, no. 26. February 9, 20 t5. pp. 7132·7221. See also hnp:lfwww.acf.hhs.gov/cblresoun:c/afcarspropose<f.rule.overview. 
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including compliance with the Indian Child Welfare Act (ICWA).

24 A fi nal AFCARS ntl e, incorporating 

the initial and supplemental proposals, is expected before the end of20 16. 

National Child Abuse and Neglect Data System (NCANDS) 

9 

In 1988 Congress required HHS to develop a national data collection and analysist,rogram that made use 

of existing data gathered by individual states concerning child abuse and neglect.

2 HHS, in consultation 

with state agencies and technical expens established specific reporting standards and the resulting system 

is known as NCANDS.

26 In I 996, Congress required states, as a condition of receiving certain funding 

under the Child Abuse Prevention and Treatment Act (CAPT A), to annually report - "to the maximum 

extent practicable - certain child abuse and neglect information."

27 (For example, how many children 

were reponed to the state during the year as victims of child abuse and neglect and how many of those 

children did the state determine were victims of abuse and neglect during the year?) These CAPT Aspecified data elements are primarily reponed to the Children's Bureau via NCANDS. 

Because there is not absolute statutory requirement that states provide data, NCANDS is considered a 

voluntary reponing system and there arc no fonnal regulations on the system. Nonetheless, all states 

report NCANDS data annually to the Children 's Bureau. Among other things the data are used to infomt 

policymaking and may be used for accountability purposes. Most, but not all of this data is provided on a 

child level (rather than aggregate or summary) basis. That means specific infonnation (e.g., race ethnicity, 

age, type of maltreatment) is reponed for each child determined to be a victim of child abuse and neglect. 

As required by Jaw, HHS annually produces a report that summarizes infomtation reponed via 

NCANDS. 28 The report provides both national and state level data. 

Data from both AFCARS and NCANDS are used to annually produce a report, Child Welfare Outcomes. 

showing state perfomtance on certain child welfare outcome measures and additional information as 

required by Congress or otherwise supplied by HHS.2') In addition, AFCARS and NCANDS are the two 

child welfare data sources HHS has used to develop national standards to be used in the Child and Family 

Services Review (CFSR). 

Development of the National Standards 

The regulations implementing federal reviews of child welfare agency practice provide that the HHS 

secretary may use AFCARS and NCANDS data to develop statewide data indicators for any of the CFSR 

outcomes related to safety, permanency, or well-being and that these data indicators may be used to 

"Fcdero/ Register vol. 81. no. 67. April7. 2016. pp. 202083-20301. See also hnp://www.ael:hhs.gov/silcsidefault/fileslcbl 

afcars_snpm1_ovcrvicw.pdf. 

25 1lle requirement was included irl 1988 anlerldments to the Child Abuse Prevcmion And Tteatmcnt Act (CAPT A) (P.L. 101-

294). This provision is included in currem law al Sec. 103(cXI)(C)ofCAPTA [42 U.S.C. §S 104(cXI)(C)J. 

26 Fordiscu$$iOn ofdevelopmem. see Itt IS, ACF. ACYF, Children's Bureau, Child M11trearment2014. pp 

21 NNS. ACF, ACYF. Children's Bureau. Child M11treatmcnt20/4, Chapter I, ''Background ofNCANDS.'' p. 2. See also Sec. 

106(d) of CAPT A [42 U.S.C. §SI06a(d)). See also NCANDS infonnmion a-•ailable a1 hup:/lwww.acf.hhs.gov/cblresearch-dam· 

tcchnofog_v/reporting·Systcmslncands. 

:s See series ofrcpons titled Child i\4tlflrcatmem, available at hnp://www.acf.hhs .gov cblresea.rch..cfat~Hechno logy tatjst ics· 

rcscarchfchild4 mohrcatmcnl. 

29 11le initial outcome measures followed in this repon. k1l0wn as Chlld uetmre Outcomes, were developed pursuant to Section 

479A of1he Social Security AC·I, which was first added 10 1he law in 1997 (P.L. 105·89). Addilionnl dala have subsequen1ly been 

required and HHS has also used the report to discuss state performance on national standards. The Child nt:Jiilrc Outcomes 

report is typic-ally quite lengthy. You can also review the data on the online data pon.al for the repon 

hup://ewoutcomes.ac:f.hhs.gov/datalovcrvicw. 
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detem1ine whether a state is determined to be "in substantial confon11i ty" with federal child welfare 

policy. Further, the regulations note that "when appropriate," the HHS secretary may "add, amend, or 

suspend'' any such data indicators.

30 To date, HHS has consistently developed national standards related 

to safety (maltreatment in foster care, and recurrence of maltreatment) and permanency (timeliness to 

pen11anency, placement stability, re-entries to care) outcomes for each of the three rounds of CFSR.31 

However, for each round, the way the standards were developed - and consequently tl1e way a state's 

performance was measured - varied. 

10 

For round three, there are seven national standards and each standard is set at the national average among 

all children served. This means that the average is effectively weighted by child rather than by state (as 

was the case in previous iterations of the standards) and thus the performance of states serving more 

children has a larger effect on the national standard than do states serving fewer children.

32 According to 

HHS, setting tl1e national standard at the overall national average performance represents "a reasonable 

benchmark that would appropriately challenge states to improve their performance. 33 

Risk Standardized Performance 

The process of risk adjustment standardizes the state's age (and for some indicators, entry-rate) profile on 

a given indicator to the national caseload. h is computed to help ensure comparability across states and to 

the national standard. Any assessment of whether a state meets or exceeds the standard is to be based on 

the risk-adjusted performance, not the "observed perfon11ance." (The "observed perfonnance'' is 

calculated as the percentage (or rate) based entirely on the reported data without adjustment by age and/or 

rate of entry.) 

Risk adj ustment by age recognizes that the likelihood of a child experiencing a given outcome is known 

to vary considerably based on a child's age. For example, the risk that a child will be detem1ined by the 

state to be a victim of abuse or neglect is much higher for younger children than for teenagers and the risk 

that a child will leave foster care to pem1anency also varies considerably by age. 

Risk adjustment by the state's rate of entry to foster care recognizes that states with very low rates of 

entry to foster care (i.e., number of children entering foster care for every I ,000 children in the state's 

population) are likely to have brought in a more challenging group of children than a state with a high rate 

of entry. Children with more challenges are less likely to leave care quickly and they may also be more 

likely to re-enter care. 

JO 45 C.F.R. § t355.34(b)(4) 

31 HHS has never developed a national standard related to any of the three well·being outcomes included in the CFSR. rhis is 

very possibly due in some par110 l9ck of relevant AFCARS or NCANDS data to speak to those outcomes and might also be 

related to the fact that I) the role of the agency in ensuring well-being outcomes of children served may be harder to separate 

from other age11cies; and/or 2) the mos1 obvious tCderaJ requiren'tc-nts are more prooess-based. For example. the child welfare 

agency is responsible for working with t-ducational agencies to ensure educational stability for children in care. This work (a 

process) is i11tended 10 im1>rove educational outcomes for children in care. How·ever, while this child welfare age-ncy work 10 

ensure educational stability for foster children may be necessary to ensure the child's acn.demic success. it is not necessarily 

sufficient to ensure that success absent the work of educational agencies. 

Jl for example. if state A has 1.000 children in care and 600/o experience the outcome of interest and state B has 100 children in 

c.ate of whom 90% experience the outcome of interc..~~ a "national" stalldard that was based on average experience of children 

scrvc.-d in these two states alone -- would be 63%. (i.e., 690 c,hiJdrcn with desired outcome divid<.."<< by total of 1,100 children 

served = 63%). By contrast, a national standard that was based on an average of the 1wo states' perfonn:mce would be 7 5% (i.e., 

the combined state performance would be 1 SOO/o of children achieving desired outcomes divided by total number of states (n=2) • 

an average perfonnance of 75%. 

ll In the lirst iteration of the CFSR. national standards were pegged at the 75th percentile of state perfom1ance on each standard. 

However, although the standards focused on the same kind of safety and permanency issues, the calculation of that perfom1ancc 

was significantly difl"ercnt than is the C3SC for this current iteration of the stnndn.rds. 
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Once a state's risk-standardized perfonnance is dctenn ined, a margin of error for that performanc.e is 

calculated. The margin of error is necessarily greater for states with smaller case loads and thus these 

states will have a wider risk-standardized performance range, and vice versa. As long as any value in the 

state's risk-adjusted range (from low end of confidence inrerval to high end of confidence interval) 

matches or is better than the national standard, the state's performance is considered to meet (or match) 

the standard. 

Data Quality 

Before it calculated the national standards for CFSR round 3, the Children's Bureau perforn1ed certain 

data quality checks on data submitted by states for periods used to establish those standards. Data quality 

may be considered subpar if a certain percentage of records do not include needed infonnation (e.g., date 

of birth, date of entry to foster care, date of discharge from foster care, reason for discharge. etc} 

Alternatively a state may fail a data quality check if a certain percentage of records doesn't appear logical 

(e.g., date ofbinh is reported as after date reported for child's entry to foster care; age of child is given as 

21 or older at entry or discharge; virtually every child is reponed as having entered foster care for the first 

time etc.), Finally, a state's data may be disqualified if an insufficient share of record 10 numbers matches 

across reponing periods or across different data sets (i.e., AFCARS and NCANDS) or if the state 

obviously ' 'dropped" records for a child across the time period.:>< 

Different pieces of information (data) from different reporting periods and different data sets are needed 

to calculate each of the seven national standards. Because each standard drew on multiple reponing 

periods and multiple data elements, a state may have been excluded based on data quali ty c.oncems on just 

one element and for one period. Alternatively, a state's data quality may have been subpar for multiple 

reporting periods and/or for multiple data periods.

3

s 

For each standard, data from between 3 and 6 states (includes Puerto Rico) were excluded from 

calculation of national standards based on data quality. However, all states met the vast majority of these 

data quality checks across multiple time periods. Missing data was a far less more common data quality 

concern than child 10 records not properly linking or dropped records. Additionally, data quality was a 

more common problem with NCANDS, which as discussed above is considered a "voluntary'' system, 

than for AFCARS. (States whose data were excluded from creation of a given national standard are listed 

in a note accompanying the memorandum's Figures 1-7, showing state performance on the standard.) 

Planned Revision of the National Standards 

Information about each of the seven national standards. as they were developed for the third round of the 

CFSR, is discussed below based on data available on the Children's Bureau website, or in formal 

regulations, prior to the October II , 2016 announcement that the standards would be revised and state 

performance recalculated.36 CRS believes the inforn1ation provided below rema ins relevant because HHS 

J<~ See CFSR Round J norkbot.,k(May 2015) for time periods rclcvan1 to each standard, a table lisring all data quality irems. and 

tables.. showing by Slate. any data item thai failed the quality check. 

u for example. on the one extreme Florida was excluded rrom development of five national standards - including three related to 

timely permru1ency. one C011ccrning placement stability. Md 011e concen1ing re-emrics to roster care) - because for a sir1gle 6-

month reporting period the State's data indicated that 97.2% of children served were entering care based on a first removal. TI1e 

data quality standard for this issue sets the limit for this infonnation at 95%. Accordingly, while f lorida met the data quality 

limilS on that specific issue for each or the other relevant reponing periods. and it supplied all the data needed 10 calculate the 

standards, it was excluded from the national standards calculation based solely on that single data quality issue in a single 

reporting period. By contrast, Nonh Carolina and (luerto Rico, failed to meet one or more data quality standards for all or most of 

1he re-poning periods used to calculate the standards and both were excluded Crom calculation of most of the national stMdards. 

,. HHS, ACF. ACYF, Children's Bureau, Technical Bulletin 9 and traJtSminat teller. O<:tober II. 2016, Available 31 

(continued ... ) 
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does not imend to change what it has already announced that it will be measuring. Instead it seeks to 

perfect the computer code it wrote to ensure that it obtains a more accurate measurement of state 

performance. 

12 

For example, the number of days children spent in foster care is relevant to determining the national 

standard for maltreatment of children in foster care, as well as placement stability. lfHS, in reviewing its 

computer code has identified several ways in which it may have over<omued placement days (e.g., it 

included days in care after a child turned age I 8) and at least one way that it under-counted days in care 

(i.e., it did not account for the extra day in leap years). Perfecting the code to address an over-count of 

days in care could, if large enough for a given state, worsen its performance (although that worsened 

perfommnce would also be incorporated into the revised national standard and so would lower the 

standard as well). At the same time, correcting for an undercount of placement days, if large enough. 

could improve state performance and raise the naiional example. 

In a separate, possibly more troubling example, HHS notes two ways that it may have undercounted 

recurrence of maltreatment. In one situation, the computer code was written to rule out recurrence of 

maltreatment if there were two reports of maltreatment for a child but the maltreatment was reported to 

have occurred on the same date. The intention was to ensure that if a child was reported twice for the 

same occu.rrence of maltreatment, this was not treated as recurrence. However, as HHS now 

acknowledges, as the code was written, it ruled out a child that met this criteria, without first checking 

whether a third report of maltreatment occurred at some later date in the 12-month period. 

In sum, HHS has stated that it intends to carefully review all of its code and will release revised national 

standards and state performance related to those standards before the end of the calendar year. This may 

change all or some of the values of the national standards and the state ranking of performance on those 

standards. At the same time, CRS is providing the following description of the measures because they are 

expected to be unchanged; it is providing figures of state performance based on the previously published 

standards and performance measures to illustrate how the standards compare to observed and riskstandardi.zcd perfom1ance. However. the values of those standards and state performance are expected to 

change. 

Seven National Standards 

Two of the national standards relate to ensuring children arc protected from abuse and neglect and five 

concern ensuring pem1anence and stability in living situations for children experiencing foster care. Each 

of those standards is described below and that description is followed, in each case, by a figure showing 

state perfonnance against the national standard (as ca.lculated in May 20 I 5). 

The national standard tor each measure is indicated by a red vertical line shown in each figure. State 

performance values shown in these figures are the state's observed perfom1ance (red circle), as well as 

two markers for its risk-standardized performance: (RSP) range (black horizontal line) and midpoint of 

the RSP range (blue bar). The states, which for purposes of this discussion include 52 j urisdictions (50 

states, DC and PR) are ranked, best to worst performance, based on the midpoint of their risk standardized 

perfonnance. However, a state was considered in compliance with the national standard if any value in its 

RSP range- which represents the low and high end of statistical confidence in the state's risk 

standardized perfom1ance - equaled or was better than the national standard. When reading each figure, if 

the state's RSP range (black horizontal line) crosses, touches, or is better than the national standard (may 

( ... contirlued) 

https://training.cfsrportal.orglresources/3 1 OS#CFSR%20Technicai%20Bulletins%20and%20Related"lo20Jnformation. 
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be to the left or right of national standard depending on the measure and as indicated in each figure), it 

was in compliance with the nat·ional standard. 

Recurrence of Maltreatment 

This indicator has traditionally been used as p81t of assessing whether a state achieves the following 

safety outcome: Children are lirst and foremost protected from abuse and neglect. 

13 

It is focused on all children (under age 18) who come to the auention of the child welfare agency (via a 

report of abuse or neglect) and for whom the state determines abuse or neglect occurred. (It is not limited 

to children in foster care.) Specifically it asks - Of all the children who were found by the state to be 

victims of abuse or neglect in a given year, how many were again found to be victims of abuse or neglect 

within 12 months of the earlier maltreatment findi ng? In the May 2015 workbook, the national standard 

was set at 9. I% recurrence. 37 

Maltreatment is more onen determined for younger children. A state's performance is risk-adjusted by the 

age of children when the first maltreatment finding is made. Data used for this indicator are reported by 

states via NCANDS, and HHS must link data across two report years to determine the state's 

perfom1ance. 

Figure I shows state perfonnance on this measure as calculated in May 2015. A state was considered to 

be in compliance with the national standard for recurrence of maltreatment if any va lue in its RSP range 

equaled or was le'ss than the national standard (9.1 %). Therefore, if the state's black RSP range line 

crosses, touches, or is to the left of (lower value) the red national standard line, it was in compliance with 

the national standard. 

Figu re I indicates that 27 states were in compliance with the 9.1% national standard for recurrence of 

maltreatment. This includes Washington and Vermont, both of which were considered to have a 

performance no different than the national standard. It does not include Florida, even though that state 

appears above Washington and Vermont in the tigure. This ranking happened because - even though the 

mid-point of Florida's RSP range indicated a better performance than the comparable information for both 

Washington and Vermont - Florida's entire RSP range falls to the right of the national standard; thus all 

the values in Florida's RSP range were higher !han the national standard of9. 1%. 

J' for more detailed information on the specific construction of this indicator, and the various N'CANDS data eleme-nts used as 

well as rules about excluding or i1lCiudil1g data. see the two-page f.'ttt sheet on Cf'SR Statewide Data lndicatoi'S Round 3: 

Recurrence otMa ltrealmcnt., 2015. 
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Figure I. Recurre nce of Maltreatment 

Risk standardized performance (RSP) = observed performance adjusted by age of children. A state meets the 

national standard (9. 1% - shown as red line) if any value in its RSP range includes. matches or is lower than that 

value. 

0% 

WY 

sc 

AL 

DE 

HI 

wv 

KS 

co 

NH 

NC 

WI 

NO 

AZ 

10 

TX 

NV 

KY 

MT 

GA 

AR 

MN 

CT 

MO 

Nl 

FL 

WA 

VT 

OA 

LA 

MS 

IN 

CA 

OK 

UT 

ll 

OH 

NE 

Rl 

oc 

ME 

lA 

MA 

NM 

Ml 

AK 

NY 

5% 10% 15% 

._Nationa l Sta ndard= 9.1% 

a lower % is desirable 

Among all children (whether in 

foster care or not in foster care) 

who were found to be victims of 

maltreatment during a 12· 

month period. what percent 

were found to be victims again 

within 12 months? 

- Risk Standardized Performance (RSP) 1---1 RSP Ra nge 

20% 25% 

0 Observed 

Source: Chart prepared by the Congressional Research Service (CRS) based on CFSR Round 3 Statewide D<lro lnd'Kotors 

Workbook. May 2015. http://www.ad.hhs.gov/sitesldefaultlfiles/cb/cfsr _stateperformanceworkbook.pdf 

14 

N ot es: Data vsed to calculate the national standard, and to show state performance against that standard were submitted 

by states as part of the National Child Abuse and Neglect Data System (NCANOS) for FY20 12 and FY2013. Data from 

MO. PA. PR. TN and VA are not shown due to data qu:ality concerns. 
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Maltreatment in Foster Care 

This indicator has traditionally been used as part of assessing whether a state achieves the following 

safety outcome: Children are first and foremost protected from abuse and neglect. 

15 

The indicator is focused on children in foster care (under age 18) and measures the rate at which these 

children experience maltreatment while in care, regardless of who is the reported perpetrator of the 

maltreatment.

38 In the May 20 15 workbook, the national standard for this indicator was set at 8.5 

occurrences of maltreatment per I 00,000 days of foster care.39 

This measure counts all the occurrences of maltreatment for children while they were in foster care (in a 

12-month period) and then divides that by the total number of days those children were in foster care 

during that same 12-month period. The final result is multiplied by I 00,000 to allow for a more 

understandable whole number' 0 Thus the rate detennined is the number of times maltreatment was 

detem1ined to have occurred for a child in foster care per I 00,000 days of foster care. 

This measure is one of two national standards based on the number of days a child spent in foster care. 

Using days in care is particul arly useful when the likelihood of an event occurring is directly related to a 

child's length of stay in care. With regard to maltreatment in care, a longer stay provides more 

'·opportunity" for maltreatment, thus the use of placement days equalizes risk determination whether a 

child is in care for two months or the whole year. 

Maltreatment is more commonly determined to have occurred for younger children. A state's perfom1ance 

with regard to maltreatment in foster care is adjusted by the median age of children entering care, or, if 

already in care, median age on first day of the 12-month period. Data used for this indicator are reported 

by states via NCANDS and AFCARS. Data from these two systems must be linked (by child I D) to 

identify children who arc found to be maltreated (NCANDS) and children who were in foster care 

(AFCARS). The AFCARS data is also used to count the number of days a child spent in foster care. 

Figure 2 shows state perfonnance on this measure as calculated in May 2015. A state was considered to 

be in compliance with the national standard for maltreatment in foster care if any value in its RSP range 

equaled or was less than the national standard (8.5 victimizations per I 00,000 days in foster care). 

Therefore, if the state's black RSP range line crosses, touches, or is to the left of (lower value) the red 

national standard line, it was in compliance with the national standard. 

figure 2 indicates that 25 states were in compliance with this national standard. This includes Louisiana 

and Delaware. It does not include Tennessee, even though that state appears above Louisiana and 

Delaware in the figure. This ranking happened because - even though the mid-point of Tennessee's RSP 

range indicated a better performance than the comparable infonnation for both Louisiana and Delaware -

Tennessee's entire RSP range falls to the right of the national standard; thus all the values in Tennessee's 

RSP range were higher !han the national standard of 8.5 victimizations per I 00,000 days in foster care. 

lll The mahn.".3tment in foster care standard used in c..1.rlier rounds of the CFSR looked only at maltreatment reported as 

perpetrated by a foster parent or other foster caregiver. In this round, however. HHS has determined that while t11e responsibility 

for the child rests with the agency, maltreatment by any perpetrator (even by a parent if done during a ''Lrial home visit") mus1 be 

counled as the responsibility of the child welfare agency. 

39 For more detailed infom1atton on the specific construction of this indicator. and the various AFCARS and NCANDS datn 

clements used as well as rules about excluding or including data1 sec the two~page fact sh().!t on CFSR Statewide Data Indicators 

Round 3: A4.?1trcatmem in Foster Care, 2015 . 

.IC) When describing relatively rare events. statisticians often tum to a larger scale (e.g.. I 00,000) so that the rntc c:m be expressed 

as something 1hat is I or greater. Using the more common. 1,000 scale would resuh in a maltreatment rate or .085 (i.e., less 1han 

one) maltreatment per 1.000 days in t.'lrc. For another example or a rate scaled to 100.000 S<.'C the statistics related to d<'llth by 

suicide .. which are based on suicides per 100,000 individuals in the population. http://www.cdc.gov/nchslfastats/suicide.htm 
264 


26354D16.eps

Congressional Research Serv1ee 

Figure 2. Ma ltreatment in Foster Care 

Risk standardized performance (RSP) = observed performance adjusted by age of children. A state meets the 

national standard (8.5 victimizations per I 00.000 days in foster care - as shown by red line) if its RSP range 

includes or is lower !han that value. 

0 5 ':SE: VA 

o<: 

:.! :: ---i so ==----1 

MN 

':ME 

A

HI 

L

~ - 13----1 

NO 

ID 

Vl 

M

N

T 

l ~ 

KS 

GA 

TX 

NM 

sc 

TN 

LA 

DE 

NE 

N V 

WA 

IL 

er 

AR 

CA 

co 

UT 

OR 

Fl 

KY 

OH 

IN 

MD 

Rl 

AK 

OK 

Ml 

NY 

lA 

MA 

10 15 20 

.-.- National Standard : 8.50 

victimizations per 100,000 

days in care 

a lower number I$ desirable 

Amons all children in foster care 

durins a 12-month period, at 

what rate did they experience 

child maltreatmern ? 

25 

- Risk Standardized Performance (RSP) ....._..... RSP Range 

30 35 

0 Obser"Ved 

SourGe: Chart prepared by tfoe Congressional Research Service (CRS) based on CFSR Round J Statewide Ooto Indicators 

Workbook, May 201 S. hnp1/www.acf.hhs.gov/sitesldefault/fik!slcb/efsr _stateperformanceworkbook.pdf 

16 

Notes: Data used to calculate the national s-tandard, and to show state performance against that standard were submitted 

by states as part of the Notional Child Abuse and Negle<t Data Sy>tem (NCANDS) for FY2013 and the Adoption and 

Foster Care Analysis Reporting System (AFCARS) for FY20 13. Data from MS. NC. PA. PR. are not shown due to data 

quality concerns. 
265 


26354D17.eps

congress1onal t-<esearch !::ieMCe 

Permanency for Children within 12 months of Entering Care 

This indicator has traditionall y been used as part of assessing whether a state achieves the following 

permanency outcome: Children have permanency and stability in their living situations. 

1 1 

It is focused on children (under age 18) who enter foster care during a 12-rnonth period and it asks the 

question: Of those children, how many lefl foster care to .. pem1anency" within 12 months of that entry to 

care? Pem1anency in this instance means the child was formally discharged from foster care to be reunited 

with his/her parent(s), to live with a relative, for adoption or for legal guardianship. In the May 2015 

workbook, the national standard was set at 40.5%.41 

Children's speed of exit from care may be affected by age. Additionally, in states where the rate of entry 

to foster care is low - suggesting children are only brought into formal care when circumstances are most 

difficult - the speed of exit may also be slowed. Accordingly, a state's observed performance is riskadjusted by the age of children when they enter care and by the rate at which children enter foster care in 

the state (i.e., number of children entering foster care per every I ,000 children in care). 

Data used for this indicator are reported by states via the AFCARS. HHS must link data across multiple 

years (3 years, including six reporting periods) to detem1 ine the state's performance. A state with a risk 

standardized perfom1ance range that includes, matches, or is above the national standard of 40.5% meets 

(or is no different than) the national standard. 

Figure 3 shows state performance on this measure as calculated in May 2015. A state was considered to 

be in compliance with the national standard for permanency for children within 12 months of entering 

care if any value in its RSP range equaled or was greater than the national standard (40.5%). Therefore, if 

the state's black RSP range line crosses, touches, or is to the right of(higher value) the red national 

standard line, it was in compliance with the national standard. 

Figure 3 indicates that 27 states were in compliance with this national standard. This includes New 

Hampshire. It does not include Texas, even though that state appears above New Hampshire in the figure. 

This ranking happened because - even though the mid-point of Texas's RSP range indicated a better 

perfonnance than the comparable information for New Hampshire - Texas's entire RSP range falls to the 

left of the national standard (as did its observed perfonnance); thus all the va lues in Texas's RSP range 

were lower than the national standard of 40.5% pennanenc.e for children within 12 months of entering 

foster care. 

41 f or more detailed information on the specific co•l.Struction of this indic.ator, and the various CARS data elements used as 

well as rules aboul excluding or including data. see the lwo-pa.gc f3Ct shcel on CFSR Suucuide Dma ftl(/icawrs Round 3: 

Permanency in 12 months lbr Children Entering Foster C1re~ 2015. 
266 


26354D18.eps

Congressional Research Servoee 18 

Figure 3. Permanence for Children within 12 Months of Ente ring Care 

Risk standardized performance (RSP) = observed performance adjusted by age at entry to care and foster care 

entry r.~te. A state meets the national standard (40.5% - shown with red line) if its RSP range includes o r is higher 

than that value. 

0% 

sc 

M 

MN 

co 

I.A 

AL 

Wf 

UT 

KY 

MS 

GA 

MA 

OH 

HI 

10 

TN 

Rl 

WI 

IN 

NJ 

MO 

0£ 

NV 

so 

OR 

lA 

TX 

NH 

PA 

KS 

CA 

NO 

VT 

NY 

MO 

MT 

NM 

WA 

NE 

Ml 

VA 

Cl 

OK 

M. 

AK 

oc 

ME 

IL 

10% 20% 30% 

Risk Standardized Performance (RSP) 

40% SO% 60% 

0 

0 

0 

0 

4-National Standard = 40-5% 

a higher " is desirable 

Among all the children w ho enter 

foster care during a 12 ... month 

period, what percent left care 

within 12 months of that entry for 

a permanent family (via 

reunification. live with relatives, 

adoption, or guardianship)? 

1--l RSP Range 0 Observed 

70% 

Source: Chart prepared by the Congressional Research Service (CRS) based on CFSR Round 3 Stotewi<le Doto Indicators 

Workbook, May 20 IS. http://www acf.hhs gov/si<es/defau tlft~slcblcfsr _ statepcrformanc.workbook.pdf 

Notes: Data used to caloutate the national standard, and to show state performance against that standard were submitted 

by states as part of the Adoption and Foster Car~ Analysis Reporting System (AFCARS) for thr~e y~rs (April 201 1-Mar(:h 

20 14). Data for FL. NC. PR and WV are not included due to data quality issues. 
267 


26354D19.eps

Congressional ResearCh Se<vice 

Re-Entry to Foster Care 

This indicator has traditionally been used as pan of assessing whether a state achieves the following 

permanency outcome: Children have permanency and stability in their living situations. 

19 

It is focused on children (under age 18) who leave foster care for a pcnnanent home within 12 months of 

entering care. It asks: Of those children exiting to pemtanency within 12 months of entering care, how 

many re-enrer care within a year of that exit to permanency? Permanency in this instance means the child 

was fomtally discharged from foster care to be reuni ted with his/her parent(s), to live with a relative, or 

for legal guardianship. (Exi ts to adoption are excluded from the denominator in this measure because 

some states change a child's identifiers (e.g., ID code) following an adoption and this means the child's 

re-entry (numerator count) cannot be reliably tracked. In the May 20 15 workbook, the national standard 

was set at 8.3%.

42 

Children's speed of exit !Torn care may be affected by age and by the rate at which the state brings 

chil dren into care (its entry rate). Accordingly, a state's observed perfonnance is risk-adjusted by the age 

of children when they enter care and by the rate at which children enter foster care in the state (i.e., 

number of children entering foster care per every I ,000 children in care). 

Data used for this indicator are reponed by states via AFCARS. HHS must link data across three years 

(including 6 repon ing periods) to deiemti ne the state's perfonnance. A state with a risk standardized 

performance range that includes, matches, or is lower rhan the national standard of8.3% meets (or is no 

different than) the national standard. 

Figure 4 shows state performance on this measure as calculated in May 20 15. A state was considered to 

be in compliance with the national standard for re-entry to foster care if any value in its RSP range 

equaled or was less than the national standard (8.3%). Therefore, if the state's black RSI' range line 

crosses, touches, or is to the left of (lower value) the red national standard line, il was in compliance with 

the national standard. 

Figure 4 indicates that 29 states were in compliance with this national standard and they are shown as the 

first 29 states displayed in the figure (from the top). 

42 for more detailed information on the specific construction of this indicator. and the various AfCARS data elemems used as 

well as rules about exeludill£ or including data. see the IWO-page facl sheet on cr-sR Statewide Oar.a Indicators Round 3: Rc-

("ntry to Fostt•r Cue. 20 IS. 
268 


26354D20.eps

CongressK>nat Research Service 20 

Figure 4. Re-entry to Foster Care 

Risk standardized performance (RSP) = observed performance adjusted by age at entry to care and foster care 

entry rate. A state meets the national standard (8.3% - shown with the red line) if its RSP range includes or is lower 

than that percentage. 

0% 

Ml 

OE 

TX 

IN 

AK 

NE 

MS 

KS 

10 

NM 

WA 

NH 

ME 

VA 

OK 

AR 

AI. 

LA 

NO 

sc 

MO 

GA 

NV 

MT 

VI 

IU 

oc 

IL 

00 

WY 

TN 

lA 

KY 

so 

CA 

OH 

HI 

CT 

NY 

WI 

MA 

VT 

NJ 

co 

MO 

PA 

MN 

Rl 

5% 10% 15% 20% 

+----:-- 1 ----National Standard = 8.3% 

Risk Stand ard ized Pe rforma nce (RSP) 

o lower" is desiroble 

Among a ll the children who e nter 

foster care during a 12-month 

period and who left care within 12 

mont hs of that e ntry for a 

pe rmanent family (via 

reunification, live with relatives. or 

guardianship), what percent reentered care w ithin 12 months of 

lhat exit to permanency? 

e 

1---l RSP Range O Observed 

25% 

Source: Chart prepared by the Congressional Research Service (CRS) based on CFSR RCHJnd 3 Stotewk1e Ooto Indicators 

Workbook, May 20 IS. http1/www.acf.hhs.gov/sitesldefault/foleslcblcfsr _statcperformanceworkbook.pdf 

NoteJ: Data used to cakul:ate the national standard, and to show state performance against that standard were submitted 

by states as part of the Adoption and Foster Care Analysis Reporting System (AFCARS) for tllree years (April 20i i·March 

20 14). Data for FL. NC, PR and VW are not included due to data quality isoues. 
269 


26354D21.eps

Coogresslonal Research Service 

Placement Stability in Foster Care 

This indicator has traditionally been used as patt of assessing whether a state achieves the following 

pennanency outcome: Children have permanency and stability in their living situations. 

It is focused on children (under age 18) who enter foster care during a 12-month period. It asks: At what 

rate did those children move to a new placement setting? In the May 20 15 workbook, the national 

standard was set at 4.12 placement moves per I ,000 days of foster care:3 

21 

This measure counts the number of times children who entered care within a 12-momh period were 

moved to a new placement setting and then divides that by the total number of days those children were in 

foster care during that same 12-month period. The final result is multiplied by I ,000 to allow for a more 

understandable whole number. Thus the rate determined is the number of foster care placement moves for 

a child in foster care per I ,000 days of foster care. 

The placement stability indicator is one of two national standards that detennines the likelihood of an 

event based on the number of days a child spent in care- rather than a number of children experiencing 

the event. Using days in care is useful when the likelihood of an event occurring is directly related to 

length of stay in care. With regard to placement stability a longer stay provides more "opportunity" for 

placement moves thus the use of placement days equalizes the risk determination of a move whether a 

child is in care for two weeks, 60 days, or tor the whole 365 days in the 12 month-period. 

Children's li kelihood of moving may vary due to age. A state's observed performance is risk-adjusted to 

estimate placement stability in the state. Data used for this indicator are reported by states via AFCARS. 

HHS used data from a single year (two reporting periods linked) to detcnnine the state's pcrfonnance. A 

state with a risk standardized performance range that includes, matches, or is less than 4. 12 placement 

days per 1,000 days of foster care, meets (or is no different than) the national standard. 

Figure 5 shows state perfonnance on this measure as calculated in May 2015. A state was considered to 

be in compliance with the national standard for placement stability in foster care if the state's black RSP 

range line crosses, touches, or is to the lef\ of(lowcr value) the red national standard line. 

Figure 5 indicates that 27 states were in compliance with this national standard and they are shown as the 

first 27 states displayed in the figure (from the top). 

·U For more demiled infOrmarion on the Spt..'(;ificconslruction of this indicator, Md the various AFCARS ua clcrncnts used as 

well as rules about excluding or including data, see the two4 page tbct shccl on CFSR Statewide D:Jia Indicators Round 3: 

P/,u:ement Srnbility. 2015. 
270 


26354D22.eps

Congressional Research SeM<:e 

Figure S. Placeme nt Stability in Foste r Care 

Risk standardized performance (RSP) = observed performance adjusted by age at entry to care and foster care 

entry rate. A state meets the national standard (4.12 moves per 1,000 days in care- shown by red line) if its RSP 

range includes or is lower than that value. 

0 2 3 4 

Rl ~ 

cr ~'iii-'! 

NY IHO 

NE 

ME 

NH E!!i!--i:> 

lA 

wv 

WY IW--4> 

~ 

Ml '"' 1&1 

PA 0 

OH H> MD 

AZ 

OR 

10 

IL 

VA 

CA 

Mf 

MN 

WI 

TX 

I(Y 

NJ 

DE 

AK 

so 

MO 

DC 

MS 

HI 

TN 

WA 

NO 

sc 

KS 

MA 

GA 

LA 

VJ 

NV 

NM 

OK 

AR 

- Risk Standardized Performance (RSP) 

s 6 7 

- National Standard = 4 .12 

moves p er 1,000 days In care 

o lower number is desirable 

Among all children who enter 

foster care In a 12 nth period, 

a1 w hat rate were they moved to 

new plac:ement settings? 

0 

1--1 RSP Ra nge 0 Observed 

8 9 

Source: Chart prepared by the Congressional Research Service (CRS) based on CFSR Round 3 Statewide Oara Indicators 

Workbook, May 2015. http1/www.aef.hhs.gov/sitesldefaultlfileslcblefsr _stoteperformanceworkbook.pdf 

Notes-: Data used to calculate the national standard. and to show state pcrlormancc against that standard were submitted 

by states as part of the Adoption and foster Care Analysis Reporting System (AFCARS) for three years (April 20 11-March 

20 14). U.S. Census Data (child population cstirmtte by state) were used to calculate foster' cate entry rate. Data fot AL 

CO. FL. NC. PR and UT are not included due to data quality issues. 
271 


26354D23.eps

Congressional Research SeJVice Z3 

Permanency in 12 Months for Children in Care 12 to 23 Months 

This indicator was developed to help assess whether a state achieved the permanency outcome: Children 

have pennanency and stability in their living situations. 

It seeks to measure how effectively a state sticks with efforts to find a permanent home even when it is 

not successful during the child's first year in care."" Accordingly, the measure is focused on children 

(under age 18) who have been in care for at least one year ( 12 months) but not as long as two years. The 

indicator asks: Of all children who at the start of a 12-month period had already been in care for at least 

12, but not more than 23, months, how many were successfull y moved to a permanent home within that 

12-month time period? Permanency in this instance means the child was formally discharged from foster 

care to be reunited with his/her parent(s), to live with a relative, for adoption or for legal guardianship. In 

the May 2015 workbook, the national standard was set at 43.6%4 5 

Children's speed of exit ti·om care may be affected by age. Accordingly. a state's observed performance is 

risk-adjusted by the age of children at the start of the 12-month period. Data used for this indicator are 

reported by states via the AFCARS. 1-fHS used data from a single year (two reporting periods were 

linked) to determine the standard and state performance. A state with a risk standardized pcrfom1ancc 

range that includes, matches or is greater than 43.6%% meets (or is no different than) the national 

standard. 

Figure 6 shows state perfom1ance on this measure as calculated in May 2015. A state was considered to 

be in compliance with the national standard conceming permanency for children in care for at least one 

but not two years if the state's black RSP range line crosses, touches, or is to the right of(higher value) 

the red national standard line. 

Figure 6 indicates that 35 states were in compliance with this national standard and they are shown as the 

first 34 states displayed in the figure (from the top) as well as New Hampshire (some states lower). d. 

Federal law has specific tim·c frames within which states are to establish pcmWlency goals for a child and no less often than 

once e\'ery 12 rnonths while a child remains in foster care. a coun must make a determination related to continued pemumcncy 

cfTons ofthcsultc. In the recent Texas child wdf.1rc litigation. MD v. Ab!Jou.thc focus oft he cnsc is spccitically on the group or 

children in care for at lea~t 12 (sometimes 18 months). Texas has applied ditl'erent (less aggressive) pennanency eflbns for this 

gr<>tlp of children in care. 4

s For more detailed information on the specific construction of this indicator, and the various AFCARS data elements used as 

\\'ell as rules about exchading 01' including data, see the two-page fact sh¢i!t on CFSR Suucwide Data Indicators Round J: 

Permanency in 12 months /Or Children in Care 12 to 23 momhs. 2015. 
272 


26354D24.eps

Congress1onal Research Service 

Figure 6. Permanency for Children in Foster Care for at Least One but not Two Years 

Risk standardized performance (RSP) = observed performance adjusted by age of children. A state meets the 

national standard (43.6%. shown by red line) if its RSP range includes or is greater than the national standard. 

0% 

lA 

10 

wv 

UT 

'" TX 

LA 

AZ 

NE 

Ml 

AR 

NV 

Wf 

co 

VT 

HI 

GA 

OH 

MD 

MO 

sc 

N< 

Rl 

PA 

VA 

oc 

'" M>l 

KS 

WI 

NM 

so 

DE 

NO 

MA 

CA 

NJ 

WA 

Al 

OR 

ME 

MS 

MT 

NH 

OK 

KY 

CT 

NY 

ll 

10% 20% 30% 

Risk Standardized Performance (RSP) 

40% 

0 

~ 

0 

SO% 60% 70% 

t 9 

~ 

0 

0 

--National St anda rd = 43.6% 

o higher" Is desirable 

Among all children who on the 

forst day of a 12 -month period 

had been in foster care for at 

least one year, but less than 

two years. what percent left 

foster care to a permanent 

family (via reunification, live 

with relative, adoption, or 

guardianship) within one year 

of that first day? 

1--1 RSP Range O Observed 

Source: Chart prCj)ared by the Congressional Research Service (CRS) based on CFSR Round 3 Statewide Dora Indicators 

Workbook. May 2015. httpJ/www.acl.hhs.gov/sites/delault/files/cblclsr _stateperformanceworl<book.pdf 

24 

N otes: Data used to calculate che nationaJ standard. and to show stau~ performance against thac standard were submitted 

by states as part of the Adoption and Foster Care Analysis Reporting System (AFCARS) for April 2013-March 201 ~.Data 

!or FL NC. PR are not included due to data quality issues. 
273 


26354D25.eps

Coogresslonal Research Service 25 

Permanency in 12 Months for Children in Care 24 Months or More 

This indicator was developed to help assess whether a state achieved the permanency outcome: Children 

have permanency and stability in their living situations. 

It seeks to measure how effectively a state sticks with efforts to find a pem1anent home even when it is 

not successful during the child's first two years in care. Accordingly, the measure is focused on children 

(under age 18) who have been in care for at least two years (24 months). The indicator asks: "Of all 

children who at the start of a 12-month period had already been in care for at least 24 months, how many 

were successfully moved to a permanent home within that I 2-month time period?" Permanency in this 

instance means the child was fonnally discharged from foster care to be reunited with his/her parcnt(s), to 

live with a relative, for adoption or for legal guardianship. In the May 2015 workbook, the national 

standard was set at 30.3%.46 

Children's speed of exit from care may be affected by age. Accordingly, a state's observed perfom1ance is 

risk-adjusted by the age of children at the start of the I 2-month period. Data used for this indicator are 

reported by states via AFCARS. HHS used data from a single year (two reporting periods linked) to 

determine this standard and state performance. A state with a risk standardized performance range that 

includes or is greater than 30.3% was considered in compliance with this standard. 

Fig ure 7 shows state performance on this measure as calculated in May 2015. A state was considered to 

be in compliance with the national standard concerning permanency for children in care for two years or 

more if the state's black RSP range line crosses or is to the right of(higher value) the red national 

standard line. 

Fig ure 7 indicates that 33 states were in compliance with this national standard and they are shown as the 

first 3 I states displayed in the figure (from the top) as well as Maine and RJ1ode Island (lower). 

,.

6 For more demiled infOrmation on the Spt..'(:ificconslruction of this indicator, Md the various AFCARS ua clcrncnts used as 

well as rules about excluding or including data. see the two4 page tbct shccl on CFSR Statewide D:Jia lndic:uors Round 1: 

Perm.-urency in 12 momhs /i)r Children in Care 24 momhs or More, 201 S. 
274 


26354D26.eps

Congressional Research SeM<:e 

Figure 7. Permanency for Children in Care For Two Years or More 

Risk standardized performance (RSP) = observed performance adjusted by age of children. A state meets the 

national standard (30.3% - shown by red line) if its RSP range includes or is higher than the national standard. 

wv 

lA 

10 

TN 

Ill 

M 

sc 

NV 

H 

lA 

N£ 

PA 

UT 

wr 

oc 

AX 

NH 

WI 

co 

vr 

VA 

GA 

WA 

OE 

HJ 

N.. 

I(Y 

All 

MO 

NM 

MS 

lX 

IN 

MD "" 

.. 

OH 

KS 

OK 

OR 

so 

MA 

MT 

MN 

CA 

NY 

NO 

cr 

IL 

5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 

Risk Standardized Performance (RSP) 

~ 

0 

0 

0 

0 

0 

--- 9 

0 

0 

0 

0 

0 

E3--l 0 

0 

0 

0 

0 

0 

0 

.--National Standard = 30.3% 

0 An:,~~:; !~~ ~=~~ ~~ he 

fiJ$1 day or a 12-month period 

had been In foster care for two 

o years, what percent left foster 

care to a permanent family 

(via reunificatton, live with 

relative, adoption, or 

8U3rd ianship) within one year 

of that fiJ$1 day? 

1--1 RSP Range 0 Observed 

Source: Chart prepared by the Congressional Re.search Service (CRS) based on CFSR Round 3 Statewi<le Data Indicators 

Workbook. May 2015. http://www.acf.hhs.gov/sitesldefault/files/cb/cfsr _stateperformanceworl<book.pdf 

Notes: Data used to calculate the national standard. and to show state performance against that standard were submitted 

by states u part of the Adoption and Foster Care Analysis Reporting System (AFCARS) for Apri120 13-March 2014. Data 

for FL. NC, PR are not indudt!d dut! to data quality issues. 
275 

Appendix E 

276 


26354.211

L;HHIS CAMI'BfU ~rAff tm•l'CTOH 

:H.<iHUA SftfiNKII.iAN. DfM0CRA"!C!'>"~'AfT fllllfC'YJfi 

Bruce F. Nardella, President 

The MENTOR Network 

313 Congress Street 

Boston, Massachusetts 02210 

Dear Mr. Nardella: 

Jw1e 17, 2015 

The title IV-E Poster Care program benefits children who meet certain eligibility requirements 

and who have been removed from their homes due to mistreatment, lack of care, lack of 

supervision, or other problems attributed to a relative caregiver. Under the program, title IV -E 

state and tribal agencies place these children, who can no longer remain safely in their own 

homes, in temporary living arrangements with the goal of achieving permanency for them 

through family reunification, adoption or legal guardianship. The program provides federal 

funds to title IV -Estate and tribal agencies in all 50 states, the District of Columbia and Puerto 

Rico. Those agencies use the federal funds to support the daily living costs of eligible children 

by making subsidy payments to individual foster caregivers or to organizations that provide 

foster care services to a number of eligible children. Federal funds are also used by the agencies 

to meet the administrative costs they incur in managing the title IV-E program and to pay for the 

costs of training foster parents, agency staff and others. Individuals and private entities may 

apply to the title IV -E agencies to become sub-grantees or contracted providers of foster care 

services. 

Over the last several months, a number of deeply disturbing articles have appeared in the media 

regarding The MENTOR Network, which appears to be comprised of a variety of for-profit and 

not-for-protit affiliates, subsidiaries, branches and related entities (collectively referred to herein 

as "Mentor.") Mentor contracts directly v,ith title IV-E agencies in a number of states to provide 

foster care services for children who have been removed from their homes. These media articles 

have focused attention on what appear to be serious deficiencies in Mentor's screening, training 

and oversight of foster parents. According to these media stories, at least six children have died 

while in the custody of foster parents recruited or trained by Mentor. Others have been abused, 

neglected and physically injured by foster parents who were wholly unqualified to hold such a 

prominent position of trust in the lives of these children. Serious errors in judgment by Mentor 

and lapses in due diligence when screening these foster parents, as well as failures to heed plain 

warning signs regarding the unsuitability of foster parents after children have been placed in their 
277 


26354.212

homes, have reportedly Jed to a number of tragic consequences. These reports raise serious 

questions about Mentor, its operations and its business practices. 

The title IV -E program is a health program under the Social Security Act. As such, it falls within 

the oversight jurisdiction of the Senate Finance Committee. Moreover, state title IV-E agencies 

pay Mentor for foster care services in large part with federal title IV -E funds. In accordance with 

the Committee's oversight responsibility for this program, we request that you provide the 

following information to the Committee no later than close of business, July 10,2015: 

I. Please describe the corporate structure of Mentor as follows: 

a. Identify each and every Mentor affiliate, subsidiary, branch and related 

organization; 

b. For each entity so identified, state whether it is for-profit or not-for-profit, and 

whether it is tax-exempt; 

c. Describe each entity's lines of business and the services that it provides; and 

d. Identify the geographic locations where each entity carries out its primary lines of 

business and its primary place of business. 

2. For those Mentor entities identified in response to Question 1 that operate as taxexempt organizations, please provide copies of the publicly available portions of their 

IRS Form 990 filings made since 2010. 

3. Please describe Mentor's relationship to Civitas Solutions, Inc. 

4. Please describe Mentor's relationship to Alliance Human Services. 

5. Please describe Mentor's relationship to Alliance Children's Services. 

6. Please provide the total number of children who are currently in Mentor foster homes 

nationwide, as well as in Mentor foster homes in each state. 

7. Please provide a copy of every assessment or performance review of state Mentor 

programs and contracts issued by state or local title IV-E agencies from January 2012 

to the present. 

8. Have any Mentor entities identified in response to Question l as providing foster care 

services ever been the subject of a statewide investigation related to the provision of 

those services? If so, please identify the state in question, the Mentor entity 

investigated, and the results of the investigation. Please provide copies of any reports 

issued by the state investigative agencies, to the extent that they are in the possession 

of Mentor. 

9. Do any Mentor entities identified in response to Question 1 as providing foster care 

services require caseworkers to meet numerical quotas or targets for placements of 

2 
278 


26354.213

children in Mentor foster care homes? If so, please provide those numerical quotas or 

targets for each state in which they are required or imposed, together with copies of 

all written policies or procedures that describe said numerical quotas or targets. 

10. Have any Mentor entities identified in response to Question I as providing foster care 

services ever offered any employees or contractors bonuses (cash or other 

consideration) for placing individual children in foster homes, or for attaining 

numerical targets for placements of children in foster homes? If so, please describe 

when such bonuses were paid, their amounts, the conditions under which they were 

paid, and provide copies of all written policies or procedures that describe the 

payment of such bonuses. 

11. Please provide the following infmmation on a state-by-state basis for each Mentor 

entity identified in response to Question I as providing foster care services: 

a. The current average caseload of social workers employed by the entity; and 

b. The total number of social workers currently employed by the entity. 

12. For each state in which a Mentor entity identified in response to Question I has 

provided foster care services from 1 anuary 2012 to the present, please provide the 

following information on an annual basis: 

a. The total dollar amount of payments made by state, local or tribal title IV-E 

agencies to Mentor entities "'ithin that state for foster care services; 

b. The total dollar amount of payments made by Mentor entities to foster care 

providers/parents mthin that state; 

c. The total dollar amount of costs claimed by Mentor entities as overhead and 

operating expenses; 

d. The total dollar amount of payments made by local Mentor entities that provide 

foster care services within the state to Mentor corporate entities (mthin or without 

the state) for services received from those entities (please identify those services); 

and 

e. The total dollar amount of profit earned by Mentor entities for providing foster 

care services within the state. 

13. Please describe the current process employed by each Mentor entity identified in 

response to Question I as providing foster care services for investigating and vetting 

applicants who desire to become foster caregivers. Please provide copies of all 

written policies and procedures descriptive of that process. If the current process is 

different than the process employed by the Mentor entity in January 2012, please 

describe how it has changed since January 2012 and the dates of each change to the 

process up to the date the Mentor entity adopted its current process. 

3 
279 


26354.214

14. Do Mentor entities identified in response to Question 1 as providing foster care 

services currently perform criminal and non-criminal background checks on: a) 

applicants who desire to become foster caregivers; b) individuals who reside 

temporarily or full-time in the home of such applicants, or; c) individuals providing 

references for applicants who desire to become foster caregivers? If so, when did 

these tvlentor entities first begin to perform such background checks? Please provide 

state-specific responses for each category of background checks for each state in 

which a Mentor entity provides foster care services. 

15. What standards are used by Mentor entities identified in response to Question 1 as 

providing foster care services to determine whether they will approve/disapprove an 

application from an individual who desires to become a foster caregiver? Please 

provide a copy of all written policies and procedures descriptive of the process by 

which Mentor entities apply these standards when they evaluate applicants. If the 

process varies from state to state or from entity to entity, describe those differences 

and provide copies of the relevant documentation applicable to that state or entity. 

16. Please describe how Mentor entities identified in response to Question 1 as providing 

foster care services recruit or solicit applicants for the position of foster caregiver and 

provide copies of all written policies and procedures descriptive of the recruitment 

process. If the process varies from state to state or from entity to entity, describe 

those differences and provide copies of the relevant documentation applicable to that 

state or entity. 

I 7. Please describe how Mentor entities identified in response to Question 1 as providing 

foster care services train foster caregivers and the frequency and duration of such 

training. Please provide copies of all written policies and procedures descriptive of 

that training. If the training process varies from state to state or from entity to entity, 

describe those differences and provide copies of the relevant documentation 

applicable to that state or entity. 

18. Please describe how Mentor entities identified in response to Question 1 as providing 

foster care services monitor foster caregivers and the frequency of their monitoring 

activities. Please provide copies of all written policies and procedures descriptive of 

those monitoring practices. If the process varies from state to state or from entity to 

entity, describe those differences and provide copies of the relevant documentation 

applicable to that state or entity. 

19. Please describe how allegations of misconduct against foster caregivers reported to 

Mentor entities identified in response to Question 1 as providing foster care services 

are currently handled by those entities and provide copies of all written policies and 

procedures descriptive of the process for handling such allegations. If the current 

process is different than the process employed by Mentor entities in January 2012, 

4 
280 


26354.215

please describe how it has changed since January 2012 and the dates of each change 

to the process up to the date the Mentor entity adopted its current process. 

20. Please describe how Mentor entities identified in response to Question 1 use nondisclosure/confidentiality agreements and clauses with regard to: 

a. Employees of Mentor; 

b. Foster caregivers providing services on behalf of Mentor; 

c. Individuals (victims, witnesses or any others) alleging misconduct by foster 

caregivers in the performance of their foster parent responsibilities. 

21. To the extent that Mentor entities use non-disclosure/confidentiality agreements and 

clauses with respect to the above individuals, please provide copies of five 

representative agreements of each such type of agreement signed in the past five 

years together with copies of all written policies and procedures that describe the use 

of such agreements and clauses and conditions for their use. 

22. Since January 2005, has Mentor entered into any agreements containing nondisclosure/confidentiality clauses with the legal representatives of children who were, 

or are now, placed in Mentor foster care homes? For each such agreement, indicate 

the legal status (i.e., parent, guardian ad litem, etc.) of the individual who signed the 

agreement on behalf of the child. 

23. Please provide the number of settlements entered into by Mentor since 2005, either 

before or after the commencement of litigation, in which a claim for dan1ages against 

Mentor was asserted based upon the alleged negligent performance by Mentor in 

recruiting, selecting, training, or monitoring foster care providers. Please provide a 

copy of each settlement agreement with the names and addresses of specific 

individuals redacted consistent with the requirements of45 CFR Parts 205 and 1355. 

For each such settlement, please briefly summarize the allegations against Mentor. 

24. Please provide the number of judgments entered against Mentor as the result of 

litigation since 2005 in which a claim for damages against Mentor was asserted based 

upon the alleged negligent performance by Mentor in recruiting, selecting, training, or 

monitoring foster care providers. Please provide a copy of each judgment with the 

names and addresses of specitic individuals redacted consistent 'hith the requirements 

5 
281 


26354.216

of 45 CFR Parts 205 and 1355. For each such judgment, please briefly summarize 

the allegations against Mentor. 

Questions regarding this request for information may be directed to Kim Brandt, Chief Oversight 

Counsel, Majority Staff, or David Berick, Chief Oversight Counsel, Minority Staff. Ms. Brandt 

may be reached on extension (202) 224-4515 and Mr. Berick may be reached on extension (202) 

224-6399. 

Sincerely, 

Orrin 

Chairman, 

G. Hatch 

Senate Committee on Finance 

~-Ranking Member 

6 
282 

Appendix F 

283 


26354.217

- -

( ) Behavioral Health 

{ ) Juvenile Justice 

(xl Madi<ally C<lmplex 

( l MRIOD 

( l MR/DD Offender 

} Acquired Brain Injury 

) Elder Care 

) Mental Jllness 

) MR/MI 

l Education 

I Other. 

16. Service Setting/Mo<fel: (check the ONE that most closely fits} 

( l ICFIMR (Intermediate Care Facilily) ) Fam!ly/Schoot/Home Based Supports {pariodic 

( ) Group or Shared Living (3+ clients/individuals with 2417) sa(llfces tess than 2417} 

( ) Shared or Supported Living (1 or 2 clients/individuals with 2417) 

ht) Mentor Hemal Host Home 

) CllnlcaVOulpatlenl Tharapy/Rehab (OT, PT. 

l DayProgram 

( ) Group or Shared Living (3+ clientsllndMduats with less than 24n} 

{ ) Shared Of Supported Living (1 or 2 c!iantsllndivlduals with less 

} Supported EmploymenWocatlonal 

) School 

than 2417) 

) Home Health Agency Services 

19. Location of lncldoot: (ch&ck. ane) 

( ) Montor Home ( ) Primary ( l Respite 

Mentor Name: 

#of CUentsllndlvlduals Uv1ng in Home: 

{ } C!lentlind!\lldual"s Residence (group home,lCF, apt) 

( ) Cltentltncflvidual"s Slologltal Famlly/Guard!an Home 

i I Day Program 

( } Schaal 

{ ) Glient/tnd!vidual's Place of Employment 

( ) V<>hlcle 

{ ) ProgramOffice 

( l Communily 

(x) Other. Hosp"al 

:ro. Oulrome of Incident {choclr alllhlt apply) 

l Remaln in Currsnt Placement 

1 Placement Decision Pending 

1 Cliant/lndtvidua! Pfae-ed in Respite 

1 Placement Disrupted {Le. CUentllndivldua! transferred to new 

hamel program/placement within MENTOR NETWORK) 

l Dloc~e<ged from MENTOR NETWORK 

l TemporariJy or Permanently Closed Mentor Home 

l Emergency Psychiatric Evaiuetion (no hosp!truization) 

} Emef'gency Psychiatric Hospitalization 

) Emergency Medical Hospitalkatkm 

1 In-school suspansion 

1 School Suspensloo/E)(pt.lls!on 

t 1 Clientilndlviduat ArresUDetention 

txl Death 

! J Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004850 
284 


26354.218

) Located at the Time of the Incident Report 

} Unable to Locate at the Time of the !nddent Report 

)Oth<>r. 

{Suspected, Alleged or Corrflrmed) 

Caretaker. 

J Mentor 

l Mentor-Family Member 

l Staff 

j Other Carataker: 

Aneged 1\1/sconduct: 

t l Sexual Boundary/Abuse 

[ 1 Vetbal or Emotional Abuse 

[ J Physical AssauiVAbusa 

[ ] Corporatflnapproprlate Punishment 

( ] lnapproptiate Use of Restraint!Physi~llnteNentlon 

( J Neglect 

[ ] Inadequate Supe~ision 

[ ] Criminal Arrest of Caretaker 

( l AlcohoVDrug u.., by Caretaker 

[ ] Misuse of CllenUlndMduat's Funds 

[ 1 Misappropriation/Destruction of Cliantlfndiv;dusl PefSOnal 

Property 

] Other. 

SUICIDAL Cl!ENTnNDMDUAL: 

{ ] Suicidal Threats or Verbalizations 

[ J Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTnND!V!OUAL: 

t jTo OtherCilent 

t ] To Staff or Mentor 

( ]To Mentor's Famtty Member 

[ ]To other Thirtl Perty 

PHYSICAL ASSAULTS BY CLIENTIIND!VIDUAL: 

[ 1 To Otl'ler Client 

[ J To Staff or Menlor 

[ ITQ Mentor's Family Member 

[ ]To OlhetThirtl Perty 

{ JTo Animals {animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Medication Error 

1 Missing Con !rolled Subs4ance.s 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ j Illness Requiring Medical Treatment 

t l Deterioration !n Existing Medlc.al Condition 

( J Pregnancy 

[ ] Sel.zure Requiring Emergency Treatment 

( l UTI 

[ l BQwet Impaction 

( ] Pneumonia 

( ] PraS$ure Sores 

[ l Other: 

Physlcal Assault by Third Party/Other Individual in oor car 

Sexual Assault by Third Party/Other !odMdualln our care 

Theft by Third Party 

Fall 

Choking 

Bathlng!Scakllng Raleted Jniuries 

Other Bums 

Vehicle 

Swimming/Near Orownlf\g 

Other Accidentallnjury: 

EXPOSURE CONTRO LINCtOENTS: 

[ J Clientltndividual Exposed to Blood Some Pathogens 

[ l ClienVIndlvidual Exposed Third Perty to Blood Borne 

PROPERTY DAMAGE BY CUENTIINDMIJUAL: 

( 1 Property Damage Under $1,000 

[ l Property Damage Over $1,000 

[ J Vehicle Then 

[ l Fire Setting 

[ l Thalt/Shopliffing 

! l Othec 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

c!lentlindlviduaUprogram) 

[ 1 Possession of Prohibited Materials (i.e-., alcohol, 

lighter, weapon, pornography, l!l!cit drugs, etc.) 

MENTOR0004B51 
285 


26354.219

l Counsetlng/Tralntllg lor Staff/Mentor 

1 &i.f!l~c~:~:;,~t;,aw:=~r J lntamallnves.tigation Underway 

ln:terventiotrs: 

[ ]Ph)"lcot 

[ ]Ma<;hanlcal 

( !Seclusions 

( ]Chemica! 

J Substantiated ( ) Unwbstantlsle 

licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

{l<] 

Date; 

[ l Family 

Date: 

(xl Guardian Notified 

Date: .1!!1!1!1!1.!= ] Law Enforcement/Probation Notified 

Date: 

MENTOR0004852 
286 


26354.220

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004853 
287 


26354.221

8. Papulation: ( ) Adult (18+) (x) Child 

10. Date of Admission to MENTOR NETWORK: 

11. Length of -

Current PlecementJServices: 

2 Months 16 Days 

9. Service Category: (Chsclr OTlR) 

( ) Behavioral Health 

( } Juvenile Justice 

(x) Medically Complex 

( ) MRIDD 

( ) MRIDD Offender 

) At:quirod Brain Injury 

) Elder Care 

) Mental Illness 

) MR/MI 

) Education 

) Other: 

narne: 

1 B. ServiGe 5etting/Model: (chec;k the ONE that most closely fits) 

( ) ICFIMR (lnll>nmediate Care Facility) ) Family/School/Home Basad Supports (perlodk: 

( ) GroiJp or Shared Uving (3+ cllentsllndivlduals with 24fl) services less than 24!7} 

( ) Shared or Supported Living (1 or 2 clientS/individuals with 24{7) 

{x) Mentor Home/ Host Horne 

) CllnlcaVOu!pallenlTherapy/Rehab (OT, PT, Spoe<h) 

) Day Program 

( ) Gmup or Shared Living {3+ clienlsllndtviduals with lass than 24!7} 

( ) Shared or Supported Llving { 1 or 2 cllentsltndlviduals with less 

) Supported Emp!oymenWocationa! 

) School 

than 2417) 

) Home Health Agency Ser.~ices 

17. Date 

19. Location or Incident: (WJeck one) 

{ ) Mentor Home C ) Primary ( ) Respite 

Mentor Name: 

#of CfiantsllndJvlduafs living in Home: 

{ } ClientlfndMduat's Residence (group home, tCF, apt} 

I l CllenVIndlviduol's Slo!oglcal Famlly/Guartllan Home 

( ) Day Program 

( ) School 

( ) C\ianfllndllfidual's Place of Employment 

{ ) Vahk:le 

( ) Program Office 

I ) Community 

(x) Other. ;.:H;::o•:oPe,:it,a,_l ________ _ 

) Brokerage/Case Management {non-residential) 

By: (Name & Title) 

20. Outcome of lncldont; (check all that apply} 

] Rernaln in Cw"rent Placement 

] Placement Decision Pe11ding 

] Cllent/fndMdual Placed in Respite 

l Placement Disrupted (Le. CUenll!ndividualtransferred to new 

hamel program/placement within MENTOR NETWORK) 

l Discharged from MENTOR NETWORK 

] T emporart!y or Permanently Closed Mentor Home 

] Emergency Psychiatric Evaluation (no hospitalization} 

J Emergency Psychiallie Hospitalization 

l Emergency Medical Hospitalization 

] !n~sc!wol suspension 

] Schoo! Suspension/Expulsion 

] Cfl'entllndiv!duai Arrasl/Detantion 

[xJ Death 

[ l Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004854 
288 


26354.222

} located at the Time of the lnddent Report 

) Unable to Locate at the Tim<> of the Incident Report 

) Other. 

(Suspected, Alleged or Confirmed) 

Caretaker: 

J Mentor 

] Mentor Family Member 

l Staff 

J Other Caretaker: 

Allegad Misconduct: 

[ J Sexual Boundary/Abuse 

[ 1 Verbal ar Emotional Abuse 

[ J Phy>ical AssauiUAbuse 

t 1 Corporamnapproprtata Punishment 

( l Inappropriate Use of RestraintJPhys!cat intervention 

[ l Neglect 

[ l !nadeqtJate Supervision 

[ J Criminal Arrest of Caretaker 

[ ) AkohoUOrug Use by Caretaker 

[ ] Misuse of C!ientltndividual's fW!'1dS 

[ ] Misappropriat!on!Destruc.tlon of CHenUindlvidua! Personal 

Property 

] Other. 

SUICIDAL CUENTIINDMOUAL: 

[ } Suicldat Threats or Verbalizations 

( l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

t ] To Other Client 

t }To Staff or Mentor 

[ ]To Mentor's Family Member 

[ ]To O!her Third Party 

PHYSICAl ASSAULTS BY 

[ ]To Other Client 

[ ]To Staff or Mentor 

[ Jfo Mentor's Family Member 

[ ]To Other Third Party 

t JTo Animals (animal cnJelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medtcation Error 

l Missing Cantrofled Substance& 

l Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

( ] Illness Requiring Medical Treatment 

[x) Deterioration in Existing Medical Condition. 

[ l Pregnancy 

[ J Seizure Requiring Emergency Treatment 

[ J UTI 

l l Bowel impaction 

[ 1 Pneumonia 

t: ] Pressure Sores 

[ J Other. 

] Physical Assault by Thlfd Party/Other Individual in our car 

{ J Sexual Assault by Third Party/Olher Individual in our care 

( J Theff by Third Party 

( J Fall 

( l Choking 

[ 1 Bathing/Scalding Related Injuries 

[ l Other Bums 

( l Vehlole 

[ J Swimming/Near Dm'M'ling 

( l Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

( 1 CHentllndlvlduat Exposed to Blood Some Pathogens 

[ J CUenVIndlvldual Exposed Third Party to Blood Some 

DAMAGE BY CLIENT/INDIVIDUAL: 

[ Property Damage Under $1,000 

{ Property Damage Over $1,000 

t l Vehicle Theft 

[ l Fire Se«lng 

( l Thef!!Shopllftlng 

[ l other: 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

clientlindlvidualfprogram) 

C J Possession of Pruh!bitad Materials (i.e., alcohol, 

Hghtor, wf.lapon, pornography, illicit drugs, etc.) 

MENTORDD04855 
289 


26354.223

] CounseNng/Trainlng for Staff/Mefltor 

l ~J~=t!llhnr~:.::,~d'?J,~~~? J Internal Investigation Underway 

Interventions: 

[]Physical 

{ ]Mechanical 

I 

I 

[ ] Reported to AdutVChild Protective 

Ser.tices 

Date: 

) Substantiated { l Unsubstanttate 

! J Licensing Notified 

Date; 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Notified 

MENTOR0004856 
290 


26354.224

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004857 
291 


26354.225

(x} 8ehavk11a! Health 

( ) Juvenile J ustlce 

( ) Med!<ally Compla> 

{ ) MRIDD 

! J MRJDO Offender 

15. 

) Acquired Brain Injury 

l Elder Care 

1 l Mental illness 

{ ) MRIMI 

{ ) Education 

I l Other. 

name; 

'fti. Service SettJngiMOOe!: (.check the ONE that most closely fits) 

( ) ICFIMR (ln!erma<liata Care Facility) ) Famijy/SollooVHome Based Supports (periodic 

( l Group or Shared living (3+ cllenlsilndMduals with 24n) seNices tess than 24fl} 

( ) Shared or Supported LNing (1 or z clients/individuals -with 24!7} 

(x) Mentor Home/ Host Home 

) Clinlcai/Oulpatianl Therapy/Rehab {OT, PT, Speech) 

) Day Program 

( ) Clroup or Shared living (3+ ctlantsllndhliduals With lass than 2417) 

( ) Shared or Supported Living (1 or2 cUents/individuals with tess 

) Supportad EmpfoymenWocatlonal 

) School 

!han24n) 

) Home Heatth Agency SarvJ.ces 

19.location of Incident (check one) 

{x) Mentor Home (x) Primary ( } Respite 

:~;~l;•~=dlvlduals tl&ng ln Horne: { l ClienUindividual's Residence (group homa.lCF, ept} 

{ ) C!!erttllndill!dual'$ B!ologk:af Family/Guardian Home 

( l Day Program 

( ) School 

( ) CllonU!ndlvidual's Place of Employment 

( ) Vehicle 

( ) Program OffiGe 

( ) Community 

( l Olhet: 

) Brokerage/Case Management {non--residential) 

2U. Outoomo of Incident: (check all that apply} 

] Remain in Current Placement 

j F!ia(;ament Qgdslon Peru:Ung 

1 Cllent!lndlvlduat Placed ln Rasplte 

1 Placement Disrupted (i.e, ClienUlndl'llidual transferred to naw 

home! prcgrnm/plecemoot within MENTOR NETWORK) 

l Dlscha'1)ad from MENTOR NETWOOK 

J Temporarily or PermanentlY Ctosed Mentor Home 

) Emergency Psychiatric Evaluation {no hosplt.aliution) 

] Emecgef\Cy Psychiatric Hosp!tallzatiool Emergency Medical HospitaUzation 

In-school suspension 

] Schoof Susp.ensfon/Exputslon 

( J Client/Individual A.rrostiOetentinn 

!><l Death 

I l Olher: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004858 
292 


26354.226

) Localed at tile Time of ltla Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other. 

(Suspected. Alleged or Confirmed} 

Caretaker. 

l Mentor 

1 Mentor Family Member 

] Staff 

J other Caretaker: 

Alleged Mls~onduct: 

[ l Sexual 8oundary/Abuse 

( l Verbal or Emotional Abuse 

[ ] Physical Assault!Abuse 

( 1 CorporaVInapptopriate Punishment 

[ ] Inappropriate Use of RestrainliPhys!cal !ntetVenticn 

! l Negl<>et 

{ 1 Inadequate Supai'Jislon 

{ ] Criminal Arrest of Caretaker 

{ ] AlcoholiOrug Use by Caretaker 

[ J Misuse or CUenlllndhtidua!'s Funds 

( J Mlsapproprtation/Dastructlon of C!!ent!lndividual Pemonal 

Property 

] Other. 

SUICIDAL CUENTIINDIVJDUAL: 

( 1 Suicidal Threats. o.r Verbalizations 

[ J Suicidal Attempt or Gesture 

SEXUAl ASSAULT OR INAPPROPRIATE SEXUAl 

BEHAVIOR BY CUENTJlNDIVIDUAL: 

[ JToOtherCtfent 

( J To Staff or Mentor 

( )To Mentor's Family Member 

[ ]To Other Third Party 

PHYSICAL 

( ]ToOtherCfient 

r J To Staff or Mentor 

[ !fo Montor's Family Member 

[ )To Other Third Party 

r Jfo Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Self-Injurious Behavior 

] Monta! Heallh De-compensation 

J Oppo$it!Onal Behaviors. 

J Inappropriate SeXtial Comments/Threats 

]Verbal ThroaiS oiViolonco 

] Exhibitionism/Public Masturbation 

l Medk:atton Error 

J Missing con!rnllad substances 

] Serious Adverne Reaction to Medication 

MEDICAl INCIDENTS: 

( l Wness Requiring Medical Treatment 

[ 1 Deterioratii:m in Existing Medical Condition 

[ l Pregnancy 

[ 1 Seizure Requiring Emergency Treatment 

( l UTI 

{ J 8owel lmpaetion 

r ) Pneumonia 

( ] Pressure Soros. 

[ l Other: 

] Physk:al Assault by Third Party/Other !ndivldualln our car 

] Sexual Assault by Third Party/Other Individual In our care 

) Theft by Third Party 

l Fall 

] Ch<>l<Jng 

1 Bathing/Scalding ReJated Injuries 

( l Other Bums 

£ 1 Vehicle 

( 1 SWimming/Near Drowning 

r ] other Accidental Injury. 

EXPOSURE CONTROL INCIDENTS: 

[ } C!ienUindMdual ExPOsed to Blood Same Pathogens 

( l C!lentllndlvidual Exposed Third Party to Blood Some 

PROPERTY DAMAGE BY CUENTnNOIVIDUAL: 

[ J Property Oamage Under $1,000 

( ] Pr-operty Damage Over $1 ,000 

( J Vehh:;.le Theft 

[ l Flre Selling 

[ J Thei!/Shopllfling 

[ l Other. 

POSSESSION OF PROHIBITED MATERIAlS: (Defined per 

<:llentlfndMdu.al/program) 

f 1 Possession of PrOhibited Matertals {Le., alcohol, 

fighter, weapon. pornography, i!l!clt drugs, etc.} 

MENTOR0004859 
293 


26354.227

[ J lntemaltnvest1gation Underway 

interwmtioM: 

[ ]Physical 

( )Mechanical 

[ ]Seclusions 

[ )Chemical 

Enforcement 

) SubstantJatad { ) Un~tanUate 

1 1 Ueenslng NoUfled 

Dale: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

!x] 

Date: 

["l Family 

Data:-

(xl Guardian NQtllled 

lxl =~n.?.to~'"!'l!'!m~on!!!vl'llpF.::l1)b,a=tion Notified 

Data:-

MENTOR0004860 
294 


26354.228

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004861 
295 


26354.229

} Acquired Brain Injury 

1 Elder Care 

) Mentel l!lness 

) MRIMI 

) Education 

l other. 

16. Service Settlng/Modaf: (check the ONE that most ~Josely flts) 

( l ICFIMR (Intermediate Care FadUty) ) Family/School/Home Based Supports (periodic 

( ) Group or Shared living (3+ ctlentsllndhtiduafs With 2417} services less than 24f7) 

( } Shared orSupportod Living (1 or2 c!ientsflndividuals with 2417) 

{x) Mentor Horna/ Host Home 

) Clinical/Outpatient Therapy/Rehab {OT, PT, Speech) 

l Day Prognam 

( ) Group or Shared Uv!ng (3'*' cltentsl!ndivlduals with te:ss than 2:4.!7) 

{ ) Shared or Supported Living (1 or 2 cllenl9Jind!vlduals with less 

) Supported EmpfoymentNocational 

) Schoo! 

than 2417) 

) Home Health Agency SeNI<es 

19. Localian of Incident: (cheek one) 

t ) Mantor Home ( l Primary ( ) Respite 

Mentor Name: 

# of C!lentsflod1vlduals Uvtng In Home: 

I l CllenVIndlvidual's Residence (9"'"P home, ICF, opt] 

( ) Clientl!ndividual'.s Blafoglcal Family/Guardian Hpmo 

( ) Oay Program 

t } School 

( l Cllent/tndMdual's Place of Employment 

t 1 Vehicle 

t l Progmm Office 

t ) Community 

(x) Other: Hosph:e-Hospltol 

'Client deceased. 

) Brokernge/Case Management (non-residential) 

20. Outcome of Incident: (chech all that apply} 

J Remain in Current Placement 

1 Placement Decision Pending 

l Client/!ndlvldual Placed In Respite 

] Placement Disrupted (Le. CNentllndMdual transferred to new 

hamel programlp!acemaot within MENTOR NETWORK) 

l Discharged from MENTOR NETWORK 

j Tempornri!y or Permanently Closed Mentor Home 

J Emergency Psychiatric E~!uatlon {oo ho®italizal!on.} 

J Emergency Psychlatrlc Haspltaltzatlon 

J Emergency Medical Hospitalization 

J In-school su.penslon 

J Schoo! Suspenslon/Exputsion 

l Cllent/lnd!vidua! ArresVDetention 

[><]Death 

[ l Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004862 
296 


26354.230

) located at the TTme of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other. 

(Suspected, Alleged or Confirmed) 

Caretaker; 

[ 1 Mentor 

[ ] Mentor Family Member 

( l Staff 

t 1 Other Caretaker: 

Alleged Misconduct: 

( l Sexual Boundary!Abuso 

[ 1 Verba! or Emotional AOOse 

( ) Physieat Assault/Abuse 

! l ColpOrall!napproprlate Punishment 

t J lnapproprl~te Use of Rastraint/Physicallnterventlon 

[ l Neglect 

[ J Inadequate Supervision 

t 1 Criminal Arrest of Car"etaker 

( J Alcahoi/Drug Use by Caretaker 

[ 1 Misuse of CllenVfndividual's funds 

( 1 Mi:sappropriationtoestnlction of C!lantl!ndlvldua! Personal 

Property 

JOllier. 

SUICIDAL CLIENTRNO!VIDUAL: 

[ ] Suicidal Threats or Verballzations 

t ) Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTIIND!V!OUAL: 

( ] Ta ather Client 

[ ] To Staff or Mentor 

t ITo Mentor's FamltyMembat 

[ }To Other Third Party 

PHYSICAL ASSAULT'S llY CUE NT/INDIVIDUAL: 

! ]ToO!he.-Ctient 

( J To Staff or Mentor 

[ Jra Mentor's Family Member 

I ]To Other Third Party 

( }To Animals {enimal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Setf~lnjurtaus Behavior 

l Mental Health De~compensaUon 

] Oppositional Behaviors 

) Inappropriate Sexual Comments/Threats 

J Verbal Threats of Violence 

) Exhibitlonism/Miic MastllrbatJon 

} MedJcation Error 

] M1$slng ConlroUOO Substances 

1 Serious Adverse Reaction to Medication 

MEDICAL INCIDENT'S: 

[ l Illness Requiring Medical Treatment 

( ] Deterioration in Existing Medical Condition 

[ J Pregnancy 

( J Seizure Requiring Emergency Treatment 

[ l UTI 

t ] Bowel Impaction 

[ l PneumQnia 

( l Pressure Soros 

[ l Other. 

] Physk:al Assault by Third Party/Other lndivlduat in our car 

) Sexual Assault by Third Party/Other fndlvicJua! in our care 

l Theft by Third Party 

l Fall 

J Choking 

{ J Bathing/Scalding Related lnjurtes 

( l Other Bums 

( J Vehie!e 

( ] Swimming/Near Drowning 

( ] Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ 1 Clisnf.IJndNidual Exposed 1o Blood Some Palhogans 

[ l Cllentl!ndlvidua! Exposed Third Party to Blood Some 

PROPER'IY DAMAGE BY CL!ENTI!NDMOUAL; 

t ] Property Damage Under $1,000 

[ ) Property Oamaga Over $1,000 

r l Vehicle Theft 

[ ) F!re Setting 

! l Theft!ShopliUing 

[ l Other. 

POSSESSION OF PROHIBITED MATERIALS: (O.flnod per 

clientllndlviduaflprogram) 

( ] Passossion of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pomography.IUiclt drugs, etc,) 

MENTOR0004863 
297 


26354.231

(x} Counselinglfraining fcrStafflMeotor 

r l ~~~~rvi.!Jll:'~n':,';,'Vi'n~~ [ J lntemat Investigation Underway 

lmerventlons: 

( ]Physical 

[ ]Mechanical 

t ]Seclusions 

( ]Chemical 

Enforce-ment 

) Substantlaled ( } Unsubstantiate 

I l 

Mentor ta.Ued Clinical Coordinator ~o report that client's hea1th is steadily deteriorating. 

Hospice nurse came to the home on ... nd staled there was no pulse on cllent • .J:IIi!se l'!lcommended client bo 

transported to the hospice hospital so that medications could be admlnlstened and~uld be monitored. Mentor 

report the nurse stated for her to ;administer medtcations Qvery 15 minutes so that client could mmain asleep, 

however it was determined-would be better in the hospital. When paramedi-cs anived at the seene they 

transported client to the hospital. lt was believed that at one point client hed expired at the mentor homo, however 

paremedice wera able to find a heartboat Client was transported to-in ~hem-.xplrod at 

approximately- Manter received the call at approl<lmalely ~-called the coordinator to inform her. 

Coordinator called Sheriff and DFCS to lnfonn tham of client's passing. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004864 
298 


26354.232

Signature of State Print Name 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004865 
299 


26354.233

( ) Behavioral Health 

( ) Juvenile Justice 

(x) Medically Complex 

{ l MFIJOD 

( ) MRIDD Offender 

) Acquired Sraln Injury 

) Elder Care 

) Mental ll!ness 

l MF!JMI 

) Education 

l Other: 

company name: 

16. Servlce Setting/Model: (check the ONE that most closely flts) 

( } lCFIMR {Intermediate Care Facifity} l Famlly/SchooiiH<>me a .. ed Supports (periodic 

( } Group or Shared Living (3+ cUentsllndividuals with 2417) services lass than 24/7) 

{ ) Shared or Sopported Living {1 or 2 clients/individuals with 2417) 

(x) Mentor Home/ Host Home 

) Clinicai!Dulpatienl Therapy/Rehab {OT, PT, Speech) 

) Day Program 

( } Group or Shared Living (3+ clioot$/fndividuals with tes~ than 2411) 

( } Shared or Supported Uving (1 or 2 -c~entslindlv!dua.ls with less 

) Supported EmpJoymenl/Vocational 

l School than 2417) 

) Home Health Agency Services 

17. Date & Time 

19, Location of Incident: (check one} 

( ) Mentor Homo { ) Primary ( ) Resplto 

Mentor Name: 

# of Clhmtsllnd!vlduals Living In Home: 

( } C!lenvtndiv!dual's Residence {group home, ICF, apt} 

( ) Cl!enlllndividua!'s Biotcg!ca! Fam!!y/Guardian Home 

( ) Day Progrom 

( l School 

( } Ctienlllndividual's Placo of Employment 

( ) Vehicle 

{ ) Program Office 

( ) Communlly 

(xl Other: -Hospital 

) Brokerage/Case Management (non*resident!al) 

20. Outcome of Incident: (c-k oil that apply) 

l Rcma!n In Current Placement 

] Placement Decision Pending 

J ClfentJlndividual Placed In Resplte 

1 Placement ~srupted (i.e. Ctlenttlnd!vldua1 transferred to new 

home/ program/placement wlthln MENTOR NETWORK) 

J Discharged from MENTOR NETWORK 

] Temporarily or Permanently Closed Mentor Home 

l Emergency Psychiatric Evaluation {no hospitalization) 

] Emergency Psychiatric Hospitalization 

l Etm~rgern:.y Medical Hospitalization 

] In-school ~uspension 

l School Suspen~lon!Expufslon 

1 Clientllndividuai Arrest/Detention 

[x] Death 

[ l Oih•r. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004866 
300 


26354.234

} located at the Time of the tncidant Report 

} Unable to Locate at lhe Tlme of the Incident Report 

) Othec. 

(Suspected, Alleged or Conftrmed:) 

Cam taker. 

] Mentor 

1 Mentor Family Member 

l Staff 

1 Other Caretaker: 

Alleged Misconduct: 

[ J SeJOJal Boundary/Abuse 

[ ] Verbal or EmoUonat Abuse 

! l Physical As•auiVAbuse 

( J Corparalllnappropr!ate Punishment 

{ 1 In-appropriate Usa of Restraint/Physical lnteNe:ntion 

[ ] Neg!Bcl 

[ l Inadequate Supervislon 

t l Criminal Arrest of Caretaker 

[ l Alcohai/Orug Uoo by Caretaker 

( 1 Misuse of ClientltndMdl.la!'s Funds 

( l Misapproptiatlan/Oestructloo of CJ!.enlllndMdual Personal 

Property 

l Olhec 

SUICIDAL CLIENTnNOIVIDUAI.: 

( ] Suiddal Threats or Verbaliz:aUons 

( J Sulddal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAl 

BEHAVIOR BY CLIENT/INDIVlOUAL: 

[ ]To Olhar Cllenl 

f 1 To Staff or Mentor 

[ lTo Mentor's Family Member 

! l To Other Third Party 

PHYSICAL ASSAULTS BY CUENTnNDI\IlOUAl: 

! l To Other Client 

[ ]ToStafforMentor 

t ]To Mentor's Family Mambar 

! JToOtherThirdParty 

t ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Medication Error 

J Missing Controlled Substances 

) Serious Advarse Reaction to Medication 

MeDICAL INCIDENTS: 

( } i!!ness Requiring Mad!cal Treatment 

[xl Deterloratton in Ex!stlng Medical Conditlon 

[ J Pregnancy 

t ] Si~izure Requiring Emergency Treatment 

r 1 tiTI 

[ ] Sowel1mpactlon 

( J Pneumonia 

[ ] Pressure Sores 

[ l Other. 

J Phystc.a! Assault by Third Partyr'Other Individual In our car 

[ J SID:ual Assault by Third Party/Other lndlvldualln our care 

{ J Theft by Third Party 

! l FaR 

[ l Chal<ing 

[ l !lathing/Scalding Related Injuries 

[ l other Bums 

! l Vahiclo 

( J Swimming/Near Drowning 

! l Other Accidenla! Injury: 

EXPOSURE CONTROL INCIDENTS; 

1 Ctionl/tndtvfduat ExPosed to Blood Bome Pathogen~ 

J ClientJJmfMOOal Exposed Third Party to Blood Bome 

l Property Damage Under$1,000 

l Property Damage OVer $1,000 

( J Vehicle Theft 

( J FireSetllng 

! J TheftiShcplllling 

( l Olher. 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

clirantllndlvfdu.al/program} 

( l Possession of Prohibited Materials (i.e., ak.oho!, 

lighter, w·eapon, pomography, illicit drugs, ett.) 

MENTOR0004867 
301 


26354.235

[ l ~~~';!~S:~Ij,!'~~~:~ntor [ 1 Developed with CUenl/lndividual 

[ 1 lntemat Investigation UnderNay 

interventions: 

[ ]Physical 

[ )Mechanical 

[ ]Secluslooo 

[ )Chemical 

Enforcement 

Oats; 

) Substantiated ( ) UnsubstantiatOc 

[ ] Llcensing Notified 

Date: Dale; 

On- wu transf<ured from-Hospital to- Hosplbol. Records Indicated .had a 

cardiopulmonary arrest with resultant oevore anoxic brain injury. Results of euminations performed at 

Hospital ,..,vealed that- only evidence of bmin f\lnctlon was intermittent spontaneous breath. ventilation required full support. A DNR and removal of lifo support 7as pursued with the Guardian'• Office, Elhlco 

Committee, consults with the birth parents and the f""ter parent. 0 the ONR requeot was granted. On 

~--was pronoun<:ed dead. cause of death was cardiae arrest. BaS<~d upon a decision by the birth farnlly,~n Into surgery for organ donatlon.ltMentor waslnfonned than an autopsy will be 

performed as the Initial cause of cardiae arrest 1$ still undetermined. Autopey 1$ expected to be completed within 48 

hours and the body will be released to , Funarat Otrector1 as arranged by the birth family. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004868 
302 


26354.236

Sign;ture of State Director (Level 3 and 4 only) Print Name Title D.ate 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004869 
303 


26354.237

• -

{ } Sehaviorn! Health 

( } Jwlenfle Justice 

{x} Medically Complex 

( l MRIOD 

( ) MRIDD Ollimder 

) Acquired Brain Injury 

) Elder Care 

( ) MenlaiiHness 

( ) MRIMI 

( ) Education 

1 ) Other. 

16. SONic& Soltln9'!Model: (check ttoe ONE tllal most clo .. ly flts) 

{ ) ICF/MR {lnrennodiate Cam Facility) ) Family/Schoof/Home Based Supports {p<~liodic 

( ) Group or Shared LMng (3+ cllenlsllndivlduals with 2417) services Jess than 2417) 

(><) Shared or SupllQrted Living (1 or 2 clients/individuals with 2417) 

( ) Mentor Home/ Host Home 

) CllnlcaUOutpatient Th""'py/Rel1ab (OT, PT. 

) Day Program 

( ) Group or Shared LMng (3+ cllentsltndividuals with lass than 2417} 

( ) S hated or Supported Uving { 1 or 2 clientsllndMduals with less 

( ) Sopported EmploymenWocational 

( ) School 

Ulan 2417) 

} Home Health Agency Services 

1.9.location oflncldent: (check one} 

(x) Mentor Home (X) Primary { } Respite 

Mentor # of CllentslindMduiir..l!!!!a!P.s!llrrii!'niiillv!!!n!!!g~lr:n"l:Hr:o::m:::o:-: Name: -- -~2 

( ) Clienvtndiv!dual's Residence (gro1.1p home. ICF, apt) 

( } Cliontl!ndivldual's Biological FamUyJGuardhm Home 

( ) Day Program 

( ) School 

( } C!ientllnd!vidual's PJace of Employment 

{ ) Vehicle 

( ) Program Office 

( ) Community 

( ) Otha..: 

{ ) Brokerage/Case Management (non-re~dential) 

20. Outcome of Incident: (chock an that apply) 

J Remain k1 Currant Placement 

1 Pl~ament Oeclslon Pendlng 

l Cliantilndivicfual Placed in Respite 

] P!ecem;;nt Disrupted (i.e. C!ienttlndi~idual transferred to new 

hamel program/placement wllhln MENTOR NETWORK) 

l Dlscllarged from MENTOR NETWORK 

J Tempomrtly or Permanently Closed Mentor Home 

1 Emergency Psyt:hiatric Evaiuatioo ("o hospitaUzatlon) 

J Emergency Psychiatric HospitalizatiOn 

] Ematgency Medical Hospitalization 

J tn .. school ~pension 

J School Suspsrn;loo/Expulsion 

( 1 Clientl!ndividual Arrest/Detention 

(x] Dealh 

[ ] Other. 

Foster parent reported that client had been rushed to ER aft•"l•stoooed 

resuscitation attempts were unsuccessful and client was pronounced 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004870 
304 


26354.238

) Locate<~ alllle Tlmo of the Incident Report 

) Unable to l.ocate at the Time of the Incident Report 

) 0\ller. 

(5\.lspected, Alleged or Confirmed) 

Carotaksr: 

{ ] Mentor 

[ ] MeniOf Family Member 

[ ] Staff 

[ ] Other Caretaker: 

Alleged Misconduct: 

( 1 Sexual Boundary/Abuse 

[ J Verbal or Emotional Abuse 

[ ] Phy$lcal A$sauiVAbu .. 

[ ] Corpota.V!nappropriata Punishment 

( J Inappropriate Use of Restraint/Physical lnteNBnlion 

[ J Neglect 

[ ] Inadequate Supervision 

( ] Criminal Arrest of Caretaker 

( l Alcohol/Drug Usa by Caretaker 

[ l Misuse ofCIIenl/lnd!vidual's Funds 

( 1 MisappropriationiOestruttion af CUeot.l!nOhridual Personal 

Property 

J Other. 

SUICIDAL CUENTIINDMDUAL: 

[ J Suicidal Threats or Verbalizations 

[ ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT DR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTnNDMOUAL: 

[ l To Other Client 

£ 1 To Staff or Mentor 

( ]To Mentor's Fam!fy Member 

( ] To Other Third Party 

PHYSICAL ASSAULTS BY CLIENTnNDIVIOUAL: 

[ ]To rnher Client 

[ ]ToStafforMentor 

( Jro Mentor's: Family Member 

[ ]To Other Third Party 

( ]To Animals {animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

] Mls$lng ControlS<~ Substances 

l Serious Adverse Reaclion to Medication 

MEDICAL 

[ l Illness Requiring Medical Treatment 

[ ] Deterioration tn Existing Medical ConditJ.on 

( l Pregnancy 

[ l Seizure Requirtng Emergency Treatment 

[ l UTI 

[ l Bowel 1m paction 

t ] Pneumonia 

[ l 

] 

] Physical Assault by Third Party/Other lndlv!dus! tn our car 

l Sexual Assault by Third Party/Other Individual in our care 

[ ] Theft by Third Party 

[ ] Fall 

( ] Choking 

( l Bathing/Scalding Related Injuries 

[ J Other Burns 

[ l Vehicle 

[ 1 SwlmmingJNear Drowning 

[ ] Other Accidentallnfury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] Clienll!ndlvidual Exposed to 6Jood Borne Pathogens 

( J CllenUindlvldual EJ<POsed T111rd Party to Blood Borne 

PROPERTY DAMAGE BY CLIENTIINOIVIDUAL: 

[ ] PropertyDamage.Under$1,000 

[ l Property Damage Over $1 ,DOO 

[ l Vehicle The~ 

{ l Fire Setting 

[ l Thefi/ShopiiHing 

[ l Other. 

POSSESSION OF PROHIBITED MATERIALS: {DeHned per 

cl!entnndlv1dua1/program} 

[ ] Possession of Prohibited Materials {te., alcohol, 

lighter, weapon, pornography, ilticlt drugs, ate.) 

MENTOR0004871 
305 


26354.239

[ l Counseting/Training for Stai!JMentor 

r 1 ~~=:t.~cBj;,~rn":;~~~~ [x]lntemallnvestigatlon Underway 

Jnt9Nentions: 

[ ]Physical 

[ ]Ma<;hanlcal 

[ ]Seclusions 

[ ]Chemical 

) Substantiated ( ) UnsubstanUate 

r J 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004872 
306 


26354.240

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004873 
307 


26354.241

9. Service Category: (Check one) 

(x) Behavioral Health 

{ l Jt.rvenne Justice 

( ) Medically Compla. 

! PAR/DO 

( } ~D Offender 

) Acquired Brain Injury 

l Elder Care 

) Mental U!ness 

) MRIMI 

) Education 

) Other: 

15. Sa Nice Setllng/Modol: (chock the ONE that m<lSI clo .. ly flts) 

( l ICFIMR (lntennediale Care Facility) l Famlly/SchooUHome Baaed Supports (pertodic 

( ) Group or Shared Living (3+ clienisllndl.{duals wlth 24/7) services Jess than 2417} 

( ) Shared or Supported Living {1 or 2 clients/individuals wilh 2417) 

(x.) Mentor Home/ Host Home 

l Cllnicai/0\Jipatlent Therapy/Rehab (DT, PT. 

) Day Program 

( ) Group or Shared Living (3+ clienlsllndivldtJals wilh lass !han 2417) 

t ) Shared or Supported Uving (1 or 2 ciients/ind!viduats with less 

) Supported EmploymenWocath;mal 

) Sohool 

!han 24/1) 

) Ho""' Heallh Agency Services 

(x) Mentor Home ) Respite 

Mentor Name: 

# of Cli<mtslln<llvl< 

{ ) C!ientflndividuat's Re.sidence {group home, ICF, apt) 

( ) Clfentl!nl;livldua!'s Siofogical Family/Guardian Homa 

! ) Day Program 

{ ) School 

( } Ctientnnd!>Jiduars Place of Employment 

( l Vehicle 

( ) Program Offica 

( ) Community 

( l Other. 

20. Outcome of Incident (check ail that apply} 

l Remain In Current Placement 

] Placement Decision Pending 

1 Client/lndMdual Placed in Respite 

J Placement Disrupted (I.e. Cl!enl/1ndi'iidual transferred to new 

hOme/ program/placement wllhln MENTCR NETWORK) 

l Disohar;Jed lium MENTOR NElWORK 

J Tt:tmporarily or Permanently Closed Mentor Home 

l Emergency Psychiatric Evaluation {no hospttaltzaUon} 

l Emergency Psychiatric HospitaHzaUan 

I Emer;)ency Medical Kospftallza!ion 

l tn~schoo! suspension 

] School SuspensiooiExpulsic;m 

f J CUeniflnd!vidual Arrest/Detention 

(x] Dealh 

{ ] Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR000487 4 
308 


26354.242

} located at the Time of the Incident Report 

) Unable to locate at the Tl:me of the lnci:dent Report 

l Other: 

(Suspected, Alleged or Conflnned) 

Cars taker: 

[ l Mentor 

[ J Mentor Family Member 

r 1 st•ff 

( J Other Caretaker: 

Alleged Misconduct: 

( J Sexual Boundary/Abuse 

( l Vmbal or Emotional Abuse 

[ l Physical Assault/Abuse 

[ l Corporalllnappropriat(l Punishment 

[ 1 Inappropriate Use of RestrainVPhysicallntervention 

{ J Neglect 

{ J Inadequate Supervision 

[ 1 Criminal Arrest of Caretaker 

[ J AfcchaffDrug Use by Caretaker 

[ ) MiSU$e of ClienV1ndividua!'s Funds 

t l MlsapproprlatlonJDestruction of C!lentllndivfdual Personal 

Property 

1 Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

( l Suicidal Threats or Verbatizations 

t J Suicidal Attempt or Ge.sture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTIIND!V!OUAL: 

[ ] lo Other Client 

( J To Staff or Mentor 

f ]To Mentor's Family Member 

[ ] To OthorThlro Party 

PHYSICAL ASSAULTS BY 

[ l To Other Client 

( 1 To Staff or Mentor 

[ )To M<lnlofs Family Member 

[ JTo other Third Party 

[ II" a Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l MedlcaUon Error 

] Missing Controlled Substances 

J Se-rious Adverse Reaction to MedleaUon 

MEDICAL INCIDENTS: 

[ 1 Illness Requiring Medical Treatment 

[ l Deterioration in Existing Medical Condition 

[ l P"'!lflancy 

{ l Seizure Requiring Emerge-ncy Treatment 

[ l UTI 

[ l Bowsllmpaction 

( ] Pneumonia 

[ ] Pressure Sores 

[ 1 other. 

t } Physical Assault by Thirif Party/Other Individual in our car 

( l Sexvaf Assault by Third Party/Othe-r lndMdual in our care 

[ l The~ by Third Party 

[ J Fall 

[ l Cho~lng 

[ ] 13altling/Sc.atding Related Injuries 

[ ] OlherBums 

{ ) Vehicle-

[ l Swimming/Near Drowning 

[ ] Olher Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

( J Cfient!!ndividual Exposed to B'ood Bome Pathogens 

{ J Clle-ntllndivlduaf Exposed Third Party to Blood Borne 

Property Damage Under $1,000 

Property Damage Over $1,000 

Vehicle Theft 

Flre Setting 

Theft!Shoptllllng 

Other; 

POSSESSION OF 

cttenUindl•tduaUprogram) 

MATERIAI.S: (Dol!ned per 

( ] Possession of Pr'ohibltoo Matarials {I.a .• alcohol, 

lighter, weapon, pornography, llllclt drugs, etc.) 

MENTOR0004875 
309 


26354.243

(~]Counseling/Training forStaff!Menlor 

( l &!'~~=h"lt,~~~? fx] lntemaf Jnv-esttgaHon Undetway 

lntefW.fntions: 

[ ]Physical 

[ ]Mechanical 

{ ]Seclusions 

( ]Chemical 

Enfo""""""l 

[ ] Reported to AduiVCI!itd Protective 

Servic:es 

Date: 

) Substantiated ( } Unsubstantiate 

[><] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004876 
310 


26354.244

Date 

Print Name Tltle Date 

o.f State Director (Level Name Tltle Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004877 
311 


26354.245

( ) Behavioral Heall~ 

( l Juvenile Jus!lca 

(x) Medically Complex 

( l MRIDO 

( J MRIOD Offender 

15. 

) Acquired Brain Injury 

) Elder Care 

{ } Menta! Illness 

( ) MRIMI 

{ J Education 

() Olller, 

specify company name: 

16. Service Senlng/Modet: (check tho ONE that most closely fits) 

( } ICF/MR {Intermediate Care Faci1ity) ) Fam!!y/Schooi/Home Based Supports (periodic 

( } Group or Shared living {3+ clieotsllncUvldua!s with 24n) services tess than 24n} 

( ) Shared or Supported Uv!ng {1 or 2 c!ientsllndMduals with 24/i} 

ht) Mentor Home/ Host Homo 

) Cfinlcai/QutpaUont Tharapy/Rehah (OT, PT, Speech) 

) Day Program 

( ) Group Qf Shared Living (3+ cllentsfindividuals with less than 24f7) 

( ) Shared or Supported living {1 or 2 c!ient:slindividual:s with less 

) Supported EmpfoyrnenWocational 

( I School 

than 24m 

} Home Health Agency Services 

19. Location of Incident; (check on€1) 

{x) M-entor Home (x) Primary { } R-espite 

Mentor Name:: 

# Gf Clientsllndlvlduats living In Home: 5 

( } Cllani:Jtndfvlduafs Residerrce (group home. ICf:, apt} 

( } CHentf!ndividual's Blologicaf Family/Guardian Home 

( } Day Program 

( ) Schoof 

( ) Client/Individual's Piace of Employment 

( } Vehicle 

( ) Program Office 

( ) Community 

( ) Other. 

( ) Brokerage/Case Managernant (non~rosldentlal) 

20. Outcome of Incident: (r;heck sll that apply) 

1 Remal.n In Current Placement 

] Placement D~is!on Peru:l\ng 

J ClienUindlvidual Placed in Respite 

] Placement Disrupted (I.e. Client!lndMdua! transferred to new 

home/ program/placement wll~ln MENTOR NETWORK) 

J Discharge<! from MENTOR NETWORK 

1 Temporarily or Pennanently Clo-sed Mentor Home 

1 Emergency Psychiatric Evaluation (no hospitalization} 

] Emergency Psychiatric Hospitalization 

l Emergency Medical Hospitalization 

] In--school suspension 

] St;hool Su$pension/8cpuls1on 

1 CHentJindivldual Arrest/Detention 

[x] Oealll 

[ l other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004878 
312 


26354.246

I l located at tho Tim<> of tho ln<:idant Report 

( ) Unable to locate at the nme of thalnoidant Report 

( ) Olllor: 

(Suspoeted, Alleged or Confirmed) 

Carot•ker; 

[ ] Mentor 

t ] Mentor Fam!!y Member 

[ J Stan 

[ 1 Other Caretaker: 

Alleged MI$Qnduct: 

[ J SaJ<Uai Boundai'/IAbusa 

[ 1 Vema! or Emotional Abuse 

[ J Physical A!lsauiVAbuso 

[ l Corporalllnappropnato Punishment 

[ 1 Inappropriate Usa of Restrain11PhyslcallnteNention 

[ l Nogloct 

{ J Inadequate Supervision 

l 1 Criminal Amiot of Caretaker 

[ l Alcol1oi/Orug Usa by Caretaker 

( ] Misuse of CHsnVfndividuars Funds 

( ] MisapproprlatloniDestructlon ofC!ientnndividua1 Personal 

Property 

J Other: 

1 Suicidal Threahs or Verbalizations 

l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR lNAPPROPR!ATl! SEXUAL 

BEHAVIOR BY CUSNTIINOIVIOUAI.: 

[ ]To Other Client 

[ )To Staff or Mentor 

[ )To Mentor's Family Member 

[ l To Other Third Party 

PHYSICAL ASSAULTS BY CliENTHNOivtOUAL: 

[ ]To Other Client 

[ ]To Staff or Mentor 

[ Jfo Mentor's Family Member 

[ ]To Other Third Pany 

[ )To Animals {animo! cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Sel~njurious lloha>®r 

] Mentel H""lth Da·oompenoatlon 

l Opposltlonel Behavio'l! 

]Inappropriate Sexual commenlsffhreats 

] Vetbal Thtaal& ollii<llente 

J E>lllbltlonlsmll'Ubllc Masturbation 

1 Madk:atlon Error 

l Mloslng Controlled Sub•tances 

1 Serious Adverse Reaction to Medtcation 

MEDICAL INCIOSNTS: 

[ 1 Illness Requiring Medical Treatment 

t l Detertoration In Eld•Ung Medical C<lndltion 

( l Pragnaney 

( J Soi>um Roquinng Emai!Janeylmatmenl 

[ J UTI 

I l BowellmpacUoo 

r l Pneumoola 

! l Prall!lure Sores 

[ l Other: 

[ 1 Phy<lcal A!l"'ult byThlf!.j Part}#(ltharlndividuelln ow car 

1 1 Sexual ABilllUH by Thllti Part)IIOthor IMtvitlual in our care 

! l Theft by Third Party 

t l Fall 

[ 1 Oholdng 

[ l 6ath1ng!Scaldlng Related lnjurias 

[ 1 Other Bums 

l l Vehicle 

[ l Swimming/Near Drowning 

[ l Other Accidental 

EXPOSURl! 

! l CllenVIndlvldual Exposad to Blood Soma Pa!OOgen• 

[ l Cllentllndlvidual Exposad Thin:! Pany to Blood Bam a 

PROPERTY DAMAGI! BY CLIENTIINOIVIOUAI.: 

[ l Property Damage Under $1,000 

[ 1 Property Damage Over$1,000 

I l Vehicle The~ 

! l Fire Satl!ny 

[ ] Tlleff!Shoplll!ing 

[] Olller. 

POSSESSION OF PROHIBITeD MATERIALS: (Defined per 

eUentllndivldual/pfogram) 

[ ] Poosasoion of Prohibited Material> Q.e., elcohol, 

fighter, weopon, pomogmphy, ilijclt drugs, ete.) 

MENTOR0004879 
313 


26354.247

t l ~"p'f~~~~~e~~~~~~tor [ l DevaloiJe<f wiUl Clien~lndMdual 

txJ lntemat lnvestlgalion Undarway 

Interventions: 

[ ]Physical 

[ ]Mechanlcal 

[ )Seclusions 

t ]Chemical 

t Enforeement 

[ l Reportlld to Adul~hlld Protective 

Sarvicas 

Dale: 

) Substantiated ( ) Unsubstantiate 

txl 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004880 
314 


26354.248

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004881 
315 


26354.249

{ } Behavioral Health 

{ ) Juvenile Justice 

(x) Me<focally Complex 

( l MRIDD 

( l MRIDD Offender 

l Acquired Breln Injury 

} Elder Care 

J Mental Illness 

J MRIMI 

) Education 

)other: 

company name: 

16. Service Setting/Model: (check tho ONE that m<>St closely Rts) 

( ) ICFIMR (mtermedlale Care Facility) ) Famity/SchooJ/Home Based Supports {pertodlc 

( ) Group or Shared living (3+ cllonts!lndivfdualo wilh 2417) sarvlcas less than 2417) 

( ) Shaled or Supported LMng (1 or 2 cllontsllnd!Yiduals w;lh 2417) 

(x) Mentor Hom-e/ Host Home 

) Cllnlcatloutpo!leniTherapy/Rehab (DT, PT, 

) DayProgram 

( ) Group or Shared Llving (3+ cl!entsfindivlduals wfth !ass than 2417) 

i l Shared or Supported LMng (1 or 2 c!lenlsllndMduals with less 

) Supported EmplaymanWocational 

) School 

than 2417) 

} Home Health Agency Services 

17. Dale& 

19. Locatio-n of Incident (check one) 

(x) Mentor Home (Jt) Primary ( ) Raspite 

::~~~:..:~dl•lduala Living In Homo: 

( ) CllenVIndMdool'a Ra•ldence (group home,ICF, apt) 

{ } Cl!en!llndividual's Biologlcal Family/Guan:lian Home 

( ! Day Program 

t ) School 

( ) CHenU1ndivlduat's. Place of Employment 

t 1 Vehid<o 

! ) Program Dffioa 

{ ) Communlly 

( l Olher. 

( ) Bf'oketage!Case Management {non-residential) 

20. Out.com~ of Incident (chock all that appfyJ 

l Remain In Currant Placement 

) Placement Decisfon Pending 

l Cllenl!lndlvldual Placed In Respite 

] Placement Disrupted (te. CllentllndMdual transierred to new 

home/ progrnm/placement wlthtn MENTOR NETWORK) 

l Discharged from MENTOR NETWORK 

J Tempornrlly or Permanently Closed Mentor Home 

1 Emergency Psychfatrlc Evaluation (no haspftaliz.atlon) 

] Emergency Psychiatric Hospltalltatioo 

] Emergency Medical Hospttaiizatian 

J ln~school suspension 

l School Suspensian/E)(ptltsioo 

1 Clfant/1ndividual Arrest/Detention 

[~J Death 

[ 1 other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004882 
316 


26354.250

) located at the Time of the Incident Report 

) Unable to Locate at ltle Time of the lncident Report 

) Other. 

(Suspectad. Alleged or Connrmed) 

Careta/u.r: 

t 1 Mentor 

[ J Mentor Family Member 

[ l Staff 

( J Other Caretak.er; 

Alleged Misconduct: 

[ J Sexual Boundary/Abuse 

{ 1 Verbal or Emotional Abuse 

t ) Physical Assault/Abuse 

t J Corpora!l!napproprjate Punishment 

t J Inappropriate Use of RestraintiPhysicallntOI'VOntion. 

[ J Neglect 

r l tnadequate SupeNls!on 

t l Ctimloat Arrest of Caretaker 

1 1 Alcohol/Drug Use by Gareta~er 

[ ] Misuse of Client/Individual's Funds. 

[ } Misappn:lpriatian!Oestructioo of C!!enVlndhliduat Personal 

Pn;perty 

l Other. 

SUICIDAL CLIENTnNDIVIDUAL: 

[ J Suicidal Threats or Ve:rba!lzatians 

[ ] Suic:l<lal Attempt 0< Gesture 

SEXUALASSAUL TOR INAF'PROPRIATE SEXUAL 

BEHAVIOR BY CUENTflNOIVIPUAL: 

[ J To Olhor Client 

f JToStafforlv1entor 

{ ]To Mentor's Family Member 

[ ] To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

£ ]To Staff or Mentor 

( 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

MEDICAL INCIDENTS: 

( 1 Illness Requiring Medical Treatment 

t ] Deterioration in Existing Medical Condition 

[ ] Pregnancy 

r 1 Seizure Requlring Emergency Treatment 

( l UTI 

[ l Bowellmpao!lon 

( 1 Pneumonfa 

[ ] Pressure Sores 

[ l Olher. 

( Physical Assault by Third Party/Other lnd!vtdualln oot car 

[ Sexual Assault by Third Party/Other Individual in nur care 

[ Theft by Thlr<l Party 

r Fall 

r Cholting 

[ Bathing.IScaldfng Related Injuries 

{ Other Bums 

[ ] Vehicle 

( ] Swimming/Near Drowning 

[ l Other A<eidenlal 

EXPOSURE CONTROL INCIDENTS: 

[ l ClienUindlvldual Exp<lli'ed to Blood Borne Pathogens 

r l ClianVIndMdual Exposed Thlm Party to Blood Bome 

PROf't:RTY DAMAGE: BY CLtENTIJNDIVlOUAL: 

t l P"'perty Damage Undor$1,000 

t ] Property Damage Over $1,000 

( 1 Vehide Theft 

[ l RreSetting 

[ ] TheftiShnplitling 

[ l Other. 

POSSESSION OF PROHIBITED MATERIALS: (Deftned per 

cllentll'ndlviduaf!program) 

! J Possession of Prohibited Materials {i.e., alcohol. 

lighter, weapon, pornography, iltic:it drugs, etc.) 

MENTOR0004883 
317 


26354.251

[ J CaunseUfl!I{Tralnln:l/"' Staff/Mentor 

[ 1 ~~~lll."b~~~'"l' [ 1 lntemollnvesUgallon l.lndarway 

!nterventfDI!s: 

]Ph)'$1tal 

]Me<hanical 

JSec!uslons 

]Chemical 

[xl Reported to Adui!ICMd Pn>lective 

SaMces 

Date: .I!!I!!!!L 

} Substantiated € ) Unsubstantia:ta 

[ ! Licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004884 
318 


26354.252

Signatum of State Director (Lavel3 and 4 only) Print II"""' Tltla Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004885 
319 


26354.253

) Behavioral Health 

) Juvanlla JustiGe 

l Medlcafly Complex 

l MRIOD 

l MR/00 Offender 

( } Acqu!ffid Brain Injury 

( ) Elcter Care 

( } Menlii'l mness 

( l MRIMI 

{ } Education 

(xl Other. basic Care 

1Ei. Service Setllng/Model: (check the ONE that most closely fits) 

( ) ICFIMR (lnlermediate Care FaciHty) ) FamliyJSch.ooUHome Based Supports (periodic 

( } Group or Shared Living {3+ ctfentslindivlduafs wilh 24n) services less than 24!7) 

( ) Shared or Supported Living (1 or 2 cllenlsllndlviduals with 2417) 

(x) Mentor Home/ Host Home 

) CllnicaiiOutpallent Therapy/Rehab (OT, PT, Speech) 

l Day Program 

( l Group or Shared Living (3+ clientsrmdivlduals 'A!th less than 2417) 

( } Shared or Su1Jported Living {1 or 2 clientsfrndlviduafs with fess 

} Supported EmploymenWocatlonal 

) School 

than 2417) 

} Home Heafth Agency Services 

19.Location of lnclclent: (ched one} 

(X) MentorHome (x) Primary ( ) Respite 

Mentor Name; 

# of CllentsltndMduals Living In Home: 2 

( ) C!ientllndlvidual's Residence (group home, lCF, apt) 

( ) Ctlentilndivldual's Siological Family/Guardian Home 

( l Day Program 

( ) School 

( ) C!ient/lndivldual's Place of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

( ) other: 

} Brokerage/Case Management (non-residential) 

20. Outcome of lncidoot (<heck an that apply) 

l Remaln in Currant Placement 

] Placement Dadslon Pending 

1 Clianll!ndividual Placed in Respite 

] Placement Disrupted {Le. C1!entllndivtdual trarn~ferred to new 

home/ program/placemont within MENTOR NETWORK) 

J Discharged from MENTOR NETWORK 

] Temporarily or Permanently Closed Mentor Home 

J Emergency Psychiatric Evaluation (no hosp1tali.zation) 

J Emergency Psychiatrtc Hospfba!lzation 

J EmeTgency Medica! Hospita!i:zation 

J Jn~school suspension 

J School Suspen.sloni.Expu!sion. 

l CneniJ!ndividual Arrest/Detention 

IxJ Death 

[ l Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004886 

The 

The 
320 


26354.254

) Located at the Time ofthe Incident Report 

) Unable to locate at the Time of the lnddent Report 

l Othor. 

{Suspected, Alleged or C()nfirmed) 

Caretaker. 

[ J Mentor 

( 1 Mentor family Member 

{ l Staff 

( l Other Caretaker: 

Alleged Misconduct: 

( l Sexual Bmmdary/Abuse 

[ J Verbal or Emotional Abuse 

[ l Physical Assauit/Abusn 

[ ] CorpamU!napproprlate Punishment 

t ] Inappropriate Use ofRestraini.IPhysicat intervention 

! l Neglect 

[ 1 Inadequate Su:paNision 

( 1 Criminal Arrest of Caretaker 

{ } Alcohol/Drug Use by Caretaker 

( ] Misuse of CUent/!ndlvldual's Funds 

[ J Mlaapproprfation/Osstruetlon of Cllentllnd!vldual Personal 

Property 

l Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

( 1 Suicidal Threats Of Verbalizations 

t l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CU!;NTIINOIVIOUAL: 

( J To other Client 

( JToStafforMentor 

[ JTo M(lntcr's Family Member 

( ] To Other Third Party 

PHYSICAL ASSAULTS BY CUENTIINDIVIOUAL: 

! ] To Other Cllenl 

[ JToStafforMentor 

( JY'o Mentor's Family Member 

[ l To Other Third Party 

[ ]To Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

( ] Setf .. lnjurlous Behavior 

( ] Mental Health De·compensation 

(xJ Oppositional Behaviors 

[ 1 Inappropriate Sexual Comments!Threats 

[ J Verbal Threats ot Violence 

( ] ExhlbHionlsm/Publlc Masturbation 

1 Mooicallon Error 

1 Missing Controlled Substances 

1 Serlou:s Adverse Reaction to Medication 

r J Ulness Requlrtng Medical Treatment 

t ] Deteri-oration in E.xlsling 1\rfedteal Cortdltion 

[ 1 Pregnancy 

( J Seizure Requil'i"!J EmallJency Treatment 

[ l UTI 

l ] Bowel Impaction 

[ l Pneumonia 

{ ] Pressure Sores 

[ 1 Olher. 

( ] Physical As .. un by Third PartyiO!hor Individual in our oar 

t ] Sexual Assault by Third Party/Other tndividual in our care 

[ l Theft by Third Party 

! l FaU 

[ 1 Choking 

( ] Bathlng/Sc!:lldlng Related Injuries. 

[ l Other Bums 

[ l Vehicle 

( ] Swfmming!Near Drowning 

[ l Oth<>r Accldenlallnjury: 

EXPOS!.IRE CONTROL INCIDENTs: 

[ } Cliantl!ndivldual Exposed to Blood SQme P-athogens 

[ ] CJ!ant/tndivlduat Exposed Third Party to Blood aome 

1 Property Damage Under $1,000 

J Property Damag<> Over $1 ,ooo 

( 1 Vehicle Then 

[ l Fire Setting 

t l Thsft!Shopliftlng 

( l Other: 

POSSESSION OF PROHIBITED MATERIALS: {lle~nod per 

cllenVIndlvlduallprogram) 

[ J PossesSion of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pornography, illiCit drugs, etc.) 

MENTOROD04887 
321 


26354.255

J CO\lnsellngltralning lor Soaff/M..,tor l ISPISuparvlslon/Be11avioral Plan Developed with ClienVIndivldual 

J Internal InvestigatiOn Underway 

Interventions: 

[ ]Physical 

[ ]Mechanical 

[ ]Seclualooa 

[ ]Chemical 

[ JLaw 

[ l Repo~ed to AduiVChild Prolecllvo 

SeNices 

Date: 

) Sub•tanllated 1 ) UnsubOtantlate 

[xl 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004888 
322 


26354.256

Dale 

Title Date 

of State Oinu;tor (Level3 and 4 only) Nom<~ THie Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004SS9 
323 


26354.257

(x) Behavioral Health 

( ) JuvenHe Jus!lce 

( ) Medically Complsx 

( l MR/00 

( ) MRIDD Offender 

} Acquired Brain Injury 

) Elder Care 

( ) Mental tnness 

( ) MRIMI 

( ) Education 

I ) Other. 

15. Service Setting/Modal: (check the ONE that most closely fits) 

( ) ICFIMR (lntormOOiate Cara Facility) } FamUyiSchooi!Home Based Supports (periodic 

( J Group or Shared Living (3+ clients/individuals with 24fl) services: less than 24/1} 

( ) Shal13d -or Supported Living (1 or 2 clients/individuals with 24n) 

( x.) Mentor Home/ Host Home 

) Clinloal!Outpatisnt Therapy/Rehab (OT, PT, Speech) 

) Day Program 

( ) Group or Shared Living (3+ cl!entsllndhtiduals with less than 2417) 

( } Shared or Supported U11ing { 1 or 2 cUentslindividuals with less 

) Supported EmploymenWocallonal 

) School 

than 2417) 

) Home Health Agency Service$ 

19. location or Incident: {check one) 

(x) Mentor Home (x) Primary ( ) Respite 

Mentor Name: 

#of Cllents/lndivlduats Uvtng In Homl!: 

{ ) Cllent/1ndl:vidual's Residence (group home, ICF, apt) 

( ) Clientllndividuafs Biological Famify/Guardlan Home 

{ ) Day Program 

( l Scilool 

( ) Client/Individual's Place of Employment 

( ) Vehicle 

( ) Program Office 

f ) Community 

( ) Other. 

( ) Brokerage/Case Manag:emaot (norr-reskfential) 

20. Outwme of Incident: (c~ech all that apply) 

J Remain ln CUrrent Placement 

l Placement Decision Pending 

] Cllentllndividual Placed in Rosplte 

j Placement Oisruptad (i.e. ClientflndlvldtJal transferred to new 

hamaJ program/placement within MENTOR NETWORK} 

l Discharged from MENTOR NETWORK 

J Temporarily or Permanently CJ.osed Mentor Home 

] Emergency Psychlalric Evaluation (no hospitalization) 

1 Eme.l'gancy Psychiatric Hospitalization 

J Emergency Medica! Hospi(allzation 

] ln·schoo! suspension 

] School Suspension/Expulsion 

J CUentJindivldual ArrosVOetentlon 

[xl Death 

[ ] 0111er: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTORODD489D 
324 


26354.258

) Located at the Time of !11e Incident Report 

} Unable to Locate at the Time of the Incident Report 

) Olhef: 

(Suspected, Alleged or Confirmed) 

Can!! taker: 

[ ] Mentor 

t J Mentor Family Member 

t l Staff 

[ ] Other Camtaker:: 

Alleged M/5l!Oilduct: 

[ 1 Sexual Boundary/Abuse 

( l Verbal or Emotional Abuse 

[ ] Physical AssauiVAbusa 

[ ] Corporatllnappropriate P~.mlshment 

[ l Inappropriate Use of RestralnttPhysk:allntervention 

[ ] Neglect 

[ l Inadequate SupeNision 

[ ] Criminal Arrest of Caretaker 

[ 1 Alcohol/Drug Use by Caretaker 

[ J Misuse of C!lenU!ndMdual's Funds 

t l MlsaporoprialioniDestruciJon of CllenVIndMduat Persooal 

Property 

J Other:: 

SUICIDAL CUENTnNDIVIDUAL: 

{ ] Su!cldaf Threats or VerbaJizaUons 

t ] Suicidal Attempt or Gesture 

SE:XUAL ASSAULT OR INAPPROPRIATE SEXUAl 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ ]To Other Client 

[ ]ToS1l!NorMMtor 

I Jfo Mentor's Family Member 

[ ]To 0!11ef Thlr~ Party 

]To Otl1efCiient 

]To Staff or Mentor 

BY CLIENT/INDIVIDUAL: 

]To Mentor's Family Member 

]To Other Third Party 

)To Animals {animal cruelly} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

( l lllneos Requiring Medical Trealment 

( 1 Deterioration in Existing Medical Condition 

[ l Pregnancy 

I ] Seizure Requiring Emergency Treatment 

I l UTI 

[ ] Bowel Impaction 

[ J Pneumonia 

[ ] Pressure Sores 

(><] 0!11er. client became rigid, taken to ER 

J Physical A.ssautt by Third Party/Oti1ef individual In our car 

J Sen~al Assault by lhird Party/Other Individual in our c:.ara 

] Theft by Third Party 

l Fall 

l Choking 

( ] Bathing/Scalding Related Injuries 

1 l Other Bums 

[ ] Vehicle 

{ l Swimming/Near Drowning 

[ l Other Accldentetlnjury: 

EXPOSURE CONTROL INCIDENTS: 

( 1 Cl!entllndfvidual Exposed to Blood Borne Pathogens 

1 ] Cllentllndlvldual Exposed Third Party kl Blood Borne 

PROPERTY DAMAGE BY CUENTIINDIVIDUAL: 

[ l Property Damage Under $1,000 

( J Property Damage Over $1,000 

[ ] Vehicle Theft 

[ l Fire Setting 

[ J ThefVShoplllllng 

[ J Othe' 

POSSESSION OF PROHIBITED MATERIALS: (Defln<>d per 

cllent'lndlviduallprogram) 

[ l Possession of Prohibited Materials {i.e., alcohol, 

lighter, weapon, poJT10!1f"phy, iliclt drugs, ole.) 

MENTOR0004891 
325 


26354.259

] Counse!ingffrainlng for Staff/Mentor 

J ~:V':~2'~{h~~~%d~~~~~r ] lntemal tnvasUgatlon UndeMay 

Interventions: 

[]Physical 

[ }Mechanical 

[ ]Se<:lusions 

[ ]Ch<lmlcal 

[ ]law En!oreement 

[l<] Reportecl to AduiVCiliiQ Prote<:tlvs 

SeNicas 

Data: 

l Substantiated ( ) UnsUbslantiate 

Notified 

manager, WSSI informed ofcUentts and 

Informed him of client's death. Cause of 

lifoiOi:lliiaH1i11iillv <If client's death. 

CONFIDENTIAL PURSUANT TO SENATE RULE 25 MENTOR0004892 
326 


26354.260

Signature of State Oltaetor (Level 3 and 4 only} PrlntName Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004893 
327 


26354.261

(x) Behavioraf Health 

( ) Juvenile Justice 

( ) Medically Complax 

( l MRJDD 

( ) MRJDD Offender 

) Acquired Brain Injury 

l EldorCara 

( ) Menial Illness 

( ) MRIMI 

{ ) Education 

{ l Other. 

1 a. Service SettlngiMoool: (oheck tho ONE that most closely fits) 

t l ICFIMR (Intermediate Care Facility) { ) Family/Schoot/Homa Based Supports {periodic 

( } Group or Shared Living (3+ t:Hents/lnd!viduals wlth Z4f7) services less than 24{7} 

( l Shared or Supported living (1 or 2 cllentslindivi®als mth 24/7) 

(x) Mentor Home/ Host Home 

) ClinlcaVO\Itpatient Therapy/Rehab (DT, PT, Speech) 

( } Day Program 

( ) Group or Shared Living (3+ clientslindividua!s with less than 2417} 

( ) Shared or Supported Living (1 or2 d.isntslindividuals with less 

( ) Supported EmploymenWocational 

{ ) School 

than 24/7) 

) Home Health Agency Services 

19. Location of 1ncident: (check one} 

( ) Mentor Home ( } Primary { ) Respite 

Mentor Name: 

fl. of Clientsnndividuals living In Home: 

{ ) C!ientllndivldual's Residence (group hame,ICF, apt} 

{ } Client/Individual's Bkllog!cal Family/Guardian Home 

( ) Day Program 

{ ) School 

( ) Ctrentffndividuat's Place of Employment 

( } Vehicle 

( ) Program Offit:e 

! ) Community 

{x) Other: Hospital 

{ ) Brokerage/Gasa Management (nan-residential) 

20. Outcome of incident (check all that apply) 

1 Remain in Current Placement 

} Placement Decision Pending 

1 Clientllndlvidual Pla<:ed ln Respite 

1 P!acamsnt Disrupted {La. C~antllndivklual transrt:lrred to new 

home/ program/placement within MENTOR NETWORK} 

l Olschargod from MENTOR NE1WORK 

] Temporarily or Permanently Closed Mentor Home 

] Emergency Psychiatric Evaluation (no hospitalization} 

1 Emergency Psychiatric Hospital!zatlon 

] Emergency Medical Hospitalization 

l ln~school suspension 

] School Svspen:sinn!Expulsion 

) Clientllndividual ArrsstJDelsntion: 

[xl Death 

[ l Otller: 

"The attending physician called the clinical coordinator to report that-condition had worsened and that-was not expected to live. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004894 
328 


26354.262

) Located at the Time of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

} other: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

1 Mentor 

1 Menlor Famity Member 

l Staff 

l OtherCaretaker. 

Alleged Misconduct: 

[ ] Sexual Boundary/Abuse 

[ l Verbal or Emotional Abuse 

[ l Physical Al!sauiUAbuse 

t 1 Corporavtnappropriate Punishment 

[ 1 Inappropriate Use of Restraint/Physical tnterventlon 

[ l Negle<:t 

[ ] Inadequate Supervision 

[ l Criminal Arrest of Caretaker 

[ J AlcohoVDrug Use by Caretake< 

[ 1 Misuse of CHentllndividual's Funds 

[ ] Misappmpriation/DestruGtion of Cliantllndividual Personal Property 

J Olhor: 

SUICIDAL CUENT/INOI\IIDUAl: 

[ J Suicidal Threats Of Verbalizations 

( ) Suicidal Attampt or Gestura 

SEXUAL ASSAUlT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

f l To Other Client 

i )ToStafforMontor 

( ]fo Mento(s family Member 

[ ]To Olher Third Party 

PHYSICAL ASSAUlTS BY CLIENTnNOIVIDUAL: 

[ ITo Ot:herCUent 

{ JTo Staff or Mentor 

( Jfo Mentor's Family Member 

[ l To OlherThird Party 

[ !fa Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Seff~!njurious Behavior 

] Mental Health Qe..compensatlon 

] Oppositional Behav!OI"s 

}Inappropriate Sexual Commaots!Thre.ats 

J Verbal Threats of Violence 

1 Exhlbltionism/Pub!lc Masturbation 

] Medication Error 

1 Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL 

t ] !!!ness Requiring Medlcal Treatment 

{ J Deterioration in Existing Meditm Condition 

[ l Pregnancy 

[ l Seirure Requiring Eme11Jency Treatment 

[ l UTI 

[ 1 8oWi3ilmpattion 

( 1 Pneumonia 

[ l Pressure Sores 

[ l Other: 

J Physical A.asa:ult by Third Party/Other Individual in our car 

J Sexual Assault by Third PartyfOther lndivfdua1 in our care 

l Tha~ by Third Party 

[ l Fall 

[ J Choking 

[ ] Sathlng!Scalding Related Injuries 

[ l OlherBums 

[ l Vehicle 

[ J Swfmming/Near Drowning 

[ l other Accldantallnjury: 

EXPOSURE CONTROl-INCIDENT$: 

[ ] CHentlllidividuaf Exposed to Stood Borne Pathogens 

t J Clienl!!ndividual Expasad Third Party to Stood Borne 

PROPERTY DAMAGE BY CUENTitNDIVIOUAL: 

{ 1 Property Damag.e Under $1,000 

! ) PropertyDamag.eOver$1,000 

( l Vehicle Theft 

[ J Fire SeUing 

[ 1 Theft/Shoplilling 

( ] Other: 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

ellent!lndlvldual/program) 

t 1 Possession of Prohlblied Materials (I.e .. alcohol, 

lighter, weapon, pornography, !!lick drugs, etc.) 

MENTOR0004895 
329 


26354.263

J Counsallog!Tralning for Staff/Monlo< 

1 g;e\f~=~:i~"~~'t~n~i~~~r l ln1emal !nvetitigation Underway 

Interventions.· 

[ ]Physloal 

[ JMecharncal 

[ ]Seclusions 

[ ]Chemical 

[ J Reported 1o Aduii/Chnd Protective 

Sarvic~ns 

Data: 

) Subl>tantiatO<I 1 ) Unsubstanliato 

[X] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Law Enforcement/Probation Notified 

Dale: 

MENTOR0004896 
330 


26354.264

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004897 
331 


26354.265

( ) Behavioral Heallh 

( ) JuvenUa Justk:e 

{x) Medically Comple• 

l l MR/00 

( l MRIDD Offender 

) Acquired Brain lni<JIY 

) Elder Care 

( ) Mental lllness 

( l MRIMI 

( ) Education 

( l Other. 

name: 

Hi. Service Setting/Model: (~;heck the ONE that most dat~etyfits. 

( ) ICFIMR (lnlennadlale Care Facility) ) Family/Schaaf!Homa Based Supports (periodic 

( ) Group or Shared Living {3+ clientslindivlduats with 24/7) services less than 2417) 

I l Sherad or Supported Living (1 or 2 ollentsllndivldualo with 2417) 

{x} Mentor Home/ Host Home 

) CUnicai/Oulpatlent Therapy/Rehab (OT, PT, Speech) 

} Day Program 

( } Group or Shared living {3+ clientsJindl\lidua.ls 'With ~s than 2417} 

{ ) Shared or Supported Living (1 or 2 dtentsllndMduaJs with tess 

) Supported EmploymenWocatlonal 

l Sehocl 

than 2417) 

l Home Health Agency Services 

19. Location of ll'ltldent: (che~k one) 

(xl Mant<>r Homo lx) Prima,y ( l Ra•plle 

MenlorNnme: J!l!~'ji.~::;7"=~ #of CflentsJindtv1du:als L.Mng in Horne: 

( ) Ctlentllndlvidual's Residanc:e {group home, !CF, apt) 

{ ) Client/JndMdua!'a BiQiogica! Faml!y/Guardian Homa 

l l Day PrOgram 

{ } Schoof 

{ ) CUanl/lndtvidua!'s Place Gf Emptoymant 

( ) Vehicle 

( ) Program Ollice 

t ) Communlly 

( l Other: 

) Brokerage/Case Management (noo-residel'ltia!) 

20, Outcome of Incident: (check .rtt that apply) 

{x) Remain in Current Placement 

{ J Placement Decision Pending 

[ l Client/Individual Placed in Re.sp,_e 

[ ) Plac-ement Disrupted (I.e. Cllentllndivfdual transferred to naw 

home/progfl!mlplocement within MENTOR NETWORK) 

l Discharged from MENTOR NETWORK 

1 Temporarily or Permanently Closed Mentor Home 

l Emergency Psychiatric Evaluation (no hospitalization} 

] Emergency Psychiatric Hospitalization 

1 Emergency Medical Hospitalization 

1 In-school suspension 

] School Suspen.sionr'Expulsion 

J Cllentllndividual Arrest!Detention 

J Death 

txl Other. ER for respiratory distress 

Mentor contaoted On-call Coordinator to report that she and her husband brought the client to Jhe Emergency 

Room due to respiratory distress. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004898 
332 


26354.266

} Located at the Time cftha Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other. 

{Suspected, Alteged or Confirmed) 

Carotaksr; 

( ] Mentor 

[ l Mentor Family Member 

[ J Staff 

! l Other Caretaker: 

Alleged Misconduct: 

t J Sexual6oundai)I/Abu.se 

[ ] Vefbal or Emotional Abuse 

[ ] Physical A~Ssau!t/Ahuse 

t 1 Corporalllnappropriate Punishment 

[ ] Inappropriate Use of Restralnt/Physica! Intervention 

( l Negtoct 

C J Inadequate Supe.Nis!on 

{ ] Criminal Arr-est of Caretaker 

[ J Alcohol/Drug Use by Caretalle< 

[ 1 Misuse of Clientl!ndividual's Funds 

[ 1 MtsappropriatloniOestruct!on of Ctientl!ndiv!dual Personal 

Property 

J Other: 

SUICIDAL CLIENT/INOIVIDU.<\'-' 

t ] SuicidaiThreatsorVarbalizations 

[ ] Suicldal Attempt or Gestura 

SEXUAL ASSAULT OR lNAPPROPRIA TE SEXUAL 

BeHAVIOR BY CliENT/INDIVIDUAl: 

[ 1 To Other Client 

[ l To Staff or Mentor 

[ ]To Mentor's Family Member 

[ ]To OtherTlllrd Perty 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAl: 

[ JTo Other Client 

{ ]To Staff or Mentor 

[ ]To Mentor's Family Mt~mber 

[ l To Other Thirn Party 

[ Jfo. Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] MoE~.dlcation Error 

J Missing Controlled Substances 

l Serious Ad11erse Reaction to Medication 

MEDICAl INCIDENTS: 

( J Illness Requiring Medical Treatment 

[x] Deterioration !n Existing Med1cal Condition 

( ] Pregnancy 

( ] Seizure Requiring Emergency Treatment 

[ ] UTI 

( ] Bowel1mpaction 

{ 1 Pneumonia 

I 1 Pressure Sores 

[x] Other. Respiratory Dlstross 

( Physical Assault by Third Party/Other Individual in our car 

{ Sexual Assault by Thkd Party/Other Individual in our care 

[ The~ by Thin:! Party 

[ Fall 

{ Choking 

{ Balhlng!Scaiding Related Injuries 

t ] Other Sums 

[ l Vehicle 

[ l Swimming/Near Drownfng 

[ ] Other Accidental ! ' 

EXPOSURE CONTROL INCIDENTS: 

! 1 Clientlfndividual Exposed to Blood Some Pathogens 

[ 1 ClienUtndividuai Exposed Third Party to Blood Borne 

[ 1 Property Damage Under $1,000 

( ] Propqrty Damage Over $1,000 

[ 1 Vehicle Theft 

[ 1 Fire Setting 

{ l Tllaft!Shoplifiing 

[ 1 Other: 

~OSSESSION OF 

cllent/lndivldualtprogram) 

(Defined per 

[ 1 Possession of Prohibited Materials {i.G,, alcohol, 

lighter, 'NE!apon, pornography, i!l!cR drugs, etc,) 

MENTOR0004899 
333 


26354.267

l Counseling/Training for Statr!Mentor 

] 1SPJSupervfs!oi"'/Behaviom1 Plan Oe:vetoped with Cllcnlltndlvlduat 

1 !nlema! Investigation Undel'NBy 

Interventions: 

( ]Phyolcal 

f ]Mechanical 

[ }Saclusions 

{ ]Chemlt:al 

( }Law Enforcemet~t 

treatment options. 

Date: 

l Substantiated ( ) Unsubstanljate 

Licensing Nolifled 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004900 
334 


26354.268

Slgnaturn of State Director (Level 3 and 4 only) l'rln!Na!Tifl Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004901 
335 


26354.269

( lt) Behavlorat Health 

( } Juvenile Justice 

{ ) Medically Complex 

( ) MRIDO 

( ) MR!IJD Offendor 

14. 

15. 

) Acqulred Brain Injury 

) Elder Care 

) Mental Illness 

l MR/MI 

) Education 

} Other: 

name: 

15, Servlce Setting/Model; (check the ONE that most closely flts} 

( l ICFIMR {lnlermedlote Care Facility) ( ) Famlly/SchooVfloma Based SupPQrts (periodic 

( ) Group or Shared living (:3+ clientsli.ndividuals with 2417) services less than 2417} 

( ) Shared or Supported Living (1 or 2 dientsfmdividuals with 2417) 

(x) Mentor Hamel Host Home 

( ) Clinicai/Outpalient Therapy/Rehab (OT, PT, 

( l Day Program 

( ) Group or Shared living (3+ cftentslindMduals. with less than 24/7} 

( } Shared or Supported LMng (1 or 2 clientsflnd!viduals with less 

( ) Supported Employmani/Vocal!onal 

( l School 

than 2411') 

) Homa Health Agency Services 

19.location of IAcldeot (check ona) 

(x} Mentor Home {x) Primary ( ) Respite 

#of Montor Clfents/indivh,uals Nama: ~~-"~~be-~ Uvlng in Home: 2 

( ) Client/Individual's Residence {group home, !CF, apt} 

( ) ClienV!nONidual's Blofogical FamHy/Guard!an Home 

( ) Day Program 

( ) School 

{ ) Cllenl/lndividual's Place of Employment 

( ) Vehicle 

( ) Progmm Office 

( ) Community 

( ) Oiher. 

{ } Brokerage/Case Managsment (non~resicJential) 

20. Outcome of Incident: (check llll that apply) 

l Remain ln Current Placement 

1 Placement Decision Pending 

J Cllent/lndividual Placed in Ra.spiie 

] Placement Disrupted (i.e. Clientl!ndlvidual transferred to new 

home/ programlplacemanl within MENTOR NETWORK) 

l Discharged !Tom MENTOR NETWORK 

) Temporarily or PermenenUy Closed Mentor Homt> 

1 Emerg-ency Psycl\iatric Evaluation (no hospltatization} 

1 Emergency Psych.iatric Hospitalization 

] Emergency Medical Hosptta!lzatian 

] ln~school suspension 

l School Suspension/Expulsion 

J ClienUlndividual ArresVDetention 

(x] Deaih 

[ l Other: 

•••.• Mrs. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004902 
336 


26354.270

) Located at t11e Time of the Incident Report 

) Unable to Locata at the Time of the lncicte.nt Report 

l Othac 

(Suspec;:ted, Alleged -or Confirmed) 

Camt9ksr. 

[ J Mentor 

[ J Mentor Family Member 

[ 1 Staff 

( J Other Caretaker: 

Aflolged Ml$conduet: 

[ ] Sexual BoundaryfAbuSG: 

[ ] Verbat or Emotional Abuse 

[ ] Physical AssauiVAbuse 

[ l CocparaVInappropriale Punl•hment 

t ] Inappropriate Use of Restraint/Physical tnletvention 

! J Neglect 

{ ) Inadequate SupeMslon 

[ ] Criminal Arrest of Caretaker 

[ ] AlcohoVDrug Use by Caretal<er 

[ J Misuse of Client/Individual's Funds 

[ 1 MisappmpriationiDestructian of Clientllndlv!dua! Personal 

Property 

l Other: 

SUICIDAL CLIENTIINOIVIDUAL: 

{ } Suicidal Threats or Verbalizations 

[ l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTRNOIVIDUAL: 

( ]ToOlharCiient 

( ]ToStafforMentor 

( Jfo Mentor's Famlly Member 

[ ]To OIMr Thiro Party 

CUENTANOIVlOUAl: 

}To OU1er Client 

1 To Staff or Mentor 

.Jf'o Mentor's F:amUy Member 

]To OlherThlr<l Party 

.tro Antmafs (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Sell-Injurious Behavior 

] Mental Health De<ampensation 

] Oppositional Behaviors 

1 Inappropriate Sexual Comments/Threats 

] Verbal Threats of Violence 

l Exhibitionism/Public Masturb&tfon 

l Medication Error 

] Missing Controfled Substances 

l Serious. AGverset Reaction to Medlcatfon 

MEDICAL INCIOENTS: 

t J tuness Requiring Medical Treatment 

( l Datertora!.ion in Existing Medical Condition 

[ l Pregnancy 

[ l Seizure Requiring Emecyency Treatment 

[ l UTI 

{ ] eowellmpaclion 

( ] Pneumonia 

( l Pressure Sores 

( l Olher. 

Physical Assault by Third Party/Other lnd1vidu.a1 in our car 

Sexual Assault by Third Party/Other 1nctlviduat 11'1 our care 

Theft by Thiro Party 

Fall 

Cllaking 

Bath!ng!Scald!ng Ralatad fnjurf:es 

Ol.herBums 

Vehicle 

Swimming/Near Orowntng 

Olher Accldelltollnjury: 

Firs SeHing 

Thaft/Shop!ifting 

Other; 

POSSESSION OF PROH!BITEO MATERIALS: (Defined per 

cllentllndivfdua!fpmgram) 

Possession of Prohit)ited Materials (Le., alcohol, 

lighter, weapon, pornography, l!~cit drugs, etc.} 

MENTOR0004903 
337 


26354.271

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004904 
338 


26354.272

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004905 
339 


26354.273

Slgnoturo Director (len13 and 4 only) Print Name TIUe 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004906 
340 


26354.274

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004907 
341 


26354.275

(x) Behavlornl Health 

{ ) Jweni!e Justice 

( ) Medically Complex 

( l MRIDD 

( l MRIDD Offeoder 

l Acquired Brain Injury 

) EtrJerCare 

( ) Mental Illness 

( ) MRIMI 

( l Edtlcation 

( l Other: 

16. Service Setting/Model: (chock the ONE that most elos•ty ftts) 

( ) ICFIMR (lnlermedlato Care Facility) ) Family/SchooVHomo Based Supports (periodic 

( ) Group or Shared Living (3+ clients/Individuals wllh 2417} services less than 24/7) 

( l Shared or Supported Living (1 or 2 ellonlsllndMduals wilh 2417) 

(x} Mentor Home/ Host Home 

l Cllnie.ai/Oulpafienl Therapy/Rehab (OT, PT, Speech) 

l Day Program 

( ) Group or Shared living (3-t clientsllndi\liduafs INl!h less than 2417} 

{ ) Shared or Supported living {1 or 2 cltentsfindMduals with less 

} Supported EmploymenWocational 

} School 

!han 2417) 

) Home Health Agency Se-rvices 

17. Date & Time 

19.location of fncldent: {check -one} 

( ) Mentor Homo ( l Prtmary ( ) Respl!a 

Mentor Name: 

#of CUentsllndlviduaJs Living ln Home: 

( ) Cllentllndivlclual's Residence {group homa.ICF, apt) 

( ) Cllentllndividuars Blofogital Family/Guardian Home 

( ) Day Pro!Jmm 

( ) School 

( ) CllenVlndMdua.l's Place of Employment 

( l Vehicle 

( ) Program Office 

{ ) Community 

!x) Ollwr: ;.;.hO~S;::P..:.IT.;,.;AL.:;;:_ ______ _ 

) Brokerage/Case Management {non<>£esldenfia!) 

20. Outcome of tn~;ident: (c;hcck all that apply) 

1 Remain in Current P!aamtent 

J Placement Decision Pend1ng 

J C!lentl!ndividual Placed in Re$;:1ite 

] Pfacament Disrupted (Le. Clienll!n.divldi.ial transfM'&d to new 

home/ program/placement wllltln MENTOR NETWORK) 

1 Discharged from MENTOR NETWORK 

J Temporarily or Permanently Cl-osed Mentor Home 

l Emergency Psychiatric Evaluation {no hospitalization) 

] E.mergency Psychiatric Hospitalization 

J Emargoocy Medical 1-lospilalizatfon 

] Jn~schoolsuspoosion 

J School SuspenslaniExpulslon 

J ClientltndMdua! ArrestfDetentlon 

[>:]Death 

( J other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004908 
342 


26354.276

) Located at the Time of the !ncidEJnt Report 

) Unable to locate at the THna of Ute Incident Report 

)Oihef: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

[ ] Mentor 

( ) Mentor Family Member 

[ J Sta~ 

{ ] other Caretaker: 

Alleg9d Misconduct: 

[ ] Sexual Boundary/Abuse 

[ 1 Verbal or Emotional Abuse 

( ] Physicaf AssauiVAbuse 

[ l CorporaVfnappropriate Punishment 

[ ] Inappropriate Use of Ra:stralnt!Phys!cal tntervem.lon 

[ ] Neglect 

[ ] Inadequate Supervision 

[ ] Criminal Arrast of Carataker 

I J Alcohol/Drug Use by Caretaker 

[ ] Misuse of C~antflndividuat's Funds 

( l Misappmpriation!Destructicn of Cfientltndividual Personal 

Property 

l Olher: 

SUICIDAL CLIENT/INDIVIDUAL: 

t J Suicidal Threats or Verbalizations 

[ ] Suicidal Attempt or Ge:sture 

SEXUAL ASSAULT OR INAPPROPR.lATE SEXUAL 

BEHAVIOR BV CLIEI'ITIINDIVIOUAL: 

[ }To Other Client 

{ }To Staff or Mentor 

( Jfo Mentor's Family Member 

[ JToOtherThlrdParty 

PHYSICAL ASSAULTS 

( ]To Olharaient 

( l To Staff or Mentor 

[ JTo Mentor's Family Member 

[ ]To Olhe<Thin:l Party 

( Ifo Animals (anima\ cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

)Msdlcatlon Error 

)Missing ControUed Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] !llneBs Requtrlng Medical Treatment 

t ) Deterioration in Existing Medical Condition 

[ l Pregnancy 

( 1 Selz:ure Requiring Emergency Treatment 

( ] UTI 

[ l Bowel Impaction 

( 1 Pneumonia 

f l Pressure Sores 

f l Other: 

] Physical Assault by Third Party/Other Individual !n our car 

J SeX\Ial A .. ault by Third Party/Other Individual In our care 

l TheR by Third Party 

l Fall 

[ ] Choking 

t ] SathinglScald!ng Related Injuries 

( ] Other Bums 

! l Veh!de 

( l SINimming/Near Drownlng: 

f 1 Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

f ] Cttentllndividual ~posed to Blood Bom.a Pathogens 

( ] Clientllndividual Exposed Third Party to Blood Some 

PROPERTY OAI\IAGE BY CUEI'ITIINDIVIDUAL: 

{ ] Property Damage Under $1,000 

! l ProportyDemege Over$1,000 

{ J Vehicle Theft 

i l Fire Setting 

[ l Thefi!Shopllffing 

[ l Other. 

POSSESSION OF PROHIBITED MATERIALS: (De!lned per 

cllentltndlviduat/program) 

[ l Possession of Prohibited Materials (Le., alcohol, 

lighter, waapon, pomography, ltl'idt drugs, etc.) 

MENTOR0004909 
343 


26354.277

( 1 ~c;,~~=~=:~:~~~ntor ( I Developed with Client/Individual 

[ l lotemallnvastlgatlon Underway 

frrterventions: 

[ ]Pill"Oical 

[ ]Mechanical 

( ]Seclusion& 

[ ]Chemical 

) Subslantlalet! ( ) Unsub•lanUate 

[ l Licensing Notified 

Date: 

Upon rocalvln~n scans showing no brain activity th" ho&pltal policy '"to call time of death. Time of death 

w ... called at-duel<> two brain scans sllowlng no brain activity. Dr.-.1$0 stat•d !bat lltey were 

looking to secure approval for ofllan donation. Dr. d In her mport that-would remaln 

on tlfe support for organ preservation for future organ nations. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR000491 0 
344 


26354.278

Print Name Title Date 

CC Super 

Prlnt Name Title 

-

Date 

Print Name Title 

Signature of State Director (Lev~ 3 and 4 oniYl PrtntName Title Data 

- StateDir. -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004911 
345 


26354.279

( ) Seha'iioral Health 

( } Juvenile Justica 

{ ) Msdical!y Complex 

(x) MR!DD 

( ) MRIDD Offender 

) Acquired Brain Injury 

) Elder Care 

( ) Mental Illness 

( ) MR!MI 

( ) Education 

< ) Olher. 

14. If Acqu!sltlon/Partner, specify company name: 

15. 

16. Servk;a Setting/Model: {check the ONE that most closely fits) 

( ) ICFIMR (lntermedlole Care Facility) ) Family/Schoot/Hame Based Supports {pt~riodic 

( ) Group or Shared living (3+ cflent.sfindividuals !Nfth 2417) services lass than 24/7} 

( ) Shared Ot SupPorisd lMng {1 or 2 cJjents/individuals with 2417) 

{x} Mentor Home/ Host Home 

) Clinicei/Outpatient Therapy/Rehab {OT, PT, Speech) 

) Day Pmgrnm 

{ ) Group or Shared LiVing (3+ c1ientslind!viduals with les!t than 2417} 

{ ) Shared ar Supported Living (1 or 2 clientsfindlviduats with lass 

} Supported Emptoyment/VocaUonal 

) School 

than 2417) 

) Home Health Agency Services 

19, lccalion of Incident: (check ana} 

(x.) Mentor Home {x) Primary ( } Respite 

Mentor # ofCUentsllndtv1dUals Nama: .... Uvfng j"'~=-=~ tn Home: 

{ ) Cl!entr'lndMdual's Residence {group hOme, lCf, apt) 

( ) ClienVIndividuars Biological Family/Guardian Home 

( ) Day Program 

( ) School 

( ) Cllenttlndhliduars Place of Employment 

( l Vehicle 

( ) Program Office 

( } Community 

( ) Other, 

18. First Report!!<! to 

av: (Name & Ti!f<l) 

) Brokerage/Case Management {non·resfdential} 

20. Outcome of Incident: (chec-k all that apply) 

J Remain In Current Placement 

) Placement Decl~lon Pending 

1 Client/Individual Placed in Respite 

] Plac;ement Disrupted (i.e, Cllontrlndividua! transferred to new 

hamel program/placement within MENTOR NETWORK) 

l Dii!Chai!Jed from MENTOR NETWORK 

] Temporarily or ParmanenUy Closed Mentor Home 

J Emergency Psychiatric Evaluation {no hospUa!lzation) 

1 Emergency Psychiatric HospitaU.zatJon 

1 Emerge-ncy Medical Hasptta!ization 

1 ln~schooi suspension 

l Scho~ Suspension/Expulsion 

] Cflentllndlvidual ArresUOetention 

[x] Death 

[ lath ... : 

.. Client stopp!!d breathing. -was taken to ER with indications of suffocation. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004912 
346 


26354.280

) located at the Tlme of the Incident Raport 

} Unable to locate at the TimE:! of the tncldent Report 

l Other. 

{Suspected, Alleged or Confirmed) 

Caretakur. 

[ l Mentor 

t ] Mentor Famify Member 

r 1 staff 

( ] Other Caretaker: 

AJJsged Misconduct: 

[ J Se>uallloundar;/Abusa 

( 1 Verbal or Emotional Abuse 

[ 1 Physical Assautt!Abuse 

t } Corporatl!nappropriate Punishment 

( ] lnapproprtate Usa of RsstraintFPhysica! Intervention 

I l Neglect 

[ l lnadequate Supervision 

[ ] Criminal Arrest of Caretaker 

[ ] Alcohol/Drug Use by Caretaker 

[ 1 Misu~ of Cli~ntflndividual's Funds 

( ] Misappropriatlon/Oastructian of Client/Individual Persona! 

Prop arty 

l Other. 

SUICIDAL CLIENTIINOIVIOUAL: 

[ 1 Suicidal Threats or Verbalizations 

( l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTnNDIVIDUAL: 

( ] To OtherCHent 

[ l To Staff or Montor 

[ ]fo Mentor's Family Member 

[ J Ta Other Third Party 

PHYSICAL ASSAULTS BY 

( ]To Other Client 

[ 1 To Staff or Mentor 

[ Jfo Mentor's Family Member 

t ]To Other Third Party 

r ]fo Animals {animal cruelly) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self .. Jnjurlous Behavior 

J Mental Health De-campansa-uon 

J Oppositional Behaviors 

]Inappropriate Sexual CammentsfThreats 

J Verhal Threats of Vlolence 

J Exhibitionl.sm!Publk MastUt'batlon 

1 Medication EfTQr 

l Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ l Illness Requiring Medical Treatment 

( J Deterioration in Existing Medlca! Condition 

[ l Pregnancy 

t 1 SEizure ReQuiring Emergency Treatment 

[ I UTI 

[ ] Bowel Impaction 

[ 1 Pneumilnia 

[ ] Pressure Sores 

r J Other. 

[ J Physical Assault by Third Party!Other lndhridual in our car 

[ ] Sexuat Assault by Third Party/other Individual in our care 

I l Theft by Third Party 

! l Fall 

t l Choking 

[ J Bath!ng!Scalding Related lnjuries 

[ l Other Bums 

[ 1 Vehicle 

( 1 Swlmm!ng/Near Drowning 

t ] Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

t 1 Cl!entJindiVidual Expoa.ett to Stood Borne Pathogens 

( l CUanUlndlvldual Exposed Third Party to Slood Borne 

PROPERTY DAMAGE BY CL1ENT/INDtvtDUAL: 

[ J Prapjlrty Damage Under $1,000 

t l Property Damage Over$1,000 

[ ] Vehicle Theft 

[ ] Fire Setting 

( l ThefVShopliffiog 

f l Other: 

POSSESSION OF PROHIBITED MATERIALS; {Defined per 

cliontllndlvtduaUpr"'Jram) 

f l Possession of Prohibited Materials (te., alcohol, 

Hghter, weapon, pomography, ijliclt drugs, etc.) 

MENTOR0004913 
347 


26354.281

~xi ~~ffi~~~=e~~:w~~~~;ntor DeveloPed with Cflenlllndividoal 

[ ] lntemallnvestigation Underway 

Interventions: 

[ ]Physical 

( ]Mechanical 

( ]Seclusions 

£ ]Chemical 

( Enforcement 

(x) Substantiated ( ) Unsubstantiata 

[x] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

(xj 

Date: 

(x] Family 

Date:-

[x] Guarrlian Not!lled 

Date: 

[x] LawEni~~~~iiit>onNolifiad 

MENTOROD04914 
348 


26354.282

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004915 
349 


26354.283

Compliance Manager 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004916 
350 


26354.284

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004917 
351 


26354.285

{x) Beh.avlaral Health 

{ } Juvenlfe Justice 

( ) Medically Complo< 

{ ) MRIDD 

( ) MRIDD Offender 

) AcQUired Brain lnjurv 

l Elder Care 

) Manta! Illness 

l MRIMI 

) Education 

) Ottlec 

16. Service Setting/Mode!: (check the ONE that most closely fits) 

( ) ICFIMR (lnlannediala Care Facility) ) FamUv/Sc-hool/Home Based Supports (period1c 

{ ) Gtoup or Shared lh•ing (3+ clients/individuals with 24f7) services !ass than 2417) 

t ) Shared or Supported Living {1 or 2 cllentslindMduals with 2417} 

(x.) Mentor Home/ Host Home 

l CHnlcal/Oulpatient Therapy/Rehab (OT, PT, Speech) 

) DayProgram 

( ) Group or Shared Uvfng (3+ clientsJind!vlduals Villh less than 2417) 

( ) Shared or Supported Lhrlng (1 or 2 c!ientsllndividuals with less 

) Supported Emp!oymentNocational 

) Schoo! 

than 2417) 

) Home Heaf\tl Agency Services 

19.Locat1on of Incident (check one) 

( ) Mentor Home (x) Primary ( ) R~!iplte 

Mentor Nam&: 

# >:~f Clfentslind!vfduals LMng ln Home: 

( ) Cl!entllnd!vidua!'s Resldenc::e(group home, !CF, apt) 

( ) ClienVIndlvidual's Siologkal Family/Guardian Home 

( l Day Prog<am 

( ) School 

{ l Cllentr'tndivldual's Place of Employment 

( l Vehicle 

( l Program Office 

( ) Community 

( ) Other: 

) Brokerage/Case Management {non-residential) 

2:0. Outcome of Incident: (check al1 that apply} 

] Remain in CU&ant Placement 

J Placement Deci-sion Pending 

1 CHenU!ndivldua! Placed In Respite 

J Placement Disrupted (i.e. Cflenutndividuaf transferred to new 

hamel program/placement within MENTOR NETVVORK} 

l Discharged from MENTOR NETWORK 

J Temporarily orPerm.,nently Closed Mentor Home 

J Emergency Psychiatric Evaluation (no hospitalization} 

1 Emergency Psychiatric Hospitalization 

l Emergency Medical Hosp!tali~Uon 

] !n-scilool suspension 

] School Suspansion/ExpulsiDn. 

{ ] Cllentllndivldual Arrest/Detention 

[x] Ooath 

[ J ottler. 

.. Client was In the bathtub. Foster parents daughter discovered•• blue. She called 911 and gave mouth-to-mouth 

resuscitation. Client was pronounced dead at the hospital. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004918 
352 


26354.286

} Located at the Time Df the Incident Report 

) Unable to Locate at the T1me of the Incident Report 

J Other: 

{Suspected, Alleged or Conflrmed} 

Carotaker: 

[x] Mentor 

(x) Mentor Family Member 

( ] Staff 

[ J Other Caretaker: 

Alleged Mlscondt.~t:t: 

( l Sexual Boundary/AbuS<! 

[ J Verbal cr Emotional Abuse 

t J Physil;31 Assault/Abuse 

[ J Corpomlf!nappropriate Punlshment 

E ] Inappropriate Use of Rf.lstralnt!Physical tnterventlon 

[ l Negle<;t 

[ x l Inadequate Supervision 

{ l Criminal Arrest of caretaker 

! l Alcohol/Drug Use by Caretaker 

t 1 Misuse of Client/Individual's Funds 

[ ] Misappropriationtoestruction of Cltentl!ndiltidua! Personal 

Property 

l Other. 

SUICIDAL CUE:NTIINDIVIOUAL: 

[ ) Suidda! Threats -or Verbalization& 

( l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENT~NDIVIDUAL: 

{ ] To Other Client 

( J To Staff or Mentor 

( }To Mentor's Family Member 

[ ]To Other Third Party 

PHYSICAL CUENTnNDIVIDUAL: 

t l To Other Client 

t ] To Staff or Mentor 

[ Jfo Menklr's Family Member 

( l To Othar Third Party 

! ]To Animals (animal cruerty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

J Seff~lnjurious Sehavlor 

] Mental Health Qe..compe.nsation 

) Oppositional Bahavtors 

] Inappropriate Sexual Comments/Threats 

] Verbal Threats uf Violence 

) &hibilionism/Publlc Masturbation 

l Medlcalion Error 

l Missing Controlled Substm:as 

l Serious Adverse Rsacl:ion to MedicaUon 

MEPlCAL 

[ l Illness Requiring Medical Trealment 

[ ] Deterioration ln Existing Medical Condition 

t l Pregnancy 

[ ] Seizure Requiring Emer'gency Treatment 

[ l \ITI 

£ l Bowel lmpaclion 

[ J Pneumonia 

[ l Pressure Sores 

r 1 other. 

t ] Physical Assault by Third Party/Other Individual in our car 

( ] Sexual Assault by Third PartytOther lndlvklualln our c:are 

t l Theft by Thlro Party 

t ] Fall 

t l Choking 

[ ] Bathing/Scalding Related Injuries 

[ ] OtherBums 

[ l Vehicle 

[ J Swimming/Near Drowning 

[ l Other Accldaniallnjury: 

EXPOSURE CONTROL INCIDENTS: 

( l Cfienll1ndividual Exposed to Blood Some Pathogens 

[ J ClietiUindivldual Exposed Thlro Party to 61ood Some 

BY CLIENTRNDIVIDUAL: 

Property Damage: Under $1,000 

Property D•mago Over $1,000 

Vehicle Theft 

Fire Setting 

Theii/Shoplifting 

Other:: 

POSSESSION OF PROHIBITED MATERIALS: (Oeftnecl per 

ctientllndMduaUprogram} 

[ 1 Possession of Prohibited Materials (I.e., alcohol. 

lighter, weapon, pornography, illicit drugs, elc.} 

MENTOR0004919 
353 


26354.287

[ ] g~}S~~~~~~~;~~~:ntor [ l Developed With CilenUindlvidual 

[ ) lntemellnvestlgatkm Underway 

lntetVenlions: 

[ ]Physical 

( }Mechanical 

( )Seclusions 

f ]Chemical 

[x] Reported to AdultlChild Protective 

Services 

Date; 

) Substantiated ( ) Unsubstantlate 

[ J licensing Notified 

Date: 

] Funding Source Notified 

Date: 

J Family Notlfied 

Date: 

[xJ Guardian Notlfied 

DalE:-

] Law EnfOrcement/Probation Notified 

Date: 

Mentor c.alled ease manager.- to ..-eport that foster parents bio daughter,- had dist:overed client was 

underwater in the tub and was "blue". Client started mouth to mouth and called 911. Paramedics transported client 

to-Hospital whor~ pronounced dead. M.E.-was called. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004920 
354 


26354.288

PrlntName Title Data 

Case Miloager 

Print Name Title 

-

Date 

Signature PrlntNamo Date 

Signature of State Director (Level ~ and 4 only) Prlntllame Tille Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004921 
355 


26354.289

( } Baha\'iaral Heattll 

( ) Juv.aoila Justice 

( ) MedleaHy Complex 

{ l MR/00 

( l MRIDD Offender 

) Acquired Brain Injury 

) Elder Care 

) Mental Inness 

l MRIMI 

( l EdtJ<alion 

(xJ Other: MF 

16. Service Setting/Model; (chock the ONE !hat mQs! closely fits) 

t l ICFIMR (lnterme<Jiata Caffl Facilily) ) family/School/Home Based Supports {periodic 

( ) Group or Shaffld living (3+clients/lndMduals wllh 2417) services less than 24n) 

( l Shared or Suppol1e<l Living (1 or 2 clients/Individuals with 24n) 

{x) Mentor HomeJ Host Home 

) ClinlcaVOulpalient Therapy/Rehab (OT. PT, Speech) 

l DayProgram 

{ } Group or Shared Living (3+- clienWin<llviduals wtth less than 2417} 

{ } Shared ar Supported Living {1 or 2 dientsliodividuals with lass 

} Supported EmploymenWocational 

l School 

than 2417) 

) Home Health Agency Services 

1£1. location of Incident: (chech. one) 

{ ) Mentor Home ( ) Prtmary ( ) Respite 

Mentor Name; 

#of Cllents!indlvlduats living in Home: 

< ) Cllentllndlviduat's Residence (group home, !CF, apt) 

( ) Cl!entf!ndMdual's BloJogtcal Family/Guardian Home 

( ) OayPro!)fOm 

(:x) School 

( ) Cll'6ntllndividual's Place of Employment 

( ) Vehicle 

( ) Pr.ogram Office 

( ) Community 

( ) Other: 

l SrokemgaiCaaa Men"9"fl!en! (non-residential) 

%0, Outcome of Incident (ehscl€ afl that apply) 

j R~maln ln Current Placement 

] Placement Dac.lston Pending 

l ClienVIndivlduat Placed in RaspUe 

J Placement Disrupte<J (I.e. ClienV!ndivldual transferred to new 

home/ program/placement wl!ltln MENTOR NElWORK) 

J Dlschal!led from MEtofTOR NETWORK 

l Temporarily or Pennanenlly Closed Mentor Home 

Emergency Psychtatric Evaluation (no hospltaHzation} 

] Emergency Psych!atric: Hosp!tafizatlon 

1 Emergency Medfcal Hospltalizatkm 

J ln~school suspension 

] School SusponsionfExputsion 

( l Clientllndividual AITBstiOetention 

(xJ Oealh 

[ l Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 28 MENTOR0004922 
356 


26354.290

) Located at the Tlme of the Incident Report 

) Unable to locate at the Time of the tncldent Report 

) Other. 

(Suspected, Alleged or Confirmed) 

Caretaker: 

l ] Mentor 

f l Mentor Family Member 

( ]Staff 

[ ] OtlleT Caralaker. 

Alleged Misconduct: 

[ ] Sexual Boundary/Abuse 

l ] Vefbal or EmoUonat Abuse 

t ] Physical A:;;saultiAbuse 

[ ] Corporalllnappropriata Punishment 

t ] Inappropriate Use of RestraintlPhys;!cat lnteNention 

[ l Naglect 

t l Inadequate Supervision 

t J Criminal Arrest of Caretaker 

[ J Alcohol/Drug Use by Caretaker 

I l Misuse of Clien!JlndivldtJafs Funds 

t ] MlsappmprlationtDsstruction of Cllsnt/lndl'vldua! Personal 

Property 

1 other: 

SUICIDAL CLIENTIINOIV!DUAL: 

( ) Suicidal Throats or Vertalizations 

t ) Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

!lEHAVIOR BY CLIENT !INDIVIDUAL: 

I )To OtherCIIenl 

{ }To Staff or Mentor 

[ ]To Mentor's Family Member 

[ ]To Other Third Party 

PHYSICAL ASSAULTS !lY 

( J To Other Client 

[ ]To Staff or Mentor 

( ]To Mentor's Family Member 

[ ]To Other Third Party 

[ J:ro Animals (animal cruelly) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Self~!nJurious Behavior 

l Menta! Heaf1h Oe-<:ompansation 

] Oppositional Beha11iors 

] Inappropriate Sexual Comments/Threats 

] Verbal Threats of Vio!onee: 

J ExhlbliJonismiPublic Masturbation 

1 Medication Error 

1 Mlsslng Controlled S!lb5tances-

] Serious Ad\leTEe Reaction to Medication 

J Illness Requi:ring Medical Treatment 

J Oeterit:lr.atiw in ExiSting Medical Condition 

J Pregnancy 

] Seizure RequiTing Emergency Treatment 

[ l UTI 

[ ) BowellmpactJon 

( I Pneumonia 

[ 1 Pressure Sores 

[ l Other: 

( Physlcat Assault b~ Third PartytOther lndMdualln our car 

( Saxuat Assault by Third Party/Other lndl\'!dual in our care 

[ Theft by Third Party 

[ Fall 

[ J Choki09 

[ ] Bathing/Scalding Related Injuries 

i ] OtherBums 

I l Vehicle 

! l S..;mmingiNear Drown109 

1 l Other Accidental 

EXPOSURE CONTIIOL INCIDENTS: 

[ J CUentl!ndividual Exposed to Blood Borne Pathogens 

( l C!lentl!ndividual Exposed Th!rd Party to Blood Some 

PROPERTY DAMAGE BY Cl.IENTIINDIVIOUAL: 

[ l Property Damage Under$1,000 

[ l Property Damage Over $1,000 

t J Vehicle Theft 

[ ] Fire Setting 

] Theft/Shopllfti09 

l Other: 

POSSESSION OF PROHIBIT!;D MATERIALS: (Define<! per 

clk>nUin~lviduallpr"'lram) 

[ J Possession of Prohibited Materials (i.e., akohol, 

lighter, weapon, pornography, l!llcit drugs, etc.) 

MENTOR0004923 
357 


26354.291

l Counseting/Tminlng for Staff/Mentor 

ll:\',i~~~';Xf~~~~ 

] Internal tnveiligaHon Undqrway 

interventions: 

[ ]Physical 

[ jMechanl<:a! 

[ }Seclusions 

( ]Chemical 

( J Reported to Adui1/Child Prolecti"" 

Se!Viee.s 

Oate: 

) Substantiated ( ) Unsubstantiate 

[ l licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Funding Source Notified 

Dale: 

l Family Notified 

Date: 

[xl Guarolan Notified 

Date: 

]law 

Data: 

Notified 

MENTOR0004924 
358 


26354.292

Signature of State Director {Level 3 and A only) Print Name Date 

- StateDir. -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004925 
359 


26354.293

( ) Behavioral Health 

( ) Juvenile Justice 

{><) Medically Complex 

( ) MRIDD 

( l MR/00 Offender 

15. 

) Acquired Brain Injury 

) Elder Care 

} Menta! Illness 

) MRJMI 

} EducaUon 

) Olher: 

16. Service Salting/Model: (check the ONE that m0$t cto-sely fits} 

{ J ICFIMR (lnteonedlale Cane Facility) Famlly/SchooVHome Basad Supports {periodic 

( ) Group ot Shared living (3+ clientsllndMduals wllh 24n} seovlces less than 2417) 

( ) Shared or Supported Ll•lng ( 1 or 2 ellentsiindlvlduals with 2417) 

{x} Mentor Home! Host Home 

( ) Clinical/Outpatient Therapy/Rehab (OT, PT, Speech) 

( ) Day Program 

{ ) Group or Shared u._-ing {3+ c:!ientsllndividua!s with tess than 24!7} 

( } Shared or Supported living {1 or 2 clientsllndfvidua!s with less 

{ ) Supported Emp!oymen.Wocatlona! 

( l School 

!han 24/7) 

) Home Health Agency SeJVices 

19. Location of lnddent (check one} 

( ) M-entor Home ( ) Primary ( } Respite 

Mentor Name: 

#of Cllentsllndividua1s Living In Home: 

{ ) ClienU!ndividua!'s Rasklance (groyp horne, 1CF, apt) 

( ) C!ienlllndividual's Biological Family/Guardian Home 

( ) Day Program 

{ ) School 

( ) C!ientllndividual's Place of Employment 

( ) Vehicle 

{ ) Program Office 

( l Community 

(x} Other. i!!!l!!!!!l!!!!!l!!!l!!t ______ _ 

-Client died on-

{ ) Brokarags!Case Management (non-residential) 

20. Outcome of Incident: (check all that apply) 

1 Remain in Current Placement 

1 Pta-cement Decision Pending 

l Clieniltnd!vldua1 Placed in Respite 

1 Placement Disrupted (Le. ClientJlndMdualltansfcrrad' to new 

home/ progrnmlplacement withJn MENTOR NETWORK} 

l Discharged from MENTOR NE"TWORK 

) Temporarily or Permanently Cfosed Mentor Home 

1 Eme19ency Psychiatric Evaluation (no hospitalization) 

J Emergency Psychlatrtc Hospitalization 

] Emergency Medicral HospitaliZation 

1 In-school suspension 

] School Suspension/Expulsion 

J Clienlllndividual ArresllOetentlon 

(xJ Dealh 

[ l Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004926 
360 


26354.294

) located at the Ti.ms of ths Incident Report 

} Unable to Locate at the Time of the tnddent Report 

l other. 

{Suspected, Alteged or Conflrmad) 

Catetakor: 

[ l Mentor 

{ ] Mentor Family Member 

[ ]Staff 

t l 01har Caretaker: 

Alleged Mlsc<mduct: 

I l SoX\Ial SoundaryiAbuse 

[ 1 Verbal or Emotionat Abuse 

t ) Physh;;al Assaurt/Abuse 

[ l Corporalllnappropriate Punishment 

[ l Inappropriate Uee of Re•tralnUPhyslcallnterwmUon 

( ] Neglect 

( l Inadequate Super.Jiston 

( J Criminal Arrest cf Caretaker 

[ l Alooholi0ru9 Use by Caretaker 

C ] Misuse of ClienVInd!vidual's Funds 

( l MlsappropriationJDest:rucUon {jf C!ient'!ndividual Persona! 

PrPperty 

l Other. 

SUICIDAl C:LIEIITnNOIVlDIJAl: 

[ ] Suicidal Threats or Verbalizatklns 

[ l Suic!daf Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

SEHAVIOR BY CLIENTnNDIV1DIJAL: 

[ ] To Other CHant 

[ ]'To Staff or Mentor 

[ ]To Mentor's Family Member 

[ l To Other Thl«l Party 

PHYSICAl ASSAULTS BY 

[ ]To Other Client 

[ ]ToStafforMontor 

l :rro Mentor's Famity Member 

[ l To Other Thi«l Party 

[ ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Self~tnjurious Behavklr 

1 Mental Health D&-eompensatlon 

l OpposiUonal Behaviors 

] Inappropriate SaJ~:ual CommentsiThreat::s 

l Verbal Threats of Violence 

] E:xhlbitionlsmlPub!lc Me.sturbation 

Ufoess Requiring Medlcal Treatment 

Oeterioratlon in Existing Medical Condition 

Pregnane~ 

Seizure Requiting Emeryency Treatment 

UTI 

Bowallmpaction 

Pneumonia 

PresSll!e Sorf!!'s 

Other. 

[ J Physical Asoaun by Thl«l Party/other Individual in our ca< 

[ J Sexual Assault by Third Party/Oiher Individual In our care 

[ 1 Theft by Thl«l Party 

[ J Fall 

[ l Choking 

[ J Bathing!Scalding Related Injuries 

{ 1 Other Bums 

( l Vehicle 

t j Swimming/Near Drowning 

£ l Other Accldental l 

FlreSeWng 

Theft/Shopllffing 

Other. 

POSSESSION 01' 

ctlenl/lndlvlduallprvgram) 

MATERIALS: (Defined per 

PosseSSion o! Prohibited Materials (Le .. alwhol, 

lighter, weapon, pornography, Illicit drugs, etc.) 

MENTORODD4927 
361 


26354.295

[ l ~Ws:~~rof'(/f~!"v!!]=•tor t l Developed w~u;' CllenYindlvidual 

[ ]l"tamallnvaotlgatlon Underway 

!f'llrJMUt{ionS:: 

[ )Physical 

[ ]Machanlcol 

( 1Secluslons 

[ ]Chemical 

( JLB'W Enforcement 

t l Roported to AduiUChit<l ProtOO!iva SOI\'Ioeo 

Dele: 

l Substantiated 1 J unsubslontrnte 

[ l licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Fund!f1\l So""'" No«lied Dole: 

] Family NoUfled 

Date; 

l Guardian N<lllfiad 

Dale: 

]law EnfrnoemanUProbation Notilied 

Data: 

MENTOR0004928 
362 


26354.296

Super. 

Date 

StateDir. -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004929 
363 


26354.297

{>:} Behavioral Kealth 

( ) Juvenile Justice 

( l Medically Co"'''lex 

( l MRIDD 

( l MRIDD Offender 

) Acquired Brain Injury 

) EMerCara 

! I Mental illness 

( l MR!MI 

( l Education 

( ) Olhsr. 

14.1f 1\cqu!slijon/Partner, apaclfy CO"'!'Bny name: 

18. Service Setting/Model: (check the ONE thai most do..,ly flls) 

( ) ICFIMR (ln!Brmedlate Cane Facility) ) Famlfy/SchooVHome Basad Supports (periodic 

( ) Group or Shared Living (3-t- clientsJindMduals with 2417} services lass than 2417) 

I ! Shared or Supported Living (1 or 2 cllentsllndlviduols with 2411) 

(xl Mentor HomeJ Host Home 

) ClinlcaiiOUtpa!lenl Therapy/Rehab (OT, PT, Speecl>) 

l OayProgram 

( ) Group or Shared LMng {3+ clients/lndividuals wilh IHs than 24n) 

{ ) Shamd or Supported Living {1 or 2 c!Jentslindlvidua!s with !ass. 

) Supported EmploymenWocaljona! 

) Sc.hoot 

than 2417) 

) Home Heallh Agency Services 

19. Location of Incident (c.ht:H:Ic one} 

( ) Mentor Home { ) Primary { ) Respite 

Mentor Name: 

#of Ctlentsllndtvlduats living in Horne: 

( ) Cl!entl!ndividual's Residence (group home, ICF, apt) 

{ ) ClienVlndiv!dual's Biological Family/Guardian Home 

! l DayProgram 

( ) School 

( ) CllenVtndlvidual's ?face of Employment 

( l Vehicle 

( ) Progrom Office 

( l Community 

(x) OlhOf: Hospital 

) Brokerage/Case Management (norHesldential} 

20. OJJ!come of lncld<>nl: (check aff that apply) 

l Remain in Currant P!acel"l'tent 

J Pl<'lCement Decision Pending 

J C!ient/lndividual Place(! ln Respite 

3 Placamant Disrupted (i.e. C!ienb'!ndividua! transferred to new 

home/ program/p!ocomenl w»hln MENTOR NETWORK) 

l Discharged from MENTOR NETWORK 

l Temporarily or Pennanently Closed Mentor Homa 

l Emergency Psychiatric Evaluation (no h(lspitallzation} 

l Emergency Psychiatric HospUalizaUoo 

1 Emergency Medical Hospitalization 

J In-school .suspension 

J Schoo! SuspensloniExpulsloo 

J C!ientJlndividual Arrest/Detention 

[><]Death 

r ] Olhec 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004930 
364 


26354.298

) Located at tho Time oftha Incident Report 

} Unable to Locate at tha Time of the Incident Rapor1 

l Other: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

[ l Montor 

( ] Mentor Family Member 

r l Staff 

( J Other Caretaker: 

AIJagfld Misconduct: 

t l Sexual Boundary/Abuse 

[ l Verbal or Emotional Abuso 

[ l Physical A .. autVAbuse 

[ J Crnporalflnapproprtote Punisllmant 

t l lnapproprlatei.Jse of RestrainVPnyslealtntervention 

r J Neglect 

[ J lnadequa!B Supervision 

{ l Crim!nat Atmst nf Caretaker 

[ l AleohOVDrug Usa by Can>takar 

t l Misuse of CllenVbtdMduars Funds 

t l MisappropriationtDestrud:ion of CHenUfndividuBl Personal 

Property 

l other: 

SUICIDAL CUENTIINOIVIOUAL: 

( 1 Sutcidal Threats or Varbal!zatk:ln5 

£ J Suicidal Attompt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

( 1 To Other Client 

[ ] To Staff or Mentor 

[ Jfo M<>ntor's Feml!y Member 

( ]To Other Third Party 

I>Y CLIENTRNOIVIOUAL! 

] To Oth<lr Client 

J To Staff or Mentor 

]To Mentors Family Member 

)To OtherTnlro Party 

JTo Anlmals (animal enmity) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Se!Hnjurious Behavior 

] Mental Health De-compensation 

] OppDs!Uanat Sehavlors 

] lnappmprlata SexuB! Commentstrhreats 

l VE:'tltal Threats of Violence 

l El<hlbltlanlsm/Publlo Masturbation 

I Medication Enror 

l Missing Cootro!ad Substances 

l Sarious Advel"5e Reaction to Medication 

[ 1 Illness Requiring Medical Treatment 

( l Deterioffllion In Exls6ng M<>dieal Condltion 

[ l Pregnancy 

[ l Sotzuro Raqulrtng Emergency T'""!moot 

[ J UTI 

[ l Bowollmpactlon 

[ l Pn<rumonia 

( J Pressure Soms 

[ l Other: 

Physical As .. •ft by Third PartyiOihar lrnfividua! In our car 

[ J Sa""" ASsault by Third PartyiOIIIorlndividuat in our care 

r 1 Tban by Third Party 

( I Fall 

[ ] Cholling 

[ l Bethlng!Scaldlng Reletird lnju~e• 

[ l Other Bums 

[ l Velliele 

[ l SwimmlnQJNoar Drowning 

[ l Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

( ] C-lk5nt/tndhtfduai Elo;posed to Blood Borne Patll!J9ens 

[ ] Client/IndiVIdual Exposed Third Pllfly to Blood Borne 

Property D•m•s• Under $1,000 

Property Damage Over $1.000 

Vahic1e Theft 

Fire Setting 

Thsft!ShoptiftinQ 

Other: 

POSSESSION OF PROHII!ITEO 

eli<lntllndlvlduaVprogram) 

[ ) Pdssessian nf Prohibited MaterialS {i.e., arcoho!, 

lighter, weapon, pornography, illicit drugs, etc.) 

MENTOR0004931 
365 


26354.299

( l tntem-al tnvasl!gstion Underway 

Interventions: 

r JPhyoical 

r ]Mechanleol 

! ]Seclusions 

[ }Ckemlcol 

t ]Law Enforcement 

) Substantiated ( l Unsubstantiata 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[xl 

oat&: 

!JFoml!y 

Date: 

txJ Guardian Notified 

Date: J l Law En orcemGnttProbation Notified 

Data: 

MENTOR0004932 
366 


26354.300

Coord. 

Signature of State Olrector (Levell and 4 only) Pr1ntName Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004933 
367 


26354.301

( ) Behavioral Heatlh 

( ) Ju11e<lile Justice 

(x) Medically Complex 

( l MR/00' 

{ l MR/00 Offender 

) Acquired Brain Injury 

) SdarCare 

) Mental Illness 

) MR/MI 

) Education 

J Other: 

16. Service Setting/Model; {check the ONE that most closely fits) 

( ) ICFIMR {Intermediate Care Facility) ) Famity/SchQo!/Home Based Supports{portadlc 

( ) Group ar Shared Living {3+ cUentsllndividuats with 24/7) services less than 2417) 

( } Shared or Supported Living (1 or 2 client&'lndividuals wilh 2417) 

(x) Mentor Home! Host Home 

) ClinlcaYOulpaUsnt Therapy/Rehab (OT, PT. 

) Day Program 

( ) Group or Shared living {3+ c.llenlslindivlduals with less than 24n} 

( } Shared or Supported Uving (1 or 2 cUentsllndlv!duals with tess 

) Supported Emp!oym-enWocational 

) Schoo1 

than 2417) 

) Home Health Agency SeNices 

19. Location of tnddent: (check cne} 

( ) Mentor Home 11<1 Primary ( ) Respite 

Mentor Name; 

fl of ClientsllndivlduaJs Uvlng ln Home; 

( } C!ienUindi.,.ldual's Residence {group home,ICF, apt) 

( ) CUentllndi'llldual'$ Biological Famt!y/Guardian Heme 

{ l Day P<ogram 

{ ) scnool 

( ) CllenV!ndtvidual's Place of Employment 

{ ) Vehicle 

( ) Program Office 

( ) Community 

( ) Other. 

l Brokerage/Case Management (non~residenfial) 

20. Outcome of Incident (check all that apply) 

1 Remain ln Current Placement 

J ?tacement Daclslon Pending 

J Cllentllnd!vldual Placed !n Reaptte 

1 Placement Disrupted (i.e, C!ienlllndividual transferred to new 

home/ program/placement within MENTOR NETWORK) 

l Dlsctlaf9ed from MENTOR NETWORK 

J Tempotarily or PeiTI"'Snentty Ctosed Mentor Home 

l Emergency Psychiatric Evaluation (no hospitalization) 

1 Emergency Psychiatric Hospitalization 

] Emergency Medica! Hos.pita!i:zat!on 

] ln .. school suspension 

l Sctmo! Suspenslon/Expulslon 

( ] CtientJindivldual Arrest/Detention 

[><]Death 

[ l Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004934 
368 


26354.302

) Located at the Time of the Incident Report 

) Unabfe to Locate at the Time of the Incident Report 

) Other. 

(Suspected, Alleged or confirmed) 

Ca18taker. 

( ] Mentor 

( ) Mentor Family Member 

[ 1 Staff 

[ J Other Caretaker. 

Alleged Misconduct: 

[ l Sexual Boundary/Abuse 

I ] Verbal or Emotional Abuse 

{ l Physical Assault/Abuse 

( l Corporntllnappropriate Punishment 

[ l Inappropriate Use of Restraini/Physlcallntervontlon 

[ l Neglect 

( l Inadequate Supervlslon 

[ Criminal Arrest of Caretaker 

1 l Alcnhoi/Drug Use by Caretaker 

{ ] Mlswse of Clkmtllndivtduat's Funds 

[ 1 Misappropriation/Destruction of Clienlllndlvldual Personal 

Property 

J Other: 

SUICIDAL CUENTnNDIVIDUAL: 

I ) Suicidal Threats or Verb~lizaiions 

t ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ l To Other Client 

[ J To Staff or Mentor 

[ JTo Mento~s Family Member 

! ]To Other Third Party 

PHYSICAL ASSAULTS BY CUENTIINDIVIDUAL: 

( ]To Otl1er Client 

( ]ToSiafforMen!or 

( Jro Mentor"s Family Member 

! l To Olhec Third Party 

{ Jro Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

J Se~-lnjurtous Behavior 

] Mental Health Oewcompensalion 

l Oppositional Behalliors 

] Inappropriate Sexual Comments/Threats: 

] Verbal Threats of Violence 

1 Exhibitionism/Public Masturbation 

J Medla~tlon Error 

]Missing Controlled Substances 

J Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

! 1 Illness Requlling Medical Trealman! 

[ J Deterioration in E)(lsUng Medical Condition 

( l Pregnancy 

[ 1 Seizure Requlring Emergency Treatment 

t 1 un [ ] Bowel lmpaction 

[ J Pneumonla 

[ J Pressure sores 

( l Other: 

( Physical Assauft by Third Party/Other !ndtvtduaJ in our car 

( Sexual Assault by Third :Party/Other Individual in our care 

[ Thsft tty Third Party 

! fall 

[ l Choking 

[ l Bathlng/Soaldlng Relate<! lniurtes 

[ l Other Bums 

[ J Vehicle 

[ ] Swimming/Near Drowning 

[ J Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] C~en~lndivi<!ual Exposed to Blood Borne Pathogens 

( l CllenVIndlvidual Exposed Third Party lo Blood Some 

PROPERTY DAMAGE BY 

[ ] Property Damage Under $1,000 

[ ] PropertyDamagaOver$1,000 

[ J Vehicle Theft 

[ l FimSeltlng 

[ l ThefiiShoplifling 

I l Other. 

POSSESSION 

ollenl/lndlvldua~prognun) 

MATERIALS: {Defined per 

[ l Poasessloo of Prohibited Matadals (Le., alcohol, 

lighter, weapon, pornography, illicit drugs, etc.) 

MENTOR0004935 
369 


26354.303

] Counseling/Training for Sla!IIMento< 

1 ~.fv~!llhWe"n'!llv::'Jr'vid~~r ( 1 Internal lnvea\igatton Underway 

Interventions: 

! )Ph!f!!ical 

( }Mechanical 

[ )Seclusions 

[ )Chemica! 

( Enforcement 

Oats: 

) Substanliated ( ) Unsubstantiate 

r~J 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

!><1 

Data: 

[x] Famfty 

Data:-

!xl Guardian Notlfled 

Dele: •lf!lf!l:o::::. 

) Law Ert'trcementtPfobatron Noliflsd 

Dote: 

MENTOR0004936 
370 


26354.304

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004937 
371 


26354.305

Signature of Person CompleUng Form Print Name Title Date 

cc 

Signature of Manager/Director Pr1ntName Title -

Date 

Signature Print Name Title Date 

Signature PrtntName Tltle Date 

Signature of State Olnctor (Level 3 and 4 only) PrtntName TIUe Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004938 
372 


26354.306

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004939 
373 


26354.307

(x) Behavioral Health 

{ } Juvenile Justice 

{ } Medically Complex 

( ) MR!OD 

( } MRIDD Offender 

) Acquired Brain Injury 

} Elder Care 

) Me!'llal !ftness 

) MRIMI 

) Education 

) Other. 

14. lf Acqulsltlon/Par1ner, specify company name: 

15. 

Hi. Servk:e Setling/MQ((el: {check the ONE that most closely ftts) 

( ) ICF/MR (Intermediate Care Facility) } Family/School/Home Based Supports (periodic 

( ) Group or Shared Living {3+ dientslindividuals with 24/7) services less than 24/7) 

( ) Shared or Supported living {1 or 2 c:llents/individuats with 24/7) 

( x) Mentor Hamel Hcst Home 

} Ctin!cai!Outpatient Therapy!Rehab (OT, PT, Speech) 

) Day Program 

( ) Group or Shared LMng (3+ cltentslindividuals with less than 2417) 

( ) Shal"ed or Supported Living (1 or 2 c:lientslind!viduafs with less 

} Supported EmploymenWocalional 

) School 

than 24/7) 

) Home Health Agency Services 

19. LO<::ation of Incident: (check one) 

{x) Mentor Home (x) Primary ( ) Respite 

Mentor Name: 

# of CUentslindlviduals U\l'lng in Home: 

( ) ClienUindlvldual's Residence (group home,ICF. apt) 

( ) CllenVIndlv!duel's Biological Family/Guardian Home 

( ) Day Program 

( ) SchoOl 

{ ) ClienVIndividual's Place of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

( ) Other: 

} Brokerage/Case Management (non-residential} 

20. Outcome of Incident (checlc all that apply) 

] Remain in Current Placement 

] Placement Decision Pending 

J CJienUindividual Placed in Respite 

J Placement Disrupted (Le. Cl!enL'!ndlvidua! transferred to new 

hamel program/placement within MENTOR NETWORK) 

J Discharged from MEt-ITOR NETWORK 

J Temporarily or Pennanentty Closed Mentor Home 

1 Emergency Psychiatric Evaluation (no hospitalization} 

] Emergency Psychiatric Hospitalizatlon 

] Emergency Medical Hospitalization 

] ln~school suspension 

l School Suspension/Expulsion 

J C!tenUindividual ArresVOatenlion 

{x] Death 

[ ] Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004940 
374 


26354.308

) Located at the Time of the Incident Report 

) Unable to Lot.ate at the Time of the lnc:ident Report 

) Other: 

{Suspected, Alleged or Confirmed) 

Camtalcar: 

l Mentor 

] Mentor Family Member 

] Staff 

] Other Caretaker. 

Alleged Misconduct: 

[ ] Sexual BoundaryfAbuse 

{ ] Verbal or Emotional Abuse 

{ ] Physical Assault' Abuse 

t ] Corporalflnapproprlete Punishment 

[ J Inappropriate Uso of RestraintiPhyslcallnterventlon 

[ l Naglect 

[ J Inadequate Supervision 

[ ] Criminal Arrest of CaretakQr 

[ ] Alcohol/Drug Use by Caretaker 

[ 1 Misuse- of Clientllndivldual's Funds 

{ l Misappropriation/Destn.Jction of Clientflndividual Personal 

Property 

] Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

{ ] Suicidal Threats or Verbalizations 

[ ] Suicidal Atlempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTnNDIVIDUAL: 

[ ] To Othar Client 

[ l To Staff or Mentor 

! ]To Mentor's Family Member 

[ ] To other Third Perty 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ 1 To Other Client 

[ } To Staff or Mentor 

[ ]To Mentor's family Member 

( ]ToOiherThird Party 

[ ]To Animals {animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

) Missing ControUed Substances 

] Serious Adverse Reaclittn to Medication 

MEDICAL INCIDENTS: 

[ ] ltlness Requiring Medical Treatment 

[ ] Deterioration in Existing Medica! Condition 

[ l Pregnancy 

( ] Seizure Requiring Emergency Treatment 

[ J un ( ] Sowellmpaction 

[ ] Pneumonia 

[ ] Pressure Seres 

[ J Other. 

[ ) Physical Assault by Third Party/Oiher Individual in our car 

[ ] Sexual Assault by Third Party/Other Individual in our care 

[ J Theft by Third Party 

[ J Fell 

( ] Choking 

[ ] BathirlQIScalding Related Injuries 

( } Other Bums 

[ ] Vehicle 

( l Swimming/Near Drowning 

[ 1 Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

( ] ClienUindividua! Exposed to Blood Borne Pathogens 

( ] ClienUindividua! Exposed Third Party to Blood Some 

PROPERlY DAMAGE BY CLIENT/INDIVIDUAL: 

[ ] Property Damage Under $1 ,000 

( ] Property Damage Over $1,000 

[ ] Vehide Then 

[ l Fire Setting 

[ J Theft/Shoplifting 

[ I Olher: 

POSSESSION OF PROHIBITED MATERIALS: (DeRned per 

c::litmtlfndlv1dual/program) 

[ ] Possession of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pomogmphy, I!Ucit dn.JQS, etc.) 

MENTOR0004941 
375 


26354.309

] Counseling/Training fer Staff/Mentor 

J B>:~~~~~th"@~n~1~~i~~~r ] Internal Investigation Underway 

Interventions: 

]Physical 

]Mechanical 

]Seclusions 

]Chemical 

Enforcement 

[ ] Reported to AduiUChlld Protective 

Services 

Date: 

) Substantiated ( } Unsubstantlate 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[ x] Funding Source Notified 

Date:-

[ J family Notified 

MENTOR0004942 
376 


26354.310

Print Name Title Date 

cs 

Print Name Title 

PM - PrfntName Date 

Director (Level 3 and 4 only) Print Name Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004943 
377 


26354.311

( ) Behavioral Heal111 

( ) Juvenile Justice 

( ) Medically Complex 

{x) MR/00 

{ } MRIDD Offender 

} Acquired Brain lnjuf')' 

) Elder care 

) Mental Illness 

) MRIMI 

) Education 

) Other: 

16. Service SettingiModef: {check the ONE that most closely fits) 

( ) ICF/MR (lnlenne<iiate Care FacUlty) } Family/Schoo!/Home Based Supports {periodic 

( ) Group or Shared l..Ning (3+ c!ienWindividuals with 24n) services less than 2417) 

( ) Shared or Supported Living (1 or 2 clienlslindi:viduals wiih 24/7) 

(x) Mentor Home/ Host Home 

} Clinical/Outpatient Therapy/Rehab (OT, PT, Speech) 

) Day Program 

( ) Group or Shared Uving (3+ clients/individuals with less than 24n) 

( ) Shared or Supported Uving {1 or 2 clieotslindi\llduals with less 

) Supported EmploymenWocational 

} School 

than 2417) 

) Home Heallh Agency Services 

19. Location of Incident: (check one) 

{ ) Mentor Home ( ) Primary ( ) Respite 

Mentor Name: 

I# of Clients/Individuals Living In Home: 

( ) Clientllndividual's Residence (group home, ICF, apt} 

( ) Client/Individual's Biological Family/Guardian Home 

( } Day Program 

( ) School 

{ } Cl!eni/Jndividual's Place of Employment 

( ) Vehicle 

( } Program Office 

( ) Community 

(x) 0111er. Hospital 

) Brokerage/Case Management (non-residential) 

20. Outcome of Incident: {check all that apply) 

] Remain in Current Placement 

) Placement Decision Pending 

] Cllentllndiv!dual Placed in Respne 

J Placement Disrupted (Le. Cllentlh,dividual transferred to new 

home/ program/placement wlthfn MENTOR NETWORK) 

J OischaflleO from MENTOR NETWORK 

] Temporarily or Permanently Closed Mentor Home 

] Emergency Psychiatric Evaluation {no hospitalization} 

] Emergency Psychiatric Hospitalization 

] Emergency Medical Hospltaltzalion 

l ln~school suspension 

l School Suspension/Expufsion 

] Client/Individual Arrest/Detentlor~ 

[xJ Death 

[ ] Olher: 

•"Client has been in the hospital due to vital pneumonia for 10 days .• was referred to hospital, but died prior to those 

arrangements. Cause of death listed as vital pneumonia and bacterial sepsis, 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004944 
378 


26354.312

) Located at the Time of the Incident Report 

) Unable to Locate at the Time of the. Incident Report 

) Other. 

(Suspected, Alleged or Conflrmed) 

carstalulr: 

] Manter 

1 Mentor Family Member 

1 Staff 

] Other Caretaker: 

Alleged Misconduct: 

[ ] Sexual Boundary/Abuse 

[ J Verbal or Emotional Abuse 

[ J Physical Assault/Abuse 

[ ] Corporatllnappropriate Punishment 

[ J Inappropriate Use of RFJstralnl/?hysicallntervenUon 

[ 1 Neglect 

( l Inadequate Supervision 

[ ] Criminal Arrest of Caretaker 

( ] Alcohol/Drug Usa by Caretaker 

[ ] Misuse of Client/Individual's Funds 

{ J Misappropriation/Destruction of Client/Individual Personal 

Property 

l Other: 

SUICIDAL CUENT/INDIVIDUAL: 

[ 1 Suicidal Threats or Verbalizations 

[ ] Suicidal Attempt Qr Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTnNDIVIDUAL: 

( ] To Other Client 

[ ]To Staff or Mentor 

[ ]To Mentor's Family Member 

[ ]To Other Third Party 

PHYSICAL ASSAULTS BY CUENT/INDIVIDUAL: 

[ 1 To Other Client 

[ ] To Staff or Mentor 

[ ]To Mentor's Family Member 

[ 1 To other Third Party 

[ ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

] Missing Contrnlled Substances 

J Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] lllrless Requiring Medical Treatment 

[ ] Deterioration in Existing Mcdicat Condition 

[ 1 Pregnancy 

[ ] Seizure Requiring Emergency Treatment 

[ ] l/TI 

( ] Bowellmpaclion 

( l Pneumonia 

[ ) Pressure Sores 

[ I Other. 

] Physical Assault by Third Party/other Individual in our car 

] Sexual Ass~ult by Third Party/Other Individual in our care 

J Then by Third Party 

1 Fall 

[ ] Choking 

[ I Balhmg/Scalding Related Injuries 

( 1 Other8ums 

( l Vehicle 

[ l SWimming/Near Drowning 

[ ] Other Acddenlalln]ury: 

EXPOSURE CONTROL INCIDENTS: 

[ J Client/Individual El(JJOSed to Blood Bome Pathogens 

{ l ClienU!ndividual Exposed Third Party to Blood Some 

PROPERTY DAMAGE BY CLIENTilNDIVIDUAL: 

t 1 Property Damage Under $1,000 

[ ] Properly Damage Over $1,000 

[ ] Veh.ic!e Theft 

( 1 Fire Setting 

[ ] Theii/ShopUfting 

[ ] Other. 

POSSESSION OF PROHIBITED MATERIALS: {Defined per 

cJientllndlvlduallprogram) 

[ ] Possession of Prohibited Materials (i.e,, alcohol, 

lighter, weapon, pornography, illicit drugs. etc.} 

MENTOR0004945 
379 


26354.313

] Counsellng{Trainlng for Staff/Mentor 

1 ~!'Ji,~~:~~~h~~~t%d?J~~~ 1 lntemallnvesUgation Underway 

lntervenffons: 

[ ]Physical 

[ ]Mechanical 

{ ]Seclusions 

[ ]Chemical 

[ ]law Enforcement 

[ l Reported to Adult/Child Protective 

Services 

Date: 

) Substantiated ( ) Unsubstantiate 

[ 1 Licensing Notified 

Date: 

[x] Funding Source Notified 

Dale:-

[x] Family NoUfled 

Dale:-

] Guardian Notified 

DatEt: 

] Law Enforcement/Probation Notified 

Date: 

The Mentor.-. was sitting with the client at the hospital on- This fever had rise to 104a that momlng 

and client did not appear to be functioning well. Ms.- observed labored breathing and then saw the client stop 

breathing. Ms.- called for the nurse, who stated client was deceased. Mentor staffs are providing support and 

assistance to the family regarding funeral arrangements. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004946 
380 


26354.314

Title Date 

Program Manager 

Title 

-

Date 

Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004947 
381 


26354.315

{ ) Behavioral Health 

{ } Ju.,.enile Justice 

(x} Medically Complex 

( ) MRIOD 

( ) MRIDD Offender 

) Acquired Brain Injury 

) Elder Care 

) Mental Illness 

) MR/MI 

) Education 

) Other. 

' " ' ' ' " ',,,' '',:,, ' 

14.1f Acquisition/Partner, specify company name: 

15. 

1 B. Service Setting/Model: (check the ONE that most closelyflts) 

( ) ICF/MR (Intermediate Care Facility) ) Famiiy/Schaoi/Hame Based Supports (periodic 

( ) Group or Shared Living (3+ clientsllndlviduals with 247) service5less than 2417) 

( ) Shared or Supported Uv!ng {1 or 2 clientsllndlviduats wUh 24!7) 

(x) Menlor Home/ Host Home 

) Clinical/Outpatient Therapy/Rehab (OT, PT, 

) Day Program 

( ) Group or Shared Living {3+ clients/individuals with less than 2417) 

( ) Shared or Supported Living {1 or 2 clients/individuals with less 

) Supported EmploymentNocationa! 

{ ) School 

than 24f7) 

19. Location of Incident: (check one} 

( ) Mentor Home ( ) Primary ( ) Respite 

Mentor Name: 

# of Cllents/indlvldual5 living fn Home; 

( ) Client/Individual's Residence (group home, ICF, apt) 

( ) Cllent/lndtvidual's Biological Famlty/Guardlan Home 

( ) Day Program 

( l School 

( ) ClienVIndtvldual's Pface of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

(x) Other. :.:ho:::•::JP::;il::a::_l ________ _ 

( ) Brokerage/Case Management (non~residential) 

20. Outcome of Incident (check all that apply} 

1 Remain In Current Placement 

J F'tacement Decision F'endlng 

] CllenUindlvidual F'laced in Respite 

l F'lacement Disrupted {Le. CllenUindividual transferred to new 

home! programlplacament wlth1n MENTOR NETWORK) 

] Discha'l)e<J ~om MENTOR NETWORK 

] Temporarily or F'ermanent!y Closed Mentor Home 

] Emergency F'sychiatric Evaluation {no hospitalization) 

] Emergency F'sychlatrlc Hospitalization 

] Emergency Medical Hospitalization 

1 ln~school suspension 

J School Suspension/Expulslon 

1 CllenUindivldual ArresUDetent!on 

[x] Death 

[ I Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004948 
382 


26354.316

) located at the Time of the Incident Report 

} Unable to Locate at the Tlme of the Incident Reporl 

) Other: 

{Suspected, Alleged or Confirmed} 

Caratalcer: 

[ ] Mentor 

[ ] Mentor Family Member 

[ ] Staff 

[ 1 Other Caretaker: 

Alleged Misconduct: 

[ ] Sex.uaiBoundary/Abuse 

( ] Verba! or Emotional Abuse 

[ J Physical Assault/Abuse 

( } Corporatllnappropriate Punl$hment 

( 1 Inappropriate Use of Restralni!Physlca!lntervention 

[ J Neglect 

[ ] Inadequate Supervision 

{ ] Criminal Arrest of Caretaker 

[ ] AlcoholfDrug Use by Caretaker 

[ ] Misuse of Client/Individual's Funds 

[ ] Misapproprietion/OeslrucUon of ClienUindividua! Personal 

Property 

] Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

t l Suicklal Threats or Verbalizations 

[ } Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTnNOIVIDUAL: 

[ ] To Other Client 

( ] To Staff or Mentor 

( JTo Mentor's Family Member 

[ ] To Other Thin:! Party 

PHYSICAL ASSAULTS BY CLtENTnNDivtDUAL: 

[ J To Other Client 

[ ] To Staff or Mentor 

( JTo Manter's Family Member 

( ] To Other Third Party 

[ }To Animals {animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self-Injurious Behavior 

1 Menta! Health Oe-rompensation 

J Oppositional Behaviors 

} Inappropriate Sexual CommentS/Threats 

l Verbal Threats of Violence 

1 Exhibitionism/Public Masturbation 

] Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] Illness Requiring Medical Treatment 

[x] Deterioration in Existing Medical Condition 

[ J Pregnancy 

[ ] Seizure Requiring Emergency Treatment 

[ ] UTI 

[ ] Bowel Impaction 

( ] Pneumonia 

( 1 Pressure Sores 

[ ] Other: 

] Physical Assault by Third Party/Other Individual in our car 

1 Sex.ual Assault by Third Party/Other lndi'Jidual in our care 

] Theft by Third Party 

J Fall 

[ J Choking 

[ ] Bathing/Scalding Related Injuries 

[ J O!herBums 

[ ] Vehicle 

( J SwimmingfNear Drowning 

( J Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

t l ClienUindlvidual Exposed to Blood Bome Pathogens 

( 1 Clientllndlvidua1 Exposed Third Party to Blood Bomc 

PROPERTY DAMAGE BY CLIENTnNDlVJDUAL: 

[ 1 Property Damage Under $1,000 

{ 1 Property Damage Over $1,000 

[ J Vehicle Theft 

{ ] Fire Setting 

[ J Thefi/Shoplifting 

[ J Other: 

POSSESSION OF PROHIBITED MATERIALS: (DoHnod per 

clientllndlvtdual/program) 

( ] Possession of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pornography, illicit drugs, e!c.) 

MENTOR0004949 
383 


26354.317

] Counsetling!Training for Slaft/Mentor 1 ISP/Supervlskln/Behavioral Plan DeveloPed with ClienVlndlvidual 

} lntemallnovestigalion Underway 

Interventions: 

[ !Physical 

[ }Mec:han!cal 

[ JSedusions: 

[ ]Chemical 

[ Enforcement 

( ] Reported to Adu!VChild Protective 

Services 

Date: 

) Substantiated ( ) Unsubsta11tiate 

( ] Licensing Notified 

Date: Date: 

Per mentor, •• client•s G-tube dislodged and she was instructed by clients pediatrician to take client 

to the emergency room ~ Center~ for replacement of G·tube. Upon arrival at the ER, mentor 

reports that sh.e was Informed that client's G·tube had to be replaced by th.e physician who originally inserted it. 

According to Mrs-. client's vital signs were taken and-had a fever of 103 and-oxygen saturation was 

86. ER staff gave client a surito7 for the fever. Mentor reports that she was Instructed by h.ospitat staff to 

transport client to Hospital. In transit, Mrs.-reported that client was having difficulty 

breathing and she had to stop the vehicle several times to suction ctJenL Upon arrival at-, client was 

reported to be having convulsions. Client's temperature had risen to 107.8. According tci-Mri~l, ER staff 

provided care throughout the day to lower client• a fever and assist to the DNR Order, hospital 

staff could not respond when client's heart stopped beating. the MENTOR office 

al-to that she was taking client to the ER to 

du~ng. client's coordinator, spoke 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004950 
384 


26354.318

Print Name Title Date 

Proglilffi Supervisor 

Print Name Title 

Program Manager--

Date 

3 and 4 only) Print Name Title 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004951 
385 


26354.319

(x) Behavioral Health 

( ) Juvenile Justice 

( ) Medically Complex 

( ) MR/DD 

( ) MR/DD Offender 

) Acquired Brain Injury 

) ElderCare 

) Mental Illness 

) MR/MI 

) Education 

) Other: 

16. Service Setting/Model: (check the ONE that most closely fits} 

{ ) ICFIMR (Intermediate Care Facility) ) Family/School/Home Based Supports (periodic 

{ } Group or Shared Living (3+ clientsJindividua!l:i wilh 24/7) services less than 24/7) 

( ) Shared or Supported living (1 or 2 clients/individuals with 24n} 

(x) Mentor Home/ Host Home 

) ClinicaVOutpatlenl Therapy/Rehab (OT, PT, Speech) 

) Day Program 

( ) Group or Shared Living {3+ clients/individuals with less than 2417) 

( ) Shared or Supported Living (1 or :z cllen1slindivlduals with less 

} Supported EmploymentNocatlonal 

} School 

!han 2417) 

) Home Health Agency Services 

19. Location of Incident (check one} 

{x) Mentor Home (x) Primary ( ) Respite 

Mentor Name; 

#of Cllents/lnd.lvid\lals Uvlng In Home: 

( ) ClienVlndivklual's Residence (group home, ICF, apt) 

( ) Client/Individual's Biological Family/Guardian Home 

{ ) Day Program 

( ) School 

( ) Clienf/lndividual's Place of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

( ) Other: 

} Brokerage/Case Management (non-residential) 

20. Outcome of Incident: (check all that apply} 

J Remain in Current Placement 

] Placement Decision Pending 

J Olenf/lndMdual Placed in Respite 

] Placement Disrupted (i.e. C!ienL'Individual transferred to new 

home/ program/placement within MENTOR NETWORK) 

] Discharged from MENTOR NETWORK 

J Temporarily or Pennanemly Closed Mentor Home 

1 Emergency Psychiabic Evaluation {no hospitalization} 

} Emergency Psychiatric HospitaHz.alion 

1 Emergency Medical Hospitallzalion 

1 In-school ~spension 

1 School Suspension/Expulsion 

] Client/Individual ArresUDetention 

[x] Death 

[ J Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004952 
386 


26354.320

) Located at the Time of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

[ ] Mentor 

( l Mentor Family Member 

[ l Staff 

[ J Other Caretaker: 

Alleged Misconduct: 

( ) Sexual Boundary/Abuse 

( J Verbal or Emotional Abuse 

( ] Physical AssauiVAbuse 

[ ] Corporal/Inappropriate Punishment 

[ ] Inappropriate Use of Restraint/Physical Intervention 

! 1 1-leglec! 

[ ] Inadequate Supervision 

[ ] Criminal Arrest of Caretaker 

[ ] Alcohol/Drug Use by Caretaker 

[ ] Misuse of Client/Individual's Funds 

[ ] Misappropriation/Destruction of ClienU!ndividual Personal 

Property 

] Other: 

SUICIDAL CLIENT/INDIVIDUAL: 

( ] Suicidal Threats or Verbalizations 

[ l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENT/!NDIVIDUAI.: 

[ ] To Other Client 

[ ] To Staff or Mentor 

{ ]To Mentor's Family Member 

t 1 To other Third Party 

PHYSICAL CLIENT/INDIVIDUAL: 

[ ] To Other Client 

[ 1 To Staff or Mentor 

[ ]To Mentor's Family Member 

{ }To Other Third Party 

( ]To Animals (animal Cn..Jelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

) Medication Error 

] Missing Controtled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

( 1 Illness Requiring Medical Treatment 

{ l Deterioration in Existing Medical Condition 

( ] Pregnancy 

( ] Seizure Requiring Emergency Treatment 

[ l UTI 

( ] Bowel Impaction 

[ l Pneumonia 

[ J l='ressure Sores 

[ 1 Other. 

] Physical Assault by Third Party/Other Individual in our car 

] Sexual Assault by Third Party/Other Individual in our care 

1 The~byThlnl Party 

1 Fall 

] Choking 

1 Bathing/Scalding Related Injuries 

[ ] Other Bums 

[ I Vehicle 

( ] Swimming/Near Drowning 

[ ] Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

( ] ClienVIndivldual Exposed to Blood Borne Pathogens 

[ ) Client/Individual Exposed Third Party to Blood Bome 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

{ ] Property Damage Under $1,000 

{ 1 Property Damage 011er $1,000 

[ 1 Vehicle Theft 

[ ] Fire Setting 

[ 1 Theft/Shoplifting 

[ J O!hec 

POSSESSION OF PROHIBITED MATERIALS: per 

cllentllndlvfdual/program} 

[ ] Possession of Prohibitod Materials (i.e., alcohol, 

lighter, weapon, pornography, illicit drugs, elc.) 

MENTOR0004953 
387 


26354.321

[x] Counseling/Training for Staff/Mentor 

r 1 ~:v'~~~rh~r:n~~d~r~r [ ] Internal Investigation Underway 

Interventions: 

]Physical 

)Mechanical 

Dale: 

) Substantiated ( ) Unsubslanliate 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Date: 

( J Famiy 

Date: 

(xJ Guardian Notified 

Dale:-

) Law Enforcement/Probation Notified. 

Dale: 

MENTOR0004954 
388 


26354.322

Print Name Date 

Supervisor 

Print Name TIUe 

-

Date 

Program MWlllger 

Director -

Signature of State Director (Level 3 and 4 only) Print Name Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004955 
389 


26354.323

) Acquired Brain Injury 

) Elder Care 

( ) Mental Illness 

( ) MRIMI 

( ) Educaoon 

( ) Ot~or: 

16. Service Selling/Model: (check the ONE that most closely fits) 

( ) ICF!MR (Intermediate Care Facllily) ) Family/School/Home Basad Supports (periodic 

( ) Group or Shared Living (3+ clklntsfmdlviduals with 24/7) services less than 2417) 

( ) Shared or Supported Living (1 or 2 clientsrlfldivlduals with :2417} 

(x) Mentor Home/ Host Home 

) CllnlcaVOutpatiant Therapy/Rehab (OT, Pr, Speech) 

J DayProgram 

( ) Group or Shared LMng {3+ clients/individuals with tess tttan 2417) 

( ) Shared or Supported living {1 or 2 dlentslindlvldllals witt\ less 

} Supported EmploymentNacatlonal 

J School 

than 24/7) 

) Home Health Agency Services 

19.locatlon of Incident (check one} 

( ) Mentor Home ( ) Primary ( ) Respite 

MentiK'Name; 

#of Clients/Individuals Llvlrtg In Home: 

( ) C!ienVlndividual's Residence (group horne, ICF, apt) 

( ) Client!lndivldual's Biological FamHy/Guardian Home 

( ) Day Program 

( ) School 

( ) ClienV!ndiv!dual's Place of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

(x) Other: Modical C 

} Brokerage/case Management (non .. residentJa!) 

20. Dut~ome of Incident: (check all thst apply) 

l Remain in Current Placement 

] Placement Dectsfon Pending 

] Cllentllndlvlduet Ptaced In Resptle 

] Placement Oisrupled {I.e. ClienVIndivtdual transferred to nEl'N 

home! program/placement within MENTOR NETWORK) 

J Discharged from MENTOR NETWORK 

1 Temporarily Qr PermanenUy Closed Mentor Home 

) Emergency P:»Yvh!atric EvaluaUon {no hospHaUza.Uon) 

J Emergency Psychiatric Hospltal.ization 

J Emergency Medical Hospitalization 

] !n~school suspension 

l School SuspenslonlE:KpUision 

] Client/Individual ArresVDetention 

[x] Death 

[ J Other: 

medical conditions, 

since 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004956 
390 


26354.324

) Located at the Time of the Incident Report 

) Unable to Locate at the Tlme of the Incident Report 

) Other: 

(Suspected., Alleged or Confirmed) 

Caretaker. 

[ ] Mentor 

( ] Mentor Family Member 

[ ] Staff 

[ ] Other Caretaker: 

Alleged Misconduct: 

[ 1 Sexual Boundary/Abuse 

[ 1 Verbal or Emotional Abuse 

[ ] Physical AssaulliAbuse 

[ ] CorporaUinappropriate Punishment 

[ ] Inappropriate Use of RestraintiPhysicallntervention 

[ ] Neglect 

[ ] lnadequale Supen~!sion 

[ J Criminal Arrest of Caretaker 

[ ] Alcohoi/Dn.sg Use by Caretaker 

[ ] Misuse of ClienVIndividual's Funds 

( J Misappropriation/Destruction of Clienlllndivldual Personal 

Property 

J Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

[ ] Suicidal Threats or Verbalizations 

[ ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTnNDIVIDUAL: 

[ ] To Other Client 

[ l To Staff or Mentor 

[ ]To Mentor's Family Member 

( ]To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

( ]To Staff or Mentor 

{ lfo Mentor's Family Member 

[ 1 To Other Third Party 

[ ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Opposil/onal Behaviors 

] Inappropriate Sexual Comments/Threats 

) Ver'bal Threats of Violence 

] Exhibitionism/Public Masturbation 

} Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaclion to Medication 

MEDICAL INCIDENTS: 

[x] Illness Requiring Medical Treatment 

(x] Deterioration In Existing Medical Condition 

[ 1 Pregnancy 

[ ] Seizure Requiring Emergency Treatment 

[ 1 UTI 

{ ] BowellmpacUon 

( ] Pneumonia 

[ ] Pressure Sores 

[ 1 Other: 

] Physical Assault by Third Party/Other Individual in our car 

] Sexual Assault by Third Party/Other lndivldual in our care 

] Theft by Thirll Party 

[ ] Fall 

[ 1 Choking 

[ ] Balhlng/Scalding Related Injuries 

[ J Olher Bums 

[ 1 Vehicle 

[ ] Swimming/Near Drowning 

[ ] Other Accidental injury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] C~enlllndividual E)(posed to Blood Some Pathogens 

[ ] CtienV!ndlv!dual Exposed Third Party to Blood Borne 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

{ ] Property Damage Under $1,000 

{ ] Property Damage Over $1,000 

[ ] Vehicle Theft 

( } Fire Setting 

[ 1 Theft/Shoplifting 

[ l Other. 

POSSESSION OF PROHIBITED MATERIALS; (Deflned pe' 

cllentllndivldual/program) 

( J Possession of Prohibited Materials (i.e., alcohol. 

lighter, weapon, pornography, illicit drugs, etc.) 

MENTOR0004957 
391 


26354.325

[ ] Counseling/Training for Staff/Mentor 

£ l ~~~~t:3,~n~"rt~~~~~ [ ] lntemallnvestlgalion Underway 

) Substantiated { ) Unsubstantiate 

[ ] Licensing NoHfled 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

(x] Guardian NotUied 

Date: 

] Law EnfarcemenVProbation Notified 

Date: 

MENTOR0004958 
392 


26354.326

Data 

of State Director (Level3 and 4 only) Print Name Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004959 
393 


26354.327

16. Service Setting/Model: (check the ONE that most closely Rts) 

( ) !CF/MR {Intermediate Care Facility) ) Family/School/Home Based Supports (periodic 

( ) Group or Shared Living (3+ clients/individuals w!lh 24f7) services less than 24f7) 

( ) Shared or Supported Living (1 or 2 cllantsflndividuals with 2417) 

(x) Mentor Home/ Host Home 

) Clinical/Outpatient Therapy/Rehab (OT, PT, Speech) 

) Day Program 

t ) Group or Shar-ed Living (3+ dlentslindividuals with less than 2417) 

( ) Shared or Supported living (1 or 2 clients/individuals with tess 

) Supported EmploymenWocatlonal 

) School 

than 2417) 

) Home Health Agency Services 

19. Location of Incident: (check one} 

(x) Mentor Home (x) Primary ( ) Respite 

Mentor Name: 

#of CllentsJindivlduals Living in Home: 2 

( ) Client/Individual's Residence (group home, ICF, apt) 

{ ) Cllenlflndlvldual's Biological Family/Guardian Home 

{ ) Day Program 

( ) School 

( ) Client/tndividua!'s Place of Employment 

( ) Vehicle 

( ) Program Office 

( } Community 

( ) Other. 

) Brokerage/Case Management (non~resJdential) 

20, Outcome of Incident: (check all that apply} 

] Remain in Current Placement 

] Placement Decision Pending 

J Clienll!ndMdual Placed in Respite 

] Placement Disrupted {I.e. Cl!enU!ndMdual transferred to new 

heme/ programlp!acamant withln MENTOR NETWORK) 

] Discharged From MENTOR NETWORK 

J Temporarily or Permanently Closed Mentor Home 

J Emergency Psychialrlc Evaluation (no hospitalization) 

l Emergency Psychiatric Hospitalization 

] Emergency Medical Hospitalization 

1 In-school suspension 

J School Suspension/Expulsion 

1 Cllenlllndividual ArresVDetentlon 

[x] Death 

[ l Other: 

and determining client was unresponsive. 

Client examined at Hospital ER and 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004960 
394 


26354.328

) Located at the Ttme of the Incident Report 

} Unable to Locate at lhe Time of the Incident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

[ ] Mentor 

[ J Mentor Family Member 

r 1 stan 

[ ] Other Caretaker; 

Alleged Misconduct: 

[ ] Sexual Boundary/Abuse 

[ ] Verbal or Emotional Abuse 

( l Physical AssauiVAbuse 

[ ] Corporal/!napproprlate Punishment 

[ ] Inappropriate Use of RestrainVPhyslcal Intervention 

[ J Neglect 

( } Inadequate Supervision 

[ 1 Criminal Arrest of Caretaker 

[ J Alcohol/Drug Use by Caretaker 

[ l Misuse of C~enVlndividual's Funds 

( ] M!sapproprietion/Oestruction of CllenVIndlvidual Personal 

Property 

l Olher. 

SUICIDAL CLIENT/INDIVIDUAL: 

( J Suicidal Threats or Verbalizations 

t ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

IIEHAVIOR IIY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

[ J To Staff or Mentor 

[ ]To Mentor's Family Member 

[ ]To other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ]To Olh01' Client 

( J To Staff or Mentor 

[ ]To Mentor's Family Member 

( l To Other Third Party 

[ ]To Anlmals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

J Medication Error 

] Missing Controned Substances 

1 Serious Adverso Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] Illness Requiring Medical Treatment 

(x] Deterioration In Existing Medical Condition 

[ ] Pregnancy 

[ ] Seizure Requiring Eme~ency Treatment 

[ ] UTI 

( l Bowel Impaction 

[ 1 Pneumonia 

[ ] Pressure Sores 

[x] Olher. DDA at Hospital 

] Physical Assault by Third Party/Other individual in our car 

] Sexual Assault by Third Party/Other Individual in our care 

1 Theft by Thiro Party 

1 Fall 

[ ] Choking 

t 1 Bathing/Scalding Related Injuries 

{ ) Other Bums 

[ ] Veflicle 

[ ] Swimmlng!Near Drowning 

[ ] Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] C!ienV!ndividual Exposed to Bfood Some Pathogens 

[ l ClienVIndividual ~posed Third Party to Blood Borne 

IJA,MA.GE BY CLIENT/INDIVIDUAL: 

Property Damage Under S1,000 

Property Damage Over $1,000 

Vehicle Theft 

Fire Setting 

Theft!Shoplifting 

Other: 

POSSESSION OF PROHIBITED 

cllentllndividuallprogram) 

(Defined per 

[ J Possession of Prohibited Materials (i.e,, alcohol. 

lighter, weapon, pornography, Hlicit drugs. etc.) 

MENTOR0004961 
395 


26354.329

[x] Counseling/Training for StafflMentar 

r 1 ~!'~~g:d~~~~t~h~:~~r [x] lntemallnvestigation Underway 

Interventions: 

( ]Physical 

( ]Mechanical 

[ ]Seclusions 

t ]Chemical 

[ ]Law Enforcement 

[ J Reported to Adult/Child Protective 

Services 

Date: 

) Substantiated ( } Unsubstantiate 

Licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

( x J Funding Source Notified 

Dale:-

( l Family Noiified 

Date: 

[ x] Guardian Notified 

Date:-

] Law Enforcement/Probation Notified 

Date: 

MENTOR0004962 
396 


26354.330

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004963 
397 


26354.331

Signature of Person Completing Form Print Name nue Date 

Clinical Coordinator 

Signature of Manager/Director Print Name Title 

-

Date 

Program Manager 

Signature Print Name Title 

-

Date 

Signature Print Name Title Date 

Signature of State Director (Levell and 4 only) Print Name Title Date 

State Director -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004964 
398 


26354.332

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004965 
399 


26354.333

) Ac~uirsd Brain InJury 

} Elder Care 

} Mentall!lness 

) MRIMI 

16. Service Setting/Model; (check the ONE that most closely fits) 

( ) ICFIMR (Intermediate Care Facility) } Family/School/Home Based Supports (periodic 

( ) Group or Shared Uving (3+ clients/individuals \'lith 24n) services less than 2417) 

( ) Shared or Supported Living (1 or 2 dientsllndivlduals with 24/7) 

(x) Mentor Hamel Host Home 

) Cllnlcal/Oulpatiant Theropy/Rehab (OT, PT, 

) Day Program 

{ ) Group or Shared living (3+ clients/individuals with lass than 24/7) 

( ) Shared or Supported Uvlng (1 or 2 c!ienlsllndlvlduals with less 

} Supjlorted Emp{oymenWocational 

} School 

than 2417) 

19. locaUon of Incident {check ana) 

( ) Mentor Home ( ) Primary ( ) Respita 

Mentor Name: 

#of CllentsJindlviduals living in Home: 

( ) Cllentltndividual's Residence (group home,ICF, apt) 

( ) Client/Individual's Biological Family/Guardian Home 

( } Day Program 

{ ) School 

( } ClienVJndividual's Place of Employment 

(x) Vehicle 

{ } Program Office 

( ) Community 

( ) Other. 

) Brokerage/Case Management (non-residential) 

20. Oulcome of Incident: {check all that apply) 

1 Remain in Cumtnl Placemf!11t 

l Placement Decision Pending 

} ClienUindividual Placed in Respite 

] Placement Di15rupted (i.e. ClienVIndividual transferred to new 

home/ program/placement within MENTOR NETWORK) 

l Olschat!Jed rrom MENTOR NETWORK 

J Tem!Jorarily or Permanently Closed MentOf Home 

J Emergency Psychialric Evaluation {no hospitalization) 

] Emergency Psychiatric Hospitalization 

] Emergency Medical Hospitalization 

1 ln~school suspension 

J School Suspension.IExpulsion 

J CUenU!ndividua! ArrestJDelention 

[x] Death 

[ l other: 

to the store and noticed 

1, who responded and 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004966 
400 


26354.334

} Located at the Time of the Incident Report 

} Unable to Locale at the Time of tho l11cident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

] Mentor 

] Mentor Family Member 

] Staff 

] Other Caretaker: 

Al/oged Misconduct: 

( ] Sexual Boundary/Abuse 

[ ] Verbal or Emotionat Abuse 

t } Physical AssauiUAbuse 

[ ) Corporal/Inappropriate Punishment 

[ ) Inappropriate Use of Restraint/Physical Intervention 

( ] Neglect 

( ] Inadequate SuPQrvision 

( ] Criminal Arrest of Caretaker 

[ ] Alcohol/Drug Use by Caretaker 

[ ] Misuse of ClienVIndl\lidual's Fu11ds 

[ ] Misappropriation/Destruction of ClienUindividual Personal 

Property 

] Other: 

SUICIDAL CUE NT/INDIVIDUAL: 

[ ] Suicidal Threats or VerballzaUons 

[ J Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

( J To Staff or Mentor 

[ ]To Mentor's Family Member 

( 1 To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

( ]To other Client 

( ] To Staff or Mentor 

( ]To Mentor's Family Member 

[ 1 To Other Third Party 

[ ]To Animals {animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] Illness Requiring Medical Treatment 

[ ] Deterioration in E;~:i-sting Medical Condition 

[ J Pregnancy 

( J Seizure Requiring Emergency Treatment 

[ l UTI 

[ 1 Bowellmpaction 

[ ] Pneumonia 

( ] Pressure Sores 

( l Other: 

Physical Assault by Third Party/Other Individual in our car 

Sexual Assault by Third Party/Other Individual in our care 

Thaft by Third Party 

Fall 

Choking 

Bathing/Scalding Related Injuries 

Other Bums 

Vehicle 

Swimming/Near Drowning 

Other Accldentallnjury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] Cllenl/lndlv!duel Exposed to Blood Borne Pathogen::; 

[ ] ClienVIndividual Exposed Third Party lo Blood Some 

Property Damage Under $1,000 

Property Damage Over $1,000 

Vehicle Theft 

Fire Setting 

Theft/Shoplifting 

Other: 

POSSESSION OF PROHIBITED per 

ctlentlindlviduaUprogram} 

[ ] Possession of Prohibited Materials {i.e., alcohol, 

lighter. weapon, pomography, illicit drugs, otc.) 

MENTOR0004967 
401 


26354.335

J Counseling/Training for Staff/Mentor 

1 ~J~~~=~~rh~Ji~~tf~d~~~~ l !ntemal !nvesUgat!on UnderNay 

Interventions: 

)Physical 

)Mechanical 

)Seclusions 

]Chemical 

)law Enforcement 

[xJ Reported to AdutVChlld Protective 

Services 

Date:-

} Substantiated ( ) Unsubstentlate 

[x] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[xJ Funding Source NotlfJed 

Date:-

{x] FamllyNoUfiiid 

Dote:-

[xJ Guardian Notified 

I xl ~:~n-~fo!!ro!'!e!!m~en!!!u~P~ro:t:b:::.alion Notifie<J 

Date:.,. ...... .,.._ 

MENTOR0004968 
402 


26354.336

Signature of Person Completing Form Print Name~ Title Date 

- Progrum Manager 

Signature of Manager/Director Print Name Tltte 

-

Date 

Program Director 

Signature Print Nama Title 

-

Date 

Clinical Supenisor 

Signature Print Nama Title 

-

Date 

Stare QA Manager 

Signature of State Director (Level 3 and 4 only} Print Name Tille 

-

Date 

St.ate Director -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTORDDD4969 
403 


26354.337

11. 

( ) Behavioral Health 

( ) Juvenile Justice 

(x.) Medically Complex 

( ) MRIOD 

( ) MRIDD Offender 

) Acquired Brain Injury 

) Elder Care 

) Mental Illness 

) MRIMI 

) Education 

) Other: 

14. tf Acquisition/Partner, specify company name: 

15. Program Name: 

Children's 

16. Service Setting/Model: (check the ONE that most closely fits) 

( ) !CF/MR {lntennediale Care Facility) ) Family/School/Home Based Supports {periodic 

( ) Group or Shared Living (3+ clients/individuals with 24n) services Jess than 2417) 

( ) Shared or Supported UWlg (1 or 2 cllentslindlv!duals with 2417) 

(x) Mentor Home/ Host Home 

) CllnlcaVOulpaUent Therapy/Rehab (OT, PT, Speech] 

) Day Program 

( ) Group or Shared Living (3+ clients/individuals with less than 24n) 

( ) Shared or Supported LMng (1 or 2 ~;Uonlslindividuals with less 

) Supported Emp!oymeoWocaticnal 

) School 

than 24n) 

) Home Health Agency SeNices 

19. Location of Incident (check one} 

( ) Mentor Home ( ) Primary { ) Respite 

Mentor Name: 

#of Clients/individuals Uvlng In Home: 

( ) Client/Individual's Residence (group home, !CF, apt) 

( ) Client/Individual's Biological Family/Guardian Home 

( ) Day Program 

{ ) Sr;hool 

( ) ClienV!ndividuaf$ Place of Employment 

( ) Vehh:;Je 

( ) Program Office 

( ) Communlillyil••••------ (x} Other: • 

-Client died from multiple organ failure. 

) Brokerage/Case Management (non-residential) 

20. Outcome of Incident (cheek all that apply) 

l Remain in Current Placement 

J Placement Decision Pending 

1 CUenUtndividual Placed in Respite 

] Placement Disrupted {i.e. Client/Individual transferred to new 

home/ program/placement within MENTOR NETWORK) 

] Discharged from MENTOR NETWORK 

J Temporarily or Permanently Closed Mentor Home 

} Emergency Psychiatric Evaluation (no hospitalization) 

l Emergency Psychiatric Hospitalization 

1 Emergency Medical Hospl1alizatlon 

1 !nwschool suspension 

] School Suspension/Expulsion 

[ } ClienVIndividual ArresVDatention 

[x] Death 

[ ] Dther: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004970 
404 


26354.338

) Located at the Tlme of the Incident Report 

) Unable to locate at the Time of the Incident Report 

) Other: 

{Suspected, Allaged or Confirmed) 

Carataker. 

] Mentor 

] Mentor Family Member 

l Staff 

l Other Caretaker: 

Alleged Misconduct: 

[ ] SexuaiBoundaryfAbuse 

( ] Verba! or Emotional Abuse 

[ J Physical As&auU/Abuse 

[ ] Corporal/Inappropriate Punishment 

( ] Inappropriate Use of RestrainUPhystcallnlervention 

[ ] Neglect 

[ ] Inadequate SupcNlsion 

{ ] Criminal Arrest of Caretaker 

[ ] A!cohoUOrug Use by Caretaker 

[ 1 Misuse of Clienlflndividua!'s Funds 

[ } Misappropriation/Destruction of Clientllnd\vidua! Personal 

Property 

J Other: 

SUICIDAL CLIENT/INDIVIDUAL: 

[ 1 Suiddal Threats or Verbalizations 

( 1 Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAl 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ l To Other Client 

{ ]To StaN or Mentor 

{ Tfo Mentor's Family Member 

[ J To Other Third Party 

PHYSICAL ASSAUlTS BY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

( }To StaFf or Mentor 

[ ]To Mentor's Family Member 

[ ]To Other Third Party 

[ }To Anfmals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

] Missing Controlled Substances 

l Serious Adverse Reaclion to Medication 

MEDICAL 

[ ) Illness Requiring Medical Treatment 

[ ] Deterioration in Existing Medical Condition 

[ 1 Pregnancy 

[ ] Seizure Requiring Emergency Trealment 

[ 1 UTI 

[ ] Bowel Impaction 

[ 1 Pneumonia 

[ 1 Pressure Sores 

[ l Other: 

] Physical Assault by Third Party/Other Individual in our car 

[ ] Sexual Assault by Third Party/Other Individual In our care 

( l Theft by Thkd Party 

( l Fall 

[ ] Choking 

( ) Bathtng!Scatdlng Related Injuries 

( ] Other Bums 

( 1 Vehicle 

{ l Swimming/Near Drowning 

{ ] Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ J CUenlflndividual Exposed to Blood Some Pathog-ens 

[ ] ClienVIndividual Exposed Third Party to Blood Bome 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

[ ] Property Oamo:~ge Under $1,000 

[ } PropertyOamageOvar$1,000 

[ j Vehicle Theft 

( l Fire Setting 

( ] TheftlShoplifting 

( J Other: 

POSSESSION OF PROHmiTED MATERIALS: (Deflned per 

cllenlllndfvldual/program) 

[ ] Possession of Prohibited Materials {Le., alcohol, 

lighter. weapon, pornography. i!licit drugs, elc.) 

MENTOR0004971 
405 


26354.339

[ xl CounselingfTrainl~ for Staff/Mentor 

[ 1 ~~~~~tf:'@ll'ant1~~~~ ( J lntemalln11astlgation Underway 

Interventions: 

[ 1Pi1ysical 

[ )Medtanical 

[ )Seclusions 

[ }Chemical 

( }Law Enforcement 

{ 1 Reported to AduiUChild Proleclive 

Services 

Date: 

) Subslontloled ( ) Unsubstantfale 

Licensing Noti~ed 

Date: 

t ] Funding Soun:;e Notified 

Date: 

[x] Family 

Date: 

l Guardian 

Date: 

] Law EnfcrcemenVProbatlon Notified 

Dale: 

-was taken to the Emergency Room on--due to trouble breathing. Whlloin the 

Emergency Room,.temperature spfked to 108 degrees.- was stabilized as best ae possible and admitted to 

the Pediatric Intensive Care Unit. heaHh began to decompensate over night and.was in multiple organ 

failure by the following morning. The treating phyelclan slated thai he felt- had some kind of underlying 

infection causing tile multiple organ failure; however, he could not verify this. He stated that the blood cultures were 

negative) and was too sick to do a splnal tap ... kidneys had shut down, and ho was not outputting 

any urine. Thareforet a urinalysis could not be done. health continued to decline, until the doctor felt there 

was no chance of recovery. Consent was obtained by the guardian of OCFS for a Do Not Resuscltate order1 as well 

as consent for no escalation of treatment and withdrawal of treatment. On .-the treating 

physician :spoke to botll the birth family and the foster family regarding all of the options, including continuing 

treatment and continuing to provide all treatment available; continuing to provide the treatment that.ls receiving 

at this Ume, but not eecalaUng that treatment; or withdrawing all treatment. All birth family and foster family 

-

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004972 
406 


26354.340

Signahue of Person Completing Form Print Name Title Dale 

Trainer 

SignJt-..re of Manager/Diredor Print Name Title 

-

Date 

- PM 

S1gnature Print Name Title 

-

Date 

NurSe 

Signature PrlntName Title 

-

Date 

Signature af StatE! Dlredor (Levol 3 and 4 only) Print Name Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004973 
407 


26354.341

15. 

( J Acquired Brain Injury 

( J Elder Care 

( J Mental Illness 

( l MRJMI 

( J Education 

( ) Other. 

15. Service Setting/Model: (c~eck the ONE that moat cJo .. ly fits) 

( ) ICF/MR (lntennedlate Care Facility) ) Famlty/SchooVHome Based Supports (periodic 

( J Group or Shared Living (3+ cUents/lndivlduals with 2417) services less than 24/7) 

( J Shared or SuppMed Living (1 or 2 cllenlsllndlvldualswllh 2417) 

{x) Mentor Home/ Host Home 

) CllnlcaVOutpallent T~arnpy/Rehab (OT. PT. 

) Day Program 

( ) Group or Sharad Living (3+ clients/individuals with lass than 2417} 

( ) Shared or Supported Llving {1 or 2 cllent&l'lndlvidua!s with less 

) Supported Emplo~men,UVocational 

) School 

than 24/7) 

~ HQme l'iealth Agency SeNices 

19. Location of Incident (check one} 

(x) Menlor Home (x) Primary ( ) Resplle 

Mentor Name: 

# cf Cllont.s/lndlvtduals Living In Home: 2 

( ) ClienVfndiVIdua.!'s Restdenca (group home,!CF, apt} 

( ) CllenVIndividual's Bfologlcaf Family/Guardian HQme 

( l Day Program 

( ) School 

( ) CllenVIndivlduaJ's Fllace of Employment 

( l Vehicle 

( ) Program Office 

( ) Comrnunlly 

( 1 au ... : 

) BrokeragaiCasa Management (non·residerrtiat) 

20. Outcome of lncident: (cher:lf all rhat apply) 

] Remain in Current Placement 

l l'lecQment Decision Pending 

J ClienVIndlvtdual Placed In Respite 

} Placement Disrupted (i.e. Caent/lndlv!dual transferred to new 

hemal programlplecement within MENTOR NETWORK) 

[x] DischB'IJOd from MENTOR NETWORK 

[ ] Temporality or PermanenUy Closed Mentor Home 

[ ] Emergency Psychiatric Evaluation (no ttospltalization) 

( ] Emergency Psychiatric HoSp:ilalization 

( ] Emergency Medical Hospitallzatlon 

r l ln~school oospenslon 

[ ] School Suspension/Expulsion 

[ ] Cllentllndivldual Arresl!Oetent!on 

[x] Death 

[ J Other. 

by phone at-stating that Mentor found- dead ln.hed between 

contacted ~11 and the pollee and paramedics were dispatched to the Mentor's home. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004974 
408 


26354.342

) Located at the Time of the Incident Report 

) Una~e to Locate at the Time of the Incident Report 

)other: 

(Susp~;~~;btd, Alleg~;~d or Conftrm~;~d} 

Caretaker: 

1 Mentor 

] Mentor Family Member 

J Staff 

] Other Caretaker: 

Alleged Misconduct: 

[ l Sexual Boundary/Abuse 

l J Verbal or Emotional Abuse 

( 1 Physical Assault/Abuse 

[ ] Corporal/Inappropriate Punishment 

[ 1 Inappropriate Use of RestrainllPhysicallntervenlion 

[ ] Neglect 

[ } Inadequate Superw<ision 

[ ] Criminal Arrest of Caretaker 

[ ] AlcohoVOrug Use by Caretaker 

[ ] Misuse of C!ienVIndlvldual's Funds 

[ ] Misappropriation/Destructlon of Client/Individual Personal 

Property 

] Other: 

SUICIDAL CLIENT/INDIVIDUAL: 

( ] Suicidal Threats or Verbalizations 

[ J Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT~NDIVIDUAL: 

[ ] To Other Client 

( l To Staff or Mentor 

( If o Mentor's Family Member 

[ ] To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT~NDIVIDUAL: 

[ J To Other Client 

[ l To Staff or Mentor 

[ Jfo Mentor's Family Member 

[ ]To Other Third Party 

[ rro Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Medication Error 

1 Missing Controlled SubSI.ances 

l Serious Adverse Reaction to Medi-cation 

MEDICAL INCIDENTS: 

[ 1 Illness Requiring Medical Treatment 

[ J Deterioration in Existing Medical Condition 

[ I Pregnancy 

[ ] Seizure Requiring Emergency Treatment 

[ I UTI 

( 1 Bowel Impaction 

( 1 Pneumonia 

( ] Pressure Sores 

[ I Ot!ler. 

] Physical Assault by Third Party/Other Individual in our car 

1 Sexual Assault by Third Party/Other Individual in our care 

] Theft by Third Party 

I Fell 

] Choking 

t ] Balh!ng/Scaldlng Related Injuries 

( ] OlherBums 

[ I Vellicie 

( ] Swimming/NearDro't'rnfng 

[ ] other Accidental 

EXPOSURE CONTROL INClCENTS: 

{ ] Client/Individual Exposed to Blood Borne Pathogens 

[ ] ClienVInctivldual Exposed Third Party to Blood Some 

PROPERTY DAMAGE BY CLIENT~NDI\I1DUAL: 

[ j Property Damage Under $1,000 

[ ] Property Damage Over $1,000 

( ] Vehicle Theft 

t ] Fire Setting 

[ 1 Theft/Shoplifting 

[ I Other. 

POSSESSION OF PROHIBITED MATERIALS: (Deft ned per 

cllentllndlviduallprogram) 

[ ) Possession of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pornography, inicit drugs, etc.) 

MENTOR0004975 
409 


26354.343

J Counseling/Training for Staff/Mentor 

J ~J;~~!rh~~r~~i~~~r J Intern~ Investigation Underway 

Interventions: 

[ ]Physical 

[ ]Mechanict:~l 

r 

[ 

r 

[ J RePQrted to Adult/Child Protective 

Services 

Data: 

(x] Funding Source Notified 

Date: ... !!!~11..- [ J Family NoUned 

) Substantiated Date: ( } Unsubstanllate [x] Guaroian Notified 

{ } Licensing Notified 

Date: 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004976 
410 


26354.344

Print Name Tl:tle Date: 

cc 

Name Title 

-

Date 

?M - Print Name Title Date 

Print Name: Date 

SD -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004977 
411 


26354.345

·.···:.~s·~;<,:~A~~\l]i:0\;;~~.···~~HE~and.t;Oil"'<!•111I! .. ~I'!!M'!Il'!l!'!.~~!!!J~•~'!!! ... ,fu:;c:0••0!1~~ Please PRINT Cleariy or Type In Legible Font(10-12) • DO NOT Leave Blanks. Complete All Boxes. 

' .. c .... ::.< . i~<~.><•; A :C !AI.. IA1ff{)N'.: ··· 

1. Clientflndividual's Name: 12.Level: ()1 ()2 ()3 

J. Guardian: ) Self (x) State ( ) Parenl(s) ( ) Olher. J4.Log#:-

5. 008: 15 Years 2 ~ 7. Gender: 

9, Population: ( ) 

-A.dult (16+) (x) Child 

10. Date of Admission to MENTOR NETWORK: 

11. Length of -Current Placement/Services: 

4 Years 

6. Age: 

9. Service Category: (Cheek one} 

( ) Behavioral Health 

( ) Juvenile Justice 

(x) Medically Complex 

( ) MRIDD 

( ) MRIDD Offender 

) Acquired Brain Injury 

) Elder Care 

) Menlalltii'\Sss 

) MRIMI 

) Education 

) Other: 

• S,~£mQ~J:!: >JlR.OGRAl\IINFOR!\fAlliON • 

12.State: " "'14~ti'A~q~'J;itl~;;;p~,rt~~;:'~J,;~IfY''~~·;p~nv name: 

I 15. Program Name: 

(x)4 

.. '.: ·.· ... 

16. Ser~ice Setting/Model: (check the ONE that most closely fits) 

( ) ICF/MR (Intermediate Care Facility) ) Family/School/Home Based Supports (periodic 

( ) Group or Shared LMng {3+ clients/individuals \'rllh 24/7} seNices less than 24/7} 

{ ) Shared or Supported Livlng (1 or 2 clientsfmdividua!s with 2417} 

{x) Mentor Home/ Host Home 

) C!lnicai/OutpatienlTherapyfRehab (OT, PT, Speech} 

) Day Program 

( ) Group or Shared Living (3+ clients/individuals with Jess than 24{7} 

( ) Shared or Supported Living (1 or 2 clients/individuals with less 

) Supported EmploymenUVacational 

) School 

than 2417) ) Brokerage/Case Management (non~residentiat) 

) Home Health Agency Services 

.SECTIONCi lNCIDEN!f.INFORMA'lliON :'"' 17. Date & nme of Incident: 

19. Location --of Incident: {check one} 

(x} Mentor Home (x) Primary { } Respite 

::~~~~e~~~~!dlvlduaJs LUng In Home: 

( ) ClienU!ndlvidual's Residence (group home, ICF. apt} 

( } Clfent/lndi\'ldual's Biologkal Family/Guardtan Home 

( ) Day Program 

( ) School 

( } ClienUindividual's Place of Employment 

( ) Vehide 

( ) Program Office 

( ) Community 

( ) Other: 

18. First Reported to MENTOR NETWORK: 

By: (Name & ntte) 

foster parent 

20. Outcome of Incident: (chock alf that apply) 

l Remain In Current Pracement 

] Plaeement Decision Pending 

] Client/tndlvldual Placed in Respite 

--

) Placement Disrupted {I.e. Cl!entflndivldual transferred to new 

hamal program/placement within MENTOR NETWORK) 

J Discharged from MENTOR NET"VVORK 

J Tempc~rarily or Permanently Closed Mentor Home 

) Emergency Psychiatric Evaluation (no hospitallzation) 

J Emergency Psycfl!atric Hospitalization 

J Emergency Medical Hospitalization 

] In-school suspension 

] School Suspension/Expulsion 

] ClienUindividua! Arrest/Detention 

[xj Death 

[x] Other: ER Visit 

21. Summarize In 2~3 sentences the key aspeets of the Incident for entry into Risk Management database. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004978 
412 


26354.346

} Located at the Tirne of the Incident Report 

) Unable to Locate at the Tlme of the Incident Report 

l Other. 

(Suspected, Alleged ar Confirmed} 

COfffltaker: 

{ ] Mentor 

{ } Mentor Family Member 

[ J Staff 

t ) other Caretaker: 

Alleged Misconduct: 

( ] Sex.ual Boundary/Abuse 

( ] Verbal or Emotional Abuse 

[ ) Physical AssaulVAbuse 

[ J Corporal/Inappropriate Punishment 

[ ] Inappropriate Use of Restraini/Physical Intervention 

[ J Neglect 

( ] Inadequate Supervision 

( ) Criminal Arrest of Caretaker 

[ ] Alcohol/Drug Use by Caretaker 

[ ] Misuse of Client/Individual's Funds 

{ 1 Misappropriat!onJDe-struction of Client/Individual Personal 

Property 

J Other: 

SUICIDAL CLIENT/INDIVIDUAL: 

[ l Suicidal Threats or Verbaliz-ations 

[ J Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

f 1 To Other CUent 

t ] To Staff or Mentor 

[ }fa Mentor's FamUy Member 

[ ]To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

[ ] To Staff or Mentor 

[ jro Mentor's Family Member 

[ ]To Other Third Party 

[ }fo Animals (anlrnaJ cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[x) Illness Requiring Medical Treatment 

[ ) Deterioration In ExJsting Medical Condition 

[ ] Pregnancy 

[ ] Seizure ReqUiring Emergency Treatment 

( l UTI 

( ] Bowellrnpaction 

( 1 Pneumonia 

[ } Pressure Sores 

[ ] Other: 

) Physical Assault by Third Party/Other Individual in our car 

] Sexual Assault by Third Party/Other Individual in our care 

l Theft by Third Party 

l Fall 

} Choking 

{ ] Bathing/Scalding Related Injuries 

{ ] Other Sums 

[ ] Vehicle 

[ ] Swimming/Near Drowning 

( ] Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] CllenVIndividual Exposed to Blood Some Pathogens 

( ] Cl!ent/lndividual Exposed Third Party to atood Bome 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

( ] Property Damage Under$1,000 

t 1 Property Damage Over $1,000 

( ] Vehicle Theft 

[ ] Fire Setting 

[ l Theft/Shoplifting 

[ ] Other: 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

clientlindlvlduallprogram) 

[ 1 Possession of Prohibited Materials (I.a., alcohol, 

lighter, weapon, pornography, ilticit dn.Jgs, etc.) 

MENTOR0004979 
413 


26354.347

the assigned worker-received a eall from foster.arent . Worker 

was minor was transported tO--Hospital in via ambulance. Worker was 

Informed that the mfnor had labored breathing and became limp after walking up in vomit. Worker contacted nurse 

clinician , on-call worker , on-call supervisor, and paged the program manager 

er and nurse clinician a~t-Hospital and were informed that the minor passed 

away at Worker was informed by-iti3ft~ medica1 personnel tried to resuscitate the minor for an 

hour but were unable. The worker and nurse clinician alo'!i.!::!th the foster parent were told by the nursing staff to 

go to the coroner's office. Worker spoke with Investigator- and was informed that the autopsy would be 

performed tomorrow and the cause of death should be available by noon. Worker called the Hotline. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004980 
414 


26354.348

Print Name Title 

Program Coordinntor 

Print Name Title Data 

Su~rvisor - Prlnt Narne Tltle Date 

State Director -

CONFIDENTIAL PURSUANT TO SENATE RULE 25 MENTOR0004981 
415 


26354.349

(x) Behavioral Health 

( ) Juvenile Juslke 

( ) Medically Complex 

( ) MR/DD 

( ) MR/DD Offender 

!'!Q9JMM.~Q~'!lQ~ 

{ ) Acquired Brain Injury 

{ ) Elder Care 

{ ) Mental Ulness 

( l MR!MI 

( } Education 

( l Other. 

14. If Acquisition/Partner, speclfy company name: 

15. 

16. Service Setting/Model: (check the ONE that most closely nts) 

( ) ICF/MR (Intermediate Care Facility) Family/School/Home Based Supports (periodic 

( ) Group or Shared Living (3+ clients/lndividuals with 24!7) services Jess than 2417) 

( ) Shared or Supported living (1 or 2 clientslindi'o'iduals with 24!7) 

(x) Mentor Hamel Host Home 

( ) Clinical/Outpatient Therapy/Rehab (DT, PT, Speech) 

( ) Day Program 

( ) Group or Shared Uving (3+ cUents/indMduals with less than 24/7) 

( ) Shared or Supported li"Ving (1 or 2 clients/Jndi'o'idua!s with less 

( ) Supported EmploymenVVoc:ational 

( ) School 

!han 2417) 

) Home Heaft.h Agency Services 

19. Location of Incident: (cheek one) 

{x) Mentor Home (x) Primary ( ) Respite 

Mentor Name: 

# of Clients/Individuals Livtng In Home: 

( ) Client/Individual's Rosidenco {group home, tCF, apt) 

( ) Client/Individual's Biologlcal Family/Guardian Home 

( ) Day Program 

( ) School 

( ) Cllent/lndl'o'!dua!'s Place of Employment 

( ) Vehicle 

{ ) Program Office 

{ ) Community 

( ) Other: 

( ) BrokerageJCase Management (non-residential) 

20. Outcome of Incident: (check all that apply) 

] Remain in Current Placement 

] Placement Decision Pending 

] C!ienUindlvidual Placed In Respite 

] Placement Disrupted (i.e. CUent/lndividua! transferred to new 

home/ prograrnfplacement within MENTOR NElWORK} 

l Discharged from MENTOR NETWORK 

l Temporarily or Permanently Closed Mentor Home 

] Emergency Psyc.hiatric Evaluation (no hospitalization) 

] Emergency Psychiatric Hospitalization 

] Emergency Medical Hospita~zatlon 

] ln-schoot suspension 

) School Suspension/Expulsion 

[ 1 Client/Individual ArresVDetention 

[x] Dealh 

( ] Other: 

**Client was transported t~ Hospital due to having trouble breathing and gasping for breath. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004982 
416 


26354.350

) Located at the Time of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other. 

(Suspected, Alleged or ConHrmed) 

Caretaker: 

[ 1 Mentor 

[ ] Mentor Family Member 

[ ] Staff 

[ ] Other Caretaker: 

Alleged Misconduct: 

[ 1 Sexual Boundary/Abuse 

[ 1 Vefbal or Emotional Abuse 

( 1 Physical Assault/Abuse 

[ 1 CorporaVtnappmpriate Punishment 

[ ] Inappropriate Use of Restraint/Physical Intervention 

[ l Neglect 

[ ] Inadequate Supervision 

{ ] CriminaiArrestafCaretaker 

[ ] Alcohol/Drug Use by Caretaker 

[ ] Misuse of Client/Individual's Funds 

{ ] Misappropriation/Destruction of Client/Individual Personal 

Property 

l Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

[ J Suic!dal Threats or VerbalizaUons 

( ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ J To Other Client 

[ ]ToStafforMentor 

[ ]To Mentor's Family Member 

{ ] To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

( J To Other Client 

[ JTo Staff or Mentor 

[ ]To Mentor's Family Member 

[ J To Other Thiltl Party 

[ ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Oppositional Behaviors 

] Inappropriate Sexual Comments/Threats 

1 Verbal Threats of Violence 

] Exhibit!onlsm/Public Masturbation 

] Medication Error 

) Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] Illness Raquiring Medica! Treatment 

[ ] DeleriOfation in Existing Medical Condition 

[ ] Pregnancy 

( J Seizure Requiring Emergency Treatment 

[ 1 UTI 

t J Bowel Impaction 

[ J Pneumonia 

( l Pressure Sores 

[ 1 Other. 

] Physical Assault by Third Party/Other Individual in our car 

] Sexual Assault by Third Party!Other Individual in our care 

1 Then by Thirn Party 

] Fall 

[ ] Choking 

( ] Bathiog/Scalding Related lnjurtes 

( ] OtherBums 

[ 1 Vehicle 

[ ] Swimming/Near Drowning 

( J Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

( l ClienUlndividual Exposed to Blood Bome Pathogens 

( ] ClienUindividual Exposed Third Party to Blood Some 

PROPERTY DAMAGE BY CLI!:NTIINDIVtDUAL: 

( J Property Damage Under $1,000 

[ l PropertyDamageOver$1,000 

( ] Vehicle Theft 

{ ] Fire Setting 

[ 1 TheRIShoplming 

[ ) Other: 

POSSESSION OF PROHIBITED MATERIALS: (Deft ned per 

ctf.entlfndlvlduallprogram) 

( J Possession of Prohibited Materials (I.e., alcohol, 

lighter, weapon, pornography, Illicit drugs. etc.) 

MENTOR0004983 
417 


26354.351

( 1 !ntemallnvesligation Underway 

interventions: 

]Physical 

]Mechanical 

)Seclusions 

]Chemical 

[x} 

Date: 

) Substantiated { ) Unsubslantiate 

[ ] licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Date:-

[x] Guardian Notified 

] ~~e~nforcemen&robalion Notified 

Date: 

MENTOR0004984 
418 


26354.352

had reportedly just went to sleep at reportedly picked up the 

client who had and began to clean-up and Issue a breathing treatment. Per mentor the 

client was "gasping for and making a.Ji!!:imWL.noise" therefore the mentor caUed 911whlle continuing to issue 

a breathing treatment. Per mentor at approx--she had to phone 911 approx 5 minutes prior to getting through 

to an actual switchboard operator who issued the ambulance. At approx --the ambulance arrived and began 

working on the client to stabilize-breathing. After working with the client for approx 5 minutes mentor was 

instructed to meet them at- Hospital. Per mentor she arrived at~pttal approx-while numerous 

doctors trfed to work with the client to stabilize~h. At appro~ the client was pronounced dead. On 

caiJ coordinator was caUed at -by the on call at Hospital to~ 

Mentor that tho client went Into cardiac wrtter at~iheclients passlng. This writer phoned detailed voice message regarding the 

was appeared to be very 

conversation. Per mentor the doctor Informed her that the client had too many health Issue and they were surprise 

the-( the client) made It this long. Mentor explained that she tried to do everythin she could to try and help the 

client with-breathing and was hopeful that the client would "come throu has has in the past when-had 

breathing difficulties". Mentor explained that the DCS CM supervisor was contacted by- Hospital 

and informed of the sH.uation with the client. spoke with mentor to send his apologies fir the clients 

passing. Clients biological was notified of her-passing. Mentor laft the hospital at 

approx -die to the act that was en route to say her "goodbyes" to client. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004985 
419 


26354.353

Signature of Person Completing Form Print Name 

-

Signature of Manager!Oirector Print Name 

-

Signature Print Name 

-

Signature Print Name 

Signature of State Director (Level 3 and 4 only} Print Name 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Title 

PM 

Titlo 

PM 

Title 

SD 

Title 

Title 

Date 

-

Date 

-

Date 

-

Date 

Date 

MENTOR0004986 
420 


26354.354

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004987 
421 


26354.355

......... · .. · • ;~l::~~p~~~~:~:~:;::.~=~~~~~~·:,~~:~~Qs ·~·;;a~~1• ·. i. ;' A •l"' rATION· .• ·.• •.·.•• . •· 

1. C/ientllndividua/'s Name: jz.Level: ) 1 ( )2 ( )3 

3. Guardian: ) Self (x) Stale ( ) Paren~s) ( ) Other. 14.Log#:-

S.DDB: jr. Gender: 

8. Population: ( ) 

-Adult (18+) (x) Child 

10. Data of Admission to MENTOR NETWORK: 

11. length of -

Current PlacementJServices: 

3Years 

..... 

12.State: 

... . .. · . I 13. City: 

I 

&.Age: 4 Years 

9. Service Category: (Check one) 

{x) Behavioral Health 

( ) Juvenile Justice 

{ ) Medically Complex 

( ) MRIDD 

( ) MRIDD Offender 

( 

( 

( 

( 

} Acquired Brain Injury 

) 8derCare 

} Mental illness 

) MRIMI 

( ) Education 

( ) Other. 

!R.QI:!MM'mfQ~'!!QJ~ .••• 14. If Acquisition/Partner, specify company name: 

15. Program Name: 

(x)4 

1 B. Service Setting/Model: (check the ONE that most closely fits) 

( ) ICF/MR (lntennediate Care Facility) ) Family/School/Home Based Supports (periodic 

( } Group or Shared Uving (3+ clients/Individuals with 2417} services less Ulan 2417) 

( ) Shared or Supported Living (1 or 2 clients/individuals with 2417) 

(X) Mentor Home/ Host Home 

) C~nicaVOutpatient Therapy!Rehab (OT, PT, Speech) 

) Day Program 

( } Group or Shared Living (3+ c!ients!IAdlviduals wltllless thar1 24n) 

( ) Shared or Supported living {1 or 2 i:llents/individuals with less 

) Supported EmploymenWocatlonal 

} School 

than 2417} ) Brokerage/Case Management (non--residential) 

) Home Health Agency Services 

.·.· .. SECTION Ci INCIDElNTiJNFORMATION 17. Date & Time of Incident: 

19. Location of Incident: (check one) 

{Jt) Mentor t-tome (x) Primary ( ) Respite 

#of Mentor CJ1entsnndlvl1uats Name: ~-~~""-~'iii.., Living In Home: 3 

( ) Client/Individual's Residence {group home, !CF, apt) 

( } C!ienVIndividual's Biological Family/Guardian Home 

( ) Day Program 

( ) School 

( ) C!ienVIndlvidual's Place of EmpiQyment 

( } Vehicle 

( ) Program Office 

( } Community 

( ) Other. 

16. First Reported to MENTOR NETWORK: 

By: (Name & Title) 

MENTOR 

20. Outcome of Incident: (check all that apply} 

] Remain in Currenl Placement 

] Placement Decision Pending 

] CllentJ!ndlvictual Placed ln Respite 

] Placement Disrupted (Le. CUentJind!vidual transferred to new 

home/ programtplacement within MENTOR NETWORK) 

J Discharged from MENTOR NE1WORK 

J Temporarily or Permanently Closed Mentor Home 

l Emergency Psychiatric Evaluation (no hospitalization) 

] Emergency Psychiatric Hospila!izatlon 

1 Emergency MOOica! Hospitalization 

1 ln·school suspension 

] School Suspenslon/Expulslon 

] Clientnndividual ArresVDetention 

[x] Death 

[ ] Other: 

21. Summarize in 2·3 sentences the key aspects of the Incident for entry lnto Risk Management database. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004988 
422 


26354.356

} Located at the Time of the Incident Report 

) Unable to Locate at the Time ol lhe Incident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Car&taker: 

) Mentor 

] Mentor Family Member 

J Staff 

l other Caretaker: 

Alleged MI.$COnduct: 

[ J Sexual Boundary/Abuse 

{ ] Verbal or Emotional Abuse 

[ 1 Physical Assault/Abuse 

[ ] CorporaVInapproprtate Punishment 

( ] Inappropriate Use of Restralnt!Physicallnlervenlion 

[ J Neglect 

[ ] Inadequate Supervision 

( ) Criminal Arrest of Carotall:er 

[ l Alcohol/Drug Use by Caretaker 

[ ] Misuse ofCiientllndlvlduel's Funds 

[ J Misepproprlatlon/Deslruction of CUentllndMdual Flersonal 

Property 

J Other: 

SUICIDAl CliENTnNDIVIDUAL: 

[ 1 Suicidal Threats or Varbaltzatlons 

f 1 Suicidal Attempt or Gesture 

SEXUAl. ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVlDUAL: 

[ ]To Other Client 

[ J To Staff or Mentor 

( ]To Mentor's Family Member 

[ ]To Other Third Party 

PHYSICAL ASSAUlTS BY 

[ ]To Other Client 

( J To Staff or Mentor 

£ Jfo Mentors Family Member 

! J To Other Third Party 

t ]To Anlmals (anima! cruG-Ity) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Self~lnjurlous Behavior 

] Mental Hea1th De-compensation 

] Oppositional Behaviors 

]Inappropriate Sexual Comments/Threats. 

] Verbal Threats of Violence 

l ExhibitionismfPubUc Masturbation 

] Medicatkm Error 

) Mlsslng Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

( ] Illness Requiring MecRcal Treatment 

( J DetenoraUon In Existing Medical Condition 

! ] Pregnancy 

[ l Selzu~ Requiring Emergency Treatment 

[ l UTI 

[ ] Bowellmpaellon 

[ 1 Pneumonia 

( 1 Pressure Sores 

[x1 Othar. decanulated 

r 1 

[ 1 

( l 

[ l 

( 1 

[ J 

[ J 

[ l 

[ l 

[xJ 

Physical Assault by Third Party/Other Individual In our car 

Sexual Assault by Third Party/Other Individual in our cere 

Theft by Third Party 

Fall 

Choking 

Bathing/Scalding Relatad Injuries 

other Bums 

Vehicl13 

Swimming/Near Drowning 

Other Accidental injury: client 

EXPOSURE CONTROL INCIDENTS: 

[ J CllenVIndivtduat E><posed to Blood Borne Pathogens 

[ ] CHenVIndlvidual Exposed Third Party to Blood Some 

PROPERlY DAMAGE ElY 

t l Property Damage Under$1.000 

[ 1 Prt>perty De mage Over $1,000 

[ 1 Vehicle Theft 

[ 1 Fire Salting 

[ 1 Thell/Shoplifling 

[ l Other: 

trac 

per 

cflentllndlvfdual/program} 

[ l Po .. eoelon of Prohibited Materials (I.e., alcohol, 

Ughter, weapon, pornography, illicit drugs, etc.) 

MENTOR0004989 
423 


26354.357

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004990 
424 


26354.358

Print Name 

DirofOps -

Date 

Signature of State Director (Laval3 and 4 only) Print Name Tltle 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004991 
425 


26354.359

11, Length of Current PlacementJServioos: 

10 Days 

) Acquired Brain Injury 

) Elder Care 

) Menta! Illness 

) MRIMI 

16, Service SeUingfModel: {check the ONE that most dosoly fits) 

( ) ICF/MR {ill1ermediale Care Faoi«ty) ( ) Family/Schooi!Home Based Supports (periodic 

{ ) Group or Shared living (3+ dients/indMduals with 24n} services less than 2417) 

( ) Shared or Suppot1ed Living {1 or 2 cllentsiindlvidiJato wllh 2417) 

(x) Mentor Home/ Host Home 

( ) CllnlcaVOutpatlent Therapy/Rehab {OT, PT, Speech) 

( ) DayProgram 

( ) Group or Shared LMng (3+ clients/indiViduals with lese than 2417) 

( ) Shared or Supported Living {1 or 2 dientsfindivldua!s with less 

( ) Supported Emp!oymenWocational 

( l School 

than 2417) 

) Home Health Agency Smvtc.es 

19. Location of Incident (check one) 

(x) Mentor Home (x) PrimafY ( ) Respite 

Mentor-Name: 

#of Client&Jindivlduals Living In Home: 2 

( } Clieni/lndlvldual's Re5idence (gmup home, ICF, apt) 

( ) Cllentllndlvldual's Biological FamUy/Guard!an Home 

( } Day Program 

( ) School 

( ) Client/Individual's Place of Employment 

( ) Vehicle 

( ) Program Office 

( } Community 

( ) Othec 

( ) Brokerage/Case Management {non-residential) 

20. Outcome of Incident: (cher:k all that appfy) 

] Remain In Current Placement 

] Placement Declston Pencting 

} Client'lndividual Placed in Re~pite 

1 Placement Disrupted {I.e. Client/Individual transferred to new 

home/ program/placement within MEriTOR NETWORK) 

[x] Discharged From MENTOR NElWORK 

f ] Temporarily or Permanently Closed Mentor Home 

( } Emergency Psychiatric Evaluation (no hospitalization) 

{ ] Emergency Psychiatric Hospitalization 

[x] Emergency Medica! Hospitalization 

[ ) ln~school suspension 

[ ) School Sl.J.spension/El<putslon 

( ] Client/Individual ArresVDetenllon 

(x] Death 

( ] 0111er: 

n"''"'''."''noivAin.crib after apnea monitor alarmed. Mentor and EMTS performed CPR. Child was 

'""""'"'~reo .• was admitted to the hospital where .subsequently died 18 hours later at 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004992 
426 


26354.360

) Located at the Tima of the Incident Repc~rt 

) Unabte lo Locate al the Time of the Incident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

( ] Mentor 

( l Mentor Family Member 

[ J Staff 

[ 1 Other Caretaker: 

Alle9ed M/$conduc:t: 

) Sexual Boundary/Abuse 

J Verbal or Emotional Abuse 

] Physical Assau!VAtluse 

] Corporal/Inappropriate Punishment 

] Inappropriate Use of RestrainUPhy:sicallntoTVention 

J Negloot 

] Inadequate Supervision 

] Criminal Arrest of Caretaker 

] AlcohoVDrug Use by Caretaker 

J Misuse of C!ienUindividua\'s Funds 

] Misappropriation/Destruction of ClienUlndividua! Personal 

Property 

] Other: 

SUICIDAL CLIENTftNDIVlDUAL: 

[ ] Suicidal Threats or Verbalizations 

( ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ l To O!her Client 

[ ]ToStafforMentor 

{ ]To Mentor's Family Member 

( 1 To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

( ) To Staff or Mentor 

[ ]To Mentor's Family Member 

[ J To Other Third Party 

[ ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Illness Requiring Medical Treatment 

[ x] Deterioration in Existing Medical Condition 

( ] Pregnancy 

[ } Seizure Requiring Emergency Treatment 

[ 1 UTI 

[ J Bowellmpaction 

[ l Pneumonia 

[ J Pressure Sores 

[ J other: 

Physical .A.ssault by Third Party/Other lndi'w'idual in our car 

Sexual Assault by Third Party/Other Individual in our care 

Theft by Third Party 

Fall 

Choking 

Bathing/Scalding Related Injuries 

Other Bums 

Vehicle 

Swimming/Near Drowning 

Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ 1 ClienUtndividual Exposed to Blood Bome Pathogens 

{ ] Clientllndividua! Exposed Third Party to Blood Borne 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

[ 1 Property Damage Under $1 ,000 

( l Property Damage Over $1,000 

[ ] Vehicle Theft 

[ J Fire Selllng 

[ ] Theii/Shoplifling 

[ J Other: 

POSSESSION OF PROHIBlTED MATERIALS: (Defined per 

clientJindlvlduallprogram} 

[ } Possession of Prohibited Materials {Le., alcohol, 

lighter, weapon, pornography, illicit drugs, etc.) 

MENTOR0004993 
427 


26354.361

] Counseling!Tralntng fOt Staff/Mentor 

1 ISP/Supervisicn/Behav!orat Plan Developed with CHentllndlvfdual 

] !ntemallnvestigation Underway 

fntervenlions: 

[ ]Physical 

[ }Mechanical 

[ 

[ 

[ 

( l Reported to Adult/Chijd F'rotective 

Services 

Date: 

) Substantiated { ) Unsubstanliate 

[x) Licensing Notified 

Date:-

[x] Funding Source Notified 

Date:-

[ ] Family NoUfted 

Date: 

(x) Guardian Notified 

Dale:-

[x.J Law Enfon:emeni/Probation Notified 

Date:-

Mentor reported that she immGdiately responded to tha alarm and went to side. She found-not 

breathing and non-responsive. Mentor reports she began administering CPR and called 911, she then resumed CPR. 

Mentor reports that EMTs arrived within 7-8 minutes and took over the care and then police arrived. Mentor then 

notified this writer the CC on case. Mentor and her husband were interviewed y police and then went 

to Thfs writer arrived at hospital after notifying PM, DSS worker, 055 Intake worker, D55 

supervisor and MENTOR nurse. Upon arrival this writer introduced herself to Officer- This writer was informed 

that a team was currently working o-. This writer met with the mentors and sat with them for a while. This 

writer called DSS workers to update 011- status and requested that birth mom be notlfled. This writer then 

met with the pollee who the departed. Attending physician informed this writer that-would be transferred 

to another This writer was informed that the child lost pulse and had to be resuscitated twice. From the 

initial never breathing on-own. 055 worker and birth parents arrived shortly after. This writer 

was transported PICU at -This writer, the mentors, OSS 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004994 
428 


26354.362

Signature of State Director (Level3 and 4 only} PrintNamo TIUe Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004995 
429 


26354.363

15. Program Name: 

TFC 

( ) Acquired Brain Injury 

( J Elder Care 

( ) Mentaltllness 

( ) MRIMI 

( ) Educallon 

( ) Olhar. 

16. Service Setting/Model: (check the ONE that most closely flts) 

( ) ICFIMR (Intermediate Care Facility) ) Family/SchooVHome Based Supports (periodic 

( ) Group or Shared Living (3+ clients/individuals with 24n} services less than 24!7) 

( ) Shared or Supported Living (1 or 2 cllentslindivlduals with 24!7) 

(x) Mentor Hamel Host Home 

) Clinical/Outpatient Therapy/Rehab (DT, PT, Speech) 

) Day Program 

( ) Group or Shared Living {3+ clients/Individuals with lass than 24f7) 

{ } Shared or Supported Living {1 or2 clients/individuals wilh less 

) Supported EmploymenWocationa! 

( ) School 

than 24/7) 

} Home Health Agency Services 

\9. Location of Incident: (checlc one) 

{ ) Mentor Home (:x:} Primary ( ) Respite 

Mentor Name: 

#of Cllentsltndivlduals Living In Home: 

( ) Client/Individual's Residence (group home,ICF, apt) 

( ) ClienVlndivldual's Biological F'ami!y/Guardian Home 

{ ) Day Program 

( ) School 

( ) ClfenVlndividual's Place of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

( ) Other. 

{ ) Brokerage/Case Management (non.-residential} 

20. Outcome of Incident: (check all that apply) 

1 Remain In Current ~lacem.ent 

] Placement Decision Pending 

l CUenl/lndividuel Placed In Respite 

1 Placement Disrupted (i.e. C!ientllndl..,ldua! transferred to new 

home/ program/placement within MENTOR NEn'VORK) 

] Discharged from MENTOR NETWORK 

1 Temporartly or Permanently Closed Mentor Home 

] Emergency Psychiatric Evaluation (no hospitalization) 

} Emergency Psychiatric Hospitalization 

1 Emergency Medical Hospitalization 

] ln~school suspension 

J School Suspension/Expulsion 

] ClientllndMdual ArresVDetentlon 

[x] Death 

( ] Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004996 
430 


26354.364

Hospital via ambulance. Shortly after arriving at the hospital It was repartee by hospital meclcal staff that the 

client hec died 

I. > _,•: ' · .> Atioffi8wcl~t Pilv1ieg8d arili c~nfld~ntlai:.Risk i.i'an3sJoinlritiP~r Fi~Vl8w"• :J>aae2 

CUentllndlvldual Name: Log#: 

- ..•.. t<,<' ..... \. ·.•·· ""'~SNn;•. ,;,;;-;. "". 1, .•.. ,•;• ;; •:·-····.• . DEATH (death of clientlindMduaf is a Level41nc!dent}: CLIENTIINOIVlOUAL BEHAVIORAL: 

( ) E)(pected Death of C1ienVJndivldual [ J Self~lnjurious Behavior 

(x} Unexpected Death of Client/Individual [ ] Mental HeaHh De-compensation 

CLIENT/INDIVIDUAL ELOPEMENT/AWOL: [ ] Opposl!lonal Beha'Jiors 

( ) Located at the Time of the lnck:lcnt Report [ ]Inappropriate Sexual Commenls!Threats 

( ) Unable to Locate at the Time of the Incident Report [ l Verbal Threats of Violence 

( } Other: [ ] Exhibltionism!Public Masturbation 

CARE-TAKER MISCONDUCT: MEDICATION INCIDENTS: 

(Suspected, Alleged or Confirmed} ( ] Medication Error 

Caretaker: [ ] Missing Controlled Substances 

[ ] Mentor [ ] Serious Adverse Reaction to Medication 

[ J Mentor Fami~ Member MEDICAL INCIDENTS: 

[ J Slalf [ J Ulness Requlrlng Medical Treatment 

[ J Other Care,aker: [ J Deterioration in ExisUng Medical CondiUon 

Alleged Misconduct: [ J Pregnancy 

( J Seizure Requiring Emergency Treatment [ l Sexual Boundary/Abuse [ J UTI [ 1 Verbal or Emotio~ Abuse 

[ 1 Physical AssaoliJAbuse [ l Bowel Impaction 

[ l Pneumonia [ ] Corporal/Inappropriate Punishment ( J Pressure Sores [ ] Inappropriate Use of RestrainllPhyslcallntervention [ l Other: [ ] Neglect 

[ ] Inadequate SupeNision CLIENTflNOIVIOUAL INJURY BY: 

[ l Criminal Arrest of Caretaker [ J Physical Assault by T'I'Urd Party/Other lndivid\Jal in our car 

[ 1 A!cohoiJOrug Use by Caretaker [ J Sexual Assault by Third Party/Other Individual In our care 

[ ] Misuse of Clientflndividual's Funds [ J Theft by Third Party 

[ 1 Misappropria1!on/DestrucUon of CtienVInd!viduai Petsonal [ J Fa!! 

Property [ J Choking 

[ J Other: [ J Bath!ng/ScaJding Related Injuries 

[ l Other Bums 

[ J Vehide 

[ I Swimming/Near Drowning 

( I Other Accidental Injury: 

SUICIDAL CLIENT/INDIVIDUAL: EXPOSURE CONTROL INCIDENTS: 

[ J Sujcidal Threats or Verbatizattons [ l CHenVIndividual Exposed to Blood Bome Pathogens 

[ ] Suicidal Attempt or Gesture [ 1 Clienlilndividual Exposed Third Party to Blood Borne 

Pathoaens 

SEXUAl ASSAULT OR INAPPROPRIATE SIOXUAL Pf'.OPEf'.TY DAMAGE BY CUENTflNDIVIDUAL: 

BEHAVIOR BY CLIENT/INDIVIDUAL: [ 1 Property Damago Under $1 ,000 

[ ]To Other Client [ I Property Damage Over $1,000 

[ ] To Staff or Mentor [ 1 Vehicle Thert 

[ ]To Mentor's Family Member ( 1 Fire Settlng 

[ J To Other Third Party [ I ThefUShoplifting 

[ I Other: 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: POSSESSION OF PROHIBITED MATERIALS: (Deflned per 

[ ]To Other Client client/Individual/program} 

[ l To Staff or Mentor [ l Possession of Prohibited Materials (i.e., alcohol, [ ]ra Mentor's Famlfy Member 

[ l To Other Third Party lighter, weapon, pornography. illititdrugs, etc.) 

[ ]To Mimals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004997 
431 


26354.365

J Counseling/Training for SlaH'/Mentor 

1 ~:j=~~~~~tX~~~ru~r J Internal Investigation Underway 

Interventions: 

)Physical 

]Mechanical 

]Seclusions 

JChemlcat 

]law Enforcement 

[ 1 Reported to Adult/Child Protedlve 

Services 

Date: 

) Substantiated ( ) UnsubstanUate 

{ 1 Licensing Notified 

Date: 

( x 1 Funding Source Notified 

Date:-

(xl Family Notified 

Date:-

} Guardian Nolified 

Date: 

) Law EnforcemenUProbation Notified 

Date: 

0 called to report, upon checking on client this morning at ap:~ro,xin1at•elyl··· 

in-bed grasping for air. Reportedly, after turning client over on-side to check airway 1 went 

back. -checked for a pulse, and the pulse was shallow. -1 called the emergency medical services, who 

instructed to administer CPR. The-Police Department arrived at the home and felt a shallow pulse. Mentor 

further reported that EMs arrived and put client on automatic CPR and transported client to Hospital. 

Reportedly, primary mentor1 and- drove behind the ambulance. While waiting in the waiting 

area of the hospital, the ER nurse reported to the mentors that client had died. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004998 
432 


26354.366

Print Name Title Date 

cc 

Print Name TIUe 

-

Date 

PM 

Title 

-

Date 

Signature of Stete Director (Level3 and 4 only) Print Name Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0004999 
433 


26354.367

8. Population: ( ) Adult (18+) (x) Child 

10. Date of Admission to MENTOR NETWORK: 

11. Length of -CurTent Pla~;emenVServices: 

1 Years 9 Months 

g_ Service Category: (Check ons) 

(x) Behavioral Health 

( ) Juvenile Justice 

( ) Medically Complex 

( ) MRIDD 

{ ) MRIDD Offender 

( 

( 

( 

( 

) Acquired Brain Injury 

) Elder Care 

) Mental Illness 

) MRIMI 

{ ) Education 

( ) Other: 

16. Service Setting!Model: (check the ONE tha1 most closely fits) 

{ ) ICF/MR {Intermediate Care Facility) ) Family/School/Home Based Suppor1s (periodic 

{ ) Group or Shared Living (3+ c!ientslindivldua!s with 24/7) services less than 24/7) 

{ ) Shared or Suppor1ed Uvlng (1 or2 clientsllndividuals with 24/7) 

(~) Mentor Home/ Host Homo 

) Clinica!IOutpatient Therapy/Rehab {OT, PT, Speech) 

) Day Program 

{ ) Group or Shared Living {3+ dientslindivlduals with less than 24/7} 

( } Shared or Supported Living (1 or 2 clients/individuals with less 

) Suppor1ed Emp!oymenWocational 

} School 

than 24/7) ) Brokerage/Case Management (non~resldenlial} 

) Home Health Agency Services 

SECflON.C: .. JNCJDENT INFORMA'IIION , . 

18. First Reported to MENTOR NETWORK: 

19. Location of Incident: (r;heck one) 

(x} Mentor Home (x) Primary ( ) Respite 

Mentor Name: 

#of Cllen~sNndivlduals Uvlng in Home; 

( ) ClienUlro:lividual's Residence {group home, !CF, apt) 

{ ) CllenUlndlviduel's Biological Famlly/Quardian Home 

{ ~ Day Program 

( ) School 

{ ) Client/Individual's Place of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

( ) Other: 

By: (Name & Title) 

Mentor 

20. Outcome of Incident (ch&ck all that apply) 

l Remain in Current Placement 

l Placement Decision Pending 

l Client/Individual Placed in Respite 

1 Placement Disrupted (I.e. ClientllndMdual transrerred to new 

home/ program/placement within MENTOR NETWORK} 

] Discharged from MENTOR NETWORK 

) Temporarity or Permanently Closed Mentor Home 

J Emergency Psychiatric Evaluation (nD hospitalization) 

] Emergency Psychiatric Hospitalization 

] Emergency Medical Hospitalization 

] In-school suspeflSion 

] School Suspension/Expulsion 

[ ] Clienlllndlvidual Arrest/Detention 

[l<] Death 

[ J Olher. 

21. Summarize in 2-3 sentences the key aspects of the for entry into Risk Management database. 

-On--. mentor, arrived horne at- and found her client deceased, -=aued the police 

immediately. -states that the police told her thai it appeared to be suicide. At the lime of this report, the official police 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOROOOSOOO 
434 


26354.368

Attomevtellont Prlvlloa8d alld Confidential: Risk MOn_...ent/Paor,R&vitlw cC y Y CPaae2 

Client/Individual Name: Loa#: 

cc' c ...;,_ 

"' ; <::>.~Sol. AU ~).1 it'nlliv' •• cc • cc c 

DEATH (death of client/individual is a Level4 incident): CLIENTnNDIVlDUAL BEHAVIORAL: 

( ) Expected Death of ClienVIndlvidual [ ] Setf.Jnjurfous Behavior 

(x) Unexpected Deafll of Cllentllndividual [ 1 Mental Health De-compensation 

CLIENTIINDIVlDUAL ELOPEMENT/AWOL: [ ] Oppositional Behaviors 

( ) located at the Time of the Incident Report ( J Inappropriate Sexual Comments/Threats 

( ) Unable to Locate at the Time of the Incident Report [ l Verba! Threats of Violence 

( ) other. t ] Exhibitionism/Public Masturbation 

CARE-TAKER MISCONDUCT: MEDICAllDN INCIDENTS: 

(Suspected, Alleged or Connrmed) [ 1 MedlcaUon Error 

Caretaker: [ } Missing ControiJed Substances 

[ } Mentor [ ] Serious Adverse Reaction to Medication 

[ ] Mentor Family Member MEDICAL INCIDENTS: 

[ J Staff [ J Illness Requiring Medical Treatment 

[ ] Other Carelaker: [ J Deterioration in Existing Medical Condition 

Alleged M/seondur:t: [ J Pregnancy 

( l Sexual Boundary/Abuse [ J Seizure Requiring Emergency Treatment 

I J UTI [ ] Verbal or Emotional Abuse [ 1 Bowel Impaction [ ] Physical AssauutAbuse 

[ 1 CorporaVInapproprtate Punlshment [ J Pneumonia 

[ ] Inappropriate Use of RestralntlPhyslcallnterventlon [ J Pressure Sores 

[ 1 Ne~eot [ J other: 

l ] Inadequate Supervision CLIENTnNDMDUAL INJURY BY: 

[ ] Criminal Arrest of Carelaker [ J Physical Assault by Third Party/Other Individual in our car 

[ ] Alcohol/Drug Use by Caretaker [I Sexual Assault by Third Party/Other Individual in our care 

[ ] Misuse of C!!enttlndl._.idual's Funds [ J Theft by Third Party 

[ J Misappropriation/Destruction of CIJentl!ndivldual Personal [ J Fall 

Property ! I Choking 

[ l Other: [ 1 Bathing/Scalding Related Injuries 

[ J Other Bums 

[ J VehiclA 

! I Swimming!Near Drovming 

I I Other Accidental Injury: 

SUICIDAL CLIENT/INDIVIDUAL: EXPOSURE CONTROL INCIDENTS: 

[ ] Suicidal Threats or Verbalizations [ l Client/Individual Exposed to Blood Some P~hogens 

[ ] Suicidal Attempt or Gesture [ J Client/Individual Exposed Third Party to Blood Borne 

Pathogens 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

BEHAVIOR BY CLIENT/INDIVIDUAL: [ J Property Damage under $1,000 

[ ] To Other aient [ J Property Damage Over $1,000 

( ] To Staff or Mentor [ J Vehicle Theft 

( ]fo Mentor's Family Member [ J Fire Setting 

[ l To other Third Party [ J Theft/Shoplifting 

[ J Other: 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: POSSESSION OF PROHIBITED MATERIALS: {Deflned per 

[ 1 To Other Client cllentllndMdua1Jprogram} 

[ l To Staff 01' Mentor [ l Possession of Prohibited Matsrials (i.e., alcohol, [ ]To Mentor's Family Member 

( J To Other Third Party lighter, weapon, pornography, ilficit drugs, etc.) 

[ Jfo Animals (animal crualty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005001 
435 


26354.369

( x] Counseling/Training for Stafi!Mentor 

r 1 ~~~g:t~~:ntl!,odrr~r:r [ l Internal Investigation Undorway 

interventions: 

[ 

[ 

[ 

[ 

[ J Reported to AdtJit/Chlld Protective 

SeNice.s 

Date: 

) Substantiated ( ) Unsubstantlala 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005002 
436 


26354.370

Print Name Title Date 

Coord. 

PrlntNarrwt Title 

-

Date 

PM 

Print Name Title 

-

Date 

Sfgnature Print Name Title 

-

Date 

- QA 

Signature of State Director (Level 3 and 4 only) Print Name ntle 

-

Date 

Stnte Dir. -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005003 
437 


26354.371

10. Date of Admission to MENTOR NETWORK: 

11. Length of -Current PlacemenLIServices: 

3 Years 7 Months 

12. 

( ) Behavioral Health 

( } Juvenile Jusllce 

(x) Medically Complex 

! ) MRIDD 

! l MRIDD Offender 

} Acquired Brain Injury 

} Elder Care 

} Mental !Uness 

l MR!MI 

) Education 

) Other: 

16. Service Setting/Model: (check the ONE that most closely fits) 

{ ) !CF/MR (Intermediate Care FacHity) ) Family/School/Home Based Supports (pertodic 

( ) Group or Shared Living (3+ c!ient.slind!viduals with 2417} services less !han 24/7) 

( } Shared or Supported Living {1 or 2 clients/illdividuals wj:th 24/7) 

(x} Mentor HomeJ Host Home 

) ClinicaVOutpatient Therapy/Rehab (OT, PT, 

) Day Program 

( } Group or Shared Living (3+ clients/individuals with less than 2417) 

( ) Shared or Supported Living {1 or 2 clients/individuals with less 

) Supported EmploymenWocational 

) School 

than 24fl) 

) Home Heatth Agency SerJices 

17. Date 

19. Location of lnddent: {check one) 

( } Mentor Home { } Primary ( ) Respite 

Mentol'" Name: 

#of Cllentsnndlvlduals Livtog In Home: 

( ) ClienUindiv!dual's Residence {group home, !CF, apt) 

( ) ClienUindiv!duars Biological Family/Guardian Home 

( ) Day Program 

( ) School 

( ) Clientllndivldual's Place of Employment 

( ) Vehicle 

( } Program Office 

( } Community 

(x) Other. ::H::.o•::JPc:it=a::.l ________ _ 

} Bro~erage/Case Management (non-residential) 

20. Outcome of Incident: (check all that apply} 

l Remain In Current Placement 

J Placement Decision Pending 

J Clientflnd!vidual Placed in Respite 

J Placement Disrupted (i.e, ClieoUindivldual transferred to new 

home/ program/placement within MENTOR NETWORK) 

l Discharged from MENTOR NETWORK 

) Temporarily or Permanently Closed Mentor Home 

1 Emergency Psychiatric Evaluation (no hospitalization) 

] Emergency Psychiatric HospitalizaUon 

] Emergency Medica! Hospitalization 

] In-school suspension 

l School Suspension/Expulsion 

1 Client'lndlvidua! Arrest!Detention 

[x] Death 

[ l Otller: 

"'"Client died in the hospital as a result of RSV and pneumonia. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOROOOS004 
438 


26354.372

) Located at the Time of lhe Incident Report 

} Unable to Locate at the Time of tile Incident Report 

) Other: 

(Suspected, Alleged or Connrmed) 

Caretaker: 

] Mentor 

] Mentor Family Member 

] Staff 

1 Other Caretaker. 

Alleged Misconduct: 

[ J Sexual Boundary/Abuse 

[ ] Verbal or Emotional Abuse 

[ ] Physical Assault/Abuse 

[ l Corporalflnappropr1ate Punishment 

[ 1 Inappropriate Use of Restraint/Physlcallnlet\lention 

! J Neglect 

[ ] Inadequate Supervi$ion 

[ ] Criminal Arrest of Caretaker 

[ ] AlcohoVOrug Use by Caretaker 

[ ] Misuse of Cllenlllndividual's Funds 

[ l Misappropriation/Destruction of Cllentllndividua! Personal 

Property 

] Other: 

SUICIDAL CUENTnNDIVIDUAL; 

[ 1 Suicidal Threats or Verbalizations 

( 1 Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

( ] To Other Client 

[ ] To Staff or Mentor 

[ Jro Mentor's Family Member 

[ l To Other Third Party 

BY CLIENT/INDIVIDUAL: 

] To Other Client 

J To Staff or Mentor 

]To Mentor's Family Member 

]To Other Third Party 

lfo Anlmals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

( ] Illness Requiring Medical Treatment 

[ ] Deterioration in Existing Medical Condition 

[ 1 Pregnancy 

( J Seizure Requiring Emergency Treatment 

[ ] UTI 

[ ] Bowel Impaction 

[ ] Pneumonia 

[ ] Pressure Sores 

[ J Other. 

( ] Physical Assault by Thin:l Party/Other Individual in our car 

( ] SoJrual Assault by Third Party!Other Individual in our care 

[ l Theft by Third Party 

( l Fall 

[ 1 Choking 

{ 1 Bathing/Scalding Related Injuries 

I } Other Bums 

( ] Vehicle 

( ] Swimming/Near Drowning 

[ ] Othor Accidental injury: 

EXPOSURE CONTROL INCIDENTS: 

t l C!ientl!ndividual Exposed to Blood Some Pathogens 

( ] CllenV!ndividuat Exposed Third Party to Blood Bome 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

[ 1 Property Damage Under $1,000 

( ] Property Damage Over $1,000 

( ] Vehicle Theft 

( ] Fire SeWng 

[ 1 TheftJShoplifting 

! l Other: 

POSSESSION OF PROHlBITED MATERIALS: (Defined per 

client/Individual/program) 

[ ] Possession of Prohibited Materials {i.e., alcohol, 

lighter, 'Neapon, pornography, illicit drugs, etc.~ 

MENTOR0005005 
439 


26354.373

l lntemallnvestigalion Underway 

lnlerventlons: 

[ ]Physical 

[ ]Mechanical 

[ 

[ 

) Substanliated { ) Unsubstantiate {x] ~~~~ian Nolified 

J ~=~n·,/o~rc~e~me!!!!JlnUP!!!,ro"b"'a'tion Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005006 
440 


26354.374

Signature of Person CompleUng Form Print Name Title Date 

Clinical Super, 

Signature of Manager/Director Print Name ntte 

-

Data 

PM 

Signature Print Name ntte -

Date 

Signature Print Name TIUe Date 

Signature of State Director (Level 3 and 4 only} Print Name TIUe Date 

so -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005007 
441 


26354.375

(X} Behavioral Health 

( ) Juvenile JusUce 

( ) Medically Complex 

t ) MR/DD 

( } MR/DD Offender 

. flmQ~!I~WQlli'f~TI.Q~ 

) Acquired Brain Injury 

) Elder Care 

) Mental11!ness 

) MRIMI 

) Education 

) Other: 

14. tf Acquisition/Partner, specify company name: 

15. 

16. Service Setting/Model: (check the ONE that most closely Hts) 

( ) ICF/MR {Intermediate Care Facility) ) Family/SchooVHome Based Suppor1s (periodic 

( ) Group or Shared Living {3+ clients/individuals with 24f7) services less than 24n) 

( ) Shared or Supported Living (1 or 2 clients/individuals with 2417) 

(x) Mentor Home/ Host Home 

) Clinlcai/DolpotlentTherapy/Rehab (OT. PT. Speech} 

} Day Program 

( ) Group or Shared living (3+ clienlsJindividuals with less tha0 2417} 

( ) Shared or Supported Living (1 or 2 clients/individuals with les-s 

) Supported EmploymenWocational 

) School 

than 2417) 

) Home Health Agency Services 

19. Location of Incident: (check one) 

(x) Mentor Home (x) Primary ( ) Respi1e 

;:~~~~::.=1~\fivlduals Uvlng 2 hama: ( } C!ienL'Individual's Residence (group home.ICF, apt) 

( ) Client/Individual's Biological Family/Guardian Homo 

( ) Day Program 

( ) School 

( ) Client/Individual's Plate of Employment 

( } Vehicle 

( ) Program Office 

( ) Community 

( ) Other; 

) Brokerage/Case Management (non~res!dential) 

20. Outcome of Incident (check all that apply} 

] Remain in Current Placement 

} Placement Decision Pending 

1 Clientllndividual Placed in Respite 

l Placement Disrupted {i.e. Cllentltndividuallransferred to new 

home/ prograrnlplacement within MENTOR NETWORK} 

] Discharged from MENTOR NETWORK 

J Temporarily or Permanently Closed Mentor Home 

J Emergency Psychiatric Evaluation (no hospitalization} 

l Emergency Psychiatric Hospl!a!ization 

] Emergency Madlcal Hospftalizalion 

J In-school suspension 

] SChool SuspensionJExpulsion 

] C!ienL'Individual Arrest!Delantion 

[x] Death 

[ J other; 

"When the mentor's adult daughter.- brought a bottle to client, -was not breathing. -called the mentor 

to call g11 and began CPR. Paramedics revived client, but-died at Hospital shortly after arrival. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005008 
442 


26354.376

} Located at the Time of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Caretaker. 

J Mentor 

J Mentor Family Member 

] Staff 

l Other Careta~er: 

A/Jeged Misconduct; 

( l Sexual Boundary/Abuse 

[ J Verbal or Emotional Abuse 

[ 1 Physical Assault/Abuse 

{ 1 Corporal/Inappropriate Punishment 

I 1 Inappropriate Use of RestralniJPhysicat Intervention 

[ 1 Neglect 

[ ] Inadequate Supervision 

( 1 Criminal Arrest of Caretaker 

[ ] Alcohol/Drug Use by caretaker 

( l Misuse of Client/Individual's Funds 

[ } Misappropriation/Destruction of Cllantilndivldual Personal 

Property 

l Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

[ J Suicidal Threats or Verbalizations 

( ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

{ ]To Other Client 

[ 1 To Staff or Mentor 

( )To Mentor's Family Member 

[ ]To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

r ] To Other Client 

( l To Staff or Mentor 

{ ]To Mentor's Family Member 

[ ] To Other Third Party 

[ ]To Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self-Injurious Behavior 

J Mental Health O~Mompensation 

] Oppositional Behaviors 

J Inappropriate Sexual CommentS/Threats 

J Verbal Threats of Violence 

) Exhibitionism/Public Masturbation 

] Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

{ J Illness Requiring Medical Treatment 

( ] Deterioration in Existing Medical Condition 

( J Pregnancy 

[ ] Sei.zure Requirfng Emergency Treatment 

[ 1 UTI 

[ ] Bowellmpaction 

t J Pneumonia 

( ] Pressure Sores 

[ 1 Othor. 

) Physical Assault by Third Parl)I/Other lndlv!dualln our car 

l Sexual Assault by Third Party/Other Individual in our care 

1 Theft by Third Party 

1 Fall 

] Choking 

{ ] Bathing/Scalding Related tnjurtes 

t } other Bums 

( 1 Vehlde 

( ] Swimming/Near Drowning 

{ ] Other Ae:c!dental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] CUenV!ndlvidua! Exposed to Blood Bome Pathogens 

[ 1 ClienVIndividual Exposed Third Party to Blood Some 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

[ ] Property Damage Under$1,000 

( ) PrapertyDamageOver$.1,000 

[ l Vehicle Theft 

( 1 Fire Setting 

[ ] TheFt/Shoplifting 

[ 1 Other: 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

cllenUindivlduaJ/program) 

{ 1 Possession of Prohibited Materials (Le., alcohol, 

lighter, weapon, pornography, illlcit drugs, elc.) 

MENTOR0005009 
443 


26354.377

] CounsalingfTraining for StafUMentor 

J g;~~~~~~~~"@lr:,~aJi~~j~r J !ntemallnvestigaUon Underway 

( 1 Reported to Adu!VChild Protective 

Services 

Date: 

) Substantiated ( ) Unsubstanl.iate 

( J Licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Funding Source Notified 

Date: 

1 Family NoUfled 

Date: 

] Guardian Notified 

Data: 

J Law EnforcemenVProbation Notified 

Date: 

MENTOR000501 0 
444 


26354.378

Signature of Person Completing Form Print Name Title Date 

Signature of Managor/Director Print Name Title Date 

Signature Print Name Title Date 

Signature Print Name Title Date 

Signature of State Director (Level 3 and 4 only) Print Nama Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005011 
445 


26354.379

12. State: 

• -

) Acqul/00 Brain Injury 

) Elder Care 

) Mental illness 

) MRIMI 

16. Service Setting,..,.,odsl: (check the ONE that most closely fits) 

{ l ICFIMR (Intermediate Care Facility) ) Famlly/Schooi!Home Basad Supports (periodic 

( ) Group or Shared Living (3+ cllentslihdlvlduals With 24f7} services less than 2417) 

( ) Share-d or Supported Uving (1 or 2 clients/Individuals with 2417) 

(x) Mentor Home/ Host Home 

) CllnlcaVOutpatlent Therapy/Rehab (OT, PT, Speech) 

) OoyProgram 

1 ) Group or Shared Living (3+ cients/indivlduals with less than 2417) 

( l Shared or Supportad Uvlng (1 or 2 e!lentsiindividuals with less 

) Supported EmploymonWocatlonal 

) Scnool 

than 2417) 

} Home Health Agency Services 

19. Locat!on of Incident: {check one) 

{ ) Montor Home ( ) Primary ( ) Respite 

Mentor Name: 

#of Cllant:sllndlvlduals Living fn Home: 

{ l C!ient!lndiv!di.Jol's Residence {group home. !CF1 apt) 

( ) Cl!IJntl!ndJvidual's Biological Farnily!GuBidian Home 

{ ) Day Program 

( ) School 

( ) Ctientf!ndMrluaf's Place of Employment 

( ) Vehicle 

( } Program Office 

(x) Communily 

( ) Other: 

) Brokerage/Case Mar1agement (non .. resldential) 

20. Outcama of Incident (check all that apply) 

} Remain in Current Placement 

J Placement Oec:is!on Pending 

J C!tenl/l11.dh.'ldual Placed in Respite 

) Placement Disrupted (I.e. CUontltndlvldual transferred to new 

home/ program/placement within MENTOR NETVIORK) 

l Discharged from MENTOR NETV!IORK 

) Temporarily or Permanently Closed Mentor Home 

} Emergency Psychiatric Evaluation (no hospitalization) 

l Emergency Psychiatrlt:;: HospllalizaUon 

l Emergency Medical HospitallzaUon 

] ln¥schoo1 suspension 

) School Suspension/Expulsion 

1 Clfentl!ndividual Arrest/Detention 

[x] Death 

[ J Other: 

.. Client had a seilure while on vacation v.ilh foster parents.- diad at the hospital. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005012 
446 


26354.380

} Located at the Time of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

CaretaJ(er: 

[ J Mentor 

[ ] Mentor Family Member 

[ 1 Staff 

( ] Other Caretaker: 

Afleged Misconduct: 

[ 1 Sexual Boundary/Abuse 

t l Verbal or Emotional Abuse 

( 1 Physical Assault/Abuse 

( ] Corporal/Inappropriate Punishment 

( ] Inappropriate Use of Reslraint/Physicallnlervenlion 

[ ] Neglect 

( 1 Inadequate Supervision 

[ ] Criminal Arrest of Caretaker 

[ J AlcoooVDrug Use by Can>taker 

[ } Misuse of ClienUindividual's Funds 

[ 1 Misappropriation/Destruction of Clienttlndivldual Personal 

Property 

] Other: 

SUICIDAl CliENT/INDIVIDUAl: 

( ] Suicidal Threats or Verbalizations 

[ ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR tNAPPROf'RIATE SEXUAL 

BEHAVIOR BY CliENT/INDIVIDUAL: 

[ ) To Other Client 

( ] To Staff or Mentor 

[ }fo Mentor's Family Member 

{ 1 To Other Third Party 

PtiYSICAL ASSAULTS BY CliENT/INDIVIDUAL: 

[ ] To Other Client 

{ J To Staff or Mentor 

{ }fo Mentor's Family Member 

t ] To Other Third Party 

[ }fa Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAl INCIDENTS: 

[ J Illness Requiring Medical Treatment 

( 1 Deterioration in Existing Medical Condition 

( ) Pregnancy 

[.X] Seizure Requiring Emergency Treatment 

[x] UTI 

( J Bowel Impaction 

[ ] Pneumonia 

( ] Pressure Sores 

[ 1 Other. 

] Physical Assault by Third Party/Other Individual in our car 

) Sexual Assault by Third Party/Other Individual In our care 

l Theft by Third Party 

] fall 

{ l Choking 

( ] Bathing/Scalding Related Injuries 

( ] OtherBums 

[ ] Vehicle 

t J SwlmmingJNear Drowning 

[ ] Other Accidental 

EXPOSURE CONTROL INCIDENTS: 

[ ] Client/IMMdual Exposed to Blood Borne Pathogens 

t 1 ClienUindividual Exposed Third Party lo Blood Some 

DAMAGE BY CLIENTnNDIVJDUAl: 

Property Damage Under $1,000 

Property Damage Over S1 ,000 

Vehicle Theft 

Fire Setting 

Theft/Shoplifting 

Other: 

POSSESSION OF PROHIBITED MATERIALS: (Defined I"" 

c::ll-entllndlvldual/program) 

{ ] Possession of Prohibited Materials (i.e .. alcohol, 

lighter, weapon. pornography, illicit drugs, etc.) 

MENTOR000501 3 
447 


26354.381

] Counseling/Training for Staff/Mentor 

1 ISP/Suparvislon/Behavioral Plan Developed with CllenUlndlvidoal 

] lntemaJ lnvesligation UndeF'Nay 

Interventions: 

[ ]Physical 

( ]Mechanical 

( )Seclusions 

[ ]Chemica! 

[ ]law Enforcement 

l l 

) Substantiated ( ) Unsubstantiate 

-had experienced an increase In the amount and intensity of-seizures over the past several months, 

according to the medical staff at the School.- medical condition had been followed through 

~hysiclan at tho school and~edicatlons had boon adjusted accordingly. In addition to-dally regimen of 

medications,- had received two pm medications while in the school. The first is a Uquld Valium administered 

to be ~begins twitching. The second was a rectal syringe of medication to be administered if oral 

medication. The foster parent was to do seizures which included 

removing any surrounding objects and placing a pillow undeAead. 

-also had Diabetes.~ was managed The foster parents administered a blood sugar test 

twice a day and documentod-.lood sugar levels. They were directed to a~er.diet and aetiv.!!x_level, 

depending on the results of-blood sugar level. The foster parents were diligent in monitoring-diet, adhering 

to a strict time schedule for eating, as well as the kinds of foods-ate to keep-blood sugar down. There had 

been no s1 niflcant issues with blood su ar that da . 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005014 
448 


26354.382

-was on vacation with Mentor family, traveling noticed~was 

making some unusuaf sounds that often preceded a seizure. The foster parent car over Into the. Watne 

House while he monitored- In tho event-was going into a grand mal seizure. The foster parent said that 

-lips turned an ashen color, which he has never observed a seizure, so he called 911. While the 

ambulance was en route, they instructed the foster was not did 

(there was no The am~b~~u~:~·~:n;;c~~·~~~il~i;~~;!J!!~,~J~! 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005015 
449 


26354.383

Signature of Person Completing Form Print Name Title Date 

C'inical Coordinator 

Signature of ManageriOirector Print Name Title 

-

Date 

,LCSW~ Program Manllger 

Signature Print Name Title -

Date 

Signature Print Name Title Data 

Signature of State Director {level 3 and 4 only) Print Name ntle Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005016 
450 


26354.384

} Acquired Brain Injury 

) Elder Care 

) Mental Illness 

l MRIMI 

16. Servl~a Sehlng/Model: {check the ONE that most closely fits) 

( ) !CF/MR (llll.ermediate Care Facility) ) Family/School/Home Based Supports (periodic 

( ) Group or Shared Living (3+ clients/individuals with 2417} services less than 24f7) 

( ) Shared or Supported Uving (1 or 2 clients/individuals with 24/7} 

(x) Mentor Home/ Host Horne 

) CllnioaUOutpallent Therapy/Reha~ (OT, PT, Speech) 

) Day Program 

( ) Group or Shared Living (3+ clientslindividu;]!S with less than 24f7) 

( ) Shared or Supported Living {1 or 2 dientsfindlviduals With tess 

) Supported Emp!oymenUVocationa! 

( ) School 

than 24/7) 

) Home Health Agency Se!"Vlces 

19. Location of Incident: (check ono} 

( ) Mentor Home ( ) Primary ( ) Respite 

Mentor Name: 

#of Clients/Individuals Living In Home: 

( ) ClienVIndividual's Residence (group home,ICF, apt) 

( ) Client/Individual's Biological Family/Guardian Home 

{ ) Dey Program 

( ) School 

( } Cllenlllndividua!'s Place of Employment 

{ ) Vehicle 

{ ) Program Office 

( ) Communlit·y····L _____ _ {x) Other: 

( ) Brokerage/Case Management {norrresidenlia!) 

20. Outcomo of Incident: (r;hec:k ;~II that apply) 

} Remain in Current Peacement 

1 Placement Decision Pending 

l Client/Individual Placed in Respile 

1 Placement Disrupted (i.e. Client/Individual transferred to new 

home./ program/placement within MENTOR NET\NORK) 

1 Discharged from MENTOR NETWORK 

] Temporarily orPermanenUy Closed Mentor Home 

] Emergency Psychiatric Evaluation (no hospitalization} 

] Emergency Psychiatric Hospilallzalion 

] Emergency Medical Hospitalization 

] In-school suspension 

] School Suspension/Expulsion 

J ClionVIndividual ArresVOetention 

[x] Death 

[ J Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005017 
451 


26354.385

} Lo!::3ted at the Time of the Incident Report 

} Unable to Locate at the Time of the Incident Report 

) Other: 

{Suspected. Alleged or Confirmed) 

Caretaker: 

) Mentor 

] Mentor Family Member 

] Staff 

J other Caretaker. 

Alleged Ml$t::onduct: 

t ] SGX\.10-I acundaryJAbus.a 

t l Verbal or Emoti<:>na! Abuse 

t J Physical Ass.au!tiAbuse 

[ 1 Corpon'll/lnapproprlate Punishment 

[ l Inappropriate Use of Restralnt!Physit:a11ntervention 

[ ) Noglec:t 

t ) tnadequale SupervisJon 

[ J Criminal Arre.st of Caretaker 

[ J AlcohotiDrug u .. by Caretaker 

[ ) Misuse of CHenVIndividuat's Funds 

[ ) Mlsapproprlat!onfOestrucUon of C!lsnUindJvkluat Perso~1 

Property 

) Other: 

SUICIDAL CLIENT/INDIVIDUAL: 

{ 1 Suicidal Threats or Verbalizations 

{ ) Suicidal Attempt or Gesture 

SEXUI\L 1\SSAULT OR INAPPROPRII\TE SEXUAL 

BEHAVIOR BY CUENTIINOIVIOUAL: 

[ } To Other Client 

( J To Slaff or Mentor 

[ jTo Mentor's Family Member 

{ ]To Other Third Party 

ASSAULTS BY CLIENTJINOIVIOUAL: 

l To Oth-er Client 

] To Staff or Montor 

]f o Mentor's Family Membe-r 

l To Other Third Party 

)To Animals (animat cruelty~ 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self-Injurious Behavior 

] Merttal Health De~compeMation 

] Oppositional Behaviors 

J !oa:ppropriate Sexual CommeotS/Threats 

J Verbal Thrusts of Violence 

l Exhibitionism/Public Masturbation 

] Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

] Illness Requiring Medlcal Treatment 

] Deterioration in Existing Medical Condition 

( 1 Pregnancy 

( l Seizure Requiring Emorgen<:y Treatment 

[ 1 UTI 

[ l Bowel Impaction 

( ] Pneumonia 

t ] Pressure Sores 

[ 1 Other: 

[ ] Physicaf ~$Suit by Third Party!Other Individual in our car 

[ J Sex.ua:l Assault by Third Party/Other Individual in our caru 

[ 1 Theft by Thiro Party 

[ l Fall 

r l Choking 

( l Bathing/Scalding Related Injuries 

( l OtherBums 

[ l Vohiclo 

( 1 Swimming/Near Drowning 

[ ] Other Accidental 

EXPOSURE: CONTROl. INCIDENTS; 

[ ] C!ientJ!ndividua! E)(posed lo Blood Borne Pathogens 

! J CllenVIndMdual Exposed Third Party to Blood Borne 

PROPERTY DAMAGE llV CLIENTnNDlV1DUAL: 

( ] Property Damage Under$1,000 

{ ] Property Damage Over $1 ,000 

[ l Vehicle Theft 

[ l FlraSetting 

I J ThefliShoplifting 

[ l Other. 

POSSESSION per 

cflentilndlvldual/program) 

[ ] Possession of Prohibited Matertals (Le., alcohol, 

lighter, weapon, pornography, Illicit drugs, etc.) 

MENTOR000501 8 
452 


26354.386

] CounselingfTraining for StaffJMentor 

1 ~:v~~g:d'~rh"'~~~t1~JrJi~~r 

[ ] Reported to AduiVChild Protective 

Services 

Date: 

( x] Funding Source Notified 

Date:-

( ] Famijy Notified ] lntemallnvestigatlon UnderNay 

Interventions: 

]Phyotcot 

Date: ) Substantiated { ) Unsubstantiate (x] Guardian Notirted 

]Mechanical 

[ ] Licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Date: 

l Law NoUfiad 

Date: 

MENTOR0005019 
453 


26354.387

Signature of Person Completing Form Print Name Title Date 

PM 

f Manager/Director Print Name Title 

-

Date 

- Deputy Stnte Dir. 

Signature Print Name nue -

Date 

-- State Dir. 

Sl51nature Print Name Title Date 

Signature of State Director (Level J and 4 only) Prlnt Name Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005020 
454 


26354.388

3. Guardian: ) Setf {x} Stale ( } Parent(s) ( } Other: 

5.006: 

8. Population: ( ) 

-Adult (16+) (x) Child 

10. Date of Admission to MENTOR NETWORK; 

11. Length of -Current P!acemenliServlces: 

• Years 6 Months 17 Days 

6. Age: 

9. Service Category; (Check one} 

(x) Behavioral Health 

( ) Juvenile JusUce 

( ) Medically Complex 

( I MRIDD 

( ) MR/00 Offender 

) Acquired Brain Injury 

) Elder Care 

) Mental Illness 

) MRIMI 

) Education 

) Other: 

SE;ffiQ~ !J: !'JiQQ~M !NJQJ:!M~!!.Q\'L .............•.......... 12.State: 14.1f Acquisition/Partner. specify company name: 

15. Program Name: 

Child Protective Services 

16. Service Setting/Model: (check the ONE that most closely fits) 

( ) !CF/MR (lntermedla.te Care Facility) ) Family/SchooVHome Based Supports (periodic 

( ) Group or Shared Living (3+ clients/individuals with 24/7) services less than 24/7) 

( ) Shared orSupponed Living (1 or 2 c:liefltslindtvk:luals with 24/7} 

(x) Mentor Hamal Host Home 

) C~nicai/Ou!palient Therapy/Rehab (OT, PT, Spceech) 

) Day Program 

( ) Group or Shared Living (3+ clients/individuals with less than 2417) 

( ) Shared or Supported Living (1 or 2 dierttsfindividuals with less 

) Supported EmploymenWocationa! 

) School 

thao 2417) ) BrokeragefCase Management (non·residential) 

} Home Health Agency Services 

SECTION Ci INCIDENT INFORMATdON, 17. Date & Time of Incident: 

19. Location of Incident: (chgclc one) 

( ) Mentor Home ( ) Primary ( ) Respite 

Mentor Name: 

#of Clients/fndfviduafs Living In Harne: 

( ) Client/Individual's Residence (group home, ICF, apt) 

{ ) Clienlllndividual's Biological Family!Guardian Home 

( ) Day Prngram 

( ) School 

( ) Client/Individual's Place of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

(xl Other: Hospital 

18. First Reported to MENTOR NETWORK: 

By: (Name & nile} -

CPS Caseworker 

20. Outcome of Incident: (check all that apply) 

J Remain in Currant Placement 

] Placement DecisiQn Pending 

J Clientl!odivldual Placed in Respite 

] Placeme11t Oisr'Upted (i.e. Client/Individual ttansferred to new 

home/ program/placement within MENTOR NETWORK) 

] Discharged from MENTOR NE1WORK 

] Temporarily or Permanently Closed Mentor Home 

1 Emergency Psychiatric Evaluation (no hospllalization) 

] Emergency Psychiatric Hospitalization 

J Emergency Medical Hospitalization 

l ln·SChoo! suspension 

J School Su.spension!Expulsion 

l Client/Individual Arrest/Detention 

[x] Death 

[ l Other: 

21. Summarize In 2.-3 sentences the key aspects of the ineldent for entry into Risk Management database, 

.... _had s-eizures requiring Paramedic transport to the hospital,- was on life support since- Brain scan 

detected that.was brain dead o,_ 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005021 
455 


26354.389

) Located at lhe Time of the Incident Report 

• Unable to Locate at the Time of the Incident Report 

) Other: 

{Suspected, Alleged or Confirmed) 

Care-taker: 

[ ] Mentor 

( 1 Mentor Family Member 

( J Staff 

( ] Other Caretaker: 

Alleged Misconduct: 

[ J Sexual Boundary/Abuse 

{ ] Verbal or Emotional Abuse 

( 1 Physical Assault/Abuse 

t 1 Corporal/Inappropriate Punishment 

{ l Inappropriate Use of Restraint/Physlcallntervention 

l 1 Neglect 

[ ] Inadequate Supervision 

[ 1 Criminal Arrest of Caretaker 

( 1 Afcohoi/Drug Use by Caretaker 

[ 1 Misuse af Client/Individual's funds 

[ ) Misappropriation/Destruction of ClienU!ndividual Personal 

Property 

J Other: 

SUICIDAL CUENT/INOIV!DUAL: 

( l Suicidal Threats or Verbalizations 

( ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

(x]To other Client 

( ] To Staff or Mentor 

[x_n-o Mentor's Family Member 

[ J To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ 1 To Other Client 

{ ] To Staff or Mentor 

( ]ro Mentor's Family Member 

[ J To Other Third Party 

[ ]ro Anlma16 (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self-Injurious Behavior 

] Met~tal Health Dao.eompensation 

1 OppositionaiBehaviolli 

)Inappropriate Sexual Comments/Threats 

J Verbal Threats of Violence 

] E:;.;hibltionism/Public Masturbation 

1 Medication Error ] Missing Controlled Substances 

} Serious Adverse Reaction to Medicatlon 

MEDICAL INCIDENTS: 

[ ) Illness Requiring Medical Treatment 

[ ] Deterioration in Existing Medical Condition 

( ] Pregnancy 

( ] Seizure Requiring Emergency Treatment 

[ ] UTI 

[ ] Bowel Impaction 

[ ] Pneumonia 

( J Pressure Sores 

[ 1 Other: 

BY: 

Physical Assault by Third Party/Other Individual in our car 

Sexual Assault by Third Party/Other lncfividual in our care 

Theft by Third Party 

Fall 

Choking 

Bathing/Scalding Related Injuries 

Olher Bums 

Vehicle 

Swimming/Near Drowning 

Other Accfdenla! Injury: 

EXPOSURE CONTROL INCIDENTS: 

( ] Clientllndivldual Exposed to Blood Bome Pathogens 

( 1 Client/Individual Exposed Third Party to Blood Bome 

PROPERTY DAMAGE BY CUENTIINOIVIOUAL: 

{ ] Property Damage Under $1,000 

[ ] Property Damage Over $1,000 

( J Vehicle Theft 

[ ] Fire Setting 

[ ] Theft!Shoptlf\ing 

[ J other: 

POSSESSION OF PROHIBITED MATERIALS: (Oeflnod per 

client/individual/program) 

( J Possession of Prohibited Materials {i,e., alcohol, 

lighler, weapon. pornography, liUc!t drugs, etc.} 

MENTOR0005022 
456 


26354.390

J CounsetingfTralning for Staff!Mentor ] ISPISupervlsioniBehavioral Plan Developed Mth Client/Individual 

] lntemallnvesUgatlon Underway 

lnfi!Nanlions: 

]Physical 

]Mecflanlcal 

]Seclusfons 

]Chemical 

Enforcement 

[ J Reported to AduiVChlld Protective 

Services 

Date: 

) Substantiated ( ) Unsubstantlate 

[ J Licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Funding Source Notified 

Date: 

l Family Noi11iad 

Date: 

l Guardian Notilled 

Date: 

J Law EnforcamenVProbatlon Notified 

Date: 

MENTOR0005023 
457 


26354.391

Signature of Person Completlng Form Print Name TIUe Date 

PM 

Signature of Mana.gar/Director Print Name nue 

-

Oate 

- Deputy State Director 

Signature Print Name Title 

-

Date 

- State Director 

Signature Print Name Title 

-

Date 

Signature of State Director (leve13 and 4 only} Print Name TIUe Oate 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005024 
458 


26354.392

a. Populatlon: ( ) Adult (18•) (x) Child 

10. Date of Admission to MENTOR NETWORK: 

11. Length of -Current Placement/Services; 

9, Service Category: (Check ono) 

(x) Behc:~vioral Health 

{ ) Juvenile Justice 

{ ) Medically Complex 

( ) MRIDD 

( ) MRIDD Offender 

) Acquired Brain Injury 

) Elder Care 

) Mental !!!ness 

) MRIMI 

) Education 

} Other. 

.~J!:criON.!!i J>ROGR.Al\{ 1Nl'QR!\fATION 

13.City: 14.ff ACQU'iSitl~oniPartr;er: sP~~u=Y~ompany name: 

15. Program Name: 

Child Protective Services 

16. Service Setting/Model: (check the ONE that most closely flts) 

( ) ICF/MR (lntarme<liale Care Facility) ) Family/SchooUHome Based Supports (periodic: 

( ) Group or Shared living {.3+ clients/individuals with 24/7) services less than 2417) 

( ) Shared or Supported Living (1 or 2 clients/individuals with 24/7} 

(x} Mentor Home/ Host Home 

) Clinical/Outpatient Therapy/Rehab (OT, PT, Speech) 

) Oay Program 

{ } Group or Shared Living (.3+ clients/individuals with less than 2417) 

( } Shared or Supported Uving (1 or 2 clienlslindividua!s wilh tess 

) Supported Em~oymanWocational 

) School 

lha11 2417) } Brokerage/Case Management {non-residential) 

) Home Health Agency Services 

.SEcriON.C: INCIDENT INEORMA'1liON 

19. Location of Incident: (~her::k one) 

{x) Mentor Home (x) Primary ( ) Respite 

::~~l~e~~~~;dfvlduals Lhtlng In Home: 

( ) Cl!anlflndivldual's Residence (group home, !CF, apt) 

( ) Client/Individual's Blo!ogk:a! Family/Guardian Home 

( ) Day Program 

( } School 

( } ClienV!ndividual's Place of Employment 

{ ) Vehicle 

( ) Program Office 

( ) Community 

! ) other. 

18. First Reported to MENTOR NETWORK: 

By: (Name & Title) 

20. Outcome of Incident: (check iJIJ that apply) 

] Remain in Cunent Placement 

} Placement Decision Pending 

1 ClienlJ!ndMdual Placed in Respite 

} Plac;ement Disrupted (i.e. CUenV!ndivldua! transferred to new 

home/ program/placement within MENTOR NETWORK) 

[ ) Discharged from MENTOR NETWORK 

[ 1 Temporarily or Permanently Cfosad Mentor Homo 

[ ) Emergency Psychiatric Evaluation {rto hospitalization) 

[ l Emergency Psychiatric: Hospitalization 

( J Emergency Medical Hospitalization 

[ 1 In-school suspension 

( 1 Schoof Suspension/Expulsion 

{ } CHenVIndMduat ArrcsVOetantlon 

[x] Death 

[ J Other. 

21. Summarize In 2-3 sentences the key aspects of the Incident for entry into Risk Management database. 

··cuent was admitted to o~ On -at -the client passed away. The cause of death is 

believed to be a bowel obstruction. An autopsy is pending. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005025 
459 


26354.393

) Located at the limo of the Incident Report 

) Unable to locate at the Time of the Incident Report 

} Other. 

{Suspected, Alleged or Confirmed) 

CaretaKer: 

] Mentor 

1 Mentor Family Member 

] Staff 

] Other Caretaker: 

Alleged Misconduct: 

{ J Sexual BoundaryfAbuse 

( l Verbal or Emotional Abuse 

[ ] Physlcal AssauiVAbuso 

[ ] Cotporalllnapprnpriate Punishment 

( 1 Inappropriate Usa of Restra1nt1Phys!caltnterventlon 

[ J Neglect 

[ ] Inadequate Supervision 

{ ] Criminal Arrest of Caretaker 

( ) Alcohol/Drug Use by Caretaker 

[ ] Misuse of ClienV!ndividual's Funds 

( ] Misappropriation/Destruction of Cf!enUindlvidual Personal 

Property 

J Other: 

SUICIDAL CLIENT/INDIVIDUAL: 

[ ] Suicidal Threats or Verbalizations 

[ ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

( ] To other Client 

( ] To Staff or Mentor 

[ ]To Mentor's Family Member 

[ ]To Olher Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ] To other Client 

[ J To Staff or Mentor 

[ ]To Mentor's Family Member 

( l To other Third Party 

{ ]fo Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] Illness Requiring Medical Treatment 

[ ) Deterioration In Existing Medical Condition 

[ J Pregnancy 

( J Seizure Requiring Emergency Treatment 

[ ] UTI 

( 1 Bowel Impaction 

[ ) Pneumonia 

[ 1 Pressure Sores 

[ 1 Other: 

Physical Assault by Third Party/Other Individual in our car 

Sexual Assault by Thl.rd Party/Other Individual in our care 

The~ by Third Party 

Fall 

Choking 

Bathing/Scalding Related Injuries 

Other Burns 

V~hicle 

SwimmingfNear Dro·wning 

Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

( J Client/Individual Exposed to Blood Bome Pathogens 

[ J ClienUindividua! E~posed Third Party to Blood Borne 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

[ ] Property Damage Under $1,000 

[ ) Property Damage Over $1,000 

[ J Vehicle Theft 

[ l Fire Setting 

( ] ThetiJShopliftlng 

{ ] Other: 

POSSESSION OF PROHIBITED MATERIALS: per 

cllentllndlvldual/program) 

( J Possession of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pornography, il!icil drugs, etc.) 

MENTOR0005026 
460 


26354.394

~ ~ ~cp~~~~~~~~~~~~~o~;~~~ntor Developed with ClienUindividual 

[ J lntemallnvestlgation Underway 

Interventions: 

( ]Physical 

( ]Mechanical 

[ ]Seclusions 

[ )Chemlcal 

Enforcement 

Date: 

) Substantiated ( ) Unsubstantiate 

(X] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Date; 

J Guan:llan Notified 

Date: 

1 Law Enfon::ernentiProbatlon Notified 

Date: 

MENTOR0005027 
461 


26354.395

Signature of Person Campletfng Farm P'rint Name Title Date 

- Pro~ram Manager 

Signature 

-

Date 

-

Date 

-

CONFIDENTlAL PURSUANT TO SENATE RULE 26 MENTOR0005028 
462 


26354.396

3. Guardian: )Self (x)Slate ( )Parsnt(s) { )Other. 

S.DOB; 

B. Popu!aUon: ( ) 

-

Adult(18+) (x) Child 

10. Date of Admission ta MENTOR NETWORK: 

11. Length af -

Current Placement/Services: 

6.Age: 

9. Service Category: (Chec;k one} 

{x) Behavioral Health 

( ) Juvenlle Justice 

{ ) Medicaily Comptex 

( ) MRIDD 

( ) MRIDD Offender 

) Acquired Brain Injury 

} Eldet Care 

) Mental !!!ness 

) MRIMI 

) Education 

) Other: 

SE<:;l'I()N B: !',Il()(iMI\:IJ.l'IF()~:riQN .·. 12. State: 14.1f Acquisition/Partner, specify company name: 

15. Program Name: 

Child Protective Services 

16. Service Setting/Model: (check the ONE that most closely fits) 

( ) ICF/MR {Intermediate Care Facility) Family/School/Home Based Supports (periodic 

( ) Group or Shared li'.'ing (3+ clientS/individuals wilh 24f7) services less than 24f7) 

( } Shared or Supported Living (1 or 2 clients/individuals with 24/7) 

(x) Mentor Hamel Host Home 

ClinicaUOutpatiant Therapy/Rehab {OT, PT, Speech) 

Day Program 

( ) Group or Shared living {3+ cllents/lndividuals with less than 2417) 

( } Shared ar Supported Living {1 or 2 clients/individuals with less 

Supported EmploymenWocational 

School 

than 24/7) ) Brokerage/Case Management (non·residential) 

} Home Health Agency Services 

SECTION.C: INCIDENT li'<FORMAlfiON 17. Date & Time of Incident: 

19. Location of incident: (check one) 

(x) Mentor Home (x) Primary { } Respite 

Mentor Namo: ~~w.~~~:..-~-; # of Cflentsllndlvl:uals living in Home! 

i ) CllenVlndividual's Residence (group homS,iCF."aPf> 

( ) CUentllndividual's Biological Family/Guardian Home 

i ) Day Program 

( ) School 

( ) ClienUlndividual's Place of Employment 

( ) Vehicle 

{ ) Program Office 

{ } Community 

( ) Other. 

18. First Reported to MENTOR NETWORK: 

By: (Name & Tille) -

CPS Caseworker 

20. Outcome of Incident: (check a!/ that apply) 

] Remain In Current Placement 

l Placement Decision Pending 

J CllenUindlvldual Placed In Respite 

J Placement Disrupted {i.e. Client/Individual transferred to new 

home/ program/placement within MENTOR NETWORK) 

J Discharged from MENTOR NETWORK 

l Temporarily or Permanently Closed Mentor Home 

J Emergency Psychiatric Evaluation {no hos.plta!ization) 

) Emergency Psychiatlic Hospttallzation 

1 Emergency Medical HospitalizaUon 

] In-school suspension 

] School SuspensionJExpulsion 

( ) C!lantllndlvidual Arrest/Detention 

(x] Death 

[ ] Other: 

21, Summarize In 2~3 sentences the key aspects of the Incident for entry Into Risk Management database. 

,...Client had seizures requiring Paramedic transport to the hospital. Client was on life support since--rain scan 

detected thal .. s brain dead onCONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005029 
463 


26354.397

AltomeVICilent Privll-d and cOnfidential: Risk Mariaoament!Peer Review ,; P-2 

Cllentlfndlvldual Name: Loa#: 

,. ''0:' • ...... ~•~'•""'• ~~·.:'b .' DEATH (death of client/individual is a Level4 incident); CLIENT/INDIVIDUAL BEHAVIORAL: 

(x) Expected Dealh of Clientllndividual [ 1 Self·lnjurious Behavior 

( ) Unexpected Death of CllenVIndividual [ ] Mental Health Oe·compensation 

CLIENT/INDIVIDUAL ELOPEMENT/AWOL: [ ] Oppositional Behaviors 

( ) Located at the Time of the Incident Report ( ] Inappropriate Sexual Comments/Threats 

( ) Unable to Locate at lhe Tlme of the Incident Report ( ] Verbal Threats of Violence 

( ) Other. [ ] ExhibiUonismJPubltc Masturbation 

GAf<t•lAKER MISCONDUCT: MEDICATION INCIDENTS: 

(Suspected, Alleged or Confirmed) [ J Medication Error 

Caretaker. [ J \\llissing Controlled Substances 

[ 1 Mentor [ 1 Serious Adverse Reaction to Medication 

[ ] Mentor Family Member MEDICAL INCIDENTS: 

[ J Staff t I Illness Requiring Medical Treatment 

[ ] Other Caretaker: [ J Deterioration in Existing Medical Condition 

Alleged Misconduct: [ l Pregnancy 

[ 1 Sexual Boundary{ Abuse ( l Seizure Requiring Emergency Treatment 

[ ] Verbal or Emotional Abuse ( l UTI 

( ] Physical Assault/Abuse ( l Bowel Impaction 

[ ] Corporalllnappropriate Punishment ( J Pneumonia 

[ ] Inappropriate Use of Restraint.IPhysic.allntervention ( l Pressure Sores 

[ ] Neglect [ J Other; 

[ 1 lnadequalo Supervision CLIENT/INDIVIDUAL INJURY BY: 

[ ] Criminal Arrest of Caretaker ( J Physical Assault by Third Party/Other Individual in our car 

{ 1 AlcohoiiDn.Jg Use by Caretaker [ l Sexual Assault by Third Party/Other Individual in our care 

[ 1 Misuse of ClientllndiiJldual's Funds [ l Theft by Third Party 

[ 1 Misappropriation/OestrucUon of Cl!enUlndividual Persona! [ 1 Fall 

Property [ l Choking 

[ 1 Other. [ l Balhlng/Scalding Related Injuries 

{ 1 Other Burns 

[ J Vehicle 

[ J Swimming/Near Dtowning 

[ 1 Other Accidental Injury: 

SUICIDAL CLIENT/INDIVIDUAL: EXPOSURE CONTROL INCmENTS: 

[ 1 Suicidal Threats or Verbalizations [ J C!ienUlndMdua! Exposed to Blood Bome Pathogens 

{ 1 Suicidal Attempt or Gesture [ 1 Client/Individual Exposed Third Party to Blood Borne 

Palhoaans 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

BEHAVIOR BY CUENT/INDIVIDUAL: ( l Property Damage Under $1,000 

( J To other Client [ l Property Damage over S1 ,000 

( ] To Staff or Mentor [ 1 Vehicle Theft 

[ JTo Mentor's Family Member [ J Fire Setting 

[ )To Other Third Party ( l Theft/Shoplifting 

[ 1 Other: 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: POSSESSION OF PROHIBITED MATERIALS: (Deflne<l per 

( ] To Other Client clientlindlvlduallprogram} 

[ ] To Staff or Mentor [ J Possession of Prohibited Materials (La., alcohol, [ ]To Mentor's Family Member 

[ ] To Other Third Party lighter, weapon, pornography, illicit drugs, etc.) 

[ ]To Animals (animal cn;e!ty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005030 
464 


26354.398

] Counselingffraining for Staff/Mentor 

1 ~:J~~C:~thru~e~~~~\~~r J Internal !nve$ligation Underway 

Interventions: 

( ]Physical 

[ ]Mechanical 

( ]Seclusions 

[ ]Chemical 

[ 

[ J Reported to AduiVChild Protect;ve 

Services 

Date: 

) Substantiated { ) Unsubstantiate 

[ ] Licensing Notified 

Date: 

J Funding Source Nolified 

Date: 

J Family Notified 

Date: 

J Guardian Notified 

Data: 

1 Law Enforcemeni!Probalion Notified 

Dale: 

On-client was placed on life support equipment following seizures at HospitaL Tests Indicated 

that.wQ non-responsive, pupils were fixed and dilated. The mentor was present at the rida,lb~y~a!m~b!u!la~n~c·e~form her home to Hospital Emergency room and when the client was transported to .. ~ 

Hospital. Program Manager came to- Hospital to sit with the mentor until CPS officially 

relinquished the program's responsibility for medical consent and care. At --CW- spoke by telephone to CPS and informed PM that the mentor and/or Program no longer had to sign medical consent and coutd 

leave the hospital. The biological mother was expected to agree to tum off life support sometime soon, and the 

client was expected to pas awa~ CW- reported that the client passed away on- CW reported 

that when client was defined at-which was the time of the death according to the state ofCONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005031 
465 


26354.399

Signature of Person Completing Form Print Name Title Date 

Progrnm Manager 

Signature of Manager/Director Print Name Tltla 

-

Data 

Signature Print Name Title Date 

QA 

Signature Print Name Title 

-

Date 

- Deputy State director 

Signature of State Director (Leve13 and 4 only) Print Name Title 

-

Date 

- State Director -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005032 
466 


26354.400

: ·:. < > i Cc . ·..•. \.Z THE ~:FQJct N,~TW - ENT .:< ... · •. ~:_P~ge r1 

Please PRINT Clearly or Type In Legible Font (10~12) • 00 NOT Leave Blanks. Complete All Boxes. 

.. :•. . ·.··:•:.: .. · ::rr lT. ~:rliiN'. :;: . 

1. C!ientlfndividua!'s Name: J2. Level: ( )1 ()2 ( )3 (x)4 

3. Guardian: ( l Self {x}State ( ) Parent(s) ( )Other: I·· Log#: 

5.008: - 6. Age: 1 Years 7 M j1. Gender: 

8. Population: ( l Adult (18+) (x) Child 9. Service Category: (Check one) 

10. Date of Admission to MENTOR NETWORK: (x) Behavioral Health { ) Acquired Brain tnjury 

- { ) Ju11eni!e Justice ( ) Elder Care 

{ ) Medically Complex ( ) Mental Illness 

11. Length of Current PlacemenVServices: { l MRIDD { ) MRIMI 

{ ) MRJDD Offender ( ) Education 4 Months 10 Days ( ) other. 

1istate: I ,SECTIQ~~: !'S,QqltJ\~~:IN!Q.~I!QN' 13. City: 14.1f Acqufsltion/Partner, specify company name: 

I 1 S. Program Name: 

TFC 

16. Service Setting/Model: (check the ONE thilt mostdosely fits} 

( ) ICFIMR (Intermediate Care Facility) ( ) Famlly/SchooVHome Based Supports {periodic 

{ ) Group or Shared Living {3+ clienls/individuals with 2417) services less than 24(7) 

( ) Shared or Supported living {1 or 2 clients/individuals with 24f7) ( l Clinical/Outpatient Therapy/Rehab (OT, PT, Speech) 

(x) Mentor Hamel Host Home ( l Day Program 

{ ) Group or Shared Li11ing (3+ dientsllndi'ltiduals 'Nith less than 24/7) ( ) Supported EmploymentNocat!onal 

( ) Shared or Supported Living (1 or 2 c!lentsllndlv!duals with less ( l School 

than 24/7) { ) Brokerage!Case Management (non~residential) 

{ ) Home Health Agency Services 

. ·.· . ·· SECTlONC: INCIDENTINFORMATdON . ... 17. Date & Tl{l'le of Incident 1 B. First Reported to MENTOR. NETWORK: 

By: (Name & Tille) 

mentor 

19, Location of Incident: {checJf. one) 20. Outcome of Incident: (check s/1 that apply) 

(.x) Mentor Home (x) Primary ( l Respite [ J Remain in Cun'ent P!acemen.t 

Mentor Name: [ J Placement Decision Pending 

#of Cllents/indlvldu<~ls living in Home: ~ [ J Client/Individual Placed in Respite 

( ) Client/Individual's Resldem:e (graup home, ICF, apt) [ J Placement Disrupted (i.e. C!ientl!ndividual transferred to new 

( ) CUenUindlvidual's Biological Family/Guardian Home home/ programlp!acement within MENTOR NETINORK) 

( ) Day Program [ l Discharged from MENTOR NETWORK 

( ) School [ ] Temporarily or Permanenl!y Closed Mantor Home 

( ) Client/Individual's Place of Employment [ } Emergency Psychiatric Evaluation (no hospitalization) 

{ } Vehicle [ J Emergency Psychiatric Hospitalization 

{ ) Program Office [ ] Emergency Medical Hospitalization 

( ) Community [ ) !n~schoo! suspension 

< ) Other: [ 1 Schoo! Suspension/Expulsion 

[ ] ClienVIndtvidual Arrest/Detenlion 

[><l Death 

[ ] Other: 

21, Summarize In 2-3 sentences the key aspects ot the Incident for entry Into Risk Management database. 

a medically fragile 18 month old stopped breathing while at the foster care home, efforts to revive- at 

home were unsuccessful. EMS transported-to a hospital where.could not be revived. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTORDDD5033 
467 


26354.401

.· .. ··.:·.: • Aitoii\a~CIIoniPrlvll~d and 'cenfldt!riUal: Rl~k Mlin.ki~menW~efRevlew•• .. 'page 2 

ClientJindivldual Name: Loa#: 

.. : '•(: •. ·· EC:ce~:.: ;.:;::_.;:;·;c" '.ii .:.: ";;,,''di'r'>l;'~·t~'ilfili!i·'· • . <··~··~:•>cl'. :.:.: DEATH {death of cl!entfindivldualls a Level 4 incident): CLIENTRNDIVIDUAL BEHAVIORAL: 

( ) Expected Death of ClienVIndividual [ ] Self~lnjurious Behavior 

(x) Unexpected Death of ClienUindividua! [ ] Mental Heallh De-compensation 

CLIENT/INDIVIDUAL ELOPEMENT/AWOL: [ } Oppositional Behaviors 

( ) Located at the Time of lha Incident Report [ )Inappropriate Sexual Comments/Thrnats 

( ) Unable to Locate at the Time of the Incident Report ( ] Verbal Threats of Violence 

( ) Other: [ ] Exhibitionism/Public Masturbation 

CARE· TAKER MISCONDUCT; MEDICATION INCIDENTS: 

(Suspected, Alleged or Confirmed) [ J Medication Error 

Caretaker: [ ) Missing Controlled Substances 

( 1 Mentor [ J Serious Adverse Reaclion to Medication 

( ] Mentor Family Member MEDICAL INCIDENTS: 

[ ] Staff [ l Illness Requiring Medlca! Treatment 

( 1 Other Care!aker. [ l Deterioration in Existing Medica! Condition 

Alleged Misconduct: [ l Pregnancy 

( } Selma! Boundary/Abuse [ J Seizure Requiring Emergency Treatment 

[ l Verbal or Emotional Abuse I l UTI 

( ) Physical Assault/Abuse [ J Bowel impaction 

[ J Pneumonia [ l Corpor.t!flnappropriate Punishment [ l Pressure Sores ( } Inappropriate Use of Restra!nLIPhyslcallntervention ( l Other: [ l Neglect 

( ] Inadequate Supervision CLIENTRNDIVIDUAL INJURY BY; 

( ) Criminal Arrest of Caretaker [ J Physical Assault by Third Party/Other Individual in our car 

[ 1 Alcohol/Drug Use by Caretaker [ l Sexual Assault by Third Party/Other Individual in our care 

[ ] Misuse of Clienlflndividual's Funds [ l Thefi by Thir<l Party 

( 1 Misapproprialion1Destruc1ion of Client/Individual Personal [ l Fall 

Proper1y ( l Choking 

[ ] Other: [ l Bathing/Scalding Related Injuries 

[ l Other Bums 

[ I Vehicle 

[ I Swimming/Near Drowning 

[ l Other Accidental Injury: 

SUICIDAL CLIENT/INDIVIDUAL: EXPOSURE CONTROL INCIDENTS: 

[ ] Sutcida! Threats or Verbalizations [ l Cl!enV!ndlvidual Exposed to Blood Borne Pathogens 

[ ] Suicidal Attempt or Gesture ( l ClienVIndlvidual Exposed Third Party to Blood Some 

Pathoaens 

SEXUAL ASSAULT OR INAPPROPRLA TE SEXUAL PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

BEHAVIOR BY CLIENT/INDIVIDUAL: [ l Property Damage Under $1,000 

[ l To Other Client [ l Property Dam(3ge Over $1,000 

[ l To Staff or Mentor [ l Vehicle Thefl 

[ ]T'o Mentor's Family Member [ l Fire Setting 

[ ]To Other Third Party [ l Theft/Shoplifting 

[ l Other: 

PHYSICAL ASSAULTS BY CLIENTRNDIVIDUAL: POSSESSION OF PROHIBITED MATERIALS: {Deflned per 

[ J To Other Client cllentllndlvlctuaUprogram) 

[ ] To Staff or Mentor [ l Possession of Prohibited Materials (i.e., alcohol, [ JTo Mentor's Family Member 

( ) To Other Third Party lighter, weapon, pornography, illicit drugs, etc.) 

( ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005034 
468 


26354.402

[x] Counseling/Training for Staff/Mentor 

c 1 ~~~~~d"~fh~~~~drr~~~r ( l lntemallnvestlgation Underway 

Interventions: 

[ ]Physical 

( }Mechanical 

( ]Seclusions. 

( ]Chemica.\ 

Enforcement 

[ ] Reported to AduiVChlld Protective 

Services 

Date: 

) Substantia;ted { ) Unsubstantiate 

[ ] Licensing Notified 

Date: 

[x] Funding Source Notified 

Dale:-

[ J Family Notlfled 

Date: 

[ x 1 Guardian Notified 

Dale:-

] Law EnforcemenUProbatlon Noltfied 

Date: 

24. .. . , . : .· . . ..• . . SECI'ION H: .INCIDENT NARRATIVE .. .. . . •• • .; ; . .. :· .••.. Desc~~ ~ th,~ !n,cf~e~t ~~ ch~~~~cal !'~'· ,l~~lu~ w~~· w~~t, w~,~~~ W,~n 3f!d h~~-I!~~~~JnJi~~~~:~,aUG~,~ ' ' ' Iri~r:ve'ntio~s ~~ -~r~nt ~!Report f.~vol\le~f!t,o' o~~~--~~~~ su~'~ I,<Wt enforcelneO~:e~~~~ '~dl~t;~,, ' ' 

~tC~,hi~ud~ ~o~rce~ 9' lnforin~lorl (e.g. ,.Me!ltor r8~.~" ~r ~S~ ~bserVed; .• ~). , ~~~ n~:,~!l~~~~e' Uti~ s~~~~~,~~~Sease,,r.!Bfu~ger+ ' ' "' ' · ,, ' ',, 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005035 
469 


26354.403

Si9nature of Person Completing Farm Print Name T!Uo Date 

PC 

Si9nature of Manager/Director Print Name Title 

-

Date 

PM 

Signature Print Name Title 

-

Date 

Signature Print Name Title Date 

Signature of State Director {Levell and 4 only) Print Name Tltle Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005036 
470 


26354.404

1. ClienVIndividual's Name: 

3. Guardian: ) Self (x) State ( ) Parent(s) ( ) Other: 

5. DOB: 

8, Population: (x) 

-Adult (18+) ( ) Child 

10, Date of Admission to MENTOR NETWORK: 

11. Length of -Current PtacemenVServices: 

6. Age: 18 Years 1 

9. Service Category: (Cht?Jck one) 

(x} Behavioral Health 

( ) Juvenile Justice 

( ) Medically Complex 

( l MRIDD 

( } MRIDD Offender 

) Acquired Brain Injury 

) Elder Care 

) Montal !!!ness 

l MRIMI 

) Education 

) Other. 

1ic11y: 

!;ECf.I()N }l! !'_g()(l!lAMJN¥Qfu'\1i\'@"()N 12. Stale: 14.lf Acquisition/Partner, specify company name: 

15. Program Name: 

16. Service Setting/Model: {check the ONE that most closely fits) 

( ) ICFIMR {Intermediate Care facility) ) Family/Schoo!/Home Based Supports (periodic 

( ) Group or Shared living (3+ clients/individuals "Nith 24/7} services less than 24/7) 

( ) Shared or Supported living {1 or 2 clients/individuals with 24n} 

(x) Mentor Home/ Host Home 

) Clinical/Outpatient Therapy/Rehab (OT, PT, Speech) 

) Day Program 

( } Group or Shared living (3+ clients/individuals with less than 24/7) 

{ ) Shared or Supported Living (1 or 2 clients/individuals with less 

) Supported EmploymenVVocational 

) School 

than 24/7) ) Brokerage/Case Management (non-residential) 

) Home Health Agency Services 

SECTION C: INCIDENT L"\\FORMATION 

17. Date & Time of Incident 

19. Location of Incident: (chac;k one) 

{ ) Mentor Home { ) Primary ( ) Respite 

Mentor Name: 

#of Clientslindlviduals Living In Home: 

( } Cllentllndividual's Residence {group home,ICF, apt) 

( ) Clienlflndividua!'s Biological Family/Guardian Home 

( ) Day Progr.3m 

( ) School 

( ) ClienV!ndividual's Place of Employment 

( } Vehicle 

( ) Program Office 

( x} Community 

( ) Other: 

1a. Fi111t Reported to MENTOR NETWORK: 

By: (Name & nile) 

Coroner's Office 

20. Outcome of Incident: (check all that apply) 

] Remain In Current Placement 

] Placement Oeci~on Pending 

] Clientllndivldual Placed ln Respite 

] Placement Oisn.Jpted (i.e. ClienVIndividual transferred to new 

home/ program/placement within MENTOR NETWORK) 

] Discharged from MENTOR NETVVORK 

] Temporarily or Permanently Closed Mentor Home 

] Emergency Psychiatric Eva!ua!lon (no hospitalization) 

J Emergency Psychiatric Hospitalization 

1 Emergency Medica! Hospitalization 

] In-school suspension 

] School Suspanslon/E)(pulsion 

1 Cllenlflnd!vidual Arrest/Detention 

[x] Death 

[ l Other: 

21. Summarize in 2-3 sentences the key as pacts of the Incident for entry into Risk Management database • 

..... The Coroner's Office notified ~entor that client's body was idenHfied by fingerprints and that-was 

deceased. Additional information could not be released, due to the fact that-death is currently under investigation by the 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005037 
471 


26354.405

) Located at the Time of the Incident Report 

} Unable to Locate at the TlfTle of the Incident Report 

l Ot~e<: 

(Suspected, Alleged or Confirmed} 

Caretaker: 

{ ] Mentor 

r l Mentor Family Member 

[ J Staff 

l ] Other Caretaker: 

Allsged Misconduct: 

( ] Sexual Boundary/Abuse 

( ] Verbal or Emotional Abuse 

[ J Physical Assau!VAbuse 

( ) Corporalllnappropriale Punishment 

{ } Inappropriate Use of RestraintJPhysica! lntervsntlon 

[ l Neglect 

{ 1 Inadequate Supervision 

{ ] Criminal Arrest of Caretaker 

[ ] Ah:ohoi!Drug Usa by Camtaker 

[ ] Misuse of C!ientfindlvidual's Funds 

{ ] MisapproprlaUon/Destruction of ClienVIndlvfduaJ Personal 

Proporty 

J Other: 

SUICIDAL CUENT/INOIVIDUAL: 

t 1 Suicidal Threats or Verba1i.zatians 

( l Sukldat Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

fiEHAVIOR BY CLIENT/INDIVIDUAL: 

[ ] To Other CHent 

[ }To Staff or Mentor 

( ]To Mentor's Family Member 

( ]To other Third Party 

BY CLIENT/INDIVIDUAL: 

] To Olher Client 

J To Staff or Mentor 

If a Mentor's Family Momber 

]To Other Third Party 

Jro Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

l Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MeDICAL INCIDeNTS: 

[ l Ulness Requiring Medlc~! Treatment 

( ) Deterioration in -Existing Medical Condition 

[ l Pregnancy 

[ ] Seizure Requiring Emefgency Trealment 

[ J UTI 

[ J Bowel Impaction 

{ ] Pneumonia 

{ ] Pressure Sores 

r l Other: 

[ l Physlcal Assault by Third Party/Other Individual in our car 

( ) Sexual Assault by Third Party/Other Individual in our care 

[ ] Theft by Third Party 

[ J Fall 

t J Choking 

[ ] Bathing/Scalding Related lnjurias 

[ ] Other Bums 

[ l Vahicle 

t 1 Swimming/Near Drowning 

[ l Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

t ) Cli.enVIndividuaf Exposed to Blood Bon-te Pathogens 

[ ] Client/Individual Exposed Thlrd Party to Stood Borne 

PROPERTY DAMAI;E BY CLIENT/INDIVIDUAL: 

t ] Property Damage Under $.1,000 

t J Property Da:r'rlag9 Over $1,000 

( J Vehicle Theft: 

( J Fire Setting 

[ l Theft/Shoplifting 

[ ] Other: 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

cllent/Jndlvlduallprogram) 

[ 1 Possession af Prohiblled Materials (Le., alcohol, 

lighter, weapon, pornography, !!licit drugs, etc.) 

MENTOR0005038 
472 


26354.406

1 CounsslingiTraining for StaffiMentot 

J !SPISupervts.ion/Behavioral Plan De..,IOjle<l with ClienVIndivi<lual 

j lntemallnvesttgatlon Underway 

Interventions; 

r ]Physical 

( ]Mechanical 

[ ]Secluslon.s 

( ]Chemical 

Enforcement 

[x) Reported to Adu!VChnd Protective 

Services 

Date: 

) Substanliated {x} Unsubstanti.ate 

(x) 

J Funding Source Notified 

Date: 

notified by the Coroner's Office that 

identified to be deceand. The coroner's offiCe requested 

wtth contact Information for the caseworker and fO!iter 

paren~ as well as the sister. Additional details surrounding- death could not be 

released, because It is being The Identification cf-.;ody was made base don 

fingerprints. Th OF§S .line was contacted. According to hottine worker,~ a report Is being taken as 

lnforrnaUon only. A port Is being prepared. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005039 
473 


26354.407

Stgnatura of Person Completing Form Print Name Title Date 

Children's Prog. Super. 

Slgnatura of ManagerJDirector PrlntName Title 

-

Date 

Children's Pro g. Super< 

Signature Print Name Title 

-

D-ate 

- PM 

Signature Print Name Title 

-

Date 

Slgnatu(e of State Director (Levell .cmd 4 only) Print Name Title Date 

State Dir. -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005040 
474 


26354.408

) Aeqult1ld Brain lnjul)' 

) El~arC.r~ 

) Menlallllne•• 

l MRIMI 

) Education 

l Other: 

16. Service Setting/Model: (check the ONE that most closely fits) 

( ) ICF/MR (lnlanncdiole Care Faclllly) l Family/Sctlooi/Home Based S\lllpm1s (pariodlc 

( ) Group or Shamd Uvlng (3+ cllen!slindl'liouals v.ilh 241T) se<vlceslesslhen 2417) 

( ) Shamd or Supported Living (1 or 2 ~rrentsliMividuals \'lith 2417) 

(x) Mentor Hotnel Host Home 

l C1inlcaVOUtpotient Therapy/Rehab (OT, PT, Spoech) 

) Day Program 

( ) Group or Sharao Living (3+ cllanl<;llndlvkluals Min loss than l4/7) 

( ) Sharnd or Supported LMng ( 1 or 2 cUenlslindlvlcAA>Is with less 

l Supported Emptoymeni/Vocat!Qnal 

) School 

limn 2417) 

} Home Health Agency Services 

19. Loca!lon oflncicfent (chock one) 

(x) Mentor Home {x} Pritnaty ( ) Respite 

::;~,;e~~:;;:dlvlduah, LJng In Morna: 5 

( ) CllenVindMduol's Rooldonoe (group home.ICF, apt) 

{ ) CllenVInd.ivlduaf's Bio!ogica! FamUy/Guardfan Homo 

( ) Day Program 

( ) School 

( ) Chontf!ndMdual's Place of Ernptoyment 

( ) Vehlde 

( l Progrom Office 

( ) Communfiy 

( ) Other: 

) Srolterage/Ca:se Manag-ement (110'n-res.identtal) 

20. Outoome of l!lddent: (check all !hot Of'Piy} 

J Remain In Current Placement 

) Pl:ar:.et'l1en! Oedsion PQndlng 

] Cllent!lndlvidua! Pfaced: in Rrtspite 

l Placement DISrupted (I.e. CllonVIndiVIdlnd lnlnsferred to new 

home/ p!'<>flf"m/placement within MENTOR NETWORK) 

] Discharged from MENTOR NETWORK 

l Te:mporarliy or Permanently Closed Mentor kome 

I EmO!lloncy Psychiatric Evaluall<m (no hosJ)11olit:atl01l} 

J Emergency Poyehlatric Hospilallzil\ioo 

l Emergency Medical HospUallzallon 

)ln·sch<:<>lsuspenoion 

J khoot SU$pensionfE.l(pulsion 

! J Cllenlllndividuol ArresUOelentlon 

(xJ Death 

[ l Other: 

---had CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005041 
475 


26354.409

) Located at the Time of the tncklent Report 

) Unable to Locate at the Time of the Incident Report 

J Other: 

(Suspet::ted. Alleged or Confirmed) 

Car&ta.ker. 

{ J Mentor 

i J Mentor Family Member 

[ l Slaff 

[ l Other Caretaker: 

Alleged Mlsr:onduct: 

[ ] Sexual Boundary/Abuse 

( J Verbal or Emotio-nal Abuse 

t J Physical Assault/Abuse 

[ ) Corporal/fnappmpliate Punishment 

[ 1 Inappropriate Use of Restra!nt/Phy$icallnter\lention 

( l Neglecl 

( } Inadequate Supef'Jis!on 

[ 1 Criminal Arrest of Carelaker 

[ ] A!cohoVDrug Use by Caretaker 

t l Misuse of Clfentflndividua!'s Funds 

( ] Mlsapptoptlation/Destruc:t!on of Cl!ent/rndlvidual Personal 

Property 

1 O!her: 

SUICIDAL CLIENT/INDIVIDUAL: 

t J Suicidal Threats or Verbalizations 

( 1 Sutcldal Attempt or Gesture 

SS<UAL ASSAULT OR INAPPROPRIATE SEXUAl 

BEHAVIOR BY CLIENTJINOIVIDUAL: 

{ }To OtherCUent 

[ ]To Staff or Mentor 

( 11"h Mentor's Family Member 

[ 1 To 011\erThlrd Party 

ASSAULTS BY CUENTIINOIVIDUAL: 

1 To Other Client 

J To Staff or Mentor 

JT o Mentor's Family Member 

] To Other Third Party 

]To Animals (animal cruelly) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self~lnJurious Behavior 

] Mental Heaflh De-.compensation 

J Oppositional Behaviors 

l Inappropriate Sexual Commants!Threats 

] Verbal Threats of Vlofence 

1 E>:hibitionlsm/Pub!!c Masturbation 

J Medication Error 

] h-fissing Co-ntrotted Substances 

J Serio-us Advarse Reaction to Medicallcn 

( l Illness Requiting Medical Treatment 

( l Deterioratio-n in Existing Medical Condition 

[ J Pregnancy 

£ J Seizure Requiring Emergenty Treatment 

[ l UTI 

t J Bowellmpat:tion 

r l Pneumonia 

[ 1 Pressure Sores 

( l Olhar. 

[ ] Ph:ysital Assault by Third Party/Other-Individual in our ~r 

( J Sexual Assault by Third Party/Other tndlviduaf in our care 

( 1 Theft oy Third Party 

[ I Fall 

[ l Choking 

( ] Bathing!Sca!dlng Related Injuries 

[ l Other Burns 

[ ] Vahlole 

( 1 Swimming/Near Dro~A~nlng 

( 1 Other ACcidental Injury: 

S<POSURE CONTROL INCIDENTS: 

{ ] CtienUlndivldual Exposed to Stood Some Pathogens 

( ] ClienUindlvldual Exposed Third Party to Slood Borne 

Fire Setting 

Theft/Shopllfting. 

Other: 

POSSESSION OF PROHIBITED MATERIALS: {Define<i per 

cllentllndlviduallprugram) 

[ ] Possession of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pomography, illicit drugs, etc.} 

MENTOR0005042 
476 


26354.410

{xl Counseting;Tralning for Staff/Mentor 

{ ] g;:J~~:d~h~~'t1~oJrJ:~~ t J lntemat !m1e5tlgaUon Underway 

Interventions: 

!Physical 

]Mechanical 

{ } Reported to Adult/Child Protective 

Services 

Date: 

) Substantiated { ) Unsubstantiate 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[x] FundlngSoorce Notified 

Date; 

( l Family Notified 

Date: 

[x) Guardian Notified 

Date: 

1 Law Enforcement!Probation Notified 

Date: 

MENTOR0005043 
477 


26354.411

Title 

Clini!;al Coordinator 

Mannger -

Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 25 MENTOR0005044 
478 


26354.412

8. Population: ( ) Adult (18+} (x) Child 

10. Date of Admission to MENTOR NETWORK: 

11, Length of -Current Placement/Services; 

11 Months 

9. Sorvico Cat~ory: (Check one) 

{ } Behavioral Health 

{ } Juvenile Justice 

(x) Medi~::al!y Complex 

( ) MRIOD 

( ) MRIDD Offender 

} Acquired Brain Injury 

) Elder Care 

l Mental tnness 

) MRIMI 

) Education 

) Otlter. 

.. :§~Ctr'~QN~l ;:fSQ.lit~M:~!!Q!'!MJS:!!QN:\ 14. ff AcqulsiUon!Partner, speetfy company name: 

15. Program Name: 

16. Service Setting/Mode{: (check the ONE that most closet~ fits} 

( ) ICFIMR {Intermediate Care Facility) } FamUy!Schooi!Home Based S\lpports (par!odic 

( ) Group or Shared Living (3+ clients/individuals INith 24/7) services less than 24£7} 

{ ) Shared or SuppOrtEd Li~lng (1 or 2 cllentsflndivldualswlth 2417) 

(x} Mentor Home/ Host Home 

) CHnical/OutpaUent 11terapy/Rehab (OT, PT, Speech} 

) Day Program 

{ ) Group or Shared Living (3+ cl!entslindividuafs with less than 2417) 

( ) Shared or Supported Living (1 or 2 diants/indivfduals With tess 

} Supported Emptoyment'Vocational 

~ School 

tltan2417) ) Brokerage/Case Management (non~resident!a!) 

) Home Health Agency Services 

SECtr'ION C: •INCIDENT INFO fl\TION. 

19. Location af Incident: (check o.-.e) 

( l Mentor Home ( ) Primary ( ) Respite 

Mentor Name: 

# of CUents!lndfviduals 1.ivfng In Home; 

( ) Client/Individual's Residence {group home, ICF, apt) 

( ) Client/lndivtdual's Biological Famlfy/Guard!an Home 

{ } Day Program 

( ) School 

( } GllentJlndfvidual's Place of Employment 

{ } Vehide 

{ ) Program OffiL;:e 

( ) Community 

(x) other: Children's Hospital 

21. Sumrnariz& in 2~3 sentences the key .aspects of 

18. First Re)lOrled to MENTOR NETWORK: 

By: (Name & Tille) -

PM 

20. Outcome of Incident: (check. all that apply) 

J Remain In Current Placement 

] P!aooment Occlsion Pending 

1 Cfientl!ndMdual Placad in R-espite 

1 Placement Disrupted (Le. C1lentllndividual transferred to new 

home/ pragram.lplacament within MENTOR NETWORK) 

[ x] Discharged from MENTOR NETWORK 

[ ) Temporarily ot Pennemantly Closed Mentor Home 

{ l Emergency Psychiatric Evaluation (na hospita!lzatlonf 

[ ] Emergancy Psychiatric HtJspitalizatioo 

t ] Emergency Medica! Hospitalization 

( J ln~school suspension 

t l School Susptmslon/Exputsfon 

[ 1 Client/Individual Arrest/Detention 

[xj Death 

[ J Other. 

-entry Into Risk Management database . 

··o..-~the 

Failure secondary to RSV 

•• l1>assed away a!-Children's Hospital from Acute Hypoxic Respiratory 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005045 
479 


26354.413

) Located at the Time of th-e. fncident Report 

) Unabfe to Locate at the Time of the Incident Report 

) Other: 

(Suspected, Alleged or Confirmed} 

Caretaker: 

] Mentor 

l Mentor Famity Member 

l Staff 

J Other Caretaker: 

Alleged Mlsr;onduct: 

( l Sexual BaundaryfAbusa 

( ] Verbal ot Emotional Abuse 

[ ] Physical AssautuAbusa 

[ 1 Corporal!lnappraprfate Punishment 

t ) Inappropriate Use of RestraintJPhyslcallnk~l"llel'ltlon 

[ 1 Negreor 

( ) Inadequate Supervision 

( J Criminal Arrest of Caretaker 

( ] Alcohol!Orug Use by Caretaker 

{ J Misuse of Cllenlllndividual's Funds 

t ] MisappropriationfDastruction of C!ianV!ndividua! Personal 

Property 

] Other: 

SUICIDAL CLIENTI!NDIVIDUAL: 

t ] Suicidal Threais or Verbalizatlons 

t 1 Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ )To 011rer CHen! 

[ JTo Staff or Mentor 

{ ]To Mentor's Family Member 

[ ]To Other Third Party 

PHYSICAL ASSAULTS BY CLIENTflNDIVIDUAL: 

[ J To Other Cltent 

( ] To Staff or Mentor 

{ JTo Mentor's Family Member 

[ 1 To Other Thitd Party 

r rro Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

J Medication Error 

] Missing Contro1!ed Substances 

J Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

{ 1 Illness Requiring Medical Treatment 

( } Deterioration in Existing Medical Condition 

[ 1 Pregnancy 

t l Seizure Requfring Emergency Treatment 

t 1 un [ 1 Bowel Impaction 

( J Pneumonia 

{ J Pressure Sor-es 

[ l Other: 

t J Physical Assault by Third Party/other individual in our car 

l J Sexual Assault by Third Party/Other Jndlvidualln our care 

[ ] Theft by Thir<l Party 

t l Fall 

[ 1 Cho~ing 

( J BathinglScafding Related fnjuries 

t l other Bums 

[ 1 Vehicle 

[ J Swimming/Near Drowning 

[ l Other Accidental 

EXPOSURE CONTROL INCIDENTS: 

[ l Cllenvrnctlvidual Expose4 to Blood Some Pathogens 

( l Client/Individual Expos(ld Third Party to Slooct Bomo 

PROPERTY DAMAGE BY CUENTIINDMDUAL: 

t 1 Propert)l Damage Under $1,000 

t ] Property Damage Over S1,000 

[ l Vehicle Theft 

( 1 Fire Setting 

[ ] ThefUShopfifting 

[ l Oi11er: 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

elhmtllndlvlduaJJprogr.am) 

[ l Po;;session of Prohibited Materials {f,e,, alcohol, 

lighter, weapon, pornography, illicit drugs, etc.) 

MENTOR0005046 
480 


26354.414

Reported to AduiUChild Protective 

Services 

} SubstanUated Date: ····- { ) UnsubstanUate 

{ } Licensing Notified 

Date: 

Date; 

{x] 

Date:-

[x] Guardian Notilied 

Date:-

] law EnforcementiProbatlon Notified 

Date: 

Acute Hypoxic 

grandmotherj foster parants 

~~•d"lliiiiiiiij'j,h~ad been at the hospital for several hours and 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005047 
481 


26354.415

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005048 
482 


26354.416

8. PopufaUon: ( ) Adult (18+) (X) Child 

10. Date of Admission to MENTOR NETWORK: 

11. Length of -Current PlacementJServlces: 

9. Service Category: (Cher:k one} 

( x) Behavioral Health 

( ) Juvenite Justice 

( ) Medically Complex 

( l MRIDO 

( ) MRJDD Offender 

} Acquired Brain l.njury 

} ElderCare 

) Menta! Illness 

) MRIMI 

) Education 

) Other: 

§~ffi:!PNlW ~l,!QQMM!!'IF9RM4'!!Q!'l •. 14.lf AcqulsltioniPartnetl specffy company name: 

• - 15. Program Name: 

16. Service SeWng!Model: (ch~k the ONE that most closely fits} 

( ) ICFIMR (Intermediate Care Facility) ) famijytSchooVHome Based Supports {periodic 

{ } Group or Shared Living (3+ clientstind!vidua!s with 2417) services less than 2417) 

( } Shared Df Supported Living {1 or 2 c!ientSJ1ndividuafs with 2417) 

(:x.) Mentor Home/ Host Home 

) CUnica!IOutpatient Therapy/Rehab {OT, PT. Speech) 

) Day Program 

{ } Group or Shared LMng (3+ cUantsf!ndividuats INith lass than 24!7) 

{ } soared or Supported Living {1 or 2 cUentslindtvidualswilh less 

) Supported EmptaymenWocatlonal 

} School 

than 2417) ) Brokerage/Case Management (non-residential} 

) Home Health Agency Services 

SECTION G: IN<::IfiENT:'INFORMA!tiON 

19. Location of Incident: (check one) 

he} Mentor Home: (x) Primary ( } Re-spite 

::~~~~e~=:dMdua1s lJng in home: t ) CHantlfndivkfual's Residenc.e {group home, ICF, apt) 

( ) Cl!enUindtviduai's Biological FamilyiGuardian Home 

{ ) Day Program 

( ) S<:hoot 

{ ) ClientJindivfdual's Place of Employment 

{ ) Vehicle 

{ ) Program Office 

{ ) Community 

( ) Other. 

1&. First Reported to MENTOR NETWORK: 

By:(Nam&& 11tfel 

mentor 

20. Outcome of tncident (check all that apply} 

t )( l Ri'!tna!n ln Current Ptacamel'lt 

{ l Placetnsnt Decision Pending 

l l C/ienVtndlvldoa/ Plae<>~ In Respite 

l J Pfacem~nt Disrupted (i.e, C!ienVIndividual transferred to new 

home/ program/placement withln MENTOR NETWORK) 

l Discharged from MENTOR NETWORK 

J Tempori;irlty or Permanently Closed Mentor Home 

J Emergency Psychiatric Evaluation (no hospitalization} 

1 Emergency Ps~chiatric HospitaliZation 

[x] Emergency Med1cal Hosp!talizat!on 

[ l In-school suspension 

f J School Suspension/Expulsion 

[ l CllenUindlvldual ArresVDetenUon 

r 1 Death 

[ l Other21. Summarize ln 2~3 sentences the key aspects of the Incident for entry into Risk Management databa". 

'"'"Client became ill with a fever and sore thro-at.~was taken to the ER wher~ was diagnosed with a lung infection, 

Client was admitted into the hospital, 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005049 
483 


26354.417

} Located at the Time of the Incident Report 

} Unable lo Locate at the Time of the Incident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

] Mentor 

1 Menlor Family Member 

l Sta~ 

] Other Caretaker: 

Alleged Misconduct; 

t 1 Sexual SoundaryfAbu.se 

[ ] Verbal or Emotional Abuse 

I 1 Physical Assau!VAbuse 

t l Corporafflnappropriata Punishment 

t ] lnappropr1<:J;te Use of RestraintJPhysicallnterv.ention 

[ I N"9lect 

( 1 Inadequate Supervision 

( 1 Criminal Arrest of Caretaker 

[ 1 AlcohoVDrug Use by Caretaker 

[ l Misuse: of CHentlfndivldua!'s funds 

{ ] Misapprppriation/Destructfon of C!lentllm1ividuat Persona! 

Property 

J O!her: 

SUICIDAL CLIENT/INDIVIDUAl: 

[ ] Suicidal Threats or Verbalizations 

( J Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ )To OltterC!ient 

[ 1 To Staff or Mentor 

( ]To Mentor's Family Member 

[ ] To Olhar Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ 1 To Other Client 

[ 1 To Staff or Mentor 

( JTo Mentor's Family Member 

[ ]To Other Third Party 

[ }To Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

l Missing ControHed Substances 

J Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[x] mness Raquirlng Medical Treatment 

( ] Oeterioratlon In Existing Medlca! Condition 

[ l Pregnancy 

t ] Sei'Zure Requiring Emergency Treatment 

[ 1 UTI 

t l Bowel Impaction 

{ ] Pneumonia 

[ ] Pressure Sores 

[ l other. 

] Physical Assault by Third Part.yfOther Individual in our csr 

[ l Sexual Assautt by Third Party;Otller fnrli't'idu(l.l in our care 

[ 1 Theft by Third Party 

[ l Fall 

[ ] Choking 

t l BathingJScald!ng Related !njuric:;s 

[ 1 Other8ums 

[ ] Vehicle 

( J SWimming/Near Dro'NTling 

[ 1 Other Accidental InJury: 

EXPOSURE CONTROL INCIDENTS: 

[ J CtienUindividuaf Exposed to B!ood Borne Pathogens 

t ] Cllentllndillidual Exposed Third Party to Blood Some 

BY CLIENT/INDIVIDUAL: 

] Property Damage Under $1,000 

] Property Damage Ov~r $1,000 

l Veh~le Theft 

[ ] Fire Setting 

[ 1 ThefVShoplifllng 

[ J Other: 

POSSESSION OF PROHIBITED MATERIALS: {DeflnMI p!tr 

clfentlindlvfdu011fpmgram) 

{ ] Possession of Prohibited Materials (Le., attohol, 

lighter, we11pon, pornography, Hlidt drugs, etc,) 

MENTOROOOSOSO 
484 


26354.418

] CcunsellngfTraioing for Staff/Mentor 1 ISP!SupeTVIsianfBehavloral Plan Developed w!th CUef\\llndlvlduol 

] !nlema1 tnvestigaUon Underway 

Interventions: 

t ]Physical 

r ]Mechanical 

f ]Seclusions 

[ ]Chemlcol 

]law Enforcement 

[ J Reported to Allult!ChUd Protaclive 

$ei'Vlc .. 

Date: 

) Suba.tantiated { ) Uns.ubstantle.te 

!><] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005051 
485 


26354.419

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005052 
486 


26354.420

) Acquired Brain Injury 

) Elder Care 

( ) Mental illness 

( l MR/Ml 

( ) Eduoatwn 

( ) Other. 

16. Sorvlco SctUng!Modol: (che<l< the ONE thai mast closelyli!s) 

( ) ICFIMR {Intermediate ca.e Faellity) ) FamllyiScnooi/Home Based Supports {periodic 

( ) Group or Shared Living (3+ cllant•Andividuals >lith 2417) services leas than 2417) 

( ) Shared or Supported Living (I or 2 cliantslindMduals '111112417) 

(x) Mentor Home! Host tiome 

) Cllni<:aVOulpetient Therapy/Rehab (OT, PT, Speech) 

l DayProgrnm 

( } Group or Shared Living (3+ cJientslindivfdua!s with less than 2417) 

{ ) Shared or Supported Uving (1 or 2 dients/indivkfuals wlth le-ss 

l Supported EmploymenWooational 

l School 

than 2417) 

) Home Health Agency SaMc.es 

19. location -of locldent: (check OM} 

{ ) Mentor Home { ) Primary { ) Raapita 

Mentor Name; 

#of Clllilntollndlvlduals LMngln Home: 

( ) Cllentllndivldualts Resfdence (group home, !CF, apt) 

( ) Cfiantllndivfdua!'s Biol-ogical Family/Guardian Home 

( ) Day Program 

{ ) School 

I ) CllenVIndivldual's Place of Employment 

( ) Ve~icle 

( ) Program Office 

{x) Commtmity 

( J Other: 

) Brokerage/Case Management (non-residential) 

20. Outcome of Incident: (check Dll that apply) 

l Remain in Currant Placement 

l Plac<!rt1ant Oacl!llon Pending 

l Cl\entllndlvlllu>l Placad In Re'l'~• 

1 Placement lllsrupte(! (l.a. CllenVIn<IMd..al translerrod to new 

hamel program/placement within MENTOR NElWDRK) 

l Oischargad from MENTOR NETWORK 

] TemporarltyorPerm:anent!y Cfos:ed Mentor H-ome 

J Emergenoy Psyehlatrlc Evaluation (no hospl!ellta!lon) 

l Emergency P$)'cll1Etrlc Hospitall:ation 

1 Emergency Medica! Hospitahatfo.n 

J In-school S\llll)anslon 

l School Suspension/E:qml~ion 

[ l CilenVIndMduaiA!TeeUDatention 

{x) Death 

t J Othec 

the rodeo lrnil ride with-foster family and was staying >Mth them in the family RV. Onwas not able to rou••• CPR was performed, and EMs were called. They were not able to 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005053 
487 


26354.421

) Located at the T!tne of the Incident Report 

) Unah'e to Locate at the Time of the Incident Report 

1 Other; 

(Suspected, Alleged or Confirmed) 

Carat.aker: 

{ ] Men1or 

[ J Mentor Family Member 

[ l Staff 

[ J Other Caretaker: 

Allegrnl Misconduct: 

[ ] sexual Boundary/Abus,c, 

[ ] Verbal or Emotional Abuse 

( J Phys-ical Assau!VAbuse 

( ] CorporaUinapproprlate punishment 

{ 1 Inappropriate Use of RestrainliPhyslcal Intervention 

[ l Neglact 

t l lnadaqt.~ate Supervision 

[ ] Crimlnal Arrest of Caretaker 

( ] AlcohoUOtug use by Carelaker 

l 1 Mtsu.s:e of CUeniJlndivldual's Funds 

[ J Misappropriation/Destruction of Chentllnrlivldual Personal 

Property 

l Other: 

SUICIDAL CliENTIINDIVIDUAl: 

[ l Suicidat Threats or Verbalizations 

( l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTIINDIVIDUAL: 

[ JTo Other Client 

( 1 To Sfaff or Montor 

[ Jfo Mentor's Family Member 

[ J Ta Other Third Party 

PHYSICAL ASSAULTS BY CLIENTnNDIVIDUAL: 

[ ]To Other Client 

[ J To Staff or Mentor 

( lfo Mentor's Family Member 

( l To other Third Party 

{ Jfo Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Setr~lnju-rtous Behavior 

1 Mental Health De~compensa!ion 

] Oppositional Behaviors 

J lnappmpriate Sexual Comments/Threats 

] Verbal Threats of VIolence 

J Exhibitionism/Public Masturbation 

] Medication Error 

l Missing Controlted Substances 

] Serious Adverso Reaction to Medication 

MEDICAL INCIDENTS: 

( 1 tllness Requiring Medical Treatment 

( J Deterioration ln Existing Medical Condition 

( J Pregnan~y 

[ ] Seizure Requiring Emergency Treatment 

[ l UTI 

t l Bowel Impaction 

f 1 Pneumonia 

( ] Pressure Sores 

( J Other: 

Physical AssaUlt by Third Party/Other Individual in our car 

Sexual Assault by Third Party/Other Individual in our care 

Theft by Thin:! Party 

Fall 

Choking 

Bathing/Scalding Relate<:i lnjurias 

Other Bums 

Vehicle 

SwlmmlrlgtNear D-rowning 

Other Accidental 

EXPOSURE CONTROL INClDE:NTS: 

t l Cllentlfndividual Exposed to Blood Some Pathogens 

( I CtienUindMdual Expose;:! Third Party to Blood Borne 

t Property Damage Under $1,000 

[ Property Oamage Over $1,000 

[ Vehlcte Than 

[ Fire Setting 

! l Theft!Shoplifiing 

[ ] Other. 

OF PROHIBITED MATERIALS: per 

ctienllindlviduallprogram) 

( l Possession of Prohibited Matenals (I.e., alcohol, 

lighter. weapon, pornography, UMdt drugs, etc,) 

MENTOR0005054 
488 


26354.422

J Counseling/Training for Staff/Mentor 

1 ~~~~:d'~l?t,rt~Fe~~~~od~~~~~V 1 lntemal Investigation Underway 

Interventions: 

[ ]Physical 

( ]Mechanical 

( ]Seclusions 

[ !Chemical 

[ }law Enforcement 

t x) Reported to Adult/Child Protective 

Services 

} Substantiated Date: ····- ( ) Unsubstantiate 

( ] Licensing Notifis.d 

Date: 

(x] Funding: Sour'CB Notified 

Date:-

J Family Notified 

Date: 

] Guardian Notified 

Data: 

J Law EnforcementlProbation Notified 

Date: 

Mr.- ~eported that M:rs-was unable to rouse-for bt4akfast in the morning. CPR was started by 

the-, and EMs wera called. Paramedics worked on but were not able to revive- The police on 

the scene have determined at this point that It appears all of th1t famlz was suffering from carbon monoxide 

poisoning. An autopsy will be performed o Inspector interviewed Mr. and MIS.- and 

two of the foster children and reports he fee1s this was a tragic accident. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOROOOSOSS 
489 


26354.423

Signature of Person Completing Form Print Name Title Date 

- PM 

Signature ofManager(Dlrector Print Name Tille 

-

Date 

- PM 

Signature Print Name Tille 

-

Date 

Signature Print Name Title Oate 

- StareQA 

Signature of State Olr~tor (level 3 and 4 only) Print Name Title 

-

Oate 

- State Dir. -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005056 
490 


26354.424

9. SoMco Category: {CI1ock one} 

( ) Behavioral Health 

( ) Juvenlla Justice 

(x) Medically Complex 

( ) MRIDD 

( ) MR/DD Offender 

) Acquired Smln Injury 

) ElderCare 

( ) Menlall»ness 

( l MRIM! 

( ) Education 

( I Othar. 

16. Service SeUlng/Modet: (check U.e ONE that most closely fits) 

( ) ICF!M~ {lntsmtodlate care Facility) ) Fern!ly/Schooi!Home Based SuPPOrts (pe~odlc 

( 1 Group a< Shomd living (3+ dlents/lndividuots ilith 2417) ael'vfcoslasslhan 24!7) 

( ) Shared or Supported living (1 a< 2 ctlentollndlvldual$ wllh 2417) 

(x) Mentor Heme/ Host Ha<no 

) OinltallOutpatJent Therapy/Rehab (OT, PT, Speech) 

1 DayProgl!lm 

( ) Group or Sherod Llvlflg {3+ dlentMndMduals With tess than 2417) 

{ ) Shared or Supported LMng (1 or 2 cliMtsllndivfduals with less 

l SuPP~M Emplo}'manWocalional 

) School 

than24!7) 

l HomaHeallhAgano:ySeMtes 

19. Location oflnclt!ene (check 0110) 

(x) Mentor Homo (x) Primary ( 1 Rasp!te 

# Mentor ofCfionll!/lndivl.talslMng "•'"'" ~~~~·l!!l!!b=:=:-~--. ln flome: $ 

( l CllenVItu!lvldual's Rest®nca (group noms, lCF, apt) 

( l CUenYindilllduat's Biological Family/Guardian Home 

t ) Oay Program 

( l School 

( ) CUent!lndlvfdual'$ Place of Employment 

( ) Vel>k:le 

l )~rogramOf!ica 

( ) Communi!)' 

< ) Other. 

) Btokorage/Coss Mansgamsnt (non-re$1denUal) 

20. OUtcome of ln<:ldent (cheok aH lhot apply} 

l Remain In CIJI'I'lln! Placamen! 

1 Placement Decision Pending 

l cuenUltu!M<lua! PiaOOd In Respila 

l Placement Disrupted (i.e. Cllen!/tndM<lual lrei'ISiel'tM to new 

home/ pregmmlplacomenl wttltln MENTOR NElWORK} 

l O!schorgad !'nlm MENTOR NE1WORK 

l Temporarily orf'ormanenUy Closed Ment<>r Home 

l Emergan~y Ps)IChlalric Evaluation (no hospitaiW.tion) 

J Emsrganoy Ps)IChlotrtc Hospitalization 

1 em_..,y Ml><flcat Hospltolimlon 

)III-$Chooi1!U$p&nslon 

I Sc!wo! Susponslon/Expulslon 

t J Cl!enVlndlvldual An-est!Oetenlion 

(x] Death 

r 1 Other. 

the coordinator of 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005057 
491 


26354.425

) Located at the rme of the Incident Report 

) Unable to Locate at the Tlmeofthe lnddent Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Caretaker: 

[ ] Mentor 

( ] Mentor Family Member 

[ l Staff 

r J Other Caretaker: 

Alleged Misconduct: 

[ 1 Sexual Boundary/Abuse 

[ ] Verbal or Emotional Abuse 

[ ] Physical Assault/Abuse 

[ J Corporal/Inappropriate Punishment 

[ J lnepprnpriale Use of Restraint1Physical1ntervention 

[ 1 Neglect 

[ l lnadequata Supervision 

[ ] Criminal Arrest of Caretaker 

[ 1 AlcolroUDr\lg Use by Caretaker 

[ J Misuse of ClientllndMdual's Funds 

( 1 Misappropriation/Destruction ofCtientllndividual Persona! 

Property 

1 Other. 

SUICIDAL CUENTnNDMDUAL: 

( ) Suiddallhreats or Verbalizations 

[ 1 Suicidal Abempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE S£XUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ JTa otherCIIeflt 

[ !To Staff or Mentor 

[ Jro Mentor"s Family Member 

[ ] ToOiherThlrd Party 

JTo Other Client 

1 To Staff or Mentor 

Jfo Mentor's Family Member 

]To Other Third Party 

]fo Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[ J Self-Injurious Behavior 

[ J Mental Health De-compensation 

[x] Oppositional Behaviors 

[ 1 Inappropriate Sexual Comments/Threats 

[ 1 Verbal Throats of Violenca 

[ l ExhlbltiOil!sm/Publl<: Masturbation 

l Medication Error 

1 Missing Controlled Substances 

1 Serious Adverse Reaction to Medicallon 

MEDICALINClOENTS: 

[ 1 lllne5S Requiring MedicaiTreatrnent 

[ l Da\ariO<BIIon in El<lstlns Medical Condition 

[ ] PreQnaney 

( ] Sel2ure Requiring Emergency Treatment 

[ I UTI 

[ ] Bowel Impaction 

[ 1 Pneumonia 

[ 1 Pressure Sores 

[ l Other. 

[ 1 PhysiCal Aasautt by Third Parlylotherln<!Mdualln our car 

[ 1 Sexual Assauk by Third Party/Oihar Individual in our care 

[ 1 Theft by Thlfd Party 

[ 1 Fall 

l J Choking 

[ ] Bathing/Scolding Related Injuries 

[ J Qthar Bums 

[ 1 Vehicle 

[ J Swimming/Near Drowning 

r J other Accidental 

EXPOSURE CONTROL INCIDENTS: 

[ ] Cllanlllndivtdual Exposad to BlOOd Bome Pathogans 

[ ] Client/IndiVidual Exposad Thlrd Party to Blood Bome 

CLIENTIINDMDUAL: 

[ l Property Damage Under $1,000 

[ l Property Damage Over $1,000 

l J Vehicle TheH 

[ J Flro Setting 

[ 1 Theii/Shopliltlng 

[ l Other: 

POSSESSION OF 

cnentJindlvlduaUprogram) 

MATERIALS: 

[ 1 Possession of Prohibited Materials (I.e., alcohol, 

lighter, weapon, pomography,liUclt drugs, etc.) 

per 

MENTOR000505R 
492 


26354.426

[xl CounseHnglrrl!lnil'lg k>r Stai!IMentor 

( l ~~~"'!:t=~.=.t~ (xJ lnt~mallnveotl~tion Unde.way 

lntet'V$nliorts-: 

[ ]Physfoal 

t )Meenanlcal 

[ J$eclusloru> 

( ]Chemle31 

{x]law Enforcement 

{X) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005059 
493 


26354.427

Print Name THie Data 

cc 

Print Name Tltle 

-

Data 

PM 

Print Name Title 

-

Data 

Print Name Title 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOROOOSOSO 
494 


26354.428

( ) Behavioral Health 

( l Ju\lenile Justice 

(x) Medically Complex 

I l MRIDD 

( ) MR/00 Offender 

( ) Acquired Brain Injury 

( ) Elder Care 

( ) Mental Illness 

I l MRIMI 

( l Education 

I ) Other: 

16. Sel\'lce Setting/Model: (check the ONE that most closely Ills) 

( } ICF/MR (Intermediate COre Facail!l) ) FamilyiSchooUHome Based Supports (periodic 

( ) Group or Shared LMng (J+ cllentsllndMduals with 2417) setvices less than 24n) 

I l Shared or Supported Ulllng {1 or 2 clientsrondividuels with 2417) 

(x} Mentor Home/ Host Home 

) C:l!niceUOulpatienl Thempy!Rehab (OT, PT, 

) Day Program 

( ) Group or Shared Lllllng (3+ clienlollnolvlduals>Mih less than 2417) 

( ) Shared or Supported Ulllng {1 or2 clieniS/indMduaiS with less 

) Supported EmploymonWocallonal 

l School 

than 2417) 

19. Locelion of Incident (check one) 

(x) Mentor Home (x) Primary ( ) Resplle 

Mentor Name: q #of Clients/IndividualS Ll g In Home: 1 

I ) Cllenlllndlvldual's Residence (group home, ICF. apt) 

( ) CllenVIndMdual's B!«ogltal Family/Guardian Home 

( ) Day Program 

( ) School 

( } Clfent/!ndividual's Place of Employment 

( ) Vehicle 

1 ) Progmm Office 

I ) Community 

I l Olhar: 

) Brok011!1ge/Caoe Management (non-residential) 

20. Outcome of Incident: {check aU !hal apply) 

l Remain in Current Placement 

1 Placement Decision Pending 

l c:llenVIndlvidual Placed in Respite 

l Platamenl Disrupted (i.e. ClienUindMdualtranslarrad to naw 

home/ program/placement within MENTOR NETWORK) 

l Discharged 11om MENTOR NETWORK 

J Temporarily or Pemlanenlty Closed Mentor Home 

l Emergency Psychiatric Evaluation (no hospHallzation) 

] Emergency Psychiatric Hospitalization 

J Emergency Medical Hospllalizallon 

J In-school suspension 

l School Suspansion/E'Pul91on 

[ J CllanUindlvldual AnestJDetention 

[xJ Deeth 

[ I Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005061 
495 


26354.429

) Located at the Time of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other: 

(Suope<:ted, Alleged or Conflnned) 

Cat&tak.er: 

] Mentor 

] Mentor Family Member 

] Slaff 

] Other Caretaker. 

Allagad Misc-onduct: 

[ ] Sexual Boundary/Abuse 

t ] Verbal or Emotional Abuse 

[ 1 Physical AssauiUAbuse 

[ ] CorporaVInappropriate Punishment 

[ ] Inappropriate use of RestralnVPt'lyslcatlntervention 

( ] Neglect 

[ ] tnadequate SupeNision 

[ ] Criminal Arrest of Caretaker 

[ J AlcohoVDrug Use by Caretak-er 

( 1 Misuse of CUantllndivlduat's Funds 

( ] MlsappropriaUon/Destruction of CHentJlndividuaf Pei'SOnal 

Prtlperty 

] Other: 

SUICIDAL CUENTIINOIVIDUAL: 

[ ] Suicidal Throats or Verbalizations 

t ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTIINDIVIOUAL: 

[ )To Olher Client 

{ 1 To Staff or Mentor 

[ jr o Mentor's Family Member 

[ ] To other Third Party 

PHYSICAL ASSAULTS BY CUENT/INDIVIDUAL: 

[ ] To other Client 

[ ]To Staff or Mentor 

[ Ifo Mentor's Family Member 

[ ]To Other Thlnl Party 

( }ro Artima!s (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[ ] 111noss Raqulrlng Medica! Troalment 

[ ] Deterioration in E:xisting Medieal Condition 

[ ] Pregnancy 

[ ] Seizure Requiring EmE!fljency Trealmenl 

( ] UTI 

[ ] Bowellmpaclion 

( l Pneumonia 

[ J Pressure Sores 

[ J CHher. 

[ ] Physical Assault by Third Party/Other Individual ln our car 

( ] Sexual Assault by Third Party/Other lndlvltfual in our care 

( ] Thefi by Third Party 

r 1 Fall 

[ l Choking 

( 1 Bathlng/$caldlng Relatad Injuries 

( ] OtherBums 

[ 1 Vehicle 

r l Swimming/Near Drowning 

[ J Other Accidental! 

EXPOSURE CONTROL INCIDENTS: 

[ ] ClienUtndividual Exposed to Blood Berne Pathogens 

{ l C1ienUindlvldual Exposed Third Party to Blood Bome 

PROPERTY DAMAGE BY CUEtiTIINDIVIDUAL: 

[ ] Property Damage Under $1,000 

( l Property Damage Over $1,000 

[ l Vehicle Tholl 

( ] F!reSetting 

[ l Theft/Shoplifting 

( l Other: 

POSSESSION OF PROHIBlTED per 

cllentllndlvtdua!fprogram) 

[ ] Possession of Prol'libited Materials (Le •• alcohol, 

lighter, """pon, pomOQrap/ly, Illicit drugs, etc.) 

MENTOR0005062 
496 


26354.430

I l ~=~Je~r:'1t~tor I l OeveloP<!d With Clionlllndi\lidual 

{ ] fntetnallnvesligatton Underway 

lnterwntlons: 

1 ]Ph}'Sleal 

( ]Mechanical 

( ]Seclusions 

1 ]Chemleel 

1 Substantiated 1 ) UnsubstanUate 

r l Llcenslng Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 2S MENTOR00050S3 
497 


26354.431

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Title 

PC 

Title 

Date 

-

Date 

-

MENTOR0005064 
498 


26354.432

) Behavioral Health 

} JU\Ienf!a Justice 

) Medically Complex 

) MR/00 

) MRJDD OITeMder 

J AcqUired Brain mJury 

J EJderCare 

) Mental Illness 

) MRIMI 

J Education 

(xl Oltleo 

16. SeNice Selling/Model: (check the ONE that most closely flts) 

( ) ICFIMR (lntennedtale Care Facility) l Family/SchooVHome Be>ed Supports (periodic 

( l Group or Shared living (3+ c!l<ontslindividuals wilh 2417) services less lhan 2417) 

( ) Shared or Supported Living {1 or 2 clients/individUals wilh 2417) 

(x) Mentor Home/ Host Horne 

) C1inlcai/0Uipatient Therapy/Rehab (OT, PT. 

) DayProgram 

( 1 Group ar Shared Living (3+ cfi<ontslindlviduals wilh less than 2417) 

( ) Shared or Supported Living (1 or 2 clisnts/indivldllals wilh tess 

J Supported EmploymsnWocaUonal 

) Schaal 

than 2417) 

) Home Health Agency Servtws 

19. location of lncidant (t:het:lc one} 

{x) Mentor Horne {x) Primary { J Resp~e 

Mentor Name: 

#of Clients/individuals Uvlng In Home: 4 

( ) CUent/lndivlduars Residence {group home,ICF, apt) 

( ) Cllen~llldivldual's 9iological Family/Guardian Home 

( l Day Program 

( ) School 

( } Client/Individual's Place cf Employment 

( ) Vehicle 

( J Program Office 

( ) Community 

( ) Othoc 

l Brokerage/case Management (non-,.;dential) 

20. Outcome of Incident: (che<;k olllhot opp/y) 

1 Remain ln Current Placement 

) Plaeement Deeision Pending 

] Client/fndlvidual Placed in Respite 

l Placement Disrupted (i.e. CllonVIndividualtransferred to new 

home/ program/placement within MENTOR NETWORK) 

] OiscltOI]led from MENTOR NETWORK 

J Temporarily or Permanenlly Closed Menter Heme 

] Emei!Joncy P>ychia!rlc EvaluaUon (no hospltallzallon) 

l e:""'rgoncy Psychialrlc Hospitalization 

] Emergency Medical Hospitalizallen 

J fn .. school suspension 

l School SUspeMslon/EJqlulsioo 

[ ] Client/Individual ArrestiDetenUon 

[x] Death 

[ ]Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005065 
499 


26354.433

) Located at the Ttme of the Incident Repor1 

) Unable tc Locate at the Time of the Incident Report 

) Other. 

(Suspected, Alleged or Conflrmed) 

caretalcer. 

[ 1 Menlo< 

[ 1 Mentor Femlly Member 

[ 1 Staff 

t l Other Caretaker. 

Alleged 111/sconduet: 

[ ] Sexual Boundary/Abuse 

[ ] Verba! Of Emolional Abuse 

t l Physics! AS .. uiVAbuse 

( 1 COtporaVInappropriate Punishment 

[ J Inappropriate Usa of Restraint/Physical Intervention 

[ 1 Noy!ec! 

[ l lnedequate Supervision 

[ ] Criminal Armst of caretaker 

l ] AlCOhOl/Drug Usa by Ca!t!taker 

[ ] Misuaa of CiienVIndllliduel's Funds 

[ 1 MiseppropriatiorVO .. tructlon of CtienUindivldual Personal 

Property 

l Other. 

SUICIDAL CLIENTnNDIVIDUAL.: 

( ] Suicidalllnats or Verbalizations 

[ 1 Suicidal Attempt or Go slurs 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTMIDIV!DUAL: 

[ JT o Other Client 

[ }ToStafforMentor 

t ]fo Mentor's Family Member 

[ JToOtherThinlPerty 

PHYSICAL ASSAULTS BY CL.IENTIINDMDUAL.: 

[ ]To Other Client 

t ]To. Staff or Mentor 

[ Iro Mentor's Family Member 

[ ]To OtherThlnl Party 

[ Jro Animals (animal cruelly) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

I Self·lnjurlous Behavior 

1 Mental Health Oe-<:ompensaUon 

] Oppositional Behaviors 

l Inappropriate Sexual Comments/Threats 

] Verbal Threats of VJOienee 

] Exhlbilionlsm/Publlc Masturbation 

l Medication Error 

I Missing Controlled Substancas 

J Serious Adverse Reaction to MedicatiOn 

MEDICAL lNCIOENTS: 

t ] Illness Requiring Medical Treatment 

[ ] Deterioration in E>lstlng Medical Condition 

( l Pregnancy 

( J Seizure Requiring Emergency Treatment 

r 1 un l l Bowel Impaction 

[ ] Pneumonia 

[ ] Pressure Sores 

[ l Other. 

[ J PhySical AssauH by Third PartyiOther Individual in our car 

[ J Sexual Assault by Thild Party/OthertndMduallo our care 

l I Theft by Thild Party 

[ J Fall 

[ 1 Choking 

[ J Bathing/Scalding Related tnjurtes 

( ] Other Bums 

[ ] Vehicle 

[ l Swimming/Near Drowring 

( l Oilier Accidentallnlll<Y' 

EXPOSURE CONTROL INCIDENTS: 

[ J Ctlenutndividuat Exposed to Blood lll>me Palhogens 

l l ClienUindividuat Exposed Third Party to Blood Berne 

PROPERTY DAMAGE BY CUENTnNDMDUAL: 

( ] Property Damage Under $1,0:00 

[ J Property Damage Over $1,000 

[ J Vehicle Theft 

I l Are Setting 

[ ] Thef\IShopllfting 

[ l Other. 

POSSESSION par 

client/Individual/program) 

[ J Possession of Prohibited Materials {I.e., alcohol, 

Jlghter, weapon, pomography, illicit drugs, etc.} 

MENTOR0005066 
500 


26354.434

[xJ Counsel!ng!Tralnlt!gforStalflMelltor 

t I ~:=w~n~~w.~.ru~r [ I !ntemallnvesligalion Underway 

Interventions: 

[ JPI\y<ical 

[ JMedlanical 

t )Seclusions 

r ]Chemical 

[ Jl.llw Enforcemanl 

t 1 ROl>Orled to Adult/Child Protective 

SeM:a• 

Oats: 

J Subslanlialad { ) UnsubstanUate 

[ l Licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

txl Funding Source No6fied 

[ 1 ~::~ JIJJIIillll•t 

Dale; 

[x] Guan:lian Nolilied 

Dale:-

! Law Enfo<cemant/Proballon Nolffied 

Date: 

MENTOR0005067 
501 


26354.435

TIUe Pate 

TFC Coordinator 

Print Name TIUe 

-

Dale 

PM 

Supetvisor 

-

Date 

Print Name Title 

-

Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005068 
502 


26354.436

{ I Sahallloral Hea1111 

l 1 Jwenlle Justice 

(x) Medically Complex 

{ ) MR/00 

< ) MR/00 O!fender 

1 Atq\llred Brain Injury 

) Elder Care 

1 Mental Illness 

I MRIMI 

) Education 

) 01!1ar. 

16. Service Selling/Model: (check the ONE thai most closely fits) 

( 1 ICF/MR (Intermediate Care Facilily) J Famlty/ScnooiiHome Based Suppor!S (penodlc 

( l Group or Shar<>d LMng (g+ cllenlsflndlvlduals with 2417) services less 111an 2417) 

( ) Shored or Supported LMng (1 or 2 clients/individuals with 2417) 

(x) Mentor Home/ Host Home 

) CllnlcaYOutpallem Therapy/Rehab {OT, PT, Speech) 

) Day Progrem 

( 1 Group or Shared U.lng (3+ cllent$11ndlvlduals wllh Jess than 2417) 

( ) Shared or Supported LMng (1 or 2 croenlslindMduals with less 

) Supported EmploymenWocartonal 

) School 

than 2417) 

) Home Health Agency Services 

19.Location of lnctdent: (cheek one) 

(x) MentorHome (x) Primary ( J Respite 

Mentor Name: ~~·!l!!!!ll.,;,:=-~-.. • af C11entslindlvl~ats L V1Mg ln Home! 2 

( J Cllenllln~tvldual's Residence (group nome, ICF, apt) 

{ l CUenrtlndlvldual's alologtcal Fomlly/Guardlan Horne 

( ) DayPitlgratn 

( l School 

( ) CUentllndlvldual's Place of Employment 

( } Vehicle 

{ l Program Office 

( l Community 

( l other. 

( J Brol<ernge/Case Managament(non-resldenrtal) 

20. Outcome of Incident: {check alllhol apply) 

J Remain In Cu""'nt Placement 

] Placement Decision Petufing 

J ClienUindMdual Placed in Respite 

] Placement Dlsnrpted {i.e. CUerrtl!ndividuaf trartsferred to new 

home/ program/placement within MENTOR NElWORK) 

l Dischal"!jet! ftom MENTOR NETWORK 

1 TemporarUy or PermaMntfy Closed MentQr Homa 

] Emergency Psychiatric Evaluation (no hospitalization) 

J Emergency Psychiatric Hospitalization 

J Emergency Medical Hospltallzalion 

] In-school suspension 

] School Suspension!Expulsion 

( ] ClienUlndlvlduel Arresi!Oetention 

[X] Deeth 

r J Other. 

.. Client passed away from medical causes after going to bed onCONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005069 
503 


26354.437

) Located at the Time of the tnddent Report 

) Unabfe to Locate at the Time of the Incident Report 

) Other: 

(Sus~l!d, Alleged or Connrmed) 

Carataker: 

[ ) Mentor 

( l Mentorfamily Member 

[ l Staff 

( ] Other Caretaker: 

Allagad Misconduct: 

[ ] Se>ual BoundS!YIAbuse 

( ] Verbal or Emotional Abuse 

[ 1 Physical AssauiVAbuse 

[ ] Corporal/Inappropriate Punishment 

( 1 Inappropriate Use of Re:sttalnt/Physicat InterVention 

[ J Neglect 

[ l Inadequate Supervision 

( ] Criminal Arrest oi Catataket 

{ 1 Alcohol/Drug u .. by Carelaker 

[ ! Misuse of ClienWndividuel's Funds 

I 1 MlsappropliaUon/Destruction of Clientllndlvldual Persona! 

Property 

1 Other. 

SUICIDA~ CUENTnNDIVIDUAL: 

[ ) Suicidal threats or Verbalizations 

[ J Suicidal Allempl "' Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTIINDMDUAL: 

[ l Tt> Other Client 

[ ]To Staff or Mentor 

[ ]To Mento~• Famil)' Member 

[ ]To Other Thin! Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ] To other Ctient 

[ ]ToStallorMantor 

[ :rro Mentor's Famity Member 

[ }To Olher Third Party 

[ ]To Animals (""imal cruelly) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l SelNnjUrious Behavior 

] Mental Heatth De--compensation 

] Oppositional8ehaviOIB 

]Inappropriate Sexual Commentsrrhreats 

] Verbal Threa1S of VIolence 

J E>hibiUonlsm/PUbllc Mastur!Jauon 

1 Medication Error 

l Missing ConlrOIIed Substances 

] Serious Adverse Reaction to Medication 

MEDICAL 

E J 1m ness R-equiring Medical Treatment 

[ ] Detarioratlon In E>is~ng Medical CondiHon 

[ J Pregnancy 

[ ] Seizure Requiring Emergency TrealmEmt 

[ l UTI 

r ] Bowe!lmpaction 

( l Pneumonia 

[ J Pressure Sores 

[ l Other. 

[ ] PhySical As.sault by Third Party/Otlrer Individual in our car 

[ ] Se>ual Assault by Third Party/Other ln~M<Jual in our cera 

[ 1 Theft by Thin! Party 

( I Fell 

[ 1 Choking 

[ J Balhlng/Scoldlng Related Injuries 

[ l OlherBums 

[ ] Vehicle 

[ ] Swimming/Near Orownlng 

t l Other Accidental 

EXPOSURE CONTROL INCIDENTS: 

[ ] Cflen1/lndivldual Exposed to Blood Bome Palhogens 

[ l ctienUindivldual Expo.ad Thin:! Party to Blood Borne 

PROPERTY DAMAGE BY CLIENTnNDIVIDUAL: 

[ ) Property Damage Under$1,000 

( J PropettyOamegeO.er$1,000 

[ J Vehicle Theft 

[ ] Fire Setting 

( l Theft/Shopllftlng 

[ l Other. 

POSSESSION OF PROHIBITED MATERIAI.S: (Defined per 

cllentflndlllfduallprogram) 

[ J Possession of Prohibned Materials (i.e., alcohOl, 

lighter, weapon, pornography, Illicit drugs, etc.} 

MENTOR0005070 
504 


26354.438

1 Counseling/Training for SlaffJMentor ] ISP/Supervlslon/Bohaviofal Plan Devakljled with CliantllndiYidual 

l lntemallnvestigation Underway 

Interventions.: 

[ ]Physical 

[ ]Mechanical 

[ ]Seduslons 

[ lCha"'lcal 

Date: 

) Substantiated ! ) Unsubstanllale 

licensing Notified 

Date: 

J 

Dale: 

~d gone to bed at at approxlm~ 

-to check on-and correctly placed on- nose, butwlth the oxygen machine not yat turned wa' leaning back and-mouth slightly open. She 

notlced.was bleu and took-form the chalt and CPR, also having a family momber call EMS. The first 

responder arrived within four minutes but was unable to bring the client baci<. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005071 
505 


26354.439

Title Date 

Program Supervisor 

Print Name T!Uo 

-

Date 

Program M;mager 

PrJntName Title 

-

Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005072 
506 


26354.440

(><) Behavioral Heallh 

( ) Juvenile .fusllce 

( l Medically Cornple• 

( ) MRJOQ 

( ) MR/DQ Offender 

) Acquired Brain Injury 

) Elder Care 

) Mental mness 

) MRIMI 

) Education 

)Oiher: 

16. Service Setting/Model: {check the ONE that most closely fits) 

( ) ICFJMR (Intermediate Care Faclllty) ) FamllyJSchooiJHome Based Supports (periodic 

( ) Group or Shared liVIng (3+ dientslindlviduals with 24/7) services less than 2417} 

( ) Shanad or Supported living {1 or 2 dlenlsftndlvlduals with 24/7) 

(x) Mentor Home/ Host Home 

) ClinicaVOutpationtTherepy/Rehab (OT, PT, Speech) 

) Oay Program 

( ) Group or Shared living (3+ dienlsilndlviduals wi1h lass than 2417) 

{ } Shared or Supported living (1 or 2 clients/indMduats Wilh tess 

} StJpporlad EmploymenWocational 

I Scl1ool 

than 2417) 

) Home Health Agency Services 

19. location of Incident; (chack ana) 

(xl Mentor Home {x) Primary ( ) Respite 

::~~~~::.:;,;,flvlduJs tJng In Horne: 3 

( l CijenUil'ldlvidual's Residence (group home, ICF, apt) 

( ) ClienVIndlviduat11 Biological Family/Guardian Home 

( ) Oay Program 

( ) School 

( ) Clierttllndlvkfual'a Place of Employment 

( ) Vellicle 

( ) Program Office 

( ) Community 

( l Other. 

J Brnkerage/Case Management (non-residential) 

20. Outcome of Incident: {chacf( all that apply) 

] Rernaln In Current Placament 

1 Placemaot Decision Pending 

J Cllen~lndtvidual Ploced In Respite 

1 Placement DiS:NPted {te. Ctientltndividual traMferred to new 

home/ prograrnlplaoem""l within MENTOR NETWORK) 

J OIO<hal!led from MENTOR NETWORK 

l Temporarily or Permanentty Closed Mentor Home 

1 EITle'.rgeney Psychiatric Evaluation (no hoapitafitation) 

1 Emergency Psychiatric Hospitalization 

l Em"'9"ncy Medical Hospitalization 

] In-school suspension 

] School SuspensioniExputslon 

[ J Client/Individual Arrest/Detention 

[xJ Death 

! 1 Other: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005073 
507 


26354.441

) Located at the ilme of the Incident Report 

} Unable to Locate at the Time of the Incident Report 

) Other: 

{Suspected) Alleged or Confirmed) 

Caretaker. 

( J Mentor 

! ] Mentor Family Member 

! ] Staff 

[ J Olher Caretaker: 

Alleged MlsC<Jnduct: 

[ l So,..al B"'"'dary/Abuse 

{ 1 Verbal or Emotlonal Abuse 

[ 1 Physical Assault/Abuse 

( l C<>rporaVlnappropriate Punishment 

[ ] Inappropriate Use of Restraint/Physical fntetvenUOn 

[ l Neglect 

t 1 Inadequate Supervision 

[ J Criminal Arrest of Caretaker 

t ] Alcohol/Drug Use by Caretaker 

( 1 Misuse of cnentllndividual's Funds 

[ ] MisappropriationJDeSiructlon of CUentJindiv!dual Persona! 

Property 

1 Other: 

SUICIDAL CUENT~NDIVIDUAL: 

[ l Suicldal Threats or Verbalizations 

( l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTIINDMDUAL: 

[ l To Other CUent 

[ 1 To Staff or Mentor 

[ rro Mentor's Family Mamber 

[ ]ToOtharThlrdParty 

PHYSICAL ASSAULTS BY CLIENTIINDIV1DUAL: 

[ ] To Other Client 

[ jTo Staff or Mentor 

[ ]To Mefltor's Family Member 

[ ] To Other Third Party 

[ IT'o Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Self~lnjurious BehaVior 

] Mental Health De-compensation 

J Oppositional Behaviors 

] Inappropriate Sexual CommentS/Threats 

1 Verballhreats of VIolence 

] Exhibitionism/Public Masturbation 

] Medication Error 

] Mlsslng Controlled Substances 

] Sertous Adverse Reaction to Medication 

[ J Illness ReqUiring Madical Treatment 

[ ] Deterioration in &!sting Medical Condition 

[ ] Pregnancy 

[ ] Seil.ure Requiring Emergency Treatment 

[ ] UTI 

( l Bowel Impaction 

[ 1 Pneomonla 

t ) Pressure Sores 

[ I Other. 

[ J Physical Assault by Third Party/Other Individual In our car 

( ] Sexual Assault by Third Partyfother Individual in our care 

[ ] The~ by Third Party 

[ J Fall 

[ l Choking 

[ ] Bathing/Scalding Related Injuries 

[ l Other Bums 

[ l Vehicle 

[ ] Swimming/Near Drowning 

1 ] Other Accidental 

~XPOSURE CONTROL INCtD~NTS: 

( J CUentllndividual Exposed to Blood Bome Pathogens 

( l Client/Individual Exposed Third Party to Blood Bome 

PROPERTY DAMAGE BY CLIENTANDIV1DUAL; 

[ I Property Damage Under $1,000 

[ ] Property Damage OIJer$1,000 

[ l Vehicle Then 

t l Rre Setting 

[ ] Theii/Shopliltlng 

[ 1 Other. 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

cllentfindtvfduallprogram) 

[ ] Possession of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pornography, Illicit drugs, etc.) 

MENTOR000507 4 
508 


26354.442

r 1 ~P/S=~=~~;~~=ntor [ l Dewlojled with CUenUindlvidual 

[ l lntemal hwestlgalion underway 

Interventions: 

]Physical 

]Mechanical 

]Seclusions 

]Chemical 

(x] Reported to Aduii/Chlld Protective 

SeNk:es 

Date: 

) Substantiated ( ) Unsubstantlate 

[ J Licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[x] Funding Source Notified 

Date:-

] Family Notified 

Date: 

l Guart!ial1 Notified 

Date: 

] Law Enforcement/Probation Notified 

Date: 

MENTOR0005075 
509 


26354.443

QA 

Sf1jnatute of State Dlre<lor 

- -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005076 
510 


26354.444

( ) Behavil)(!ll Heallh 

( ) Juvenne Justice 

(x) Medically Complex 

( J MRIDD 

( ) MR!DD Offender 

) AcQuired Brain Injury 

) ElcterCam 

} Mental Inness 

J MRIMI 

( ) Education 

l l Other. 

16. Service Setting/Model: (chock the ONE that mast clooely nts) 

( ) ICF/MR (lntennedlate care Facility) ( l Family/School/Home Based Supports (periodic 

( ) Group or Shared Living (3+ clients/individuals with 2417) services less than 2417) 

( ) Shared or Supported Living (1 01' 2 cllenlsllndivlduals With 24n} 

(x) Mantflr Homef Host Home 

( ) ClinlcaUOutpaUent Therapy/Rehab (OT, PT, 

( ) Day Program 

( ) Group or Shared Living (3+ cllentsl'mdividuels M!h IMSihan 241?) 

( l Sh""'d or Supported Llvir1q (1 or 2 cllenlsllndlvidualo \vith less 

( ) Supported EmploymenWocational 

( ) Sthool 

!han 2417) 

) Home Health Agency Services 

19. LocaUon of Incident: (c:her;k one) 

(x) Mentor Home (xl Primary ( ) Respite 

Mentor Name~ 

# of CU.antsllndivtduats Living tn Home: 

( ) Cl!entllnctivldual's Residence (group home, ICF, apt) 

( l CHenlllndlvidual's Biolagcal Fam!ly/Gua!tllan Home 

( l Day Program 

( ) School 

( ) Cl!entJindi'vidu:al's Place of Emptoyment 

( ) Vehicle 

( 1 Program Office 

( ) Community 

1 ) Other. 

( J Broketage/Cese Management (non-residential) 

20. Outeom& of Incident: (chock all that apply} 

l ~emaln in Currenl Pl~enl 

1 Placement Decision Ponding 

J CUenUind\vidual Plaoad In Respite 

J Placement Disrupted (i,a. CUenl/lndividuat transferred to new 

home! progmmlplacament wlthln MENTOR NETWORK) 

(~) Discharged from MENTOR NElWORK 

( l Temporarily or Permanently Closed Mentor ~a 

( 1 Emel!jency Poyehietric Evaluation (no hospl!allzaffon) 

[ J Emergency Psychiatric Hospi!allzation 

( l Emergency Mod'o:al Hospilallzation 

[ J In-school SUSpension 

[ l School Suspensfon/Expulalon 

[ J CllenUindividual Anest!OetenUon 

[x] Daath 

[ l Other. 

~client, aged~opped breathing at-on-There Is a DNR order preventing intervention. Client was 

declared dead atCONFIDENTIAL PURSUANT TO SENATE RLiLE 26 MENTOR0005077 
511 


26354.445

) Located at the Time of tl'la Incident Repon: 

) Unable to Locate at the Time of ltle Incident Report 

I Other. 

(Suspected, Alleged or Confirmed) 

Caretilher: 

[ I Montor 

[ 1 MentorFemily Member 

[ 1 Staff 

( ) Other Caretaker: 

Alleged Mlst:om:luct: 

[ 1 Sexual Boundary/Abuse 

[ ] Verbal or Emotional Abuse 

[ l Phy51cal AssaufVAbuse 

! 1 Corporalilnappropriale Punls!lment 

[ 1 Inappropriate Use of RE!strainUPhysicaf fnt£'lrvenUon 

[ J Neglect 

! J Inadequate SupeNision 

[ J CriminaiArrestofCaretal<er 

[ J Alcolmi/Drug Use by Caretaker 

t 1 Misuse ofCiientflndJ\tidual's Funds 

( 1 Mlsapproprtallon/Desbuction of CUenllfndividual ~ersonal 

Property 

J Other: 

SUICIDAL CUENTnNDIVIDUAL: 

t ] Suicidal Threats or Verbaliz.alions 

[ J Suicidal Atlempt "'Gesture 

SEXUAL ASSAUlT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTITNOIVIOUAL: 

( ]To Other Client 

{ ]ToStafforMentor 

[ Jro Mentor's Famiiy Member 

[ ]To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

( ] To Other Client 

( l To Staff or Met1tor 

[ lfo Mentor's Family Member 

[ 1 To Other Third Party 

[ ITo Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

J Sel~lnjurious Behavior 

1 Mental Health De-compensation 

J Opposil!onal Behaviors 

]Inappropriate Sexual CommentS/Threats 

J Verllal Threats of Violence 

) ExhibitionismJPublic Masturbation 

] Medication Error 

] Missing Conlrotted Substances 

l Serious Adverse Reaction to Medication 

MISOIC!\l.INCIDISNTS: 

( ] illness Requiring Medical Treatment 

[ ] Deterioration in Existing Medical Condition 

[ I Pregnancy 

( ] Setzure Requiring Emergency Treatment 

[ l UTI 

[ 1 Bowellmpac6on 

( ] Pneumonia 

( ] Pre~sure Sores 

[ l other. 

[ J Physical Assaun by Third Party/Other Individual In our car 

[ l Sexual Assault by Third Party!Otflor lndlvidualln our care 

[ I Theft by Thlrd Party 

[ 1 Fall 

[ 1 Choking 

[ l Bathing/Scalding Related Injuries 

[ I Other Bums 

[ 1 Vehicle 

( l Sv.immlng/Near Drowning 

[ J Other Acci<lentat Injury: 

EXPOSURe CONTROL INCIOISNTS: 

[ I CHenVIndivldual Expose<! to Blood 8Qme Pathogens 

[ l CllenUindividual Exposed Third Party to Bk!Od Borne 

l Property Oamagellnder $1,000 

l Property Oamago Over $1,000 

1 Vehlcle Theft 

[ 1 Fire Salting 

[ l Theft/Shoplifting 

[ 1 Other. 

OF PROHIBITeD MATERIALS: (Deflnod per 

cllent/indiYldual/program) 

[ 1 Possession or Prohibited Materials (I.e .• alcoh.ol. 

lighter, weapon, pornography, Kllclt drugs, etc,) 

MENTOR0005078 
512 


26354.446

txl Col!flsellrtglfralnlnJ!J:" Staff/Mentor 

r 1 ~~=n~g,"\l\.nv;~:Jt~~r [ J lntamaltnveetig.Uon Underway 

tnretvwrffons: 

t JPhysloal 

[]Mechanical 

I JSoctuSk>ns 

! ]Chemical 

Date: 

1 Subotantlatl!d ( ) Uneubstanliata 

[ l Llcemfng Noti1led 

Dato: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[xJ Fun<fingSolllw 

Dati!: 

[xl Famlly 

Dam: 

t JGuardiao 

Da!tt: 

{><) Law En/on:amentlf'Tobatlan Nol!lled 

Dattt: •• L 

MENTOR0005079 
513 


26354.447

Print Name 

of State Director (Level only} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Title 

PC 

Date 

-

MENTOROOD5080 
514 


26354.448

) AcQuired Brain Injury 

) Elder Care 

) Menta! Illness 

) MRJMI 

) Education 

) Other. 

specify company name: 

Hi. Service Setting/Model: (check the ONE that most closely fits) 

( l ICF/MR (lntermedial<! Care Facility) ) Famlly/Schoof/Home Based Supports (periodic 

( l Group or Shared Living (3+ clianWindividuals with 2417) services less than 2417) 

( ) Sha"'d or Supported Living (I or2 clienlsilndividualswith 2417) 

(x) Mentor Homef Host Home 

! Clinical/Outpatient Therapy/Rehab (OT, PT, Speech) 

J Day Program 

( ) Group or Shared Living {3+ cllentslindividua!S >Mth lo$S than 2417) 

( ) Shared or Supported Living (1 or 2 clientslindivlduats with less 

) supported EmploymenWocationat 

) School 

than 24/7) 

} Hom$ Health Agency Services 

19.location of Incident {theclc one} 

( ) Mentor Home (x) Primary ( ) Respite. 

Mentor Nl.'lme: 

#of Cllontsnndlvlduals Uvlng in Home: 

( ) Cflentllndividual's Rasldance {group home, !CF, apt) 

t ) Cl!entflnd1viduafs Blolog1cal Family/Guardian Home 

( J Day Program 

( l School 

( ) Ctlent/tndMdual's Place of Employment 

( l Vehicle 

( ) Program Office 

( ) Community 

( ) Other: 

) Brokerage/Case Management (non-resldentlal} 

ZD. Outcorne of Incident (chad all that apply) 

J Remain in Current Placement 

] Placement Oecf$kon Pending 

l Ciien~lndivldual Placed in Reop!te 

1 Placement Disrupted (i.e. CUentl\ndividua! transfarred ta new 

home/ programlplacemont within MENTOR NETWORK) 

l Dischaflled from MENTOR NETWORK 

] Temporarily or Permanently Closed Mentor Home 

] Emergency Psychiatrn:; EvaluaUon {no hospitallntion) 

1 Emergency Psychiatric Hospitalization 

] Emergency Medical Hospitalization 

1 ln~school suspension 

l Schoc! Suopension/E><p\Jislon 

1 Client/Individual ArrestiOetent!on 

[x] Death 

[ l Other. 

•• Client passed away on_ .. in a persistent vegetative state and was venmator dependent 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005081 
515 


26354.449

) Located at the Time of the Incident R~ 

) Unable to Locate at the Time of the Incident Report 

) Other: 

(Suspectedf Alleged or Confirmed) 

Caretaker. 

[ 1 Mentor 

( ) Mentor Family Member 

( 1 Staff 

[ J other Carelal<er. 

Allogod Misconduct: 

[ 1 Se>ual Boundary/Abuse 

l J Verbal or Emo6onat Abuse 

[ 1 Physical AssatJIVAiluse 

( ] CorporaiJ!nappropriate Punishment 

( ] Inappropriate Usa of A.estraint/Physlc:a11nterventlon 

[ J Neglect 

[ 1 Inadequate Supervision 

( 1 Criminat Arrest of Caretaker 

[ J AlcohoVDrug Use by Caretaker 

[ l Misuse ofCiienVlndMduel's Funds 

( ] MisapPrepriation!Oestruction of Clientl!ndivfdua! Personal 

Properly 

1 Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

( ] suicidal Threats Of VertlalizaUons 

[ ] SUicidal Attempt or Gesture 

SEXIiAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ JTo Other Client 

{ ]To Staff or Mentor 

{ ]To Mentor's Fam11y Member 

[ ]To other Third Party 

] To OtherCUent 

1 To Staff or Mentor 

]T"o Mentor's FamUy Member 

]To Other Third Party 

}To Animals (animal c;:ruetty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Self-Injurious Behavior 

] Mental Heahh De~compensation 

1 Oppositional Behaviors 

]lnatJI>'OJ)liate Sa>ual Comments/Threats 

l VBI!Jal Threats of VIOiencs 

1 Exhibitionism/Public Masturbation 

] Medication Error 

] Missing Controlled Substances 

] Serious Adverse Reae:t!oo to Medication 

MEDICAL INCIDENTS: 

[ ] Illness- Reqoiring Medical Treatment 

[ 1 Deterioration In Existing Medical Condition 

[ l Pregnancy 

( ) Seizure Requiring Emergency Treatment 

[ l UTI 

[ J Bowellmpactlon 

[ ] Pneumonia 

( ] Pressure Sores 

[ l othac 

[ ] Physical Assault by Third Party/Othar Individual in our car 

[ ) Sexual Assault by Thirtl Party/Other tndlvidualln our care 

[ I Theft by Third Party 

[ l Fall 

[ ) Choking 

t J Bathing/Scalding Related Injuries 

( l Other Bums 

[ ] Vehicle 

[ ] Swimming/Near Drowning 

[ I Other Accidental Injury 

EXPOSURE CONTROL INCIDENTS: 

[ l Client/Individual Exposed 10 Blood Borne Pathogens 

[ J CllenUindlvidual Exposed Thirtl Party to BlOod Borne 

PROPERTY DAMAGE BY CLIENT/INDIVIDUAL: 

[ I Property Damage Under ~1,000 

[ l Properly Damage Over $1,000 

( ] Vehicle Theft 

[ l Fire Setting 

[ J Thefl!Shoplifllng 

[ 1 Other. 

cllentltndivlduallprogram} 

MATERIALS: (Doflned per 

[ ] Possession of Prohibited Materials (i.e •• alcohol, 

tighter, weapon, pornography, illicit dru!j5, etc.) 

MENTOR0005082 
516 


26354.450

txl Counsellng/Tralnlng fQr Staff!Meofl:!r 

l l ~~=-:Ill,~~\== l l lntemallnveSifgallon Underway 

Jnterveni!QrtS: 

{ JPhysl<:al 

! ]Mechanical 

( ]Seclusions 

t JCnemlo.al 

[x} Ropolted to A<!U!IIChlld Protective 

Sof\'1.,.. 

Date:-

) Substantiated ( ) Unsuhstantiate 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

txl Funding Source Nolllled 

Date: ( J Family Noll:!!iled!!!'!!!!!I!!!!:...-

Date: 

r X] Guarnlan Not!ftod 

Date: 

(x] t.awEn!"i'§!ii~~iiiiiD:nNolilled 

Oate: I!!!!!!!!!!!!!!!!!..-

MENTOR0005083 
517 


26354.451

Signature of State Director (Lavell Print Name Title 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTORODD5084 
518 


26354.452

16. Sen~lco Selling/Model: {checl< the ONE lh•t most closely fite) 

( ) ICFIMR {lntonnedlate Care FacUlty) ) Famlly/SchooVHome Based Suppo<la (periodic 

( ) Group or Shared LMng {3+ cltentsllndivlduol• Wllh 2417) oervlces le .. than 2417) 

( ) Shared or Supported Living (1 or 2 cllenlsllndlvlduals With 2417) 

(x) Mentor Home! Host Home 

( l ctlnieaUOutpatloot Therapy/Rehab (OT, PT, 

( ) Day Program 

( ) Group or Shared Living (3+ c!ienlollndlvldualo wllh less than 24n) 

( ) Sha"'d or Supported living (1 or 2 t:llentsllndividualo wl!h tess 

( J Supported EmploymooWocational 

( I School 

then 2417) 

l Homo Health Agency ServiCes 

19. location of lncldant (cl!ack one} 

( ) Mentor Homo ( ) Plimary ( J Resplta 

Mentor Namo: 

# of Clients/Individuals living In Home: 

( l Cllenlllndlvldual's Residence {group home, ICF, opt) 

( 1 Cllenlllndividuars Elo!oglcal Family/Guardian Home 

( l OayP~UQram 

()Sc!hool 

( ) CUentflndMdual's Placa of Employment 

( ) Vehicle 

( ) P!1>Qr3m0fllce 

( ) Community 

{x) 011\er: Friend's Home 

( ) BroltOI>ge/Csae Management (notHe!ildentlal) 

20. OtJt<:ome of lncldon~ (cllvck .n lh<rt opp/y} 

) Remeln In Cummt Placement ) Placement D<!ciSioo Pendlt1g 

l Cllenlllndlvldual PlaOfld in ReS!lit& 

1 Placement Olstupted (I.e. Cllenlllndlllldual \ranslerted to new 

homel p!OQramlplacement wllllln MENTOR NETWORK) 

J Discharged fl'om MENTOR NETWORK 

J Tempomrily or Permenentty Closed Meotor Horne 

] EmergEncy l'sy!:hlellfc Evalu.,ion (no hospltaU.,I!on) 

l Em&fll"ncy Paychlalrl<: Hosp1tatlzatlon 

l ErnergE!flcy Medical Hospltallzallon 

1 In-school suspeMlon 

l Schocl Suspension!Elqlulslon 

( ] Cllenlllndlvidual Arrest!Delootlon 

[x] O.ath 

[ l Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005085 
519 


26354.453

} Located at the Time of the Incident RepOrt 

} Unable to Locate at tha Time of the Incident Report 

) Other. 

(Suspected, Alleged .,.. Confirmed) 

Ca.mtakar: 

l Mentor 

] Mentor Family Member 

J Sial! 

1 Other Caretaker: 

Allagod Mlscanduct: 

[ l Sexual B<>undaty/Abuse 

( ] Verbal or Emotional Abuse 

( l Physical AssaultfAbusa 

C J CotporaVlnappropriate Punishment 

[ J Inappropriate Use or RestralnUPhysicallntetVention 

[ 1 Negklct 

[ l Inadequate Supervision 

t l Criminal Arrest or ~retaker 

[ J A!cohoUDrtJQ u .. by Caretaker 

[ J Misuse M ClienVInE!ividtJaf's Furlds 

( l MisappropriatiOn/Destruction of Client/Individual Persona! 

Property 

J Other. 

SUICIDAL CUENTIINDIVIDUAL: 

[ 1 Suicidal Threats or Verbalizations 

( ] Suicidal Attempt or Gesture 

SEl!UAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTIINDIVlDUAL: 

I J To Other CUent 

[ ]To Staff or Mentor 

[ Jro Mentor"s Family Member 

[ }To OlherThlnl Porty 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ]To Olhar Client 

[ 1 To Staff or Mentor 

[ ]To Mentor's Family Member 

[ ]To OlherThirn Party 

[ ]l"o Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

1 Missing Controlled Substances 

1 Serious Adverse Reaction to Medlcation 

MEDICAL INCIDENTS: 

( ] Illness Requiring Medical Treatment 

( ] Deterioration In Existing Medical Condition 

t ] Pregnancy 

[ ] Seizure Requiring Emergency Trealrnent 

[ l UTI 

[ ] Bowel Impaction 

t ] Pnellmonta 

[ ] Pressure Sores 

[ ] other. 

[ J ~hysical AssaUlt by Thlrn PartyiOihar Individual in our car 

[ 1 Sexual Assau~ by Thlrn Party/Other Individual in our caro 

[ l Theft by Thin:! Party 

( l Fall 

[ J Choking 

[ ] Balhlng!Scalding Relaled Injuries 

[ J Other Bums 

( ] VehiCle 

( 1 SWimml11!J!Near Drowning 

[ J Other Accidentallnlury: 

El!POSURE CONTROL INCIDENTS: 

{ ] CllenVIndivldual Exposed lo Blood Borne Pathogens 

[ J CllenUindMdual Ei<POSOd Tninl Party to Blood B<>me 

PROPERTY 

[ ] Property Dam890 Und<w $1,000 

r 1 Property Dam890 o"" s1 ,ooo 

[ J Vehicle Theft 

( ] Fire Setting 

[ J TheH/Shopllfting 

( ] Olher: 

POSSESSION OF PROHIBITED per 

~llent/lndivldual/program} 

[ 1 Possession of Prohibited Materials (I.e., alcohol, 

lighter, weapon, pornography. illicit drugs, etc.} 

MENTOR0005086 
520 


26354.454

[ l Counll$llng/Trainln~rl>t Stalf!Mentor 

( I =~~il,''llt'i,=:'U:,V [ 1 Internal Investigation Underway 

Interventions: 

I ]Physical 

I !Me<ho!licat 

r ]Seclusions 

! )Chemieal 

! 

( l Licensing Nohfied 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005087 
521 


26354.455

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005088 
522 


26354.456

8. Population: ( ) Mult(18+) (x) Child 

10. Date of Admission to MENTOR NETWORK: 

11. Length or -

Current Placemen11Services: 

2Years 

9. Sel'lioe Category: (Cir«k one) 

( ) Behavioral Health 

( ) Juvenile Justice 

(x) Medically COmplex 

( ) MRIOD 

( ) MRIOD Otfendor 

) Acquired Brain Injury 

) Elder Care 

) Mental Illness 

) MR/MI 

) Education 

) Other: 

name: 

16. Service Settlng/Mod.el: (chec:k the ONE that most closely fits) 

( ) ICFIMR {Intermediate Ca"' Facllily) { ) FamilyJSchooi/Home Based Supports (periodic 

l ) GltHip or Shared Living (3> clleniSI1ndMduals with 2417) services lass (Jlan 2417) 

{ ) Shared or Supported Living (1 or 2 clienls/individuals with 2417) 

(x) Mentor Hamel Host Home 

l Cllnicai/OutpatleniTherapy/Rehab (OT. PT. 

) Day Program 

( ) Group or Shared Living (3+ cliontslindl'iiduats with less than 2417) 

( ) Shared or Supported u .... Jng (1 or 2 clients/individuals with tass 

) Supported EmploymenWooallonal 

) School 

than 2417) 

) Home Health Agency Services 

11. Oate & 

19.locatlon of Incident: (e~k """) 

( ) Mentor Home { ) Primary ( ) Respite 

Mentor Name: 

# ofCUents/lndfviduals Uvtngln Home; 

( ) C!ientllndividual's Residenc:a (group home, ICF, apt) 

{ ) Client!Jndivldual's Biological Family/Guardian Home 

( ) Day Program 

( ) School 

{ ) Client/lndiiJiduat's Place o.f Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

(x) Other. Hospital. 

) Brokerage/Case Management (non-residential) 

ZO. Outcome of Incident: (check an that apply} 

J Remain in Currant Placement 

] Ptacemeot Decision Pending 

1 ClientJindividual Placed in Respite 

l Placement Disrupted (i.e. Client/Individual transferred to new 

hamel program/pla<:amsnt within MENTOR NETWORK) 

l Oischaryed from MENTOR NETWORK 

] Temporality or PannanenUy Closed Mentor Home 

l Emergency Psychiatric E"aluation (no hospitalization} 

1 Emergency Psychiatric Hospitalization 

1 Emergency Medical Hospitallzation 

] !n~schoal suspension 

J School Suspen>lon/Expulsiorl 

1 Cfientnndividual ArmstiDatention 

[x] Death 

[ 1 Other. 

CONFlDENTlAL PURSUANT TO SENATE RULE 26 MENTOR0005089 
523 


26354.457

I 

) Located at the Time of the Incident Report 

} Unable to L~ate at the Time of the Incident Rep,n1 

) DIJ1et: 

{Suspeclad, Alleged or Confirmed) 

Caretalcer: 

) Mentor 

1 Mentor Family Member 

] Staff 

J Other Caretaker: 

Alleged Mlsconduet: 

[ 1 Sexual Boundary/Abuse 

( 1 Verbal or Emotional Abuse 

t J Physical AssauiVAbtlse 

! 1 Col]loraVInappropriala Punishment 

t 1 Inappropriate Use or Restraint/Physical Intervention 

[ 1 Neglect 

t J Inadequate. Supervision 

( J Criminal Arrest of Caretaker 

l 1 Alcohol/Drug Use by Caretaker 

[ l Misuse of ClienUindlvlduat's Funds 

[ l MlsaPJ)foprlationJOestructlan of CUentllndivldua! Pers,mal 

Property 

1 Dll1er. 

SUtCIDAL CLIENT/INDIVIDUAL: 

t l Suicidal Threats or Verbalizations 

( ] Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENTnNDMDUAL: 

I J Ta Other Client 

[ ]To Staff or Mentor 

[ }fa Mentor's Family Member 

[ l To Other Third Party 

] To other Client 

]To Staff or Mentor 

BY CUENTIINOIVIOUAL: 

1J'o Mentor's FamHy Member 

l To 0111er Third Party 

Jfo Animals (animal cruetty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[ 1 Illness Requiring Medical Treatment 

t J Deterioration in Existing Medlc:al Condition 

[ l Pregnancy 

[ l Seizure Req1.1irlng Emergency Treatment 

[ I UTI 

( l Bowellmpactlan 

t 1 Pneumonia 

[ ) Pressure Sores 

[ l 0111er. 

[ ] Physica!As:sauftbyThlrd Party/Otherlndi-viduafln our car 

( 1 Sexual Assault by Third Party/Other lndMdual in our care 

[ l Theft by Third Party 

[ 1 faij 

[ ] Choking 

I 1 8<1111ing1Scaldlng Rolated Injuries 

1 1 0111erBums 

[ l Vehicle 

t 1 Swimming/Near Drowning 

[ ] Other Accidenlallnjury: 

EXPOSURE CONTROL INCIDENTS: 

{ 1 Client/Individual Exposed to Blood SOme Pathogens 

( l ClienUindlvldual Exposed Third Party to Blood Some 

[ ] Property Damage Under $1,000 

[ J Property Damage Over $1 ,DOD 

[ J VehiCle The~ 

t l Fir& Setting 

[ 1 Theft/Shoplifting 

I l Oll1er: 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

c:Jientllndivfduallprogram} 

( ] Possession of Prohibited Materia$ (i.e., alcohol, 

lighter, weapon, pomogmphy,llllcit drugs, etc.) 

MENTOR0005090 
524 


26354.458

[ J tntemal lnve$tlgati0n Underway 

lnterventfotrs: 

( ]Physical 

( ]Mechanical 

( )Seclusions 

( ]Chemical 

Enforcement 

Services 

Oate; 

) SUbstantiated ( ) Unsubstantiata 

l J Ueensing Notifi•d 

Dato: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Date; 

MENTOR000509 1 
525 


26354.459

Pr1ntName 

Signature of State Director (Level 3 and 4 only) Print Name 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Title 

PC 

Oirec;:tor of Operations 

Title 

Date 

-

Date 

MENTOR0005092 
526 


26354.460

( 1 Behavioral Health 

( ) Juvenile Justice 

(x) Medically Complex 

I l MR/00 

I ) MRIDD Offender 

15. 

( ) Acquired Brain Injury 

( 1 Elder Care 

( ) Mental mnass 

( ) MRIMI 

( ) Education 

( ) Oilier. 

16. Se!vlce SeUing/Model: (check the ONE lllat most eiO!l&ly flts) 

! l ICFIMR (Intermediate Care Facilily) ) Family/School/Home Basad Supports (periodic 

( ) Group or Shamd LMng (3+ clients/Individuals willl 2417) services less than 24n) 

( ) Shared ar Supporied living (1 or 2 cllentsrl!ldMduals with 2417) 

( x) Montor Home/ HQSt Home 

) CllnieaVOutpatlent Therapy/Rehab (OT, PT. 

) Day Program 

( ) Group or Shared living (3+ clients/Individuals with tess than 2417) 

( ) Shanld or Supporied livil1g (1 or 2 clients/Individuals with less 

l Supported EmploymenWocatlonat 

) SChool 

than 2417) 

) Home Health Agency Services 

19. Location of Incident (chock one} 

( ) Mantor Home ( l Prtmary ( l Respite 

Mentor Nama: 

#of Ctlants/hlcllvlduals Living In Home: 

( l CllanUindlvldual's Residence (group home, ICF, apt) 

( ) CtlentllndMdual's Bio:lag!cal Famify!Guardlan Home 

( ) Day Program 

1 ) School 

( ) Clientlfndividual's Ptace of Employment 

( l Vehicle 

( ) Program Office 

( ) Community 

{x) 0111.,.: Hospital 

••cuentdiedon-at-

) Brokerage/Case Management(non·residenUa!) 

20. Outcome of lnddent: (check all that apply) 

] Remain In Currant Placement 

) Placement Decision Pending 

] ClienUindiYidual Placed In Resplle 

] Placement Disrupted (i.e.. C!lenlllndividual transferred to new 

home/ program/placement within MENTOR NETWORK) 

] O!scharged from MENTOR NETWORK 

l Temporarily or PermanenUy Closed Mentor Home 

1 Emetgency Psychiatric Evaluation (no hospitalization) 

] Emergency Psychiatric HcspitaNzation 

] Emergency Medical Ho'l"talizallon 

] ln~school suspension 

] School Suspensloo/Expulsion 

[ ] CUenVIndlvldual ArresUDe1enUon 

[x] Death 

[ l Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005093 
527 


26354.461

} Located at the Time of the lt1Cldent Report 

} Unable to Locate at the Time of the Incident Report 

)Other. 

(Suspected, Alleged or Conflnnad) 

CaTS taker: 

l Menter 

] Mantor Family Member 

J Staff 

l Other Caratakor: 

Al/ogod Misconduct: 

[ J Sexual Boundary/Abuse 

[ ] Verbal or EmoUonal Abuse 

[ J Physical AssauiVAbuse 

[ 1 CorporaJJ!napproprtate Punishment 

( 1 Inappropriate Use of Restrainl/Pflysicallntarvenllon 

L l Neglect 

[ 1 Inadequate Supervision 

[ l Criminal Arrest of Caretaker 

[ ] Atcohot/Otug Use by Caretaker 

t J MlsuseofCIIonVtndlviduars Funds 

[ ] Misappropriation/Destruction of Client/Individual Personal 

Property 

] Diller. 

SUICIDAL CLIENT/INDIVIDUAL: 

( l Suicidal Threats or Verbalizations 

[ J Suicidat Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

( }To Other Client 

[ ]ToStaffnrMentor 

( ]To Menlofs Family Member 

( ] To Olher Third Party 

BY CLIENTnNDIVlOUAL: 

] To Other Client 

] To Staff or Mentor 

]fo Mentor's Family Member 

l To Olhor Third Party 

]To AnimalS (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Setf.fnjurlous Behavior 

J Mental Health De-compensation 

] Oppositional6eha'viors 

] Inappropriate saxuat CommentsiThreats 

]Verbal Threats cfViolencs 

] Exhibitionism/Public Maslurbatlon 

] Medication Error 

1 Missing ControUed Substances 

) Serious Adverse ReacUon to Medication 

MEDICAL INCIDENTS: 

[ ] UlneSIS Requiring Medical Treatment 

[ ] Deteriom.tton fn Existing Medical Condition 

L l Pregnancy 

( ] Seizure Requiring Emergency Treatment 

L l UTI I ] Bowellmpactlon 

{ 1 Pneumonia 

[ l Pressure Sores 

£ I Other. 

( Physical Assault by Third Party/other Individual in our car 

[ J Sexual Assault by Third Party/Other Individual in our care 

! 1 Then byTirirn Party 

[ 1 Fall 

[ I Cho~ing 

[ 1 Batmnglscalding Related Injuries 

{ l OlherBums 

L l Vehicle 

( l Smmlng/Near Drowning 

L I Olhar Accidenlallnjury: 

EXPOSURE CONTROL INCIDENTS: 

( l CuenV!ndlvldual Exposed to 61o0d Borne PalhogOIIS 

{ 1 ClienV!ndilridual Exposed Thirn Party to Blood Borne 

F'ROPERTY DAMAGE BY CUENTIINOIVIDUAL: 

[ I Property Damage Under $1,000 

[ 1 Property Damage Over $1,000 

[ J Vehicle Theft 

[ ] Fire Sanlng 

! l Theft/Shoplifting 

[ 1 Olher. 

POSSESSION OF PROHIBITED MATERIALS: (Defined par 

clientlindloviduallprogram) 

( l Possession of Prohibited Materials (i.e., alcoflot, 

ttghter, weapon. pornography, ilticit drugs, ate.) 

MENTOR0005094 
528 


26354.462

l Counsetlng!Tralning lor Staff/Mentor 

1 ~:.=~~~~~~r 

l lntomallnv&stlgatlon lJnder.vay 

lntervenuon~: 

[ ]Physical 

[ ]Mechanical 

[ ]Seclusions 

[ ]Ch..,ioal 

Enforcement 

[x] Reported to AduiVChlld Proteotive 

Servtcas 

Date: 

) Substantiated ( ) Unsubstantiale 

[ J Licensing Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005095 
529 


26354.463

Print TWo Date 

Program Coordinator 

PrlntName THio 

-

Date 

Manager -

Date 

Signature of state Director (Level3 and 4 only) PrfntName Title Dote 

- Director of Operations -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005096 
530 


26354.464

ij, Service Categol)': (Check ono) 

<xl Beh>Morat Haallh 

( l JwenHe Justice 

( l Medloaly Complex 

I l MR/00 

( ) MRIDD Offender 

) Acquired Brain lniUIY 

) EldetCa1e 

) Mentallllnsss 

)MRIMI 

) Education 

) 011!«: 

name: 

16, Service Setting/Model: (chock the ONe that most closely ~Is) 

1 ) ICFIMR (lntermsdlate Care Facllll)') ) FamHy/Schooi/Home Based Suppblls (periodic 

set\l!ces lesslhan 2417) ( ) Group or Shared l!vtng (3+ cliontsrlfld!vtduats I'Aih 2417) 

( ) Shal'E!d or Supported Uvtng (1 or 2 clientsrmdlvlduals wllh 2417) 

(x) Mentor Home/ Host Home 

l CHnlcai/OutpaUent Therapy/Rehab (OT, PT. 

1 Day Program 

( ) Group or Shared t.Mng (3+ cllenll!llndlvlduafs I'Aih !esslhan 2417} 

( l Shared or Supported Living (1 or 2 cllanll!findlvlduels with laos 

( ! Supported EmptoymanWocationat 

( I School 

lhan 2417) 

) Home Health A9"11<Y Services 

19.Localion of Incident (check ono} 

( ) Mentor Home ( ) Primal)' ( ) RespUe 

Mentor Name: 

#of Cllontollndlvlduals Living In Home: 

( l Cllenllindlvidual's Residence {group home, ICF, apt) 

( ) CllenVIndMdual's 6Jologlcel Family/Guardian Home 

t l Day Pnogram 

{ l School 

( ) Cllerrtllncfwldual's Place of Employment 

( ) Vehicle 

( ) Pnogram Offlca 

( l Community 

lx) other. Exiting school bus outside home 

( 1 Bnokerage/Case Management (fiOtH'aaldantlal} 

20. Dultomo of Incident (check aU that apply) 

[ 1 Remain In current Ploeement 

[ l Placement Decision Pending 

[ l CllenUindMduat Placed in Respile 

[ l Placement Disrupted (I.a. Ctie11UindMdual transferred to new home/ program/placement within MENTOR NETWORK) 

l Dlschal!led hom MENTOR NElWORK 

J Temporarily or Pennanently ClOsed Mi!t'tor Heme 

l Emei!Jency Psychlabic Evaluation (no hosplll>fizatlon) 

l Emergency Psychiatric Hosplt!llil:aden 

J Emergency Medical Hospllallzadon 

l In-school suspension 

l School Suepenalon/Expuislon 

l J Client/Individual Arrest/Detention 

r .. l Death 

[ I Other: 

" Client exited the school bus and was struck by a truck •• was pronounced dead on the scene. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005097 
531 


26354.465

) Located at the Time of 1he Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other: 

(Suspected, Alleged or Confirmed) 

Caretlllcer: 

[ 1 Mentor 

[ 1 Mentor Family Member 

[ l Sta~ 

[ ] Other Caretaker. 

Affeged Mlscooduct: 

[ ] Sexual Boundary/Abuse 

( ] Vertlal or Emollonal At>use 

[ ] Physical AssauiVAbose 

[ J Corpora!/lnappropriala Punishment 

[ ] Inappropriate Use of Restrain11Physica.llnterventlon 

[ l Neglect 

[ l Inadequate Supervision 

[ l Criminal Arrest of Caretaker 

[ ] AlcohoUDrug Use by Caretaker 

[ J Misuse of Cliantl1ndivldual's Funds 

[ ] Misappropriation/Destruction of Client/Individual Personal 

Property 

l Other: 

SUICIDAL CUENTIINDIVIDUAL: 

t ] Suicidal Threats or VerballzaUons 

[ l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR I NAP PROPRIA TE SEXUAL 

BEHAVIOR BY CUENTIINDIVIDUAL: 

[ 1 To Other Client 

[ ] To Staff or Mentor 

( ITo Mentor's Family Member 

[ ] To Other Third Party 

PHYSICAL ASSAULTS CLIENT/INDIVIDUAL: 

[ 1 To Olher Client 

( ]To Staff or Mentor 

[ Jfo Mentor's Family Member 

[ ]To OtherThi<d Party 

( ]To Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

J Setr~lnjurious Bshavior 

] Mental Health Oe~compensatlon 

] Oppositional Behaviors 

] Inappropriate Sexual Comments!Threats 

] Verbal Threats of Violence 

] Exhlbitionism!Public Masturbation 

] Medication Error 

1 Missing ConlroNed Substances 

] Serious Advel'Se Reaction to Medication 

MEDICAL INCIDENTS: 

( l Illness Requiring Medica! Treatment 

[ ] Deterioration in Eltisting Medical Condition 

[ I Pregnarn:y 

[ ] Seizure Requlring Emergency Treatment 

[ ] UTI 

[ ] Bowel Impaction 

[ ] Pneumonia 

[ ] Pressure Sores 

[ ] Other: 

] Physical Asso<Jit by Third Party/Other Individual in our car 

] Sexual AsS81l11 by Third Party/Other Individual In our care 

l Theft by Third Party 

[ ] FaD 

( J Choking 

[ J Bathing/Scalding Relaled Injuries 

[ ] Other Bums 

[ 1 Vehicle 

[ 1 Swimmfng/Near Drowning 

[ ] Other Aa:ldentallnjury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] CliantllndMdUal Exposed to BloOd SOme Pathogens 

( ] Cl!en111ndivklual Exposed Third Party to Stood Borne 

PROPERTY DAMAGE BY CUENTIINDIVIDUAL: 

[ l Property Demage Under$1,000 

( 1 Property Damage Over $1,000 

[ ] Vehicle The~ 

[ l Fire Sel11ng 

I ] Thell'Shop!l~ing 

[ J Other. 

POSSESSION OF PROHIBITED MATERIALS: {DeHned per 

clientllndMduallprogram} 

( ) Possession of Proh!bJt.ed Materials {I.e., atcohof, 

lighter, weapon, pornography, iNicit drugs. etc.) 

MENTOR0005098 
532 


26354.466

I l ~'/.~"~~~==n1or I l Dewa!:l' with Cll&nt/llldlvidual 

( 1 Jntemat Investigation Underway 

Interventions: 

[ ]Physical 

[ ]Mechanical 

[ ]Seclusions 

( )Chemlcsl 

t l Reported to AdulVChild ProtoctiW 

Services 

Date: 

) SubslanUatao ( l Unsubslantlata 

[x] 

from school to the fo•tor homo on lho school bus. It was raport.O that a truck hitbus to cross the street, A Pssserby callecl 911, and once the param.Oics arrlv.O, 

stopp.O breathing. The justice ofthe rer Wll$ contact.O, In whlch.pronouncoti--

caii.O the program manegar at tc report the incident. PM arrlv.O on the see~ 

to tllejustlca of tho peece. Area was >~hut <>ff for -ro;dmatety three houra. Child was transported 

Examine~s offiCe for autopsy. All pertinent contects were made to CPS, licensing, 

The driver of the vehi<:!e was detained end taken into custody 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005099 
533 


26354.467

Print Name Date. 

Print Name T!Ue 

-

Data 

PM 

Signature 

-

Date 

Signature of State Director (Levell and 4 only) Print Name Title Data 

- State Dir, -

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR00051 00 
534 


26354.468

';",,," 

12.Siate: • -

(x) Bahavlo"'! Health 

1 l Juvenlle JusUoe 

( 1 Medloally COmplex 

( ) MRIOD 

( ) MR/00 Ol!endar 

( I Acq"IM! S"'ln Injury 

( l EldorCare ( ) Mental f!lness 

{ I MRJMI 

( 1 EduoaHon 

( l Other: 

1 ti. Servloe Setting/Model: {cl1eck lh• Of'IE that mosl<losely nts) 

{ l ICF/MR (lntenne<fiate Cats Facility) ) Family/School/Home Baaed Supports (periodio 

( 1 Group or Shared LMng (3+ ellants~ndlvidua!• with 24n) se!Vicesle .. than 2417) 

( l Shared or Sup)l<lrted Llvltlg (I or 2 clientS/Individual• wllh 2417) 

(x.} Mentor HomeJ Host Home 

l CllnlcaiiOutpallen! Therapy/Rehab (OT, PT 

l DayProgram 

( I G10up or Shated Living (3+ ellontSIIndMdua!s wilh laS>~ then 24n) 

( l Shated or Supported Llvl"'l (1 or2 ellentsfmdMduala with laos 

( ) Supported EmploymenWocolional 

( ) School 

than 2417) 

l Horne Health Agency Services 

19. Location ollncldent (chock one} 

lxl Mentor Horne lxl Prtmary t l Respl!& 

MontorName:J• 

# of CUantsllndlvldUals Uvln111n Homo' 2 

( ) CUenVIndividual's Residence (glOUp home, lCF, apt) 

t l Cllenlltndlvldual's Bioiol!lcal Fsmlly/13\Jardlsn Home 

! l Dsy Prog"'m 

( l School 

( ) Cllentllndividual"s Place of Employment 

( ) Vehicle 

( ) Program Office 

( ) Community 

( ) Other. 

1 ) Bmkerage/Caoe Management {non-tesldanUal) 

20. Outcome of Incident: (choc~ sll that llPP1Y} 

J Remain in Cuttent Placement 

l Plaooment Decision Pending 

l Cllenlllndlvldual Placed In R .. pl!e 

J Pla<:omont Disrupted (I.a. Cllenlllndlv~al transferred«> now 

horne/ programlplaesrnent whhin MENTOR NETWORK) 

l Dischal\led f!llm MENTOR NETWORK 

l Ternpomrity or Permanently Closed Mentor Home 

1 Emergency Psyclllatrk: Evalua6on (no hos.pital!zallon) 

l Emel\lancy Peyclliatrk: HOs.pilallz:allon 

l Em1>fgency Medical Hospitalization 

]ln•SchoolsuspsnSion 

J Scllool Sus)lSn!iioniExpulsion 

[ J Cfientl!ndlvldual AmlatiDatentlon 

[xJ Death 

[ J O!her. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR00051 01 
535 


26354.469

) Located at the Time of the lnddent Report 

) Unable to Locate at the Time of the Incident Report 

) Other: 

{Suspected, Alleged or Confirmed) 

Caretaker. 

] Mentor 

] Mentor Family Member 

J Staff 

l Other Caretaker: 

Alleged Mls.:;onducL· 

[ ] Se><Ual Boondary/Abuse 

( } Verbal or Emollonal Abuse 

{ ] Physical Assault/Abuse 

[ 1 CorporaUinapptopriate Punishment 

[ ] Inappropriate Use of RestraintJPhysbllnterventlon 

( 1 Neglect 

( l Inadequate Supervision 

( ] Criminal Arrest of Caretaker 

[ J Alcohol/Drug Use by Caretaker 

[ 1 Misuse of ClienUindividual's Funds 

[ l Misappropriation/Oestruction of CtienUindividual Personal 

Property 

J Other: 

SUICIDAL CLIENTnNOIVJOUAL: 

[ ] Suicidal Threats or Verbalizations 

[ ] Suicidal Atl&mpt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BV CUENTIJNOIVIDUAL: 

( JToOtherClient 

[ ]ToStafforMentor 

{ Jfo Mentor's Famlty Member 

{ ] To Other Third Party 

PHYSICAL ASSAULTS BY 

[ J To other Client 

[ ] To Staff or Mentor 

[ ]T-o Mentor's Family Member 

1 l To Other Third Party 

[ ]To Animals (animal Cl'\lelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Medication Error 

l Missing Controlled Sullslances 

l Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] Olness Requiring Medical Treatment 

[ ] Deterioration in Existing Medical Condition 

[ l Pragnancy 

[ ] Seizure Requiring Eme'IJency Treabnent 

[ 1 UTI 

[ ) 8owellmpaction 

{ ) Pneumonia 

t ] Pressure Sores 

[ ] Otheo 

( ] Physical Assault by Third Party/Other Individual in our car 

[ ] Sexual Assault by Third Party/Other Individual in our cara 

1 J Than by Third Party 

[ J Fall 

1 J Choking 

[ l Salhing/Scelding Related Injuries 

[ 1 O!herBums 

[ l Vehicle 

[ l Swimming/Near Drowning 

[ ] Other Accldentallnjury: 

EXPOSURE CONTROL INCIDENTS: 

[ J CflanUindM®al Exposed to Blood Bome Pathogens 

[ ] ClionUindMdual Exposed Third Party to Blood Bome 

[ PropertyDamageUnder$1,000 

[ J Property Damage Over $1,000 

( l Vehl<la Theft 

[ l Fire Setting 

( l TheltJShoplifting 

[ J Other. 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

clientlindlvldual/program) 

[ l Possession of Prohibited Materials (La., ak;ohol, 

lighter, weapon, pornography, lllitft drugs, ate.) 

MENTOR00051 02 
536 


26354.470

[ l ~'l>"ffl~:W.:~~~'::i~~~· [ l Devoloj)ed wilh Client/Individual 

[x] Internal Investigation Underway 

lnlerventlons: 

r !Physical 

( ]Mechanical 

( )Seclusions 

! ]Chemical 

[x]law 

(x] Reportad to AduiVChlld Protective 

SeMces 

Data: 

l Substantiated ( ) Unsubs1antiate 

(X) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

I l Funding Source Notified 

Data: 

(x] Family Notified 

Date:-

[ 1 Guardian Notified 

Oats: 

MENTOR00051 03 
537 


26354.471

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR00051 04 
538 


26354.472

( ) Behavioral Health 

( ) Juvenile Justice 

(x) Medically Complex 

( l MRIOO 

( ) MRIOD Offender 

Name: 

( ) Acqulte<l Brain Injury 

( ) EldarCara 

( ) Menta! illness 

( l MRIMI 

( ) Education 

( ) Ottler: 

16. Service Setting/Model: (chec:k the ONE that most closely nts) 

( l ICFIMR (lnlermodiato Care Facility) ) Familj/School/Home Based Supports {pertodic 

( l GroUp or Shared Living (3+ clients/individuals with 2417) servlteslsss than 2417) 

( ) Shared orSUppodod Living (1 or2 cllanls/individuals with 2417) 

(.x) Mentot Hamel Host Home 

l ClinicaiiOutpatlonl Thempy!Rehab (OT, PT. 

) Day Program 

( l Group or Sharad Living (3+ clients/Individuals with loss than l417) 

( ) Shared orSUpportedLMng (1 or2 clientsllndivldualswith lsss 

) Supported EmploymaniM>catlonal 

) School 

lhan2417) 

) Homa Health Agency Services 

19. Location of lncldent (ch«k one) 

( ) Mentor Homo l l Prlmruy ( ) Respite 

Mentor Name: 

#of Cl!antsllndivfduals Uvlng In Home: 

( l ClienVIndlvldual's Resldonce (group home,ICF, apt) 

( ) C!ie-nllfndfvk:lual's Biological Femity/Guan:llan Home 

( ) Day Program 

( ) School 

{ ) ClientitndMdual's Place of Employment 

( ) Vehlo!e 

( ) Progrem Office 

( l Community 

(xl Other. Hospital. 

) Brokerage/Case Management (nan~residential} 

20. Outcome of Incident: (char:k aft Ym apply} 

] Remain In Current Placement 

J Placement Deeision Pending 

] Client/Individual Placed in Respite 

l Placement Disl'\lpted (i.e. CUentllndfvidual transferred to new 

home/ progcam/placementwtthln MENTOR NE'TWORK) 

l Dlscllarged from MENTOR NE'TWORK 

l Temporarily or PermanenUy Closed Mentor Home 

l Emergency Psychiatric Evaluation (no hospitalization} 

l Emetgency Psychlatrfc tiospitarozatlon 

] Emergency Medical Hospitalizatton 

] In-school suspension 

l School Suspension!Exputsion 

l CllenVlndlvlduaiA<restllletenllon 

[x] Doath 

[ I Other. 

emergency surgeries on-On-client's condition deteriorated and-died at approximately 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005105 
539 


26354.473

l Locate<! at the 11me of tho Incident Rap<>rt 

) Unable to Locate at the rtme of the Incident Report 

l Other: 

(Suspected, AUeged or Confirmed) 

Canrtalter: 

( ] Mentor 

[ 1 Mentor Family Member 

I l Staff 

( ] Other Caretaker: 

Alleged Mlst:onduct: 

t ] Sexual Boundary/Abuse 

[ l Ve.rbal or Emotional Abuse 

[ ] Physical AssauiUAbu.., 

[ l Corporal/Inappropriate Punlsnment 

[ 1 Inappropriate Use of Restraint/Physical Intervention 

[ ] Neglect 

[ 1 lnad8Qllate Supervision 

[ ] Criminal Arrest of Caretaker 

[ l AtcohoVDrug Use by c.,..taker 

( 1 Misuse of Cllenttlndivldua1's Funds 

[ ] Misappropriation/Oestructlon of Client/Individual Personal 

Property 

] Other: 

SUICIDAL CLIENTnNDIVIDUAL: 

( l S1.1icidal Threats or Verbalizations 

t l S1.1icldal Attempt or Gest.ure 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

SEHAVIOR BY CUt:NTnNDIVIDUAL: 

[ I To Ottler Client 

[ ]To Staff or Mentor 

t ]ro Mentor's Famtly Member 

( J To Other Third Party 

ASSAULTS BY CLIENTANDIVIDUAL: 

1 To Other Client 

l To Staff or Mentor 

]To Mentor's Family Member 

]To OtherThlrd Party 

rro Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

1 Missing C011trolled SubstaMes 

l Serious Adverse Reaction tc Medication 

MEDICAL INCIDENTS; 

( ) lllnes$ Requiring Medical Treatment 

[ ] Deterioration in EXisting Medical Condition 

[ ] Pregnancy 

( l Seizure Requiring Emergency Treatment 

[ ] UTI 

[ J Bowel lmpactlon 

[ ] Pneumonia 

[ ] Pressure Sores 

[ l Other: 

( ] Physical Assault by Third Party/Other lrntividual in our cer 

[ l Sexual Assault by Third Party/other Individual in our care 

[ ] Thefi by Third Party 

[ I Fall 

[ 1 Choking 

[ ) Bathing/Scalding Related Injuries 

( ] OtharB1.1ms 

[ ] Vehicle 

[ ] Swimming/Near Drowning 

[ ] Other Accidootallnjury: 

EXPOSURE CONTROL INCIDENTS: 

[ ] Clientllndivkll.lal Exposed to 8food Borne Pathogens 

[ l ClienVIndivldual E"Posad Third Party to Blood Some 

Property Oamaga Unde:r$1,000 

Property Oam.aga Ovel' $1,000 

Vehicle Theft 

Fire SetUng 

Theft/Shoplifting 

other. 

POSSESSION OF PROHIBITED per 

clferttlltldlvlduaVpragram} 

[ J Poseesstan of Prohibiloed Materials (i.e., alcof'lol, 

lighter, weapon, pornography, lUicit drugs, etc.} 

MENTOR00051 06 
540 


26354.474

] Counseling/Training for Staff/Mentor 

1 lSP/Supervisicn/Beha\lioral PJan Developed With ClionllltKfovidual 

} lnternallnvesligation Underway 

Interventions: 

r ]Physical 

( JMochanlcal 

[ ]Seclusions 

[ ]Chemical 

Enforcement 

Date: 

} Substantiated ( } UnsubslanUato 

[ ] Licensing Notified 

Date: 

Data:-

[ x] Guardian No6fted 

Date: 

] Law EnforcementtPro&aUon Notified 

Date: 

Client received twa emergency surgeries on-due to a suspected bowl obstruction and then necrotic bowel. 

Following the second surgery, doctors had dl-l eeplng client's blood pressure up. Client deteriorated the 

momlng o,_and died at appra•lmately 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR00051 07 
541 


26354.475

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTORD005108 
542 


26354.476

( ) Behavioral Health 

(x) Juvenile Justice 

( ) Medically Complex 

( l MR/00 

( ) MR/00 Offen<ler 

) Acquired Brnln Injury 

) Elder Care 

} Mental Illness 

) MRIMI 

) Education 

) Other; 

18. Service Satling/Mo<l<ll: (check the ONE t!lat moot cl-ly filS) 

( l ICFIMR (lntennediate Care Facility) ) Family!SchOCIIHome Basod SupporiS (pariodle 

( ) Group or Sllared LMng (3• cllentsllndMdualo with 2417) services tess than 2417) 

( ) Sharod or Supported Living (1 or 2 clientsfmdlviduals will12417) 

(X) Mentor Home/ Host Homo 

) Cllnlcai!OutpatieniThernpy!Rehab (OT, PT. 

l DayProgrnm 

( } Group or Shared Living (3+ cllanlslindividuals with less than 2417) 

( ) Shared or Supported Living (1 or 2 clientsJ"tndi'oliduats with less 

) Supported Employmeni/Vocational 

) School 

than 2417) 

) Home Heal1h Agency Services 

19. Location of Incident (check one) 

( ) Mantot Home { ) Primary ( ) R-espite 

Mentor Name: 

# of CHants/indiVIduals Uving In Home: 

( ) ClienU!ndMdual'o Raoidence (group home, ICF, apt) 

( ) ClienUindlvldual's Biological Femlly/Guardlan Home 

( ) Day Program 

( ) School 

( ) ClientflndMdual's P1ace of Employment 

( ) Vehicle 

( ) Program Office 

(x) ( ) Com""""l·ty··········· Other. 

l Brokeraqe/Case Managamant (non-residential) 

20. Outcome of Incident: (ohsck olllhot apply) 

1 Remain in Current Placement 

) Placem~:~nt Oec~on Pending 

1 Clientllnd!vidual Plated in Respite 

1 j:)l.1cemant Disrupted {i.e. Cfien11lndividual transferred to new 

~orne/ program/placement within MENTOR NETWORK) 

J lli$dlarg<>d from MENTOR NETWORK 

J TamporarilyorPennanently Closed MenlorHomo 

] Emergency Psychiatric EvaluatitJn {no hospitatization) 

1 Emergency Psychiatric HoapltalizaUon 

J Emergency Medical Hospitalization 

] In-school suspension 

J School Suspenslor1/Expuloior1 

1 ClientllndlvidUal Arresb'Oetention 

[xJ Daalh 

[ J Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005109 
543 


26354.477

) Located at the Time of the Incident Report 

) Unable to locale at the -nme of the Incident Report 

) Olher: 

(Suspected, Alleged or Conflrmad) 

Caretaker: 

( J Mentor 

( J Mentor Family Member 

( J Staff 

{ J Other Caretaker. 

Allaged MlscondU<:t: 

{ ] Sexual Boundary/Abuse 

[ ] Verbal or EmoUonal Abuse 

( I Physical AssautUAbuse 

( J CorporaVInSpproprlate Punishment 

[ ] Inappropriate Use ~f RestrainUPhysical Intervention 

( J Neglect 

( J inadeqiJato Supervision 

t l Criminal Arrest of Caretaker 

£ J AlcohoVOrug Use by Caretaker 

( J Misuse of Cllanlilndivk:lua!'s Funds 

1 ] Misappropriation/Destruction of ClienUindlvlduai Personal 

Property 

J Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

[ l Suiddat Threats or Verbalizations 

[ ] Suicldat Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

t ]To Sl<!florMentor 

[ Jfo Mentor's Family Member 

[ ]To Other Thin:! Party 

ASSAULTS BY CLIENT/INDIVIDUAL: 

] To Other Client 

l To Sial/ or Mentor 

Iro Mentor's F$m!ly Member 

]To OtnerThin:l Party 

j[o AnimalS (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Seif·-lnjurious Behavior 

l Mental Health Qe-.compensation 

] Oppositional Behaviors 

] Inappropriate Sexual Cormnsnts/Threats 

1 Verbal Threats of Violence 

1 Exhibitionism/Public Masturbation 

] Medication Error 

l Missing Controlled Substances 

J Serious Adverse Reaction to Medlc:atlon 

MEDICAL INCIDENTS: 

[ ] llfness Requiring tl!\edlcal Treatment 

[ ] Detertoratlon in Existing Medical CondltLon 

[ J Pregnancy 

[ J Seizure Requiring Emergency Treatment 

[ J UTI 

[ ] BowellmpacUon 

{ ] Pneumonia 

( ] Pressure Sores 

[ l Other. 

[ l Physical Asoault by Thin:! PartyiO!her Individual ill our car 

[ ] Sexual Assault by Third Party/Other Individual in: our care 

t J Theft by Thin:! Party 

[ ] Fail 

[ J Choking 

[ ] B.athlng/Scelding Related Injuries 

[ ] OtherBums 

[ J Vehicfa 

[ l Swimmin!jiNear Drownil\g 

( 1 Other Acr:identoi lnjul)': 

EXPOSURE CONTROL INCIDENTS; 

( 1 ClienVIndlvldual Exposed to Blood Some Pathogens 

[ J CiienU!ndlvldual Exposed Thin:! Party to Blood Borna 

( J Property Damage Under $1,000 

( ] Property Damage Over $1.000 

[ 1 Vehicle Theft 

( l Flre SeHing 

[ ] Theii/Shopliffing 

[ ] Other. 

POSSESSION OF PROHIBITED MATERIALS: (tleflnad per 

cllenlllndlvlduallprogram) 

[ ] Possession of Prohibited Materials (i.e., alcohol, 

lighter, weapon, pomography, illicit drugs, etc.) 

MENTOR000511 0 
544 


26354.478

1 Counsollngll'ralning for SraffiMemor 

1 ~~"='~~"t~C,~=r [x] lntemallnvesllgalion Underway 

lnlerventlons: 

[ ]Physical 

[ !Mechanical 

[ ]Seclusi<ms 

[ !Chemical 

Date: 

} Subs!anUaled ( } Unsubstanbsle 

[ 1 

--~~ .. ~tor,took-andanotherchlldln hercaretoalocalwaterarea near 

~o~saw-swlmml,. When.w<>ntunderthewater and did not emerge, she called 911. The loc"l pollee arrived and searched for In th& water. Subsequently, 

the Mentor reported that the authorities had recovered- body. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOROD05111 
545 


26354.479

Print Name 

Print Name 

Print Name 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Title 

Recn.titer 

Title 

TIUe 

Date 

-

Date 

MENTOR0005112 
546 


26354.480

{ ) Behavioral Health 

( ) Juvenile Justice. 

(x) Medically Complex 

( l MRIDD 

( ) MRIDO Offender 

) Acquired Brain Injury 

) Elder Care 

) Mental Illness 

) MRIMI 

l Education 

)Other. 

name: 

16. 5ervice Setting/Model: (check tho ONE that m<>st clcsofy flu) 

{ ) fCFIMR (fnlennedlate Care Fadllly) ) Famny/Schooi/Horne Based Supports (periodic 

( ) Group or Shared Living (3+ clients/individuals with 2417) services Jess than 24f1) 

( l Snared or Supported Living (1 or 2 clients/individual• with 2417) 

{xl Mentor Home/ Hoot flame 

l Clink:ai/Outpatlenl The,.pyiReha~ (OT, PT. 

) Day Program 

{ ) Gtoup or Shared liVIng (3>elienlslindivlduals ..;th l .. s than 2417) 

( l Shared or Supported living (1 or 2 cllenls/indivlduals ..;lh less 

) supported EmploymenWoeallonal 

) School 

lhan2417) 

) Home Heallh Agency Se<vlcas 

19. L-ocation of Incident; (check one) 

(x) Mentor Home {x) Primary { ) Respite 

~:~:;;;.~:r~d'•'JJ. tl.lno I. Hom•: 2 

( ) ClienUimlividual's Residence (group homo, ICF, apt) 

( ) Cllentllndivkfuat's Biological Family/Guardian Home 

( l Day Program 

1 l Sel1ool 

( ) Client/Individual's Place of Employment 

( ) Vehicle 

( ) Program Offi<e 

( ) Community 

( ) Other. 

) Brokerage/Case Managernant (non-residential) 

20. Ovtcome of Incident: (check aU that apply) 

] Remain in Current Placement 

J Placement Decisi-on Pending 

l CllenUtndilllduel Placed In Respite 

] Placement OtSNpted (i.e, ctientllndlvldual transferred to new home/ programlplacementwllhln MENTOR NETWORK} 

J DischaiJied from MENTOR NETWORK 

] Tempotwily or PermanenUy Cfo!ied Mentor Home 

] Emergency Psychiatric EvaluaUon (no hospitar!Uticn} 

] Emergency Psychiatric Hospitall.zation 

l Emergency Medical HospltaHzalion 

1 ln-scl'tool suspensio11 

] School SuspensloniExpulslon 

1 ClieoUindlvidual Arresl/Ootentlon 

l•J Death 

[ l otner. 

• On-the client passed away as a result of. medical C<Jnditlons. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005113 
547 


26354.481

l Located at the Time of the Incident Report 

) Unable to Locate at the nme of the Incident Report 

l Other. 

(Suspected, Alleged or Confirmed) 

Careta/fer: 

r 1 Mentor 

[ J Mentor Family Member 

[ l Staff 

[ J Othar caretaker. 

Alleged Mlsoanduct: 

[ ] Seltual Boundary/Abuse 

t 1 Verbal or Emotional Abuse 

[ J Physical AssauiVAbuse 

[ I CorpOialllnapprnpriate Punishment 

[ 1 lnappropriate Use of Restraint/Physical Intervention 

[ l Neglect 

[ J Inadequate SupeNision 

[ ] Criminal Arrest of Caretaker 

( l Alcoh<>VOrug Use by Caretaker 

[ l Misuse ~I CHenUifl<li'lidual's funds 

t 1 MisappropriationJOeslruction of Clientl!ndiv!dual Personal 

Property 

l Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

[ l Suicidal Threats or Vertafizalions 

[ ) Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTIINDIVIDUAL: 

( }To Other Client 

( }To Staff or Mentor 

( ]To Mentor's Family Member 

[ ]To Other Third Petty 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

t }To OlherC!iant 

[ ]To Staff or Mentor 

[ ]To Mentor's Family Member 

[ ]To OtharThln:t Par1y 

[ ]To Animals (animal cruerty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] llfne.ss Requiring Medical Treatment 

t l Deterioration in Existing Medical Condition 

[ l Pregnancy 

( l Seizure Requiring Emergency Treatment 

[ l UTI 

[ 1 Bowel Impaction 

[ 1 Pneumonia 

[ ] Pressure Sores 

[ l Other. 

( ] Phystcal Assault by Third Party/Other Individual in ollt car 

[ 1 Sexual Asseult by Third Par1yl0ther Individual ln our care 

r 1 Then by Thln:t Par1y 

[ I Fall 

[ l Choking 

[ ] Bathing/Scalding Related Injuries 

{ ] Other Bums 

[ J Vooicle 

( ] Swimming/Near Drowning 

[ I Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ l CfienUindivldual Expa•od to Bload Borne Path~ens 

[ J CfienlilndiVidual Exposed Third Party to Blood Some 

PROPERTY DAMAGE BY CUENTIINDMDUAL: 

[ ] Property Damage- Under $1,000 

[ J Property Damage Over $1,000 

[ ] Vehicle Theft 

[ l Flre Settlng 

[ l Thai\/Shoptlftlng 

[ l Other: 

POSSESSION OF per 

cllontltndlvldual/pragram) 

( l Possession of Prohibited Materials (I.e .• alcohol, 

tighter, weapon, pornography, iHicil drugs. etc.) 

MENTOR0005114 
548 


26354.482

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005115 
549 


26354.483

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005116 
550 


26354.484

9. Service Categ-ory: (Chaclc ona) 

{~) 8$havioral Heallfl 

{ ) Juvenile Justice 

( ) Medltally Complex 

( ) MRIOD 

( l MRIOD Offendet 

) Acquired Brain Injury 

) Elder Care 

) Mental INness 

) MRIMI 

1 Educallon 

l other. 

15. SONice Setting/Model: {check the ONE that mast closely Ill!>) 

( l ICFIMR {lnlennedlate Cara Facility) ) F amily/SchooVHome Based Supports (poriodlc 

( l Group or Sharad Living {3+ clienlsllndividuels with 2417) services less than 2417) 

( l Sharad or SuppOrted Living (1 or 2 clients/indMduels with 2417) 

(x) Mentor Home/ HQ>II Home 

) Clinicat!Outpallent Therapy/Rehab(OT, PT, Speech) 

) DayProgram 

{ 1 Group or Shared living (3+ clients/individuals wiltllesslhan 2417) 

( ) Shensd or SuppOrted Living (1 or 2 clients/individuals wiltlless 

) Supported EmplaymenWacotlonal 

l Schaal 

then24fl) 

l Home Health Agency SONices 

19, Location of Incident: (check one} 

( l Mentor Home ( ) Primary 1 l Respite 

Mentor Nama: 

#of Cl'-"1$/lndlviduals Living In Homo: 

( l Cllent/lndivl<lual's ReSidonca {group home, ICF, apt) 

( ) Cltentilndlvldual's Biological FamilyfGuardian Home 

( ) Dey Program 

( l S<haol 

( ) Client/Individual's Place of Employment 

( l Vehlde 

( ) Program Office 

(x} Communily 

( l Other. 

) Brokerage/Case Management (non.r&Sidential) 

2D. Oulcome of lncl<lent (check all 1/Jal apply) 

1 Remaln In Current Placement 

1 Fl!acetnent Decrslon Pending 

l CllentllndMdUal Placed In Respite 

1 Placement Disrupted (i.e. Glienlllndivlduaf lransferrQd to new 

home/ program/placement within MENTOR NSIWORK) 

l Discharged from MENTOR NETWORK 

J Temporarily or PEmllanenlly Clocsed Mentor Home 

J Emergency Psychiatric Evaluation (no haspit.afization~ 

] Emergoru;y Psychiatric Hospitaflzation 

l Emergency Medical Hospitalization 

J In-school suspension 

1 School Suspension/Expulsion 

[ ] Client/Individual Arrest!Oetention 

[>:]Death 

I l Olher: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005117 
551 


26354.485

} Located at the Time of the Incident Report 

) Unab1a to Locate at the Time of the Incident Report 

) Other. 

(Suspected, Alleged "' Confirmed) 

Caretaker. 

[ J Mentor 

[ l Mentor Family Member 

( 1 Staff 

[ 1 Other Caretaker: 

Altego<l Mhloanduct: 

t l Sexual Boundary/Abuse 

[ l Veltal or Emotional Abuse 

[ ] Physical AssauiUAbuse 

( ] Corporal/Inappropriate Punishment 

( ] Inappropriate Us&Qf Restraint/Physical intervention 

[ 1 Negloci 

[ l lnadeqllata Supervision 

[ l Criminal Arrest of Caretaker 

[ J AlcohoVOrug Use by Caretaker 

1 1 Misuse of CllonUlndMUual's Funds 

[ I Misappropriation/Destruction: of C!iantllndividual Personal Property 

l Other: 

SUICIDAL CUENTnNDIVIDUAL.: 

{ ] Suicidal Threats or Verbalizations 

[ xl Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ J To Other Client 

[ ]TcStafforMentor 

( ]To Mentor's Family Member 

[ )To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ] To Other Client 

[ ) To Staff or Mentor 

[ ]To Me-ntor's Family Member 

[ ]To Other Third Party 

[ ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

]Medication Error 

J Missing Conlrolled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL 

( l Illness Requiring Medical Treatment 

[ J Deterioration in EJdsting Medical Condition 

[ l Pregnancy 

[ ] Seizure Requiring Emergency Treatment 

[ l UTI 

[ I Bowel Impaction 

f ) Pneumonia 

[ l Pressure Sores 

[ I Other: 

( Physical Assault by Thlr<l Pat1y!Other Individual in our car 

[ 1 Sexual Assault by Thir<l Party/Other IndiVidual in ourt:are 

I 1 Theft by Third Party 

I 1 Fall 

[ 1 Choking 

[ J Bathing/Scalding Related Injuries 

[ 1 Oilier Bums 

[ 1 Vehicle 

[ J Swimming/Near Drowning 

[ J Other Accidental 

EXPOSURE CONTROL INCIDENTS: 

[ I CllenlllndiVidual Exposed to Blood Some Pathogens 

[ 1 Client/Individual Exposed Third Party to Blood Borne 

[ J Property Damage Under $1,000 

I l Property Damage Over $1,000 

I 1 Vehicle Theff 

( J Fire Setting 

l I Thcft/Shopllfling 

t l Other. 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

cllenUindlvlduoUprogram) 

( ] Posoession of Prol1lbited Materials (i.e .. alcohol, 

lighter, weapon, pomograptty, illicit drugs, etc.) 

MENTOR0005118 
552 


26354.486

[ l Counseling/Training for Staff/Mentor 

r 1 ~~~~~~'!n~.l'~~r [ l Jntemallnvestig•tion Underway 

lnterventiolls: 

]Physical 

]Mechanical 

]Seclusions 

]Chemical 

enrorcomem 

[ J Reportod to AduiUChlld Protective 

Serviees 

Oate: 

l Substantiated ( ) UnsubstanUate 

r 1 

[ ] Funding Source Notified 

Date: 

[x] Family Notified 

Date:-

[xl Guardian Notified 

Oata: 

On-call worke..-wa• eontact.ct by-. th"grandmother of , Inform worker~ hed eommitted suicide this momlng whil&at a friend's home, 

that-friend's mother found- hanging from a tree rn their front yard. 911 was called 

able ~life. Ms •• reports that no police report is available at this time. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005119 
553 


26354.487

Signature of State Dlrec:tor {level 3 and 4 only) Print Name TIHe Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005120 
554 


26354.488

(xl BehaVioral Health 

( ) Juvenile Jusfice 

( ) Medically Complex 

( l MRIDO 

( ) MRIDD Offender 

) Acquired Brain lnju.y 

) ElderCa"' 

) Menial Illness 

) MRIMI 

) EduoatiOfl 

) Othar. 

16. Service SeWng/Model: (choc~ the ON~ that most closely flts) 

( ) ICF/MR (lntormedlale Care Facility) ) Family/School/Home Basad Supports {periodic 

{ ) Group or Shared living {3+ clients/individuals with 2417) servlees less !han 2417) 

( ) Shared or Supported LIVing ( 1 or 2 tllentsllndliilduals with 2417) 

(x) Mentor Ho""'l Host Home 

) CllnicaUOutpatlent Therepy/Flehab {OT. PT, 

l Day Program 

( } Group or Shared Living {3+ clientsllndivlduals with less than 2417) 

} Shared or Supported Living (1 or 2 clients/individuals Wt"ttt less 

than 24/7) 

) Supported EmploymfJfiWocalional 

l School 

} Brok.erag-eJCase Management (non-residential} 

) Home Health Agency Services 

19. L.ocatlon of Incident: (check one) 

( ) Mentor Home ( ) Primary { ) Respite 

M~ntor Name~ 

N of Cllen.,llm!lvtduals UYlng In Home: 

( } ClienUindMdual's Residence (group homo.. ICF, apt) 

( ) CUentltndivldual's Biologlc:a! Farnlly/Gua.tdian Horne 

( ) Day Program 

( ) School 

( } Client/individual's Pl~e of Emptoyment 

{ ) Vellicle 

{ ) Program Office 

{ ) Community 

{x) Other: on run status .. grandmothers hous 

By: (Name & 1itle) 

20. Outcome of Incident (choek all tbt apply) 

] Remain in Current Placement 

] Placernent Decision Pending 

] CllenUindlvldual Plat>!C In Respite 

l Placement Disn.rpted (i.e. ClienVIndividua.l transferrad to new 

home/ pmgramlp!ecement wtthln MENTOR NETWORK) 

I Dis<:flalged fmm MENTOR NETWORK 

1 Temporarily or Permanentty Closed Mentor t1ome 

] Emergency P5ychlatric E\taluation (no hospitalization) 

l Ef!10199ncy Psychiatric Hosp;!ali:afion 

] EIT\Sill<lncy Ml!dical HoSpitalization 

] In--school suspension 

1 School Suspenslonl~xpulslon 

] Cllent/lndMdual Arrest/Detention 

[xJ Doath 

I l Dlher: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005121 
555 


26354.489

) Located at lhe Time of ill a Incident Report 

) Unable to Loeate at the Time of the Incident Report 

} Other. 

(Suspected, Alleged or C-onfirmed} 

Cam hiker; 

[ ] Mentor 

I l MentorFarnlly Member 

I l Staff 

1 l Olhor Caretaker: 

Alleged MfscandU<t: 

1 l SeJo;aiBoundary/Abusa 

t 1 Verba! or Emotional Abuse 

[ l Physical AssauiUAbuse 

( 1 Corporalllnappro!Jriate Punishment 

[ ] Inappropriate Use ofRestraintJPhysicallnlerventiOn 

[ 1 Neglect 

1 l Inadequate Supervision 

1 l Criminal Arrest of Caretaker 

1 1 AlcohoWDtug Uoe by Caretaker 

{ 1 fl/lisuse of ClientltndMduars Funds 

t } Misappropriation/Destruction of C!lenlllndhlidual PetSDnaf 

Property 

l Other. 

SUICIDAL CLIENTnNDIVIDUA~: 

( 1 Suicidal Thteats or Verbalizations 

( I Suicidal Altempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUA~ 

BEHAVIOR BY C~IENTnNDIVIOUAL: 

( ]To Other Client 

[ )To Stall or Mentor 

( :rro Mentor's Family Member 

[ ]To OthorThird Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL; 

[ ]To Olher Client 

[ 1 To Staff or Mentor 

t }fa Mentor's Family Member 

[ l To Other Third Party 

[ ]fo Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Meo!cation Error 

J Mis5ing Controlled Substances 

l Serious Adwrsa Reaction to Medication 

MEDICAL INCIDENTS: 

[ l Illness Requiring Me<fica! lreatrnent 

[ 1 Deterioration In Existing Medical Condition 

[ l Pregoancy 

[ 1 Seizure Requiring Emergency Treatment 

{ ] UTI 

[ 1 Bowellrnpaction 

1 1 Pneumonia 

[ ] Pressure Sores 

1 1 Olher. 

t Physical AssauR by Third Party/Oiher ltldividual in otlf car 

[ J SelQJal Assault by Thfrd Party/Other Individual in our care 

r J Then by Third Party 

[ J Fall 

( J Choking 

{ 1 Bethiog/Scalding Relate<! Injuries 

1 l Oll>orBums 

[ 1 Vehicle 

( l S>Wnrnlng/Noar Crowning 

[ ] Other Accidenlallnjury; 

EXPOSURE CONTROL INCIDENTS: 

( J CtlenVtndlvirlUa! Exposed to Blood Borne Pathogens 

1 1 CtionUindivirlUal E•pooe<f Third Party to BlOOd Borne 

PROPERTY DAMAGE BV 

I I Property Oamage Under$1,000 

[ ] Property Damago Over $1,000 

[ ] Vehicle Theft 

[ 1 Fl"' Selling 

! J Theft/Shopli~lng 

1 l Olhor: 

POSSESSION OF PROHIBITED MATERIALS; per 

clientlindMduallpmgram) 

[ ] Passe:Ssion of Prohibited Materials (i.e.1 alcohol, 

lighter, weapon, pornography, Illicit drugs, etc.) 

MENTOR0005122 
556 


26354.490

1 Counseling/TRllnlng for Staff/Mentor 

l ~=~ll.·~.:n~= J Internal ln.estigalion Underway 

Interventions: 

[ )l'hysica! 

[ ]Medlaoical 

[ )Seclusions 

I }Chemical 

[ }Law Enforcement 

anything to 

couple clays, 

too upset and gave It to pollee confirmed the event and stated that the 

[ ) Reported to AduiVChild Proteetlve [ I Funding Soun:e Notified 

Services 

oate: 

) Substantiated ( ) Unsubstandate 

licensing NotiFied 

Date: 

Notified 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR00051?3 
557 


26354.491

state Director (level 3 and 4 only) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005124 
558 


26354.492

(x) Beha'lioral Health 

( ) Juvenie Justice 

( ) Medically Complex 

! I MRIOO 

( ) MRIOO Offender 

l Acqulrod Brain Injury 

) Elder Care 

( ) Mental Illness 

( l MRIMI 

( ) Education 

t 1 Other. 

16. Service Setting/Model: (check !ho ONE!hel most clooelytlts) 

{ l ICFIMR (lnte<medlato Care Facility) ( J Famlly/SohooUHome Based Supports {pllliodic 

{ l Gnrup or Shared lilting (3+ cllentsilndiltlduals with 2417) services less lhan 24tr} 

( l Shared or Supported Lllling (1 or2 cllentsilndiltldualswlth 2417) 

btl Mentor Hemet Host Home 

Cllnlcai/Oulpatlent Therapy/Rehab (OT, PT, 

( ) Cay Program 

( I G<Oup or Shared LMng (3+ cllenls/lndivlduala with lllss than 2417) 

( ) ~dorSupportedU\Iing(1 ar2c!ientslindMduafswithless 

( J Supported EmplaymonWocational 

( ) SchOOl 

than24!7) 

( l Home Health Agency Services 

19. location of Incident (cheek one} 

( l Montor Homo ( ) Primary ( ) Respite 

Mentor Name: 

it of Cllentallnd1vtduals Uvlng in Home: 

( l ClienUindividual's Residence (group home, ICF, apt) 

( ) C!ieotifndlvlduaf's Biological Family/Guardian Home 

( l Cay Program 

t l Schaal 

( ) Client/lndividuai's Pt~e of Employment 

( ) Vehicle-

( l Program Ollice 

(x) Community 

I ) Other. 

( ) Brokmage!Case Management (non-residential) 

20. Outcome of Incident: (chock all that apply) 

] Remain Jo CUrrent Placement 

] Placetnant Oociskm Pending 

J ClientllndiYidual Placed In Rest>lle 

J Placement Disrupted (i.e, Clientlindivldual transferred to new 

heme/ program/placement within MENTOR NElWORK) 

l Oisch"'!led from MENTOR NETWORK 

] Tempora.rify or Pennanently Closed Mentor Home 

] Emergency F'syehiatric Evaluation (no hospltatization) 

] Emergency Psychiatric HospitaUzatfon 

l Ema'ljOncy Medical Hospitalization 

1 In-school suspension 

J School Suspenslon/Exputsloo 

( J CllenVIndiltldual ArrestiDetentlon 

[x] Oaalh 

( J Other. 

-client was on an approved weekend visit with h~. Mr.-=aUed······· Mentor, and 

shared- had been shot and kiUed While In a~Ood Resiitlrant In the eommunlty. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTORDD05125 
559 


26354.493

) Located at the Time of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

) Other. 

(Suspected, Alleged or Conftnned) 

Carafaker. 

( ] Mentor 

r_ ] Mentor Family Member 

[ J Staff 

I 1 Other Caretaker: 

Allogad Mlsoonduct: 

I J Sexual Boundary/Abuse 

[ ] Verbal or Emotional Abuse 

[ ] Physical Assault/Abuse 

[ J Corp<m~lnnappropriate Punishment 

( ] Inappropriate Use of Restraini!Ph~sicallntervention 

I J Neglect 

[ J Inadequat-e Supervision 

[ ] Crimlna.J Arrest of Caretaker 

1 1 AlochoVDrug Use bY Caretaker 

[ 1 Misuse of Clienlflndivldual's Funds 

[ J Misappropriation.IOestructlon of CHentJlodividual Personal 

Proporty 

1 Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

[ J Suicidal Threats or Veibatizafions 

( J SU.icidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ ]lo Other Client 

[ )ToStafforMaotor 

t ]To Mentor's Family Member 

[ ]ToOtherThirdParty 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ]To Other Client 

[ 1 To Staff or Mentor 

[ Jro Mentor's Family Member 

[ 1 To Other Third Party 

[ Jfo Animals (animal cruelly) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[ ] lttness Requiring Medical Treatment 

( ] Deterioration in Existing Medical Condition 

( ] Pregnancy 

I 1 Seizute Requiring Emergency Tteatment 

I l UTI 

[ ] BowallmpacUon 

( ] Pneumonia 

[ ] Pressure Sores 

[ 1 Other. 

1 Physical Assault by Third Patty/Other lndi\lidual in our car 

[ 1 Se•uat Assault by Third Party/Other lndMdUal in our care 

[ 1 The" by Thlrtl Party 

[ J Fall 

[ 1 Choking 

[ 1 Batlhilg/Scaldlng Related Injuries 

[ 1 Other Bums 

[ 1 Vehiclo 

[ ] Swimming/Near Drowning 

[ l Other Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ 1 Clientl!ncflvkluaJ Exposed to Blood Borne Pathogens 

[ 1 cr.enUindMdual Exposed Thlrtl Party to BloOd BQme 

PROPERTY DAMAGE BY CUENT/tNOtviOUAL: 

[ 1 Property Damage UnO<r $1.000 

[ J Properiyoamageav.,.S1,000 

[ l Vehicle Theft 

[ l Fire Setling 

[ ] Theft/Shoplifting 

[ ] Other. 

POSSESSION Of PROHIBITED MATERIALS: (Defined per 

ctlenUindlvldual/program) 

[ ] Possession of Prohlblted Materials (i.e., alcohot, 

lighter, weapon, pornography, illicit drugs, etc.) 

MENTOR0005126 
560 


26354.494

[ l COunselingrTrolnlng for SlafiJMonlor [ J ISPISuperv!ski111Bahav!oml Plan D<woloi»<! wllh Clie!ltllr>dMd..-1 

r l lnlornallnvestigalion Underway 

JntervrtmtiQM: 

r ]Physical 

[ ]Mechanical 

r jSecluslono 

r ]Cnemltol 

Dale: 

) SUbstanlla!ed ( ) Unsubs!anliale 

[X) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005127 
561 


26354.495

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005128 
562 


26354.496

(x) Behavioral Health 

( ) Juvenile Juslica 

( ) Madically Complex 

! ) MR/00 

( ) MR/00 otrendar 

) Acquire<! 8r11ln Injury 

) Elder Care 

) Menial !Unasa 

) MR/MJ 

) Education 

I Other. 

16., Service Setting/Model: (chedt the ONE that must c1osely fits) 

l ) ICFIMR (Intermediate Care Facilijy) ) Family/School/Home Based Supports (periodic 

( ) Group or Shared Living (3+ dieniSIIndivlduals wilh 2417) services less than 2417) 

( ) Shared or SuppQrted Living {1 or 2 clientslindNiduals with 2417) 

(x) Menlt!rHorno/Ha.tHome 

l Clinical/outpatient Therepy/Rehab(OT, PT. 

l Day Program 

! ) Group or Shared Llvil\9 (3+ clienl$/indivlduals with less than 2417) 

( I Shared or Supported Uvi119 (1 or 2 clieniSIIndlvlduals wilh less 

l SuppQrted Employrnent/Vocalional 

l School 

than24/7) 

) Horne Heallh Agancy Services 

19. Location of Incident (chock ono) 

!x) Montor Home (x) Primary ( ) Respite 

Mentor Name: 

fl of CUantsllndlvtduals l..lvfng In Home: 

{ } ClientlltldMdual's Residence (group home, ICF, apt) 

( } Clientltndivtdual's Blolcgical FamltyiGuard!an Home 

( ) Day Pr<Jgram 

( ) School 

( ) Clientllndividual•s Ptaca of Empk!yment 

( ) Vehicle 

( ) Prog""" Office 

l l Community 

( ) Other. 

) Brokeragetcase Management (non-residenUal) 

20. Outcome of Incident: (cho<;k all that apply) 

1 Remain In Current Platement 

l Placement Decision Pending 

1 Cllent/1ndlvidual Place<! in Respite 

J Placemel"!t DlsnJpted (i.e. ClienlllndlVidual transferred to new 

home/ programlplacsment within MENTOR NETWORK) 

l Discharged from MENTOR NElWORK 

J Temporarily or PermanenUy Closed Mentor Home 

1 Emergency.Psychiabic Eva.luaUon (na hospitalization) 

l Emergency Psychiatric Hospitalization 

] Emergency Medical HospilaUzalion 

l In-school suspension 

J School SuspensloniExplllslon 

( ] Cl:i&nlllndividual Arrest/Detention 

[x] Oeeth 

[ l Other: 

call coordinator dien!-had stopped breathing. At the time of 

-.,as being transported to-Hospital- was pronouneed dead at 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005129 
563 


26354.497

} located at the nme of the Incident Report 

) Unable to Locate at the Time of the Incident Report 

)Oiher. 

(Suspected, Alleged or Confirmed) 

Caretaker. 

[ ] Mentor 

[ J Mentot Family Membor 

[ J Staff 

( ] Other Caretaker: 

Allogod Mtsconduef: 

( ] Sexual Boundary/Abose 

[ J Verl!al or Emotional Abuse 

[ 1 Physical AssauiVAbuse 

[ ] CJrporaVInapproprtate Punishmoot 

[ l Inappropriate Use of Restraint/Physical !nte.vention 

[ ] Neglect 

[ J Inadequate Supervision 

( ] Criminal Arrest of Caretaker 

[ l Alcohol/Drug Use by Caretaker 

[ l Misuse of Cfiant/111\fivtduars Funds 

( ] MisappropriaUoniOestrucUOn of Client/Individual Personal 

Property 

] Other. 

SUICIDAL CliENTflNDIVIDUAL: 

( 1 Sulddaf Threats or Verbalil.!llions 

[ I Suiddal Atlampt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CU~NTnNDIVIDUAL: 

[ I To Olher Client 

( ]To Staffer Mentor 

[ ITo Mentors Family Member 

[ JTO Other Third Party 

PHYSICAIL ASSAULTS BY 

[ J To OtherCtient 

[ 1 To Staff or Mentor 

[ ]To Mentor's Family Member 

[ J To 01her Third Party 

[ )fo Animals (animal cruelly) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

1 Medication Error 

] Missing Controlled Substances 

1 Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

[ J Illness Requiring Medical Tr<>atment 

[ ] Deterioration in Existing Medical Condltlon 

[ l Pregnancy 

[ ] Seizure Raqu1ring Emergenr.::y Trea1ment 

[ l UTI 

[ l BowellmpacUon 

[ ] Pneumonia 

[ l Pressure Sores 

[ ] Olfler. 

[ ] Physical Assault by Third Party/other Individual in our car 

[ J S.UCual Assauft by Third PartyiOiher lndll'l<lualln our care 

[ J TheR by Third Party 

( J Fall 

[ J Choking 

[ ] Bathing!Scaldin!J Related Injuries 

( 1 OlherBums 

! 1 Vehicle 

[ I Swimmlng!Near Drowning 

( l Olher Accidental 

EXPOSUR~ CONTROL INCIDENTS: 

[ 1 Cilen~lndlvidual Exposad to Blood Some Palhogens 

[ ] CllooU!ndlvldual exposed Third Party to Blood BorM 

BY CUENTnNDIVIDUAIL: 

[ ] Property Oomago Undsr$1,000 

[ l f'ropertyDamageOver$1,000 

[ l Vel'licte Theft 

[ 1 Fire SoHing 

[ J Theii/Shopllfting 

[ l 01her. 

PROHIBIT~O MATERIALS: (Defined per 

cUentJindlvldual/program) 

[ l Possession of Prohibited Materials {i.e., alcohol, 

llghter, weapon, pornography, illicit drugs, etc.) 

MENTOR0005130 
564 


26354.498

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005131 
565 


26354.499

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005132 
566 


26354.500

9. SeNlce Category: (Check one) 

( ) Behavioral Health 

( ) Juvenile JusUce 

(x) Merllcolly Complex 

( ) MR/OD 

( ) MR/00 Offender 

15. 

) A<qulrad Brain Injury 

) EklerC!lle 

l Mental illness 

) MAIM! 

) Edu..Uon 

)Other. 

15. Sennce Setting/Model: {check 111e ONE that most closely fits) 

( ) ICFIMR {lntennediate Cere Facility) l Family/School/Home Basad Supports (periodic 

( ) Group or Shared LMng (3+ clienls~ndividuats with 2417) services less Ulan 2417) 

( l Shared or Supported Living (1 or 2 cliantslindivlduals with 2417) 

(x) Mentor Home/ Host Home 

l CllnlcaVOutpallent Therapy/Rehab (ot, PT, Speech) 

l Oay Program 

( ) Group or Shared living (3+ clientslindi'liduals with less than 2417) 

( ) SharadorSupportadLiving(1 or2cllentsllMividualswithleos 

) Supported EmploymenWocaUonal 

) School 

than 2417) 

{ ) Home Health Agency Se,...lcas 

19. Le<etlon of tnddent: (chock ono) 

(x) Menlor Home (:It) Primary ( ) Resplte 

Montor Nama: ,--~~~~"*~=-_:__, # Of Cllon~ndlvfduals LMng [II Home: 1 

( ) CUantl1ndMdual's Residenca (group home, ICF, apt) 

( ) Cllenlllndlvldual's Biological Family/Guardlan Horne 

( ) Day Program 

( ) School 

( ) Client/Individual's Place of Employment 

( ) Vahicla 

( ) Program Office 

( ) Community 

( ) Other. 

) Brokerage/Case Management (non-residential) 

18. 

20. OUlcome of Incident: (chock •II !hat apply} 

1 Ramatn. in Current Placement 

] Placement Decision Pending 

J Cllen~lndMdual Placed In Resplle 

J Placement Oisrupled {I.e. Clienl/lndividuallransferred to new 

home/ program/placement within MENTOR NETWORK) 

l O!schargad !rom MENTOR NETWORK 

] Temporal'lfy or Permanently Closed Mentor Home 

] Emergency Psychiatric EvaluaUon {no hospitatiZaUon} 

] Emergenc;y Psychiatric Hospitalization 

] Emergency Medical Hospitalization 

] ln-school sospenston 

J School Suspension/ExpulSion 

[ J CllenUindMdual ArresVDetention 

[x] Oealh 

[ J Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005133 
567 


26354.501

) LoeatO<I at tho Till1e of tho Incident Report 

} Unable to Locale at the Time of the Incident Report 

l Other. 

(SUspecl<!d, AI logO<! or ConffnnO<I) 

Caretaker: 

t l Mentor 

( ) Mentor Family- Member 

( l Staff 

[ 1 Other Careta'Ker. 

Alleged Misconduct: 

[ J SID<ual Boundary/Abuse 

t 1 Verbal or Emotional Abuse: 

[ 1 Physical As$auft1Ahuse 

[ l Corp<Jrolllnappropriate Punishment 

t ]lnappropriate: Use of RestreinVPhysical intervention 

t 1 Neglect 

[ Jlnadoquale SupoNision 

r 1 Criminal Arrest orcarntokar 

t l Alcohol/Drug u.., by Caretaker 

( J MIS\lseofCRonU111tllvlduars Funds 

t J Misapptopriatlon/Oasttuction of Cl!anl/fndividual Personal 

Property 

l Other. 

SUICIDAL CUENTnNDIVIDUAL; 

[ l Sulchtal Throats or Vertmllzatkln:;. 

[ l Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR tlY CLIENTRNDIVIDUAL: 

[ ]To OlhOf Client 

t ]To StafforMenltlr 

( ]l'o Mentor's Family Member 

[ l To other Thhd Pariy 

CUENTIINDIVIDUAL: 

] To Other Client 

] To Staff or Mentor 

Jf'o Menton Family Member 

]To Other Third Party 

lfoAnlmels (animal cruelly) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[ l Illness Requillng Medlel!l Treatment 

[ l Oelerioro~on In Existing Medical CondiUon 

[ l Pl'll9!1l1MY [ J Seizure Requiring EmellJenoy Treatment 

t 1 un £ l Bowellmpa~on 

t l Pneumonia 

( l Pressu"' Sores 

r 1 Other. 

t J Physical AssauK by Thll'd Party!Other Individual In our oar 

( J S&l<lial Assau« by Third Party/Other lndlvldualln our care 

( l Theft by Third Party 

[ l Fall 

[ J Choking 

[ J BalhingiSCaldlng Related lnjur!<ls 

( 1 Other Bums 

[ J Vehicle 

[ l Swimmlng/~ar Drowning 

( ] Other Aocldentallnjury; 

EXPOSURe CONTROL tNCIOENTiS: 

[ J Cllentflndlvkiuar EixpoMd to Stood Scln'lo P~thogens 

[ 1 CllenUindividual Expose<! Third Pariy to 61ood Borne 

PROPERTY DAMAGE BY CUENTIINDIVIDUAL: 

[ J PropertyDamageunder$1,000 

[ J Properly Damage Over $1,~00 

I l Vehicle ThoR 

[ l Fire Se\tiflll 

l l Thofi/SnopMftlng 

( l Other. 

cllenUindMduallp,.,gll!m) 

( l Possession of Prohibif<ld Materials (I.e., alcohol, 

tigntsr, weapon, pomograph~. Ulleltdrogs, oto.) 

per 

MENTOR()005134 
568 


26354.502

[x] CounsalingiTralning for Slaff/Menlor 

[ J ~:~g:~:L~~~tX~drrJ:!r (::x:] fntemalln..,esligalion Underway 

[ J Reported to Adult/Child Protective 

Services 

Date: 

) Substantiated { ) Unsubstanliate 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

[ x] Funding Source Notified 

[x} Family Oete:il' N!!uo ~ :: 

[x]:~~.Jii&J Dete:-

1 law EnforcemenvPiilbiiUon NoiiHed 

Date: 

MENTOR0005135 
569 


26354.503

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005136 
570 


26354.504

(x) Be~avioral Kealth 

( ) Juvenile Justice 

( ) Medically Complex 

( ) MRIDD 

t ) MRIOO Offender 

) Aequlrnd Brain Injury 

) Elder Care 

) Mental illness 

l MRIMI 

) Educali<>n 

) Other: 

ta. Service Seltlng/Model: (check the ONE that most cfoselyli!o) 

( } ICFIMR (lntenmadiale Care Facility) ) Family/School/Home Based Supports (periodic 

( ) Group or S~arad living (3+ dientsr.,dlvfduals with 2411) services less than 2417) 

( l Shared or Supported Living (1 or 2 dlenlsllndlvlduals with 2417) 

(x) MEffltar Home/ Host Home 

) CllnicaiiOutpatielll Therapy/Rehab (OT, PT, Speech) 

l Day Program 

( ) Group or Shared living {3+ clienlslindividuals with less than 24n) 

( ) Share.d or Supported Living (1 or 2 clientsftndiViduals with less 

I Supported EmploymenWooational 

) School 

Ulan 2417) 

) Home Heatth Agemcy Services 

19. Location of Incident: {cheek ono) 

( ) Mentor Home ( 1 Pnmary ( ) Respite 

Mentor Namfl!: 

t of Cllantsllnlllvkhlals living In Hom<~: 

{ ) CUe.nVIndiVidual's Residence (group home, ICF, apt) 

{ ) CN13ntflndMdual's Biological Famlly/Guardlan Home 

( l Day Program 

( l School 

! } Ctfentl1ndividuars fltace of Ef'T'!Plovment 

( ) Vehicle 

( l Program Oftlca 

( ) Community 

(x) Other. Prospective Adoptive Placement 

} BrohmgeiCaw ManagE~ment (nono.teSfdantial) 

20. Outcome of Incident: (cheek all that apply) 

] Remain. in Current Placement 

] Placement Decision Pending 

] ClienUindlvfdual Placed In Respite 

l Placement Disrupted (i.e. Client/Individual transferred to new 

hamel program/placement within MENTOR NETWORK) 

l Oischergod !rom MENTOR NETWORK 

) Tamporarily oi'P9t'J'Tia0ently Closed Mentor Hom1;1 

l Emergertcy Psychiabic Eve1uation (no hospitalization) 

] Emergency Psychiatric Hospitalization 

l Emergency Medical Hospitalization 

] !rrschoolsuspansion 

] School Suspension/Expulsfon 

] C1ientl1ndividuat ArrestJOetentJon 

[xl Death 

[ l Other: 

party 

found 

at the 

aboutresidence of an 

by~ve 

approved prospective 

team a few 

adopllve 

hour.> later 

placement 

at the botlom 

at-a! the 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005137 
571 


26354.505

} Located at the Time of the Incident Report 

) Unable to Locate at the Time of the lncldent Report 

) Other. 

(Suspected, Alleged 01' Confirmed) 

Carutaker: 

[ ) Mentor 

[ ) Mentor Family Member 

[ l Staff 

( 1 Other Caretaker: 

Alleged llllsconduct: 

[ 1 Sexual Boundary/Abuse 

[ ] Verbal or Emotiooal Abuse: 

[ l Physical AssauiVAbuse 

[ ] Corporal/Inappropriate Punishment 

[ 1 Jnappropriate Use of Restraint/Physical Intervention 

[ 1 Neglect 

t 1 Inadequate Supe.vision 

[ l Criminal Arrest of Caretaker 

[ J AloohoVDrug Use by Caretaker 

1 J Misuse ofclionUindividuars Funds 

[ ] MisappropriatloniDestruction of ClienV!ndlvidual Personal 

Property 

I Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

I l Suicidal Threats or Verbaftzalfons 

[ 1 Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

( ]TootherCI!ent 

[ ) To Staff or Mentor 

( ]To Mentor's Family Member 

t ]To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAl.: 

[ ]To Other Client 

[ ]ToStafforMentar 

[ ]To Mentor's Family Member 

[ l To other Third Party 

t ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Medication Error 

J Missing Conln:liled Substances 

1 Serio\.IS Adverse Reaction to M&dieation 

MEDICAL INCIDENTS: 

[ ] Illness Requiring Medical Treatment 

[ J Deterioration in Existing Madicat Condition 

[ l Pregnancy 

( ] Seizure Requiring Emergency Treatment 

[ l UTI 

[ ) Bowel impaction 

[ ] Pneumonia 

[ ] Pressure Sores 

r J Other: 

[ ] Physical Assault by Third Party/Other IndiVidual In our car 

[ ] Sexual Assault by Third Party/Other lndMdualln our care 

[ ) The~ by Third Party 

[ ] Fall 

[ l Choking 

[ ] Balhing/Scalding: Related Injuries 

[ ] Other Bums 

( l Vehicle 

[ ] Swimming/Near Drowning 

[ ] Other Acddenlal 

EXPOSURE CONTROL INCIOENTS: 

( ] Cllenutndivldual Exposed to Blood Borne Pathogens 

[ J CHenUindividual Exposed Third Party lo Blood Borne 

CLIENT/INDIVIDUAL: 

] Property Damage Under $1,000 

] Property Damage Over$1,000 

[ l Vehicle Theft 

[ ] Fire Selling 

[ J Theft/Shoplifting 

( l Other. 

POSSESSION OF PROHIBITED MATERIALS: {Defined per 

cllentilndlvldual/program) 

[ J Possession of Prohibited Materials (i.e., alcohoJ, 

tighter, weapon, pomography, illicit drugs, ate.) 

MENTOR0005138 
572 


26354.506

[xl Counseflng/TIIIinlng for StalfJMentor 

r 1 ~=!!B.=~~~~r [ ) lntematlnvesUgallon Underway 

lntervenHom~: 

( ]Physical 

{ ]Mechanical 

[ }Seclusions 

[ ]Chemical 

[ Enforcement 

[ J Reported to Adult/Child Protective 

Set'Vices 

Date: 

) SubstantiaCed ( ) Uns~,:~bstanttate 

[ l Ucenslog Notified 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Funding Source Notified 

Date: 

) Family Notified 

Date: 

] Guanllan NoUfled 

Dal<t: 

] Law Enforcement/Probation Notified 

Date: 

MENTOR0005139 
573 


26354.507

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005140 
574 


26354.508

(x) Behavioral Health 

( } Juvenlte Justice 

( l Medically C01111llex 

( ) MR/00 

{ l MR/00 Offender 

) Acqulted Brain Injury 

} Ekl.erCare 

l Menial Inness 

l MR!MI 

} Education 

l Other: 

16. SerW:~ Setting/Modet (check lhe ONE that most closely fils) 

( ) !CF/MR (Intermediate Cera Faclity) l Family/School/Home Based Supports (periodic 

( ) Group or Shared Living (3+ clients/individuals with 24(1) services less than 24/7) 

( J Shared or Supported living (1 or 2 clients/individuals with 2417) 

(x) Merrtl:lr Home/ Host Home 

) Clinlcai/Oulpatientiherapy/Rehab (OT, PT, 

J Oay Program 

( ) Group or Shared living (3+ cllenlsllndMduats with less than 2417) 

{ ) Shared or Supported Living (1 or 2 cUentslindivlduals wtth tess 

l Supported EmploymentNocatlonal 

) School 

than 2417) 

( ) Home Health Agency Services 

19. location ollncldent: (chock one) 

( } Mentor Home ( ) Primary ( ) Respite 

Mentor Nam6: 

# ofCffantsnndivlduals Uvlng in Horne: 

( ) Cilenl/lndlvi<lual's Res1denoo (group horne, ICF, apt) 

( ) Cfren!l!nd:Mtfual's Biological Family/Guardian Home 

( ) DayProgram 

( ) School 

( ) Ctlentltndivl.duaf's Place of Employment 

( ) Vehlcie 

( ) Program Office 

< l Community 

{x) Other: Field trip with Summer Program. 

) Brokerage/Case Management {non--residential) 

20. Outcome of Incident; (cheele all that apply) 

J Remain ln Current Plar:ement 

] Placement Decision Pending 

) Cflenl!lndlvlduat Plat:ed ln Respite 

] Placement Disrupted {I.e. CllenlllndMdual transferred to naw 

homf;h' program/placement wtthln MENTOR NETWORK) 

l Discharged from MENTOR NETWORK 

] Temporarily or Permanently Closed Mentor Home 

] Emergency Psychtatric Evaluation (no hnspitaUzalion) 

] Emergency Ps.ychiallic Hospltaftzatran 

J ~cy Medical Hospitalization 

] tn~school suspension 

] School Suspension/Expulsion 

] Cijentllndividual ArresVDetention 

[~]Death 

[ ] Other. 

•••••• Marine Recovery Unit recovered Clients body from the 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005141 
575 


26354.509

) located at !he Time of !he Incident Report 

) Unable to locate at the Time of the ln<ident Report 

)Otttar. 

(Suspected, Alleged or Confirmed) 

Canrtakor. 

[ l Mentor 

[ J Men!Of Family Member 

[ J Staff 

I l Other Caretake<; 

Allog<!d Misconduct: 

t ] Sexual Boundary/Abuse 

( J Verbal or Emotional Abuse 

t J Physical Assau!VAbuse 

( ] Corpo<al/lnappropriate PuniShment 

[ ] lnapproiJril!.te Use of Resbainl/PhysicaJ Intervention 

I I Negle<:l 

1 J Inadequate Supervision 

I ] Criminal Arn::!st of Carelaker 

[ l Alcol1oi/Orug Uos by Care Iaker 

[ J Mlsuss of ClienUindlvldual's Funds 

[ J Misappmprfat1an10esfructlon of Clienl/lndl\lidual Personal 

Property 

l Olher: 

SUICIDAL CLIENTIINDMDUAL: 

[ l Suicidal Threats or Verbalfzalions 

[ 1 Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUE:NTIINDIVIDUAL: 

( ] To Olher Client 

[ l To Staff or Mentor 

[ Jfa Mentor's Family Member 

[ ]To Ottter Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

[ ]To Olher Client 

[ ]To Slaff or Mentor 

{ Jro Mentor's Family Member 

[ ]To O!herThird Party 

t tro Antmals {animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self·lnjurtous BehalliOf 

] Menial Heal!h De-compensation 

J Oppositional Behaviors 

]Inappropriate Sexual Comments/Threats 

J Verbal Threats of Violence 

] E)thibitlonism/Public Masturbation 

l Medication Error 

1 Missing Controlled Substances 

] Serious Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

( J Illness Requiring Medical Treatment 

( } OeteriQraijon In Existing Medical Condition 

[ J Pregnancy 

[ ] Seizure Requiring Emergency Treatment 

( ] UTI 

( ] Bowel Impaction 

( ) Pneumonia. 

[ l Pressure sores 

[ l Olhar: 

I ] Physf~al Assault by Thin:l PartylOther Individual in our car 

[ 1 Se-Xtlal Assault by Third PoutyiOther Individual in our care 

[ ] Theft by Third Party 

[ l Fall 

I J Choking 

[ J Balhlng/Soaldlng Relatod Injuries 

( ] Other Bums 

( ] Vehicle 

[ 1 Swimming/Near Drowning 

[ ] Other Acoidentallnjury: 

EXPOSURe CONTROL INCIDENTS: 

[ l ClianUlndMdual Exposed to Blood 80fne Pathogens 

[ ] ClianUindMdual Exposod Third Party to Blood Some 

BY CLIENTIINDMDUAL: 

Property Damage Under $1,000 

Property Damage OVer $1,000 

Vehicla Theft 

Ft .. setting 

Thefl!Shopliftlng 

Other. 

POSSESSION OF PROHIBITED MATERIALS: (Doflned per 

cJientlfndfviduatlprogram) 

( ) Possession of Prohibited Materials (i.e., alcohol, 

iight61, weapon, pornography, iMicil drugs, etc.) 

MENTOR0005142 
576 


26354.510

[x] ~~~~efi~~~~~~nkJr [ l Develor.d wilh CllenUindlvl®al 

(x] lntemal Investigation Underway 

lntervenlio/1$: 

[ ]Physical 

[ ]Mechanical 

[ ]Seclusiolls 

[ ]Chemical 

Date: 

l Subsiantlated ! 1 Unsubslantlala 

[X] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005143 
577 


26354.511

Data 

-

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005144 
578 


26354.512

(x) Behavioral Health 

( ) Juvenile Justice 

( 1 Medically Complex 

( I MR!OO 

! ) MR!DD Offender 

) Acqulned Brain Injury 

) Elder Cane 

) Mental ll!ness 

l MR!MI 

) Education 

)Oiher. 

16. Service Setting/Model: (chock tho ONE that most closely fils) 

( ) ICF/MR (lnla""odiale Care Fac'uity) ) Famlly/Schoo/IHoma Based Supports (periodic 

( ) Group or Shared llving (3+ clients/indivfduats. wflh 24/7} services Ienihan 2417) 

( ) Stiared or Supported Living {1 or 2 clients/individuals wi1t1 24/7) 

(.x) Mentat Home/ Host Home 

) Clinitat/Oulpatlent Therapy/Rehab (OT, PT. Speech) 

) DayProgram 

( ) Group or Shared liV'ing (3+ dientslindividuals with less than 24n) 

( } Shared ur Supported Living (1 or 2 clienlsllndividuals with less 

) Supported EmploymenWocatlonal 

) School 

lhao 24/7) 

) Home Heakh Agency Services 

1 ~. location of Incident: (cll<lck ono) 

(x} Mentor Home h<l Primary ( ) Respite 

Mentor Name: 

#of Cllont•llndlvlduats Ull!ngln Home: a 

) C1ientltndivfdual's Residence {group home, ICF, apt} 

) Cllentl1ndividuars Biological Family/Guardian Home 

) Day Program 

) School 

) Cliantlfndividual's Place of Employment 

) Vehicle 

) Program Office 

) Community 

) Other. 

+Client passed away on-

) Brokerage/Case Management {non-residenllat) 

20. Out!::ome of Incident (check all that apply) 

1 Remain in Currant Placement 

] Placernant Daelsic;n Pending 

1 Clientflndividual Placed in Respite 

1 Placement DiSI\Ipted (Le. Clteol/lndfvidual transferred to new 

horne/ program/placement within MENTOR NETWOR1<} 

l OoS<:hargod ~om MENTOR NETWORK 

] Temporarily or Permanently Closed Mentor Home 

1 Emergency Psychiatric Evaluation {no hospitaliZation) 

] Emergency Psychiatric Hospitalization 

J Emergency Medtcal Hospitalization 

1 lrw:chOol suspension 

l Sehoot Suspension/Expulsion 

[ ] Client/Individual ArresUOetention 

[x] Dealh 

[ ] Diller. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005145 
579 


26354.513

) Located at the Trme ofltle Incident Report 

) Unable to Locate at the Time of the Incident Report 

)Other. 

{Suspected, Alleged or Confirmed) 

Caretaker: 

] Mentor 

l Mentor Family Member 

l Slaft 

] other Caretaker. 

Alleged /lllsconduct: 

( l Sexual Boundary/Abuse 

[ ] Verbal or Emotional Abuse 

[ ] Physical AssauH!Abuse 

[ J Carporalffnappropriate Punishment 

[ J Inappropriate Use or Restraint/Physical Intervention 

[ l Neglect 

[ 1 lnadaq1,1ate Suparvision 

( } Criminal Arrest of Caretaker 

( ] Ak:ohoUDrug Use by Caletaker 

t l Misuse ~fCiientllnclividual's Funds 

[ ] Misapproprlalion/Destruction of Client/Individual Personal 

Property 

l Other. 

SUICIDAL CLIENTflNDIVIDUAL: 

[ 1 Suk:ldal Threats or Verbalizations 

( JSuicidatMemptorGesture 

SEXUAL ASSAULT DR INAPPROPRIATE SEXUAL 

BEHAVIOR SY CLIENT/INDIVIDUAL: 

t }To Other Client 

( ]ToStafforMontor 

[ JTo Mentor's Family Member 

[ ]To Other Thiltl Party 

PHYSICAL ASSAULTS BV CLIENT/INDIVIDUAL: 

[ ] To Other Client 

[ l To Staff or Mentor 

[ ]To Mentor's FamUy Member 

[ 1 To Other Thiltl Party 

[ ]To Animals (animal crually) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medlcalian Emit 

J Missing Controlled Substances 

] S..nous Aclve"'e Reaotion to Medl<:a~on 

MEDICAL 

[ l Illness Requiring Medical Treatment 

( ] Deterioration in Existing Medical Condition 

[ l Pregnancy 

( ] Seizure Requiring Emergency Treatment 

[ l UTI 

[ ] Bowellmpaetion 

[ ] Pneumonia 

t ] Pressure Sores 

[ J Other. 

( 1 Physical Assault by Third Party/Other Individual in our car 

( J Sexuel Assault by Thin! ~rty/Other Individual in wr care 

( l ThoR by Thlltl Party 

( ] Fall 

[ l Choking 

( ] Bathing/Scalding Related Injuries 

[ l Other Bums 

( 1 Vehicle 

[ J S'Nimming/NearDfUIMling 

! 1 Other Accidenlallnjury: 

EXPOSURE CONTROL INCIDENTS: 

( l ClienU!ndividual Exposed to Blood Some Pathogens 

( J ClienU!ndhi!dual Expossd Thiltl Party to Blood Soma 

PROPERTY DAMAGE BV CLIENT/INDIVIDUAL: 

( J PropartyOamageUnder$1,000 

[ I Property Damage OVflf $1,000 

[ l Vehk:le Theft 

( J Flre Setllng 

( l Theft!Shoplifllng 

[ 1 Other: 

POSSESSION OF PROHIBITED MATERIALS: {O..Hned per 

cllantlfndlvlduatlprogram) 

[ ] Possession of Prohibited Materials (I.e., alcohol, 

lighter, weapon, pomograpfly, illicit drugs, etc_) 

MENTOR0005146 
580 


26354.514

[ J CounseRng!Tralnlng fur Sla-tO< 

[ l ~~MsJl,"=~ 

[ J mtomallnveotlgation Underway 

Interventions: 

[ ]Physical 

( ]Mechanical 

( ]Seclusions 

( ]Chemical 

~nforcemont 

Date: 

) SubSiantialed ( ) Unsubstantlale 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] \..aw Enforcement/ProbaUon Notified 

Date: 

MENTOR0005147 
581 


26354.515

Signature of State Director {Level 3 and 4 only} Print Name Title Data 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005148 
582 


26354.516

!J. Service Category; (Check one) 

( I Behavioral Health 

( l JJM!nlle Justice 

(><) Meditallt Complex 

( l MRIDD 

( l MRIDD Offender 

) Acqulrnd Brain Injury 

) Elder Care 

J Mental Illness 

) MRIMI 

) Education 

) other. 

16, Servlce Settlng!Mo<!el: (oheok !he ONE that most olo .. ly flts) 

{ ) ICF/MR (Intermediate Care Faality) ) Family/School/Home Based Supports (periodic 

( ) Group or Shared Living (3+ diantsllndMduels With 24/7) services less than 2417} 

( l Shared or Supported LMng (1 or 2 cllenlsllndMduals with 2417) 

(x) Mentor Horne/ Host Home 

l CllnlcaUOU1patlent Thsrapy/Aehab (OT, PT. Speech) 

l Dayf>nlgram 

( ) Group Qf Shared living (3+ clients/individuals wlth lass lhan 24/1} 

( ) Shartid or Supp0119.d Living {1 or 2 clients/individuals with less 

) SuPIJO(Ied EmploymenWocational 

) School 

than 2417) 

) Home Health Agency SeMc9s 

19. Location of Incident (•hock one) 

(x! Men!or Home (:x) Primary ( ) Respile 

Mentor Name-: 

#of Clientsllndlvlduals Ltvlngln Home: 

{ ) CUentllndlvidual!s. Residence {group home. ICF. apt) 

( ) Cfientllndivfdual's Btological F.aml!y/G~.:~ardlan Home 

( ) Day Program 

( l School 

( ) Client/Individual's Pla~;e of Employment 

( ) Velllcle 

( l Program Office 

( l Community 

( ) Other: 

) BrokeragefCasa Management (non-resldenttat) 

20. Outcome of !m:ident: (~;he~;k aN that apply) 

] Remain in Currant Placement 

l Placement Oecislon Pending 

l ClienUindividual Placed in Respite 

J Placement Oisrupted {I.e. Cllentl!ndlvldual transfertad: to new 

homo/ program/placement within MENTOR NElWORK) 

1 Discharged ~om MENTOR NElWORK 

J Temporarfty or Farm:anently Closed Mentor Home 

1 Emergency Psychiatric Evaluation (no hospitalization) 

] Emergency Psychlalrk: Hospltalizatton 

] Emergency Medical Hospitalization 

] ln~school suspension 

] School Suspenston/Expulsion 

] Client/Individual ArrestfOetention 

[xj Death 

[ 1 Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005149 
583 


26354.517

) located at the Time of the lnddent Report 

) Unable to Locate at the llme of the Jncldent Report 

) Olher. 

(Suspected, Alleged or ConHrml!d) 

Camtal<er. 

[ l Montor 

{ ] Mentor Family Member 

! ] Staff 

t ] Other Caretaker: 

Alleged M!sconduc1: 

[ J SaxuaiBouooary/Abuse 

! J Verbal or Emotional Abuse 

t l Physical Assault/Abuse 

( 1 Corporalflnappropriate Punlshmel\l 

[ l Inappropriate Use of Restraint/Physical fnterventlon 

( 1 Neglect 

{ 1 Inadequate SUpervision 

t J Criminal Arrest of Caretaker 

{ l Alcohol/Drug Use by Caretaker 

[ J Misuse of CllenUindMdual's Fun<ls 

t J Mlsappropriation!Oestruction of CHenlllndlvidual Personal 

Property 

l Other.: 

SUICIDAL CUENTnNDIVlDUAL: 

( ) Suicidal threats or VarbalizaHons 

[ l Suicidal Attempt Of Gesturn 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CllENTIINDIVIDUAL: 

t l To Other Client 

[ ]To StatrorMentor 

[ ]ro Mento~s Family Member 

t 1 To Olher Thin:l Perty 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

( ) To Other Client 

[ 1 To Staff or Mentor 

( ]To Menlor"s Family Member 

! ] To Other Thlfd Party 

( ]To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self-Injurious Behavior 

J Mentm Health De-compensation 

1 Oppositional Behaviors 

] Inappropriate Sexual Comments/Threats 

1 Verbal Throats of VIolence 

J ExhlbitionisrnJPublic Masturbation 

1 Medication Error 

J MISSing Controlll!d Substances 

1 Serious AdvetSe Reaction to Medication 

MEDICAL INCIDENTS: 

[ ] IJIMss Requiring Medical Treatment 

[ 1 Deterioraflan In Existing Medical Condition 

[ 1 Pregnancy 

( 1 Seizure Requiring Emergency Treatment 

[ J UTI 

[ 1 Bawellmpacllon 

! 1 Pneumonia 

[ ] Pres!iure Sores 

t I Other. 

J Physical Assault by Thinl Party/Other lndhlidualln aun:ar 

( ] SelCual Assault by Third Party/Other lndMduat ln our cam 

[ 1 Theft by Third Party 

[ J Fall 

t J Choking 

[ 1 Bathing/Scalding Related Injuries 

1 1 Dlhl!fBums 

[ 1 Vehicle 

[ ) SWimming/Near Drowning 

[ 1 Other Accidental 

EXPOSURE CONTROL INCIDENTS: 

[ 1 ClienUindlvldual Exposed to Blood Borne Palhogens 

[ ] Cl!enttlndividuat Exposed Third Party to Blood Borne 

PROPERTY DAMAGE BY CllENTnNDIVlDUAt.; 

( 1 Property Damage Under$1,000 

[ ] PropertyDamageOver$1,000 

[ J Vehicle Theft 

( ] Fire Setting 

[ J Thefl/Shopllfllng 

[ l Other. 

POSSESSION OF PROHIBITED MATERIALS: {Doflned per 

dlentnndivldualtprogram) 

[ ] Possession of Prohibited Materials (i.e •• alcohol, 

Hghter, weapon, pornography, illicit drugs, etc.) 

MENTOR0005150 
584 


26354.518

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005151 
585 


26354.519

Title Date 

PrQgrom Coordinator 

Title 

-

Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005152 
586 


26354.520

(x) BehaviOral Health 

( ) JLNenlle Justice 

( ) Medically Complox 

( l MRIOO 

( l MR/00 Offender 

15. 

) Acquimd Brain lnfury 

l Elder Care 

) Mentallftness 

! MRIMI 

) EciUcallon 

l Other: 

16. Servloe Sellil1g/Modal: (chec~ the ONE that most closely ftts) 

{ J ICF/MR (lntennedlate Care Faollity) ) Family/School/Homo Based Supports (periodic 

( ) GroUjl or Shared living (3+ ollentslindivlduals with 2417) sol'lices loss than 24n) 

( l Sham<! or Supported Living (1 or 2 clientslindivlduals with 2417) 

(x) Mento< Home/ Host Home 

) CllnicaUOutpallon! Therapy/Rehab (OT, PT. Speech) 

l Oay Program 

( ) Group or Shared Living (3+ clientsllndiYiduals with less than 2417) 

( ) Shared or Supported Living (1 or 2 ollentsnndMduals with less 

( ) Supported EmploymenWocatlonal 

{ ) School 

than 2417) 

) Homo Health Agency Services 

t9. Looation oftncldent: (r:hec~ one) 

(x) Mentor Home (x) Primary ( l Respile 

MantorNamo: 

# ofCI!enlllffndlVId!u!aJI!s'l'u'l!v~!n~g~ln=Ro=m:::o:::--...,2 

( ) ClienUlndividuel's Residence (grnup horne,ICF, apt) 

( ) CUentlfndividual's Biological FamilytGuardiart Home 

( ) Dey Pnogram 

( ) School 

( ) Client/Individual's Place of Employment 

( ) Vehicle 

( ) Prog"'m Office 

( l community 

( ) Other: 

( l Bmkerage/Case Management(non-resldentlal) 

20. Outcome of lncidont (check all that apply) 

1 Remain in Current Placement 

) Placement Oecmion Pending 

l Cliant/lndhiidusl Placadln Respite 

1 Placement otsrupted (i.e. ClienlllndMdual transferred to new 

home/ programlplecement wltilln MENTOR NETWORK) 

J Oi5tharged from MENTOR NETWORK 

] Temporarily or Perrnanenuy Closed Mentor Home 

] Emergency Psychiallic Evaluation (no hospitalization} 

] Emergency Psychiatric Hospilalizallon 

] Emergency Medical HospitalizatiOn 

1 In-school suspension 

J School Suspension/Expulsion 

[ ] CtientJtnd!vidual ArresiJDetention 

[x] Oeath 

[ ]OtMr. 

parem cauec on-call to report !hat. was unresponsive when trying to wake~p. The C02 detector and 

but 1/lere was no fire in the home. Mentor called 911 at1d paramedics arrived at the home. The 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005153 
587 


26354.521

) l.otaled at 1M Time of the lnoldent Report 

( ) UnabJe to Locate at the Time of the Incident Report 

( l Other. 

{Stnrpected, Alleged or Conffnnad) 

Caretaker: 

( ] Mentor 

( J Menlbtfamily Member 

( J Staff 

[ ] other Caretaker~ 

AlltJged Misconduct: 

[ l Sexual Boundary/Abuse 

[ l Verbal or Emotional Abuse 

[ l Physical AssauiVAbuse 

I l Colponllllnapproprtate Punlst!menl 

[ J Inappropriate Use of l'!estralnVP!!yslcal Intervention 

[ 1 Neglect 

( l Inadequate Supervision 

[ 1 Criminal Arrest of Caretaker 

[ ] Alcohol/Drug Use by Caretaker 

[ l Misuse ofCIIenVIndividual's Funds 

[ l MisappmpriationiOastrucllon of ClienVIndividual Personal 

Property 

1 Other. 

SUICIDAL CUENTnNDIVlDUAL: 

t ] Si.Jlcldal Threats or Verbalizations 

1 J SulddS! AUempt or Gesture 

SEXUAt.ASSAU~ TOR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTnNDMDUAL.: 

[ ]To OlherCUent 

( ]To Staff or Mentor 

[ ]fo MenlofsFamlly Membor 

t ]To Other Thin:! Party 

PHYSICAL ASSAULTS BY 

[ ]To Other Client 

[ ] To Staff or Mentor 

[ ]fo Mentofs Family Member 

( ]To OlherThlm Party 

[ ]fo Anlmels {animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

J Self·lnjurtous Behavior 

J Mental Health Cle-<ompansatlon 

J Oppositional Behaviors 

J inappropriate Sexual Commentsffhreats 

1 Verbal Threats of Violence 

1 ExhlbiHonlsmiPubllc Masturbation 

]Medlcallon Enror 

l Missing Controlled Subsl!mces 

J Sertous Adverse Reaction to Medication 

MEDICAL INCIDENTS: 

( J ~ness Requiring Medical Treatmeot 

[ ] Detertoratlon In Existing Medical Condition 

( 1 Pregnancy 

t l Seizure Requirtng Emergene-y Treatment 

[ J lJTl 

[ l Bowel Impaction 

[ ] Pneumonia 

[ l Pressure Sores 

t J Other: 

[ J P!!yslcal Assault by Thlm Party/Other lndMdual in our car 

[ J Sexual Assault by Thlm Party/Other IndiVIdual In our cate 

[ J Then by Thim Party 

( J Fall 

( J Choking 

( J Bslhlng/Scaldlng Related Injuries 

( J Other Bums 

[ J Vehicle 

[ J Swimming/Near Drowning 

[ ] Dlher Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ l CllenVIndlvldual Exposed to 8i<lod Bome Pathogens 

r l CllenVindlvidual Exposed Thlm Party to Blood Bsma 

I [ J 

[ 1 

( J 

( J 

[ l 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

ctfentlfndlvlduallprogram} 

[ J Possession of Prohibited Materials (La., alcohol. 

lighter, weapon, pornography, illicit drugs, etc.} 

MENTOR0005154 
588 


26354.522

~"l ~'l>~~~~~~:.;::tor DeveloPed willl ClienUirniMdual 

[x] lntemallnvestigation Underway 

Interventions: 

[ ]Physical 

[]Med>anical 

( ]Seclusions 

[ )Chemical 

Date: 

) Substantiated ( ) UnsubstanUata 

1 J Licensing Notified 

Date: 

be spending the night at home again. also notified of the arrangements 

stay at her sister's home another night. Agency staff are continuing to support the biological mother 

family. Funeral arrangements are pending. An autop$y Is to be completed to determine the cause of death. 

Notified 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005155 
589 


26354.523

Print Name 

of Stale Director (Level 3 and 4 only) Print Name Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005156 
590 


26354.524

) Acquired Brain Injury 

} Elder Care 

) Mental Illness 

l MR!MI 

) Education 

l Olher: 

16. Service SeHing/Model: (checl< the ONE that most closely llts) 

( l ICF/MR (Intermediate care Facility) ) Farnlly/School/11orne Based Supports (periodic 

( l Group or Shared Living (3+ ctient$/lndiYiduals With 2417) services less than 24!7} 

( ) Share< or Supported living (1 or 2 clientslindMduats with 24/7) 

(x) Mentor 11ornBII1ost 11ome 

) Cinicai/OUipeUent Therapy/Rehab (OT, PT, Speech) 

) Day Program 

( } Group or Shared Living (3+ clientsfindividuals v.oilh iess than 2411) 

( } Shared or Supported Uvtng {1 ar2 clients/Individuals with less 

) Supported EmploymenWacaUooal 

) School 

than 24/7) 

) Home Health Agency Services 

19-.loca.tion of lncldent: (check one) 

{x) Mentor Home (x} Primary ( ) Respite 

Mentor Name: 

# of Clientsltndivlduals UVin1J In Home: 5 

( ) ClienVIndlvldual's Re$1dence (group horne,ICF, apt) 

( ) CUenUindividuaJ's Biological Family/Guardian Home 

( } Day Program 

( ) School 

( ) Cfien!Jlncf'Mdual's Ptac@ of Employment 

( } Vehicle 

{ ) Program Office 

( l Community 

( l other. 

) Brol(erage/Case Management (non-resklentlal) 

2D. Outcome of Incident: (check all that apply) 

J R.emaln In Current Placement 

l Placement Decl$1on Pending 

l ClienfJindividual Placed in Respite 

1 Placement Oisrupt<>d (i.e. Cllenlllndlviduat transferred to new 

home/ program/placement within MENTOR NETWORK) 

1 Discllarged f""" MENTOR NETWORK 

J Temporarily or Permanently Closed Mentor Home 

] Emergency Psychiatric Evaluation (no hospitalization) 

J Emergency Psychiatric Hospitalization 

1 Emergency Medical Hospita!lzation 

] !n~schoo! suspension 

] Schoof SuspenslonJExpulston 

[ ] C!lentltndMdual Arrest/Delention 

[x] Death 

[ J Other. 

+The fosterfamiiywent to check on the client for I morning feeding. The client had no signs oflffe and was pronounced 

dead at Hospital. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005157 
591 


26354.525

) Located at the Time of thel~cldsnl Report 

) Unable to Locate at the Time of the Incident Report 

) Other. 

(Suspeded1 Alleged or Confirmed) 

caretaker: 

1 1 Mentor 

l l Montor FamUv Member 

I l Staff 

[ ] Other Caretaker.: 

Alleged Mlsccnduct: 

l l Sexual Bouodary/Abuse 

[ ] Verbal or Emotional Abuse 

{ l Physical As,.uiVAbuso 

[ ] Corporal/Inappropriate Punishment 

t 1 lnappm-priate Use of RestralntiPhyslcal InterventiOn 

( ] Neglect 

1 ]Inadequate Supa!Vision 

[ ] Criminal Arrest of Caretaker 

[ ] AlcohoVDrug Usa by Caretaker 

( l MiSUse ofCtientlfndivfdual's Funds 

[ ] Mi:SapproprtationiDestructlon of Ctlentllndlvldual !'ersonal 

Property 

l Other: 

SUICIDAL CUENT/!NDIVIDUAL: 

[ ] Suicidal Threats or Verbalizations 

[ J Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CUENTIINDIVIDUAL: 

[ ]To Olhar Client 

[ l To Staff or Mentor 

t Jro Mentots Family Member 

[ ]To Other Third Party 

PHYSICAL ASSAULTS BY CLIENT/INDIVIDUAL: 

( ]To OlherCiient 

[ ] To Staff or Mentor 

1 Jro Mentots Family Member 

{ ] To Other Third Party 

( Jl"o Animals (animal cruatty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

l Medication Error 

J Missing ControKed Substances 

J Serious. Adverse Reaction to Medteation 

MEOICAL INCIDENTS: 

[ ] ntness Requiring Medical Treatment 

( ] Deteriofiltion in Existing Medical Condition 

[ J Pregnancy 

( 1 Seizure Requiring Emergency Treatment 

[ l UTI 

[ ] BowellmpacUon 

[ ] Pneumonia 

( l Pressure Sores 

[ 1 Other. 

[ ] Physical Assault by Third Pa~/Other Individual In our car 

t 1 Sexual Assault by Third Party/Othar Individual in our"""' 

[ ] Theft by Third Pa~ 

t 1 Fall 

[ J Choking 

[ J Bathing/Scalding Related lnjun'es 

[ l Other Bums 

[ l Vehicle 

( J Swimming/Near Drowning 

( l Other Ae<:iden!al 

EXPOSURE CONTROL INCIDENTS: 

[ J ClienVlndlvtduaf Exposed to SJoOO Some Pathogens 

[ l ClienUindivldual EJ<!)Osed Third Pa~ to Blood Borne 

PROPERTY DAMAGE BY 

[ 1 Property Damage Under$1,000 

[ l Prope~DamageOver$1,000 

[ l Vehicle Theft 

( ] Fire Setting 

[ ] Theft/Shoplifting 

[ l O!hec 

POSSESSION OF PROHIBITED MATERIALS: (Defined per 

dlentllndMduallprogram) 

( l Possession of Prohibited Materials (i.e., altohol, 

lighter, weapon. pornography. illicit drugs, etc.) 

MENTOR0005158 
592 


26354.526

( "l CounHiingiTfalnlng lor Slaff/Mentor 

r l ~~~"'61:.:X:i',I~\= r X] lnlemsllnvestigalion UndeiWay 

lnterventiofls: 

r JPhysicat 

[ )Mechanical 

[ )Seclusions 

( )Chemical 

t Enforcement 

) Substantiated (x) Unsubstantiate 

(X] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005159 
593 


26354.527

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005160 
594 


26354.528

( ) Behavioral Health 

( l Jwanlla Juslice 

(><l Medl<:al!y Complex 

( l MR/00 

{ l MRJOO Offender 

} Acquired Brain lnjury 

) Elder Care 

) Mental Illness 

) MRIMI 

) Educa!Jon 

!Other: 

18, Servk:o SeHing!Modei: (eheck tho ONE that mast closely fits) 

( l ICF/MR (lnteone<liate Care Focillty) ) Family/School/Home Based Supports (perio<flG 

( ) Group or Sherad living (3+ dlenlslindivlduals with 2417) services less than 24!7} 

( ) Shared or Supported Living (1 or 2 cliantsllndivldvals with 2417) 

(x) Mentor Hamal Hoot Home 

( ) CUnlcai!OtllpatiantTherapy/Rahai>(OT, PT, Spaech) 

( l Day Progrnm 

l l Group or Shared living (3+ dienlsllndivlduals with tess than 2417l 

{ } Shared or Supported LMng {1 or 2 cUentsrandtvk:lua!s with tess 

( l Supported EmploymantJVoca!Jonal 

( ) School 

than2417] 

} Home Hei!tth Agency Services 

19. Location of Incident (check one) 

(x) Mentor Home (x) Primary ( } RespHe 

Mentor Name: 

#of Cllante/lncllvldUats Ll<ling tn Home: 2 

( ) ClienllindMdual's Residence (group hams~ 

( ) Cfientllndividuai's Blologi<:al Family/Guardian Home 

I l Day Program 

( l School 

( } Clientllndlvldual's Ftace of Empklyme.nt 

( } Vehicle 

( l Progrnm Office 

( ) Community 

{ ) Other. 

+Client passed away. 

( ) Brokemge/Cese Management (""""""'sldenlla!) 

20. Outcome of Incident: (check all that apply) 

] Remain In CuiTSnt Placement 

l Placement Decision Pending 

l CllenUincllvidual Placed in RespHe 

] Placement Disrupted (i.e. Clientl!ndMdual tmnsfetred to new 

home/ prognun/piacement within MENTOR NeTWORK) 

l Oisthatged from MENTOR NeTWORK 

l TernpomrilyorPermanenUy Closed Mentor Home 

l Emergency Psychiatric Evaluation (no hospilallza!Jon) 

] Emergency Psychiatric Hosptiallzatlon 

l Emergency Medical Hospitalinllon 

] I~'Schoof suspension 

l School Suspensioo/Exputsion 

( l Clientflndividual Arrest/Detention 

[z) Oaath 

[ ] Olher. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005161 
595 


26354.529

) Located at the Time of the Incident Report 

) Unable to Locate at lha Time of the Incident Report 

) other. 

(Suspected. Alleged or Confirmed) 

Caretaker. 

[ ] Mentor 

[ l Mentor Family Member 

! l Staff 

[ J Other Caretaker: 

Alleged Miscondud; 

[ ] Sexual Boundary/Abuse 

[ 1 Vernal or Emotional Abuse 

[ 1 Physical Assaul11Abuse 

( ] Corp.orafllnappropriate Punishment 

[ 1 Inappropriate Use of Restraint/Physical Intervention 

I 1 Nsgle<t 

[ 1 Inadequate Supervision 

[ ] Criminal Arrest of Caretaker 

[ 1 Atcahoi!Orug Use by Caretaker 

[ J MlsuS<I of CilenVIn<lividuars Funds 

[ ] Mlsappropriation/Destruc:Uon of Clian.tilndividual Personal 

Property 

l Other: 

SUICIDAl CLIENTIINDIVIDUA~: 

[ J Sulddal Threats or Vert>aliz.aUons 

[ ]Suicidal Attempt or Gesture 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

BEHAVIOR BY CLIENT/INDIVIDUAL: 

[ !To other Client 

[ )To Staff or Mentor 

[ )r~ Mento(s Family Member 

[ ]To OlherThlrd Party 

PHYSICAL ASSAULTS BY CLIENTnNDIVIDU!\l: 

[ l To Other CHant 

! }To Staff or Mentor 

[ ]l"o Mentot's Family Member 

( 1ToOtherThirt1Party 

[ JTb Animals (animal cruelty} 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Medication Error 

J Missing Controlled Substances. 

1 Serious Adverse Reacti<>n to MedicaUon 

MEDICA~ INCIDENTS: 

[ ] ll!ness Requiring Medical Treatment 

{ ] Deterioration in Existing Medical Condition 

[ 1 Pregnancy 

[ 1 Seiz.ure Requiring: Emergency Treatment 

[ 1 UTI 

( 1 SowellmpacUon 

[ l Pneumonia 

[ ] Pressure Sores 

[ 1 other: 

J Physical Assault by Third Party/Other Individual In our car 

l Sexual Assault by Third Party/Other tndlvldual in our care 

1 Theft by Thlrtl Party 

1 Fall 

[ J Choking 

[ l Bathing/Scalding Rolatod lnjunus 

[ J OtherBurns 

[ 1 Vehicle 

( ] Swimming/Near Drowning 

[ l other Accidental Injury; 

EXPOSURE CONTROL INCIDENTS: 

[ 1 CllenUindlvi<lual Exposed to Blood Borne Pathogens 

[ 1 Cllentllndivldual Exposed Third Party to etood Borne 

[ J Property Damage Undar$1,000 

[ 1 Property Damage Over $1,000 

[ ] Vehicle TheR 

l l Fire Setting 

[ 1 Thefi/Shopllfllng 

[ l Other. 

cUentllndMdual/program) 

(Defined per 

l ] Possession of Prohibited Materials {i.e., alcohol, 

lighter, weapon, pornogr.~phy,lllic;it drugs, etc.) 

MENTOR0005162 
596 


26354.530

J Counseling/Training for Staff/Mentor 

l ~~~~~"l!r~~~Jie\:.\".1' ] lntemallnvesligallon Unde<Way 

Interventions: 

[ ]Physical 

[ ]Mechanical 

[ ]Seclusions 

[ ]Chemical 

Enforcement 

[ l Reported lo Mull/Child ?roteellve [ l Funding Source Notllled 

SeMee$. Data: 

Date: [xJ FannilvNotlfied 

) SubstanUated ( ) Unsubstantiate [x] ~;:'.'.u,.,.l)!!!• 

( l Licensing Notified 

Oat a: 

Thia WQ:rket reeelvEKI a call from the on call sarvice ca 

needing a call back due to the passing of her foster child Is a medically the following 

Notiliod 

diagnoses: cerebral palsy, seizure disorder, g-tube, brain calcifications, hip dysplasia, nlssan, GERD, visual 

impairments, and developmental delays •• ltes been placed wHit the Mentor Network in the specialised fostar home 

of since-This was a pre-adoptive placement and the adoption subsidy was !leering 

completion. Thill worker called Ms-back aroun Ms-reported that client had woken up 

around-- having a frt an~-=PAP mask moved o~facewhlch Is not unusual asedoes not Ilks tha CPAP mask. Fost!!:Parent repositioned the mask, calmed client down, andewent back to sleep .• 

remained connected to all "'-monitoring devices. M~then stated that she tllmJIIII. back to sleep. Ms 

-reported that she was woken up by an alamn on tllerrts monitoring devices at-Sha found that client was not breathing and blue. She called 911 and began CPR on tllerrt. When the 

~=!!~arrl~iv~edii! had already paned. The Coroner pronounced 

Client 

had attllnded all follow up app()intments related to the surgey was current with all medical 

specialists. Per the coroner, • ewas not goi'1Ji!o complet and autopsy duo to Clients severe medical 

luues and no concams about other factors contributing to-death. The coroner determined Cilento death to be of 

natural causes.-Mentorwltl seek dire<:Uon from DCFS and legal raletad to aut()psy. Clients parenls no longer 

have parental rights and.doas not have any contact with family members. A diligent saerch will be condueted to locate and Inform biological parents. · · 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005163 
597 


26354.531

Welfare Specialist 

Program Manager 

re of State Director (Level 3 and 4 only) Print Name Title Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005164 
598 


26354.532

( ) Behavioral Health 

{ l Juvenile Ju•tice 

(x:) Medically Complex 

( ) MRIDO 

( ) MRIDO Offander 

1 Acquimd Brain Injury 

) Elder Cam 

( ) Mental Illness 

( }MR!Mt 

I I Edueo!lon 

( ) Other: 

16. Service Setting/Model: (check the ONE that most closely flts) 

( ) ICFIMR (lnt....,odlato Cam Facllily) ( ) Family/School/Homo Based Supports (periodic 

( ) Group or Shared Living (3+ clients/individuals with 2417) services lass than 2417) 

( ) Shared or Supported llvlnQ (1 or2 cllantsllndivlduals with 24/7) 

{;t} Mentot Home! Host Home 

) Cllnicai/Otltpallent TherapyJRahab (DT, PT, Speech) 

) Day Program 

( ) Group or Shared Living (3+ clients/individuals wllh less than 2417) 

( } Shared or Supported Living (1 or 2 clients/individuals with less 

) Supported EmploymanWoca!lonat 

) School 

than 2417) 

) Home Hearth Agency Services 

t9. Loea!lon o/ Incident (chock one) 

( 1 Mentor Home ( ) Prtmary ( ) Respite 

Mentor Name: 

II of Cllentshndivfduats Living In Home: 

( ) Client/Individual's Restdenc:e (group home, ICF, apt) 

( ) ctlanUindlvldual's Biological Family/Guardian Home 

( ) Day Program 

{ ) School 

{ ) CJienlllndividual's Place of Employment 

( ) Vehfcle 

{ I Program Office 

( ) Cammunily 

(x) Olhec Medical Ce 

) Brokerage/Case Management (non-residential) 

20. Outcome of Incident: (check a// that apply) 

l Remain in Current Placement 

} Placement Decision Pending 

l ClienUindlvidu!'ll Pl,acad in Respite 

J Placement Disrupted {I.e. CllenVIndivldual tmnsferred to new 

home/ program/placement wilhln MENTOR NETWORK) 

J Discharged from MEt>ITOR NETWORK 

1 Temporartly orPennanenUy Closed Ment<>r Home 

] Emergency Psychiatric: Evaluation (no t'tospitatizadon) 

l Emef1jency Psychiatric Hospllallzatlon 

] Emeryency Medical Hasp:HalizaUan 

] Jn-school suspension 

l School Suspenslon!Expul>ion 

( ) ClienUindlvldua! Amls!I!Jelenllon 

(x] Death 

( ] Other. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005165 
599 


26354.533

) Located at the Time oftne Incident Report 

) Unable to locate at the Time of the Incident Report 

l Other. 

(Suspected, Alleged or Conflrmed} 

Canna-or: 

[ J Menloc 

t ! Mentor Family Member 

[ ] Staff 

[ ] Other Caretaker: 

Alleged Mlsc:cnduct: 

[ ! SeX\Ial Baundaf)IIAbuse 

[ ] Vetbal or Emotional Abuse 

[ J Physical Assaui\IAbuse 

( l Corpo.ralllnappropriate Punishment 

[ ] Inappropriate Use of RestralntJPhyslcal Intervention 

[ J Na!jlecl 

t l Inadequate Supervision 

[ ] Criminal Arrest of Caretaker 

[ l AlcohoUDrug Usa byC.rotake< 

[ 1 Misuse ofCtienlflndiv;dual's Funds 

[ ) MisapproprlatlontDestrucllon of ClienVlndividual Personal 

Property 

1 Other. 

SUICIDAL CLIENT/INDIVIDUAL: 

[ l Suicidal Threats ot Verbalizations 

( l SuiCidal Attempt or Gestura 

SEXUAL ASSAULT OR INAPPROPRIATE SEXUAL 

EIEtiAVIOR ElY CUENTIINDIVIDUAL: 

( l To Other Client 

[ ]To StalforMentor 

[ JroMentor's Family Member 

( l To Other Third Party 

PHYSICAL ASSAULTS BY CUENTIINDIVIDUAL: 

[ }ToOtherCIIent 

[ l To Staff or Mentor 

( Jfo Mentor's Family Member 

[ J To Other Thin:! Party 

[ )To Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Ufness Requiring Medical Treatment 

[ l Deterioration In Existing Med!cat Conditlcn 

[ l Pregnancy 

( ] Seizure Requiring Emergency Treatment 

[ l UTI 

I J Bowel Impaction 

[ l Pneumonia 

[ 1 Pressure Sores 

t 1 Olher: 

t Physk;aiAssault by Th!n:l Party/other Individual In our car 

{ Sexual Assault by Third Party/Other tndMdual In our cam 

( Theft by Thln:l Party 

[ l F•ll 

[ ! Choking 

[ ] Balhing!Scalding Relatad Injuries 

[ ] Other Bums 

[ 1 Vehicle 

[ I Swimming/Near Drowning 

[ l Olher Accidental Injury: 

EXPOSURE CONTROL INCIDENTS: 

[ J Clienlllndlvklual Exposed to Blood Bome Pathogens 

[ J CllenUindlvldual Exposed Thln:l Party to BlOOd Bonte 

POSSESSION OF PROHIEIITED MATERIALS: (Defined per 

t:tllentJindivlduiJltprogram} 

L ] Possession of Prohibited Materials (i.e,, alcohol, 

lighter, weapon, pornography, illicit drugs, etc.) 

MENTOR0005166 
600 


26354.534

I l ~'P~~~:~~~".A:r::i~~or I l Oe\leloped with C!lenVIndMdual 

! J Into mal Investigation UndefWily 

Interventions: 

[ )Ph)'!Ocal 

( )Mechanical 

[ }Seclusions 

[ JChamleal 

[ 

) Substanfiated ( ) lJnsub.tanttato 

{X] 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005167 
601 


26354.535

Date 

Coordinator -

Date 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005168 
602 


26354.536

(x) Behavioral Health 

( ) Juvenne Justice 

( ) Medically Complex 

( ) MRIDD 

( ) MRIDD Offender 

) Acquired Brain Injury 

) Elder Care 

( ) Mental Illness 

( ) MRIMI 

{ ) Education 

( ) Olher: 

16. Service Se«lnll'Model: (check the ONE that most closalyflts) 

I ) ICFIMR (lnlermediale Care Faclllty) ( ) Family/School/Home Basad Supports (periocfoc 

( ) Group or Shared Living (3+ cJlentsllndMduals with 2417) 661'\l!oos less than 2417) 

I ) Shared or Supported Living (1 or 2 ellen Is/individuals wilh 2417) 

(.x) Mentor Home/ Host Home 

( ) Clinicai/Oulpatianl Therapy/Rehab (OT, PT, Speech) 

I ) Day Program 

( ) Group or Shared Uving {3+ dlentsJindMduaJs with less than 2417} 

( ) She red or Supported Uvlng (1 or 2 clients/individuals with less 

( } Supported Emp!o)lmenWocallonal 

( ) School 

than 2417) 

) Home Health Agency Services 

19. LocaUon of lncldent: (check one} 

( ) Mentor Home (x) Primary ( ) Respite 

Man tar Name: 

N of Cllentsllndivfduals Uvlng In Home: 

( ) Cllenlllndhfiduaf's Residence (group home, ICF, apt} 

( ) C~ent/lndMdual's Biological FamUy/Guardlan Home 

( ) Day Program 

( ) School 

( ) Cllentflndlviduat's Place of Employment 

( ) Vehicle 

( ) Program Of/Ice 

( ) Community 

( l Other: 

( ) Brokerage/Case Management (non-residential) 

18. First Reported to 

By: (N<Jme & Titl<l) 

20. <Mcome of Incident: (choc~ all !hat apply) 

] Remain in Current Placement 

] Placement Decision Pending 

] ClientllndJvldual Placed in Respite 

] Placement Disrupted (l.e. Cllenlllndlvidual transrerred to new 

home/ programlplocemant wlthln MEtrrOR NElWORK) 

1 Discllargad from MENTOR NElWORK 

J Temporarily or PerrnanenUy Closed Mentor Home 

) Emergency Psychiatric EvaluaUon (no hosplta6zation} 

] Emergency Psychiatric Hospitalization 

[xj Emergency Medical Hosp/lllllzation 

[ ] In-school suspeMkln 

[ ] School Suspe11sion/Expulsion 

( ] CllentflndMdual ArresttDetenllon 

[ J Death 

[ l Ot/1ar. 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005169 
603 


26354.537

l Located at the llme of the Incident Report 

) Unabfe to Locate at the Time of the Incident Report 

l Other: 

(Suspected, Alleged or Confirmed) 

c.,.. taker: 

f~l Mentor 

( l Menter Family Member 

( J Staff 

t ] Other Caretaker: 

Alleged Misconduct; 

( ] Sexual B<lundary/Abuse 

[ ] Verbal or Emotional Abuse 

[><] Physical AssauiUAhuse 

[ J CorporaVInappropriate Punishment 

[ 1 lnapprnprfate Use of Restraint/Physical Intervention 

[ 1 Neglect 

t ] Inadequate: Supervision 

[ ] Criminal Arrest of Ca"'taker 

[ 1 Alcohol/Drug Use by Caretaker 

( ] MJsuse of CllentllndMdual's Funds 

( J Misappropnation/Oastruc:lion of ClienUindividual P.,.nal 

Property 

l Other: 

SUICIDAL CLIENT/INDIVIDUAL: 

( ] Suicidal Threats or Verbalizations 

( J Suicidal Attempt cr Gesture 

SEXUALASSAULTOR INAPPROPRIATE SEXUAL 

EIEHAV!OR ElY CUENTI!NDMDUAL: 

I ]To Oilier Cliant 

[ }To Staff or Mentor 

[ ]ro Mentor's Famtly M<lmber 

( ]To Other Third Party 

PHYSICAL ASSAULTS BY CLIENTI!NDIVIDUAL: 

{ 1 To Othar Client 

[ I To Staff or Mentor 

t ]roMentor'sFamllyMember 

( }To Other Third Party 

[ ]ro Animals (animal cruelty) 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Self·lnjurlous Behavior 

J Mental Health De-compensation 

) Oppositional BehaviorS 

] Inappropriate Sexua1 CommentsiThreets 

1 Verbal lhraats of Violence 

l ExhlbltionlsmiPIJblic Masturbation 

J Medication Error 

l Missing Controlled Substances 

J Serious Adwrse Reaction to Medication 

txJ IIIMSS Requlrtng Medical Treatment 

[ ] Deterioration in E:cistlng Medical Condition 

[ l Pregnancy 

t l Set%ure Requiring Emeigency Treatment 

[ l UTI 

[ l Boweltmpaction 

[ J Pneumonia 

[ ] Pressure Sores 

[xJ Other. emergency hospitallullon 

[ I Physical A,;sault by Third Party/Other Individual In our car 

[ ] Sexual A$sault by Third Party!Other 1ndivldual in our tare 

[ J Theft by Third Party 

I I Fat! [ J Choking 

( J Bathing/Scalding Related Injuries 

( J Other Bums 

( ] Vehicle 

( J Swimming/Near Drowning 

[ l Other Accidentallnjul)l: 

EXPOSURE CONTROL INCIDENTS: 

[ J ClienVIndivldual Exposod to Blood Some Pathogens 

[ J CllenUindividuat Exposed Third Party to Blood Borne 

PI!OPERTY DAMAGE BY CLIENTIINDIVIDUAL: 

[ l Property Damage Under $1,000 

[ J PropertyDamageOver$1,000 

[ l Vehicle Thaft 

[ l Fi"' SeHing 

( l TheJt/Shopllftlng 

[ l Other: 

POSSESSION PROHIBITED MATERIALS: (Deftned per 

olienlllndlvfdual/program) 

{ J Possession of Prohibited Materials (i.e., afr.:ohof, 

lighter, weapon, pornography, illicit drugs, etc.) 

MENTOR0005170 
604 


26354.538

[ x] C<Hmsellngfl'l'alning for Staff/Mentor 

[ I ~=i:llJ."?~~~ t ) fntemalln\1'8stigation Underway 

tnterventlcms: 

[ ]Physical 

[ )Meellanical 

[ JSocluSions 

[ ]Chemical 

[ 

[x) Reported to AduiiiChlld PmtecUve 

Setvlces 

Dato: .!!!!!!!!!!!L_ 

} Substantiated ( ) Unsubstantlate 

[ 1 Ll<:onsing Notille<l 

Date: 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

] Guardian Notified 

Date: 

] Law Enforcemen.tiProbaUon Notified 

Date: 

MENTOR0005171 
605 


26354.539

Signature Print Name Title Date 

Signature of State 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 MENTOR0005172 
606 

Appendix G 


26354CS1.eps

....- T h e --. 

M

ENTOR 

-...J:etwor!_... 

Foster care works to assure the safety and well-being 

of about 415,000 US children and youth 

The mission of foster care Is to assure the safety and well-being of children and youth whose parent(s) or guardian(s) are unable 

appropriately care for them, typically (though not exclusively) because of abuse or neglect in the home or the grave risk of it. Its 

is a temporary arrangement in which foster children exit to a permanent home as promptly as circumstances allow- most comm

through reunification with family. 

• 702,000 us children were victims of neglect or abuse in FFY 2014, per federal data. Overwhelmingly, the most likely perp

the maltreatment was a parent (78.1% of perpetrators), with an unmarried partner or relative of a parent accounting for 

10.0%. (By contrast, foster parents represented only 0.3% of all perpetrators.) 

At any given moment, several hundred thousand American children are in the foster care system. According to information colle

the US Department of Health and Human Services, approximately 415,000 children were in foster care in September 2014. Abou

entered foster care and 238,000 exited during FFY 2014. 

The needs and circumstances of children and youth within this overall foster care population vary greatly, as do the types of fost

that are required and provided. In many states, independent child placing agencies work with governmental child welfare autho

identify, support and supervise foster care placements that are appropriate to each child. Some child placing agencies may tend 

foster children with more or greater risk factors than do others. 

The MENTOR Network ("TMN-") is a national network of local health and human services providers and is among the nation's larg

independent child placing agencies. Since 2005, TMN has been entrusted with the foster care placements of approximately 44,00

children and youth during more than 14 million days of service. 

March 2016 

COOFIDENTW. PIJRSUAI<T TO SEMTE RUlE 28 

26354CS2.eps

--

..__ 

MEN

T

O R 

Serving more children and youth with heightened risk factors 

relative to others in foster care 

Children and youth entering foster care programs overseen by TMN carry heightened risk factors far more often than is the case fo

foster care population as a whole. This is demonstrated by comparing the percentage of children who require Therapeutic Foster 

("TFC" ), which is specialized foster care geared toward children and youth with severe mental, emotional or behavioral health nee

those who are medically fragile. 

Seventy-five percent of TMN's foster care population requires and receives TFC and/or higher-acuity-level foster care services, as 

By contrast, the average prevalence of TFC among foster children In the 28 states with data reported in a 2013 Boston University s

was just 17.3%. 

TMN serves a greater share offoster children 

with heightened risk factors 

• Therapeutic Foster Care 

Children In foster care served by 

The MENTOR Network 

Children in foster care nationally 

(for 28 stotes reporting} 

Basic Foster Care 

0% 20% 40% 60% 80% 100% 

"of Foster Youth served 

Sowu: TM SO Sat e Chfrtbooll on l'o.ter C11•,1o$tOn The MENTOIII HftWOtlc 

Mafch 2016 

CONFIOENnAL PURSUANT TO SENATE RULE 26 

Some actual children and youth 

· •wnes"' ;sa 2o-vearo6d wh.h Cystic Rbrosls who requires dally ther

SpeCial diet. He came into care due to l"'"'edlcal neglect and his 

u ... "Davicl1" born to a mother hersetf tho'4ht to have fetal Alcohol Syn

came Into foster care a t 3(e 7 without lancuaae skills, not enrolled and not toilet trained. 

• bom deaf, entered at aee 4. He arr'l\ltd at his TFC fost

unabtt to with no SOdal.sl41ls ind hea\f!ly medicated

· "'Roben. • a teenaser in since the t ae of slx, entered TFC 

Oppositional Defiant Disorder and a history of se...ere • ncer betwAo

academic performance. 

"Rachel," age 7, has AOHO.sellures Jod lntellectuitl disabilities. She 

care after her mother threw ht.r aea•n.st a WitM, tfusinl traumalit l:w

ScM.It<e Profile-s of I In 04 fo$cer hm.fv.ba.eA»oeiitooft 11nd the St11te Pelley l.nd Aft¥0/Qf:Y ftMOUtce C.-nttr 

26354CS3.eps

..-- Th~ ---...... 

MENT ~ OR 

Sustaining foster child mortality rates that are comparable to national norms 

TMN sustains child mortality rates that are comparable to national norms, even though children entering its foster care programs c

heightened risk factors far more often than is the case for the foster care population as a whole. This is demonstrated by examining

the rate of deaths from all causes per 100 children in foster care, a widely employed measure of performance in this regard, and (b

as a percentage of all discharges from foster care. 

Over the past ten years, the average mortality rate for children In foster care services at TMN has been very similar to, and more re

is equal to or better than, mortality rates in foster care nationally as reported by the Adoption and Foster Care Analysis and Report

System (AFCARS), a standard source for characteristics of children in foster care. In addition, AFCARS mortality data is understood t

under·represent deaths within the foster care population, as the data includes more than 4,000 runaways (and mortality is known 

high among this group of children). 

Indeed, TMN's average mortality rate for foster children is now approaching that found among the general population of all US chi

0.80 

0.70 

Mortality rate In TMN foster care programs has been very similar to, 

and more recently equal to or better than, national norms 

Benchmarking Child Mortality Benchmarking Child Mortality: Deaths as% of Dis

-- AfCARS 

...... 

I -- 

l 0.60 

-- AfCARS (Tot•l Pep) ,0_ 

! 0.50 

! 0.40 ••••• US-tJAccdOll r-r~-· ! 0.30 ..... -- 

5 

-- TMN S.YUI AWfJit 

I o.-

& 0.20 

I ::1 .. Fosttt Care Monltrty =:~:=:::: 3 0.10 s*a-: 

- : ' -- 

TMH MnuJI MOfUlty Q 0.00 

IUtt I 

FY09 FYlO FYll FY12 FY13 FY14 FY09 FYlO FYll FY12 FY13 FY14 

Soutu li~l'll'ly ~elOlO, .MCNI\. CDOIIV\J~M'O•~tjl'fid ot TMN ,U fof JY2005·201A 

MJrch 2016 

CONFIC>E'ITIAI. PI,IR$I,IAIIT TO SENATE RUlE M 

26354CS4.eps

..-T h e: ------. 

MENTO ~ R 

The MENTOR Network serves significantly more children and youth with heigh

risk factors relative to others in foster care, and sustains child mortality rates th

comparable with national norms 

Youth Requiring TFC and/or Higher-Acuity-Level 

Services: TMN vs. National Foster Care Populations 

75% 

100 1 

75 

Average Mortality Rate: 

Last Five Years (2010·2014} 

0.5 

0.4 ~:J 75% of vooth served by 

TMN receive TFC and/or 

hlgher·OaJlty·l..,..l servi~ 4 times the 

rate of typi<OI su te foster 

c.are populittons § 0.3 i 

3 0.2 

z 

0 

i 0.1 

0.0 

AfCAAS TMN AfCARS (Total Pop

Note: Each State has its own definitions and methodologies for assessorc the acuity level of children in care, and assigning the level o

for the child (including the per diem rate the State will P'V forth" level of service). There is no uniform definition of acuity level, and 

be multiple levels within and/or in addition to the TFC designation on a given State. For instance, specialized services for children con

•medically fragile• may require physician/R.N. oversight, overnight monitoring or other specific mandates based on the needs of the 

these fall under the •higher-acuity-level services• label in the chart above. Although national data on the prevalence of higher-acuity

services is not available, TMN's internal data show that approxomately 14%of foster youth served by TMN (the shaded portion of the 

left) require these higher-acuity-level services, wothin or beyond the deSignation of TFC, depending on the State. 

MlifCh 2016 

CONFIDeNTIAL PURSUAHT TO S£NATE RUlE 2t 

26354CS5.eps

..-----The---

MENTOR 

Sourcing and Methodology 

1. Children and youth in foster care 

Sources: Information about the number of children and youth in foster care is from The AFCARS Report (Preliminary FY 2

Estimates), U.S. Department of Health and Human Services, Administration for Children and Families, Administration on 

Youth and Families, Children's Bureau, published in September 2015 and retrieved from 

http://www.acf.hhs.gov/sites/default/files/cb/afcarsreport22.pdf. Information about the number of children maltreated 

relationship to the perpetrator(s) is from Child Maltreatment 2014, U.S. Department of Health and Human Services, Adm

for Children and Families, Administration on Children, Youth and Families, Children's Bureau, published in January 2016 a

retrieved from http://www.acf.hhs.gov/sites/default/flles/cb/cm2014.pdf. These represent the most recent publicly ava

from these sources. 

2. Therapeutic Foster Care as a share of overall foster care population 

Sources: Information about average prevalence ofTFC is as from Gonyea, J.G., Bachman, S.S., Rajabiun, S., Springwater, J

C.R., Hirschi, M. & Little, F. The 50 State Chartbaok on Foster Core, a resource administered by Boston University and fun

MENTOR Network Charitable Foundation, published in 2013 and retrieved from (or calculated using data retrieved from) 

http://www.bu.edu/ssw/research/usfostercare/. States covered are: Al, AK, AR, CO, CT, DC, DE, Fl, GA, ll, KS, ME, MD, M

NV, NH, NY, ND, OR, Rl, SC, SD, TN, VT, WA, WV and WI. TMN's foster care population is 25% "basic" or traditional foster 

75% Therapeutic Foster Care, a portion of which receives higher-acuity-level services exceeding TFC levels. 

3. Examples of children and youth in TFC 

Source: The descriptions of representative children and youth in TFC are from descriptions of individuals profiled in publi

The State Policy and Advocacy Resource Center (SPARC) and the Foster Family-based Treatment Association (FFTA), and 

from https:/Jch ildwelfarespa rc. files. wordpress.com/2013/07/therapeutic-foster-ca re-exceptional-<are-for-complex-trau 

impacted-youth·in-foster-care.pdf. Best Practices in Treatment Foster Core for Children and Youth with Medically Fragile 

Conditions, Foster Family-based Treatment Association, retrieved from 

http:/Jwww.lmls100us2.com/ffta/FFTA/Learn/FFTA Publications/New FFTA Content/Learn/FFTA Publications.aspx?hk

52-e618· 428e·84d8·9f7420262570. 

March2016 

CONFIDENTIAL PUR.SUANT TO SENATE RVI.E 26 

26354CS6.eps

MENTOR 

-...::;etwor,!.-

4. Deaths of children aged 0·22 years while enrolled in foster care services at TMN and deaths as a percentage of all discharges 

Source: Analysis by The Center for Developmental Disabilities Evaluation Center (CODER). Based at the Eunice Kennedy S

Center, a part of the University of Massachusetts Medical School, CODER has contracted with TMN since 2010 to provide 

Independent analysis of various aspects of TMN's operations, services and outcomes. Information about deaths came fro

incident reports, TMN incidents reported to the insurance carrier, and other corporate files/records. The number was va

all children discharged from services for which TMN had a valid Social Security Number (SSN). (Note: A few thousand disc

not include aSSN so additional verification was not able to be performed with the United States Social Security Death Ind

population used to calculate the rate is the count of any children enrolled in these services for at least one day during the 

year according to TMN enrollment systems. Discharges represents a unique count of children and youth leaving services 

year. The data is presented as a 5-year moving average given the small size of the population enrolled in TMN services co

other sources. 

5. Reported deaths of children in foster care in the US and deaths as a percentage of all discharges 

and foster Care Analysis and Reporting System (AFCARS) (http://www.acf.hhs.govD which collects case

information from state and tribal Title IV·E agencies on all children in foster care and those who have been adopted with 

agency involvement. Title IV·E agencies are required to submit AFCARS data semi-annually. 

mortality rate stated by AFCARS is an under-representation of deaths within this population due to the lack o

information about runaways. The data includes more than 4,000 runaways that do not have follow-up to determine mor

and mortality is known to be high among this group of children. 

6. Deaths of children aged 0-22 years living in the United States 

U.S. Healthy People 2020, retrieved from https:/Jwww.healthypeople.gov/2020/data·search/Search·the·Data. 

Marth2016 

CONFIDENTIAl PURSUANT TO SENATE RUlE 26 
613 


26354CS7.eps

State #Children in 

Foster Care 

MA 433 

MD 290 

PA 200 

NJ 232 

OH 263 

AL 221 

GA 290 

FL 236 

sc 181 

NC 224 

IN 57 

LA 89 

TX 301 

TOTAL# 3,017 

% 

-- The: .__ 

MENTOR 

.......__Ne:twor ~ 

TMN Foster Care Population 

By Service Level 

Basic TFC Higher 

Level Level Acuity level 

4 426 3 

7 178 105 

43 90 67 

0 175 57 

63 133 67 

0 176 45 

122 137 31 

149 46 41 

25 156 0 

90 134 0 

34 23 0 

2 87 0 

221 80 0 

760 1,841 416 

25% 61% 14% 

Higher-Acuity-Level 

Services 

Enhanced TFC 

BMP + BTIT 

CRR 

Second Chance/DAP 

Level V or Medical 

TFC w/ Enhanced Cervices 

Specialty Medically Fragile 

Enhanced Rates 

Source: The MENTOR Network (October 30, 2015) 

Backup Data and Explanation of Mortality Analysis, March 2016 

CONFIDENTIAL PURSUANT TO SENATE RULE 26 

Page 1 
614 


26354CS8.eps

State 

AL 

AK 

AR 

co 

CT 

DE 

FL 

DC 

I-- GA 

ll 

K5 

ME 

MD 

MO 

MT 

- NV 

-·NH 

NY 

NO 

OR 

Rl 

sc 

so 

TN 

VT 

WA 

wv 

WI 

AVERAGE% 

Percent of Children in Foster Care Nationally 

Receiving Therapeutic Foster Care (TFC) 

Percent (%)of Foster Number (II) of Children in 

Children in TFC TFC 

10.1 529 

11 166 

7 300 

22.4 1,512 

20.2 640 

35 281 

10.S 2,686 

25.7 442 

10.1 902 

15 2.723 

1 51 

27.6 375 

27 1,643 

U.l 872 

10.7 181 

10.2 438 

24.6 ISS 

12 2,900 

30 280 

4.5 400 

14.8 296 

13.1 700 

8 133 

50 3,418 

17.5 175 

10 1,137 

27.6 891 

15.4 1,292 

17.3 25,518 

Number (II) of Children 

in Foster care 

5,186 

1.490 

4,285 

6,774 

2,533 

802 

25,582 

1,718 

8,929 

------

14,080 

5,135 

1,359 

6,085 

7,227 

1,826 

4,706 

1,036 

8,296 

936 

7,678 

1,994 ·-

5,362 

1,662 

6,836 

941 

11,371 

3,429 

8,394 

155,652 

S<>urce: Tile 50 State Chartbaak on Foster Co~. 2013 

Badc.up Data and EJcplanation of Mort•lity Analysis, March 2016 CONFIDENTIAl PURSUANT TO SENATE RULE 26 Page 2 
615 

Æ 


26354CS9.eps