GAO

United States General Accounting Office

Report to Congressional Requesters

June 2000 FOSTER CARE

HHS Should Ensure

That Juvenile Justice

Placements Are

Reviewed

GAO/HEHS-00-42

Page 1 GAO/HEHS-00-42 Use of Foster Care Funding

Contents

Letter 3

Appendixes Appendix I: Scope and Methodology 24

Appendix II: Fiscal Year 1998 Title IV-E Funding Claimed and

Number of Placements, by State 27

Appendix III: Provisions of State Licensing Regulations for Child

Care Institutions Related to Physical Restriction of

Residents 29

Appendix IV: Provisions in State Licensing Regulations That Relate

to Procedural Requirements in Title

IV-E Funded Foster Care Cases 32

Appendix V: Comments From the Department of Health and Human

Services 42

Related GAO Products 46

Tables Table 1: Number of Title IV-E Funded Juvenile Justice and Child

Welfare Placements in California and Cost per Day, by

Setting and Level of Care Received, Fiscal Year 1998 13

Table 2: Number of Title IV-E Funded Juvenile Justice and Child

Welfare Placements in Texas and Cost per Day, by Setting

and Level of Care Received, Fiscal Year 1998 15

Abbreviations

CFS child and family services

DSS Department of Social Services

HHS Department of Health and Human Services

ISP individual services plan

JPC Juvenile Probation Commission

PRS Department of Protective and Regulatory Services

TYC Texas Youth Commission
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United States General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-281545 Letr

June 9, 2000

The Honorable George Miller

Ranking Minority Member

Committee on Resources

House of Representatives

The Honorable Charles Rangel

Ranking Minority Member

Committee on Ways and Means

House of Representatives

The Honorable Henry A. Waxman

Ranking Minority Member

Committee on Government Reform

House of Representatives

The Honorable Pete Stark

Ranking Minority Member

Subcommittee on Health

Committee on Ways and Means

House of Representatives

The Honorable David R. Obey

Ranking Minority Member

Committee on Appropriations

House of Representatives

The Honorable John Conyers

Ranking Minority Member

Committee on the Judiciary

House of Representatives

The Honorable Barbara Lee

House of Representatives

Each year, the federal government spends over $3 billion to finance foster

care placements for about half a million children. Under title IV-E of the

Social Security Act, which authorizes federal foster care funding, foster

care placements may be based on a judicial determination that remaining in
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the home would be contrary to the welfare of the child. These

determinations are made in both dependency (child welfare) and

delinquency (juvenile justice) cases. Although most foster care funds

support child welfare placements, they may also be used to support

juvenile justice placements.

Since the early 1980s, the Department of Health and Human Services (HHS)

has been approving title IV-E reimbursements for foster care placements

made by juvenile justice agencies for children in the juvenile justice

system. However, the Social Security Act prohibits using foster care funds

for placements in facilities operated primarily for detention. In addition,

the act stipulates specific procedural requirements intended to protect the

welfare of all children in foster care placements supported by title IV-E

funds. These include developing a written case plan for each placement, a

court or administrative case review at least every 6 months, a permanency

hearing within 12 months of placement, and “procedural safeguards” to

protect parents’ rights when a child is removed from the home. Concerned

that compliance with provisions of the law may be more difficult in juvenile

justice placements, you asked us to (1) determine the number of title IV-E

foster care placements made by juvenile justice agencies in fiscal year 1998

and the amount of federal care funding expended for these placements, (2)

describe how selected states ensure that title IV-E funds are not used for

placements in detention facilities and ensure that procedural requirements

to protect the welfare of children in title IV-E funded juvenile justice cases

are met, and (3) assess HHS’ processes for ensuring the appropriate use of

funds and compliance with these procedural requirements in title IV-E

funded juvenile justice placements.

To conduct our work, we reviewed state licensing regulations for child care

institutions in the 10 states that HHS data showed had claimed the most

fiscal year 1998 title IV-E funding for all foster care maintenance

expenses—primarily food, shelter, and clothing: California, Illinois,

Maryland, Michigan, Missouri, New York, North Carolina, Ohio,

Pennsylvania, and Texas. To estimate the number of title IV-E funded

juvenile justice placements in fiscal year 1998 and the federal dollars

expended for both maintenance and administrative costs, we surveyed all

50 states and the District of Columbia. We also did fieldwork at state and

county child welfare and juvenile justice agencies in California and Texas

to determine how they attempt to ensure that title IV-E procedural

requirements are met. However, we did not independently verify the

effectiveness of these activities. We reviewed a total of 18 cases during our

fieldwork to obtain some indication of how the systems that are in place to
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ensure facility eligibility and procedural requirements operate and what

issues arise related to placement eligibility for title IV-E funds and

compliance with title IV-E procedural requirements in cases involving

juvenile justice placements. We did not determine, in these cases, if

facilities in which children were placed were eligible for title IV-E funding,

if procedural requirements were met, or if children received the services

they required. We also interviewed HHS officials and reviewed pertinent

laws, regulations, and documents, including regulations issued in January

2000 revising the objective, scope, and methodology for HHS title IV-E

eligibility and child and family services review systems. (For a detailed

description of our scope and methodology, see app. I.) We conducted our

work between January 1999 and May 2000 in accordance with generally

accepted government auditing standards.

Results in Brief In fiscal year 1998, about $300 million in title IV-E funds was used to

support foster care placements of children in the juvenile justice system.

Almost half of the states used some portion of their title IV-E funds in this

way. Nearly 60 percent of the total amount of title IV-E funding used for

juvenile justice placements was used by California. The $300 million used

for children in the juvenile justice system is 10 percent of all fiscal year

1998 title IV-E expenditures; however, the 15,000 juvenile justice system

children supported by those funds constituted only about 4 percent of all

children supported by foster care funds. The disproportionate spending on

juvenile justice system foster care children may be attributable, in part, to

the greater levels of—and thus more costly—supervision that, according to

juvenile justice officials, many children in the juvenile justice system need.

To ensure that title IV-E funds are not being used for placements in

detention facilities, the 10 states that used the largest amount of such

funding in fiscal year 1998 rely primarily on the requirements that a facility

must meet in order to be licensed as a child care institution. Licensing

regulations in those states establish standards designed primarily to ensure

a healthy and safe physical environment for the children. In some states,

these regulations allow a facility to engage in some restrictive practices

that have been associated with detention; however, the regulations permit

such practices only under certain circumstances, such as when children

pose a threat to themselves or others or when such practices are necessary

in order to manage inappropriate behaviors. State licensing regulations

also play a role with regard to meeting title IV-E procedural requirements

intended to protect the welfare of children in foster care cases—namely,

that case plans be developed, administrative case reviews be conducted,
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and procedural safeguards be in place. States enforce their licensing

regulations through periodic on-site visits and facility inspections. In

addition to their licensing regulations, the two states whose procedures we

examined more closely, California and Texas, have administrative

regulations for protecting children in foster care, which address in detail

the title IV-E procedural requirements.

HHS has acknowledged that states have sometimes encountered difficulty

in determining whether the facilities in which juvenile justice system

children are placed qualify to receive title IV-E funding and in meeting

procedural requirements in these cases. Consequently, HHS has provided

guidance to states on what constitutes detention and is currently in the

process of developing additional guidance on that subject. In addition, HHS

conducts two broad oversight reviews in each state, a title IV-E eligibility

review and a child and family services (CFS) review. Title IV-E eligibility

reviews primarily verify children’s and foster care providers’ eligibility for

title IV-E funding in a random sample of title IV-E funded foster care

placements in each state. CFS reviews, in part, assess systems states use to

determine the eligibility of foster care providers for title IV-E funding and

systems states use to ensure that procedural requirements are met in title

IV-E funded placements. CFS reviews collect information for this

assessment through interviews with state and community representatives

and a review of a random sample of title IV-E funded cases in each state. It

is not clear based on new regulations for eligibility and CFS reviews

whether the results of these reviews will enable HHS to determine if title

IV-E funding is being used for placement in appropriate facilities or if

procedural requirements are being met in juvenile justice cases—and, thus,

whether these reviews, as designed, constitute adequate oversight of the

use of title IV-E funds in these cases. Therefore, we are recommending that

HHS review a sufficient number of title IV-E funded juvenile justice

placements in child care institutions in those states having such

placements to determine with a reasonable degree of assurance whether

facility eligibility and procedural requirements are being met for such

cases. In its comments on a draft of this report, HHS agreed that more

information is needed to understand and address issues surrounding the

use of title IV-E funding in juvenile justice cases and suggested other means

than those we recommended for collecting this information. Therefore, we

modified the language of our recommendations to accommodate the use of

alternative means of accomplishing their intended effect.
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Background Federal funds for foster care are authorized under title IV-E of the Social

Security Act. The foster care entitlement program provides matching funds

to states to cover the cost of maintaining neglected and abused children in

foster care placements, such as foster family homes or child care

institutions, also referred to as group homes.1 To receive title IV-E funds, a

state must submit to HHS for approval a plan that protects the rights of

foster care children and families and defines a statewide service delivery

system for the foster care maintenance program authorized by the act.

These state plans must include, in part, how agencies will ensure that (1)

the children and the foster homes or child care institutions in which the

children are placed meet title IV-E eligibility criteria and (2) procedural

requirements in the act are met in title IV-E funded placements.

Children qualify if they have been removed from the home pursuant to a

voluntary agreement entered into by their legal guardian or as the result of

a judicial determination that continuation in the home would be contrary to

their welfare, and their families meet eligibility criteria related to income

level.2 Title IV-E funded placements are typically for children in the child

welfare system. However, HHS has issued several policy statements

specifically allowing eligibility claims for title IV-E funding for foster care

placements for juveniles who are wards of the court.

Foster homes and child care institutions qualify for title IV-E funding if they

are licensed by the state and not operated primarily to detain children who

have been determined to be delinquent. In a policy statement issued in

1982, HHS stated that the term “child care institution” may not include

“detention facilities, forestry camps, training schools, or any other facility

operated primarily for the detention of children determined to be

delinquent.” The statement also noted that “primarily” refers to the use of

the facility for detention purposes and that determining whether a facility

operates primarily for detention depends on who operates it, for what

purposes it exists, from whom it receives its major financial resources, the

circumstances of the children who reside there, and its economic viability

if it did not house children adjudicated delinquent. In 1988, HHS issued a

1

These include private nonprofit or for-profit child care institutions and public child care

institutions housing up to 25 residents.

2

Specifically, the criteria in effect are those in the Aid to Families with Dependent Children

program—precursor to the Temporary Assistance to Needy Families program—on July 16,

1996.
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policy statement emphasizing that “the two factors that will be

determinative in identifying such a facility are (1) it must be a physically

restricting facility and (2) it would not be operational without a population

of children who have been adjudicated delinquent.”

The nature and purpose of facilities’ restrictive practices were addressed in

a 1988 Departmental Grant Appeals Board decision in which California

appealed HHS’ decision to disallow IV-E payments for placements in a Rite

of Passage facility. HHS’ Departmental Grant Appeals Board cited a number

of physically restrictive practices as indications that a facility’s primary

purpose may be detention. These practices include location in a remote

area, confiscation of personal belongings, pursuit of runaways, constant

supervision of residents, and use of isolation as punishment. The board,

while drawing a distinction between restrictive practices for the purpose of

detention and restrictive practices for the purpose of treatment, recognized

that treatment is an integral part of a juvenile justice placement even when

the treatment’s primary purpose is detention. According to current HHS

regulations, a detention facility, “in the context of the definition of child

care institution in section 472(c)(2) of the [Social Security] Act means a

physically restricting facility for the care of children who require secure

custody pending court adjudication, court disposition, execution of a court

order or after commitment.”3

According to federal requirements related to state foster care plans, states

are responsible for establishing and maintaining licensing regulations for

facilities. These regulations must represent minimum standards related to

admission policies, safety, sanitation, and protection of the civil rights of

children placed in foster family homes and child care institutions and, to a

reasonable extent, be in accord with the standards recommended by

national organizations concerned with standards for such institutions or

homes. The Child Welfare League of America recommends that licensing

standards for child care institutions cover facility administration,

personnel qualifications, the personal rights of residents, services and

activities provided to residents, and provisions to ensure a healthy and safe

physical environment.

3

45 C.F.R.
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State child welfare agencies are also responsible for ensuring that

procedural requirements are met in title IV-E funded foster care

placements. The Social Security Act4 requires that there be a written case

plan for each title IV-E funded foster care placement and specifies that this

plan address such concerns as the appropriateness of the placement, the

treatment and services the child needs, meeting the child’s health and

educational needs, and services needed to improve the conditions in the

home. The act also requires a court or administrative review in these cases

at least every 6 months to monitor compliance with the case plan, the

necessity for and appropriateness of the placement, the progress made in

improving the home, and when the child is likely to return home or when

an action to terminate parental rights is likely to be initiated. A permanency

hearing is also required within 12 months of the child’s entrance into foster

care to decide what the child’s permanency goal should be—to return

home, remain in foster care, or be adopted. Finally, the act requires that

“procedural safeguards” be applied to protect a parent’s rights when a child

is removed from the home, when there is a change in the child’s placement,

and when decisions are made concerning the parent’s right to visit the

child.

States are responsible for carrying out specific monitoring and evaluation

activities; HHS has oversight responsibility for the title IV-E program in

general. Federal law requires states to monitor and periodically evaluate

their own activities to ensure that children and placements qualify for title

IV-E funding and that procedural requirements are met in IV-E funded

cases. States must also submit statistics to HHS on the legal status of

children in title IV-E funded placements and their demographic

characteristics, location, and length of stay in foster care. In addition to

reviewing state foster care plans and approving those that meet federal

requirements, HHS is required by the Social Security Act to evaluate and

periodically monitor states’ compliance with these plans and to collect and

publish state data pertaining to the incidence and characteristics of foster

care in this country. In addition, according to its strategic plan, HHS has

identified the importance of supporting the state-administered title IV-E

program by ensuring that (1) procedures for monitoring the program allow

for a realistic examination of the experiences of families and children, (2)

best practices related to the program are disseminated, and (3) HHS’

4

Sections 471(a)(16) of the Social Security Act require states to develop case plans for title

IV-E eligible children. Section 475(1) of the act sets forth the requirements regarding the

content of such plans.
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technical assistance and training are relevant and useful to states and

localities in administering their title IV-E programs.

Title IV-E funds are meant to cover a portion of states’ costs for food,

shelter, clothing, daily supervision, school supplies, general incidentals,

liability insurance for the child, and travel to the child’s home for visits.

States set the basic rates they pay foster parents and child care institutions

for these maintenance costs.5 States set higher payment rates for foster

care placements that provide higher levels of care needed by children with,

for example, psychological or behavioral problems or exceptional physical

care needs. The higher rates correspond to the higher levels of supervision

that are needed. To determine the amount of reimbursement states receive

for a placement under title IV-E, a state’s payment rate for that placement

(minus the costs not allowable under title IV-E) is multiplied by its title IV-E

matching rate, which is the same as its Medicaid matching rate and based

on per capita income. These matching rates vary from 50 to 83 percent,

averaging about 57 percent across all states.

5

According to the American Public Human Services Association, the basic rate for foster

care varies across states because the expenses states factor into their basic rate vary by

state. In addition to the cost of room and board, clothing, supervision, and child care, for

example, a state’s rate can include the costs of school supplies, liability insurance for the

child, reasonable travel to the child’s home for visits, personal allowances, recreational

activities, and other general incidentals.
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A Small Proportion of

Title IV-E Funds Are

Used for Juvenile

Justice Placements,

but These Placements

Are More Costly

Of the more than $3 billion in title IV-E funding claimed in 1998, 10 percent

was used to finance foster care placements for children in the juvenile

justice system. Nearly half of the states indicated they had used title IV-E

funds to finance juvenile justice placements in 1998, with three states

accounting for about 80 percent of total title IV-E funds expended for

juvenile justice placements. While title IV-E juvenile justice placements

consumed 10 percent of all title IV-E funds claimed nationwide, they

account for only about 4 percent of all title IV-E foster care placements.

One reason for this disproportion is that compared to child welfare

children, juvenile justice children were more often placed in facilities that

provided a higher level of supervision, which costs more.6

Almost Half the States

Claimed Title IV-E Funds in

1998 for Juvenile Justice

Placements

We estimate that, in fiscal year 1998, about $318 million, or 10 percent, of

total title IV-E funds was used to finance placements for children in the

juvenile justice system.7 Of the 41 respondents to our survey, 23 states

indicated they had used title IV-E funds to finance juvenile justice

placements in fiscal year 1998.8 About 60 percent of the total amount of title

IV-E funding for juvenile justice placements by these states went to

California. New York and Pennsylvania combined accounted for another 24

percent. (See app. II for a state-by-state breakdown of title IV-E funds used

to finance juvenile justice placements and the number of these placements

in fiscal year 1998.)

6

It should be noted that, according to HHS, many juvenile justice children in title IV-E

placements are placed in out-of-state facilities, which increases cost. Because we did not

obtain data from states that distinguished between in- and out-of-state placements, we could

not determine what effect out-of-state placements have on the disproportion of title IV-E

funds expended on child welfare versus juvenile justice children. According to California

officials, 15 percent of their title IV-E funded juvenile justice placements in November 1998

were in out-of-state facilities.

7

Not all states could provide both the dollars claimed and the number of juvenile justice

placements made. We estimated these numbers for those states.

8

Eighteen states could provide the amount claimed for and/or the number of juvenile justice

placements funded under title IV-E. For a few additional states, we were able to develop

estimates.
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Title IV-E Funded Juvenile

Justice Placements Use a

Disproportionate Amount of

Total Title IV-E

Expenditures

While the juvenile justice placements reported nationwide consumed 10

percent of total title IV-E expenditures in fiscal year 1998, they accounted

for only about 15,000—or 4 percent—of all children placed in foster care.

Such disproportions occurred, to varying degrees, across the states that

used these funds—including California and Texas, which together

accounted for about 35 percent of all title IV-E funded juvenile justice

placements nationwide. For juvenile justice placements in California—

where the disproportion was most dramatic—24 percent of the fiscal year

1998 title IV-E funds claimed was used for just 6 percent of all the state’s

title IV-E funded placements. In Texas, 12 percent of the year’s title IV-E

funds was used for juvenile justice placements, which represented about 8

percent of the state’s placements.

According to California and Texas officials, juvenile justice children require

higher levels of care or supervision than do children in the child welfare

system and, consequently, are placed in homes and child care institutions

in which care is more costly. In California, 69 percent of juvenile justice

placements—compared to 6 percent of child welfare placements—were in

child care institutions, which receive higher payment rates than do foster

homes. In addition, a greater percentage of juvenile justice children were

placed in child care institutions that provide higher levels of care. (See

table 1.) As the level of care (determined primarily by staff-to-child ratios)

increases, the state payment rate and, thus, the title IV-E allowable amount

increases. For example, the title IV-E allowable amount for child care

institutions with care levels 1 and 2 averages $44 per day per child. At care

levels 9 and 10—which may entail as many as four full-time workers

supervising six children (a two-to-three staff-to-child ratio)—the title IV-E

allowable amount averages $122 per child per day. In fiscal year 1998, 54

percent of juvenile justice children in institutions received care at levels 9

through 14, compared to 42 percent of child welfare children. The levels of

care in part explain why California’s title IV-E funded juvenile justice

placements averaged about $120 a day per child—five times the per diem

cost for the state’s child welfare placements in that year.9

9

Children in juvenile justice placements in California also tend to be older than those in the

state’s child welfare placements, and the IV-E allowable amount increases as the age of the

child increases.
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Table 1: Number of Title IV-E Funded Juvenile Justice and Child Welfare Placements in California and Cost per Day, by Setting

and Level of Care Received, Fiscal Year 1998

a

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

b

State payment rates include maintenance costs and the administrative costs associated with

maintenance as well as the cost of treatment and other services. Rates vary by age of child. Amount

represents the average of the base rate for each age range.

c

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

maintenance.

d

Data not available.

e

Foster family agencies provide homes or other living arrangements for children who alternatively

would be placed in a child care institution.

f

Agencies can receive more—up to $51 per day for a child from 15 to 19 years of age—if they provide

additional care and services.

g

Referred to in California as group homes.

h

The data California provided to us placed these children in the child care institution category. State

officials, however, noted that for children receiving levels of care 1 or 2, it could not be determined with

certainty whether the care was provided in child care institutions or through foster family agencies.

i

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

j

In California, there is a different IV-E allowable rate for each group home; consequently, the allowable

amount shown is the average of the individual amounts for which the state could seek title IV-E

reimbursement for all placements in the two levels of care.

k

Other placements include medical facilities and shelters.

l

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

mNot applicable.

Source: GAO analysis of statewide data provided by California.

Juvenile justice Child welfare Cost per daya

Number Percent Number Percent

State

payment

rateb

Title IV-E

allowable

amountc

Foster family homes 428 13% 47,301 72% $15 d

Foster family agenciese 565 17 13,012 20 14f d

Child care institutionsg

Care levels 1 and 2 650h 20 1,929h 3 47i $44j

Care levels 3 and 4 12 0 21 0 68i 66j

Care levels 5 and 6 78 2 66 0 89i 82j

Care levels 7 and 8 318 10 183 0 109i 101j

Care levels 9 and 10 788 24 470 1 133i 122j

Care levels 11 and 12 383 12 719 1 151i 134j

Care levels 13 and 14 60 2 423 1 172i 155j

Otherk 23 1 1,177 2 d d

Total 3,305 100%l 65,301 100%lmm
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Texas also bases its payment rates on the level of care provided in foster

family homes and child care institutions (see table 2). At care levels 5 and 6,

for example, children have 24-hour supervision and staff-to-child ratios are

greater than those at care levels 3 and 4. In Texas, almost 70 percent of the

children in the juvenile justice system were placed in foster family homes

and child care institutions at care level 4, 5, or 6, compared to less than 20

percent of child welfare placements. The levels of care in part explain why

Texas’ cost per juvenile justice placement averaged $30 a day in fiscal year

1998 while its cost per child welfare placement averaged $18 a day.

Table 2: Number of Title IV-E Funded Juvenile Justice and Child Welfare Placements in Texas and Cost per Day, by Setting and

Level of Care Received, Fiscal Year 1998

a

The daily rate rounded to the nearest dollar.

b

State payment rates include maintenance costs and the administrative costs associated with

maintenance as well as the cost of treatment and other services. Unlike rates in California, rates in

Texas do not vary by age of child.

c

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

maintenance.

d

Other placements include medical facilities and shelters.

Juvenile justice Child welfare Cost per daya

Number Percent Number Percent

State

payment

rateb

Title IV-E

allowable

amountc

Foster family homes

Care level 1 0 0% 2,967 45% $16 $13

Care level 2 1 0 704 11 34 30

Care level 3 3 1 669 10 58 52

Care level 4 34 12 443 7 83 68

Care level 5 0 0 1 0 100 85

Care level 6 0 0 0 0 187 161

Foster group homes and child care institutions

Care level 1 0 0 112 2 16 13

Care level 2 11 4 106 2 34 30

Care level 3 74 25 417 6 58 52

Care level 4 95 32 457 7 83 68

Care level 5 70 24 261 4 100 85

Care level 6 4 1 89 1 188 161

Otherd 3 1 392 6 e e

Total 295 100%f 6,618 100%fe e
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e

Not applicable.

f

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

Source: GAO analysis of statewide data provided by Texas.

State Licensing

Regulations Are Used

to Ensure Appropriate

Use of Title IV-E Funds

and Compliance With

Procedural

Requirements

To ensure that title IV-E funds are used appropriately and that title IV-E

procedural requirements are met, the 10 states claiming the most fiscal

year 1998 title IV-E funding rely on licensing regulations and other

administrative regulations. The states’ licensing regulations establish

minimum standards for child care institutions, where many juvenile justice

children in title IV-E funded foster care are placed, to ensure the safety and

well-being of children. To qualify for title IV-E funds, facilities need to be

licensed or approved as child care institutions. Although title IV-E prohibits

the use of funds to finance placements for detention purposes, some states’

licensing regulations allow, under certain circumstances, restrictive

practices that could be associated with detention. States’ licensing

regulations also address title IV-E procedural requirements intended to

protect the welfare of children, including requirements to develop a case

plan, conduct periodic administrative reviews, and follow procedural

safeguards. Each of these 10 states uses several monitoring mechanisms to

ensure child care institutions comply with licensing regulations. California

and Texas also have administrative regulations that establish standard

procedures—which mirror title IV-E procedural requirements—as well as

monitoring procedures to ensure these procedures are followed in

individual cases.

Licensing Regulations Allow

for Practices Sometimes

Associated With Detention

and Address Most Title IV-E

Procedural Requirements

Each of the 10 states’ licensing regulations for child care institutions

establishes minimum standards regarding facility administration and

personnel qualifications, intake procedures and children’s personal rights,

services and activities to be provided, and practices to ensure a healthy and

safe physical environment for children. Several provisions in these

regulations specifically address restrictive practices. Others establish

procedures that mirror title IV-E procedural requirements intended to

protect the welfare of children.
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Child care institutions are eligible to receive title IV-E funds if they meet the

licensing standards set for these institutions by the state. While facilities

operating primarily for the detention of children determined to be

delinquent are ineligible to receive title IV-E funds, some provisions

governing the practices of licensed child care institutions allow for certain

restrictive practices. For example, although none of the 10 states allow

facilities to isolate or restrain a child as a form of punishment, some allow

facilities to use short-term isolation and physical restraint to prevent

children from posing a risk or threat to themselves, others, or physical

property, and to manage inappropriate behaviors.10 Maryland and Michigan

also allow locks to be used for reasons other than security. Specifically,

licensed child care institutions in Maryland are allowed to lock doors as

part of “secure care programs” for children who are deemed delinquent,

and licensed child care institutions in Michigan are permitted to lock the

doors of “behavior management rooms.” Similarly, when we asked staff in

county probation departments in California and Texas about the restrictive

practices in 18 title IV-E funded juvenile justice cases we reviewed in their

states, we learned that in 7 of these cases the facility served primarily

children in the juvenile justice system. While this information alone does

not constitute sufficient evidence to disqualify these facilities for title IV-E

funding, it illustrates how difficult it may be to distinguish between juvenile

justice placements in detention and nondetention facilities without more

knowledge about the facilities in these cases and the nature of the

treatment they provide. This information also emphasizes the importance

of adequate oversight of the use of title IV-E funds for juvenile justice

placements.

Licensing standards for child care institutions in the 10 states also contain

provisions that address three procedural requirements under title

IV-E: (1) development and updating of case plans; (2) review by a court or

an administrative body of children’s status at least every 6 months; and (3)

procedural safeguards for notifying parents about their child’s placement,

any changes in the placement, and about reviews and hearings that take

place.11 None of the state licensing regulations we reviewed addressed

permanency hearings. All 10 states’ licensing regulations require a case

10See app. III for a description of the specific provisions related to each of these restrictive

practices in the licensing regulations for child care institutions in each of these 10 states.

11See app. IV for a description of the specific provisions related to title IV-E procedural

requirements in the licensing regulations for child care institutions in each of these 10

states.
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Page 17 GAO/HEHS-00-42 Use of Foster Care Funding

plan for each child that includes an educational program and provides for

health care. All also require reviews of case plans on a regular basis,

ranging from once a month to once a year. Some states’ regulations for case

plans require child care institutions to specify steps and time frames for

tracking progress toward long-range goals. Michigan’s licensing

regulations, for example, require that case plan reviews evaluate progress

toward family reunification. All states’ licensing regulations also contain

procedural safeguards regarding admission, visitation, and services to

families.

All of the 10 states have systems in place to ensure licensed child care

institutions continue to comply with all provisions in licensing regulations,

including those covering restrictive practices and title IV-E procedural

requirements. For example, California and Texas officials told us that, to

enforce their licensing regulations, they conduct annual on-site visits,

which include reviews of case records and files to ensure that the facility is

providing required services, interviews with children and staff, and a visual

inspection of the facility.12 They also stated that they investigate complaints

and have procedures for levying penalties for noncompliance, including

denying renewal of, temporarily suspending, or revoking a license.

California and Texas Also

Have Administrative

Regulations That Address

Procedural Requirements in

Title IV-E Funded Cases

When we looked more closely at how California and Texas ensure that title

IV-E procedural requirements are met, we found that in addition to their

licensing regulations, their child welfare agencies also have administrative

regulations that address title IV-E procedural requirements and contain

processes for enforcing these requirements. In California, the Department

of Social Services (DSS) is responsible for enforcing compliance with these

procedural requirements; in Texas, the Department of Protective and

Regulatory Services (PRS) has this responsibility.

DSS regulations require children in foster care in California to be visited at

least monthly; the child welfare agency in each county is responsible for

conducting these visits with children in its jurisdiction. For title IV-E

funded juvenile justice cases, the juvenile probation department in each

California county, through formal agreements with the county child welfare

agency, is required to conduct monthly visits with children in these cases,

monitor the services they receive, and ensure that title IV-E procedural

requirements are met. According to DSS officials, California has recognized

12California and Texas also conduct prelicensing inspections.
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Page 18 GAO/HEHS-00-42 Use of Foster Care Funding

that juvenile justice agencies and the courts play key roles in ensuring that

title IV-E funded juvenile justice cases are managed in accordance with the

law. As a result, California is developing special training for probation

officers on procedural requirements that accompany title IV-E funding. To

address concerns related to the courts’ role in ensuring that procedural

requirements are met in title IV-E funded juvenile justice cases, California

recently passed legislation placing into state law many of the federal

procedural requirements in the Social Security Act. According to DSS

officials, this legislation will better ensure that the procedural requirements

are met, particularly in title IV-E funded juvenile justice cases. These

officials stated that, as regulatory rather than legislative requirements,

courts that usually handle juvenile justice cases involving title IV-E funded

placements were not legally bound to follow them. As a result of title IV-E

requirements being placed into state law, the courts must see to it that, in

juvenile justice cases, procedural requirements are met.

In Texas, PRS is responsible for ensuring that procedural requirements are

met in all title IV-E placements and that children receive the services they

require. To ensure that these requirements are met in juvenile justice

placements, PRS contracts with two state-level juvenile justice agencies:

(1) the Juvenile Probation Commission (JPC), which oversees county

juvenile probation agencies in the state, and (2) the Texas Youth

Commission (TYC), which handles juvenile justice cases statewide that

require more resources than local probation departments can provide.

According to PRS officials, to monitor compliance with these contracts,

PRS annually reviews the case files for a sample of title IV-E funded

juvenile justice cases from each agency. PRS officials also stated that the

department contracts with a private agency, Youth for Tomorrow, to

monitor licensed child care institutions in Texas in order to ensure that

they are providing the types and level of services that the children in their

care require.

JPC and TYC each have a system in place to comply with the title IV-E

procedural requirements in their contracts with PRS. JPC officials told us

that the agency, through contracts with county probation departments,

requires probation department staff to review cases on a quarterly basis

and to contact on a monthly basis every child in title IV-E funded

placements, the parent or guardian, and the caregiver in each placement.

Officials also noted that JPC staff audit the caseload of title IV-E funded

juvenile justice placements twice per year. Similarly, TYC officials told us

that the agency contracts with placement service providers and requires

them to follow the agency’s policies regarding procedural requirements,
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Page 19 GAO/HEHS-00-42 Use of Foster Care Funding

which mirror title IV-E requirements. To monitor these contracts, TYC

officials told us that they regularly review each provider’s service delivery

processes and periodically review provider performance in each case,

relative to the needs of the youth in the placement. TYC officials also noted

that, for each case, the agency reviews the case record and case plan every

month for the duration of a placement and conducts a 6-month

administrative review and a permanency hearing.

HHS’ Title IV-E

Reviews Not Likely to

Provide Sufficient

Information on

Juvenile Justice

Placements

According to HHS, some states have claimed title IV-E funds for children

placed in facilities not eligible for title IV-E reimbursement. HHS has

recognized that states might encounter difficulty in determining whether a

specific facility would qualify to receive title IV-E funding for the placement

of juvenile justice children. HHS has also found that states face unique

challenges in meeting title IV-E procedural requirements within a juvenile

justice framework. HHS is in the process of developing additional guidance

on what constitutes detention and on meeting procedural requirements in

juvenile justice placements. It began this initiative by issuing in December

1998 a request for public comment on these issues.13 A total of 17 states and

5 facilities responded along with several advocacy and professional groups.

The comments provided examples of the issues states face in determining

facility eligibility and meeting procedural requirements in juvenile justice

placements. Our review of the comments shows that states differ on how

they believe detention should be defined, and some have explicitly asked

HHS to clarify the definition. To address these facility eligibility issues,

HHS is continuing to review these comments and is considering its options

for creating more comprehensive guidance related to title IV-E eligibility of

facilities in juvenile justice placements. HHS also addressed comments

related to satisfying procedural requirements in title IV-E juvenile justice

cases in its new regulations for title IV-E eligibility and CFS reviews.

HHS carries out its title IV-E oversight responsibilities primarily through its

title IV-E eligibility and CFS reviews. HHS recently revised the regulations

for these two reviews, in part, to respond to federal legislation requiring the

department to modify its approach to monitoring state compliance with

federal child welfare requirements, including title IV-E eligibility and

procedural requirements. The new regulations, which went into effect on

March 27, 2000, specify a new objective, scope, and methodology for these

1363 Fed. Reg. 67484-67485 (Dec. 7, 1998).
B-281545

Page 20 GAO/HEHS-00-42 Use of Foster Care Funding

reviews. Through statewide and on-site assessments, CFS reviews are

intended to ensure that individual states “substantially conform” to their

foster care requirements and other program requirements under title IV-E,

as well as title IV-B, of the Social Security Act.14 Title IV-E eligibility reviews

focus on verifying eligibility for title IV-E funding by reviewing records for a

random sample of title IV-E funded placements in each state. The purpose

of these reviews is to validate the accuracy of a state’s claims to ensure that

payments are appropriate—that is, they are made on behalf of eligible

children, to eligible homes and institutions, and at allowable rates. CFS

reviews, as designed, focus primarily on results or outcomes and,

according to HHS, do not cover eligibility requirements for children or

facilities. They examine, state by state, (1) indicators of safety,

permanency, and child and family well-being and (2) systems affecting a

state’s capacity to deliver services leading to these outcomes. To obtain

information for these assessments, HHS relies on statewide data on

outcome indicators, interviews with state and local community

representatives, and reviews of case records.

As part of its title IV-E eligibility reviews, HHS intends to randomly sample

in each state 80 cases from a sample of 88 cases in the primary review from

all title IV-E funded placements in the state; during the on-site component

of its CFS reviews, HHS intends to review a sample of 30 to 50 cases

selected from a sample of 150 individual cases drawn from all cases of

children served by the state in foster care and in their own homes.15 The

remaining cases would be reviewed only in the event of a discrepancy

between the on-site findings and the statewide assessment. While HHS

looks at a sample of individual cases as part of each of its reviews, the

sample sizes are small, so relatively few juvenile justice cases will be

selected for review. Moreover, protocols for its title IV-E eligibility and CFS

reviews have not been finalized, and at this point it is not clear what

specific information related to eligibility and procedural issues in juvenile

justice cases will be collected.

14Title IV-B of the Social Security Act authorizes funds to states for a broad range of child

welfare services, including family preservation and family support services.

15For CFS reviews, case samples will be drawn from all title IV-E funded foster care

placements and cases that receive services funded under title IV-B of the Social Security

Act.
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Page 21 GAO/HEHS-00-42 Use of Foster Care Funding

Conclusions Juvenile justice placements constitute a small proportion of all title IV-E

placements. However, states have on occasion claimed reimbursement for

juvenile justice placements at facilities that were not eligible for such

reimbursement and, in many of the title IV-E funded cases we reviewed, the

facility served primarily children in the juvenile justice system.

Furthermore, according to HHS, states find it particularly difficult in

juvenile justice cases to meet title IV-E procedural requirements intended

to protect the welfare of children. In light of these findings, we believe it is

important for HHS to exercise adequate oversight of title IV-E funded

juvenile justice placements to determine the extent to which title IV-E

funding is appropriately used and procedural requirements are met in these

cases. To do this, HHS needs sufficient information about

• facility eligibility and compliance with procedural requirements in

individual title IV-E funded juvenile justice cases and

• the state and county systems used to determine if the facilities in title IVE funded juvenile justice cases are eligible for title IV-E funding, as well

as systems used to ensure that procedural requirements are met in these

cases.

Although states have primary responsibility for making title IV-E facility

eligibility decisions and meeting procedural requirements in juvenile

justice placements, we believe that as the ultimate steward of title IV-E

funds, HHS has responsibility to exercise close oversight of the use of

those funds. Collection of such information will allow HHS to identify the

nature and magnitude of any problems that may exist in these cases.

Recommendations We recommend that the Secretary of HHS direct the Assistant Secretary,

Administration for Children and Families, to review title IV-E funded

juvenile justice placements in child care institutions in states that have

such placements in order to collect information needed to determine

whether or not the facility in which the child was placed was a detention

facility.

We also recommend that, in each state having title IV-E funded juvenile

justice placements in child care institutions, HHS review a sufficient

number of such placements to provide a reasonable degree of assurance

that detention facilities are not receiving title IV-E funds and that

procedural requirements intended to protect the welfare of children are

being met in juvenile justice placements. Depending on the results of the
B-281545

Page 22 GAO/HEHS-00-42 Use of Foster Care Funding

initial review in a given state, HHS could decide whether it would be

necessary to review the same number of juvenile justice cases in that state

in the future.

Finally, we recommend that for those states having title IV-E funded

juvenile justice cases, HHS ensure that the adequacy and effectiveness of

state and county systems used to (1) determine if the facilities in which

juvenile justice children are placed are licensed and otherwise eligible for

title IV-E funding and (2) ensure that procedural requirements are met in

title IV-E funded juvenile justice cases are examined.

Agency Comments We gave HHS an opportunity to review a draft of this report; its written

comments are reproduced in app. V. While HHS agreed that more

information is needed to understand and address issues related to placing

juvenile justice children under foster care, it did not agree with our

suggestions on how to obtain such information. HHS said that the

disproportion we found—10 percent of title IV-E funds spent on juvenile

justice placements that constitute 4 percent of all title IV-E funded foster

care placements—was insufficient to justify revising its review systems for

the foster care program. We did not, however, base our recommendations

on the disproportion HHS cites. Rather, they were based on concern for the

welfare of the children involved, given that title IV-E funds have been

claimed for juvenile justice placements in ineligible facilities and that

meeting procedural requirements intended to protect the welfare of

children can be difficult in juvenile justice cases. Although the magnitude

of federal expenditures involved is certainly an important consideration,

we believe that ensuring the appropriateness of placements for and the

welfare of 15,000 juvenile justice children is important as well. While there

have been inappropriate placements in the past, and difficulties have been

encountered in meeting procedural requirements, the extent to which these

situations exist now is unknown and needs to be determined.

HHS’ comments to our draft report also indicated to us that the department

believed that our proposal to modify its title IV-E eligibility and CFS

reviews to sample enough juvenile justice cases to provide reasonable

assurance that the extent of problems with these cases was measured

would involve more work than necessary. HHS said that it had two

mechanisms—the partial CFS review and the partial review for state plan

requirements outside the scope of a CFS review—that could be used as an

issue-specific, targeted approach to identify and respond to problems with

juvenile justice placements. The intent of our proposed recommendation
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Page 23 GAO/HEHS-00-42 Use of Foster Care Funding

was to have HHS determine the extent of problems with juvenile justice

foster care placements and to correct problems that may exist. HHS

believes it can adequately accomplish these objectives through alternative

means, which we found satisfactory. Therefore, we modified the language

of our recommendations to allow for the use of alternative means to

accomplish their intended effect.

California and Texas also commented on a draft of the report; HHS also

provided technical comments. These comments were incorporated where

appropriate.

We will send copies of this report to the Honorable Donna E. Shalala,

Secretary of HHS, and program officials in California and Texas. We will

also send copies to child welfare program directors in all other states and

make copies available to others on request.

If you have any questions concerning this report, please contact me at (202)

512-7215 or Clarita Mrena at (415) 904-2245. Susan Riggio, Cornelius

Williams, May Lee, Patrick DiBattista, and Traci Gleason Wright also made

important contributions to this report.

Cynthia M. Fagnoni

Director, Education, Workforce, and

Income Security Issues
Page 24 GAO/HEHS-00-42 Use of Foster Care Funding

Appendix I

Scope and Methodology ApApenednxidexiIs

To determine the number of title IV-E funded juvenile justice and child

welfare placements nationwide, the amount of title IV-E funds used by each

state for juvenile justice and child welfare placements, and the ages of

children in title IV-E funded juvenile justice placements, we conducted a

survey of all 50 states and the District of Columbia. We asked each state to

provide this information statewide for their fiscal year 1998. We conducted

follow-up calls to encourage states to complete the survey and to clarify

responses when necessary.

In response to our survey, 23 states indicated that they had claimed title IVE funding for juvenile justice placements during fiscal year 1998; 1 17 states

and the District of Columbia indicated they had not. The remaining 10

states did not respond to our survey.

While all of the 23 states that indicated they had financed juvenile justice

placements with title IV-E funding could provide the total amount claimed

that year, only 17 could provide the amount claimed for juvenile justice

placements alone. To determine what proportion of all title IV-E funding

nationwide during fiscal year 1998 was used for juvenile justice

placements, we used estimates of the amount each of the other five states

claimed for these placements.2 We estimated this amount in these states by

multiplying the total title IV-E funding each state indicated they claimed by

14.5 percent. We used this percentage because, across the 17 states that

could provide the amount claimed for juvenile justice placements, 14.5

percent of the total title IV-E funding claimed was for juvenile justice

placements. For example, in Alabama we estimated that $991,543 in title IVE funding, or 14.5 percent of the total $6,833,512 claimed, was for juvenile

justice placements.

1

See app. II for state-by-state information on the amount of title IV-E funding claimed for

juvenile justice placements and the number of these placements.

2

These states include Alabama, Indiana, Minnesota, Pennsylvania, and Virginia.
Appendix I

Scope and Methodology

Page 25 GAO/HEHS-00-42 Use of Foster Care Funding

Similarly, only 18 of the 23 states that indicated they had claimed title IV-E

funding for juvenile justice placements could provide the number of

juvenile justice placements for which these funds were claimed. To

determine what proportion of all title IV-E funded placements nationwide

were juvenile justice placements, we used estimates of the number of

juvenile justice placements in two of the four states that could not provide

this number.3 We multiplied the total number of title IV-E funded

placements in each state by 6.4 percent because 6.4 percent of all title IV-E

funded placements across the 18 states that could provide this number

were juvenile justice placements. For example, in Alabama we estimated

that 79 title IV-E funded placements, or 6.4 percent of the total 1,235

placements for which the state claimed title IV-E funding, were juvenile

justice placements.

To determine what systems are in place in states to ensure title IV-E funds

are not used for placements in detention facilities and that procedural

requirements are met in title IV-E funded cases, we conducted in-depth

fieldwork in California and Texas. We visited state-level agencies in both

states and met with officials from county agencies in Los Angeles and San

Bernardino counties in California and Dallas and Harris counties in Texas.

As part of this fieldwork, we reviewed the case files of a total of 18 children

in title IV-E funded juvenile justice placements. These reviews examined

case planning, administrative reviews, permanency planning, and efforts to

reunify the children in these cases with their parents. We also obtained

information on selected features of most of the facilities in these cases

from probation officers and title IV-E program staff in county probation

departments in Texas and county probation officers in California.4 We did

not independently determine in these cases if the facilities in which

children were placed were eligible for title IV-E funding, if procedural

requirements were met, or if children received the services they required.

We also obtained state administrative data relevant to IV-E funded

placements in 1998. These data included breakdowns of the title IV-E

funded juvenile justice and child welfare populations in these states by

3

We estimated this number for Alabama and Indiana. Minnesota and Virginia could provide

neither the number of juvenile justice placements nor the total number of placements for

which title IV-E funding was claimed, so there was no basis for estimating the number of

juvenile justice placements in these states.

4

Features included whether the facility was located in an isolated or remote area, whether

the facility was locked, facility policies regarding visitation and telephone calls and pursuit

of runaways, and whether the facility primarily serves youth in the juvenile justice system.
Appendix I

Scope and Methodology

Page 26 GAO/HEHS-00-42 Use of Foster Care Funding

level of care received, type of foster care placement or placement setting,

and the state payment rate and the title IV-E allowable amount paid for

such care. Finally, we conducted extensive interviews with officials in the

state and county agencies responsible for administering title IV-E funding.

To determine how provisions in state licensing regulations for child care

institutions reflect eligibility criteria for title IV-E funding and address title

IV-E procedural requirements, we reviewed licensing regulations in the 10

states claiming the most federal foster care funding during 1998. In addition

to California and Texas, we reviewed licensing regulations in Maryland,

Ohio, North Carolina, Missouri, Illinois, New York, Michigan, and

Pennsylvania.

To identify the processes HHS has in place to ensure that title IV-E funds

are only used for placements that qualify for this funding and that title IV-E

procedural requirements are met in juvenile justice cases, we reviewed

pertinent laws, regulations, and other documents and interviewed program

officials from the department. We conducted our work between December

1998 and May 2000 in accordance with generally accepted government

auditing standards. We did not independently verify the data states

provided to us.
Page 27 GAO/HEHS-00-42 Use of Foster Care Funding

Appendix II

Fiscal Year 1998 Title IV-E Funding Claimed

and Number of Placements, by State ApendxiI

Amount of title IV-E funding claimed

Number of placements for which title IV-E

funding was claimed

State Total

For juvenile justice

placements Total Juvenile justice

Alabama $6,833,512 $991,543a 1,235 79b

Alaska 8,630,748 917,789 489 52

Arizona 39,781,393 0 4,224 0

Arkansas 20,167,765 0 c 0

Californiad 779,431,192 188,900,670 70,696 4,317

Colorado 27,760,609 3,419,368 4,432 416

Connecticutc — — ——

Delaware 6,476,120 140,078 405 5

Washington, D.C. 31,141,626 0 2,350 0

Florida 111,048,387 0 10,130 0

Georgia 26,265,132 0 7,410 0

Hawaii 10,294,557 0 1,920 0

Idaho 3,830,200 0 497 0

Illinois 470,708,348 0 43,061 0

Indiana 28,454,479 4,128,745a 5,346 341b

Iowac — — ——

Kansas 12,061,336 0 1,725 0

Kentucky 34,061,773 915,654 5,071 66

Louisiana 52,170,448 5,337,890 3,561 481

Maine 44,315,875 0 3,109 0

Maryland 74,320,191 1,361,650 1,941 327

Massachusettsc — — ——

Michigan 185,380,873 0 9,080 0

Minnesota 27,657,424 4,013,093a cc

Mississippi 10,443,760 0 1,009 0

Missouri 61,145,850 0 10,507 0

Montanac — — ——

Nebraskac — — ——

Nevadac — — ——

New Hampshire 9,604,538 960,454 1,002 225

New Jersey 43,100,000 0 c 0

New Mexico 3,699,023 0 1,100 0

New York 380,423,754 36,000,000e 58,655 2,456
Appendix II

Fiscal Year 1998 Title IV-E Funding Claimed

and Number of Placements, by State

Page 28 GAO/HEHS-00-42 Use of Foster Care Funding

a

State used title IV-E funds for juvenile justice placements but could not provide statewide data on the

amount claimed for juvenile justice placements. Entry is our estimate of the amount based on the

percentage of title IV-E funds other states, in general, claimed for juvenile justice placements.

b

State used title IV-E funds for juvenile justice placements but could not provide data on the number of

these placements statewide. Entry is our estimate of the number based on the percentage of all title IVE funded placements in other states, in general, for juvenile justice placements.

c

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

d

It should be noted that, in 1999, California no longer authorized placements in (that is, decertified)

three out-of-state facilities that received title IV-E funds during 1998. The state has not determined

whether these decertifications should be retroactive to 1998, which would require these facilities to

return title IV-E funds they received for placements in that year.

e

State provided an approximate amount.

f

State indicated that it claimed title IV-E funding for juvenile justice placements but did not provide the

data we requested.

North Carolina 35,825,085 0 7,726 0

North Dakota 8,618,741 1,356,542 1,121 83

Ohio 295,000,000 1,338,872 28,000 344

Oklahomac — — ——

Oregonc — — ——

Pennsylvania 269,864,495 39,157,339a 31,223 3,910

Rhode Island 15,837,832 160,416 2,115 41

South Carolina 17,424,000 0 2,160 0

South Dakota 2,851,781 40,642 564 2

Tennessee 28,856,741 12,737,366e 5,874 673

Texas 79,944,180 9,901,770 11,545 889

Utah 16,075,312 584,096 2,019 276

Vermontf — — ——

Virginia 36,199,110 5,252,491a cc

Washington 20,974,310 0 4,882 0

West Virginiac — — ——

Wisconsinc — — ——

Wyoming 224,372 29,075 303 19

Total $3,336,904,872 $317,645,543 346,487 15,002

(Continued From Previous Page)

Amount of title IV-E funding claimed

Number of placements for which title IV-E

funding was claimed

State Total

For juvenile justice

placements Total Juvenile justice
Page 29 GAO/HEHS-00-42 Use of Foster Care Funding

Appendix III

Provisions of State Licensing Regulations for

Child Care Institutions Related to Physical

Restriction of Residents ApendxiI

Discipline Isolation Locks Restraints

California

Any form of discipline that

violates a child’s personal rights

is prohibited. Acceptable forms

of discipline include exclusion in

an unlocked living, sleeping, or

play area; institution of fines

under certain conditions;

prohibition against attendance at

or participation in planned

activities; and prohibition against

use of entertainment devices,

such as telephones, televisions,

radios, and phonographs.

(See discipline column.) Resident children cannot be

locked in any room, building, or

facility premises by day or night.

Facility is permitted to use any

other means for securing

exterior doors and windows or

for protection of residents

provided residents are able to

exit the facility.

(See discipline column.) Physical

restraining devices may be used

for the protection of a child with

special health care needs during

treatment and diagnostic

procedures such as, but not

limited to, intravenous therapy or

catheterization procedures.

Illinois

Discipline may only be used to

help children develop self-control

and learn to assume

responsibility for their actions.

Acceptable discipline includes

assigning special or additional

tasks and/or removing privileges

for periods not to exceed 1

month, restriction to the child’s

sleeping quarters or room for

periods not to exceed 3 hours

per day, or restriction to the

premises or specified areas of

the premises for periods not to

exceed 3 days.

Confinement is limited to

children who pose a threat of

physical harm to themselves or

others. A child may not be kept

in confinement more than 30

minutes beyond the point at

which the child ceases

presenting the specific behavior

for which the confinement was

ordered or any other behavior for

which confinement is an

appropriate intervention.

Confinement may be used to

prevent runaway only when the

child presents a threat of

physical harm to self or others.

Key locks may not be used on

locked confinement room doors.

Automatic mechanisms are to

release the child from

confinement in the event of a fire

or other disaster.

Physical restraint may be used

only as a therapeutic measure

when a child presents a threat of

physical harm or dangerous

behavior reasonably expected to

lead to physical harm to self or

others. Physical restraints are

not to be used until after other

less restrictive procedures or

measures have been explored

and found to be inappropriate.

No child is to be subjected to

mechanical restraints unless

prescribed by a licensed

physician.

Maryland

Prohibited disciplinary measures

include assigning physically

strenuous exercise or work and

the withholding of meals, sleep,

mail, family visits, or program

participation other than

recreation or leisure activities.

A child may not be kept in a

locked room away from the

general population unless it is

clearly necessary to prevent

imminent physical harm to the

child or other individuals or to

prevent imminent and

substantial destruction of

property.

Facility with “secure care

program” may employ locked

doors or other means to care for

alleged or adjudicated

delinquent children.

Restraints can only be used

when (1) failure to do so would

result in harm to self or others or

would result in property damage,

(2) ordered by a physician or

court of competent jurisdiction,

and (3) permitted by state law.
Appendix III

Provisions of State Licensing Regulations for

Child Care Institutions Related to Physical

Restriction of Residents

Page 30 GAO/HEHS-00-42 Use of Foster Care Funding

Michigan

A child care facility may receive

approval to use a “behavior

management” room for a child

who is out of control and is in

danger of harming self or others.

The rooms are to be used only

for the time needed to change

the behavior compelling its use.

(See discipline column.) The door to the behavior

management room may be

equipped with a security-locking

device that operates by means

of a key or is electrically

operated and has a key override

and emergency electrical backup

in case of a power failure.

(See discipline column.)

Missouri

Facilities are to have written

policies and procedures

prohibiting discipline that may

adversely affect a child’s health

or physical or psychological wellbeing.

Locked isolation for the purpose

of discipline is not to be used. A

facility with a residential

treatment program may use

locked isolation when a child

presents a danger to self or

others or poses a threat of

serious property damage and in

the shortest intervals possible

until the child regains reasonable

self-control.

(See isolation column.) Restraints are to be used only to

end disturbances that threaten

physical injury to the child or

others or do serious property

damage.

New York

Discipline is to be prescribed,

administered, and supervised

only by adults. Deprivation of

meals, snacks, mail, or visits by

family as methods of discipline

are prohibited.

Room isolation as a method of

discipline is prohibited.

No child is to be confined to a

locked room for any reason.

Restraints are to be used without

purposely inflicting pain or harm

and only when other forms of

intervention are either

inappropriate or have been tried

and proven unsuccessful.

Restraint, including room

isolation, will never be used for

punishment or for the

convenience of staff.

North Carolina

Isolation or locked custody is to

not be used as punishment.

Appropriate work tasks or

denials of privileges are

acceptable methods of

discipline. Corporal punishment

or denials of meals are not to be

used as punishment.

(See discipline column.) No locks are to be installed on

exits and on room doors that

would prevent occupants from

getting out by the simple

operation of a single knob or

lever.

(Not specifically addressed in

state regulations.)

Ohio

Facilities must have disciplinary

policy and procedures to prohibit

all cruel, unusual practices and

punishments.

Isolation can be used exclusively

for the behavior management of

a child who is out of control.

All locks on doors to any room or

storage area in which a child

could be confined are to be of

the type that permit the door to

be unlocked from either side of

the door.

Isolation, physical, chemical, or

mechanical restraint may not be

used as a means of punishment.

(Continued From Previous Page)

Discipline Isolation Locks Restraints
Appendix III

Provisions of State Licensing Regulations for

Child Care Institutions Related to Physical

Restriction of Residents

Page 31 GAO/HEHS-00-42 Use of Foster Care Funding

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

Pennsylvania

A licensed facility may not use a

method of physical restraint,

isolation, security, or physical

barriers that would prevent a

child from leaving the facility.

Placing a child in a locked

room—including rooms with any

type of door locking device, such

as a key lock, spring lock, bolt

lock, foot pressure lock, or

physically holding the door

shut—is prohibited.

Locks may be used as a means

of external security to keep

persons out or deny access to

an area but not to exit.

Use of mechanical restraint is

prohibited. No child is to be

restrained for purposes of

punishment or for the

convenience of others. Restraint

may be used only in cases of

emergency where there is the

occurrence or serious threat of

violence to self, others, or

property.

Texas

Any discipline or control must fit

the needs of each child. Children

must not be punished by shaking

or striking; denied food, mail, or

family visits as punishment; or

subjected to cruel, harsh,

unusual, or unnecessary

punishment. Physical

punishment (that is, spanking) is

permitted only in basic care

facilities, not in facilities serving

mentally retarded or emotionally

disturbed children. If the facility

has a behavior therapy program,

it must have clearly written

policies and procedures for the

program and be approved by the

state’s Department of Protective

and Regulatory Service. If a

facility’s policy permits physical

punishment, a complete

description of any physical

punishment administered must

be recorded. The punishment

must be administered by a staff

member and witnessed by

another staff member. If a child

is restricted to the facility for

more than 24 hours, the

restriction must be recorded in

the child’s record. Denial of

“edible treats” may be used as

part of an individual behavior

management program.

A child must not be placed alone

in a locked room. Children must

not be placed in a dark room.

Children in a behavior therapy

program and required to be

placed in a locked time-out must

not be placed in a locked timeout room for more than 15-

minute intervals. Children in a

locked time-out room must be

watched or visually monitored on

a continuous basis by the foster

parent or child care worker. If a

child in an individual behavior

management program is

restricted to the facility for more

than 24 hours, the restriction

must be recorded in the child’s

record.

(See isolation column.) Physical holding for restraint or

mechanical restraints must be

used only when necessary to

protect the child from injury to

self or others. If physical restraint

is to be used other than in an

emergency, it can be used only

upon the orders of a licensed

physician. An order for physical

restraint must designate the type

of restraint, the circumstances,

and the duration of its use.

(Continued From Previous Page)

Discipline Isolation Locks Restraints
Page 32 GAO/HEHS-00-42 Use of Foster Care Funding

Appendix IV

Provisions in State Licensing Regulations That

Relate to Procedural Requirements in Title

IV-E Funded Foster Care Cases ApendxiIV

Case/service plan Case reviews/program progress reports Procedural safeguards

California

— Plan development: Needs and services

plans are to include (1) reason for

placement; (2) education and training

history; (3) ability to care for and groom

oneself and to manage money; (4) on- and

off-site visitation privileges with family

members and friends; and (5) other specific

services, including those required by the

child’s parent or guardian.

— Services to family: Licensees must have

a policy regarding participation of the child

and authorized representative in the

development of the needs and services

plan.

— Education: Licensees are to ensure each

child’s attendance at an educational

program in accordance with state law.

— Health services: Licensees are to obtain

and maintain in each child’s record medical

and dental insurance coverage information

and consent forms completed by the child’s

authorized representative. Licensees are not

to accept any child with special health care

needs unless the licensee has obtained an

individualized health care plan for the child.

Licensees must have procedures for

reviewing and evaluating needs and

services plans, which are to be updated at

least every 6 months to determine (1) the

child’s need for continuing services and (2)

the facility’s recommendation regarding the

feasibility of the child’s return home,

placement in another facility, or move to

independent living.

— Resident visitation: Needs and services

plans are to identify the child’s needs

regarding visitation, including the frequency

of and any other limitations on visits to the

family residence and other visits inside and

outside the facility.

— Services to family: Licensees must have

a policy regarding participation of the child

and authorized representative in the

development of the needs and services

plan.

— Admission/intake procedures and

practices: Licensees are to develop,

maintain, and implement intake procedures

that will specify (1) needs and services plan

requirements and (2) signature of child and

authorized representative that they (a) were

offered the opportunity to participate in plan

development and (b) approved the plan.
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 33 GAO/HEHS-00-42 Use of Foster Care Funding

Illinois

— Plan development: Plans for services for

each child and family must be in writing,

reviewed at least every 6 months, and

signed by all the parties involved. Plans are

to describe the services to be provided and

how these services (1) will meet the needs

of the child and family and (2) are directed

toward resolution of the need for placement.

Plans also must establish a time frame for

termination of services and care in the

facility.

— Education: Each child is to have the

opportunity and be encouraged to complete

high school or vocational training in

accordance with aptitude. Those excluded

from school or unable to benefit from usual

school attendance are to be provided

education, training, or work experience

consistent with their needs and abilities.

Each child is to be permitted and

encouraged to participate in extracurricular

activities. The group home must ensure that

each child has available necessary school

supplies, materials, and equipment and

must maintain contact with and seek

cooperation of those serving the educational

needs of its children.

— Health services: Each child is to be

examined by a physician within 30 days

before placement and screened for

communicable diseases within 72 hours. If

an emergency, the physical examination is

to be scheduled within 5 days after

placement and completed within 15 days

after placement. Children must also be

examined annually, or more frequently if

findings and medical opinion indicate need,

and given a dental examination at least

annually with diagnosed dental defects

treated promptly.

Licensees are to assess with the referring

agency, child, and/or family the child’s need

for placement, the purpose for referral to the

specific institution, and the institution’s

ability to serve the child. Each child’s plan

for services must be reviewed at least every

6 months and signed by all parties involved.

— Resident visitation: Children are not to be

deprived, as discipline, of visits or weekly

telephone contacts with family, attorneys or

legal assistants, assigned caseworkers, or

other persons who have established a

parenting bond with the child. Children are

to be allowed to visit families other than their

own and friends in the community when the

living conditions of the family to be visited

are known and the visits are approved by

the child care facility. The facility is to ensure

that visits with the child, on or off the facility’s

premises, are in the child’s best interests.

— Services to family: Families are involved

in developing and improving service plans

for the child and family.

— Admission/intake procedures and

practices: Children are to be admitted only

upon written consent or application of parent

or guardian; upon court order; or, in

emergency situations, upon authorization of

an officer of the law or a department child

protective services worker. No person who

has attained age 18 is to be admitted unless

referred by a parent or a guardian, including

an agency having legal responsibility for the

person under Illinois statute.

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 34 GAO/HEHS-00-42 Use of Foster Care Funding

Maryland

— Plan development: Licensees are to have

and follow written policies regarding

individual service planning. Service plans

are to be developed within 30 days after

admission and are to identify the child’s

needs with respect to (1) counseling and

drug and alcohol abuse, (2) education, (3)

family relationships, (4) health care, (5) life

skills development, (6) recreation, (7) social

work, (8) program goals, and (9) the time

planned to achieve goals.

— Services to family: Licensees are to invite

to participate in the admission process and

in the development of the individual service

plan and the discharge plan the (1)

representative designated by the placing

agency and (2) child’s parent if consistent

with the child’s permanency plan.

— Education: Licensees are to (1) ensure

that each child who is of mandatory school

attendance age and who has not earned a

secondary school diploma or a certificate of

completion, and each child who is eligible for

special education services attends school or

is provided with appropriate education

services; (2) work cooperatively with the

local school system to ensure that the

children attend the local school whenever

possible; and (3) when applicable, obtain a

certificate of approval for educational

programs in nonpublic schools and child

care and treatment facilities.

— Health services: Licensees are to (1)

have and follow a written plan for the

provision of preventive, routine, and

emergency medical, dental, and mental

health care for children; (2) obtain written

authorization from a parent or other

authorized individual for nonemergency

medical, dental, or mental health care; (3)

authorize emergency medical, dental, or

mental health care if a parent cannot be

reached.

Licensees are to review and update

individual service plans at least every 90

days.

— Resident visitation: Licensees are to have

and follow a written policy regarding

communications—which include visitations,

telephone contacts, correspondences, and

reports—between the child and others.

When consistent with the child’s service

plan, family members are to be encouraged

to participate in the program.

— Services to family: Licensees are to give

the child’s parent and, as appropriate, the

child a written description of the program

that includes (1) the program mission and

admission and discharge policies, (2) daily

routines, (3) treatment strategies and

disciplinary practices, (4) visiting hours and

other procedures related to communications

with the child, and (5) procedures for

registering grievances regarding the child’s

care.

— Admission/intake procedures and

practices: Licensees are to have and follow

written policies regarding admission,

individual service planning, and discharge,

and invite to participate in the admission

process and in developing the individual

service plan and the discharge plan the

representative designated by the placing

agency and the child’s parent if consistent

with the child’s permanency plan.

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 35 GAO/HEHS-00-42 Use of Foster Care Funding

Michigan

— Plan development: Service plans are to

be developed within 30 days of admission

and with resident, parents, and the referral

source. Plans are to include (1) an

assessment of the resident’s and family’s

strengths and weaknesses in the areas of

education, economics, psychology, society,

and health as they relate to the resident’s

needs; (2) parent and child visitation plans;

(3) treatment goals to remedy problems of

the resident and family and time frames for

achieving the goals; (4) indicators of goal

achievement; (5) persons responsible for

coordinating and implementing the resident

and family treatment goals; (6) staff

techniques for achieving the resident’s

treatment goals; and (7) the projected length

of stay and next placement.

— Education: Licensees are not to admit a

child for care unless an appropriate

educational program can be provided in

accordance with Act No. 451 of the Public

Acts of 1976, as amended (§380.1 et seq of

the Michigan Compiled Laws, known as the

School Code of 1976) not later than 5 school

days after admission and continuously

thereafter for each resident of school age.

— Health services: Licensees are to

establish and follow written health service

policies and procedures for (1) routine and

emergency medical and dental care, (2)

health screening procedures, (3)

maintenance of health records, and (4)

storage and dispensing of medications and

personnel authorized to dispense

medications.

Services plans are to be updated and

recorded by the social services worker for

each child at least once every 3 months

following the initial plan. Updated service

plans are to be developed with the resident,

the resident’s parents, and the referral

source, unless documented as

inappropriate. Updated service plans are to

include (1) progress made toward achieving

the goals established in the previous plan;

(2) any changes in the plan, including new

problems and new goals to remedy the

problems; and (3) indicators of goals and

time frames for achievement.

— Resident visitation: Facilities are to make

provisions for visits between each resident

and the resident’s parents, except where

parental rights have been terminated or the

resident’s record contains documentation

that visitation is detrimental to the resident.

— Services to family: Facilities are to have a

program statement that specifically

addresses the services that will be provided

to residents and parents directly by the

institution and the services provided by

outside resources.

— Admission/intake procedures and

practices: Service plans developed for each

child within 30 days of admission include (1)

an assessment of the child’s immediate and

specific needs, (2) the specific services to

be provided by the institution and other

resources to meet the child’s needs, and (3)

a description of the child’s placement

circumstances and general physical and

emotional state at the time of admission.

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 36 GAO/HEHS-00-42 Use of Foster Care Funding

Missouri

— Plan development: From the time a child

is admitted, a preliminary written service

plan must be developed and documented in

the child’s record within 15 days for each

child admitted by plan for placement or

within 72 hours for emergency placement

admissions. The service plan must identify

and include (1) the child’s individual needs

in addition to basic needs for food, shelter,

clothing, routine care, and supervision; (2)

specific strategies and their frequency to

meet the child’s needs, including

instructions to staff; (3) specific strategies

and frequencies for family involvement,

including a defined plan for visitation and

engaging the family in services for the child;

(4) specific strategies to meet the

recreational and developmental needs of the

child; (5) the estimated length of stay; and

(6) the date and signature of the treatment

team coordinator and a signed and dated

attendance sheet of all other participants.

— Services to family: The service plan must

also identify and include time-limited goals

and preliminary plans for discharge,

including plans for reintegration into family

and community.

— Education: The facility administrator is

responsible for ensuring compliance with

Missouri statutes pertaining to a child’s

education.

— Health services: The facility is to have a

written health care program plan that

addresses preventive medical eye, hearing,

and dental care.

The service plan review with the date and

signature of the treatment team coordinator

and a signed and dated attendance sheet of

all other participants in the review must be

documented in the child’s record. Reports of

the evaluations in summarized form are to

be included in the child’s record and shared

with the parent, guardian, or legal custodian.

The service plan review must include (1) an

evaluation of progress toward meeting the

child’s needs; (2) an evaluation of progress

toward family reunification; (3) any needs

identified since the plan was developed or

last reviewed and strategies to meet the

needs, including instructions to staff; and (4)

an update of the estimated length of stay

and discharge plans, if changed.

— Resident visitation: agencies are to

develop written visitation policies. An

agency is to encourage and support

contacts between a child and the family

while the child is in care, unless the rights of

the parent to contact the child have been

terminated or restricted by court order.

— Services to family: The admission

assessment must be in writing and include

specific information on (1) the

circumstances that led to the child’s referral;

(2) the immediate and long-range goals of

placement; and (3) the parent’s or legal

guardian’s expectations for placement,

family involvement, and duration of the

child’s stay in care.

— Admission/intake procedures and

practices: Intake policies are to be in writing

and are to identify services and programs

offered. Whenever possible, an agency is to

arrange for one or more preplacement visits

by the child (except in emergency

placements) and, when appropriate, arrange

for at least one or more preplacement visits

by the child’s parent, guardian, or legal

custodian. When a child is self-referred,

efforts are to be made to contact the child’s

parent, guardian, or legal custodian within

24 hours. If the parent, guardian, or legal

custodian cannot be contacted, the

agencies are to notify the appropriate public

agency. All efforts to notify the appropriate

public agency, parent, guardian, or legal

custodian are to be documented in the

child’s case record.

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 37 GAO/HEHS-00-42 Use of Foster Care Funding

New York

— Plan development: A case planner is

assigned to each child and is responsible for

assessing the need for, providing or

arranging for, and coordinating and

evaluating the provision of services to

children in foster care and services to

parents of children in foster care.

— Services to family: Casework contacts

are defined as individual or group face-toface contacts between the case planner and

a child’s parents or relatives for the purpose

of guiding parents and relatives toward a

course of action aimed at resolving

problems or needs of a social, emotional,

developmental, or economic nature that are

contributing to the need for foster care.

— Education: Licensees are to take such

steps as may be necessary to make certain

that all children receive education

appropriate to their needs and in

accordance with the requirements of the

state’s Education Law and are to make

certain that each child receives appropriate

educational and vocational guidance.

— Health services: Each child must have

complete medical examinations and is to be

provided, when necessary, with eyeglasses,

hearing aids, and prosthetic or other

adaptive devices. Food is to be of good

quality, properly prepared, served at regular

hours, sufficient in quantity, and meet

nutritional standards recommended by the

National Research Council. To the extent

possible, nutritional requirements based on

a child’s religious beliefs are to be met.

During the first month of placement,

casework contacts are to be held with the

child’s parents or relatives as often as is

necessary to implement the tasks in the

family and children’s services plan but, at a

minimum, are to occur at least twice, unless

compelling reasons are documented why

such contacts are not possible. After the first

month of placement, casework contacts are

to be held with the child’s parents or

relatives at least once every month if the

permanent planning goal for the child is to

return to the parents or relatives and

quarterly if the child’s permanent planning

goal is for adult residential care or to

prepare for independent living. Casework

contacts may include either face-to-face

contacts or telephone consultations.

— Resident visitation: For children with a

permanency planning goal of returning to

parents or relatives, contacts between the

caseworker and the child’s parents or

relatives are to be scheduled to occur in the

home of the parents or relatives to whom the

child will be discharged as often as is

necessary to implement the tasks in the

family and children’s services plan.

— Services to family: Social service officials

must provide care and services as directed

by the family court judge to encourage and

strengthen the parental relationship when

the court finds that such efforts will not be

detrimental to the best interests of the child.

— Admission/intake procedures and

practices (see case reviews).

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 38 GAO/HEHS-00-42 Use of Foster Care Funding

North Carolina

— Plan development: A written plan of care

for each child is to be developed at the time

of admission and reviewed at least

semiannually by facility staff; parents and

legal custodians; and the child, where

appropriate. This plan of care is to include

(1) the expectations and goals for the child

and (2) the tasks and activities of facility

staff, parents, and legal custodian to meet

the needs of the child while in care.

— Services to family: Each facility is to

provide those services to children and their

families that it has stated it will provide in

each child’s plan of care. Licensees are to

evaluate each child’s placement needs on a

regular basis and are to include in this

review the parents, relatives, and the agency

with legal responsibility for the child.

— Education: Children are to attend the

public school to which they are assigned,

unless an alternative education plan is

agreed upon by the child, the facility, and the

responsible person or placement agency.

— Health services: Facilities are to have a

planned program of medical care. No child is

to be accepted into a program without

having had a physical examination within 90

days prior to admission, which is to include a

signed statement by a licensed medical

provider specifying the child’s current

medical condition and prescribed

medications.

Each child’s plan of care is to be reviewed at

least semiannually by facility staff, parents,

legal custodian, and, when appropriate, the

child.

— Resident visitation: Resident visitation

and telephone calls are to be planned on an

individual basis. Visitation policies are to be

developed through consultation with and the

approval of the legal custodian of the child.

— Services to family: Each facility is to

provide services that it stated it will provide

in children’s written plans of care. In reviews

of each child’s placement needs, licensees

are to include the parents, relatives, and the

agency with legal responsibility for the child.

— Admission/intake procedures and

practices: Admission policies are to be

clearly defined in writing and are to be

reviewed annually and changed as needs

and conditions in the community change. A

written plan of care for each child is to be

developed at the time of admission and

reviewed at least semiannually by the group

home staff, parents, legal custodian, and,

when appropriate, the child. Written

placement agreements, signed by

authorized persons, are to include the

services to be provided by the facility and

the responsibilities of parents and legal

custodians, indicating responsibility for (1)

the child’s financial and medical needs and

fees to be paid; (2) consent for emergency

medical treatment; and (3) determining

length of stay, visitation expectations and

limitations, and the schedule of review

conferences.

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 39 GAO/HEHS-00-42 Use of Foster Care Funding

Ohio

— Plan development: Service plans are to

be in writing and contain, at a minimum, (1)

goals and objectives; (2) the time frame

projected for meeting placement goals and

objectives and projected placement plans

upon discharge; (3) the educational,

counseling, recreational, vocational, and

medical activities or services that will be

provided by facility; (4) any specialized

services that will be provided or arranged;

(5) frequency of progress reports; and (6)

specifications for visitation between child

and family or friends.

— Services to family: The facility is to (1)

develop and review a service plan for each

child with authorized representative, parent,

or guardian and (2) keep the parent,

guardian, or custodian informed of health

care provided to the child while at the facility.

— Education: The child has the right to

participate in an appropriate educational

program.

— Health services: Within 5 working days of

admission, the facility is to secure a

placement medical screening of the child

conducted by a licensed physician,

registered nurse, licensed practical nurse, or

physician’s assistant. Health care is to

include dental and optical examinations by

licensed practitioners.

At least every 90 days after the initial review

of a child’s service plan, all individuals

involved in the development and

implementation of the plan are to review and

make any necessary amendments. Such

reviews are to be documented in case

records and are to include an assessment of

the current adjustment of the child and a

determination of whether the child should

remain in the facility.

— Resident visitation: Service plans are to

contain specifications for visitations between

the child and family or friends. Facilities are

to develop a handbook for residents and

their families, which contains visiting hours

and communication policies.

— Services to family: The facilities’

handbooks must also describe the roles and

responsibilities of the family in the care and

treatment of the child.

— Admission/intake procedures and

practices: Facilities are to have written

individual child care agreements for each

child with the person or agency holding

custody of the child. Facilities are to

document, at the time of admission, a

physical description of each child or teenage

mother, any available medical information,

the name and authority or relationship of the

person placing the child, and the reason for

placement.

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 40 GAO/HEHS-00-42 Use of Foster Care Funding

Pennsylvania

— Plan development: Licensees are to

develop and begin implementing an

individual service plan (ISP) for each child

within 30 days of admission. The plan is to

include (1) service goals; (2) time-limited

objectives to be used for evaluating progress

toward these goals; (3) specialized activities

or services that the facility will provide,

arrange for, or coordinate, and methods for

measuring accomplishment; (4) a schedule

of the child’s visits by or with a parent or

guardian; (5) anticipated duration of stay;

and (6) the persons responsible for and their

role in implementing the plan, and methods

of assessing progress.

— Education: Children of compulsory school

age are to be enrolled in or have access to a

basic education. Children beyond the age of

compulsory school age are to have an

opportunity to access career counseling and

continuing education. Academic and

vocational programs operated on facility

grounds are to meet applicable

requirements of the state’s Department of

Education.

— Health services: Licensees are to ensure

each child receives a health screening

within 24 hours of admission. The screening

may be conducted by a licensed physician,

nurse practitioner, registered nurse, licensed

practical nurse, physician’s assistant, or a

specially trained direct care staff person.

Licensees are to establish written policies

and procedures governing the provision of

health care, including preventive, routine,

and emergency medical and dental care; the

administration of medication; and staff

training.

Licensees are to review each child’s ISP at

least once every 6 months to determine

progress in achieving the plan’s goals and

objectives. The first ISP review is to occur

no later than 6 months from the date the

child was placed in the facility or, for certain

children, no later than 6 months from the

initiation date of the ISP. Subsequent

reviews are to be held no later than 6

months from the date of the previous review.

If appropriate, ISPs are to be modified or

revised as a result of these reviews. ISP

review results are to be recorded in the

child’s record.

— Resident visitation: Licensees are to

arrange family visitations that are convenient

for the family and the facility. Visitations and

communications between a child and the

child’s parents, attorney, clergy, or placing

agency may not be restricted or terminated

without a written court order.

— Services to family: Licensees are to

provide the child’s parents or guardian (1) an

opportunity to participate in the ISP

development and reviews and to sign the

initial or revised or modified ISP and (2) a

copy of the initial and each amended ISP.

— Admission/intake procedures and

practices: Licensees may accept a child for

care if it receives in writing (1) a description

of the circumstances that make placement

necessary, (2) the needs of the child that the

facility must address, and (3) the child’s legal

status.

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Appendix IV

Provisions in State Licensing Regulations

That Relate to Procedural Requirements in

Title IV-E Funded Foster Care Cases

Page 41 GAO/HEHS-00-42 Use of Foster Care Funding

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

Texas

— Plan development: Licensees are to

complete an intake study for each child

accepted for placement (see

admission/intake procedures and practices)

and, within 30 days of admission, develop

an initial plan of service after conferring with

the child and the child’s parents or

managing conservator. The plan of service

is to specify the objectives of placement,

how the child’s needs will be met, and the

estimated length of stay.

— Services to family: The parents or

guardian cooperate with the child-placing

agency in developing and carrying out the

plan of service for each child.

— Education: Licensees are to arrange an

education appropriate for each child. The

facility is to provide for the social and

educational needs of each child; each child

is to be permitted to attend the public free

schools in the district in which the foster

parents reside free of charge to the foster

parents.

— Health services All children are to be

examined each year by a licensed physician

and at least once a year by a licensed

dentist or a dental hygienist working under

the supervision of a licensed dentist.

Provisions are to be made for emergency

medical and dental care. All medications are

to be given by foster parents or an adult staff

member, except when a child is participating

in a medically approved self-medication

program. Prescription medications are to be

in the original container, labeled with the

child’s name, a date, instructions, and the

prescribing physician’s name.

Plans of service are to be reviewed and

updated by conference every 6 months.

Conferences are to include a representative

from the group home who meets the same

qualifications as the person doing the intake

study, the child’s parents, and the child.

Updated plans are to note achieved or

changed objectives. The child’s parents are

provided copies of updated plan summaries.

— Resident visitation: Contacts between the

child and family are to be allowed unless the

rights of the parents have been terminated

by court order or family contact is not in the

child’s best interest. If limits are put on

communication or visits for practical reasons

(such as expense), such limitations are to be

determined with the participation of the child

and family. Children may not be denied visits

with their families as punishment.

— Services to family: A written plan of

service must be developed and documented

in the child’s record within 30 days of

admission for each child in care. The plan

must be based on the admission

assessment. A copy or summary of the plan

must be given to the child, when

appropriate, and the child’s parents. Staff

who work with the child must implement and

follow the plan.

— Admission/intake procedures and

practices: Facilities may not accept a child

for care until an intake study has been made

and a determination that the placement

meets the needs and best interests of the

child and family. In addition to the parents’ or

managing conservator’s expectations of

placement, the intake study is to describe

the child’s (1) family circumstances and

relationships that make placement

necessary; (2) developmental and medical

history; (3) understanding of placement; (4)

personality, behavior, and interests; (5)

school history; (6) previous placements; (7)

legal status; and (8) needs. The study is

also to describe the immediate and longrange goals of the placement and the family

member or managing conservator who will

be responsible for the relationship between

the home and the child.

(Continued From Previous Page)

Case/service plan Case reviews/program progress reports Procedural safeguards
Page 42 GAO/HEHS-00-42 Use of Foster Care Funding

Appendix V

Comments From the Department of Health

and Human Services ApendxiV
Appendix V

Comments From the Department of Health

and Human Services

Page 43 GAO/HEHS-00-42 Use of Foster Care Funding
Appendix V

Comments From the Department of Health

and Human Services

Page 44 GAO/HEHS-00-42 Use of Foster Care Funding
Appendix V

Comments From the Department of Health

and Human Services

Page 45 GAO/HEHS-00-42 Use of Foster Care Funding
Page 46 GAO/HEHS-00-42 Use of Foster Care Funding

Related GAO Products

Foster Care: States’ Early Experiences Implementing the Adoption and

Safe Families Act (GAO/HEHS-00-1, Dec. 22, 1999).

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

1995).

Residential Care: Some High-Risk Youth Benefit, but More Study Needed

(GAO/HEHS-94-56, Jan. 28, 1994).

Foster Care: State Agencies Other Than Child Welfare Can Access Title IV-E

Funds (GAO/HRD-93-6, Feb. 9, 1993).

Child Welfare: Monitoring Out-of-State Placements (GAO/HRD-91-107BR,

Sept. 3, 1991).

Youth Camps: Nationwide and State Data on Safety and Health Lacking

(GAO/HRD-89-140, Sept. 20, 1989).

Foster Care: Use of Funds for Youths Placed in the Rite of Passage Program

(HRD-87-23BR, Dec. 9, 1986).

Review of Certain Aspects of Group Home Care for Children in California

(GAO/HRD-85-62, July 19, 1985).

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