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“They ar
are everybody’s children, and nobody’s children. They are the forgotten
children in the Texas foster care system. Some of them find homes with caring
foster parents, or in treatment centers with experienced and caring providers.
And some do not. Some foster children have been moved among 30, 40 or even
more all-too-temporary “homes.” Some have been sexually, physically and
emotionally abused while in the system; some have run away and joined the
ranks of the missing. A few have even died at the hands of those entrusted with
their care. This report gives these children something they need—a voice.”
—Carole Keeton Strayhorn
Texas Comptroller
Fellow Texans:
Like many other Texans, I have been disturbed by numerous published accounts alleging waste,
fraud and abusive conditions in our state’s foster care system. As Comptroller, I have a special
obligation to consider such allegations, since it is my statutory duty to monitor the economy
and the expenditures of this great state. Late last year, I launched an investigation in the hope of
protecting these most vulnerable of our children. After many unannounced visits to foster care
facilities and talking to children in the state’s care, I realized that the scope of the problem goes
far beyond what I had anticipated.
In Texas, we pride ourselves on taking care of our own. Today, we are failing at this task. Some
Texas foster children receive the compassion and care they deserve, but many others do not.
The heartbreaking truth is that some of these children are no better off in the care of the state
than they were in the hands of abusive and negligent parents.
Each and every child in Texas deserves to be protected against violence and abuse. But too of-
ten, we are not meeting this minimum standard. Despite the untiring efforts of many well-mean-
ing and caring individuals, a lack of effective oversight has allowed many Texas foster children
to languish in care; to be shuttled among dozens of temporary residences; and even to suffer the
same kinds of mistreatment they received in their own homes.
Our children are our most precious resource. We waste this resource when we do not nurture
them and help them grow into strong and productive adults. Many of our foster children are physi-
cally and psychologically damaged. We must defend them against further injury.
It has been said that any society can be judged by how it treats its weakest members. My inves-
tigation shows that Texas can and must be judged harshly.
We are not doing all that is necessary to protect our children. Texas is great, but we can do better.
Sincerely,
Forgotten Children — i
ii — Forgotten Children
Cover photo
taken in
January 2004
at a therapeutic
camp which cares
for Texas foster
children.
PRIVACY NOTICE
This report was prepared to help Texas foster children. To ensure their
privacy, their names have been changed and other information that might
lead to their identification has been omitted. Concerned parents and foster
parents provided much of the detail in the report’s case studies.
Forgotten Children — v
vi — Forgotten Children
Table of Contents
Introduction - Crisis in Texas Foster Care ............................................................ xi
Appendices
Contributors ......................................................................................................................................253
Appendix 1 – Survey Results ...........................................................................................................255
Appendix 2 – Foster Care in Other States .....................................................................................257
Appendix 3 – Technical Recommendations Concerning Rate Setting .......................................275
Appendix 4 – Comparison of Therapeutic Camp Standards .......................................................283
Forgotten Children — ix
x — Forgotten Children
Introduction
Some foster children have been moved The system reflects a legacy of weak leader-
among 30, 40 or even more all-too-temporary ship; an atmosphere of helpless acquiescence
“homes.” Some have been sexually, physically to the status quo; a reluctance to look too
and emotionally abused while in the system; closely into dark corners; and a culture of
some have run away and joined the ranks of self-protection and buck-passing.
the missing. A few have even died at the hands
of those entrusted with their care. DPRS’ problems are many and varied:
This report gives these children something • it uses limited taxpayer dollars inefficiently;
they need—a voice.
• it tolerates wide disparities in the quality
The mission of the Department of Protective of the services it purchases;
and Regulatory Services (DPRS), now called
the Department of Family and Protective Ser- • it offers caregivers a perverse financial in-
vices, is to protect the unprotected—children, centive to keep children in restrictive en-
the elderly and people with disabilities—from vironments by paying them more money
abuse, neglect and exploitation. The system to provide children with expensive and
responsible for protecting our foster children restrictive placements, and offering them
sometimes is little better than the homes from little incentive to help children return to
which they were taken. their homes or become adopted;
Some of these children are not safe, and their • it operates an inefficient dual system of
futures are uncertain. They didn’t ask to be foster care, thus creating a conflict of in-
put in foster care, and many endured great terest in which the agency regulates itself;
suffering before entering the system.
Forgotten Children — xi
Introduction
• it fails to take advantage of opportunities to ing what happens to them when they
increase federal funding and develop inno- leave the system; and
vative approaches to providing services;
• it does not survey foster children – their
• it frequently moves children from one primary customers – as required by law.
caregiver to another, sometimes hun-
dreds of miles apart, offering them little On the bright side, there are facilities and pro-
chance at stability; viders in Texas that are doing good things for
foster children. And it is important to high-
• it relies on an antiquated placement system light the bright spots.
that requires caseworkers to make count-
less telephone calls to place children; Some facilities aggressively seek community
support. Websites of these facilities list nu-
• it has a history of inadequate licensing merous ways “you can help or give.” Ways
standards, weak contract monitoring and to assist include monetary contributions,
ineffective licensing investigations that al- planned gifts, corporate partnerships, gifts in
low the same problems to continue fester- honor or memory and donations of clothing,
ing at the same facilities for years, exploit- books, shoes and diapers. Some providers
ing children as well as the state’s finances; sponsor golf tournaments, garage sales and
other fund raising activities. These private
• it holds some residential facilities to a lower providers also encourage community volun-
standard than other residential facilities; teers to assist children with activities, stud-
ies, holiday parties and meal preparation.
• it provides little accountability for dis- One Emergency Shelter has the support of lo-
turbing amounts of psychotropic medica- cal professional chefs that prepare meals for
tions prescribed to foster children; foster children four times a week.
• its heavy caseloads and high caseworker Yet other facilities have isolated themselves
turnover often prevent the agency from from their communities.
performing required visits with foster
children; This report provides new and detailed infor-
mation on a troubled agency. The Comptrol-
• it mixes potentially dangerous children, ler’s office hopes that its findings and recom-
such as sexual offenders and those with mendations will gain the attention needed to
violent criminal records, with others; make real changes in Texas foster care.
• it often fails to adequately serve children Texas taxpayers pay for foster care and have
with special needs, such as the medically the right to expect that the state will do its
fragile and children with mental retarda- part to ensure that foster children are safe and
tion; have a chance to build a prosperous future.
The problems encountered while preparing
• it fails to address the educational needs this report run so deep and so wide that sim-
of foster children; ple fixes will not work. And waiting will not
do. The state must take immediate action, so
• it has no good plan for preparing foster that fundamental change can begin now.
children for adulthood, or even for track-
Forgotten Children — 1
CHAPTER 1 The Texas Foster Care System
Forgotten Children — 3
The Texas Foster Care System CHAPTER 1
In fiscal 2003, DPRS spent $315.4 million on and train foster families and group home per-
the daily care of foster children. These costs sonnel for the state-run system.
included daily room and board; medical ex-
penses; and specialized therapeutic treatment Emergency shelters, residential treatment
for children needing extra attention.3 An ad- centers (RTCs) and therapeutic camps (for
ditional $30 million was spent for various purposes of this report, therapeutic camps
services, such as evaluation, counseling and will be included in the RTC category, unless
training, purchased exclusively for children otherwise noted), and private child placing
in DPRS foster homes. agencies (CPAs) that place foster children in
family homes and foster group homes con-
While DPRS attempts to find permanent stitute the outsourced portion of foster care.
placements for all of the foster children in its Emergency shelters and RTCs provide train-
care, it does not always succeed. About 900 ing for the staff who work in their respective
Texas foster children in state care “age out” facilities. CPAs recruit and provide training
DPRS’ foster of the system each year, leaving foster care for the foster families in their networks.
care system when they become eighteen or upon gradua-
includes both tion from high school.4 In fiscal 2003, the state-run side of DPRS’ fos-
state-run and ter care operations provided 27 percent of
outsourced A Dual System total days of foster care delivered to individ-
elements. DPRS’ foster care system includes both state- ual children (Exhibit 2). Outsourced services
run and outsourced elements. provided the other 73 percent.5
Exhibit 2
Total Paid Days in Foster Care
Fiscal Year 2003 Emergency Shelters 3%
Residential Treatment
Centers 14%
4 — Forgotten Children
CHAPTER 1 The Texas Foster Care System
through special “permanency hearings” held sible to their city of origin, so that family and
six months from the date on which DPRS re- community ties can be maintained.9
ceived conservatorship and every four months
thereafter, as long as the children remain in DPRS, however, often places children well
temporary managing conservatorship. If the away from their hometowns. In theory, such
court orders DPRS to be permanent manag- placements should occur only when no closer
ing conservator of a child, the court’s over- provider is available or when a distant loca-
sight continues in the form of semiannual tion is best positioned to respond to a child’s
placement review hearings until the child is specific needs. According to DPRS data, only
adopted or emancipated. 42 percent of children are placed in their
home counties.10 Interviews conducted by the
Foster care is meant to be a temporary situ- Comptroller review team, however, indicate
ation, lasting only until the child can return that many placement decisions are made by
home safely. The placement can become per- CPS caseworkers based on their relationships
manent, however, if a family cannot solve its with providers.
problems sufficiently to allow its children to
live in the family home without danger. In such Levels of Care and Service Levels
cases, CPS can recommend to the court that DPRS pays its care providers different rates
the parent-child relationship be terminated for different types of service, depending large-
and the child be placed with a permanent fos- ly upon each foster child’s individual needs.
ter family, adoptive family or other caregiver.6
DPRS contracts with Youth For Tomorrow
Some children enter the foster care system (YFT), a nonprofit firm headquartered in Arling- DPRS often
because their parents cannot meet their med- ton, Texas, to assess children coming into the places children
ical or behavioral needs. In such instances, foster care system. YFT assigns them to service well away
the parents may voluntarily terminate their level categories that determine the environ- from their
parental rights in order to place the children ment in which they will be placed, the amount hometowns.
in DPRS’ care. In fiscal 2002, 815 children fell and intensity of services they will receive and
into this “Refusal to Accept Parental Respon- how much the state will pay for their care.
sibility” category. From fiscal 1998 to 2002, an
average of 772 children entered the system YFT reviews the files of children referred to it
this way each year.7 by DPRS after their initial evaluation. In addi-
tion, YFT evaluates foster children’s records
Because many children coming into the foster periodically to determine if their service
care system have severe physical and emo- needs have changed. YFT performs these sub-
tional problems, DPRS first places them in an sequent reviews at least annually, and quar-
emergency home or emergency shelter for ex- terly in the case of children receiving more
amination and assessment. Agency policy re- intense services.
quires that each child entering its care receive
physical, dental and psychological assessments DPRS selected YFT for this role through a
within ten days. Other tests may be performed competitive bidding process in 1990, and
if deemed necessary by medical personnel. since then has retained the contract through
three subsequent rounds of competitive bids.
According to DPRS, the agency tries to place Its most recent contract, awarded in 2004,
children within the community from which supplies the firm with $1.2 million annually.11
they were removed to help ensure stability and
facilitate family reunification, when appropri- The organization completes about 3,900 ini-
ate.8 This policy conforms to federal require- tial service-level determinations and 21,400
ments that children be placed as close as pos- service-level reviews each year.12
Forgotten Children — 5
The Texas Foster Care System CHAPTER 1
Exhibit 3
Level of Care Service System in Effect Until September 1, 2003
Level Environment
LOC 1 Foster family environment that provides regular parenting.
LOC 2 Foster family environment with services that improve a child’s functioning in one or more areas of occasional
need.
LOC 3 Therapeutic foster family and group homes, residential treatment centers, therapeutic camps and halfway
houses for children with repetitive minor problems in one or more areas of functioning.
LOC 4 Therapeutic foster family and group homes, residential treatment centers, therapeutic camps and residential
programs licensed by the Texas Commission on Alcohol and Drug Abuse (TCADA) for children with substantial
problems in one or more areas of functioning.
LOC 5 Residential treatment centers, therapeutic camps, residential group care facilities serving mentally retarded
children and residential programs licensed by TCADA for children with severe problems in one or more areas of
functioning.
LOC 6 Residential treatment centers, inpatient psychiatric hospitals or homes for mentally retarded or autistic
children with one or more severe impairments, disabilities or needs and who are unable or unwilling to
cooperate in their own care.
Source: Summarized from Texas Department of Protective and Regulatory Services, Child Protective Services Handbook, Appendix 6340.
In addition, YFT performs more than 200 on- correspondingly more specialized and expen-
site reviews of foster care providers each year sive treatment needs for children (Exhibit 3).
to ensure that they can meet DPRS’ standards
for the provision of moderate, specialized and The 2003 Legislature directed DPRS to rede-
intensive services. These reviews typically in- sign the LOC system to one based on services
volve a small number of interviews with care- provided, in order to save $22.2 million annu-
givers and foster children.13 ally in foster care payments. Effective Septem-
ber 1, 2003, DPRS consolidated the six levels
Until September 1, 2003, DPRS provided sepa- of care into four “service levels”—basic, mod-
rate reimbursement rates for six “levels of care,” erate, specialized and intense. To do so, the
or LOCs, reflecting increasingly difficult and agency combined LOCs 1 and 2 (the lowest
levels in terms of resource intensity and cost)
to form the “basic” service level; combined
Exhibit 4 LOC 3 with the less-aggressive population
Service Level System in LOC 4 to form “moderate”; combined the
more-aggressive segment of the LOC 4 popu-
Implemented September 1, 2003
lation with LOC 5 to form “specialized”; and
renamed LOC 6 as the “intense” service level
Service Level Corresponding Level of Care Classification (Exhibit 4).
Basic LOC 1, 2
A child with a basic service classification typi-
Moderate LOC 3, less aggressive children from LOC 4 cally will be placed with a foster family, the
Specialized More aggressive children from LOC 4, LOC 5 least restrictive environment DPRS offers,
while a child with a specialized or intense clas-
Intense LOC 6 sification usually will be placed in an RTC.
Source: Texas Department of Protective and Regulatory Services.
6 — Forgotten Children
CHAPTER 1 The Texas Foster Care System
Exhibit 5
Foster Children by Provider Classification and Level of Care
Fiscal 2003
Residential Treatment
252 148 484 643 1,018 268 2,813
Facilities
Child Placing Agency
3,454 1,736 4,164 2,697 1 0 12,052
Foster Homes
*Note: 2,146 children were served in emergency shelters and homes; 671 children were served in placements outside the foster care
system, such as nursing homes, mental health/mental retardation facilities, hospitals and juvenile justice facilities.
Source: Texas Department of Protective and Regulatory Services.
Forgotten Children — 7
The Texas Foster Care System CHAPTER 1
manent conservatorship), which can stretch Child placing agencies (CPAs), in turn, must
from one to ten years or more, experience an pass through a portion of these payments to
average of 8.8 placements. The longer chil- the foster families and group homes with which
dren are in foster care, the more placements they contract, at the following minimum rates:
they are likely to have. basic, $20; moderate, $35; and specialized,
$45.14 With the remaining “administrative” por-
DPRS pays providers of residential foster care tion of the rate, CPAs must also provide the
a flat daily rate based on the intensity of ser- supplemental therapies, respite care, training
vice needed by a child. Reimbursement rates and other support for foster families.
rise with levels of service. For fiscal 2004, the
range of payments starts at $20 a day for basic CPS Funding
care by a foster family and rises to $202 per Over the past five years, DPRS expenditures
day for intense services delivered in RTCs. for foster care payments and adoption sub-
Daystar, an RTC in Manvel, Texas, receives a sidies; child and family services, including
special rate of $277 per day for children with investigations and child placement; and pur-
the most intense needs. chased service contracts have increased.
From 1999 to 2003, expenditures for foster
Exhibit 7 details the rates DPRS will pay its care payments and adoption subsidies rose
care providers in fiscal 2004 and 2005. by 73 percent. Child and family services and
Exhibit 7
Foster Care Daily Reimbursement Rates
For Fiscal 2004 and 2005
8 — Forgotten Children
CHAPTER 1 The Texas Foster Care System
Exhibit 8
Increase in CPS Expenditures and Number of Children
80%
70 CPS Expenditures
60
50 Number of children
in paid foster care expendi-
40
30 -
dies,child and family
20 services and pur-
Number of FTEs in
chased service con-
10 paid foster care
tracts.
0
1999 2000 2001 2002 2003 2004* 2005* * Appropriated
Sources: Legislative Budget Board and Texas Department of Protective and Regulatory Services.
purchased services spending rose by 31 per- The 2003 Legislature increased 2004-2005
cent and 37 percent, respectively. appropriations for foster care payments and
adoption subsides while slightly reducing the
The number of children in foster care has ris- amounts set aside for child and family servic-
en as well. From fiscal 1999 to 2003, the total es and purchased service contracts. The agen-
number of children in foster care rose by 40 cy’s appropriation for foster care payments
percent (Exhibit 8).15 is $350.4 million, including nearly $6 million
in supplemental funding, for fiscal 2004 and
Due to the fact that children spend varying $370.5 million for fiscal 2005.16
lengths of time in foster care, however, a more
appropriate measure of children for expendi-
ture analysis is full-time equivalents (FTEs).
For the purpose of this analysis, a single child
Exhibit 9
in foster care for 30 days can be considered
to represent one FTE, as would three children Children in Texas Foster Care,
who each spend 10 days in foster care. Exhib- Based on Full-Time Equivalents (FTEs)*
it 9 shows the relation between total children Fiscal 1999-2003
and FTEs. Over the past five years, the num-
ber of FTEs has increased by 37 percent. Total Number of
Total Number of FTEs*
Fiscal Year Children in Paid
Foster care reimbursements have risen more in Paid Foster Care
Foster Care
rapidly than the foster care population, due in 1999 18,626 10,969
part to an increase in reimbursement rates in
fiscal years 2000 and 2002 (Exhibit 10). 2000 20,900 11,991
2001 22,670 12,751
Purchased service contract expenditures in-
2002 24,515 13,973
creased by 36 percent between fiscal 1999 and
2000, due to the transfer of the Communities 2003 26,133 14,999
in Schools program from the Texas Workforce
*One FTE equals one month’s residence in foster care.
Commission to DPRS. Source: Texas Department of Protective and Regulatory Services.
Forgotten Children — 9
The Texas Foster Care System CHAPTER 1
10 — Forgotten Children
CHAPTER 1 The Texas Foster Care System
proved by a permanency planning team (PPT) High workloads, coupled with the emotion-
made up of any adult who provides care or ally intense nature of the position and low
services towards the child’s treatment, as well salaries, often lead to “burnout,” and many
as the person who can legally speak on the caseworkers do not stay with the job for long.
child’s behalf, such as a guardian or attorney. In fiscal 2003 alone, 23.5 percent of DPRS’
Typically, a PPT will include the caseworker, caseworkers left the agency.25
the child’s attorney, the foster parent or care
provider, any therapists the child is seeing and Licensing
the biological parent or parents, if the court DPRS can contract for residential foster care
has not terminated parental rights. A trained only with facilities licensed by the DPRS Child
DPRS “convener” facilitates this review. Care Licensing Division (CCL), which enforces
minimum standards to ensure the basic health
Subsequent PPT reviews are held after the and safety of children in residential care.26
child has been in care for five months, nine
months and every six months thereafter, or State law requires CCL personnel to inspect
more frequently if the child’s circumstances each facility caring for Texas foster children
change. When possible, these reviews pre- and to make at least one unannounced visit
cede court hearings.22 each year, to ensure that facilities meet DPRS
minimum standards of care. The standards
Caseworker visits and turnover cover all facets of an operation, including
DPRS policy requires caseworkers to visit the organization and administration, staffing and
children in their care at least once a month, training, service management, child behavior
and to visit them at their places of residence management, general child care and health
at least every three months.23 Interviews with and safety.27 DPRS statistics
providers and DPRS statistics, however, indi- indicate that
caseworkers
cate that caseworkers are not visiting children DPRS policies also require that CCL examine
are not visiting
as often as they are required to. Caseworkers some facilities more frequently, such as those
children as
are responsible for ensuring that each child that have a higher frequency of violations.28 In often as they are
receives all treatment services deemed neces- addition, state law requires that CCL investi- required to.
sary by his or her case plan. gate each report of a possible licensing viola-
tion, including instances of abuse and neglect.
According to DPRS, the agency has a rela- The division was responsible for inspecting
tively low caseworker-to-supervisor ratio—six more than 600 facilities and conducted inves-
to one—to ensure that caseworkers have the tigations of about 2,800 complaints in fiscal
supervisory and administrative support they 2003. Of these, nearly 1,000 investigations in-
need to do their jobs. For the most part, super- volved abuse and neglect allegations.29
visors do not perform the direct client services
provided by caseworkers, but instead super- DPRS has not significantly updated its licens-
vise caseworkers and monitor their case files ing standards since the 1980s, but at this writ-
to ensure that they meet agency standards. ing is drafting major revisions.30
Forgotten Children — 11
The Texas Foster Care System CHAPTER 1
Child Protective Services’ contracts fall into two In addition, CCL workers may notify contract
major categories: residential services contracts managers informally through email or tele-
and purchase of services (POS) contracts. phone correspondence when serious licensing
violations, such as incidents of child abuse,
Residential contracts require private caregiv- occur in a contract facility. CCL staff may
ers to provide DPRS-referred children with place providers on probation when consider-
an array of services including daily childcare, ing whether to revoke their licenses, but case-
appropriate educational, recreational and vo- workers do not always stop placing children
cational activities, behavior management and there, depending upon whether they consider
diagnostic services and medical care. The the children’s health or safety to be at risk.35
Contract Management Division managed 295
residential contracts across the state worth a
budgeted $285 million in fiscal 2003.32
Endnotes
POS contracts are used to obtain services for 1
Legislative Budget Board, Fiscal Size-Up 2004-
DPRS staff, such as training for staff and fos-
05 (Austin, Texas, December 2003), p. 172.
ter parents and YFT evaluations, and services
2
such as psychological counseling and psychi- DPRS data provided on January 20, 2004.
atric care for children under the agency’s di- 3
DPRS data provided on November 7, 2003.
rect care. DPRS received $93 million in appro- 4
Texas Department of Protective and Regulatory
priations for POS contracts for 2004-05.33 Services, Education and Training Vouchers
Program (Austin, Texas, 2003), p. 1.
DPRS, like all agencies under the adminis- 5
DPRS data provided on November 7, 2003.
trative guidance of the Health and Human
6
Services Commission, is exempted from Texas Department of Protective and Regulatory
Services, 2003 State Plan (Austin, Texas,
most general state purchasing requirements. December 1, 2003), “Description of Services for
Since the September 1, 2003 reorganization CPS.”
of health and human services, agencies under 7
Texas Department of Protective and Regulatory
the HHSC “umbrella” must follow the com- Services, 2002 Data Book, p. 54, “Confirmed
mission’s guidelines, which require agencies Victims of Child Abuse/Neglect by Type Fiscal
to document that their purchasing decisions Year 2002”; 2001 Data Book, p. 54, “Confirmed
consider a number of factors including costs, Victims of Child Abuse/Neglect by Type Fiscal
quality, reliability, value and probable vendor Year 2001”; 2000 Data Book, p. 54, “Confirmed
Victims of Child Abuse/Neglect by Type Fiscal
performance.34 Year 2000”; 1999 Data Book, p. 55, “Confirmed
Victims of Child Abuse/Neglect by Type
DPRS conducts “open-enrollment” contract- Fiscal Year 1999”; p. 55; and 1998 Data Book,
ing. In practical terms, this means that any in- “Confirmed Victims of Child Abuse/Neglect
dividual or facility that meets minimum DPRS by Type of Abuse/Neglect, Fiscal Year 1998,”
(Austin, Texas).
licensing requirements and receives a DPRS li-
8
cense can seek contracts to provide residential Texas Department of Protective and Regulatory
Services, DPRS Handbook (Austin, Texas,
care without undergoing a bidding process.
January 2003), Section 6122, “Selecting a
Substitute Caregiver at the Time of Removal.”
DPRS policy states that contract managers 9
Interviews with staff, Texas Department of
must visit each contracted facility’s site annual-
Protective and Regulatory Services, Austin,
ly. In addition to this visit, their contract renew- Texas, December 2, 2003.
al decisions depend heavily on CCL inspections 10
Texas Department of Protective and Regulatory
and investigations. Contract managers consult
Services, Management Reporting and Statistics,
a computer database to review each facility’s “Children in Foster Care Placed in Legal
licensing status and violation history. Region/County by ALOC, August 2003,” Austin,
Texas, November 6, 2003.
12 — Forgotten Children
CHAPTER 1 The Texas Foster Care System
11 23
DPRS data provided on November 13, 2003; and Texas Department of Protective and Regulatory
Texas Department of Protective and Regulatory Services, DPRS Handbook, Section 6511,
Services, Purchased Child Protective Services “Contact with the Child.”
Contract Number 2003123419 (Austin, Texas, 24
August 2002), p. 1. Interviews with staff, Texas Department of
Protective and Regulatory Services.
12
DPRS data provided on November 13, 2003. 25
DPRS data provided on December 8, 2003.
13
Texas Department of Protective and Regulatory 26
Services, Purchased Child Protective Services Texas Department of Protective and Regulatory
Contract Number 2003123419, p. 6. Services, “Residential Child Care Contract,”
Austin, Texas, Clause 10, p. 2.
14
Texas Department of Protective and Regulatory 27
Services, “Foster Care Reimbursements,” Tex. Hum. Res. Code Ann. §42.044(b) and
http://www.tdprs.state.tx.us/Adoption_and_ Texas Department of Protective and Regulatory
Foster_Care/About_Foster_Care/foster_care_ Services, Consolidated Minimum Standard
reimbursements.asp. (Last visited January 30, for Facilities Providing 24-Hour Child Care,
2004.) Austin, Texas, available in pdf format at http://
www.tdprs.state.tx.us/Child_Care_Standards_
15
Data provided by the Department of Protective and_Regulations/default.asp (Last visited
and Regulatory Services on November 7, 2003. January 28, 2004.)
16 28
Tex. H.B. 1, 78th Leg., R.S. (2003), p. II-103. Texas Department of Protective and Regulatory
17 Services, “About Child Care Licensing,” (http://
Tex. H.B. 1, 78th Leg., R.S. (2003), p. II-110. www.tdprs.state.tx.us/Child_Care/About_
18
Interview with DPRS staff, Austin, Texas, Child_Care_Licensing/default.asp#24hour).
February 20, 2004. 29
Tex. Hum. Res. Code Ann. §42.044(c) and
19
Youth for Tomorrow, January 2004 Report, Texas Department of Protective and Regulatory
February 13, 2004, Arlington, Texas. Services, 2000 Data Book, pp. 90-91.
30
20
U.S. Department of Health and Human Texas Department of Protective and Regulatory
Services, Administration for Children and Services, draft of proposed residential child
Families, “Helping Families Achieve Self- care standards, September 1, 2003.
Sufficiency: A Guide on Funding Services 31
Tex. H.B. 2292, 78th Leg., R.S. (2003)
for Children and Families through the TANF
32
Program,” www.acf.dhhs.gov/programs/ofa/ Data provided by DPRS.
funds2.htm. (Last visited January 30, 2004). 33
Texas Department of Protective and Regulatory
21
Texas Comptroller of Public Accounts, Services, Legislative Appropriations Request
“Assessment and Management Letter,” by 2004-2005 (Austin, Texas, October 29, 2002),
Public Consulting Group, Inc., Austin, Texas, pp. 67-69.
December 8, 2003. 34
Tex. Gov’t Code Ann. §2155.144.
22
Texas Department of Protective and Regulatory 35
Services, 2003 State Plan, “Description of Interviews with DPRS Contract Policy and
Services for CPS.” Contract Management staff, Austin, Texas,
November 12, 2003.
Forgotten Children — 13
The Texas Foster Care System CHAPTER 1
14 — Forgotten Children
CHAPTER 2
T exas foster children receive care that often varies in qual-
ity from provider to provider. Some caregivers supply
high-quality care and others do not—but every provider who
Raise the Bar meets DPRS licensing and contracting standards receives the
Forgotten Children — 15
CHAPTER 2 Raise the Bar on Quality
Forgotten Children — 17
Raise the Bar on Quality CHAPTER 2
Exhibit 1
Number of Paid Days and Amount Spent on Foster Care
Fiscal 2003
• helping to prepare children for placement ment. Beyond providing daily care, the role of
with a relative or an adoptive parent or CPAs and RTCs is at best advisory even though
long-term placement in the foster care they may have better information about the
system when family reunification is im- children in their care.
possible; and
• serving as an advocate for the child and In fiscal 2003, CPAs, RTCs and emergency shel-
speaking on his or her behalf in court ters accounted for about 73 percent of all paid
hearings. days of foster care and 90 percent of all foster
care payments. As Exhibit 1 shows, the Texas
The private foster care system consists of foster care system is largely outsourced today.
nonprofits, for-profit entities and faith-based
organizations. These entities recruit, train System Costs
and monitor the caregivers with whom they CPA foster homes provide basic foster care
place children. at a lower cost than do DPRS foster homes.
DPRS reimburses all foster caregivers on a per-
Private foster care entities fall into three ba- day, per-child basis. Its payments to CPAs and
sic categories: child placing agencies (CPAs) RTCs, however, cover services that payments
residential treatment centers (RTCs) and to DPRS-contracted foster homes do not.
emergency shelters. They provide a range of
placement options including emergency shel- For example, CPA and RTC payments cover
ters and assessment centers, foster families, the costs of services such as counseling,
group homes, therapeutic camps and institu- evaluation, testing, case planning, case man-
tional facilities. agement, foster home recruitment and foster
family training. DPRS’ payments to the foster
CPAs and RTCs have caseworkers just like families and group homes of the state-run side
CPS. At present, however, their case manage- of the system do not cover such services; the
ment activities are restricted to providing daily agency must purchase services for its foster
care and advising on long-term planning for the families separately.
child. CPAs and RTCs, for the most part, have
not been allowed by DPRS to work with the In fiscal 2003, DPRS spent more than $30
children’s biological families, present reports million to purchase additional services for
at court hearings or, most importantly, to have children in state-run foster care.1 In addition,
input on decisions about placement and treat- DPRS employs 128 caseworkers and seven
18 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
supervisors to recruit and train foster families same rigor for DPRS foster homes as it does
and group home personnel, at annual payroll for private CPAs and their homes. Private
costs totaling more than $6,283,000 excluding CPAs say this is especially true for therapeu-
benefits.2 Another 814 caseworkers, 49 super- tic foster care.8
visors and 57 administrative technicians ad-
minister foster care and oversee children in Other state agencies have separated these
both the public and private sides of the sys- roles because when an agency provides both
tem, at an annual payroll cost totaling more services and contracts for the same service,
than $30,421,000 excluding benefits.3 the agency tends to hold itself to lower stan-
dards than the contracts and to favor its own
A March 2003 report by the Texas State Auditor’s entities. For example, MHMR has separated
Office (SAO) compared the cost of public ver- the roles of provider and contractor for local
sus private foster care. SAO found that DPRS’ mental health and mental retardation authori-
use of private entities to provide foster care ties. A task force formed to review this issue
has doubled since 1998. SAO also concluded noted that when a local mental health and
that, after accounting for all services and costs, mental retardation authority acted as both
CPAs provide basic foster care at a slightly low- a direct provider of services and a contrac-
er cost than do DPRS foster homes. tor for such service that a conflict exists that
makes the playing field uneven and affects
The report indicated that CPAs provide basic- consumer choice. The local MHMR authori-
level foster care, including various additional ties both controlled the number and types of ...since CPS
services, for $1.21 to $2.29 less per day, per providers within their areas and had the last and CCL are
child than do DPRS foster homes, and yet tend word on where a client would be served.9 divisions of
to pay foster families more. According to the DPRS, the
study, CPAs pay their foster parents an average Moreover, since CPS and CCL are divisions of agency in effect
of 17 percent more than the rate DPRS pays to DPRS, the agency in effect is regulating itself, is regulating
the foster homes with which it contracts.4 creating a significant potential for conflicts of itself, creating
a significant
interest.
potential for
According to one CPA, DPRS indicated in
conflicts of
February 2004 that in response to budgetary Changing the System interest.
cuts, it would attempt to first place children in In 2001, DPRS created a public/private initia-
DPRS foster care and adoptive homes because tive called the Strength Through External Part-
they believe it to be more cost efficient.5 nerships (STEP) to develop a vision for the
agency for the new millennium. Using fund-
While higher payments to foster parents do ing provided by the Casey Foundation, DPRS,
not directly translate into a higher quality of private foster care agencies and child welfare
service, they do help guarantee that a reliable experts from the Child Welfare League of
pool of caregivers will be available. America (CWLA) recommended that all foster
care services be delivered through contracted
Unequal Accountability providers.10 The DPRS response to the STEP
DPRS certifies its 11 regional CPS offices as report was that further study would have to
child placing agencies, which allows the agency be done on the issue of providing all foster
to operate its own system of foster homes.6 As care services through contracted providers.11
with the private CPAs, CPS is subject to regu-
lar DPRS inspections of its homes.7 And, again DPRS district directors told the Comptrol-
like the CPAs, the CPS regional offices recruit, ler review team that they do not oppose the
train and monitor their own foster homes. use of private foster care agencies and would
not oppose outsourcing the entire foster care
Private CPAs, however, have stated that DPRS system if it proved to be cost-effective. They
does not enforce licensing standards with the noted that DPRS attempted to outsource its
Forgotten Children — 19
Raise the Bar on Quality CHAPTER 2
foster care activities in the Fort Worth area Before the PACE project began, moreover,
through its Permanency Achieved through DPRS did not allow its private contractors to
Coordinated Efforts (PACE) program, which claim Medicaid reimbursements directly from
ran from September 1998 to March 2001. the federal government. All medical costs
were to be covered by the daily rate; DPRS
DPRS paid a private child placing agency, then would pursue Medicaid reimbursement
the Lena Pope Home, Inc., a fixed per-diem to defray the state’s costs. As part of the PACE
amount to treat all foster children with thera- project, DPRS allowed the Lena Pope Home
peutic needs in a 10-county region of North to claim Medicaid reimbursements, giving the
Texas. The initial per-child, per-day rate (also contractor an additional source of revenue.
called a capitated rate) of $72.40 was calcu-
lated based on historical payment data for the During the course of the project, however,
area. The pilot ended when the Legislature did DPRS changed its rules and began encourag-
not provide additional funding to make the ing all foster care providers to claim Medicaid
program feasible for the PACE contractor. reimbursement. This allowed providers out-
side the PACE network to receive higher reim-
The goals of the project were shorter stays in bursements than those in the PACE network,
foster care, fewer moves between placements since the Lena Pope Home was retaining the
and the maintenance of “least-restrictive” Medicaid reimbursements for children in the
placements.12 PACE attempted to place foster project. From the caregivers’ perspective, par-
children in foster care homes, rather than in ticipating in PACE was less profitable than re-
shelters, and to provide therapeutic support maining outside the subcontractor network.16
to allow children with greater needs to stay in
such homes rather than in residential facilities. Focus group participants in the PACE evalua-
PACE also arranged adoptions for children tion had other criticisms, noting that:
who had been in foster care for years.
• the time period allotted for program plan-
The official program evaluation of the first ning and startup was insufficient;
two years of the PACE project did not show • DPRS’ Austin office conducted most of
better outcomes for these children than for the planning for the project, and may not
a statewide matched control group.13 This have considered or understood local con-
comparison may have been flawed, however, ditions adequately, since court practices
given the difficulties inherent in creating such and procedures often vary considerably
a “matched group,” and the relatively small from county to county;
number of cases involved.14 Numerous prob- • community participants such as judges, ad-
lems with DPRS’ execution of the program vocates and volunteers often learned about
also may have skewed the results. PACE only when it affected a child or fami-
ly with whom they were working. This lack
The original PACE proposal projected a pro- of advance knowledge about the project
gram population of 200 foster children per caused some to view it negatively; and
month. In reality, the project averaged 432 • DPRS Child Protective Services staff wor-
children per month because the contrac- ried that PACE might eliminate their jobs,
tor was required to take all children in the and received little information or training
10-county region and DPRS’ projections un- on their roles in the project, while at the
derestimated the number involved.15 This same time, their work responsibilities in-
doubled the provider’s costs and workload. creased.17
In addition, the PACE provider was forced to
establish an unexpectedly large network of The PACE pilot project ended when the Legis-
providers to deliver therapeutic services. lature declined to give DPRS additional fund-
20 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
ing to allow the Lena Pope Home to increase 12,405 children during this period were placed
the rates it paid to its subcontractors.18 in either foster family or group homes.
The DPRS district directors told the review As shown in Exhibit 2, the number of licensed
team that the PACE project was a good idea beds in fiscal 2003 CPA foster and group homes
but failed to produce anticipated savings was 19,720. Statewide, this means that the
for the state. Some of the project’s benefits CPAs could have cared for all of the children
included the development of standardized in the foster care system that were placed in
forms and training for DPRS and the CPA. either a foster family or group home and still
Moreover, DPRS and the Lena Pope Home had more than 7,300 empty beds.22
successfully collaborated to ensure that the
project addressed the best interests of each This excess capacity was confirmed through
child in the project. a Comptroller review team survey of the nine
largest CPAs, which showed they had capac-
The district directors generally believe that ity for another 2,270 children immediately.23
outsourcing the entire foster care system is a According to the executive director of the
good idea, but they noted that it could prove Texas Alliance of Child and Family Services,
difficult to persuade CPAs to assume respon- a nonprofit organization representing private
sibility for basic-level children since the reim- agencies and individuals that serve children
bursement rate is so low for this group.19 and families in Texas, “Private non-profit
agencies have increased the capacity of pri-
In interviews with Comptroller staff, however, vate foster homes by 20 percent over the past
The private
some CPA representatives voiced no concern two years, while the number of state operated sector has
over the reimbursement rate and called it suf- foster homes has remained stable.”24 sufficient
ficient to provide the necessary care. They did, statewide
however, criticize the way DPRS handled the Since CPAs pay foster families more on aver- capacity to care
PACE project. Providers who participated in age than does DPRS, their ability to recruit ad- for all children
PACE said that the project simply added an- ditional families is enhanced.25 Many CPAs use in the foster
other layer of bureaucracy to the system while charitable donations and fundraising to sup- care system.
making participation financially undesirable.20 plement the per-day rate they pay their foster
care providers. DPRS has not been able to tap
System Capacity into these community resources effectively.
The private sector has sufficient statewide ca-
pacity to care for all children in the foster care The use of CPAs and their community and
system. Most foster care agencies around the philanthropic connections could provide aug-
nation use some sort of outsourcing to either mented funding for services to children and
supplement or provide all of their foster care. allow DPRS to focus on its primary goal of
As noted above, in Texas 90 percent of all fos- protecting vulnerable populations.
ter care dollars already go to private foster
care agencies. Lessons from Kansas
Kansas was the first state in the nation to com-
In fiscal 2003, the foster care system cared for pletely outsource its adoption, foster care and
more than 26,100 children; however, the aver- family preservation programs and shift them
age number of children in care per month in to a managed care or “capitated” payment
fiscal 2003 was 16,214.21 According to DPRS, method.26 On March 1, 1997, private agencies
during fiscal 2003, CPA foster family and group assumed responsibility for all foster care ser-
homes cared for 8,250 children in August, the vices in Kansas. The Kansas Department of
highest monthly total for that year. During Social and Rehabilitation Services monitors
that same period, CPS foster family and group these entities to ensure program quality.27
homes cared for 4,155 children. In other words
Forgotten Children — 21
Raise the Bar on Quality CHAPTER 2
The state’s effort included performance-based Kansas Action for Children recommended that
contracts with private service providers. Three the state strengthen its prevention programs;
large private, nonprofit agencies initially re- require service providers to offer a range of
ceived contracts to provide foster care, adop- services, from foster family placement to
tion and family preservation services for a one residential treatment centers to specialized
-time payment of between $13,000 and $15,000 therapeutic services; give foster children bet-
per child.28 Today, five private lead agencies ter representation in the state court system;
subcontract with 25 nonprofit providers to of- refine and strengthen outcome and perfor-
fer foster care services and programs in Kan- mance measures; improve its communication
sas.29 The University of Kansas works with with and training of foster parents; improve
the Department of Social and Rehabilitation transition programs designed to ensure that
Services to provide training and evaluation foster children can enter the adult world suc-
services for the private agencies.30 cessfully; and create initiatives to increase
the adoption of special-needs children.33
The change from state to privatized adoption
and foster care was accompanied by con- In 2003, the Child Welfare League of America
siderable public controversy and systemic (CWLA) released a report analyzing Kansas’
problems.31 According to Kansas Action for outsourcing efforts. The report found that the
Children, an advocacy group for children’s speed with which Kansas changed its foster
welfare issues, the managed care model had care system—moving to full outsourcing in
several problems, the foremost being a lack one year—caused significant cash flow prob-
of attention to prevention programs and ser- lems for some private contractors. The report
vices that keep children out of foster care in identified four major issues that should be
the first place. Other problems included: taken into account by other states contem-
plating a similar system:
• lack of an inclusive planning process in-
volving all concerned parties; • rapid systemic changes are not advisable;
• hurried implementation and no experi- • reliable cost data are crucial;
mentation using pilot projects; • outsourcing will not necessarily control
• lack of historical cost data to develop costs; and
case rates; and • outcomes and performance measures are
• lack of a pool of child welfare staff that critical and must be refined based on ex-
could be hired by contractors.32 perience.34
Exhibit 2
Number of Licensed Beds in the Texas Foster Care System
Fiscal Years 1999 through 2003
22 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
While the transition to outsourcing was diffi- point of contact for services within each
cult, Kansas now has one of the nation’s best region;
systems for collecting data and measuring • significant reductions in social worker
the system’s successes and shortcomings.35 caseloads; and
The “managed care” model, which paid a flat • the creation of extensive management in-
rate per child, was changed in July 2000 to a formation systems to track data on child
system that reimburses contractors monthly placement and service activities.38
based on the number of children they serve,
to help caregivers avoid cash flow problems. Florida’s Outsourcing
In addition, the state revised contract out- The Florida Legislature mandated the out-
comes and performance goals to better focus sourcing of the state’s foster care and re-
on meaningful improvements in care.36 lated programs in 1998. The act required the
Florida Department of Children and Families
The CWLA report attributes many successes to (DCF) to develop a plan for moving to a con-
Kansas’ move to outsourcing. According to the tracted model, including alternatives to total
CWLA, in the six years in which Kansas has op- outsourcing, over a three-year period.39 The
erated its new system, service levels between legislation emphasized community participa-
rural and urban areas have become more eq- tion, quality checks and annual evaluations of
uitable; children now move through the fos- private providers.40
ter care system more quickly; the number of
adoptions has increased; children and families Each community designed its own system for
surveyed report positive experiences with care local circumstances, according to an executive
providers; state employment has been reduced, director of one of the lead foster care contrac-
lowering public costs; and data collection tech- tors. The state required communities to de-
niques and systems have improved.37 velop proposals to select lead contractors for
their areas; these were then evaluated by DCF.
According to the Kansas Children’s Service Areas may have one or more lead contractor,
League (KCSL), one of the lead CPAs in Kan- depending on local conditions and DCF ap-
sas, the new system has produced a number proval. For one year, localities receiveed fund-
of positive outcomes: ing for startup activities. “This enabled the
state to work side by side with the lead agency
• the use of residential and institutional fa- to get them started,” said the contractor.41
cilities and group home settings has been
cut in half, in favor of family homes; Each community selected a lead contractor to
• the number of adoptions has quadrupled; serve in much the same role as Kansas’ lead
• disruptions in placements and recidivism agencies. The state then distributed a capped
(return to foster care) have fallen by 50 amount of foster care funding to these lead
percent; contractors, who arranged for the provision
• children are placed closer to their birth of a complete range of foster care services for
homes, so that family members can be in- their communities.
volved in counseling efforts; and
• kinship care (full-time care by someone DCF continues to run the state’s child abuse
related to the child by family ties or a sig- hotline and investigate complaints of abuse.
nificant prior relationship) and kinship
involvement activities have increased. The contractor must accept all children
agreed upon in the contract; must find a place
In addition, KCSL noted: for any child removed from his or her home
within four hours, regardless of time of day;
• the development of a 24 hour/seven-day- and must have the child assessed for services
a-week system of placement, with a single within 21 days of coming into care. The lead
Forgotten Children — 23
Raise the Bar on Quality CHAPTER 2
24 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
to effectively monitor, license and audit the tem and the case management activities for
new foster care system and the private pro- which contracted providers will be responsi-
viders within it. ble (Exhibit 3). In addition, it is expected that
improved management information systems
Shifting all daily care and case management may be necessary and should be an allowable
activities to contracted foster care providers expenditure for this pool of money.
would allow the state to eliminate 814 case-
worker, 49 supervisory and 57 administra- DPRS will retain $15 million of the $30 million
tive technician positions dealing with foster it currently spends on purchased services.
care case management, and 128 caseworker DPRS should direct these savings to enhanc-
and seven supervisory positions dealing with ing their management information systems
foster and adoptive home development and and improving contract management. Any re-
recruitment. By eliminating a total of 1,055 maining money could be used for promoting
FTEs – 942 caseworker, 56 supervisory and 57 kinship care or providing adoption subsidies.
administrative technician positions – DPRS
would free $36,704,000 in annual salary costs, Many of the caseworkers affected by outsourc-
which could be redirected to build a foster ing could be hired by the private sector with
care system with greater accountability. the above mentioned grant funds. Interviews
with providers in Florida indicated about 75
In addition, in fiscal 2003, DPRS spent $30 percent of state foster care employees were
million on purchased services for residential hired by the private sector when the state out-
child care. According to DPRS, these pur- sourced its system. The high level of turnover
chased service dollars were spent primarily among CPS caseworkers, 23.5 percent in fiscal
on public sector foster care homes and the 2003, means that most if not all of the posi-
children in those homes. Most of the pur- tions would be eliminated through attrition.
chased service dollars would not be needed in
their current form in a completely outsourced DPRS staffing levels and foster care provided
system as the daily rate paid by DPRS to the by DPRS foster homes should be reduced
private sector is a bundled rate which already gradually. One-third of the care provided by
includes these services. Conservatively, half DPRS foster homes and the reduction of 302
of the purchased services expenditures, or full-time equivalent positions (FTEs) should
$15 million, could be freed up for stronger ac- occur by the beginning of fiscal 2006; an ad-
countability and better care. ditional third of the care and 302 additional
FTEs should be reduced by the beginning of
To outsource the 1,516,647 days of care at the fiscal 2007; and the final third of the care and
basic care rate, DPRS foster homes provided 301 additional FTEs should be reduced by the
in fiscal 2003, $21,233,000 of the projected beginning of fiscal 2008. In addition, purchased
$51,704,000 should be applied toward the services should be reduced proportionate to
bundled daily rate paid to private sector CPAs. the care and FTE reductions indicated above.
In addition, 150 qualified personnel should be
added to the contract monitoring and licens- Even with a total reduction of 905 FTEs,
ing functions at DPRS, to bring DPRS staffing DPRS would continue to have nearly 3,500
resources in these areas up to 200 FTEs. At caseworker FTEs to investigate child abuse
an average salary of $45,000 per year, these and neglect cases and to provide family pres-
new employees would cost $6,750,000 annual- ervation services. In addition to investigation
ly. The remaining $23,721,000 should be paid and family preservation services, DPRS would
to contracted foster care providers through continue to provide intake services through its
incentive grants for the express purpose of statewide hotline which takes all abuse and
hiring more caseworkers to handle the addi- neglect calls. DPRS’ other divisions -- Child
tional children coming into the private sys- Care Licensing (CCL), Adult Protective Ser-
Forgotten Children — 25
Raise the Bar on Quality CHAPTER 2
Exhibit 3
Fiscal Impact
26 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
17 31
Texas Department of Protective and Regulatory Kansas Action for Children, A Case for
Services, Evaluation for Project PACE: Final Contract Reform: The Development of a
Report, p. 71. Single Regional Contract for Foster Care and
18 Adoption Services in Kansas (Topeka, Kansas,
Texas Department of Protective and Regulatory
July 2003), p. 1.
Services, Evaluation for Project PACE: Final
32
Report (Austin, Texas, February 2002), pp. 3-4, Kansas Action for Children, “the Kansas Child
20-28 and 64. Welfare System: Where Are We? Where Should
19 We Be Going?” Topeka, Kansas, 2001, pp. 16-17.
Interview with Texas Department of Protective
33
and Regulatory Services staff, (Austin, Texas, Kansas Action for Children, Best Interest of
December 2, 2003). the Child: Emerging Issues in Child Welfare
20 (Topeka, Kansas, January 2003), p. 2.
Interviews with Foster Care Providers, (Austin,
34
Texas, November 21, 2003 and December 1, Child Welfare League of America, An
2003). Assessment of Privatization of Child Welfare
21 Services: Challenges and Successes, by
DPRS Operating Budget, Fiscal Year 2004
Madelyn Freundlich and Sarah Gerstenzang
(Austin, Texas, December 1, 2003), p. 39.
(Washington D.C., 2003), pp. 49-61, 64-71.
22
Texas Department of Protective and Regulatory 35
“Kansas ‘Pioneer’ in Child Services,” Lawrence
Services, response to Comptroller data request,
Journal-World (February 5, 2004).
February 2004.
36
23 Kansas Action for Children, A Case for
Texas State Comptroller of Public Accounts,
Contract Reform: The Development of a
Survey of the Nine Largest CPAs, (Austin,
Single Regional Contract for Foster Care and
Texas, January 28, 2004).
Adoption Services in Kansas, p. 1.
24
Interview with executive director, Texas 37
Child Welfare League of America, An
Alliance of Child and Family Services, Austin,
Assessment of Privatization of Child Welfare
Texas, January 27, 2004.
Services: Challenges and Successes, pp. 49-61,
25
Texas State Auditor’s Office, A Review of 64-71.
the Texas Department of Protective and 38
Kansas Children’s Service League, “Child
Regulatory Services’ Foster Care Payments to
Welfare System: Privatization KCSL Talking
Child-Placing Agencies, p. 13.
Points,” http://www.kcsl.org. (Last visited
26
William Eggers and Adrian Moore, February 5, 2004.)
“Privatization: A Growing Trend in Child 39
Florida Legislature House Bill 3217, 1998.
Welfare,” Intellectual Ammunition (June
40
1, 1997), http://www.heartland.org/Article. Florida Department of Children and Family
cfm?artId=941. (Last visited February 2, 2004.) Services, Community-Based Care, Current
27 Status: January 6, 2004 (Tallahassee, Florida,
Kansas Department of Social and
January 6, 2004), p 1.
Rehabilitation Services, “Foster Care/
41
Reintegration Services,” http://www.srskansas. Phone interview with Florida foster care
org/services/fostercare.htm. (Last visited provider, (January 2004).
November 26, 2003.) 42
Interview with Florida foster care provider,
28
American Federation of State, County and (January 2004).
Municipal Employees, “Kansas’ Privatization 43
Interview with executive director, Texas
of Child Welfare Services—Not the Land of
Alliance of Child and Family Services, Austin,
Oz After All!,” http://www.afscme.org/pol-leg/
Texas, January 27, 2004.
cwfs03.htm. (Last visited November 26, 2003.)
29
Access Kansas, “Foster Parenting in Kansas,”
http://www.accesskansas.org/fostercare/what_
agencies.htm. (Last visited November 26, 2003.)
30
University of Kansas, Office of University
Relations, “Kansas First to Reform Foster Care
and Adoption,” http://www.ur.ku.edu?News/
97N/JunNews/Jun16/fosterca.html. (Last visited
November 26, 2003).
Forgotten Children — 27
Raise the Bar on Quality CHAPTER 2
28 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
Quality Contracting
Contract for quality foster care.
Exhibit 1
Child Welfare Outcomes Measured by the Child and Family Service Review
Safety
1. Children are, first and foremost, protected from abuse and neglect. (Texas failed this measure.)
2. Children are safely maintained in their homes whenever possible and appropriate. (Texas failed this measure.)
Permanency
3. Children have permanency and stability in their living situations. (Texas failed this measure.)
4. The continuity of family relationships and connections is preserved for children. (Texas passed this measure.)
Well-Being
5. Families have enhanced capacity to provide for their children’s needs. (Texas failed this measure.)
6. Children receive appropriate services to meet their educational needs. (Texas failed this measure.)
7. Children receive adequate services to meet their physical and mental health needs. (Texas failed this measure.)
Source: U.S. Department of Health and Human Services, Administration for Children and Families.
Forgotten Children — 29
Raise the Bar on Quality CHAPTER 2
dren were placed in foster homes or facilities Data Analysis System, a national database of
close to parents or relatives, and caseworkers child welfare data based on detailed informa-
tried to place them with relatives.2 tion from each state.8
30 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
Exhibit 2
Examples of Child and Family Outcome Measures
Forgotten Children — 31
Raise the Bar on Quality CHAPTER 2
and contractors indicated that doing so was Moreover, the HHSC goals are individually
a positive step.14 tailored to each child and have no meaning
as to the overall performance of the contrac-
In Texas tor. Outcome measures should be aggregated
In 1996, the Texas Sunset Advisory Commis- and then evaluated on some objective basis,
sion, a legislative agency charged with review- in order to determine how well the contrac-
ing Texas programs, found that the DPRS con- tor is performing overall. HHSC has overall
tracting process did not measure the quality responsibility for health and human services
or effectiveness of care provided, and offered contract management and can assist DPRS in
caregivers no incentives to make improvements devising meaningful outcome measures.19
in their quality of care. Sunset recommended
requiring DPRS to modify its contracting pro- DPRS has attempted to develop such outcome
cess to include quality measures and to hold measures, yet the measures that were adopted
contractors accountable for performance.15 by the agency in December 2003 have raised
some foster care providers’ questions about
DPRS has The 1997 Texas Legislature responded to their applicability, and doubts concerning the
attempted to these recommendations by requiring DPRS quality and interpretation of the data used to
develop such client services contracts to include “clearly measure these outcomes.20 In addition, a DPRS
outcomes, yet Quality Assurance Workgroup, which includ-
defined goals that can be measured to deter-
the measures ed DPRS staff and external stakeholders, such
mine whether the objectives of the program
that were as providers, developed a different set of 14
adopted by are achieved.”16 To date, however, DPRS has
failed to include specific, measurable goals in outcome measures and 37 indicators in mid-
the agency in
its residential child care contracts. 2003.21 DPRS rejected most of the workgroup’s
December 2003
have raised measures in favor of the ones listed below.
some foster In 2003 foster care contracts, DPRS merely cites
care providers’ outcome measures found in rules adopted by In December 2003, DPRS’ Advancing Resi-
questions the Texas Health and Human Services Commis- dential Childcare Project finalized a series
about their sion (HHSC). These rules state that each child of outcome measures for foster care. These
applicability, in care is required to have a service plan con- measures are:
and doubts taining specific behavioral goals. The contract-
concerning the 1. The child is safe in care, measured by the
ing agency (DPRS) is given the responsibility to
quality and percentage of children in placement with no
develop goals in each child’s individual service
interpretation validated abuse or neglect by caregivers.
of the data used plan, in conjunction with the provider.17
2. The child moves toward permanency,
to measure
Due to confusing language, DPRS’ contracts measured by the percentage of moves
these outcomes.
do not clearly state who is supposed to moni- that a child makes to a less restrictive or
tor a child’s progress. Even more perplexing, permanent placement.
DPRS contract language measures children’s 3. The child is cared for in his or her own
behavioral goals based on whether the con- community, measured by the percentage
tractor meets licensing standards or complies of children cared for in the region of con-
with levels of services and contract monitor- servatorship.
ing performed by the agency, none of which 4. The child is placed with siblings when ap-
effects an individual child’s progress. The con- propriate, measured by the percentage of
tractor cannot determine what constitutes a sibling groups in non-restrictive care in
“passing grade,” nor can DPRS, without mean- the same foster home or facility.
ingful or numeric results.18 The contracts fail 5. The child maintains/improves in adaptive
to differentiate between contract performance functioning, measured by the percentage
and the improvement of children. of children at the Basic Services Level or
moving to a lower service level.
32 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
6. The child maintains behavior without the Programs found that there are factors that can
use of psychotropic drugs, restraints or help predict successful educational, income,
seclusions, measured by the percentage and mental and physical health outcomes for
of children maintaining behavior without former foster children. The Casey Family Pro-
use of these interventions.22 grams is a Seattle-based national foundation that
provides direct services for children, youth and
Foster care providers have expressed a families in the child welfare system and studies
number of specific concerns about these child welfare practices and policy. The factors
outcomes. For example, the placement of a identified in the study include such items as:
child, as referenced in measures three and
four, measures the performance of DPRS, not • life skills preparation;
caregivers; DPRS and the court system have • completing high school or earning a GED
the final say in where a child is placed. before leaving foster care;
• scholarships for college or job training;
Additionally, the indicator proposed for mea- and
suring the outcome “children are safe” is • participating in clubs and organizations
misleading. The sole proposed indicator is for youth while in foster care.26
In general,
the percent of children in placement with no foster
validated abuse/neglect by caregivers; in fis- Such factors as these also may be considered caregivers
cal 2003, DPRS had 98 validated allegations of in outcome measures. At this writing, DPRS worry that a
abuse or neglect by caregivers, which means plans to begin collecting data on foster care performance-
that 99 percent of children in foster care would outcomes in 2004, and to incorporate some based
be considered safe. This, however, ignores type of performance measures into its 2005 contracting
the fact that none of the children in a facility contracts for foster care.27 Thus, DPRS plans system may
or foster home subject to a valid complaint to incorporate these measures more than evaluate them
of neglect or abuse are safe until the facility eight years after state law required them. at least in
has taken action to prevent abuse. Moreover, part based on
outcomes that
DPRS data on incidents of abuse or neglect Texas Payment Systems
are controlled
omit instances of child-on-child abuse and re- Texas pays private providers of residential largely by
ports that were administratively closed with- foster care a flat daily, per-child rate, based on school districts,
out sufficient investigation. (See Chapter 5, the intensity of service each child needs. More doctors,
Abuse and Neglect.) The indicator also ignores intense levels of service are reimbursed at therapists
the fact that licensing standard violations can higher levels. For 2004, the range of payments and DPRS
directly affect the safety of children.23 starts at $20 a day for basic care by a foster caseworkers.
family and rises to $202 per day for intense
Providers also are concerned about the mea- services delivered at a residential treatment
sure concerning the use of psychotropic drugs, facility.28 For 2004, DPRS pays one provider a
restraints or seclusions. They note that the daily rate of $277 per child to care for a small
measure assumes that any use of a psychotro- number of children who require exceptional
pic drug, restraint or seclusion is inappropri- levels of care.29
ate, and they disagree with this assumption.24
Texas’ system for reimbursing foster care
In general, foster caregivers worry that a per- providers does not create incentives to serve
formance-based contracting system may eval- children in the most home-like environments,
uate them at least in part based on outcomes shorten their stays in foster care, find them
that are controlled largely by school districts, adoptive homes or smooth their successful
doctors, therapists and DPRS caseworkers.25 transition into adult life. A recent study by the
U.S. Department of Health and Human Ser-
Additionally, a 2003 study of more than 1,000 vices found that per-diem payments such as
foster care alumni served by the Casey Family Texas uses may encourage the inefficient use
Forgotten Children — 33
Raise the Bar on Quality CHAPTER 2
of state resources because children may be Children with greater needs can receive the
categorized at a higher level of treatment— extra services they require because the con-
and cost—than is necessary.30 tractor has no incentive to use resources un-
necessarily on children with lesser needs.
The present flat rate system gives providers
no incentive to request a lower service level, Capitated payments are more flexible. Con-
A recent study which would reduce their payments. In ef- tractors are not locked into providing a certain
by the U.S. fect, it creates a perverse incentive either to set of services to receive a specific reimburse-
Department deliver more services than needed or to pro- ment. And contractors have the freedom to
of Health
long treatment longer than necessary. provide additional services or supports that
and Human
can allow children to function in less-intensive
Services found
that per-diem Payment Options and Incentives placements. For example, a capitated system
payments such States may incorporate financial incentives to provides contractors with an incentive to serve
as Texas uses improve the quality of care provided to foster children in foster homes rather than more ex-
may encourage children. The Adoption and Safe Families Act pensive residential treatment facilities.31
the inefficient allowed states to request federal approval to
use of state waive certain federal requirements (and thus Capitated systems might tempt some provid-
resources, are called waivers), so that they can use Title ers to deny some children appropriate servic-
because IV-E federal funding to test innovative ideas. es to maximize their return on the contracted
children may be amount. Such abuses, however, can be mini-
Other states continue to devise financial al-
categorized at mized by linking the renewal of provider con-
ternatives to improve foster care outcomes
a higher level of
and encourage contractors to use state and tracts to outcomes, and by requiring provid-
treatment—and
federal funding cost-effectively. ers to report and document the services they
cost—than is
necessary. provide to each child.
Capitated foster care systems, also called
managed care systems, the most common In Other States
examples of which are health maintenance At least 17 states have used managed care
organizations, are intended to control costs (capitated) systems to provide foster care
while guaranteeing the delivery of necessary services. Georgia, Illinois, Kansas, Massachu-
services. In a capitated system, states pay setts and Tennessee have operated statewide
monthly fixed amounts to foster care provid- models; county-based programs have been
ers who are expected to plan for and meet used in Indiana, Michigan, Wisconsin, Califor-
all the needs of all the children in their care. nia, Colorado, Florida, New York, Ohio and
These amounts are calculated, in advance Wisconsin.32 The federal government reports
of providing services, to allow providers to that Connecticut, Maryland and Washington
meet a range of different needs. Usually, this also have tested managed care initiatives.
rate is set at a specific monthly payment per
member, called a “capitated” rate. One or a Some of these states have used waivers from
At least 17 limited number of providers generally pro- the federal Title IV-E funding program to help
states have used vide the services. pay for these programs. These waivers allow
managed care states to use federal funds to test different
(capitated) Because capitated payments are calculated ways of serving foster children. Yet, waivers
systems to on an aggregated basis across the entire are not always required.33
provide foster
child population, the contractor may choose
care services.
which services are appropriate for each indi- From November 2001 to June 2003, Colorado
vidual child. Contractors then have an incen- used a Title IV-E waiver program in Arapahoe
tive to avoid losses; unnecessary treatments County (near Denver) to serve children aged
and overly-lengthy stays that will cost them 10 or older who were considered “at risk” or
money, rather than the state. Any excess can had experienced multiple placements, and
be used for children whose care costs more. who also were considered likely to age out of
34 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
the foster care system without a permanent Washington state is testing alternate managed
family placement. This waiver covered both care approaches at different sites. Washing-
residential and non-residential services. ton’s Clark County is participating in a pro-
gram targeting foster children needing rela-
Arapahoe County negotiated a performance- tively high levels of care. The county has been
based contract with a consortium of provid- designated as a contractor to the state, man-
ers and paid its members a standard, capitat- aging the state’s payments to provide services
ed rate for care coordination and residential for foster children in the program, and assum-
treatment. The county paid for nonresidential ing part of the risk for excessive costs.35
services on a fee-for-service basis. The county
also established a control group of children In Texas: Lessons from PACE
who did not participate in the waiver program, DPRS attempted to apply these principles to
to compare costs at the end of the program. foster care in a 1998 pilot project. From Sep-
tember 1998 to March 2001, DPRS contracted
At the end of each contract period, the state with the Lena Pope Home, a nonprofit orga-
calculates an average per-case cost for youths nization serving children and families in Fort
in the treatment and control groups. If the Worth, to care for foster children with thera-
treatment group’s costs were lower than peutic needs and their siblings in a 10-county
those for the control group, the consortium region of North Texas.36 This program, called
receives reimbursement for 100 percent of Permanency Achieved Through Coordinated
these costs as well as a portion of the savings. Efforts (PACE), was intended to be a Texas Illinois’ foster
If the treatment group costs were higher than model for outsourced foster care services, care system
the control group’s, the consortium becomes but was discontinued due to a number of offers bonuses
responsible for a portion of the higher costs. problems, including an unexpectedly large to contractors
caseload, insufficient funding and inadequate that move more
Arapahoe County continues to use this payment planning. Financial issues were at the heart of than a specified
arrangement, although the state decided it did percentage of
the project’s failure and need to be addressed
not need to continue using the Title IV-E waiver their caseload
in future projects.37 Since the end of the proj-
to fund it. Colorado has indicated that it wishes into permanent
ect, DPRS has not attempted to test or design living
to contract with additional provider consortia similar innovations. (For a full discussion of arrangements.
to create a competitive bidding environment. the PACE project and additional recommen-
dations, see pp. 19-21.)
Michigan also has a managed care payment
system funded through a Title IV-E waiver. Bonuses and Penalties
The state has developed managed foster care
Some states use systems of bonus payments or
contracts in six counties that provide “wrap-
financial penalties to enforce quality contract-
around” services—an extensive roster of
ing provisions. Illinois’ foster care system offers
services including counseling, in-home fam-
bonuses to contractors that move more than a
ily services, parental education, training and
specified percentage of their caseload into per-
support services, respite care and household
manent living arrangements.38 Michigan uses
management training—that are not ordinarily
a performance-based system that provides in-
covered under Title IV-E payments. The state
centives to encourage and reward the adoption
provides each contractor with a single pay-
of children in the foster care system.39
ment of $14,272 for each child served, regard-
less of the amount of time over which ser-
Penalties are more difficult to administer, since
vices will be provided. Providers are respon-
they would be levied after services have been
sible for managing these funds to provide the
purchased. They may involve withholding all
services required, and risk financial losses if
or part of future payments. In some instances,
their costs exceed the fixed amount paid for
they could involve audits and recoupment of
the population they serve.34
funds spent on unauthorized items. This would,
Forgotten Children — 35
Raise the Bar on Quality CHAPTER 2
however, entail both administrative overhead HHSC has overall responsibility for
for audits and significant delays before re- health and human services contract man-
coupment. Depending on their nature, penal- agement and can assist DPRS by drawing
ties also could discourage potential contrac- on expertise in other state agencies. The
tors and thus reduce the capacity of the foster team should include foster care parents
care system. For these reasons, they must be and providers, performance contracting
designed carefully and used judiciously. experts from the State Auditor’s Office or
other state agencies and other stakehold-
The measures on which bonuses and penalties ers with relevant expertise in outcome-
are based should be clear and easily measured. based contracts.
For foster care, the most common measures
seem to be length of stay in foster care and This team should develop clearly defined
length of time until adoption. Comparisons and measurable performance standards
typically are made to past performance or to for foster care contracts. The team should
a control group. Deciding which children to rely on the recommendations of contract-
compare, time periods for comparison and ing experts and the experiences of other
other factors should be weighed carefully and states that have already developed sever-
modeled in advance to ensure that perfor- al generations of performance contracts.
The licensing mance goals are reasonable and achievable.
process alone, The standards should directly relate to
however, Licensing and Service Quality factors that a foster care provider can
cannot DPRS relies mainly on its Child Care Licens- control. New contracts should encourage
determine ing (CCL) Division to determine whether a providers to provide quality foster care
the quality contractor meets minimum standards and is and should allow them flexibility in meet-
of services, ing performance standards. Standards
qualified to provide services. CCL determines
according to should include critical elements that iden-
whether a provider has a poor performance
the inspector tify poor-quality providers who should not
general of history, and if any of its board members or
employees have a criminal background.40 be awarded future contracts and whose
the U.S.
DPRS has access to data from YFT and con- existing contracts should be revoked.
Department
of Health tract managers’ reviews.
and Human B. The performance team’s outcome
Services. The licensing process alone, however, cannot measures should be used instead of
determine the quality of services, according to the existing DPRS outcome measures.
the inspector general of the U.S. Department
of Health and Human Services. The inspector Most of the existing measures are flawed
general also found that states rarely revoke li- for use in performance contracting be-
censes or deny renewals to correct problems cause they do not measure actions under
at residential treatment facilities. State licens- the direct control of the foster care con-
ing standards address basic issues of health, tractor or because the performance indi-
protection and safety, but are not intended to cators are inexact or inappropriate.
ensure the suitability of placements and the
quality of care provided.41 C. DPRS should use outcome-based con-
tracts for all foster care services be-
ginning in fiscal 2005.
Recommendations
The foster care performance team should
A. HHSC should create a foster care per- adopt recommendations in time for DPRS
formance team to develop criteria for to issue outcome-based contracts in fis-
outcome-based contracts and measur- cal 2005.
able outcomes for residential care.
36 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
DPRS should compare its foster care pro- The fiscal impact of Recommendation D
grams and results to those in other states. would depend upon the structure and number
Formal comparisons of Texas’ foster care of programs created and cannot be estimated
services and programs with those of oth- in advance. If the length of stay in foster care,
er states would allow DPRS to measure or the intensity of care is reduced, the state
its own success and identify model prac- will realize savings.
tices and programs it could adapt to its
own operations. Illinois’ effort could pro- If Texas uses federal Title IV-E funds to support
vide a model for this activity. incentive payments, waivers are not always
required. The necessity of federal waivers may
D. HHSC and DPRS should revise pay- depend upon the nature of such incentives.
ment methods to create financial in-
centives for reducing the length of Title IV-E waivers are not a particularly ad-
stay and institutionalization of chil- vantageous funding source for incentive
dren in foster care. payments because eligibility for Title IV-E
depends upon family income of the child at
These payment methods could vary by re- the time of placement, and those eligibility
gion and for specialty services. Alternate thresholds are not adjusted for inflation. Con-
methods of financial incentives are not sequently, the number of Title IV-E-eligible
mutually exclusive. A proposal may con- children decreases each year.
tain some combination of managed care,
bonuses or penalties or other incentives.
Financial models should be designed to
coordinate with plans for foster care out- Endnotes
sourcing so that Texas may realize both 1
National Conference of State Legislatures,
financial and organizational reforms.
“1998 State Legislative Responses to the
Adoption and Safe Families Act of 1997,” http://
HHSC, DPRS, local county officials, local www.ncsl.org/programs/cyf/asfaslr.htm. (Last
providers and other stakeholders must visited November 20, 2003.)
work together to develop financial incen- 2
U.S. Department of Health and Human
tives that reinforce rather than under- Services, Administration for Children and
mine the foster care system. Consultant Families, “Child Welfare Reviews: Child and
expertise, beyond that of DPRS or child Family Services Review, Summary of Findings,
Texas,” http://www.acf.hhs.gov/programs/
welfare experts, may be required to build
cb/cwrp/staterpt/tx/index.htm. (Last visited
financial incentive programs that work. November 16, 2003.)
Texas needs to build on examples that 3
U.S. General Accounting Office, “Child Welfare:
work in individual communities rather New Financing and Service Strategies Hold
than impose a statewide solution. Promise but Effects Unknown,” Washington,
D.C., July 20, 2000, pp. 15-23.
4
U.S. General Accounting Office, Child Welfare:
Fiscal Impact New Financing and Service Strategies Hold
Promise but Effects Unknown, pp. 1-2.
These recommendations would improve con-
5
tracting procedures and provide greater over- U.S. General Accounting Office, “Child Welfare:
New Financing and Service Strategies Hold
sight for state spending. Promise but Effects Unknown,” p. 9; and
Massachusetts Department of Social Services,
HHSC could use existing funding to imple- Statement of Robert Wentworth, Senior
ment Recommendation A. For example, DPRS Manager: Testimony before the Subcommittee
supports a Quality Assurance Workgroup; this on Human Resources of the House Committee
on Ways and Means, Public Hearing,
funding could instead be used to develop the Washington, D.C., July 20, 2000, pp. 1-2.
foster care quality assurance team.
Forgotten Children — 37
Raise the Bar on Quality CHAPTER 2
6 20
Illinois Department of Children and Family Texas Department of Protective and Regulatory
Services, FY 2004 Cook County Private Agency Services, Advancing Childcare Residential
Performance Contract Program Plan, Relative Project, Developing a Quality Assurance
and Traditional Foster Care, Springfield, System for Residential Childcare, Austin,
Illinois, May 2003, p. 7. Texas, December 22, 2003, p. 1.
7 21
Illinois Department of Children and Family Texas Department of Protective and Regulatory
Services, FY 2004 Cook County Private Agency Services, ARC QA Workgroup, Individual
Performance Contract Program Plan, Relative Child Outcome Final Recommendations,
and Traditional Foster Care, p. 6. Austin, Texas, August 28, 2003.
8 22
Illinois Department of Children and Family Texas Department of Protective and Regulatory
Services, “Signs of Progress in Child Welfare Services, Advancing Childcare Residential
Reform,” http://www.state.il.us/dcfs/docs/signs. Project, Developing a Quality Assurance
htm (Last visited November 25, 2003); and System for Residential Childcare, p. 2.
Child Welfare League of America, “The National 23
Data Analysis System,” http://www.cwla.org/ Texas Department of Protective and
ndas.htm. (Last visited January 7, 2004.) Regulatory Services, “Consolidated Minimum
Standards for Facilities Providing 24-Hour
9
U.S. Department of Health and Human Services, Child Care,” “Minimum Standards for Child-
Administration for Children and Families, Placing Agencies,” “Minimum Standards
“Progress Report to the Congress: An Overview for Independent Foster Family Homes,”
of the Child Welfare System Today,” www.acf. “Minimum Standards for Independent Foster
hhs.gov/programs/cb/publications/congress/ Group Homes,” and “Minimum Standards for
index.htm. (Last visited November 3, 2003.) Emergency Shelters,” Austin, Texas, January
10 2004, available in pdf format at http://www.
Philadelphia Division of Social Services,
tdprs.state.tx.us/Child_Care/Child_Care_
Quality Management Unit, “Performance Based
Standards_and_Regulations/default.asp. (Last
Contracting,” www.phila.gov/quality/contracting/
visited January 28, 2004.)
index.html. (Last visited November 17, 2003.)
24
11 Texas Department of Protective and Regulatory
Philadelphia Division of Social Services,
Services, Advancing Childcare Residential
Quality Management Unit, Quarterly Update
Project, Developing a Quality Assurance
(July 2003), pp. 2-3.
System for Residential Childcare, p. 3.
12
U.S. General Accounting Office, “Child Welfare: 25
Texas Department of Protective and Regulatory
New Financing and Service Strategies Hold
Services, Advancing Childcare Residential
Promise but Effects Unknown,” p. 8.
Project, Developing a Quality Assurance
13
U.S. General Accounting Office, “Child Welfare: System for Residential Childcare, p. 1.
New Financing and Service Strategies Hold 26
Casey Family Programs, Assessing the Effects
Promise but Effects Unknown,” p. 12.
of Foster Care: Early Results from the Casey
14
U.S. Department of Health and Human National Alumni Study, by Peter J. Pecora, Chris
Services, State Innovations in Child Welfare Downs, Ronald C. Kessler and A. Chris Downs
Financing, by Westat and Chapin Hall Center (Seattle, Washington, October 3, 2003), p. 5.
for Children, Rockville, Maryland and Chicago, 27
Interview with Texas Department of Protective
Illinois, April 2002, http://aspe.hhs.gov/hsp/CW-
and Regulatory Services staff, Austin, Texas,
financing03/. (Last visited November 7, 2003.)
November 18, 2003.
15
Texas Sunset Advisory Commission, Department 28
Texas Department of Protective and Regulatory
of Protective and Regulatory Services: Staff
Services, “Foster Care Reimbursements,”
Report, (Austin, Texas, 1996), pp. 2-3.
http://www.tdprs.state.tx.us/Adoption_and_
16
Tex. Hum. Res. Code Ann. §40.058. Foster_Care/About_Foster_Care/foster_care_
17
reimbursements.asp. (Last visited January 20,
1 Tex. Admin. Code §351.13 2004.)
18
Texas Department of Protective and Regulatory 29
Interview with Texas Department of Protective
Services, Residential Child Care Contract, and Regulatory Services staff, Austin, Texas,
Austin, Texas, September, 2003. January 5, 2004.
19
Tex. H.B. 2292, 78th Leg., R.S. (2003).
38 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
30 36
U.S. Department of Health and Human Texas Department of Protective and Regulatory
Services, Assistant Secretary for Planning and Services, “Child Welfare Demonstration
Evaluation, State Innovations in Child Welfare Project,” (Austin, Texas), www.tdprs.state.
Financing, by Westat and Chapin Hall Center tx.us/Child_Protection/Keeping_Children_Safe/
for Children (Rockville, Maryland and Chicago, childwelfare.asp. (Last visited January 7, 2004.)
Illinois, April 2002), http://aspe.hhs.gov/hsp/CW- 37
Texas Department of Protective and Regulatory
financing03/. (Last visited January 20, 2004.)
Services, Evaluation for Project PACE: Final
31
U.S. Department of Health and Human Services, Report, Austin, Texas, February 2002, p. 68.
Assistant Secretary for Planning and Evaluation, 38
U.S. Department of Health and Human
State Innovations in Child Welfare Financing.
Services, Assistant Secretary for Planning and
32
U.S. General Accounting Office, Child Welfare: Evaluation, State Innovations in Child Welfare
New Financing and Service Strategies Hold Financing.
Promise but Effects Unknown, pp. 15-23. 39
U.S. Department of Health and Human
33
U.S. General Accounting Office, Child Welfare: Services, Administration for Children and
New Financing and Service Strategies Hold Families, “Progress Report to the Congress:
Promise but Effects Unknown, pp. 1-2. An Overview of the Child Welfare System
34 Today,” http://www.acf.hhs.gov/programs/cb/
U.S. Department of Health and Human Services,
publications/congress/overview.htm. (Last
Administration for Children and Families,
visited November 3, 2003.)
“February 2003 Summary of IV-E Child Welfare
40
Waiver Demonstrations,” http://www.acf.dhhs. Interview with Texas Department of Protective
gov/programs/cb/initiatives/cwwaiver/summary. and Regulatory Services staff, November 13,
htm. (Last visited January 5, 2004.) 2003.
35 41
U.S. Department of Health and Human U.S. Department of Health and Human Services,
Services, Administration for Children and Office of Inspector General, State Oversight
Families, “Managed Care Payment Systems,” of Residential Facilities for Children,
http://www.acf.dhhs.gov/programs/cb/ Washington, D.C., May 2000, pp. 3, 13 and 16.
initiatives/cwwaiver/managed.htm. (Last visited
January 5, 2004.)
Forgotten Children — 39
Raise the Bar on Quality CHAPTER 2
40 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
Different Facilities,
Different Conditions
Some Texas foster children sent to residential facilities can Some locations are clean and welcoming, but others are far
find themselves in clean, safe engaging environments. Others less suitable. Some display sound business practices and so-
are less lucky. Despite the fact that DPRS licenses and moni- licit community involvement, while others do not. Yet all of
tors all of these facilities, their conditions vary widely. Each them receive the same daily reimbursement rates for each
child’s fate seems to be left to the luck of the draw—to the level of service. There are no photos of children due to pri-
decisions and opinions of individual caseworkers. vacy restrictions.
• Sleeping Facilities
• Medication Storage
• Classrooms
• Conflicts of Interest
Forgotten Children — 41
CHAPTER 2 -DISPARITY
42 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
Forgotten Children — 43
Raise the Bar on Quality CHAPTER 2
44 — Forgotten Children
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Forgotten Children — 45
board, providers are reimbursed through the USDA free- and reduced-price lunch and breakfast program. This facility also receives charitable donations and weekly donations from the local food bank.
Food preparation area at a therapeutic campsite, littered with trash.
DPRS standards for permanent camps require trash to be stored in containers with lids. This facility receives a daily rate for each child ranging from $80 to $115.
46 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2
individual campsite food preparation areas were unsanitary. This facility receives a daily rate for each child ranging from $80 to $115.
Forgotten Children — 47
Food Preparation at a therapeutic campsite.
Children at this facility prepare their own meals at night and on weekends in this area. This facility receives a daily rate for each child ranging from $80 to $115.
48 — Forgotten Children
Raise the Bar on Quality
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CHAPTER 2
Forgotten Children — 49
dishes was not evident.
Dining area at a residential treatment center that serves foster children.
The facility is making improvements based on recommendations from the local fire marshal. This facility receives a daily rate from DPRS for each child ranging from $80 to $115.
50 — Forgotten Children
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Forgotten Children — 51
According to the National Dairy Council, freezing milk is not recommended. “It causes undesirable changes in milk’s texture and appearance.”
Informational chart on the door of a freezer at an Emergency Shelter that serves foster children.
This chart provides precise instructions for freezing food .
52 — Forgotten Children
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Forgotten Children — 53
Milk storage at a kitchen facility at a charter school that serves foster children.
54 — Forgotten Children
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Forgotten Children — 55
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56 — Forgotten Children
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Commercial style kitchen at a residential treatment center that serves foster children.
When the Comptroller review team entered the kitchen, they were told hairnets were required by the Health Code.
Raise the Bar on Quality
Forgotten Children — 57
Kitchen at a residential treatment center that serves foster children.
This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115. This facility has been found to be deficient in meeting standards for food preparation.
58 — Forgotten Children
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Forgotten Children — 59
Cafeteria at a residential treatment center that receives strong financial support from the community.
Foster children may select from a wide range of foods.
60 — Forgotten Children
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at the campsites. DPRS has been licensing camps like this one for more than twenty years.
Makeshift outhouse at a therapeutic campsite.
Foster children use this facility rain or shine, 365 days a year. DPRS standards allow permanent camps to use privies only when a water supply is not available. Water is available at this camp-
site. This outhouse does not meet Texas Department of Health standards. This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115.
64 — Forgotten Children
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Bathroom at a residential treatment center that cares for both male and female foster children.
This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115.
Raise the Bar on Quality
Forgotten Children — 65
Raise the Bar on Quality CHAPTER 2
66 — Forgotten Children
CHAPTER 2
Forgotten Children — 67
ness camp were discharging raw sewage on the ground.
Bathroom at a residential treatment center.
This facility receives a daily rate from DPRS for each foster child ranging from $80 to $277.
68 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2
Forgotten Children — 69
Shower at a residential treatment center.
Many children at this facility have sought medical treatment for athlete’s foot. This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115.
70 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2
Forgotten Children — 71
Storage for bath soap at a therapeutic camp shower.
There was no commercial bath soap or shampoo available at the shower—only this soap which appeared to be homemade. This facility receives a daily rate from DPRS for each foster child
ranging from $80 to $115.
72 — Forgotten Children
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CHAPTER 2
CHAPTER 2 Raise the Bar on Quality
Forgotten Children — 73
Raise the Bar on Quality CHAPTER 2
74 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
Sleeping Facilities
Forgotten Children — 75
Open fire pit and sleeping quarters for foster children at a therapeutic camp.
Foster children gather around the fire pit at night. There is no electricity or heat. This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115.
76 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2
Forgotten Children — 77
Foster children sleep in these conditions 365 days a year, during all types of weather.
Sleeping platform at a therapeutic campsite.
Foster children have limited space for their possessions. A toothbrush and tube of toothpaste lay on the floor near the door. During the winter, plastic sheeting is used to provide limited protec-
tion from the cold. This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115.
78 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2
Forgotten Children — 79
Sleeping platform at a therapeutic campsite.
This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115.
80 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2
Forgotten Children — 81
Beds at an emergency shelter.
This facility receives a daily rate from DPRS for each foster child of $94 . Each child receives a custom-made quilt like those below.
82 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2
Forgotten Children — 83
Bedroom at a residential treatment center.
This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115.
84 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2 Raise the Bar on Quality
Forgotten Children — 85
Bedroom at a “no pay” facility.
This facility offers care for foster children at no cost to the state. The state does not take full advantage of placing foster children in “no pay” facilities.
86 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2 Raise the Bar on Quality
Isolation Areas at
Residential Treatment Centers
Forgotten Children — 87
Raise the Bar on Quality CHAPTER 2
88 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
Forgotten Children — 89
Raise the Bar on Quality CHAPTER 2
90 — Forgotten Children
CHAPTER 2
Forgotten Children — 91
Raise the Bar on Quality CHAPTER 2
92 — Forgotten Children
CHAPTER 2 Raise the Bar on Quality
Forgotten Children — 93
Raise the Bar on Quality CHAPTER 2
94 — Forgotten Children
CHAPTER 2
Forgotten Children — 95
Wood cutting and recreation area at a therapeutic camp for foster children.
This facility has limited recreational facilities. For punishment the children cut and chip wood that is then used in campfires and for cooking . This facility receives a daily rate for each child
ranging from $80 to $115.
96 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2
Forgotten Children — 97
Living area at a residential treatment center that serves foster children.
This facility receives a daily rate from DPRS for each foster child ranging from $80 to $115.
98 — Forgotten Children
Raise the Bar on Quality
CHAPTER 2
CHAPTER 2 Raise the Bar on Quality
Forgotten Children — 99
Playground at an emergency shelter that cares for young foster children.
This play area is covered with astroturf to help provide a safe environment. This facility aggressively seeks community support. It receives a daily rate from DPRS for each foster child of $94.
Medication Storage
Locked medication cabinet at a residential treatment center that serves foster children.
This facility was found to be deficient regarding expired medications.
Raise the Bar on Quality
Medicine bags for group foster homes were properly locked for containing controlled substances.
Classrooms
Play area and teacher’s desk at a charter school that serves foster children.
Raise the Bar on Quality
Conflicts of Interest
This residential treatment center, which serves girls in foster care, has widespread community support and children are given the opportunity to select from a full range of donated clothing,
One DPRS initiative funded through these This would allow the state to reallocate some ...DPRS could
programs is preplacement services—services TANF funds to other eligible services within free TANF
provided to children who remain with their bi- DPRS or other state agencies. dollars for use
ological parent or parents but are considered elsewhere in
DPRS or in
at risk for foster placement. Preplacement ser-
vices attempt to help children and their fami- Fiscal Impact other agencies.
lies remain together through marriage coun-
TANF funds replaced by Title IV-E reimburse-
seling, family therapy and other assistance.
ments could be assigned to other TANF-eli-
gible services within DPRS or another state
Some of the administrative costs for preplace-
agency. Federal Title IV-E reimbursements
ment services that DPRS currently claims
would be matched from state general revenue
under TANF could instead be pursued under
currently allocated to DPRS or available from
Title IV-E.
another state agency.
Medicaid Services
HHSC and DPRS should expedite the delivery of foster
children’s Medicaid information to caregivers.
Medicaid Reimbursement
HHSC and DPRS should provide foster care contractors
with assistance and training to help them claim Medicaid
reimbursement for foster care services.
Funding Flexibility
HHSC should request federal waivers and
increase funding flexibility to prevent
institutionalization of foster care children.
July 16, 1996.7 Without adjustment for infla- officers of residential treatment centers to dis-
tion, this means that fewer families will be cuss additional services needed (such as week-
eligible for assistance. end respite care); the need for case managers
and mentors to participate in the program; and
Other Funding Opportunities opportunities to prevent potential revenue loss
Improvements to foster care delivery do not due to the anticipated decrease in reliance on
necessarily require Title IV-E funding. residential treatment services.9
Since the program began, the county’s use of New Jersey uses a 1915(c) waiver to serve
residential treatment for eligible children has children up to age 13 who test positive for the
fallen by 60 percent and inpatient psychiatric human immunodeficiency virus (HIV). Waiver
hospitalization has dropped by 80 percent. services include case management, private
The average overall cost of care per child has nursing services, medical day care, personal
fallen from more than $5,000 per month to care and intensive supervision for eligible
less than $3,300. children who reside in foster care homes.13
According to the director of Wraparound Mil- Texas has not used 1915(c) waiver funding
waukee, the main challenges to the program’s specifically for foster care services. The state
implementation were the need to work across does, however, have multiple 1915(c) waiver
systems (such as juvenile justice and Medicaid) programs serving children. One of these pro-
and to educate care providers on the program’s grams serves medically dependent children
goals and structure. Wraparound Milwaukee and aged and disabled individuals, offering
staff met extensively with the chief executive services such as:
tance and training to take advantage of tense service level with families. DPRS paid
waiver provisions; and Texas Mentor the residential treatment center
• determining how other initiatives affect rate for the children, and at least half of these
waiver outcomes and cost-effectiveness. payments were passed on to the families. Ad-
ditional services for the children were pur-
States that create Title IV-E waiver programs chased by Texas Mentor or paid for by other
must be prepared to involve local adminis- state agencies.17
trators and other stakeholders in the waiver
development and implementation process; Pooling Local Dollars
provide stakeholders with ongoing education Funding for child services often is a mix
and training; and seek feedback from program of federal, state, local and private dollars.
participants.15 HHSC has initiated a series of pilot projects
in several counties to pool funds from vari-
Wraparound Services in Texas ous sources and use them to provide mental
The most promising feature of waiver pro- health services to children and their families
grams is the opportunity they present to of- in their homes, with the intent of keeping the
fer complex arrays of services from various children out of foster care.
providers in wraparound programs. In Texas,
however, foster children eligible for current In 1996, community groups in Brownwood
Medicaid waivers must go on waiting lists and Austin created initiatives to provide com-
with hundreds of other children. munity-based mental health services through
However, foster a grant from the Robert Wood Johnson Foun-
children eligible Texas has implemented two pilot programs dation and funding from the MHMR. In 2000,
for current to provide wider arrays of services for foster HHSC expanded this effort by creating the
Medicaid children in a family-based setting. Texas Integrated Funding Initiative (TIFI),
waivers must a program that pools a variety of revenue
go on waiting
EveryChild Inc., a coalition of individuals and sources to provide family- and community-
lists with
organizations dedicated to developing alterna- based services for children with multiple
hundreds of
other children. tives to institutional placement for children needs. From a group of 14 applicants, HHSC
with disabilities, has received a Family-Based selected Harris County, Tarrant County, the
Alternatives Model Project grant from the Rural Initiative Project (headquartered in
Texas Council for Developmental Disabilities Floydada, Texas) and the Tri-County MHMR
(TCDD) to place children with profound devel- Services (headquartered in Conroe, Texas) to
opmental or physical disabilities with families join the initiative.18
in the Austin and San Antonio areas. Every-
Child Inc. works with several agencies, includ- Children throughout the state could benefit
ing DPRS and the MHMR, to serve these chil- from similar collaborative efforts and from
dren. The organization recruits foster families examining opportunities to coordinate service
and helps them obtain the services they need to delivery and maximize federal reimbursement.
keep the children in their homes. It has placed
10 children who were in institutions with fami-
lies, reuniting two with their birth families and Recommendations
placing eight more with foster families.16
A. HHSC should combine federal, state
and local funding to create “wrap-
In May 2002, DPRS created a pilot project to
around” managed care programs for
place medically fragile children with severe
foster children.
mental retardation or mental health issues in
family-based settings. The agency contracted
This might involve:
with Texas Mentor, a child placing agency, to
place nine children with a specialized or in-
4 11
Jennifer Miller, “Child Welfare Waivers: What U.S. Department of Health and Human
are We Learning?” available in pdf format Services, Centers for Medicare and Medicaid
from http://www.aphsa.org/cornerstone/ Services, “Overview of Home and Community-
cwwlearning.pdf. (Last visited November 28, Based Services Programs (Children),”
2003.) available in pdf format from http://cms.hhs.
5 gov/medicaid/1915c/children.pdf. (Last visited
U.S. Department of Health and Human January 21, 2004.)
Services, Administration for Children and
12
Families., “Ohio: Capped IV-E Allocations and Interview with Maggie Friend, policy
Flexibility to Local Agencies,” http://www.acf. consultant, Minnesota Department of Human
hhs.gov/programs/cb/initiatives/cwwaiver/ Services, St. Paul, Minnesota, December 4,
oh.htm. (Last visited January 21, 2004.) 2003.
6 13
U.S. Department of Health and Human New Jersey Department of Human
Services, Administration for Children and Services, “Home- and Community-Based
Families, “February 2003 Summary of IV- Service Programs,” http://www.state.nj.us/
E Child Welfare Waiver Demonstrations”; humanservices/dds/njwaiver.html. (Last visited
and interviews with Sandra Lock, program January 21, 2004.)
manager, State of Indiana ICWIS Project, 14
Indianapolis, Indiana, November 14, 2003 and U.S. Department of Health and Human
December 4, 2003. Services, Centers for Medicare and Medicaid
Services, “Home and Community-Based
7
Pew Commission on Children in Foster Care, Services Summary Report,” available in pdf
“The Child Welfare Financing Structure,” by format at http://cms.hhs.gov/medicaid/services/
K.O. Murray, available in pdf format from regular.pdf. (Last visited January 21, 2004.)
http://pewfostercare.org/research/docs/ 15
MurrayPaper2.pdf. (Last visited January 21, Jennifer Miller, “Child Welfare Waivers: What
2004.) are We Learning?”
16
8
Milwaukee County Behavioral Health Division, Interview with Nancy Rosenau, executive
“Wraparound Milwaukee 2002 Annual Report,” director of EveryChild Inc., Austin, Texas,
available in pdf format from http://www.legis. December 3, 2003.
state.ia.us/GA/80GA/Interim/2003/comminfo/ 17
Interview with Texas Department of Protective
childwel/milwaukee.pdf. (Last visited January and Regulatory Services staff, Austin, Texas,
21, 2004.) December 8, 2003.
9
Interview with Bruce Kamradt, director, 18
Texas Health and Human Services Commission,
Child and Adolescent Services for the “Texas Integrated Funding Initiative,” http://
Milwaukee County Mental Health Division, www.hhsc.state.tx.us/tifi/communities.htm.
Milwaukee, Wisconsin, November 20, 2003; and (Last visited January 22, 2004.)
Milwaukee County Behavioral Health Division,
“Wraparound Milwaukee 2002 Annual Report.”
10
Interview with Jim Wotring, director,
Programs for Children with a Serious
Emotional Disturbance, Michigan Department
of Community Health, Lansing, Michigan,
November 23, 2003.
Background Recommendation
A review of some charter schools located at RTC contracts with charter schools should
Texas’ RTCs indicated some are not seek- include mandatory participation in the
ing reimbursement for services they provide SHARS program. A review of
through Medicaid’s School Health and Related some charter
Services (SHARS) program, which is adminis- schools located
Fiscal Impact at Texas’ RTCs
tered in Texas by HHSC in cooperation with
indicated some
the Texas Education Agency.
Medicaid reimbursement through SHARS are not seeking
would provide greater federal funding to cov- reimbursement
SHARS allows Texas public schools, including for services they
er services, such as counseling, provided by
charter schools, to receive federal Medicaid provide through
charter schools at foster care facilities. This
reimbursement for certain services provided Medicaid’s
amount would vary according to the number
through special education programs. These School Health
of children receiving services and the type and Related
services include assessment, audiology, coun-
and amount of services provided. Services
seling, school health services, medical ser-
vices, occupational therapy, physical therapy, (SHARS)
Federal reimbursement would reduce the program.
psychological services, speech therapy and
impact of allowable costs reported in the
special transportation.
residential centers’ biennial cost reports, thus
reducing the average cost per child used to
Children eligible to receive these services
calculate DPRS reimbursement rates. This
must be Medicaid-eligible, with one or more
could result in lower daily rates for services
disabilities as defined in the federal Individu-
provided in RTCs and potentially a cost sav-
als with Disabilities Education Act, and have
ings to the state.
an individual educational plan prescribing the
services they should receive.
Care System More DPRS caseworkers often fail to make required visits with the
foster children assigned to them. This could be remedied
Accountable through formal documentation requirements for such visits.
• Contracts . . . . . . . . . . . . . . . . . . . . . . . 161 DPRS should strengthen and fully enforce its licensing stan-
dards. Its Residential Child Care Licensing Division should
• Rate Setting . . . . . . . . . . . . . . . . . . . 183 apply current licensing standards for permanent therapeutic
camps to all therapeutic camps and immediately move foster
children from camps that do not meet those standards. The
Texas Department of Health and its affiliates should assume
responsibility for health inspections of all foster care residen-
tial facilities. DPRS should revoke the licenses of facilities with
repeated violations or those with ongoing patterns of allega-
tions that may affect the health, safety and well being of the
children in their care.
Caseworkers
Until our recommendation eliminating the dual foster
care system is implemented, DPRS should ensure that its
caseworkers regularly visit their assigned foster children.
DPRS has no guidelines or standard questions The Comptroller review team performed
for caseworker-child visits. Caseworkers are 18 site visits to emergency shelters, foster
required to document their visits in monthly homes, residential treatment facilities, thera-
case file notes, entering them into a central peutic camps and child placement agencies
computer system for their supervisors’ ap- throughout the state. Each entity said that it
proval. Once the supervisor approves these had children in care that were not visited by
notes, they become a part of the case file. caseworkers regularly. Several said they had
had children for more than a year who had of children – have retired or were
not received a single caseworker visit.4 pushed into early retirement. Young,
inexperienced women make up the
The starting salary for Child Protective Ser- majority of caseworkers partly be-
vices (CPS) caseworkers is $2,409 per month. cause the pay and workload is so darn
Seasoned caseworkers can make up to $2,718 bad. The compassionate, caring work-
per month. The minimum qualifications for ers are eventually beaten down by the
a starting caseworker include a degree from overloaded system, or they seek other
an accredited four-year college or university; employment. DPRS state-level admin-
computer and typing skills; a valid Texas driv- istration say their hands are tied...or,
ers license; access to reliable transportation; there are not enough resources...or,
and three character references. Caseworkers whatever to deflect any responsibility
must pass a criminal background check. They on them. No one appears to have the
also must be willing to work in stressful en- courage, knowledge and skills to push
Without vironments and be willing to make visits in beyond the box, to find innovative
regular visits, children’s homes.5 methods that actually work.
caseworkers
cannot be
New CPS caseworkers often are recent col-
certain that
every child lege graduates who may have trouble coping Recommendations
in their care with the stressful nature of the work and its
A. DPRS should establish formal guide-
is safe and large caseloads. According to the 2002 DPRS
lines and documentation standards
cared for State Plan, caseworkers handle an average
for caseworker-child visitation.
appropriately. caseload of 21 cases. The Comptroller’s re-
view team visits to district offices, however,
Caseworker visits are essential to guar-
found that caseloads often are substantially
antee that foster children are receiving
higher, at times reaching 35 to 40 children.6
proper care. Caseworker visits provide a
The Child Welfare League of America recom-
link to the biological families and homes
mends a caseworker to case ratio of 1 to 12-15.7
of foster children. In addition, casework-
ers provide stability for foster children as
Many caseworkers find that they cannot cope
they move through the foster care system.
with heavy workloads and the emotionally in-
tense nature of the work. In fiscal 2003, 23.5
Formal guidelines and prescribed ques-
percent of DPRS’ caseworkers left the agency.
tions would ensure that these visits are
Turnover rates rose as high as 31 percent in
effective, while making it easier for the
some areas of the state.8
agency to objectively review its case-
workers’ performance and evaluate the
High turnover overburdens the system, guar-
care children are receiving.
anteeing that caseloads remain high and inter-
fering with the caseworkers’ most important
B. DPRS should use caseworker-child
responsibility to ensure through regular visits
visitation as one of its performance
that foster children receive the help they need.
measures.
One respondent to the Comptroller’s foster
DPRS should strive to ensure that case-
care survey said:
workers comply with the agency’s rules
on visitation. At minimum, DPRS should
Too many challenges, far too few re-
meet the federal standard and earn a
sources. Older, experienced workers
passing grade on federal reviews. Includ-
– who grew up in the 50s and 60s, in
ing visitation as an agency performance
the midst of social change, and want-
measure would help ensure that DPRS
ed to make a difference in the lives
applies its resources to reach this goal.
Fiscal Impact 3
Texas Department of Protective and Regulatory
Services, ad hoc data request from the IMPACT
These recommendations could be implement- database, (Austin, Texas, January 2004).
ed with existing resources. 4
Interviews with emergency shelter, RTC and
CPA staff, November 2003 through February
2004.
5
Texas Department of Protective and Regulatory
Endnotes Services, caseworker job posting found at
www.tdprs.state.tx.us/jobs/C11277.htm. (Last
1
Texas Department of Protective and Regulatory visited January 19, 2003.)
Services, DPRS Handbook (Austin, Texas, 6
January 2003), Section 6511, Contact with the Interviews with Texas Department of
Child. Protective and Regulatory Services staff,
Austin, Texas, December 2, 2003.
2
Texas Department of Protective and Regulatory 7
Services, Texas Child and Family Services Child Welfare League of America,
Review, Te
Texas Program Improvement Plan, “Recommended Caseload Standards,” www.
response to the U.S. Department of Health and cwla.org/newsevents/news030304cwlacaseload.
Human Services, Administration for Children htm. (Last visited January 19, 2003.)
and Families, 2002 Child and Family Service 8
DPRS response to Comptroller data requests,
Review (Dallas, Texas, April 2003), p. 16. Austin, Texas, December 8, 2003.
Licensing
DPRS should strengthen and fully
enforce licensing standards.
A Therapeutic Camp1
One therapeutic camp serves troubled boys who ler review team found perishable food in ice chests
have histories of physical or sexual abuse. with no ice, dirty dishes, outdated food, rusty cans
and trash strewn around the kitchen and dining pa-
Some boys stay for years at the camp, living in ques- vilion on an unannounced visit in January 2004. The
tionable conditions. Exposed day and night in open Comptroller review team did not observe detergent
shelters with little more than old blankets and sleep- or soap at the kitchen pavilion in at least one of the
ing bags, they endure extremes of hot and cold, wind, campsites.
rain and insects. These children cook their own din-
ners and all meals on weekends. They walk down Each campsite also has a makeshift urinal located at the
dark trails to makeshift outhouses that discharge site, called a “pee wall.” The urinal is a wooden, three-
sewage on the ground and have no ready access to sided structure with a small ceramic bucket located
hot water and soap.2 near the back wall that has a pipe into the ground.
DPRS pays the camp $1.3 million annually for about Each morning, the boys walk to an old shower facility
36 foster children to stay in these conditions. This at the main site and shower in several stalls. The facil-
amounts to about $97.65 per day, or $35,642 per year, ity is an open locker room with three lavatories.
per child.3
Education and “Therapy”
Life at Camp The camp does not require its children to attend its
The boys’ shelters look like picnic pavilions, with school, an on-site campus of a local independent
four poles, a raised plywood floor and a tarpaulin school district. According to camp employees, chil-
roof. Three or four homemade wooden cots or rusty dren who do not attend school pursue vocational ac-
metal frame beds sit around the edges of the sleep- tivities or chop wood to occupy their time. The boys
ing platforms. do not have homework after the school day, and re-
turn to their campsites after school.
The four campsites are set in a few secluded acres of
woods, surrounded by 137 acres of forest. The camp- Documentation in the contract manager’s file related
sites are home, often for years, to abused or neglected a parent’s concern that her son was exposed to ac-
boys from ages 9 to 18 in DPRS’ custody, and about 15 counts of “abnormal sex acts” and that she was not
under county juvenile probation authority. The camp- told that sex offenders were not segregated from
sites sit well away from each other and from a central other residents. DPRS recently cited the camp for
campus that houses the main office, a kitchen and violating restraint standards by using “victim empa-
dining facility, showers, laundry, storage, basketball thy therapy” in which the boys were held down on
court, workshop, guest quarters and a school. the ground against their will.
Beginning December 1, the boys wrap sheets of plas- Although some of the younger boys and some of the
tic around their beds to keep out wind and rain. The older ones who are watched more carefully have
pavilions are unheated, exposed to the elements, and their own campsites, boys with tendencies to act
the campsites have little light at night. out sexually or who have violent or criminal back-
grounds are intermixed with others who have no
According to camp staff, for hot water at the camp- such histories, as well as some who have been physi-
sites, the boys must chop wood and heat water on cally abused. At one campsite, a nine-year old boy
a barbecue pit. The children cook 11 of their own slept near a counselor “to protect him from the other
meals at the campsites every week. The Comptrol- boys,” according to one camp staff person.
(continued)
than for RTCs, which serve children with the In addition, licensing inspectors have applied
same, and sometimes more severe, problems. a set of standards for therapeutic campsites
that should apply only to short-term camping
RTC personnel responsible for the overall forays into the wilderness instead of to perma-
treatment program and evaluating admissions nent camps that have children living in them
assessments must have at least a master’s de- for months and years. (See Appendix 4.)
gree in a mental health field or be a licensed
master of social work. Therapeutic camps, The Comptroller review team found that
by contrast, lack these standards. However, RCCL has not coordinated adequately with
standards require the individual with overall the Texas Department of Health and local
responsibility for administering the facility to health departments concerning violations of
hold a child-care administrator’s license, which health and sanitation regulations in therapeu-
requires a minimum educational level of high tic camps. This situation let one therapeutic
school equivalency.7 At a therapeutic camp, camp avoid meaningful health and sanitation
this individual could perform these tasks. inspections for years; the accompanying case
study tells this story in detail.
tion of others who benefit financially from the third of the 24 facilities selected for this study
facility, such as subcontractors or vendors.9 according to this schedule.12
Furthermore, DPRS is not following its own In addition, DPRS does not train other DPRS
policy calling for more frequent inspections workers who visit facilities on its licensing
of higher-risk facilities. Agency plans call for standards. Consequently, the agency is miss-
RCCL to inspect facilities every three to five ing opportunities to obtain credible reports of
months, six to nine months or 10 to 12 months, possible violations from its own workers.
according to their compliance histories and
other risk factors, but DPRS inspected only a
Fiscal Impact 7
Texas Department of Protective and Regulatory
Services, “Consolidated Minimum Standards
These recommendations could be completed for Facilities Providing 24-Hour Child Care,”
with existing agency resources identified in Austin, Texas, January 2004, available in pdf
format at http://www.tdprs.state.tx.us/Child_
Chapter 2. Local health departments already
Care/Child_Care_Standards_and_Regulations/
inspect most facilities. Recommendation C default.asp. (Last visited January 28, 2004.)
gives the Texas Department of Health and lo- 8
Texas Department of Protective and Regulatory
cal health departments the authority and re- Services, “Consolidated Minimum Standards
sponsibility to ensure that health regulations for Facilities Providing 24-Hour Child Care,”
are enforced in all facilities. Additional costs Austin, Texas, January 2004, available in pdf
would be negligible. format at http://www.tdprs.state.tx.us/Child_
Care/Child_Care_Standards_and_Regulations/
default.asp. (Last visited January 28, 2004.)
9
Texas Department of Protective and
Endnotes Regulatory Services, “Chapter 748: Facility-
Based Residential Child Care,” Austin, Texas,
1
Texas Department of Protective and Regulatory September 1, 2003. (Draft document.)
Services, Residential Child Care Contract, 10
Texas Department of Protective and Regulatory
Clause 10, p. 2. Services, Licensing Policies and Procedures
2
Texas Department of Protective and Handbook, §4400(B).
Regulatory Services, “Consolidated Minimum 11
Data based on 24 facilities reviewed from
Standards for Facilities Providing 24-Hour Texas Department of Protective and Regulatory
Child Care,” “Minimum Standards for Child- Services, “Search for a Child Care Operation,”
Placing Agencies,” “Minimum Standards http://www.txchildcaresearch.org/ppFacilitySe
for Independent Foster Family Homes,” archResidential.asp.
“Minimum Standards for Independent Foster
12
Group Homes,” and “Minimum Standards for Data based on 24 facilities reviewed from
Emergency Shelters,” Austin, Texas, January Texas Department of Protective and Regulatory
2004, available in pdf format at http://www. Services, “Search for a Child Care Operation,”
tdprs.state.tx.us/Child_Care/Child_Care_ http://www.txchildcaresearch.org/ppFacilitySe
Standards_and_Regulations/default.asp. (Last archResidential.asp.
visited January 28, 2004.) 13
Robert W. Gee, Austin American-Statesman,
3
Tex. Hum. Res. Code, 42.044(b). “Hays Residents Fight Proposal for Camp for
Troubled Youths,” December 20, 1999.
4
Texas Department of Protective and Regulatory
14
Services, “About Child Care Licensing,” http:// Texas Department of Protective and Regulatory
www.tdprs.state.tx.us/Child_Care/About_ Services, 2003 Data Book, p. 97.
Child_Care_Licensing/default.asp#24hour. r
r. 15
Tx. Hum. Res. Code, §42.072 (c) and interview
(Last visited January 28, 2004.) with Texas Department of Protective and
5
Tex. Hum. Res. Code, 42.044(c). Regulatory Services staff, January 7, 2004.
6
Interview with Texas Department of Protective
and Regulatory Services staff, November 12,
2003.
Data Integrity
DPRS should ensure the integrity of
the information in its databases.
quently, the report is not listed in the DPRS tion concerning licensing violations
public database that records complaints.6 to the intake phone center.
One facility director told Comptroller staff that C. DPRS should develop a quality assur-
the CCL investigator instructed the facility to ance system that performs sample
quit calling the intake phone center when inci- audits of reports, investigations and
dents occur and to call the investigator instead.7 inspections to ensure their complete-
ness and validity.
In general, the Comptroller review team found
that the CCL database often omits relevant in- D. DPRS should develop criteria and
formation that decision-makers should have questions for licensing investigations
to assess a facility’s record. The agency’s new and should require workers to fully
licensing database, launched in 2002, is a sig- document their inspections, investi-
nificant improvement over the previous data- gations and administrative closures
base. Even so, a Comptroller review of several in the CCL database; the reasoning
facilities’ records for 2003 found the infor- behind their decisions; and any fol-
The agency mation on facilities inadequate to accurately low-up actions taken thereafter.
databases hold judge compliance with licensing standards.
significant
promise to Key problems involve the lack of information Fiscal Impact
provide useful on why DPRS closes cases without investi-
management These recommendations could be implement-
gating them and who authorized the closure,
information ed with existing agency resources.
how the investigator reached the decision on
for other
divisions in cases that were investigated and what actions
the agency, as the facility will take to avoid repetitions of the
well as support same problem.
Endnotes
to facilities;
however, The agency databases hold significant prom- 1
Texas Department of Protective and Regulatory
the lack of ise to provide useful management informa- Services, Consolidated Minimum Standards
attention tion for other divisions in the agency, as well for Facilities Providing 24-Hour Child Care,
within the as support to facilities; however, the lack of Austin, Texas, January 2004, available in pdf
agency to format at http://www.tdprs.state.tx.us/Child_
attention within the agency to ensure their in- Care/Child_Care_Standards_and_Regulations/
ensure their tegrity is undermining their strength. default.asp. (Last visited January 28, 2004.)
integrity is
2
undermining Texas Juvenile Probation Commission, “Year
their strength. 2003 Case Summaries,” http://www.juvenilelaw.
Recommendations org/CaseSummaries2003/03-3-04.HTM. (Last
visited January 3, 2004.)
A. DPRS should require the facilities it
3
licenses to immediately report all se- Texas Department of Protective and Regulatory
Services, “Search for a Child Care Operation,”
rious incidents involving runaways, http://www.txchildcaresearch.org/ppFacilitySear
missing children, arrests of children chResidential.asp. (Last visited March 4, 2004.)
and all potential licensing violations 4
Information provided by Texas Department of
to the agency’s intake phone center. Protective and Regulatory Services, November
25, 2004.
These reports should be made regardless 5
Communication from county health inspector
of which agency holds managing conser- to Texas Department of Protective and
vatorship of the children involved. Regulatory Services, January 20, 2004.
6
Information from DPRS, February 4, 2004 and
B. DPRS should require its contract March 16, 2004.
managers and other staff to immedi- 7
ately report any findings or informa- Interview with facility director, February 5, 2004.
Contracts
HHSC and DPRS should improve
contracting practices.
CMD checks to verify whether the vendor has may include a breakdown of any fiscal errors
paid its taxes or has any unresolved licensing identified, deficiencies in program operations
violations. The contract is executed after all and a calculation of questioned costs. The
vendor and DPRS signatures are in place.3 contract manager’s report also identifies areas
that require technical assistance or corrective
CMD personnel also make on-site visits to action. Unresolved problems may be referred
monitor contractor operations. Before such for alternative dispute resolution.4
visits, they review contractor records, includ-
ing cost reports submitted by each contractor, Every two years, contractors that provide
the contractor’s licensing history and any viola- 24-hour residential child care are required
tions of licensing standards noted in the past. to submit financial information reporting all
expenses incurred in providing these services
After these visits, the contract managers com- at licensed facilities. This information is pro-
pile reports summarizing their findings, con- vided in a document called the cost report.
clusions and recommendations. The findings The Cost Reporting and Fiscal Analysis Unit
Exhibit 1
Types, Numbers and Amounts of DPRS Foster Care-Related Contracts
Fiscal 2003
Fiscal 2003
Administered by Contractor Type Clients Served Number of
Total Expenditure
Contracts
Residential Foster Care
Statewide DPRS central office Child placing agencies, Foster children 295 $285,000,000
residential treatment referred to DPRS
centers, therapeutic and placed in
camps private care
CPS Each of the 11 Foster families and Foster children 3,337* $31,000,000
District regional offices group homes placed in public
within the five care
districts
Purchased Services
Statewide DPRS central office Training institutes; DPRS staff training; 66 No data available from
adoption services; foster children DPRS
Youth For Tomorrow services
assessments
CPS Each of five district Medical, therapeutic, Children placed 606 $30,000,000
District offices legal and training with a foster
professionals family or group
home, adult family
members, adult
caregivers
*These agreements to care for foster children may not be formalized in a written contract.
Source: Texas Department of Protective and Regulatory Services.
conducts desk reviews or selected on-site au- Allowing providers to pick and choose among
dits on each cost report to ensure that the fi- foster children and the services they deliver
nancial and statistical information submitted undermines the entire foster care system. It
conforms to all applicable federal and state prevents the state from ensuring that each
rules, regulations and instructions.5 child has a safe and appropriate care envi-
ronment. It also puts caseworkers in a bind
Contrary to standard governmental and pri- when contractors can dictate which children
vate business practice, DPRS does not write they will serve. For example, caseworkers
the contracts it signs with providers of resi- sometimes have to make quick decisions and
dential foster care. Each year, DPRS gathers say desperate things to acquire emergency
selected providers to write—not simply com- housing for a child. Some contractors told the
ment on or negotiate, but write—key provi- Comptroller review team that it is not unusu-
sions in boilerplate contracts they will sign al for a caseworker to misrepresent a child’s
for the coming year.6 condition to gain admission.10
Most government and private business con- “No-reject, no-eject” contract clauses requir-
tracts are written in a businesslike environ- ing providers to serve all children referred to Contractors
ment, with one side proposing terms and con- them by DPRS could strengthen the system. can refuse
ditions and the other responding. States also Caseworkers would have no cause to mis- admission to
any child they
offer “take-it-or-leave-it” contracts with terms represent a child’s condition and providers
choose and can
giving the state significant power over its re- would be better prepared to care for the child.
require DPRS to
lationship with its vendors. DPRS’ practice According to child welfare experts in Kansas, remove a child
of allowing providers to negotiate their own Illinois and Florida, the no-reject, no-eject with as little
terms from the start certainly contributes to clauses in their provider contracts are essen- as 24 hours’
the general weaknesses of DPRS provider tial to providing daily foster care.11 notice to the
contracts detailed in this report, and places caseworker.
foster children and state and federal funding No-reject, no-eject clauses have caused some
at risk of abuse. financial instability for providers in other
states. Therefore, effective clauses must en-
In giving its vendors such control, DPRS has able providers to serve all children while
crippled its ability to enforce performance mitigating the financial consequences of dif-
standards and other key contractual obliga- ficult-to-serve children or unexpectedly high
tions. And DPRS’ Contract Policy Division caseloads. A comprehensive study by the U.S.
has only one attorney to review and approve Department of Health and Human Services
hundreds of contracts and amendments. found that financial risks for providers could
be limited by contracts stipulating the type
Furthermore, the contracts are poorly written. and duration of children’s treatment, and al-
They lack effective provisions to prevent con- lowing providers some control over case re-
flicts of interest and are so out-of-date that cur- ferrals and decisions about children’s care.12
rent contracts still require all parties to meet
obsolete year 2000 technology standards.7 Ohio uses a random assignment of cases to
contractors so that no one contractor is over-
No-Reject, No-Eject burdened with costly cases. Tennessee places
More seriously, the contracts allow providers maximum limits on the number of children a
to reject or eject children placed with them.8 provider can reject and minimum limits on
Contractors can refuse admission to any child the number of children providers accept each
they choose and can require DPRS to remove month.
a child with as little as 24 hours’ notice to the
caseworker.9 A no-reject, no-eject clause in DPRS foster
care contracts is necessary for a successful,
completely outsourced foster care system. sees to establish their own procurement rules
Several providers told the Comptroller review and regulations. HHSC agencies must docu-
team that they have the desire and the capac- ment that their purchases consider a number
ity to care for more children, but also want to of factors including costs, quality, reliability,
be more involved in management decisions.13 value and probable vendor performance.16
An effective no-reject, no-eject clause that
mitigates financial hardships and involves One major difference between HHSC agen-
providers in the daily management of children cies and other state agencies is that HHSC
would accomplish a successful transition to allows “open-enrollment” contracting in the
an effective, outsourced foster care system. acquisition of residential services. That is,
all providers licensed by DPRS are eligible to
POS Contracts receive contracts, regardless of their past or
The five district CPS offices manage most POS present performance. The number of foster
contracts, while CMD manages statewide POS children referrals a provider will receive—
contracts such as the one for evaluations per- and therefore the amount the provider will be
formed by Youth for Tomorrow (YFT). Four paid—generally is decided by individual CPS
CMD contract managers—only one of whom caseworkers.17 Numerous interviews con-
is an attorney—handle 66 statewide POS con- ducted by the Comptroller review team with
tracts. Each of the five district offices has at providers during site visits indicated that, in
least one employee to manage district POS many instances, CPS caseworkers based their
contracts.14 decisions about placements on their personal
relationships with providers.
Open- Children who require only the most basic level
enrollment of care and are cared for in the state-run side of DPRS does not limit its number of potential
contracts also the foster care system receive services through contractors based on the number of slots it
are open-ended POS contracts. These services include: needs for specific types of care, such as that
in terms of cost. offered by residential treatment centers.
• evaluation and testing; Moreover, while DPRS caseworkers may en-
• individual, family and group counseling; courage individual organizations to obtain
• adoption and post-adoption counseling; licenses and become providers, the agency
• parent and caregiver training; does not study regional or local needs for par-
• substance abuse counseling; ticular types of foster care.
• translation services; and
• counseling and support offered through Open-enrollment contracts also are open-end-
DPRS’ Preparation for Adult Living (PAL) ed in terms of cost. The only cost limitation
program.15 specified in the residential child care contract
is a “subject to the availability of appropriated
In fiscal 2003, district-administered POS con- funds” clause.18 DPRS contracts may specify
tracts for foster care services averaged less than terms of service and, often, an agreed cost per
$50,000 each, but 10 contracts exceeded $500,000 unit of service, but generally do not limit the
and one totaled $1.1 million (Exhibit 2). number of children to be referred or dollars
to be paid, unless such limits are specified in
Open Enrollment subsequent contract amendments. In some re-
cently expired contracts, the Comptroller re-
State law exempts DPRS and all other agen-
view team found blanks where the dollar val-
cies under the Health and Human Services
ue of the original contract should have been.
Commission’s (HHSC) oversight from many of
the purchasing requirements that most other
Open-enrollment arrangements are most
state agencies and institutions of higher edu-
common in health and human services agen-
cation must follow. This exemption, however,
cies. In 1998, for example, about 55 percent of
also requires HHSC and each agency it over-
Texas’ spending on health and human services A 1996 SAO review of contract administration
was awarded to providers who received their at health and human service agencies noted
contracts based simply on their enrollment in that competition in contracting can help mea-
a program.19 Most government agencies, by sure the quality and cost of public services
contrast, obtain services through public bid- and reduce the risk of bias or favoritism in the
ding processes. selection process. SAO found that use of open
enrollment, by contrast, limits agencies’ abil-
Exhibit 2
Ten Largest Purchase of Service (POS) Contracts for Foster Care Services
Fiscal 2003
Total
Total Adults Total
Contractor City Children Services Rendered
Served* Amount
Served
Spaulding For
Houston 449 1,039 $ 1,103,197 Adoption, camping, post-adoption
Children
Adoption, camping, consultation,
DePelchin casework, counseling/therapy,
Houston 2,870 283 $ 918,993
Children’s Center evaluation/testing, parent/caregiver
training, post-adoption
Lutheran Social Adoption, camping, Preparation for
Austin 1,873 143 $ 862,223
Services South Adult Living (PAL), post-adoption
Harris County
Consultation, casework, evaluation/
Children’s Crisis Houston 4,564 1,507 $ 791,385
testing
Care Center
Harmony Family
Abilene 4,439 2,893 $ 653,305 Casework
Services Inc.
Basic needs, casework, counseling/
Catholic Charities Fort Worth 1,231 1,384 $ 630,099 therapy, PAL, parent/caregiver training,
translation
Lutheran Social
Dallas 2,049 139 $ 626,089 Camping, PAL, post-adoption
Services Of Texas
Consultation, casework, counseling/
Brenda M. Keller Dallas 339 1,702 $ 538,579 therapy, evaluation/testing, substance
abuse, translator
Children’s Shelter
San Antonio 2,204 276 $ 521,234 Adoption, consultation, casework
Of San Antonio
ity to objectively select the most qualified and Noncompetitive purchasing may be used for
efficient contractors. Without procedures for purchases valued at no more than $5,000.26
evaluating and selecting contractors, agen-
cies may not receive the best value for the Alternative purchases are those defined by
public’s money.20 rule either as “streamlined” or aggregated
purchases that do not exceed certain dollar
In Texas, contracting problems in other thresholds; multiple-award and blanket con-
health and human service programs have led tracts; and open-enrollment contracts.27
In Texas, to reforms. A 2003 Comptroller report, Lim-
contracting ited Government, Unlimited Opportunity, Cooperative purchasing methods allow agen-
problems in found that the state’s nursing home contract- cies to join purchasing cooperatives or groups
other health ing process, also based on open enrollment, to generate economies of scale.28
and human provided insufficient controls to guarantee
service the quality of nursing home care.21 Signature Authority
programs have
led to reforms. DPRS often contracts with state agencies and
In response, state law now requires the Tex- universities for some services such as staff
as Department of Human Services (DHS) to training. According to DPRS purchasing pro-
include clearly defined minimum standards cedures, if such contracts are valued at or in
that relate directly to the quality of care in its excess of $100,000, they must be approved and
nursing home contracts. DHS cannot award signed by the agency’s executive director. Con-
a contract to a nursing facility that does not tracts valued at less than $100,000 but more
meet the minimum standards, and will termi- than $25,000 may be approved and signed by
nate the contractual arrangement if a facility’s the deputy executive director. For interagency
quality of care fails to meet them.22 contracts worth less than $25,000, the district
director may approve and sign them.
Purchasing Methods
HHSC’s purchasing rules and methods for the Signature approval rules for other types of
agencies under its governance, such as DPRS, purchases are much simpler. If a contract
are found in Title 1, Part 15, Chapter 391 of is for residential child care, private services
the Texas Administrative Code. They allow such as counseling or the services of a lo-
DPRS to acquire goods and services through cal government—for education or commu-
four main methods: nity mental health services, for example—the
only approval and signature required is that
• competitive purchasing, of a DPRS district director, regardless of the
• noncompetitive purchasing, amount of the contract (Exhibit 3).
• alternative purchasing, and
• cooperative purchasing. Reportedly, DPRS’ executive director delegat-
ed signature authority to the district directors
HHSC rules define competitive purchasing as because most of these contracts provide cli-
including competitive sealed bidding, compet- ent services and are therefore managed by the
itive proposals and competitive negotiations districts. Even so, the practice weakens the
with more than one potential vendor.23 Indi- oversight for millions of dollars.
vidual HHSC agencies may waive competitive
requirements for purchases worth less than Purchasing in Other Agencies
$100,000 but must obtain HHSC approval to do In contrast to DPRS, most state agencies
so if the procurement is expected to exceed limit the amount they will pay on a specific
that amount.24 An important exception to these contract, and specify the dollars per unit and
rules states that all professional services must number of units of service to be purchased.
be obtained through a competitive process.25 Most state contracts, moreover, are subject to
multiple approvals.
For example, most non-HHSC agency purchas- ing costs, quality, reliability, value and prob-
es of consultant or professional services are able vendor performance. Other state agencies
subject to the following general conditions: select only the bidder offering the best value
to the state, unless the IFB or RFP specifically
• for purchases valued at less than $2,000, states that multiple awards will be made.
no bids are required; In contrast
• for purchases valued between $2,000 and Screening to DPRS,
$10,000, three informal bids are required; Before signing a contract with a corporation most state
• for purchases valued at more than $10,000 or limited liability company, DPRS performs agencies limit
and less than $25,000, a formal invitation a financial background check to ensure that the amount
for bid (IFB) must be issued publicly and it is current on its state taxes. DPRS does they will pay
vendors on the Texas Building and Pro- on a specific
not, however, check the business history of
curement Commission’s (TBPC’s) Central contract, and
the corporation’s principals—its executive
specify the
Master Bidders’ List must be notified; and financial officers—to determine whether dollars per unit
• for all consultant or professional service they are or have been principals in other enti- and number
procurement awards valued more than ties doing business with DPRS or other state of units of
$14,000, the agency must notify the Legis- agencies, are current on their state taxes or service to be
lative Budget Board (LBB); are the subject of litigation directly related to purchased.
• for all consultant or professional service a state contract.30 Most state
purchases reasonably foreseen to exceed contracts,
$15,000, the agency must receive prior ap- DPRS’ failure to perform comprehensive moreover,
proval from the Governor’s Office of Bud- background checks on corporate principals, are subject
get and Planning and notify the LBB; and to multiple
to the extent the law allows, prevents it from
• for purchases of goods or services valued approvals.
ensuring that it does not contract with poor
at more than $25,000, a formal advertise- or fraudulent providers who may be doing
ment must be placed on the Electronic business under a new name.
State Business Daily Web site.29
No-Pay Contracts
HHSC-agency open-enrollment contracts can
In June 2003, DPRS had non-financial (“no-
be procured through an IFB, which is similar to
pay”) contracts with just 11 long-term resi-
a request for proposal (RFP) but provides less
dential childcare providers who were caring
detailed specifications. HHSC agencies, how-
for 30 DPRS-referred children. These pro-
ever, often select all or most bidders who come
viders, most of whom offer long-term group
reasonably close to HHSC standards for meet-
Exhibit 3
Current Signature Authority for DPRS Contracts
Exhibit 4
Location of No-Pay Foster Care Providers
Pampa
Amarillo
Lubbock
Dallas
Tyler
El Paso
Clint San Angelo Waco
Round Rock
Austin Brenham
Houston
San Antonio
Goliad
Beeville
Corpus Christi
home living arrangements, are licensed by The Comptroller review team surveyed all no-
DPRS and are, by law and contract, required pay providers identifiable through DPRS in-
to comply with DPRS terms and conditions. formation to gauge their working relationship
The only difference between them and other with DPRS and to determine their ability to
providers is that they are not reimbursed by accept more children (Exhibits 4 and 5).
DPRS for the services they provide.31
The providers’ responses were revealing.
No-pay providers are charitable, nonprofit cor- Several said that they had repeatedly notified
porations organized under the federal Internal DPRS that they had room to take more chil-
Revenue Code Section 501(c)(3). They receive dren, but had received no response. The pro-
financial support from a variety of sources in- viders were baffled by this silence, particularly
cluding grants, gifts and donations; families in light of the state’s current budgetary woes.
who voluntarily place their children in these
facilities; county juvenile probation depart- Many said they wished to be the first provider
ments; and Medicaid and private insurance.32 CPS contacted, not the last. One complained
Because they do not accept DPRS funds, they that CPS caseworkers acted rudely toward his
are exempt from its financial audits. staff. A few said that they had a good working
relationship with CPS management, but rela-
Exhibit 5
Charitable Provider Capacity as of January 2004
DPRS
No. of Estimated Potential
Children
Current Charitable Providers Location Licensed Current for DPRS
Currently
Beds Population Placements
Served
Children’s Village Tyler 32 18 9 14
Brenham, Houston,
Texas Baptist Children’s Home 56 50 2 4
Round Rock
West Texas Boys Ranch San Angelo 40 20 0 20
Cal Farley Boys Ranch
Amarillo, Pampa 392 372 0 0
(3 facilities)
Genesis House* Pampa 16* - - 0
Beeville, Corpus Christi,
South Texas Children’s Home 118 85 20 0
Goliad
Casa De Esperanza De Los Ninos Houston 49 49 0 0
Lee and Beulah Moor Children’s
El Paso, Clint 150 62 6 12
Home (2 facilities)
Dallas, Houston, Lubbock,
Methodist Children’s Home 408 350 7 58
San Antonio, Waco
Presbyterian Children’s Home** Austin 180 total 170 total 3 0
TOTALS 1,425 1,176 47 108
*Provides drug treatment care, not foster care, and therefore is not included in totals.
**Has both nonprofit and for-profit facilities.
Source: Texas Comptroller of Public Accounts.
charitable, used fully equipped gyms, pools These business practices allow contractors
and/or buildings reserved especially for recre- to buy and sell to themselves, marking up
ational activities. Others provided as little as a costs at each step, approving occasionally
single outdoor basketball court. (See photos exorbitant salaries for themselves and their
of these facilities in Chapter 2.) family members, thereby diverting hundreds
of thousands of tax dollars from children into
Conflicts of Interest their personal accounts.
DPRS contracts for residential services do
not prohibit business transactions between DPRS does not examine these relationships,
closely related parties. The same individuals but merely requires vendors to check a box
may own residential facilities, pharmacies on a form if related-party transactions are in-
and management companies as separate cor- volved. The Comptroller review team found
porate entities, all buying from one another no evidence that DPRS has ever audited or
“at cost” and then passing those “costs” to investigated a related-party transaction as a
DPRS that are added into the calculation of result of this information.
future rates. In addition, several providers are
run by married couples and family members The results of one series of related-party
who approve each others’ salaries. transactions were reported in an October
Exhibit 6
Bexar County Psychologist Contract History
2003 series of Dallas Morning News articles. with Daystar’s owner, it had no authority to
The series highlighted the intricate corporate examine their finances.37 But an examination
structure of Daystar Residential Treatment of Daystar’s fiscal 2002 contract with DPRS—
Center, a home for emotionally disturbed fos- and its 2003 amendment and the DPRS draft
ter children near Houston, and its sister orga- 2004 contract for all vendors which feature
nizations, all of which were run by the same the same terms—tells a different story.
individuals, one of whom earned more than
$1.5 million in 2002. (See the case study of The 2002 contract states, in section 31, sub-
Daystar on page 174.) section C:
In a letter to the News responding to the ar- Contractor shall make available
ticles, DPRS stated that, since it had no con- at reasonable times, at reasonable
tractual agreement with businesses affiliated places within the State of Texas, and
The articles reported on the alleged interwoven cor- The pharmacy’s state license was put on probation,
porate structures of the non-profit company that runs and a former employee was found guilty of Medicaid
the RTC and several related, for-profit corporations, billing fraud in 2002.3
which together earned revenues just shy of $26 mil-
lion in 2002. The exposé also raised questions about Daystar receives a higher per-day rate for some chil-
the companies’ business practices, and about DPRS’ dren in its care—$277.08 versus $202 for other, simi-
inability to recover allegedly “unallowable” expenses. lar providers—by virtue of its selection by DPRS for
participation in the Exceptional Care Pilot Project.
The Comptroller team reviewed documents and tax The project, which began in March 2001 and is ex-
forms pertaining to this case and found a truly tangled pected to continue until 2005, is intended to provide
story. care for difficult-to-place children with severe emo-
tional problems.4
Take, for example, the corporate structure of Daystar,
the nonprofit corporation that owns the RTC where
the 15-year-old died. Five for-profit corporations sup-
plying Daystar are owned and managed by just two Endnotes
individuals. The wife of the majority owner is the 1
corporation’s president. The couple earned nearly $1 Doug J. Swanson, “Owner Reaps Million through Foster
Homes,” Dallas Morning News (October 19, 2003).
million from its operations in 2002.
2
Swanson, “Owner Reaps Million through Foster
Homes.”
Another company owned by the couple leases the RTC
3
its facility and several vehicles. A pharmacy they own “Pharmacist Pleads Guilty to Defrauding the State,” The
provides the RTC with prescription drugs for its chil- Houston Chronicle (July 20, 2002).
dren; this company paid the couple $32,000 in 2002. 4
University of Texas, School of Social Work, “Evaluation
of the Exceptional Care Pilot Project: Final Report,”
The sister facility at which the 16-year-old died in (Austin, Texas, 2002).
2001 is run by another corporation that paid the cou-
ple $433,000 in 2002.
DPRS. The contract lacks integrity without not maintain reliable information on contrac-
language to prohibit this practice. The con- tor performance.
tract includes an obsolete provision that re-
quires contractors to comply with year 2000 Sunset called for the DPRS board and execu-
technology practices. tive management to establish objectives for
contract administration and communicate
All too often, the revised contract’s terms ap- them to staff and contract providers. It also rec-
pear to favor providers over foster children. ommended centralizing oversight of contract
For example, either DPRS or the contractor administration by placing primary responsibil-
can cancel a contract by giving a 30-day no- ity for all contracting in the state office.42
tice. Should a contractor exercise this option,
children’s stability could be at risk unless a A 2000 SAO review of DPRS also criticized
suitable transition plan is put in place first. contract management. SAO concluded that
This provision could be removed without serious gaps in the agency’s oversight of care-
harm to the state because section 45 states givers could undermine its efforts to protect
the contract can be terminated at any time by the children in its care. Part of the problem, in
mutual consent; if a contractor simply cannot SAO’s view, was the way in which the agency
continue providing services, the parties can parceled out responsibility for various con-
mutually agree to terminate the contract and tracting functions among multiple divisions,
arrange a reasonable transition of services. including Legal, Program, Internal Audit and
district offices. For example, SAO found that
Contract Management no individual or group within the agency had All too often,
the revised
The Contract Policy Division conducts quality specific responsibility for evaluating the mea-
contract’s terms
assurance assessments to evaluate whether sures used to assess residential caregivers’
appear to favor
the agency’s contract policies are effective, contract performance.43 providers over
and provides training and technical assistance foster children.
to help DPRS contract managers improve the CPD’s Contract Administration Handbook
contract management and administration provides a considerable degree of informa-
process. This process is intended to ensure tion on the completion of paperwork, but little
selection of the best overall vendors and to guidance on how to evaluate contractor per-
establish risk management and monitoring formance. Contract managers are not trained
procedures to ensure that contractors achieve to evaluate how well a contractor delivers ser-
performance objectives and outcomes.41 vices; their assessments of residential contrac-
tors tend to concentrate more on the specifics
In spite of its quality assurance program, how- of licensing standards than broader issues of
ever, DPRS has a lengthy history of poor con- quality of care. SAO found that these assess-
tract management and monitoring. In 1996, ments rarely present a useful discussion of
for instance, the Sunset Advisory Commis- contractors’ strengths and weaknesses.44
sion reported weaknesses in DPRS’ contract
administration. Moreover, DPRS’ contract managers give resi-
dential facilities a minimum of 30 days’ notice
Among other issues, Sunset noted that the before a site visit.45 This gives contractors am-
agency’s decentralized approach (which ple opportunity to present their operations in
leaves much of the responsibility for contract- the best light. Surprise visits could avoid this
ing to district offices) created inconsistencies possibility and give DPRS confidence that it
in contractor selection and monitoring. Sun- is seeing a more accurate picture of how con-
set also found that DPRS lacked an effective tractors actually operate.
contracting procedures manual and did not
apply contract evaluation techniques consis- DPRS established a Contract Administration
tently across the state. Moreover, DPRS did Division to address contract administration
weaknesses identified by Sunset and SAO and adequate oversight. A score just four points
established a Contract Task Force in April higher on this contractor’s RAI would have
2000 to accelerate progress toward better triggered a more thorough review that might
outcomes.46 However, residential care con- have identified potentially harmful deficien-
tracts still lack measurable outcomes to hold cies in the contractor’s services.48
providers accountable. As described below,
DPRS’ risk assessment and records manage- Poor Records
ment practices are still inadequate.
The Comptroller’s review team analyzed nu-
merous records related to contract manage-
Risk Assessments ment and found some out-of-date and irrel-
The Contract Policy Division uses a risk as- evant information. For example, audited fi-
sessment instrument (RAI) to determine moni- nancial statements for some contractors were
toring requirements for residential service more than four years old. One contractor file
contracts worth $10,000 or more; in theory, the contained an RAI that provided no informa-
higher the score, the more likely a contractor is tion in four risk categories. DPRS, in fact,
to receive relatively frequent visits from a con- provided no evidence that RAI instruments,
tract manager. The RAI results are used to pre- and other assessment tools used to monitor
...despite pare a monitoring schedule for higher risk con- contracts, are validated regularly to ensure
allegations tracts that is included in an annual statewide that they effectively measure financial risk
and findings monitoring plan for Contract Management. and quality of care.
of sexual
misconduct at SAO urged DPRS to include more risk factors HHSC Contracting Functions
a therapeutic in its risk assessment process, noting that
camp in 2000— The 2003 Texas Legislature, as part of a move
the RAI did not adequately assess the quality
allegations that to consolidate state health and human ser-
of care. DPRS has revised its RAI to include
resulted in the vices, required HHSC to centralize contract
more risk factors, from 10 in fiscal 1999 to 18
provider being administration and contract management
considered in fiscal 2004. Even so, CMD’s monitoring still
systems for the agencies it oversees, includ-
for license seems to focus mostly on technical issues.
ing DPRS. In response, HHSC has transferred
revocation—the purchasing and contract administration staff
facility received For example, despite allegations and findings
from the health and human service agencies
a low risk of sexual misconduct at a therapeutic camp in
under its “umbrella” to its central office.
rating in fiscal 2000—allegations that resulted in the provider
2002 and 2003. being considered for license revocation—the
At present, however, HHSC has no plans to
facility received a low risk rating in fiscal 2002
consolidate all contract management func-
and 2003.47
tions, as the legislation requires. After the
2003 legislation passed, HHSC negotiated
The Comptroller’s review team analyzed
with health and human service agencies and
completed risk assessment instruments for a
reached a consensus that only contract ad-
number of contracts to determine if high risk
ministration and some auditing functions
contracts were appropriately identified. One
would be consolidated at HHSC; contract
contractor received a score of 54 on its RAI,
monitoring would remain a duty of the indi-
including a risk score of 16 (the highest) for
vidual agencies.49
“history of noncompliance” due to the death
of a child at the facility. This overall score fell
State law requires HHSC to develop a con-
in DPRS’ acceptable range, meaning that an
tract management handbook “that establishes
in-depth monitoring visit would not be need-
consistent contracting policies and practices
ed. Yet CMD did not include any risk points
to be followed by health and human services
in the “Quality of Services” area. Clearly, it is
agencies.”50 HHSC does not yet have such a
reasonable to assume that the death of a child
handbook, but an internal committee led by
could be the result of poor services and in-
the agency’s director of administration is de-
veloping one that will include procedures and TBPC rules and procedures could provide
policies for contract administration and man- valuable guidance to DPRS and HHSC for
agement. Once the HHSC handbook is devel- contract management and administration.
oped, the agency plans to “tweak” it at a later
time to apply it to the other health and human State Auditor
service agencies under its authority. SAO is the independent auditor for Texas
state government charged with improving
State law also requires HHSC to develop a the performance and accountability of Texas
single, statewide risk analysis procedure for state government. SAO helps state agencies
contract administration and monitoring, but by reviewing their operations, management
it has not and has no plans to do so.51 HHSC and accountability systems and by assessing
has not begun a review of DPRS’ contracts for fiscal and management controls.
foster care services. Comptroller staff were
told that the agency is concerned that modifi- SAO could identify strategies to correct defi-
cations to these contracts could create disrup- ciencies in DPRS accountability systems. For
tions in services for foster children. Instead, example, the 2000 SAO review of DPRS found
the office plans to address low-risk purchases that foster care services used to develop rates
first, such as office supplies, because these are not controlled adequately.54
purchases present few challenges.
SAO also serves in a human resources adviso-
HHSC does plan to conduct a comprehensive ry role to state agencies. As such, it could help
review of contract language in client services DPRS identify monitoring staff and skill sets
contracts. The focus of this review, however, needed to establish more effective contract
will be to develop consistent definitions and administration and management systems.55
measures across agencies, not necessarily to
review contract elements such as conflict-of- An SAO review could help CPS staff to antici-
interest provisions. pate future problems with non-performance
or noncompliance; identify program “trig-
Texas Building and Procurement gers” that have caused problems; predict and
Commission address the impact of changes in program
As noted earlier, HHSC is exempt from TBPC rules, changes in participant staff, and chang-
rules and procedures for contract administra- es in program funding; and ensure that more
tion, management and monitoring that ap- of each foster care dollar goes to the direct
ply to most state agencies and institutions of care of children.
higher education.52
SAO also could review DPRS’ technology
TBPC has established contract management systems and data input processes to improve
and monitoring rules and procedures for reimbursement timeliness and accuracy. For
these agencies, and offers a variety of ser- example, several providers, including some
vices designed to help them comply with its survey respondents, complained of not being
regulations. These services include vendor reimbursed for children in their care within
training, counseling, mediation and problem the 30-day period required by the state’s
resolution, as well as a vendor tracking da- Prompt Pay Act. And some providers re-
tabase to provide state agencies with infor- ceived payments for children who were not in
mation on vendors’ past performance. TBPC their care.56 One facility’s accounts receivable
also performs purchasing audits of the agen- records indicated that the facility was owed
cies and institutions under its authority and more than $100,000. The provider explained
reviews proposed contracts and requests for that once 90 days have passed on an overdue
proposals submitted by state agencies.53 account, it is almost impossible to get the
problem straightened out.57
The problem occurs because caseworkers not…” It also should eliminate any provi-
do not always promptly enter the date that a sions that are obsolete or do not promote
child moves to a facility into the DPRS com- financial accountability.
puter database that tracks children’s place-
ments. If the caseworker waits too long to en- Contractors unable to meet these new
ter a child’s new placement into the database, terms should be given a grace period to
the facility where the child previously resided restructure their financial or corporate
may receive a payment that should go to the agreements, but in no case should that
child’s new facility, causing confusion and grace period extend past August 31, 2004.
late payments. If the caseworker leaves the
position without correcting the problem–and B. HHSC should require DPRS to dis-
turnover is high at the agency–then reconcili- continue its practice of allowing pro-
ation becomes more difficult.58 viders to dictate contract terms.
To address these and other billing problems, Contracts should include provisions that
DPRS made changes to its programming in require contractors to meet outcomes
October 2003 to expedite processing. DPRS and financial accountability standards
also increased its corrected payment runs that protect the safety and well being of
from twice per month to weekly. foster children.
This would help DPRS better manage its appropriate charitable providers before
expenditures and provide greater over- seeking placements with similar, for-pay
sight and accountability. providers.
H. HHSC and DPRS should fully use J. HHSC, in coordination with SAO,
charitable no-pay caregivers to aid should perform complete, on-site fi-
Texas foster children. nancial audits of selected providers.
DPRS should establish and maintain an The DPRS Residential Care contract in-
active database of placements offered by cludes a statement that any acceptance of
charitable providers under no-pay con- funds by a contractor is also acceptance
tracts, and attempt to place children with of the SAO’s authority to audit or investi-
14 31
Interview with Texas Department of Protective Data provided by Texas Department of
and Regulatory Services staff, Austin, Texas, Protective and Regulatory Services, December
November 20, 2003; and Texas Department of 11, 2003.
Protective and Regulatory Services, “State Plan 32
– Foster and Adoptive Home Licensing,” http:// Texas Department of Protective and Regulatory
www.tdprs.state.tx.us/About/State_Plan/2003_ Services, “Non Financial Residential Child
4descriptionCPS.asp. (Last visited February 11, Care Contract (form 2282NF),” Austin, Texas,
2004.) July 2003, p. 5; and the University of Texas at
Austin, School of Social Work, “2002 Texas
15
Data provided by Texas Department of Resource Manual of Facilities and Programs
Protective and Regulatory Services, December for Children and Youth,” pp. 85-453.
10, 2003. 33
The Texas Department of Protective and
16
Tex. Gov’t Code Ann. §2155.144. Regulatory Services approved a rate of $34
17 per child for basic children in child placing
Interview with Texas Department of Protective agencies for fiscal 2004 and 2005. In addition,
and Regulatory Services staff, Austin, Texas, the department also approved a $2 supplement
November 12, 2003. only for fiscal 2004, making the fiscal 2004 rate
18
Texas Department of Protective and Regulatory $36. The rate is expected to return to $34 for
Services, Residential Child Care Contract, fiscal 2005.
(Austin, Texas, September 2003), pp. 13 and 16. 34
Interviews with active and retired Texas
19
Texas Comptroller of Public Accounts, Study of Department of Protective and Regulatory
Payment Methods, Austin, Texas, December 15, Services staff, Austin, Texas, December 2003.
1998, p. 5. 35
Interview with Jennifer Noack, Texas State
20
Texas State Auditor’s Office, Contract Board of Examiners of Psychologists, Austin,
Administration at Selected Health and Human Texas, December 3, 2003.
Services Agencies, Phase Three (Austin, Texas, 36
Interview with Texas Department of Protective
February 1996), pp. 22-23. and Regulatory Services staff, Austin, Texas,
21
Texas Comptroller of Public Accounts, Limited December 16, 2003.
Government, Unlimited Opportunity, “HHS 37
Letter from board members, Texas Department
1: Contract for Quality Nursing Home Care,” of Protective and Regulatory Services, to the
http://www.window.state.tx.us/etexas2003/ Editor, Dallas Morning News (October 29,
hhs01.html. (Last visited February 11, 2004.) 2003).
22
Tex. H.B. 2292, 78th Leg., R.S. (2003). 38
Texas Health and Human Services Commission,
23
1 Tex. Admin. Code §391.101 and §391.151. Enterprise Project Office, HHSC Uniform
Contract Terms & Conditions, Version 1.2
24
1 Tex. Admin. Code §391.109 and §391.131. (Austin, Texas), p. 19, available in pdf format
25
1 Tex. Admin. Code §391.36. from http://www.hhsc.state.tx.us/about_hhsc/
contracting/rfp_attch/General_TC.pdf. (Last
26
1 Tex. Admin. Code §391.103. visited February 5, 2004.)
27 39
1 Tex. Admin. Code §391.105. Texas State Auditor’s Office, An Audit Report
28 on the Department of Protective and Regulatory
1 Tex. Admin. Code §391.107.
Services’ Administration of Foster Care
29
Texas Building and Procurement Commission, Contracts, Austin, Texas, August 2000, pp. 24
“Bidding Requirements and Dollar Limits and 31.
or Thresholds,” http://www.tbpc.state.tx.us/ 40
Texas Department of Protective and Regulatory
stpurch/2-11.html (Last visited January 7, 2004);
Services, Residential Child Care Contract,
Texas Governor’s Office, “Consultant Contract
Form 2282cx, September 2003, p. 6.
Guidelines,” http://www.governor.state.tx.us/
41
divisions/bpp/guidelines (Last visited February Texas Department of Protective and Regulatory
11, 2004); and Tex. Gov’t Code Ann. §2155.083 Services, Contract Policy Division, 2003 Quality
and §2254.006. Assurance Review Process.
30 42
Interview with Texas Department of Protective Texas Sunset Advisory Commission,
and Regulatory Services staff, November 12, Department of Protective and Regulatory
2003. Services: Staff Report, Austin, Texas, 1996, pp.
59-67.
43 50
Texas State Auditor’s Office, An Audit Tex. Gov’t Code Ann. §2155.144(j).
Report on the Department of Protective and 51
Regulatory Services’ Administration of Foster Tex. Gov’t Code Ann. §2155.144(i); and
Care Contracts, pp. 1-2. interview with Health and Human Services
Commission staff, January 16, 2004.
44
Texas State Auditor’s Office, An Audit 52
Report on the Department of Protective and Tex. Gov’t Code Ann. §2155.144.
Regulatory Services’ Administration of Foster 53
Texas Building and Procurement Commission,
Care Contracts, pp. 6 and 22. “Procurement,” http://www.tbpc.state.tx.us/
45
Interview Texas Department of Protective stpurch/index.html. (Last visited February 11,
and Regulatory Services staff, Austin, Texas, 2004.)
December 2, 2003. 54
Texas State Auditor’s Office, The Department
46
Texas State Auditor’s Office, An Audit of Protective and Regulatory Services’
Report on the Department of Protective and Administration of Foster Care Contracts,
Regulatory Services’ Administration of Foster (Austin, Texas, August 2000), pp. 11-12.
Care Contracts, p. 3. 55
Texas State Auditor Web site: http://www.sao.
47
Texas Department of Protective and Regulatory state.tx.us/Services/ (Last visited February 12,
Services, risk assessment instruments for fiscal 2004.)
2002 and 2003. 56
Texas Comptroller foster care survey,
48
“Critics Say State Oversight of Foster Homes interviews with various providers and Tex.
Too little, Too late: Audits Not Designed to Govt. Code, Chapter 2251 (Prompt Pay Act).
Recover Funds Paid for Disallowed Expenses,” 57
Interview with provider.
Dallas Morning News (October 19, 2003),
58
p 23A; and Texas Department of Protective Interview with Texas Department of Protective
and Regulatory Services, Risk Assessment and Regulatory Services staff.
Instrument (RAI), Fiscal Year (FY) 2003.
49
Tex. H.B. 2292, 78th Leg., Reg. Sess. (2003);
and interviews with Texas Health and Human
Services Commission staff, Austin, Texas,
December 8, 2003 and January 16, 2004.
Rate Setting
HHSC should assume responsibility for the residential foster
care rate-setting process and ensure that the agencies under
its oversight use consistent cost report audit policies.
ited to inter-fund loans and transfers, interde- ly and, ultimately, to produce a more accurate
partmental loans and transfers, intercompany cost report database for rate calculation.
loans and transfers and employee loans not
considered salary. Also, the value of donated A more detailed discussion of these issues
goods and inkind services are unallowable.5 can be found in Appendix 3.
Fiscal Impact 4
Interview with staff, Texas Department of
Protective and Regulatory Services, Austin,
All recommendations could be implemented Texas, November 14, 2003.
using existing resources. 5
Allowable costs also are codified in the Code of
Federal Regulations, 45 CFR, Part 74; 48 CFR,
Part 31; and U.S. Office of Management and
Budget Circulars A-87, A-122 and A-110. The
Endnotes state regulations are found in 40 Tex. Admin.
1
Texas Department of Protective and Regulatory Code §§732.240-732.256 and 40 Tex. Admin.
Services, “Foster Care Reimbursements,” Code §§700.1801-700.1806.
http://www.tdprs.state.tx.us/Adoption_and_
Foster_Care/About_Foster_Care/foster_care_
reimbursements.asp. (Last visited December
18, 2003.)
and Safety of All DPRS should take decisive steps to stop the abuse and neglect
of Texas foster children.
Foster Children The agency currently places sexual predators and children with
violent criminal histories alongside other foster children. This
• Abuse and Neglect . . . . . . . . . . 189 practice must stop. All child-on-child abuse must be reported
and tracked, and all complaints and allegations should be thor-
• Medication . . . . . . . . . . . . . . . . . . . . 199 oughly investigated.
DPRS should obtain FBI criminal history checks for all adults who
• Medically Fragile work with foster children, and all such checks should be com-
Children . . . . . . . . . . . . . . . . . . . . . . . . 209 plete before these persons begin work. Foster caregivers should
test their employees for drug use, and DPRS should consider re-
• Foster Children with quiring psychological testing of caregivers.
Mental Retardation . . . . . . . . . 213 Many foster children receive psychotropic medications, some-
times in disturbing amounts and combinations. The Health and
• Foster Child Fatalities . . . . . . 219 Human Services Commission should create a review team to ex-
amine the diagnostic services, medication, treatment and therapy
• Missing Foster Children ... 227 delivered to Texas foster children. This team also should develop
a best-practices manual for the appropriate use of medications.
Medical “passports” documenting medical and therapeutic
treatment as well as all medications being administered should
accompany each foster child to all foster homes and medical ap-
pointments.
More than a thousand Texas foster children are considered med-
ically fragile and nearly 3,000 have mental retardation. DPRS
should improve the assessments and services provided to medi-
cally fragile foster children and create a Medicaid catastrophic
case management program to guide their care in an efficient
and effective way. Children with mental retardation should be
identified properly and their services coordinated with the ap-
propriate health and human service agencies.
DPRS should require foster caregivers to use appropriate behavior
management systems that incorporate safe personal restraints.
All foster child deaths should be investigated thoroughly.
DPRS should intensify its efforts to find missing Texas foster chil-
dren. As part of this effort, the agency should develop a Web site
providing the public with information about these children.
“cruel sexual abuse of other children,” accord- ter homes, residential treatment facilities and
ing to a letter the facility’s executive director therapeutic camps, from January 2002 to Janu-
wrote to a DPRS contract manager.7 ary 2004, include complaints of child-on-child
sexual abuse. DPRS caseworkers, juvenile
At another therapeutic camp, the county sher- probation officers, child therapists and other
iff charged a 17-year old and another teen with professionals filed many of these complaints
aggravated sexual assault of a younger boy in based on children’s allegations; few resulted in
October 2003. The alleged rape was reported a finding of abuse or neglect or licensing viola-
to staff; the camp director, however, did not tions involving neglectful supervision.9
report it to DPRS until after the younger boy
ran away from the camp for the third time DPRS does not track or report on the extent of
that week and contacted a sheriff’s deputy. child-on-child abuse in foster care. If a DPRS
The sheriff’s office placed the other boys un- investigator found that a child had abused an-
der arrest after questioning them.8 other child, he or she would be required to en-
ter the child’s name into a DPRS central regis-
DPRS investigative reports for ten facilities, in- try that identifies child abusers. Once entered
cluding child placing agencies that operate fos-
Angela’s Story
Angela, (name changed to protect confidentiality), age her to an orthopedic specialist. Because it would take
14, named the women she said had abused her and the another week to see a specialist, the director took her
other children at the facility. Angela said they punched to a hospital instead.2
girls in the stomach when they got mad at them, and
that one of the women pushed her down the stairs. The hospital immediately found that her leg was
badly broken, and that the lack of medical treatment
She said it happened after one of the other girls had caused a severe bone infection. After surgery,
shoved her off a bench, which hurt her leg. She said Angela had to spend six months in the hospital, sev-
she was moving slowly because her leg hurt and that eral months of it in traction. According to hospital
one of the staff became angry with her for being slow. records, Angela was malnourished when she arrived
She said the staff member told the other girls to go in and required a feeding tube for several months.3
their rooms and close their doors.
The facility director reported Angela’s injury to DPRS
When Angela finally reached the top of a flight of on April 2, shortly after she took her to a hospital.
stairs, she said the staff member told her she was go- Her report indicated that Angela had injured herself
ing to “teach her a lesson.” According to Angela, the “while playing” and would need surgery.4
staff member pulled her injured leg up and pushed her
down the stairs. Then a staff member sat her in a chair DPRS began its investigation of the director’s report
downstairs because she was unable to climb the stairs. on April 4, 2003. The same day, the agency received
She said she slept in the chair for the next week.1 a second call, reporting that Angela said that a staff
member had pulled her up the stairs by her hair and
The facility’s director, a registered nurse, said she pulled her injured leg up for being slow. On May 20,
took Angela to a medical clinic the next day, where a DPRS closed this complaint as “not subject to regula-
doctor said Angela’s leg was not broken. A week later, tion.” The report is not listed on DPRS’ public data-
she said she took Angela again to the clinic, and again base of reports and investigations.5
the doctor said that her leg was not broken. The fol-
lowing day, the director took Angela to the clinic for In its investigation of the director’s report, DPRS
a third time; the doctor then recommended sending found that, since the facility had sufficient staffing
into the central registry, however, the record ment decisions. And facilities accepting chil-
would stay with the child for life. dren into their care cannot know whether they
are making their other children vulnerable.
For this reason, DPRS employees often are re-
luctant to brand a foster child in this way, and Adult Abuse of Foster Children
state law actually precludes entering a child’s Adult abuse of children also is a problem in
name in the registry as a perpetrator before the some foster homes and facilities. In fiscal 2003,
age of ten. DPRS’ databases do not provide any DPRS employed 12 investigators in its Child
other avenues to track child-on-child abuse.10 Care Licensing (CCL) division to look into 966
reports, most of which involved alleged adult
Without solid information, the public and the abuse or neglect of children. Of these, the
state’s leadership cannot know the true extent agency found 98 valid, or about 10 percent.11
of the problem. DPRS, in turn, cannot identify
which facilities have the most problems and The Comptroller review team, however, con-
which children may be dangerous to other chil- ducted an in-depth review of reports, com-
dren, or devise policies to combat the problem.
Caseworkers cannot make informed place-
(continued on page 193)
when Angela was injured, sought medical treatment tions that may be related to abuse and neglect. DPRS
for her and documented it, that no breach of licens- investigated and ruled out abuse. According to DPRS’
ing standards had occurred. The agency closed this investigations to date, no one at the facility has done
investigation on May 28.6 anything wrong, and the facility is in complete com-
pliance with its standards.
Because DPRS did not investigate the second report,
which contained Angela’s allegation of abuse, no one On the DPRS Web site list of licensing investigations
asked critical questions. No one asked the other girls if and violations, Angela’s story is just one of the 90 per-
they saw Angela climb the stairs on the evening of the cent of reports, complaints or allegations that DPRS
alleged incident. No one asked the girls or staff mem- does not find to be valid.8
bers if they had seen Angela sleeping in a chair down-
stairs, or being unable to walk without crutches. No
one asked hospital staff members whether the injury
to her leg was consistent with a playground injury. No Endnotes
one reviewed her medical records to learn that she had 1
Advocate’s interview of child, September 7, 2003.
been malnourished when she entered the hospital.
2
Texas Department of Protective and Regulatory
The facility and DPRS also failed to request an FBI Services.
background check of other states for the staff mem- 3
Hospital records.
ber Angela said pushed her, even though this individ- 4
Texas Department of Protective and Regulatory
ual had only recently moved to Texas before starting Services.
work at the facility. As it happens, this person had a 5
Texas Department of Protective and Regulatory
criminal record in her state of prior residence, includ-
Services.
ing a 1997 third-degree felony conviction for grand
6
theft, a 1999 probation violation and a charge of bat- Texas Department of Protective and Regulatory
Services.
tery in August 2001.7
7
State of Florida, Twentieth Circuit Court, Criminal
DPRS received yet another call about Angela’s injury Justice Information System, public database, 1997-2003.
a few months later. This caller reported that children 8
Texas Department of Protective and Regulatory
at the facility suffered from numerous medical condi- Services.
plaints or allegations and their ensuing inves- mother came to the school briefly,
tigations involving ten facilities dated from but the foster mother merely be-
January 2002 through December 2003, and rated [the child] for coming to the
found that the public database and published nurse’s office and then flatly refused
information underreport complaints, includ- to take [the child] home or to take
ing abuse and neglect complaints, and do not [the child] for medical attention.…
paint a true picture of the situation. At the time of the report [the caller]
was considering calling 911. [The
The CCL division closes some cases with- child] appears to be very ill.
out investigation. These cases are “adminis-
tratively closed—not subject to regulation.” Although this incident happened at a school
However, for CCL to administratively close and not at a licensed facility or foster home,
a case, the complaint has to fall outside the the CCL division still must investigate if the
regulations of the agency or the CCL, be a re- foster caregiver is involved or if abuse or ne-
port that did not provide enough information glect may be happening at a facility or foster
to investigate or be duplicative of other com- home. This foster mother continues to care
plaints that have already been investigated.12 for up to six children in her therapeutic foster
home and has a clean record with CCL.14
The Comptroller review team found instances
of allegations of abuse and serious licensing Those allegations that the CCL division inves-
violations that were administratively closed tigates are rarely ruled valid, even when the
but did not meet the criteria for administra- complaint and complainant appear credible,
tive closure. State law charges DPRS with in- such as when teachers, medical clinics, law
vestigating all such complaints. Some of these enforcement and facility employees report The CCL
cases involve multiple children and series of eyewitness evidence that is documented. division
incidents over time.13 Listed below is an ex- closes some
ample of one complaint about a foster home To determine if a complaint is valid, DPRS cases without
that DPRS did not investigate due to adminis- policy uses a standard called “a preponder- investigation.
trative closure: ance of evidence,” also called “the 51 percent
rule.” This phrase means that the evidence
[The child] was enrolled on Tues- simply must be judged more valid than not.15
day at [high school] by the foster In situations where children allege that adults
mother. The foster mother repeat- abused them, the evidence often boils down
edly berated and warned [the child] to a child’s word.
not to be going to the nurse’s office
because “there’s nothing wrong Many reports originate with children, although
with you.” However, [the child] has some reports derive from observations by em-
end-stage renal failure and has dial- ployees at foster care facilities, medical staff
ysis three times a week. [The child] at clinics or hospitals, teachers, law enforce-
takes numerous medications…. ment, DPRS caseworkers and others. The
[The child] “shuts down” however Comptroller review team found allegations
when the foster mother begins of physical and sexual abuse, medical neglect
to berate [the child]. Today [the and drug use by staff. Numerous profession-
child] came to school, after having als, as well as the children themselves, made
been absent yesterday, presumably serious allegations of abuse, neglect and ex-
for dialysis. [The child] became ill ploitation to DPRS, to little avail.
shortly after coming to school and
began throwing up. [The child] was Some incidents were never investigated;
brought to the nurse’s office and the those investigated were rarely found valid.16
foster mother was called. The foster Some of the allegations that DPRS investiga-
tors found invalid at one facility are listed in investigators review, and children may fear
the accompanying text box (see page 192).17 retaliation when answering questions during
an investigation. Moreover, many children are
Of 47 such complaints called in to DPRS simply too young to complain. These factors
about this facility from January 2002 through weight the investigations heavily in favor of
December 2003, CCL administratively closed the facility.
10 and did not investigate them. Among the
remaining 37, DPRS found four complaints at DPRS also might be compromising some of
least partially valid and rejected 32. One was its investigations by delaying them. Although
never investigated. DPRS initiated investigations on seven of the
47 complaints within one day of the com-
Of the four complaints DPRS found at least plaint, 18 took as long as six or more days to
partially valid, one involved a personal re- begin. In one complaint involving a child who
straint resulting in serious injury to a child. said she was becoming suicidal, citing taunts
Another involved neglectful supervision when and threats from staff members, DPRS did
staff slept, allowing children to engage in sex- not open an investigation for 14 days. In an-
ual activity. The third involved withholding other incident in which police transported a
food as punishment, but the allegation itself bruised child to a hospital, DPRS did not be-
involved serious staff abuse of a child who gin its investigation for six days.21
ran to police and was found to have sustained
a bite mark on his arm, choke marks on his Evidence may disappear during such delays.
neck, severe bruising on his left arm and a hit Both incidents, and others, occurred after
Some incidents on his left temple. The licensing investigator January 2003, when HHSC established rules
were never was “unable to determine” if abuse had oc- concerning investigations to require timely re-
investigated; curred. The fourth involved not reporting a sponses in order to preserve evidence.22
those serious incident to DPRS when a staff mem-
investigated ber was fired for having sex with a child.18 Finally, none of the reports of allegations that
were rarely are administratively closed are listed on the
found valid. According to the investigative reports, DPRS DPRS public Web site on facilities. This incom-
investigators generally rely on interviews and plete picture of facilities’ track records can be
reviews of facility documents to determine the misleading to the public.
“preponderance of evidence,” even when other
documents like medical records, police reports Need for Screening
or utility bills might substantiate an allegation. DPRS rules and standards require Texas crimi-
nal background checks for foster parents and
Investigators also appear to give more weight staff providing direct care for children. They
to the statements of facility staff than to those also require a check of the DPRS central regis-
of children and other adults, even though try for abuse and neglect for any history of hav-
clear patterns often exist that might corrobo- ing abused or neglected a vulnerable person.
rate their stories, such as similar complaints However, DPRS rules and standards require a
from different children over time.19 FBI criminal history check of records in other
states only if the individual currently lives out-
“Although these children sometimes fabricate side of Texas or if there is reason to believe
stories, children’s complaints should be taken other criminal history exists.23
seriously. Investigators should look for pat-
terns in allegations of children’s complaints,” DPRS also does not check abuse and neglect
according to a child abuse expert.20 central registries in other states, and no na-
tional registry exists.
In addition, it should be noted that facilities
control the content of the facility documents
DPRS rules require completed background with other background and interview infor-
checks before child placing agencies and mation on prospective caregivers to assess
other private foster homes can have access their suitability. In order to comply with fed-
to foster children. Facilities such as residen- eral requirements involving non-discrimina-
tial treatment centers, however, do not have tion, facilities can use psychological testing
to wait until DPRS completes background as a conditional requirement after making an
checks before they hire staff and give them employment offer to someone.27
access to children.
20 25
Interview with Ben G. Raimer, M.D., Professor El Paso Police Department, Recruiting
of Pediatrics, The University of Texas Medical Division, “Application Process,” http://www.
Branch in Galveston, February 3, 2004. ci.el-paso.tx.us/police/eppdemp_apply.htm.
21 (Last visited January 5, 2004.)
Data provided by DPRS.
26
22 Gateway Woods Foster Specialized Foster Care
1 Tex. Admin. Code §351.503. Program, “How Do I Become a Foster Parent?”
23
40 Tex. Admin. Code §745.627, and Texas http://www.gatewaywoods.org/services/
Department of Protective and Regulatory fostercare/. (Last visited December 5, 2003.)
Services. 27
Interview with Cathy Eback, Product Support
24
Texas Department of Protective and Regulatory Specialist, Pearson Assessments, Bloomington,
Services, Consolidated Minimum Standards Minnesota, January 6, 2004.
for Facilities Providing 24-Hour Child Care
(Austin, Texas, January 2004), available in pdf
format from http://www.tdprs.state.tx.us/Child_
Care/Child_Care_Standards_and_Regulations/
default.asp. (Last visited February 5, 2004.)
Medication
HHSC should create a Foster Care Medical Review Team
to review the diagnostic services, medication, treatment
and therapy delivered to Texas children in foster care.
that more than 9,500 Florida foster children efits, possible side effects and alternative
had received psychotropic drugs in 2000. treatments;
• examination by a qualified pediatric psy-
The report cited as one “disturbing discovery” chiatrist before any use of these drugs;
the use of psychotropic drugs on preschool- • improved, readily accessible medical re-
ers; the federal Food and Drug Administra- cords for each foster child;
tion has little data on the possible long-term • efforts to ensure that everyone adminis-
effects of such drugs on young children. The tering psychotropic medication to foster
report lists possible side effects from these children can recognize the side effects of
medications as: such medications; and
• creation of “Medical Passports” contain-
• decreased blood flow to the brain; ing complete and current treatment his-
• cardiac arrhythmia; tories for each foster child that are made
• disruption of growth hormone, leading available to each physician they see.3
to suppression of growth in the body and
brain; In response to the SAC report, the Florida
• permanent neurological tics; Department of Children and Families created
• psychosis; a telephone hotline staffed by seven psychia-
• depression; trists to respond to questions from foster par-
• insomnia; ents, caseworkers and judges about medica-
• agitation and social withdrawal; tions and possible side effects.
No formal • suicidal tendencies; and
investigation • Tardive dykinesia (central nervous sys- In Texas
related to tem disorder characterized by twitching
psychotropic No formal investigation related to psychotro-
as a side effect of prolonged anti-psychot- pic medication given to Texas foster children
medication
ic drug use). has ever been conducted.
given to Texas
foster children
has ever been SAC also found that many of the medica- Youth for Tomorrow (YFT), the private con-
conducted. tion records they reviewed lacked adequate tractor responsible for assigning foster chil-
or accurate information on how consent for dren to DPRS’ service levels, has no physi-
the medication was obtained and what sort cians, nurses or pharmacists on its staff, and
of information was provided to children and does not attempt to assess the appropriateness
their parents or guardians. SAC learned that of medication.4 DPRS investigations have re-
primary care physicians, rather than pediatric vealed that some children are not getting ther-
psychiatrists, prescribe many of these medi- apy as directed, medications are not properly
cations. In the sample group of 1,180 case files locked, there are missed doses of medication
examined, 67 percent lacked any documenta- and poor medication documentation.
tion of monitoring for side effects. The drugs
most often administered were stimulants and The Comptroller review team asked DPRS how
atypical antipsychotics. its caseworkers would know if a child is being
overmedicated. DPRS responded as follows:
SAC recommended the following reforms:
The caseworker observes the behav-
• creation of a quality assurance program ior and appearance of the child and
to monitor the use of psychotropic drugs reads the progress and facility re-
in children; cords if the child appears to be in a
• creation of a standardized, written con- stupor, slow to respond and has leth-
sent form to be obtained before starting argy. When the records are checked,
any child on psychotropic medication, the physician’s orders and dosages
providing information about risks, ben- and medication compliance is [sic]
noted. The caseworker is not a medi- Physicians must carefully monitor many of
cal doctor, however, and does not the medications prescribed to foster children,
have the extensive training on medi- and some drugs can be accurately monitored
cations that a medical staff would only with blood tests. An assortment of physi-
have. There is some training for CPS cians are prescribing these types of medica-
staff on medications, but [casework- tions to foster children, and while some are
ers are] not expected to be the medi- child psychiatrists, others are family practi-
cal expert for the child.5 tioners and pediatricians.
The review team collected Medicaid data from A leading child psychiatrist has expressed
DPRS and provided them to the HHSC’s Drug concern regarding children receiving multiple
Utilization Review Program to determine the medications of the same class, such as two
types, dosages and cost of medications given stimulants or antidepressants.8 Data show this
to foster children. The data were for the month may be the result of a child seeing more than
of November 2003. While there were data con- one physician, but may also be due to individu-
straints (due to some invalid Medicaid num- al physicians providing multiple prescriptions.
bers), the results were nevertheless revealing.
The existing data cannot specify the total
One child, for instance, had 14 prescriptions number of foster children taking each medi-
for 11 different medications, at a cost for the cation, but can be used to identify the most
month of $1,088.03. These included: common psychotropic drugs administered to A leading child
Texas foster children (Exhibit 1). psychiatrist
ABILIFY 15MG TABLET* has expressed
concern regard-
FLUVOXAMINE MAL 100MG TAB* In addition, many children are receiving an-
ing children re-
TRILEPTAL 600MG TABLET* tibiotics and Guanfacine, an antihypertensive
ceiving multi-
CONCERTA 36MG TABLET SA* medication used to treat high blood pressure ple medications
REMERON 15MG SOLTAB* and aggressive behavior in children. of the same
REMERON 30MG SOLTAB* class, such as
STRATTERA 40MG CAPSULE* A professor of Pediatrics at the University of two stimulants
STRATTERA 25MG CAPSULE* Texas Medical Branch in Galveston observed or antidepres-
LITHIUM CARBONATE 300MG CAP* the following after reviewing the medication sants.
LITHIUM CARBONATE 150MG CAP* data:
CLOBETASOL 0.05% CREAM
DE-CONGESTINE TR CAPSULE 1) There appears to be an aggressive use of
GUAIFENESIN LA 600MG TAB SA multiple psychotropic medications.
DOCUSATE SODIUM 100MG CAP 2) Prescribing practices would suggest that
these children are likely severely dis-
*Indicates medication is psychotropic drug. Two turbed, raising questions such as:
of the medications are from the same class (an-
tidepressant), and two are used to treat ADHD. • What diagnostic testing was done to
confirm these diagnoses?
Three children received 30-day prescriptions • What are the qualifications of those
for 90 tablets (three tablets per day) of Zyprexa making these diagnoses?
(20MG) at a cost per prescription of $1,559.70 • Are these foster parents appropriately
each. Zyprexa is an “atypical antipsychotic” trained to manage these patients?
drug used in the treatment of schizophrenia.6 • Are appropriate laboratory tests being
The same physician prescribed this drug for done to monitor potential side effects
all three children and all were filled at the of these medications?
same pharmacy.7
(continued on page 204)
Exhibit 1
Psychotropic Drugs Commonly Prescribed to Texas Foster Children
Class of
Medication Uses Side effects/warnings
Medication
Abilify Antipsychotic Abilify is used to treat schizophrenia. It has not Common side effects include headache, weak-
been studied in children under 18 years of age. ness, nausea, vomiting, constipation, anxiety,
problems sleeping, lightheadedness, dizziness,
sleepiness, restlessness and rash.
Adderall Central nervous Adderall is a mixture of different amphet- Although generally well tolerated, the main
system (CNS) amine salts that can help to reduce or improve side effects include loss of appetite, insomnia,
stimulant the symptoms of ADHD (Attention Deficit weight loss, abdominal pain and depression.
Hyperactivity Disorder).
Clonidine Antihypertensive Clonidine is a common antihypertensive Common side effects include dry mouth,
agent. Other reported clinical uses include the sedation, dizziness and constipation. While
treatment of opiate and alcohol withdrawal. generally safe, toxic doses can cause serious
It is also used as a pediatric preanesthetic; for cardiopulmonary instability and central ner-
pediatric postoperative pain management; vous system depression in children and adults.
and the treatment of migraine headaches, Children are particularly susceptible to toxic re-
nicotine addiction, menopausal flushing, at- action from relatively small doses (i.e., normal
tention deficit disorder, Tourette’s syndrome adult therapeutic doses).
and pediatric panic and anxiety disorders.
Concerta CNS stimulant Concerta is used to treat ADHD, it contains Should not be taken by patients with signifi-
methylphenidate, the same medication found cant anxiety, tension or agitation; allergies
in the brand-name drug called Ritalin, but the to methylphenidate or other ingredients in
Concerta tablet is formulated with a special Concerta; glaucoma, Tourette’s syndrome, tics
drug-release system that allows the medica- or family history of Tourette’s syndrome; or cur-
tion to be released slowly over time. rent/recent use of monoamine oxidase inhibi-
tors (MAOI). Should not be taken by children
under six years of age.
Depakote Anticonvulsant Depakote has been proven effective in the Depakote can cause serious or even fatal liver
treatment of manic episodes associated with damage, especially during the first six months
bipolar disorder, also known as manic depres- of treatment. Children under two years of age
sion. are the most vulnerable, especially if they are
also taking other anticonvulsant medicines
and have certain other disorders such as men-
tal retardation. Caution should be taken when
Depakote is administered with other medica-
tions, including aspirin.
Class of
Medication Uses Side effects/warnings
Medication
Lexapro Antidepressant Lexapro, the newest member of a family of The most common side effects reported are
medications known as selective serotonin nausea, insomnia, sexual dysfunction, in-
reuptake inhibitors (SSRIs), is used to treat creased sweating and fatigue.
anxiety symptoms associated with depression.
Risperdal Atypical Risperdal is used to treat schizophrenia and Common side effects include anxiety, sleepi-
antipsychotic psychotic disorders. It may also be useful in ness, restlessness, tremors, muscle stiffness,
treating acute mania and severe depression in dizziness, constipation, nausea, indigestion,
combination with antidepressant medications. runny nose, rash and rapid heartbeat.
Seroquel Antipsychotic Seroquel is used to manage the manifesta- Reported side effects include sleepiness; hy-
tions of psychotic disorders including schizo- potension (abnormally low blood pressure);
phrenia. digestive problems (constipation, dry mouth,
indigestion); and dizziness. Such effects gen-
erally are mild and improve without specific
treatment. Seroquel should be used with
particular caution in patients with known car-
diovascular disease, cerebrovascular disease or
conditions associated with hypotension.
Trazodone Antidepressant Trazodone is used in the treatment of depres- In rare cases, may cause liver damage; can
sion and to reduce the symptoms of agora- cause dizziness and drowsiness.
phobia, drug-induced insomnia, essential
tremor, repetitive screaming and some pain
syndromes.
Trileptal Antiepileptic Trileptal is used to treat partial seizures in Trileptal can cause low sodium in the blood.
adults and children, when taken alone or with Signs of low levels of blood sodium include
other seizure medicines. nausea, extreme drowsiness and discomfort,
headache, confusion and “dullness.”
Zoloft Antidepressant Zoloft is prescribed for major depressive dis- Common side effects include abdominal pain,
orders, a persistently low mood that interferes agitation, anxiety, constipation, decreased sex
with everyday living. Zoloft also is used to drive, diarrhea or loose stools, dizziness, dry
treat obsessive-compulsive disorder and panic mouth, fatigue, gas, headache, decreased ap-
disorder. petite, increased sweating, indigestion, insom-
nia, nausea, nervousness, pain, rash, sleepi-
ness, sore throat, tingling or “pins and needles,”
tremor, vision problems and vomiting.
Zyprexa Antipsychotic Zyprexa is used to treat schizophrenia and Common side effects include headache, agita-
acute mania associated with bipolar disorder. tion, drowsiness, constipation, dry mouth,
upset stomach, vomiting and diarrhea.
Source: Medline, U.S. National Library of Medicine.
• Are these children receiving appropri- …to be perfectly blunt, have these
ate counseling services? children been “medicated” into com-
• Are these children receiving appropri- pliance for home expectations, or are
ate interventions in our public school these children’s behaviors sufficiently
systems? aberrant to warrant these medication
• Are there “trends” among physician practices?9
prescribers?
• Are there “trends” among foster homes? Costs and Cost Containment
An October 2003 article in WebMD Medical
The physician went on to say: News reported that the cost of treating men-
tal illness in children has risen sharply, due
to the increasing use of new and more expen-
sive drugs such as Risperdal, Wellbutrin and children and teens.10 In March 2004, the FDA
Celexa—drugs being marketed briskly to the issued a public health advisory regarding an-
medical community. tidepressant medications. The agency asked
manufacturers of ten antidepressants includ-
From 1997 to 2000, the use of medications to ing Zoloft and Lexapro (commonly given to
treat mental illness in children rose by about Texas foster children) to include in their la-
5 percent, but the costs of those medications beling a warning statement that recommends
rose by 65 percent over the same time period. close observation and monitoring of adults
The article also notes that, in most instances, and pediatric patients treated with these
the newer medications have not been spe- drugs for worsening depression or emergence
cifically approved by the Food and Drug Ad- of suicidality.
ministration (FDA) to treat mental illness in
The document lists questions children and their par- 13. How long will my child need to take this medica-
ents should ask: tion? How will the decision be made to stop this
medication?
1. What is the name of the medication? Is it known 14. What do I do if a problem develops (e.g. if my child
by other names? becomes ill, doses are missed, or side effects de-
2. What is known about its helpfulness with other velop)?
children who have a similar condition to my child? 15. What is the cost of the medication (generic vs.
3. How will the medication help my child? How long brand name)?
before I see improvement? When will it work? 16. Does my child’s school nurse need to be informed
4. What are the side effects which commonly occur about this medication?
with this medication?
5. What are the rare or serious side effects, if any, In conclusion, AACAP states:
which can occur? Treatment with psychiatric medications is a
6. Is this medication addictive? Can it be abused? serious matter for parents, children and ado-
7. What is the recommended dosage? How often will lescents. Parents should ask these questions
the medication be taken? before their child or adolescent starts taking
8. Are there any laboratory tests (e.g. heart tests, psychiatric medications.3
blood test, etc.) which need to be done before my
child begins taking the medication? Will any tests
need to be done while my child is taking the medi-
cation? Endnotes
9. Will a child and adolescent psychiatrist be moni- 1
Mark D. Simms, M.D., “The Crisis in Health Care for
toring my child’s response to medication and
America’s Foster Children,” available in pdf format
make dosage changes if necessary? How often from www.igpa.uiuc.edu/events/confHighlights/pdf/
will progress be checked and by whom? simms.pdf. (Last visited January 26, 2004.)
10. Are there any other medications or foods which my 2
U.S. Food and Drug Administration National
child should avoid while taking the medication? Consumers League, “Food & Drug Interactions,” http://
11. Are there interactions between this medication vm.cfsan.fda.gov/~lrd/fdinter.html. (Last visited January
and other medications (prescription and/or over- 19, 2004.)
the-counter) my child is taking? 3
The American Academy of Child and Adolescent
12. Are there any activities that my child should avoid Psychiatry and Foster Children, “Psychiatric
while taking the medication? Are any precautions Medications for Children and Adolescents, Part III:
recommended for other activities? Questions to Ask,” March 2001, http://www.aacap.
org/publications/factsfam/medquest.htm. (Last visited
February 4, 2004.)
Overmedication, which may be detrimental This measure will allow physicians to pre-
to the child, is an unnecessary expense to the scribe drugs not on the list if Medicaid deems
state. Medicaid pays for the health care costs them medically necessary; otherwise, they
of Texas foster children, including their pre- must use either clinically appropriate gener-
scription costs. To address the rising cost of ics or a preferred brand-name drug.
pharmaceuticals, some states have created
Medicaid preferred drug lists (PDLs), which Medical Records
are lists of preferred generic and cost-effec- Federal law states that a foster child’s health
tive brand-name drugs. Commercial health care record is to be reviewed, updated and
plans and employers have used PDLs to man- given to the foster care provider at the time
age their drug costs for many years. of placement. A recent health care study of
children in foster care in Texas by the federal
The 2003 Legislature directed that the Texas Office of Inspector General (OIG) reported
Medicaid program create a PDL and require that the foster care providers of 46 percent of
prior authorization for prescriptions of drugs the children studied never received medical
not on the PDL. The first phase of the PDL histories for the children in their care.11 This
was to be implemented on February 9, 2004. study noted that children in the lower levels
After this date, physicians must obtain autho- of service were less likely to have their medi-
rization from Texas Medicaid’s Vendor Drug cal records at the time of placement.
Program before a pharmacy can dispense a
drug not on the PDL. Foster care providers stated that not having
a child’s medical records made it difficult for
them to effectively care for foster children.
A Doctor’s Viewpoint
Ben G. Raimer, M.D., is a professor of Pediat- agreed with him. We cautiously decreased the medi-
rics at the University of Texas Medical Branch cations in all four of the boys and then treated them
in Galveston. Dr. Raimer has worked with chil- appropriately as indicated. The adoptive father told
dren with developmental disorders for more me that he had noted it to be a fairly common prac-
than 25 years and has served as an expert wit- tice…that “some” foster parents sought out medica-
ness in cases related to child abuse and ne- tions for children to:
glect. According to Dr. Raimer:
(1) make them more submissive during care and
“I noted in my own practice several months ago four
young children placed into adoption in a family for (2) be able to draw down more financial reimburse-
whom I provide care. The adoptive father brought ment for the care.
the children to my attention because he felt that, al-
though they likely had some behavioral problems as- Apparently, DPRS provides additional funding for
sociated with family drug abuse and environmental the care of children who are on multiple medica-
neglect, none of them seemed sufficiently disturbed tions and/or carry a diagnosis related to psychologi-
and/or exhibited troublesome behaviors [sufficient] cal problems.…
to warrant the large dosages of multiple psychotro-
pic medications that had been prescribed to all of If I may, I would suggest that a panel of pediatricians
them during foster care. and child psychiatrists be convened to review the di-
agnostic services, the medication practices and the
On further examination of the children and [a] review treatment interventions of children in foster care.”
of the scanty medical histories that were provided, I
Other foster parents identified in the OIG re- plete medication, medical and therapy
port stated that children with serious medical history. This passport would stay with
conditions were placed in their care, but that the child during their entire time in fos-
the foster parents did not receive medical re- ter care, even if they change placements,
cords for those children. physicians, therapists, etc.
6 10
Eli Lilly and Company, “Understanding WebMD, “High Cost of Mental Illness in
Zyprexa,” http://www.zyprexa.com/ Children,” October 14, 2003, http://my.webmd.
understanding/index.jsp. (Last visited January com/content/article/75/89733.htm?lastse
25, 2004.) lectedguid={5FE84E90-BC77-4056-A91C-
7 9531713CA348}. (Last visited January 26, 2004.)
E-mail from Kim Pham, Drug Utilization
11
Review, Program Health and Human Services Department of Health and Human Services,
Commission, December 12, 2003. Office of Inspector General, Children’s Use of
8 Health Care Services While in Foster Care:
Interview with John Sargent, M.D. Texas, (Washington D.C., February 2004), pp.
9
E-mail communication from Ben G. Raimer, 13-14, http://oig.hhs.gov/w-new.html.
M.D., professor of Pediatrics, University of Texas
Medical Branch in Galveston, February 3, 2004.
Hanna’s Story
(Names have been changed to preserve confiden- ments every 4-6 hours around the clock, Pul-
tiality.) micort, Cefzil, and Pediasure for nutrition.
In September 2003, DPRS changed its level of care Additionally, she receives physical therapy
system to the present service levels. One stated pur- from a therapist 5 days per week, plus from
pose for this change was to help the agency focus her foster parents. She routinely requires vis-
more intently on the needs of its foster children. its to seven subspecialists, all more than one
hour away from the parents’ home. These
Hanna was born in 2002. She is a foster child current- specialists include a neurologist, a cardiolo-
ly being cared for by a foster mother in a small Texas gist, an otolaryngologist, pulmonologist, de-
town. Her foster mother, Mackenzie, loves working velopmentalist, gastroenterologist, and an
with children with special needs and has adopted ophthalmologist. She is also seen in our office
several children with Down’s Syndrome. Mackenzie one to two times per week.
contracts directly with DPRS to care for Hanna.
I do not see how one could label her basic
Following the adoption of the service level system, when she requires so much work to keep her
Hanna was reclassified as needing basic services fed, give her medications, physical therapy
only, the lowest of the service levels. Her foster plus all of the hours they spend in physician
mother was astounded by this decision. offices. Please have a medical specialist look
at her requirements so that you can reap-
After months of complaints to DPRS, the foster praise her care.
mother asked the child’s pediatrician to intervene.
In December 2003, the pediatrician wrote a letter to In January 2004, Hanna was raised to the moderate
DPRS containing the following information: service level. Mackenzie says she does not under-
stand why Hanna isn’t classified at a still-higher lev-
Hanna is an 18 month old Down’s Syndrome el, but is grateful for the small increase. She does
baby who had recently been downgraded to not believe that the contractor responsible for as-
a “Basic Baby” status. I was alarmed to hear signing children to service levels examined all the
this decision. Anyone who knows her true information on Hanna that was sent to them. (The
medical condition would not consider her to review team contacted the contractor regarding
be anything but medically fragile requiring Hanna’s service level; the organization stated that
high maintenance on a daily basis. it believes the moderate level is appropriate for her
medical diagnosis.)
Her diagnoses include: Trisomy 21, gastro-
esophageal reflux syndrome, discoordinated To make matters worse, Hanna’s caseworker did
swallow, history of repeated aspiration caus- not see the child for seven months and would not
ing pneumonias, heart murmur, laryngomala- return telephone calls. Now the caseworker sees
cia, hypotonia, left dacryostenosis, astigma- Hanna every month, but only at the CPS office; he
tism, reactive airway disease requiring fre- has never been to the child’s foster home. Macken-
quent nebulizer treatments, periventricular zie is now changing to a child placing agency, in-
leukomalacia, and seizure disorder. stead of contracting directly with DPRS, so that she
can receive more support.
She is currently on the following medications:
Phenobarb, Prilosec, Xopenex nebulizer treat-
data, moreover, do not include all the children Human Services (DHS) and the Texas Coun-
in CPS-contracted foster homes, at the basic cil on Early Childhood Intervention Services
service levels. Thus, there may be even more (ECI). Local school districts provide such as-
young foster children with mental retardation sessments as well.
whose conditions have not been identified.
Institutionalization
Inadequate Assessments In fiscal 2003, the YFT data showed that of
DPRS’ caseworkers and the personnel of the 2,779 children diagnosed, 667 with mental
its contractor for child evaluation, YFT, of- retardation were receiving DPRS-paid care in
ten have little or no experience in assessing residential facilities.8
children’s developmental disabilities. This
can result in inappropriate assignments to A June 1999 U.S. Supreme Court decision,
the various service levels, leading in turn to Olmstead v. L.C., requires states to work to
inadequate support and services. Similarly, deinstitutionalize children. The court ruled
treatment plans developed by therapists and that states should serve persons with dis-
caseworkers lacking experience in children’s abilities in community settings rather than
developmental disabilities may be inappropri- institutions whenever possible, stating that
ate for a child’s needs. “unjustified institutional isolation of persons
with disabilities is a form of discrimination.”9
Advocacy Inc., a group that supports the rights In response, the HHSC created a “Promoting
In fiscal 2003... of people with disabilities, has expressed con- Independence Plan” to meet the requirements
667 children cern about the adequacy of foster children’s of the Olmstead decision by providing com-
with mental assessments. A representative of the group munity-based services for persons with dis-
retardation told the Comptroller review team that the fos- abilities, including children.10
were receiving ter care system “lacks expertise about what
DPRS-paid care types of supports children with significant de- Texas’ foster children, however, thus far have
in residential velopmental disabilities need to be successful largely been left out of this effort. In fact, the
facilities. in families.”6 Comptroller review team found that HHSC
and MHMR staff and private advocacy groups
A disability expert at the Texas Center for were largely unaware of the hundreds of in-
Disability Studies explains: stitutionalized foster children, despite efforts
on their part to obtain this information.11
For children with significant develop-
mental disabilities, or children with Coordinating and Finding Resources
special health care needs, expertise DPRS, ECI, MHMR and DHS have related
in abuse and neglect is not enough. responsibilities toward Texas’ children with
We must develop expertise within the mental retardation. ECI identifies and pro-
system to identify who these children vides assistance to young children with de-
are, appropriately assess the function- velopmental disabilities; MHMR assists those
al supports and services they need, with mental retardation; and DHS provides
assign appropriate levels of care, and developmentally disabled children with
match these kids with families who health-related assistance through Medicaid
have the experience and skills to meet community waiver programs.
the challenges of raising a child with
disabilities.7 These agencies do not work closely enough
to maximize federal, state and local revenue
State bodies that assess children with devel- for foster care and see that funds are used ef-
opmental disabilities include DPRS, the Texas ficiently to help foster children with develop-
Department of Mental Health and Mental Re- mental disabilities.
tardation (MHMR), the Texas Department of
MHMR and DHS have Medicaid waiver pro- ing for community-based programs for foster
grams that can provide various community- children and consider adding new waiver pro-
based services for a limited number of children grams and new waiver slots. This would allow
who otherwise would be institutionalized. more children under DPRS conservatorship to ...use current
DPRS foster children must go on a waiting leave institutional settings such as MHMR in- state foster
care funds to
list to obtain these services, like anyone else. termediate care facilities and nursing homes
draw down
These waiting lists currently have thousands for placements in the community.
more federal
of families with children waiting for care. Medicaid
Children who leave state schools currently go Supplemental Security Income (SSI) pay- funding for
to the top of the MHMR waiting lists. ments these children receive could be used to community-
pay for room and board in community-based based programs
It may make more financial and clinical sense, care. For foster children requiring more in- for foster
however, to use current state foster care funds tense services, costs may be covered for children...
to draw down more federal Medicaid fund- many children by a combination of Medicaid
Janie’s Alternatives
Note: The following fictional example illustrates possible alternative care arrangements for a child with mental retardation.
Janie is a 12-year-old girl with mental retardation liv- If MHMR enrolled Janie in its Home and Community-
ing in a foster care facility. based Services Waiver program, she could receive ser-
vices while living in a family home, either that of her
The facility makes few allowances for Janie’s condi- own parents or with foster parents. She would have a
tion and instead seems to ignore her. She is in the caseworker to check on her and make sure that she
company of other children who are likely to make received services appropriate to her needs, such as
fun of her “slowness” and who may mistreat or abuse counseling, therapy, minor home modifications, den-
her. Janie shares a room with five other girls; she has tal treatment, nursing, residential assistance, respite
learned to be as “invisible” as possible. care for her parents or foster family and supported
employment opportunities. Services would be flex-
If her caregivers follow DPRS procedures, they will ible and individualized.
arrange for her to receive a monthly Supplemental
Security Income (SSI) check when she “ages out of Janie would spend her days in classes appropriate to
the system” at 18. If Janie is lucky, she may be put in her age and ability, probably in a public school system
touch with a local Texas Department of Mental Health near her home where she could develop enduring re-
and Mental Retardation (MHMR) caseworker, who lationships in her community. As an adult, she could
can help her find affordable housing and put her on a stay in a group home setting or, with her caseworker’s
waiting list for other services. help, could move into an apartment, her own home or
a shared household, depending on her wishes and her
If Janie lived in one of MHMR’s small intermediate independent living skills. She could pay for her room
care facilities (such as a six-bed home), by contrast, and board either with her SSI check or other personal
she would have shift staff trained in dealing with men- resources.
tal retardation to monitor her well-being and help
her with a variety of needs including guidance and She could also work to earn some money, either in
training in the skills of daily living, such as personal “supported” employment or through work in a shel-
hygiene. Her days would be somewhat regimented: tered environment. Through the local MHMR center,
meals, recreation and activities are scheduled for the she could engage in social and recreational activities,
group as a whole. and a caseworker would remain available to her for
the rest of her life.
dollars and SSI payments, additional changes ment team should include a representative
in the Medicaid program (such as a revised of the local mental retardation authority.
Medicaid rehabilitation waiver discussed in a
succeeding recommendation), and a more so- B. HHSC should maximize federal re-
phisticated packaging of Medicaid services. imbursements for the care of foster
children with mental retardation.
Community-based approaches depend upon
the state’s ability to recruit, train and monitor HHSC should expand the number of slots
foster parents who can take care of children for the Medicaid waiver program whether
with developmental disabilities. If insufficient expanding existing waivers or creating a
numbers of such parents are found, place- new one for foster care children. HHSC
ments in small, Medicaid-funded group homes should use the DPRS foster care funds as
serving six or fewer children are a better match. SSI funds could be used for room
choice than DPRS’ large institutional settings. and board.
The use of Medicaid funding for foster care is For those children who cannot be served
financially advantageous to the state. The fed- in foster families, HHSC should use DPRS
eral government supplies just over 60 percent funds as match for small group homes rath-
of Medicaid funding, and nearly all children in er than place children with mental retarda-
foster care are eligible.12 tion in residential treatment facilities.
Foster care Foster care children with mental retardation C. HHSC should appoint a task force on
children should be cared for in a system that is de- foster care children with developmen-
with mental signed for their special needs. “Janie’s Alter- tal disabilities to obtain input from ex-
retardation natives” shows the difference that community pert advocates on the development of
should be cared placements in settings that provide services a more comprehensive and “seamless”
for in a system to children with mental retardation can make service system for such children.
that is designed
in the life of a child.
for their special
The task force should provide advice on
needs.
implementation of the above recommen-
Recommendations dations. It should include representatives
of HHSC, other relevant state agencies,
A. HHSC should design an assessment child placement agencies, mental retarda-
system that ensures that children tion providers, foster families, youths and
with developmental disabilities are young adults who have received services
identified properly. from DPRS and foster care facilities, as
well as mental retardation/developmental
DPRS caseworkers should be trained to disability experts, disability advocates,
screen all foster children for potential de- medical professionals and family mem-
velopmental disabilities as soon as they bers of children with disabilities to review
enter the foster care system. HHSC should the agency efforts and make recommen-
assist in developing procedures across dations for guidelines. They should devel-
agencies to ensure that young children are op guidelines to reduce residential insti-
screened appropriately by professionals tutional placements and to revise current
experienced in children’s developmental DPRS service levels to ensure that foster
disabilities, and receive an array of edu- care families who take care of develop-
cational, social, behavioral and medical mentally delayed children are adequately
services tailored to suit their needs. In the trained and supported to properly take
case of children likely to be eligible for care of such children and that their care
mental retardation services, the assess- is carefully monitored. They also should
11 12
Interview with HHSC staff, Susan Murphy, Texas Health and Human Services Commission,
Advocacy Inc., and Colleen Horton, Texas Texas Medicaid in Perspective, Fourth Edition
Center for Disability Studies, the University (Austin, Texas, May, 2002), p. 1-1.
of Texas at Austin, Austin, Texas, January 12,
2004 and phone interviews with MHMR staff,
November 14, 2003, January 8, 2004, January
20, 2004 and January 27, 2004.
the children died after being placed at a resi- Abuse and Neglect
dential facility. Child Protective Services in- A 1999 study conducted in North Carolina, and
vestigated the remaining cases. another performed in Colorado in 2002, found
that states do not record as many as 60 per-
Of the fatalities for which data on the cause of cent of child deaths due to abuse or neglect.
death were provided, two were due to abuse The studies found that neglect is the most un-
and neglect by a foster caregiver; three were der-recorded form of fatal maltreatment.
from unknown causes; three were suicides;
five were the result of traffic accidents; and Part of the problem is that states define abuse,
18 deaths were the results of medical condi- neglect and child homicide differently, but the
tions or complications, including one death studies also noted that incomplete investiga-
from Sudden Infant Death Syndrome (SIDS). tions may rule some deaths actually due to
(SIDS is the sudden death of an infant under abuse and neglect as accidents, homicides or
one year of age that cannot be explained af- SIDS.5 No one has conducted similar studies
ter a thorough case investigation, complete in Texas.
autopsy, examination of the death scene and
clinical history review.)4 One of the deaths indicated in the chart be-
Part of the low as caused by foster caregiver abuse
problem is Of the 18 deaths from medical complications was a two-year old boy who died of blunt
that states or natural causes, 10 were the result of abuse head trauma in 2002. A coroner ruled the
define abuse, or neglect injuries received before the chil- death a homicide. Despite substantial bruis-
neglect and dren entered foster care. ing over much of his body, the child’s foster
child homicide
differently, mother denied doing anything to hurt the
but the studies
also noted that
incomplete Exhibit 1
investigations Child Deaths in DPRS Conservatorship 1999-2002
may rule some
deaths actually
due to abuse DPRS-Stated Cause of Death Fiscal Years
and neglect
as accidents, 1999 2000 2001 2002
homicides or Foster Caregiver Abuse or Neglect (includes restraints) 2 2 4 2
SIDS.
Suicide 1 3 0 3
Drowning 2 1 0 0
Vehicle Accidents 4 0 0 5
Other Accidents 1 0 1 0
Unknown or Undetermined 1 1 1 3
Uncategorized * * 10 13
Total 16 21 38 44
*Data unavailable
Source: Texas Department of Protective and Regulatory Services.
child, insisting that she was playing with him restrained her at a residential treatment cen-
and that he simply went limp. The District At- ter; another died after a restraint at a school.
torney presented charges of murder against Two children who were not foster children
the foster mother to the Grand Jury. DPRS also died in residential childcare in fiscal 2003
removed the other three foster children in her after being restrained.9
care from the home.
Texas’ licensing standards and their enforce-
The Texas foster parent of the child who died ment do not adequately protect children from
of SIDS in 2002 had a prior DPRS record of death and injury from restraints. Although the
emotional abuse and medical neglect of an standards prohibit certain restraint actions,
elderly woman whom she cared for in her such as placing a child face down and placing
home. Before the baby died, DPRS received pressure on the child’s back, these standards
allegations that this person had abused the have not been sufficient to prevent deaths and
baby. According to two witnesses, the foster injuries.10
mother repeatedly pushed the child’s face
into stroller cushions to muffle his crying. The In addition to these deaths, DPRS found 155
DPRS investigator ruled out abuse or neglect licensing violations related to physical re-
regarding these allegations due to “a lack of straint in residential facilities while investigat-
evidence.” Concerning the child’s death, the ing abuse complaints in fiscal 2003, including
investigator determined that, since the medi- injuries, inappropriate or excessive restraints
cal examiner ruled that the child died of SIDS, and inadequate training or supervision. Most
no abuse or neglect occurred.6 occurred in residential treatment centers, Texas’ licensing
which treat many children with severe behav- standards
Physical Restraints ioral problems.11 and their
enforcement do
Some deaths related to “physical restraints”—
To learn about safer restraints—and find not adequately
as the name implies, the act of immobilizing
protect children
a child by holding him or her tightly—have some protection from liability—some pro-
from death and
been highly publicized over the past decade viders have purchased and used materials
injury from
across the country. for “Prevention and Management of Aggres- restraints.
sive Behavior (PMAB®),” a training program
The Hartford Courant, in a five-part 1998 se- designed by the Texas Department of Mental
ries on physical restraints that drew national Health and Mental Retardation (MHMR) for
attention, estimated that “Fifty to 150 people use with adult patients, to reduce the chance
die every year as a result of being physically of death and injuries from physical aggres-
restrained or put in seclusion in institutional sion.12 Although the program has been suc-
settings.”7 The federal government is current- cessful in MHMR facilities, it is not without
ly considering legislation on restraints. risk, and the agency cautions that:
Children who die from restraint usually as- Although it is designed to reduce
phyxiate, either because of excessive pres- the danger inherent in any attempt
sure on the chest or due to pressure on the to manage aggressive behavior,
stomach that causes them to choke on their there is a risk of serious injury or
own vomit; some have heart attacks.8 death when teaching, learning, dem-
onstrating, and using PMAB®, even
Two Texas foster children died during or when the procedures are performed
soon after restraint in fiscal 2000. In addition, correctly.13
a 2001 death at a residential treatment facil-
ity, labeled an accident, also occurred after MHMR sells the manuals, tapes and training
physical restraint. One foster child who died materials for $600, but does not provide train-
in fiscal 2002 did so after several employees (continued on page 223)
Melissa’s Story1
Melissa, a blind two-year-old foster child regularly to have been assembled incorrectly or that its screws
kicked her portable crib “until she tire(d) herself and were not tightened. He said “the lower portion of the
(fell) asleep,” according to her foster mother.2 Family crib where [Melissa] was supposedly lying was on the
members said that Melissa spent most of her days in a ground.” He also noted that the pillow and blanket
walker, since she was unable to support herself sitting that the foster mother said the child was using in the
up, but stayed in a portable crib at naptime and at night. crib were in the next bedroom on a double bed.
According to Melissa’s foster mother, when Me- The foster grandmother said she found Melissa face
lissa was younger, she was medically fragile due to up with her head sideways at an angle, with part of
CHARGE Syndrome, a rare disorder often resulting her body on the floor and part on the crib mattress.
in blindness, profound hearing loss, heart malforma- The foster mother and grandmother said that the
tions, retarded growth, blocked sinuses, lung conges- screws had been loose before and that a handy man
tion and physical deformities.3 Since becoming older, tightened them. The 12-year-old biological daughter
the foster mother said Melissa required only basic could not remember when she last saw Melissa, but
care, was not medically fragile and did not need sur- said that she had heard her banging on her crib that
gery for a hole in her heart. morning. That evening, however, no one heard the
bed collapse. The foster mother speculated that the
Besides her foster mother and grandmother, Melissa child suffocated when the crib fell.
lived with five foster siblings and the foster mother’s
two biological children. Her foster brothers’ ages DPRS closed an investigation for neglectful supervi-
were 2, 1 and 4 months. Her foster sisters’ ages were sion with a finding of “unable to determine.” The li-
9 and 2. The foster mother’s biological children were censing investigator had not received the medical
14 and 12 years old. examiner’s findings, but reported that the examiner
said that no abuse was found. The licensing investiga-
One Saturday evening, as part of a regular routine, her tor did not find any violations.
foster mother put Melissa to sleep at 6:30 p.m. The
foster mother had a monitor and could hear Melis- According to the detective involved in the case, the au-
sa’s usual “pattern of noises and kicking.” The foster topsy found the cause of death to be “undetermined,”
grandmother said she checked on Melissa about 7 meaning that the medical examiner could not find a
p.m. and found her sleeping. The foster mother said cause and did not find any signs of abuse; he ruled
the door to Melissa’s room is always open, and people that the blood in the diaper was not caused by abuse.
are always passing by and looking in. About 9 or 9:30 The county medical examiner refers all child deaths
p.m., the foster grandmother decided to wake Melissa to an expert local death review committee, but DPRS
and “finish feeding her.” She found Melissa motion- did not refer the case to any of its internal or external
less in a collapsed crib. review personnel or committees. Agency policy re-
quires only that deaths determined to be from abuse
According to the foster mother, she put Melissa on the or neglect be referred to a death review committee.4
kitchen table and began CPR, and when there was no
response, they called EMS. When EMS arrived, Me- Consequently, no one asked questions that could lead
lissa was “somewhat stiff” and pronounced dead at to improvements in DPRS policies, standards and pro-
the scene. Melissa did not appear to have any trauma, cedures, or that could improve care of children in this
except that there was blood and stool in her diaper. foster home. For instance, no one asked why Melissa
was “finishing being fed” at 9 p.m., when she already
A detective at the scene reported that he observed had been fed at 6 p.m. and left in her crib awake. No one
the crib and found that the bottom, wooden part of it asked why the foster mother could not hear a crib col-
had been dismantled. He said that the crib appeared lapse over the monitor when she had no problems hear-
ing Melissa’s “noises and kicking” when she was awake. views with witnesses, the police report, a letter to the
No one asked why the foster mother noticed nothing foster parent announcing the findings and a misfiled
amiss when she put the younger children to bed earlier. form belonging to an unrelated case file.
The foster mother’s use of a portable crib with loose The CCL investigator referenced police photographs
screws was not cited as a violation, though standards but did not include them in the file. The investigator
require equipment and furniture to be safe for chil- ordered CPS medical records, physician records and
dren. CribSafe.net recommends that portable cribs a copy of the autopsy and medical examiner’s report,
not be used as permanent beds. They are not subject but these were not in the file because DPRS closed
to as many safety requirements, are smaller than reg- the case before the investigator received them.
ular cribs, are “not suitable to the rigorous wear and
tear of daily crib use” and should not be used at all
after a child is 18 months old. The organization also
cautions that children have suffocated due to extra Endnotes
mattresses placed in cribs; Melissa’s had two.5 1
The child’s name has been changed for privacy reasons.
2
No one questioned the appropriateness of placing a Except as otherwise noted, all information is from
medically fragile child in a house with seven other the Texas Department of Protective and Regulatory
Services.
children and only two caretakers. Despite the fact
3
that DPRS’ licensing investigator found “no viola- WebMDHealth.com, “CHARGE Syndrome,” http://
tions,” the foster home exceeded the number of chil- my.webmd.com/content/healthwise/8/1944.htm?lastsel
ectedguid={5FE84E90-BC77-4056-A91C-9531713CA348.
dren allowed according to the agency’s licensing stan-
(Last visited February 1, 2004.)
dards. These require that a foster family shall not care
4
for more than six children, nor more than two infants Texas Department of Protective and Regulatory
Services, CPS Handbook (Austin, Texas), Section 2313.
under 18 months old, including biological children.
5
ChildSafe.net, “Non-Full Size Cribs and Portable Cribs,”
Melissa’s death file contains a report form, the intake http://www.childsafe.net/for_parents/portable.html.
(Last visited January 8, 2004.)
call report, a contact log with summaries of inter-
ing outside of its facilities. MHMR’s PMAB® ly during the training session, such as accom-
trainers are certified to teach PMAB® only modations that a person’s size may require.15
within the MHMR system and only for so long
as they work in the system. Residential fos- In sum, residential child care providers who
ter care providers who purchase the program attempt to use this system may increase chil-
with the intent of applying it in their facili- dren’s risk of injury or death, as well as their
ties, then, do so without certified trainers and own liability.
without the endorsement or the legal or orga-
nizational support of MHMR.14 Although some providers use other systems
available on the market that provide certified
PMAB® staff at MHMR caution that the agency trainers, the Child Welfare League of America
developed the system for adults, not children, states that “physical restraint techniques, in-
and that it does not take into account the psy- cluding the positions, holds and the number of
chological aspects of the physical and sexual staff involved, vary widely as do the points of
abuse that many foster children have experi- view on the safety of particular strategies.”16
enced. Furthermore, reading the materials and
watching the videos do not provide aspects of In Texas, policies even differ between agen-
training that a certified instructor gives verbal- cies. For example, TDMHMR policies allow
a maximum of 15 minutes for a personal re-
straint, but DPRS standards allow a maximum facility supposedly had the child under close
of 30 minutes for a child under 9 and one hour watch, since he ran away three days before
for other children.17 the incident. Employees at the facility knew
the child was gone for an hour before he set
Medically Fragile Children himself on fire. The facility’s policy was to
Of the 44 children who died in fiscal 2002, 18 wait two hours before notifying anyone that
had medical conditions or complications, in- a child had run away. DPRS ruled out neglect-
cluding the SIDS death. The Comptroller’s re- ful supervision in this case and did not find
view of the files of 28 of the children who died any licensing violations because the facility
in fiscal 2002 found that two of them were followed its approved policies.21
medically fragile yet placed in foster homes
located in rural areas where medical care may Inadequate Investigations, Files
be more difficult to obtain.18 Most of the files on child deaths in 2002
lacked adequate documentation on the cause
In one case, a foster mother in a rural area of death, contributing factors, culpability, the
drove a child with a high fever to a doctor and basis for investigators’ decisions, the reason
then to a local hospital, which called an am- for the case closure or any recommendations
bulance that then took an hour to find a hos- that might prevent such deaths in the future.
pital that could meet the child’s needs. The The only document common to all files re-
child died soon after arrival. In another case, viewed was the intake form from the phone
a child had to be taken by ambulance from center concerning the incident. Most files in-
At times, West Texas to Lubbock for treatment.19 cluded the DPRS child death report forms and
however, DPRS licensing investigation reports, but some did
takes no action Response to Preventable Deaths not contain even these items.
at all against
facilities where DPRS’ response to children’s deaths related to
preventable causes, such as physical restraint Most of the files did not provide any evidence
children have
or a lack of supervision, has varied. DPRS of referrals to child death committees; medi-
died under
questionable rarely revokes a facility’s license for a child’s cal examiner reports and autopsies; hospital,
circumstances. death, but may start the process by placing a doctor and ambulance records; police re-
facility on probation. ports; or related photographs or tape record-
ings. Most files did not record the child’s facil-
For example, DPRS placed one facility on pro- ity admissions, treatment and service plans,
bation in May 2002, after a coroner ruled a Feb- including medications; the foster home place-
ruary 2002 restraint-related death a homicide. ment history; the foster home and facility his-
DPRS lifts probation when a facility makes tory of licensing violations; the background
changes to comply with its standards; in the on any prior allegations of abuse or neglect
2002 case, the facility changed its behavior by the caregiver; or logs and progress notes
management and restraint system, made train- concerning the child.22
ing and supervisory improvements and was
released from probation in January 2003.20 The DPRS Web site, annual report and data
book have no information on child deaths in
At times, however, DPRS takes no action at foster care. Although DPRS’ reports on total
all against facilities where children have died deaths of children in its conservatorship as a
under questionable circumstances. performance measure, the agency provides
no other public information about the deaths,
For instance, DPRS took no action against such as cause of death or whether abuse or
a residential treatment center when a boy neglect for a caregiver was involved.
prone to self-mutilation managed to run away
and burn himself to death at a nearby gas sta- Concerning the restraint that precipitated
tion. The incident occurred even though the one child’s death, the DPRS public Web site
for licensing violations explains that “the use could prevent child deaths, files must be
of force during a restraint of resident at [facil- complete.
ity] was not reasonable and did not minimize
risk of physical discomfort, harm or pain,” The files should include all forms and in-
and says “excessive force was used during a formation related to the case, including
restraint.” The Web site fails to mention that the agency’s child death report forms; in-
the child died after the restraint.23 take and licensing investigation reports;
referrals to child death committees;
medical examiner reports and autopsies;
Recommendations hospital, doctor and ambulance records;
police reports; and related photographs
A. DPRS should identify behavior man- or tape recordings.
agement systems that incorporate safe
personal restraints appropriate for The files also should contain each child’s
use with children and require that con- facility admissions, treatment and service
tractors use only approved systems. plans, including medications; the foster
home placement history; the foster home
DPRS should consult with experts and and provider history of licensing viola-
other agencies to identify the systems tions; the background on any prior allega-
and should ensure that licensed facilities tions of abuse or neglect by the caregiver;
use trainers certified to teach the systems and any logs and progress notes concern-
that facilities select. DPRS should adopt ing the child.
licensing standards that reflect the select-
ed systems.
Fiscal Impact
DPRS should ban the use of Prevention
and Management of Aggressive Behavior These recommendations could be implement-
(PMAB®) materials at facilities not oper- ed with existing agency resources.
ated by the Texas Department of Mental
Health and Mental Retardation. Other
commercial systems exist that providers
can purchase. Endnotes
1
U.S. Department of Health and Human Services,
B. DPRS should thoroughly investigate
“Child Maltreatment 2001, Table 5-2: Child
each foster child death, refer every Fatalities in Foster Care, 2001,” http://www.acf.
foster child death case to the state hhs.gov/programs/cb/publications/cm01/table5_
risk director and internal and external 2.htm. (Last visited February 6, 2004.)
child-death review committees, and 2
Interview with Texas Department of Protective
should place the results of the reviews and Regulatory Services staff, January 13, 2004.
in the child’s death investigation file. 3
Texas Department of Protective and Regulatory
Services, Operating Budget for Fiscal 2004
DPRS should maintain all child death in- (Austin, Texas, December 1, 2003), p. III.A.3.
vestigation files at both the state and re- 4
U.S. Department of Health and Human Services,
gional levels. National SIDS/Infant Death Resource Center,
“What is SIDS?” http://www.sidscenter.org/
C. DPRS should standardize the forms, SIDSFACT.HTM. (Last visited January 3, 2004.)
information and documentation re- 5
National Clearinghouse on Child Abuse and
quired in child death files. Neglect Information, “Child Abuse and Neglect
Fatalities: Statistics and Interventions,”
To allow reviewers the opportunity to (Washington, D.C., August 2003), p. 1.
recommend policies and procedures that
6 14
Data provided by Texas Department of Interview with Texas Department of Mental
Protective and Regulatory Services, December Health and Mental Retardation staff, December
10, 2003. 12, 2003 and Texas Department of Mental
7 Health and Mental Retardation, “Prevention
Eric M. Weiss, “Hundreds of the Nation’s Most and Management of Aggressive Behavior
Vulnerable Have Been Killed by the System (PMAB®).”
Intended to Care for Them,” Hartford Courant
15
(October 11, 1998). Interview with Texas Department of Mental
8 Health and Mental Retardation staff, December
Eric M. Weiss, “Hundreds of the Nation’s Most 12, 2003.
Vulnerable Have Been Killed by the System
16
Intended to Care for Them,” Hartford Courant Child Welfare League of America, “Fact
(October 11, 1998) and Jonathan Osborne and Sheet: Behavioral Management and Children
Mike Ward, “When Discipline Turns Fatal: in Residential Care,” http://www.cwla.org/
Texas Lacks Tough Law on Prone Restraint advocacy/secresfactsheet.htm. (Last visited
that’s Banned in Three States,” Austin January 3, 2004.)
American-Statesman (May 18, 2003). 17
Texas Department of Protective and Regulatory
9
Data provided by Texas Department of Services, Consolidated Minimum Standards
Protective and Regulatory Services, December for Facilities Providing 24-Hour Child Care,
10, 2003. (http://www.tdprs.state.tx.us/Child_Care/Child_
10 Care_Standards_and_Regulations/default.asp)
Texas Department of Protective and Regulatory and 25 Tex. Admin. Code §415.263.
Services, “Consolidated Minimum Standards
18
for Facilities Providing 24-Hour Child Care,” Data provided by Texas Department of
(Austin, Texas, January 2004), available in Protective and Regulatory Services, 2002.
pdf format from http://www.tdprs.state.tx.us/ 19
Child_Care/pdf/MS-24H-January-2004.pdf. (Last Data provided by Texas Department of
visited January 5, 2004.) Protective and Regulatory Services, 2002.
20
11
Texas Department of Protective and Regulatory Data provided by Texas Department of
Services, “Personal Restraint Violations as a Protective and Regulatory Services and
Result of a Residential Care Abuse/Neglect residential treatment facility, January 20, 2004.
Investigation for Fiscal Year 2003,” Austin, 21
Data provided by Texas Department of
Texas, January 21, 2004. (Excel spreadsheet.) Protective and Regulatory Services, 2002.
12
Texas Department of Mental Health and Mental 22
Data provided by Texas Department of
Retardation, “Prevention and Management of Protective and Regulatory Services, 2002.
Aggressive Behavior (PMAB®),” http://www.
23
mhmr.state.tx.us/centraloffice/humanresourc Texas Department of Protective and Regulatory
esdevelopment/shrdpmaboverview.html. (Last Services, “Search for a Residential Child Care
visited December 17, 2003.) Operation,” http://www.txchildcaresearch.org/
ppFacilitySearchResidential.asp#Operation.
13
Texas Department of Mental Health and Mental (Last visited January 5, 2004.)
Retardation, “Prevention and Management of
Aggressive Behavior (PMAB®),” http://www.
mhmr.state.tx.us/centraloffice/humanresourc
esdevelopment/shrdpmaboverview.html; and
Texas Department of Mental Health and Mental
Retardation, “PMAB® Purchasers” (internal
document).
children for lengthy periods. Several caregiv- notify DPRS at all, but simply place a written
ers reported that they had called caseworkers report of the incident into its files.10
to request visits because more than a year had
passed since they had last seen their charges.7 DPRS also does not require its caseworkers to
notify law enforcement about missing foster
According to DPRS, the problem is common. children immediately. The agency’s current
Among 14,309 children in foster care for all policy only requires caseworkers to notify law
three months of the first quarter of fiscal 2004, enforcement within 24 hours after a facility
27 percent of the children were not visited by reports a child missing. The National Center
a caseworker.8 for Missing and Exploited Children (NCMEC)
recommends calling law enforcement as soon
The Comptroller review team also found that as a child is noticed as missing.11
some foster care providers receive payments
for children who are not in their care, but are According to the NCMEC, those first few
caring for other children without receiving hours can be critical in finding a missing
reimbursement.9 This problem indicates that child. In July 2002, one boy who ran away
the database that tracks children and their lo- from a Texas residential treatment center was
cation is inaccurate, since DPRS’ accounting known to be missing for an hour before law
system depends on it to generate payments. enforcement, and the facility, learned that he
had set himself on fire at a nearby gas station.
Since caseworkers are not actually seeing all The facility’s policy was to wait two hours be-
DPRS licensing fore notifying police of runaways; an immedi-
children and the database on their location is in-
standards do
accurate, DPRS cannot know with any certainty ate call might have saved the boy’s life.12
not require
foster care that it does not have children experiencing the
facilities to same sort of peril as Rilya Wilson faced. In addition, DPRS does not have any poli-
immediately cies or standards requiring it to notify the
report all Reporting Missing Children NCMEC, which publicizes information on
missing Caregivers report a missing child by calling missing children on the Internet.
children to the agency’s statewide intake phone bank,
DPRS. a hotline for all reports and complaints. The DPRS does not track information on how
computerized intake form, however, does not many missing children are found, how long
include a field for identifying the child as a they were missing or the circumstances in
foster child. This omission makes the imme- which they were found. According to DPRS:
diate tracking and reporting of missing foster
children impossible. …the percentage of children returned
from runaway status, abductions or
DPRS licensing standards do not require fos- unauthorized absences is not tracked
ter care facilities to immediately report all and neither is the length of time chil-
missing children to DPRS. Instead, they re- dren were away from the authorized
quire facilities to have a written policy stating placement. The placement type from
when they will report children as missing to which children have run away or gone
law enforcement and the managing conser- to an unauthorized placement has not
vator, which may or may not be DPRS. Con- been tracked and is not available.13
sequently, providers may wait hours before
notifying anyone. The statewide intake form, filled out when
calls come in to the phone center, also does not
Even then, if another agency, such as a ju- include a field that identifies foster children so
venile probation authority, is the managing that data on these children can be tracked.
conservator of the child, the facility may not
DPRS policy requires caseworkers to attempt the state’s 362 missing foster children. The
to persuade children in unauthorized living sit- new unit uses a missing child database that
uations to return to their approved placements, offers information, including photographs
and to assess the risk of abuse or neglect in the and medical information, to law enforcement,
unauthorized living situation. The policy also the medical community, schools and others.
requires caseworkers to provide notice of such In addition, the agency enlisted the NCMEC
situations to their supervisors, the licensing di- to train its staff in the investigation of reports
vision and any other affected parties, such as of missing and abducted children.19
the courts. It does not require caseworkers to
attempt to learn why the child left the autho-
rized arrangement or to identify an alternative Recommendations
approved placement.14 Furthermore, DPRS
A. DPRS should capture accurate, time-
does not track or report on children’s stated
ly information in the agency’s foster
reasons for leaving authorized care.
child database.
In October 2002, DPRS began requiring case-
B. DPRS should upgrade licensing stan-
workers to increase their efforts to find miss-
dards to include a requirement that
ing children. Besides checking with law en-
foster care providers notify the agen-
forcement, Texas caseworkers now must
cy and law enforcement immediately
make other attempts to locate the child, such
of missing children.
as contacting relatives, former caregivers or
other social service agencies. If a missing child
DPRS should refer all missing children’s
is younger than 16, the appropriate Child Pro-
cases to the NCMEC. DPRS should part-
tective Services regional director must review
ner with NCMEC to provide training for
the case on a quarterly basis. DPRS also has be-
its staff on investigating reports of miss-
gun researching trends and patterns that may
ing and abducted children.
predict who is at risk of becoming a missing
foster child, including information on facilities
C. DPRS should develop a missing child
and the characteristics of missing children.15
database.
Even so, the agency’s efforts are not as ag-
The database should include informa-
gressive as others around the country.
tion such as photographs and medical
records, and when children are found, it
In Other States
should track the children’s stated reasons
On September 17, 2002, Michigan became for leaving. DPRS should share appropri-
the first state to establish a Web site listing ate information with authorities and or-
the names and photographs of missing foster ganizations.
care children.16 The state posted information
on 198 missing foster care children, and the D. DPRS should develop a page on its
postings helped to locate five missing chil- Web site providing the names and pho-
dren.17 Initial objections to revealing informa- tographs of missing foster children.
tion about the children faded when it became
apparent that the program worked.18 This page should link to agencies and
organizations searching for missing chil-
Illinois also has taken steps to find missing dren and should publicize DPRS’ state-
children as quickly as possible, and once wide intake hotline number.
found, to place them in settings that meet
their needs. In November 2003, the state E. DPRS should include a field in its
opened a Child Location and Support Unit to statewide, computerized intake sys-
oversee 24-hour statewide efforts to locate
Longterm Outcomes
DPRS should improve the transitional services offered to
foster children who “age out” of the foster care system.
cal and mental illness; nearly half have been services.12 For 2004, DPRS has 31 contracts
homeless at least once. Their low educational with local groups, as well as several others for
levels and job skills are likely to ensure on- statewide events.13
going financial hardship. Many youths in the
study have reacted to their precarious circum- Casey Family Programs, a Seattle-based na-
stances by refusing any additional assistance tional foundation that provides direct ser-
or engaging in risky behaviors such as illegal vices for children, youth, and families in the
drug use and criminal activity.8 child welfare system and studies child-wel-
fare practices and policy, has formed a part-
The Texas Foster Care Transitions Project and nership with Texas’ PAL program. DPRS can
Texas Department of Criminal Justice have take advantage of initiatives and research
studied the number of former Texas foster the foundation has conducted at the national
children in the criminal justice system. Among level and in other states. Casey Family Pro-
a sample of 513 such persons, 26 (5 percent) grams is collaborating with DPRS to design
had been or were currently incarcerated in a new transitional services for youths who will
state prison. This figure, moreover, does not age out of foster care. This effort, called the
include those in city or county jails or incar- Texas State Strategy Systems Improvement
cerated in other states.9 A comparison of data Effort (TSS), is developing independent living
provided by the Texas Department of Criminal training models and tools for foster parents
Justice and DPRS found that over 10 percent and DPRS staff. For example, DPRS uses the
For 2004, of former foster children have been incarcer- Ansell Casey Life Skills Assessment (ACLSA),
DPRS expects ated or are still incarcerated in Texas prisons. a tool for assessing a child’s abilities.14
to receive $5.4
million in
Chafee funds,
Preparation for Adult Living In addition, TSS plans to begin a data collection
which will be In Texas, federal Chafee program funding effort in 2004 that will allow DPRS to track what
supplemented supports DPRS’ Preparation for Adult Living happens to children who leave foster care, pro-
by another (PAL) Program. PAL provides independent ducing information comparable to data collect-
$1.3 million living services—life skills training, vocational ed by other states and enabling Texas to meet
in state and and educational services, supportive services, expected federal reporting requirements.15
local matching financial benefits and case management—to
funds. youths who age out of foster care. DPRS embarked upon a similar effort in 2000,
attempting to track former foster children
For 2004, DPRS expects to receive $5.4 million by matching their Social Security numbers
in Chafee funds, which will be supplemented against higher education, employment and
by $1.3 million in state and local matching state prison databases, but privacy issues
funds.10 DPRS also uses Chafee funding to raised at the last minute caused DPRS to sim-
develop conferences for teens leaving foster ply drop the effort.16
care, provide newsletters and establish com-
munity partnerships with organizations that Even without such problems, tracking youths
can assist teens. who have left foster care is difficult at best.
They often change jobs and residences fre-
In 2002, Texas provided PAL services to near- quently, and many become homeless.17
ly 4,300 youth aged 16 to 20, and another 500
aged 14 and 15.11 About 5,300 were eligible One-Stop Center In Bexar County
for services in 2002, but about 700 of these Bexar County has a model independent liv-
received independent living services prior to ing program supported by the Casey Family
2002. Twenty-nine DPRS employees are as- Programs. The Community Transition Ser-
signed to PAL, with one PAL coordinator in vices Center is a “one-stop” service center for
each agency district. The agency contracts foster youth aged 14 to 21. The center offers
with various organizations to provide direct these youth help with finding jobs, planning
careers, enrolling in community college and face a barrier to employment are eligible for
finding housing. Program alumni offer peer WIA. Those eligible include foster children,
support to current participants.18 DPRS’ state school dropouts, runaways, pregnant and par-
plan for independent living states that the enting teens, those with criminal records and
agency will consider using similar centers in the illiterate.
other parts of the state.19
Texas’ 28 local work force boards use WIA
The one-stop approach appears to be more funding to provide employment and training
successful than other Texas independent liv- services. Some areas have developed col-
ing programs. In a recent evaluation of the laborative initiatives to help foster children
Community Transition Services Center, the prepare for departure from DPRS care.24
Casey Family Programs found that partici- Beaumont’s effort involves the Texas Educa-
pants improved their overall “life skills” by, on tion Agency (TEA) and the Texas Rehabilita-
average, 25 percent. Improvement in money tion Commission as well as local work force
management skills was estimated as high as board staff.25
72 percent.20 By contrast, DPRS reports that,
on average, foster teens completing the gen- In addition, some states have used Medicaid
eral PAL curriculum demonstrated only a 6.5 to support independent living services. New
percent improvement in life skills.21 Jersey, for example, uses state and federal
Medicaid funds to finance independent living
Another indicator of the center’s success activities for youths in group foster homes
is that 35 percent of Texas foster youth re- and residential treatment centers.26 These The one-stop
corded as receiving assistance from local services are financed under Medicaid because approach
workforce development boards are located in they are considered rehabilitation services. A appears
the San Antonio region. Yet the area’s Alamo wide range of independent living and other to be more
Workforce Development Board serves only 10 services can be added to the state Medicaid successful than
percent of the state’s total number of youths plan to benefit foster children. Another issue other Texas
independent
in work programs.22 While data on foster in this report fully discusses the Medicaid re-
living
youths served by such local work programs habilitation options.
programs.
are sketchy at best, it appears that meaning-
ful linkages between the one-stop center and
local work programs are solid. Recommendations
A. HHSC and DPRS should seek non-
Dallas has developed a similar one-stop cen-
traditional independent living funds
ter for teens, the Transition Resource Action
from multiple federal sources.
Center, and the city of Houston may join with
faith-based groups to start a similar center.
Under state law, HHSC must submit any
Foster teens in rural areas, however, have
necessary changes to the state Medicaid
transportation problems and may not be able
plan for obtaining additional Medicaid
to benefit from existing urban facilities. DPRS
funding for foster care. HHSC’s guidance
may need specially-designed efforts to reach
may also be helpful as DPRS works with
rural areas.23
the Texas Workforce Commission (TWC),
TEA and other relevant agencies
Federal Funding for Transitional
Services
B. DPRS should form partnerships with
Federal work force funding could be used to the state’s local work force develop-
help other communities offer similar services. ment boards to expand transitional
The federal Workforce Investment Act (WIA) services for Texas foster teens and
makes foster children eligible for its youth create one-stop centers for foster care
services. Participants aged 14 to 21 and who youth, using existing workforce funds.
12 20
Interview with Texas Department of Protective Casey Family Programs, San Antonio PAL
and Regulatory Services, Austin, Texas, Classes Evaluation Report, by Jill Leibold and
January 14, 2004. A. Chris Downs (Seattle, Washington, July 10,
13 2002), p. 9.
Texas Department of Protective and Regulatory
21
Services, “Active/Open PAL Contracts As of Data provided by Texas Department of
1/20/2004,” Austin, Texas, January 20, 2004. Protective and Regulatory Services, December
(Excel spreadsheet.) 10, 2003.
14 22
Texas Department of Protective and Regulatory Texas Workforce Commission, “Foster
Services, “Chafee Foster Care Independence Children Request,” Austin, Texas, January 22,
Program, 2002-2003 Progress Report and 2004. (Excel spreadsheet.)
Application for 2004 Funds.” 23
Interview with Texas Department of Protective
15
Interview with Texas Department of Protective and Regulatory Services staff.
and Regulatory Services staff, January 14, 2004. 24
Interview with Roger A. Smith, program
16
E-mail communication from Texas Department specialist, Contract Management Department,
of Protective and Regulatory Services staff, Workforce Development Division, Texas
January 20, 2004. Workforce Commission, Austin, Texas, January
17 14, 2004.
Interview with Peter J. Pecora, senior director,
25
Research Services, Casey Family Programs, Interview with Texas Department of Protective
Seattle, Washington, January 11, 2004. and Regulatory Services staff.
18 26
“Who Else is Making a Difference for Foster Dick Mendel, “Fostered or Forgotten,”
Youth in Transition? Four Models Worth Advocasey (Fall 2001), p. 11.
Watching,” Advocasey (Fall 2001), pp. 26-27.
19
Texas Department of Protective and Regulatory
Services, “Chafee Foster Care Independence
Program, State Plan for Fiscal Years 2001-
2004,” http://www.tdprs.state.tx.us/Child_
Protection/Preparation_For_Adult_Living/
chafee.asp. (Last visited December 10, 2003.)
Academic Needs
TEA should provide the Legislature with information on the educational needs
of foster children. Caseworkers should consider foster children’s educational
needs when making placement decisions. Outreach programs should ensure
awareness of state funding for foster children’s college expenses.
Too many foster children leave the system anywhere in the state’s college and university
with inadequate education and job skills. One system. With 700 students aging out of the fos-
Texas study of 513 former foster children ter care system each year, thousands of former
found that almost half had no high school di- foster children each year would be at an age at
ploma and nearly 40 percent were receiving which they could be eligible for this benefit.
welfare assistance.5
One Texas The 2003 Texas Legislature extended this ben-
study of 513 Higher Education efit to Texans who were in foster or residential
former foster care at some point and later were adopted. As
The Texas Higher Education Coordinating
children found of fall 2003, Texas now offers these students
that almost half Board provides leadership for and coordination
of the public higher education system in Texas. free tuition and fees at any public university or
had no high
community college, without limit as to when
school diploma
and nearly Texas students who are in foster care when the benefit can be used or for how long.9
40 percent they become adults are eligible for free tuition
were receiving and fees at Texas public colleges and universi- Federal Findings
welfare ties. To receive this benefit, students must: The U.S. Department of Health and Human
assistance. Services (HHS) is conducting a national re-
• have been in the care or conservator- view of child welfare services in every state.10
ship of DPRS on the day before their 18th These reviews are designed to monitor state
birthdays, the day of their graduation compliance with federal law and rules, to ex-
from high school or the day they received amine child and family outcomes due to wel-
a General Educational Development fare services and to provide assistance to the
(GED) certificate; states’ efforts to improve the lives of children
• enroll in a public college or university in and families.11
Texas within three years of the relevant
date mentioned above, but no later than In June 2002, HHS issued a final report on its
their 21st birthdays; and review of welfare services for Texas children
• enroll in classes for which the college re- and families.12 The report concluded that Tex-
ceives tax support (tax-supported classes as does not meet federal standards for educa-
typically concern “core” subjects such as tional services. For example, it found that in 16
math and science).6 percent of the cases studied, DPRS, the agency
responsible for Texas’ foster children, had not
There are no time limits on the use of these met children’s educational needs.13
benefits. In fiscal 2002, a total of 639 postsec-
The report
concluded that ondary students received this benefit at a cost Two major problem areas cited in the review
Texas does not of $758,832.7 Of those receiving these awards, were poor assessment of foster children’s
meet federal 207 used them at a public university; two at a educational needs and a lack of follow-up by
standards for public health-related institution; 21 at a public caseworkers to determine if recommended
educational technical institute (Texas State Technical Col- educational services for these children were
services. lege or the Lamar Institute of Technology); 25 actually being provided. Community com-
at a public state college (Lamar State College ments gathered as part of this review indicat-
at Orange and at Port Arthur); and 384 used the ed that, while foster parents often are strong
award to attend a public community college.8 advocates for the academic needs of their
children, caseworkers need additional train-
Each year, more than 700 Texas foster children ing on educational issues.
are “emancipated” from the system because
they turn 18. All of these young adults are eli- Comptroller review team site visits to foster
gible for free tuition, but the fiscal 2002 data care facilities across the state reinforced the
indicate that many do not take advantage of federal findings. For example, staff members
the benefit, with only 639 students enrolled at one site reported that caseworkers attend-
ed special education Admission, Review and In recent years, Texas school districts have
Dismissal meetings only about 30 percent of served an increasing number of severely dis-
the time.14 DPRS reports that it has developed turbed or disabled students in their own class-
a plan to improve the deficiencies identified es rather than sending them elsewhere for ser-
by the federal review.15 vices. TEA provides financial incentives to en-
courage the early return of disabled students
Children with Special Needs in residential care to the public school system.
TEA coordinates with eight other state agen- School districts can increase their revenues by
cies on issues related to residential care for providing educational services to RTCs that
foster and other children with disabilities. serve foster children within their boundar-
These agencies include DPRS, the Texas De- ies. Students placed in these facilities receive
partment of Human Services, MHMR, TDH, the state’s “residential care and treatment”
Texas Interagency Council on Early Child- funding weight, which provides the highest
hood Intervention, Texas Commission on Al- amount of state funding per child.
cohol and Drug Abuse, Texas Juvenile Proba-
tion Commission and the Texas Youth Com- TEA reports the majority of Texas foster chil-
mission. The memorandum of understanding dren who receive special education services
that formalized this arrangement defines re- are served by local school districts.19
sponsibilities for each agency regarding chil-
dren with disabilities served by residential
treatment centers, foster care and medical, Recommendations
emergency or correctional facilities.16 TEA reports
A. TEA should include information on
the majority
the education of Texas children in
Texas foster children who are placed in spe- of Texas foster
foster care in its state dropout plan children who
cial education programs can receive educa-
and annual reports to the Legisla- receive special
tional and support services from a school
ture; TEA also should provide this education
district or another facility contracting with
information to DPRS. services are
the district. These services can be provided
served by local
as part of a day program or in a residential
TEA should use its research and evaluation school districts.
treatment facility. Children may be placed in
funding targeted for low income, at-risk
residential treatment settings by their school
and homeless students to study the current
district, their parents or a state agency.17 TEA
conditions of foster children and should de-
estimates that school district Admission, Re-
velop recommendations for improving their
view and Dismissal committees have placed
social, academic and vocational futures.
about 80 Texas students in residential treat-
ment. A majority of these students are diag-
As part of this effort, TEA should investi-
nosed as emotionally disturbed.18
gate the effectiveness of emerging educa-
tional settings, such as Internet-based curri-
Other states may send foster children to Texas
cula and charter schools, including charter
residential treatment facilities. Texas school
schools that are part of, or provide services
districts are required to charge tuition for
through, residential treatment centers.
educational services provided to out-of-state
students in a public school setting, including
TEA should report this information to the
those served in residential care. TEA’s Divi-
Texas Legislature and DPRS, and make it
sion of Special Education also maintains a list
available on the agency’s Web site so that
of approved nonpublic schools that serve fos-
it can be used by college and university
ter children with disabilities on its Web site at
departments of education and social work
<http://www.tea.state.tx.us/special.ed>.
and the state’s 20 regional education service
centers in their staff training programs.
13 16
U.S. Department of Health and Human 19 Texas Admin. Code, Chapter 89, Subchapter
Services, Administration for Children and AA, Division 3.
Families, “Child Welfare Reviews: Texas 17
(Executive Summary),” http://www.acf.hhs. Interview with Gene Lenz, deputy associate
gov/programs/cb/cwrp/staterpt/tx/summary. commissioner for special education, and Laura
htm. (Last visited December 6, 2003.) Taylor, director, special education monitoring,
Texas Education Agency, Austin, Texas,
14
Interview with residential treatment center November 17, 2003.
staff, December 4, 2003. 18
Interview with Linda Crawford, director,
15
Texas Department of Protective and Regulatory and Tommy Cowan, assistant director for
Services, “Texas Child and Family Service interagency coordination, Texas Education
Review, Texas Program Improvement Plan,” Agency, Austin, Texas, November 20, 2003.
http://www.tdprs.state.tx.us/About_PRS/State_ 19
Plan/2003_18TexasPIP_matrix.asp. (Last visited Interview with Gene Lenz and Laura Taylor.
January 19, 2004.)
Academic Data
The state’s Public Education Information Management System should track
information on students in foster care. Education services provided by foster
care facilities should be included in district and campus report cards.
and residential treatment programs produced ready collects data on foster children in
little information about these children.6 PEIMS as part of the larger “at-risk” and
homeless student populations.
The current draft of TEA’s state dropout plan
for 2003-2014 contains no strategies to ad- Recommendation B could be incorporated
dress the needs of foster children, because no into TEA’s ongoing district and campus report
data are available on their academic perfor- card system. No new funds would be needed.
mance or high school graduation rates.7
Recommendations Endnotes
1
A. TEA should include “foster care” as U.S. General Accounting Office, Foster Care:
a separate data element in the state’s States Focusing on Finding Permanent
PEIMS. Homes for Children, but Long-Standing
Barriers Remain (Washington, D.C., June
2002), p. 4.
Accurate data on the academic achieve- 2
...TEA’s state ment and progress of foster care children Illinois Department of Children and Family
Services, “This is SACWIS,” http://www.state.
dropout plan should be available to educators, counsel- il.us/dcfs/siwcas/index.shtml. (Last visited
for 2003-2014 ors, caseworkers and other service pro- November 24, 2003.)
contains no viders through PEIMS. Students served in 3
strategies to Kentucky Cabinet for Families and Children,
any foster care setting should be readily “The Kentucky Foster Care Census,” http://
address the
identifiable through the system. www.trc.eku.edu/fostercare/. (Last visited
needs of foster
October 27, 2003.)
children,
because no data B. TEA should include educational ser- 4
California Department of Social Services,
are available on vices provided by all of the state’s “Child Welfare Services/Case Management
their academic foster care facilities in district and System,” http://www.hwcws.cahwnet.gov/
performance campus report cards. index.asp. (Last visited November 30, 2003.)
or high school 5
Texas Education Agency, “PEIMS Data
graduation Research on foster children highlights Standards,” http://www.tea.state.tx.us/peims/
rates. their fragility and vulnerability. Service standards/wedspre/e1017.html. (Last visited
December 5, 2003.)
providers should be subject to ongoing
6
public scrutiny on the quality of the educa- Center for Public Policy Priorities, All Grown
tional services they provide to foster chil- Up, Nowhere to Go: Texas Teens in Foster
Care Transition (Austin, Texas, 2001), p. 23.
dren. DPRS caseworkers should use these
7
data in making placement decisions. Texas Education Agency, 2003-14 Strategic
State Dropout Prevention Plan, Texas
Education Agency (Austin, Texas, April 2003).
Fiscal Impact
Recommendation A could be incorporated
into TEA’s ongoing management of PEIMS
data elements with existing funds. TEA al-
Grandparents Program. This effort began as a Texas has 18 local Foster Grandparent pro-
national demonstration project in 1965.10 To- grams and one statewide program sponsored
day, it is part of Senior Corps, which includes by the Texas Department of Mental Health
the Retired and Senior Volunteer Program and and Mental Retardation and headquartered at
Senior Companion Program. Foster children the Austin State School.16
are eligible to receive mentoring through the
program, but the majority of its volunteers are An April 16, 2002, editorial in the Boston Globe
concentrated in elementary schools and early reported that when the Foster Grandparent
childhood centers.11 Program began, a third of the nation’s elderly
were living in poverty. At present, with just 10
Foster Grandparents recruits low-income per- percent of the country’s seniors living in pov-
sons, aged 60 or above, to serve as foster grand- erty, the program is having difficulty recruit-
parents to children with disabilities or chronic ing volunteers. The editorial recommended
health conditions; children who are in the hos- that Congress eliminate income restrictions
pital or homes for dependent and neglected so that all seniors can participate.17
children; or who receive services through day
care centers, schools, early intervention pro- The national Foster Grandparent Program,
grams, Head Start programs or other programs while certainly a worthwhile effort, cannot by
serving children with special needs.12 itself meet the needs of Texas’ foster children,
since it is limited to low-income senior vol-
An additional Program volunteers must meet age and in- unteers and primarily serves early childhood
Texas initiative programs and elementary schools.
come eligibility requirements and provide 20
is needed to
hours or more of service per week, and re-
harness the
ceive small stipends in exchange. All volun- An additional Texas initiative is needed to
power of senior
volunteers and teers must undergo a background check and harness the power of senior volunteers and
improve the telephone interview and receive both pre-ser- improve the lives of foster children so that
lives of foster vice and in-service training.13 they may all have a brighter future.
children so that
they may all A 1998 study of foster grandparenting in Head
have a brighter Start (preschool) programs found that senior Recommendations
future. volunteers provide emotional support and en-
A. DPRS should partner with volunteer
courage the development of children’s social,
and advocacy organizations to de-
behavioral, language and academic skills.14
velop a Texas Foster Grandmas and
Grandpas Program.
A 2001 progress report indicated that these
program volunteers serve primarily in el-
DPRS should work with volunteer organi-
ementary schools (34 percent), Head Start
zations that address issues related to se-
programs (16 percent), day care programs (13
nior citizens, volunteerism, advocacy and
percent), preschools (8 percent) and middle
foster children, such as the Children’s Ad-
schools (5 percent). The report did not list
vocacy Centers of Texas, American As-
foster care facilities as a specific area of ser-
sociation of Retired Persons and Texas
vice, although volunteers did serve in home-
Court Appointed Special Advocates to
less/battered women shelters (2 percent) and
develop the program.
social service agencies (2 percent). The larg-
est group served by the program was learn-
The goal should be to provide a foster
ing-disabled children (10,900), followed by
grandma or grandpa volunteer for every
developmentally delayed children (7,000) and
foster child. All volunteers should be sub-
abused and neglected children (3,300)—all
ject to a criminal background check using
conditions common among foster children.15
state and national databases.
14 16
Westat, Effective Practices of Foster Corporation for National and Community
Grandparents in Headstart Centers Service, “Joining Senior Corps Foster
(Rockville, Maryland, 1998), pp. 9-11. Grandparents Program: Foster Grandparent
15 Programs in Texas,” http://www.seniorcorps.
Corporation for National and Community org/joining/fgp/state.asp?usestateabbr=tx. (Last
Service, Foster Grandparents Accomplishment visited February 5, 2004.)
Report, October 1999-September 2000, by
17
Aguirre International (Washington, D.C., April Alan Solomont and Marc Freedman, “Helping
2001), pp. 7-12. Elders Help the Country and Themselves,” Boston
Globe (April 16, 2002), Op-Ed Section, p. 21.
Contributors
Executive Administration: Legal Staff:
Carole Keeton Strayhorn, Comptroller Jesse Ancira, General Counsel
Billy Hamilton, Deputy Comptroller Clay Harris
Mike Regan, Associate Deputy Comptroller Don Neal
Jesse Ancira, Executive Assistant and John Wright
General Counsel
Ruthie Ford, Special Assistant Project Support:
for Expenditure Analysis Kaye Tucker, Director, Taxpayer Publications
James LeBas, Special Assistant Daryl Janes, Manager, Information Services
for Revenue Estimating Ruth Soucy, Manager, Open Records
Mark Sanders, Special Assistant for
Communications Graphics and Layout Support:
Eddie Solis, Special Assistant Dwain Osborne, Team Leader
for Legislative and Border Affairs Jo Ann Reyes, Coordinator
Irene Abeita
Fiscal Management Division: Gilbert Conwoop
Ken Welch, Director Tammy Gray
Suzy Whittenton, Assistant Director Jack Grieder
Edd Patton
Expenditure Analysis: Tyra Peterson
Ruthie Ford, Manager Johnnie Sielbeck
Tom Currah, Assistant Manager Brad Wright
Diane Thomas, Project Manager
Rand Harris, Assistant Project Manager Editorial Support:
Leonard Gabriel, Executive Assistant Greg Mt. Joy, Team Leader
Vicki Anderson Bruce Wright, Coordinator
Susan Biles Angela Freeman
Phyllis Coombes Pam Wagner
Linda Gibson
Laure McLaughlin Printing:
Clint Winters Ben Dukes, Manager
Mary Beth Berndt
Tax Policy: Larry Keneipp
Cathryn Cox James Oliver
David Dennis Tony Perez
Beverly Jimmerson Charles Rayos
Maria Mendez-Lewis Kenneth Wallace
Revenue Estimating:
James LeBas, Chief Revenue Estimator
Tamara Plaut
John Wieferman
Appendix 1
Survey Results
DPRS Customer Service consumers, but more than 300 came from
Texas legislators.
The 1999 Texas Legislature enacted new legis-
lation (S.B. 1563) requiring all state agencies DPRS should confidentially survey all chil-
to inventory their customers, survey them dren in foster care aged 10 and above. The
concerning customer satisfaction and set children should be asked questions regarding
standards for customer service. DPRS’ most the quality of their care and their living con-
recent report on customer service, prepared ditions, food and recreational opportunities,
in response to this legislation, is for the 2001 and asked what could be done to make their
and 2002 fiscal years. life in foster care better. These survey results
should be reported to the Legislative Budget
In preparing this report, DPRS chose to sur- Board and the Governor’s Office of Budget
vey residential care providers (including shel- and Planning, as required by state law.
ter and residential facility directors and DPRS
foster parents) but not children in foster care. DPRS also should include data from its Om-
(The DPRS Preparation for Adult Living Pro- budsman’s Office in its report to better depict
gram conducts surveys of foster children, but the opinions of its customers.
only those who are older and preparing to exit
the system; this information is not included in Comptroller’s Foster Care Survey
the agency report on customer service.)
As part of this review, the Comptroller’s of-
The U.S. General Accounting Office has cited fice developed an online survey to gauge the
examples of child and family outcome mea- opinions of persons participating in the foster
sures used by other states and localities that care system. The survey was discussed in the
gauge youths’ satisfaction with foster care Dallas Morning News and publicized by ad-
services and their placements. Since foster vocacy groups. It was not a random sample of
children are indeed among DPRS’ primary those involved in the foster care system; par-
customers, Texas’ legislation in fact requires ticipants were self-selected, which may influ-
the agency to survey foster children. ence the results.
DPRS’ report on customer service also fails A total of 243 people responded to the survey.
to mention or include complaints made to Forty-nine percent of the respondents identi-
its Ombudsman’s Office. In fiscal 2003, the fied themselves as parents or foster parents;
ombudsman received more than 2,500 com- an additional 19 percent were residential care
plaints about DPRS’ Child Protective Services providers or social workers. Eighteen per-
and Residential Child Care Licensing divi- cent classified themselves as “other,” with the
sions. Most of these complaints were from remaining respondents representing foster
children, advocacy groups and persons in law and an additional 30 percent rated them as fair.
enforcement, education and medicine. Only 4 percent found DPRS’ service excellent.
In all, the foster care system received poor When respondents were asked about the
marks. Seventy-six percent of respondents in- DPRS foster care Web site, only 33 percent
dicated that they do not think that Texas’ fos- said it provided useful information. A total of
ter care system works well; 57 percent said the 31 percent thought telephone access to the
same about the residential treatment system. agency was helpful, with 59 percent finding
When asked how they would rate the service telephone access unhelpful.
provided by DPRS, 49 percent responded “bad”
Exhibit 1
Survey Respondents by Type
Other
18%
Advocacy
7%
Parent
Medical 24%
1%
Foster Parent
Education 25%
4%
Foster Child
Law Enforcement 2%
0%
Social Worker
12%
Residential Care Provider
7%
Source: Comptroller Online Survey Results.
Exhibit 2
Foster System Care
Works Well
NA
7% YES
17%
NO
76%
Appendix 2
Foster Care in Other States
• California children were 50 percent more Model Programs and Initiatives: None
likely than the national average to be re- identified.
moved from their families by the state af-
ter an abuse or neglect report; Policy, Advocacy and/or Parental Issues:
• California children stay in foster care lon- California failed all seven measures in the fed-
ger than children in other states (a me- eral HHS review of its foster care program and
dian of 26 months compared to a national faces federal penalties if it does not develop
median of 20 months); and implement a corrective plan by 2005.11
• 10 percent of all California children who
had experienced a verified instance of
abuse or neglect experienced an addi- Florida
tional episode within six months; and
• 1 percent of California foster children State Agency: Florida Department of Chil-
dren and Families
were abused by their caregivers.6
ties (Pasco, Pinellas, Manatee and Sarasota) relating to issues such as sibling files and in-
from the Florida Department of Children and formed consent.20
Families to the state attorney or Attorney
General’s office. A three-year phase-in period Gov. Bush has appointed a blue-ribbon panel
was scheduled for these efforts. Local non- to investigate child protection issues in Flor-
profit agencies can bid to provide child wel- ida and make recommendations for improve-
fare services as part of this initiative. Local ment. This panel held public hearings, made
sheriffs may elect to perform child abuse or recommendations and issued a progress re-
neglect investigations themselves or subcon- port in January 2003.21
tract these services.16
Funding Issues: The Florida Department of
Florida’s foster care system has been criti- Children and Families reports that it received
cized for removing children from their biolog- a $524 million increase in funding for chil-
ical parents too quickly and too often. Nation- dren’s protective services under the state’s
al children’s advocacy groups cited the disap- current governor. The department is request-
pearance of five year-old Rilya Wilson from ing $1 billion for fiscal 2005 to increase chil-
foster care in January 2001 as an example of dren’s safety and shift to a community-based
the need for systemic reform.17 system of foster care.22
The 2001 death of a 17-month-old child (Latiana Title IV-E Waivers: None.
Hamilton) in a crowded foster home, and the
arrest of her foster mother for first-degree mur- Model Programs and Initiatives: In Novem-
der, added to existing concerns about the Flor- ber 2003, Gov. Bush and Children and Family
ida foster care system. A February 2001 report Services Secretary Jerry Regier announced a
indicated that 16 percent of the state’s foster new initiative, titled No Place Like Home, de-
homes had more children than were allowed by signed to increase adoptions by raising public
their licenses; 62 foster homes across the state awareness. The initiative focuses on recruit-
were caring for more than 10 children.18 ing adoptive parents and streamlining adop-
tion procedures. Florida received $3.5 mil-
In May 2002, the Department of Children and lion from the federal Department of Health
Family Services was ordered to pay $5 million and Human Services in October 2003, more
in damages to a group of six siblings who had money than any other state, for its efforts to
been starved and physically as well as sexu- increase adoptions.23
ally assaulted while in foster care. These sib-
lings were placed in a foster home from which Policy, Advocacy and/or Parental Issues:
the parents’ own biological child had been Children’s advocates have filed a federal law-
removed due to sexual assault. The state de- suit against the Florida Department of Chil-
partment was found to have not visited these dren and Family Services ((Bonnie L. v. Jeb
foster children for more than a year.19 Bush) asserting that the state runs crowded
and poorly supervised foster homes that put
In 2002, an oversight committee appointed children at risk of abuse and neglect.24
by the governor issued a report criticizing
the Department of Children and Families for Children who are missing from the state foster
keeping such poor records that they were care system are an ongoing public concern in
endangering children. Their review of more Florida. The Florida Department of Children
than 1,000 foster children’s cases found that and Families listed 489 missing foster children
almost all of them were incomplete and disor- on its Web site as of February 25, 2004. Rilya
ganized. In addition, the state’s record keep- Wilson, whose 2001 disappearance was cited
ing violated various state and federal laws as an example of the need for systemic re-
form in Florida’s foster care system, remains field service areas provide child protection
on this list.25 and other direct services.29
Child advocates also have expressed concern The Department of Children and Family Ser-
about the amount of psychotropic drugs giv- vices participates in the federal Statewide
en to children in foster care, asking whether Automated Child Welfare Information System
these drugs are being prescribed to control (SACWIS), which was authorized by the U.S.
behavior rather than to address mental health Congress in 1993. The U.S. Department of
problems. An internal Department of Chil- Health and Human Services reimburses states
dren and Families memo reported in the Palm for 50 to 75 percent of the cost of developing
Beach Post estimated that more than a fourth and implementing the system.
(28 percent) of all Florida foster children ages
13 and older were being overmedicated. On The director of the Illinois Department of Chil-
November 19, 2003, Children and Families dren and Family Services has used this initia-
Secretary Jerry Regier called for a complete tive to develop the Best Practice Integration
investigation into this matter.26 Project, a statewide system for the dissemi-
nation of model child welfare practices.30 The
Another continuing issue has been the backlog information system is designed to help ensure
of cases. Children and Families Secretary Jerry statewide excellence and consistency in case
Regier announced in February 2003 that the management. The Department of Children
agency’s backlog had been reduced to fewer and Family Services reports that the incorpo-
than 15,000 cases for the first time since 1999. ration of best practices in casework has been
The caseload was at 30,038 in December 2002, highly successful.31
when the effort to reduce the backlog began.27
The department maintains a foster parent ho-
tline (1-800-624-KIDS) in addition to its child
Illinois abuse hotline (1-800-25-ABUSE). The depart-
ment also develops materials for local agencies
State Agency: Illinois Department of Chil- to use in recruiting adoptive and foster parents.
dren and Family Services
Demographic Profile: The Illinois Depart-
State Agency Web Site: http://www.state. ment of Children and Family Services reports
il.us/dcfs that 19,719 Illinois children were in foster
care as of October 31, 2003. Of these children,
Overview: The Illinois Department of Chil- 12,140 (62 percent) resided in Cook County.
dren and Family Services administers child In Cook County, the majority of the children
welfare programs, including foster care ser- in foster care (10,055 out of 12,140, or 83 per-
vices. The department oversees six field of- cent) were African American. In the rest of
fices, including three for Cook County and the state, there were 4,047 white, 3,057 Afri-
one each for the state’s northern, central and can American and 216 Hispanic children in
southern regions. At present, the Cook Coun- foster care. Slightly more foster children were
ty central regional office is being eliminated, males (10,535) than females (9,176). The dis-
and its services moved to the Cook County tribution of children in foster care across age
North and South regional offices.28 levels was fairly even.32
The state’s six (soon to be five) service re- History: Illinois faced a statewide crisis in
gions are in turn divided into field service its child welfare programs in the early to mid-
areas. These areas are partitioned into local 1990s. The state reported that 17.1 out of ev-
area networks (LANs), which administer child ery 1,000 Illinois children were living in foster
welfare services and programs. The state’s care, the highest rate in the nation. Foster
care caseloads averaged 50 to 60 per social million in general revenue (out of $1.4 bil-
worker. By 1996, children in Illinois spent an lion total) for the Department of Children
average of 56 months in foster care, and the and Family Services. This proposal includes
foster care system had become a source of $13 million in new dollars for training private
considerable controversy. child welfare agency staff; $20.9 million in
new money for adoptions and guardianships
The Illinois Department of Children and Fami- and a reduction of $30.1 million in foster care
ly Services concluded that one major problem services, which mirrors the fall in the state’s
was the state’s contracting system. The depart- foster care population. The state expects an
ment reports that its former fee-for-payment 8 percent decrease in foster care caseloads
system worked against permanent adoption, for fiscal 2004.35
since local agencies lost money for each child
adopted unless a new child became available Title IV-E Waivers: Illinois received a Title
at the same time. Thus, the foster care service IV-E waiver from the federal government for
provider system received rewards for keeping its subsidized guardianship program, which
large numbers of children in foster care. Un- allows children in kinship (extended fam-
der this system, only 8 percent of all children ily) care to be placed permanently with their
in foster care were being moved to permanent relatives. The state has reported significant
homes each year. improvements in permanent placements
through this waiver; the number of children
Illinois changed its contracting system to per- placed permanently with relatives rose from
formance-based contracts that reward activi- 1,276 in 1998 to 2,199 in 1999.
ties supporting and encouraging permanent
adoption. The state also provides financial These placements are managed through per-
incentives linked to accountability. For ex- formance contracts. The state has used sav-
ample, all Cook County providers now are ings from these placements to reduce state
expected to accept 24 percent of their cases social worker caseloads.36 Six other states
as new referrals and move 24 percent of them have received this waiver.37 Evaluation of
into permanent homes annually. This change this waiver program suggests positive effects.
has increased adoptions and led to improve- Follow-ups with 2,276 children indicate that
ments in local agency performance.33 children served under the waiver were more
likely to be placed in permanent homes.38
The Department of Children and Family Ser-
vices’ fiscal 2004 budget request indicates A second Title IV-E waiver allows Illinois to
that foster care caseloads have dropped dra- provide services to families with substance
matically, from 50,044 in fiscal 1996 to 20,719 abuse problems. The state has used this waiver
in fiscal 2003. The state has begun assessing to hire “recovery coaches” who work with fam-
the degree to which children are in danger of ilies upon completion of substance abuse pro-
neglect and abuse more accurately through grams. Program participants include custodial
the use of a standardized risk assessment in- parents with substance abuse problems and
strument, which in turn has lowered foster parents whose infants were exposed to harm-
care placements. Illinois also has increased ful levels of drugs and alcohol before birth.
its investment in “front-end” or prevention
services, to address abuse or neglect in their The state’s third Title IV-E waiver provides en-
earliest stages. These achievements have oc- hanced training for private agency foster care
curred within a statewide emphasis on in- staff and an evaluation of the results of this
creasing child safety.34 training. This training program is designed to
increase the number of children placed in per-
Funding Issues: The Illinois governor’s pro- manent homes. Illinois is the only state with
posed budget for fiscal 2004 includes $838 this type of waiver.39
Model Programs and Initiatives: Illinois partment to reduce caseloads to its current
has received a number of national awards and average of 16 per caseworker.43
recognition for its foster care programs.
Performance Contracting. Illinois began per-
The Illinois Department of Children and Fam- formance contracting in 1997. The state cred-
ily Services reports that it is the country’s its this system with making it a national lead-
largest state agency for children’s welfare to er in child welfare reform. The performance
receive accreditation from the Council on Ac- contracting program received an award from
creditation for Children and Family Servic- the Harvard Innovations in American Govern-
es.40 Illinois also received the White House’s ment program in 2000. One of the criteria for
Adoption Excellence Award in 1998 and 1999 this award is that the program can be easily
for its efforts to increase the number of chil- replicated by other states.44
dren moving from substitute care into perma-
nent homes.41 Prevention. A key element of Illinois’ success-
ful restructuring of its foster care program is
The National Adoption Information Clearing- to provide prevention services to reduce the
house of the Administration for Children and number of children entering foster care. The
Families reports that, from 1995 to 1998, Illinois early intervention program provides services
realized the largest percentage change (101 to families in crisis before a child abuse or ne-
percent) in finalized adoptions of any state. glect investigation is finalized. The state also
(Texas reported a 75.9 percent improvement has developed the goal of “early permanency,”
in adoption rates over the same period.).42 meaning that a child is placed in a permanent
living situation as soon as possible. This effort
By 1999, Illinois tripled its number of adop- has reduced the number of children in foster
tions (7,113) over the prior year’s results. care from 51,331 in 1997 to 20,508 in 2003, a
The state estimates that nearly 40,000 Illinois decrease of 60 percent.45
children were placed in permanent homes be-
tween 1997 and June 2003. Wraparound Services. Illinois uses the “wrap-
around” service concept, which stresses in-
Benchmarking. Illinois’ Department of Chil- teragency coordination as a primary part of
dren and Family Services benchmarks its the planning process. Wraparound services
child welfare measures, such as the num- are coordinated through a child and family
ber of children in out-of-home care, to other team. Each foster child’s wraparound plan is
states and the national median. Data analysis reviewed and modified on an ongoing basis.
is based on information from the National The goal of the wraparound approach is to
Data Analysis System. return children to the community with a mini-
mal level of specialized support services. Par-
Foster Care, Out of Home Placement and ents are included as important members of
Residential Care. The Illinois Department of the child and family team. Services are com-
Children and Family Services’ 2003 report on munity-based, while more restrictive settings
progress in child welfare reform indicates that are used only to stabilize children in crisis.46
the state has reduced the number of children
served in foster care (a 60 percent drop since Policy, Advocacy and/or Parental Issues:
the 1990s); the average length of time spent State Representative Jim Meyer (R-Naper-
in foster care (25 months versus 44 months); ville), hosted an October 21, 2003 forum for
the use of residential and group settings (60 Illinois foster parents. The group’s most fre-
percent fall from 1995 to 2003); and use of quent concerns were combative administra-
out-of-state residential programs (fewer than tors, lack of mental health support and bureau-
20 children). These reforms allowed the de- cratic “red tape.” Foster parents also reported
that Medicaid restrictions (e.g., on dental and
eye care) create barriers to adequate health agencies initially received contracts to pro-
care for their children. An additional concern vide foster care, adoption and family pres-
was a lack of support for foster children who ervation services for a set (“capitated”) fee
“age out” of the system. Foster care person- of between $13,000 and $15,000 per child.54
nel at the meeting reported that their needs This “managed care” model, which paid a flat
include more funding, a larger pool of foster rate per child, was changed in July 2000 to a
parents and more staff training.47 system that reimburses contractors monthly
based on the number of children served. Con-
tract outcome and performance goals also
Kansas have been revised.55
State Agency: Kansas Department of Social The Heartland Institute reports that private
and Rehabilitation Services service providers have surpassed the state’s
performance goals in several areas, including
State Agency Web Site: http://www.srskan- safety, number of placements, continuation of
sas.org family and community relationships and sib-
ling placement. Kansas state administrators
Overview: On March 1, 1997, private agencies view privatization and performance-based
took responsibility for all foster care services contracting as the keys to improving child
in Kansas. The Department of Social and Re- welfare programs.56
habilitation Services monitors these agencies
to ensure program quality.48 The department purchases adoption and fos-
ter care services as well as administration,
Kansas operates a statewide data system for placement, counseling and follow-up services
foster care, the Family and Child Tracking Sys- from a network of private service providers.
tem (FACTS). A federal review of the system Kansas’ performance standards for private
described it as “fragmented,” and criticized it providers are very strict, particularly when
for being unable to easily generate manage- compared to those previously used in the
ment reports. Many state department manag- state’s adoption and foster care program.57
ers maintain their own data systems that are
incompatible with FACTS.49 Five contractors and 25 nonprofit providers cur-
rently offer foster care services and programs
Demographic Profile: According to the Chil- in Kansas.58 The University of Kansas works
dren’s Defense Fund, 6,569 Kansas children with the Department of Social and Rehabilita-
were in foster care in January 2003.50 The Casey tion Services to provide training and evaluation
Foundation estimates that Kansas’ foster care services for private foster care agencies.59
population is 68 percent white, 22 percent Afri-
can American and 7 percent Hispanic.51 The Children’s Alliance of Kansas (http://www.
childally.org) is a statewide association repre-
History: Kansas is the first state in the nation senting all of the private agencies that deliver
to completely privatize its adoption, foster foster care services. Member agencies work
care and family preservation programs.52 In to coordinate services, programs and issues.
1996, the state contracted for adoption servic- This organization offers a variety of services
es with strict performance-based incentives and programs, including case management;
that quickly produced improvements. During training for foster and adoptive parents, state
the first year of privatization, adoptions in- agency staff and local service providers; foster
creased by 26 percent.53 parent recruitment; advocacy; residential and
emergency care and transition services.60
Kansas’ privatization effort included perfor-
mance-based contracts with private service
providers. Three large, private, nonprofit
Funding Issues: The Kansas Department were intended to help foster care teenagers
of Social and Rehabilitation Services’ fiscal make the transition to independence, instead
2004 budget of $2 billion will be spent on ad- were used to provide direct services to foster
ministrative costs (7 percent), direct service children under the age of 18, according to the
delivery (10.6 percent) and direct assistance, report.64 The Department of Social and Reha-
grants and benefits (82.1 percent). Of the di- bilitation Services responded that it is examin-
rect assistance grants and benefits expendi- ing this issue, but denied any wrongdoing.65
tures, $184 million will be spent on children
and family services. The December 2002 death of a child in fos-
ter care (nine-year-old Brian Edgar) resulted
Like many other states, Kansas has struggled in public questioning of the state’s privatized
with budget shortfalls and program cuts. The system. Brian’s foster parents and babysitter
fiscal 2004 Social and Rehabilitative Services were charged with suffocating him. A total of
budget has had some funds restored by the gov- 37 children have died in foster care in the six
ernor. The department anticipates eliminating years since the state system was privatized,
one out of every six central office positions and but obviously there is no way to know what
one out of every eight field office positions.61 would have happened if the children had re-
mained in state care.66 Spokespersons for the
The state department combines federal and state maintain that the privatized foster care
state funds to offer a single, one-time fixed system continues to serve children safely.67
rate per child to foster care service provid-
ers. Researchers at the University of Kansas
report that this approach has led to effective, Michigan
integrated foster care programs. The prior
State Agency: Family Independence Agency
state payment system was a fee-for-service
model that provided no incentive for moving
State Agency Web Site: http://www.michi-
children into permanent homes. Under the
gan.gov/fia
current system, children who remain with
agencies for long periods of time cost the
Overview: The Family Independence Agency
agencies money, so an incentive is created to
administers foster care as well as the state’s
move children to permanent placement.62
other public assistance and welfare pro-
grams. The state office oversees more than
Title IV-E Waivers: None.
100 county-level family independence agen-
cies that in turn provide child and family wel-
Model Programs and Initiatives: Re-
fare services.68
searchers at the Heartland Institute describe
the privatization of foster care in Kansas as a
Demographic Profile: The Michigan Family
great success. The state’s performance-based
Independence Agency reports that it had iden-
contracts have been praised by these re-
tified 19,549 children as abused or neglected
searchers for ending cycles of abuse and ne-
at the end of fiscal 2003. Of these, 17,342 (89
glect that kept thousands of Kansas children
percent) were living in out-of-home care. This
lingering in foster care for years.63
caseload includes 10,224 African American
children (52 percent); 8,310 white children
Policy, Advocacy and/or Parental Issues:
(42 percent); 692 multi-racial children (4 per-
In February 2002, the Kansas Appleseed Cen-
cent); and 188 American Indian children (less
ter for Law and Justice released a study that
than 1 percent). The agency reports a sub-
accused the Department of Social and Rehabil-
stantial increase in kinship (extended family)
itation Services of misusing $2.5 million in fed-
care for foster children, from 3,365 in 1990 to
eral funds from the John Chafee Foster Care
6,348 at the end of 2003.69
Independence Program. These funds, which
History: Child and family services in Michi- caseworkers; and percent of adoptions in the
gan went through a federal review in Septem- permanent foster care population.73
ber 2002. Michigan met the federal criteria for
four of the standards measured (rate of recur- In 1984, Michigan established foster care re-
rence of child maltreatment, maltreatment of view boards to review services and programs
children in foster care, foster care re-entry provided to foster children. The initiative is ad-
rates and percentage of finalized adoptions ministered by the Michigan Supreme Court and
within 24 months of entry into foster care), staffed by citizen volunteers who serve on 30
and failed to meet two—the percentage of local review boards throughout the state. These
children reunited with their families and the boards review local court and agency actions,
percentage of children experiencing no more services and programs for foster children.74
than two placements during their first 12
months in foster care.70 Michigan has implemented a pilot pay-for-per-
formance project to reimburse private agen-
Funding Issues: Michigan’s payment rates cies for foster care services. The goals of the
are based on the U.S. Department of Agricul- project are to reduce the time children spend
ture’s estimated cost of raising a child. The in foster care and increase the number of per-
Family Independence Agency reviews the manent placements.75
rates annually and makes cost-of-living ad-
justments. Supplemental funds also are avail- Policy, Advocacy and/or Parental Issues:
able for special-needs children.71 In September 2002, almost 40 percent of the
Michigan Family Independence Agency staff
Title IV-E Waiver: Michigan has a Title accepted early retirement packages. Many of
IV-E managed care payment system waiver. The these positions were eliminated as part of the
state has developed “wraparound” managed agency’s transition to a greater use of tech-
care contracts for children in foster care. The nology; for example, any complaints about
state pays a single case rate of $14,272 for each day care or nursing facilities now must be
foster child, regardless of the amount of time made online. Advocacy organizations have
over which services are provided. An addition- expressed concerns that the state’s most vul-
al bonus payment of $1,586 is available for each nerable populations, including those in foster
child that is adopted, reunited with his or her care, will suffer a decline in services as a re-
family, moved to an independent living situa- sult of this move.76
tion or placed in a permanent foster care home.
Four other states have similar waivers.72 In December 2002, the Detroit Free Press re-
ported that 302 foster children were missing.
Model Programs and Initiatives: The Michi- The Free Press reviewed the court files for
gan Family Independence Agency issues an- these missing children and found that many
nual report cards for every public and private of them could be located if someone actually
child placing agency in the state, based on fac- made an effort to find them. The Family Inde-
tors including the number of children moving pendence Agency responded by saying that it is
from one placement to another; the number of trying to track down these missing children.77
temporary court wards in out-of-home care for
0-11 months, 12-15 months, 15-24 months or In May 2003, a Wayne County prosecutor filed
more than 24 months, by age; average length criminal neglect charges against social work-
of time from termination of parental rights un- ers and doctors in the state’s foster care system
til adoption; number of sibling groups split in over the beating deaths of two four-year-old
placement; number of children placed outside boys in foster care. Advocates claim the state
of the county of jurisdiction; number of case- foster care system is poorly managed and plac-
workers per child; experience levels of state es children at risk of further neglect and abuse.
The prosecutor in the case had previously in-
vestigated a case in which a 15 year-old female of the state’s foster children in out-of-home
died of malnutrition while in foster care.78 placements are in family foster care.84
abled Minnesotans in particular, will bear the History: On May 10, 2000, local and national
impact of the loss of state services.91 children’s advocates, including private attor-
neys and Children’s Rights Inc., filed a civil rights
suit, Brian A. v. Sundquist, against the state
Tennessee of Tennessee, alleging that it was endangering
thousands of foster children. Eight foster chil-
State Agency: Tennessee Department of dren were named as plaintiffs. The suit asked
Children’s Services the district judge to order the governor to fix
what was described as a “grossly mismanaged
State Agency Web Site: http://www.state. and overburdened child welfare system.”97
tn.us/youth
This lawsuit provided numerous allegations
Overview: The Tennessee Department of Chil- of the state’s failure to care for foster children,
dren’s Services administers the state’s foster despite a series of audits, legislative hearings
care program. The department places foster and local news investigations. Evidence gath-
children with relative caregivers, who must ered from public records indicated that some
meet the same criteria and receive the same foster children remain in emergency shelters
level of support as other caregivers; shared for as long as six months; others spend several
homes, which are run by private agencies ap- years in foster care without adoption and that
proved by the state; foster homes for medically white foster children receive better treatment
fragile children and emergency foster homes than African American foster children.98
for children who need immediate shelter.92
In July 2001, a settlement in the Brian A. case
The U.S. Department of Health and Human mandated substantial changes in the state’s
Services reports that the Tennessee foster foster care program. The reforms were to be
care program does not comply with any of its overseen by an independent panel of child
seven outcome measures for children’s safe- welfare experts and an external monitor. The
ty, permanency and well-being. Of greatest settlement will be monitored until 2006.99
concern is the lack of permanent placements
for children in foster care; only 31 percent of Funding issues: Like other states, Tennessee
children in cases reviewed by HHS had been has faced budget shortfalls that have created
placed in a permanent home. HHS also found challenges in serving children and families.
that the department did not respond to child In November 2003, Gov. Bredesen reported
abuse reports in a timely manner in almost a that a rise in the state’s welfare rolls would
third (29 percent) of the cases reviewed.93 greatly increase its budget challenges. Among
proposed cuts are subsidies for kinship care,
Tennessee’s automated child welfare informa- which may increase the number of children in
tion system, TN KIDS, has been implemented in state foster care.100
several installments. The first supports the state
agency’s intake and referral activities. This sys- Title IV-E Waivers: None.
tem includes information on all foster children’s
status, demography, placement and goals. Sub- Model Programs and Initiatives: The TN
stantial future enhancements are planned.94 KIDS data system has received an award from
the National Association of State Information
Demographic Profile: According to the Officers. It was designed to create a single
Children’s Defense Fund, 10,144 Tennessee data system for children’s welfare services in
children were in foster care in January 2003.95 the state.101
The Casey Foundation estimates that the
state’s foster child population is 58 percent In September 2003, Tennessee was among
white, 39.2 percent African American, and 1.5 the 25 states that received a federal bonus
percent Hispanic.96
for increasing its number of adoptions of fos- wide, about 5,100 families are registered as
ter children. The state received a bonus of foster care providers.108
$1,148,000 as part of this initiative.102
Demographic Profile: According to the Chil-
Policy, Advocacy and/or Parental Issues: dren’s Defense Fund, 10,148 Wisconsin chil-
A November 2003 report by the court-ap- dren were in foster care in January 2003.109 The
pointed monitor in the Brian A. case indi- Casey Foundation estimates that the state’s
cates that the state is not making enough foster care population is 49.6 percent African
progress in complying with the settlement. American, 40.8 percent white, 5.1 percent His-
The monitor reported that the state is in full panic and 3.2 percent American Indian.110
compliance with only 24 out of 136 provisions
of the settlement. Among other findings, the The Department of Health and Family Ser-
monitor stated that the state makes timely in- vices reports that more than 95 percent of the
vestigations of only 37 percent of the abuse or Wisconsin children in foster care have juve-
neglect reports it receives.103 nile court-ordered placements. About half of
these children return to their homes within
On November 20, 2003, the plaintiffs in the six months. Almost 80 percent of the state’s
original Brian A. lawsuit filed a motion charg- special-needs adoptions are by foster parents
ing the governor and commissioner of the who want to provide a permanent home for
Department of Children’s Services with con- their foster child.111
tempt of court for their failure to follow the
terms of the settlement.104 History:: A 1993 lawsuit ((Jeanine B. et. al. v.
Scott McCallum et. al.) charged that the Mil-
waukee County foster care program did not
Wisconsin comply with federal law. The state department
took over the Milwaukee County foster care
State Agency: Wisconsin Department of
system in 1998, but additional charges were
Health and Family Services
filed in 1999 and 2000, and the case became
certified as a class action suit. A settlement ne-
State Agency Web Site: http://www.dhfs.
gotiated in 2002 includes foster care provisions
wisconsin.gov
related to permanent homes, child safety and
well-being, monitoring and enforcement.112
Overview: The Wisconsin Department of
The settlement was hailed by children’s advo-
Health and Family Services administers pro-
cates as unique in that a government agency is
grams related to children and family services,
being held accountable for producing specific
disability and elder services, public health
outcomes for foster children, such as place-
and health care financing.105 Its Division of
ment with permanent families.113
Children and Family Services administers
programs and services in the areas of child
Funding Issues: Wisconsin has adopted a
welfare, child protective services, foster care
uniform monthly reimbursement rate for fos-
and adoption, substance abuse, domestic vio-
ter caregivers. Supplemental and/or excep-
lence, teen pregnancy and licensing of chil-
tional payments may be made based on the
dren’s facilities. The division also oversees
needs of the individual child. The rate varies
the Brighter Futures Initiative, a state-local
by age group, from $302 monthly for infants
partnership designed to ensure a better future
to four-year-olds to $391 monthly for 15- to
for every child in the state.106
18-year-olds. The department also publishes
guidelines for expenditures on food, clothing,
The Department of Health and Family Ser-
housing and personal care, which are based
vices reports that 84 percent of the foster
on the cost of raising a child as calculated
children it placed in out-of-home care in 1996
by the U.S. Department of Agriculture. Chil-
were placed in family foster homes.107 State-
11 22
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Appendix 3
Technical Recommendations Concerning Rate Setting
1. DPRS should calculate separate rate components for direct care and for other
cost centers such as administration, facility and other operating costs.
DPRS prescribes the following screening cri- DPRS’ rate-setting methodology differs from
teria for selecting cost reports to be included those used for nursing facilities and interme-
in rate calculations for residential services: diate care facilities for the mentally retarded,
both of which also offer 24-hour residential
• Average occupancy rate is at least 50 per- facilities.
cent (30 percent for emergency shelters).
In fiscal 2002 • State placements represent at least 40 per- Nursing Facilities
and 2003, cent of days of service for LOCs 5 and 6. For nursing home reimbursements, HHSC
DPRS was • At least 30 percent of days of service must uses case mix indexes (CMIs) based upon time
unable to adopt be delivered in a given LOC for a facility studies. In developing the CMIs, measured pe-
rates based to be included in rate calculations for that riods of the time of key direct care staff were
fully upon its level (LOCs 3 - 6). allocated to clients; the times were weighted
methodology • Total costs must be less than two standard to reflect the relative compensation of differ-
due to funding deviations above or below the mean.2
shortfalls. ent types of direct care staff; and clients were
grouped largely according to similar weighted
These criteria presumably are intended to staff times, with some consideration given to
limit the effect of extremely low occupan- particular clinical issues. Direct care costs
cies on reimbursement rates and to ensure are adjusted for inflation and summed across
that those rates adequately reflect the costs all providers; the resulting grand mean is mul-
of serving state-placed residents classified at tiplied by a set of CMIs (standardized for the
appropriate levels of care. particular case mix during the cost reporting
period under consideration) corresponding
The rates derived from this methodology, to the various care levels.5
however, are subject to further adjustments
based upon appropriations and “professional The nursing facility methodology includes av-
judgment.” erage costs for all providers in the rate calcu-
lation for all care levels, and the case mix al-
In fiscal 2002 and 2003, DPRS was unable to location occurs at the end of the process. Rate
adopt rates based fully upon its methodology categories were developed by grouping cli-
due to funding shortfalls. For fiscal 2004 and ents’ resource usage, based on a time study.
2005, at the direction of the Legislature, DPRS
compressed its six levels of care to four ser- Private ICFs-MR
vice levels in an effort to save more than $22
In the case of private (non-state) intermedi-
million in the foster child system.3
ate care facilities for the mentally retarded,
(ICFs-MR), the rate system includes five lev-
As previously noted, DPRS continues to calcu-
els of need, each broken down by three facil-
late rates based on the six LOCs; these levels
ity sizes. Rates for the 15 payment categories
then are weighted based on an estimate of the
are based on a direct care component model
distribution of days of service (during a prior
that reflects assumed staffing levels needed
six-month period, allowing a reasonable time
for each level of need and facility size; uni-
lag for completion) to clients with characteris-
form wages for each of several staff types
tics corresponding to the four new levels. In cal-
(with a factor for employee benefits); and a
culating rates, administration costs are reduced
component for indirect costs based upon a
to stay within appropriations, focusing most of
percentage of direct care costs.6
the effect on the lower levels and minimizing
the impact on the higher levels (LOCs 5 and 6)
Key distinctions of interest between the
ICF-MR and foster care methodologies in-
clude the source of information used for mak- ICF-MR rates consist of two basic compo-
ing level-of-need distinctions (HHSC uses nents, direct care and indirect. The nursing
assumptions based upon consultation with facility rate method groups costs into four
industry, advocates and state representatives, cost centers: direct care staff, other direct
while DPRS uses time studies); the develop- care, dietary and general and administrative.
ment of ICF-MR rates based upon staffing The rates for the direct care components are
assumptions versus foster care rates derived based on grand means, but the other two
directly from statistics derived from cost re- components are based on medians. In addi-
ports; and HHSC’s recognition of cost differ- tion, nursing facility rates include a “use fee”
ences among different facility sizes. component, based on appraised property val-
ues, to cover facility costs.
DPRS’ 24-hour residential child care method-
ology calculates rates based upon one statis-
tic representing aggregate or total (allocated) Recommendation
costs for each level of care. It also bases the
DPRS should calculate separate rate
entire rate on an unweighted mean statistic,
components for direct care and for other
with providers whose costs are greater than
cost centers such as administration, facil-
or equal to two standard deviations above or
ity and other operating costs, as do other
below the initial mean excluded from the final
long-term care methodologies.
calculation. Once costs are allocated to levels
of care for each facility, no distinction is made
Rates based on statistics representing each
between cost centers such as direct care, ad-
of several cost centers tend to limit the effect
ministration, facility or operating.
of extreme values in each, resulting in a more
conservative measure of central tendency
Other rate methodologies typically recognize
than does the current methodology.
such distinctions—at least the distinction be-
tween direct care and other costs—and calcu-
late individual rate components corresponding
to these cost centers. Under the latter approach,
Fiscal Impact
the resulting rates are less likely to be inflated by This recommendation could change rates for
some providers’ relatively high administration, each service level. It would have no overall
facility, or operating expenses and individual fiscal impact because the total appropriation
components are clearly defined for purposes of amount is capped, and rates would continue
designing incentives, funding and so forth. to be adjusted to meet the appropriated level.
A more efficient way to address this issue is days of service delivered, and in LOC 6, the
through separate rates by facility size, such as figure is nearly 39 percent.
those used in the ICF-MR program. Although
different facility size groups may be appropri- A brief examination of the distribution of ser-
ate for these distinct programs, the underly- vice volume and costs among facilities deliver-
ing principle is the same. If staff-to-resident ing LOC 6 services as reported in the year 2000
ratios vary significantly by size of operation, cost report database illuminates some key is-
separate weighting factors may be appropri- sues. A total of 20 residential facilities included
ate for each level of care and for each bed-size in the year 2000 database delivered some LOC
category, a determination that would require 6 days of service. The LOC 6/Intensive rate
another time study. benchmark derived from these data was based
only on four facilities that delivered 61.3 per-
Of the different statistics that might be em- cent of LOC 6 days, since LOC 6 days of service
ployed as cost benchmarks in calculating did not represent at least 30 percent of total
rates for any of these programs, the unweight- days in any of the remaining 16 facilities.
ed mean across providers, whether by level of
care as in foster care or across all providers as The unweighted mean representing these four
in nursing facilities, tends to produce higher facilities and constituting the benchmark rate
rates than alternatives such as a mean weight- for 2004 under the current method is $179.22.
ed by days of service or a median so weighted. The weighted median, by contrast, is $164.51,
Weighted medians tend to be the most conser- which also is the cost of the highest-volume
vative measure of central tendency. provider. Moreover, the weighted median re-
mains the same based on all 20 providers re-
Changes in this statistic from one reporting pe- porting LOC 6 services for the year 2000. This
riod to the next tend to reflect cost factors af- latter result is somewhat unique to LOC 6,
fecting a broad spectrum of providers. In other which is characterized by a higher concentra-
long-term care programs, the mean or median tion of volume among a few facilities than is
statistics used as cost benchmarks for rates the case with other LOCs.
are enhanced by a percentage adjustment to al-
low for additional variation in costs due to any In 2000, the highest-volume provider deliv-
number of factors. The percentage adjustment ered 26.4 percent of total LOC 6 days of ser-
factor in residential programs such as nursing vice among the 20 providers in the database,
facilities and assisted living is 7 percent, while and 43.1 percent of the days reported by the
the factor applied to the median statistics in four facilities included in the benchmark rate
community care programs is 4.4 percent.7 The calculation. The next highest-volume facility
factor appropriate for residential foster care delivered 25 percent of the days and the other
may be determined to be something differ- two delivered less than 20 percent each. As a
ent based on any number of considerations result of the relative volume of the highest-
deemed significant by policymakers. volume provider and the distribution of costs
and volume among the others, the weighted
The residential foster care method also dif- median rate benchmark in this case would
fers from the approaches applied in other cover the projected costs of providers deliver-
long-term care programs in that facilities are ing 69.2 percent of the LOC 6 days of service.
included in the rate calculation for a given
LOC only if they deliver at least 30 percent Although the unweighted mean LOC 6 rate
of their days of service in that level. This ex- benchmark was $179.22, a figure that would
cludes a large portion of facilities from rate cover projected costs of providers deliver-
calculations. In LOC 3 and 4, excluded facili- ing 73.5 percent of LOC 6 days of service, the
ties represent about a third of the residential DPRS Board adopted a Level 6/Intensive daily
rate of $202. This action reportedly reflects
In the other LOCs, days of service are less The factor appropriate for residential fos-
concentrated among a few facilities, but costs ter care may be consistent with the seven
still vary over a wide range within each level. percent used for nursing facilities, or may
This variation within levels, in conjunction be determined to be something different,
with the recent reconfiguration of service/ based on any number of considerations
payment levels, suggests the need to examine deemed significant by policymakers.
the underlying sources of cost variation with-
in and among levels before concluding that B. DPRS should incorporate more pro-
simple modifications, such as those outlined vider cost report data in the rate cal-
in the example above for Level 6/Intensive, culation process.
are all that is needed. A more thorough analy-
sis should focus not only on aggregate costs, DPRS should use the existing time and mo-
but also should address the rationale for al- tion study and cost report data to adjust
locating administration, facility and other op- the cost allocation process so that it can
erating costs by level of service. incorporate providers that do not meet cur-
rent rate calculation thresholds because of
The ICF-MR rate methodology, for example, is their proportion of days in each level. In
based on a model in which such indirect costs evaluating the structure of the rate classes,
vary more by facility size than by level of care. It DPRS should take into account not only
is noteworthy that the Home and Community- levels of care, but other potential sources
Based Services program, which is the commu- of cost variation such as facility size (at
nity care counterpart of ICF-MR, includes foster levels below 6/Intensive), and evaluate
care rates by levels of need, developed through alternatives for screening facilities to be
the same type of modeling procedure. Since the included in rate calculations for each level
setting is a foster family home, however, facility and adjusting for low usage of resources.
size distinctions are not applicable.
Background Recommendation
Although much of DPRS’ rate-setting method DPRS should use an objective means to
is objective, the final rates do not necessar- adjust its rates to appropriation limits.
ily reflect the outcome of the rate calculation.
DPRS uses the outcomes of the calculation DPRS either should exclude the “professional
and applies two layers of adjustments. judgment” process in favor of proportional
adjustments, or more clearly specify criteria
First, DPRS applies a process of “professional by which adjustments should be made by lev-
judgment.”10 This is a process whereby DPRS el of service.
staff determines whether some rates should
be adjusted by a higher percentage than oth-
ers, based on their expert judgment of reim- Fiscal Impact
bursements needed by service level.
This recommendation could be implemented
with existing resources.
Then the rates are adjusted to meet appropri-
ation requirements.
4. DPRS should cap funds for administration and require recovery of funds
expended above the cap.
Background Recommendation
DPRS has not capped the amount of dollars DPRS should cap funds for administra-
providers can spend on non-direct service. tion and require recovery of funds ex-
pended above the cap.
Instead, DPRS identifies 24-hour residential
service providers with administrative costs It should be noted that this recommendation
exceeding 25 percent of total costs. Exceed- is for the recovery of administrative funds
ing this threshold places providers at risk of above a determined threshold, not for “un-
receiving an on-site audit. allowable costs.” Under the current system,
rates are prospective prices to be paid for ser-
MHMR, by contrast, has capped expenditures vices delivered. These prospective rates are
on non-direct services by community centers based on historical expenditures identified
at 10 percent.11 While MHMR has not set this by federal statute and state rule as “allowable
cap in its rules, it has included it in its con- costs.” Any expenditures identified as “unal-
tracts with the community centers. lowable costs” are not considered in the de-
velopment of the prospective rate. Any unal- LOCs used in fiscal year 2003 to attain greater
lowable costs are at the providers’ expense, efficiencies in classifying of foster children and
reduce costs.” In addition, Rider 21 specified
not the state’s and therefore, there is nothing
that the modified rate system was to be in
to recover. effect no later than October 1, 2003.
4
Interview with staff, Texas Department of
Protective and Regulatory Services, Austin,
Fiscal Impact Texas, November 14, 2003.
5
This recommendation would not result in a 1 Tex. Admin. Code §§355.306-355.307.
fiscal impact to DPRS. It would, however, di- 6
1 Tex. Admin. Code §355.456.
rect more dollars into direct care. 7
1 Tex. Admin. Code §§355.503, 355.505,
355.5902, 355.6907, 355.307; 40 Tex. Admin.
Code §46.27.
8
Endnotes 1 Texas Department of Protective and
Regulatory Services, Rate-Setting Database,
1 Austin, Texas, 2003.
40 Tex. Admin. Code §700.1802.
9
2 State Auditor’s Office, “New Foster Care and
40 Tex. Admin. Code §700.1802.
Adoption Subsidy Rates Proposed by the
3 Department of Protective and Regulatory
Rider 21, Tex. H.B. 1, 78th Leg. R.S. (2003),
Texas Department of Protective and Regulatory Services,” Austin, Texas, January 25, 2003.
Services, p. II-110, states that the appropriation 10
Interview with staff, Texas Department of
for foster care assumed $22,231,477 in savings
Protective and Regulatory Services, Austin,
“due to the redesign of the Foster Care Levels
Texas, November 14, 2003.
of Care (LOC) system to one based on services
provided.” Rider 21 expressed a legislative 11
Interview with staff, Texas Department of
intent that DPRS work with the Health and Mental Health and Mental Retardation, Austin,
Human Services Commission “to create a LOC Texas, December 1, 2003.
rate system that merges certain of the current
Appendix 4
Comparison of Therapeutic Camp Standards
The standards for “primitive or wilderness” camps are far less strict than the standards for
“permanent” camps and do not adequately protect children’s health.
Excerpts from DPRS’ Consolidated Minimum Standards for Facilities Providing 24-Hour Care,
“Section VI, §7300 Additional Specialized Standards for Therapeutic Camps”
Change
Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year
Chapter Page Issue Name in FTEs
2004 2005 2006 2007 2008
2008
Contract for quality
2 37 - Increase CBE Increase CBE Increase CBE Increase CBE 0
foster care.
Pursue Medicaid
funding for
rehabilitative
3 129 - $10,100,000 $10,100,000 $10,100,000 $10,100,000 0
services delivered
to foster children in
RTCs.
Pursue more federal
Title IV-E funding
3 131 - $7,000,000 $7,000,000 $7,000,000 $7,000,000 0
for preplacement
services.
Expedite the
delivery of foster
3 134 children's Medicaid - $2,100,000 $2,100,000 $2,100,000 $2,100,000 0
information to
caregivers.*
Provide foster
care contractors
with assistance
and training
3 136 - $2,100,000 $2,100,000 $2,100,000 $2,100,000 0
to help them
claim Medicaid
reimbursement for
foster care services.*
Include mandatory
participation by
charter schools in
3 143 - Increase CBE Increase CBE Increase CBE Increase CBE 0
the School Health
and Related Services
program.*
Change
Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year
Chapter Page Issue Name in FTEs
2004 2005 2006 2007 2008
2008
Improve the
assessment and
5 212 services provided to - Increase CBE Increase CBE Increase CBE Increase CBE 0
foster children who
are medically fragile.
Improve the
assessment and
5 217 services provided to - Increase CBE Increase CBE Increase CBE Increase CBE 0
foster children with
mental retardation.
Improve the
transitional services
offered to foster
6 236 - Increase CBE Increase CBE Increase CBE Increase CBE 0
children who "age
out" of the foster
care system.
Total Increase in Federal
- $21,300,000 $21,300,000 $21,300,000 $21,300,000 -
Funds for Direct Care
* Reimbursed directly to medicaid provider.
Change
Fiscal Year Fiscal Year Fiscal Year Fiscal Year Fiscal Year
Chapter Page Issue Name in FTEs
2004 2005 2006 2007 2008
2008
Eliminate the
2 24 inefficient dual - - $17,235,000 $34,469,000 $51,704,000 -905
foster care system.
Improve contracting
practices to
safeguard the state's
4 180 - $1,340,000 $1,340,000 $1,340,000 $1,340,000 0
responsibilities to
foster children and
Texas taxpayers.
Improve efforts to
5 230 find missing foster (Cost CBE) (Cost CBE) (Cost CBE) (Cost CBE) (Cost CBE) 0
children.
Total Redirected into
$0 $1,340,000 $18,575,000 $35,809,000 $53,044,000 -905
System Oversight