Report by the Office Inspector General (OIG)regarding ?State Oversight of Residential Facilities For Children?
http://oig.hhs.gov/oei/reports/oei-02-98-00570.pdfHighlights from that report:
Staff at the Administration for Children and Families (ACF) asked the Office of Inspector General (OIG) to review State oversight of children?s residential facilities. The ACF?s immediate concern is how States license and monitor residential care facilities.
For the purpose of this study, we define residential care as 24-hour group care of children provided by paid staff unrelated to the children. Children who are placed in residential care often need services that other settings do not provide, such as SPECIALIZED COUNSELING.
We selected a purposive sample of nine States (California, Florida, Mississippi, New York, Pennsylvania, South Dakota, Tennessee, Texas, and Utah).
There is no universally accepted set of licensing standards. The 15 year old Model Licensing Law DOES NOT SET OUT SPECIFIC LICENSING STANDARDS
and IS NOT WIDELY KNOWN. Further, although most States address most standards, there is some variability. Of the 34 key standards that we identified, ONLY 8 ARE ADDRESSED BY ALL 9 sample States.
Furthermore, State standards generally DO NOT ADDRESS THE APPROPRIATENESS OF PLACEMENT or QUALITY OF SERVICES. State standards generally do not deal with EVALUATING A CHILD'S PLACEMENT or set criteria for judging the quality of services in a facility. Some licensing specialists feel that the licensing process does not ensure quality of care, nor is it intended to.
[Enter the ICPC- Interstate Compact on Placement of Children in out-of-state facilties]
Almost all sample States report monitoring all facilities on-site annually. Licensing staff often discover violations. States impose corrective action plans that outline what a facility needs to do to correct the violation.
States rarely revoke licenses or deny a renewal. Instead, States use other techniques to deal with facility weaknesses, such as stopping a facility from accepting new children.
In addition to monitoring, sample States identify problems through complaints and critical incident reports. Usually, specialized staff or licensing staff investigate complaints. All nine States require facilities to report critical incidents such as suspected cases of abuse or neglect.
In addition to the licensing agency, facilities are commonly monitored by multiple agencies that include local fire and health departments and the contracting agency that places children.
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State licensing standards address the health, protection, and safety of children. They are not intended to ensure the suitability of placement and quality of care. Therefore, PLACING AGENTS (ED CONS) SHOULD NOT USE LICENSURE AS A SUBSTITUTE FOR A PRE-PLACEMENT VISIT when placing children in residential facilities.
Staff at the Administration for Children and Families (ACF) asked the Office of Inspector General (OIG) to review State oversight of children?s residential facilities. The ACF?s most immediate concern is how States license and monitor residential care facilities, and in particular WHAT A LICENSE SIGNIFIES. The OIG found in the recent inspection, ?Interstate Compact on the Placement of Children: Implementation?(OEI-02-95-00043) that STATES RELY ON LICENSING, NOT SEPERATE ON-SITE REVIEWS OF FACILITY SERVICES, TO DETERMINE THE SUITABILITY OF RESIDENTIAL FACILITIES WHEN THEY PLACE A CHILD ACROSS STATE LINES.
[Anyone else see a problem here?]
For the purposes of this study, we define residential care as 24-hour group care of children provided by paid staff unrelated to the children. It does not include boarding schools, hospitals, or recreational camps.
[It does include Wilderness]
Two types of residential care are group homes and residential treatment centers. Group homes generally serve 12 children or less and often include children that are the same gender and/or age group. Residential treatment centers usually offer more services to children than group homes and have a more troubled population of children. Residential treatment centers are generally larger than group homes and may house both boys and girls of different ages.
Some children may be placed into residential care as a last resort because they cannot be controlled in a family environment. Children are also placed into these facilities from the mental health and juvenile justices systems, and occasionally by parents. [And Ed Cons]
Title IV-E. Title IV-E of the Social Security Act establishes an open-ended entitlement program that reimburses a portion of States? foster care maintenance costs for children who meet Federal eligibility requirements. Title 42 of the Code of Federal Regulations establishes limits for these payments. It specifies that Federal foster care maintenance payments for child care institutions (residential facilities) are restricted to the ?cost of (and the cost of providing) food, clothing, shelter, daily supervision, school supplies, child?s personal incidentals, liability insurance of child, reasonable travel to the child?s home for visitation,? and administration/operation costs associated with above [42 CFR 675(4)].
The Act defines child-care institutions as either a public child-care institution that accommodates no more than 25 children or a private child-care institution that is not limited in the number of children it can accommodate. In addition, an institution must ?BE LICENSED BY THE STATE IN WHICH IT IS SITUATED or has been approved, by the agency of such State responsible for licensing or approval of institutions of this type, as meeting the standards established for such licensing, but the term shall not include detention facilities, forestry camps, training schools, or any other facility operated primarily for the detention of children who are determined to be delinquent.?
Title IV- E assigns States the responsibility to establish and maintain standards for foster family homes and child care institutions that receive funding under it. These standards should include admissions policies, safety, sanitation, and protection of civil rights. States must arrange for a PERIODIC AND INDEPENDENT AUDIT of the programs that receive Title IV-E. These audits must be conducted at least every three years.
In the early 1980s, under contract with ACF, the CWLA wrote a Model State Licensing Law for the placement of children which addresses, among other things, residential facilities. The Model Law presents generic guidance for the licensing process but does not provide specific standards.
We selected a purposive sample of nine States (California, Florida, Mississippi, New York, Pennsylvania, South Dakota, Tennessee, Texas, Utah.) These States include a geographic mix of large and small States. These nine States represent 40 percent of the national population under age 18 in 1997. The CWLA estimates these nine States also represent over 45 PERCENT OF THE NATIONAL CAPACITY OF RESIDENTIAL FACILITIES.
State Standards Review. We first collected policies, procedures and laws pertaining to the licensing and monitoring of residential facilities from four States. These four States were identified by a child welfare expert as having model standards. The four WERE NOT IN OUR SAMPLE. We then developed a review instrument based on the common licensing practices found in the standards from the four States. Using the instrument, we compared the policies, procedures, and laws collected from our nine sample States to the practices of the model States. This comparison can be found in Table A in the report.
All sample States require facilities to meet applicable building and fire safety standards. All States also have additional building requirements such as minimum square footage of bedrooms, and the provision for recreational space. Many States also mandate safety procedures such as requiring that all toxic chemicals and medications be stored in a locked cabinet.
Eight of the States require the facility director to have at least a bachelor?s degree and related work experience. Four States require that direct care staff have at least a high school diploma. In addition, most States require that employees attend an orientation and have a minimum amount of training each year. Three States require health related training, such as first aid and cardio pulmonary resuscitation.
All sample States require that facilities have a treatment plan for each child. [REALLY???] Seven States also require that progress reports be written for each child on a periodic basis.
Eight of the nine States? standards protect children?s rights, in varying ways, such as their right to have MONEY, BELONGINGS, PHONE CALLS, AND MAIL. The remaining State?s standards do not address these issues. [Wonder which that might be?]
One State prohibits the use of restraints and one State DOES NOT HAVE POLICIES ON THEIR USE. The other seven States either address the use of restraints in their standards or REQUIRE FACILITIES TO DEVELOP THEIR OWN POLICIES. [Isn't that comforting?] Several States require that restrained children be monitored every 10 to 15 minutes. Some States limit the time of restraints. Typically, the restraint must only be used to protect a child from injury to herself or others.
Six States regulate the use of isolation. Two States prohibit its use and another does not address isolation in its policies. Of the six States that regulate, three prohibit the use of a locked room for isolation. Two of the States that allow locked rooms require the isolation be documented and approved or discussed with the child?s placing agency (or parent). Most States limit the time a child can be isolated. The limits range from 1 to 12 hours.
As mentioned in the background of this report, the Model Licensing Law was written by CWLA, under contract with ACF, over 15 years ago. Although it provides guidance to States about licensing procedures, it does not set out specific licensing standards. Furthermore, this model law is not widely known.
Although most States address most standards, as Table A shows, there is some variability. Of the 34 key standards that we identified, only 8 are addressed by all 9 sample States. For instance, two States do not require child abuse background checks of facility staff. Only three States require facility staff to have first aid training. Also, not all States mandate progress reports and medication logs. The most variability among States is in the area of restraints and isolation, where no standard has more than six States addressing it.
State standards generally do not require licensing staff to evaluate the appropriateness of a child?s placement into a facility. Licensing staff members note that this responsibility rests with the CHILD'S PLACING AGENCY. [State, Parent/Guardian/Ed Con] This distinction is ESPECIALLY IMPORTANT IN INTERSTATE CASES when a child from one State is being placed in a residential facility in another States. A previous Office of Inspector General inspection (OEI-02-95-00043) found that States generally RELY ON LICENSING, not separate on-site reviews of facility services, to determine the suitability of residential facilities when they place a child across State lines.
Typically State licensing standards do not set criteria for judging the quality of services in a facility. For example, State standards require that facilities develop a treatment plan for each child but the standards do not offer details on what the plans should include. Most of the State LICENSENSING SPECIALISTS we interviewed feel that the licensing process DOES NOT ENSURE QUALITY OF CARE, nor is it intended to. As one specialist explains, ?the legislation defined our role as HEALTH AND SAFETY, when it comes to program quality it is a BUYER BEWARE SITUATION.?
Review of Program Description. During the application process, eight States require facilities to submit a WRITTEN PROGRAM DESCRIPTION. Typically, it describes the services the facility will offer and how they plan to provide these services. These program descriptions are generally reviewed by the licensing staff. The ninth State reports that although this information is not required, facilities usually provide it.
All but one sample State report monitoring all facilities, on-site, at least once a year. The remaining State reports monitoring facilities on-site, but could not report how often it occurs. All facilities agree that they are monitored by licensing staff on-site at least once a year. A monitoring visit can be either announced or unannounced. Only TWO States conduct UNANNOUNCED VISITS.
Interviews with Staff and Children. In all nine States, the licensing staff member or the licensing specialist report that they interview facility staff and children during monitoring visits. However, facilities in two of the sample States report that these interviews did not occur during their last monitoring visit.
The licensing staff members say that these interviews give them an opportunity to find out WHAT IS ACTUALLY HAPPENING in the facilities on a day-to-day basis. Topics that they discuss with children may include the food, treatment goals, unmet needs, or the child?s interactions with staff (especially disciplinary issues). Most States interview the direct care staff and several States also interview the director of the facility.
Many licensing staff members believe that interviewing is the most important part of the monitoring process. One member says that interviewing shows how the agency is actually doing, rather than just looking at compliance with health and safety standards. Another believes that interviewing allows him to find out if MANAGEMENT'S PHILOSOPHY FOLLOWS THROUGH TO FRONT LINE STAFF.
Two States say they have never revoked a facility license. Instead, States use other techniques. The ACF staff point out that this practice is consistent with commentary in the Model Licensing Law which says that ?children should not be subjected to the trauma that closing a residence would create.? Some States stop new children from being placed in the facility. Other States have the legal authority to impose monetary penalties on a facility that violates licensing standards.
Licensing staff members report that the most common type of violations are safety hazards and problems with the facility records. [Then something's wrong] Common safety hazards range from unlocked toxic substances, inappropriate staff-to-child ratios, and fire code violations to torn carpets and exposed nails. Problems with the facility records generally involve missing documentation, such as an immunization record or a doctor?s report from a child?s medical exam. Staff training requirements not being met is also a common violation.
Reporting. All States are prepared to handle complaints. Licensing staff members say that complaints are usually made by parents, facility staff, or other concerned parties calling the licensing office. In four States, complaints can also be made by calling the State child abuse hotline. States report that the two most common complaints are suspected child abuse and violations of licensing standards, such as inadequate food or inappropriate discipline or treatment of children. Other types of complaints include poor working conditions for the staff and parents being denied access to their children.
[Sound familiar to anyone else?]
State Oversight of Residential Facilities For Children 18 OEI-02-98-00570
All nine States require facilities to report suspected incidents of abuse or neglect. However, ONLY six States require every death or serious injury to be reported to the licensing office. The other States require deaths to be reported to the proper local authorities.
Most State licensing staff members report that they investigate the death of a child. As they do with abuse and neglect investigations, the licensing staff usually work with another specialized unit. These units include the State Department of Internal Affairs, county investigators, child protection unit and State Attorney General. Only one State reports that the licensing staff does not coordinate their investigation with any other agency. [Hmm]
The licensing staff in six States report that facilities are also monitored by their contracting agency. These contracting agencies are usually the county or district offices of the State responsible for placing dependent children into foster care. These agencies often have a contract for some or all of the beds in a residential facility. The contract will outline the services that the facility agrees to provide to the children. The contacting agency monitors this contract to ensure the facility is providing the services. According to ACF Children?s Bureau staff, many of the State child welfare agencies that contract with licensed facilities for placement of children using Title IV-E funds have ADDITIONAL CONTRACTING REQUIREMENTS that are monitored in a variety of ways. Quality and intensity of services issues are generally addressed by these requirements.
Three facilities also have voluntary accreditation and are monitored by the Council on Accreditation (COA). The facilities report that the COA monitoring assesses the quality of the services they provide to children. [Therapeutic or Academic only?]
State licensing standards address the health, protection, and safety of children. They are not intended to ensure the suitability of placement and quality of care. Therefore, placing agents should not use licensure as a substitute for a pre-placement visit when placing children in residential facilities.
While we found that most States address most standards, we note some differences in standards and licensing procedures. Given this variability, we see an opportunity to STRENGTHEN STATE LICENSING AND ENCOURAGE ACF TO TAKE A LEADERSHIP ROLE. [There's someone door to knock on!] By working with States and others ACF can provide training and technical assistance where needed or serve as a focal point for information sharing.
We received comments on the draft report from the Administration for Children and Families (ACF). (See appendix for the full text of the comments.) The ACF agrees that the variability in licensing standards IS A CONCERN. They are taking an outcome-based [?] approach to monitoring States. We think this outcome-based approach is appropriate, at this time. However, we will remain vigilant to potential vulnerabilities in residential care for children.
