1 115TH CONGRESS " 1st Session ! COMMITTEE PRINT S. PRT. 115 –18 AN EXAMINATION OF FOSTER CARE IN THE UNITED STATES AND THE USE OF PRIVATIZATION PREPARED BY THE STAFF OF THE COMMITTEE ON FINANCE UNITED STATES SENATE ORRIN G. HATCH, Chairman RON WYDEN, Ranking Member OCTOBER 2017 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00001 Fmt 6012 Sfmt 6012 R:\DOCS\26354.000 TIMD congress.#13 Printed for the use of the Committee on Finance AN EXAMINATION OF FOSTER CARE IN THE UNITED STATES AND THE USE OF PRIVATIZATION VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00002 Fmt 6019 Sfmt 6019 R:\DOCS\26354.000 TIMD 1 115TH CONGRESS " 1st Session ! COMMITTEE PRINT S. PRT. 115 –18 AN EXAMINATION OF FOSTER CARE IN THE UNITED STATES AND THE USE OF PRIVATIZATION PREPARED BY THE STAFF OF THE COMMITTEE ON FINANCE UNITED STATES SENATE ORRIN G. HATCH, Chairman RON WYDEN, Ranking Member OCTOBER 2017 Printed for the use of the Committee on Finance U.S. GOVERNMENT PUBLISHING OFFICE WASHINGTON 26–354—PDF : 2017 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00003 Fmt 5012 Sfmt 6012 R:\DOCS\26354.000 TIMD congress.#13 For sale by the Superintendent of Documents, U.S. Government Publishing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800 Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001 COMMITTEE ON FINANCE ORRIN G. HATCH, Utah, Chairman CHARLES E. GRASSLEY, Iowa RON WYDEN, Oregon MIKE CRAPO, Idaho DEBBIE STABENOW, Michigan PAT ROBERTS, Kansas MARIA CANTWELL, Washington MICHAEL B. ENZI, Wyoming BILL NELSON, Florida JOHN CORNYN, Texas ROBERT MENENDEZ, New Jersey JOHN THUNE, South Dakota THOMAS R. CARPER, Delaware RICHARD BURR, North Carolina BENJAMIN L. CARDIN, Maryland JOHNNY ISAKSON, Georgia SHERROD BROWN, Ohio ROB PORTMAN, Ohio MICHAEL F. BENNET, Colorado PATRICK J. TOOMEY, Pennsylvania ROBERT P. CASEY, Jr., Pennsylvania DEAN HELLER, Nevada MARK R. WARNER, Virginia TIM SCOTT, South Carolina CLAIRE MCCASKILL, Missouri BILL CASSIDY, Louisiana A. JAY KHOSLA, Staff Director JOSHUA SHEINKMAN, Democratic Staff Director INVESTIGATIVE STAFF Senate Finance Committee Majority Staff KIMBERLY BRANDT, Chief Oversight Counsel DONALD ABBOTT, U.S. Secret Service Detailee BECKY SHIPP, Health and Human Services Policy Advisor JOHN A. CARLO, Senior Oversight Counsel Senate Finance Committee Minority Staff IAN M. NICHOLSON, Investigator EMILY DOUGLAS, SRCD/AAAS Congressional Fellow DAVID M. BERICK, Chief Investigator LAURA BERNTSEN, Chief Human Services Advisor DOUGLASS V. CALIDAS, Legislative Fellow (II) VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00004 Fmt 0486 Sfmt 0486 R:\DOCS\26354.000 TIMD CONTENTS Page Executive Summary ................................................................................................. I. Introduction .......................................................................................................... II. Overview of the Problem and Justification for the Committee Investigation ........................................................................................................................ A. Child Abuse and Neglect and Foster Care ................................................ B. Federal Financing of Foster Care Services ................................................ C. Recent Committee History on Foster Care and Related Issues ............... D. Initial Media Reports About For-Profit Foster Care and Children’s Deaths ............................................................................................................ E. MENTOR and Private Foster Care Agencies ............................................ F. Therapeutic Foster Care .............................................................................. III. The Committee’s Investigation and Surveys of the States: Foster Care Services and Performance ................................................................................... A. The 50-State Overview Letter and Request .............................................. B. The 5-State In-Depth Letter and Request ................................................. C. U.S. HHS Child and Family Services Reviews ......................................... D. The MENTOR Letter and Request ............................................................ IV. Findings From the Committee’s Investigations and Surveys ........................ A. Use of Private Child Welfare Services ....................................................... B. Background Checks ..................................................................................... C. Child Welfare Workforce Operations and Concerns ................................. D. Physical and Mental Well-Being of Children in Foster Care .................. E. Failure to Identify and Respond to Risk to Children ............................... F. Actions When Maltreatment Is Substantiated in Foster Homes ............. G. MENTOR Incident Reports ........................................................................ H. MENTOR Mortality Report ........................................................................ I. Financial Settlements From MENTOR ....................................................... V. Oversight of Child Welfare Services and Protecting Vulnerable Children .... VI. Conclusions ........................................................................................................ VII. Recommendations ............................................................................................ Recommendations for States and Tribes ........................................................ Recommendations for the Department of Health and Human Services (HHS) ............................................................................................................. Recommendations for Congress ....................................................................... Appendix A—50-State Overview Letter ................................................................. Appendix B—Responses to 50-State Overview Letter .......................................... Exhibit 1—Response From Alabama, Department of Human Resources .... (III) VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00005 Fmt 5904 Sfmt 5904 R:\DOCS\26354.000 TIMD 1 2 3 3 3 4 5 6 8 8 8 9 10 10 11 11 13 14 16 17 18 20 23 26 27 29 31 31 31 32 35 38 39 IV Page Appendix B—Responses to 50-State Overview Letter—Continued Exhibit 2—Response From Alaska, Department of Health and Social Services .......................................................................................................... Exhibit 3—Response From Arkansas, Office of the Governor ...................... Exhibit 4—Response From California, Health and Human Services Agency, Department of Social Services ............................................................... Exhibit 5—Response From Colorado, Office of the Governor ....................... Exhibit 6—Response From Connecticut, Department of Children and Families ......................................................................................................... Exhibit 7—Response From Delaware, Department of Services for Children, Youth, and Their Families ................................................................. Exhibit 8—Response From Guam, Department of Public Health and Social Services ................................................................................................... Exhibit 9—Response From Hawaii, Office of the Governor .......................... Exhibit 10—Response From Illinois, Department of Children and Family Services .......................................................................................................... Exhibit 11—Response From Indiana, Department of Child Services .......... Exhibit 12—Response From Iowa, Department of Human Services ............ Exhibit 13—Response From Kansas, Department for Children and Families .................................................................................................................. Exhibit 14—Response From Kentucky, Cabinet for Health and Family Services .......................................................................................................... Exhibit 15—Response From Maryland, Department of Human Resources . Exhibit 16—Response From Massachusetts, Office of the Governor ........... Exhibit 17—Response From Minnesota, Department of Human Services .. Exhibit 18—Response From Nebraska, Office of the Governor .................... Exhibit 19—Response From New Hampshire, Department of Health and Human Services ............................................................................................ Exhibit 20—Response From New Jersey, Department of Children and Families ......................................................................................................... Exhibit 21—Response From New Mexico ....................................................... Exhibit 22—Response From New York, Office of Children and Family Services .......................................................................................................... Exhibit 23—Response From North Dakota .................................................... Exhibit 24—Response From Oklahoma, Department of Human Services ... Exhibit 25—Response From Oregon, Office of the Governor ........................ Exhibit 26—Response From Pennsylvania, Department of Human Services .................................................................................................................. Exhibit 27—Response From South Dakota, Office of the Governor and the Department of Social Services ............................................................... Exhibit 28—Response From Tennessee, Department of Children’s Services .................................................................................................................. Exhibit 29—Response From Texas, Department of Family and Protective Services .......................................................................................................... Exhibit 30—Response From Utah, Department of Human Services ........... Exhibit 31—Response From Washington, Department of Social and Health Services ............................................................................................. Exhibit 32—Response From West Virginia, Department of Health and Human Resources ......................................................................................... Exhibit 33—Response From Wisconsin, Department of Children and Families ................................................................................................................. Exhibit 34—Response From Wyoming, Department of Family Services ..... Appendix C—5-State In-Depth Letters .................................................................. Exhibit 1—Letter to Georgia, Department of Community Health ............... VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00006 Fmt 5904 Sfmt 5904 R:\DOCS\26354.000 TIMD 47 51 55 62 66 69 74 79 82 88 93 97 101 107 114 120 126 130 134 139 153 158 162 166 172 179 184 189 201 206 209 213 219 222 223 V Page Appendix C—5-State In-Depth Letters—Continued Exhibit 2—Letter to Illinois, Department of Children and Family Services .................................................................................................................. Exhibit 3—Letter to Massachusetts, Department of Children and Families .................................................................................................................. Exhibit 4—Letter to Maryland, Department of Human Resources .............. Exhibit 5—Letter to Texas, Department of Family and Protective Services .................................................................................................................. Appendix D—Congressional Research Service Memorandum on the U.S. HHS Children and Family Services Reviews .............................................................. Appendix E—Letter to The MENTOR Network ................................................... Appendix F—MENTOR Level 4 Incident Reports ................................................ Appendix G—MENTOR Mortality Report and Backup Data .............................. Exhibit 1—Foster Care Mortality Analysis .................................................... Exhibit 2—Backup Data and Explanation of Mortality Analysis ................ VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00007 Fmt 5904 Sfmt 5904 R:\DOCS\26354.000 TIMD 228 233 238 243 248 275 282 606 607 613 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00008 Fmt 5904 Sfmt 5904 R:\DOCS\26354.000 TIMD AN EXAMINATION OF FOSTER CARE IN THE UNITED STATES AND THE USE OF PRIVATIZATION EXECUTIVE SUMMARY Foster care placements for children who are victims of abuse and neglect have historically been managed by a combination of private and public resources. However, the need for specialized foster care services and a shortage of foster care homes in recent years has led to the privatization of many core foster care services. Today, both non-profit and for-profit private agencies contract with and provide foster care services on behalf of State agencies. In 2015, 671,000 children in the United States were provided out-of-home foster care services. There are no official statistics on what proportion of these children received contracted foster care, case management, or other services. State child welfare agencies report they have procedures in place to monitor child welfare providers’ performance and outcomes. But this investigation conducted by the bipartisan staff of the U.S. Senate Finance Committee shows that these policies are not always followed; exceptions are made, waivers are granted, profits are prioritized over children’s well-being, and sometimes those charged with keeping children safe look the other way. High turnover among staff sometimes makes it impossible to develop case plans to ensure that children are ‘‘on-track.’’ Foster parents with questionable backgrounds, who lack the skills to provide care to vulnerable children, are given licenses to parent challenging children, and these children are then inadequately monitored. The outcome of this investigation shows that the child welfare system does not always protect children. The data collection and oversight structures at both the State and Federal levels make it difficult and sometimes impossible to monitor the operations of the child welfare system, as well as its private contractors. A recent bout of national media attention concerning questionable behavior by private for-profit agencies, abuse and neglect by foster parents working for those providers, and in some instances abuse and neglect which caused children’s deaths, led the Finance Committee to investigate this issue. As the Finance Committee has primary jurisdiction over Federal child welfare and foster care funding and policy (largely through the Social Security Act), the Committee launched an investigation in April 2015 to examine the privatization of foster care services. One specific private company, The MENTOR Network, one of the largest for-profit providers of foster care services in the United States, was used as a case study to highlight the problems that exist with the privatization of human services. This report documents the findings of this inves(1) VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 2 tigation and reveals problems with child welfare contracting practices as well as public agency oversight of such contracts and services. The investigation was conducted by collecting information from public child welfare agencies across the Nation concerning their general policies and practices, including how they contract with and monitor private agencies. The Committee also gathered information from The MENTOR Network, specifically, by reviewing incident reports about the deaths of children in the company’s care, an internal ‘‘mortality report,’’ legal settlements, case notes, foster parent applications, and other related documentation. The Committee staff concluded that children who are under the legal authority of their State, yet receive services from private forprofit agencies, have been abused, neglected, and denied services. The very agencies charged with and paid to keep foster children safe too often failed to provide even the most basic protections, or to take steps to prevent the occurrence of tragedies. In MENTOR’s case in particular, investigations into fatalities were never followed up after the fact; autopsy reports which were pending years ago were excluded from files; and the vast majority of children who died were not the subject of internal investigations, even when their deaths were unexpected. The MENTOR Network issued a report which falsely claimed that its death rates are in line with national death rates and the rates of death among all children in the foster care system. Moreover, families of these and other victims of inadequate care have received millions of dollars in financial settlements, significant enough for The MENTOR Network to receive less favorable terms from its insurer. As the role of private for-profit and non-profit providers of foster care services has grown, oversight of these entities by State agencies—as well as Federal oversight of the States—has been inadequate. The Finance Committee staff has made recommendations to HHS, the States, and to Congress addressing these shortcomings. I. INTRODUCTION The privatization of foster care, and specifically for-profit foster care, has been a growing trend in the delivery of child welfare services over the past few decades.1 Recent national media attention concerning questionable performance by these private agencies, including abuse and neglect by foster parents working for these agencies, and in some instances abuse and neglect which led to children’s deaths, led the Senate Finance Committee (hereinafter, the ‘‘Committee’’ or ‘‘SFC’’) to investigate these issues. The Committee has jurisdiction over Federal child welfare and foster care funding and policy in the United States, and thus has a responsibility in ensuring children receive the most suitable placements to appropriately support their healthy development. Chairman Hatch and Ranking Member Wyden launched an investigation in April 2015 to examine the privatization of foster care 1 Flaherty, C., Collins-Camargo, C. and Lee, E., ‘‘Privatization of child welfare services: Lessons learned from experienced states regarding site readiness assessment and planning.’’ Children and Youth Services Review, Vol. 30, No. 7, pp. 809–820, http://www.sciencedirect.com/ science/article/pii/S0190740907002538. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 3 services within the context of the larger child welfare system. One specific private company, The MENTOR Network (hereinafter, ‘‘MENTOR’’), was used as a case study in order to highlight some of the problems that exist with the privatization of human services in general. At the time the Committee initiated the investigation, MENTOR reported it was the ‘‘leading provider of home- and community-based health and human services to must-serve individuals and families.’’ 2 MENTOR continues to make this claim today.3 This report documents the findings of this investigation and reveals problems with child welfare contracting practices as well as public agency oversight of such contracts and services. II. OVERVIEW OF THE PROBLEM AND JUSTIFICATION FOR THE COMMITTEE INVESTIGATION A. CHILD ABUSE AND NEGLECT AND FOSTER CARE According to the National Child Abuse and Neglect Data System (NCANDS), in 2015 there were 683,000 children who were victims of abuse or neglect in the United States, representing a rate of 9.2 victims per 1,000 U.S. children.4 In instances where children are abused or neglected and cannot safely remain at home or with relatives, they are placed in foster care. According to the Adoption and Foster Care Analysis and Reporting System (AFCARS), 671,000 children were served by the foster care system in 2015 either because they were already in foster care, or because they newly entered foster care that year.5 When children are placed in foster care, they are most often placed in one of three settings: nonrelative foster care (45%), relative/kinship care (30%), or institutions/group homes (14%).6 Foster care placements can occur either through a child’s State or public child welfare agency, or through private entities that contract with public child welfare agencies to find placements for children. These private organizations can be non-profit or for-profit agencies. The private agencies that were the focus of this report (specifically MENTOR) provide non-relative foster care for children outside of institutional settings. B. FEDERAL FINANCING OF FOSTER CARE SERVICES The Committee has jurisdiction over many areas of public finance including the Internal Revenue Code, major health-care programs such as Medicare and Medicaid, and Social Security. Federal 2 Civitas Solutions, Inc., U.S. Securities and Exchange Commission, 2014 10–K filing for the fiscal year ending September 30, 2014, https://www.sec.gov/Archives/edgar/data/1608638/ 000119312514445499/d798786d10k.htm. 3 Civitas Solutions, Inc., U.S. Securities and Exchange Commission, 2017 10–Q filing for the quarterly period ending March 31, 2017, https://www.sec.gov/Archives/edgar/data/1608638/ 000160863817000017/civi3311710q.htm. 4 U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, ‘‘Child Maltreatment 2015,’’ Report, January 2017, https://www.acf.hhs.gov/ sites/default/files/cb/cm2015.pdf. 5 U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, ‘‘Trends in Foster Care and Adoption,’’ Published: June 30, 2016, last reviewed: March 13, 2017, https://www.acf.hhs.gov/cb/resource/trends-in-foster-care-and-adoption-fy15. 6 U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, ‘‘Foster Care Statistics 2015,’’ Report, pp. 2–4, March 2017, https:// www.childwelfare.gov/pubpdfs/foster.pdf. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 4 child welfare policy is largely guided by the Social Security Act, originally established in 1935.7 Foster care services are partly funded through titles IV–B and IV–E of the Social Security Act. In addition, services and supports for children and their families, including foster care, can be funded through title XX and title IV– A of the Social Security Act. Federal assessment and monitoring of State child welfare systems are also covered by title IV–E. Thus, potential misuse or mismanagement of these funds to place children in foster homes where they may potentially be unsafe is of keen interest to the Committee. C. RECENT COMMITTEE HISTORY ON FOSTER CARE AND RELATED ISSUES The Committee and its members have a long history of working to improve the State and Federal child welfare systems. For decades, the child welfare advocacy and provider communities, as well as families and children impacted by the system, have recognized that the government is no substitute for a family when it comes to raising children. Frequent news stories highlighting traumatic experiences children in foster care sometimes face have led Congress to take steps to improve the system in two key ways: first, to do more to ensure that foster care is an intervention used only when in the best interest of the child; and second, to ensure that when foster care is necessary, it is of the highest possible quality and promotes normalcy. In the 114th Congress, the Committee held several hearings and roundtable discussions related to the child welfare system, its incentives, and its funding structure. Specifically, in May 2015, the Committee held a hearing entitled ‘‘No Place to Grow Up: How to Safely Reduce Reliance on Foster Care Group Homes.’’ 8 The purpose of the hearing was to examine how Congress can best address the challenges facing foster children and protect them from the unfit environment and risk of sex trafficking found in group homes. In August 2015, the Committee held a hearing entitled, ‘‘A Way Back Home: Preserving Families and Reducing the Need for Foster Care.’’ 9 Its purpose was to explore safe alternatives to foster care and better understand the interventions, services, and funding mechanisms States and Tribes are using—or would like to use—to help keep families and children safely together. And in February 2016, the Committee held a hearing entitled ‘‘Examining the Opioid Epidemic: Challenges and Opportunities.’’ 10 The purpose of this hearing was to examine the opioid abuse epidemic and its effect on the health and child welfare systems, as well as to consider solutions. Committee members heard testimony detailing the links 7 U.S. Social Security Administration, Social Security Act of 1935, https://www.ssa.gov/history/35act.html. 8 U.S. Senate Finance Committee, ‘‘No Place to Grow Up: How to Safely Reduce Reliance on Foster Care Group Homes,’’ Committee Hearing, 114th Congress, May 19, 2015, https:// www.finance.senate.gov/imo/media/doc/20209.pdf. 9 U.S. Senate Finance Committee, ‘‘A Way Back Home: Preserving Families and Reducing the Need for Foster Care,’’ Committee Hearing, 114th Congress, August 4, 2015, https://www. finance.senate.gov/imo/media/doc/20779.pdf. 10 U.S. Senate Finance Committee, ‘‘Examining the Opioid Epidemic: Challenges and Opportunities,’’ Committee Hearing, 114th Congress, February 23, 2016, https://www.finance. senate.gov/imo/media/doc/23291.pdf. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 5 between rising opioid use and fatalities and the corresponding strain on State foster care systems. As a result of these hearings and working closely with stakeholders from the foster care provider community, State groups, advocates, and current and former foster youth, the chairman and ranking member developed a bipartisan proposal, ‘‘The Family First Act.’’ Working with House Ways and Means Committee Chairman Brady and Ranking Member Levin, Chairman Hatch and Ranking Member Wyden introduced the bipartisan / bicameral ‘‘Family First Prevention Services Act of 2016’’ (H.R. 5456/S. 3065).11 The House of Representatives passed H.R. 5456 by voice vote on June 21, 2016.12 The goal of this legislation was to increase the availability of prevention services so that more children can stay at home with their families and avoid the trauma associated with foster care when safely possible. The legislation also aimed to reduce the unnecessary use of congregate care and group homes. While the legislation ultimately was not enacted into law, the Committee continues to work to advance the goals of the legislation. The findings of this investigation underscore the importance of holding States accountable for their child welfare system management and outcomes, as well as providing States with the tools necessary to improve their capacity to both prevent foster care (when it is possible to do so without jeopardizing the safety of children) and to ensure that children who enter foster care are safe from harm. D. INITIAL MEDIA REPORTS ABOUT FOR-PROFIT FOSTER CARE AND CHILDREN’S DEATHS In 2015, BuzzFeed News 13 and Mother Jones 14 reported similar stories concerning the private, for-profit foster care company, MENTOR. The reports provided evidence of a company that prioritizes profits over children’s well-being; a company that skirted corners when screening foster parents, that increased social workers’ caseloads, that hired unlicensed workers, and whose primary mission was to ‘‘fill beds’’ in order to increase company profits. According to these reports, children were placed in homes with individuals who had been convicted of kidnapping and other serious crimes, with parents who had substance abuse problems, and in homes where caretakers had previous ‘‘failed’’ foster care placements. Some children were deprived of emotional care, were sexually abused, and even beaten to death in their foster homes. The news articles included both allegations of wrong-doing and information that was substantiated through criminal trials and lawsuit settlements to families of the children who had been harmed. 11 S. 3065: ‘‘Family First Prevention Services Act of 2016,’’ 114th Congress, https:// www.congress.gov/bill/114th-congress/senate-bill/3065; see also: Kelly, John, ‘‘Massive child welfare Finance bill planned for 2016,’’ The Chronicle of Social Change, December 18, 2015, https://chronicleofsocialchange.org/child-welfare-2/massive-child-welfare-finance-bill-plannedfor-2016/14890. 12 H.R. 5456: ‘‘Family First Prevention Services Act of 2016, Actions/Overview,’’ 114th Congress, https://www.congress.gov/bill/114th-congress/house-bill/5456/actions. 13 Roston, Aram and Singer-Vine, Jeremy, ‘‘Fostering Profits,’’ BuzzFeed News, February 20, 2015, https://www.buzzfeed.com/aramroston/fostering-profits?utm_term=.xwMQrm3yR#.qfOw 1kDqO. 14 Joseph, Brian, ‘‘The Brief Life and Private Death of Alexandria Hill,’’ Mother Jones, October 26, 2015, http://www.motherjones.com/politics/2015/02/privatized-foster-care-mentor/. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 6 The Committee received numerous questions and expressions of concern from the public as a result of these news accounts. The chairman and ranking member also felt strongly that the allegations in the press accounts deserved a more thorough examination. As a result, the chairman and ranking member directed the majority and minority oversight teams to investigate the issue of privatization within the foster care system using MENTOR as a case study, as it is among the largest providers of private foster care services in the United States.15, 16 Because the Committee did not conduct an in-depth investigation of other providers, direct comparisons cannot be made with other private providers. However, it did collect State-level data on the performance of other for-profit and non-profit providers, and it is also notable that MENTOR is by no means alone when it comes to negative attention and questionable practices. For example, the following headlines demonstrate that contracting practices, provider quality, and inadequate oversight issues are rampant across States and providers: • ‘‘Foster care scandal deepens: ‘Every single staff person has a criminal record’ ’’ (The Oregonian, January 9, 2016).17 • ‘‘Federal Judge: Texas Foster Care System Violates Children’s Rights’’ (The Texas Tribune, December 17, 2015).18 • ‘‘Suit Alleges Widespread Deficiencies in South Carolina Foster Care’’ (The New York Times, January 12, 2015).19 • ‘‘Report Finds ‘Blatant Lack of Oversight By DCF’ In Licensing of Foster Home Where Toddler Died’’ (WBUR News, October 1, 2015).20 • ‘‘State Must Step up on Foster Care Deaths’’ (The Courier, June 11, 2017).21 • ‘‘Minnesota Faces Penalties for Failed Placements of Foster Children’’ (The Star Tribune, February 10, 2014).22 E. MENTOR AND PRIVATE FOSTER CARE AGENCIES MENTOR, headquartered in Boston, Massachusetts, is a for-profit service agency that describes itself as a ‘‘national network of local health and human services providers in 35 States offering an 15 McBeath, Bowen, Collins-Camargo, Crystal, and Chuang, Emmeline, ‘‘Portrait of Private Agencies in the Child Welfare System: Principal Results From the National Survey of Private Child and Family Serving Agencies,’’ National Quality Improvement Center on the Privatization of Child Welfare Services, September 2011, http://muskie.usm.maine.edu/helpkids/public privateresources/nspcfsareportfinal.pdf. 16 Civitas Solutions, Inc., 2014 10–K filing (September 30, 2014). See Footnote 2. 17 Theriault, Dennis C., ‘‘Foster care scandal deepens: ‘Every single staff person has a criminal record,’ ’’ The Oregonian, January 9, 2016, http://www.oregonlive.com/politics/index.ssf/2016/ 01/foster_care_scandal_deepens.html. 18 Walters, Edgar and Ramshaw, Emily, ‘‘Federal Judge: Texas Foster Care System Violates Children’s Rights,’’ The Texas Tribune, December 17, 2015, https://www.texastribune.org/2015/ 12/17/judge-foster-care-system-violates-childrens-rights/. 19 Blinder, Alan, ‘‘Suit Alleges Widespread Deficiencies in South Carolina Foster Care,’’ The New York Times, January 12, 2015, https://www.nytimes.com/2015/01/13/us/suit-allegeswidespread-deficiencies-in-south-carolina-foster-care.html?_r=2. 20 Conway, Abby Elizabeth, ‘‘Report Finds ‘Blatant Lack of Oversight by DCF’ in Licensing of Foster Home Where Toddler Died,’’ WBUR News, October 1, 2015, http://www.wbur.org/ news/2015/10/01/auburn-foster-child-death-investigation. 21 Hines, Doug, ‘‘State Must Step up on Foster Care Deaths,’’ The Courier, June 11, 2017, http://wcfcourier.com/opinion/editorial/state-must-step-up-on-foster-care-deaths/article_b4d69f 95-4402-54ac-a294-83ce38eb1625.html. 22 Serres, Chris, ‘‘Minnesota faces penalties for failed placements of foster children,’’ The Star Tribune, February 10, 2014, http://www.startribune.com/state-faces-penalties-for-failed-placements-of-foster-children/244571021/. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 7 array of quality, community-based services to adults and children[. . .].’’ 23 It is owned by Civitas Solutions, Inc., a publicly traded company. Civitas is majority owned (approximately 68%) by Vestar Capital Partners and management investors.24 Public investors hold roughly 32% of the company according to the company’s filings with the Securities and Exchange Commission (SEC).25 The group emphasizes its work with higher-risk youth in foster care, particularly those with intellectual or developmental disabilities, or who are medically fragile. According to information reported in MENTOR’s SEC filings for 2014, it was the leading provider of human services to 29,100 clients in 36 States during that year—12,600 in residential settings and 16,500 in non-residential settings.26 With regard to the foster care population, which is the focus of the Committee’s investigation, MENTOR served 10,300 at-risk children, adolescents, and their families in 18 different States in 2014. By way of comparison, according to a 2011 national survey of non-profit and for-profit private child welfare agencies conducted by the National Quality Improvement Center on the Privatization of Child Welfare Services, only 13 child and family-serving agencies, or 3%, provided services in more than one State.27 This survey also showed that nationally the largest private agency budgets range from $17 million to $140 million. Again, for comparison, in 2014 MENTOR reported to the SEC that its gross revenue for serving at-risk youth was $203 million and that its net revenue for this same population was about $198 million.28 Private child welfare agencies across the country largely rely on public government contracts in order to provide services to children and families. In 2011, half of the surveyed child and family-serving agencies reported that almost 100% of their revenue came from public contracts.29 This is also the case for MENTOR.30 The Committee focused on MENTOR’s work as a provider of foster care services, since it was one of the largest providers of those services nationally. At the time the Committee began its investigation, MENTOR provided foster care services to thousands of children who are involved with their State’s child welfare system. As recently as 2015, MENTOR provided foster care services to children in 15 different States.31 Since the Committee launched its investigation, MENTOR has withdrawn from a number of States. During FY 2015, MENTOR discontinued at-risk youth services in 23 ‘‘The MENTOR Network.’’ Available on the company’s website, http://thementornetwork .com/. 24 On its own, Vestar owns 53% of the company’s shares according to the Civitas Solutions, Inc. U.S. Securities and Exchange Commission 2016 10–K filing for the fiscal year ending September 30, 2016, https://www.sec.gov/Archives/edgar/data/1608638/000162828016022032/ civi-930201610xk.htm. 25 Civitas Solutions, Inc., 2014 10–K filing (September 30, 2014). See Footnote 2. 26 The Committee began its investigation in 2015, which is why 2014 SEC information is reported here. See Footnote 2. 27 McBeath, B., Collins-Camargo, C., and Chuang, E. See Footnote 15. 28 Civitas Solutions, Inc., 2014 10–K filing (September 30, 2014). See Footnote 2. 29 McBeath, B., Collins-Camargo, C., and Chuang, E. See Footnote 15. 30 Statement by Civitas Solutions: ‘‘We derive approximately 90% of our revenue from contracts with state and local government agencies, and a substantial portion of this revenue is state-funded with federal Medicaid matching dollars,’’ 2014 10–K filing, p. 16. See Footnote 2. 31 Roston, A. and Singer-Vine, J. See Footnote 13. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00015 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 8 the States of Florida, Louisiana, Indiana, North Carolina, and Texas.32 F. THERAPEUTIC FOSTER CARE In representations to the Committee, MENTOR claims to largely serve high-risk children classified as in need of therapeutic foster care (TFC) because they are medically complex or fragile. There is no uniform definition of TFC in the field or in statute, but the Foster Family-based Treatment Association describes it as ‘‘a clinical intervention, which includes placement in specifically trained foster parent homes, for youth in foster care with severe mental, emotional, or behavioral health needs. This includes medically fragile or developmentally delayed youth whose physical and emotional health needs require more intensive clinical and medical intervention than can be accommodated in traditional foster care.’’ 33 Many States claim reimbursements from Medicaid for components of TFC services. A 2015 report by the Medicaid and CHIP Payment and Access Commission noted that 3% of child Medicaid enrollees receive TFC services.34 States may also claim reimbursement under title IV–E for some of the costs associated with TFC. There is significant variation across States and providers both with regard to eligibility for and the provision of services related to TFC. A study that was commissioned and funded by MENTOR showed that 17.3% of U.S. children in foster care were in TFC-level placements.35 MENTOR reports that 75% of its caseload is comprised of TFC-level placements.36 In its 2014 SEC filings, MENTOR reported billing Medicaid for the provision of at-risk youth services.37 III. THE COMMITTEE’S INVESTIGATION AND SURVEYS OF THE STATES: FOSTER CARE SERVICES AND PERFORMANCE A. THE 50-STATE OVERVIEW LETTER AND REQUEST In April 2015, the Committee requested information from all 50 governors regarding their States’ privatization of child welfare and / or foster care services.38 For example, the Committee asked each State to describe its process used to select and contract with private agencies providing child welfare services as well as the process 32 Civitas Solutions, Inc., 10–Q filing for the period ending March 31, 2017, p. 20. See Footnote 3. (Note: Illinois terminated its contract with AHS/MENTOR on July 1, 2015.) 33 Boyd, Laura W., ‘‘Therapeutic Foster Care: Exceptional Care for Complex, TraumaImpacted Youth in Foster Care,’’ State Policy Advocacy and Reform Center, Report, July 2013, https://childwelfaresparc.files.wordpress.com/2013/07/therapeutic-foster-care-exceptional-carefor-complex-trauma-impacted-youth-in-foster-care.pdf. 34 Medicaid and CHIP Payment and Access Commission (MACPAC), ‘‘Report to Congress on Medicaid and CHIP,’’ Report, June 2015, https://www.macpac.gov/wp-content/uploads/2015/ 06/June-2015-Report-to-Congress-on-Medicaid-and-CHIP.pdf. 35 Gonyea, J.G., Bachman, S.S., Rajabiun, S., Springwater, J.S., Tobias, C.R., Hirschi, M. and Little, F., ‘‘The 50 State Chartbook on Foster Care.’’ Retrieved March 28, 2017. As originally cited on p. 5 of the MENTOR Mortality Report in Appendix G, Exhibit 1, http://www.bu.edu/ ssw/research/usfostercare/. 36 The MENTOR Network, ‘‘Backup Data and Explanation of Mortality Analysis Final,’’ March 2016. Supplied by MENTOR to the Finance Committee. See Appendix G, Exhibit 2. 37 Statements by Civitas Solutions: ‘‘We derive approximately 90% of our revenue from contracts with state and local government agencies, and a substantial portion of this revenue is state-funded with federal Medicaid matching dollars,’’ p. 16; ‘‘We derive revenues for our I/DD and ARY services and a significant portion of our SRS services from Medicaid programs,’’ p. 9. See Footnote 2. 38 See Appendix A for the complete 50-State Overview Letter. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 9 used to inspect the safety of foster care settings in which children are placed. The Committee also asked States to outline how they investigate and respond to allegations and substantiations of maltreatment when a child is in out-of-home care. Thirty-three (33) States responded to that request with information prepared by their child welfare administrators (see Appendix B for State responses to the 50-State Overview Letter).39 B. THE 5-STATE IN-DEPTH LETTER AND REQUEST In March 2016, the Committee sent in-depth inquiries to five States regarding their child welfare operations in order to obtain more information about MENTOR and its affiliates as well as other for-profit and non-profit providers in each State.40 The request for additional information was sent to the directors of the State child welfare agencies in Georgia, Illinois, Maryland, Massachusetts, and Texas. These States were selected because they were served by MENTOR and highlighted in news accounts that documented serious allegations of mismanagement of services and mistreatment of children served by private foster care agencies. As of today, MENTOR still provides foster care services in Georgia, Maryland, and Massachusetts; it no longer provides those services in Illinois or Texas. The primary goal of the request for additional information was to compare performance indicators of the public agencies and private agencies providing foster care services. The Committee sought information related to standard performance measures for foster care using the Child and Family Services Reviews’ (CFSRs) performance metrics as a basis (see subsection C below). Among the many questions directed to the State agencies, SFC staff focused on the following information from these select States: • Physical and behavioral subgroups (special needs, physically disabled, infants, etc.); • Maltreatment during a foster care episode; • Rate of maltreatment in foster care; • Permanency outcomes (reunification, adoption, guardianship); • Physical and mental health screenings of children in foster care; • Children receiving monthly caseworker visits; • Average caseload for each caseworker employed by the contractor; and • Total cost to the State under the contract. Four out of five States complied with the Committee’s request for this detailed information. Despite repeated contact with the Commonwealth of Massachusetts, its public child welfare agency never 39 The States that responded: Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Delaware, Guam, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Utah, Washington, West Virginia, Wisconsin, and Wyoming. 40 See Appendix C for copies of the 5-State In-Depth letters. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00017 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 10 complied with official requests from the Committee to provide the requested in-depth information.41 In addition to the performance metrics, the Committee also asked these five States for copies of any rankings or reviews of contractors, as well as performance and investigative reports of MENTOR, particularly in the case of reports relating to the death, sexual abuse, or injury to a child while in the care or custody of foster parents recruited or employed by MENTOR. Each of the four responding States complied with this request. In addition, Illinois provided Committee staff an extensive ‘‘Statewide Specialized Foster Care Review’’ focused on Alliance Human Services/Illinois MENTOR, which was conducted prior to the State terminating services with the company.42 (The Committee’s initial official requests for information from State child welfare agencies are in Appendices A and C.) C. U.S. HHS CHILD AND FAMILY SERVICES REVIEWS The Children’s Bureau in U.S. Department of Health and Human Services (HHS) conducts Child and Family Services Reviews (CFSRs), which are periodic reviews of State child welfare systems, to achieve three goals: (1) ensure conformity with Federal child welfare requirements; (2) determine what is actually happening to children and families as they are engaged in child welfare services; and (3) assist States in helping children and families achieve positive outcomes. The first CFSR round began in 2001. HHS is currently conducting the third round of CFSRs between 2015 and 2018. In October 2016, SFC staff asked the Congressional Research Service (CRS) to provide a compilation and ranking of State-level data and indicators from AFCARS that are used in the CFSR assessments (see Appendix D).43 The CRS analysis provided the Committee with national data concerning the performance of all States in the country, including those States that did not respond directly to the Committee’s requests. D. THE MENTOR LETTER AND REQUEST The Committee sent its first letter to Bruce Nardella, the President and CEO of MENTOR, in June 2015. This initial letter and correspondence requested information about the company’s structure, performance, and standards. Specifically, the Committee requested the total number of children served nationwide; copies of assessments and performance reviews conducted on MENTOR; average caseloads of MENTOR caseworkers; processes for investigating, vetting, and training potential foster parents; details surrounding the use of bonuses for placing children; processes for handling allegations of misconduct against foster caregivers; copies of settlement agreements entered into by MENTOR since 2005; total 41 For purposes of clarification, Massachusetts did respond to the initial 50-State Letter to provide overview information about their State, but did not submit any documentation to the Committee in response to the 5-State In-Depth Letter. 42 Illinois Department of Children and Family Services, Division of Quality Assurance and Research. ‘‘Alliance/Illinois MENTOR Statewide Specialized Foster Care Review,’’ Report, August 8, 2014, Print. 43 Stoltzfus, Emilie, Memorandum prepared by the Congressional Research Service: ‘‘Statewide data indicators used in the Child and Family Services Review (CFSR),’’ October 27, 2016. Available in Appendix D. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 11 funding received from States; nondisclosure/confidentiality clauses; and critical incident reports. Additionally, because MENTOR operates under different names in different States, questions regarding its corporate structure, affiliates, and related organizations were asked as well.44 (The Committee’s official request for information from MENTOR is available in Appendix E.) IV. FINDINGS FROM THE COMMITTEE’S INVESTIGATIONS AND SURVEYS A. USE OF PRIVATE CHILD WELFARE SERVICES One of the first goals of the Finance Committee’s investigation was to determine the extent to which States use or rely on contracted child welfare services. Information obtained by the Committee from the initial 50-State Letter shows that of the 33 States that responded, 31 use private agencies to provide services to children in foster care and 16 of these States contract with for-profit and non-profit providers. The nature of contracted services provided by the entities described in responses to the 50-State Letter varied considerably. Twenty States volunteered that services from private providers are targeted toward the specialized population of youth needing TFC. With the exception of two States, administrators were adamant that they were obligated to provide oversight— and that they provided this oversight—of all foster care placements. According to the responses, private agencies might recruit, screen, train, and provide case management services to foster families, but the public agencies were responsible for approving all placements and for ensuring that children were living in safe conditions. For example, Texas wrote that children are placed in homes that are ‘‘directly overseen by child protective services.’’ 45 Delaware wrote that the State ‘‘retain[s] . . . legal and case management responsibilities for meeting the needs of all children in foster care, whether they are placed in a [public] foster home or private provider home. . . .’’ 46 Other States reported inconsistent information. For example, Massachusetts reported that the public agency handles 96% of placements for the almost 11,000 children in the State who are in out-of-home care. Cases that involve a conflict of interest with the child welfare agency (for example, employees who are the subject of maltreatment allegations), adoptions, or unaccompanied refugees who are minors are handled by private contract agencies. Nevertheless, in that same response, Massachusetts also reported statistics showing that roughly 35% of its foster care caseload is managed by a contracted agency.47 Similarly, Maryland reported ‘‘we contract with private providers for placement services only,’’ but then went on to say ‘‘100% of Maryland foster youth are placed by the public agency.’’ 48 Oregon listed two county-run shelters and a 44 In Illinois, for example, MENTOR operated under the name Alliance Human Services. from Texas to the 50-State Overview Letter, Appendix B, Exhibit 29. from Delaware to the 50-State Overview Letter. 47 Massachusetts, Department of Children and Families, Letter to SFC, June 10, 2015, p. 1. The full response is listed in Appendix B, Exhibit 16. 48 Maryland, Department of Human Resources, Letter to SFC, July 20, 2015, p. 1. See full response listed in Appendix B, Exhibit 15. 45 Response 46 Response VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 12 Youth Villages facility as ‘‘for-profit’’ entities when other sources identified these entities as non-profits.49 News reports out of Oregon also show how the non-profit/for-profit distinction can be abused, and even non-profit entities can be used for financial gain. For example, the director of the now-shuttered Oregon foster care provider ‘‘Give Us This Day’’ was accused of using three non-profit organizations to buy property for personal use ($100,000), remodel and furnish her home ($213,000), and pay for trips, meals, clothes, and beauty expenses including cosmetic surgery ($249,800).50 When asked what types of services private agencies provide, 21 States indicated they were used for case management, even if this task was shared or duplicative of services provided by the public agency. Twenty-eight States indicated that private agencies provide support, services, or training to foster families. All States have licensing standards, but only six (California, Kansas, Kentucky, Illinois, Tennessee, and Texas) reported that they require all of the agencies that contract with the State to be accredited. In addition, some States, such as Illinois, use benchmarks that private agencies are expected to meet, such as an annual permanency rate of 40%. The business model is to reward top-performing agencies with ‘‘a greater share of new, incoming foster cases.’’ 51 MENTOR is one of the largest contractors providing foster care services in many of the States the Committee staff examined. Information provided by Texas in response to the 5-State In-Depth Letter showed that when combining the number of children served from all MENTOR jurisdictions, it ranked either 5th or 6th in total size among all Texas private child welfare agencies from 2010– 2013, before Texas stopped contracting with the company. It was always the largest for-profit provider. In Maryland, for each of the years the Committee staff reviewed in-depth information, MENTOR always had the highest number of children receiving contracted services among all providers. With regard to the financing of private child welfare services, information from the four States that responded to the 5-State InDepth Letter shows that between 2010 and 2015, these States spent between $63 million and $291 million annually on private child welfare services. Roughly 20% of these expenditures went to pay for-profit agencies for services. This means these States paid between $18 million and $50 million annually to companies that profited from children and families involved with the foster care system. Using MENTOR as an example, in 2015 MENTOR Maryland was paid an average of $47,542 per foster child, for a total approaching $16 million. The contractor with the highest annual rate per child in 2015 in this one State was paid an average of $69,242 per child. 49 United States District Court, District of Oregon, Portland Division, United States of America v. Mary Holden Ayala, 3:16–CR–00495–HZ; https://www.justice.gov/usao-or/press-release/file/ 965436/download; Lincoln County, Oregon Juvenile Shelter website; http://www.co.lincoln.or. us/juvenile/page/shelter; Douglas County, Oregon Juvenile services website, http://www.co. douglas.or.us/departments.asp#Juvenile. 50 Theriault, Dennis C., ‘‘Oregon accuses foster care provider of ‘plundering’ $2 million in state funds,’’ The Oregonian, October 15, 2015. Updated: October 16, 2015, http://www.oregonlive. com/politics/index.ssf/2015/10/oregon_accuses_foster_care_pro.html. 51 Illinois DCFS Letter to SFC, December 15, 2015, pp. 2–3. Full response is listed in Appendix B, Exhibit 10. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 13 B. BACKGROUND CHECKS All of the States that responded to the Committee’s 50-State Overview Letter described, in various levels of detail, how they assess children’s safety in out-of-home placements and specifically among potential or current foster parents. Sometimes there were variations in public versus private settings, but all described a process that involves some version of a State criminal background check, a national or Federal background check, and a check into their own State’s child abuse and neglect registry—and sometimes in registries of other States where potential foster parents have recently lived. Some States volunteered information showing or suggesting that positive findings of criminal activity or a history of maltreating children do not automatically close a door to family foster care. For example, California wrote: ‘‘For persons with criminal convictions, the Department of Justice provides the county child welfare agency with the record information report [which is reviewed], to determine whether the crimes are those for which an exemption may be granted.’’ 52 These kinds of exemptions and waivers turned up in the materials reviewed by Committee staff concerning MENTOR’s operations in other States. In response to inquiries from the Committee, MENTOR wrote: ‘‘as a part of our commitment to quality, MENTOR entities conduct criminal and non-criminal background checks on prospective foster parents in accordance with local/State requirements and regulations. This has always been part of our practices. Not only do background checks support our rigorous vetting efforts to find the most qualified, caring foster parents, they are also a requirement of the States and referring agencies with whom we partner.’’ Yet, several news accounts tell a different story.53, 54 Most notably is one media account which notes that MENTOR placed children in a home with a household member who had previously been convicted of aggravated kidnapping and robbery when she kidnapped a pregnant convenience store employee.55 Similarly, the Committee staff determined that MENTOR is often out of compliance with its own guidelines, as well as State guidelines, with respect to conducting background checks of those who care for foster children or those who are routinely in homes where foster children are placed. In the State of Texas, case records showed that on four separate occasions in an 8-month period, MENTOR was instructed to conduct background checks on a frequent visitor to a foster home. That check was never completed.56 Even when MENTOR met background screening guidelines, it sometimes waived the outcomes of the findings. For example, in the Committee staff ’s investigation of documents from MENTOR Maryland, the Committee staff found that the husband of a foster parent, who was later convicted of sexually abusing foster children in their home, had been the subject of four previous abuse allega52 Response from California to 50-State Overview Letter. See Appendix B, Exhibit 4. Brian. See Footnote 14. 54 Ansari, Talal, and Roston, Aram, ‘‘Parent at Nation’s Leading For-profit Foster Care Firm Facing Murder Charges,’’ BuzzFeed News, February 23, 2016, https://www.buzzfeed.com/ talalansari/parent-at-nations-leading-for-profit-foster-care-firm-facing?utm_term=.nkGzyWJJD#. od1APe11V. 55 Roston, A. and Singer-Vine, J. See Footnote 13. 56 MENTOR bates numbers 0001822–1823. 53 Joseph, VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 14 tions. The MENTOR worker marked in handwriting on the criminal background search results, ‘‘Not Mentor [sic] parent,’’ presumably indicating that the husband’s criminal history was irrelevant because the foster mother was the primary caretaker. Similarly, MENTOR Texas noted in documentation provided to the Committee that in one case potential foster parents reported that they or family members had been convicted of a crime, but no further information was provided. The exact quote is: ‘‘Yes, no description given.’’ 57 These individuals went on to become MENTOR foster parents, and the foster mother killed a 3-year-old foster child by blunt force trauma to the head.58 In another case reviewed by Committee staff, during the vetting process for one particular set of MENTOR foster parents in Maryland, the foster father indicated that he had a preference for ‘‘white, male children.’’ This was not seen as a red flag to the agency. Male children who were subsequently placed with this MENTOR foster parent were sexually abused. In fact, media accounts report that children who disclosed abuse were not believed at first and were instead sent back to live with their abusive foster father. Eventually a foster child was believed and the case moved through the legal system.59 C. CHILD WELFARE WORKFORCE OPERATIONS AND CONCERNS Caseworker Turnover. The child welfare field consistently has high rates of turnover among its workforce. The national range of turnover among child welfare workers is 30–40% annually.60 When there is movement among staff, children are often served by many different caseworkers, which can make it difficult for children to form relationships with their caseworkers, for caseworkers to put together a treatment plan for children, and for cases to be adequately monitored.61, 62 Many records and news accounts referenced the high turnover rate among staff at MENTOR; it was of keen interest to the Committee staff to examine this at the State and provider level. Illinois reported that MENTOR had trouble maintaining qualified staff. Its overall turnover rate for caseworkers was actually consistent with national norms, but the turnover rate for therapists working with MENTOR children was 44% in 2012. At one Illinois site, the turnover rate for therapists was 80% in 2013. In this same year, the turnover rate for MENTOR child welfare program direc57 Notes from MENTOR Texas Documents: Clemon and Sherill Small Case. Brian. See Footnote 14. A. and Singer-Vine, J. See Footnote 13. 60 U.S. General Accounting Office, ‘‘Child Welfare: HHS Could Play a Greater Role in Helping Child Welfare Agencies Recruit and Retain Staff,’’ Report to Congressional Requesters, No. GAO–03–357, March 2003, http://www.gao.gov/new.items/d03357.pdf. 61 Illinois DCFS Report. See Footnote 42. 62 Garner, Bryan R., Hunter, Brooke D., Modisette, Kathryn D., Ihnes, Pamela C., and Godley, Susan H., ‘‘Treatment staff turnover in organizations implementing evidence-based practices: turnover rates and their association with client outcomes,’’ Journal of Substance Abuse Treatment, March 2012, pp. 134–142, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3268938/. See also U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, ‘‘Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues,’’ January 24, 2013, https://www.google.com/url?sa=t&rct=j&q=&esrc= s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiZ_avJka_VAhWG5yYKHajECAMQFggo MAA&url=https%3A%2F%2Fstore.samhsa.gov%2Fshin%2Fcontent%2FPEP13-RTC-BHWORK% 2FPEP13-RTC-BHWORK.pdf&usg=AFQjCNGxewm3bHzmpsqu5zeWfUdqYhVpiw. 58 Joseph, 59 Roston, VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00022 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 15 tors in Illinois was an astounding 82%. In its own periodic reviews of MENTOR, the State of Georgia also noted concerns about staff turnover. In the Macon, Georgia jurisdiction, MENTOR staff turnover reached 83%. Caseload Size. Another workforce issue is the size of caseloads that child welfare professionals carry. Despite the field’s attention to caseload size in the child welfare profession, Committee staff found it difficult to obtain this information from the States that were investigated. Three States that responded to the 5-State InDepth Letter do not maintain information on the average caseload per caseworker employed by each private contractor. Georgia indicated that it tracks this information, but it was not easily accessible to the State or the Committee, stating, ‘‘There is no comprehensive database that collects average caseload numbers.’’ Apparently caseload size is one of many indicators that is recorded on paper files during periodic onsite reviews of private foster homes and other similar agencies. This information is never transmitted into an electronic database. To further complicate matters, Georgia also insisted that it does not use ‘‘caseworkers,’’ per se. Instead, the State uses the term ‘‘case support workers,’’ a distinction which almost prevented SFC staff from obtaining any information about the caseload sizes in that State. National standards for special needs children or children requiring TFC services indicate that workers should not have more than 10–12 cases per worker.63 Illinois contracted with MENTOR to provide TFC services at the ratio of 10 cases per worker. The State learned that MENTOR was not in compliance with this standard. In some instances the ratio was as high as 14.5 to 1.64 Even though Illinois required specific levels of case management, it did not maintain a data reporting system that would ensure these levels were met and monitored. Maryland indicated that, should caseloads exceed what is contracted, a corrective action plan would be put in place. Communication. Communication within the company was also noted to be a problem. When the State of Illinois was conducting its own annual review and subsequent comprehensive investigation of MENTOR, the Illinois team had to provide copies of the two previous reports from the Illinois Office of the Inspector General to MENTOR company officials, as they were not aware of the prior investigations completed by the State about their company. Nor were company officials aware of commitments made by previous MENTOR officers as a result of these reports. In these reports, Illinois child welfare administrators noted that ‘‘interagency communication issues were evident at the onset of the review.’’ Multiple Violations. Maryland conducted periodic reviews of MENTOR from 2010–2015. Each review noted any specific violation of regulations. Committee staff examined 22 quarterly reviews that were conducted of MENTOR Maryland. In only two of those quarters were no violations noted. Common and repeated violations included missing documentation from employee hiring, missing foster parent case files and child client case files, concerns around 63 Hughes, Sean and Lay, Suzanne, ‘‘Direct Service Workers’ Recommendation for Child Welfare Financing and System Reform,’’ Child Welfare League of America, January 2012. 64 Illinois DCFS Report. See Footnote 42. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00023 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 16 board management and oversight of MENTOR operations, and licensing and staffing issues. In many cases, foster parents did not document the required hours of annual training, nor did children’s case files document all medical and psychiatric exams. FBI clearance checks were also incomplete in some cases. These reviews, over a period of 6 years, also noted frequent changes in the MENTOR Maryland Board’s composition and a high rate of staff turnover at MENTOR. Recruitment Bonuses. MENTOR provides incentives for recruiting new foster parents to the company. Specifically, the company provides financial incentives for employees who recruit new foster parents that result in the placement of a child through MENTOR. Employees who oversee recruitment efforts in each State are called ‘‘recruitment managers.’’ Between 2012 and 2014, MENTOR reported paying an average of $92,000 each year in bonuses to employees for foster parent recruitment, which is about what a State would pay annually to take care of two children who were placed with MENTOR families. According to MENTOR, this is an average of $3,800 per recipient. In addition, MENTOR also provides incentive payments to foster parents who recruit other foster parents to have a child placed in their home through MENTOR. The financial bonus for this action is $250 for each new foster parent/foster home. According to MENTOR records, in 2014 and the first 8 months of 2015, foster parents received bonuses totaling $126,000 for the recruitment of new foster parents, which, using MENTOR’s own numbers, would represent about 500 new foster parents. There is evidence that similar bonuses or incentives are used by State and other private foster care agencies as well.65 While Committee staff were unable to document a direct impact on child care resulting from these bonuses, further investigation regarding the use of bonuses and incentives may be warranted. D. PHYSICAL AND MENTAL WELL-BEING CHILDREN IN FOSTER CARE OF SFC staff sought to determine the physical and mental wellbeing of children in foster care and if this varied by provider type. According to Federal policy, all States must develop a plan for the oversight and coordination of health-care services for children who are in foster care. This plan must involve the State’s Medicaid agency and input from health-care and child welfare experts. One of the most basic elements of this plan is to determine the timeline under which children will have an initial health-care screening upon entering foster care. The American Academy of Pediatrics recommends that children and youth receive comprehensive health65 For example, in Kentucky State foster parents receive bonuses ranging from $100–$250 for each ‘‘resource home’’ that is successfully recruited. State of Kentucky, Department for Community Based Services, ‘‘Chapter 12.2.3: Recruitment bonus,’’ Standards of Practice Online Manual; http://manuals.sp.chfs.ky.gov/chapter12/22/Pages/1223RecruitmentBonus.aspx. Also, AdoptUSKids, which is a project of the Children’s Bureau within HHS, recommends using recruitment incentives for both staff and existing foster/adoptive parents to increase the pool of potential placements for children. See McKenzie Consulting, Inc., ‘‘Practitioner’s guide: Getting more parents for children from your recruitment efforts,’’ AdoptUSKids, https://www. adoptuskids.org/_assets/files/NRCRRFAP/resources/practitioners-guide-getting-more-parentsfrom-your-recruitment-efforts.pdf. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 17 care screenings within 30 days of entering foster care.66 States vary considerably in their own timelines, ranging from requiring health screenings within 24 hours to 30 days after a child enters foster care. Health-care screenings are one of the items on which States are assessed in the periodic CFSRs, but a 2015 review of children’s health-care needs and services by the Inspector General of HHS showed that one-third of children in foster care did not receive one of their health-care screenings. Further, one-quarter of the children received their health-care screening late.67 In the 5-State In-Depth Letter, States were asked to determine what portion of children in public State agencies and private agencies had a full physical and mental health assessment within 60 days of entering foster care. According to the Illinois DCFS review of MENTOR, children being served by Illinois MENTOR did not have their physical or mental health needs met in a timely manner. Mental health assessments in Illinois are to be completed within 30 days of contact with a therapist, a standard that MENTOR met for only 60% of cases reviewed by the State. Foster children served by MENTOR in Illinois waited an average of 122 days before having contact with a psychotherapist. A treatment plan is to be established within 45 days of a mental health assessment, a standard that was met for only 73% of MENTOR cases reviewed by the State. Finally, treatment plans are to be updated every 5 months, a standard which MENTOR met only 52% of the time. By way of comparison, Georgia transmitted data on physical and mental health assessments reporting compliance rates for assessments within 60 days of placement. The performance in this area was very poor for both MENTOR and the entire State, at 12% and 11%, respectively. In other instances, MENTOR ranked better than the State averages in its compliance with the 60-day mark. In Texas, the overall rate for the State was 73%, but for MENTOR it was 84%. A similar situation was true in Maryland, where overall only 60% of children in the State were seen by a health provider for a physical and mental health exam within 60 days of entering foster care, but MENTOR met this mark 69% of the time. E. FAILURE TO IDENTIFY AND RESPOND RISK TO CHILDREN TO The documents that were provided by MENTOR and in responses to the 5-State In-Depth Letter showed that public agencies and MENTOR repeatedly failed to identify and respond to the risk that was presented to children in out-of-home care. During the 2015–2016 reviews that Georgia conducted with its contracted service providers, the MENTOR jurisdiction in Athens reported 41 ‘‘significant events,’’ which included four child protection investigations (each unsubstantiated), two suicidal / homicidal threats, one ‘‘child-on-child sexual event,’’ and two ‘‘child-to-child 66 American Academy of Pediatrics, ‘‘Fostering health: Health care for children and adolescents in foster care, 2nd edition,’’ 2005, Report, p. 22, https://www.aap.org/en-us/advocacyand-policy/aap-health-initiatives/healthy-foster-care-america/documents/fosteringhealthbook. pdf. 67 U.S. Department of Health and Human Services, Office of Inspector General, ‘‘Not all children in foster care who were enrolled in Medicaid received required health screenings,’’ Report, OEI–07–13–00460, March 2015, https://oig.hhs.gov/oei/reports/oei-07-13-00460.pdf. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 18 physical confrontations.’’ Despite these reports, the State gave this particular MENTOR jurisdiction an overall qualitative safety score of 93%. Yet, of the two caregiver homes randomly selected for the jurisdiction’s annual review, the second home presented environmental risks to the foster children. The case notes reviewed by Committee staff read: ‘‘the provider stored the garden tools, rake, lawn mower and the bottom of a water cooler in the living room.’’ In this same review, one of the ‘‘well-being strengths’’ listed is the ‘‘documentation of the younger children’s academic needs being met,’’ despite the fact the review also noted the following: • The caregiver reported the two youth have no ambition, motivation, or life goals; • The youth refuse to attend school. . . . Similarly, under the category of ‘‘Well-being Areas Needing Improvement,’’ the review noted two youth failing in school, not making adequate progress, and not receiving tutoring or academic support, in addition to a lack of documentation explaining more than five unexcused absences. A MENTOR foster parent in Texas killed one of her foster children.68 Case notes reviewed by Committee staff indicate there were clear warning signs that the safety and well-being of children in her care were compromised before the fatal abuse, but Texas MENTOR failed to see the risk to the children placed with her and ultimately did not protect the children being served. MENTOR described the foster mother and her partner as ‘‘mature, responsible, healthy individuals capable of meeting the needs of a child placed in their care.’’ Yet the records also show that the foster mother reported being overwhelmed and uncertain if she could care for foster children. Children placed in her care were removed with ‘‘negative outcomes,’’ placements in the home ‘‘failed,’’ and Early Childhood Intervention staff felt that children should not be in this particular foster home. Further, the foster parents were investigated by the Texas Department of Family and Protective Services for concerns about children in their foster home. Records from MENTOR report that the children in this home had bruises and the foster mother reported that the children would make false allegations against her and her partner. Texas MENTOR did not terminate their license, but instead reinforced its commitment to working with this family with case records stating that MENTOR staff ‘‘agree that this family should continue to work as foster parents. . . . We will be decreasing the number of children the family is licensed to care [for] in efforts to ensure the family remains a Mentor [sic] family.’’ F. ACTIONS WHEN MALTREATMENT IS SUBSTANTIATED IN FOSTER HOMES All of the MENTOR children who were highlighted in media accounts and were maltreated by their foster parents were living in very high-risk situations. (As previously noted, in one MENTOR home, children had disclosed their maltreatment, but their disclosures were dismissed by those in a position to take action. The preceding section noted the presence of bruises on children and the in68 Joseph, VerDate Mar 15 2010 16:09 Oct 16, 2017 Brian. See Footnote 14. Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 19 vestigation of maltreatment in one MENTOR home where a child was killed.69) As a result, in the 50-State Letter, SFC asked States about their procedures for when maltreatment is substantiated in a foster home. In such a situation, this would mean it was confirmed, founded, or substantiated that a foster child was being abused or neglected in his or her foster placement. According to data presented in a report to Congress by the U.S. Department of Health and Human Services, the State median of maltreatment among children who were in foster care from 2010–2013 was 0.35%.70 Missouri, Wyoming, and Virginia had the lowest rates, as determined by the 2015 NCANDS and AFCARS datasets; the highest rates were in New York, Iowa, and Massachusetts.71 Of the 33 States that responded to the 50-State Letter, only 9 indicated that substantiation for abuse or neglect in a foster home would unequivocally result in the revocation of a foster home license: Arkansas, Delaware, Indiana, Kansas, Nebraska, New Hampshire, South Dakota, Tennessee, and Wisconsin. All of the other responding States report that license revocation is one possible outcome when maltreatment is substantiated. Many of the States compared the rates of re-victimization of children in foster care based on their foster home setting: public, private non-profit, or private for-profit. There was no evidence that children who were in privatized foster care settings were more likely to be re-victimized than children in publicly run foster homes. Some of the information provided by the States about maltreatment in foster care raised serious concerns. Massachusetts reported the number and percentage of substantiated child maltreatment episodes as a share of the total foster care population. Of the 44,240 children in substitute care during Federal fiscal years 2010– 2014, Massachusetts reported 739 instances of maltreatment in foster care, which is 1.67% of all children in care. 72 At face value, this might appear to be a relatively low rate, but as previously noted, it is well above the State median of 0.35%. Further, data used in the third round of the CFSRs shows that Massachusetts had the highest rate of child re-victimization in the Nation 73 and it steadily climbed between 2010 and 2013.74 In response to the 5-State In-Depth Letter, Maryland reported that it does not track the occurrence of maltreatment in foster care by provider or by type of provider, which means that the performance of individual contractors and type of contractor is not monitored in this way. Texas reported that ‘‘serious instances of confirmed abuse and neglect cases result in licensure revocation.’’ But, it only reported one instance of that happening between 2010 and 2014, despite the fact that the State also provided the Committee with data showing there were 295 instances of confirmed maltreat69 Roston, A. and Singer-Vine, J. See Footnote 13. 70 U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, ‘‘Child Welfare Outcomes 2010–2013—Report to Congress,’’ Report, February 1, 2016, https://www.acf.hhs.gov/cb/resource/cwo-10-13. 71 Stoltzfus, Emilie, Memorandum prepared by the Congressional Research Service. See Footnote 43. 72 See Appendix B, Exhibit 16—Response From Massachusetts, Office of the Governor. 73 Stoltzfus, Emilie, Memorandum prepared by the Congressional Research Service. See Footnote 43. 74 ‘‘Child Welfare Outcomes 2010–2013—Report to Congress.’’ See Footnote 70. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 20 ment among children in foster care in that same time period. 75 Further documentation provided by Texas shows that between 2010 and 2015 about 7% of youth in foster care had an episode of maltreatment against them substantiated; the rate was 8% for Texas MENTOR.76 There is also a troubling example from Massachusetts that was captured by investigative journalists where the State changed its determination of whether an infant died from child abuse or neglect.77 A 2-month-old infant died in a Massachusetts foster home that was run by MENTOR. Initially the case was ruled by the State as a death related to neglect because of unsafe sleeping conditions. There is a provision in Federal law which requires States to release information about abuse and neglect-related deaths to the public.78 When journalists used this provision to press the Massachusetts Department of Children and Families to release information about the infant’s death, the substantiation of neglect was reversed by the State—2.5 years after the death. Instead, the State ruled that the death was not related to neglect. This meant that Massachusetts was no longer required to release information about the circumstances relating to and causes of the infant’s death. Accordingly, this information and the record can remain sealed from the public. G. MENTOR INCIDENT REPORTS The Committee staff requested that MENTOR submit all of its highest-level incident reports from FY 2005 to FY 2014 for review. This would allow SFC staff to investigate the most serious cases where children died or were seriously harmed. MENTOR submitted a total of 98 ‘‘level 4’’ incident reports which capture the agency’s most serious incidents of injury, assault, abuse, or other similar events; 86 involved the death of a child.79 The other cases involved 75 See Appendix B, Exhibit 29—Response From Texas, Department of Family and Protective Services. 76 Maltreatment in foster care was for many years measured as a percentage of children in foster care who had a substantiated or indicated report of maltreatment where the perpetrator was coded as the child’s foster care provider (i.e., the perpetrator was the child’s foster parent or a staff member at a group home or institution where the foster child was placed). The State median data cited above, for example, uses that metric. Further, the data provided by Massachusetts and Texas on the number of children maltreated while in foster care from FY2010– FY2014 appears to use a similar if not identical metric. By contrast, when it separately reported a percentage of children in Texas foster care who were maltreated, the State appears to have made this calculation based on all reports of maltreatment of children in foster care, without regard to the perpetrator of the abuse or neglect. HHS has begun to move its measurement of maltreatment of children in foster care to include maltreatment without regard to who is the perpetrator. However, the new HHS calculation, which measures incidents of maltreatment for every 100,000 days of foster care provided by the State, also takes certain steps to ensure that reports of maltreatment for children in foster care do not unintentionally capture those reports that were responsible for bringing a child in to foster care. 77 Roston, Aram, ‘‘In an unmarked grave, a baby’s untold story,’’ BuzzFeed News, June 18, 2015, https://www.buzzfeed.com/aramroston/in-an-unmarked-grave-a-baby-who-died-on-forprofit-foster-co?utm_term=.wt0VkV8zl#.aqARDROwG. 78 Child Abuse Prevention and Treatment Act, ‘‘2.1A.4, Assurances and requirements, Access to child abuse and neglect information, Public disclosures.’’ The full statute can be found at https://www.acf.hhs.gov/cwpm/programs/cb/laws_policies/laws/cwpm/policy_dsp.jsp?citID= 68. 79 See Appendix F for a sample of the level IV incident reports provided by MENTOR. The company provided Committee staff all death-related level IV incident reports for children in foster care under MENTOR for FY2005–FY2014, with the exception of one incident report that could not be located by the company. In addition, Committee staff reviewed non-death-related level IV incident reports provided to the Committee for those years, in addition to death-related and non-death-related incident reports for FY2015. The Committee staff considered all of these reports in its analysis. Committee staff cannot draw conclusions about this full time frame given VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00028 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 21 psychiatric admissions, allegations of sexual assault perpetrated against foster children, allegations of sexual assault committed by foster children, and accidents or injuries that happened to foster children. Table 1 shows that about half of the reports (45%) involved a child with a behavioral health concern and 40% involved a child who was medically complex. Of the cases that involved a death, almost three-quarters (73%, or 62 cases) of the deaths were listed as ‘‘unexpected,’’ which is a check box on MENTOR’s incident report form. Table 1. Summary of Incident Reports Reviewed Area of Assessment No. Percent Behavioral health 44 45% Blank 2 2% Juvenile Justice 3 3% Medically Complex 39 40% Missing Incident Report 1 1% Mentally Retarded / Dev. Delay 3 3% Other 6 6% 98 100% Yes 23 27% No 62 73% 85 100% Yes 13 13% No 84 87% 97 100% Service Category (Indicated by MENTOR) Total Death Was Expected? * Total ** Was an Internal Investigation Launched? Total * Calculation only includes death cases. ** One incident report for a death was not provided to the Senate Finance Committee. Table 2 shows that of the deaths that were unexpected, an internal investigation was launched only 21% of the time (13 cases—set bold in Table 2), which suggests MENTOR does not seek opportunities to learn from unexpected critical incidents. The child welfare profession,80 along with many other professions including law enthat the most recent reports were provided after the Committee staff ’s analysis and have not been fully reviewed. 80 See the National Center for the Review and Prevention of Child Deaths, https:// www.ncfrp.org/. See also: Hochstadt, N.J., ‘‘Child death review teams: a vital component of child protection,’’ Child Welfare, 2006 July–August, 85(4): 653–70, https://www.ncbi.nlm.nih.gov/ pubmed/17039823. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00029 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 22 forcement,81 health care,82 and transportation,83 is moving in the direction of increasing transparency and trying to learn from crises. In many cases and jurisdictions, this includes systematic reviews of incidents that result in unexpected deaths. The Committee staff also determined that in at least nine of the incidents, there were financial settlements paid to families of the victims. Table 2. Internal Investigations and Death Expected/Unexpected Death Expected? Internal Investigation? Total No Yes No 49 (79%) 23 (100%) 72 Yes 13 (21%) 0 (0%) 13 62 (100%) 23 (100%) 85 Total At the most basic level, MENTOR’s incident reports have typos, errors, inconsistencies, and missing information. More concerning instances include inaccurate information and diagnostically implausible conditions. For example: • MENTOR’s incident reports are incomplete. For example, several reports mention that an internal investigation is underway, but the outcome is never indicated. Similarly, other reports note that an investigation by law enforcement is underway, but there was never any follow-up information available from the incident reports to indicate the outcomes of these investigations. • One MENTOR incident report was missing. In the list of incident reports that was presented to Committee staff, one incident report was not provided. In fact, the company was unable to locate the document. Yet, documentation attached to that case ID indicated that the outcome of the case was serious enough to warrant a settlement from MENTOR with the family. • MENTOR’s incident reports include information that is diagnostically inaccurate. For example, one report documenting the death of a 2 month-old infant described the deceased as being ‘‘oppositional.’’ At best, this was an error. At worst, it was an actual (although implausible) diagnosis, since the conditions leading to a diagnosis of ‘‘oppositional defiant disorder’’ need to persist for a minimum of 6 months before a diagnosis can be made.84 Even then, it is developmentally inappropriate to give an infant this kind of diagnosis. The average age of onset for oppositional defiant disorders is be81 See ‘‘Critical Incident Review Library’’ at The Police Foundation, https://www. policefoundation.org/critical-incident-review-library/. 82 Wald, Heidi and Shojania, Kaveh G., U.S. Department of Health and Human Services, ‘‘Chapter 4: Incident reporting,’’ Agency for Healthcare Research Quality—Archive. Retrieved March 28, 2017, https://archive.ahrq.gov/clinic/ptsafety/chap4.htm. 83 National Transportation Safety Board, ‘‘History of the National Transportation Safety Board.’’ Retrieved March 28, 2017, https://www.ntsb.gov/Pages/default.aspx. 84 American Academy of Child and Adolescent Psychiatry, ‘‘Oppositional defiant disorder: A guide for families by the American Academy of Child and Adolescent Psychiatry,’’ Report, 2009, https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/odd/odd_resource_center_ odd_ guide.pdf. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 23 tween ages 5–15.85 Similarly, in another case, a 4-month-old infant who also died was described as having ‘‘behavioral health’’ problems when the field widely recognizes that most serious mental / behavioral health conditions are not diagnosed until adolescence or early adulthood. Even when more childhood-based conditions are treated (such as attention deficit/hyper-activity disorders) the average age of onset is 4–11 years old.86 • MENTOR’s incident reports contain information that conflicts with media accounts of incident. One incident report documents the death of a 4-year-old child and states that the child died from cardiac arrest. Media accounts of that incident (which were discovered by the Committee staff based on the State and age of the deceased, as well as the date of death) indicate that the foster mother of the child was convicted of second degree manslaughter in the death of the child. MENTOR also reached a legal settlement with this family. H. MENTOR MORTALITY REPORT In response to the national attention concerning children who died on MENTOR’s watch and the investigation by SFC staff, MENTOR conducted its own analysis of children who died in the company’s care. This MENTOR ‘‘mortality report’’ was completed through a contract held with a research center at a public university in the company’s home State (see Appendix G, Exhibits 1 and 2).87 In this analysis, MENTOR concludes that its child death rates are in keeping with the rates of deaths among foster children and among the youth population (in general) at the national level. As discussed further in this section, these conclusions are inaccurate and they appear to misrepresent the experiences of children who are served by MENTOR. The company did not have the report independently validated. When SFC staff inquired about having the report ‘‘peer reviewed’’ by independent researchers with expertise in child maltreatment, MENTOR indicated that this would only be possible with the company’s approval. Committee staff found this report to be inaccurate and misleading. The report used unequal points of comparison between deaths that occurred under MENTOR’s watch and national rates of the deaths of foster children, according to AFCARS. MENTOR’s report included a comparison of its own annual death rate based on the total number of children in its care each year, with the national, annual death rate of foster children. This national rate is based on the number of children who were in care on the single date of September 30th, which is when annual counts are taken. The result is the appearance of the national death rate being much 85 Kessler, Ronald C., Amminger, G. Paul, Aguilar-Gaxiola, Sergio, Alonso, Jordi, Lee, Sing, and Ustun, T. Bedirhan, ‘‘Age of onset of mental disorders: A review of recent literature,’’ Current Opinion in Psychiatry, Vol. 20, No. 4, 2007, https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1925038/. 86 Ibid. 87 Note: On October 5, 2017, MENTOR provided Committee staff with an updated mortality analysis, which reflected data through August 2017. To the extent Committee staff feels this data meaningfully changes the analysis in the Committee Print, Committee staff will make this information available on the Committee website in the future. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00031 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 24 higher than MENTOR’s death rate, when in fact the opposite is true, as explained below. In addition to these false conclusions, MENTOR’s methods and standards of analysis are not consistent with the field, nor are they employed by HHS or the Centers for Disease Control and Prevention (CDC). For example, the report stated the rate of child deaths per 100 live children, as opposed to 100,000 live children, which is what is used by HHS 88 and the CDC.89 Using the numbers provided in its own report, MENTOR’s average rate of death for 2010–2014 is .074 per 100 foster children served (or as the field would express it, 74 per 100,000 children served), as compared with national rates of .052 per 100 foster children served (or 52 per 100,000 children served). Yet, MENTOR concludes: ‘‘The MENTOR Network serves significantly more children and youth with heightened risk factors relative to others in foster care, and sustains child mortality rates that are comparable with national norms’’ (bold emphasis in the original document). In fact, MENTOR’s death rate among foster children is 42% higher than the national average. Figure 1 demonstrates MENTOR’s misleading display of information. The red comment box points to MENTOR’s inclusion of a national death rate that is based on point-in-time counts of the number of children in foster care on a single day. Using this number in the denominator makes it look like the death rate among children in foster care is higher than is actually the case. The Committee staff concluded that this information is not a valid comparison. The black comment box points to the national death rate that is based on the total numbers of children served annually in foster care, which provides a more accurate estimate of the death rate among foster children. The blue comment box points to the death rate among foster children who are being served by MENTOR. This is also based on the number of children served annually by MENTOR. This chart clearly shows that the blue bar and rate, which captures MENTOR’s death rate, is higher than the black bar and rate, which captures the comparable national death rate of children who are in foster care. 88 U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, Children’s Bureau, ‘‘Child Maltreatment 2015,’’ Report, January 19, 2017, https://www.acf.hhs.gov/sites/default/files/cb/cm2015.pdf. 89 Kochanek, K.D., Murphy, S.L., Xu, J., and Tejada-Vera, B., U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, ‘‘Deaths: Final Data for 2014.’’ National Vital Statistics Reports, Vol. 65, No. 4. June 30, 2016, https://www.cdc.gov/nchs/data/nvsr/nvsr65/ nvsr65_04.pdf. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 25 Further, in its mortality report, MENTOR also states: ‘‘Mortality rate in TMN [The MENTOR Network] foster care programs has been very similar to, and more recently equal to or better than, national norms.’’ To substantiate this, MENTOR provided a line chart of death rates for 2009–2014, with data points that are too small to decipher and no numbers. The chart appears intended to capture the national death rate among those aged 0–22. Regardless, this chart is also misleading. Mortality information collected by Committee staff from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) database shows that the national death rate in the United States between 2009 and 2014 among those aged 0–22 is 54.7 per 100,000 in the population.90 That means that the MENTOR death rate (74 per 100,000) among youth aged 0–22 is 35% higher than the national average. Furthermore, MENTOR’s graphical analyses only focused on 5 years of data, 2009–2014, but in its report, MENTOR included 10 years of data. Figure 2 displays the full 10 years of rates of children’s deaths per 100,000 for 2005–2014. There are only 2 years during which MENTOR’s death rates were at or below the foster care population and national averages.91 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 26354.CP1 90 For more information about the WONDER database, visit its website https://wonder.cdc.gov/. 91 The national data in Figure 2 is for youth ages 0–22, which is the same age range that MENTOR used in their mortality report. 26 Finally, in the MENTOR conclusion cited above in this section, the company highlights its contention that it serves ‘‘significantly more children and youth with heightened risk factors’’ and therefore a higher death rate should be expected among its served population. However, as noted earlier in the report, when the Committee staff examined MENTOR’s incident reports, it found that of the cases involving a death, nearly three-quarters of those cases (73%) indicated that MENTOR itself concluded the death was ‘‘unexpected.’’ In short, MENTOR’s own incident reports do not support the conclusion that MENTOR’s fatality rate is attributable to these heightened risk factors. I. FINANCIAL SETTLEMENTS FROM MENTOR The documentation provided by MENTOR allowed Committee staff to review over 20 financial settlement agreements resulting from alleged negligence and /or damages. However, this did not capture the full range of such settlements. According to documents reviewed by Committee staff in reference to Maryland dated between 2005 and 2015, there were 22 settlements of claims against MENTOR. Illinois submitted materials to the Committee indicating that there had been nine similar settlements in the State. In almost all of the MENTOR legal documents the plaintiffs and settlement amounts are redacted. However, the documents from Illinois cite a total of $19.5 million in payouts. Given the numerous settlements made between MENTOR and dozens of parties, MENTOR has likely paid many millions of dollars in wrongful suit settlements. In fact, in its 2014 SEC filings, MENTOR wrote: ‘‘Several years ago, we experienced a spike in claims filed against the Company, and we could face an increase in claims in the future. As a result of the prior increase in claims, we received less favorable insurance terms and have expensed greater amounts to fund potential claims.’’ 92 VerDate Mar 15 2010 16:09 Oct 16, 2017 Solutions, Inc., 2014 10–K Filing (September 30, 2014), p. 13. See Footnote 2. Jkt 000000 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 26354.CP2 92 Civitas 27 V. OVERSIGHT OF CHILD WELFARE SERVICES AND PROTECTING VULNERABLE CHILDREN The States that responded to the 50-State Letter were adamant about their oversight of children in their foster care systems, regardless of the nature of the children’s placement. That said, the information provided to and reviewed by SFC staff describes systems that do not always keep children safe or allow their performance to be readily evaluated. In fact, one State—Massachusetts— failed to comply with a request from the Committee to submit more detailed information about its child welfare services. To further complicate matters, the complex and fragmented nature of the child welfare system makes it difficult for the Federal Government, and others, to monitor the operations and outcomes of children who are involved in the system. Some of the problems SFC staff encountered in trying to evaluate and compare the performance of States and providers through this review are as follows: • Georgia does not specifically record data about children needing TFC services, which means the State is likely unable to track the well-being of this subpopulation (and likely many others). • Data from Illinois provided point-in-time measurements for a single date on two key measures (siblings placed in same living arrangement and average caseload per caseworker), as opposed to over a period, such as a fiscal year or multiple fiscal years. SFC staff repeatedly raised this issue with Illinois staff and requested a State average across all providers which would have given the Committee at least some benchmark for comparison purposes. The State was unable to provide this information. • Maryland only provided the Committee with data on private TFC placements, as opposed to data about their entire child welfare population with subpopulations that might have included those needing TFC placements. • Not all child welfare indicators are available electronically. Some States collect information, perform reviews, and maintain data in paper files that are never entered into an electronic database or that are never synthesized into a single report or review. Without more systematic procedures in place, it is almost impossible for States to have any meaningful oversight over their own systems or the agencies that provide contracted services for them. • The field lacks a consistent language about child welfare services, clients, and operations, which makes it difficult to make comparisons between States and between providers. For example: » There is no uniform definition of what constitutes TFC. Some States use the term ‘‘treatment foster care,’’ instead of ‘‘therapeutic foster care,’’ although the spirit of the definition, the needs of the children, and the services provided would be similar. Other common terms used include ‘‘special needs’’ children or ‘‘medically fragile’’ children. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00035 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 28 » One State does not use the term ‘‘caseworkers’’ and would not provide client-to-caseworker ratios until SFC staff established that this State called these employees ‘‘case support workers.’’ MENTOR calls its caseworkers ‘‘child welfare specialists.’’ » The terms that States use to refer to the private agencies with which they contract to provide foster care services vary as well. Some States refer to these agencies as ‘‘child placement agencies.’’ Another common term is ‘‘contract agencies’’ or ‘‘foster care agencies.’’ • States have varying definitions and conceptualizations of what it is that private child welfare agencies do in their States. Some States do not use the term ‘‘child placement agencies’’ to refer to contract agencies, while others do. This is because the State has control over and responsibility for placing children in foster homes. So when the Committee asked States, ‘‘What proportion of the children in foster care in your State is placed by the public agency, not-for-profit providers, and for-profit providers,’’ many States indicated ‘‘zero’’ for anything outside of the public agency because they maintain that all children are placed by the State. Other States (which maintained that the public agency places all children) still provided rates of children placed by contracted agencies. This meant it was impossible for SFC staff to determine the proportion of children living in homes that for all intents and purposes are run by private agencies. • With regard to substantiations of maltreatment in foster care, the Committee asked States to indicate in ‘‘how many of these instances . . . were children placed by: not-for-profit providers, for-profit providers, and public providers?’’ Some States indicated ‘‘zero’’ for the first two categories, again because they maintain that children in their State are not placed by contracted agencies, they are only placed by public agencies, even if the foster parents work for and are managed by a contracted agency. Thus, the information obtained from different States was not always comparable. • Other States maintain that public employees provide full case management services for the children in their care, yet private agency workers set up appointments for the clients, make arrangements for services, provide transportation, provide support for foster parents, and visit the children in their foster care placements. According to the National Association for Social Workers, the definition of case management services is: ‘‘A process to plan, seek, advocate for, and monitor services from different social services or health care organizations and staff on behalf of a client.’’ 93 This seems consistent with the services private agencies provide children who are in the protective care and custody of their State, even if the public agencies call it otherwise. 93 National Association of Social Workers, ‘‘NASW Standards for Social Work Case Management,’’ Report, 2013, https://www.socialworkers.org/practice/naswstandards/CaseManagement Standards2013.pdf. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 29 • The Committee staff noted the various ways and outcomes by which child welfare agencies and government documents discuss the maltreatment of children involved with child welfare agencies. CFSRs, which are implemented by HHS and monitor State-level child welfare outcomes, track the percentage of any recurrence of maltreatment among all children in the State. The standard: States should not be above 9.1%. In 2013, 19 States failed to meet this benchmark. • Maltreatment of children in foster care is measured as the number of children who were victims of substantiated maltreatment per 100,000 days spent in foster care. The national standard is set at 8.5 per 100,000 days. In 2013, 22 States exceeded this standard. A document prepared by HHS for Congress showed that the State median of maltreatment of children in foster care is 0.35%. Meanwhile, individual States submitted rates to SFC that ranged from 2% to 20%. These varying ways for measuring and reporting the same construct make it difficult for regulators to monitor outcomes and the well-being of children involved with their State’s child welfare system. • The third round of CFSRs is being conducted between 2015 and 2018. In late 2016, HHS discovered an error in the syntax the Department used to electronically gather information from the States regarding their program performance. Information is still being gathered, but States that submitted data before the error was discovered will not be assessed in the areas that were affected by the syntax error. Thus, a major Federal mechanism that is in place for monitoring child welfare performance in the States is not fully functional and means that for some States, there will be approximately a 10-year gap on the Federal assessment of some child welfare performance indicators. • Not all of the States responded to inquiries from the Committee. » Seventeen States failed to respond to the 50-State Letter. Those States were: Arizona, Florida, Georgia, Idaho, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nevada, North Carolina, Ohio, Rhode Island, South Carolina, Vermont, and Virginia. » Massachusetts failed to respond to the 5-State In-Depth Letter. Despite repeated assurances from the Massachusetts Department of Children and Family Services that ‘‘continuing efforts are being made to collect and prepare the information’’ with ‘‘the full intention to send a response to the Committee,’’ a response to the Committee’s questions was never received. VI. CONCLUSIONS Despite the limitations on information supplied to the Committee, there is sufficient information from this single private agency and the States to show that children who are under the legal authority of their State are often ill-served. Some children served by MENTOR were abused, neglected, and denied services, and the VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00037 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 30 very State agencies that have been charged with and paid to keep them safe have likely contributed to their suffering and deaths. As documented by MENTOR’s incident reports, investigations about fatalities were never followed up, autopsy reports which were pending years ago are not part of case files, and the vast majority of children who died were not the subject of an internal investigation—even when their deaths were unexpected. MENTOR issued a report to the Committee which falsely claimed that its death rates are in keeping with national death rates and the rates of death among children in the foster care system. Add to this complicated narrative the fact that the families of MENTOR victims have received millions of dollars in financial settlements, significant enough for MENTOR to have received less favorable terms from its insurer in 2014. The Committee staff recognizes that a case study of one provider does not allow for direct comparisons with other individual providers, and thus, cannot draw conclusions regarding MENTOR’s operations in relation to other contracted agencies, forprofit or otherwise. Regardless, information collected for this report shows that MENTOR repeatedly placed the health and well-being of children at risk. State agencies would likely counter concerns about their performance by noting the procedures they have in place to monitor private agencies. For example, Illinois notes that all licensed foster homes are physically inspected at least twice each year, with licenses valid for 4 years. Maryland states that it assesses all private TFC providers quarterly. This same State noted that providers can find themselves on the agency’s ‘‘hotlist’’ by not complying with contractual obligations or by committing license violations. In such situations, providers would not be able to take in new clients until a corrective action plan is generated and subsequently completed. Even though MENTOR repeatedly failed to meet all State licensing criteria in 20 of the 22 quarters reviewed that the Committee examined, MENTOR continues to operate in Maryland. Illinois described a similar regulatory approach, but MENTOR no longer operates in that State. State oversight guidelines are in place in almost every State in the Nation, either written into State statute or as part of agency policy. This investigation and precipitating media reports show that these policies are not always followed, exceptions are made, waivers are granted, and sometimes professionals serving children look the other way. The documents reviewed in this investigation show a system that does not always protect children. Profits are sometimes prioritized over children’s safety and well-being. Turnover among staff sometimes makes it impossible to develop case plans to ensure that children are ‘‘on-track’’ and being monitored. Foster parents with questionable backgrounds who seemingly lack the skills to provide care to vulnerable children are given licenses to parent challenging children and then are often inadequately monitored. Further, the data and oversight structures at both the State and Federal level make it difficult and sometimes impossible to monitor the operations of the child welfare system itself, as well as its private contractors. Thus, the bipartisan Committee staff sets forth the following recommendations. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 31 VII. RECOMMENDATIONS Recommendations for States and Tribes • Improve outreach, customer service, and support services for those interested in becoming foster parents to attract and retain high-quality foster families. • Support enhanced oversight of foster families to ensure robust background checks, home study assessments, and ongoing placement oversight. • Frequently review performance of child welfare service providers /contractors to ensure child safety, permanency, and well-being standards are being met. • Track child safety and well-being related outcomes at the individual provider level, including whether children served by specific providers have higher than average needs (e.g., medically fragile, special needs, or therapeutic foster care placement, etc.). • Set standards for maximum caseload size for child welfare workers, which may include differentiated standards based on variations in case type (e.g., medically fragile children, children in therapeutic foster care placements, etc.) or activity (e.g., investigations of abuse or neglect, case planning for children in foster care). • Provide greater funding for the training of front-end staff charged with making removal and placement setting decisions for children entering foster care or at risk of entry. • Revoke contracts from child welfare service providers who are unable to demonstrate the capacity to provide safe foster care placements for children. • Provide subsidized guardianship payments to relatives willing and able to provide safe placements for children who can no longer remain at home. • Ensure child death review teams are transparent, timely, and well-staffed. Require the timely publication of the results of child death reviews while ensuring appropriate and robust privacy protection of sensitive data. • Make placement setting decisions based on the assessed strengths and needs of children entering foster care using an age-appropriate, evidence-based, validated, functional assessment tool to ensure children receive the appropriate level of care in the least restrictive, most family-like environment. • Establish child welfare ombudsman offices through which children in care, family members, child welfare workers, foster parents, whistleblowers, and members of the public at large can submit comments and concerns about misconduct within the child welfare system. Recommendations for the Department of Health and Human Services (HHS) • Work to engage States, Congress, and the broader child welfare community in understanding the purpose and Statespecific relevance of the CFSRs and ensure this process contributes to meaningful improvement and reform. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 32 • Seek and provide clarification on how States and Tribes are defining, using, and overseeing the delivery of Therapeutic Foster Care (TFC) and establish a common definition of TFC for the purposes of Medicaid and title IV–E. • Develop a uniform definition of ‘‘child abuse and neglect fatality’’ and provide guidance related to determining and reporting such fatalities and ensure States and Tribes are using this new definition when reporting data via the National Child Abuse and Neglect Data System (NCANDS). • Aid States in developing the means and mechanisms to accurately collect provider-specific outcomes data, consistent with the metrics and definitions associated with AFCARS, NCANDS, and the CFSRs. • Establish maximum caseload guidelines to promote manageable caseload sizes for the child welfare workforce. Recommendations for Congress • Support both funding and oversight for States and Tribes to enhance foster parent recruitment and retention activities to ensure robust background checks, home studies, ongoing placement oversight, and strong support services for foster parents. • Support both funding and oversight for States and Tribes to enhance caseworker recruitment and retention activities to ensure child welfare caseworkers are both prepared to enter the field and given the support services necessary to carry out their jobs effectively. • Allow States and Tribes to use title IV–E funds to support evidence-based services aimed at safely preventing foster care entries. • Consider de-linking subsidized guardianship payments from the Aid to Families with Dependent Children (AFDC) income standard so that States and Tribes can receive a Federal match on behalf of all children placed in subsidized guardianship placements and promote equity in the payment rate for kinship placements. • Require all States to report to the National Child Abuse and Neglect Data System (NCANDS) using standard definitions and provide support for this data collection and reporting. • Consider legislation creating an explicit private right of action for children and youth in foster care tied to components of the case plan and case review requirements defined under section 475 of the Social Security Act.94 • Consider statutory changes requiring HHS to assess fiscal penalties on States for failing to meet CFSR outcomes or system requirements and develop a penalty reinvestment structure under which assessed penalties must be used by the State to address the key identified deficiencies (rather than be deposited into the Federal Treasury). • Consider amending section 479A of the Social Security Act to require States to collect, and HHS to audit, provider94 ‘‘Compilation of the Social Security Laws,’’ Social Security Act, section 475, https:// www.ssa.gov/OP_Home/ssact/title04/0475.htm. VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 R:\DOCS\26354.000 TIMD 33 specific child outcomes data in addition to State-specific data on outcomes such as: child fatalities, maltreatment in care, recurrence of maltreatment within 6 months, exits from foster care by reason for the exit (adoption or guardianship, reunification, emancipation), time to reunification, re-entry rates, and the average number of placements. Ensure this performance data is available to the public and considered by States or Tribes before making or renewing a contract with the provider. • Consider prohibiting Federal title IV–E reimbursements for providers who consistently perform poorly on key safety, permanency, and well-being indicators. Charge HHS with auditing States and providers to determine which providers shall be excluded from Federal title IV–E reimbursement. • Require States to make their contracts with private child welfare service providers publicly available and include details on whether such providers are private not-for-profit or private for-profit. 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Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.109 145 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00154 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.110 146 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00155 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.111 147 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00156 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.112 148 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00157 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.113 149 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00158 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.114 150 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00159 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.115 151 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00160 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.116 152 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00161 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.117 153 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00162 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.118 154 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00163 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.119 155 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00164 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.120 156 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00165 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.121 157 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00166 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.122 158 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00167 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.123 159 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00168 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.124 160 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00169 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.125 161 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00170 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.126 162 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00171 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.127 163 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00172 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.128 164 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00173 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.129 165 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00174 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.130 166 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00175 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.131 167 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00176 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.132 168 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00177 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.133 169 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00178 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.134 170 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00179 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.135 171 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00180 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.136 172 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00181 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.137 173 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00182 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.138 174 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00183 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.139 175 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00184 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.140 176 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00185 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.141 177 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00186 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.142 178 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00187 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.143 179 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00188 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.144 180 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00189 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.145 181 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00190 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.146 182 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00191 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.147 183 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00192 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.148 184 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00193 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.149 185 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00194 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.150 186 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00195 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.151 187 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00196 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.152 188 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00197 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.153 189 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00198 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.154 190 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00199 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.155 191 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00200 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.156 192 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00201 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.157 193 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00202 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.158 194 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00203 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.159 195 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00204 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.160 196 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00205 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.161 197 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00206 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.162 198 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00207 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.163 199 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00208 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.164 200 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00209 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.165 201 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00210 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.166 202 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00211 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.167 203 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00212 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.168 204 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00213 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.169 205 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00214 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.170 206 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00215 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.171 207 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00216 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.172 208 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00217 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.173 209 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00218 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.174 210 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00219 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.175 211 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00220 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.176 212 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00221 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.177 213 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00222 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.178 214 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00223 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.179 215 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00224 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.180 216 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00225 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.181 217 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00226 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.182 218 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00227 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.183 219 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00228 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.184 220 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00229 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.185 221 222 Appendix C VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00230 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00231 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.186 223 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00232 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.187 224 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00233 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.188 225 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00234 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.189 226 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00235 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.190 227 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00236 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.191 228 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00237 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.192 229 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00238 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.193 230 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00239 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.194 231 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00240 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.195 232 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00241 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.196 233 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00242 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.197 234 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00243 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.198 235 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00244 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.199 236 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00245 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.200 237 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00246 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.201 238 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00247 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.202 239 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00248 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.203 240 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00249 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.204 241 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00250 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.205 242 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00251 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.206 243 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00252 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.207 244 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00253 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.208 245 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00254 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.209 246 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00255 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.210 247 248 Appendix D VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00256 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00257 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D01.eps 249 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00258 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D02.eps 250 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00259 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D03.eps 251 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00260 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D04.eps 252 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00261 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D05.eps 253 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00262 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D06.eps 254 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00263 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D07.eps 255 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00264 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D08.eps 256 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00265 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D09.eps 257 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00266 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D10.eps 258 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00267 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D11.eps 259 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00268 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D12.eps 260 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00269 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D13.eps 261 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00270 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D14.eps 262 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00271 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D15.eps 263 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00272 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D16.eps 264 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00273 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D17.eps 265 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00274 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D18.eps 266 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00275 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D19.eps 267 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00276 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D20.eps 268 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00277 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D21.eps 269 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00278 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D22.eps 270 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00279 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D23.eps 271 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00280 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D24.eps 272 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00281 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D25.eps 273 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00282 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354D26.eps 274 275 Appendix E VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00283 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00284 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.211 276 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00285 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.212 277 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00286 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.213 278 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00287 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.214 279 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00288 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.215 280 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00289 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.216 281 282 Appendix F VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00290 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00291 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.217 283 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00292 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.218 284 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00293 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.219 285 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00294 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.220 286 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00295 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.221 287 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00296 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.222 288 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00297 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.223 289 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00298 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.224 290 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00299 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.225 291 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00300 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.226 292 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00301 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.227 293 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00302 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.228 294 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00303 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.229 295 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00304 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.230 296 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00305 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.231 297 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00306 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.232 298 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00307 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.233 299 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00308 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.234 300 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00309 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.235 301 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00310 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.236 302 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00311 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.237 303 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00312 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.238 304 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00313 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.239 305 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00314 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.240 306 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00315 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.241 307 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00316 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.242 308 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00317 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.243 309 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00318 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.244 310 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00319 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.245 311 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00320 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 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26354.262 328 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00337 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.263 329 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00338 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.264 330 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00339 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.265 331 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00340 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.266 332 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00341 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.267 333 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00342 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.268 334 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00343 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.269 335 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00344 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 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26354.278 344 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00353 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.279 345 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00354 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.280 346 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00355 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.281 347 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00356 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.282 348 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00357 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.283 349 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00358 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.284 350 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00359 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.285 351 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00360 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.286 352 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00361 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.287 353 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00362 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.288 354 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00363 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.289 355 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00364 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.290 356 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00365 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.291 357 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00366 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.292 358 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00367 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.293 359 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00368 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 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26354.518 584 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00593 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.519 585 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00594 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.520 586 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00595 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.521 587 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00596 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.522 588 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00597 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.523 589 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00598 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.524 590 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00599 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.525 591 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00600 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.526 592 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00601 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.527 593 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00602 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.528 594 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00603 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.529 595 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00604 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.530 596 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00605 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.531 597 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00606 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.532 598 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00607 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.533 599 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00608 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.534 600 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00609 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.535 601 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00610 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.536 602 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00611 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.537 603 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00612 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.538 604 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00613 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354.539 605 606 Appendix G VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00614 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00615 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354CS1.eps 607 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00616 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354CS2.eps 608 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00617 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354CS3.eps 609 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00618 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354CS4.eps 610 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00619 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354CS5.eps 611 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00620 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354CS6.eps 612 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00621 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354CS7.eps 613 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00622 Fmt 6601 Sfmt 6621 R:\DOCS\26354.000 TIMD 26354CS8.eps 614 615 VerDate Mar 15 2010 16:09 Oct 16, 2017 Jkt 000000 PO 00000 Frm 00623 Fmt 6601 Sfmt 5011 R:\DOCS\26354.000 TIMD 26354CS9.eps Æ