This is the accessible text file for GAO report number GAO-04-1017 entitled 'D.C. Child And Family Services Agency: More Focus Needed on Human Capital Management Issues for Caseworkers and Foster Parent Recruitment and Retention' which was released on September 24, 2004. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Report to Congressional Committees: United States Government Accountability Office: GAO: September 2004: D.C. CHILD AND FAMILY SERVICES AGENCY: More Focus Needed on Human Capital Management Issues for Caseworkers and Foster Parent Recruitment and RetentionD.C. Child and Family Services Agency: GAO-04-1017: GAO Highlights: Highlights of GAO-04-1017, a report to congressional committees: Why GAO Did This Study: The District of Columbia’s Child and Family Services Agency (CFSA) is responsible for ensuring the safety and well being of about 3,000 children in its care and ensuring that services are provided to them and their families. In fiscal year 2003, CFSA’s total budget was about $200 million. Concerns have been raised about CFSA’s supply of caseworkers, the foster care and adoptive homes, and the quality and timeliness of mental health services for foster care children. To help address these issues, the Congress appropriated $14 million in fiscal year 2004 to CFSA, the Department of Mental Health (DMH), and the Metropolitan Washington Council of Governments (COG) specifically for foster care improvement. GAO examined CFSA’s (1) strategies for recruiting, retaining, and managing its caseworkers; (2) efforts to license an adequate supply of safe foster and adoptive homes; and (3) efforts to collaborate with DMH and the Family Court to provide timely mental health services to foster care children. GAO also reviewed plans for and use of the federal foster care improvement funds. What GAO Found: CFSA actively recruited caseworkers and implemented retention strategies; however, caseworkers cited several management practices they said lowered their morale and adversely affected their ability to perform their duties. CFSA employed several recruitment approaches recommended by a number of child welfare organizations and exceeded most of its staffing goals for fiscal year 2003. Caseworkers cited high salaries and the training for new caseworkers as factors that encouraged them to remain at CFSA. However, GAO found a general consensus among the caseworkers with which GAO met that some management practices—poor communication, a lack of resources, poor supervision, and no rewards and recognition program—adversely affected their performance and morale. Agency officials said they had made some changes and were planning to take other actions to address these issues. CFSA has developed goals and strategies for recruiting new foster and adoptive homes and improved licensing requirements. CFSA has made progress licensing new families, although more families have stopped serving than expected. Further, CFSA does not have processes for identifying the reasons foster parents stop serving or for determining the effectiveness of its recruitment strategies. CFSA has standardized and raised licensing requirements for all foster and adoptive homes, but as of May 2004, 308 foster homes were unlicensed, with about 22 percent of CFSA’s foster children residing in them. CFSA has begun collaborating with DMH and the Family Court to centralize and track mental health services for foster care children, but challenges remain to ensuring timely delivery. CFSA and DMH designed a standard process for referring foster care children to DMH for assessment and treatment and for tracking service delivery. DMH has also started expanding its service capacity for foster care children. For example, it has begun recruiting additional evaluators to perform assessments. While CFSA began using a database to track service delivery in August 2004, it has not analyzed the service delivery data collected on paper prior to August 2004 to determine whether foster care children were receiving timely services. Additionally, CFSA and DMH still face certain challenges, such as integrating caseworkers and Family Court judges into the new referral process. CFSA, DMH, and COG have spending plans that are consistent with the statutory language providing the federal funds, but only a small portion of the foster care improvement funds had been obligated or spent as of June 2004, in part because funding was not received until March 2004. Further, it is unclear how the District and COG plan to support some of these programs in the long-term because future funding is uncertain. What GAO Recommends: GAO recommends that CFSA address the human capital issues of its caseworkers and assess its efforts to recruit and retain foster parents. CFSA agreed with these recommendations. www.gao.gov/cgi-bin/getrpt?GAO-04-1017. To view the full product, including the scope and methodology, click on the link above. For more information, contact Cornelia M. Ashby, 202-512-8403, ashbyc@gao.gov. Contents: Letter: Results in Brief: Background: CFSA Has Actively Recruited Caseworkers and Implemented Retention Strategies; however, Caseworkers Cited Management Practices That Adversely Affected Their Performance and Morale: CFSA Has Developed a Recruitment Plan and Established New Licensing Standards for Foster and Adoptive Homes, but More Foster Families than Expected Have Stopped Serving: CFSA Has Begun Collaborating to Centralize and Track Mental Health Services for Foster Care Children, but Challenges Remain to Ensuring Timely Delivery: Uncertainties Exist in the Long-Term and Short-Term Funding Status for Some of the Projects Included in the Plan: Conclusions: Recommendations: Agency Comments and Our Evaluation: Appendix I: Objectives, Scope, and Methodology: Appendix II: Comments from the District of Columbia's Child and Family Services Agency: Appendix III: Comments from the District of Columbia's Department of Mental Health: Appendix IV: Comments from the Metropolitan Washington Council of Governments: Appendix V: GAO Contacts and Staff Acknowledgments: GAO Contacts: Staff Acknowledgments: Tables: Table 1: Monetary Recruitment Incentives for Caseworkers in Fiscal Year 2003: Table 2: Retention Incentives Offered to Caseworkers by CFSA in Fiscal Year 2003: Table 3: Examples of Existing and Planned Services in the District Mental Health System for Foster Care Children: Table 4: Types and Purposes of Assessments for Children in Foster Care: Table 5: Purposes and Plans for the Foster Care Improvement Funds: Table 6: Funds Received and Expended by CFSA, DMH, and COG as of June 30, 2004: Figures: Figure 1: Staffing Goals Set by CFSA and Achievement Levels for Fiscal Year 2003: Figure 2: Recruitment and Attrition Pattern of CFSA's Foster Families: Figure 3: CFSA's Standard Process for Referring Foster Care Children to DMH: Abbreviations: BSU: Behavioral Services Unit: BSW: Bachelors of Social Work: CFSA: Child and Family Services Agency: CFSR: Child and Family Services Review: COG: Council of Governments: CSSP: Center for the Study of Social Policy: DMH: Department of Mental Health: FAPAC: Foster Parent Advocacy Center: HHS: Department of Health and Human Services: MSW: Masters of Social Work: NCIC: National Crime Information Center: RFPs: requests for proposals: United States Government Accountability Office: Washington, DC 20548: September 24, 2004: The Honorable Mike DeWine: Chairman: The Honorable Mary Landrieu: Ranking Minority Member: Subcommittee on the District of Columbia: Committee on Appropriations: United States Senate: The Honorable Rodney P. Frelinghuysen: Chairman: The Honorable Chaka Fattah: Ranking Minority Member: Subcommittee on the District of Columbia: Committee on Appropriations: House of Representatives: The District of Columbia's Child and Family Services Agency (CFSA) is the agency with primary responsibility for the child welfare system in the District of Columbia (the District). In fiscal year 2003, CFSA was responsible for about 3,000 children, and its operating budget, which was comprised of funds from the District of Columbia government, the federal government, and private sources, was about $200 million. Many parties are involved in the District's child welfare system, and several agencies provide essential services. For example, the Department of Mental Health (DMH) is responsible for arranging, among other things, evaluations to determine the mental health status and treatment needs of children in foster care. The D.C. Family Court was created as a court solely dedicated to matters concerning the District's children and families and, as such, it has jurisdiction over cases involving child abuse and neglect. In addition, CFSA works with agencies in Maryland, Virginia, and other states to arrange for placements of District children and also works with private agencies to place children in foster and adoptive homes. Because CFSA was plagued with mismanagement and had failed to protect some of the children under its care, the U.S. District Court has been and remains involved with the agency's management and operations. In 1995, the U.S. District Court placed CFSA in receivership.[Footnote 1] In 2001, the receivership ended, and CFSA then served a 1-year probationary period. The U.S. District Court appointed the Center for the Study of Social Policy (CSSP) to monitor and assess CFSA's performance. CSSP worked with CFSA and developed an implementation plan to help the agency achieve reforms ordered by the court and meet professional standards of care for the children it serves.[Footnote 2] This plan, which the court approved on May 15, 2003, covers outcomes and activities for CFSA through December 31, 2006, and sets performance benchmarks at 6-month intervals. The court-appointed monitor and we have reported[Footnote 3] that the management and operations of CFSA have improved since the receivership. Yet, there are still concerns that the agency may not have an adequate supply of skilled caseworkers or safe homes for foster care and adoptions and that mental health services needed for some children in foster care have not been provided in a timely manner. To help address these and other concerns about the District's foster care program, the Congress appropriated $14 million in fiscal year 2004 to CFSA, DMH, and the Metropolitan Washington Council of Governments (COG)--an organization of government officials from the greater Washington, D.C., metropolitan area that works cross jurisdictionally to address issues facing the area. CFSA received funds to upgrade its technology, expand services to foster children, and implement a student loan repayment program for caseworkers. DMH received funds to help it provide mental health assessments and treatment to foster children in a timely fashion. Finally, COG was appropriated funds to develop a plan for recruiting new foster parents and a respite care program--a support network of individuals to care for foster children when the foster family needs to take a break or attend to other matters. Congress is interested in knowing whether CFSA's strategies, processes, and operations will help it to sustain the improvements previously reported and further improve the District's foster care system as well as what steps are planned or have been taken to use the appropriated funds. Specifically, we were asked to assess (1) CFSA's strategies for recruiting, retaining, and managing its caseworkers; (2) CFSA's efforts to license an adequate supply of safe foster and adoptive homes; (3) CFSA's efforts to collaborate with DMH and the Family Court to provide timely mental health services to foster care children; and (4) CFSA's, DMH's, and COG's plans for and use of the federal foster care improvement funds. To make these assessments, we reviewed and analyzed key documents and discussed these issues with knowledgeable and affected parties. Our steps included reviewing best practices and standards for child welfare agencies developed by various child welfare organizations, CFSA's recruitment and retention plans for caseworkers and for foster and adoptive parents, licensing requirements for all foster and adoptive homes, as well as relevant reports and data. We conducted discussion groups with CFSA's caseworkers and supervisors; we also held a group interview with foster and adoptive parents. For the discussion groups with caseworkers and supervisors, we selected participants on a random basis, with participation being voluntary. We also reviewed key DMH and COG documents, and we analyzed the spending plans and budget data for CFSA, DMH, and COG. Additionally, we interviewed CFSA, DMH, Family Court, and COG officials, as well as national experts. We conducted our work between October 2003 and September 2004 in accordance with U.S. generally accepted government auditing standards. See appendix I for more details on our scope and methodology. Results in Brief: CFSA has carried out various strategies to recruit and help retain its caseworkers; however, caseworkers told us that several management practices adversely affected their ability to perform their duties and lowered their morale. CFSA implemented several recruitment strategies recommended by child welfare organizations and exceeded most of its staffing goals for fiscal year 2003. For example, CFSA used the Internet to post positions, advertised in nationally circulated publications, and recruited at a number of schools of social work across the country. By doing so, CFSA was able to hire 147 new caseworkers and exceed its goal to have 300 caseworkers and 60 supervisors on board at the end of fiscal year 2003. Regarding retention efforts, CFSA has provided several incentives to encourage caseworkers to remain with the agency, many of which are suggested by national child welfare organizations. The agency paid retention bonuses to staff that agreed to remain at the agency for 1 to 2 years and reimbursed required professional licensure fees. Further, many of the caseworkers we spoke with said that the relatively high salary CFSA paid played a big role in their decisions to remain at the agency. However, we found a general consensus among these caseworkers that CFSA's management practices hindered their performance and lowered their morale. They said that the agency had not provided them with needed resources such as reliable transportation needed to visit children or cell phones needed to contact families or the office. Caseworkers also reported that CFSA's management did not consistently communicate with them about policy changes and that many supervisors had not fulfilled their responsibilities. Further, caseworkers said and CFSA's management acknowledged that the agency did not have a program to reward and recognize caseworkers for good performance. Subsequent to our discussions with caseworkers, CFSA purchased cell phones and cars. Also, CFSA officials told us they are planning to improve their communication practices, establish requirements to help improve the quality of supervision, and develop a rewards program. CFSA has taken several steps to license an adequate supply of safe foster and adoptive homes; however, more foster families stopped serving than expected, and many homes remained unlicensed. In January 2004, the agency developed a plan to recruit foster and adoptive families. In addition to ongoing recruitment activities, such as public service announcements and television advertisements, CFSA intends to establish a second unit in October 2004 with staff dedicated to recruiting new homes. One of the goals in CFSA's fiscal year 2004 recruitment plan is to license 100 new foster families. According to agency officials, 170 new families had been licensed as of July 7, 2004. Further, the plan estimated that 50 families would leave the system during fiscal year 2004, but as of May 31, 2004, 77 families had left. CFSA does not have processes for evaluating its current recruitment methods or learning why foster parents leave. In 2004, CFSA also established temporary, 120-day licenses to accelerate placement of foster children with their relatives when such placements are available in the District. These homes, known as kinship homes, house about 30 percent of CFSA's children. Additionally, CFSA closed certain foster care homes that did not meet its licensing standards and established a process to monitor homes where children have been placed outside the District. While CFSA planned to have 80 percent of all children in licensed homes by June 2003, the court-appointed monitor reported that it fell short of that goal. Nearly a year later, about 22 percent of children in foster care--495 children--remained in unlicensed homes. In a further effort to improve services for children in foster care in the District, CFSA is collaborating with DMH and the Family Court to centralize and track the provision of mental health services, including assessments and treatment. In March 2004, CFSA began implementing a standard referral process, designed in concert with DMH, that links foster care children to the mental health system when assessment or treatment is ordered by the Family Court or requested by caseworkers. From March through June 2004, the Behavioral Services Unit in CFSA manually tracked referral data and was able to report on the number of assessments completed and foster care children enrolled in the mental health system. However, the agency did not analyze this referral information to determine whether or not services were being initiated or assessments were being completed and reported within the statutory timeframes. In August 2004, CFSA began entering data into a database it developed to track the status and timeliness of referrals of foster care children to DMH for mental health services. Meeting these timeframes depends in part on DMH's ability to expand its capacity to provide services to foster care children. To this end, DMH has begun efforts to recruit new evaluators to complete assessments, certify additional treatment providers, and contract with providers for new types of treatment targeted to the needs of foster care children. While CFSA's and DMH's reforms were designed to better link foster care children to mental health services, the agencies continue to face several challenges to ensuring the timely delivery of services, including completing complex types of assessments that may take longer than the specified statutory timeframes and integrating caseworkers and Family Court judges into the new referral process. CFSA, DMH, and COG have plans to expend the foster care improvement funds on long-term projects for which future funding for some projects is uncertain; and all three have obligated a small portion of these funds as of June 30, 2004. In February 2004, as required by statute, the organizations developed and submitted expenditure plans to the Congress explaining how they intended to use the funds. Additionally, the organizations developed detailed budgets based on the expenditure plans that specify how much of the money is to be used for different types of expenses. CFSA's major planned expenses include student loan repayments for caseworkers, equipment and labor for technology upgrades, the hiring of new personnel, and direct support services to children and families. The major expenses budgeted at DMH include the hiring of psychologists and psychiatrists to conduct psychological assessments of children, the contracting of crisis intervention and support services to facilitate mental health treatment, and the costs of training and mentoring by human services support agencies. Most of COG's planned expenses will be used to pay personnel and to provide funding to community organizations to provide respite care services to foster parents. All three organizations' planned expenditures are consistent with the stated purpose of the legislation. However, most of these planned expenditures are for operating costs of long-term programs, and the funding of some of these programs in the future is uncertain. Only a small portion of the $14 million appropriated for foster care improvements has been obligated, in part, because the organizations did not receive funds until March 2004. Specifically, as of June 30, 2004, about 90 percent of the $14 million remained unobligated. We are making recommendations to the Director of CFSA that would (1) help address human capital management issues for caseworkers by establishing processes to ensure consistent and effective communication with caseworkers about agency operations and developing strategies to help ensure that supervisors fulfill their responsibilities, (2) provide a process for evaluating the strategies used to recruit foster parents, and (3) identify factors affecting foster parents' decisions to stop serving. We received comments from the Acting Director of CFSA, the Director of DMH, and the Executive Director of COG. CFSA agreed with our recommendations and identified additional steps it has taken or plans to take to address the issues raised in the report. Additionally, CFSA, DMH, and COG provided information to help clarify the report, and DMH and COG included information on their plans to sustain their programs in the future. We incorporated this information as appropriate. See appendixes II, III, and IV, respectively, for CFSA, DMH, and COG comments. Background: The child welfare system is designed to promote the well being of children by ensuring their safety and permanency and by strengthening families to enable them to successfully care for their children. Families become involved with the child welfare system after a report of abuse or neglect has been made and confirmed. When agency officials determine that a child may be further harmed or mistreated if left in the home, the child may be placed in foster care. The federal government has allocated about $7 billion each year to investigate abuse and neglect of children in this country, provide placements to children outside their homes, and deliver services to help keep families together. The federal Department of Health and Human Services (HHS) is responsible for the administration and oversight of federal funding to states to support the child welfare system. Title IV-E of the Social Security Act, as amended, is a major source of federal funding and is primarily used to pay for the room and board of children in foster care. While HHS is responsible for setting standards and monitoring the nation's child welfare system, state child welfare agencies are responsible for administering the programs and monitoring the children and their families. Child welfare caseworkers, assisted by their supervisors, are at the core of the child welfare system. They are responsible for the management of individual cases and for performing many critical tasks. For example, child welfare caseworkers investigate reports of abuse and neglect; arrange placements when children must be removed from their homes; develop plans for the care of individual children; conduct visits with the children and foster families; attend court hearings; maintain records on each case; and coordinate with other agencies to obtain services for the children, including mental health care. The primary role of supervisors is to help caseworkers perform these functions, thereby meeting the needs of families and carrying out the agency's mission. Child welfare agencies face a number of challenges in recruiting and retaining caseworkers and supervisors. We previously reported that low salaries hindered agencies' abilities to attract and retain child welfare workers and their supervisors.[Footnote 4] Furthermore, we found that high caseloads, administrative burdens, a lack of supervisory support, and insufficient time to take training were issues that impacted caseworkers' abilities to work effectively and their decisions about staying in the child welfare profession. CFSA manages the child welfare system for the District. CFSA receives Title IV-E funding as well as other funds to support its programs. In fiscal year 2003, CFSA's budget included $65 million primarily from two federal sources--Medicaid[Footnote 5] and Title IV-E. The Medicaid funds are used to cover various expenses related to services for children in foster care, such as specific therapeutic and medically necessary care. Other sources of funding for CFSA include the District government and private grants. In fiscal year 2003, CFSA's operating budget was $208 million. CFSA's strategic goals for 2002-2004 are to (1) recruit and retain caseworkers, (2) investigate abuse and neglect reports, (3) expedite permanency for children, (4) recruit and retain foster homes, (5) promote agency and neighborhood-based resources, (6) enhance agency information system, and (7) complete court requirements. Like CFSA, the District's mental health service agency was placed in receivership in the 1990s.[Footnote 6] When DMH was established in 2001, the mental health system lacked the infrastructure to meet the needs of children, youth, and their families.[Footnote 7] Among other problems, DMH lacked a sufficient number of providers to accommodate the needs of the District's foster care children. To better link foster care children to mental health services, CFSA began to contract directly with mental health providers for services. Consequently, the mental health service delivery system for foster care children was fragmented with no single system of providers or service standards and no centralized information system to track the provision of services to foster care children. Further, the courts had no aggregate information on court-ordered mental health services for foster care children. Mental health services are considered critical for children who have suffered abuse or neglect. For children in the District, assessment and treatment are among the mental health services available through DMH. Assessments are evaluations conducted by mental health professionals to determine the mental health status and treatment needs of an individual. For children in foster care, assessments are generally requested or ordered on a case-by-case basis. Treatment, such as individual or family counseling and group therapy, can be initiated when the result of an assessment indicates that it is needed. Over the years, the Congress has enacted laws and provided funds to help improve the District's child welfare system. The D.C. Family Court Act of 2001[Footnote 8] established the D.C. Family Court and, among other things, established procedures intended to improve interactions between the court and social service agencies in the District. Also, the Congress authorized funds to the District in fiscal year 2002 for the completion of a plan to integrate the District's computer systems with those of the Family Court and for CFSA's caseworks to help implement family court reform.[Footnote 9] On January 23, 2004, the Congress passed the District of Columbia Appropriations Act, 2004,[Footnote 10] (the act), which included an appropriation of $14 million for foster care improvements in the District. Funds were appropriated for fiscal year 2004 only, to CFSA, DMH, and COG for specific programs. The act appropriated the funds as follows: * $9 million for CFSA, of which $2 million would be to establish an early intervention program to provide intensive and immediate services to foster children; $1 million would be to establish an emergency support fund to purchase necessary items to allow children to remain in the care of a licensed, approved family member; $3 million would be to establish a student loan repayment program for caseworkers; and $3 million would be to upgrade CFSA's automated case management system, known as FACES, to a Web-based system and to provide computer technology to caseworkers; * $3.9 million for DMH to provide all court-ordered or agency-required mental health screenings, assessments, and treatment to children in the care of CFSA; and: * $1.1 million for COG to develop a program in conjunction with the Foster and Adoptive Parents Advocacy Center[Footnote 11] to provide respite care for and recruitment of foster parents. The act also stipulates a timeframe for DMH to provide mental health services to foster care children. The law requires the DMH Director to (1) initiate court-ordered or agency-required mental health services within 3 days of notification, (2) complete court-ordered or agency- required assessments within 15 days of the request, and (3) provide the court with all assessments within 5 days of completion. CFSA Has Actively Recruited Caseworkers and Implemented Retention Strategies; however, Caseworkers Cited Management Practices That Adversely Affected Their Performance and Morale: CFSA has implemented various caseworker recruitment and retention strategies; however, caseworkers told us about several management practices that adversely affected their ability to perform their duties and lowered their morale. The recruitment strategies included posting announcements on the Internet, visiting schools of social work across the country, developing relationships with local schools of social work, and offering monetary incentives. CFSA successfully hired 147 new caseworkers, which enabled the agency to exceed most of its staffing goals and lower caseworkers' caseloads. Additionally, CFSA has held discussions with staff, established partnerships to allow caseworkers to pursue graduate degrees, and offered monetary incentives to help recruit and retain caseworkers. However, caseworkers and supervisors reported some human capital management issues that were not contributing to a positive work environment. CFSA caseworkers and their supervisors told us about a lack of resources and poor communication and supervision, and that the agency did not have a program to reward good performance. We heard these concerns consistently from caseworkers with varying lengths of service and found these same concerns in agency records of exit interviews. CFSA Conducted Several Recruitment Activities and Exceeded or Met Its Staffing Goals: In fiscal year 2003, CFSA conducted several recruitment activities, some of which were new. These recruitment activities followed the recommendations of the court monitor and included several of the strategies endorsed by public and private child welfare organizations. The recruitment activities CFSA used include the following: * Recruiting on the Internet. CFSA posted job announcements on the agency's Web site, and used Internet job sites such as "monster.com", "ihiresocialworkers.com", and the Web site for the National Association of Social Workers to recruit caseworkers. * Recruiting at schools of social work across the country. CFSA targeted a number of schools across the country by sending recruitment teams, mailing announcements to the schools, and using schools' internal Web sites to generate employment interest. According to agency officials, targeted schools were located in Delaware, Maryland, New Jersey, New York, North Carolina, Pennsylvania, South Carolina, and Virginia. * Advertising in media publications. CFSA advertised in media publications such as the Washington Post, Social Work Today--a national magazine for social workers seeking jobs and wanting to connect with others in the social work profession--and the Employment Guide--a national weekly employment magazine. * Developing ongoing relationships with local schools of social work. CFSA developed relationships with Howard University, the Catholic University of America, the University of the District of Columbia, George Mason University, Virginia Commonwealth University, and Bowie State University--universities located in the Washington, D.C., metropolitan area. * Attending regional and local career fairs. CFSA attended career fairs in New Orleans, New York, and Pennsylvania, and local job fairs in Washington, D.C., and Maryland. * Targeting universities and colleges for bilingual and/or bicultural staff. CFSA conducted outreach activities directed to students at colleges focused on producing licensed caseworkers that speak Spanish and are well acquainted with the Latino/Hispanic culture. CFSA recruited at San Diego State University and New Mexico State University--universities with large Hispanic populations. * Using monetary incentives. CFSA introduced a number of monetary incentives to attract new caseworkers. CFSA awarded bonuses to newly recruited caseworkers that had achieved a high academic grade point average, needed to relocate, or had bilingual skills. CFSA also established an employee referral program. CFSA employees can receive a $1,000 or 2 days off, if they refer a licensed caseworker to CFSA who joins the agency and completes 6 months of continuous service. Table 1 lists the monetary recruitment incentives CFSA offered and paid in fiscal year 2003. Table 1: Monetary Recruitment Incentives for Caseworkers in Fiscal Year 2003: Recruitment incentive: Academic achievement bonus; Description of incentive: Designed to make CFSA more competitive with other agencies. Eligible applicants must have a grade point average of 3.5 or above. The bonus amounts ranged from about $1,000 to $3,500; Number awarded: 28; Total dollar value awarded: $59,460. Recruitment incentive: Reimbursement for relocation expenses; Description of incentive: Designed to attract qualified licensed caseworkers that reside in areas outside the Greater-Washington- Baltimore Metropolitan area. Candidates must agree to remain at least one year. The amount reimbursed cannot exceed $3,000; Number awarded: 5; Total dollar value awarded: $6,857. Recruitment incentive: Bonus for bilingual caseworkers; Description of incentive: Designed to attract licensed caseworkers that speak Spanish or any other language for which CFSA has a current or projected need. The bonuses are for $500; Number awarded: 2; Total dollar value awarded: $1,000. Recruitment incentive: Employee referral fee; Description of incentive: Designed to encourage CFSA employees to refer licensed caseworker applicants. The referred caseworker must complete six months of continuous employment before the referral fee is paid. The referring employee can receive $1,000 or a 2-day time off award; Number awarded: 1; Total dollar value awarded: $1,000. Source: CFSA data. [End of table] CFSA's recruitment activities and the resulting new hires enabled the agency to meet or exceed its staffing goals. CFSA hired 147 caseworkers in fiscal year 2003 and by doing so was able to exceed its staffing goals of 300 caseworkers and 60 supervisors. At the end of fiscal year 2003, the agency employed 309 caseworkers of which 285 had masters of social work degrees (MSWs) and 24 had bachelors of social work degrees (BSWs). Additionally, CFSA met its goal to double the agency's bilingual staff by hiring 5 caseworkers that can communicate in English and other languages such as Spanish and sign language. CFSA's staffing goals and achievements are summarized in figure 1. Figure 1: Staffing Goals Set by CFSA and Achievement Levels for Fiscal Year 2003: [See PDF for image] [End of figure] Furthermore, according to CFSA managers, the new hires have facilitated reduction of each caseworker's caseload, as required by the court monitor. As of December 26, 2003, CFSA reported that the average caseload was 17 cases, down from the average of 27 in 2002. However, the court monitor reported that some caseworkers had caseloads that exceeded the September 30, 2003, benchmark for caseload standards set forth in CFSA's implementation plan.[Footnote 12] For example, while caseworkers responsible for investigations should carry no more than 16 cases, the caseload ranged from 1 to 39 cases, and 15 workers had caseloads higher than the benchmark. CFSA analyzed its caseworker recruitment effort and identified areas for improvement. CFSA's June 2004 recruitment and retention plan identified several fruitful recruitment efforts such as its efforts to advance relationships with local schools of social work and its use of the Internet to identify candidates. Also, the plan states that the agency will revise its recruitment efforts based on further analysis of the results. CFSA Has Begun to Implement Strategies to Help Retain Caseworkers: Retaining caseworkers is a challenge that CFSA as well as other child welfare agencies face. In fiscal year 2003, CFSA's attrition rate for caseworkers was about 15 percent. We could not determine if this was an improvement because CFSA did not have data for 2002[Footnote 13]. As of June 2004, about 45 caseworkers had left CFSA in fiscal year 2004--just over 15 percent of the staff. Our previous work on child welfare caseworker retention identified several causes of caseworker turnover and identified practices to help improve retention, such as university training partnerships and bonuses.[Footnote 14] In 2003, CFSA developed a work plan that included strategies to help retain well-qualified caseworkers by improving the agency's work environment. Experts in the child welfare community endorsed several of these strategies. The plan's goals are to create a supportive and professionally stimulating environment and promote continuing education for its supervisors. To help meet these goals, the agency has done the following: * Sought employee feedback to identify good practices as well as areas in need of improvement. CFSA officials conducted surveys, held discussions with staff, and reviewed data from exit interviews to identify good practices as well as areas for improvement. CFSA began conducting exit interviews and issued an exit interview analysis report in fiscal year 2003. The report contained data on the employee's position, program division, and the reasons given for leaving the agency. Agency officials told us they used this information to improve recruitment and retention efforts. * Required supervisory training. Supervisors of caseworkers are required to attend training classes for 12 days, over a 5-month period. The classes cover topics such as leadership effectiveness, case consultation, and other topics designed to improve supervisors' skills. * Established partnerships to allow caseworkers to pursue graduate degrees. CFSA has agreements with Howard University and the Catholic University of America, two universities in the District of Columbia, to allow its caseworkers to pursue master's level degrees in social work. CFSA, in partnership with these universities, will provide scholarships, stipends, and other sources of financial support. Employees who receive this benefit must agree to remain with the agency for a period of time or repay any financial support provided. A pilot program is scheduled to begin in September 2004. * Developed financial incentives. To encourage workers to remain at the agency, CFSA offered service agreement bonuses, reimbursement for first-time licensure fees, and additional income allowances. Table 2 describes the financial retention incentives and the number awarded in fiscal year 2003. Table 2: Retention Incentives Offered to Caseworkers by CFSA in Fiscal Year 2003: Retention incentives: Service agreement bonus; Description of incentive: Designed to encourage new caseworkers to remain at the agency. This is a one-time bonus to licensed caseworkers that have been with the agency for at least 90 days and sign a 1-or 2- year continued service agreement. The bonus amount ranged from $800 to $2,500 and varied based on the length of the service agreement and the caseworker's base salary; Number awarded: 39; Total dollar value awarded: $62,300. Retention incentives: First-time licensure fee reimbursement; Description of incentive: Designed to assist newly hired caseworkers with the cost of obtaining licenses for the first time. CFSA reimburses the application fee after the license is obtained. Caseworkers must sign a 1-year continued service agreement. The maximum fee reimbursement was $176; Number awarded: 22; Total dollar value awarded: $2,890. Retention incentives: Additional income allowance; Description of incentive: Designed primarily to retain experienced caseworkers in case management and supervisory positions who have been with the agency for at least 1 year and agree to remain for 1 or 2 additional years. This allowance may be renewed. If employment is terminated early the employee must repay the allowance. The amount of the allowance depends on the caseworkers experience and the length of the service agreement. Allowances ranged from $2,080 to $6,500; Number awarded: 109; Total dollar value awarded: $512,705. Source: CFSA data. [End of table] In addition to these retention strategies, caseworkers told us that CFSA's training program for new caseworkers and the higher than average salary paid by CFSA were important factors that contributed to their decisions to remain with the agency. CFSA's pre-service training for new caseworkers was cited as a positive experience by several caseworkers that participated in our discussion groups and several who completed exit surveys. This training lasts 8-½ weeks and greatly exceeds the average training time of about 3-½ weeks offered by most child welfare agencies. CFSA's training program involves both classroom study and on-the-job training, and gradual assumption of case responsibilities under close supervision. Caseworkers also cited CFSA's high salaries as a key incentive for continuing to work with the agency. CFSA's current average salary for a master's level caseworker is $41,440 compared with the national average of $37,097 at other public agencies. The student loan repayment program funded by the Congress in fiscal year 2004 may further help CFSA's retention and recruitment efforts, once the program has been implemented. Caseworkers who have worked or will work full-time for CFSA in a nonsupervisory capacity are eligible to apply for CFSA's loan repayment program. In addition, CFSA states that it determined caseworkers in a private agency under contract to CFSA will also be eligible for the loan repayment program.[Footnote 15] According to agency officials, the program offers up to $18,000 to caseworkers with MSWs and $10,000 for those with BSWs toward repayment of student loans. The exact amount will depend on the size of the loan and the number of qualified program applicants. Caseworkers must complete 2 years of service before any loan payments are made. CFSA pays one-half the total payment at the end of the caseworkers third year and the remaining half at the end of the fourth year. Initially, applications for the program were due August 16, 2004, and candidates had to sign a continuing service agreement to work for CFSA by September 3, 2004. According to agency officials, CFSA extended its application deadline to September 16, 2004. Many Caseworkers Cited Management Practices That Affected Their Ability to Perform Their Duties and Their Morale: During discussion sessions and in exit interviews, caseworkers said that they did not have adequate support in terms of resources to do their jobs. The caseworkers said that they did not have cell phones needed to maintain contact with foster families or with the office, and they did not have enough cars to make needed visits to monitor children under their care. Also, they reported not having adequate office space to hold confidential discussions with families and others involved with their cases. Supervisors also cited the lack of resources as a problem that hindered caseworkers' abilities to perform their duties. According to CFSA managers, in May the agency bought a fleet of new cars, and in June of 2004, the agency bought new cell phones for every caseworker. Additionally, CFSA is planning on adding shuttles to drop and pick up caseworkers from regularly traveled destinations to help reduce the need for cars. CFSA caseworkers also told us that management did not consistently communicate with them about issues affecting the agency and its operations. We also reported on this concern in our December 2000 report.[Footnote 16] During our recent meetings with caseworkers and supervisors, they said, for example, that changes in policy and procedures were not always communicated effectively or consistently throughout the agency. Many caseworkers said that they were not aware of such changes until they were in the process of completing an essential task, such as requesting a clothing voucher for a foster care family, and that caseworkers often heard of policy changes from each other. In exit interviews from January 2003 through May 2004, some employees suggested that communication be improved between all levels of management and staff, especially related to policy changes. For example, one employee filling out the exit interview form said that, "What is policy on Monday may not be policy on Friday…. CFSA must improve the way it communicates policy to its caseworkers. E-mails do not appear to be effective. The trickle down method of providing information to supervisors is also ineffective." National child welfare organizations and other human capital experts suggest that management should maintain clear lines of communication and involve employees in the decision making process of changing policies. CFSA managers explained that while they have a formal procedure for communicating policy changes and routinely include caseworkers in the decision making process, changes to practice standards that affect day-to-day operational matters are communicated through less formal methods. According to agency officials, these changes are communicated during staff meetings, via e-mail messages, and newsletters. In addition, caseworkers said that many supervisors had not fulfilled their responsibilities. They cited examples of supervisors not being available to help them during a crisis to provide guidance and support and not providing answers to questions affecting their work. One caseworker said in an exit interview, "My supervisor seldom kept our supervisory conferences or team meetings scheduled. She pushed tasks down that were managerial duties and failed to state priorities when assigning multiple tasks." Several caseworkers said that their supervisors had not provided them feedback about their performance. We reviewed a random sample of caseworkers' personnel files and analyzed those for 31 caseworkers who were hired on or before December 31, 2000. According to a CFSA official, these caseworkers should have had performance appraisals in their files for 2001, 2002, and 2003. While nearly all of the performance appraisals for 2003 were in the files, only 1 of the 31 files included an appraisal for all 3 years. The primary role of child welfare supervisors is to help caseworkers perform their duties. In addition to assigning cases, supervisors should monitor caseworkers' progress in achieving desired outcomes, provide feedback to caseworkers in order to develop their skills, support the emotional needs of caseworkers, and help make decisions about cases. The quality of supervision of caseworkers at CFSA is not a new issue. We also reported that social workers cited the quality of supervision as a reason for their decisions to resign in December 2000. Subsequently, to help improve the quality of supervision, CFSA required its supervisors to complete several training courses. However, as of August 2004, 12 of CFSA's 59 case-carrying supervisors have completed the training, as required. Furthermore, according to agency officials, CFSA's supervisors were not held accountable for performing their supervisory duties. CFSA officials indicated in 2000 that they planned to take steps to help enhance accountability for management and supervisory employees, including developing a new agency performance appraisal system. CFSA's managers acknowledged in 2004 that the performance of some of its supervisors still needed to improve. The agency's 2004-2005 recruitment and retention plan includes a new goal that focuses on providing supervisors and managers with more training and support to help increase the quality of supervision. Also, agency officials said that CFSA is developing new performance measures to better hold caseworkers and supervisors accountable for performing their duties. Furthermore, caseworkers said and CFSA managers confirmed that the agency does not have a program to reward or recognize individuals who perform well, make outstanding contributions, or achieve exceptional results. The agency honors all of its caseworkers annually during the month of May for Social Worker Appreciation Month with a Social Worker Appreciation Day celebration. Human capital experts have said that an individual recognition program is an important element and that workers who are recognized and rewarded for hard work are more likely to achieve maximum performance. Some caseworkers said in discussion groups with us and during exit interviews that a formal rewards and recognition program would enhance their morale, help create a positive work environment, and improve staff retention. Agency officials said that they are planning to develop policies and procedures for a formal rewards and recognition program. CFSA Has Developed a Recruitment Plan and Established New Licensing Standards for Foster and Adoptive Homes, but More Foster Families than Expected Have Stopped Serving: CFSA has taken several steps to recruit and license an adequate supply of safe foster and adoptive homes.[Footnote 17] The agency developed a recruitment plan and intends to establish a second recruitment unit devoted to recruiting new foster families[Footnote 18] and finding homes for children who are difficult to place, including teens and children with special needs.[Footnote 19] Also, CFSA has established new licensing requirements for congregate care[Footnote 20] and kinship homes.[Footnote 21] While CFSA has placed new emphasis on recruitment of foster and adoptive families, as of May 30, 2004, more foster families stopped serving than expected. Further, CFSA does not have a process for evaluating its recruitment strategies or the attrition of families from the foster care program. In addition, according to CFSA data, about 22 percent of foster children in CFSA's care were residing in unlicensed homes as of May 2004. Agency officials said that they were attempting to license these homes on a case-by-case basis. CFSA Has Developed Strategies and Goals for Recruiting New Homes, but Does Not Have a Process to Evaluate Its Strategies: In January 2004, the CFSA created a recruitment plan that includes strategies and goals for recruiting foster and adoptive homes. According to agency officials, this is the first such plan. The recruitment plan identifies specific strategies for recruiting new families. For example, the agency plans to invite current foster parents to hold social gatherings to interest others in becoming foster families and to continue the "Wednesday's Child" program which uses television commercials to feature individual District children who are available for adoption. In addition, the plan calls for increasing the roster of licensed foster families by 50 at the close of fiscal year 2004. For 2005, the agency plans to increase its supply of foster families by another 100 homes. In order to have an additional 50 families licensed, CFSA estimated that it must bring approximately 1,000 interested families to its orientation sessions since about one- tenth of the families who have attended past sessions became licensed, and an average of 50 families have left the program each year. Figure 2 summarizes the foster family recruitment and attrition patterns. Figure 2: Recruitment and Attrition Pattern of CFSA's Foster Families: [See PDF for image] [End of figure] In addition to CFSA's own recruitment plan, COG prepared a report for CFSA in 2003 that identifies specific, targeted recruitment strategies.[Footnote 22] This report identifies strategies designed to attract potential foster and adoptive parents with certain demographic characteristics from different neighborhoods in the District. For example, the COG report suggests that CFSA should partner with a local women's professional sports team to host a "Foster Care Day" and conduct a presentation on foster parenting during halftime. The report states that this recruitment strategy would reach families from various District neighborhoods who would work well with children who have special needs. In commenting on a draft of this report, agency officials said that they have incorporated some of the suggestions in the COG report, such as involving coaches and others working with children in sports by partnering with the District's Department of Parks and Recreation. CFSA also plans to establish a second unit dedicated to recruiting new foster and adoptive parents. The agency currently has one recruitment unit that includes a seven-person team--a supervisor, a social services assistant, and five recruiters, each of whom carries a caseload of 20- 30 hard-to-place children targeted for adoption. The team plans to recruit new foster and adoptive parents through community outreach activities and child-specific recruiting, a strategy used to find permanent homes for children who are traditionally the most difficult to place. CFSA plans to launch a second recruitment unit in October 2004. The new unit will also have seven staff members and will focus on community outreach activities and child-specific recruiting. Although CFSA's plan calls for the evaluation of its foster parent recruitment efforts, we found that CFSA had not developed a process to measure the effectiveness of its recruitment strategies and to learn why prospective families do not complete the licensing process. CFSA's recruitment plan alludes to the agency's FACES database as a potential tool for collecting such data, but agency officials told us that the system does not capture the information. Such evaluation is commonly considered good practice. CFSA Established and Enforced Its Licensing Standards, Broadened Its Oversight of Homes, and Has Taken Steps to Strengthen Contracts: In April 2004, CFSA established a process for issuing temporary licenses for kinship foster homes in the District. Kinship homes house about 30 percent of the children in CFSA's care. Requirements for the temporary license include a home study, criminal background check via the National Crime Information Center (NCIC), and a health history of primary caregivers. [Footnote 23] Once a child is placed, the family must apply for a nontemporary foster family license. Temporary licenses are good for 120 days and may be renewed once for 90 days as long as the family has made a good faith effort to comply with the nontemporary licensing process. According to agency officials, CFSA's goal is to be able to issue a temporary license in 3 days. As of May 2004, two temporary licenses had been issued and both took 2 weeks to process. Agency officials reported that they are currently working with Maryland officials to develop a temporary license for Maryland kinship placements--a step designed to further expand safety checks and decrease the length of time some children spend in emergency placements. In August 2001, CFSA instituted new licensing standards for congregate care homes, and in 2003 CFSA closed those that did not meet these standards. Prior to these new standards, congregate care facilities received a facility inspection but were not licensed. The standards cover the physical safety of the facility, staff credentials, staffing ratios, and required background checks for staff. In 2002, just after the publication of the new licensing standards, most of these facilities--25 of the 28 facilities--were issued provisional licenses in order to allow them time to make physical upgrades required in the new standards. However, as of June 2003, 4 of the 25 congregate care homes had been closed because they could not meet these licensing requirements. Like traditional foster homes, congregate homes are monitored regularly and licenses must be renewed each year. Agency officials reported that although some challenges remain--for example, facilities have had difficulty finding staff with the credentials needed to meet CFSA's requirements--the new licensing requirements have greatly improved the quality of congregate care. CFSA broadened its oversight of out-of-state and private agency placements in order to help ensure a consistent level of safety. In 2003, the agency added staff to a unit that reviews the licenses of out-of-state[Footnote 24] homes and manages contracts with private agencies that help place CFSA's children in neighboring states. This oversight process gives CFSA the opportunity to remove a child from a home if it finds a serious problem with a family's license and, in the case of a less significant licensing issue, the agency can work with the private agency to help correct the problem. Because of previous problems, CFSA began requiring out-of-state private agencies to provide foster families with support workers--caseworkers who make monthly visits and act as a liaison between the agency and the foster parent. Foster parents who live in Maryland and participated in our discussion groups told us that in the past they experienced many problems obtaining a support worker but for the most part these problems had been resolved. Additionally, CFSA has taken steps to establish performance-based contracts with congregate care providers and private agencies. Agency officials expect performance-based contracting to further improve the quality of foster care homes by requiring contractors to achieve specific, measurable outcomes on the level of safety and quality of care they provide to foster children. As a first major step in moving toward performance-based contracting, CFSA issued two requests for proposals (RFPs). The first RFP, which closed in September 2003, sought contracts for congregate care facilities that provide emergency care, group homes, homes for teen parents and their children, and/or independent living services. CFSA received 30 viable proposals for congregate care providers, and agency officials planned to make awards for congregate care in August 2004. The second RFP closed in February 2004 and sought contracts to help place children in traditional foster homes. As of August 2004, CFSA was in the process of evaluating the proposals it received. The implementation plan requires all CFSA contracts to be performance-based by September 2005, and officials said that CFSA plans to meet this requirement. CFSA Has Made Progress in Licensing New Families; however, More Families Stopped Serving than Expected, and CFSA Has Not Determined Reasons Why: While fewer families than expected have participated in CFSA's orientation programs, more families than expected have been licensed but more stopped serving. As of June 30, 2004, the agency reported having processed 448 families through orientation, just under 50 percent of its goal to have 1,000 interested families participate in an orientation session. CFSA also reported that about 170 new families were licensed--exceeding its goal of 100 new families. However, agency officials also reported that as of May 30, 2004, 77 families stopped serving--significantly more than the agency's projected loss of 50 families for fiscal year 2004. Nonetheless, as of June 30, 2004, there was a net gain of about 90 families. If in the last quarter of fiscal year 2004, the number of newly licensed families continues to exceed or at least equals the number of families who stop serving, CFSA should be able to exceed its goal to have a net increase of 50 newly licensed families. With respect to adoption, CFSA finalized 288 adoptions as of June 30, 2004, a number that exceeds the 208 adoptions finalized as of June 2003. If CFSA continues to find adoptive homes for children at its current rate, the agency should exceed the 315 adoptions it finalized at the close of 2003.[Footnote 25] However, CFSA has not determined why foster families stop serving each year. Child welfare experts recommend that agencies conduct exit interviews with foster families and use these data to help improve the program. Agency officials said that they believe the main reasons families stop serving as foster parents are that they become adoptive families, have served for many years, and are "retiring" from service, or cannot meet licensing requirements because of issues such as a change in employment status. However, agency officials could not provide documented support for these statements and, therefore, cannot be certain that foster parents do not stop serving for other reasons. In addition to systematically identifying the reasons families leave the foster program, agency officials can learn about ways to improve the program from exit interviews. Foster parents we met with identified several ways that CFSA could improve the program. For example, foster parents suggested that CFSA change some of its training requirements and that CFSA improve the way information about a foster child is maintained because information has been lost when a child's caseworker changed. We previously reported that CFSA's automated case management system, FACES, lacked data on many foster care cases and noted that information missing from the automated systems can be lost and that such missing information requires caseworkers to spend more time to become familiar with children's cases that are transferred.[Footnote 26] By increasing the net supply of foster homes available, the agency reports that it expects to achieve other important benefits. If there are more traditional foster homes, CFSA can reduce the number of children placed in congregate homes as required by the implementation plan. Further, with more traditional foster homes, CFSA reports that it will likely be able to facilitate more adoptions, given that foster parents often decide to adopt once they live with a child. For example, as of March 2004, 614 foster children (about 62 percent of children under CFSA's care with a goal of adoption) were living with a family who intended to adopt them. Furthermore, the respite care program being developed by COG with the foster care improvement funds may also help increase the net supply of homes. Foster parents said during congressional hearings and group interviews that a respite program would, in the long run, reduce attrition because it would reduce stress and burn-out. COG has designed a respite program that will recruit families from the District and other surrounding jurisdictions who will voluntarily provide respite care. COG's goal is to make 700 respite care placements by March 2005; however, the organization does not yet know how many respite families will be required to provide this number of placements. As of August 9, 2004, COG officials reported that 6 families already licensed as foster care providers had verbally committed to serving as respite families. In addition, 10 families had completed training but were not yet licensed. COG officials also reported that on August 6, 2004, they began soliciting respite requests from foster families and that they plan to begin offering respite services on August 30, 2004. In commenting on a draft of this report, COG officials said that they were assessing the number of foster families that need respite and will use that information to gauge the number of respite families required to meet the need. Some Foster Children Remain in Unlicensed Homes: CFSA has taken a number of steps to ensure that children are placed in licensed foster care homes, yet as of May 2004, 495 children--about 22 percent of children in CFSA's care--were in unlicensed homes. It is the agency's policy not to place children in unlicensed homes, and measures such as the temporary license for kinship homes and greater oversight of out-of-state placements have been taken to prevent children from being placed in unlicensed homes. CFSA officials told us that the majority of the 308 unlicensed homes that remained as of May 2004 entered the foster care program before the new licensing standards were issued and that many are kinship homes and homes located in Maryland. CFSA is working to correct this situation by examining these homes on a case-by-case basis to identify the specific barrier each home faces in becoming licensed and, if possible, to resolve that issue. The emergency support fund made possible by Congress's 2004 appropriation may help by providing money to help families make improvements--such as, installing a ramp for a disabled child or splitting a larger bedroom into two for greater privacy for siblings--that will help them become licensed. CFSA Has Begun Collaborating to Centralize and Track Mental Health Services for Foster Care Children, but Challenges Remain to Ensuring Timely Delivery: CFSA has begun implementing a centralized mental health referral process in collaboration with DMH and the Family Court and has developed a database to track service delivery; however, challenges remain in meeting the statutory timeframes for initiating services and for completing and reporting on assessments. To increase the continuity of care between the foster care and mental health systems, CFSA and DMH designed a standard process for referring foster care children to DMH for mental health assessment and treatment and for tracking service delivery. In addition, officials from each agency have met routinely with Family Court judges to discuss the referral process and other issues that may affect efforts to link foster care children to mental health services. CFSA and DMH began using the referral process in March 2004, and CFSA began using its newly developed database for tracking service delivery in August 2004. In conjunction with CFSA's efforts to centralize and track mental health services, DMH has started expanding its capacity to provide services to foster care children. Efforts include recruiting additional evaluators to perform assessments, certifying additional mental health providers to deliver treatment, and contracting with providers for new types of treatment. While progress has been made to better link foster care children to mental health services, several challenges remain for CFSA and DMH in order to meet the statutory timeframes, such as completing complex and time-intensive assessments and integrating caseworkers and judges into the new referral process. CFSA Has Created a Referral Process and Designed a Database for Tracking Service Delivery: In March 2004, CFSA--in concert with DMH--began implementing a standard process for referring foster care children to mental health services. CFSA and DMH staff developed the new referral process to increase continuity of care between systems and to ultimately improve the effectiveness of mental health services for foster care children. In an effort to collaborate on the new referral process, CFSA and DMH officials have held regular meetings and workgroups to plan, make decisions, and share information regarding mental health services for foster care children. For example, the agencies have made hiring and contracting decisions together and have begun efforts to co-locate staff. These strategies are consistent with those cited by a national expert as indicators of a state's commitment to coordinate care for children across multiple public systems.[Footnote 27] In addition to working together, both CFSA and DMH have been meeting with Family Court judges to present information on the new referral process and to discuss ways to ensure that judges are ordering the most appropriate services and that services are delivered on a timely basis. Under the new referral process, CFSA's newly established Behavioral Services Unit (BSU) coordinates referrals for mental health assessments or treatment, which are then delivered primarily by DMH through its network of evaluators and providers.[Footnote 28] A child's case is forwarded to BSU when a Family Court judge issues an order for mental health services or when a caseworker makes a request for services.[Footnote 29] In the case of assessments, a BSU specialist determines whether the type of assessment requested or ordered is clinically appropriate for the child.[Footnote 30] When the assessment request or order is deemed appropriate, the caseworker submits a referral package to BSU. After reviewing the package for quality and completeness, BSU forwards it to DMH's Assessment Center, which is responsible for coordinating assessments of foster care children for the Family Court and CFSA.[Footnote 31] Unless an evaluator is specified in a court order, the Assessment Center assigns the child to the first available evaluator to conduct the assessment. Upon completion of the assessment, DMH sends the report to BSU and to the Family Court. When a child is referred for treatment, BSU contacts DMH's Access Helpline--a telephone hotline providing crisis emergency services, enrollment assistance and information, and referral 24 hours a day and 7 days a week--to enroll the child in the mental health system. Enrollment, which the Access Helpline is to complete within 24 hours of referral, includes assigning the child to a core services agency.[Footnote 32] The core services agency is notified of the enrollment and is required to contact the child's caseworker within 7 days of enrollment to set the first appointment for treatment. Figure 3 summarizes the referral process. Figure 3: CFSA's Standard Process for Referring Foster Care Children to DMH: [See PDF for image] [A] The referral package for an assessment includes extensive information on a child, such as demographic information; previous school, police, or health reports; and a developmental history. [B] If the referral package for an assessment is incomplete, the Assessment Center will send it back to BSU without assigning an evaluator. [C] In some cases, Family Court judges order that a specific DMH evaluator perform an assessment. In addition, judges occasionally order specialized assessments, such as neuropsychological evaluations, that are only performed by some evaluators. [D] DMH's contracts with evaluators require that an assessment be completed and the final report on the assessment be submitted to DMH and the Family Court, when applicable, within 14 days of when the evaluator last saw the child. [E] The referral for treatment includes basic information on the child, such as the child's Social Security number and assigned caseworker. [F] The child's caseworker is expected to accompany the child to the first appointment for treatment. [End of figure] To electronically track mental health service delivery, CFSA created a database to capture data on new referrals for services for foster care children and, began entering service delivery information in August 2004.[Footnote 33] Prior to the implementation of the database, BSU was using paper referral forms to manually collect information on foster care children being referred for mental health services. According to CFSA officials, preliminary data showed that as of July 2004, BSU was receiving between 80 and 100 referrals for mental health services a week, 40 percent of which were for assessments and 60 percent for treatment. CFSA and DMH also reported that, from mid-March 2004 through May 2004, CFSA completed 141 assessments and DMH's Assessment Center completed 111 assessments.[Footnote 34] With regard to treatment, from mid-March 2004 through May 2004, DMH enrolled 286 foster care children to begin treatment in a certified core services agency, of which there are 13. According to CFSA officials, DMH's core services agencies were able to accept 95 percent of the referrals of foster care children for treatment. CFSA treatment providers accepted the remaining 5 percent, which were for specialized services that a DMH provider did not offer, such as attachment therapy.[Footnote 35] While officials were able to report some of the data collected manually, CFSA had not analyzed the information to determine whether foster care children were receiving mental health services within the statutory timeframes. [Footnote 36] However, Family Court judges and a CFSA report noted that completed assessments could take from 30 to 60 days. BSU officials indicated that once CFSA's database is fully operational, every child's electronic file would include information from caseworkers, court orders, and DMH. For example, the file will capture demographic data, the assigned caseworker, the child's mental health diagnosis, and, where applicable, the judge assigned to the case. Additionally, the database will allow BSU to establish an electronic record for each service referral. According to CFSA officials, these electronic records would reflect when the service was requested or court-ordered, the mental health evaluator or treatment provider that accepted the referral, and the date the service was delivered.[Footnote 37] To collect data on the first treatment appointment, BSU staff plan to call the child's core services agency to ensure that treatment was delivered. This approach may be burdensome for BSU, since approximately 50 to 60 children are being referred to the core services agencies on a weekly basis. CFSA officials anticipate that the database will capture information on all referrals made after the initial date of implementation. CFSA officials also said that temporary staff were hired to enter the data for the referrals made since March 17, 2004. It was also noted that the agency intends to link this database to FACES, the District's automated case management system. As of September 2004, CFSA officials said that revisions to FACES to allow the linkage was being planned. DMH Has Started Expanding Its Capacity to Serve Foster Care Children: Timely delivery of mental health services will largely depend on DMH's ability to expand and sustain its existing capacity to provide services. DMH plans to increase the number of evaluators available to conduct assessments, certify and train additional providers to deliver treatment, and contract for new types of treatment. The new types of treatment for foster care children will add to the variety of services previously available to foster care children in DMH's system. Table 3 identifies examples of key existing and planned services for foster care children. According to DMH officials, expanding its capacity to provide services to foster care children is a formidable task. For example, recruiting qualified evaluators is difficult due to the level of education needed to perform assessments, as well as competition with neighboring jurisdictions for qualified staff. Table 3: Examples of Existing and Planned Services in the District Mental Health System for Foster Care Children: Services/initiatives: In operation as of July 2004[A]: School-based program; Description: Primary prevention strategies for all students; early intervention provided at first occurrence of emotional, behavioral, or social concerns; treatment for students with a variety of mental health problems; crisis service for emergent needs; and family support. Services/initiatives: In operation as of July 2004[A]: Mental health rehabilitation services; Description: Nine services, including services such as crisis and emergency care, medication treatment, and community-based intervention, covered by Medicaid and intended to facilitate a consumer's recovery from mental illness. Services/initiatives: In operation as of July 2004[A]: Alternative Pathways; Description: Intervention strategies implemented at truancy centers, the courts, and police department processing centers that are aimed at diverting children and youth with mental health concerns from the juvenile justice system and preventing them from further penetration into the justice system. Services/initiatives: In operation as of July 2004[A]: Crisis services; Description: Emergency response available 24 hours a day and 7 days a week via the Access Helpline, on- site assessment within one hour of referral by the Helpline, and coordination for hospitalization. Services/initiatives: In operation as of July 2004[A]: Acute care; Description: Inpatient care provided by private hospitals in the community. Services/initiatives: Planned as of July 2004: Multisystemic therapy; Description: Family-and community-based treatment delivered in homes, neighborhoods, schools, and communities for foster care youth with complex clinical, social, and educational problems. Services/initiatives: Planned as of July 2004: Mobile crisis; Description: Face-to-face mobile response and stabilization services provided at the site of a child's escalating behavior available for children in foster care. Services/initiatives: Planned as of July 2004: Intensive home and community-based services; Description: Intensive services provided in the home and community where the child lives by a team of professionals available 24 hours a day and 7 days a week. Services/initiatives: Planned as of July 2004: Trauma treatment; Description: Specialized traumatic stress treatment interventions, such as cognitively based therapy. Source: GAO analysis of DMH data. [A] The table lists examples of key services available for foster care children as of July 2004, but is not a comprehensive list. [End of table] DMH has made some progress in expanding its capacity to meet the assessment and treatment needs of foster care children. DMH officials noted that efforts are underway to recruit additional evaluators and transition CFSA evaluators to DMH's Assessment Center. For example, CFSA officials meet with their evaluators to encourage them to contract with DMH. Regarding treatment providers, as of June 2004, 10 organizations specializing in serving children and families had applied for DMH certification to be a core services agency, specialty provider, or subprovider. In addition to new evaluators and treatment providers, DMH has begun a competitive grant process to make several new types of treatment available to foster care children. As of August 2004, DMH had approved grants for providers to deliver multisystemic therapy, intensive home and community-based services, and mobile crisis services and was awaiting proposals to deliver trauma treatment. DMH estimated that 300 to 500 foster care children would be served under these grant programs within 1 year of the grant contracts being signed. DMH officials noted that providers would not be able to begin delivering services before the end of fiscal year 2004. Initially funded by the $3.9 million in federal foster care improvement funds, DMH has strategies in place aimed at sustaining the additional assessment and treatment capacity. In terms of financing the increased capacity for assessments, DMH's director said that the department would continue to fund evaluators to provide assessments, which represents approximately $1.1 million of the federal funds; however, the volume of assessments presents a challenge to meeting the statutory timeframes after fiscal year 2005. As for treatment, which represents approximately $2.5 million of the federal funds, DMH expects that Medicaid will largely cover the cost of the new types of treatment under the mental health rehabilitation services option.[Footnote 38],[Footnote 39] Challenges Remain to Ensuring the Timely Delivery of Mental Health Services: While significant steps have been taken to better link foster care children to mental health services, CFSA and DMH face challenges to ensuring the timely delivery of these services due to the complex working environment in which they operate. For example, before assessments can be conducted, caseworkers must prepare referral packages, which include extensive amounts of information on a child. The caseworkers' ability to prepare and submit referral packages to BSU quickly can depend in part on how well they know the child or can obtain access to information about the child's demographics; previous school, police or health reports; and developmental history. A CFSA official estimated that it could take caseworkers from 2 days to several weeks to prepare a referral package. Further, the need for more intensive, complex assessments for some foster care children can affect the extent to which services are provided on a timely basis. In particular, DMH officials noted that meeting the statutory timeframes for completing and reporting on assessments could be problematic, because some complex assessments such as bonding studies, which determine the extent to which a child has bonded with his or her caregiver, require multiple appointments, and may take longer to complete than other assessments. (See table 4 for a list of the types and purposes of assessments for children in foster care.) Additionally, some types of assessments have prerequisites that can lengthen the time needed for completion. For example, to complete a neuropsychological assessment, the child must first undergo a psychological assessment. To the extent that some foster care children may require more complex, time-consuming assessments than others, it may be difficult for DMH to meet the statutory timeframes of completing the assessment within 15 days of the request or court order and providing the results to the Family Court within 5 days of its completion. According to one national expert in mental health system reform, other jurisdictions generally have not legislated timeframes for mental health systems to provide services, in part because different assessments vary in the length of time required for completion.[Footnote 40] Table 4: Types and Purposes of Assessments for Children in Foster Care: Type: Behavioral; Purpose: To determine the cause or function of behavior to develop the most effective treatment plan. Type: Bonding/attachment; Purpose: To report on the relationships that a child has with biological and substitute caregivers by use of direct observation of interactions and play. Type: Neuro-psychological; Purpose: To measure a person's cognitive, perceptual, and motor performance to obtain clues to the extent and locus of brain damage. Type: Psychiatric; Purpose: To evaluate individuals based on their behavior in relation to physical, genetic, environmental, social, cognitive, and emotional components. Type: Psycho-educational; Purpose: To determine an individual's cognitive and educational functioning. Type: Psychological; Purpose: To determine an individual's cognitive, emotional, behavioral, and social functioning. Type: Sexual abuse; Purpose: To determine if sexual abuse occurred and victims' mental health status as a result of the abuse. Type: Sexual offender; Purpose: To determine if an individual has a propensity towards sexual abuse of a child. Source: GAO analysis of CFSA and DMH data, as of May 2004. [End of table] In addition to operating in a working environment that has extensive information requirements and variations regarding individual need, CFSA and DMH are working to better integrate caseworkers and judges into the new referral system. While BSU is in place to provide clinical expertise in making mental health service referrals, caseworkers and judges may not be aware of or understand how to use the office. For example, one Family Court official said that some judges have ordered that a specific DMH evaluator perform an assessment, which may delay its completion due to the evaluator's availability. A CFSA official working as a liaison to the Family Court also indicated that caseworkers continue to contact DMH directly to link children to mental health services, which may delay the court order going through BSU for processing. To help educate caseworkers about the new referral process, officials from BSU created a fact sheet providing caseworkers guidance on how to link children to mental health services. In addition, in May 2004, a BSU official began meeting with caseworkers to formally present the new process and answer questions. As mentioned previously, CFSA has also presented the referral process to Family Court judges, and DMH is exploring ways to have its staff available during Family Court hearings to answer questions related to mental health services. Uncertainties Exist in the Long-Term and Short-Term Funding Status for Some of the Projects Included in the Plan: In February 2004, CFSA, DMH, and COG submitted spending plans to the Congress outlining how they intended to use the foster care improvement funds, and in March 2004, they received the funds. As of June 30, 2004, they reported obligations of about $1.5 million of their appropriated funds, with about $419,000 of that total having been expended. Most of the planned expenditures outlined in the spending plans are for operating costs that would continue in the future once the programs are established. How the District and COG plan to fund some of these initiatives in the long term is uncertain. CFSA, DMH, and COG Have Planned Expenditures for Purposes Identified in the Act: Following the passage of the act on January 23, 2004, the organizations could not receive funding until 30 days after they submitted a plan. The District submitted a spending plan for CFSA and DMH on February 9, 2004, and COG submitted its spending plan on February 13, 2004. The expenditures included in the plans are consistent with the stated purposes in the legislation. Table 5 summarizes the purposes for the funds as designated in the law and the planned expenditures listed in the spending plans. Table 5: Purposes and Plans for the Foster Care Improvement Funds: Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish an early intervention program to provide intensive and immediate services to foster children; Public Law 108-199: Appropriated funds: $2 million; Spending plans: Proposed expenditures: $700,000; Spending plans: Description: Personnel costs (salaries & benefits). Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish an early intervention program to provide intensive and immediate services to foster children; Spending plans: Proposed expenditures: $500,000; Spending plans: Description: Training and communications. Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish an early intervention program to provide intensive and immediate services to foster children; Spending plans: Proposed expenditures: $200,000; Spending plans: Description: Meeting expenses (e.g., facilities & transportation). Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish an early intervention program to provide intensive and immediate services to foster children; Spending plans: Proposed expenditures: $530,000; Spending plans: Description: Services for children and families that are not currently available at sufficient levels (e.g., substance abuse treatment). Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish an early intervention program to provide intensive and immediate services to foster children; Spending plans: Proposed expenditures: $70,000; Spending plans: Description: Overhead. Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish an Emergency Support Fund to purchase necessary items to allow children to remain in the care of a licensed, approved family member; Public Law 108-199: Appropriated funds: $1 million; Spending plans: Proposed expenditures: $920,000; Spending plans: Description: Emergency expenses for relatives (e.g., furnishings & home repairs). Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish an Emergency Support Fund to purchase necessary items to allow children to remain in the care of a licensed, approved family member; Spending plans: Proposed expenditures: $73,000; Spending plans: Description: Personnel costs (salaries & benefits). Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish an Emergency Support Fund to purchase necessary items to allow children to remain in the care of a licensed, approved family member; Spending plans: Proposed expenditures: $7,000; Spending plans: Description: Overhead. Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish a loan repayment program for social workers; Public Law 108-199: Appropriated funds: $3 million; Spending plans: Proposed expenditures: $2,750,000; Spending plans: Description: Student loan repayments for qualified social workers with masters and bachelors degrees to accept and extend their tenure in the District. Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To establish a loan repayment program for social workers; Spending plans: Proposed expenditures: $250,000; Spending plans: Description: Contract for Loan Repayment Program design and administration. Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To upgrade (FACES) computer database and technology as well as to provide computer technology for social workers; Public Law 108-199: Appropriated funds: $3 million; Spending plans: Proposed expenditures: $2,170,000; Spending plans: Description: Upgrade FACES to Web-based architecture. Organization and total funding: Child and Family Services Agency; $9 million; Public Law 108-199: Purpose of funding: To upgrade (FACES) computer database and technology as well as to provide computer technology for social workers; Spending plans: Proposed expenditures: $830,000; Spending plans: Description: Computer technology for caseworkers (e.g., new laptops or tablet PCs). Organization and total funding: Department of Mental Health; $3.9 million; Spending plans: Proposed expenditures: $300,000; Spending plans: Description: Staffing of project team to oversee the implementation and coordination of all program services outlined below. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court- ordered or agency-required mental health screenings and assessments for children under the supervision of CFSA; Spending plans: Proposed expenditures: $1,030,000; Spending plans: Description: Costs for expanded psychologists and psychiatrists. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court- ordered or agency-required mental health screenings and assessments for children under the supervision of CFSA; Spending plans: Proposed expenditures: $70,000; Spending plans: Description: Staff and home visits/ assessments. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court- ordered or agency-required mental health screenings and assessments for children under the supervision of CFSA; Spending plans: Proposed expenditures: $47,000; Spending plans: Description: Supplies and materials. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court-ordered or agency required mental health treatments for children under the supervision of CFSA; Spending plans: Proposed expenditures: $1,725,000; Spending plans: Description: Mobile crisis and community based intervention teams to provide immediate assistance. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court-ordered or agency required mental health treatments for children under the supervision of CFSA; Spending plans: Description: Community support teams to provide a range of interventions to high risk children involved in multiple systems. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court-ordered or agency required mental health treatments for children under the supervision of CFSA; Spending plans: Description: Community treatment setting for older adolescents who are aging out of care. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court-ordered or agency required mental health treatments for children under the supervision of CFSA; Spending plans: Description: Specialized therapy and child traumatic stress treatment. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court-ordered or agency required mental health treatments for children under the supervision of CFSA; Spending plans: Proposed expenditures: $150,000; Spending plans: Description: Staffing coordination between DMH and CFSA. Organization and total funding: Department of Mental Health; $3.9 million; Public Law 108-199: Purpose of funding: To provide all court-ordered or agency required mental health treatments for children under the supervision of CFSA; Spending plans: Proposed expenditures: $578,000; Spending plans: Description: Training. Organization and total funding: Metropolitan Washington Council of Governments; $1.1 million; Public Law 108-199: Purpose of funding: To develop a program in conjunction with the foster and adoptive parents advocacy center to provide respite care for and recruitment of foster parents; Spending plans: Description: Although COG presented a detailed spending plan, it did not include a breakdown of expenditures. The plan indicated that COG would (1) provide services for resource parents caring for children in the DC child welfare system, (2) recruit and train respite care families to care for foster children covering emergency, planned or ongoing respite care situations, and (3) assist CFSA in developing a recruitment video and purchasing media ads targeted to demographics most likely to foster children with special needs. Source: District of Columbia government and the Metropolitan Washington Council of Governments. [End of table] CFSA's spending plan outlined a strategy for accomplishing the objectives of each of its programs as established under the act. According to the plan, CFSA would: * establish an early intervention program through the implementation of Facilitated Family Team Meetings that would focus on permanency options for foster children; * create an emergency support fund for kinship caregivers to pay for necessary expenses such as lead abatement, home repairs and renovation, and child care, in order to help these caregivers become or remain licensed foster homes; * establish a student loan repayment program for caseworkers; and: * enhance CFSA's ability to share information within and outside the agency by upgrading the agency's child welfare tracking database, FACES, to a Web-enabled system, providing laptop computers for caseworkers and enhancing CFSA's networking capabilities to enable this Web-based initiative. The budgets from the three organizations provided details about the planned expenses. The major expenses detailed in CFSA's budget are related to the hiring of new personnel for Facilitated Family Team Meetings, student loan repayments to caseworkers, equipment and labor for technology upgrades, and direct support services to children and families. DMH's spending plan identified funding for expanded psychiatrist and psychologist hours for assessment and mental health treatment, such as that provided by mobile crisis intervention teams and specialized therapy. DMH's budget confirmed these as the major portions of the federal funds. COG's spending plan outlined programs for providing respite care for and the recruitment of foster parents, but it did not provide a monetary breakdown of how the funds would be spent. However, COG's budget identified the expenditures for the respite care and recruitment programs, and the major expenses budgeted were for personnel costs and funds that would be passed through to contractors and community organizations to provide respite, recruitment, and related training services. Furthermore, COG officials indicated that they have until March 2005 to expend all of its funds. Future Funding for Some of the Long-Term Projects in the Plan Is Uncertain: While the expenditures proposed in the District and COG spending plans appear to be in line with the intentions of the act, it is unclear how the District and COG plan to support all of the programs and initiatives outlined in the spending plan in the long-term. Although the District's fiscal year 2005 proposed budget for CFSA reflects realignment of agency funds as a means to continue the early intervention program that was funded in fiscal year 2004 with federal funds, it does not address funding for continuing the other CFSA programs. Also, CFSA has reported that the student loan repayment program would be made available only to staff currently on board due to the expiration of the funds on September 30, 2004, although these funds are intended to support a multiyear strategy that would allow CFSA to retain highly qualified caseworkers over time. The District's proposed budget for fiscal year 2005 for DMH includes a realignment of funds to support some mental health treatment services. For fiscal year 2005, the budget includes funds to support programs designed to help foster care children, such as Multi-Systemic Therapy services. Also, DMH officials said that they are working to include the new types of treatment in the services reimbursed under the District's Medicaid program as a longer-term mechanism to fund additional services. With regard to assessment, it is unclear how the District plans to sustain the funding necessary for the additional evaluators. According to the DMH director, DMH would continue to fund evaluators to provide assessments. In addition, COG officials told us that they would likely need an additional $500,000 from the federal government to continue their respite care initiative through the end of fiscal year 2005 and hope that private sources would support the respite program in the future. In commenting on a draft of this report, COG officials said that they had received a partnership commitment from a private source and would seek further funding as needed. As of June 30, 2004, Only a Small Portion of the $14 Million Had Been Obligated or Spent: The District and COG did not receive authority over their funding until 6 months into fiscal year 2004. Following passage of the act on January 23, 2004, the District and COG could not receive funding until 30 days after they submitted a spending plan. On March 17, 2004, the District received the $14 million payment, less a 0.59 percent rescission,[Footnote 41] for a total of $13,917,400. The District's Office of Budget and Planning granted CFSA budget authority for its share of funds, $8,946,900 on March 22, 2004, and granted DMH budget authority for its funds totaling $3,876,990 on March 17, 2004. The District sent COG its payment of $1,093,510 on March 25, 2004. As of June 30, 2004, CFSA, DMH, and COG reported a small portion of the funds appropriated for foster care improvements were obligated or spent. CFSA reported that it had outstanding contractual obligations of $183,105 and had expended $31,998, resulting in 2.4 percent of its funding under the act being expended or obligated. DMH reported that it had $704,527 in outstanding contractual obligations of the funds and had expended $190,538, totaling 23.1 percent of its funding under the act. COG reported that it had expended $196,307 of its funds, and that it had incurred $145,043 in outstanding contractual obligations, representing 31.2 percent of its funding under the act. In all, over $12.4 million of the foster care improvement funds, appropriated for fiscal year 2004 only, remained available 9 months into fiscal year 2004. Table 6 provides details on the organizations' expenditures and obligations as of June 30, 2004. Table 6: Funds Received and Expended by CFSA, DMH, and COG as of June 30, 2004: Organization: CFSA; Funds received: $8,946,900; Expenditures and obligations: Funds Expended: $31,998; Expenditures and obligations: Outstanding Contractual Obligations: $183,105; Total funds expended and obligated: Amount: $215,104; Total funds expended and obligated: Percent: 2.4; Funds remaining: Amount: $8,731,796; Funds remaining: Percent: 97.6. Organization: DMH; Funds received: $3,876,990; Expenditures and obligations: Funds Expended: $190,538; Expenditures and obligations: Outstanding Contractual Obligations: $704,527; Total funds expended and obligated: Amount: $895,065; Total funds expended and obligated: Percent: 23.1; Funds remaining: Amount: $2,981,925; Funds remaining: Percent: 76.9. Organization: COG; Funds received: $1,093,510; Expenditures and obligations: Funds Expended: $196,307; Expenditures and obligations: Outstanding Contractual Obligations: $145,043; Total funds expended and obligated: Amount: $341,350; Total funds expended and obligated: Percent: 31.2; Funds remaining: Amount: $752,160; Funds remaining: Percent: 68.8. Organization: Total; Funds received: $13,917,400; Expenditures and obligations: Funds Expended: $418,844; Expenditures and obligations: Outstanding Contractual Obligations: $1,032,675; Total funds expended and obligated: Amount: $1,451,519; Total funds expended and obligated: Percent: 10.4; Funds remaining: Amount: $12,465,881; Funds remaining: Percent: 89.6. Source: GAO analysis of data from the District of Columbia government and the Metropolitan Washington Council of Governments and GAO analysis. Data are unaudited. Differences are due to rounding. [End of table] Conclusions: Many steps have been taken to help improve the District's foster care system, but most of the programs and initiatives will need sustained attention and ongoing support. CFSA has implemented effective recruitment strategies and established retention incentives to help recruit and retain skilled caseworkers. CFSA has also developed a plan to recruit foster and adoptive families and instituted practices to better ensure the safety of foster and adoptive homes. While these efforts are promising, CFSA will need to continue to support these initiatives and monitor their effectiveness. Several other initiatives have just begun and will need sustained attention to ensure they are fully implemented. COG has not yet licensed families to provide respite or offered respite placements and is not certain about the number of families that will be needed to support the program. CFSA's and DMH's process for providing mental health services for foster care children was recently initiated, and it is uncertain whether these services are being provided in a timely fashion. In addition, there are several challenges remaining to ensuring the timely delivery of mental health services, including DMH's ability to expand its capacity to provide services. Furthermore, while the expenditures proposed in the District and COG spending plans appear to be in line with the intentions of the act, it is unclear how the District and COG plan to support some of the programs and initiatives outlined in the spending plan in the long- term. However, some of CFSA's management practices have not created a positive work environment for its caseworkers. Caseworkers play a critical role in the District's child welfare system, and CFSA needs its caseworkers to be productive, motivated, and committed in order to make further improvements to the District's child welfare system. Without making further changes in its management practices, CFSA may experience decreases in productivity and increases in attrition of its caseworkers. Further, low morale may affect caseworkers efforts to fulfill their duties and provide adequate care to the children they manage. Without consistent and effective communication strategies, caseworkers may not be aware of what services they can provide to foster care children and their families or the processes for obtaining such services. Without supervisors fulfilling their responsibilities, CFSA caseworkers are left without guidance and direction on how to improve on their performance and fulfill their case management duties. Additionally, caseworkers may not be making the best decisions about their cases, which in turn can affect the care and services provided to children and their families. In addition to having a cadre of highly skilled and motivated caseworkers, an adequate number of safe, foster, and adoptive homes is a critical factor to improving foster care in the District. Despite CFSA's new efforts and attention to recruiting foster and adoptive families, the agency does not have a process for assessing the effectiveness of its recruitment efforts. Therefore, the agency does not know which efforts are most productive and which strategies should be continued or abandoned. Additionally, CFSA does not have sufficient information about the reasons foster families stop serving and leave the foster care system because it does not have a process to solicit feedback from them. Such information could help the agency improve its program and help reduce the attrition of foster families. Recommendations: To build upon the improvements underway, we recommend that the director of CFSA take the following three actions: * Address human capital management issues that affect caseworkers by establishing processes to consistently and effectively communicate information about agency operations and developing strategies to help ensure that supervisors fulfill their responsibilities. * Develop a systematic method to evaluate its foster parent recruitment efforts to help identify the most effective strategies. * Conduct exit interviews with foster parents who stop serving to identify the factors affecting their decisions and develop an action plan to address those factors that relate to systematic issues. Agency Comments and Our Evaluation: We received written comments from CFSA on a draft of this report. These comments are reprinted in appendix II. CFSA agreed with each of our recommendations and said that it plans to implement them. CFSA provided additional information to clarify the issues in the report, and we made changes to the report to reflect several of these comments. Specifically, we (1) revised the maximum student loan repayment amounts and the application deadline, (2) updated the number of finalized adoptions, (3) changed the new recruitment unit operational date from August to October, (4) noted that CFSA has implemented some suggestions from the COG report, (5) corrected the information on licensing for kinship homes, and (6) noted that CFSA has begun entering data on mental health referrals made since March 2004. CFSA provided other information and data that we did not incorporate because the data could not be corroborated in time for this report. We also received written comments on a draft of this report from DMH. These comments are reprinted in appendix III. DMH provided information to clarify and provide context for three areas in the report: sustainability, building provider capacity, and improving the timeliness of evaluations and assessments. We made changes to recognize DMH's plan to sustain the programs begun with federal funding. Specifically, we note a realignment of funds to support various mental health services that could help the District's foster care children. Also, we added information on DMH's plans to include new types of treatment in the services reimbursed under the District's Medicaid program. With regard to DMH's efforts to meet the timeliness requirements for completing evaluations and assessments, we did not change the report to reflect the new information provided. DMH did not include supporting documentation for the timeframes reported, and we could not verify the data on the timelines for completing assessments. Additionally, we received written comments on a draft of this report from COG. These comments are reprinted in appendix IV. COG provided us with information on its plans to obtain long-term funding for its program and to assess the number of respite providers it will need. We modified the report to reflect these comments. We will send copies of this report to the Acting Director of CFSA, the Director of DMH, the Executive Director of COG, appropriate congressional committees, and other interested parties. We will also make copies of this report available to others on request. In addition, the report will be available at no charge on GAO's Web site at http:// www.gao.gov: If you have any questions about this report, please contact me on (202) 512-8403. Other contacts and staff acknowledgments are listed in appendix V. Cornelia M. Ashby: Director, Education, Workforce, and Income Security Issues: [End of section] Appendix I: Objectives, Scope, and Methodology: To identify Child and Family Services Agency's (CFSA) strategies for recruiting, retaining, and managing its caseworkers, we reviewed key CFSA documents, analyzed data, and interviewed several experts and agency officials. Specifically, we reviewed CFSA's strategic and annual plans for fiscal years 2003 and 2004 and CFSA's recruiting and retention plans for fiscal years 2003, 2004, and 2005. We reviewed CFSA data, such as worker caseload counts, attrition data, and exit interviews. To check the frequency with which performance appraisals were being held, we reviewed personnel folders for a random sample of 80 caseworkers, of which we excluded 49 caseworker files to include only those hired on or before December 31, 2000. We reviewed national standards for child welfare agencies set by the Child Welfare League of America and the Council on Accreditation. Additionally, we met with several CFSA program officials and the court-appointed monitor, the Center for the Study of Social Policy (CSSP). We also interviewed national child welfare experts from the Child Welfare League of America, Council on Accreditation, the Department of Health and Human Services (HHS) Children's Bureau, Institute for Social Welfare Research, Council on Social Work Education, National Association of Social Workers, and Casey Family Services. We also used discussion groups to obtain the opinions and insights of CFSA supervisors and caseworkers regarding their opinions of CFSA's recruiting, retention, and management support of caseworkers. Discussion groups are a form of qualitative research in which a specially trained leader, the moderator, meets with a small group of people who have similar characteristics and are knowledgeable about the specific issue. The results from the discussion groups are descriptive, showing the range of opinions and ideas among participants. However, the results cannot serve as a basis for statistical inference because discussion groups are not designed to (1) demonstrate the extent of a problem or to generalize results to a larger population, (2) develop a consensus for an agreed-upon plan of action, or (3) provide statistically representative samples with reliable quantitative estimates. The opinions of many group participants showed a great deal of consensus, and the recurring themes provide some amount of validation. After an initial group interview with supervisors selected by CFSA officials, we conducted four discussion groups--one with supervisors and three with caseworkers. We randomly selected participants to help ensure that they represented a cross section of the organization. Attendance on the part of invited participants was voluntary. For the three discussion groups that were held with caseworkers, we had one with employees who had been at CFSA for 1 year or less, one discussion group with employees who had been at CFSA 1-6 years, and one with employees who had been at CFSA more than 6 years. A trained discussion group moderator led the discussions while our analysts took notes. We developed a discussion group guide to assist the moderator in leading the discussions. To assess CFSA's efforts to license an adequate number of safe homes for foster care placements and adoptions, we reviewed CFSA documents, analyzed related data, interviewed agency officials, and held group interviews with foster and adoptive parents. Specifically, we examined CFSA's plan for foster and adoptive parent recruitment and retention and its resource development plan. We also reviewed CFSA's licensing policies for traditional foster, kinship, and congregate care placements. We analyzed CFSA data on the number of children in unlicensed foster homes, people attending orientation sessions, foster homes issued a license from October 2003 through June 2004, and the attrition rates for foster families from October 2003 to May 2004. We also evaluated the number of foster families with the intent to adopt their foster children as of March 2004, and the number of children in CFSA's care waiting to be adopted as of March 2004. We reviewed HHS' Child and Family Services Review (CFSR) on CFSA, the Implementation Plan issued by CFSA's court-appointed monitor, and other national studies on recruiting foster parents. We met with CFSA program officials and the court-appointed monitor to discuss CFSA's processes and goals for licensing foster parents. We coordinated with D.C.-based organizations, the Foster Parent Advocacy Center (FAPAC) and the Foster Parent Association, to hold group interviews with foster parents. Additionally, we interviewed officials from the Adoption Resource Center in Washington, D.C. and the Metropolitan Washington Council of Governments (COG). To determine how CFSA has collaborated with the Department of Mental Health (DMH) and the D.C. Family Court to provide mental health services to foster care children and what challenges remain, we analyzed CFSA and DMH planning documents, notices of available funding, provider contracts, and documentation of internal procedures for referring foster care children to mental health services. Prior to its implementation, we previewed CFSA's database for tracking mental health referrals and reviewed the documents used to collect and log the data. We also reviewed preliminary data on the number of assessments completed and the number of children enrolled with DMH treatment providers from mid-March 2004 through May 2004. We interviewed CFSA and DMH program officials and D.C. Family Court judges. In addition, we interviewed national experts in coordinating care for children across public systems, including the court monitors for the District's child welfare and mental health systems, respectively. To report on CFSA's, DMH's, and COG's plans and use of their fiscal year 2004 federal funds for foster care improvements, we reviewed the agencies' spending plans, budget data, and unaudited reports of obligations and expenditures. We interviewed financial and program personnel from all three organizations and from within the District's central Chief Financial Officer's office. [End of section] Appendix II: Comments from the District of Columbia's Child and Family Services Agency: GOVERNMENT OF THE DISTRICT OF COLUMBIA: Child and Family Services Agency: Office of the Acting Director: September 16, 2004: Cornelia M. Ashby: Director, Education, Workforce, and Income Security Issues: Government Accountability Office: Washington, D.C. 20548: Re: CFSA Comments on GAO Draft Report No. 04-1017: Dear Ms. Ashby: Thank you for the opportunity to comment on your September, 2004 draft report. As you know, CFSA serves approximately 2,800 children in foster care and another 3,150 children living in their birth homes and receiving services. We appreciate that the report recognizes many improvements CFSA has already made in social worker and foster and adoptive parent licensing, recruitment and retention; access to mental health services; and use of specially appropriated federal dollars. We also appreciate your thoughtful recommendations that should translate into even better results. We agree with each of your recommendations and plan to implement them this fall. However, we wish to discuss several areas in which additional information will clarify issues raised in your draft report and to identify a few areas in which modifications are in order. Social Worker Recruitment and Retention: As the draft report recognizes, CFSA has made considerable strides in social work recruitment, exceeding ambitious recruitment targets for FY03. We have done so by using new advertising strategies combined with incentives. Now that we have been successful in bringing new workers into CFSA, we must turn our attention to retention. To do so, we focused significant portions of the upcoming year's recruitment plan on retention efforts. Strategies already identified in the June 2004 plan include implementation of the student loan repayment program as well as a rewards and recognition program for workers. Specifically, participants in the student loan repayment program must sign an agreement to remain with CFSA for a total of four years, although workers who have already been here two or more years need to agree to stay only another two years. In late August, we increased the maximum repayment amounts from $10,000 to $18,000 for MSWs and from $5,000 to $10,000 for BSWs (see Draft report, page 16) with a tenure bonus for workers with five years' tenure at CFSA. [NOTE 1] We are currently meeting with union representatives and social work staff to develop a tailored rewards-and-recognition program for employees. In the meantime, CFSA uses incentives such as academic achievement incentives, bonuses for bilingual workers and reimbursement for relocation expenses, as well as District of Columbia incentive awards, which include quality step increases and other monetary awards as well as time off of up to three full days without charge to leave. Our intent is to develop a program that encompasses all staff and rewards superior performance or recognizes specific accomplishments. Clearly, social workers are the backbone of any child welfare system, but they rely heavily on a highly motivated and qualified support team who should also benefit from this new program. We expect this program to be implemented this fall. We also agree that improvements in policy dissemination to workers and infusion into case practice will have a positive impact on retention, and are working to improve in this area. (Report, page 16-17.) Thus, now policy is presented in several ways-through meetings with supervisors who, in turn, present new policies to staff, Program All staff meetings held each month; incorporating new policies into existing training; training sessions specifically about new policies; and notices in CFSA's employee newsletter. In addition, our computer system notifies staff through "version notes" and "alerts" that advise when online policies are updated. We also have recently established a process for issuance of administrative directives and protocols to provide guidance to staff while we finalize formal policy. This multi- faceted approach should help to reduce worker frustration. Quality supervision is another essential factor in social worker retention that we have begun to address. First, we improved management tools so that supervisors now know each worker's caseload and the status of case plans and visits for each worker on each case. We developed a case consultation supervisory guide, [NOTE 2] which is intended to standardize supervision in Program Operations, so that supervisors review all key aspects of cases during weekly supervision. Supervisors will participate in a peer review process where they will have an opportunity to review cases of their peers and provide feedback and consultation. We will also use this year's Performance Management Plans (PMPs) to ensure supervisors are held accountable for providing quality supervision to their units. The PMPs will include clear standards for weekly supervision as well as requirements for completion of mandatory supervisory training. We will tie the award of any incentives to these standards. On the issue of training of supervisors, information in the draft is not wholly accurate. We require all new supervisors to complete the five-module "Mastering the Art of Supervision." One module is offered per month (with the exception of August and December). Supervisory staff enroll in the module closest to their hire date and continue each month until they complete all five modules. [NOTE 3] Modules cover the following topics: Table 1: [See PDF for image] [End of table] In 2003, out of a total of 20 (not 61) new case-carrying supervisors, 11 (not 5) completed all five modules; 7 completed four modules; 1 completed 3 modules; and 1 supervisor, who was on maternity leave, completed no modules. [NOTE 4] Two supervisors hired in 2004 and each supervisor who has not completed all five modules are currently scheduled for the relevant training. In addition to this basic course, we are requiring additional training for supervisors in 2004, which focuses on applying what is learned in training and the supervisors' role in incorporating the learning in case practice. Required courses include Transfer of Learning Process (9 hours given by Child Welfare League of America), Writing Effective Court Reports (12 hours), Safety Model Training (Intake and Investigation Supervisors - 9 hours and for other administrations - 1 hour overview), Engaging Families in the Process of Change: A Supervisor's Guide (9 hours), Engaging Fathers (3 hours), and Supervisory Case Consultation Tools (6 hours). Our Training Director is currently reviewing automated data to provide status reports to supervisors and their managers of their status in completing these required courses. We also recognize the need to continue to focus on caseload equalization. As you note in the draft, page 13, while our average caseload is below 17, we have a number of workers with caseloads greater than that and others with caseloads well under 17. In an attempt to address this issue, and in addition to aggressive recruitment of workers, we are reviewing how cases are assigned and how we are using training units to determine if changes in these areas will positively affect caseloads distribution. We are also evaluating other strategies to address caseload equalization. Foster and Adoptive Home Licensing, Recruitment, and Retention: We are pleased that you recognize our progress in licensing, recruiting, and retaining foster and adoptive homes. We are proud of our first-ever Foster and Adoptive Parent Recruitment/Retention Plan and expect to learn much from our efforts this year. As of August 31, 2004, we have exceeded our FY 04 goals for finalized adoptions, with 368 finalized adoptions. [NOTE 5] We also have finalized 242 guardianships, where kin who become legal guardians for children receive subsidies from the District. This means that so far in FY 04, 600 children have gained permanent families. Recruitment effortrs: We have concentrated improving our foster/adoptive parent recruitment efforts in several areas. We reallocated positions to create a second recruitment unit. Hiring will be completed this month, and the unit will be operational in October. We are developing a short survey to gain information about why families decide to stop fostering, which we will distribute in early October to every foster parent who dropped out in FY04. (Response to report, page 24). We will use information from this survey to update next year's recruitment/retention plan. We also worked with foster parents on a policy relating to information CFSA provides to foster parents when a child is placed, which includes, for example, a board and care agreement, medical screening and immunization information, birth certificate, social security and Medicaid cards, visitation plans, and any court orders. (Response to report, page 25). Foster parent support workers follow up with foster parents to ensure they received a placement packet. We have just completed training all Program Operations staff about the placement packet, and implementation is underway. Additionally, our new contracts with our child placement licensing agencies require them to provide foster parent support workers who will provide support to foster parents and also monitor licensing status. We have implemented some suggestions from the Council of Governments (COG) report referred to on page 21 of your draft. For example, we identified a contact affiliated with the Mystics, the local women's basketball team, who we hope will assist us in events or programs designed to improve community awareness. To involve coaches and others working with children in sports, we partnered with the District's Department of Parks and Recreation, which now advertises our need for foster and adoptive homes in its magazine and through flyers at its recreation centers. We are also finalizing several media strategies aimed at foster and adoptive parent recruitment. Using grant funding from the Freddie Mac Foundation, which we expect to receive shortly, we will hold "foster ware" parties, purchase promotional items for giveaways at community events, and develop exhibits and informational kits for prospective parents. We are working with COG to develop a recruitment video, one of the initiatives from the federal appropriation. Licensing: Turning now to the licensing issues, we wish to correct the discussion in the report related to kin licensing (page 22). The District has had licensing requirements and standards for kin homes since 2001, not April 2004. In 2004, with the consent of the Court Monitor, we instituted emergency, temporary licensing of kin, which provides for preliminary key safety checks and prompt placement of children. Kin must then complete the full procedure for regular licensing. We have licensed 26 kin homes under this program, and have denied several licenses based upon results of the preliminary safety check. We were able to establish this program because we now have direct access to national criminal background data from the National Criminal Information Center (NCIC). We recently proposed this temporary kin placement program to Maryland (page 26), and are optimistic about reaching an agreement that would permit us to implement it for Maryland kin homes. We continue to work to ensure all of our children are placed in licensed foster homes. As you know, when the agency came out of receivership, most of our foster homes did not have licenses. According to the Court Monitor, 33% of foster homes had a current license in May 2001. As of July 31, 2004, 75% of foster homes have a current license. We are using multiple strategies to address the two categories of unlicensed caretakers--those who have never been licensed and those who were previously licensed but whose licenses have expired. Our initial efforts concentrated on those caretakers who had never been licensed. This group, in large part, includes both traditional and kin foster parents who have been caring for children for years, including before the requirement for licensure. While focusing on this group, we have learned that some licenses of licensed homes are expiring without timely renewal, which we are also working to address. The rise in license expirations and continued work with the never- licensed families have required us to revise strategies to ensure that all children reside in licensed homes. Those strategies include improved internal tracking of license status and correction of our own records. We have held several licensing fairs that provided caretakers with a convenient, "one-stop" means of completing a number of licensing requirements: In-service, First Aid, and CPR training are typically offered as well as scheduling of fire inspections, fingerprinting, and other services. We also reviewed our contracts with licensing agencies and, as a result, modified statements of work, increased oversight, and limited new referrals to selected contractors. The former CFSA Director and Deputy Director for Licensing & Monitoring conducted site visits to contractors with high rates of unlicensed homes to discuss improved performance. Last month, contractors received letters from the Deputy Director for Licensing & Monitoring to reinforce CFSA's continued expectations for performance improvement. We also expect to address this issue through the performance-based contracts that are now being finalized. Access to Mental Health Services: As noted in the draft report, CFSA created a referral process and internal database for tracking service delivery. CFSA and Department of Mental Health (DMH) plan to co-locate staff from DMH by October 31, 2004, after they have completed orientation with DMH. Temporary staff have been hired to enter the data for the 1600 referrals that have been made since March 17, 2004. This process should be completed by the end of September. CFSA will begin recruitment of two data entry personnel early in October, who will maintain the database. The database includes demographic information about the child or parent and the date and type of service requested. Under the new system of care, children and families are linked to a Core Service Agency, through Department of Mental Health, that will provide the requested services. Core Services Agencies are Medicaid certified therapeutic providers who provide services such as individual therapy, grief counseling and individual therapy. Update on Use of Federal Dollars: With the federal dollars not available until March 12, 2004, CFSA developed a strategy with the District's Office of the Chief Financial Officer whereby we expect to obligate nearly all of the federal dollars by September 30, 2004, consistent with our spending plan. With respect to the Student Loan Repayment program, we modified the program to increase the maximum repayment amounts. As of September .9, 2004, after we announced the modification, we had signed service contracts or approved applications awaiting signature from 102 workers, for a total of $1,499,059. We have another 71 in the applications process. If all 71 are approved, the combined amount of loan commitments will be $2.4 million dollars. We also extended the application deadline to September 16, 2004. We have executed a three- year contract with a consultant to serve as project manager. Projected cost of this contract (which includes project management and communication materials) is $200,000. Our revised projections show us being able to obligate most of the money by September 30. We anticipate obligating the $2,982,300 for Upgrading Computer Technology for Social Workers by September 30, 2004. A total of $2 million is being obligated to a competitive contract for upgrading the FACES case management system to web-based architecture; $500,000 is allocated to purchasing laptops (with contract award within the next week); $249,223 is paying for District staff and consultants performing the work; and $120,000 has been transferred to the District's Office of the Chief Technology Officer to purchase network routers and switches. The remaining $113,077 will purchase software and hardware to improve network reliability and security. To date, we have spent $122,356 of the Early Intervention Fund and obligated an additional $990,011 and spent $50,478 of the Emergency Support Fund for Kin. We update expenditures and obligations weekly to ensure we will use all of the Congressional appropriation. Thank you once again for the opportunity to respond to your draft report. Feel free to contact me at 442-4177 if you have any questions. Signed by: Brenda Donald Walker: Acting Director, CFSA: Cc: Carolyn Taylor: GAO: Robert Bobb: City Administrator: Neil Albert: Deputy Mayor for Children, Youth and Elders: Natwar Gandhi: Chief Financial Officer: Brenda Donald Walker: Acting Director: 400 Sixth Street, SW: Suite 5039: Washington, DC 20024: Phone: (202) 442-6175: Fax: (202) 727-7700: E-mail: Bdonald@cfsa-dc.org: NOTES: [1] We have the following additional technical corrections to the sections relating to social worker retention and recruitment. Page 10 at the bottom: targeted recruitment focused on schools in Maryland, Virginia, New York, New Jersey, Pennsylvania, North Carolina, Delaware, and South Carolina but not in California and Florida. On page 16, the average CFSA MSW salary with one year of experience is $48,380, not $41,440. [2] Training on the use of the tool began September 8, 2004. [3] Enrolling supervisors in the module closest to their hire date began recently. Previously, supervisors had three months to enroll in the course per the LaShawn Implementation Plan. [4] Since 2002, 12 supervisors completed all five modules, 14 others completed four modules, 7 completed three modules, 2 completed two modules, and 6 completed one module. Eighteen did not complete any modules. [5] Your report refers to 288 as of June 30, 2004 (page 24). [End of section] Appendix III: Comments from the District of Columbia's Department of Mental Health: GOVERNMENT OF THE DISTRICT OF COLUMBIA: DEPARTMENT OF MENTAL HEALTH: Office of the Director: September 15, 2004: Ms. Cornelia M. Ashby: Director, Education, Workforce, and Income Security Issues: 441 G Street, N.W., Room 5928: Washington, D.C. 20548: Dear Ms. Ashby: I am writing to thank you for the opportunity to review and comment on the preliminary draft report titled "D.C. CHILD AND FAMILY SERVICES AGENCY: More Focus Needed on Human Capital Management Issues for Caseworkers and Foster Parent Recruitment and Retention" (GAO-04-1017), which includes the 3.9 million dollars in congressionally appropriated funds to improve mental health services for foster care youth allocated to the District of Columbia's Department of Mental Health (DMH). I would like to clarify and provide additional context for three areas in this report, they include: sustainability, building provider capacity and improving the timeliness of evaluations and assessments. First concerning sustainability, I would like to address the two references in the report, found on pages 36 and 40, which state that the GAO is unclear as to how DMH plans to sustain its major services initiatives once the congressional funds have been exhausted. In anticipation and in preparation for receipt of these funds, DMH and CFSA identified sustainability as key criteria in its selection of the types of service capacity that was needed and would be developed for foster care youth using these funds. DMH and CFSA identified best or promising practice service interventions that could be substantially financed through Medicaid, entirely or partially, utilizing DMH's current menu of Mental Health Rehabilitation Services (MHRS) as the funding mechanism to accommodate Multisystemic Therapy, Intensive Home and Community Based Services and Mobile Response and Crisis Stabilization Services beyond year one of the start-up period for the service providers selected to deliver these services. Each of the Notices of Funding Availability (NOFA) contained the following statement: "The ongoing nature of these funds is not certain; therefore, CFSA and DMH have adopted a strategy to assure that the MST, IHCBS, MRSS described in this RFA and supported through these grant funds can be sustained beyond the grant period. It is envisioned and expected that grantee/s must currently be or become certified as a Core Service Agency, Sub-Provider or Specialty Provider through the DMH certification process. To sustain the MST, IHCBS, MRSS model described in this RFA beyond the grant period, the successful grantee/s shall accept Medicaid reimbursement through the DMH's Mental Health Rehabilitation Services (MHRS) option to assure the continuation of the services after year one. Therefore, certification is required within six months of the grant award, with the capability to begin billing for Medicaid for these services in the last quarter of the grant period." The DMH and CFSA sustainability strategy was articulated/conveyed to member/s of the GAO review team as follows: * Copies of all the NOFA's were transmitted to the GAO DMH review team; * Sustainability strategy was described by the contract Project Manager at the exit briefing held in July with CFSA; and: * Sustainability strategy was conveyed in an e-mail transmission to the GAO DMH review team on August 19, 2004. I am requesting that the report reflect the sustainability effort, as detailed in this transmittal, in the final report and as briefly referenced on page 32 of the draft report by the following statement: "Officials further said that DMH is working to include the new types of treatment in the services reimbursed under the District's Medicaid program as a long-term plan to fund the additional services." Secondly, the DMH has utilized this federal payment to purchase expert training and technical assistance consultation to organize and build administrative and operational capacity within seven service provider agencies that serve CFSA youth and their families. The purpose of this support is to assure that the administrative infrastructure within these agencies is aligned with the expectations of the MHRS requirements that are necessary to be clinically prepared and financially viable child and adolescent rehabilitation provider. Finally, regarding meeting the timeliness requirement to perform assessments and evaluations, the draft report discusses ". . .DMH's ability to expand its capacity and states, in part, that both agencies continue to face challenges ensuring the timely delivery of services, including completing complex types of assessments that may take longer than the specified statutory timeframes..." An update to this section of the report should include the following progress that has been made in meeting the timeliness requirements includes: * DMH evaluator capacity has grown from six to twenty; and: * DMH wait time for a psychiatric exam from the point of referral has gone from three months to less than one month and from two months to one week for psychological exams. Thank you for the opportunity to comment and clarify this issue. If you have any questions, I can be reached at 202-673-7440. Signed by: Martha B. Knisley: Director: Cc: Brenda Donald-Walker, Director, CFSA: Roque Gerald, Director, OCP, CFSA: Ella Thomas, Director, OPPPs, DMH: John Gibbons, Project Manager, DMH: [End of section] Appendix IV: Comments from the Metropolitan Washington Council of Governments: METROPOLITAN WASHINGTON COUNCIL OF GOVERNMENTS: September 16, 2004: Carolyn M. Taylor: Assistant Director: Education, Workforce and Income Security: U.S. General Accounting Office: 441 G. Street, NW Room 5G333: Washington, DC 20548: Dear Ms. Taylor: Please find enclosed the Metropolitan Washington Council of Governments' response to the D.C. Child and Family Services Agency report draft of September 2004. We appreciate the opportunity to participate in the study and look forward to continuing our exciting work on the "Work of Heart" Respite and Recruitment Project. If you have any further questions, I can be contacted at 202-962-3260. I look forward to receiving the final copy of the report. Sincerely, Signed by: David J. Robertson: Executive Director: Metropolitan Washington Council of Governments: The Metropolitan Washington Council of Governments is pleased and honored to be the recipients of this appropriation and have worked diligently to plan and implement a proven model of respite care for the District of Columbia's foster children and foster families. We are sure that making respite services available to the District's foster families will greatly reduce the burnout rate, reduce attrition and therefore stabilize placements for children. We have also made great strides in partnering with the District's Child and Family Services Agency to provide quality foster parent recruitment and training services to District of Columbia residents interested in providing foster care. By providing these recruitment services, the District of Columbia will have a greater pool of foster families within the District, therefore enabling foster children to be placed in communities and environments in which they are familiar. Long-term funding for the Respite Project: It is COG's plan to continue to apply for additional federal and local government funds, as well as private funds, to support this project. COG has already received a partnership commitment from a corporate funder for the "Work of Heart" recruitment project and will continue to seek further private funding as needed. Number of Respite Foster Families Needed: COG is currently assessing the number of foster families that need respite and will use that number to gauge how many respite families are required to meet the need. Currently, we have 28 families participating in the licensing process. [End of section] Appendix V: GAO Contacts and Staff Acknowledgments: GAO Contacts: Carolyn M. Taylor, (202) 512-2974, or at taylorcm@gao.gov: Anjali Tekchandani (202) 512-7149, or at tekchandania@gao.gov: Staff Acknowledgments: The following individuals also made important contributions to this report: Susan Barnidge, Joah Iannotta, JoAnn Martinez, Deborah Peay, James Rebbe, Lori Ryza, Norma Samuel, Vernette Shaw, Zakia Simpson, Walter Vance, and Carolyn Yocom. FOOTNOTES [1] The receivership was an arrangement in which the U.S. District Court appointed a person to temporarily manage the agency with broad authority to ensure full compliance with requirements established by the court in an expeditious manner. [2] On October 23, 2000, the court signed the LaShawn A. v. Williams Consent Order (C.A. No. 89-1754), which outlined a process for terminating the receivership upon the satisfaction of certain specified conditions. [3] GAO, D.C. Child and Family Services: Better Policy Implementation and Documentation of Related Activities Would Help Improve Performance, GAO-03-646 (Washington, D.C; May 27, 2003); Center for the Study of Social Policy, LaShawn A. v. Williams: An Assessment of the District of Columbia's Progress as of September 30, 2003 in Meeting the Implementation and Outcome Benchmarks for Child Welfare Reform (Washington, D.C; Feb. 9, 2004). [4] GAO, Child Welfare: HHS Could Play a Greater Role in Helping Child Welfare Agencies Recruit and Retain Staff, GAO-03-357 (Washington, D.C; Mar. 31, 2003). [5] Medicaid is a joint federal-state health insurance program for certain low-income, aged, and disabled people. [6] The U.S. District Court for the District of Columbia placed the D.C. Commission on Mental Health Services, DMH's predecessor agency, in receivership in 1997. The first receiver was appointed in October 1997 and resigned in March 2000. The court then issued a consent order establishing a transitional receiver to develop a plan for the District to resume full control of its mental health system. This transitional receivership was terminated in May 2002, and the court appointed a monitor to oversee the District's implementation of the plan. [7] See GAO, District of Columbia: Receiver's Plan to Return Control of Mental Health Commission Is Evolving, GAO-01-157 (Washington, D.C; Oct. 30, 2000) and District of Columbia: Status of Reforms to the District's Mental Health System, GAO-04-387 (Washington, D.C; Mar. 31, 2004). [8] Pub. L. 107-114, 115 Stat. 2100 (Jan. 8, 2002). [9] Pub. L. 107-96, 115 Stat. 929 (Dec. 21, 2001). For more details on the planned reform practices in the District's Family Court see GAO, D.C. Family Court: Additional Actions Should be Taken to Fully Implement Its Transition, GAO-02-584 (Washington, D.C; May 2002). [10] Pub. L. 108-199, 118 Stat. 3, 111. Div. C, Tit. 1, (Jan. 23, 2004). [11] The Foster and Adoptive Parents Advocacy Center (FAPAC) is an organization that assists foster, kinship, and adoptive parents of children in the District of Columbia. [12] CFSA's Implementation Plan was developed in conjunction with CSSP, the court-appointed monitor. The plan covers outcomes and activities for CFSA through December 31, 2006, and sets interim performance benchmarks to assess improvements at 6-month intervals. [13] CFSA officials previously estimated that the agency lost about one-third of its caseworkers between January 1999 and July 2000. [14] GAO-03-357. [15] As part of a related review on the use of federal foster care improvement funds, we will review CFSA's expenditures of those funds. [16] GAO, District of Columbia Child Welfare: Long-Term Challenges to Ensuring Children's Well-Being, GAO-01-191 (Washington, D.C; Dec. 2000). [17] Licensing requirements for foster homes in the District are the same as those for adoptive homes with one exception--the social evaluation focuses on questions relevant to adoption or providing foster care as appropriate. A license approves both the family and the physical space of their home. Licensed homes and families are used interchangeably in this section. [18] Families are recruited to provide (1) traditional foster homes-- families who provide 24-hour care, supervision, and support for children, or (2) therapeutic foster care--24-hour care, supervision, and support for children who require more structure and therapeutic services to address their physical, emotional, and behavioral needs. [19] Children with special needs include those who have physical or developmental disabilities, who are 5 years old or older, or are adopted with sibling groups. [20] Congregate care homes include group homes, independent living placements (ILPs), and therapeutic facilities. Group homes provide services to children in large family-type settings, ILPs are monitored apartments for teens who are preparing to live independently when they turn 18, and therapeutic facilities offer specialized medical and mental health care for children and teens. Congregate care homes are designed to provide placement for children who have not done well in the family setting or for those awaiting placement with traditional foster families. [21] Kinship homes are those in which a relative or unrelated person with longstanding ties to the child provides care for a child that has been neglected, abused, or is at risk for neglect and abuse. [22] Center for the Support of Families and the Metropolitan Washington Council of Governments. Strategic Recruitment: Finding Foster and Adoptive Families in Your Communities. Internal report produced for D.C. Child and Family Services Agency, (Washington, D.C; 2003). [23] NCIC is an information center managed by the Department of Justice. [24] The majority of CFSA's out-of-state placements are in Maryland and Virginia. [25] According to agency officials, as of August 2004, CFSA finalized 368 adoptions. [26] GAO, D.C. Child and Family Services: Better Policy Implementation and Documentation of Related Activities Would Help Improve Performance, GAO-03-646 (Washington, D.C; May 27, 2003). [27] This expert, who has worked with several states to coordinate care for children across systems, outlined the following strategies as indicators of commitment to collaboration: (1) state agencies have a mechanism to make decisions together, (2) agencies are working together at the level of care, (3) staff members are co-mingling either through co-location or multiagency teams, (4) financial incentives support collaboration at the level of care, and (5) agencies are measuring the effect of collaboration on the child. [28] In the event that DMH cannot accept the referral, BSU will forward it to a CFSA contractor to complete the assessment or provide the treatment. [29] In addition to requests from caseworkers, health professionals participating in D.C. KIDS--a health program for children in the District's foster care system--can contact BSU to make a referral for mental health services. According to CFSA officials, all children should receive a medical examination, which includes a behavioral screening, through D.C. KIDS within 30 days of entering care. If the examination suggests the need for a more in depth mental health assessment or treatment, the child is referred to BSU to begin the process. [30] BSU's determination of the clinical appropriateness of the assessment is based on whether the type of assessment is age- appropriate, warranted by the child's behavior, and will result in additional information about the child's mental health needs. The determination also takes into account whether the child had been assessed previously. [31] In addition to providing evaluations of foster care children, the Assessment Center completes assessments of children in the juvenile justice system and some adults involved in child custody dispute cases. [32] Core services agencies are DMH-certified rehabilitative services providers that are responsible for determining the needs of its consumers--including adults and children and youth--working with consumers to develop treatment plans, providing and/or coordinating services to meet objectives of the treatment plans, and billing DMH for services. [33] These data were not available through DMH's information system, which tracks claims for reimbursement of treatment delivered but does not separately identify children in foster care. Further, reimbursements for assessments are not captured in DMH's system. [34] From fiscal year 2001 to fiscal year 2003, CFSA increased its referrals to the Assessment Center by 35 percent. DMH projected the increase in CFSA demand for assessments to continue in fiscal year 2004. [35] Attachment therapy is used to help children who experienced neglect or abuse so that they can form healthy relationships and attachments to others. [36] These timeframes require DMH to initiate services within 3 days of notification, complete assessments within 15 days of the request, and provide the Family Court with all assessments within 5 days of completion. [37] To ensure the reliability of information in the database on a continuing basis, a CFSA official said that DMH will co-locate a staff person who will focus on data quality and integrity by overseeing the database and monitoring the ongoing relationship between CFSA and DMH. [38] This option, which expands the services reimbursable under Medicaid, includes nine services, such as emergency and crisis care and community-based interventions, intended to facilitate the recovery from mental illness. [39] In the District of Columbia, the federal government contributes 70 cents of each Medicaid dollar spent. [40] Another expert also noted that while assessments and treatment must have timeliness components to ensure that children receive needed services, the definition of what is timely will vary according to the needs of the child. [41] The Consolidated Appropriations Act, 2004, Pub. L.108-199, included a provision for an across-the-board 0.59 percent rescission to be deducted from the budget authority provided for any discretionary accounting in the act. 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