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Appendix H
Child and Family Services Reviews: Pathway to Substantial Conformity

The table below shows how a State's substantial conformity with the Child and Family Services Reviews outcomes and systemic factors is determined. Section 1 of the chart provides information on the outcomes (and the items and data indicators within each), how the items are rated, how substantial achievement is determined for each case reviewed, and how substantial conformity with the outcomes is determined. Section 2 provides information on the systemic factors (and the items within each), how the items are rated, and how substantial conformity with the systemic factors is determined. The last two columns in both sections provide information on the Program Improvement Plan (PIP) requirements for addressing nonconformity with the outcomes and systemic factors and the penalties assessed if the State does not meet the PIP benchmarks or timeframes.
Section 1: Outcomes
Outcomes	Item/Data Indicator	How the Item Is Rated	Determining Substantial Achievement on Individual Cases	Determining Substantial Conformity With the Outcome	PIP Requirements for Addressing Nonconformity	Penalties
Safety Outcome 1: Children are, first and foremost, protected from abuse and neglect.	Timeliness of Initiating Investigations of Reports of Child Maltreatment (Item 1)	Strength, Area Needing Improvement, or Not Applicable	All applicable items are rated as strengths (disregard items rated as not applicable).	In 95% of the cases reviewed (90% for the initial review), this outcome must be rated "substantially achieved," and the data indicators must meet the national standards.	The PIP must include strategies for making measurable improvements on the item(s) contributing to the determination of nonconformity and for bringing the data indicators that are out
	Repeat Maltreatment (Item 2)	Strength, Area Needing Improvement, or Not Applicable
Safety Outcome 1: Children are, first and foremost, protected from abuse and neglect. (continued)	Absence of Recurrence of Maltreatment (data indicator) Absence of Maltreatment of Children in Foster Care (data indicator)	Conformity or Nonconformity With the National Standard			of conformity up to the national standard (or to achieve the amount of progress negotiated by the Children's Bureau Regional Office and the State). Safety outcomes determined not to be in substantial conformity must be given priority in the PIP and addressed in less than 2 years.	Relevant portion of the PIP is not completed. The penalty applies until the outcome is determined to be in substantial conformity or the State successfully completes the relevant portion of the PIP. Penalties are withheld at the point that the State fails to meet approved timeframes or benchmarks of progress in the PIP.
Safety Outcome 2: Children are safely maintained in their homes whenever possible and appropriate.	Services to Family to Protect Child(ren) in the Home and Prevent Removal or Re-entry Into Foster Care (Item 3)	Strength, Area Needing Improvement, or Not Applicable	All applicable items are rated as strengths (disregard items rated as not applicable).	In 95% of the cases reviewed (90% for the initial review), this outcome must be rated "substantially achieved."	The PIP must include strategies for making measurable improvements on the item(s) contributing to the determination of nonconformity.	Same as above.
	Risk Assessment and Safety Management (Item 4)	Strength, Area Needing Improvement, or Not Applicable
Permanency Outcome 1: Children have permanency and stability in their living situations.	Foster Care Re-entries (Item 5)	Strength, Area Needing Improvement, or Not Applicable	Item 7 and the relevant item(s) (8, 9, or 10) rated for this case must be rated as strengths, and no more than one of items 5 and 6 (if applicable) may be rated as an area needing improvement (disregard items rated as not applicable). If the State is using concurrent planning for the case being reviewed and, therefore, the reviewer rated two of the relevant items (8 and 9, 8 and 10, or 9 and 10), then both must be rated as strengths.	In 95% of the cases reviewed (90% for the initial review), this outcome must be rated "substantially achieved," and the data indicators must meet the national standards.	The PIP must include strategies for making measurable improvements on the item(s) contributing to the determination of nonconformity and for bringing the data indicators that are out of conformity up to the national standard (or to achieve the amount of progress negotiated by the Children's Bureau Regional Office and the State).	Same as above.
	Stability of Foster Care Placement (Item 6)	Strength, Area Needing Improvement, or Not Applicable
Permanency Outcome 1: Children have permanency and stability in their living situations. (continued)	Permanency Goal for Child (Item 7)	Strength, Area Needing Improvement, or Not Applicable	Item 7 and the relevant item(s) (8, 9, or 10) rated for this case must be rated as strengths, and no more than one of items 5 and 6 (if applicable) may be rated as an area needing improvement (disregard items rated as not applicable). If the State is using concurrent planning for the case being reviewed and, therefore, the reviewer rated two of the relevant items (8 and 9, 8 and 10, or 9 and 10), then both must be rated as strengths.	In 95% of the cases reviewed (90% for the initial review), this outcome must be rated "substantially achieved," and the data indicators must meet the national standards.	The PIP must include strategies for making measurable improvements on the item(s) contributing to the determination of nonconformity and for bringing the data indicators that are out of conformity up to the national standard (or to achieve the amount of progress negotiated by the Children's Bureau Regional Office and the State).	Same as above.
	Reunification, Guardianship, or Permanent Placement With Relatives (Item 8)	Strength, Area Needing Improvement, or Not Applicable
	Adoption (Item 9)	Strength, Area Needing Improvement, or Not Applicable
	Other Planned Permanent Living Arrangement (Item 10)	Strength, Area Needing Improvement, or Not Applicable	Same as above.	Same as above.	Same as above.	Same as above.
	Timeliness and Permanency of Reunifications (data indicator)	Conformity or Nonconformity With the National Standard
	Timeliness of Adoptions (data indicator)	Conformity or Nonconformity With the National Standard
	Achieving Permanency for Children in Foster Care (data indicator)	Conformity or Nonconformity With the National Standard
	Placement Stability (data indicator)	Conformity or Nonconformity With the National Standard
Permanency Outcome 2: The continuity of family relationships and connections is preserved for children.	Proximity of Foster Care Placement (Item 11)	Strength, Area Needing Improvement, or Not Applicable	No more than one of the applicable items for this outcome is rated as an area needing improvement (disregard items rated as not applicable).	In 95% of the cases reviewed (90% for the initial review), this outcome must be rated "substantially achieved."	The PIP must include strategies for making measurable improvements on the items contributing to the determination of nonconformity.	Same as above.
	Placement With Siblings (Item 12)	Strength, Area Needing Improvement, or Not Applicable
	Visiting With Parents and Siblings in Foster Care (Item 13)	Strength, Area Needing Improvement, or Not Applicable
	Preserving Connections (Item 14)	Strength, Area Needing Improvement, or Not Applicable
	Relative Placement (Item 15)	Strength, Area Needing Improvement, or Not Applicable
	Relationship of Child in Care with Parents (Item 16)	Strength, Area Needing Improvement, or Not Applicable
Child and Family Well-Being Outcome 1: Families have enhanced capacity to provide for their children's needs.	Needs and Services of Child, Parents, and Foster Parents (Item 17)	Strength, Area Needing Improvement, or Not Applicable	Item 17 must be rated as a strength, plus no more than one of the remaining applicable items may be rated as an area needing improvement (disregard items rated as not applicable).	In 95% of the cases reviewed (90% for the initial review), this outcome must be rated "substantially achieved."	The PIP must include strategies for making measurable improvements on the item(s) contributing to the determination of nonconformity.	Same as above.
	Child and Family Involvement in Case Planning (Item 18)	Strength, Area Needing Improvement, or Not Applicable
	Caseworker Visits With Child (Item 19)	Strength, Area Needing Improvement, or Not Applicable
	Caseworker Visits With Parent(s) (Item 20)	Strength, Area Needing Improvement, or Not Applicable
Child and Family Well-Being Outcome 2: Children receive appropriate services to meet their educational needs.	Educational Needs of the Child (Item 21)	Strength, Area Needing Improvement, or Not Applicable	Item 21 is rated as a strength.	In 95% of the cases reviewed (90% for the initial review), this outcome must be rated "substantially achieved."	The PIP must include strategies for making measurable improvements on item 21.	Same as above.
Child and Family Well-Being Outcome 3: Children receive adequate services to meet their physical and mental health needs.	Physical Health of the Child (Item 22)	Strength, Area Needing Improvement, or Not Applicable	All applicable items are rated as strengths (disregard items rated as not applicable).	In 95% of the cases reviewed (90% for the initial review), this outcome must be rated "substantially achieved."	The PIP must include strategies for making measurable improvements on the item(s) contributing to the determination of nonconformity.	Same as above.
	Mental/Behavioral Health of the Child (Item 23)	Strength, Area Needing Improvement, or Not Applicable

Section 2: Systemic Factors
Systemic Factors	Item	How the Item Is Rated	Determining Substantial Conformity With the Systemic Factor	PIP Requirements for Addressing Nonconformity	Penalties
Systemic Factor 1: Statewide Information System	The State is operating a statewide information system that, at a minimum, can readily identify the status, demographic characteristics, location, and goals for the placement of every child who is (or within the immediately preceding 12 months, has been) in foster care. (Item 24)	Strength or Area Needing Improvement	One item (requirement) is associated with this systemic factor. For the systemic factor to be in substantial conformity it must be rated a 3 or 4, meaning that the item is in place and functioning as required.1	The PIP must include strategies for making measurable improvements on this item (requirement).	A 1% penalty (increased to 2% and 3% in subsequent reviews for continuous nonconformity) is applied to the systemic factor if it is determined not to be in substantial conformity or the relevant portion of the PIP is not completed. The penalty applies until the factor is determined to be in substantial conformity or the State successfully completes the relevant portion of the PIP. Penalties are withheld at the point that the State fails to meet approved timeframes or benchmarks of progress in the PIP.
Systemic Factor 2: Case Review System	The State provides a process that ensures that each child has a written case plan to be developed jointly with the child's parent(s) that includes the required provisions. (Item 25)	Strength or Area Needing Improvement	Five items (requirements) are associated with this systemic factor. For the systemic factor to be in substantial conformity, it must be rated a 3 or 4, meaning that all of the items are in place and no more than one fails to function at the level described in each requirement.	The PIP must include strategies for making measurable improvements on the items (requirements) that contributed to a determination of nonconformity.	Same as above.
	The State provides a process for the periodic review of the status of each child, no less frequently than once every 6 months, either by a court or by administrative review. (Item 26)	Strength or Area Needing Improvement
	The State provides a process that ensures that each child in foster care under the supervision of the State has a permanency hearing in a qualified court or administrative body no later than 12 months from the date the child entered foster care and no less frequently than every 12 months thereafter. (Item 27)	Strength or Area Needing Improvement
Systemic Factor 2: Case Review System (continued)	The State provides a process for termination of parental rights proceedings in accordance with the provisions of the Adoption and Safe Families Act. (Item 28)	Strength or Area Needing Improvement	Five items (requirements) are associated with this systemic factor. For the systemic factor to be in substantial conformity, it must be rated a 3 or 4, meaning that all of the items are in place and no more than one fails to function at the level described in each requirement.	The PIP must include strategies for making measurable improvements on the items (requirements) that contributed to a determination of nonconformity.	Same as above.
	The State provides a process for foster parents, pre-adoptive parents, and relative caregivers of children in foster care to be notified of, and have an opportunity to be heard in, any review or hearing held with respect to the child. (Item 29)	Strength or Area Needing Improvement
Systemic Factor 3: Quality Assurance System	The State has developed and implemented standards to ensure that children in foster care are provided quality services that protect the safety and health of the children. (Item 30)	Strength or Area Needing Improvement	Two items (requirements) are associated with this systemic factor. For this systemic factor to be in substantial conformity, it must be rated a "3" or "4." To be rated a "4," both items must be in place in the State and functioning at the required level. To be rated a "3," both items must be in place and item 31 must be functioning at the required level; item 30 does not need to be functioning at the required level for a finding of substantial conformity on this systemic factor. If item 31 is not in place or is not functioning at the required level, however, the systemic factor is rated either a "1" or "2" depending on the State's performance on item 30. If item 30 is in place, but not functioning, the factor is rated a "2." If item 30 is neither in place nor functioning, the factor is rated a "1."	The PIP must include strategies for making measurable improvements on the item(s) (requirement[s]) that contributed to a determination of nonconformity.	Same as above.
	The State is operating an identifiable quality assurance system that is in place in the jurisdictions where the services included in the Child and Family Services Plan (CFSP) are provided, evaluates the quality of services, identifies strengths and needs of the service delivery system, provides relevant reports, and evaluates program improvement measures implemented. (Item 31)	Strength or Area Needing Improvement
Systemic Factor 4: Staff and Provider Training	The State is operating a staff development and training program that supports the goals and objectives in the CFSP, addresses services provided under titles IV-B and IV-E, and provides initial training for all staff who deliver these services. (Item 32)	Strength or Area Needing Improvement	Three items (requirements) are associated with this systemic factor. For the systemic factor to be in substantial conformity, it must be rated a 3 or 4, meaning that all of the items are in place and no more than one fails to function at the level described in each requirement.	The PIP must include strategies for making measurable improvements on the items (requirements) that contributed to a determination of nonconformity.	Same as above.
	The State provides for ongoing training for staff that addresses the skills and knowledge base needed to carry out their duties with regard to the services included in the CFSP. (Item 33)	Strength or Area Needing Improvement
	The State provides training for current or prospective foster parents, adoptive parents, and staff of State licensed or approved facilities that care for children receiving foster care or adoption assistance under title IV-E that addresses the skills and knowledge base needed to carry out their duties with regard to foster and adopted children. (Item 34)	Strength or Area Needing Improvement
Systemic Factor 5: Service Array and Resource Development	The State has in place an array of services that assess the strengths and needs of children and families and determine other service needs, address the needs of families in addition to individual children in order to create a safe home environment, enable children to remain safely with their parents when reasonable, and help children in foster and adoptive placements achieve permanency. (Item 35)	Strength or Area Needing Improvement	Three items (requirements) are associated with this systemic factor. For the systemic factor to be in substantial conformity, it must be rated a 3 or 4, meaning that all of the items are in place and no more than one fails to function at the level described in each requirement.	The PIP must include strategies for making measurable improvements on the items (requirements) that contributed to a determination of nonconformity.	Same as above.
	The services in item 35 are accessible to families and children in all political jurisdictions covered in the State's CFSP. (Item 36)	Strength or Area Needing Improvement
	The services in item 35 can be individualized to meet the unique needs of children and families served by the agency. (Item 37)	Strength or Area Needing Improvement
Systemic Factor 6: Agency Responsiveness to the Community	In implementing the provisions of the CFSP, the State engages in ongoing consultation with tribal representatives, consumers, service providers, foster care providers, the juvenile court, and other public and private child- and family-serving agencies and includes the major concerns of these representatives in the goals and objectives of the CFSP. (Item 38)	Strength or Area Needing Improvement	Three items (requirements) are associated with this systemic factor. For the systemic factor to be in substantial conformity, it must be rated a 3 or 4, meaning that all of the items are in place and no more than one fails to function at the level described in each requirement.	The PIP must include strategies for making measurable improvements on the items (requirements) that contributed to a determination of nonconformity.	Same as above.
	The agency develops, in consultation with these representatives, Annual Progress and Services Reports pursuant to the CFSP. (Item 39)	Strength or Area Needing Improvement
	The State's services under the CFSP are coordinated with services or benefits of other Federal or federally assisted programs serving the same population. (Item 40)	Strength or Area Needing Improvement
Systemic Factor 7: Foster and Adoptive Parent Licensing, Recruitment, and Retention	The State has implemented standards for foster family homes and child care institutions that are reasonably in accord with recommended national standards. (Item 41)	Strength or Area Needing Improvement	Five items (requirements) are associated with this systemic factor. For the systemic factor to be in substantial conformity, it must be rated a 3 or 4, meaning that all of the items are in place and no more than one fails to function at the level described in each requirement.	The PIP must include strategies for making measurable improvements on the items (requirements) that contributed to a determination of nonconformity.	Same as above.
	The standards are applied to all licensed or approved foster family homes or child care institutions receiving title IV-E or IV-B funds. (Item 42)	Strength or Area Needing Improvement
	The State complies with Federal requirements for criminal background clearances as related to licensing or approving foster care and adoptive placements and has in place a case planning process that includes provisions for addressing the safety of foster care and adoptive placements for children. (Item 43)	Strength or Area Needing Improvement
Systemic Factor 7: Foster and Adoptive Parent Licensing, Recruitment, and Retention (continued)	The State has in place a process for ensuring the diligent recruitment of potential foster and adoptive families who reflect the ethnic and racial diversity of children in the State for whom foster and adoptive homes are needed. (Item 44)	Strength or Area Needing Improvement	Five items (requirements) are associated with this systemic factor. For the systemic factor to be in substantial conformity, it must be rated a 3 or 4, meaning that all of the items are in place and no more than one fails to function at the level described in each requirement.	The PIP must include strategies for making measurable improvements on the items (requirements) that contributed to a determination of nonconformity.	Same as above.
	The State has in place a process for the effective use of cross-jurisdictional resources to facilitate timely adoptive or permanent placements for waiting children. (Item 45)	Strength or Area Needing Improvement

¹ Refer to chapter 5, section B, for the criteria used in rating this systemic factor. back

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