Congressional Testimony on Status of Child Welfare in Baltimore
On May 28, 2007, important testimony was submitted to the U.S. House Ways and Means Committee. The testimony is entitled The Status of the Child Welfare System in Baltimore, Maryland and Recommendations for Reform, and was written by counsel representing the class of Baltimore City’s foster children: Rhonda Lipkin and the Public Justice Center, Inc., Mitchell Y. Mirviss, Venable LLP and Gary S. Posner, Whiteford, Taylor & Preston.
This is recommended reading. In 11 succinct pages, counsel report that the care of Baltimore’s 6600 foster children has deteriorated to some of the worse levels in the 18 years since the State agreed to a court order in 1988 that then mandated substantial reforms. Despite numerous plans, proposals and promises put forward by successive administrations of both political parties, Maryland has failed to improve the most basic services – health, access to education, a family – to the children in its care. Ironically, the cost of providing foster care has increased even as the quality of care and number of children in foster care has decreased, due in part to reliance on expensive congregate care placements and insufficient family care placements, lack of cost saving preventive measures, and poor administration.
All is not lost however. Counsel provide recommendations for reforms in certain key areas, including:
- placement of children;
- provision of comprehensive health services to children in foster care (which should not be difficult in Baltimore City, the home of the Johns Hopkins and University of Maryland medical schools and hospital systems as well as numerous other highly regarded hospitals and medical care institutions, and given that children in foster care are automatically eligible for Medical Assistance);
- planning for permanent placement of children rather than continual temporary placements; and
- in strategic planning and administration.
The full report:
The Status of the Child Welfare System in Baltimore, Maryland and Recommendations for Reform
Submitted by Rhonda Lipkin and the Public Justice Center, Inc., Mitchell Y. Mirviss, Venable LLP and Gary S. Posner, Whiteford, Taylor & Preston L.L.P. Counsel for Baltimore City’s foster children
Thank you for the opportunity to submit this statement on behalf of the approximately 6,600 children currently in foster care in Baltimore City and those who will enter the foster care system in the future. Significant improvements must be made to the foster care system both in Maryland and nationally to prevent yet another generation of foster youth spending their childhoods being moved from temporary placement to temporary placement with less than adequate health care and education and, as a result, entering adulthood woefully unprepared to be productive, healthy and happy citizens. Solutions are available – a number of proposed reforms are set forth in this statement; implementation of those and other solutions requires increased funding, creative and thoughtful programming and a commitment to listening and responding to children and their families.
Unfortunately, by Maryland’s Department of Human Resource’s (“DHR”) own data assessment, the care of Baltimore City’s foster children has deteriorated to some of the worst levels in the 18 years since the United States District Court entered a Consent Decree ordering comprehensive improvements in Baltimore City’s child welfare program. Some of the alarming statistics for 2006 include:
Ø Baltimore City Department of Social Services (“BCDSS”), responsible for providing homes and services to the children, continues to lose foster homes at an alarming rate - more than half of its homes during the last five years, dropping from a high of more than 3,000 homes in August 2001 to only 1,366 at the end of 2006. Largely as a result, the number of children in group homes and residential placements rose from 834 as of Aug, 31, 2001 to 1,536 as of May 30, 2006, a nearly 85% increase. The cost of group placements averages $60,000 per year, close to eight times the basic foster care subsidy rate of $635 per month ($7,620 per year).
Ø Caseworkers failed to make mandatory monthly visits of children in 33% of continuing foster care cases.
Ø For children entering foster care, 21% of children entering foster care did not have initial health screens and 56% did not have timely comprehensive health assessments. 64% of children in continuing care did not receive periodic medical and dental care as required by federal and state law.
Ø One quarter of children in continuing care were not placed in school within one week after placement; 75% of children in relative placements needing special education referrals did not receive them; and 34% of children in unlicensed placements with relatives did not have their education monitored by BCDSS.
Ø 45% of children in continuing foster care had no documentation of any visits with their parents, even though their permanency plans were reunification.
Ø Service agreements for families with a permanency plan of reunification were not completed in 25% of continuing foster care and 34% of continuing kinship care cases.
Ø Funds to prevent foster care placement have fallen to their lowest levels in more than a decade and are serving less than 60% of the families served in 1999.
Despite numerous plans, proposals and promises, Maryland has failed to improve the most basic services – health, access to education, a family – to the children in its care. It continues to shortchange the children of Baltimore City who, in FY2005, made up 65% of the foster care population while receiving only 40% of the state’s child welfare funding.
These failures are not attributable to one particular governor’s administration nor to one particular political party. As with many state programs, attempts at reform are often disrupted by changes of administration which result in changes of leadership and direction at DHR. This problem underscores the importance of enforceable federal laws mandating that states provide basic decent care to the children they remove from parental custody. Current federal laws, while increasingly helpful, still remain insufficiently specific and unenforceable. In addition, many of the problems set forth herein reflect inadequate federal funding under both Title IV-E maintenance and administrative payments and IV-B program grants as well as in the Medicaid program.
Although Maryland has spent countless hours and money in creating multiple plans for improvement over the past ten years, including Maryland’s Program Improvement Plan submitted in response to its dismal results in its Child and Family Services Review, there is little to show for it. An infusion of funding for meaningful prevention and family preservation programs, recruitment and support for foster and adoptive parents and support for kinship caregivers and subsidized guardianships would result in significant savings over time.
However, money is far from the only need in Maryland. Proper administration of the child welfare system would bring significant savings to Maryland while a status quo approach will continue to result in skyrocketing budget overruns. In just the last three years alone, Maryland has squandered hundreds of millions of dollars by failing to have proper placements for children. The number of children in foster care has continually decreased over the past five years, and yet Maryland’s foster care maintenance costs have increased by 75% (from $204.1 million to $353.1 million) from FY2005 to FY2008 alone, reflecting the massive shift from foster home to congregate care placements. This is a staggering waste of money that has been caused by Maryland’s degradation of foster homes and the placement of children in expensive, unnecessary, and inappropriate high-end congregate care settings – even though the children do not need these placements and do not want them – they want families. Yet the damage to the children far outweighs the travesty of wasted dollars. A truly comprehensive plan is needed to reduce Maryland’s dependence on congregate care that has caused this staggering increase in cost.
These are abused and neglected children, most of whom have experienced harm or deprivations that are difficult to imagine. They are the State’s responsibility. One would have hoped that the many reports and audits showing how badly the system is broken would have compelled Maryland to make the investments necessary to fix the system but, to date, that is not so.
Key Areas Needing Reform
The placement “system” is in fact an ad hoc patchwork of programs that developed locally without any planning as to needs, priorities, service gaps, etc. Monitoring has been poor, and providers have been allowed extremely broad deference in programming, selection of children, and rejection of children. Group homes now are a dominant form of placement, and their quality is mixed. Maryland has not performed nor commissioned a comprehensive needs assessment for placements since 1989. Children are moved from placement to placement without much regard for their needs or whether more focused intervention could prevent removal.
One example of the depth to which the system has fallen was revealed in June 2005 when BCDSS admitted using a rented unlicensed office building as an overnight shelter for children in its care. The facility had only four thin floor mattresses available only in the girls’ room (none were available in the boys’ area); there were insufficient blankets and pillows (again only enough for four children); there were no shower or bath facilities; no toiletries; no first aid or other health care provisions; and no arrangements for adequate meals. The boys had to stay in a small waiting room area, where there was no room to sleep – they could only sit in hard chairs with armrests that made it impossible to lie down. Moreover, these were not just short-term stays. One girl stayed for twenty-three consecutive nights; one boy had to sit up in the chairs for seven consecutive nights. These children were not in school, and their activities during the day were minimal if they did not find placements. Many just followed their caseworker and spent the day sitting in another BCDSS office, only to return that evening.
All told, 150 children stayed at Gay Street in 2005, most for multiple nights with another 50 staying there in 2006. Mixed together were children who had been in foster care nearly their whole lives and children whose first night in foster care was being spent one the floor of an office in the same filthy clothing in which they had been removed from their parents’ home. The mix of population was extremely inappropriate. Younger preteen girls were mixed with much older late adolescents, some of whom had severe mental illnesses and posed definite risks to the younger children. Even a two-year old with a feeding tube ended up in Gay Street.
Even after the disclosure, BCDSS was shockingly slow in remediating conditions and still has not created any long-term solutions. While conditions have been approved, air mattresses and toiletries are now available, it remains an office building – with no shower or bath facilities, no licensed supervision other than on-duty Child Protective Services Workers during the night and on weekends, and no hot food other than microwaveable oatmeal and McDonald’s. Furthermore, to avoid use of the facility in late 2005 and in 2006, BCDSS turned to housing children overnight in motels. These youths were not accompanied at the motels by BCDSS employees nor employees of licensed placement agencies; instead, BCDSS used local “mentoring” programs to transport and supervise the children. These unlicensed providers had no legal requirement compelling them to ensure that their employees had passed criminal background checks, yet those employees transported and spent nights (and days) alone with children awaiting placement in hotels or motels.
Needed reforms to the placement system must address:
Ø Increase in the foster care reimbursement rate. Even though foster home reimbursement rates were frozen for fourteen years between 1992 and the end of 2005, DHR opposed in 2006 and 2007 a bill supported by advocates statewide to raise stipends over three years to the amount documented by the USDA as the cost of rearing a child. While Maryland has increased the subsidy significantly in the past two years, it is still far from adequate and there is no legal requirement that increases continue (or even be maintained).
Ø Restoration of child care subsidies. Maryland continues to refuse to restore child care grants to foster parents and kinship care providers, even though DHR has acknowledged that the loss of child care assistance in 2002 was reported by foster parents as the principal reason why so many had left the system.
Ø Need for a wide variety of placements. BCDSS does not maintain a meaningful supply of emergency foster homes, even though the lack of such placements explains in large part the use of the illegal and unlicensed Gay Street facility and of motels. BCDSS has not targeted the two most pressing areas of foster home shortages: homes for infants and for adolescents, including homes (as well as other programs) that will care for teen parents with their children. There are inadequate diagnostic shelter facilities and insufficient supply of therapeutic foster homes. As a result of the lack of sufficient long-term placements, there are often overstays in short-term shelter and diagnostic shelter facilities.
Ø Maryland’s plans for foster home recruitment and retention aim low and achieve less. In January 2006, Maryland issued a recruitment and retention plan that called for only a 4% increase in foster homes statewide (only 154 homes) over an eighteen month period ending December 2006. Yet during the first two-thirds of the implementation period, Maryland lost nearly that number of homes in Baltimore City alone.
Ø Maryland has squandered available resources, such as up to $1 million for supports to foster parent and relative caregivers that was returned to the federal government after a lack of use in FY 04 and a similar refund in FY 05 (the exact amount is not known).
Ø Lack of responsiveness to caregivers’ concerns and complaints. The abusive and disdainful manner in which many caseworkers and supervisors treat foster parents and kinship care providers is shameful. DHR cancelled contracts for support centers several years ago and has not restored them. While there are new foster parent associations (after the former ones were defunded by DHR), they are not sufficiently independent to act as an advocacy body for caregivers. Caregivers still have minimal access to court proceedings. As a result, disastrous decisions may be made to remove children with limited input from the caregivers. No ombudsman exists to investigate complaints or redress legitimate grievances. The cumulative effect of this is that word-of-mouth has made it very difficult to recruit and retain foster parents.
Ø Long delays in processing of foster home applications and general deterrence of restricted foster care applications by relatives. Even though state regulation requires applications to be processed within four months, delays of a year or more are common. Caseworkers historically have discouraged relative caregivers from applying to be foster parents, sometimes complying with a requirement that they advise caregivers about foster home licensure in only 60% of the appropriate cases (according to Defendants’ data).
Ø Failure to provide foster parents and kinship caregivers with information about the children.
Ø Lack of automated and efficient system for finding placements. There is no comprehensive list of placement options, no automated system to determine vacancies, and no meaningful system to link providers and BCDSS in problem-solving (such efforts have been short-lived).
Ø No comprehensive needs assessment.
Ø Group homes are overused and under-monitored. Their programming often is poor. They have low tolerance for typical teen behaviors, and DHR has long condoned precipitous and unjustified removals. Simple and inexpensive steps to reduce their use, such as sitting down with teens in foster care to talk about relatives and others who might be placement resources, are not taken.
Ø Limited utilization of new treatment modalities. Caseworkers leave treatment issues to the providers. As a result, best practices and improvements noted elsewhere in dealing with mental health, adolescence and other issues have lagged in Maryland.
Ø Lack of placements for siblings.
Ø Slow interstate compact referral processing.
Ø Criminal background checks; CPS history checks; and fire, sanitation, and safety inspections for caregivers. According to 2004 CAPS data, the most recent available, far too many foster home and kinship placements have not had required criminal background checks (more than 25% of foster homes and nearly 50% of relative placements) or fire, health and safety assessments (35% of foster homes lacked annual safety inspections).
Ø Overall lack of coordination between the responsibility for finding placements for children (which falls upon BCDSS) and the responsibility for creating, funding, monitoring, and maintaining placements (a DHR duty).
Provision of comprehensive health services to children in foster care should not be difficult in Baltimore City, the home of the Johns Hopkins and University of Maryland medical schools and hospital systems as well as numerous other highly regarded hospitals and medical care institutions. Moreover, all children in foster care are automatically eligible for Medical Assistance. Yet Maryland has failed to provide even the most basic appropriate care to the children in foster care in Baltimore City, reflecting what Maryland’s Secretary of DHR has acknowledged to be a broken system. Not only do Baltimore City and Maryland have the resources to provide excellent, let alone, decent health care, there are numerous models around the country from which they can draw in designing and implementing such a system. Until recently Maryland has refused to consider much less implement these models which have been evaluated with recommendations for basic components of any successful system by the American Association of Pediatrics (“AAP”) and the Georgetown University Child Development Center. Some progress may be in the workings; this month, DHR, with the assistance of the Annie E. Casey Foundation, finally convened a workgroup to look at alternatives to the current system.
Some of the basic features of such a system which BCDSS currently lacks include:
Ø Initial screening and separate comprehensive assessments. In the early 1990s, Maryland had a contract through the University of Maryland Medical System to provide comprehensive assessments of children entering foster care. That contract was cancelled after only two years. The high quality of the UMMS assessments gradually has fallen to a poor patchwork of decentralized community-based physical examinations and unconnected mental health assessments. Several years ago, DHR adopted a policy to obtain the physical examinations immediately or shortly after entry into care, so health histories typically are not included or reviewed in many if not most cases. Even vaccination information may be missing. The “assessments” typically are a short handwritten EPSDT medical form that, to a layman, often is illegible, and in any event is ill-suited for a comprehensive assessment. Lab reports are reviewed subsequently and are not incorporated into the document. The mental health/developmental reports are done by any provider available, ranging from excellent (if the child is in a diagnostic placement and already receiving mental health) to poor (a counselor at a group home may be required to write the report). They are not coordinated with the somatic assessments, and they typically are not distributed to the attorneys, the Court, or the parties. As a result, they may be buried in the file and ignored.
Ø Timely access to and provision of health care services and treatment. BCDSS caseworkers and supervisors chronically fail to ensure compliance with needed mental health therapy, specialized medical treatment, referral follow-up, etc. According to DLS audits, in 2002, 28% of children did not receive recommended treatment; in 2004, 48% lacked recommended mental health treatment. For 2004, DHR’s own data showed that 20% of foster care cases and 33% of adoptions cases did not receive recommended mental health treatment. Specialized care, ranging from orthodontia to surgery, often is not provided as well, despite obvious and sometimes urgent need.
Ø Prompt collection of health histories for children entering care.
Ø Management of health care data and information, and careful monitoring of ongoing health care needs of children in OHP and health services provided to them. The unit in place only monitors intake cases – ignoring 95% of the children who are in longer-term care.
Ø Coordination of care, including alerts to workers and caregivers of health needs of children in OHP and follow-up of unmet needs. Maryland has taken the position that Managed Care Organization (“MCO”) in which each child must be enrolled serves as the “medical home” because it retains historical knowledge about the child. This is not acceptable under the AAP standards, and for obvious reasons. The MCOs are not care providers, and their only purpose is to fund or not fund medical services. If they do not serve the functions of a “medical home,” their centralized nature is utterly immaterial. Moreover, children who change placements, particularly between group homes, may be required to change doctors and MCOs.
Ø Collaboration among all public health and social services systems serving children in OHP.
Ø Family participation (both caregiver and, where possible, parents)
Ø Resolution and coordination of transportation responsibilities for health care.
Ø Immediate and continuous Medical Assistance coverage.
Ø Attention to cultural issues.
Ø Monitoring and evaluation of effectiveness of comprehensive health care system; and
Ø Training and education of caseworkers, youth, parents and caregivers.