Free Order - District Court of Connecticut - Connecticut

Case 2:89-cv-00859-AHN

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Juan F. Court Monitor's Review of Children in Overstay Status (60 Days) within Temporary Congregate Care Placement Settings and Juan F. Court Monitor's Review of Adolescents in Temporary Placement Old Shelter Model Facilities Civil Action No. H-89-859 (AHN) March 17, 2008

Submitted by: Juan F. Court Monitor's Office 300 Church Street - 4th Floor Wallingford, CT 06492 Telephone: 203-741-0458 Fax: 203-741-0462 E-Mail: [email protected]

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Table of Contents for Section One: Juan F. Court Monitor's Review of Children in Overstay Status (60 Days) within Temporary Congregate Care Placement Settings Report Section One Executive Summary Introduction to Juan F. Court Monitor's Review of Children in Overstay Status (60 days) within Temporary Congregate Care Placement Settings Vignettes Demographics Decision to Place at a Temporary Placement Setting Maintaining Siblings Prior Placement History Medical and Psychological Assessment DSM Diagnosis Appropriateness of Overstay at Temporary Placement Barriers to Discharge Treatment Planning Efforts Social Worker Visitation with Child in Placement Visiting Resources Discharge Planning Update Considerations Table of Contents for Section Two: Adolescents in Temporary Placement - Old Shelter Model Facilities Report Section Two Introduction Decision to Place at the Shelter Maintaining Sibling Groups Prior Placement Histories Medical and Psychological Assessment DSM Diagnosis Discharge Planning Activities Barriers to Discharge Social Worker Visitation to Child In Placement Visiting Resources Treatment Planning Considerations Page 55 56 56 56 57 58 59 60 61 61 61 62 Page 5 11 14 19 20 21 21 23 24 27 28 31 31 32 32 40 51

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Charts, Crosstabulations and Tables for Section One: Juan F. Court Monitor's Review of Children in Overstay Status (60 Days) within Temporary Congregate Care Placement Settings
Chart, Crosstabulation or Table Chart 1: Distribution of Overstay Population within the Temporary Placement Provider Pool on October 1, 2007 Crosstabulation 1: Child's Race*Child's Ethnicity Crosstabulation 2: Where was the child immediately prior to this temporary setting?*What type of temporary Placement is this provider? Crosstabulation3: What type of temporary placement is this provider?*Are there any needs identified by the MDE or subsequent evaluations that remain unmet and are a barrier to discharge? Crosstabulation 4: What type of temporary placement provider is this provider? * Does this child have a diagnosed mental health disorder? Crosstabulation 5: Does this child have a diagnosed mental health disorder?* Is medication management in place? Crosstabulation 6: What type of temporary placement is this provider?*Is In-Home Services a barrier to discharge? Crosstabulation 7: What type of temporary placement is this provider?* Is Community Resources Needed the barrier to discharge? Crosstabulation 8: What type of temporary placement is this provider?* Is Placement Resource Required - Family Setting the barrier to discharge? Crosstabulation 9: What type of temporary placement is this provider? Is Placement Resource Required - Facility Setting the barrier to discharge? Crosstabulation 10: What type of temporary placement is this provider?* Is "Other Required Resource" the barrier to discharge? Crosstabulation 11: What is the current permanency goal?* What is the concurrent permanency goal? Crosstabulation 12: Is there a discharge plan identified for this child? * Is this a formal discharge plan that identifies placement, services, visiting resources/transition with input from DCF, SW, SWS, FASU and or provider? Crosstabulation 13: Area Office * Is this a formal discharge plan that identifies placement, services, visiting resources/transition with input from DCF, SW, SWS, FASU and or provider? Crosstabulation 14: What is the timeframe for discharge? * What type of temporary placement is this provider? Crosstabulation 15: Area Office * What is the timeframe for discharge? Crosstabulation 16: Placement Provider Name * On December 31, 2007 where was child placed? Crosstabulation 17: Area Office * On December 31, 2007 where was child placed? Crosstabulation 18: What is the discharge location identified? * What type of temporary placement is this provider? * Area Office Table 1: Has this child had a psychiatric or psychological evaluation in the last year? Table 2: Frequency of Axis I Diagnosis for Children in Temporary Placement greater than 60 days Table 3: Appropriateness of Overstay at Temporary Placement by Placement Provider Type Table 4: "Other" barriers preventing discharge from temporary settings Table 5: Participants in Discharge Planning Table 6: Placements by Level of Care for those discharged by December 31, 2007 Table 7: What was the discharge location identified? Table 8: Is there documentation of specific individualized recruitment efforts on behalf of this child? Page 19 20 22 23 24 26 28 28 28 29 29 32 33 34 39 40 42 46 50 24 25 27 30 36 41 49 49

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Charts, Crosstabulations and Tables for Section Two: Adolescents in Temporary Placement - Old Shelter Model Facilities Chart, Crosstabulation or Table Crosstabulation 1: Does child have a diagnosed mental health disorder?* Has this child had a psychiatric or psychological evaluation in the last year? * Is medication management in place? Crosstabulation 2: Is there evidence of a CANS referral?* Is there a 469 request actively being attended to for this child? Crosstabulation 3: What is the timeframe for discharge?* What is the discharge location identified? Crosstabulation 4: What is the current permanency goal? * What is the concurrent permanency goal? Table 1: Area Office Distribution Table 2: Barriers to discharge from shelter Page 57 60 60 62 55 61

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Section One: Juan F. Court Monitor's Review of Children in Overstay Status (60 Days) within Temporary Congregate Care Placement Settings

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Juan F. Court Monitor's Review of Children in Overstay Status (60 Days) within Temporary Congregate Care Placement Settings Executive Summary The Juan F. Action Plan required a review of the population of children in Connecticut who were in overstay status in temporary congregate care placement settings for 60 days or longer on October 1, 2007. In all, 144 cases were found to meet the criteria for inclusion in our review. The sample included children in the SAFE Home, STAR, PDC, and Temporary Sub-Acute provider settings. The Monitor's Office, in conjunction with the Department of Children and Families Quality Improvement Division collected data on this population using the methodology and tools crafted over a period of several weeks with input and agreement from both the plaintiffs and DCF Administration. Cases were reviewed during the fourth quarter 2007. The Juan F. parties had determined that review of the two remaining older model shelter programs, Salvation Army Youth Emergency Shelter and Marshall House, would be excluded given the impending closing in the first quarter 2008. However, the Monitor determined this population of 18 children 1would also be reviewed given concerns regarding discharge planning that were identified in this review (n=144). These additional data are incorporated as a separate section within this document beginning on page 53. A decision to follow these cohorts via a longitudinal review and consideration of the need for additional point in time reviews will be points of discussion between the Monitor and the Juan F. parties subsequent to the release of this report. A number of the identified issues related to safety, permanency, and well-being could be better understood through a periodic review of this cohort. While there is, and always will be, additional work required to continue improvements regarding systemic issues, there were many valiant documented efforts by DCF staff to manage and advocate for services to meet the multiple needs of the children. It must be stressed that many of the cases reviewed demonstrated tremendous commitment by the temporary placement provider community to providing quality care for these children. During recent visits to temporary congregate care provider programs and specifically in discussion with these providers, it is evident that much of the assessment of the strengths and needs of these children are clearly identified by the clinical staff on site at the STAR and PDC programs and regular updates on individual children are developed and shared by all temporary care providers. This information is well documented in their files and is reportedly shared with the DCF staff routinely. A clear disconnect emerges when viewing the providers' feedback in comparison with review findings. The providers' efforts are not consistently translating into comprehensive discharge planning and
Note: this total will fluctuate given the continued use of these two placement options. We have been advised that new entries to these placement settings recently ceased. The Marshall House and SAYES programs are being phased out and will cease operations effective March 30, 2008 and April 30, 2008 respectively.
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informed treatment planning development to address the safety, permanency and wellbeing needs. LINK narratives, medical, mental health and educational icons are also lacking some of the information that has been established by the providers during the children's stay in their facilities. While the data collected for this review provides an aggregate picture of the needs and issues of those in temporary placement awaiting discharge we do not want to lose sight of the individual circumstances of the children within the sample group. A set of four vignettes is provided on page 14 of the report to offer this individual perspective and provide a frame of reference for the children we are referencing. Highlights of Findings: The following is a brief summary of the attached report related to a review of the population of 144 children residing in temporary placements 60 days or longer on October 1, 2007. 1. Demographics of the sample included 87 males and 57 females with ages ranging from seven months to 18.5 years old on October 1, 2007. Race and ethnicity was most frequently identified as White and Non-Hispanic, followed by Black/African American and Non-Hispanic, and then White and Hispanic. Of the 144 children, 105 cases (72.9%) had a documented rationale for placement in the temporary congregate care setting. In 39 cases (27.1%), availability alone was the documented rationale. However, in addition to these 39 cases, reviewers detailed instances in which there was another identified consideration cited, (i.e. maintaining siblings together, need for clinical assessment, medical needs, etc.) that could have been met in a family setting, if such resources were available at the time of removal or disruption. Unfortunately, sufficient foster care resources and community resources were not available, resulting in a placement in the congregate care setting. This population of children often had multiple placements during the previous twelve month period. Eighty-two children, or a total of 56.9%, had two or three placements during the period, and 27 of the children (18.8%) in the population exceeded three placements during the period. Of the 144 children, 27 had placement in more than one temporary setting during the twelve month period. Thirty-five of the children also had placement in a temporary care setting prior to September 2006. Of the cases reviewed, 67 children (46.5%) had an identified formal discharge plan from the temporary congregate care setting with an identified discharge placement setting, necessary services, visiting resources, and transitional plans with input from a variety of involved participants. A total of 74 children (51.4%) had an informal plan in place that referenced one or more levels of placement being pursued but had 7

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little to no action steps identified. Three children (2.1%) had no specific planning documented for discharge. 6. In 95 of the 144 cases (66.0%), the children were deemed 'inappropriately' in overstay status (stays greater than 60 days) in the temporary placement setting as the result of the variety of barriers noted within the full report that follows. This 'inappropriate' designation signified a delay in discharge that was detrimental to the child's well-being and/or permanency needs. The results from Outcome Measure 15 are often negatively impacted by these types of situations noted in the records of these 95 children. Multiple barriers to discharge were identified for children within this sample. · The inability to locate a family setting was most often the barrier noted (n=93). · This was followed in decreasing order by the need for a facility setting (n=44), and in-home services (n=11). · Eighty-one cases also had a documented "other" barrier. Social Workers and Social Work Supervisors repeatedly indicated that the child was the barrier, rather than the system issues and/or system failures that often led to the increase in acting out behaviors; making placement decisions more difficult. Reviewers indicated that these case records often reflected unaddressed traumas, case management issues (not always related to those staff currently assigned to the case), inadequate discharge planning, multiple moves, ineffectual treatment, and excessive lengths of stay as the genesis of many of the behavioral declines identified as barriers. Placements to SAFE Homes most frequently occurred (41.8%) as a result of removals from home. Placements to STAR programs were largely the result of disruptions from foster care (both DCF foster care and therapeutic foster care.) While appropriate consideration appears to be given to use the PDC and STAR programs for children with multiple disruptions and clinical needs, there appears to be an increase in the number of children with multiple moves and clinical needs entering the SAFE Homes as well. Of the 91 children in the SAFE Home population, 53.9% had an Axis I diagnosis. Medication Management was in place for 36.3% of this SAFE Home subsample, and 1:1 services were documented for 11.0% of this population. The needs of these children pose difficulty given the level of clinical staffing available on site at several of these locations. This situation is compounded when local community providers have wait lists for evaluations or therapeutic services. Multidisciplinary Examinations were documented at a rate exceeding the Outcome Measure 22 - Multidisciplinary Examinations requirement, as 140 children or 97.2% documented compliance with the requirement.

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11.

Documentation of recent mental health evaluations (within 12 months) was absent in 34 cases, 19 of these 34 children had an Axis I diagnosis that was impacting discharge planning efforts. A follow-up review of this cohort was conducted 90 days on December 31, 2007 to determine the recent placement status of the children. Of the 144 children reviewed, 85 children (59.0%) were discharged to another placement setting by December 31, 2007. Therefore, 59 children remained and were in the temporary placement setting a minimum of 120 days at this juncture2. Of those 85 children discharged, 87.1%were placed in a setting identified in the record as of the October 1, 2007 cut-off date. On the surface this is promising, however the reviewers' comments identified a theme that emerged repeatedly - the identified discharge plan/setting was not always the level of care optimally desired or appropriate. Approximately one quarter of the 85 children discharged had narratives reflecting changes in the selection of a discharge placement type throughout the child's time at the temporary setting; as efforts to locate the optimal placement and treatment resources over a period of time were not successful. Many cases had conflicting or incomplete information regarding the child's current behavioral health status. LINK narratives, medical, mental health and educational icons are also lacking up to date information that has been established by the providers during the children's stay in their facilities. Providers' efforts are not consistently translating into comprehensive discharge planning and informed treatment planning development to achieve continued safety, permanency and wellbeing. Additional information requested from Social Workers and Social Work Supervisors via phone or email often clarified matters, but in many instances this required research in hard copy documentation, or contact with the ARG or provider. A surprisingly low number of children (2 of 144 or 1.4%) are documented as having learning disorders on the DSM Axis documentation reviewed. This is significant given the number of children receiving special education services or requiring 504 considerations within this group, and is inconsistent with the number of times educational issues were noted within case narratives and discharge planning. Ninety-nine children had a least one diagnosed mental health disorder identified. Medication management to address these disorders was documented in 74 of these instances. Treatment plans developed after the placement in the temporary setting often failed to have identified action steps for discharge planning activities.

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Thirty-two children remained in a SAFE Home Setting, eleven children remained at the STAR program setting, eight children remained in the PDC setting, and eight children remained in the temporary sub acute program setting.

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· · · · 18.

57.6% failed to have specific action steps for DCF related to discharge of the child from the temporary setting. In 56 instances (43.1%) there were no specific goals or action steps for the child related to discharge planning from the temporary setting. In the 112 cases with parental or guardian involvement, more than half (55.4%) failed to identify specific action steps for the parent(s) or guardian related to discharging the child from the temporary setting. 67.7% failed to have specific action steps for the temporary placement provider related to discharge of the child from the temporary setting.

In 93.8% of the cases reviewed, the social worker met the monthly visitation standard required by Outcome Measure 16 - Social Worker Visitation with Child in Out-of-Home Placement, but in only 63% of these visits was there documentation of a discussion with the child's caretakers regarding discharge efforts at those visits.

A wealth of information about the children in temporary congregate care has been gleaned from both the data collection efforts and discussions with the DCF staff and providers serving the children included in this review. Based upon the data analysis from this review of temporary placement cases, a number of recurring themes are evident. Considerations are offered on page 50 of the full report in an effort to illuminate those areas requiring improvement and possible starting points from which the Department may implement corrective actions. Many of these considerations have been the subject of recent discussions and some are actively being addressed. Additional considerations regarding the old model shelters are located on page 61.

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Juan F. Court Monitor's Review of Children in Overstay Status (60 Days) within Temporary Congregate Care Placement Settings Introduction As part of the Juan F. Action Plan, a review of the population of children in overstay status in the temporary congregate care placement settings in Connecticut greater than 60 days was required. The Monitor's Office in conjunction with the Department of Children and Families Quality Improvement Division collected data on this population using the methodology and tools crafted with input and agreement from both plaintiffs and DCF Administration over a period of several weeks. In all, 144 cases were found to meet the criteria for inclusion in our review. Cases were reviewed during the fourth quarter 2007. The review included a reading of LINK case record narratives, and contact with the assigned social worker or social work supervisor requesting their input related to discharge planning and barriers to discharge. The Court Monitor also attended provider meetings whose membership includes the temporary congregate care providers throughout the year, and visited several temporary placement sites. This offered additional perspective to the process. The providers in this cohort of temporary congregate care settings included 18 Safe Homes, two Permanency Diagnostic Centers (PDC), ten STAR Homes, and two Temporary Sub-Acute Centers as follows:
SAFE Home Providers
Brainard Home (Village for Families & Children) Chapman House - Family Service of Greater Waterbury Safe Home Community Health Resources Safe Home Community Solutions South Windsor Safe Home Starshine Safe Home Family & Children's Aid, Danbury Family & Children's Aid Shelton Safe Home Grube Safe Home Waterford Country School Safe Home Kids Cottage (Children's Center) Kids in Crisis Nursery Klingberg Family Centers Safe Home Olyniciw Safe Home Waterford Country School Rainbow House Waterbury Youth Services Safe Home Safe Harbors (Camp Street) Safe Harbors (Parker Avenue) Safe Haven Village for Families and Children Safe Home Wheeler Clinic Safe Home Windham Safe Home WCS

STAR Programs
Bristol House - Community Residences CARE - Children's Center Kids in Crisis Manchester House Community Residences Miller House - Bridge Family Center Portman House Community Residences Rita - Waterford Country School Thomas Bent - Waterford Country School West Hartford STAR Program Winifred House - Bridge Family Center

PDC
Family & Children's Aid PDC Sankofa PDC - Village for Families & Children

Temporary Sub-Acute Center
Kids Inn (Boys Village Temporary Sub-Acute) Wheeler Clinic STAR

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The temporary sub-acute facilities were included due to their licensing classification in LINK. The two older model Shelter programs (Marshall House and Salvation Army Youth Shelter (SAYES) were excluded at the discretion of the parties due to impending closure of those programs by the end of the first quarter 2008. Subsequently, the Monitor determined that this small population should be reviewed in light of viability of discharge plans and given the impending closure. These findings are reported separately given the differing time period and slight deviation in methodology from the larger sample set. The Department has provided a brief description of the levels of care within this temporary placement array to give some context to the similarities and differences. Initially, the SAFE Homes were intended for children under age 12 and to serve primarily children experiencing a first time placement and the PDCs were intended to serve children who were coming from an existing placement. While it is still true that the PDCs primarily serve children coming from an existing placement, the SAFE Homes now serve both populations equally. The primary distinction now is that the PDCs are contracted to provide a higher level of clinical care and the expectation is that the children placed there will be coming with identified mental health and behavioral issues.3 SAFE Homes This service provides short- term congregate care for children, primarily aged three (3) to twelve (12), who have experienced a removal from their home due to abuse, neglect or other significant risk factors. The focus of this service is to assist in the stabilization of each child, to avoid multiple initial placements that often accompany emergency removal and to complete a multidisciplinary exam in order to assist with treatment planning. This service shall accommodate sibling groups. Permanency Diagnostic Centers (PDC) This service provides immediate, overnight care for children who have experienced multiple placements and have significant mental health and/or medical and high-risk behavior management needs. Clinical assessment, high levels of structure and supervision and care coordination related to family reunification or other permanent placement is provided. The majority of children and youth served in this program will have likely experienced multiple placements. They may have experienced abuse, neglect or abandonment and will likely be in crisis as a result of these. The contractor will likely encounter a variety of special needs including medical concerns mental health and potential high-risk behaviors. Short Term Assessment and Respite Homes (STAR Programs)
SAFE Home and PDC Definitions provided by Office of Foster Care and Adoption Services Program Supervisor, Sarah H. Gibson, JD, MSW. STAR program definitions were provided from Dr. Robert Plant.
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STAR is a new model of short term care for children and adolescents that provides 24-hour care to children and youth, ages twelve through seventeen who are involved with the child welfare system and require short-term emergency placement. STAR offer children and youth many advantages over the old model Emergency Shelter system. These programs provide greater opportunity for youth to be served in their own communities by providing enhanced statewide geographic coverage. Additional advantages include: smaller settings that reduce the likelihood of institutionalized behaviors and that will support improved supervision and the development of nurturing relationships. Gender specific, trauma informed, and clinically driven services and supports better meet the needs of youth who may have been abused, neglected and/or are struggling with the removal from their home. The program model has been designed according to the following principles and components of care: · Children and adolescents will be served in small, less institutional settings · These settings will be geographically proximal to where the children live and/or the DCF area office that supports them · Services will be gender specific and will include gender-sensitive and culturally competent practices · Program staffing will provide improved supervision especially during key times of day (e.g., after school, weekends, holidays, etc.) · Services will be informed by an overarching clinically based philosophy of care that is trauma informed · An array of on­site clinical services will be provided · Aftercare services and supports will assist with the transition back home or to other community based settings

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Vignettes The data collected for this review provides an aggregate picture of the needs and issues of children and adolescents in temporary placement awaiting discharge. However, it is easy to lose sight of the circumstances of these individual children. The following four vignettes are provided to offer perspective and a frame of reference to this population of children4. "Joshua" and "Douglas" Siblings "Joshua" and "Douglas" are non-Hispanic, African American brothers who were ages 10.5 and 5.5 years old respectively when placed via 96 hour hold in a Safe Home as a result of a drug raid on their home in the spring 2007. The case had been open for almost one year, at the time of removal due to a substantiation of physical and educational neglect. The family was known to the Department since 2000. Prior substantiations included physical neglect, emotional neglect, and medical neglect with substance abuse of the parent identified on more than one occasion. In spite of several substantiations, this was the first removal for the brothers. The SDM at removal considered the home to be unsafe, and safety risk related to reunification remains "high". "Joshua" is in fourth grade and is a regular education student diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). He is on daily medication to address this diagnosis. He has a therapist and recently began IOP therapy to address trauma due to exposure to long term parental substance abuse by his mother, abandonment by his father, and domestic violence within his home. His worker describes "Joshua" as handsome and athletic. He likes to play football. "Douglas", attends kindergarten and has improved his on-task time once switched into a smaller classroom setting. While identified as very active, "Douglas" has no identified behavioral health concerns. He was placed in play therapy to address the trauma of removal, long-term exposure to parental substance abuse, and domestic violence. He has a history of nocturnal enuresis that has greatly improved since entry into the SAFE Home. "Douglas" has history of asthma, and was not up to date with immunizations at the time of removal. Both boys were engaged with therapists within two weeks of removal. All medical and behavioral health needs identified by the Multidisciplinary Examination (MDE) were attended to in a timely manner. The boys were routinely transported to visits with their parents in prison on a regular basis. Treatment plans were completed timely. While they did not incorporate action steps or goals related to discharge from the SAFE Home, there was a formal documented plan that was developed during meetings with input from the SW, SWS, SAFE Home, and the

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Names have been changed, and identifying information removed to ensure confidentiality.

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Therapeutic Foster Care (TFC) Director entrusted with locating a therapeutic foster home for the siblings. A TFC home willing to accept the siblings was identified in July 2007. The Department was concurrently researching all relatives that were identified for placement consideration. A relative of "Douglas" living out of state looked promising as a longer term resource for both boys, but due to the delays with ICPC, the Department determined that placement in a foster home would be necessary. Interstate Compact for the Placement of Children (ICPC) is still ongoing as of March 2008. The Area Office remained adamant about keeping the boys together. A Community Provider clinician and SAFE Home staff agreed that eldest child required TFC level of care and it would be beneficial for the younger child given the trauma of circumstances leading to removal. A home was identified within the first several weeks of placement. Meetings were held and pre-placement visits were scheduled. The first identified placement fell through during this transition when it was identified that "Joshua" could potentially pose a safety risk to the infant child in the home. There were also concerns given the foster mother's work schedule. The TFC agency kept matching efforts going, and another TFC placement was identified. Visits with this family began in September and transition was complete by October 2007. The children's needs were identified promptly, services were provided quickly to address medical and mental health needs, and concurrent efforts related to licensing a relative were immediately pursued for long term permanency in light of parent's incarceration for the next several years. Communication between the Department and various providers was frequent and purposeful. Delays occurred because of the issues with the initial foster care match but the TFC agency took only two weeks to identify another possible match. Transitional visitation took place until the date of placement in October. The length of stay in the SAFE Home was 206 days. Update: Following a recent court determination, the boys are committed to the Department. The TFC mother appears to be a good match for children's needs, and although behavioral issues have been ongoing, the siblings continue in this home. "Tracy" "Tracy" is a 13 year old non-Hispanic, African American female adolescent. "Tracy" has been known to the department for over a decade. Her family has had four substantiations which included emotional and physical neglect related to substance abuse. This is the second placement episode for "Tracy" who spent five months in DCF Foster Care in 2004-2005. This most recent out of home placement episode occurred on the date of case opening, in beginning of 2007, when mother brought "Tracy" in to the DCF office due to her pending incarceration. There were no caretakers available to provide care. Due to aggressive behaviors, "Tracy" was placed in a Permanency Diagnostic Center.

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"Tracy" is diagnosed with Post Traumatic Stress Disorder (PTSD), and Oppositional Defiance Disorder (ODD). She also has a history of asthma. She is currently taking an anti-depressant drug in attempt to improve aggressive behaviors. An MDE was done timely in March 2007. Recommendations included psychiatric evaluation, dental and vision care, Intensive Outpatient services, and Extended Day Treatment. "Tracy" had the psychiatric evaluation at the PDC in which she was placed. Educational programming was closely monitored. Visits with mother were provided. The discharge plan at the time of placement was therapeutic foster care. Narrative reveals that a TFC Network referral was made shortly after placement at the PDC. There was a lack of therapeutic family settings to match child to. There was no current DCF469. No individualized recruitment was noted. Months went by and "Tracy's" behaviors regressed while at the PDC requiring police involvement on more than one occasion. In August, the PDC asked for "Tracy's" removal after several instances in which child was aggressive with other younger children and staff at the PDC. It was noted that "Tracy" shows no remorse after these incidents. A treatment plan was created in May 2007 and included some steps regarding discharge for child and parent. There were no steps for the providers or DCF. The mother will require a long period of support and training for reunification to be successful. Services are needed now that mother is back in the community. Discharge planning should be more specific relating to these services. "Tracy" required a more intensive level of care from the point of entry into the PDC to the date of discharge to the residential where she is currently placed. Providers were clear that they could not provide her with the level of care necessary given her individual needs. "Tracy" presented a risk to others at the PDC. There was no formal discharge plan, although there are meetings documented including the therapist, psychiatrist, ARG, SWS, SW and Residential Placement Team. CANS was begun in June but was not submitted until mid August 2007. Update: In December, it was noted that a residential setting may be available for possible placement. This discharge was accomplished in mid-January 2008. Length of stay at the PDC was 348 days. "Cheryl" "Cheryl" is a multi-racial non-Hispanic 16 year old female. "Cheryl" has been diagnosed as having Bipolar Disorder, Mood Disorder-NOS, Substance Abuse, and has had a history of running away from home and engaging in risky sexual behavior. "Cheryl's" family has been known to the Department for over a decade, with multiple unsubstantiated referrals relating to domestic violence prior to the most current substantiation of emotional and physical neglect. There has also been FWSN activity. The most recent case opening was in early 2006. "Cheryl's" father's parental rights were terminated at the request of the mother. Their relationship was domestically violent. Her mother's current paramour is a reported a substance abuser that reportedly shared drugs with "Cheryl". 16

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"Cheryl" has been in foster care for one month in 2006. The most recent entry into care occurred as the result of the family friend, with whom "Cheryl" was residing via a probate arrangement, reporting she could no longer keep her and that the mother refusing to allow her to return home. "Cheryl" spent two days in a foster home and was placed at a STAR program in July 2007. A psychiatric/psychological evaluation was documented and medication management was put into place including a combination of three medications including two anti-psychotic drugs and an anti-depressant. The MDE was conducted within two weeks of placement. Mental health needs and substance abuse, the need for a therapeutic mentor, and routine dental care was identified. "Cheryl" also has asthma and currently uses daily medication and fast-acting inhaler to address this as necessary. "Cheryl" was identified as obese and a smoker. MDE suggests SW should address this with her. Relative resources were sought. An older sister emerged as a possible resource, but the sister failed to follow through with licensing requirements and the Department sought to secure a Group Home level of care after a great deal of discussion with the ARG, SWS, Clinician, "Cheryl", "Cheryl's" attorney and mother. (It was documented that while TFC may be an option, the parties felt the group home could better provide life skills and address "Cheryl's" mental health issues.) Meetings were documented bi-weekly. The ARG was very active in addressing both educational issues as well as mental health. The Safe Home clinician was key to helping "Cheryl" accept the Group Home placement, as she had wanted very much to live with her elder sister. There was a team approach. The CANs was submitted in a timely manner after the decision to pursue the Group Home, when FASU identified the likelihood that placement would not occur with the sibling or any other relative that had been proposed. While the treatment plan developed in August 2007 did not include steps related to discharge planning, there was a formal discharge plan identified for the child with input from various DCF staff, the SAFE Home, "Cheryl" and her mother, the attorney, and the Clinician. Discharge planning was well done after the disappointing follow-through by her relative. However, the need for a therapeutic mentor and substance abuse treatment did not appear to be addressed while at the temporary placement. The Mentor service was delayed due to the unknown location of placement post-SAFE Home. It is unclear why the substance abuse treatment was not pursued more rigorously. "Cheryl" was placed at a Group Home in October 2007. Length of Stay at the STAR was 106 days. Update: While "Cheryl" was an exemplary member of the Group Home, in late February 2008 she was reported AWOL after not returning home from her part-time job. The Group Home reported they would be unable to hold her bed. Several days later "Cheryl" contacted the Group Home and requested transportation to return. They advised her that she was no longer a resident. This situation was not brought to the SW's attention until the SW phoned the mother the following day. The mother advised SW that she did not know where "Cheryl" was but that she called her to tell her she did try to go back to the Group Home and they refused. SW contacted the Group Home and was advised that the bed had not yet been allocated to another adolescent. SW was unable to locate "Cheryl" to return her to the Group Home. Child remains AWOL. 17

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"Susan" "Susan" is an 18 year old white non-Hispanic female diagnosed with ADD, PTSD, Bipolar Disorder and Borderline Personality Disorder. A combination of anti-psychotics and an anti-depressant were included in her medication management. "Susan" was in the 10th grade at the Clinical Day School when she entered a psychiatric hospital in January 2007. "Susan" has a history of suicide attempts, anorexia/bulimia, cutting, inappropriate and risky sexual behaviors, and poor hygiene. She also has asthma which is controlled through daily medication. This is a voluntary services case at the request her adoptive parents. "Susan" was adopted at the age of eight years. She did well with her adoptive family until puberty, when disturbing behaviors began to surface/resurface after years of relatively good mental health. "Susan" is smart, and can advocate for herself. Her adoptive mother is also an avid advocate. "Susan" was most recently placed into a STAR program in April 2007 from the psychiatric hospital because there were no sub-acute beds available. A sub-acute provider had accepted "Susan" but placement was pending an available bed. The most recent treatment plan for this child was developed in June 2007 and included steps for the child to work toward discharge, but failed to identify actions necessary for the parent, DCF or providers. The stated permanency goal is APPLA. There is no concurrent plan. When we first reviewed this case six months into the placement at the STAR, there was no discharge plan. There were options being considered to seek TFC, regular foster care, group home and residential. There had been a great deal of conflict over the level of care required prior to this that seemed to stall placement efforts. In a meeting in late October 2007 all of the parties met (mother, STAR staff, and DCF) and agreed that child required residential care given her decline since entering the STAR program. A CANS was required to seek this level of care, as the initial CANS had suggested a TFC level and several months had passed with no resource located. The ARG documented a consultation with the SWS on this case. The therapist and mother were of opinion that residential was necessary while DCF began toying with the idea that a DCF foster home with supports may be acceptable. The SWS reported routine, frequent meetings related to discharge, however only two meetings were documented between the DCF staff and the STAR program during the period. Update: Abruptly in December the discharge shifts to group home as a possible bed was located for "Susan". Per the narrative all parties were in agreement with this level of care. In February 2008 "Susan" was placed in a Group Home setting. Length of stay at the STAR was 297 days.

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Population Demographics There were 91 children in Safe Homes, 13 children in the PDC, 29 in the STAR homes, and 11 within the temporary sub-acute centers in overstay status per the database identified by the Department on October 1, 2007. At the time of the sample, the highest number of children in any given facility in overstay status were 11 children resident in the Klingberg Family Center Safe Home. The distribution of the sample of 144 children within this temporary placement provider pool is provided in the following chart: Chart 1: Distribution of Overstay Population within the Temporary Placement Provider Pool on October 1, 2007 (n=144)
Placement Provider Name
6 4 8 1 7 5 5 2 4

6 2 5

8

3

3 1

7

9

6

1 7

5

8

4 11 3 2 3 7

Winifred House Windham Safe Home Wheeler Clinic STAR Wheeler Clinic Safe Home West Hartford STAR Waterford Country School Safe Home Village for Families and Children Safe Home Thomas Bent Shelter Sankofa House Safe Haven Safe Harbors Rita Shelter Rainbow House Portman House Miller House Manchester House Klingberg Family Center Safe Home Kids Inn Kids in Crisis STAR Kids in Crisis Kids Cottage Grube Safe Home Family & Children's Aid Safe Home Family & Children's Aid PDC Community Solutions South Windsor Safe Home Community Health Resources Safe Home Chapman House CARE - Children's Center Bristol House Brainard Home

Of the 144 children included in our sample, the range of length of placement as of October 1, 2007 was 60 days to 1,278 days with a median of 183 days at the temporary placement. The sample population (n=144) included 87 males and 57 females. Ages ranged from seven months to 18.5 years, with an average age of 10.5 years of age. Residents were most frequently identified as White and Non-Hispanic. 19

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Full details related to race and ethnicity are provided in the crosstabulation below. Crosstabulation 1: Child's Race * Child's Ethnicity
Child's Ethnicity Blank (none Non-Hispanic Selected) Unknown 0 2 0 .0% 100.0% .0% 40 0 0 97.6% .0% .0% 48 0 1 66.7% .0% 1.4% 0 0 0 .0% .0% .0% 15 0 0 100.0% .0% .0% 103 2 1 71.5% 1.4% .7%

Child's Race

American Indian/Alaskan Native Black/African American White UTD Multi-racial

Total

Count % Count % Count % Count % Count % Count %

Hispanic 0 .0% 1 2.4% 23 31.9% 14 100.0% 0 .0% 38 26.4%

Total 2 100.0% 41 100.0% 72 100.0% 14 100.0% 15 100.0% 144 100.0%

Children's legal status was most frequently identified as Committed (92 or 63.9%), followed by TPR/Statutory Parent (18 or 12.5%), OTC (17 or 11.8%) Not Committed (6 or 4.2%) and DCF Custody - Voluntary Services (1 or 0.7%). Decision to Place at a Temporary Placement Setting Records were reviewed to determine the rationale for the determination for placement in the STAR or Safe Home settings. Of the 144 children 72.9% had clearly documented rationales for placement in these congregate type settings. In 39 cases (27.1%), it appeared that availability alone was the deciding factor for placement at the temporary setting. Documented reasons for the remaining 105 cases included the following: · 26.2% allowed for siblings to remain together · 17.2% were selected due to the 24 hour staffing patterns and level of structure/supervision available. · 18.6% were selected to allow for clinical assessment or immediate therapeutic services · 6.2% were selected as the child was familiar with the placement due to prior placement experience in the setting · 2.7% were selected due to concerns regarding sexually perpetrating/reactive children that required close monitoring · 1.4% were selected as they could meet the needs of medically complex children · 0.7% was selected to allow for close proximity to parent. For three of the children, in addition to the identified rationale above there were additional notes related to the availability of Spanish speaking caretakers in the Safe Home setting.

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However, many of the documented rationales for selection of this congregate setting over family setting were in fact, secondary in nature as the main rationale was the need for immediate placement and the lack of available and appropriate foster and therapeutic foster homes. For example, a sibling group of two or three should be able to be accommodated in a family setting, if not immediately then certainly within 60 days of coming into placement. The pool of medically complex foster parents should be able to accommodate the needs of children requiring medically complex care well within the span of 60 days. Coordination of community services also plays a role in ability to match to a family setting, as wait lists for counseling services, and evaluations, makes a placement in these programs the most efficient way to provide clinical/therapeutic intervention in a timely manner. In reviewing placement with the temporary providers by geographic catchment areas of the local office, 50.7% of the placements were within the area served by the assigned DCF Office. This poses additional burden on both the area office and temporary placement provider related to continuity of both education and established community provider service provision, as well as frequency of visitation with family or kin. Maintaining Sibling Groups There were 82 children within the sample that were a member of a sibling group having at least one additional sibling in out of home placement. In 42 cases, the child was in the identified temporary placement setting with one or more of the siblings also in custody. Valid reasons for separation of siblings were identified in the majority of the situations where siblings could not be maintained in placement together. These included: · 16 children were separated for reasons related to mental health needs · 6 children were separated for safety reasons as inappropriate sexual contact was known to have occurred between siblings · 5 children were separated from siblings due to medical needs · 3 children were separated to allow a sibling's placement with a relative resource · 1 child was separated from sibling that had just reunified with parents under trial home visit · 1 child was separated from sibling that was resident in a CHAPS program that could not accommodate this younger child. There were seven situations with siblings in placement for which lack of resource appeared to be the primary reason for separation rather than a clinically based determination. There were four cases in which siblings had TPR status. In one of these cases, the sibling wanted no further contact with the child in the temporary placement. In the other three situations, siblings remained in contact but were not designated for the same permanent resource and were therefore not maintained together. Prior Placement Histories Children within the sample (n= 144) were reviewed for length of current placement episode, and number of placements prior to the temporary setting during the period of September 1, 2006 through October 1, 2007. Of the sample set, placement in this 21

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temporary setting was the first placement in the episode for 62 of the children (43.1%) in the sample. A total of 32 children (22.2%) had experienced one prior placement to the temporary setting during the period (a total of two placements). Twenty-three children (16.0%) had two placements prior to the temporary setting (total of three placements). Sixteen children (11.1%) had three prior placements (for a total of four placements) and 11 children (7.6%) had five or more prior placements during the period. Current episodes in placement ranged from 63 days to 15.3 years as of October 1, 2007, with an average length of stay of 1.9 years. Thirteen of the children had at least one hospitalization of greater than 24-hour observation; seven had had two such episodes. Children with histories including the hospitalizations in 2007 were most frequently in Safe Homes (7) followed by Sub-Acute Settings (5), and STAR and PDC (4 each). Twenty-seven of the children had had prior placement in a temporary congregate setting during the year. Thirty-five children had placement experience in a temporary congregate setting at some point prior to 2006. In 45 instances, children in the sample entered the temporary congregate care placement directly from their home (31.3%), this was followed closely by 41 children disrupting from DCF Foster Care Placements (28.5%). For a full accounting of prior placement settings see the crosstabulation below. Crosstabulation 2: Where was the child immediately prior to this temporary setting? * What type of temporary placement is this provider?
Where was the child immediately prior to this temporary setting? Home DCF Foster Care Therapeutic Foster Care Hospital SubAcute/PRTF Shelter, Safe Home or STAR Program Other5 Total What type of temporary placement is this provider? SAFE Home 38 31 5 3 0 0 14 91 PDC 2 1 3 3 0 3 1 13 STAR 3 9 6 4 1 2 4 29 Sub-Acute 2 0 1 5 0 3 0 11 Total 45 41 15 15 1 8 19 144

Others included: Family friend through informal arrangement (4), Relative (2), Temporary Guardian (2), Detention (2), Homeless Shelter (2) DCF Licensed Relative (2), TFC Respite Home (1), Medically Complex Foster Home (1), Children's Center Crisis Intervention Program (1), Pre-Adoptive Home (1) and AWOL (1).

5

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Medical and Psychological Assessment Of the 144 children within the sample, there were 22 children that did not have a documented Multidisciplinary Examination (MDE) following their date of entry into care. Of this total, however, 16 children had documented exception codes entered in the appropriate field to identify a circumstance that allowed for exclusion of this requirement. Upon further review, another two cases met the exception criteria but failed to properly document such. Although timeliness of the MDE was not a measurement within this review process data indicates a total of 97.2% had an MDE or appropriately documented the exception code. In eight instances, an assessment or need identified at the MDE was still not fully addressed or resolved at the point of review and was an impediment to discharge. In 27 cases, reviewers identified treatment interventions previously identified by the MDE or subsequent evaluations that were not fully implemented as of the October 1, 2007 cut-off date. Crosstabulation 3: What type of temporary placement is this provider? * Are there any needs identified by the MDE or subsequent evaluations that remain unmet and are a barrier to discharge?
Are there any needs identified by the MDE or subsequent evaluations that remain unmet and are a barrier to discharge? What type of temporary placement is this provider? SAFE Home PDC STAR Sub-Acute Total yes 12 4 8 3 27 no 73 8 18 7 106 UTD 6 1 3 1 11 Total 91 13 29 11 144

As shown in the table above, the PDC provider group had the highest rate of unmet assessments/needs, with 30.8% of the 13 children in their care still awaiting some type of service or assessment identified to assist in the discharge process. Also of concern is a lack of recent assessment documentation. In addition to the 11 situations identified above, there were 34 or 23.6% of this population who were identified as having no documented psychiatric or psychological evaluation documented within the last twelve months, but of this total, 19 children were identified as have an Axis I diagnosis that was presumably dictating level of care decisions. This raises a question as to how discharge planning could be considered informed and accurate given out of date assessments or missing documentation. Another area of concern is conflicting information in the behavioral health record, case narratives and treatment planning documents. Frequently the behavioral health profile was incomplete or altogether missing from the LINK record. When conflicting 23

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information was identified within the record, or no information could be located in relation to diagnosis, reviewers clarified the official diagnosis information with a SW and/or a SWS. In many cases, this was not readily available to the SW or SWS and required contact with the ARG, the child's clinician, or a review of information not included in LINK before the response could be provided. Table 1: Has this child had a psychiatric or psychological evaluation in the last year
Yes No N/A - Not Indicated by Initial Screening Total Frequency 88 34 22 144 Percent 61.1% 23.6% 15.3% 100.0%

DSM Diagnosis Axis I designated diagnosis (Clinical Disorders and Other Conditions that may be the focus of Clinical Attention) for the 144 children were identified through review of the medical profile, narrative entries, treatment plan documents, and contact with the SWS or SW. Of the 144 children, forty-five children (31.3%) had no DSM diagnosis on record at the point of review. Ninety-nine children had at least one identified Axis I diagnosis on record. In many cases, multiple entries were designated (53 children had more than three identified diagnosis on Axis I). Placement in the more clinical settings (Sub-Acute, PDC and STAR) appears to reflect appropriate consideration of children's behavioral health needs, in that the majority of the children with no clinically diagnosed disorder were placed in the Safe Home setting. However, the SAFE Home providers, who often are not staffed with on-site clinical personnel, are being used to serve a population of children with diagnosed mental health or behavioral conditions. Of the 91 children in the SAFE Home subsample, 53.9% had an Axis I diagnosis. Medication management was in place for 36.3% of this SAFE Home subsample, and 1:1 services were documented for 11.0% of this population. Crosstabulation 4: What type of temporary placement is this provider? * Does this child have a diagnosed mental health disorder?
Does this child have a diagnosed mental health disorder? What type of temporary placement is this provider? SAFE Home PDC STAR Sub-Acute Total yes 49 13 26 11 99 no 42 0 3 0 45 Total 91 13 29 11 144

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The following table provides a frequency of the Axis I Diagnosis identified for the full sample. Table 2: Frequency of Axis I Diagnosis for Children in Temporary Placement Greater than 60 Days
Diagnosis Adjustment Disorder No Identified Diagnosis Attention Deficit Hyperactivity Disorder Post Traumatic Stress Disorder Oppositional Defiant Disorder Depressive Disorder (all types) Mood Disorder Bipolar Disorder Reactive Attachment Disorder Conduct Disorder Dysthemic Disorder Disruptive Disorder Rule Out Post Traumatic Stress Disorder Rule Out Reactive Attachment Disorder Asperger's Disorder Attention Deficit Disorder Enuresis or Encopresis Sexual Abuse of Child or Sexually Reactive Expressive Language Disorder Intermittent Explosive Disorder Pervasive Development Disorder Impulse Control Disorder Neglect of Child Psychosis or psychotic features Rule Out Bipolar Disorder Autistic Disorder Generalized Anxiety Disorder Learning Disorder Rule Out Mood Disorder Cognitive Disorders Fetal Alcohol Syndrome Hearing Deficit Mental Disorder due to Medical Condition Parent-Child Relationship Problem PICA Rule Out Explosive Disorder Rule Out Oppositional Defiant Disorder Rule Out Psychotic Disorder Schizophrenia - Paranoid Type Tourette's Disorder Frequency 45 45 35 34 24 21 12 10 10 8 8 6 6 6 5 5 5 5 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 Percentage 31.0% 31.0% 24.1% 23.5% 16.6% 14.5% 8.3% 6.9% 6.9% 5.5% 5.5% 4.1% 4.1% 4.1% 3.5% 3.5% 3.5% 3.5% 2.8% 2.8% 2.8% 2.1% 2.1% 2.1% 2.1% 1.4% 1.4% 1.4% 1.4% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7%

Forty-four of the children with an identified Axis I diagnosis remained in temporary placement (44.4%) at our follow-up review on December 31, 2007. Of the 45 children with no identified Axis I diagnosis, 15 or 33.3% remained in the temporary placement on December 31, 2007. A surprisingly low number of children, two of the 144 reviewed, are documented as having learning disorders from the DSM documentation available and reviewed in LINK. This is significant given the number of children receiving special education services or 25

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requiring 504 considerations within this group, and is inconsistent with the number of times educational issues were noted within case narratives and discharge planning. This is a concern, as educational issues that remain unidentified or unaddressed will lead to acting out behaviors making placement planning a more challenging proposition. Use of DCF Educational Consultants as part of the treatment and discharge planning was very infrequently documented. It is unclear if the current staffing levels currently in place are adequate for the demands not only of this population but for the full population of children in placement. Axis II diagnosis (Personality Disorders/Mental Retardation) was also captured. One hundred and fourteen children did not have an identified Axis II diagnosis identified. Of the thirty children with at least one e