Response and Evaluation Process for Case Management of Children in Foster Care

PURPOSE: This rule implements House Bill 1414 (2020), which amended section 210.112, RSMo. The purpose of this rule is to reg ulate the response and evaluation process for case management services that are identified in the amended statute. (1) Purpose and Scope. (A) The purpose of this regulation is to implement the amendments to section 210.112, RSMo, that were enacted into law in HB 1414 of the 2020 regular session of the Missouri General Assembly. This regulation applies to case management services, whether provided by employees of the Children’s Division (hereinafter the “division”) or by Foster Care Case Management Contractors (FCCMs). (B) In implementing this regulation, the safety and welfare of children shall be the paramount consideration. (2) Definitions. For the purposes of this section the following definitions shall apply: (A) “Accrediting body” shall refer to the Council on Accreditation of Services for Children and Families, Inc., the Joint Commission on Accreditation of Healthcare Organizations, or the Commission on Accreditation of Rehabilitation Facilities; (B) “CFSR” shall mean the Child and Family Services Review process, standards, goals, and measures established by the Administration of Children and Families of the United States Department of Health and Human Services; (C) “CFSR-OSRI” shall refer to the CFSR On-Site Review Instrument utilized by the Administration of Children and Families of the United States Department of Health and Human Services; (D) “Case management services” shall include assessments, case planning, placement services, service planning, and con current planning for children. These services include, but are not limited to: 1. Coordinating and facilitating the provision of services necessary to ensure the safety and well-being of the child, to meet the needs of the child’s parent(s) or caretaker, and to pro mote timely permanency; 2. Facilitation of family support team meetings; 3. Facilitation and/or supervision of visits between chil dren and their family members; 4. Preparation of court reports; 5. Attending and participating in court hearings; and 6. Coordination of services and provisions in compliance with federal and state law, and directed by Children’s Division policy and regulation; (E) “Child” or “Children” shall mean any individual who has been placed under the supervision of the division or in the legal or physical custody of the division by judgment or order of a juvenile or family court; (F) “Direct Service Providers” means any person or entity who is providing case management services to children and fami lies of children who are under the jurisdiction of the juvenile court and who are either placed under the supervision of the division or placed in the legal or physical custody of the divi sion. This applies to alternative care Children’s Division Case Managers and their supervisors, and to FCCMs; (G) “Foster Care Case Management Contractors,” “FCCM,” or “FCCMs” shall mean any individual or entity which has a contract with the children’s division to provide case manage ment services for children. It also shall mean any contractor or subcontractor of an FCCM which provides case management services. It does not mean individual employees of the FCCM; (H) “Large Contractor” shall mean any FCCM which is con tracted to provide case management services for one hundred (100) or more children. It shall also refer to the lead FCCM con tractor and their sub-contracted partner agencies; (I) A “near fatality” means any physical injury or illness of a child caused by suspected or substantiated child abuse or ne glect that, as certified by a physician, places the child in serious or critical condition; (J) “Provider” shall mean the Children’s Division and FCCM, but shall not mean individual employees of the division or FCCMs; (K) “Response and Evaluation Team” or “the R&E Team” shall refer to the Response and Evaluation Team established pursu ant to 210.112.3, RSMo; (L) “Sentinel events” shall mean any critical incident as de scribed in 13 CSR 35-71.070, any unusual event as described in 13 CSR 35-73.050 and— 1. A child fatality or near fatality; 2. An incident that causes serious emotional harm or se rious bodily injury to a child. For purposes of this regulation a serious emotional or physical injury occurs when it is medi cally reasonable or necessary for a child to obtain professional medical intervention as a result of something that happens to the child while placed with the individual or organization; 3. A child elopes from his or her placement; 4. A fire in a location routinely occupied by children, which requires the fire department to be called; 5. A report of child physical abuse, emotional abuse, sexual abuse, or neglect pertaining to a child; and 6. Whenever a child attempts to harm him/herself or oth ers, including suicide attempts; (M) The term “serious bodily injury” means bodily injury which involves substantial risk of death, extreme physical pain, protracted and obvious disfigurement, or protracted loss or impairment of the function of a bodily member, organ, or mental faculty; and (N) Children with “Special Needs” shall include children who have physical, behavioral, or mental health conditions that require specialized care. (3) Evaluation Tool and Metrics. (A) The division shall establish and implement a uniform evaluation tool, metrics, and performance outcome goals for providers to evaluate the quality of case management services. Performance outcome goals, but not metrics, may be adjusted regionally to account for regional differences in the availabil ity of services, provided that the same performance outcome goals apply to all providers in the same region; provided that the performance outcome goals that apply to the division shall be adjusted to take into consideration the factors set forth in subsection (3)(F). The division shall establish the tool in con junction with the R&E Team and other appropriate individuals. The division may establish and implement the evaluation tool in phases as described elsewhere in this regulation. The eval uation tool may draw from the following sources of data and information: 1. Data contained in the information system of the divi sion, including Family and Children Electronic System (FACES); 2. Data from surveys; 3. Detailed case reviews of individual cases of children as described below; 4. Data and information from federal CSFR reviews; 5. External audits and program reviews; 6. Reports from an accrediting body; and 7. Other sources of information as may be necessary. (B) The division will publish the proposed tool for Phase I on its website by April 1, 2022, and solicit comments from provid ers, stakeholders, and the public. Providers may recommend alternative metrics based on the best interests of the child. In making such recommendations the providers shall explain, in writing, how the alternative metrics are in the best interests of the child and promote the safety and welfare of children. The division and the R&E Team will review the comments, and the R&E Team will submit recommendations based upon the comments within thirty (30) days of receipt of the comments. The division will consider the public comments and recom mendations of the R&E Team and publish final evaluation tools and metrics for Phase I on or before July 31, 2022. The final, Phase I evaluation tools, metrics, and performance outcome goals shall be implemented by and applicable to all effective October 1, 2022. (C) The evaluation tool shall include selected metrics and performance outcome goals from the CFSR and the CFSR-OSRI. (D) By October 1, 2022, the division, in conjunction with the R&E Team and following the procedures set forth in subsection (3)(B), shall implement and all providers are required to utilize and implement a uniform, standardized stakeholder feedback tool. This tool will collect data from stakeholders pertaining to the quantity, quality, and effectiveness of case management services that the division and FCCMs provide. 1. The tools may be surveys and will also provide space for stakeholders to provide narrative feedback and comments. 2. Separate stakeholder feedback tools shall be designed for and provided to each of the following categories of stake holders: children twelve (12) years of age or older, parents or legal guardians of children, foster parents or resource provid ers, juvenile officers, and judges of juvenile and family courts. 3. Stakeholder feedback tools shall be submitted on the following schedule: A. Children twelve (12) years of age or older: annually and at the conclusion of the time the child is in care; B. Foster parents and resource parents annually; C. Parents or legal guardians of children in care, annu ally; D. Juvenile officers, annually; and E. Judges of the juvenile and/or family courts who pre side over proceedings under Chapter 211, RSMo–annually. (E) The evaluation tool for providers shall include metrics and performance outcome goals for the following domains listed below. The division may implement these in phases, but it shall implement at least one metric and performance out come goals for each domain in Phase I no later than October 1, 2022; implement additional metrics and performance goals in Phase II no later than October 1, 2023; and implement all remaining metrics and performance goals in Phase III no later than October 1, 2024. The division may implement additional performance outcome goals and metrics or make amendments to any domain, performance outcome, goal, or metric in con junction with the Response and Evaluation Team following the process set forth in subsection (9)(B) of this regulation as may be necessary and appropriate. Some metrics and performance outcome measures may apply to more than one (1) domain. To the maximum extent possible, the metrics and performance outcome measures shall be based upon, and preferably mirror, the federal CSFR and Program Improvement Plan (PIP) metrics, measures, and goals. The achievement of the deadlines spec ified in this regulation are contingent on the availability of information processing capability and the availability of funds that are necessary for implementation. The division, with the permission of the Department of Social Services, may extend the deadlines for implementation of a goal or metric if it is not technically feasible or if there are insufficient funds to imple ment by the deadline. The domains are— 1. Safety Domain. The purpose of the Safety Domain met rics and performance outcome goals is to ensure, to the maxi mum extent possible, that children are kept safe from the risk of abuse and/or neglect for the duration of their experience within the child welfare system. Metrics and performance outcome goals will be developed and implemented to address the following: A. Worker/child visits; B. Reports of abuse and/or neglect of a child; C. Sentinel events; and D. Any other metrics and outcome goals that may be re quired by law or that the division may decide are appropriate; 2. Well-Being Domain. The purpose of the Well-Being Domain metrics and performance outcome goals is to ensure, to the maximum extent possible, that children receive the nec essary care and services for them to grow, develop, and thrive for the duration of their experience within the child welfare system. Metrics and performance outcome goals will be devel oped and implemented to address the following: A. Parent/child visits to the extent that they are not con trary to the orders of the court; B. Healthy Child and Youth program compliance (i.e. compliance with federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements and stan dards). This will include timely completion of Healthy Children and Youth (HCY)/EPSDT screenings and also timely compliance with diagnosed and prescribed treatment; C. Residential–Placement of a child in a residential or institutional setting shall be in compliance with the require ments of federal and state law; D. Education–such as achievement of identified, devel opmentally, and age appropriate educational milestones; E. All case managers and supervisors successfully com plete training in providing trauma informed and trauma based services; and F. Any other metrics and outcome goals that may be re quired by law or that the division may decide are appropriate; 3. Permanency Domain. The purpose of the Permanency Domain metrics and performance outcome goals is to ensure, to the maximum extent possible, that children achieve perma nency and are discharged to a safe and appropriate placement from the care and supervision of the child welfare system in a timely manner. Metrics and performance outcome goals will be developed and implemented to address the following: A. Worker/parent visits; B. Re-entries into foster care; C. Timely achievement of the child’s court approved permanency plan; D. Stability of placements; E. Provision of services to meet the needs of older youth; F. Timely development and effective implementation of a primary and concurrent permanency plan for each child; G. Development and implementation of a social service plan to address the reasons why the child is in care; and H. Any other metrics and outcome goals that may be required by law or that the division may decide are appropri ate; and 4. Service Domain. The purpose of the Service Domain metrics and performance outcome goals is to ensure that pro viders are effectively and efficiently managing the services that they are providing. Metrics and performance outcome goals will be developed and implemented to address the following: A. Caseloads–including caseloads per case manager and the number of changes in case manager that a child may expe rience while a child is in care; B. Effective ratio of supervisors to supervision of case managers; C. Timely reporting of sentinel events; D. Cases returned to the division due to catastrophic costs or court order for case management by Foster Care Case Management agencies; and E. Any other metrics and outcome goals that may be re quired by law or that the division may decide are appropriate. (F) All metrics and performance outcome goals for the divi sion shall be designed to take into consideration the following factors: 1. The fact that caseloads of FCCM case managers are capped; and 2. The fact that FCCMs may return cases to the division due to catastrophic costs or court order for case management. (G) The division, in conjunction with the R&E Team, shall de velop objective standards and criteria to identify cases which a provider may feel are anomalous and should not be considered in developing the case management tool. The standards and criteria shall be implemented following the process and dead lines established in subsection (3)(B) of this regulation. (H) To calculate the performance and outcome scores, the division will calculate for each provider the percentage of the performance outcome goal for each item in each domain being scored under 13 CSR 35-35.100 that each provider actually achieved for that item during the phase for the period. The percentage achieved for each item under each domain shall then be multiplied by the weight factor (if any) assigned to each item. The net sum of the weighted percentages will be the total score for each provider for the period. The performance outcome goals for the period and the weights to be assigned to each item will be established by the division, in conjunction with the Research and Evaluation team and other individuals, following the procedures specified in this regulation. (4) Collection of Data. (A) Effective October 1, 2022, the division and FCCMs shall implement policies and procedures to require their staffs to timely record all of the necessary data in the information sys tem. Information shall be timely posted if it is posted no later than the fifteenth day of each calendar month for the preced ing calendar month or sooner as may be required by policy of the division. (B) The division and each FCCM shall develop and implement a system to track the timely and accurate recording of data in the information system by October 1, 2022; this may include implementing a system to send reminders to staff or prohibit completion of data entries when mandatory data fields are not timely completed. (C) The division will publish a list on its website describing the specific items of data that providers will be responsible for recording and reporting. The division will publish its first list of data items on or before April 1, 2022, to be effective July 1, 2022. The division shall send a notice by e-mail to all providers noti fying them when a change has been made in the data points at least one (1) quarter prior to the effective date of the list to en sure that providers have notice and an opportunity to prepare. (D) Detailed Case Reviews. 1. The division and the R&E Team will utilize the informa tion and findings from individual case reviews from the feder ally required, statewide CFSR process. 2. In addition to the CFSR process, the division, in con junction with the R&E Team, may develop and implement a detailed case review process if necessary to supplement the CFSR process and/or to ensure the quality of data that is being reported and utilized for calculating metrics and performance outcome goals and measures. The division and the R&E Team may also utilize detailed case reviews as part of the process of identifying and providing technical assistance to provid ers who are having difficulty meeting performance outcome goals and measures, and for other purposes as provided in the contract. 3. When a case has been selected for a detailed individual case review, the provider providing case management services will be given the opportunity to propose different evaluation metrics if the case may have circumstances far beyond those which would be expected. A. The division, in conjunction with the R&E Team and other stakeholders, shall develop and implement objective standards and criteria for identifying cases which will be eval uated on different evaluation metrics. The division shall utilize the process described in subsection (3)(B) for developing, pub lishing, and implementing the standards and criteria. B. The provider shall make the request to apply different evaluation metrics in writing within ten (10) days of the date that the division identified the case for a detailed review. The request shall include: (I) A detailed explanation for why the generally appli cable criteria and metrics for conducting case reviews cannot be reasonably and appropriately applied to the case and why the case may have circumstances far beyond those that would be expected; and (II) Explain in detail what performance measures and metrics the provider proposes that the division and the R&E Team apply to the review of the case. C. The provider shall have the burden of proving that the case falls far beyond what is expected and what alternative metrics should be applied by clear and convincing evidence. D. The division and/or the R&E Team shall conduct a full case review of each and every case that a provider identifies as a case that should be evaluated using different evaluation metrics. (E) The division will collect data and all providers will provide data on a monthly basis provided that Detailed Case Reviews will be conducted when necessary to supplement other data sources as determined by the division in conjunction with the R&E Team. (F) Providers shall make available all data, files, records, and information pertaining to each and every case to the division and the R&E Team to perform their duties under section 210.112, RSMo, and this regulation. This includes information main tained in physical and electronic formats. Providers shall direct their staffs to provide true, complete, accurate, and timely information to the division and the R&E Team members when performing their duties under this regulation. Providers shall make their employees and subcontractors available for inter views when conducting detailed case reviews. (G) Providers shall ensure that staff are trained and have the opportunity to enter data into the information system in a timely manner to ensure that the data retrieved from the infor mation system is timely and accurate. Data for the preceding calendar month shall be entered into the information system no later than the fifteenth day of the following calendar month or sooner as may be required by policy of the division. (H) The data and metrics shall be analyzed and reported in the aggregate across the whole system, and then by judicial circuit, county (or city within a county), and provider. (5) The division and the R&E Team will develop, propose, and implement a system for reviewing and working with providers who request assistance or who show signs of performance weakness. Performance weakness shall be defined and mea sured with reference to the metrics and performance outcome goals as discussed in this regulation, in addition to other pro visions in the contract. (A) The division, in conjunction with the R&E Team, will identify objective performance measures and standards based on the metrics and performance goal outcome scores as calcu lated in subsection (3)(H) to identify providers who are showing areas in weakness of performance. This may be done in phases so as to be consistent with the phased implementation of the evaluation tool and metrics and performance outcome goals. The division will give the public and stakeholders thirty (30) days to submit comments and suggestions. The division will consider the comments and then publish the operational per formance measures and standards on the division’s website consistent with the phased implementation deadlines. (6) Data Reporting. (A) The division, in conjunction with the R&E Team, shall de velop and implement a standardized format for analyzing and reporting the data and lessons learned from the data. This will ensure that data is analyzed and reported in a consistent and comparable manner from quarter to quarter. The division will follow the procedures specified in this regulation for develop ing and implementing the reporting tools. (B) All measures, metrics, and performance measures shall be designed to take into consideration the following factors: 1. The fact that case loads of FCCM case managers are capped; and 2. The fact that FCCMs may return cases to the division due to catastrophic costs or court order for case management. (C) The division will publish the report quarterly on its web site. The report for the preceding quarter shall be published on or before the last day of the end of the last month of the sub sequent calendar quarter. The initial report shall be published no later than March 31, 2023, for the October 1, 2022, through December 31, 2022, quarter. (D) In developing the standardized format for reporting, the R&E Team shall be responsible for determining how to aggre gate cases for the division and large contractors; so that perfor mance and outcomes may be compared effectively while also protecting confidentiality. (7) Conflicts of Interest. (A) Private Providers shall not participate in conducting de tailed case reviews under this regulation when they or one (1) of their officers, employees, or subcontractors have a conflict of interest. It shall be considered a conflict of interest— 1. For an officer or employee of a FCCM or private provider to conduct a case review of a case managed by the FCCM or private provider which employs them; and/or 2. For an officer or employee of a FCCM or private provider to conduct a case review of a case managed by a subcontractor of the FCCM or private provider which employs them; and 3. Where the provider or the employee of the provider has any interest in the underlying case. (B) Division staff shall not conduct detailed case reviews of cases under this regulation arising from the circuit where the division staff member conducting the review is assigned. The division may assign special staff not affiliated with any one (1) particular circuit or region to conduct case reviews. (C) No person shall conduct a detailed case review of a case in which he or she participated as a case manager or supervi sor. (8) All members of the R&E Team shall maintain the confidenti ality of all information, documents, and data that they receive in the performance of their duties as members of the R&E Team to the same extent that the information, documents, and data is confidential in the hands of the division, its employees, and contractors. R&E Team members shall submit requests for ac cess to information and data to the division for review. (9) Review and Evaluation of the Evaluation Tools, Metrics, and Reporting Format. (A) The R&E Team shall review the evaluation tool and report format established under this section at least twice each year and submit a report to the division making any recommenda tions for changes in the tool. The reports shall be due each year on or before July 1 and January 1 with the first report being due July 1, 2023. (B) The division may amend the evaluation tool, metrics, and report formats as may be necessary to ensure that information is collected and reported in an accurate, efficient, and useful way. The division will utilize the following process to amend the evaluation tool and report format: 1. The proposed amendments will be submitted to the R&E Team for review and comment. The R&E Team will have thirty (30) days to provide comments; 2. The division will then publish an announcement of the proposed amendments to all providers and to the public by an announcement on the division’s website. The announcement will give providers and the public thirty (30) days to submit written comments; 3. The division may, but is not required to, hold one (1) or more public hearings to solicit comments. These public hearings may be held in person, virtually, or by telephone conference; and 4. The division will consider the comments from the R&E Team and other sources and publish the final amendments on the division’s website. The amendments shall be effective on the first day of the calendar quarter following the publication of the amendment; provided however, that the effective date of the amendment shall not be less than thirty (30) days from the date of publication. (C) Twenty-four (24) months after the first publication of the tools and metrics established under this regulation the R&E Team and the division shall conduct a comprehensive review of the tools and metrics established pursuant to the process established in section 210.112, RSMo, and this regulation. The division shall publish a report on its evaluation within six (6) months of commencing the review. AUTHORITY: sections 207.020 and 660.017, RSMo 2016, and sec tion 210.112.8, RSMo Supp. 2021.* Emergency rule filed June 11, 2021, effective July 1, 2021, expired Feb. 24, 2022. Original rule filed June 11, 2021, effective Jan. 30, 2022. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.112, RSMo 2004, amended 2005, 2011, 2018, 2020; and 660.017, RSMo 1993, amended 1995.