Public Knowledge Deliverable Submittal: 2.3 Initial ... › DHS › DHSNEWS › CWIndependent...1 1911 SW Campus Drive, #457 Federal Way, WA 98023 June 9, 2016 Clyde Saiki Oregon Department

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1911 SW Campus Drive, #457 Federal Way, WA 98023 June 9, 2016 Clyde Saiki Oregon Department of Human Services Child Safety in Substitute Care Independent Review 500 Summer Street NE Salem, OR 97301 Public Knowledge Deliverable Submittal: 2.3 Initial Assessment Materials

Dear Mr. Saiki:

I am pleased to submit the enclosed Initial Assessment Materials for the Child Safety in

Substitute Care Independent Review Project. This deliverable consists of 12 inquiry areas

and associated potential system gaps identified in Phase II of the independent review. This

cover letter provides additional details about the deliverable and next steps.

Initial Observations and System Gaps – This document was prepared for the External

Advisory Committee members in preparation for a meeting on May 27, 2016. It contains 12

initial inquiry areas and an overview of associated potential system gaps observed during the

Initial Assessment. Inquiry areas are questions the independent reviewers had after reviewing

and analyzing reports and documentation, initial system data, results of interviews with 15

key informants, and data from two focus groups. Potential system gaps are areas where

further inquiry is needed to determine whether there is a gap in the system that affects the

safety of children and youth in substitute care. Initial research questions are included for

each of the potential gaps. The document includes an overview of the Phase II

methodology, the criteria used to identify the inquiry areas and potential system gaps, and

the sources and contributors to the Initial Assessment.

Next Steps – The independent review team will select final inquiry areas for Phase III based

on several factors, including:

2

• Input on prioritization from External Advisory Committee members and the Project

Coordination Team

• Whether and how other entities or efforts are able to examine and/or address

potential system gaps

• The level of effort required to examine each of the potential system gaps, and

consideration of schedule and budget constraints of the independent review

• Maintaining a balanced view of the system

• Evaluating where the system would most benefit from an objective third party

review

Upon selecting final inquiry areas, the independent review team will design the Inquiry

Protocol deliverable and conduct Phase III the Comprehensive Assessment – a deep dive

into the selected inquiry areas. This will include focus groups, surveys, and further document

and data review.

Upon completion of the Comprehensive Assessment, the independent review team will

produce a Final Assessment & Review Report. This report will highlight the existing

strengths of the System and will include best or promising practices and recommendations

to address System gaps.

We have enjoyed working with you and your team on this deliverable and trust it meets the

needs of the project. If you have any questions or require clarification, please contact me at

(541) 206-4341.

Sincerely,

Melissa Davis

Project Manager

Child Safety in Substitute Care Independent Review

Initial Assessment – Inquiry Areas & Potential System Gaps

Prepared for the External Advisory CommitteeBy Public Knowledge, LLCMay 23, 2016

CONTENTS

I.Introduction 3II.Methodology 4III.InquiryAreasandPotentialSystemGaps 12IV.ContributorstotheInitialReview 46V.DocumentReviewSources 49

I. INTRODUCTION

o Public Knowledge, LLC has completed the initial assessment phase of the Child Safety in Substitute Care Independent Review.

o This document presents initial inquiry questions and potential System gaps observed during the initial assessment. n The document includes portions of the Initial Assessment Report,

which will be finalized in June 2016.

o The purpose of this document is to help the External Advisory Committee members prioritize the inquiry areas for the next phase of the independent review – the comprehensive assessment. n The Final Assessment Report will be finalized in early fall 2016.

3

II. METHODOLOGY

The initial assessment was comprised of three steps shown below.

4

Ini$alAssessmentMethodology

DataandDocumentReview

AssessmentPar$cipants-Interviewsand

Mee$ngs

As-IsRegulatorySystemMapsandAuthority

Inventory

Thisdocumentpresents possibleinquiry areasforthecomprehensivereview.Thesearenotfindingsorconclusions.

II. METHODOLOGY

5Thisdocumentpresents possibleinquiry areasforthecomprehensivereview.Thesearenotfindingsorconclusions.




Mee$ngs


Inventory

Approach:

Compiledandanalyzedallthestatutory,administra4ve,andpolicyauthori4esusedtoinformeachofthethreesystemdomainsanddevelopedone-pagemapsofthestepsandcategoriesofthedomain.

1. Reviewedregula4ons2. Developedinventory3. Createddomainsummaries4. Mappedhigh-levelregula4onsandprocessstepsforeachdomain5. Createdsummariesofmapswithcita4ons6. ValidatedmapswithSMEs7. ReviewTeamusedmapsduringKeyInformantInterviewstoiden4fypoten4alsystemgaps

Outputs:

SystemDomainMaps,MapSummaries,andAuthorityInventory

II. METHODOLOGY





Mee$ngs


Inventory

Approach:

Compiledandrevieweddocumentsanddatacollectedduringtheassessment.

1. Collecteddataanddocuments2. Researcheddataanddocuments3. Catalogueddocumentscollected4. Reviewedandsummarized5. Conductedasecondaryreviewa>erobserva@onsandpoten@alsystemgapswereiden@fied6. Pulledoutrelevantdataandquotes

Outputs:

Quan$ta$veDataandHistoryofPoten$alSystemGaps

II. METHODOLOGY

Typesofdocumentsreviewed:*

o Auditso CFSR(Child&FamilyServicesReviews)andother federaldocumentso Emailso Investigativereportso Legislationo Legislativereportso Litigation(22cases)o Mediaarticleso Safetyreviewso Taskforcereportso Othermiscellaneousdocumentation*Fulllistattheendofthisdocument


II. METHODOLOGY





Mee$ngs


Inventory

Approach:

Conductedin-depth,qualita2veinterviewswith15individualkeyinformantsandtwogroupstocollectinforma2onfromawiderangeofpeoplewhohavefirsthandknowledgeaboutthesystem.Heldindividualandgroupmee2ngswithExternalAdvisoryCommiEeemembersandheldmee2ngswiththeDHSInternalResourceCommiEee.Analyzedqualita2vedataandiden2fiedhighlevelinquiryareasandpoten2alsystemgaps.1. WorkedwithEACtoiden2fykeyinformants2. Iden2fiedfocusgroupsneededfortheini2alassessment3. Developedinterviewprotocolandfocusgroupfacilitatorsagendas4. Conductedinterviewsandmee2ngs5. Datacollec2onandanalysis

Outputs:

Qualita$veData,Observa$ons,andPoten$alSystemGaps

II. METHODOLOGY


5

1

3 3

1

6

4

1211

32

45

**Counted twice

IRCmembersnotincluded

Participantsininitialassessment,bytype:

II. METHODOLOGY


Participantsininitialassessment,bygeographiclocation:

II. METHODOLOGY

PurposeofKeyInformantInterviews:

Qualitativeinterviewswithpeoplewhoknowwhatisgoingonwithinasystemorcommunity.Thepurpose istocollectinformation fromawiderangeofpeoplewhohavefirsthandknowledgeaboutthesystemorthecommunity inwhichthesystemoperates.Theseexperts,withtheirparticularknowledge andunderstanding, canprovide insightonthenatureofsystemproblemsorstrengths.

*AdaptedfromUCLACenterforHealthPolicyResearchandEducationDevelopmentCenter(educationpolicyresearch

association)


III. INQUIRY AREAS & POTENTIAL SYSTEM GAPS

Thefollowingarenotconclusionsorfindings.Conclusionswillnotbedrawnuntilthereviewteamfinalizesthecomprehensiveassessment.Thefollowingsectionoutlinesasetof12inquiryareas andpotentialsystemgapsthattheindependent reviewteamheardorobservedduringtheinitialassessmentphase.

InquiryArea– Questions theindependent reviewerswereleftwithafterhearingtheinitialassessment participants’ thoughtsonandexperienceswithintheSystem.Theywerealsoinformedbyourinitialreviewofreportsandotherdocumentation.

PotentialSystemGaps– Potentialareaswherefurtherinquiry isneeded todetermineifthereisagapintheSystem, andidentify recommendations forrepairingthegap.

NotestotheReader:o Allquestions andstatementsrefertoissueswithbothDHS-certifiedfosterproviders,

andlicensedChildCaringAgenciesunlessotherwisespecified.o Thisdocument isfocusedoninquiryquestions andgaps.Therearealsostrengthswithin

theSystem,whichwillbehighlightedinthefinalinitialreport.o The12inquiryareasarepresentedinanordercorrespondingtothe independentreview

team’sassessmentofpriority,accordingtothecriteriaonthenextpage.


III. INQUIRY AREAS & POTENTIAL SYSTEM GAPSTheindependentreviewteamusedthefollowingcriteriatoidentifytheinquiryareasandpotentialsystemgapspresentedinthisdocument:

Aninquiry areaorpotentialsystemgapwasincludedwhenit:o Directlyimpactssafetyofchildren andyouthinsubstitutecare.*o Hasunknown orvariablecausalfactors(areaswithvarianceinresponse amongexternaladvisors,

keyinformants, orinitialassessment focusgroupparticipants).o IsactionableandwithinthecontrolofOregonLegislature,Governor, DHS,anditssystem

stakeholders toaddress.o Fitsintooneormoreofthethreesystemdomains identified forthereview(Response toAllegations

ofAbuse, LicensingandOversightofProviders, andSupportandTrainingofProviders).o Relatestooneormoreoftheassessment dimensions identified forthereview(Accountability and

Communication, Workforce, andCulturalResponsiveness).o Canbemeasured(eitherqualitatively orquantitatively).o Could benefitfrombroaderperspectives abouthowtosolvetheproblem (aneedforbestpractices,

emergingpractices,andexpertise).o Wasidentified bymorethanonesourceduringtheinitialassessment phase.o Theindependent reviewteamhasobservedorexperienced theproblemandisleftwithsignificant

questions aboutthenatureoftheproblem

*See nextpagefordefinitionofchildandyouthsafety


III. INQUIRY AREAS & POTENTIAL SYSTEM GAPS

Definition ofchildandyouthsafety

Theindependentreviewteamusedthefollowingdefinitionofchildandyouthsafetytoidentifytheinquiryareasandpotentialsystemgapspresentedinthisdocument:

Child&YouthSafety isthestateofbeingfreefromabuseandneglect.Abusemeansanyofthefollowing:physical injury causedbyotherthanaccidentalmeans;mentalinjury causedbycrueltyincluding verbalharassment, threats,andseclusion; sexualabuseorexploitation;andabandonment.Neglectisthefailuretoprovide thecarenecessarytomaintainphysical andmentalhealth.Abuse andneglectaredefinedby Oregon StatutesintheJuvenile Chapter(419B.005),andinChildWelfareServicesChapter(418.205,definition ofabuse recentlyaddedbySenateBill1515).


1 - Does the System disempower and silence the voice of children and youth?PotentialSystemGap1.1.Childrenandyouthexperienceanoftenunsafeenvironmentforreportingabouttheabuse

andneglecttheyexperience.

DocumentationReviewandAssessmentParticipantsReport:• Children andyouthsometimes faceretaliationbyfostercareproviders.• Fosterchildrenoryouthmayhavetomovetoanewplacement, sometimes

leavingbehind siblings.• Abuse reportsmaymeanafosterchildoryouthhastomovetoamore

intensive leveloffostercare.• DHScaseworkerinterviewsarefrequently notconfidential.

InitialInquiryQuestions:1. Whatismissing fromthefostercareproviders’ andfosteryouth’s “toolkit”thatleadstochildren and

youthliving inunsafe, unsatisfactory, oruncomfortable environments (i.e.conflictresolution skills).2. WhataboutDHSculture,practice,orpolicy supports penalizing,ratherthansupporting fosteryouth

forraisingsafetyconcerns?3. Whatismissing fromtrainingandsupervision thatallowsDHScaseworkerstointerviewfoster

children andyouth aboutsafetyconcernsinaconfidentialmanner.

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“Kidsarefearfulaboutcomingforwardbecausethereareinthehomewheretheyaremakinganallegation.Iftheysaysomethingitwillonlygetworse.”- KeyInformant

Thisdocumentpresents possibleinquiry areasforthecomprehensivereview.Thesearenotfindingsorconclusions.

1 - Does the System disempower and silence the voice of children and youth?PotentialSystemGap1.2.Theworkingassumptionappearstobethatchildrenandyoutharelyingaboutabuseto

manipulatethesystem.

DocumentationReviewandAssessmentParticipantsReport:• Hotlineworkersandcaseworkersmaynotconsistently takeallegationsofabusefromchildrenor

youthseriously andmayfailtofollowuponreportsmadebychildrenoryouth.• Filinganabusereportmaybeachildoryouth’s onlyoption forgettingattentiontoanonabuse

relatedissuewiththeirplacement.• Stereotypes orprevious behavior oftenfollowchildren andyouth throughtheSystem,whichaffects

theircredibility asreporters(i.e.,some youthbecome“notorious” andthereforediscredited).

InitialInquiryQuestions:1. WhatisitaboutDHSculturethatpromotes’ employees’ distrust inchild oryouthreports?2. Dointermediateavenuesexistforchildrenandyouthtoraiseotherconcerns abouttheirplacements

outside ofabuseorneglect?Aretheyeffective?3. Whatistheresponse toallegationsofabusebyreportertype(child/youth, vs.adult)?Isthereany

varianceinthetypeoffollowuprequired forreportsbyachildoryouth vs.anadult?


1 - Does the System disempower and silence the voice of children and youth?PotentialSystemGap1.3.TheSystem’smessagetochildrenandyouth isfrequentlyto“makethisplacementwork”

ratherthantryingtounderstandwhyitmaynotbeworking.

DocumentationReviewandAssessmentParticipantsReport:• Theimpetus isoftenonchildrenandyouthtocreateandsustain asuccessful placement, ratherthan

onDHSorthefosterprovider.• Fosteryouthbeartheburdenofadjusting toplacementsthatareunhealthy (weheardreportsof

mold, construction, orfumes);wheretheiremotionalneedsareneglected;orwheretheirreligious,ethnic,orsexualidentityarenotaccepted.

• Caseworkers oftencommunicatethatchildrenoryouth should“makeitwork”becausetherearen’tenoughotheroptions.

InitialInquiryQuestions:1. HowdoesDHSmatchchildrenandyouthtosubstitute careplacements?2. Howprevalentisthemessage“makeitwork”?(youth, caseworker,andsupervisory perspectives)3. Howarecaseworkerstrainedandsupported torespondwhenchildrenoryouthreportunsafe

conditions?


“Children’sneedsmustoftenfitwithintheexistingservicesystemsratherthantheservicesbeingwrappedaroundthechild’sneeds.”- CFSRStatewideAssessment2007

2 - Can the System provide the right placement for the right child or youth at the right time?PotentialSystemGap2.1.Spaceavailabilitydrivesplacementdecisionsratherthanoptimalmatchbetweenchildor

youthneedsandprovidercapabilities.

DocumentationReviewandAssessmentParticipantsReport:• Thegrowthrateofsubstitute careplacementsinOregonhasnotkeptpacewiththegrowthrateof

thenumber ofchildren inneedofsubstitute careservices.• Currentprovider paymentratesforbothDHS-certifiedhomesandlicensedCCAsareinadequate.• Alimitednumber ofcertifiedfosterhomes (bothDHS-certifiedandlicensedCCAs) andlicensed

residential facilitiesleadstopoorplacements, poorplacementsleadtosafetyissues.• Caseworkersmaypressure placementstotakeadditional childrenoryouththeyarenotqualified to

serve,certificationviolations maybeoverlooked, andfosterparentsorresidential facilitystaffmaynotbewelcomingtothenewchildrenoryouththeyarepushed totakein.

InitialInquiryQuestions:1. Whatarethecurrentapprovedbeds availableateachlevelofcare?2. Whatarethecurrentlevelsofcareneedsofthefostercarepopulation?3. Howwellareproviderratesmatchedwithlevels ofcarerequirements?4. AtwhatrateareOregon’s residentialtreatmentfacilitiesclosing?Whatarethecitedreasons?5. Whatlevelofcareassessment isbeingusedtoappropriately placeyouth?6. Whateffortsarebeingdonetorecruitandretainsubstitutecareproviders atalllevels ofcare?


2 - Can the System provide the right placement for the right child or youth at the right time?PotentialSystemGap2.2. High-needsyouthareplacedinenvironmentswithproviderswhocannotmeettheirneeds,

increasingrisktoallresidentsoftheplacement.

DocumentationReviewandAssessmentParticipantsReport:• Residentialtreatmentfacilitiesthatspecializeinproviding treatmenttohigh-needs childrenhave

limitedspace,andproviders arecancelingtheircontractswithDHSatanunusually highrate(wehaveheardreportsof10+inlastsixmonths).

• Fewhomefostercareproviders havethespecializedtrainingneededtoproperly careforhigh-needschildren.

• Tensionsmaygrowbetweenthehigh-needs childandtheprovider,whichcreatesapotentiallyunsafeenvironment forthehigh-needs child,otherchildrenthatmayberesidinginthesameplacement,andeventheprovider.

InitialInquiryQuestions:1. Howoftenareabuseallegationstiedtoinappropriateplacementdecisions?2. Whatarethestate’scurrentresourcesforservinghigh-needs children andyouthwhoneedPRTFor

RTClevelofcare?3. Whatarethecurrentneedsrelatedtoplacementtypes?4. Whatmedicalnecessity andassessments areusedtoensuretheseyouthareplacedappropriately?5. WhatistheclosurerateforResidentialTreatmentFacilities(RTFs)?


3 – Does the System rely on anecdotal information or reliable safety data that is routinely collected and communicated?

PotentialSystemGap3.1. DHShasmadeinsufficienteffortstocollectusefuldatatoshare informationacross

entitiesanddrivesafetydecisions.

DocumentationReviewandAssessmentParticipantsReport:• ThecurrentSystemisincidentdriven;itprevents aholisticviewofabuse

reports,hotline calls,certificationviolations, andothersafetyinformation.• Allegationsofabusearetrackedbythechild oryouth, notlinkedby

substitute careprovider, makingitimpossible toknowiftherehasbeenahistory ofconcernorallegationsagainstaprovider.

• ChildWelfare(ORKIDS),ORLO,andOAPPIuseseparatedatasystems thatarenotinterfacedandareofvaryingmaturitylevels.

InitialInquiryQuestions:1. Whatarethecurrentsystemcapabilities inChildWelfare,ORLO,andOAPPI?2. Whatroutinereportingregardingchildsafetyisneededatalllevels andinallpartsofDHSandthe

System?3. WhatarethecurrentIT/dataanalystcapabilities attheseagencies?Andwhatisneeded?


Wereviewedthe22substantiatedlegalcasesagainstDHSforabuseofachildoryouthinsubstitutecareoverthepast5yearswithanawardorsettlementover$50,000.

Ofthosecases,21wereforabuseofchildrenoryouthinDHScertifiedhomes.However,anecdotalevidenceoftenpointstoabuseoccurringinlicensedCCAs.

3 – Does the System rely on anecdotal information or reliable safety data that is routinely collected and communicated?

PotentialSystemGap3.2.TheSystem’sdatadeficienciescausesubjectivityindecisionmakingandfailtohold

Systemplayersaccountable.

DocumentationReviewandAssessmentParticipantsReport:• Thecurrentdatasystemdoesnothaveadvancedcapabilities toshareinformationoridentify trends,

haslimitedqualityassurancemonitoring capabilities, andlacksanaccountabilitysystemtoensureaccuratesafetydeterminations.

• Staffdonotconsistently inputdataaccuratelyortimely.• Datalimitations impedeacomprehensive viewofindividual cases.

InitialInquiryQuestions:1. Whatarethecurrentsystemcapabilities inORKIDS,ORLO,andOAPPI?2. HowdoesOregoncomparetootherstatesintermsofdatacollectionandreportingcapabilities?3. Whatwouldittaketoreportabuseallegationsbyprovider?Bycaseworkerorsupervisor?4. Whatroutinereportingregardingchildsafetyisneededatalllevels andinallpartofDHSandthe

system?5. WhatarethecurrentIT/dataresearchercapabilitiesattheseagencies?Andwhatisneeded?


4. Is the system of response to abuse in care driven by the experience of the child or youth?PotentialSystemGap4.1. OAAPIandCPSusedifferentlegalstandards andrulesregardingsafetyincare.

DocumentationReviewandAssessmentParticipantsReport:• Currently, CPSandOAAPIeachuseaseparatedefinition ofchildabuseandneglect.• SB1515adoptsasingle, standarddefinition ofabuse(theoneusedbyOAAPI)acrossallindividuals in

licensed carefacilities.• Theadministrative structureneeded toefficiently andeffectively implementthisstatutorychange

remainssiloed anduncoordinated.• Thedefinition included inSB1515does notincludeDHScertifiedfosterhomes.• Children andyouthexperienceabusethesamewayregardlessoftheirplacementtype.

InitialInquiryQuestions:1. NowthatOregonhasasingle,commondefinition ofabuse,whatarethecontradictions,

redundancies andinefficiencies thatmayremainintheprocess forresponding toallegationsofharmincare?

2. Whoistheappropriateentitytoindependently andobjectively respond toallegationsofharmincare?


4. Is the system of response to abuse in care driven by the experience of the child or youth?PotentialSystemGap4.2. Thesystemofresponsefails todiscernbetweenabuseallegations andcriticalincidentreports,

potentiallyobscuring truesafetyissues.

DocumentationReviewandAssessmentParticipantsReport:• ChildCaringAgenciesmustreportcriticalincidents,but“criticalincident” isnotclearlydefinedordifferentiatedfrom

“abuseallegations.”• Thehighvolumeofreportsburdenstheresponsesystemandmakesitdifficulttoswiftlyidentifyandrespond to

substantiveissues.• Theincreasedfocusonreportingcriticalincidentsinchildcaringagenciesseemsmayhavetheunintended

consequenceofcloudingthesystem’sabilityto targetresourcestowardmitigatingthemostsubstantivesafetyrisks.

InitialInquiryQuestions:1. Whatisthedefinitionofa“criticalincident”andhowisthiscriteriacommunicatedtoproviders forgeneratinga

criticalincidentreport?2. Howmanycriticalincidentreportsaregeneratedpermonthandwhathasbeen theoutcomeofthesereports?What

percentagehaveidentifiedissueswithharmincare,skilldeficienciesinprovider staff,orsurfacedother riskissues?Whattypesoffollow-upactionsaretaken?

3. Howmanyallegationsofabuseincarearereportedpermonthandwhathasbeen theoutcome?Whatpercentagearescreenedout,investigated,founded?Whattypesoffollow-upactionsaretaken?

4. Isthereatendency toover- orunder-reportduetouncertaintyaboutwhichcircumstancesconstituteacriticalincident?


4. Is the system of response to abuse in care driven by the experience of the child or youth?PotentialSystemGap4.3. Administrativesystemsdonotadequatelycoordinateregardingfindingsand

consequencesofsafetyallegationsinsubstitutecare.

DocumentationReviewandAssessmentParticipantsReport:• Severaladministrativebodies haveresponsibility andauthoritywhenapotentialinstanceofabuseof

achildoryouthinsubstitutecareisreported.• Thereisaninconsistent efforttoengagetheappropriateentities, sharerelevantinformation, and

agreeonfollow-up actionstointerruptorpreventfurtherharm.• Ancomplicated,disorganized systemputschildren andyouth alreadyinthecustodyofthe

Departmentattheriskof“fallingthroughthecracks.”

InitialInquiryQuestions:1. Which entityisstatutorilyresponsible forwhataspectsofallegationresponse, andhowarethey

administratively organizedtocarryoutthoseroles? Isthereasingleentityinchargeofcoordinatingallpartiesandmonitoringoutcomesoftheprocess?

2. Wherearetheopportunities forincreasingefficiency, improving effectiveness andpromotingobjectivity betweentheactorsinvolved inallegationresponse?

3. Whatistherelationship betweentheprinciples oftheOregonSafetyModelandthesystemofresponse tosafetyallegationsincare?


5 – Is the determination of whether a report meets the threshold for abuse or neglect a subjective decision, or are standards consistently applied?

PotentialSystemGap5.1. Hotlinescreenersreceiveonlybrieftrainingtolearntheprotocolforrespondingtoanallegationofabuseorneglectbeforetheyareassignedtothehotline.

DocumentationReviewandAssessmentParticipantsReport:• Screenersareexpectedtomakecriticaldecisions aboutcomplex circumstancessurrounding

allegationsofharmincarewithonly3hoursoftraining.• Withsuchbrieftrainingandlimitedknowledge, screenersrelyontheirsubjective judgmentand

personal experiencetodeterminetheoutcomeofareportofabuseincare,resultingininconsistent,unreliable determinations.

• Screenersdonothavestandardpracticesortoolstouseduringthescreeningprocess.

InitialInquiryQuestions:1. Howmanyscreenersareavailabletohandlecallvolumes?Howdoes thiscomparetootherstates?2. Whatistherateofaccuracyinscreeningallegationsofharmincare?Howisthismeasured?3. Whatinthetrainingcurriculumpreparesscreenersformakingcriticaldecisions aboutallegationsof

harmincare?What,ifany,standardizedtoolsareusedtoguidethesescreeningdecisions?4. Whatisthespecificsupervisory reviewofscreenerdecisions (exceptionbasis, randomsample, every

report,screenedoutonly)?



PotentialSystemGap5.2. Blindspots inscreenerobjectivitymayputchildrenandyouthatrisk.

DocumentationReviewandAssessmentParticipantsReport:• Screeners’ biasesmayconfound theirdecisions involving children andyouth insubstitutecare,

especiallywhenthereporterisabiologicalparent,arelative,orthefosteryouth themselves.• Thescreenermayactonavarietyofassumptions affectingtheirobjectivity.• ThescarcityofsubstitutecareplacementsthroughoutOregonmayimpactscreenerobjectivity,

leadingtoflaweddecision-making basedontheassumption thatweneedtokeepplacementsintactsincetherearesofewplacementresources.

InitialInquiryQuestions:1. Whatarescreeningoutcomesbyreportertypeforallegationsofharmincare?2. Istheredisparity betweenscreenerdecisions forsimilar allegationsforchildren andyouth incare,

versus kidsnotincare?3. HowistheOregonSafetyModelappliedtosituationswhenthechildoryouth isincare?4. HowistheDifferentialResponseprotocolimpactingscreeningdecisions intheDistrictswherethis

newpracticeisfully implemented?



PotentialSystemGap5.3. Insufficientsupervisionandscarceongoingtrainingforscreenerscompromisetheirability

toaccuratelyidentifyandrespondtoallegationsofharmincare.

DocumentationReviewandAssessmentParticipantsReport:• Screenersreceivelittlesupervisory support orcontinuing skill building opportunities.• Without standardizedscreeningtoolsavailable,screenersarenotadequatelyidentifying safety

issues duringthescreeningprocess.• InitialAssessment participantscorroboratedfindings inrecentCIRTReviewsregardingsupervisory

support, training,andscreeningtools.

InitialInquiryQuestions:1. Whatisthecontentandavailabilityofcontinuing educationforscreeners?2. Whatdataisavailabletoscreenersduringthescreeningandinvestigation process?3. What,ifany,communicationoccursbetweenhotline staffandcaseworkersorcertifiers/licensors?4. Whatisthequalityandquantityofsupervision thatscreenersreceive?5. Whatisthesupervisory ratioforscreeners?6. Whattheaverageworkload/caseload forascreener?7. Whatistheoptimalstaffingmodeltosupport thescreenerfunction?


6 – Caseworker home visits appear to be the main accountability mechanism for substitute care providers – are they adequate to keep children and youth safe in care?

PotentialSystemGap6.1. DHS,ORLO,andOAAPIarenotadequatelystaffedtoconduct eitherunannouncedor

plannedprovidervisits.

DocumentationReviewandAssessmentParticipantsReport:• Caseworkers rarelymaketherequiredmonthly contactwithallthechildren, youth, andparentson

theircaseload, duetohighcaseloads.• Caseworkers cannotensurethesafetyofchildreninsubstitute carewithoutseeingtheminthose

placements.• Somehistorical studiesputOregon’s caseloadsattwicewhatisappropriate.

InitialInquiryQuestions:1. WhatarecurrentcaseloadsforOregoncaseworkers?2. Whatarecurrentstaffingloads forOregonsupervisors?3. Howoftenarevisits toprovidersmade?Whereisthisdocumentedandtracked?4. Howoftenareunannounced visitstoprovidersmade?Whereisthisdocumented andtracked?5. WhataretheadditionalresourceandstaffingneedscreatedbyHB1515atDHS,ORLO,andOAPPI?



PotentialSystemGap6.2. Caseworker homevisitsareinadequateanddonotappeartomeetfederalstandards.

DocumentationReviewandAssessmentParticipantsReport:• Duringcaseworkervisits, caseworkers oftenonly seethe“frontroom,” areoftenfocusedonthe

physical homeratherthantheyouth’s experience,andarefrequentlynotvisitingthechildrenandyouthintheprovider homeorfacility, butratheratahearingoratschool.

• Thelackofthoroughness invisits doesnotmeetregulatorystandardsandmayputchildren andyouthatrisk.

InitialInquiryQuestions:1. WhatdatadoesOregonhaveregardingcompliancewithregulationssurroundingmonthly face-to-

facevisits?2. Isthereasoncaseworkers aren’tconductingtheseappropriately relatedtocaseloadortraining?3. Howaresupervisors andDHSleadership holdingworkersaccountableforthisrequirement?4. Aretheexistingpolicies andprocedures regardingface-to-facevisits adequate?



PotentialSystemGap6.3. CloserelationshipsbetweenDHScaseworkersandfosterfamiliesmayblurboundaries,

puttingchildrenandyouthatrisk.

DocumentationReviewandAssessmentParticipantsReport:• Attimes,caseworkers reportedlyspend timeoutside ofworkwithDHSfosterparentproviders at

community events,dinnerswithfamilies, socialfriendships, andmore.• Theserelationships werereportedaspotentiallyinterferingwiththecaseworkers’ abilitytohold the

providers accountable.• Thismaybemoreprevalentinruralareas– insmalltowns“everyone knows everyone.”• Blurredboundariesmaybeharmingchildren andyouth inplacementswithsafetyconcerns.

InitialInquiryQuestions:1. Isthisanurbanorruralissue, orboth?2. Arethereexistingpolicies overseeing thispotentialconflictofinterestorblurredboundaries?3. Isthereanydatatosupport thesereports?4. Howistheombudsman usedtoaddressingthisconcern?Howshould theombudsmanbeused?



PotentialSystemGap6.4. DHSturnoverandpoortransitions are“rampant,”whichdisruptrelationshipsandaffect

safety,especiallywhenthereisamismatchedplacement.

DocumentationReviewandAssessmentParticipantsReport:• Assessment participantsusedtheword“rampant”multipletimestodescribe caseworkerturnover in

Oregon.• Turnoverandlackoftransitionfromonecaseworkertothenextmayallowsafetyconcernsand

issues toslipthroughthecracks.• Anewcaseworkermaynotknowifareportorissue isneworisacontinuing historicalproblem,

potentially resultinginissues notbeingaddresseduntiltheyareincrisis.

InitialInquiryQuestions:1. Whatisthedataregardingcaseworkerturnover?2. Istheredataaboutreasonsforcaseworkersleavingtheagency?3. Whatworkforceandorganizationaldevelopmentworkhasbeendonetodecreaseturnover?4. Howaresupervisors supporting andtrainingcaseworkerstodecreaseturnover?5. Whathasbeendonetoadequatelytraincaseworkersandscreenthosehiredtoensurelongevity?6. Whathasbeenputinplacetosupport caseworkerswithcaseloadsabovenationalstandards?


7 – Has past DHS leadership at all levels of the organization reinforced a focus on child and youth safety?

PotentialSystemGap7.1. ADHScultureofagencyprotectionismmayhaveresultedinSystemactorsmissingkey

safetyissuesacrossallsubstitutecaresettings.

DocumentationReviewandAssessmentParticipantsReport:• DHSleadershipmaynothaveadequately balancedloyalty totheagencywiththedutytohold staff,

providers, andotherkeyplayersaccountable tochildandyouthsafetywhileincare.• ThecultureofDHSappearstohavebecomeunbalanced towardagencyprotectionismattheexpense

ofchildandyouthsafety.

InitialInquiryQuestions:1. DoesDHShaveasetofcorevalues thatareconsistently appliedintrainingandperformance

assessments ofstaff?2. Howisthevalueofchildandyouthsafetyinsubstitute carereinforced atalllevelsintheagency?


7 – Has past DHS leadership at all levels of the organization reinforced a focus on child and youth safety?

PotentialSystemGap7.2. DHSleadershipatalllevelsoftheorganization hasallowedbreakdowns inaccountability,transparency, andcommunicationtobecomeobstaclestoaddressingsafetyrisks.

DocumentationReviewandAssessmentParticipantsReport:• BlurredlinesofauthoritywithintheSystemcausebreakdowns.• Theauthorityanddecision-making powerofsupervisors anddirectorsappeartobeuncleartostaff.• Frontlineworkersareinthebestposition toidentify Systembreakdowns, buthavefewavenues for

callingattentiontothoseproblems.• Decisions thatarevitaltosafetyaredelayedorotherwise deferredtojustafewindividuals within

theorganization.• Therearenoclearaccountabilitymechanisms inplacetorespond toviolations, andnostandardway

torecognizeorincentivizegoodwork.

InitialInquiryQuestions:1. Whatisthecurrentescalationpathforreportingsafetyconcerns, startingwithcaseworkersand

hotline staff?2. Wherearethedecision points forDHSleadership inaddressing safetyconcerns?


8 – Is there sufficient System-wide awareness of how issues of equity and cultural competence affect safety in care?

PotentialSystemGap8.1. Fearofbeinglabeledculturallyincompetentorracistmayhavecompromisedstaffand

management’sabilitytomakesoundsafetydecisions.

DocumentationReviewandAssessmentParticipantsReport:• Stafffearappearingculturallyincompetent,whichmaycompromise theirabilitytomakeobjective

decisions, potentially overlooking safetyissues.• Allegationsofstaffprejudiceorracismhavesevereconsequences, inpartduetoalackofclear

expectationsandsupport fortoughdecisions withintheSystemasawhole.• Thesafetyissues andlicensing violations thatescalatedovertimeatGiveUsThisDaymayreflectthis

dynamic.

InitialInquiryQuestions:1. HowisDHSstaffsupported tomakedifficult decisions thatrequirebalancingtwostrongly held

valuessuch as“Keepingchildrenandyouthsafe”and“Honoringculturaldifferences”?2. Whatistheprocess(beyond training)forsupportingDHSstafftoovercomebiases, prejudices, or

culturallyincompetent action,whilealsoremainingvigilantaboutmitigatingsafetyissues?3. Whateffortshavebeenmadetocreatealearningenvironment acrossDHSanditspartnersregarding

culturalcompetencyinpractice?



PotentialSystemGap8.2. Fearofbeinglabeledculturallyincompetentorracisthascompromisedstaffand

management’sabilitytomakesoundsafetydecisions.

InitialInquiryQuestionsContinued:4. DHSprovides inadequatetraining,coachingandreinforcement forstaffandproviders incultural

competencyasitrelatestoensuring safety.5. Whattrainingisprovided inculturalcompetency forstaffandproviders, bothpre-service and

throughouttheirinvolvement inchildwelfare?6. HowareDHSstaffandproviders trainedandsupervised tobalancebeingresponsive toculturalneeds

withenforcingrulecompliance?

Noteonthispotentialgap:Demonstratingmutualrespectforculturaldifferences andhonoringculturaltraditions, norms, andconnections ofchildren andyouth incareisclearlyavalueembracedbyDHS.However,thereisinsufficientknowledgedevelopment, skill building, andeffortinshifting valuesacrosstheworkforcetoensuretheseskills areconsistently practiced,especiallywhensafetyisatrisk.Theinitialassessment process revealedaneedforsharedagreementaboutwhatconstitutes culturalcompetencyasitrelatestoensuring thesafetyofchildrenincare.Thismanifested throughbothwhatassessment participantssaid,andwhattheydidnotsay.SeeServiceEquity FrameworkandtheCoreValuesofRespectandServiceEquityfromDHS’swebsite.



PotentialSystemGap8.2. Safetydecisionsareconfoundedbythetensionbetweenapreferenceforculturally-matchedorculturally-relevantplacementsandthescarcityofsuchplacements.

DocumentationReviewandAssessmentParticipantsReport:• Culturally appropriateplacementsarepreferredforchildren insubstitute care.• African-AmericanandNativeAmericanchildrenandyoutharedisproportionately represented inthe

substitute caresystem, yetdiversityinthegeneralpopulation inmanyareasofthestateislimited.• Staffsometimeshavetochoose betweendisrupting aculturally-relevant placementinresponse to

safetyrisks, ormaintainingaculturally-relevant placementwiththehope thatsafetyconcerns intheplacementdonotescalate.

InitialInquiryQuestions:1. Otherthanremovaltoanotherplacement,whattoolsareavailabletocaseworkersforintervening

earlywhenissues ariseinplacementthatmaylaterescalatetothreatensafety?2. Whatistheincidenceofharmincareallegationsforculturally-matchedplacementsvs.culturally

mixedplacements?3. Howareissues ofculturalresponsiveness andculturalcompetencytakenintoaccountduring

screeningandinvestigationprotocols? Inplacementdecisions?


9 - Are all players involved in keeping children and youth safe in care recognized and valued?PotentialSystemGap9.1. Keyplayersaremissingfromthesupport teamforeachchildandyouth.

DocumentationReviewandAssessmentParticipantsReport:• Keyplayersbringuniqueperspectives, skill sets,andproblemsolving capabilities necessaryto

effectively planfor, adequatelycarefor,andprotectchildren andyouth insubstitute caresettings.• TheSystemappearstoplaceahighervalueontheroleofstateactors,whilethosewhoadvocatefor

thechild oryouth, suchasattorneysorCASAs, areleftoutofimportantconversations ordecisions.• Whenappropriate, biologicalparentscanbekeyplayersthatareoftenmissing fromtheteam.

InitialInquiryQuestions:1. Aretherewrittenprotocols forinvolving keyplayers, including attorneys,CASAs, andbiological

parents(whenappropriate), amongothers?2. Arecaseworkersdiscouraged fromincluding biologicalparentsorCASAs orothersfromcaseplanning

orresponse toissues?


9 - Are all players involved in keeping children and youth safe in care recognized and valued?PotentialSystemGap9.2. Systemsiloespreventrecognitionof,andrapidresponsetosafetyrisksforchildrenand

youth inoutofhomecare.

DocumentationReviewandAssessmentParticipantsReport:• Systemsilos canbeseenatalllevelsoftheDHSorganization:

• Inconsistent "checksandbalances"• Limitedabilitytodocument andshareinformation regardingsafetywithanindividual casefile• Informationgatheredbyplacementcertifiersnotsharedacrossunits, particularlywith

caseworkersorhotlineworkers.• Siloed systems areinefficient. Therecanbeduplicationofefforts, barrierstodecisionmakers

effectivelyworkingasateam,andunequaltreatmentofchildrenandyouthwithinthesamesystemofcare.

InitialInquiryQuestions:1. Whatinformationdocertifierscollectpriortoplacementcertification?Withwhomisitshared?2. Which Systemactorsareresponsible forcollectinginformation collectedbycertifiers?(I.e.,doabuse

investigators havetorequestit,orisitautomaticallyprovided?) Isiteasytoobtain?3. WhatisDHScurrentlydoingtoaddressgapsininformation sharingandteamdecisionmaking?


10 – Does DHS training and support provide staff with the tools and skills needed to keep children and youth safe in substitute care?

PotentialSystemGap10.1. Trainingdeficienciesandinadequaciesinsupervisionleadtoinconsistenciesandmisapplicationofregulations, leavingcaseworkerswithoutthenecessaryexperience,

knowledge,andskillstokeepchildrenandyouthsafeinsubstitute care.

DocumentationReviewandAssessmentParticipantsReport:• Staffareoverwhelmedbytheircaseloads anditisdifficultforthemtofindthetimetoattend

trainings.• Thereisnoruleorpolicy requiringstafftoparticipateinongoingoradvancedtraining.• Trainingemphasizestheoryoverskilldevelopment.• DHSorganizationalculturedoesnotappeartoemphasizetheimportanceofcontinuing education

andtraining.• DHSdoesnotappeartoemphasizethedevelopment ofsupervisors withintheorganization.

InitialInquiryQuestions:1. Whataretheongoingtrainingrequirements forsupervisors?2. Arethereincentives toencourageongoingstafftraining?3. Whataccountabilitymechanisms areinplaceforstaff?


10 – Does DHS training and support provide staff with the tools and skills needed to keep children and youth safe in care?

PotentialSystemGap10.2. Support resourcesforstaffareinadequate,leadingtomissedopportunities toprotectchildrenandyouth.

DocumentationReviewandAssessmentParticipantsReport:• Supervisory ratiosandcaseworkers' caseloadsaregenerallyhigherthanstaffingguidelines.• Since2002,thenumber ofcaseworkers andsupervisors hasincreasedbyapproximately 13%while

theaveragechildwelfarecaseloadincreasedbyapproximately 30%.• Studies shownationalcaseloadstandardsmaybetwicewhatisreasonable, andOregon'sworkload

situation exceedstheoutdatednationalstandard.

InitialInquiryQuestions:1. DoesDHSconductperiodicreportstomonitor staffingandworkloads inrelationtotheguidelines?2. Whatstaffingresources needtobeaddedtothesysteminordertomeetbestpractices?3. Arethereanytaskscurrentlymanagedbycaseworkersthatcanbeshifted toasupport staffrole?


"Staffworkloadsareacriticalfactoraffectingthequality,accuracy,andtimelinessofchildprotectiondecisions."- KeyInformant

11 – Is training and support for substitute care providers focused on giving them the tools to deliver quality care to children and youth – or simply regulatory compliance?

PotentialSystemGap11.1. TheSystemdoesnotsupportandtrainproviders inawaythat increasestheirskillsand

abilitiesorpromotesretention.

DocumentationReviewandAssessmentParticipantsReport:• Gapsintrainingandprovider skill-sets includetrauma-informed care,attachmentdisorder,

addiction, andevendevelopmentally appropriateorrealisticbehavior forchildren andyouth,particularlyadolescents.

• Providers donotreceivechild-specific trainingbasedontheneedsofthechildrenandyouthintheircare,oradequatetrainingfortheacuityofthekidsintheircare.

• Thereisnosystematic, ongoingapproachtostrengtheningordeveloping theskills andabilities ofsubstitute careproviders.

InitialInquiryQuestions:1. Whatadvanced,skill-building trainingsexistforsubstitute careproviders?2. Whatistheamountandqualityofculturalcompetencetrainingdelivered toproviders?3. CanDHSconsistently provide child-specific trainingtoproviders withinaspecified timeframe(30

days?) ofplacement?4. AreSystemreviewers(i.e.,SafetyTeamreportsorCIRTs)citinglackoftrainingasacontributing

factortoabuseandneglectcases?


11 – Is training and support for substitute care providers focused on giving them the tools to deliver quality care to children and youth – or simply regulatory compliance ?

PotentialSystemGap11.2. ThereisnosecuremechanismforproviderstoaskforhelpandrespitefromDHSwithout

suspicionofwrongdoing orfailure.

DocumentationReviewandAssessmentParticipantsReport:• Providersmustseeksupport ontheirown.Theyreportoftenfeelinglike, orbeingtreatedlike, they

arefailingiftheyrequestsupport fromDHS.• DHSdoesnotconsistently connectproviderswithsupport groups,andnewproviders donotrealize

thatsupport isavailableornecessary.

InitialInquiryQuestions:1. Whatsupportmechanisms existfordifferenttypesofsubstitute careproviders (certifiedthrough

DHS,certifiedthroughlicensed childcaringagency,orresidentialfacility)?2. Whattypesofsupport dosubstitute careproviders saythattheyneedtobesuccessful?3. Howdoproviders currentlyrequestrespitecarefortheirplacements?4. Onaverage,whatproportionofrespiterequestsarenotfulfilled? Whathappenswhenaprovider is

notabletoreceiverespitecarewhenrequested?


11 – Is training and support for substitute care providers focused on giving them the tools to deliver quality care to children and youth – or simply regulatory compliance ?

PotentialSystemGap11.3. Providerrecruitment,retention,andprovidersupport effortsareinconsistentand

inadequate,resulting infewerappropriate placementoptionsforchildrenandyouth.

DocumentationReviewandAssessmentParticipantsReport:• DHSdoesnothaveacomprehensive statewiderecruitment,retention, andsupport planfor

substitute careproviders, resultingininconsistent andinadequateeffortstosustainandgrowplacementoptions.

• Fewerplacementoptions raisesthepossibility thatachild oryouthwillbepoorlymatchedwithaprovider, increasingtherisk ofsubsequent moves, lowerqualitycare,orabuse.

• The2016CFSRfound thatbetween2013-2015, therehasbeena20%decreaseofgeneralfosterhomes (withanincreaseof4%ofchildspecific fosterhomes).

InitialInquiryQuestions:1. Whatfactorscontributed tothe20%decreaseingeneralfosterhomesbetween2013-2015?2. Aretheratiosoffosterplacementsandfosterchildren andyouth inOregonhigherorlowerthan

theyareinotherstates?3. WhereintheSystemisthebreakdown inrecruitmentandretentionoccurring?Isitapriorityranking

fromagencyleadership, overwhelmandoverwork amonglocalofficestaff,orlackoffocusoncivilsocietypartnerships (i.e.,Embrace)?

4. Whattypesofsupports dofosterparentsneed?


12 – Is the DHS foster home certification process consistent and free from bias?

PotentialSystemGap12.1. Theexceptiondecisionmakingprocess issubjectiveandexposedtopressureswithinthe

System.

DocumentationReviewandAssessmentParticipantsReport:• Thecertificationprocess isnotwelldocumented, uses varyingstandards tograntexceptions, and

thereislittleaccountability fordecisions aboutexceptions.• Somecertifiersstrictlycomplywithcertificationstandards anddonotconsider thesituation

holisticallywithwhatmaybeinthebestinterestofthechildoryouth,whileothersaremoreliberalingrantingcertificationsduetothelownumberofavailableplacements,orpressuretokeepchildrenoryouth inrelativecare.

InitialInquiryQuestions:1. Aretherecertificationstandardsandpolicies forrelativecarethatdiffer fromregularstandards and

policies? Should therebe,accordingtobestpractices?2. Isthereevidence thatthecurrentexceptionprocess supports culturally-relevant placements?3. Isthereevidence thatabuse ismorelikely tooccurincertifiedhomeswhereanexceptionwas

granted?4. Whatdataiscollectedandsharedaboutthereasonsfortheexception?5. Whatinformationdocertifiershavetodrawon(fromtheBCUorothersources) tomakeaninformed

decision aboutanexception?


12 – Is the DHS foster home certification process consistent and free from bias?

PotentialSystemGap12.2. ThereisaninadequatefeedbackloopbetweencertifiersandotherSystemactors, leading

tosiloed communicationaboutsafetyrisks.

DocumentationReviewandAssessmentParticipantsReport:• Systemiccommunication issues thatparticipantsreportedinclude: Thereisnosystemtocoordinate

andensurecertificationstandardsareappliedequally, thereisnoreliablesourceforstafftodeterminethestatusofcertification,thereareinconsistencies betweendocumentation incertificationandadoption files, andthereisnowaytotrackabusetrendsperprovider.

• Othercommunication issues mayresultfromorganizationalculture:territorialattitudesreducecooperation, coordination, andcommunication.

• Siloed communication canleadtosafetyrisks.

InitialInquiryQuestions:1. Whatisthebusiness processforcommunication andinformationsharingbetweencertifiersand

otherentities(i.e.,caseworkers,CASAs)?2. Whatinformationisrequired tobesharedbetweencertifiersandotherentities?3. Whereissafetyinformationpotentially fallingthroughthecracks?


IV. CONTRIBUTORS TO THE INITIAL ASSESSMENT

KeyInformantInterviewso JohnDevlin,Attorney– RosenthalGreene&Devlin,P.C.o GroupInterview:FosterYouthandAlumni– OregonFosterYouthConnectiono GroupInterview:SubstituteCareProviders (CCAs)– OregonAllianceofChildren’sProgramso JohnHaroldson,DistrictAttorney– BentonCountyDistrictAttorneysOfficeo TomHeidt,DHSLicensingCoordinator – DHSCentral,LicensingUnito ThereseHutchinson,Policy,Program,&TrainingManager– DHSCentral,OfficeofAdultAbusePrevention&

Investigationo DarinMancuso,FosterCareOmbudsman– Governor’sOffice/DHSo ReneeMoseley,DeputyDirector– BridgeMeadows(communityhousingproviderwithfostercarefocus)o Hon.LindsayPartridge,Judge– MarionCounty JuvenileCourto HollyPreslar,Attorney– HollyA.Preslar,AttorneyatLawo MikeandLonnieRibiero,FosterParents– HarneyCounty,ORo LisaRomano,ExecutiveDirector– OregonCASANetworko Tawna Sanchez,InterimExecutiveDirector– Naya FamilyProgramso KimScott,President&CEO– TrilliumFamilyServiceso AngelaSherbo,SupervisingAttorney– Youth,Rights,&Justiceo RuthTaylorandParentadvisor/mentor,Facilitator&ProgramDirector– FosterParentAdvisoryCommittee&

MorrisonChild&FamilyServiceso Hon.NanWaller,PresidingJudge– MultnomahCounty CircuitCourt

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IV. CONTRIBUTORS (continued)

ExternalAdvisoryCommitteeo CarolineCruz,ConfederatedTribesWarmSpringso RobinDonart,MapleStarOregono Lene Garrett,CASAo SenatorSaraGelser,OregonStateLegislatoro JoshGraves,CatholicCommunityServiceso ChristineHartmann,OregonFosterParentAssociationo MarkMcKechnie,YouthRights&Justiceo CraigOpperman,LookingGlasso Rep.CarlaPiluso,OregonStateLegislatoro KatieRobertson,FosterCareAlumni,OregonFosterYouthConnectiono Elden Rosenthal,RosenthalGreene&Devlin,PCo ClydeSaiki,DHSDirectoro JohnSciamanna,ChildWelfareLeagueofAmericao NicoleStapp,FosterCareAlumniandAdvocate,OregonFosterYouthConnectiono Rep.DuaneStark,OregonStateLegislatoro KayToran,VolunteersofAmericao SenatorJackieWinters,OregonStateLegislatorEACSupport

o JeannineBeatrice,DHSChiefofStaffo AddieSmith,Governor’sOffice,TaskForceonDependency Representation

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IV. CONTRIBUTORS (continued)InternalResourceCommitteeo StaceyAyers,ChildProtectiveServicesProgramManager– ChildWelfareo AprilBarrett,HumanResourcesPayrollLiaison– DHSDirector’sOfficeo AnnaCox,DataCollection&ReportingManager–DHSBusinessIntelligenceUnito GeneEvans,PublicAffairsDirector– DHSDirector’sOfficeo LoraEdwards,ResearchAnalyst– OfficeofAdultAbusePreventionandInvestigationo KevinGeorge,ChildWellBeingUnitCo-ProgramManager– ChildWelfareo HarryGilmore,Children’sCareLicensingUnit– OfficeofLicensingandRegulatoryOversighto AJGoins,FederalPolicy,Planning&ResourcesCo-Manager– ChildWelfareo BrookeHall,ProgramandTraining– OfficeofAdultAbusePreventionandInvestigationo WendyHill,District14DistrictManager– ChildWelfareo MichelleJohnson,Classification&RecruitmentManager– DHSHumanResourceso Nadja Jones,TribalAffairsDirector– DHSDirector’sOfficeo KimKeller,District15ProgramManager– ChildWelfareo DebbiKraus-Dorn,Children’sResidentialManager– DevelopmentalDisabilitieso Sherril Kuhns,FederalPolicy,Planning&ResourcesCo-Manager– ChildWelfareo StacyLake,DifferentialResponseManager– ChildWelfareo JasonMak,Diversity&InclusionManager– DHSDirector’sOfficeo LauriePrice,Co-ProgramManager– ChildWellBeingUnito JodiSherwood,ProjectManager– OfficeoftheChiefOperatingOfficero BarbSouthard,DevelopmentalDisabilitiesLicensingManager– OfficeofLicensingandRegulatoryOversighto JulieSpencer,District5ProgramManager– ChildWelfareo NaomiSteenson,Administrator– Governor’sAdvocacyOffice

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V. DOCUMENT REVIEW SOURCES o 22casefilesinvolvingabuseofchildrenoryouth inDHSsubstitutecaresettledorawardedoverover$50,000.2001-

2016.o Chambers,Molly.(2016).YouthinLinnCountywithaCASAwhoareinappropriatelyplacedasof4/18/16.Providedby

S.Gelser.April27,2016.o Evans,Gene(emailcommunicationtoS.Ayers,FW:CIRTsystemicissuetracking,January26,2016)o George,Kevin(emailcommunicationtoG.Evans,RE:FCSTupdate– upcomingactionre:formerfosterparent,July18,

2012)o Kelley-Siel,Erinn (emailcommunicationtoL.Day,RE:Abuseinfostercarewhitepaper,March31,2015)o OregonDepartmentofHumanServices.(2015).Abriefingthatsummarizesourworkona)fostercaresafety;andb)

theactionitemsassociatedwithrecentmedia(I.e.,HR/Personnel,CIRT,MediaReview,etc.).Salem,OR.o OregonDepartmentofHumanServices.(2016).Auditreport:child-caringagency licensing:giveusthisday.Audit15-

005.Salem,OR.o OregonDepartmentofHumanServices.(2007).Childandfamilyservicesreview:statewideassessment.Salem,OR.o OregonDepartmentofHumanServices.(2015).2014Childwelfaredatabook. Retrievedfrom

https://www.oregon.gov/DHS/CHILDREN/CHILD-ABUSE/Documents/2014-data-book.pdfo OregonDepartmentofHumanServices(2015).Criticalincidentresponseteaminitialreporta.m.&r.m.Retrievedfrom

https://www.oregon.gov/DHS/CHILDREN/CHILD-ABUSE/CIRT/cirt-am-rm-initial-report.pdfo OregonDepartmentofHumanServices.(2011).Criticalincidentresponseteamsummariesandactionitems2009-

2011. Salem,OR.o OregonDepartmentofHumanServices(2015).Criticalincidentresponseteamsystemicissuesbriefingpaper. Salem,

OR.o OregonDepartmentofHumanServices(2010).Fostercaresafetyteamfinalreportandrecommendations. Retrieved

fromhttps://www.oregon.gov/DHS/DHSNEWS/CWIndependentReview/foster-care-safety-team-report.pdf

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DOCUMENT REVIEW SOURCES (continued)o OregonDepartmentofHumanServices.(dateunknown). ICWAagreementstatementofwork. Retrievedfrom

https://www.oregon.gov/DHS/DHSNEWS/CWIndependentReview/ICWA-Agreement-sow.pdfo OregonDepartmentofHumanServices(2015).Oregondeclaredcirts andrecommendations. Salem,OR.o OregonDepartmentofHumanServices.(2015).2015Oregonhomestudyauditfindings.Retrievedfrom:

https://www.oregon.gov/DHS/DHSNEWS/CWIndependentReview/2015%20Oregon%20Home%20Study%20Audit%20Summary.pdf

o OregonDepartmentofHumanServices.(2011).Sensitivereviewcommittee report. Retrievedfromhttps://www.oregon.gov/DHS/CHILDREN/CHILD-ABUSE/CIRT/src_report_5-11.pdf

o OregonDepartmentofHumanServices.(2012).Sensitivereviewcommittee report:conclusionsandrecommendations.Retrievedfromhttps://www.oregon.gov/DHS/CHILDREN/CHILD-ABUSE/CIRT/Sensitive%20Review%20Committee%20Report%20-%20Conclusions%20and%20Recommendations.pdf

o OregonDepartmentofHumanServices.(2014).ServiceEquityFramework.Salem,OR.o OregonDepartmentofHumanServices.(2015).TitleIV-Eprogram improvementplan:firstquarterlyupdate.Retrieved

from:https://www.oregon.gov/DHS/DHSNEWS/CWIndependentReview/Oregon%20Title%20IV-E-qrtlyupdate-9-2015.pdf

o OregonHealthAuthority. (2014).Children’smentalhealthincreasedemergencydepartmentvisitscrisisworkgrouprecommendations. Salem,OR.

o OregonJointInterimTaskForceon JuvenileCourtDependency Proceedings.(2014).Finalreport. Retrievedfromhttps://www.oregon.gov/DHS/DHSNEWS/CWIndependentReview/FinalReportJointIntereimTaskForceOnJuvenileDependencyProceedings.pdf

o OregonJudicialDepartment. (2016).Juvenilejusticementalhealthtaskforcereportandrecommendations.Retrievedfromhttp://courts.oregon.gov/OJD/docs/OSCA/JFCPD/Juvenile/JJMHTF/Finalized.Report.1.pdf

o OregonLegislativeAssembly.(2016).Senatecommitteeonhumanservicesandearlychildhood:staffmeasuresummarySB1515.Retrievedfromhttps://olis.leg.state.or.us/liz/2016R1/Downloads/MeasureAnalysisDocument/32742

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DOCUMENT REVIEW SOURCES (continued)o OregonOfficeofAdultAbuseandPrevention Investigations(2016).Giveusthisdayconcernchronology.Salem,OR.o NationalResourceCenter forChildProtectiveServices.(dateunknown).Expertreviewofthesafetyintervention

system. Retrievedfromhttps://www.oregon.gov/DHS/DHSNEWS/CWIndependentReview/NRCCPS-review-SIS.pdfo NationalResourceCenter forChildProtectiveServices.(dateunknown).Oregonsafetymodelreview:supervisingto

safety.Retrievedfromhttp://www.oregon.gov/DHS/DHSNEWS/CWIndependentReview/NRCCPS-safety-model-review-Phase%20One.pdf

o PacificResearch&Evaluation.(2015).Oregondifferentialresponse:year1sitevisitreport.Retrievedfromhttps://www.oregon.gov/DHS/DHSNEWS/CWIndependentReview/Final%20DR%20Year%201%20Site%20Visit%20Report-%2012%208%2015.pdf

o PublicKnowledge,Inc.(2002).Reviewofthechildprotectiveservicesintakeprocess.Retrievedfrom:http://library.state.or.us/repository/2008/200812221424531/index.pdf

o S.Gelser (emailcommunicationtoC.Saiki,MeetingwithGUTDYouth,December23,2016)o U.S.DepartmentofHealthandHumanServices.(2008).Childandfamilyservicesreviews: executivesummary: final

report:Oregonchildandfamilyservicesreview.Retrievedfromhttp://library.state.or.us/repository/2008/200803041323012/index.pdf

o U.S.DepartmentofHealthandHumanServices.(2009).Childandfamilyservicesreviews:programimprovementplan.Washington,DC.

o U.S.DepartmentofHealthandHumanServices.(2016).Childandfamilyservicesreviews:statewideassessmentinstruments.Retrievedfromhttps://www.oregon.gov/DHS/CHILDREN/Documents/cfsr-or-statewide-assess-2016.pdf

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