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|Title||Annual report. Citizens' Review Board for Children 2002|
|Creator||Maryland. Citizens' Review Board for Children.|
|PDI.Title||Citizens' Review Board 2002 Children Out-of-Home Placement Annual Report|
Maryland. Citizens' Review Board for Children--Periodicals.
Foster home care--Maryland--Evaluation--Periodicals.
|Description||Annual; 1997-1998-; Some vols. also have distinctive titles.; Report covers fiscal years 1996-1998.; Harvested from the web on 10/29/07|
|Format-Extent||v. ; 28 cm.|
|Copyright-Statement||This work may be copyrighted or have other restrictions on use. Please contact your librarian if you have questions on the uses of this material.|
|Full-Text||TTAABBLLEE OOFF CCOONNTTEENNTTSS Letter from the Chair Introduction…………………………………………………….……………….……………….. 1 Maryland’s Out- of- Home Placement Population…………….……………………………. 3 The Citizens’ Review Process……………………………………….………………..…….. 14 2002 Legislative Audit on Out- of- Home Placement………………….………………..… 17 CRBC’s Recommendations to Support CLAC’s Advocacy Priorities….…………..… 18 TTAABBLLEE OOFF EEXXHHI IIBBI IITTSS Profile of Maryland’s Out- of- Home Entries for FY 97 and FY 02 .……………..………. 3 Primary Reasons Children Entered Care during FY97 and FY02…………………….... 4 Percentage of Children Remaining in Out- of- Home Placement after Specified Intervals…………………………………………………………………………… 5 Five Trend on the Percentage of Children Exiting with a Permanency Plan……………………………………………………………………….….... 6 Case Closing Reasons by Length of Stay for FY 97 and FY 02……..………………… 6 Impact of Special Needs on Closing Reasons……………………………………………. 7 Percent of Children who Re- enter Out- of- Home Placement within One Year of Leaving……………………………………………………………………….... 7 Type of Placement used during FY 97 and FY 02………….…………….………….…… 8 Profile of Maryland’s Out- of- Home Population for FY 97 and FY 02….…………..….. 8 Case Flow Statistics for July 1, 2001 – June 30, 2002……………………..…..…..……. 9 Number of Child Protection Investigations Completed during FY 97 and FY 02…………………………………………………………………….….…. 10 Percentage of Child Protection Investigation with Finding of Indicated…….……… 11 Entries with parental Substance Abuse as a Case Factor by Age of Entry….……... 11 Average Number of Months to Complete Adoption Process for FY 02 Exits…….… 13 Findings and Recommendations made during the Citizen Review Process……….. 15 Summary of Permanency Plans by Concurrence Rates and Adequacy of Progress for FY 97 and FY 02……………………………………………………….…….… 16 1 I IINNTTRROODDUUCCTTI IIOONN As of June 30, 2002, 11,900 children were in Maryland’s out- of- home placement system. Crrriiitttiiicccaaalll IIIssssssuuueeesss FFFaaaccciiinnnggg ttthhheee Chhhiiilllddd Weeelllfffaaarrreee SSSyyysssttteeem Duuurrriiinnnggg FFFiiissscccaaalll YYYeeeaaarrr 222000000222 Maryland’s child welfare system experienced many challenges during fiscal year 2002 that threatened the ability to achieve and/ or maintain safety, well- being, and permanence for children under State custody. Some critical issues included: ♦ A hiring freeze for State employees that went into effect October 2001 has resulted in 260 child welfare positions being abolished and approximately 200 positions remaining vacant or frozen. ♦ Funds to support HB 7/ SB 671 ( Integration of Child Welfare and Substance Abuse Treatment Services) during fiscal years 2002 and 2003 were cut from $ 4.2 million to $ 2.3 million. ♦ The May 2002 audit on out- of- home placement conducted by the Department of Legislative Services showed a need for substantially enhanced procedures to protect children in care and document that safety protocols have been followed. CRBC’’’ sss Adddvvvooocccaaacccyyy PPPrrriiiooorrriiitttiiieeesss fffooorrr FFFiiissscccaaalll YYYeeeaaarrr 222000000333 Citizen Reviewers also advocate for changes in laws, programs, and policies so that children’s best interest are served. In 1995, the State Board of the Citizens’ Review Board for Children ( CRBC) established the Children’s Legislative Action Committee ( CLAC). CLAC is comprised of CRBC volunteers who advocate for statewide improvement in child welfare policies and legislation. Analysis of data from individual case reviews for children in out- of- home placement is one of the tools CLAC uses to understand the child welfare system and advocate for changes. Each year, CLAC establishes a list of priorities on which to focus its advocacy activities. The priorities for 2003 reflect a range of issues that must be addressed to ensure safety, permanence, and well- being for Maryland’s children in- out- of- home placement. The six priority areas for 2003 are: ♦ IIInnnttteeegggrrraaattteee Chhhiiilllddd Weeelllfffaaarrreee aaannnddd SSSuuubbbssstttaaannnccceee Abbbuuussseee TTTrrreeeaaatttmeeennnttt In September 2001, the Secretaries of the Department of Health and Mental Hygiene ( DHMH) and the Department of Human Resources ( DHR) completed a Memorandum of Agreement as a basis to implement HB 7/ SB 671. DHR and DHMH have placed nine addiction specialists in two child welfare offices, developed cross- training, and expanded the number of treatment slots tailored to the needs of women with children. The Baltimore City and Prince George’s County departments have begun referring clients for treatment. However, in 2 ½ years, DHR has yet to publicize a protocol for use by caseworkers, addictions specialists, and treatment providers. ♦ PPPrrrooovvviiidddeee pppeeerrrmaaannneeennncccyyy aaannnddd aaadddeeeqqquuuaaattteee ssseeerrrvvviiiccceeesss tttooo ccchhhiiillldddrrreeennn iiinnn kkkiiinnnssshhhiiippp cccaaarrreee Over 4,000 children live with relatives under State custody, and tens of thousands more under informal arrangements. These children are at risk for separation from siblings, difficulty enrolling in school, less access to services, a substantially lower level of financial support, and longer lengths of stay in care. ♦ Cooonnntttiiinnnuuueee tttooo iiimpppllleeemeeennnttt ttthhheee Chhhiiilllddd Weeelllfffaaarrreee Acccttt ooofff 111999999888 In January 1997, the Child Welfare League of America ( CWLA) recommended a 15: 1 caseload to staff ratio for out- of home placement caseworkers and similar ratios for related programs. This recommendation was included in Chapter 544 Acts of 1998 ( HB1133) which 2 required a plan to achieve these CWLA- recommended caseloads ratios. In fiscal 2002 and 2003, 215 new positions were added to the budget to reduce caseloads toward the goal of meeting national standards by FY 2003. The State’s hiring freeze has eliminated the ability to achieve CWLA recommended caseload. Child welfare services are a critical part of public safety. High caseload to staff ratios jeopardize children’s safety and well- being. ♦ SSStttrrreeennngggttthhheeennn Chhhiiilllddd Abbbuuussseee aaannnddd Neeegggllleeecccttt LLLaaawsss aaannnddd PPPooollliiiccciiieeesss – Maryland’s child abuse and neglect laws contain numerous loopholes. For example, reporting abuse or neglect is mandated but there is no penalty for failure to do so. Defendants accused of a crime against a child have more legal leeway than those accused of crimes against adults. Funds ($ 950,000) are needed to train physicians in diagnosing abuse and neglect, provide a telemedicine network for more efficient consultation, and reimburse physicians for time spent on forensic work and testimony related to child maltreatment. Without these enhancements, child neglect and abuse cases may not be accurately and efficiently diagnosed and children may be returned to unsafe homes. Perhaps, just as tragically, be separated due to erroneous diagnoses of child abuse or neglect. ♦ IIImppprrrooovvveee eeeddduuucccaaatttiiiooonnn,,, hhheeeaaalllttthhh,,, aaannnddd meeennntttaaalll hhheeeaaalllttthhh ooofff ccchhhiiillldddrrreeennn iiinnn ooouuuttt--- ooofff--- hhhooomeee ppplllaaaccceeemeeennnttt Many children in out- of- home placement have disabilities or conditions that interfere with life functioning, placement stability, and school performance. Fifty- eight percent of the children are of mandatory school age ( 5- 15), which makes it essential that local departments of social services and public schools collaborate to assure that children in out- of- home placement get the services they need without delay. Additionally, changes in the Medicaid program since 1997 have impacted all recipients, including children in placement. The May 2002 audit by the Department of Legislative Services showed major deficiencies in the documentation of medical and educational services for children in out- of home placement. ♦ Deeevvveeellloooppp qqquuuaaallliiitttyyy aaassssssuuurrraaannnccceee meeettthhhooodddsss fffooorrr ccchhhiiilllddd weeelllfffaaarrreee ssseeerrrvvviiiccceeesss ttthhhaaattt IIInnncccooorrrpppooorrraaattteee lllooonnnggg--- ttteeerrrm ooouuutttcccooomeee meeeaaasssuuurrreeesss Nearly 50,000 children a year are impacted by the local department of social services including child protective services, family preservation, and out– of- home placement. Systems are needed to estimate the true incidence of abuse and neglect; incorporate consumer, stakeholder, and employee satisfaction; and measure the long- term impact of agency interventions on permanency, safety and child well- being following completion of services to these children and their families. GOALLLSSS OFFF CRBC’’’ SSS 222000000222 ANNUALLL REEEPPPORTTT FFFOR OUTTT--- OFFF--- HOMEEE PPPLLLACEEEMEEENTTT ♦ To provide a profile of Maryland’s children in out- of- home placement during FY 2002. Data are obtained from CRBC’s database and from DHR’s Foster and Adoptive Child Tracking System ( FACTS). Child welfare data from fiscal year 2002 are compared with data from fiscal year 1997 to show a five - year trend. ♦ To review strengths and development needs of the out- of- home placement system as they relate to CLAC’s 2003 priorities and provide recommendations to support achievement of the priorities. ♦ To present a framework for improving accountability in the child welfare system. CRBC has been participating actively with the Accountability Work Group of the Coalition to Protect Maryland’s Children. The Coalition is exploring best practices in Child Welfare accountability systems and hopes to enter into a partnership with DHR through which a diverse panel of advocates, experts, and State and local executives would design a model accountability system. The Coalition is seeking assistance from foundations and universities for this project. 3 MMAARRYYLLAANNDD’ ’’ SS OOUUTT- -- OOFF- -- HHOOMMEE PPLLAACCEEMMEENNTT PPOOPPUULLAATTI IIOONN EEENTTTRIIIEEESSS IIINTTTO OUTTT--- OFFF--- HOMEEE PPPLLLACEEEMEEENTTT FFFOR FFFYYY 111999999777 AND FFFYYY 222000000222 CRBC defines entries into out- of- home placement as the beginning of any episode including when the child remained in care for one day. 1 Exhibit I and II show the changes and trends of the out- of- home placement entries. Exhibit I Profile of Maryland’s Out- of- Home Entries for Fiscal Years 1997 & 2002 Characteristics 1997 2002 Relative Rate of Change # of entries 5200 4111 % Male 50% 50% 0% % Female 50% 50% 0% % African- American 74% 64% - 13% % White 24% 30% + 28% % Hispanic 1% 2% + 19% % under 5 years of age ( at placement) 36% 37% + 3% % between 5- 11 years of age 38% 30% - 21% % between 12- 18 years of age 26% 31% + 18% % of children in sibling group 38% 39% + 4% % with parental substance abuse as case factor 64% 51% - 20% Children with special needs2 28% 52% % addiction/ dependency 5% 12% + 140% % emotional problems 25% 26% + 1% % mental retardation 3% 4% + 46% % developmental disabilities 5% 4% - 24% % learning disabilities 5% 3% - 31% % medically fragile 5% 13% + 159% Source: CRBC/ CIS Comparison between FY 97 and FY 02 entries into out- of- home placement show: ♦ The number entering out- of- home population decreased by 26%. Baltimore City accounts for a large percent of the decline, which explains the proportional drop in African- Americans; ♦ Documentation of parental substance abuse declined ( perhaps reflecting increased funding for treatment) but was listed as one of the case related factor for over half of the entries into out- of- home placement; and 1 SSA does not include one day episodes or disrupted aftercare in its count of entries. This will result CRBC having a higher number of entries than SSA. 2 The “ Children with special needs” category is the percentage of children at the end of the fiscal year who either ( 1) had a documented special need or ( 2) were specifically documented as having no special needs. 4 ♦ The two special needs areas that have experienced significant growth in documentation are children with addiction/ dependency problems ( primarily drug- exposed babies) and children who are medically fragile. Eighty- five percent of these children are under 2 years of age. The growth in the addiction/ dependency population probably reflects the impact of the drug- exposed infant initiative under Senate Bill 512 ( 1997) that requires mothers to participate in available treatment or face losing custody. State- wide, neglect is the primary documented reason children enter out- of- home placement. Exhibit II Primary Reasons Children Entered Care during FY 97 & FY 02 10 20 30 40 50 60 Percentage N A AB PI CN Other Blank FY 97 FY 02 Abbreviations N – neglect A – abuse including physical and sexual abuse AB – abandonment PI – parental illness CN – child’s special needs Including behavior problems Other – includes death or Incarceration of parent or caregiver Source: CRBC/ CIS LLLeeennngggttthhh Offf SSStttaaayyy iiinnn Ouuuttt--- ooofff--- Hooomeee PPPlllaaaccceeemeeennnttt fffooorrr FFFYYY 999777 aaannnddd FFFYYY 000222 CRBC uses two methods to evaluate length of stay in out- of- home placement. Actual Average Length of Stay ( AALS) - Measures how long children who left placement during a specified period had been in out- of- home placement. This method does not consider children who are currently in care and may have been in care for a long period. It can provide an overly optimistic perspective if a large percentage of children exiting in a given year have had short- term stays in out- of- home placement. The actual average length of stay for FY 97 was 21 months as compared to 29 months for FY 02. A large number of children ( especially those living with relatives) have spent many years in care and have a low exit rate. AALS will increase for several years to come as these children begin to age out of the placement system especially for jurisdictions with a large percentage of children in kinship care ( see pages 12- 13 for impact of kinship care on length of stay) . This will likely occur even if permanency planning performance continues to improve. Lower values for FY97 reflect accumulated performance during the latter half of the 1980s and the early 1990s. 5 Projected Average Length of Stay ( PALS) - Equals the average daily population during the reporting period divided by the number of exits during the reporting period. PALS is the only measurement that includes all children who were in out- of- placement for the reporting period and is less affected by children who remain in out- of- home placement for 6 months or less ( generally 1/ 3 of the population will have short stays). In FY97 PALS was 31 months and by FY99 it had increased to 39 months. By FY01 PALS had declined to 35 months and remained at 35 months for FY02. The length of time that a child has spent in care has an impact on the child’s prospects for permanent placement. Exhibit III shows that a child’s chances of leaving out- of- home placement drastically decline after the first year in care. Exhibit III Percentage of Children Remaining in OOHP After Specified Intervals 0% 20% 40% 60% 80% 100% fy97 fy99 fy01 fy97 100% 56% 43% 31% fy99 100% 56% 41% 31% fy01 100% 51% 33% 23% Initial Placement Placement beyond 1 year Placement beyond 2 years Placement beyond 3 years Exhibit III measures exit and not necessarily permanent placement. It shows that children are spending less time in out- of- home placement. This corresponds to the reduction in projected average length of stay, but it will take years for it to be reflected in actual average length of stay. EEEXXXIIITTT FFFROM OUTTT--- OFFF--- HOMEEE PPPLLLACEEEMEEENTTT By law, the highest priority for permanency planning is return home ( RH) followed by relative placement with guardianship or custody ( RP), and adoption ( A). 3 A five- year trend shows that the percentage of children exiting with a permanent placement declined in FY 02 following a steady annual increase. 3 Other closing reasons include independence/ age, guardian supports child under 18, runaway, and transferred to another jurisdiction. 6 Exhibit IV Five- Year Trend on the Percentage of Children Exiting with Permanency Plan 50% 55% 60% 65% 70% 75% 80% 85% 1997 1998 1999 2000 2001 2002 % Achieved Permanency During FY 02, 4,249 children exited placement; 4,729 exited during FY 97. For both fiscal years, the major exit reason was returned home with 42% for FY 02 and 39% for FY 97. One third of the children will exit placement within 6 months of entry and have a greater chance of being reunited with family ( parents or relatives) than children who had a longer length of stay. Exhibit V Case Closing Reasons by Length of Stay for FY 97 and FY 02 Exit Reasons for Children in Out- of- Home Placement for 6- Months or Less 10 20 30 40 50 60 70 RH RP A I Other Blank percentage 1997 2002 Exit Reasons for Children in Out- of- Home Placement for More than 6- Months 10 20 30 40 50 60 70 RH RP A I Other Blank Percentage 1997 2002 During FY 02, 19% of the children exited through relative placement and 23% were adopted. Impact of Age- at Entry on Exit Reasons Fiscal 2001 and 2002 data show that age at entry into out- of- home placement has a significant impact on closing reasons. Children who enter under age 5 are more likely to be adopted while children who enter at age 12 or above are more likely to exit through independent living. Return home appears to be less affected by age. Since Exhibit I shows a shift to older entrants, we may expect ‘ aging- out” to continue to rise. Impact of Special Needs on Exit Reasons For addiction dependency and medically fragile categories, the primary exit reasons were adoption followed by returned home. In the other special needs categories, returned home was the primary exit reason with the second major exit reason varying by the special need. 7 Exhibit VI Impact of Special Needs on Closing Reasons4 Number of Exits Returned Home Relative Placement Adoption Independent Living Other Total Addiction/ dependency 188 32% 20% 39% 3% 6% 11% Emotional problems 610 41% 14% 8% 24% 13% 36% Mental retardation 72 32% 15% 3% 26% 24% 4% Medically Fragile 194 36% 19% 38% 1% 7% 12% Developmental Disabilities 67 39% 22% 22% 7% 9% 4% Learning Disabilities 90 42% 10% 9% 23% 16% 5% Other Need 463 44% 17% 15% 10% 14% 28% TOTAL CASES * 1,684 40% 16% 17% 15% 12% 100% Enlarged percentages in bold show the most common permanency plan for the special need and the italicized percentages in bold show the second most achieved permanency plan. The exit reasons for the special needs category are also affected by age of entry as shown for ages under 2 and between 12- 18. Entered out- of- home placement under 2 years of age Of the 188 exits for children with addiction/ dependency, 161 ( 86%) were under two year of age at entry, of which 51 ( 32%) were returned home and 72 ( 45%) were adopted. In total 73 children with addiction dependency were adopted; 1 child was between 6- 11 years of age. There were 194 exits for children diagnosed as medically fragile of which 164 ( 84%) entered care under 2 years old. Of the 194, 33% were returned home and 42% were adopted. Entered out- of- home placement between 12- 18 years of age There were 566 children that exited with special needs in this age group. This was the only age category with no adoptions. Forty- four percent of the children were returned home, 26% exited through independent living, 12% were placed with relatives, and for 18% “ other” was listed as the exit reason. Reee--- EEEnnntttrrriiieeesss IIInnntttooo Ouuuttt--- Offf--- Hooomeee PPPlllaaaccceeemeeennnttt Since FY99, CRBC has tracked the percentage of children who re- enter placement within one year of leaving placement. This provides valuable information on the appropriateness of placements and the effectiveness of after- care services. Exhibit VII shows an increase in the re-entry during FY02. A rise in the re- entry rate may be a result of an increase in the percentage of children with shorter lengths of stay as shown in Exhibit III. Exhibit VII Percent of Children who Re- enter Out- of- Home Placement Within One Year of Leaving 9.5 10 10.5 11 11.5 12 FY99 FY00 FY01 FY02 East 4 * Note: The Total Cases data represent those cases where exits occurred during the 2002 fiscal year and a special need for the child was documented. The percentage of individual special needs represents the percent of those cases. 8 Maaarrryyylllaaannnddd’’’ sss TTToootttaaalll Ouuuttt--- ooofff--- Hooomeee PPPlllaaaccceeemeeennnttt PPPooopppuuulllaaatttiiiooonnn Two major changes occurred regarding where children resided while in out- of- home placement. Exhibit VIII shows greater use of pre- adoption placements and less use of unpaid kinship care. Exhibit VIII Type of Placements used during FY 97 and FY 02 Type of Placement FY 1997 FY 2002 Family and Treatment Foster Care 50% 47% Group/ Institutional Care 13% 17% Kinship Care 28% 16% Pre- Adoption 9% 20% Data on all children in out- of- home placement on the last day of the fiscal year ( June 30th) for 1997 and 2002 are shown in Exhibit IX. Exhibit IX Profile of Maryland’s Out- of- Home Population for Fiscal Years 1997 & 2002 Characteristics 1997 2002 Relative Rate of Change # of children 12016 11900 % Male 51% 52% + 2% % Female 49% 48% - 2% % African- American 79% 76% - 5% % White 19% 21% + 11% % Hispanic 1% 1% + 23% % under 5 years of age ( at placement) 41% 38% - 7% % between 5- 11 years of age 39% 39% - 1% % between 12- 18 years of age 19% 22% + 13% % under 5 years of age ( end of FY) 22% 19% - 15% % between 5- 11 years of age 42% 32% - 25% % between 12- 18 years of age 30% 39% + 29% % over 18 years of age 6% 10% + 83% % of children in sibling group 45% 55% + 24% % with parental substance abuse as case factor 76% 66% - 13% Children with special needs % addiction/ dependency 3% 8% + 172% % emotional problems 31% 30% - 1% % mental retardation 6% 6% - 7% % developmental disabilities 5% 5% + 12% % learning disabilities 7% 6% - 23% % medically fragile 4% 10% + 137% Exhibit IX suggests: o That while a larger percentage of children come into care under 12 ( age at placement data), these children may be aging in the system or older children are remaining in care longer ( end of FY data). This indicates a need to improve permanency planning outcomes. 9 o Documentation of parental substance abuse is declining, while documentation of children with addiction dependency problems is increasing. This may reflect progress in substance abuse treatment or a failure to recognize and/ or document parental substance abuse. The percentage of children with parental substance abuse as a case factor still demands more treatment resources and strongly supports the need for adequate funding to fully implement HB7/ SB671. o The percentage of children in sibling groups continues to increase requiring intense coordination between case workers if multiple workers are assigned. o Educational, medical, and mental health services need to be carefully coordinated with child welfare casework services, communicated to caregivers, and adequate funding must be provided. CASSSEEE FFFLLLOW BYYY JJJURIIISSSDIIICTTTIIION Jurisdictions differ vastly in regards to entries, exits, lengths of stay, and total population. Exhibit X Case Flow Statistics for July 1, 2001 – June 30, 2002 Jurisdiction # of Cases on 7/ 1/ 01 # of Cases Entered Placement During FY 02 Case Left Placement During FY 02 # of Cases in Care on June 30, 2002 Projected Average Length of Stay ( months) Actual Average Length of Stay ( months) Allegany 121 45 41 125 34 25 Anne Arundel 249 96 94 251 33 24 Baltimore County 629 368 323 674 25 16 Calvert 62 49 32 79 26 24 Caroline 37 17 16 38 27 13 Carroll 93 53 56 90 22 18 Cecil 90 66 69 87 16 20 Charles 118 45 33 130 47 33 Dorchester 68 13 16 65 50 19 Frederick 186 139 107 218 24 17 Garrett 72 25 29 68 32 18 Harford 242 149 142 249 22 22 Howard 123 51 34 140 49 17 Kent 11 11 8 14 28 27 Montgomery 680 206 209 677 41 28 Prince George’s 806 268 237 837 41 35 Queen Anne’s 29 22 21 30 15 24 St. Mary’s 74 28 15 87 67 16 Somerset 58 17 14 61 49 37 Talbot 42 9 9 42 91 45 Washington 233 150 159 224 17 18 Wicomico 162 41 26 177 78 22 Worcester 46 23 10 59 60 20 Baltimore City 7819 2222 2563 7478 38 34 State- wide 12050 4113 4263 11900 35 29 10 Smaller jurisdictions often show a greater gap between the AALS and the PALS than the four largest jurisdictions ( Baltimore City, Baltimore County, Prince George’s County, and Montgomery County). Smaller jurisdictions are more affected than larger jurisdictions by factors such as a few children or a large sibling group that have very short or very long lengths of stay. Addddddiiitttiiiooonnnaaalll FFFaaaccctttooorrrsss ttthhhaaattt IIInnnfffllluuueeennnccceee Caaassseee FFFlllooow Child Abuse and Neglect Laws and Policies How child abuse and neglect ( CAN) allegations are reported and investigated will impact the number of children that enter out- of- home placement, the length of stay, exit reasons, total population. The quality and accuracy of child abuse and neglect reports and investigations influence the State’s ability to ensure safety, well- being and permanence for children. Reporting Child Abuse and Neglect Data from the National Child Abuse and Neglect Data System5 suggest that Maryland has a slightly below average rate of reporting and investigating abuse. Some of Maryland’s data are estimated due to gaps in the State’s data system. Maryland’s narrow definition of abuse and neglect and weak laws governing reporting may limit reporting. Investigating Child Abuse and Neglect The 2001 Child Protection Report issued jointly by CRBC and the State Council on Child Abuse and Neglect reviewed issues associated with investigating and diagnosing child abuse and neglect. The report showed that the lack of adequate medical and legal resources needed to accurately and efficiently investigate a child abuse and neglect allegation may compromise results and ultimately the safety of the child. Some major deficiencies include lack of: ♦ training to enhance the physicians expertise in CAN including physicians in the emergency room who can conduct full forensic exams; ♦ reimbursement for conducting forensic exams, which is not covered by health insurance and which may cause a further loss of income due to court testimony; and ♦ resources to address CAN including child advocacy centers, funding, and laws and collaboration with the State’s Attorney’s Office, legal representatives and advocates. 6 Data on Child Abuse and Neglect Investigations There was an 8% increase ( 2,385) in the number of child protection investigations completed in FY02 as compared to FY97.7 Over a five- year period, the lowest number of investigations were conducted during FY97 and the highest number of investigations were conducted during FY02. Exhibit XI Number of Child Protection Investigations Completed Between 1997 and 2002 29,000 30,000 31,000 32,000 33,000 1997 1998 1999 2000 2001 2002 Source: Department of Human Resources, Social Services Administration, Research Department 5 www. acf. hhs. gov/ programs/ cb/ publications/ cm00/ table2_ 7. htm 6 CRBC and State Council on Child Abuse and Neglect, 2001 Child Protection Annual Report, p. 5 7 Department of Human Resources, Social services Administration, Research Department 11 Between fiscal years 97 and 02, the percentage of indicated cases had a low of 23% ( FY02) and a high of 29% ( FY97). Data on cases with a finding of indicated suggest that as the number of investigations increases, the percentage of cases with a finding of indicated decreases. Exhibit XII Percentage of Child Protection Investigations with Finding of Indicated 29 25 26 26 25 23 20 22 24 26 28 30 1997 1998 1999 2000 2001 2002 Source: Department of Human Resources, Child Protection During FY 02, 43% of the child protection investigations were for neglect, 37% were for physical abuse, and 13% were for sexual abuse. Twenty- eight percent of the neglect investigations resulted in a finding of indicated; as compared to 19% for physical abuse investigations, and 31% for sexual abuse investigations. 8 Additional information on child protection activities can be found in the 2002 Annual Report on Child Protection. Parental Substance Abuse Based on the anecdotal observations of review board members, underreporting of parental substance abuse in the FACTS database may be substantial. National studies also indicate a higher percentage of entries with this factor. For first entries, parental substance abuse is documented more frequently as a case factor for children under 5 years old. This reduction in re- entries may be a result of a large percentage of children under 2 years of age with addiction/ dependency problems being adopted as discussed on pages 6 and 7. For re- entries, the 5- 11 year old population appears most affected. Comparison of Exhibits I and XIII suggest that the shift towards older age at entry between 1997 and 2002 may be correlated with the reduction in percentage of cases citing parental substance abuse as a factor. Exhibit XIII Entries with Parental Substance Abuse as a Case Factor by Age at Entry 1997 10 20 30 40 50 60 70 < 5 5- 11 years 12- 18 years percentage 1st Entry Re- entry Total Entries 2002 10 20 30 40 50 60 70 < 5 5- 11 years 12- 18 years Percentage 1st Entry Re- Entries Total Entries Only 3% of 17,000 treatment slots in Maryland provide intensive service and are tailored to the needs of women or women with children. 8 Department of Human Resources, Social Services Administration, Research Department 12 There has been progress in the implementation of Integration of Child Welfare and Substance Abuse Treatment Services ( HB7/ SB 671) as discussed on page 1. Significant barriers, however, impede the ability to achieve the intended results of the law including: ♦ Lack of a written protocol for caseworkers and addiction specialists; ♦ Elimination of funds to provide cross training for addiction specialist and case workers; ♦ Lack of a systematic state- wide data collection system, including no count of cases screened for substance abuse or of parents refusing referral to the addiction specialist; ♦ Absence of child- welfare- related data in substance abuse effectiveness measures; ♦ The requirement to have the parent consent to a referral to the addiction specialist, which undermines the rationale for placing addiction specialists in child welfare offices; and ♦ Maryland’s failure to fully utilize the reunification waiver provisions of federal and State law, which could expedite permanence for many drug- exposed infants. Under the waiver, a parent whose rights to a child had previously been involuntarily terminated could be denied reunification services and the child could move more rapidly into permanent placement under guardianship or adoption. ( See page 15 on Waiver of Reunification Services). Kinship Care Kinship care is defined as “ the full- time care, nurturing, and protection of children by relatives, members of their tribes or clans, or other adults who have a family relationship to a child”. 9 Children in formal kinship care are placed through the State’s child welfare agency. Informal kinship care is privately arranged within the family. In either arrangement the children are usually entitled to Temporary Assistance to Needy Families ( TANF). Under formal kinship care arrangements the caregiver may be eligible to be licensed as a restricted foster care home and receive higher monthly payments. Advantages to Kinship Care Living Arrangements Children in kinship care experience some advantages that may not be available to children in non- relative homes such as having greater placement stability, more exposure to family ( including siblings) and family support, and possibly being placed in a familiar environment. These potential benefits may not mitigate the trauma of the precipitating abuse or neglect nor reduce the trauma associated with being separated from parents without concurrent treatment services. Common Problems in Kinship Care National studies have found that children in formal kinship experience an array of health and behavioral problems stemming from abuse and neglect while they were with their parent( s). 10 Many are placed with relatives who may have a low- income and may also have poor health. Often these relatives are not aware of available resources. Many cannot pass the home study to become a restricted foster parent, which consigns the children to poverty. Some kinship care providers are resistant to seeking adoption because it would terminate family members’ parental rights. They may also not be aware of guardianship as an option. Thus children in kinship care often remain under State custody with no prospect of achieving legal permanency. Caregivers in informal kinship care arrangements are forced to ask DSS to take custody of a child because of barriers to school enrollment and medical care. During the 2003 Legislative 9 www. cwla. org/ programs/ kinship/ factheet. htm 10 www. cwla. org/ programs/ kinship/ factsheet. htm 13 Session, Senator Kelly introduced SB 31 and 32 Education- Kinship Care which would allow a caregiver to enroll a child in school or access medical care by filing an affidavit stating that the child lives with the caregiver due to extreme family hardship ( such as drug addiction). CLAC has made supporting these bills a priority. Maryland’s Subsidized Guardianship Project As of June 30, 2002, Maryland had 1,821 children in kinship care, compared to 3,267 in 1997. Eighty percent ( 1,461) were in the custody of Baltimore City. The remaining 20% resided in 19 jurisdictions. Four jurisdictions did not have children in kinship care on June 30, 2002 ( Allegany, Baltimore, Queen Anne’s, and Talbot counties). 11 In April 1997 the U. S. Department of Health and Human Services approved Maryland’s participation in the Subsidized Guardianship Project, which the State implemented in May 1999. The intent of this five- year project is to reduce instances of children entering or remaining in long- term foster care with relatives. Children eligible for the subsidized guardianship project must be unable to return to either parent and adoption is not an option. Through this voluntary project, the relative may become the legal guardian. The project is divided into a control group who are not eligible to receive subsidy payments of $ 300 per month and an experimental group who are eligible to receive the subsidy. The University of Maryland has issued preliminary reports on the Subsidized Guardianship Project. 12 The availability of guardianship assistance was associated with very significant reductions in length of stay. The University estimates that children ineligible for subsidized guardianship have approximately a 30% chance of being in State custody 10 years after entry. For children eligible for subsidized guardianship, the probability drops to about 1 or 2%. In addition, children in both experimental and control groups scored high on a range of measures of well- being such as school attendance, grades, and physical and mental health. Adoption Process Maryland is not meeting the federal standard of completing a high proportion of adoptions within two years. Please refer to the discussion, above, under “ Parental Substance Abuse ( page 12)” regarding a missed opportunity to expedite adoption. Exhibit XIV Average Number of Months to Complete Adoption Process for FY 02 Exits Process Baltimore City Baltimore County Montgomery County Prince George’s County Other Counties Establish plan of adoption 35 15 18 File TPR13 3 6 4 Obtain TPR 14 10 12 Final Adoption 61 47 41 Data on children who exited out- of- home placement through adoption show the larger the jurisdiction the longer the process to final adoption. Baltimore City takes an average of 3 years to establish a plan of adoption, which is twice as long as other jurisdictions. The TPR process approximates the rest of the State’s time frames. 11 Social Services Administration June 2002 Monthly Management, page 25 12Maryland’s Subsidized Guardianship Demonstration Project: Implications for Youth’s Well- being, Smith, and et al, 13This data field includes only children within the CRBC review population. 14 In FY 02, 950 children achieved finalized adoption; DHR’s adoption goal for FY 02 was 850. l There were approximately 1,300 children who have had parental rights terminated and were eligible for adoption. In its FY 01 annual report, CRBC recommended that the State’s adoption goal should equal the number of children are legally free to be adopted. CRBC continues to support that recommendation. TTHHEE CCI IITTI IIZZEENNSS’ ’’ RREEVVI IIEEWW PPRROOCCEESSSS ADMIIINIIISSSTTTRATTTIIIVVVEEE REEEVVVIIIEEEWSSS Title IVB- Social Security Act section 422( b) ( 10)( ii) requires that children in out- of- home placement have an administrative review every six months. This may be achieved through a court review, a citizen review, or a panel review ( conducted by LDSS). Failure to document the review will result in a state receiving a financial penalty. As of June 30, 2002, timely administrative reviews were documented for 84.1% of children in care compared to 81.8% for June 30, 2001, which represents a 3% increase. Ciiitttiiizzzeeennn Reeevvviiieeew PPPrrroooccceeessssss ♦ Jurisdictions are required by Code of Maryland Regulations 07.06.01 ( COMAR) to submit case plans within 3 weeks of a scheduled review, make verbal presentations at the review, and respond in writing to the recommendations and findings from the review within 10 working days of receiving the report from CRBC. ♦ Interested Persons including child's caseworker, parents, relatives, and foster families are invited to the review. They provide additional information and opinions regarding the child's current and proposed living arrangement. Educational and health providers, and the child if over age ten may be invited to the initial review and subsequent reviews when the case plan changes. Siblings are reviewed together to ensure continuity and coordination of services since there may be multiple caseworkers and services providers. ♦ After the discussion, the Board makes findings and recommendations related to the child's permanency plan, current living situation, and safety. A Staff Assistant, who is an employee of CRBC, advises the Board on laws, policies, and procedures and provides technical assistance including recording the votes and findings. ♦ The Board is required to send A summary of the findings and the recommendations to parents, LDSS, the juvenile court, and caregivers, within 3 weeks after the review is held. SSSuuummaaarrryyy ooofff FFFiiinnndddiiinnngggsss aaannnddd Reeecccooommeeennndddaaatttiiiooonnnsss maaadddeee ddduuurrriiinnnggg ttthhheee Ciiitttiiizzzeeennn Reeevvviiieeew PPPrrroooccceeessssss The following findings represent the 7,838 citizen reviews that were conducted during FY 02 ( a 6% decrease over FY 01 and not the status of all children in Maryland’s out- of- home system. In rare instances, a child may have a citizen review more than once in a year. 15 Exhibit XV Findings and Recommendations made during the Citizen Review Process Votes taken during the Citizen Review Process FY 01 Results Waiver of reunification services is the denial of time- limited services to parents or guardians to assist in returning the children home. 14 The boards must decide if they agree with LDSS’ decision to pursue or not to pursue a waiver of reunification services against the mother, father, or both. Generally this finding is made at the first review. The Boards voted on the waiver 3,203 times. The Boards found 10 instances in which the waiver had been granted and 1 in which it was pending before court. Boards found 86 instances in which the waiver was not used and the Boards believed it should have been applied. Termination of parental rights results from a court action terminating parents legal rights and responsibilities and awarding guardianship to LDSS or a child placement agency. Seventy- six percent ( 76%) or 5,918 cases reviewed qualified for consideration of TPR. The Boards may find that there is a compelling reason not to pursue TPR such as the child is with relatives, parents are making progress, or the child is a teenager and does not want to be adopted. Boards voted not to file for TPR in 69% of the eligible. The Board must consider the safety of the child while living in the out- of-home placement. This includes whether all applicable safety assessments and child protection protocols have been used such as whether DSS has completed an inventory of people living in the home. The Board must also consider whether there are indicators of risk that may include, but are not limited to, parental visits that may subject the child to risk, domestic violence, and/ or a household member with a history of violence, child abuse, or child neglect. One or more safety protocols were not used in approximately 1.6% of the reviews. Of these, the Boards found indicators of risk in 61% of the cases. See pages 17- 18 for more discussion on safety. A permanency plan specifies when and with whom the child shall live and the proposed legal relationship between the child and the caregiver( s). Two votes are taken regarding the permanency plan: • The concurrence rate is the percentage of times the reviewers agree with the permanency plan. • A vote for adequate progress indicates that the responsible agencies acted in a reasonable and timely fashion to promote permanent placement. A responsible agency includes LDSS, the courts, a private child placement agency and medical and educational systems. See Exhibit XVI 14 For the waiver of reunification services and termination of parental rights, votes may not be taken if 1) the child was 18 years of age or over, 2) the parents were dead, or 3) the parental rights had already been terminated 16 Exhibit XVI Summary of Permanency Plans by Concurrence Rates and Adequacy of Progress For Fiscal Years 1997 and 2002 Permanency Plan July 1, 1996 - June 30, 1997 July 1, 2001 – June 30, 2002 # of Plans and % of Total * Concurrence Rate Progress Adequate # of Plans and % of Total * Concurrence Rate Progress Adequate # % # % Return Home 1117 11% 87% 90% 2002 27% 79% 86% Relative Placement 1600 16% 90% 91% 1120 15% 92% 90% Adoption 2327 24% 98% 84% 1983 27% 98% 83% Independent Living 1490 15% 99% 98% 1028 14% 99% 96% Long- term Foster Care 1477 15% 96% 96% 1025 14% 98% 96% Permanent Foster Care 1726 17% 98% 98% 227 3% 99% 100% Guardianship 169 2% 97% 98% 8 0% 100% 83% TOTAL 9906 95% 92% 7393 92% 89% Source: CRBC’s Information System * Note: Review cases where permanency plan was documented The shift toward more cases with plans of return home reflects implementation of the 1998 legislation and the concomitant Memorandum of Agreement between DHR and CRBC. Under the new procedures, a higher percentage of children entering care receive an initial review ( most often at six months) and follow- up reviews are spread out over longer intervals. Return home had the lowest concurrence rate and the second lowest percentage of reviews in which progress was found adequate. Board members cited high caseloads as a major barrier to progress. For plans of adoption, reviewers found that legal resources and the adoptive process, including the home study, to be the major barriers. 17 22000022 LLEEGGI IISSLLAATTI IIVVEE AAUUDDI IITT OONN OOUUTT –– OOFF –– HHOOMMEE PPLLAACCEEMMEENNTT In May 2002, the Department of Legislative Services published a report of an audit conducted through a random sample of record reviews for 162 out- of- home placement cases, and a survey of caseworkers, foster care providers, judges, and citizen review board members. Summary of Findings The audit listed several areas in which the out- of- home placement system was performing satisfactorily. ♦ Case reviews by appropriate third parties are being performed; ♦ Placement of the child is generally in the recommended type of facility; ♦ The Departments had legal justification for not pursing termination of parental right; and ♦ Reports of abuse or neglect while children are in care are generally handled in accord with regulations The audit also found alarming indications that vulnerable children are not receiving the consistent monitoring and intervention necessary to guarantee safety and a basic standard of care. ♦ Evidence that minimal standards for regular face to face contact with children and care providers are being met was missing in nearly half of the cases; ♦ Half of the children were living with adults for whom no criminal background check could be found; ♦ No record of well child examinations was found in one- third of the files; ♦ No record of an annual dental visit was available in 69% of the files; ♦ When mental health treatment was recommended, in one- fourth of the cases there was no indication that the treatment had been provided; ♦ Documentation that children were registered in school in a timely way and attending regularly was missing; ♦ 97% of the caseworkers in Baltimore City, the jurisdiction serving the largest number of child welfare clients, reported inadequate physical resources ( cars, office space, equipment, computers, supplies); ♦ 84% of caseworkers statewide reported insufficient staff resources ( caseworkers, paraprofessionals, transportation aides, clerks). 18 CRBC Response to Audit Findings DLS’ findings on safety differed significantly from the review boards findings. This is a result of different methods of reviewing the cases. ♦ As discussed on page 14, CRBC receives case plans from the local departments. Interested parties provide additional information and opinions regarding safety, well- being, and permanence. ♦ In contrast, DLS reviewed the case file. Time constraints prevent citizen reviewers from taking this approach. In response to the critical issues raised in the DLS audit, the State Board, in partnership with the State Council on Child Abuse and Neglect, and in consultation with the Social Services Administration, the local departments of social services, the Maryland Association of Resources for Families and Youth ( which represents many of the private child placement agencies), and the Maryland League of Foster and Adoptive Parents, has established new procedures for out-of- home placement review. Local boards will: ♦ Verify that required safety assessments were conducted; ♦ Require participation of child placement agencies and foster parents; ♦ Verify and document regular contact between caseworkers and the children, parents, and placement agencies involved; ♦ Inquire about criminal history records checks, foster home approvals, and reconsiderations; ♦ Increase monitoring of education, health, mental health, and dental services; ♦ Require high- level administrators to respond to case recommendation reports. In addition, the State Board has mandated that citizen review panels will review the records of the local board when reviewing a child protection investigation that subsequently involved placement and a citizen review. In this way, the citizen review process will be subject to the same type of oversight as the frontline child protection agencies. CCRRBBCC’ ’’ SS RREECCOOMMMMEENNDDAATTI IIOONNSS TTOO SSUUPPPPOORRTT CCLLAACC’ ’’ SS AADDVVOOCCAACCYY PPRRI IIOORRI IITTI IIEESS The DLS audit, findings and recommendations from CRBC citizen reviewers, as well as Maryland’s child welfare data support the advocacy priorities established by CLAC. The following recommendations will help to achieve CLAC’s objectives for FY 02. IIInnnttteeegggrrraaattteee Chhhiiilllddd Weeelllfffaaarrreee aaannnddd SSSuuubbbssstttaaannnccceee Abbbuuussseee TTTrrreeeaaatttmeeennnttt SSSeeerrrvvviiiccceeesss... • DHR should immediately issue a protocol to implement HB 7/ SB 671. • DHR should immediately initiate expanded data collection to comply with evaluation requirements for fiscal year 2004 • DHR and DHMH should find a way to resume cross- training in fiscal year 2004. Such training must serve as a forum in which child welfare staff and addiction treatment staff can interact. 19 • DHMH should continue its efforts to expand intensive treatment tailored to the needs of women with children. • DHMH should include outcomes related to child welfare in its evaluation of drug treatment programs. PPPrrrooovvviiidddeee pppeeerrrmaaannneeennncccyyy aaannnddd aaadddeeeqqquuuaaattteee ssseeerrrvvviiiccceeesss tttooo ccchhhiiillldddrrreeennn iiinnn kkkiiinnnssshhhiiippp cccaaarrreee... Keeeeeeppp ccchhhiiillldddrrreeennn iiinnn iiinnnfffooorrrmaaalll kkkiiinnnssshhhiiippp cccaaarrreee ooouuuttt ooofff ttthhheee ppplllaaaccceeemeeennnttt sssyyysssttteeem iiinnn ttthhheeeiiirrr bbbeeesssttt iiinnnttteeerrreeessstttsss... • CRBC supports SB 31 and 32 Education- Kinship Care introduced by Senator Kelley to ease school enrollment and health access barriers. ♦ We also strongly support full statewide implementation of the subsidized guardianship program, which has proven to be a fiscal and programmatic success. Cooonnntttiiinnnuuueee tttooo iiimpppllleeemeeennnttt ttthhheee Chhhiiilllddd Weeelllfffaaarrreee Wooorrrkkkfffooorrrccceee Acccttt ooofff 111999999888. ♦ The Governor should immediately fulfill his stated commitment to exempt child welfare staff from the hiring freeze. ♦ The Governor should restore the abolished child welfare positions in the FY 2005 budget request. SSStttrrreeennngggttthhheeennn ccchhhiiilllddd aaabbbuuussseee aaannnddd nnneeegggllleeecccttt lllaaawsss aaannnddd pppooollliiiccciiieeesss... We ask the General Assembly to enact the following bills: ♦ Institute a misdemeanor penalty for health professionals, educators, law enforcement personnel, and human services workers who knowingly and willfully fail to report abuse or neglect. Forty- five states have such a penalty. ♦ Require reporting when abuse or neglect is reasonably suspected to have occurred in another state. ♦ Limit the overly- broad clergy exemption in the present reporting statute. ♦ In addition, we urge the Governor to include $ 950,000 in the 2005 budget request to train physicians in diagnosing abuse and neglect, provide a telemedicine network for more efficient consultation, and reimburse physicians for time spent on forensic work and testimony related to child maltreatment. PPPrrrooovvviiidddeee qqquuuaaallliiitttyyy eeeddduuucccaaatttiiiooonnn,,, hhheeeaaalllttthhh,,, aaannnddd meeennntttaaalll hhheeeaaalllttthhh ssseeerrrvvviiiccceeesss fffooorrr ccchhhiiillldddrrreeennn iiinnn ooouuuttt--- ooofff--- hhhooomeee ppplllaaaccceeemeeennnttt... ♦ Require purchase of care providers to obtain regular medical, dental, and mental health care for the children in their care, and reliably forward reports to caseworkers; ♦ Identify and resolve the obstacles to timely school enrollment; ♦ Hold caseworkers accountable for lapses in essential functions such as visiting children; overseeing medical, dental, and mental health care access; and taking the steps necessary to effect a timely enrollment in school. ♦ Identify statewide medical and dental providers able to offer timely care to foster children and to forward required documentation to caseworkers; 20 ♦ Follow through on recommendation forthcoming from an expert panel established by DHR and DHMH to improve health care for children in out- of- home placement Deeevvveeellloooppp qqquuuaaallliiitttyyy aaassssssuuurrraaannnccceee meeettthhhooodddsss fffooorrr ccchhhiiilllddd weeelllfffaaarrreee ssseeerrrvvviiiccceeesss ttthhhaaattt iiinnncccooorrrpppooorrraaattteee lllooonnnggg--- ttteeerrrm ooouuutttcccooomeee meeeaaasssuuurrreeesss... CRBC recommends that DHR enhance its accountability system. A special effort should be made to measure long- term impact on permanency, safety and child well- being following completion of services to children and their families and to include client and stakeholder feedback among the information used to assess system performance. To further develop and work towards implementation of this recommendation, CRBC believes that certain features of a model accountability system can be laid out now. In doing so, we are working on a foundation laid in our 1997 Annual Report, which discussed a system of measurements and feedback loops required to improve care management. An accountability system encompasses performance measurements, diversity of perspectives, integration with the child welfare financing system, and control mechanisms for corrective action. Finally, accountability systems are not free; there are budgeted and unbudgeted costs to consider in the development of a model accountability system. CRBC has worked with the Coalition to Protect Maryland’s children to flesh out and broad support for this recommendation. Together, advocates have developed a preliminary framework that would incorporate various perspectives and performance measurements that reflect both the goals of the child welfare system and the various child welfare service components. These components correspond to the development over time of a typical child welfare case. Because the ultimate purpose of the child welfare system is to reduce harm to children, the framework encompasses measurements that fall outside the scope of any one particular service component. In other words, we seek to determine whether the child welfare system actually makes the children who live in Maryland safer, more stable, and better able to develop their skills, talents, and relationships. This cannot be determined by examining only the children served by DHR and the local departments of social services. CRBC recommends that the Governor issue an executive order or that the General Assembly enact legislation establishing a task force to recommend a child welfare accountability system for DHR incorporating the enhancements discussed above. MMeemmbbeer rrss oof ff t tthhee SSt ttaat ttee BBooaar rrdd Ted Kirk, Chair Representing Frederick and Montgomery Counties Nettie Anderson- Simmons, Vice Chair Representing Allegany, Garrett, and Washington Counties Carol Carson Representing Caroline, Cecil, Kent, Queen Anne’s, and Talbot Counties Cameron Carter Representing Baltimore City Richard Hall Representing Baltimore and Harford Counties Mae Kastor Representing Baltimore City Sylvia Smith Representing Baltimore City Alisa Santucci Representing the Governor James Trent Representing Calvert, Charles, Prince George’s, and Saint Mary’s Counties vacant Representing Anne Arundel, Carroll, and Howard Counties vacant Representing Dorchester, Somerset, Wicomico, and Worcester Counties STAFF Charles R. Cooper, Administrator|
|Relation-Replaces||Maryland. Foster Care Review Board. Annual report|