Substance-Affected Infants: Additional Guidance Would Help States Better Implement Protections for Children

Under CAPTA, states perform a range of prevention activities, including addressing the needs of infants born with prenatal drug exposure. The number of children under the age of 1 entering foster care increased by about 15 percent from fiscal years 2012 through 2015. Child welfare professionals attribute the increase to the opioid epidemic. GAO was asked to examine the steps states are taking to implement CAPTA requirements on substance-affected infants and related amendments enacted in 2016.

This report examines (1) the extent to which states have adopted policies and procedures to notify CPS of substance-affected infants; (2) state efforts to develop plans of safe care, and associated challenges; and (3) steps HHS has taken to help states implement the provisions.

To obtain this information, GAO surveyed state CPS directors in all 50 states and the District of Columbia and reached a 100 percent response rate. GAO also visited 3 states (Kentucky, Massachusetts, and Pennsylvania); reviewed relevant documents such as federal laws and regulations, and HHS guidance; and interviewed HHS officials. GAO did not assess states' compliance with CAPTA requirements.

All states reported adopting, to varying degrees, policies and procedures regarding health care providers notifying child protective services (CPS) about infants affected by opioids or other substances. Under the Child Abuse Prevention and Treatment Act (CAPTA), as amended, governors are required to provide assurances that the states have laws or programs that include policies and procedures to address the needs of infants affected by prenatal substance use. This is to include health care providers notifying CPS of substance-affected infants. In response to GAO's survey, 42 states reported having policies and procedures that require health care providers to notify CPS about substance-affected infants and 8 states reported having policies that encourage notification. The remaining 1 state has a policy requiring health care providers to assess the needs of mothers and infants and if they conclude that infants are at risk for abuse or neglect, CPS is notified.

In response to GAO's survey, 49 states reported that their CPS agency has policies to develop a plan of safe care; 2 reported not having such a requirement. Under CAPTA, states are required to develop a plan of safe care for substance-affected infants. Although not defined in law, a plan of safe care generally entails an assessment of the family's situation and a plan for connecting families to appropriate services to stabilize the family and ensure the child's safety and well-being. States reported that plans typically address the infant's safety needs, immediate medical needs, and the caregiver's substance use treatment needs. However, officials in the 3 states GAO visited noted challenges, including uncertainty about what to include in plans and the level of intervention needed for infants at low risk of abuse or neglect.

The Department of Health and Human Services (HHS) has provided technical assistance and guidance to states to implement these CAPTA requirements. Most states reported in GAO's survey that additional guidance and assistance would be very or extremely helpful for addressing their challenges. Nevertheless, HHS officials told GAO that the agency does not anticipate issuing additional written guidance, but that states can access technical assistance through their regional offices and the National Center on Substance Abuse and Child Welfare—a resource center funded by HHS. However, of the 37 states that reported on the helpfulness of the assistance they have received, 19 said it was only moderately helpful to not helpful. States offered suggestions for improving the assistance, such as developing substance abuse training materials for staff and holding video conferences with other states to share information. In October 2017, HHS officials explained that some states have submitted plans that include details on how they are addressing the CAPTA requirements. HHS officials reported that some of the plans submitted to date indicated that states are not meeting the requirements and those states have been asked to develop program improvement plans. Without more specific guidance and assistance to enhance states' understanding of CAPTA requirements and better address known challenges such as the ones described in this report, states may miss an opportunity to provide more effective protections and services for the children and families most in need.

GAO recommends that HHS provide additional guidance and technical assistance to states to address known challenges and enhance their understanding of requirements. HHS did not concur with the recommendation. As discussed in the report, GAO continues to believe that added guidance would benefit states.

States reported that parental drug abuse was a factor associated with the  removal of 32 percent of the children entering foster care in fiscal year  2015. In addition, the number of children under the age of 1 entering  foster care increased by about 15 percent (from 41,235 to 47,219) from  fiscal year 2012 through fiscal year 2015—an increase that many  researchers and child welfare professionals attribute to the opioid  epidemic. Infants born to women who misuse drugs or alcohol during  their pregnancy are particularly vulnerable. Many infants are born affected  by substance exposure and experience withdrawal symptoms, referred to  as substance-affected infants. A subset of these infants who were  exposed to opioids in utero may be diagnosed with neonatal abstinence  syndrome (NAS), a condition characterized by a range of symptoms,  including excessive crying, irritability, and difficulties with breathing and  feeding. The health, well-being, and safety of these infants may be  jeopardized if they are sent home with parents with substance use  disorders who do not have a system of support and are not in treatment  or recovery.

The Child Abuse Prevention and Treatment Act (CAPTA) is one of the  key pieces of federal legislation that guides child protection and includes  provisions related to substance-affected infants. Under CAPTA, state  governors are required to provide an assurance to the Secretary of the  Department of Health and Human Services (HHS) that their states have  in effect and are enforcing a law or statewide program that requires (1)  health care providers to notify child protective services (CPS) of all  infants affected by substance use or withdrawal symptoms resulting from  prenatal drug exposure, and (2) a plan of safe care be developed for all  such infants, including the affected caregiver.

You asked us to examine how states are implementing these CAPTA  requirements. In this review, we examine (1) the extent to which states  have adopted policies and procedures to notify CPS of substance- affected infants, and to guide how CPS officials respond once they  receive a notification; (2) the extent to which states have adopted policies  and procedures to develop plans of safe care for substance-affected  infants, and any challenges associated with implementing such policies  and procedures; and (3) steps HHS has taken to assist and monitor  states’ efforts in implementing CAPTA provisions related to substance- affected infants.

To address these questions, we collected and analyzed information using  several methods. To obtain information on all three research questions,  we designed and administered a web-based survey of states directed  toward CPS directors in all 50 states and the District of Columbia. The  survey was conducted between March and May 2017, with 100 percent of  states responding to the survey. The survey included open-ended and  closed-ended questions about state laws, policies, and procedures  regarding substance-affected infants; specific requirements or processes  relating to infants affected by opioids; plans for ensuring the safety and  well-being of substance-affected infants; data collection efforts;  challenges to implementing CAPTA requirements; and assistance and  guidance provided by HHS.

To minimize nonsampling errors, we pretested the questionnaire with four  states via telephone. We chose the pretest sites to include states with  moderate to high rates of drug mortalities, moderate to high NAS rates,  variation in state CPS administrative frameworks (two state-administered,  one county-administered, and one hybrid partially administered by the  state and partially administered by counties), and geographic variation  (states from the mid-Atlantic, north, south, and west). In the pretests and  expert reviews, we were generally interested in the clarity of the questions  and the flow and layout of the survey. For example, we wanted to ensure  that terms used in the survey were clear and known to the respondents,  categories provided in closed-ended questions were complete and  exclusive, and the ordering of survey sections and the questions within  each section were appropriate. The web instrument was revised based on  the pretests and expert reviews. We reviewed state officials’ responses  and conducted follow-up, as necessary, to determine that their responses  were complete, reasonable, and sufficiently reliable for the purposes of  this report. Specifically, we followed up with nine states via email and, in  August 2017, conducted a semi-structured phone interview with one  state.

To obtain more in-depth information on all three research questions about  state laws, policies or procedures, as well as challenges to implementing  the CAPTA provisions, we conducted site visits to three states (Kentucky,  Massachusetts, and Pennsylvania). These states were selected based on  their high rates of drug mortalities in 2014 and NAS in 2012, the most  recent and comprehensive publicly available data at the time of our  analysis; recommendations from subject matter experts; and for variation in state CPS administrative frameworks (two state-administered or one  county-administered). We also visited two localities in each state,  selected based on their high rates of drug mortalities and counties with a  high incidence of neonatal abstinence syndrome (NAS) or infants born  drug exposed. During the site visits we interviewed state CPS directors,  alcohol and drug abuse directors, and maternal and child health directors;  local CPS staff; and hospital staff, including hospital social workers. The  information gathered from interviews with officials from selected states  and localities is not generalizable to all states and localities and is meant  to provide illustrative examples.

To learn about the steps HHS has taken to assist and monitor states’  efforts in implementing CAPTA provisions related to substance-affected  infants, we reviewed relevant documents, federal laws and regulations,  guidance, and other information. In addition, we interviewed officials from  the Department of Health and Human Services’ (HHS) Administration for  Children and Families (ACF) and the Substance Abuse and Mental  Health Services Administration (SAMHSA) about oversight, technical  assistance, and guidance regarding CAPTA provisions related to  substance-affected infants. We also interviewed officials from the National  Center on Substance Abuse and Child Welfare—the technical assistance  provider under contract with HHS.

We conducted this performance audit from June 2016 to November 2017  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Child Abuse Prevention and Treatment Act

CAPTA, originally enacted in 1974, provides formula grants to states to  improve child protective service systems. ACF administers the CAPTA  state grant program and provides guidance and oversight to states. In  fiscal year 2017, Congress provided about $25 million for the program.

As part of the CAPTA state grant program, states are required to submit  to the Secretary of HHS plans outlining how they intend to use CAPTA  funds to improve their child protective service systems, among other  things. State plans remain in effect for the duration of states’ participation  in the grant program; if modifications are needed, these must be  submitted. In addition to state plans, states are required to submit to HHS  an annual data report providing information on agency decisions made in  response to referrals of child abuse and neglect, as well as preventive  services provided to families, among other things.

CAPTA requires state governors to provide a series of assurances in their  state plans. Since 2003, governors have had to provide an assurance that  states have in effect and are enforcing a state law or program that  includes policies and procedures to address the needs of infants affected  by prenatal substance abuse or displaying withdrawal symptoms at birth.  Under states’ policies and procedures, health care providers are required  to notify CPS of such infants. Governors must also assure that a plan of  safe care is developed for these infants. Although CAPTA does not define  “plans of safe care,” for the purposes of this report we define them as  plans to ensure the safety and well-being of infants who are born  substance-affected.

The Comprehensive Addiction and Recovery Act of 2016 (CARA)  amended certain provisions of CAPTA that relate to substance-affected  infants (see table 1).

In addition to provisions related to substance-affected infants, CAPTA  also requires governors to provide an assurance to the Secretary of HHS  that they have provisions or procedures for certain individuals to report  known and suspected instances of child abuse and neglect, which are  generally referred to as mandated reporter laws. All states have statutes  identifying persons who are required to report suspected child  maltreatment to an appropriate agency, such as child protective services,  a law enforcement agency, or a state’s toll-free child abuse reporting  hotline, according to a 2016 HHS report. Mandatory reporters often  include social workers; teachers, principals, and other school personnel;  physicians, nurses, and other health care workers; and counselors,  therapists, and other mental health professionals. The circumstances  under which a mandatory reporter must make a report vary from state to  state, according to HHS. Typically, a report must be made when the  reporter, in his or her official capacity, suspects or has reason to believe  that a child has been abused or neglected. State laws require mandatory  reporters to report the facts and circumstances that led them to suspect  that a child has been abused or neglected; they do not have the burden of  providing proof that abuse or neglect has occurred.

CPS, a division within state and local social services, is generally the  agency that conducts an initial assessment or investigation of reports of  child abuse and neglect. It also offers services to families and children  where maltreatment has occurred or is likely to occur. Typically, when  CPS agencies receive a notification about suspected child abuse,  including a substance-affected infant, social workers review the referral to  determine if it should be accepted for investigation. During an  investigation, social workers determine, among other things, the nature,  extent, and cause of abuse or neglect, and identify the person  responsible for the maltreatment. An investigation may include the  following: a visit to the hospital and/or infant’s home; observation of the  infant; risk and safety assessments; evaluation of the home environment;  background checks, including criminal record checks of adults that reside  with the family; as well as mental health evaluations.

If social workers determine that there is enough evidence to suggest that  an infant is at risk for harm or neglect, or that abuse or neglect occurred,  the case is substantiated. Once a case is substantiated, CPS develops a  case plan with the family outlining objectives and tasks for the family.  Among other things, CPS may refer the family to services in the  community, such as early intervention services, parenting classes, and  substance abuse treatment. Generally, CPS attempts to strengthen the  family and alleviate the problems which led to maltreatment. If the case is  not substantiated, but there is genuine concern about the child’s situation  and the family may benefit from services in the community, the case may  be closed and/or the family may be referred for voluntary services (see  figure 1).

Neonatal Abstinence Syndrome and Prenatal Drug Use

Prenatal maternal opioid use has increased considerably in recent years.  This increase has contributed to a significant rise in the rate of NAS.  According to a recent study, the rate of NAS has increased from 1.2 per  1,000 hospital births in 2000 to 5.8 per 1,000 hospital births in 2012,  reaching a total of 21,732 infants diagnosed with NAS.

NAS occurs with considerable variability. According to a recent HHS  report, various studies indicate that anywhere from 55 to 94 percent of  infants exposed to opioids in-utero exhibit some degree of symptoms.  Typically, infants with NAS develop symptoms within 72 hours of birth, but  may develop symptoms within the first 2 weeks of life, including after  hospital discharge. For the purpose of this report, infants exposed to  opioids ingested by mothers in utero are considered substance-exposed,  and those born negatively affected by exposure or experiencing  withdrawal symptoms are considered substance-affected. According to  experts, NAS is considered an expected and treatable result of women’s  prenatal opioid use.

Opioid exposure during pregnancy may occur for the following reasons:

Women receiving pain medication with a prescription under the care  of a physician. Medications can include fentanyl and oxycodone.

Women under the care of a physician and undergoing treatment for  an opioid use disorder with medications, such as methadone or  buprenorphine. This type of treatment is generally referred to as  medication-assisted treatment (MAT).

Women misusing opioid pain medications with or without a  prescription (such as using without a prescription, using a different  dosage than prescribed, or continuing to use a drug when no longer  needed for pain).

Women using or abusing illicit opioid, such as heroin.

Most States Reported Having Policies About Notification and Investigation of Substance-Affected Infants

State Policies Generally Require or Encourage Health Care Providers to Notify Child Protective Services of Substance- Affected Infants

In response to our survey, 42 states reported that state policies and  procedures require health care providers to notify CPS about substance- affected infants. Some states reported that they explicitly require health  care providers to notify CPS of substance-affected infants. For example,  Wisconsin reported that under its state law if tests indicate that infants  have controlled substances or controlled substance analogs in their bodily  fluids, the health care provider shall report the occurrence of that  condition to CPS.  Others reported that the requirement is met by their  states’ mandated reporter law—whereby people in certain positions,  including health care providers, are required to notify CPS about  substance-affected infants, similar to the manner in which other  mandatory reporters, like school teachers, day care personnel, and social  workers are required to report other instances of child abuse and neglect.  For example, Kentucky statute requires that “any person who knows or  has reasonable cause to believe that a child is dependent, neglected, or  abused shall immediately” make a report to the police or CPS. The  statutory definition for an abused or neglected child in Kentucky includes  situations where a child’s health or welfare is harmed or threatened with  harm because of parental incapacity due to alcohol and other drug abuse.

Of the 42 states that require health care providers to notify CPS of  substance-affected infants, 21 reported that notification is required for  infants affected by both illegal and legal use of opioids. For example, in  Massachusetts health care providers are required to notify CPS orally  and, in writing within 48 hours, about substance-affected infants  physically dependent on drugs, even if the drugs were legally obtained  and the mother is under the care of a prescribing medical professional.  Sixteen of the 42 states reported that health care providers are required  to notify CPS of infants affected only by the illegal use of opioids, and five  of the 42 states reported that they did not know if health care providers  were required to notify CPS of infants affected by the illegal and legal use  of opioids.

The other eight states reported that although they did not have policies  and procedures that require health care providers to notify CPS about  substance-affected infants, they have laws or policies that encourage  notification. Specifically, in written responses to our survey:

Two states reported that under their state mandated reporter laws  health care providers are encouraged, but not required, to notify CPS  about substance-affected infants.

Four states reported that they are working to amend their states’  policies and procedures to require that health care providers refer  substance-affected infants to CPS.

Another state reported that it encourages the notification from health  care providers, but has not sought legislation to require health care  providers to report substance-affected infants to CPS because of  concerns that any laws that criminalize prenatal substance use would  further deter substance-using pregnant women from seeking prenatal  care. The state’s law requires all hospital personnel who suspect  abuse and neglect or observe conditions that are likely to result in  abuse or neglect to notify CPS.

One state reported that all persons, including health care providers,  are required to report child abuse and neglect, but reporting depends  on whether a hospital’s policy indicates substance abuse is child  abuse or neglect. Further, the state CPS director reported  collaboration with the health care community on reporting substance  exposed infants to its child abuse hotline.

Although one state reported in our survey that it does not require or  encourage health care providers to notify CPS about substance-affected  infants, in an interview, state officials explained that its policy requires that  health care providers notify CPS if, through an assessment, they  conclude that infants are at risk for abuse and neglect. Under the state’s  law, health care providers in each county are required to assess the  needs of mothers and substance-affected infants using a protocol  established by county health departments, CPS agencies, and hospitals.  State officials told us that under the state’s law, the birth of a substance- affected infant is not in and of itself a sufficient basis for reporting child  abuse or neglect.

In addition to having policies and procedures regarding the reporting of  substance-affected infants, in written responses to our survey some  states reported providing training and guidance to support the efforts of  health care providers to notify CPS about these infants. Three states  reported that they offer mandatory reporter training to inform health care  providers that they are obligated to notify CPS about substance-affected  infants. Another state reported that its Department of Human Services  developed a guide for mandated reporters that discusses what needs to  be reported and where to make reports. Also, one state reported that it  sent a formal letter to its state hospital association about how to report  substance-affected infants to CPS. This state also sent a memo to its  CPS county directors instructing them to contact their local health care  providers on the importance of reporting substance-affected infants to  CPS and the process for doing so. In addition, during our Massachusetts  site visit, officials shared with us a memo that was sent to mandated  reporters, community partners, and other stakeholders that offered  guidance on when to file a report about substance-exposed infants.  Further, local CPS staff at one Massachusetts field office told us that  upon request they provide mandated reporter training to health care  providers.

Despite these policies, procedures, and guidance, in written responses to  our survey, a few states reported concerns about requiring health care  providers to notify CPS about substance-affected infants and the  definition of substance-affected. All of the hospitals that we visited have  policies consistent with their state’s law that require that health care  providers, primarily hospital social workers, to notify CPS about  substance-affected infants. However, one state reported that some  medical personnel have been reluctant to report some infants that are  positive for illegal and legal substances due to fears of mothers being  arrested. Another state reported that stakeholders are concerned that  having to notify CPS about substance-affected infants will have a chilling  effect on the willingness of pregnant women who use substances to be  honest with providers and seek the help and support they need and  deserve. According to one state, there is often an inherent resistance to  contacting CPS in these cases as health care providers tend to view child  welfare involvement as punitive rather than a potential resource for the  family.

In addition, three states reported in written responses to our survey  challenges understanding how to define terms, such as substance- affected, under CAPTA. For example, the Pennsylvania CPS director  expressed concerns during our site visit, suggesting that CAPTA raises  many unanswered questions, such as (1) if “affected by substances”  means at-risk of being or physically affected by substances, (2) what  policies relating to substance-affected infants should look like and  include, and (3) whether “affected by substances” should include women  who are under the care of health care or treatment providers and taking  their medications as prescribed. A Kentucky public health official told us  that a drug test, or whether the infant is affected by legal or illegal  substances, should not be the sole factor in determining CPS’  involvement with a family. Rather, a holistic view of the family, whether  the substance prohibits the mother’s ability to care for her child, and any  risk factors present that places the infant at risk should also be  considered. According to officials, an infant that is exposed to  substances, but has not been affected by the substance, can still be at  risk for child abuse and neglect.

States Reported Having Policies That Guide Decisions About Investigating Substance- Affected Infants and Their Families

In response to our survey, 46 states reported that they have policies and  procedures for deciding which notifications about substance-affected  infants are accepted for investigation. Seventeen of those states reported  that all notifications of substance-affected infants are accepted for  investigation, regardless of the circumstances. The remaining 29 states  reported that they apply specific criteria to determine if children who  present as substance-affected are accepted for investigation by CPS.

Several states reported in written responses to our survey that they  base their criteria for accepting notifications on the infant’s safety. For  these states, drug exposure does not by itself indicate that an infant’s  safety is at risk. For example, one state explained that in determining  a child’s safety risk, staff evaluate a number of factors including the  history of the family; the family’s presentation at the birthing hospital  (appearance of chaotic behavior, suspected intoxication of adults, lack  of appropriate concern or bonding with the infant); the presentation of  the infant’s physical condition; the results of any testing of parent or  child (blood, urine, etc.); discrepancies identified in the parent’s  representation of their substance use or substance use treatment; and  any other concerns noted by the reporting source.

Other states reported that their criteria for accepting notifications for  investigation are based on the degree or type of drug exposure in  question. For example, one state reported that its policy directs CPS  agencies to accept notifications for investigation when a parent has  used illegal substances or non-medical use of prescribed medication  during the last trimester of pregnancy. Another state reported that it  will accept notifications for investigation if the infant is born with a  positive toxicology or is experiencing drug withdrawal, or if the mother  tests positive for substances.

A few states reported using both risk to the safety of infants as well as  degree or type of drug as their criteria for accepting notifications. For  example, one state reported that it considers factors, such as the type  of drug, the parent’s ability to care for the child, addiction history, and  the parent’s readiness and preparation to care for the infant.

In follow-up correspondences with states that reported that they do not  have policies and procedures to decide whether to accept for  investigation notices about substance-affected infants, one state reported  that decisions are made on a case-by-case basis.

A few states reported that after receiving notifications about substance- affected infants, CPS agencies may decide to opt out of investigating  some families, referred to as “screening out” families. For example, in  Massachusetts, CPS can “screen out” referrals of mothers if the only  substance affecting the infants was used by the mothers as prescribed by  their physician. In these instances, when CPS in Massachusetts is  notified by the hospital about an infant, the screener gathers information  from the caller and consults with a supervisor to determine whether the  referral should be accepted for investigation or screened out. If the  mother is on methadone, for example, but is involved with services and is  in a treatment plan, CPS verifies with medical or other qualified providers  that the mother used the drug as part of substance abuse or medical  treatment as authorized. Additionally, CPS confirms that there are no  other concerns of child abuse and/or neglect. If CPS officials in  Massachusetts are unable to collect all the information that they need to  screen out families, for example when a mother does not sign a release  allowing CPS officials to speak with her health care providers,  notifications about substance-affected infants are accepted for  investigation.

Most States Reported Having Requirements to Develop Plans of Safe Care, but Officials We Interviewed Reported Challenges Meeting the Needs of All Families States Reported That CPS Agencies Develop Plans to Primarily Address Infants’ Immediate Safety and Medical Needs and Caregivers’ Substance Use

In response to our survey, 49 states reported that their CPS agency has  policies to develop a plan to ensure the safety and well-being of  substance-affected infants who meet the state’s criteria for investigation.  Two states reported that CPS staff are not required to develop such a  plan, even if a notification is accepted for an investigation or an  assessment. For purposes of this report, we are defining a plan of safe  care as a plan to ensure the safety and well-being of the infant. States’  approaches to identifying children and families who will receive a plan of  safe care generally fall into two categories:

38 states reported that CPS is required to develop a plan of safe care  for all notifications of substance-affected infants that are accepted for  investigation, including those that are not substantiated.

11 states reported that CPS staff are required to develop a plan of  safe care only in those instances where an investigation substantiates  the notification or uncovers an unmet need or present or emerging  danger. For example, local Pennsylvania CPS officials told us that  they only develop plans when there is a safety threat or other concern  about the infant.

Most states reported that after a notification of a substance-affected infant  is accepted for investigation, CPS always conducts a needs assessment  for the infant and caregivers. For example, one local CPS office that we  visited told us that social workers assess risk to and safety of infants, their  function (development, age appropriate behavior, etc.), and environment.  In addition, workers assess the caregiver’s ability to parent and  employment status, as well as housing. The assessments conducted as  part of the investigation inform the development of plans of safe care, as  well as decisions about the removal of infants from the home.

Among the 49 states that reported that plans of safe care are developed  for all or some substance-affected infants, 47 reported that these plans  either always or sometimes address infants’ safety needs. Plans also  address other needs, such as infants’ immediate medical and longer-term  developmental needs, as well as caregiver’s substance use treatment  needs. See figure 2 for the number of states whose plans of safe care  address various issues facing the infant and parent.

In written responses to our survey and during our site visits, officials  reported that plans of safe care and referrals for services included in the  plans are individualized based on the infant and family’s needs. For  example, Massachusetts state CPS officials told us that plans of safe  care are developed for each family based on the information that staff  collect from the safety, risk, and family assessments, as well as  information collected from individuals who may have knowledge that  would inform the family assessments, such as medical and treatment  providers, and family members. Kentucky state CPS officials told us that  the local organizations and service providers that they collaborate with to  develop the plan of safe care also vary based on the family’s needs. For  example, Kentucky will only collaborate with substance use treatment  providers to develop the plan of safe care when families have substance  use disorders.

Similarly, during our site visits, officials from two states told us that the  decision to place an infant in foster care is based on the individualized  needs of the infant and caregiver. For example, Massachusetts state  officials told us that their decision to remove a baby from the home  depends on a myriad of factors and is determined on a case-by-case  basis. Officials explained that if a mother is discharged from the hospital  and begins using drugs again and does not have adequate supports in  place to care for her baby, CPS may decide to place the infant in foster  care. However, if a mother has existing support systems in place to  mitigate safety risks, CPS may decide to keep the baby in the home.

In our survey, all 51 states reported that their agencies either always or  sometimes refer parents or caregivers to substance use treatment  programs, and most states reported that they always or sometimes refer  parents or caregivers to parenting classes or programs (49), and other  supportive services (49). CPS officials in each of the three states that  we visited told us that their plans of safe care include referrals to address  not only the immediate needs of the infants, but also the needs of the  parent or caregiver. For example, officials from a local Kentucky CPS  agency told us that staff refer mothers of substance-exposed infants to a  program called Sobriety Treatment and Recovery Team (START).  START is comprised of a social worker and a peer support mentor who  has at least 3 years of sobriety, previous involvement with CPS, and was  successfully able to regain or keep custody of her own children.  According to officials, the START program has been able to provide  participants with quick access to substance use disorder treatment.

Officials from a Massachusetts local CPS agency told us that one of the  services that they provide to parents of substance-affected infants is a  parent aide who can help monitor how the parent is caring for the infant,  such as administering the infant’s medications appropriately and ensuring  the parent is not abusing the infant’s drugs. In addition, a parent aide can  provide emotional support and help parents adjust after the infant is  discharged from the hospital. Kentucky officials noted the effect that a  healthy caregiver has on the outcome of the infant and emphasized that a  baby cannot be healthy if the mother is not. Kentucky CPS officials said  that they have found that the earlier caregivers enter treatment, the better  the outcomes are for mothers and babies. According to Kentucky officials,  parents who participate in the START program are less likely to have their  child placed in foster care.

CPS Officials Reported Challenges Involving Caseloads, Developing Plans, and Confidentiality Restrictions

Officials from the states that we visited told us that developing and  monitoring plans of safe care under CAPTA’s new requirements for  infants affected by their mother’s legal use of prescribed medications, as  well as plans for these infants’ caregivers, present challenges.  Specifically, officials reported concerns about increased caseloads,  particularly if they are required to provide plans and services for infants at  low risk of abuse or neglect, the content of plans, and confidentiality  restrictions.

Thirty-one of 50 states reported on our survey that staffing or resource  limitations was very or extremely challenging, and CPS officials across  the 3 states we visited said that the opioid epidemic has directly  contributed to increased caseloads. According to a local Kentucky CPS  office, the number of babies that met criteria for being accepted for  investigation has increased about 55 percent from 2011 to 2016, while  the number of staff has remained the same. Similarly, hospitals reported  being impacted by this challenge. For example, staff at four hospitals we  visited told us that they have delayed discharging infants from the hospital  because CPS social workers did not identify caregivers to whom infants  may be released or make plans for infants in a timely manner. In addition,  staff from three hospitals told us that some CPS workers are difficult to  contact and not especially responsive to their questions. One hospital  social worker told us that she is concerned that the changes to CAPTA  that require notifying CPS of all substance-affected newborns will  inundate the agencies with cases.

Officials from two of the three states we visited anticipated that providing  services to infants affected by the legal use of prescribed medications,  but not likely to be at risk for child abuse and neglect, will result in an  increase in the number of families referred to CPS. This, in turn, will  require a plan of safe care and further strain limited resources. Twenty- five states reported in our survey that the plan they develop for  substance-affected infants is the same as for other children in CPS care,  suggesting that states devote the same level of resources to these infants  as other cases.

The states we visited interpret CAPTA to require that plans of safe care  be developed for all substance-affected infants who are referred to CPS,  including those who may not meet usual criteria to be accepted for an  investigation. Some state officials we interviewed questioned whether the  new CAPTA requirements would allow for the best use of limited  resources. For example, one senior state CPS official questioned whether  it would be a good use of resources to develop plans of safe care for  mothers in substance use disorder treatment or mothers using opioid  medications due to chronic pain. A local CPS official we interviewed  stated that drug exposure, in and of itself, is not necessarily a safety risk,  and CPS should not intervene with families who are not at risk for child  abuse or neglect. Instead, hospitals or treatment providers should  intervene and refer families who do not meet criteria for CPS involvement,  but could benefit from additional supports, to voluntary services. Kentucky  public health officials told us that the period after a woman gives birth is a  critical time for families as mothers may be stressed, sleep-deprived,  exhausted, and may have other children in the home. This period may be  especially challenging for mothers with substance use disorders, if  adequate supports are not in place. According to officials women are  typically covered for substance use treatment during pregnancy; however,  this coverage ends roughly 60 days after the baby is born.

In written responses to our survey, some states reported that they would  rely on other agencies to develop plans of safe care. Similarly, in order to  manage limited CPS resources, officials from two of the three states that  we visited said they are considering having hospitals or other agencies  assume responsibility for developing plans of safe care when there is no  evidence of abuse or neglect and there appears to be minimal risk to the  safety and well-being of the infant. Kentucky officials told us that they  envision that CPS will be responsible for developing a plan of safe care  for notifications that are accepted for investigation, while hospitals, or  another agency, will be responsible for developing plans of safe care for  referrals that are screened out by CPS. According to CPS state officials,  the plan of safe care for the infant and the family can be part of the  discharge plan prior to the family leaving the hospital. However, officials  reported that obtaining cooperation from other agencies may be difficult.  Some state officials reported being concerned that other agencies may  not feel obligated to develop these plans, in part, because CAPTA  provides funding to child welfare, and other agencies may therefore  believe that child welfare should be responsible for developing the plan of  safe care.

Determining What to Include in the Plan of Safe Care

CPS officials we interviewed in two of our site visit states, as well as one  state we followed up with, told us that they were unsure of whether their  current plans will meet new CAPTA requirements because CAPTA does  not define a plan of safe care. For example, Massachusetts officials said  that their plans include everything that a family might need to ensure the  safety of the child, including resources to ensure stabilization and  reunification of a family, but they are not sure whether the plans meet  new CAPTA requirements, in part because they are not familiar with the  term “plan of safe care.” An official in another state was also unsure about  whether his state’s “safety plans” would meet CAPTA requirements.  According to the official, safety plans may include a treatment plan for  mothers, and referral services, such as early intervention for the child. In  practice, plans of safe care generally address gaps that place an infant at  risk for harm or neglect. However, state officials we interviewed reported  being unsure about what a plan of safe care should look like for families  where these gaps do not exist. Also, in a written response to our survey,  one state expressed uncertainty about CPS’ role if required to work with  infants who do not typically receive CPS services. For example, a  Pennsylvania official said that it is unclear what types of interventions  child welfare should conduct with families of infants exposed to legal  substances, such as medications prescribed by doctors, when the  caregivers are taking their medications correctly.

Similarly, officials also questioned whether a plan would be necessary,  and what the plan would entail, for caregivers who are already addressing  their substance use disorder and taking steps to ensure their infant’s  safety. Officials from a local Kentucky CPS office described a case in  which a mother was participating in medication-assisted treatment, had  attended counseling three times per week throughout her pregnancy, and  was continuing treatment in the postpartum period. Through CPS’  investigation, the agency found that the case was not substantiated, in  part, because there were no additional services that CPS could connect  her with that she was not already receiving.

Officials across the three states we visited also said that state and federal  drug and alcohol confidentiality restrictions may challenge their ability to  monitor plans of safe care. To monitor plans of safe care, CPS staff may  need access to confidential information in order to know how caregivers  are progressing in treatment, particularly now that these plans must  address the substance use disorder needs of the caregiver. However,  federal law restricts the disclosure and use of alcohol and drug patient  records maintained in connection with the performance of any federal- assisted alcohol and drug abuse program. Generally, confidential  information may be disclosed in accordance with the prior written consent  of the patient. State and local CPS staff we interviewed said that strict  confidentiality requirements make it challenging for drug and alcohol  treatment providers to share information about mothers and infants. A  CPS state director from Pennsylvania said that treatment providers are  often reluctant to provide CPS case workers with information or updates  on a mother’s treatment, which prevents child welfare workers from fully  understanding how mothers are progressing with their treatment and the  extent to which those in treatment are adhering to prescribed directions  as outlined by treatment providers.

In addition, one official from a state we visited said state statutes  regarding sharing of drug and alcohol treatment information may be more  restrictive than the federal statute. Some states have developed ways to  obtain confidential information about mothers in substance use disorder  treatment. For example, officials from one local CPS office told us that in  instances when they have to develop a long-term plan of safe care for  families, they have mothers sign a release of information form in order to  obtain updates about her treatment adherence from the medication- assisted treatment provider. Similarly, a local Massachusetts CPS office  told us that typically staff obtain releases from mothers so that they can  verify whether mothers are actively participating in their treatment and  that there are no records of relapse.

Although HHS Has Provided Technical Assistance and Guidance to Assist States’ Efforts to Implement CAPTA, States Want More Help

HHS Provided Technical Assistance Through a Resource Center and ACF Issued Formal Guidance and Began Its Oversight Efforts

In HHS’ role to assist states in the delivery of child welfare services, two  agencies—ACF and the Substance Abuse and Mental Health Services  Administration (SAMHSA)—provided technical assistance to states  through the National Center on Substance Abuse and Child Welfare  (NCSACW). In addition, in ACF’s role to administer and monitor states’  implementation of CAPTA, the agency has provided some guidance to  states on the provisions pertaining to substance-affected infants and has  begun its monitoring responsibilities.

ACF and SAMHSA, which leads public health efforts to reduce the impact  of substance abuse and mental illness, established the NCSACW in  2002. The NCSACW provides technical assistance to states, and has  issued publications and hosted forums to help states develop policies and  procedures around issues affecting substance-affected infants. The  technical assistance has focused on a broad range of issues, including  collaboration among service providers, and plans of safe care. With  respect to collaboration, NCSACW has issued several studies that  identify opportunities for strengthening interagency efforts to prevent,  intervene, identify, and treat prenatal substance exposure. The NCSACW  collaboration guides encourage states to involve CPS agencies with  medical providers in an interagency collaborative setting, thereby  facilitating the process for CPS agencies to be notified of substance- affected infants. Regarding plans of safe care, NCSACW has provided  technical assistance and best practices to states around development of these plans. For example, in one state it has facilitated discussion groups  to help the state develop a model plan.

From calendar year 2011 to 2016, NCSACW processed approximately  600 requests from state CPS agencies for short-term technical assistance  related to improving care for substance-affected infants and their families.  This short-term technical assistance included activities such as  responding to telephone inquiries, mailing information, identifying needed  resources, and making referrals. The NCSACW has also provided in- depth assistance to 16 states to strengthen collaboration and linkages  across child welfare, addiction treatment, medical communities, early care  and education systems, and family courts to improve outcomes for  substance-affected infants and their families. Through this in-depth  assistance, NCSACW identified areas for improvement in states,  including a lack of clarity regarding compliance with CAPTA requirements  (such as identification, notification, and developing plans of safe care)  and the need for state models to comply with CAPTA requirements to  develop plans of safe care. In one state, the project overview report  indicated that a next step for the in-depth technical assistance is to  continue development of the plan of safe care model and ensure  practices and protocols are in place across systems to meet CAPTA  requirements. The report indicated that this will include ongoing work with  hospitals to ensure consistent identification of infants with prenatal  exposure and notifications to CPS.

Although18 states reported in our survey that technical assistance from  the NCSACW was very or extremely helpful, 11 reported that it was  moderately helpful, 7 reported that it was slightly helpful, and 1 reported  that it was not at all helpful. Eleven states reported that they were not  familiar with this assistance.

Since July 2016, when the most recent amendments to CAPTA were  enacted, ACF has issued one information memorandum and two program  instructions to states about provisions relating to substance-affected  infants. According to an ACF official, information memoranda share  information with states, while program instructions provide interpretations  of the law and inform states of actions they must take. ACF issued an  August 2016 information memorandum informing states of the 2016  amendments to CAPTA. The August 2016 information memorandum also  provided states with best practices, drawing on an NCSACW guide on  collaboration for developing multi-systemic approaches to assist child  welfare, medical, substance use disorder treatment, and other systems to  support families affected by opioid use disorders.

In January 2017, ACF issued a program instruction which provided  guidance to states on implementing the 2016 amendments to CAPTA  made by CARA and informed states of the flexibilities that they have  under the law. Particularly, the guidance noted that:  “CAPTA does not define ‘substance abuse’ or ‘withdrawal symptoms  resulting from prenatal drug exposure.’ We recognize that by deleting  the term ‘illegal’ as applied to substance abuse affecting infants, the  amendment potentially expands the population of infants and families  subject to the provision [that states have policies and procedures in  place to address their needs]. States have flexibility to define the  phrase, ‘infants born and identified as being affected by substance  abuse or withdrawal symptoms resulting from prenatal drug  exposure,’ so long as the state’s policies and procedures address the  needs of infants born affected by both legal (e.g., prescribed drugs)  and illegal substance abuse.”  “While CAPTA does not specifically define a ‘plan of safe care,’ CARA  amended the CAPTA state plan requirement . . . to require that a plan  of safe care address the health and substance use disorder treatment  needs of the infant and affected family or caregiver.”  “CAPTA does not specify which agency or entity must develop the  plan of safe care; therefore the state may determine which agency will  develop the plans. We understand that in most instances the state  already has identified the responsible agency in its procedures. When  the state reviews and modifies its policies and procedures to  incorporate the new safe care plan requirements in CARA, the state  may wish to revisit its procedures regarding which agency develops  the plan of safe care, including any role for agencies collaborating  with CPS in caring for the infant and family.”

In addition, in April 2017, ACF issued a program instruction on reporting  requirements, including changes in those requirements brought about by  the 2016 amendments to CAPTA.

ACF conducted limited monitoring of states prior to the amendments  passed in 2016. According to ACF officials, if presented with evidence of  potential deficiencies, the agency would attempt to learn more about the  state’s activities. In one instance, ACF reviewed South Carolina’s policies  and found them to not be in compliance with the notification and safe care  plan requirements of CAPTA. It directed the state to develop a program  improvement plan to bring it into full compliance, which South Carolina  submitted in April 2016. In a recent progress report (February–April  2017), South Carolina reported that it was focused on updating statutes,  developing policies and procedures, training child protective service  workers, and building relations with health care providers.

In response to the 2016 amendments to CAPTA that added the  requirement for HHS to monitor state policies and procedures to address  the needs of substance-affected infants, ACF officials told us that staff in  regional offices will review states’ annual reports, submitted in June 2017.  In its program instruction describing the reporting requirements, ACF  asked each state to submit a new Governor’s Assurance, as well as a  narrative explaining what they have done in response to the  amendments. Specifically, ACF asked states to provide information on  any changes that were made in state laws, policies, or procedures related  to identifying and referring infants affected by substance abuse to CPS as  a result of prenatal drug exposure. It also requested updates on states’  policies and procedures regarding the development of plans of safe care;  a description of how states have developed systems to monitor plans of  safe care; and a description of any outreach or coordination efforts the  states have taken to implement the amendments, among other things.  According to ACF officials, as of October 1, 2017, some states have  provided information and a Governor’s Assurance demonstrating  compliance with the amended provisions and some states have been  placed on Program Improvement Plans, but the agency does not yet have  information on the status of all states. An ACF official explained that, in  their annual reports, some states either acknowledged that they are trying  to get legislation enacted to bring them into compliance with the law and it  has failed, or that they are not in compliance, for example, because they  were limiting their policies to those infants affected only by illegal  substances.

In addition, in May 2017, ACF issued a technical bulletin informing states  of the new data collection requirements that resulted from the 2016  amendments to CAPTA. ACF stated that it intends to collect data required  by the amendments to CAPTA through the National Child Abuse and  Neglect Data System, beginning with states’ submission of fiscal year  2018 data. This system is maintained by ACF and contains data from  states about children who have been abused or neglected. ACF issued a  Federal Register notice about the proposed data elements and requested  comments on the accuracy and quality of the proposed data collection,  among other things; the comment period closed in July 2017. In the  Federal Register notice, ACF notes that the 2016 amendments to CAPTA  require it to collect information from state CPS agencies on the number of  notifications from health care providers that are accepted for investigation  or screened out. Further, of those infants screened in, ACF is required to  collect data on the number of safe care plans developed for substance- affected infants as well as the number of infants for whom a referral was  made for appropriate services, including services for the affected family or  caregiver. In the Federal Register notice, ACF proposed to collect this  information using a combination of existing and new data from states.

Thirty-two states reported in our survey that they already collect data on  the incidence of substance-affected and/or substance-exposed infants; 15  of those 32 states also collect data on the incidence of NAS. Further, 18  states reported that they collect data on the number of notifications health  care providers make to CPS. Of those states, 8 reported that they collect  specific data on notifications related to infants diagnosed with NAS.

States Reported the Need for Additional Guidance and Assistance from HHS to Address Implementation Challenges

Most states reported in our survey that additional guidance and  assistance would be extremely or very helpful (see figure 3). For  example, 38 states reported that additional guidance on requirements for  health care providers to notify CPS of substance-affected infants would  be extremely or very helpful. Similarly, 37 states reported that additional  guidance on developing, implementing, and monitoring plans to ensure  the safety and well-being of substance-affected infants would be  extremely or very helpful.

In written responses to our survey, states suggested ideas for additional  guidance, training, and technical assistance to help them address the  needs of substance-affected infants. States’ suggestions ranged from  assisting in the development of substance abuse training curriculum for  staff to video conferences with other states to share information about  implementing CAPTA. A few states suggested that the guidance ACF has  provided to date is not clear and reported grappling with the meaning of  terms such as “affected” and “legal vs. illegal” substances, and two states  requested “concrete guidance” and “specificity.” A few other states  suggested that it would be helpful to obtain additional information about  meeting the requirements of plans of safe care within the constraints of  state and federal confidentiality laws, technical assistance on what plans  of safe care look like, and a format for a plan of safe care.

ACF officials told us that states have flexibility with implementing the law  and the agency does not anticipate issuing additional written guidance on  the amendments to CAPTA made by CARA. ACF officials explained, in  October 2017, that they were finalizing their review of the plans that  states were required to submit. These plans are expected to include  details on how the states are addressing the CAPTA requirements. While  ACF could not provide the number, officials reported that some of the  state plans submitted to date did not meet the requirements and those  states have been asked to develop program improvement plans. They  expect states to work with the ACF regional offices, which will provide or  facilitate technical assistance to states on their implementation of the  provisions, as needed. In addition to the review of state plans, ACF  officials explained that regional officials may learn about states’ needs for  technical assistance through meetings or informational exchanges.

Finally, the NCSACW is expected to review and prepare a summary of  CAPTA state plans, current state statutes and policies and procedures  relating to amended CAPTA requirements. In addition, according to ACF,  NCSACW will continue to offer technical assistance on the development  and implementation of plans of safe care to states. Technical assistance  may include responding to requests for information, disseminating written  materials and resources, and conducting webinars/conference calls.  Further, ACF reported that some states will receive more in-depth  technical assistance, albeit in some instances on a time-limited basis.  Undertaking these actions can enhance states’ understanding of CAPTA  requirements and better address known challenges such as the ones  described in this report. However, more specific guidance from HHS on  the issues which states have expressed confusion can assist them in  better understanding CAPTA requirements and providing more effective  protections and services for the children and families most in need.

The opioid epidemic has generated a significant increase in the number  of substance-affected infants born and diagnosed with NAS. These  vulnerable infants may be at risk for child abuse and neglect if adequate  supports and services are not available to ensure their safety. CAPTA  requires states to have policies and procedures to address the needs of  these infants and their families, including mothers with a substance use  disorder. However, states have experienced challenges implementing  new CAPTA requirements. Many states reported in our survey that they  are not completely adhering to the law. This is reflected in ACF’s review  of state plans, some of which are resulting in program improvement  plans. States cite challenges that stem, in part, from ACF’s lack of  specificity in providing guidance on implementing CAPTA requirements.  Specifically, states report that ACF has not provided clear guidance about  which substance-affected infants health care providers are required to  notify CPS about, as well what a plan of safe care is and for whom it  should be developed. Given the challenges that states reported facing in  implementing the provisions, a majority reported wanting more help from  ACF, such as trainings and teleconferences with other states, to help  overcome their challenges. Additional guidance and assistance from HHS  would help states better understand what they need to do to develop  policies and procedures that meet the needs of children and families  affected by substance use.

The Secretary of HHS should direct ACF to provide additional guidance  and technical assistance to states to address known challenges and  enhance their understanding of CAPTA requirements, including the  requirements for health care providers to notify CPS of substance- affected infants and the development of a plan of safe care for these  infants.

We provided a draft of this report to HHS for review and comment. HHS’s  comments are reproduced in appendix I. HHS also provided technical  comments, which we incorporated into our report where appropriate.

HHS did not concur with our recommendation. HHS stated that:  in January 2017, ACF clarified in guidance several of the issues  raised in the report, including the population of infants and families  covered by the provision and the state flexibility inherent in  determining which infants are “affected by” substance abuse, and the  terminology used in the federal law of what a “plan of safe care” is;

ACF believes it is necessary to allow states the flexibility to meet the  requirements in the context of their state CPS program; several of the challenges that the GAO notes are not specific to  CAPTA compliance with the safe care plan and notification  requirements; and  it does see the value in continuing to provide technical assistance to  states to address known challenges and to enhance their  understanding of CAPTA requirements.

With respect to HHS’ January 2017 guidance, state officials reported in  our survey and during site visits that they found some terms unclear and  were uncertain about what is required of them. In written responses to our  survey, states reported challenges understanding how to define  substance-affected under CAPTA. In addition, as we note in our report,  the guidance about plans of safe care described the following: “While  CAPTA does not specifically define a ‘plan of safe care,’ CARA amended  the CAPTA state plan requirement . . . to require that a plan of safe care  address the health and substance use disorder treatment needs of the  infant and affected family or caregiver.” States reported in our survey and  in follow-up discussions that this lack of specificity remained an ongoing  challenge for them. For example, as we discuss in our report, one state  that we followed up with in August 2017 was still unsure about whether its  safety plans would meet CAPTA requirements for plans of safe care. In  addition, as of October 2017, HHS confirmed that some state plans did  not meet CAPTA requirements and that the states were asked to develop  program improvement plans. Accordingly, a key ongoing challenge was  not addressed by the January guidance.

Regarding allowing states flexibility to meet CAPTA requirements, we  acknowledge in our report that HHS said that states have flexibility.  However, in our survey and site visits, states indicated that they would  find it helpful for HHS to provide them with greater specificity around  terms, including the degree of flexibility they are allowed. States added  that this would include parameters within which they can develop policies  and procedures that meet CAPTA requirements. We continue to believe  that additional guidance addressing these concerns would benefit states  and could be provided without imposing additional mandates.

Concerning HHS’ third point that some of the issues raised in the report  are not specific to CAPTA, the states we visited interpret CAPTA to  require that plans of safe care be developed for all substance-affected  infants who are referred to CPS. During our discussions with states and in  responses to our survey, state officials did not delineate which federal  requirement impacted their approach to serving children and families. As  stated in our conclusion, vulnerable infants may be at risk for child abuse  and neglect if adequate supports and services are not available to ensure  their safety.

Lastly, HHS indicated that it will continue to provide technical assistance  to states and fund demonstration sites to establish or enhance  collaboration across community agencies and courts. Although continuing  to provide technical assistance to states should be beneficial, our findings  demonstrate that additional guidance is also needed. For example, 38  states reported that additional guidance on requirements for health care  providers to notify CPS of substance-affected infants would be extremely  or very helpful. Similarly, 37 states reported that additional guidance on  developing, implementing, and monitoring plans to ensure the safety and  well-being of substance-affected infants would be extremely or very  helpful.

Overall, given the results of our review, we continue to believe our  recommendation is warranted. Effective implementation of our  recommendation should help states better implement protections for  children.

As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  appropriate congressional committees and the Secretary of Health and  Human Services. In addition, the report is available at no charge on the  GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or larink@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made key contributions to this report are  listed in appendix II.

Appendix I: Comments from the Department of Health and Human Services

Appendix II: GAO Contact and Staff Acknowledgments

Kathryn A. Larin, (202) 512-7215 or larink@gao.gov.

In addition to the contact above, Sara Schibanoff Kelly (Assistant  Director), Ramona L. Burton (Analyst-in-Charge), Kay E. Brown, Hannah  Dodd, Ada Nwadugbo, and Srinidhi Vijaykumar made key contributions to  this report. Also contributing to this report were Sandra L. Baxter, James  Bennett, Gina Hoover, Jessica Orr, Rhiannon Patterson, Jean McSween,  and James Rebbe.