Second Report

Case 2:11-cv-00084 Document 1079 Filed on 05/04/21 in TXSD Page 1 of 393
UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF TEXAS
CORPUS CHRISTI DIVISION
CIVIL ACTION NO. 2:11-CV-00084
05-04-2021
M.D.; bnf STUKENBERG, et al., Plaintiffs, v. GREG ABBOTT, et al., Defendants.
Janis Graham Jack Senior United States District Judge
SECOND REPORT OF THE MONITORS
Deborah Fowler and

Kevin Ryan, Monitors
MONITOR STAFF
Texas Appleseed Public Catalyst
Linda Brooke Lisa Alexander-Taylor

Viveca Martinez Megan Annitto
Nancy Arrigona Robin K. Coleman
Monica Benedict Eileen M. Crummy
Deborah L. Borman Jody Drebes
Clarice Rogers Frank Luby
Mahiri Moody Natalie Nunez
Shay Price Nadezhda MT Sexton
Cassie Davis Claudia C. Tahan
Adrian Gaspar Charmaine Thomas
Anna Farr Melea Weber
Beth Mitchell Aileen E. Williams
Victoria Foster Charlene E. Womack
Mary Graw Leary
Samatha Loewen
Yana Mayevskaya
Oliver Ponce
Timothy A. Ross
Diane Scott
Hanna Shaw
TABLE OF CONTENTS
I. INTRODUCTION & EXECUTIVE SUMMARY ................................................................. 8

A. SECTION IV. SCREENING, INTAKE, AND INVESTIGATION OF MALTREATMENT IN CARE
ALLEGATIONS ............................................................................................................................ 13
B. SECTION IV. ORGANIZATIONAL CAPACITY ....................................................................... 20
II. DEMOGRAPHICS OF CHILDREN IN PMC CARE ......................................................... 34
A. AGE, GENDER, AND RACE .................................................................................................... 34
B. LIVING ARRANGEMENTS AND LENGTH OF TIME IN CARE ..................................................... 36
C. LEVEL OF CARE ................................................................................................................. 39
D. GEOGRAPHIC LOCATION .................................................................................................... 39
E. SINGLE SOURCE CONTINUUM CONTRACTOR PRESENCE AND PLACEMENT OVERSIGHT ..... 39
III. OVERVIEW OF STATE DATA AND DATA SYSTEMS CHALLENGES.................. 41
A. FRAGMENTED DATA SYSTEMS ........................................................................................... 41
B. LIMITED FUNCTIONALITY .................................................................................................. 45
C. LIMITED VPN CAPACITY AND BARRIERS TO ACCESSING INFORMATION ........................... 50
IV. SCREENING, INTAKE AND INVESTIGATION OF MALTREATMENT IN CARE
ALLEGATIONS ........................................................................................................................... 51
A. REMEDIAL ORDER 3 ........................................................................................................... 51
Policy Changes and Updates about RCCI’s Secondary Screening of Allegations of Abuse or
Neglect .................................................................................................................................. 51
Change of Name for HHSC’s Residential Child Care Regulation ....................................... 52
DFPS Investigation of Allegations of Abuse or Neglect ...................................................... 53
Statewide Intake Performance .............................................................................................. 54
Background ............................................................................................................... 54
Statewide Intake Call Center Performance Analysis ................................................ 55
Methodology ......................................................................................................... 55
Volume of Calls to SWI........................................................................................ 55
Queue Times ......................................................................................................... 56
Handled Calls ........................................................................................................ 57
Abandoned Calls ................................................................................................... 58
Call Queues ........................................................................................................... 59
Calls by Day of the Week and Time of Call ......................................................... 59
DFPS Intake Screening and Maltreatment in Care Investigations........................................ 60
Data and Information Request and Production ......................................................... 60
Monitors’ Data and Information Request ............................................................. 60
DFPS Data and Information Production ............................................................... 61
Overview of Allegations in Referrals and Investigations for Maltreatment in Care 62
Intakes for PMC Children Referred to RCCI and CPI ......................................... 62
RCCI Intake Rates and Types of Abuse or Neglect Allegations .......................... 64
B. REMEDIAL ORDER 3: SCREENING AND INTAKE PERFORMANCE VALIDATION .................... 65
Methodology ......................................................................................................................... 65
1
Remedial Order 3 Secondary Screening Validation Results for RCCI and CPI .................. 69
RCCI Results ............................................................................................................ 69
CPI Intakes ................................................................................................................ 69
Remedial Order 3: SWI Original Screening Validation Results for Referrals
Assigned to HHSC ............................................................................................................ 69
Remedial Order 3: Maltreatment in Care Investigations .......................................... 70
Overview of RCCI Maltreatment in Care Investigations ..................................... 71
Methodology ......................................................................................................... 72
Remedial Order 3 Investigation Validation Results ............................................. 73
C. INVESTIGATIONS WITH SUBSTANTIAL TIME DELAYS AND GAPS CONTRIBUTING TO
DEFICIENCY ............................................................................................................................... 74
D. DEFICIENT INVESTIGATIONS FOR NEGLECTFUL SUPERVISION IN THE CONTEXT OF SELF-
HARM BY CHILDREN .................................................................................................................. 75
E. SUMMARY OF PERFORMANCE FOR RECEIVING, SCREENING AND INVESTIGATING
ALLEGATION OF MALTREATMENT ............................................................................................. 77
F. TIMELINESS OF RCC INVESTIGATIONS: REMEDIAL ORDERS 5 THROUGH 11; 16 AND 18
PERFORMANCE VALIDATION (DFPS)......................................................................................... 79
1. Recent Policy Changes ................................................................................................. 80
Data and Information Request and Production ..................................................................... 81
Remedial Orders 5 through 11; 16; and 18 Performance Validation (DFPS) ...................... 81
Methodology ............................................................................................................. 81
Remedial Order 5: Initiation within 24 Hours in Priority One Investigations .......... 84
Remedial Order 6: Initiation within 72 Hours in Priority Two Investigations ........ 85
Remedial Order 7: Timeliness of initial face-to-face contact with the alleged victims
in Priority One Investigations ........................................................................................... 87
Remedial Order 8: Initial Face-to-Face Contact with All Alleged Victims in Priority
Two Investigations within 72 Hours ................................................................................. 88
Remedial Order 9: ..................................................................................................... 89
Remedial Order 10: Completion of Priority One and Priority Two Investigations
within 30 Days .................................................................................................................. 90
Remedial Order 11: DFPS Track and Report Requirement...................................... 91
Remedial Order 16: Timeliness of Completion and Submission of Documentation in
Priority One and Priority Two Investigations ................................................................... 93
Remedial Order 18: Timeliness of Notification Letters to Referent and Provider ... 93
Summary ............................................................................................................................... 95
G. REMEDIAL ORDER B5 ........................................................................................................ 97
1. Background ................................................................................................................... 97
First Court Monitors’ Report Validation Findings ................................................... 97
Updates and Policy Changes Following the Monitors’ First Report ........................ 97
September 2020 Contempt Hearing & December 18, 2020 Contempt Order .......... 98
Updates and Policy Changes Following the Contempt Hearing ............................. 101
DFPS’ January 16, 2021 Certification of Compliance ........................................... 101
Data and Information Production........................................................................................ 102
Remedial Order B5 Performance Validation ...................................................................... 103
Methodology ........................................................................................................... 103
Performance Validation Results, Remedial Order B5 Case Read Results ............. 104
2
Summary ............................................................................................................................. 107

H. REMEDIAL ORDER 37 ....................................................................................................... 108
1. Background ................................................................................................................. 108
First Court Monitors’ Report Findings related to Remedial Order 37.................... 108
September 2020 Contempt Hearing & December 18, 2020 Contempt Order ........ 108
State’s Certification of Compliance ........................................................................ 110
Remedial Order 37 Performance Validation....................................................................... 111
Methodology ........................................................................................................... 111
Performance Validation Results ............................................................................. 111
Validation of Casework Notification .................................................................. 111
Home History Reviews ....................................................................................... 112
Verification of Home History Review Staffing .................................................. 114
State’s Remedial Order 37 Case Read Results ................................................... 120
Summary ............................................................................................................................. 122
V. ORGANIZATIONAL CAPACITY .................................................................................... 123
A. REMEDIAL ORDER 1: CPS PROFESSIONAL DEVELOPMENT TRAINING .............................. 123
1. Background ................................................................................................................. 123
First Court Monitors’ Report Performance Validation Findings ............................ 123
Policy Changes Following the Monitors’ First Report ........................................... 123
DFPS Updates to CPD Training ......................................................................... 123
SSCCs Providing Case Management Services ................................................... 126
2. Data & Information Request & Production ................................................................ 127
Monitors’ Data and Information Request ............................................................... 127
DFPS and SSCC Data & Information Production .................................................. 128
3. Remedial Order 1 Performance Validation................................................................ 131
Methodology ........................................................................................................... 131
Caseworkers Hired and Trained by DFPS .......................................................... 132
Caseworkers Hired by OCOK and 2Ingage ........................................................ 138
Summary ............................................................................................................................. 143
B. REMEDIAL ORDER 2: GRADUATED CASELOADS .............................................................. 143
DFPS Graduated Caseload Policy ...................................................................... 144
Data and Information Request and Production ................................................... 144
Remedial Order 2 Graduated Caseloads Results and Performance Validation: ..... 145
Methodology ....................................................................................................... 145
Remedial Order 2: Performance Validation Results ........................................... 146
Summary of Performance Validation ................................................................. 149
C. REMEDIAL ORDER 35, A-1, A-2, A-3, AND A-4: CASELOADS .......................................... 149
Background ......................................................................................................... 150
Data and Information Request and Production ................................................... 151
DFPS Data and Information Production ............................................................. 152
D. REMEDIAL ORDERS 35 AND A-4: CASEWORKER CASELOADS .......................................... 152
Methodology ....................................................................................................... 153
Remedial Order 35 and Remedial Order A-4: Performance Validation results . 154
Summary ................................................................................................................. 159
E. REMEDIAL ORDERS B1 TO B4: ......................................................................................... 159
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1. Background ............................................................................................................. 160

2. Data & Information Request & Production ............................................................ 160
a. Monitors’ Data and Information Request ........................................................... 160
b. DFPS and HHSC Data & Information Production ............................................. 161
c. Remedial Orders B-1 to B-4 Performance Validation ............................................ 161
d. Remedial Orders B1 – B4 Performance Validation Results ................................... 162
RCCI Caseloads .................................................................................................. 162
RCCI Interviews ................................................................................................. 166
RCCR Caseloads................................................................................................. 167
RCCR Interviews ................................................................................................ 172
Summary ............................................................................................................................. 173
VI. PREVENTING SEXUAL ABUSE AND CHILD-ON-CHILD SEXUAL AGGRESSION
175
A. REMEDIAL ORDER 32: POLICY CREATION & TRAINING OF STAFF RESPONSIBLE FOR MAKING
................................................................................................................................................. 177
1. Determinations ............................................................................................................ 177
Background ......................................................................................................................... 177
Court Monitors’ First Report Performance Validation Findings ............................ 177
September 2020 Contempt Hearing ........................................................................ 178
Updates Following the Contempt Hearing ............................................................. 180
Remedial Order 32 Performance Validation........................................................... 181
1. Methodology ........................................................................................................... 181
2. Results of Performance Validation ......................................................................... 181
3. Summary ..................................................................................................................... 184
B. REMEDIAL ORDER 4: CASEWORKER AND CAREGIVER TRAINING ON SEXUAL ABUSE ...... 184
1. Background ................................................................................................................. 184
Policy ...................................................................................................................... 184
The Monitors’ Data Information Request ............................................................... 185
DFPS Data and Information Production for Caseworker and Caregiver Sexual Abuse
Training ........................................................................................................................... 187
2. Remedial Order 4: Caseworker and Caregiver Sexual Abuse Training Performance
Validation............................................................................................................................ 189
Caseworker Training Methodology ........................................................................ 189
Caseworker Training Performance Validation Results........................................... 190
Caregiver Child Sexual Abuse Training ................................................................. 191
Summary of Caseworker and Caregiver Sexual Abuse Training Performance
Validation........................................................................................................................ 192
C. REMEDIAL ORDERS 23, 24, 28, AND 30: TRACKING AND DOCUMENTING SEXUAL ABUSE
AND CHILD-ON-CHILD SEXUAL AGGRESSION .......................................................................... 192
1. Background ................................................................................................................. 193
Policy Changes Following First Report .................................................................. 193
The Contempt Order & DFPS’ Certification of Compliance ................................. 197
D. REMEDIAL ORDERS 23, 24, 28, AND 30 PERFORMANCE VALIDATION .............................. 198
1. Methodology ............................................................................................................... 198
4
Results of Performance Validation ..................................................................................... 199

Increase in Indicators for Sexual Abuse or Sexual Aggression .............................. 199
Sexual Abuse After Children Enter Foster Care ..................................................... 200
Case Review of Sexual Victimization History in Dispositions with Reason to
Believe ............................................................................................................................ 203
Summary ............................................................................................................................. 204
E. REMEDIAL ORDERS 25, 26, 27, 29 &31: CAREGIVER NOTIFICATION ............................... 204
1. Background ................................................................................................................. 205
Policy Changes Following First Report .................................................................. 205
Contempt Hearing ................................................................................................... 206
Policy Updates that Followed the Contempt Hearing............................................. 210
Definition of “Caregiver” ................................................................................... 210
Definition of “apprised” ...................................................................................... 211
Definition of “Caregiver” ................................................................................... 213
Definition of “apprised” ...................................................................................... 214
The Court’s Contempt Order & DFPS’s Certification of Compliance ................... 216
F. REMEDIAL ORDERS 25, 26, 27, 29, AND 31 PERFORMANCE VALIDATION ........................ 220
1. Methodology ............................................................................................................... 220
Common Application .............................................................................................. 222
Placement Summary ............................................................................................... 227
State’s Case Record Reviews.................................................................................. 232
Summary ............................................................................................................................. 234
G. REMEDIAL ORDERS A7 AND A8: AWAKE-NIGHT SUPERVISION ....................................... 235
1. Background ................................................................................................................. 235
Monitors’ First Report Performance Validation Findings ...................................... 235
Policy Changes Following the Monitors’ First Report ........................................... 236
H. REMEDIAL ORDERS A7 AND A8 PERFORMANCE VALIDATION ......................................... 239
1. Methodology ............................................................................................................... 239
DFPS Certifications of Awake Night Supervision ................................................. 240
DFPS Action Related to Contractual Violations of Awake-Night Supervision
Requirements .................................................................................................................. 243
Summary ............................................................................................................................. 246
VII. REGULATORY MONITORING & OVERSIGHT OF LICENSED PLACEMENT ... 247
A. REMEDIAL ORDER 22: CONSIDERATION OF ABUSE OR NEGLECT/CORPORAL PUNISHMENT &
OBLIGATION TO REPORT SUSPECTED ABUSE OR NEGLECT ...................................................... 247
1. Background ................................................................................................................. 247
Updates & Policy Changes Following the Monitors’ First Report ......................... 248
September 2020 Contempt Hearing & The Court’s December 18, 2020 Contempt
Order ............................................................................................................................... 249
HHSC’s December 31, 2020 Certification of Compliance ..................................... 250
2. Data and Information Production................................................................................ 252
5
Remedial Order 22 Performance Validation....................................................................... 253

Methodology ........................................................................................................... 253
ECHR Validation ................................................................................................ 253
Validation of Requirements Related to Reporting Abuse or Neglect ................. 254
ECHR Validation ................................................................................................ 254
Validation of Requirements Related to Reporting Abuse or Neglect ................. 262
Summary ............................................................................................................................. 266
B. REMEDIAL ORDERS 12-19: TIMELINESS OF MINIMUM STANDARDS INVESTIGATIONS ...... 267
1. Remedial Orders 12 through 19: Timeliness of Minimum Standards Investigations . 267
Background ............................................................................................................. 268
Monitors Data and Information Request and Production ....................................... 269
Monitors Data and Information Request............................................................. 269
DFPS Data and Information Production ............................................................. 269
Remedial Orders 12 through 19 Performance Validation (HHSC) ........................ 270
Methodology ....................................................................................................... 270
Remedial Order 12: Timeliness of Observations or Interviews with Alleged Child
Victims in Priority One Investigations ....................................................................... 272
Remedial Order 13: Timeliness of Observation or Interviews with Alleged Child
Victims in Priority Two Investigations ....................................................................... 273
Remedial Order 14: Completion of Priority One and Two Investigations within 30
Days ............................................................................................................................ 274
Remedial Order 15: Completion of Priority Three, Four, and Five Investigations
within 60 Days of Intake ............................................................................................. 274
Remedial Order 16: Completion and Submission of Documentation on the Same
Day the Investigation was Completed in Priority One and Two Investigations ......... 276
Remedial Order 17: Completion and Submission of Documentation within 60
Days of Intake in Priority Three, Four, and Five Investigations ................................ 277
Remedial Order 18: Notification Letters Sent within Five Days of Investigation
Closure in Priority One and Two Investigations......................................................... 278
Remedial Order 19: Notification Letters Sent within 60 Days of Intake in Priority
Three, Four, and Five Investigations .......................................................................... 279
C. REMEDIAL ORDER 20: HEIGHTENED MONITORING .......................................................... 280
Background ............................................................................................................. 280
First Court Monitors’ Report Performance Validation Findings ........................ 281
Updates and Policy Changes Following the First Report ................................... 281
Data and Information Requests and State’s Production ......................................... 285
Methodology ....................................................................................................... 286
Performance Validation Results ......................................................................... 287
Overview and Analysis of Phase One of Heightened Monitoring .......................... 294
Phase One Operations’ Histories of Compliance Problems ............................... 296
Quality of Heightened Monitoring Plans for Phase One Operations .................. 299
Timeline for Completing Tasks Identified in Heightened Monitoring Plans ..... 304
Review of Heightened Monitoring Visits to Phase One Operations .................. 307
Review of Placement Approvals for Phase One Operations .............................. 314
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Summary ............................................................................................................. 328

D. REMEDIAL ORDER 21: REVOCATION OF LICENSES ........................................................... 328
Background ............................................................................................................. 329
First Court Monitors’ Report Performance Validation Findings ........................ 329
September 2020 Contempt Hearing .................................................................... 329
Policy Updates Following the Contempt Hearing .............................................. 331
Methodology ....................................................................................................... 333
Remedial Order 21 Performance Validation Results .......................................... 333
Pending Closure Recommendation ..................................................................... 338
Denied Closure Recommendation ...................................................................... 340
Congregate Care Facility Closures & DFPS Contract Terminations.................. 344
Summary ............................................................................................................. 366
VIII. CHILD FATALITIES..................................................................................................... 367
A. CHILD FATALITIES INVOLVING ABUSE AND NEGLECT (JULY 31, 2019 – ARIL 10, 2021) . 368
B. CHILD FATALITY INVESTIGATIONS PENDING ................................................................... 373
C. ABUSE AND NEGLECT RULED OUT/UTB; POSSIBLE NEGLECT (JULY 31, 2019 – APRIL 10,
2021) ....................................................................................................................................... 379
D. CHILD FATALITIES, NO ABUSE OR NEGLECT DETERMINED (MAY 1, 2020 AND APRIL 10,
2021) ....................................................................................................................................... 381
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I. INTRODUCTION & EXECUTIVE SUMMARY
This is the Monitors’ second comprehensive report to the United States District Court
(“Court”) in M.D. by Stukenberg v. Abbott following the mandate issued by the United States Court
of Appeals for the Fifth Circuit (“Fifth Circuit”) implementing the Court’s remedial orders.1 The
Plaintiffs are a certified class of children in the Permanent Managing Conservatorship (“PMC”) of
the Texas Department of Family and Protective Services (“DFPS”) who sought injunctive relief
against the State of Texas. At the time Plaintiffs filed suit in 2011, DFPS was part of the Texas
Health and Human Services Commission (“HHSC”).2 Now DFPS is an independent State agency
reporting directly to the Governor.3
Following a bench trial in 2014, the Court published a Memorandum Opinion and Verdict
in December 2015 finding that Texas had failed to protect PMC children from an unreasonable
risk of harm.4 The Court issued a Final Order on January 15, 2018, and following a stay order, the
Fifth Circuit adopted in part and reversed and in part and modified the remedial orders, remanding
to the Court, which issued a modified Order on November 20, 2018.5 The Fifth Circuit again
adopted in part and reversed in part the Court’s Order and issued its Judgment as Mandate on July
31, 2019.6 The Court’s November 20, 2018 Order, as modified by the Fifth Circuit on July 8,
2019,7 specifies numerous remedial orders that implement the Court’s injunction as detailed
below, charging the Monitors “to assess and report on Defendants’ compliance with the terms of
this Order.”8
On June 16, 2020, the Monitors filed the first comprehensive report (“First Report”) with
the Court, concluding that “the Texas child welfare system continues to expose children in
1
M.D. ex rel. Stukenberg v. Abbott, 929 F.3d 272, 277 (5th Cir. 2019); J. (5th Cir. July 8, 2019), ECF No. 626.
2
Effective February 2021, HHSC changed the name of its child care regulation unit, Residential Child Care Licensing
(RCCL), to Residential Child Care Regulation (RCCR). This report uses RCCR to describe this division of HHSC
even when referring to historic work done by the unit under its previous name.
3
The 85th Texas Legislature passed House Bill 5, transforming DFPS into an independent state agency reporting
directly to the Governor, H.B. 5 (TX 2017), 85th Leg., R.S.
4
M.D. ex rel. Stukenberg v. Abbott, 152 F. Supp. 3d 684 (S.D. Tex. 2015).
5
Id.
6
M.D. ex rel. Stukenberg, 929 F.3d at 277; J. (5th Cir. 2019), ECF No. 626.
7
M.D. ex rel. Stukenberg, 929 F.3d at 277.
8
M.D. ex rel. Stukenberg v. Abbott, No. 2:11-cv-84, slip. op. at 16 (S.D. Tex. Nov. 20, 2018), ECF No. 606. (“The
Monitors’ duties shall include to independently verify data reports and statistics provided pursuant to this Order. The
Monitors shall have the authority to conduct, or cause to be conducted, such case record reviews, qualitative reviews,
and audits as the Monitors reasonably deem necessary. In order to avoid duplication, DFPS shall provide the Monitors
with copies of all state-issued data reports regarding topics covered by this Order. Notwithstanding the existence of
state data, data analysis or reports, the Monitors shall have the authority to prepare new reports on all terms of this
Order to the extent the Monitors deem necessary. The Monitors shall periodically conduct case record and qualitative
reviews to monitor and evaluate the Defendants’ performance with respect to this Order. The Monitors shall also
review all plans and documents to be developed and produced by Defendants pursuant to this Order and report on
Defendants’ compliance in implementing the terms of this Order. The Monitors shall take into account the timeliness,
appropriateness, and quality of the Defendants’ performance with respect to the terms of this Order. The Monitors
shall provide a written report to the Court every six months. The Monitors’ reports shall set forth whether the
Defendants have met the requirements of this Order. In addition, the Monitors’ reports shall set forth the steps taken
by Defendants, and the reasonableness of those efforts; the quality of the work done by Defendants in carrying out
those steps; and the extent to which that work is producing the intended effects and/or the likelihood that the work
will produce the intended effects.”) Id. at 17.
8
permanent managing conservatorship (‘PMC’) to an unreasonable risk of serious harm.” On July

2, 2020, Plaintiffs filed a Motion to Show Cause Why Defendants Should Not Be Held in Contempt
for their failure to comply with Remedial Orders 2, 3, 5, 7, 10, 22, 24, 25, 26, 27, 28, 29, 30, 31,
37, and B5 (“July 2, 2020 Show Cause Motion”). The State filed written objections to the
Monitors’ First Report on July 6, 20209 and a Response in Opposition to the Motion to Show
Cause on July 24, 2020. On September 3 and 4, 2020, the Court held a hearing on Plaintiffs’ July
2, 2020 Show Cause Motion, and on December 18, 2020, found Defendants to be in contempt of
Remedial Orders 2, 3, 5, 7, 10, 22, 25, 26, 27, 29, 31, 37, and B5, but not in contempt of Remedial
Orders 24, 28, or 30.10
In preparing this report, the Monitors and their staff (“the monitoring team”) undertook a
comprehensive set of activities to validate the State’s performance, as detailed both in the
Methodology Section below and throughout this report. The Monitors requested data and
information from both DFPS and HHSC to validate the agencies’ compliance with the Court’s
remedial orders, as detailed in various sections of this report. The Monitors also requested data
and information from the Single Source Continuum Contractors (“SSCC”) with which DFPS
contracts to provide case management and placement services to foster children in DFPS regions
that have transitioned to the Community Based Care (“CBC”) model.11
9
Defendants’ Verified Objections to Monitors’ Report, ECF No. 903.
10
The Court held: “Defendants are ORDERED to file with the Court a sworn certification of their compliance with
Remedial Orders 2, 3, 5, 7, 10, 25, 26, 27, 29, 31, 37, and B5 within thirty (30) days of the date of this Order. This
sworn certification does not need to be verified by the Monitors prior to filing. Contemporaneously with this sworn
certification, Defendants are ORDERED to submit to the Monitors for verification all supporting evidence relied on
by Defendants to certify their sworn compliance with these Remedial Orders, including but not limited to documents,
data, reports, conversations, studies, and extrapolations of any type. Defendants are further ORDERED to appear at a
compliance hearing before this Court, beginning at 9:00 a.m. on Wednesday, May 5, 2021 and continuing thereafter
until the compliance hearing concludes. The hearing will be held in-person in Courtroom 223 of the United States
Courthouse at 1133 N. Shoreline Blvd., Corpus Christi, TX 78401. All of Defendants’ supporting evidence of their
compliance with Remedial Orders 2, 3, 5, 7, 10, 25, 26, 27, 29, 31, 37, and B5 is subject to verification by the
Monitors prior to the May compliance hearing. No sanctions will issue at this time, but, failing the Monitors’
verification of compliance, any sanctions as to Defendants’ performance of Remedial Orders 2, 3, 5, 7, 10, 25, 26,
27, 29, 31, 37, or B5 will be revisited at the compliance hearing. To avoid additional future sanctions as to
these findings of contempt, Defendants must comply with each of these Remedial Orders in the timeframe described.
No retroactive sanctions will be imposed at the time of the compliance hearing.”
11
CBC was formerly known as Foster Care Redesign. There are currently five regions that have transitioned to the
CBC model, or are in the process of doing so: Region 1 (Texas Panhandle); Region 2 (30 counties in North Texas);
Region 3b (seven counties around Fort Worth); Region 8a (San Antonio and Bexar County; and, effective October
2021, Region 8b (26 counties surrounding Bexar County). There are two stages to the transition to the CBC model:
In Stage I, the SSCC “develops a network of services and provides placement services. The focus in Stage I is
improving the overall well-being of children in foster care and keeping them closer to home and connected to their
communities and families.” DFPS, Community-Based Care, available at
https://www.dfps.state.tx.us/Child_Protection/Foster_Care/Community-Based_Care/default.asp According to DFPS,
“In Stage II, the SSCC provides case management, kinship, and reunification services. Stage II expands the continuum
of services to include services for families and to increase permanency outcomes for children.” Id. Two SSCCs –
OCOK and 2INgage – moved to Stage 2 of the CBC model in 2020. Stage 2 includes shifting case management
services from DFPS to the SSCC.
9
The monitoring team examined tens of thousands of documents and records, including data
files; children’s case records, both electronic and paper; investigations; critical incidents; child
fatality reports; medical examiner reports; restraint log entries; videos of critical incidents; witness
statements; interviews; policies; resource materials such as handbooks; plans; guidelines and field
guidance; child abuse, neglect or exploitation referrals to Statewide Intake (“SWI”), including E-
Reports and recorded phone calls; Awake-Night certifications; and an array of employee and
caregiver human resources and training records and certifications.
SUMMARY OF THE MONITORS’ FINDINGS
The Court’s Final Order enjoins the State “from placing children in the permanent
managing conservatorship (“PMC”) in placements that create an unreasonable risk of
serious harm. The Defendants SHALL implement the remedies herein to ensure that
Texas’ PMC foster children are free from an unreasonable risk of serious harm.”12
The Monitors’ investigation, analysis, interviews and site visits in preparation for this
report identified areas in which the State made progress toward eliminating the “substantial threats
to children’s safety” that surfaced in the Monitors’ First Report, including performance associated
with Remedial Orders 2, 3 (Receiving and Screening), 5, 7, 9, 10, 18 (DFPS only; HHSC’s
performance dropped off), 19 and B5.
• DFPS improved its performance with respect to Remedial Order 3. DFPS implemented
reforms to its secondary screening process, which had been inappropriately downgrading
a substantial number of referrals of child maltreatment in licensed foster care.13 Following
the Monitors’ First Report, the agency winnowed the criteria for downgrading referrals to
Priority None (“PN”), reassigned the secondary screeners from the unit charged with
investigating maltreatment in licensed foster care to SWI and enhanced their training. As
a result, downgrades to PN in licensed foster care fell from 29.8% (53 out of 178 intakes)
in May 2020 to just 2.2% (3 out of 138 intakes) in November 2020, which is when DFPS
formally implemented its policy and structural changes restricting PNs to a narrow set of
categories.
• SWI received 533,471 calls from February 1, 2020 to November 30, 2020. On average,
callers waited for 2.3 minutes before their calls were handled or abandoned, an
improvement of almost two minutes from the data reported in the Monitors’ First Report.14
Seventy percent (373,970) of callers waited on the queue for under one minute.
• DFPS’s compliance with Remedial Order 2 improved sharply during the period reviewed.
Just over half (56%) of the 31 new caseworkers who became eligible for primary case
management in March 2020 had caseloads that conformed to the graduated caseload
standard but about nine in every ten caseworkers who became case assignable on July 1,
2020 or later had case assignments that conformed to the graduated caseload standard as
validated by the Monitors.
12
M.D. ex rel. Stukenberg v. Abbott, No. 2:11-cv-84, slip. op. at 2 (S.D. Tex. Nov. 20, 2018), ECF No. 606.
13
Deborah Fowler and Kevin Ryan, First Court Monitors’ Report 2020, ECF No. 869.
14
During the last reporting period, the data demonstrated an average queue time of 4.2 minutes for calls placed from
August 1, 2019 to January 31, 2020.
10
• Of 815 SWI intakes assigned to Residential Child Care Investigations (“RCCI”) for a
Priority One or Priority Two investigation between April 1, 2020 and October 31, 2020,
the automated system of notification designed by DFPS to promptly communicate
allegations of abuse or neglect to the child’s primary caseworker was observed to be
working: notification occurred in almost all cases reviewed. While the quality of the
contact could not be reviewed to determine whether all allegations were discussed, RCCI
investigators contacted the child’s caseworker after the automated notification was sent in
728 (89%) of the cases reviewed.
• DFPS made substantial progress eliminating a backlog of overdue RCCI investigations by
April 6, 2021. Of the 151 Priority One and Priority Two RCCI investigations that remained
open as of April 6, 2021, the State’s data documented that 5% (8) were open for more than
30 days with an extension, and 1% (2) were open more than 30 days without an extension.
The two oldest investigations that were overdue as of April 6, 2021 without extensions
were 1 and 3 days overdue.
Although there were no license revocations for any placement (foster home, Child Placement
Agency (“CPA”), or General Residential Operation (“GRO”)) in the five-year period preceding
issuance of the mandate in this matter, since July 31, 2019 and through April 23, 2021, HHSC has
initiated revocation proceedings or denied a license for eight GROs, and DFPS has notified the
Monitors that the agency canceled contracts with three GROs. Five other GROs voluntarily
relinquished licenses after being placed on Heightened Monitoring or another type of Residential
Child Care Regulation (“RCCR”) enforcement action. At the same time, serious risks of harm to
children persist, as detailed in this Report. In its January 19, 2018 Final Order, which appointed
Kevin Ryan and Deborah Fowler as Monitors, the Court noted that “[i]n its December 2015 Order,
the Court found Texas’ foster care system was broken. Over two-years later, the system remains
broken and DFPS has demonstrated an unwillingness to take tangible steps to fix the broken
system.”15
The State’s performance in some areas, including its oversight of the care of children by the
SSCCs and certain GROs, is contrary to the Court’s remedial orders. Specifically:
• In less than 21 months since the Fifth Circuit issued the mandate in this matter (July 31,
2019 – April 10, 2021), 23 PMC children have died in State custody. These fatalities
include six children whose caregivers were determined to have abused or neglected them
in connection with their deaths or their care prior to their deaths. In addition, a seventh
child fatality is strongly suspicious for caregiver abuse. A DFPS investigation is underway
in that case and five additional child fatalities. Of the six cases involving confirmed abuse
or neglect and a seventh case strongly suspicious for abuse, SSCCs were involved with five
of the seven children. State records indicate SSCCs directly managed care for four of the
children; DFPS directly managed care for two children; and in the case of one child, C.G.,
whose death is discussed in the Monitors’ First Report, an SSCC was responsible for
placement, while DFPS was responsible for case management.
15
Id.
11
• As detailed in a report separately filed with the Court, the Monitors recently learned that
three SSCCs have housed children in unlicensed GROs. In one instance, one of the SSCCs,
Family Tapestry, has repeatedly placed children in a facility (owned by the SSCC’s parent)
that relinquished its license following a troubled history of child abuse, neglect and safety
problems, with many of the same staff members, and repeated enforcement actions, even
as fresh allegations of child maltreatment mounted.
• The Monitors discovered in December 2020 that several operations that had been identified
or should have been identified for Heightened Monitoring due to their history of abuse,
neglect and safety violations, had escaped enforcement by simply closing and opening
under a different name. The State remedied the problem after the Monitors raised concerns
to HHSC and DFPS leadership, but there is no evidence the State was correcting the lapse
on its own.
• The very low number (5) of agency foster homes recommended for closure sharply
contrasts with the State’s growing efforts to monitor its most troubled GROs. The State
recommended closure of only five agency homes between May 1, 2020 and March 16,
2021, and only three have closed. RCCI investigated two of those three homes in
connection with the fatality of a PMC child, resulting in confirmed Reason To Believe
(“RTB”) findings.
• With respect to Remedial Orders 1, 2, 26, 29, 35 and A-4, the SSCCs’ compliance with the
Remedial Orders lagged behind DFPS, raising questions about the State’s implementation
of the CBC model and its oversight of the SSCCs. In some instances, DFPS and the SSCCs
lacked the data and processes to oversee the SSCCs’ performance with respect to the
Remedial Orders.16 SSCCs’ caseloads were typically higher than DFPS; the SSCCs’
implementation of graduated caseloads was less rigorous; the SSCCs’ training for new
caseworkers appears to be substantially shorter than the Court-ordered Child Protective
Services Professional Development (“CPD”) model requires; the SSCCs’ data in some
important instances was unreliable or nonexistent; and as the Monitors assessed whether a
Common Application corresponding to a child’s placement could be found that included
all known history of sexual abuse and sexual aggression, DFPS out-performed the SSCCs
for both placements involving children with an indicator for sexual aggression and sexual
abuse.
• The Monitors’ review of the Heightened Monitoring Plans created for the most risk-prone
(“Phase One”) operations revealed gaps between operations’ safety and compliance
problems and the quality of the tasks in the Heightened Monitoring Plans intended to
reduce the risks of harm to children. Many of the tasks were similar or identical to tasks
the operations had completed under previous enforcement actions, raising questions about
whether they will reduce or eliminate the risks of harm to children as intended. Further, a
review of minimum standards variances approved for operations under Heightened
16
For example, the State represented it discovered in February 2021, that it had not been collecting and reporting to
the Monitors data on Children Without Placement (CWOP) from the SSCCs. As another example, the Monitors’
review of the graduated caseload data from the SSCCs, and the Monitors’ exchanges with the SSCCs and DFPS about
this data, indicate a gap in quality assurance and oversight.
12
Monitoring revealed that two operations repeatedly received variances related to staffing
ratios despite their troubled child safety records.
• The Monitors were not able to validate that all PMC placements in Phase One Heightened
Monitoring operations reviewed were approved by a DFPS Associate Commissioner, or,
later, a Regional Director prior to the placement, per the Court’s orders. Of the 118
placements made to operations under Phase One of Heightened Monitoring, the Monitors
were unable to validate placement approval in 77 (65%), and were unable to find a
placement request provided by the State in even more (84 of 118, or 71%).
SUMMARY OF FINDINGS BY REMEDIAL ORDER
A. Section IV. Screening, Intake, And Investigation of Maltreatment In Care

Allegations
Remedial Order 3: DFPS shall ensure that reported allegations of child abuse and neglect
involving children in the PMC class are investigated; commenced and completed on time
consistent with the Court’s Order; and conducted taking into account at all times the child’s safety
needs. The Monitors shall periodically review the statewide system for appropriately receiving,
screening, and investigating reports of abuse and neglect involving children in the PMC class to
ensure the investigations of all reports are commenced and completed on time consistent with this
Order and conducted taking into account at all times the child’s safety needs.
Receiving Allegations
• Between February 1, 2020 and November 30, 2020, SWI received 533,471 calls. During
the period analyzed, 13% (69,468) of calls were abandoned, a decrease from 18% observed
in the previous report.17
• On average, callers waited for 2.3 minutes before their calls were handled or abandoned, a
decrease of almost two minutes from the data reported in the Monitors’ First Report.18
Seventy percent (373,970) of callers between February 1, 2020 and November 30, 2020,
waited on the queue for under one minute.
Screening Allegations
• The Monitors reviewed 185 referrals received between May 1, 2020 and November 30,
2020, to ascertain whether DFPS appropriately downgraded the referrals after SWI initially
assigned them to RCCI for a Priority One or Two abuse or neglect investigation. The
Monitors determined 162 (88%) were appropriately downgraded.
17
The Monitors’ First Report found that 18% of calls were abandoned from August 1, 2019 to January 31, 2020. See
Deborah Fowler and Kevin Ryan, First Report 64, ECF No. 869.
18
During the last reporting period, the data demonstrated an average queue time of 4.2 minutes for calls placed to
SWI from August 1, 2019 to January 31, 2020.
13
• Most of the 23 inappropriately downgraded referrals arose prior to the effective date of the
new DFPS policy restricting secondary screening downgrades of intakes. The Monitors did
not identify any referrals involving maltreatment in licensed foster care that were
inappropriately downgraded in October or November 2020.
• In the Monitors’ First Report, the Monitors determined that of 174 intakes downgraded at
secondary screening between July 31, 2019 and October 31, 2019, DFPS inappropriately
downgraded 57 intake reports (33%), which contained allegations that warranted
investigation for abuse or neglect. Thus, the Monitors’ rate of disagreement with
downgrade determinations dropped by 21 percentage points from 33% in the First Report
to 12% presently.
• The Monitors reviewed 90 referrals made between May 1 and November 30, 2020, to
ascertain whether DFPS appropriately downgraded the referrals after SWI initially
assigned them to CPI for a Priority One or Two abuse or neglect investigation. The
Monitors determined CPI appropriately downgraded 88 of these intake reports (98%).
• The Monitors also reviewed 241 referrals made to SWI from January and February 2020,
which SWI sent directly to HHSC, involving a PMC child. Of these 241 referrals, SWI
assigned 76 to HHSC for a non-abuse or neglect investigation to determine whether there
was a violation of statute, administrative rules, or minimum standards and the other 165
intakes were administratively closed. Of these 241 reports, the Monitors concurred with
SWI’s determination in 98% (235) of intakes.
• The Monitors also reviewed 66 referrals that SWI sent directly to HHSC for a minimum
standards investigation in October 2020, that involved children with PMC status. The
Monitors found that SWI appropriately determined that none of these intakes contained an
allegation of abuse or neglect of a PMC child and were properly assigned to RCCR for
follow up.
• The Monitors also reviewed 88 SWI referrals from November 2020 that involved children
with PMC status and found that SWI appropriately determined that 94% (83 intakes) did
not contain an allegation of abuse or neglect of a PMC child and were properly assigned to
HHSC.
Investigating Allegations
• Of the 768 RCCI investigations DFPS completed involving PMC children between May
1, 2020 and October 31, 2020, the Monitors evaluated 403 investigations. Of those 403
RCCI investigations, the Monitors concurred with the outcomes of all 31 (8%) that resulted
in a substantiation of the allegations with a disposition of RTB.
• The Monitors found that of the 365 investigations where RCCI Ruled Out all of the
allegations, RCCI did so appropriately in 300 cases (82%); inappropriately in 18 cases
(5%); and conducted investigations with such substantial deficiencies in 47 cases (13%)
that the Monitors were prevented from reaching a conclusion.
• In addition to the 65 cases (18%), among a sample of 365 investigations that RCCI Ruled
Out between May 1, 2020 and October 31, 2020, that had substantial deficiencies or were
inappropriately resolved by RCCI, the Monitors also identified four investigations in which
14
RCCI assigned an RTB disposition to some allegations or administratively closed that had
substantial deficiencies or were inappropriately resolved by RCCI.
• In the First Report, the Monitors determined 28.6% of sampled investigations had
substantial deficiencies and/or were inappropriately resolved, and the present results for
this period reflect a significant improvement.
Remedial Order 5: Within 60 days and ongoing thereafter, DFPS shall, in accordance with
existing DFPS policies and administrative rules, initiate Priority One child abuse and neglect
investigations involving children in the PMC class within 24 hours of intake. (A Priority One is by
current policy assigned to an intake in which the children appear to face a safety threat of abuse
or neglect that could result in death or serious harm.)
• The monitoring team reviewed all 657 RCCI investigations that were opened by DFPS
between May 1, 2020 and September 30, 2020.
• The Monitors found that of 657 investigations opened by RCCI between May 1, 2020 and
September 30, 2020, 48 were assigned Priority One, requiring that DFPS initiate the
investigation within 24 hours of intake.
• DFPS initiated 79% (38) of Priority One investigations within 24 hours of intake in a
manner consistent with existing policy. Twenty-one percent (10) of investigations were not
initiated timely or did not have sufficient data to assess timeliness.
• The timely initiating of investigations represents an improvement of 11% from the
Monitors’ First Report when RCCI’s rate of initiating Priority One investigations
consistent with Remedial Order 5 was 68%.
existing DFPS policies and administrative rules, initiate Priority Two child abuse and neglect
investigations involving children in the PMC class within 72 hours of intake. (A Priority Two is
assigned by current policy to any CPS intake in which the children appear to face a safety threat
that could result in substantial harm.)
• RCCI opened 609 Priority Two investigations requiring DFPS initiation within 72 hours
of intake between May 1, 2020 and September 30, 2020. DFPS initiated 81% (494) of
Priority Two investigations within 72 hours of intake in a manner consistent with existing
policy.
• Eighteen percent (107) of investigations were not initiated timely or did not have sufficient
data to assess timeliness. One percent (8) of investigations had a documented exception
and were initiated timely.
• DFPS’s rate of initiating Priority Two investigations through face-to-face contact with each
alleged victim within 72 hours in the Monitors’ First Report was also 81%.
DFPS policies and administrative rules, complete required initial face-to-face contact with the
alleged child victim(s) in Priority One child abuse and neglect investigations involving PMC
children as soon as possible but no later than 24 hours after intake.
15
• Of the 48 Priority One investigations opened by RCCI between May 1, 2020 and
September 30, 2020, the Monitors found that 79% (38) of the investigations included initial
face-to-face contact with each alleged child victim individually within 24 hours.
• An additional 4% (2) of investigations had documentation of approved exceptions to face-
to-face contact.
• DFPS’s rate of completing initial face-to-face contact with each alleged victim in Priority
One investigations within 24 hours in the Monitors’ First Report was 68%.
Remedial Order 8: Within 60 days and ongoing thereafter, DFPS shall, in accordance with DFPS
policies and administrative rules, complete required initial face-to-face contact with the alleged
child victim(s) in Priority Two child abuse and neglect investigations involving PMC children as
soon as possible but no later than 72 hours after intake.
• Of the 609 RCCI investigations assigned Priority Two between May 1, 2020 and
September 30, 2020, 79% (484) of investigations included initial face-to-face contact with
each alleged child victim within 72 hours of intake.
• Twenty-two additional investigations (4%) had documented exceptions to face-to-face
contact. Of the 22 investigations with documented exceptions for face-to-face contact, 27%
(6) were due to the unknown whereabouts of the child; 14% (3) were due to a prior
interview with alleged victim by CPS, Law Enforcement, or a child advocacy center before
RCCI received the Intake report; 5% (1) were due to the alleged victim no longer living in
Texas; and 55% (12) were due to “other circumstances beyond the investigator’s control
preventing the interview or observation from taking place within the initiation time frame.”
• DFPS’s rate of completing initial face-to-face contact with each alleged victim in Priority
Two investigations within 72 hours in the Monitors’ first report was 81%.
Remedial Order 9: Within 60 days and ongoing thereafter, DFPS must track and report all child
abuse and neglect investigations that are not initiated on time with face-to-face contacts with
children in the PMC class, factoring in and reporting to the Monitors quarterly on all authorized
and approved extensions to the deadline required for initial face-to-face contacts for child abuse
and neglect investigations.
• Overall, in 90% (590) of all 657 investigations (both single and multi-alleged victim
investigations), DFPS was able to track and report in its data reports to the Monitors
whether face-to-face contact was made with each alleged child victim within an
investigation and the date and time that contact occurred for each child.
• In 97% (435) of the 450 investigations with one victim, DFPS was able to track and report
in its data reports to the Monitors whether face-to-face contact was made with the alleged
child victims within an investigation and the date and time the contact occurred.
• In 75% (155) of 207 investigations with more than one victim, DFPS was able to track and
report in its data reports to the Monitors whether face-to-face contact was made with each
of the alleged child victims within an investigation and the date and time the contacts
occurred.
16
Remedial Order 10: Within 60 days, DFPS shall, in accordance with DFPS policies and
administrative rules, complete Priority One and Priority Two child abuse and neglect
investigations that involve children in the PMC class within 30 days of intake, unless an extension
has been approved for good cause and documented in the investigative record. If an investigation
has been extended more than once, all extensions for good cause must be documented in the
investigative record.
• Of the 657 Priority One and Priority Two RCCI investigations opened between May 1,
2020 and September 30, 2020, 51% (337) were not completed within 30 days.
• Forty-two percent (273) of investigations were documented as completed within 30 days
of intake and 7% (47) had approved extensions and were completed within the extension
timeframe. DFPS’s rate of completing Priority One and Two investigations within 30 days
in the Monitors’ First Report was 19%.19
• DFPS made substantial progress complying with Remedial Order 10 by April 6, 2021. Of
the 151 Priority One and Priority Two RCCI investigations that remained open as of April
6, 2021, the State’s data documented that 5% (8) were open for more than 30 days with an
extension, and 1% (2) were open more than 30 days without an extension. The two oldest
investigations that were overdue as of April 6, 2021, without extensions were 1 and 3 days
overdue.
Remedial Order 11: Within 60 days and ongoing thereafter, DFPS must track and report monthly
all child abuse and neglect investigations involving children in the PMC class that are not
completed on time according to this Order. Approved extensions to the standard closure
timeframe, and the reason for the extension, must be documented and tracked.
• Of the 337 investigations that were opened by RCCI between May 1, 2020 and September
30, 2020, and were not completed within 30 days, DFPS data included extensions approved
for 82 investigations with the dates the extensions were approved, the reasons for the
extensions, and the number of additional days approved by each of the extensions.20
• Each of these 82 investigations contained at least one extension approved for either seven,
14, 21, or 30 days each.
• Of those investigations with extensions, 66% (54) included one extension, 27% (22)
included two, 6% (5) included four, and 2% (1) included six extensions. All extensions
included documented approval dates and all but two included documented reasons for the
extension.
• Five percent (8) of open RCCI investigations as of April 6, 2021 were open for more than
30 days with a current, approved extension, and 1% (2) of open RCCI investigations were
open for more than 30 days without an extension. To achieve this level of performance,
DFPS had to close at least 465 RCCI investigations involving PMC children between
19
See Deborah Fowler and Kevin Ryan, First Report 114, ECF No. 869.
20
These data matched to the investigations’ corresponding intake start date and original due date and therefore, the
Monitors were able to determine the due dates associated with the extensions to assess timeliness of completion within
the extension period.
17
March 1, 2021 and April 6, 2021. To offer perspective on that volume of closure, the
average monthly rate of closure during the past 19 months has been 120 closures per month
and has ranged between 48 and 180 investigations per month.
Remedial Order 16: Effective immediately, the State of Texas shall ensure RCCL investigators,
and any successor staff, complete and submit documentation in Priority One and Priority Two
investigations on the same day the investigation is completed.
• (Remedial Order 16 applies to both DFPS and HHSC) With respect to DFPS, the agency
advised the Monitors it uses the date the investigation was submitted to the supervisor as
the investigation completion date. Therefore, according to DFPS, investigations are
considered complete when the documentation is finally submitted to the supervisor in
compliance with this Order.
and any successor staff, finalize and mail notification letters to the referent and provider(s) in
Priority One and Priority Two investigations within five days of closing a child abuse and neglect
investigation or completing a standards investigation.
• (Remedial Order 18 applies to both DFPS and HHSC) With respect to DFPS, of the 538
(out of 657) Priority One and Priority Two RCCI investigations that were documented as
closed at the time of the Monitors’ review, the notification letter to referents was mailed
within five days of closure in 40% (213) of investigations.
• Of the remaining cases, in 1% (3) of investigations, notification letters to the referents were
not mailed timely; 56% (299) were mailed to the referent prior to supervisor approval; 3%
(17) of investigations had an anonymous reporter; and one percent (6) were unknown due
to documentation deficiencies.
• DFPS’s rate of mailing notification letters to referents within five days of investigation
closure in Priority One and Two investigations in the Monitors’ First Report was 78%.
• Of the 538 (out of 657) Priority One and Priority Two RCCI investigations that were
documented as closed at the time of the Monitors’ review, HHSC mailed notification letters
to providers in abuse, neglect, and exploitation investigations within five days of closure
in 59% (317) of investigations.
• The notification letters to providers were not mailed timely in 20% (106) of investigations.
In addition, 1% (8) were mailed prior to supervisor approval; and 20% (107) did not have
sufficient data to assess timeliness. HHSC’s rate of mailing notification letters to providers
within five days of investigation closure in Priority One and Two investigations in the
Monitors’ First Report was 65%.
Remedial Order A6: Within 30 days of the Court’s Order, DFPS shall ensure that caseworkers
provide children with the appropriate point of contact for reporting issues relating to abuse or
neglect. In complying with this order, DFPS shall ensure that children in the General Class are
apprised by their primary caseworkers of the appropriate point of contact for reporting issues,
and appropriate methods of contact, to report abuse and neglect. This shall include a review of
the Foster Care Bill of Rights and the number for the Texas Health and Human Services
Ombudsman. Upon receipt of the information, the PMC child’s caseworker will review the referral
18
history of the home and assess if there are any concerns for the child’s safety or well-being and
document the same in the child’s electronic case record.
• The Monitors rely on record reviews and interviews conducted on-site with children to
validate Remedial Order A6. Due to the pandemic, the Monitors were able to make only
one on-site visit to an operation in this period to Devereux Advanced Behavioral Health
Center – League City. The Monitors filed a report with the Court discussing findings
related to that visit on February 8, 2021, and do not include further discussion of A6 within
the Second Report.
Remedial Order B5: Effective immediately, DFPS shall ensure that RCCL, or any successor
entity, promptly communicates allegations of abuse to the child’s primary caseworker. In
complying with this order, DFPS shall ensure that it maintains a system to receive, screen, and
assign for investigation, reports of maltreatment of children in the General Class, taking into
account at all times the safety needs of children.
• The Monitors reviewed 815 RCCI intakes which SWI assigned for a Priority One or
Priority Two investigation between April 1, 2020 and October 31, 2020.
• The Monitors’ case reviews reflect that the automated system of notification designed by
DFPS to promptly communicate allegations of abuse or neglect to the child’s primary
caseworker were observed to be occurring in almost all cases reviewed. While the
notification does not include the substance of the allegations, the monitoring team verified
follow-up communication between the RCCI investigator assigned to the case and the
child’s caseworker in most cases reviewed but could not assess the quality of that
communication.
Remedial Order 37: Within 60 days, DFPS shall ensure that all abuse and neglect referrals
regarding a foster home where any PMC child is placed, which are not referred for a child abuse
and neglect investigation, are shared with the PMC child’s caseworker and the caseworker’s
supervisor within 48 hours of DFPS receiving the referral. Upon receipt of the information, the
PMC child’s caseworker will review the referral history of the home and assess if there are any
concerns for the child’s safety or well-being and document the same in the child’s electronic case
record.
• The Monitors’ case record review showed that, at least through October 31, 2020, the State
was still not complying with the timeliness standard required in Remedial Order 37.
Although in 99% of the cases the automatic notifications to caseworkers occurred within
two days of the SWI referral, the average total time from the date the case was received by
SWI to the date the Home History Review (“HHR”) staffing occurred, as documented in
the DFPS’s Information Management for Protection of Adult & Children in Texas
(“IMPACT”) system, was 8 days with a range from one to 70 days.21
21
The average total time from the date of downgrade to Priority None to the date the Home History Review staffing
occurred, as documented in IMPACT, was 7.51 days with a range of one day to 70 days.
19
• In addition to failing to comply with the timeliness requirement of Remedial Order 37, the
State frequently did not consistently document HHR staffings between the caseworker and
the supervisor. In cases in which documentation of an HHR was located, the monitoring
team did not find any staffing or a reason for failing to hold a staffing in 27% (23 of 86) of
the cases. As detailed in this report, the monitoring team again found concerns with the
quality of caseworkers’ reviews of the HHRs and staffing narratives. The State’s case read
also reflects the Monitors’ findings, having found in both the State’s June to August 2020
and September to November 2020 case record reviews that in 25% of the cases, the
caseworker’s narrative did not contain an accurate review of the HHR.
B. Section IV. Organizational Capacity
Remedial Order 1: Within 60 days, the Texas Department of Family Protective Services
(“DFPS”) shall ensure statewide implementation of the CPS Professional Development (“CPD”)
training model, which DFPS began to implement in November 2015.
• Of the 313 caseworkers who were hired by DFPS between January 1, 2020 and July 31,
2020, who did not leave the agency prior to or during training, and who should have been
subject to CPD training requirements, 97% (305 of 313) had completed CPD training as of
the time of the analysis.
• One of the SSCCs, Our Community Our Kids (“OCOK”), did not provide reliable data for
its caseworkers’ case-assignable dates in time for assessment of their performance
associated with Remedial Order 1. The repeated failure to report reliable data suggests that
neither OCOK nor DFPS was actively assessing OCOK’s conformance with training
completion requirements and case assignability prior to the Monitors’ efforts to validate
the data.
• Of the 85 caseworkers hired by 2INgage, another SSCC, who were required to complete
CPD training and stayed with the agency through training, all (100%) had completed the
“2INgage Academy” training as of January 2021. Of those 85, 79 (93%) were new hires
subject to full CPD training. On average, caseworkers completed the 2INgage training in
43 days. Ten of these new hires completed 2INgage training in just 28 days, far shy of the
time required by the Court-ordered CPD training model.
Remedial Order 2: Within 60 days, DFPS shall ensure statewide implementation of graduated
caseloads for newly hired CVS caseworkers, and all other newly hired staff with the responsibility
for primary case management services to children in the PMC class, whether employed by a public
or private entity.
• For the 601 caseworkers whose caseloads the Monitors assessed at two points in time and
the 588 workers whose caseloads the Monitors assessed at three points in time, the State
20
was in conformance with the graduated caseload standards for new caseworkers 76% of
the time.
• The agency’s compliance with Remedial Order 2 improved sharply during the period
reviewed. Just over half (56%) of the 31 caseworkers who became eligible for primary case
standard and less than half (41%) of the 141 such workers in June 2020 conformed to the
graduated caseload standard. But about nine in every ten caseworkers who became case
assignable on July 1, 2020 or later had case assignments that conformed to the graduated
caseload standard at three points in time evaluated by the Monitors.
Remedial Order 35: Effective immediately, DFPS shall track caseloads on a child-only basis, as
ordered by the Court in December 2015. Effective immediately, DFPS shall report to the Monitors,
on a quarterly basis, caseloads for all staff, including supervisors, who provide primary case
management services to children in the PMC class, whether employed by a public or private entity,
and whether full-time or part-time. Data reports shall show all staff who provide case management
services to children in the PMC class and their caseloads. In addition, DFPS’s reporting shall
include the number and percent of staff with caseloads within, below and over the DFPS
established guideline, by office, by county, by agency (if private) and statewide. Reports will
include the identification number and location of individual staff and the number of PMC children
and, if any, TMC children to whom they provide case management. Caseloads for staff, as defined
above, who spend part-time in caseload carrying functions and part-time in other functions must
be reported accordingly.
Remedial Order A2: Within 120 days of the Court’s Order, DFPS shall present the completed
workload study to the Court. DFPS shall include as a feature of their workload study submission
to the Court, how many cases, on average, caseworkers are able to safely carry, and the data and
information upon which that determination is based, for the establishment of appropriate
guidelines for caseload ranges.
Remedial Order A3: Within 150 days of the Court’s Order, DFPS shall establish internal
caseload standards based on the findings of the DFPS workload study, and subject to the Court’s
approval. The caseload standards that DFPS will establish shall ensure a flexible method of
distributing caseloads that takes into account the following non-exhaustive criteria: the complexity
of the cases; travel distances; language barriers; and the experience of the caseworker. In the
policy established by DFPS, caseloads for staff shall be prorated for those who are less than full-
time. Additionally, caseloads for staff who spend part-time in the work described by the caseload
standard and part-time in other functions shall be prorated accordingly.
Remedial Order A4: Within 180 days of the Court’s Order, DFPS shall ensure that the generally
applicable, internal caseload standards that are established are utilized to serve as guidance for
supervisors who are handling caseload distribution and that its hiring goals for all staff are
informed by the generally applicable, internal caseload standards that are established. This order
shall be applicable to all DFPS supervisors, as well as anyone employed by private entities who
is charged by DFPS to provide case management services to children in the General Class. [The
Court subsequently changed the effective date of this order to February 15, 2020.]
21
• The parties agreed to, and the Court approved, a workload standard of 14 to 17 children
per caseworker, pursuant to Remedial Order A3. As of December 31, 2020, 57% of all
caseworkers (846 of 1,495), including those employed by OCOK and 2INgage, had
primary caseloads within or below the standard of 17 children per caseworker.
From March 2020 to December 2020, conformity with the caseload standard remained
within a narrow band ranging from 52% to 58% of all caseworkers
• The Monitors found that conformity with the caseload standard varied among DFPS,
OCOK and 2INgage. Of the 1,302 DFPS workers carrying at least one PMC case on
December 31, 2020, 750 workers (58%) had primary caseloads within or below the
standard of 17 children per worker. As of December 31, 2020, the two SSCCs that are
undertaking case management, OCOK and 2INgage, had 53% and 46% of their workers
working within or below the standard, respectively. In the data the Monitors received from
March 31, 2020 to December 31, 2020, the rate of caseworkers meeting the standard at
OCOK was at its highest point on December 31, 2020; the rate of caseworkers meeting the
standard at 2INgage was at its lowest point on December 31, 2020. The rates of
caseworkers meeting the standard at both the SSCCs were lower than those at DFPS.
Remedial Orders B1: Within 60 days of the Court's Order, DFPS, in consultation with and under
the supervision of the Monitors, shall propose a workload study to: generate reliable data
regarding current RCCL, or successor entity, investigation caseloads and to determine how much
time RCCL investigators, or successor staff, need to adequately investigate allegations of child
maltreatment, in order to inform the establishment of appropriate guidelines for caseload ranges;
and to generate reliable data regarding current RCCL inspector, or successor staff, caseloads and
to determine how much time RCCL inspectors, or successor staff, need to adequately and safely
perform their prescribed duties, in order to inform the establishment of appropriate guidelines for
caseload ranges. The proposal shall include, but will not be limited to: the sampling criteria,
timeframes, protocols, survey questions, pool sample, interpretation models, and the questions
asked during the study. DFPS shall file this proposal with the Court within 60 days of the Court’s
Order, and the Court shall convene a hearing to review the proposal.
Remedial Order B2: Within 120 days of the Court’s Order, DFPS shall present the completed
to the Court, how many cases, on average, RCCL inspectors and investigators, or any successor
staff, are able to safely carry, and the data and information upon which that determination is
based, for the establishment of appropriate guidelines for caseload ranges.
Remedial Order B3: Within 150 days of the Court’s Order, DFPS, in consultation with the
Monitors, shall establish internal guidelines for caseload ranges that RCCL investigators, or any
successor staff, can safely manage based on the findings of the RCCL investigator workload study,
including time spent in actual investigations. In the standard established by DFPS, caseloads for
staff shall be prorated for those who are less than full-time. Additionally, caseloads for staff who
22
spend part-time in the work described by the RCCL, or successor entity, standard and part-time
in other functions shall be prorated accordingly.
Remedial Order B4: Within 180 days of this Order, DFPS shall ensure that the internal
guidelines for caseload ranges and investigative timelines are based on the determination of the
caseloads RCCL investigators, or any successor staff, can safely manage are utilized to serve as
guidance for supervisors who are handling caseload distribution and that these guidelines inform
DFPS hiring goals for all RCCL inspectors and investigators, or successor staff.
• The majority of RCCI investigator caseloads were within or below the guidelines between
March and December 2020.22 The caseload for RCCI investigators during this time ranged
from 9 to 14 cases, with 72% of investigators (389 of 541) having caseloads of fewer than
14 investigations per month during the period, and 14% of investigators (77 of 541) having
caseloads between 14 and 17 investigations.
• Although the majority of RCCI investigators had caseloads within the guidelines during
the period, large differences in caseload numbers existed between investigators with the
lowest and highest caseloads: investigators with the highest caseloads were assigned as
much as forty times the number of investigations than the number of investigations
assigned to those investigators with the lowest caseloads. Between March and December
2020, monthly RCCI investigator caseloads ranged from one to 45 investigations, with
35% of investigators (25 of 72) experiencing a caseload of 18 or more investigations for
one or more months and 17% of investigators (12 of 72) experiencing a caseload of 25 or
more abuse, neglect, or exploitation investigations for one or more months.
• Between March and December 2020, the majority of RCCR inspectors had caseloads
within the guidelines (one to 17 tasks assigned), although the proportion of inspectors with
caseloads within the guidelines sharply declined from a high of 92% in June 2020 to 58%
in December 2020.23
• Between March and December 2020, monthly RCCR inspector caseloads ranged from 1 to
29 tasks with 71% of inspectors (76 of 107) having one or more months with a caseload of
18 or more tasks. Fifty-eight percent of inspectors (62 of 107) had at least one month with
a caseload of 20 or more tasks. In December 2020, 21 inspectors (25% or 21 of 85) had
caseloads with 20 or more tasks assigned, while 12 inspectors (14% or 12 of 85) had
caseloads of 13 or fewer.
22
In the First Report, the Monitors found that caseload data provided by DFPS showed that on December 31, 2019,
forty-three RCCI investigators and twelve non-investigators and supervisors carried a total of 1,011 cases. Of the 43
investigators, 20 (46.5%) had more than 17 investigations.
23
By way of comparison, the Monitors’ analysis for the First Report indicated that caseload data provided by HHSC
showed that on January 1, 2020, 82 RCCR inspectors carried a total of 1,854 cases or “tasks.” Of the 82 inspectors,
fifty-four (59%) had caseloads above 17 tasks.
23
A. Section V. Preventing Sexual Abuse and Child Sexual Aggression
Policy Creation and Training of Staff Responsible for Making Determinations
Remedial Order 32: Within 90 days of this Order, DFPS shall create a clear policy on what
constitutes child on child sexual abuse. Within 6 months of the Court’s Order, DFPS shall ensure
that all staff who are responsible for making the determinations on what constitutes child on child
sexual abuse are trained on the policy.
• The Monitors’ analysis of Child Sexual Abuse (“CSA”) training data for staff responsible
for making determinations regarding what constitutes child-on-child sexual abuse shows
that almost all (95%, or 4,622 of 4,853) have completed training. The entity with the lowest
training completion rate was OCOK, at 86% (31 of 36) of OCOK staff having completed
CSA training. Of those who had not completed CSA training, 19% (43 of 231) of staff
responsible for making determinations regarding what constitutes child-on-child sexual
abuse did not have a reason for failing to complete the training. An additional 13 staff who
had not completed CSA training reported the reason as leaving the agency, but they left the
agency with enough time to complete all training.
Tracking and Documenting Sexual Abuse and Child-on-Child Sexual Aggression
Remedial Order 23: Within 60 days, DFPS shall implement within the child’s electronic case
record a profile characteristic option for caseworkers or supervisors to designate PMC and TMC
children as “sexually abused” in the record if the child has been confirmed to be sexually abused
by an adult or another youth.
Remedial Order 24: Within 60 days, DFPS shall document in each child’s records all confirmed
allegations of sexual abuse in which the child is the victim.
Remedial Order 28: Effective immediately, DFPS shall ensure a child’s electronic case record
documents “child sexual aggression” and “sexual behavior problem” through the profile
characteristic option when a youth has sexually abused another child or is at high risk for
perpetrating sexual assault.
Remedial Order 30: Effective immediately, DFPS must also document in each child’s records all
confirmed allegations of sexual abuse involving the child as the aggressor.
• The number of children flagged with an indicator for sexual abuse or sexual aggression
increased by 22% (from 991 to 1,210) between November 30, 2019 and December 31,
2020. Though a monthly trend analysis shows increases peaked in February 2020 and have
declined since then, the peak coincides with the State’s launch of the IMPACT
enhancements related to sexual victimization and would have been expected to follow this
change.
24
• The Monitors’ case review showed that 21% of children with a sexual victimization
indicator (63 of 304) had a confirmed abuse incident which occurred after entering care,
and 48% of children with a sexual aggression indicator (61 of 128) had an aggression
incident which occurred after the child entered care. Of those children whose records
indicated a confirmed incident of sexual abuse after entering care, 37% (23 of 63) were
abused by another child in their placement. A case review of substantiated findings of
Neglectful Supervision or Sexual Abuse showed that 70% (7 of 10) of cases reviewed
showed that sexual victimization was properly documented in the child’s electronic case
record.
Caseworker and Caregiver Training and Notification on Child Sexual Abuse
Remedial Order 4: Within 60 days, DFPS shall ensure that all caseworkers and caregivers are
trained to recognize and report sexual abuse, including child-on-child sexual abuse.
Remedial Order 25: Effective immediately, all of a child’s caregivers must be apprised of
confirmed allegations at each present and subsequent placement.
Remedial Order 26: Effective immediately, if a child has been sexually abused by an adult or
another youth, DFPS must ensure all information about sexual abuse is reflected in the child’s
placement summary form, and common application for placement.
Remedial Order 27: Effective immediately, all of the child’s caregivers must be apprised of
confirmed allegations of sexual abuse of the child at each present and subsequent placement.
Remedial Order 29: Effective immediately, if sexually aggressive behavior is identified from a
child, DFPS shall also ensure the information is reflected in the child’s placement summary form,
and common application for placement.
Remedial Order 31: Effective immediately, all of the child’s caregivers must be apprised at each
present and subsequent placement of confirmed allegations of sexual abuse involving the PMC
child as the aggressor.
• The State implemented the child sexual abuse training requirement in Remedial Order 4
by providing a Child Sexual Aggression course and through pre-service training for new
caseworkers. State data indicates 98.1% of case-assignable workers between July 1, 2020
and August 31, 2020 had completed the training.
• Regarding caregiver sexual abuse training, the State does not maintain a list of all
caregivers serving DFPS children or their training completion date(s), and, therefore, the
Monitors cannot validate that all or most caregivers completed the full child sexual abuse
training required by Remedial Order 4. The Monitors identified weaknesses in the State’s
certification technology which allow individuals to print a training completion certification
without successfully completing the training.
25
• The monitoring team found Common Applications that corresponded to placements

reviewed by the Monitors containing all known information related to a child’s history of
sexual abuse in 50% (234 of 465) of the placements reviewed, and containing all
information related to a child’s history of sexual aggression in 57% (83 of 145) of the
placements reviewed. The rate of finding a Common Application with complete
information corresponding to the placement reviewed did not improve over time for
children with an indicator for sexual aggression, though it did improve for children with a
history of sexual abuse. DFPS outperformed the SSCCs when the Monitors examined
results according to the entity responsible for the child’s placement.
• The monitoring team found a Placement Summary and Attachment A that included the
complete history for children with an indicator for sexual aggression in 54% of placements
(93 of 171) reviewed and found a Placement Summary and Attachment A that included the
complete history for children with an indicator for sexual abuse in 40% (226 of 565) of
cases. Of those, the Placement Summary and Attachment A were hand-signed by the
receiving caregiver on or up to 30 days before the placement in only 30% (171 of 565) of
placements reviewed for children with an indicator for sexual abuse, and only 40% (68 of
171) of placements reviewed for children with an indicator for sexual aggression. The
SSCCs outperformed DFPS on this analysis.
Awake-Night Supervision
Remedial Order A7: The Defendants shall immediately cease placing PMC children in licensed
foster care (LFC) placements housing more than 6 children, inclusive of all foster, biological, and
adoptive children, that lack continuous 24-hour Awake-Night supervision. The continuous 24-hour
Awake-Night supervision shall be designed to alleviate any unreasonable risk of serious harm.
Remedial Order A8: Within 60 days of this Court’s Order, and on a quarterly basis thereafter,
DFPS shall provide a detailed update and verification to the Monitors concerning the State’s
providing continuous 24-hour Awake-Night supervision in the operation of LFC placements that
house more than 6 children, inclusive of all foster children, biological children, and adoptive
children.
• Though relatively infrequent, DFPS continues to document instances in which operations

fail to comply with the 24-hour Awake-Night supervision requirements of Remedial Orders
A7 and A8. Of the 40 instances in which DFPS identified a violation of the Awake-Night
requirement between March and October 2020, it required a corrective action plan in only
17 instances. Five operations (Autistic Treatment Center, Bluebonnet Youth Ranch,
Presbyterian Home, Sheltering Harbor, and Whataburger Center) had more than one non-
compliance incident during the period.
B. Section VI. Regulatory Monitoring and Oversight of Licensed Placements
26
Remedial Order 22: Effective immediately, RCCL, and any successor entity charged with
inspections of child care placements, must consider during the placement inspection all referrals
of, and in addition all confirmed findings of, child abuse/neglect and all confirmed findings of
corporal punishment occurring in the placements. During inspections, RCCL, and any successor
entity charged with inspections of child care placements, must monitor placement agencies’
adherence to obligations to report suspected child abuse/neglect. When RCCL, and any successor
entity charged with inspections of child care placements, discovers a lapse in reporting, it shall
refer the matter to DFPS, which shall immediately investigate to determine appropriate corrective
action, up to and including termination or modification of a contract.
• While the Monitors’ case record reviews showed that RCCR’s Child Care Licensing and
Automation Support System (“CLASS”) update substantially improved Extended
Compliance History Review (“ECHR”) completion rates, the quality of the narratives
discussing abuse or neglect and corporal punishment findings declined: in ECHRs
reviewed between March and August 2020, 32% (43 of 135) did not include a discussion
of the abuse or neglect findings and 31% (43 of 139) did not include a discussion of the
corporal punishment findings in the narrative, while in ECHRs reviewed between
September and October 2020, 38% (85 of 223) did not include a discussion of the abuse or
neglect findings and 42% (94 of 222) did not include a discussion of the corporal
punishment findings in the narrative. Similarly, though 70% of cases included in the review
between September and October 2020 (290 of 409) revealed a pattern or trend in abuse or
neglect intakes or substantiated findings or in corporal punishment findings, only half of
those ECHRs discussed the pattern or trend in the narrative. The Monitors’ case review
also revealed a gap in applying the ECHR to foster homes: often the data and the narrative
were reflective of the CPA’s history and did not consider the history of the foster home
that was the focus of an investigation.
Timeliness of Minimum Standards Investigations
Remedial Order 12: Effective immediately, the State of Texas shall ensure the Residential Child
Care Licensing (“RCCL”) investigators, and any successor staff, observe or interview the alleged
child victims in Priority One child abuse or neglect investigations within 24 hours of intake.
• HHSC reported two Priority One investigations with intake dates between April 1, 2020
and September 30, 2020. One of those Priority One investigations included first face-to-
fact contact with an alleged child victim within 24 hours of intake.
and any successor staff, observe or interview the alleged child victims in Priority Two child abuse
or neglect investigations within 72 hours of intake.
• HHSC reported 406 Priority Two investigations with an intake date between April 1,
2020 and September 30, 2020. Forty-one percent (167) of investigations included first
face-to-face contact with an alleged child victim within three days of intake; 26% (106)
27
of investigations did not include face-to-face contacts within three days; and data were
not available for 33% (133) of investigations.
• The rate of first face-to-face contact within three days declined from the rate in the
Monitors’ First Report (59%) due to low rates in the first months of the pandemic.
and any successor staff, complete Priority One and Priority Two child abuse and neglect
investigations within 30 days of intake, consistent with DFPS policy.
• HHSC reported 408 Priority One (2) and Priority Two (406) investigations with an
intake date between April 1, 2020 and September 30, 2020. During this period, HHSC
completed 96% (392) of minimum standards investigations within 30 days of intake.
• HHSC’s rate of completing Priority One and Priority Two minimum standards
investigations within 30 days was nearly the same as the rate in the Monitors’ First
Report (95%).
and any successor staff, complete Priority Three, Priority Four and Priority Five investigations
within 60 days of intake, consistent with DFPS policy.
• HHSC reported 1,817 Priority Three, Four, and Five minimum standards investigations
with an intake date between April 1, 2020 and September 30, 2020. The priorities of
investigations broke down as follows: Priority Three (1,288); Priority Four (10); and
Priority Five (519) investigations.
• HHSC completed 98% (1,786) of investigations within 60 days of intake. HHSC’s rate
of completing Priority Three, Four, and Five minimum standards investigations within
60 days in the Monitors’ First Report was 96%.
• (Remedial Order 16 applies to both DFPS and HHSC) With respect to HHSC, the
agency reported 408 Priority One (2) and Priority Two (406) completed investigations
with an intake date between April 1, 2020 and September 30, 2020. During this period,
in 93% (381) of the investigations, the documentation was completed on the same day
the investigation was completed.
• HHSC’s rate of completing documentation on the same day the investigation was
completed in Priority One and Priority Two investigations was close to the rate in the
Monitors’ First Report (96%).
28
and any successor staff, complete and submit documentation in Priority Three, Priority Four and
Priority Five investigations within 60 days of intake.
• HHSC completed 1,817 Priority Three (1,288), Priority Four (10), and Priority Five
(519) investigations with intake dates between April 1, 2020 and September 30, 2020.
During this period, HHSC completed documentation within 60 days of the intake date
in 97% (1,765) of the investigations.
• HHSC’s rate of completing documentation on the same day the investigation was
completed in Priority Three, Priority Four, and Priority Five investigations was nearly
the same as the rate in the Monitors’ First Report (96%).
• (Remedial Order 18 applies to both HHSC and DFPS) With respect to HHSC, the
agency reported completion of 408 Priority One (2) and Two (406) minimum standards
investigations with intake dates between April 1, 2020 and September 30, 2020. Of
those 408 investigations, 93% (380) of investigations included notification to
the referent (or referent was anonymous); and notification to the provider within five
days of completion of the minimum standards investigation.
• HHSC’s reported rate of notifying the referent and provider within five days of
completion of Priority One and Priority Two minimum standards investigation was
higher than the rate in the Monitors’ First Report (77%). Previously, HHSC did not
report data indicating which investigations did not require notification to the reporter.
and any successor staff, finalize and mail notification letters to the referent(s) and provider(s) in
Priority Three, Priority Four and Priority Five investigations within 60 days of intake.
• HHSC reported completion of 1,817 Priority Three (1,288), Priority Four (10), and
Priority Five (519) investigations with intake dates between April 1, 2020 and
September 30, 2020. Of the 1,817 investigations, 96% (1,753) of investigations
included notification to the referent (or no letter to the referent was required); and to
the provider within 60 days of intake.
• HHSC’s rate (96%) of notifying the referent when required and the provider within 60
days of completion of Priority Three, Priority Four, and Priority Five investigations
was higher than the rate in the Monitors’ First Report (79%); previously, HHSC did
not report data indicating which investigations did not require notification to the
reporter.
29
Heightened Monitoring
Remedial Order 20: Within 120 days, RCCL, and/or any successor entity charged with
inspections of child care placements, will identify, track and address concerns at facilities that
show a pattern of contract or policy violations. Such facilities must be subject to heightened
monitoring by DFPS and any successor entity charged with inspections of child care placements
and subject to more frequent inspections, corrective actions and, as appropriate, other remedial
actions under DFPS’ enforcement framework.
• The State’s list of operations to be placed under Heightened Monitoring changed twice
after the Monitors validated the list sent on June 5, 2020: First, to add two CPAs and
remove seven CPAs after the State corrected a coding error that resulted in a miscount
of CPA foster homes; second, nine operations were added after the Monitors raised
concerns regarding GROs that were originally slated for Heightened Monitoring, but
fell off the list after having “closed,” only to reopen under a new name. The Monitors’
analysis for this report focused on operations prioritized for Phase One of Heightened
Monitoring. Phase One operations had the highest scores on a risk stratification
analysis used by the State.
• Between 2016 and 2020, Phase One operations analyzed accounted for 67 substantiated
findings of abuse or neglect, and more than 2,000 citations for minimum standards
deficiencies. All but one Phase One operation, A Fresh Start,24 had been placed under
some type of enforcement action at least once; some had been the focus of more than
one type of enforcement action. A comparison of tasks in the Phase One operations’
Heightened Monitoring Plans with those included in previous enforcement actions
showed that 31% (22 of 71) of the tasks included in Heightened Monitoring Plans were
similar to requirements included in the operations’ previous enforcement actions.
• The State’s Heightened Monitoring visits to Phase One operations occur on a weekly
basis, as required. Thirty-eight percent of Heightened Monitoring visits (33 of 86)
conducted by RCCR Heightened Monitoring inspectors between June and December
2020 resulted in a citation of one or more deficiencies; RCCR cited a total of 83
deficiencies in Phase One operations during Heightened Monitoring visits made during
that time period. DFPS and RCCR identified one or more allegations of abuse or
neglect or other safety or compliance problems in 23% (55 of 244) of visits, including
21 calls by Heightened Monitoring team members to SWI to report allegations
identified during the visits. After Phase One operations were placed on Heightened
Monitoring, a total of 113 allegations of abuse or neglect were made to SWI about those
operations; RCCI opened at least two abuse or neglect investigations in every Phase
One operation between June and December 2020.
24
A Fresh Start was placed under a Plan of Action in December 2020, after the operation was placed on Heightened
Monitoring.
30
• A review of requests to approve placement of a child in a Phase One operation subject

to Heightened Monitoring showed they were almost always approved: of the 133
requests provided to the Monitors by the State for the months of June through
December 2020, the Associate Commissioner of CPS, CPS Director of Field or a
Regional Director approved 131 (99%). However, the Monitors were unable to validate
placement approval by either the Associate Commissioner for CPA, or (later) the
Regional Director, for the overwhelming majority of PMC children placed in the Phase
One operations after they were placed on Heightened Monitoring. Of the 118 PMC
child placements made during that time period, the monitoring team was unable to find
approval for 65% (77 of 118) and could not find a placement approval request in the
documents provided by the State for 71% (84 of 118) of these placements.
Revocation of Licenses
Remedial Order 21: Effective immediately, RCCL and/or its successor entity, shall have the right
to directly suspend or revoke the license of a placement in order to protect children in the PMC
class.
• Though RCCR and DFPS appear to be more proactive in addressing safety shortfalls
in GROs, their implementation of Remedial Order 20 continues to fall short for agency
homes. Since the last update to the Court related to congregate care facility closures,
another eight GROs with troubled child safety and compliance histories have closed.
Of those, RCCR acted on the facility’s license in six, either denying a final license (2)
or issuing an “intent to revoke” (4), and DFPS terminated its contract with two. The
remaining GRO (Whataburger Center) relinquished its license. However, between
May 2020 and March 16, 2021, RCCR staff recommended closure for only five agency
foster homes across Texas, and of those had only approved closure for three.
Child Fatalities
After learning through the Monitors of the death of a child in the PMC General Class, the
Court Ordered on February 21, 2020: Within 24 hours of this order’s time and date, Defendants
are ordered to report to the Monitors the death of any PMC child occurring from July 31, 2019
forward until further order of this Court. Defendants are further ordered to provide to the
Monitors all records that the Monitors deem necessary and relevant including, but not limited to,
reports, interviews, witness statements, and investigations from any and all said deaths that have
occurred from July 31, 2019 forward until further order of this Court.
• In less than 21 months since the Fifth Circuit issued the mandate in this matter (July 31,
2019 – April 10, 2021), 23 PMC children have died in State custody. These fatalities
include six children whose caregivers were determined to have abused or neglected them
in connection with their deaths or their care prior to their deaths. In addition, a seventh
child fatality is strongly suspicious for caregiver abuse. A DFPS investigation is underway
in that case and five additional child fatalities. Of the six cases involving confirmed abuse
31
or neglect and a seventh case strongly suspicious for abuse, SSCCs were involved with five
of the seven children. State records indicate SSCCs directly managed care for four of the
children; DFPS directly managed care for two children; and in the case of one child, C.G.,
whose death is discussed in the Monitors’ First Report, an SSCC was responsible for
placement, while DFPS was responsible for case management.
Scope and Methodology of the Monitors’ Work
To prepare this report, the Monitors conferred in person, by phone and by video-conference
numerous times, separately, with the parties and their counsel from issuance of the mandate
through April 14, 2021. On October 9, 2020, the Monitors provided DFPS and HHSC a detailed
chart identifying reporting period deadlines by which the State could submit data and information
for the Monitors to assess performance for each remedial order in this report, taking into account
the time required by the monitoring team to analyze and validate the information, which varies by
remedial order.25 Wherever possible, the Monitors included validated data and information in this
report beyond the deadlines in order to give DFPS and HHSC the benefit of additional time to
demonstrate compliance to the Court, and to provide the Court with the most current, validated
data and information available.
To assess compliance with multiple remedial orders, the monitoring team analyzed 1,667
Awake-Night certifications for operations licensed by HHSC and under contract with DFPS to
serve PMC children.
The Monitors assessed the caseloads of 1,495 caseworkers, 106 RCCI investigators and
supervisors and 138 RCCR inspectors and supervisors. To validate the accuracy of the State’s data
with respect to workloads and graduated caseloads, the monitoring team interviewed 200 of 1,482
caseworkers who were assigned at least one PMC child, 28 RCCI investigators and supervisors
and 42 RCCR inspectors and supervisors. The monitoring team also analyzed 742 caseworkers’
CPS Professional Development (“CPD”) training records and 4,853 Child Sexual Abuse (“CSA”)
training records for CVS supervisors, program directors, program administrators, investigative
staff, and other non-CVS staff.
The monitoring team analyzed data from DFPS’s Statewide Intake (“SWI”) related to
533,471 calls placed to SWI from February 1, 2020 to November 30, 2020 and conducted an
announced site visit to SWI facilitated by DFPS. The monitoring team undertook an independent
assessment of the appropriateness of the State’s screening decisions with respect to 1,228 referrals
to SWI between January 2020 and November 2020. As part of this assessment of the 1,228
referrals, the monitoring team listened to recordings of the original referral calls in all instances
when the report was made by phone.
In addition, the Monitors examined the State’s compliance with multiple remedial orders
by examining the timeliness for all 657 RCCI child abuse, neglect or exploitation investigations
25
Email from Kevin Ryan, Monitor, to Audrey Carmical, Attorney Commissioner for Compliance, Coordination, and
Strategy, DFPS, Assistant Attorney General, et al. (October 9, 2020) (with attachment).
32
opened between May 1, 2020 and September 30, 2020 involving a PMC child. The monitoring
team also reviewed records for 736 of 2,142 placements of PMC children and assessed the contents
of the Placement Summary Form and Common Application.26
The monitoring team examined 402 of 768 investigations completed by RCCI between
May 1, 2020 and October 31, 2020 into alleged maltreatment of PMC children and youth while
they were in DFPS custody and assessed the appropriateness of RCCI’s investigations and
outcomes. The monitoring team also reviewed 815 intakes which SWI assigned for a Priority One
or Priority Two RCCI investigation between April 1, 2020 and October 31, 2020, to assess the
timeliness of DFPS’s notification to the child’s caseworker. In addition, the monitoring team
reviewed electronic records for 947 inspections for Extended Compliance History Reviews.
Due to the pandemic, the Monitors limited visits to GROs from April 2020 to April 2021.
During an unannounced daytime visit to one GRO, the monitoring team interviewed one program
administrator, one treatment director, one clinical staff, as well as 24 caregivers (including six
Awake Night staff). The monitoring team interviewed nine PMC children selected by the Monitors
during this site visit. During this visit, the monitoring team examined 17 PMC children’s files and
55 caregiver records.
26
126 of the 736 placements were in a kinship or adoptive home which does not require a Common Application. The
monitoring team reviewed the Common Application in the remaining 610 placements.
33
II. DEMOGRAPHICS OF CHILDREN IN PMC CARE
According to DFPS data, there were 9,820 children in PMC status as of December 31,
2020,27 a decrease of about 1,100 children since November 30, 2019.28 Between March 1, 2020
and December 31, 2020, 4,056 children entered PMC and 6,039 exited PMC. Therefore, DFPS
cared for 16,203 PMC children between March 1, 2020 and December 31, 2020.
A. Age, Gender, and Race
As of December 31, 2020, 36% of children with PMC status were age zero to six years old
(3,518); 23% were seven to eleven years old (2,263); and 41% were twelve to seventeen years old
(4,039).
27
The point in time analyses in this section are based on DFPS data production of children in Permanent Managing
Conservatorship (PMC) during December 2020. The number of entries to PMC, exits from PMC, and PMC children
served are based on information from DFPS data production of children in PMC during Quarter 3 FY 2020, Quarter
4 FY 2020, September 2020, October 2020, and November 2020 in addition to data from December 2020.
DFPS, RO.Inj - List of Children in PMC Q3 FY 20 - July 15-20 - 97961 (July. 16, 2020) (on file with the Monitors);
DFPS, RO.Inj - List of Children in PMC Q4 FY 20 - sept 30-20 - 99712 (Oct. 8, 2020) (on file with the Monitors);
DFPS., RO.Inj - List of Children in PMC Sept 20 - 11-2-20 - 100568 (Nov. 3, 2020) (on file with the Monitors); DFPS,
RO.Inj - List of Children in PMC Oct 20 - 11-30-20 - 100738 (Dec. 2, 2020) (on file with the Monitors); DFPS, RO.Inj
- List of Children in PMC Nov 20 - 1-4-21- 100950 (Jan. 8, 2021) (on file with the Monitors); DFPS, RO.Inj - List of
Children in PMC Dec 20 - 2-1-21- 101237 (Feb. 2, 2021) (on file with the Monitors).
28
34
Figure 2.1: Age of Children in PMC on December 31, 2020
Source: List of Children in PMC Dec 20

n=9,820
Ages 12-17 Ages 0-6

41% 36%
4039 3518
Ages 7 -11
23%
2263
The population is almost evenly split between genders—47% of children were female and 53%
were male.
The race of children in PMC status breaks down as follows: 27% (2,664) of children in
PMC on December 31, 2020 were White; 25% (2,486) were Black/African American; less than
1% (24) were Native American; less than 1% (22) were Asian; and 6% (562) were categorized as
“Other.” Additionally, 41% (4,062) of children in PMC on December 31, 2020 were of Hispanic
ethnicity. Non-Hispanic Black/African American children in PMC status appear to be
disproportionately represented compared to the racial category estimates for Texas’ population of
all children ages 0 to 17 years.29
29
See the University of Texas at San Antonio Population Estimates and Projections Program, Texas Demographic
Center, (November 2020) available at https://demographics.texas.gov/data/tpepp/estimates/. The most recently
available data is from July 1, 2019. Id.
35
Table 2.1: Race for Children in PMC on December 31, 2020 and Estimates of Total Population
in Texas by Race for Children ages 0 to 17 years, July 1, 201930,31
Estimates of Total Population in

Children in PMC on
Texas by Race for Children ages 0 to
Race December 31, 2020
17 years
Frequency Percent Frequency Percent
Non-Hispanic White 2,664 27% 2,291,470 31%
Non-Hispanic Black/African American 2,486 25% 864,794 12%
Non-Hispanic Other 562 6% 266,754 4%
Non-Hispanic Native American 24 0.2% 0 0%
Non-Hispanic Asian 22 0.2% 316,786 4%
Hispanic (of any race) 4,062 41% 3,629,684 49%
Total 9,820 100% 7,369,488 100%
B. Living Arrangements and Length of Time in Care
Based upon information provided by DFPS, 79% (7,789) of children in PMC on December
31, 2020 lived in family settings, including 24% (2,383) living with relatives or fictive kin and 4%
(406) living in adoptive homes; and 16% (1,531) of children in PMC lived in congregate care.32
Of the children in PMC on December 31, 2020, 39% (3,805) were in care for one to two years;
25% (2,502) were in care for two to three years; 31% (3,069) were in care for more than three
years; and 4% (418) were in care for less than one year. Additionally, for 26 children (less than
1%) the data did not include removal dates, thus the Monitors were unable to calculate their length
of time in care.
30
See the University of Texas at San Antonio Population Estimates and Projections Program, the Texas Demographic
Center, (November 2020) [https://demographics.texas.gov/data/tpepp/estimates/]
31
The format of the DFPS data received by the Monitors does not provide the ability to identify the racial categories
for any child of Hispanic ethnicity.
32
The living arrangement categories are based on information provided by DFPS to the Monitors on April 17, 2020,
DFPS., Living Arrangement Categories (Apr. 17, 2020) (on file with the Monitors).
36
Figure 2.2: Living Arrangements for Children in PMC on December 31, 202033
Source: List of Children in PMC Dec 2020

n=9,820
Adoptive Home
4%
406 Other
5%
500
Congregate
Care Foster Home
16% 51%
1531 5000
Relative/Fictive
Kin
24%
2383
33
The “Other” living arrangement category groups together the “Other” (3%), “Runaway” (1%), “Incarcerated”
(<1%), “Own-home/Non-Custodial Care” (<1%), and “Independent Living” (<1%) living arrangement types.
37
Figure 2.3: Length of Stay in Care of Children in PMC on December 31, 2020
Source: List of Children in PMC December 20
n=9,820
Missing Less than 1

removal date year
< 1% 4%
26 6 years plus 418
9%
870
3 to 6 years 1 to 2 years
22% 39%
2199 3805
2 to 3 years
25%
2502
Children exited from PMC status through adoption; reunification with family; having
custody transferred to relatives; or by aging out of care. Of the 6,039 children who exited from
PMC between March 1, 2020 and December 31, 2020, the most frequent reason for exit was
adoption, with more adoptions by non-relatives (2,101) compared to relatives (1,974). The
breakdown is as follows: 67% (4,075) of children were adopted; 16% (945) of children had custody
transferred to a relative; and 13% (804) of children who exited were emancipated—or aged out—
of foster care. Finally, a small number (181 or 3%) were reunified with their families or had other
outcomes (34 or 1%).
Table 2.2: Exits from PMC by Exit Outcome, March 1, 2020 to December 31, 2020
Exit Outcome Frequency Percent

Adoption 4,075 67%
Custody to Relative 945 16%
Emancipation 804 13%
Reunification 181 3%
Other 34 1%
Total 6,039 100%
38
C. Level of Care
More than half (5,796 or 59%) of children in PMC status on December 31, 2020 were in
a basic authorized level of care. For the remaining 4,024 PMC children, 1,612 (16%) were in a
specialized level of care; 1,438 (15%) were in a moderate level of care; and 386 (4%) were in an
intense level of care. The data include 527 PMC children with no recorded authorized level of
care.34
Table 2.3: Authorized Level of Care for Children in PMC as of December 31, 2020
Authorized Level of Care Frequency Percent

Basic 5,796 59%
Specialized 1,612 16%
Moderate 1,438 15%
No Authorized Level of Care Recorded 527 5%
Intense 386 4%
(TFC) Treatment Foster Care 46 0.5%
Psychiatric Transition 10 0.1%
Intense Plus 5 0.1%
Total 9,820 100%
D. Geographic Location
The county of removal for 40% (3,968) of children with PMC status on December 31, 2020
was one of five Texas counties: Bexar, Harris, Dallas, Tarrant, and McLennan.
Table 2.4: Top 5 Counties of Removal for Children in PMC on December 31, 202035
County Name Frequency Percent

Bexar 1,183 12%
Harris 1,121 11%
Dallas 859 9%
Tarrant 519 5%
McLennan 286 3%
E. Single Source Continuum Contractor Presence and Placement Oversight
As of December 31, 2021, 32% (3,168) of children in PMC status were living in regions where
Single Source Continuum Contractors (SSCCs) are in the first two stages of implementation.
34
The Monitors found that for most of those children lacking identification of an authorized level of care (486), the
placement type in the data was identified as “kin only (non-licensed).”
35
These are the counties with jurisdiction over the child’s removal case. DFPS describes these counties as the “legal”
counties in the corresponding IMPACT data.
39
Table 2.5: PMC Children From Regions with Single Source Continuum Contractor
Presence on December 31, 202036
Regions PMC Children Percent

SSCC Regions 3,168 32%
DFPS Regions 6,652 68%
All Regions 9,820 100%
As shown in the table below, Bexar County (Region 8a), where Family Tapestry is charged
with placement identification, has the greatest number of children residing in a region with SSCC
placement oversight.
Table 2.6: PMC Children From Regions with Single Source Continuum Contractor
Presence by Region on December 31, 202037
Legal PMC
SSCC Name Percent
Region Children
Saint Francis
1 663 21%
Ministries
2Ingage 2 437 14%
Our Community of
3b 885 28%
Kids (OCOK)
Family Tapestry 8a 1,183 37%
Total 3,168 100%
36
Id.
37
Id.
40
III. OVERVIEW OF STATE DATA AND DATA SYSTEMS CHALLENGES
The Monitors faced many challenges related to the State’s reported data and its data
recording systems. This section describes these challenges, their potential impact on children and
staff, and on the State’s performance associated with the Court’s remedial orders.
As discussed in the Monitors’ First Report,38 deficiencies in the data systems used by DFPS
and HHSC prevent the agencies from having access to aggregate real-time data and information
critical to child safety, including certain children’s placements; staff training; the timeliness of
child abuse or neglect investigations; and caregiver training for sexual abuse, among other areas.
These gaps add extensively to the time and staffing required by the monitoring team to validate
the agencies’ performance under these remedial orders. DFPS and HHSC have addressed some
issues mentioned in the First Report that inhibited performance and/or reporting associated with
the remedial orders, but other challenges remain. This section includes a discussion of the
persisting issues from the last reporting period in condensed form and raises new challenges.
A. Fragmented Data Systems
DFPS and HHSC share responsibility for the safety of children who are in the care of the
State’s child welfare system through a variety of connected processes, including abuse, neglect, or
exploitation investigations and regulation of licensed facilities which are the subject of several
remedial orders. The agencies, however, use different data systems to track investigations and
related information about both children in care and childrens’ caregivers. DFPS uses a case
management system called the Information Management for Protection of Adult & Children in
Texas system, (“IMPACT”), as well as a records management system called the Child Care
Licensing and Automation Support System, (“CLASS”); HHSC uses CLASS only. Responsibility
for investigating alleged maltreatment in care or risk of harm to children alternates between
agencies depending in part on the nature of the allegations and underlying facts.39
The IMPACT and CLASS systems were designed separately and serve different purposes.
The data systems reflect differences in policies, procedures, and practices related to child
maltreatment investigations conducted by DFPS and inspections and minimum standards
investigations conducted by HHSC, even though both systems involve tracking or recording
critical child safety interests. As a result, the identifiers and variable names in each data system
are distinct.40 RCCI investigators, who work for DFPS, are required to move back and forth
between both systems to complete and enter tasks associated with child maltreatment
38
39
Id. At 48 (discussion of the agencies’ divided responsibilities for investigating potential child maltreatment in care
or risk of harm to children).
40
In CLASS, for example, the field that indicates the calendar day an investigator finished each required part of an
investigation is called Date Investigation Completed. In IMPACT, the same status is recorded in a variable called Date
Approval Submitted to Supervisor. CLASS records the closing date of an investigation as Date Case Closed while in
IMPACT the same status is recorded as the Date Supervisor Approved.
41
investigations, and at times are required to enter the same data twice.41 This fragmentation of data
collection and reporting across the two systems consumes limited investigator time and makes it
more difficult to track investigation histories about children and facilities.
The Monitors’ First Report raised several issues that data fragmentation causes. The issues
detailed below continue to inhibit DFPS’s and HHSC’s performance and reporting in compliance
with the remedial orders and increase the complexity of the monitoring team’s work, requiring
additional time and expense:
• Remedial Order 1 requires the State to ensure the implementation of the CPS Professional
Development (“CPD”) training model, which requires all caseworkers to complete CPD
training prior to becoming eligible for case assignment. At present, DFPS is unable to
provide actual training completion dates. An assigned training cohort start date and an
anticipated training completion date are provided by DFPS after it performs a data match
with the Center for Learning and Organizational Excellence (CLOE), the DFPS training
division, which compiles the data from electronic and hard copy (paper) records.42 DFPS
instead uses the “case assignable” date, provided under Remedial Order 2, is used by DFPS
as a proxy for training completion. Training cohort end dates are also estimated for the
SSCCs, which provide training information independently. For one of the SSCCs, OCOK,
training dates provided to the Monitors were those dates associated with their Permanency
Academy, not the full training time period required by Remedial Order 1. OCOK was
unable to provide actual case assignable dates in time for monitoring team validation,
despite repeated requests, making the verification of training completion impossible.
• Remedial Order 2 requires statewide implementation of graduated caseloads for newly

hired caseworkers. To produce a list of staff subject to the graduated caseloads policy
requires DFPS to conduct a match between CLOE, the DFPS training division, and Data
and Decision Support (DDS). DFPS analytic staff conducted this match for the Monitors;
this analysis was not routinely produced for DFPS leadership to facilitate monitoring of its
graduated caseloads policy or the State’s performance associated with the Court’s remedial
order. Moreover, each SSCC tracks its own new caseworkers and the case-assignable dates
independent of DFPS, creating additional challenges. The Monitors’ experience with
validating this data suggests that DFPS was not accurately tracking the SSCCs’
performance associated with Remedial Order 2.43
41
For example, the business flow process described by DFPS is as follows for child protective investigations:
[A]n intake is documented in IMPACT. When all needed action in the intake has
been taken, it is closed and, if a decision is to pursue an investigation, an
investigation stage is opened. When all essential investigative tasks are completed,
the investigation is documented as complete in CLASS and IMPACT. After the
investigation is completed in CLASS, it is submitted to the supervisor in IMPACT.
After the supervisor reviews and approves, the investigation stage is closed.
DFPS, Response to Monitors’ Questions related to Remedial Order 3 Data (Feb. 3, 2020) (on file with the Monitors).
42
DFPS, RO1.1 CPD Completion as of September 30, 2019 to November 15, 2019 (Jan. 15, 2020) (amended by CLOE)
(on file with the Monitors).
43
See infra Section IV. B.
42
• Remedial Order 3 requires DFPS to “ensure that reported allegations of child abuse and
neglect involving children in the PMC class are investigated; commenced and completed
on time consistent with the Court’s Order; and conducted taking into account at all times
the child’s safety needs.” Tracking alleged perpetrators and child victims between systems
takes considerable time to learn and complete in the current system constructs, hindering
efforts to ensure child safety. Even when not confirmed, multiple reports of child
maltreatment involving an alleged perpetrator at a CPA or a GRO may indicate
unreasonable risk of serious harm and predict future substantiated reports and, therefore, if
readily available DFPS could use the information to identify the need for intervention. In
addition, children who are the subject of multiple reports may have special needs that are
not being addressed, medical issues that are not being treated, or other personal traits that
increase risk of harm.
• Remedial Order 3 also requires the Monitors to “periodically review the statewide system
for appropriately receiving, screening, and investigating reports of abuse and neglect
involving children in the PMC class to ensure the investigations of all reports are
commenced and completed on time consistent with this Order and conducted taking into
account at all times the child’s safety needs.” Because HHSC’s CLASS system cannot
distinguish children in PMC status from other children, validating the agencies’
compliance takes extensive efforts. To identify referrals from HHSC in which a PMC child
was an alleged victim of abuse, neglect or exploitation requires first locating children’s
names in IMPACT and then shifting between the IMPACT and CLASS systems after
locating child identifiers in IMPACT for use in searches. Similarly, because of the
bifurcated system used to process and store data associated with referrals to SWI, the State
is unable to provide to the Monitors a unified dataset of all referrals of abuse or neglect in
which a PMC child is the subject. Instead, both agencies provide separate listings of child
maltreatment allegations depending on how SWI screened the original intake.
• Remedial Order 4 requires all caregivers to be trained to recognize and report the sexual
abuse of children. As discussed in the Monitors’ First Report, DFPS does not have a system
that tracks this training in the aggregate for caregivers.44 For the second report, DFPS
provided 1,041 files pertaining to caregiver training. The Monitors determined that the
large number and non-standardized format of the files did not allow for verification of the
caregiver portion of Remedial Order 4. Moreover, during the last reporting period, DFPS
notified the Monitors that it was currently evaluating the feasibility of providing this
training to caregivers through the external Learning Management System, which would
streamline and largely automate training completion reports. DFPS noted in March 2020
44
Email from Tara Olah, Dir. of Implementation & Strategy, DFPS. to Kevin Ryan and Deborah Fowler, (Mar. 24,
2020) (on file with the Monitors) (including DFPS response to Monitors’ Feb. 21, 2020 Data & Information Request).
For discussion of DFPS’s challenges reporting on training of caregivers, see infra Section V (discussing the incomplete
reporting by DFPS of caregiver sex abuse training).
43
that taking this approach may require additional funding and other resources.45 More
recently, in March 2021, DFPS has indicated that it is implementing a more centralized
process for recording caregiver training completion.46
• Remedial Order 4 also requires all caseworkers to be trained to recognize and report the
sexual abuse of children. The Monitors encountered several issues with the caseworker
training data that complicated verification of Remedial Order 4. The initial caseworker
training data provided by DFPS contained an Employee ID from the training database,
while the caseload data from DFPS contained the Person ID from IMPACT. The
monitoring team requires a common identifier to match the caseworker data with the
training data. As a result, the Monitors made an additional data request that included both
the employee IDs and person IDs.
• Remedial Orders 12 to 19 set forth various requirements for HHSC investigations. HHSC,
however, is unable to disaggregate CLASS data on referrals and investigations to identify
those that pertain to PMC children only.47 Thus, the monitoring team examined the data
for all the HHSC investigations during the period from April 1, 2020 to September 30,
2020 associated with Remedial Orders 12 to 19.48
• Remedial Order 18 requires the Defendants, in part, mail notification letters to provider(s)
in Priority One and Priority Two investigations within five days of closing a child abuse
and neglect investigation or completing a standards investigation. During the monitored
period, both DFPS and HHSC mailed letters to providers. The Monitors were provided
with three data sources regarding letters to providers. DFPS and HHSC use different dates
within their different systems to determine closure of an abuse and neglect investigation.
DFPS requested that the CLASS closure date not be used to calculate compliance with the
Remedial Orders associated with RCCI investigations. DFPS instead requested the
Monitors use the date of supervisor approval in IMPACT to calculate compliance with the
Remedial Order.49 The Monitors assumed when DFPS made the request that it had
conferred with HHSC, but the Monitors learned on April 30, 2021 that HHSC instead wants
45
Deborah Fowler and Kevin Ryan, First Report 53, ECF No..869. (citing an email from Tara Olah, Dir. of
Implementation & Strategy, DFPS, to Kevin Ryan and Deborah Fowler, (Mar. 24, 2020) (on file with the Monitors)
(including DFPS response to Monitors’ Feb. 21, 2020 Data & Information Request)).
46
Email from Corliss Lawson, Associate Commissioner of Compliance, DFPS, to Kevin Ryan and Deborah Fowler,
(March 25, 2021) (on file with the Monitors) (notifying the Monitors that DFPS is in process of adding an online form
to create a database related to training completion that will be functional by April 12, 2021).
47
For a complete discussion of the HHSC response regarding this information, see Section III of the Monitors’ First
Report (discussing screening, intake, and investigation of maltreatment in care allegations) Deborah Fowler and Kevin
Ryan, First Court Monitors’ Report 2020, at 50, ECF No. 869.
48
See HHSC, Data Response Chart (Dec. 5, 2019) (on file with the Monitors) (stating that HHSC “is operations-
centric not child-centric” and as a result cannot provide PMC identifiers of children involved in HHSC referrals);
Email from Corey Kintzer, Assoc. Dir. of Litig. Dep’t, Health & Human Servs. Comm’n to Kevin Ryan and Deborah
Fowler (Mar. 24, 2020) (on file with the Monitors) (including HHSC Response to Monitors’ Feb. 21, 2020 Data and
Information Request and stating that HHSC cannot provide investigation information specific to PMC children).
49
Email from Heather Bugg, Dir. of Project Management, to Kevin Ryan and Deborah Fowler, Monitors (Jan. 4,
2021).
44
the Monitors to use a different date to mark case completion and measure compliance,
rather than the date requested by DFPS.50
• Remedial Order 20 requires DFPS to identify, track and address concerns at facilities that
show a pattern of contract or policy violations and implement heightened monitoring that
subjects them to more frequent inspections, corrective, and remedial actions. The data as
provided by DFPS and HHSC make it difficult to match and connect the records of
facilities—both family foster care homes and residential facilities—and thus, challenging
to identify patterns of child maltreatment, and contract and policy violations as required by
Remedial Order 20. For example, first, matching data across CPAs and GROs is
challenging because CLASS generates an operation number and a contract number, while
IMPACT generates a resource ID and none of these numbers match across the two systems.
Next, within IMPACT, the most common identifier is the resource ID; however, the
Resource ID it is referenced by different names in different tables within the application.51
Third, some organizations are licensed to run multiple types of facilities (e.g., a residential
treatment center and an emergency shelter), or do business as “DBA” under another name.
Therefore, two names may represent the same facility entered differently or it may
represent two different facilities operated by the same organization.”52 Finally, some
facilities provide multiple levels of care and as a result, they have two or more resource
identifications associated with a single location and a single operation number.
• Remedial Orders A7 and A8 require continuous 24-hour Awake-Night supervision for

children in certain settings. An additional data problem affecting child safety surfaced
through the monitoring team’s review of DFPS’s awake-night certifications, described in
this report.53 In 41 certifications reviewed by the Monitors, DFPS staff noted the census
sheet that DFPS brought to a facility visit did not accurately reflect the children who were
currently residing in the facility. In some instances, children were on the DFPS list, but
were not present at the placement. In others, PMC children resided in the placement but
were not on the list that DFPS was using to monitor the awake night supervision.
B. Limited Functionality
Efforts to report on performance associated with the remedial orders are hindered by
limited functionality within IMPACT and CLASS. The examples below demonstrate the limits of
the State’s child welfare data systems. As noted below, the State added or indicated it will add
enhancements to be able to report on and comply with the remedial orders.
50
Email from Nathaniel Danko, Asst Atty General to Deborah Fowler and Kevin Ryan, Monitors (April 30, 2021)
with attachment.
51
DFPS, DFPS HHSC Operation ID Cross-walk (May 21, 2020) (on file with the Monitors).
52
DFPS, Response to Monitors’ Questions related to Remedial Order 3 Data (Feb. 3, 2020) (on file with the Monitors).
53
Infra Section IV.
45
In addition, the monitoring team spent considerable effort managing data regarding PMC
children without placement (described by the State as “CWOP”) because neither IMPACT nor
CLASS track this information for the provision of an aggregate report. Instead, DFPS sends lists
of children without placement and accompanying information to the Monitors in weekly emails.
These emails are compilations of daily reports sent to a DFPS central office each day in the prior
week. To analyze and report on this data, the monitoring team enters the information from the
emails into an Excel spreadsheet and manually logs each weekly email. The DFPS data on children
without placement in 2020 excluded some of the PMC children whose placements were managed
by the SSSCs, which DFPS reported it discovered in February 2021, forcing the agency to attempt
to retroactively create a portion the information with the SSCCs. DFPS began to report the
information to the Monitors in February 2021 and made subsequent, retroactive modifications to
the information in March 2021.
Obstacles remain for accurate reporting related to the placements of all PMC children in
the class. Updates or changes to a child’s placement end or exit dates frequently lag, contributing
to differences in the number of children in care between the placement data report and the children
in care data.54 Moreover, children whose placement exits are entered into IMPACT in the month
following the actual placement end have continued to appear in that placement in data, making
validation very difficult. For children whose final PMC placement exits are entered in this way,
the final placement remains open (in error) until their 18th birthday.
•
Remedial Orders 2 and 35 require DFPS to report on the caseloads of workers carrying one
or more PMC cases. DFPS continues to report that the minimum time in which DFPS can
produce aggregate reports on caseloads is 30 days from the last day of the month that is
being monitored. This discrepancy occurs because DFPS uploads data to the State’s data
warehouse once a month with a month lag between the end date of the month and the
upload of the data.55
• DFPS shifted its policy defining the initiation of an investigation three times between May
1, 2020 and January 31, 2021.56 For investigations initiated from May 1, 2020 through
August 31, 2020, the DFPS policy in effect required initiation to occur through face-to-
face contact with all alleged victims. In September 2020, the policy in effect at the time
required initiation to occur through face-to-face contact with an alleged victim, an adult
involved in the allegation, or contact with a collateral source. The change in policy required
the Monitors to assess these two time periods separately for Remedial Orders 5 and 6, using
different methodologies and data points for each. This change presented challenges in
evaluating the data and providing a consistent assessment of timeliness across the reporting
period. In December 2020, DFPS again changed its initiation policy to require face-to-face
54
Email from Jane Burstain, Chief Data and Analytics Officer, DFPS, to Nancy Arrigona, Monitoring Team
(December 16, 2020) (including response to questions about the data in the Children in PMC and PMC placements
files).
55
Email from Tara Olah, Dir. of Project Management, DFPS to Kevin Ryan and Deborah Fowler, Monitors (Mar. 24,
2020) (on file with the Monitors) (including DFPS response to Monitors’ Feb. 21, 2020 Data & Information Request).
56
See infra Section III. B.
46
contact with one alleged victim or through an attempted contact with the victim.57 In
January 2021, DFPS changed the policy again, and required initiation to occur through
face-to-face contact with all alleged victims.
• Remedial Order 11 requires DFPS to track and report all child abuse and neglect
investigations involving children in the PMC class that are not completed on time, as well
as any approved extensions on investigation reports. For approved extensions, DFPS
reported the agency cannot provide the Monitors with details about extensions along with
the list of investigations because each investigation can have multiple extensions and
different timeframes and reasons for each.58 As a result, DFPS provided the list of
extensions to the Monitors on a separate spreadsheet tab and provided the investigation
stage ID on both tabs so the Monitors could cross-match the two tabs. While these data
allowed the Monitors to assess the extensions, it is unclear whether DFPS can track in real
time multiple extensions for good cause in the aggregate to allow for the ongoing
management of compliance with Remedial Orders 10 and 11, including the updating of
due dates and timely completion of investigations. The Monitors will continue to evaluate
DFPS’s ability to do so.
• Remedial Orders 12 and 13 address the timeliness of initiation of HHSC investigations.

HHSC remains unable to provide through CLASS the first face-to-face contact for all
alleged victims. The Monitors found, moreover, that the data field provided by HHSC for
the first face-to-face contact with an alleged child victim in a Priority One investigation
was unavailable for one of the two investigations. Therefore, the Monitors were unable to
determine whether it is blank because it did not occur for a valid reason, whether it is due
to data issues, or some other reason, without conducting a case record review in CLASS to
assess.
• Remedial Order 13 could not be assessed with full accuracy, as HHSC was not able to
provide timestamps for the “face-to-face contact with victim date” for alleged victims in
Priority Two investigations. The Monitors therefore used calendar days rather than hours
to assess whether investigations were initiated within 72-hours. In addition, timestamp data
were not available for contacts with one third of the alleged victims in Priority Two
investigations. Starting in November 2020, HHSC updated its policies and began
submitting data reports based upon case record reviews by HHSC staff which the Monitors
will assess in the next reporting period.59
57
See DFPS., Child Care Inv. Handbook §6411-6413 (in effect December 1, 2020); see also, Email from Heather
Bugg, Dir. Of Project Management, Foster Care Litigation and Compliance, DFPS, to Kevin Ryan and Deborah
Fowler (Dec. 1, 2020) (on file with the Monitors).
58
Deborah Fowler and Kevin Ryan, First Court Monitors’ Report 2020 at 53, ECF No.. 869 (discussing the email
from Tara Olah to Kevin Ryan and Deborah Fowler (Mar. 24, 2020,) (on file with the Monitors) (including DFPS
response to Monitors’ Feb. 21, 2020 Data & Information Request).
59
[See Infra reference to Section on ROs 12-19].
47
• Remedial Order 20 requires the State to identify, track, and address concerns at facilities
that show a pattern of child maltreatment and contract or policy violations. It also requires
that when DFPS determines that facilities show a pattern of contract or policy violations,
they are subject to heightened monitoring. The State’s data and data systems make the
identification of patterns and the examination of heightened monitoring time-consuming
and challenging. For instance:
The State provides the Monitors with contract monitoring reports for all operations
monitored in the year. However, these reports are PDF documents that do not include
quantifiable data. The State has indicated that non-compliance data contained in these
reports must be “translated” into quantifiable data in the State’s System of Contract
Operation and Reporting (SCOR) system in order to determine the contract categories and
number of records out of compliance for pattern analysis. Furthermore, contract monitoring
conducted by the SSCCs and provided to the State in multiple report formats must also be
translated to correspond to scoring consistent with the in the SCOR system.60
Organizations operating a facility may, and did, choose to change location or facility name,
resulting in a new contract with the State and a new resource and operation number for the facility.
These associated facilities are not automatically linked in the CLASS system, so historical
maltreatment, and contract and policy violations are effectively lost. In some instances, the
Monitors discovered that the State did not initially include facilities meeting criteria for
heightened monitoring pursuant to Remedial Order 20 were not initially included because the
original name and contract were no longer active and the new name, operated by the same
controlling person(s), did not have a history of maltreatment or violations. In one instance, for
example, an organization that would have been subject to heightened monitoring closed and
reopened in the same location with the same children in care under the same controlling person
but with a different organizational name. The State did not identify the organization subject to
Heightened Monitoring until the Monitors discovered the change and raised the issue.
Documentation to verify heightened monitoring visits, communication, compliance, and

processes are provided to the Monitors monthly in PDF files which must be compiled, scanned,
and uploaded by the State. Documentation is often incomplete. Functionality in the CLASS
system currently only allows for monitoring visits conducted by RCCR inspectors to be entered
into the system. All visits made by heightened monitoring team members other than RCCR
inspectors, all Facility Intervention Team Staffing (“FITS”) meetings, evaluation, and analysis
reports, and all other heightened monitoring communications may be documented in facility
chronology entries. In order to examine compliance with heightened monitoring requirements, the
Monitors must review PDF files as well as monitoring and chronology information found in
CLASS.
60
Discussed during a virtual meeting between the State and Monitors concerning heightened monitoring and pattern
analysis data, March 5, 2021.
48
Review of facility progress under heightened monitoring requires access to all deficiencies
cited by the State’s heightened monitoring team. In order to identify deficiencies related to
heightened monitoring, the Monitors must match the deficiencies and inspection data provided by
the State. However, the State did not provide to the Monitors an indicator identifying an inspection
was related to heightened monitoring until December 30, 2020 in the data file for inspections
conducted during the month of November 2020. A note for the newly added heightened monitoring
inspection variable in this file indicated that “some of the data in this field is manually entered
since heightened monitoring functionality is not yet in CLASS.” 61
• Remedial Order 35 requires that caseworker assignments conform to the caseload standard
of 14 to 17 children. In reviewing and validating caseload data, the monitoring team
observed that some SSCC staff carried large numbers of secondary case assignments. At
2INgage, two staff members carried 55 and 57 secondary case assignments respectively,
while at OCOK one staff member had 307 secondary assignments. In separate meetings
with the Monitors, both SSCCs reported that the high case assignments were the result of
limitations in their data systems and that the staff were not responsible for any secondary
assignment work.62 The Monitors will conduct field interviews with SSCC staff to validate
the SSCCs’ caseload data and report results in the next report to the Court.
• Remedial Order B4 requires the State to establish internal guidelines for caseload ranges,
which allow inspectors and investigators to safely manage their workloads. DFPS is able
to provide the number of RCCI investigations assigned but the minimum time in which
DFPS can produce aggregate reports on caseloads is 30 days from the last day of the month
that is being monitored. Data produced include RCCI investigations that have been
assigned to investigators who do not report through the RCCI chain of command.63 To
ensure RCCI investigations assigned to these staff are counted, DFPS reports that it
designates certain RCCI staff as the primary investigator even though they are not acting
in that capacity. Caseload analysis, therefore, may not accurately reflect investigator
workloads because of limitations to tracking investigations in IMPACT.64
There are other limitations to the State’s data systems. The systems do not have a method
to distinguish between missing data and data that are not applicable. This system defect causes
challenges in interpreting blank cells within reports. The list of placement types and living
arrangements provided by DFPS is complex and contains many categories that are not fully
defined, making it challenging to analyze and report characteristics of PMC children for validation
of remedial order compliance that requires placement type information. The race and Hispanic
ethnicity data are reported in the same field, which means there are no available data concerning
the race of children identified as Hispanic.
61
Data file “RO.20, 2 11,1, 2020-11.30.2020 Lic. Inspections 12.30.2020” uploaded to SharePoint by HHSC.
62
SSSCs explained these issues in telephone meetings with monitoring team members on January 15, 2021.
63
Email from Nancy Arrigona to Jane Burstain (Apr. 14, 2020) (on file with the Monitors) (including questions to
DFPS concerning RCCI Investigator caseload data).
64
Email from Jane Burstain to Deborah Fowler (Apr. 24, 2020) (on file with the Monitors) (including DFPS response
to questions sent by the Monitoring Team on Apr. 14, 2020).
49
While the State enhanced IMPACT’s functionality with a goal toward prospective
improvements in information tracking, these enhancements have not yet fully resolved the issues
and defects in recording and reporting identified above.
C. Limited VPN Capacity and Barriers to Accessing Information
The difficulties experienced by the monitoring team accessing information using the
State’s databases are consistent with both the Court’s 2015 post-trial findings in 2015 and the
Monitors’ First Report.65 Monitoring team members continued to routinely experience delays
when moving between screens within both IMPACT and CLASS. Access to information about
investigations requires a reviewer to move through multiple screens in two different systems,
which substantially increases the time needed to review investigative history. At times, access to
the State’s systems of record was entirely disrupted.
Inconsistent access to reports also hampered the work of the Monitors and extended the
amount of time required for the monitoring team to validate performance. The CLASS database
can produce a Compliance and Sampling Report, a standard, pre-programmed report that allows
the user to view the compliance history of a facility for a chosen time frame. When the Monitors
requested access, HHSC, which manages the CLASS database, made changes to ensure the report
was accessible for the monitoring team through CLASS. However, thereafter, the report again
became inaccessible; as a result, the Monitors had to make repeated, additional requests to HHSC
to produce these reports. Investigation reports in CLASS were at times also inaccessible to the
Monitors.
65
M.D. ex rel. Stukenberg v. Abbott, 152 F. Supp. 3d 684 (S.D. Tex. 2015) (explaining inherent problems with DFPS’s
outdated IMPACT system impede caseworkers’ ability to review important electronic case file information, resulting
in delays and frustration among caseworkers); Deborah Fowler and Kevin Ryan, First Report 55, ECF No. 869.
50
IV.SCREENING, INTAKE AND INVESTIGATION OF MALTREATMENT IN CARE ALLEGATIONS
A. Remedial Order 3
Remedial Order 3: DFPS shall ensure that reported allegations of child abuse and neglect
involving children in the PMC class are investigated; commenced and completed on time
consistent with the Court’s Order; and conducted taking into account at all times the child’s safety
needs. The Monitors shall periodically review the statewide system for appropriately receiving,
screening, and investigating reports of abuse and neglect involving children in the PMC class to
ensure the investigations of all reports are commenced and completed on time consistent with this
Order and conducted taking into account at all times the child’s safety needs.
To assess the State’s performance with respect to Remedial Order 3, the Monitors gathered
and reviewed a wide range of data relating to the safety of PMC children for analysis and
qualitative review. This section discusses the monitoring team’s assessment and review of the
statewide system for appropriately receiving, screening, and investigating reports of abuse,
neglect, and exploitation involving PMC children at several points, including referrals to SWI; the
screening of those reports to determine whether they should be investigated for child abuse, neglect
or exploitation; and investigations of child maltreatment allegations.
Policy Changes and Updates about RCCI’s Secondary Screening of Allegations of Abuse or
Neglect
Prior to November 1, 2020, DFPS policy instructed RCCI staff to conduct a secondary
review of all intakes that SWI had assigned to RCCI for investigation due its determination that
the intake contained an allegation of abuse or neglect involving children in licensed placements.
During this secondary review, RCCI was able to unilaterally confirm or override any of the
elements of SWI’s determination.66
As of November 1, 2020, DFPS eliminated this policy and restructured its secondary
review practice for intakes related to licensed placements. First, the DFPS Child Care
Investigations Handbook has eliminated the ability of RCCI to override any elements of the SWI
66
Deborah Fowler and Kevin Ryan, First Report 58-60, ECF No. 869. The previous version of the Child Care
Investigations Handbook included in Child Care Investigations §6220 provided:
All intake reports require an evaluation to determine:

(a) whether the information involves allegations of abuse or neglect;
(b) whether the information involves possible violations of the statute,
administrative rules, or minimum standards; (c) the immediate safety of children;
(d) the degree of risk to children;
(e) whether the operation is subject to a Licensing investigation; and
(f) the appropriate Licensing priority.
51
determination.67 Second, DFPS restructured the secondary screening function so that any review
of the SWI intake specialist’s determination to assign an intake for investigation is made by an
individual within the SWI RCCI Screening unit. Third, under the new policy, once the intake
specialist at SWI determines that a report related to a licensed placement should be investigated
for abuse, neglect, or exploitation, the report can only be downgraded and reclassified to a Priority
None (PN) for the following reasons:
• The allegations in the intake report reflect that another DFPS division, another state agency,
or law enforcement has investigative jurisdiction. That is, the intake report is outside RCCI
jurisdiction.
• The allegations in the intake report have already been investigated in a closed investigation,
and the intake report does not include new allegations. The intake involves the same
incident that was previously investigated, with the same alleged victim and the same
alleged perpetrator.68
In the First Report, the Monitors previously described a lack of congruence between the
Administrative Code and the DFPS Child Care Licensing Policy and Procedures Handbook that
was in place at the time.69 When the information within a referral to SWI is insufficient to
determine conclusively whether or not there are safety threats to the child, the Texas
Administrative Code supports concluding that cases should be investigated for abuse, neglect or
exploitation.70 In its prior iteration, the DFPS Child Care Licensing Policy and Procedures
Handbook section for “Downgrading an Abuse or Neglect Report” was in apparent conflict with
the Texas Administrative Code’s direction to resolve uncertainty in favor of investigation. The
Handbook previously stated that RCCI may downgrade an abuse or neglect report when the
information in the report: “1) suggest a minimum standard was violated, but not that a child was
abused or neglected; 2) or indicates that there is some risk to children, but the information is too
vague to determine that a child was abused or neglected.”71 The newly implemented DFPS policy
eliminated this conflict.
Change of Name for HHSC’s Residential Child Care Regulation
As noted previously, effective February 2021, HHSC changed the name of its child care
regulation unit Residential Child Care Licensing (RCCL) to Residential Child Care Regulation
67
DFPS., Child Care Investigations Handbook § 6211.1, available at
https://www.dfps.state.tx.us/handbooks/CCI/default.asp [hereinafter Child Care Investigations]. DFPS notified the
Monitors that it instructed staff about the new downgrade practice effective October 1, 2020 and that the policy
would be finalized and published as of November 1, 2020. Email from Audrey Carmical, to Deborah Fowler and
Kevin Ryan (October 1, 2020).
68
Id.
69
Deborah Fowler and Kevin Ryan, First Report 59-60, ECF No. 869.
70
DFPS staff must complete a thorough investigation if DFPS obtains information indicating that:
(A) there are safety threats to the child because of abuse or neglect;
(B) risk of abuse or neglect is indicated; or
(C) based on information in the report and any initial contacts, it is impossible to determine whether
or not there are safety threats to the child because of abuse or neglect or whether risk of abuse or
neglect is indicated. TEX. ADMIN. CODE § 707.489 (d) (1)(A)-(C).
71
52
(RCCR). The department maintains its charge to regulate child day care and residential child care
operations and other child care activities, as well as child care administrators and child-placing
agency administrators.
DFPS Investigation of Allegations of Abuse or Neglect

All reports that SWI determines will be investigated as abuse, neglect or exploitation are
assigned to an RCCI investigator.72 The RCCI investigator is required to assess the immediate
safety of involved children,73 to evaluate the risk to the children during the investigation,74 and to
initiate the investigation timely based on the assigned priority – 24 hours for Priority One and 72
hours for Priority Two.75 The RCCI investigator is required to conduct interviews of children and
collateral witnesses,76 to collect evidence,77 and to complete the investigation within 30 days for
both Priority One and Priority Two cases.78 RCCI’s possible findings include:
Reason to Believe (“RTB”) – A preponderance of evidence indicates that abuse,
neglect, or exploitation occurred. If the disposition for any allegation is Reason to
Believe, the overall case disposition is Reason to Believe.
Ruled Out (“R/O”) – A preponderance of evidence indicates that abuse, neglect, or
exploitation did not occur. If the dispositions for all allegations are Ruled Out, the
overall case disposition is Ruled Out.
Unable to Determine (“UTD”) – A determination could not be made because of an
inability to gather enough facts. The investigator concludes that:
• there is not a preponderance of the evidence that abuse or neglect occurred; but
• it is not reasonable to conclude that abuse or neglect did not occur.
If the disposition for any allegation is UTB and there is no allegation assigned a
disposition of RTB, the overall case disposition is UTB.
Administrative Closure (ADM) – The operation is not subject to regulation; or the
allegations do not meet the definition of abuse, neglect, or exploitation. If the
dispositions for all allegations are Administrative Closure, the overall disposition
is Administrative Closure.79
RCCI is charged with investigating allegations of abuse, neglect, or exploitation of children

in operations licensed by RCCR, which includes foster homes and GROs.80 Child Protective
Investigations (CPI) is responsible for investigating abuse or neglect of children in unlicensed
placements such as kinship foster homes. CPI’s investigative authority also includes investigating
72
DFPS, Child Care Investigations § 6100.
73
74
75
DFPS, Child Care Investigations § 6361.1-2.
76
77
78
79
DFPS, Child Care Investigations § 6622.3
80
DFPS, Child Care Investigations §1142.
53
reports of child abuse or neglect that are alleged to have occurred prior to the child’s entrance into
DFPS custody.81
Statewide Intake Performance
Background
On February 21, 2020, the Court ordered the State to provide to the Monitors the records
of all SWI calls made, the specific times of all calls made to SWI, and the wait time for each SWI
call including, but not limited to, dropped and unanswered SWI calls.82 The Court required the
State to produce these records to the Monitors by February 26, 2020, and continuing thereafter
until further order of the Court.
In compliance with the Court’s order, on February 26, 2020 and thereafter, the State
continued to produce data files containing monthly SWI call records during this reporting period
of all hotline calls made; the specific times of these calls to the hotline; and the wait time for each
call, including, but not limited to, dropped and unanswered calls.83
Calls to SWI are answered by an automated system that asks the caller a series of questions
in order to determine the way the call is routed.84 These questions include a caller’s language
preference; whether the caller is asking about the status of a case; or whether the caller wants to
learn more about online reporting.85 Depending upon the answers to these questions, the call is
routed to one of 22 “call queues.”86 If an SWI staff member is not immediately available, the caller
waits on the queue.87 If a caller hangs up before an SWI staff member answers the call, the call is
categorized as “abandoned.”88 If an SWI staff member speaks with the caller, the call is categorized
as “handled.” The automated system records the date and time that each call starts and ends; the
call queue to which the call is routed; whether the call is handled or abandoned; the time the caller
waits after being routed to a queue before speaking with an SWI staff member; and other
information.89
81
DFPS, Child Protective Services Handbook §2120, available at
https://www.dfps.state.tx.us/handbooks/CPS/default.asp [hereinafter Child Protective Services].
82
M.D. ex rel. Stukenberg v. Abbott, No. 2:11-CV-84, slip. op. at 2 (S.D. Tex. Feb. 20, 2020), ECF No. 811 (ordering
that starting February 26, 2020 and continuing thereafter in 24-hour increments until further order of the Court, the
Defendants are to provide the Monitors with records of all Statewide Intake hotline calls made and the wait time for
each call including, but not limited to, dropped and unanswered calls, and including the specific times of these calls
to the Statewide Intake hotline).
83
The data files provided by the State utilized in this section of the report are: (1) export_0819.csv; (2)
export_0919.csv; (3) export_1019.csv; (4) export_1119.csv; (5) export_1219.csv; and (6) export_0120.csv, provided
to Monitors February 26, 2020 (on file with the Monitors). Additionally, the State provided the Monitors with a Data
Dictionary defining each data element. DFPS, SWI Calls Raw Data Report – Data Dictionary (Feb. 26, 2020) (on file
with the Monitors).
84
See DFPS., SWI Abuse Hotline Call Flow- AM 5-7-2019 (Mar. 30, 2020) (on file with the Monitors).
85
Id.
86
Id.
87
See DFPS, RO3 3-13-20 Response FINAL (Mar. 30, 2020) (on file with the Monitors).
88
Id.
89
DFPS, RO3 3-13-20 Response FINAL (Mar. 30, 2020) (on file with the Monitors); DFPS., SWI Abuse Hotline Call
Flow- AM 5-7-2019 (Mar. 30, 2020) (on file with the Monitors).
54
Statewide Intake Call Center Performance Analysis
Methodology
The Monitors analyzed SWI’s Avaya call data related to the 533,471 calls made to SWI
from February 1, 2020 to November 30, 2020. The analysis examined the distribution of calls by
month, weekday, hour and call queue, the prevalence of handled and abandoned calls, and the
amount of time callers waited before the call was answered by a staff person.
Volume of Calls to SWI
On average, the SWI data recorded over 53,000 calls a month. These calls included calls
from the public as well as calls and transfers within SWI. Call volume declined at the onset of the
pandemic in April 2020, coinciding with the closure of schools and many businesses,90 but rose
from July 2020 through October 2020. Call volume in November 2020 (55,118 calls) decreased
marginally (3%) compared to November 2019 (57,076 calls).
Average call volume decreased by an average of 9,000 calls per month as compared to the
trends observed in the Monitors’ previous report.91
90
Texas Governor Greg Abbott issued an executive order on March 19, 2020 which included orders to limit social
gatherings to 10 people, limit business operations, and temporarily closed schools. See Tex. Exec. Order No. GA-08
(March 19, 2020), https://gov.texas.gov/news/post/governor-abbott-issues-executive-orders-to-mitigate-spread-of-
covid-19-in-texas.
91
The Monitors previously found an average of 62,000 calls per month from August 1, 2019 to January 31, 2020. See
55
Figure 4.1: Number of SWI Calls by Month
Source: Calls to SWI Call Center, February - November 2020

n=533,471 calls
70,000
61,113
60,000 57,092 57,563 59,313
55,118
52,418
49,977 51,675
50,000 45,682
43,520
40,000
30,000
20,000
10,000
0
Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20
Queue Times
On average, callers waited for 2.3 minutes on the queue before their calls were handled or
abandoned, an improvement by almost two minutes from the previous reporting period.92 Seventy
percent (373,970) of callers waited on the queue for under one minute; 14% (72,824) waited for
one to five minutes; 8% (44,508) waited five to ten minutes; 4% (22,178) waited ten to fifteen
minutes; 2% (10,783) waited fifteen to twenty minutes; and 2% (9,208) waited more than twenty
minutes.
92
56
Figure 4.2: Time Callers Waited before Calls were Handled or Abandoned
Source: Calls to SWI Call Center, February -November 2020

n=533,471 calls
72,824,
14% 44,508, 8%
22,178, 4%
10,783, 2%
9,208, 2%
373,970,
70%
Under 1 minute 1 to 5 minutes 5 to 10 minutes

10 to 15 minutes 15 to 20 minutes More than 20 minutes
Handled Calls
Of 533,471 calls, 87% (463,943) were answered, an increase from 82% observed in the
First Report.93 Handled calls had an average duration of 11.5 minutes. Six percent (25,528) of
handled calls lasted under one minute; 20% (94,945) lasted one to five minutes; 26% (122,014)
lasted five to ten minutes; 23% (108,017) lasted ten to fifteen minutes; 12% (56,512) lasted fifteen
to twenty minutes; and 12% (56,909) lasted more than twenty minutes.94
93
The First Report found that 82% of calls were handled from August 1, 2019 to January 31, 2020. See Deborah
Fowler and Kevin Ryan, First Report 65, ECF No. 869.
94
Percentages total 99% due to rounding. Fewer than 1% (18) of handled calls had a duration of zero minutes, a
potential indicator of data quality issues; calls that were answered should, by definition, have a duration. Calls with a
duration of zero minutes were abandoned before the caller finished navigating the automated system.
57
Figure 4.3: Duration of Handled SWI Calls
Source: Handled Calls to SWI Call Center, February - November 2020

n=463,943 handled calls
140,000
122,014
120,000 108,017
100,000 94,945
80,000
56,512 56,909
60,000
40,000 25,528
20,000
18
0
0 minutes Under 1 1 to 5 5 to 10 10 to 15 15 to 20 More than
minute minutes minutes minutes minutes 20 minutes
Duration of call
There were 991 calls in the dataset with durations longer than two hours, which may be
indicative of data system issues. Of these 991 calls, 561 (57%) lasted two to three hours; 212 (21%)
lasted three to four hours; 153 (15%) lasted four to five hours; 47 (5%) lasted five to six hours;
and 18 (2%) lasted more than six hours.
Abandoned Calls
During the period analyzed, 13% (69,468) of calls were abandoned, a decrease from 18%
observed in the previous report.95 Thirty-one percent (21,754) of all abandoned calls occurred
before the caller finished navigating the automated system. An additional 47% (32,838) of
abandoned calls occurred after callers waited for up to five minutes.
Of the 373,970 calls waiting on the queue for up to a minute, 8% (31,602) were abandoned;
of the 72,824 calls waiting for one to five minutes, 32% (22,990) were abandoned; of the 44,508
calls waiting for five to ten minutes, 20% (8,924) were abandoned; of the 22,178 calls waiting for
ten to fifteen minutes, 15% (3,379) were abandoned; of the 10,783 calls waiting fifteen to twenty
95
The First Report found that 18% of calls were abandoned from August 1, 2019 to January 31, 2020. See Deborah
58
minutes, 13% (1,450) were abandoned; and of the 9,208 calls waiting for more than twenty
minutes, 12% (1,123) were abandoned.
Call Queues
Calls were routed to 22 different queues in the reporting period. Of the 533,471 calls, the
abuse queue received the majority of incoming calls (61%, 324,391). The next most common
queues were calls from intake staff to their supervisors (14%, 74,041); calls from law enforcement
(11%, 59,642); calls to support staff (4%, 22,248); and other general calls in English including
calls pertaining to state hospitals and state supported living centers (4%, 20,845). These five
queues represent 94% (501,167) of all calls.
Only 3% (1,581) of the 59,642 calls to the law enforcement queue were abandoned. In
contrast, 16% (50,933) of 324,391 calls to the abuse queue were abandoned. On the law
enforcement queue, 86% (51,319) of calls were handled or abandoned in the first minute and 97%
(57,894) in the first five minutes. In contrast, 61% (196,791) of calls to the abuse queue were
handled or abandoned in the first minute and 77% (250,506) were handled or abandoned in the
first five minutes.
The rate of abandoned calls decreased from 22% in the previous reporting period to 16%
between February 1, 2020 and November 30, 2020. The rate of calls handled or abandoned in the
first five minutes increased from 58% in the previous reporting period to 77%.96
Calls by Day of the Week and Time of Call
SWI calls were higher in volume on weekdays than on weekends. The average weekday
call volume (296 calls per day) was more than twice the average weekend call volume (141 calls
per day). There was no difference in rates of abandonment on weekdays compared to weekends;
13% of calls were abandoned on both weekdays and weekends. Queue times also remained
constant when comparing weekdays to weekends.
96
The Monitors previously reported that, from August 1, 2019 to January 31, 2020, 22% of calls to the abuse queue
were abandoned, and 58% of calls were handled or abandoned in the first five minutes. Deborah Fowler and Kevin
Ryan, First Report 65, ECF No. 869.
59
Figure 4.4: Number of SWI Calls Handled and Abandoned by Day of the Week
Source: Calls to SWI Call Center, February - November 2020

n=533,471 calls
120,000
100,000
12,874
80,000 11,044 11,769 10,456 12,226
60,000
4,986 6,113
40,000 86,269 78,542 75,315 76,906 72,746
20,000 36,679 37,546
0
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Handled Abandoned
Sixty percent (319,866) of all calls were placed during typical work hours (9:00am through
6:00pm), with a higher rate (71%) placed during work hours on weekdays. The Monitors did not
find that abandonment rates spiked during the work week, as was observed in the previous report.97
DFPS Intake Screening and Maltreatment in Care Investigations
Data and Information Request and Production
Monitors’ Data and Information Request
To validate the State’s performance with respect to appropriately screening referrals for
child maltreatment associated with Remedial Order 3, the Monitors requested from the State, and
on an on-going monthly basis, a list of all referrals received through SWI via phone call, website,
fax, regular mail, or any other manner in which the referent expresses concern about child
97
The Monitors previously found that from August 1, 2019 to January 31, 2020, 40% of calls placed on Mondays or
Fridays between 3:00 p.m. and 5:00 p.m. were abandoned. Deborah Fowler and Kevin Ryan, First Report 66, ECF
No. 869.
60
maltreatment regarding children in the PMC General Class, regardless of placement type.98 The
Monitors requested inclusion of relevant data points about the child and the placement, including
where the child is placed at the time of the referral to SWI; licensure status; and whether the referral
was sent for an investigation. The Monitors also requested key data points about the referrals
including the date of the referral; the disposition of the report by SWI (where referred, whether it
was classified as an intake or I/R, and the priority assigned); the disposition of the report by the
office/division to which it is referred (RCCI, RCCR etc.), including whether it was referred for an
abuse or neglect investigation or a minimum standards investigation; the priority assigned to the
investigation; and any other information about how the State addressed or planned to address the
referral.99
To validate the State’s performance with respect to appropriately investigating child

maltreatment in care associated with Remedial Order 3, the Monitors requested from the State, on
an ongoing basis, a list of all investigations involving any child in the PMC General Class. The
Monitors requested key information about the investigations including the date and time of intake;
allegations; alleged victims in the PMC Class; investigator; and PMC child placement, among
other requested fields relevant to Remedial Order 3 and other remedial orders.100
DFPS Data and Information Production
For purposes of data related to SWI, the State—DFPS and HHSC together or separately—
remains unable to provide the Monitors with a unified list of all referrals to SWI involving PMC
children as an apparent result of a bifurcated system for processing and storing data associated
with referrals to SWI.101
HHSC cannot distinguish between PMC and non-PMC child-related referrals in its data.
HHSC’s data includes all referrals for that period and does not identify PMC children because, as
98
Email from Deborah Fowler and Kevin Ryan to Andrew Stephens (Sept. 30, 2019), (including Monitors’ Sept. 30,
2019 Data & Information Request) (on file with the Monitors).
99
Id.
100
The Monitors’ request included: intake stage ID number; investigation stage ID number; person ID (for all alleged
PMC victims); county where maltreatment is alleged; most recent investigator name and ID; date and time
investigation stage started; program conducting investigation; child’s placement type at intake; placement resource at
time of intake; the manner of initiation (action taken by the investigator that triggered the start of the investigation);
the date/time of face to face contacts with alleged victim(s) as applicable noting any and all untimely face to face
contacts and the reason(s) for any approved extensions to the face to face contact timeframe; the relationships of the
alleged perpetrator(s) to the child-victims. For closed investigations, the Monitors’ request included: date the
investigation is completed; date documentation is completed and submitted to the supervisor; the status of all
allegations involving all PMC children; overall investigation disposition; the reason(s) for all approved extensions to
the investigation completion date/time (when applicable); the date any notification letters are sent to parents, providers
and/or referents. See also Email from Kevin Ryan and Deborah Fowler to Andrew Stephens (Oct. 28, 2019) (on file
with the Monitors).
101
See also Section II. In response to the Monitors’ request to the State for data about referrals to SWI, the Monitors
continued to receive separate data files from both DFPS and HHSC. DFPS produced monthly data for all referrals to
SWI in which a PMC child was an alleged victim and SWI staff determined that the referral involved abuse or neglect
allegations; HHSC produced monthly data for all referrals overall to SWI that were not screened as abuse or neglect,
meaning the referrals were administratively closed, referred for an RCCR minimum standards investigation or
otherwise.
61
the agency reported to the Monitors, “[t]he agency is operations-centric not child centric. CLASS
does not contain the PMC identifier of children involved in a referral [or investigation]; the PMC
identifier is only associated with referrals of abuse or neglect in IMPACT.”102 Thus, the majority
of the 13,042 referrals included in the data reported by HHSC from May 1, 2020 through
November 30, 2020 do not include the name of the child or children associated with the referral.
Moreover, for the limited data where the name of a child is identified, PMC status is not
distinguished.103
In response to the Monitors’ request for data reporting on closed maltreatment in care
investigations, DFPS has produced regular files on closed investigations for this reporting
period.104
Overview of Allegations in Referrals and Investigations for

Maltreatment in Care
The Monitors analyzed data about maltreatment in care allegations for PMC children using
(1) data about intakes pertaining to PMC children received by SWI from May 1, 2020 to November
30, 2020;105 RCCI investigations, pertaining to PMC children in licensed facilities, that were
opened from May 1, 2020 to October 31, 2020; and (3) RCCI investigations, pertaining to PMC
children in licensed facilities, that were closed between May 1, 2020 and October 31, 2020.106
Intakes for PMC Children Referred to RCCI and CPI
From May 1, 2020 to November 30, 2020, DFPS reported 1,205 intakes for PMC children
in licensed placements that were coded as abuse, neglect, or exploitation by SWI intake specialists.
Until November 2020, RCCI performed a secondary screening function that allowed it to
downgrade intakes to Priority None without investigation if it determined that the referral did not
include allegations of abuse, neglect or exploitation. In that same time period, DFPS reported 574
intakes for PMC children in unlicensed placements that were coded as abuse, neglect or
exploitation by SWI intake specialists for investigation by CPI.
102
DFPS, Data Production Chart at 5-6 (Dec. 6, 2019) (responding to Monitors’ Sept. 30, 2019 Data and Information
Request).
103
In addition, the Monitors were also able to discern that HHSC data related to referrals is not limited to children
who are in DFPS custody. HHSC and DFPS each produced different referral files for this reporting period. For the
monthly files, the Monitors requested the production on a 15-day lag; received it on a 45-day lag; and subsequently,
beginning in September 2020, the State provided the data at a 30-day lag.
104
These files were originally produced quarterly and are now produced monthly as of September 2020. The files
separately reported on investigations conducted through RCCI and Child Protective Investigations (“CPI”).
105
DFPS, RO3.1 RCI and CPI Intakes May 2020 - July-15-20 - 98621 (July 16, 2020) (on file with the Monitors);
DFPS, RO3.1 RCI and CPI Intakes June 2020 - Aug-15-20 - 98899 (Aug. 18, 2020) (on file with the Monitors); DFPS,
RO3.1 RCI and CPI Intakes July 2020 - Sept-15-20 - 99252 (Sept. 16, 2020) (on file with the Monitors); DFPS RO3.1
RCI and CPI Intakes Aug 2020 - Sept-30-20 - 99654 (Oct. 8, 2020) (on file with the Monitors); DFPS, RO3.1 RCI
and CPI Intakes Sept 2020 - 11-2-20 (Nov. 3, 2020) (on file with the Monitors); DFPS, RO3.1 RCI and CPI Intakes
Oct 2020 - 11-30-20 - fcl 01 (Dec. 1, 2020) (on file with the Monitors); DFPS, RO3.1 RCI and CPI Intakes Nov 2020
- 1-4-21- fcl 01 (Jan. 8, 2021) (on file with the Monitors).
106
Some intakes include more than one child and more than one allegation for each child.
62
The total number of referrals received by SWI about PMC children is unknown because
the State is unable to report on the total number due to its bifurcated reporting system, as described
in Section II.
During its secondary screening between May 1, 2020 and November 30, 2020, DFPS
downgraded 185 of the 1,205 RCCI intakes (15%) involving a PMC child to Priority None (PN),
meaning that at secondary screening, the screener assigned the intake as a Priority None and
determined that RCCI would not conduct an abuse or neglect investigation. In addition, the
secondary screener downgraded 152 of 1,205 intakes (13%) from Priority One investigations to
Priority Two investigations. As reflected in the Figure below, the overall rate of downgrades fell
dramatically from May 2020 (46.6%) to November 2020 (13%). Specifically, downgrades to PN
fell from 29.8% (53 out of 178 intakes) in May 2020 to just 2.2% (3 out of 138 intakes) in
November 2020, which is when DFPS formally implemented its policy and structural changes
restricting PNs to a narrow set of categories. Moreover, consistent with the new policy, in
November, none of the reasons for downgrade to PN were due to a determination that the report
did not involve abuse, neglect or exploitation. In October 2020, only one of the five downgrades
to PN was made for that reason.
Figure 4.5: RCCI Rate of Downgrades from May 1, 2020 to November 30, 2020
Source: Analysis of TX RCCI Intake Data May - November 2020

n=1,205 unique intakes
50% 46.6%
38.7%
40% 33.2%
29.8% 29.7%
30% 25.0%
Percent
20.2% 22.5%
20% 15.7%
12.8% 13.0%
8.3%
10%
2.8% 2.2%
0%
May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20
(178) (193) (142) (185) (188) (181) (138)
Month-Year (unique intakes)
All Downgrades Downgrades to PN
During the secondary screening for CPI intakes between May 1, 2020 and November 30,
2020, DFPS downgraded 90 of the 574 CPI intakes (15.7%) involving a PMC child to Priority
None (PN), meaning that at secondary screening, the CPI staff assigned the intake as a Priority
None and determined that CPI would not conduct an abuse or neglect investigation. In addition,
DFPS downgraded 32 of 574 total intakes (5.6%) from Priority One investigations to Priority Two
63
investigations. The rate of downgrades fell from May (36.6%) to November (7.2%). Specifically,
downgrades to PN fell from 36.6% (23 out of 71 intakes) in May to just 2.4% (2 out of 83 intakes)
in November.
Figure 4.6: CPI Rate of Downgrades from May 1, 2020 to November 30, 2020
Source: Analysis of TX RCCI Intake Data May -November 2020

n=574 unique intakes
40% 36.6%
30% 26.8% 25.7%

32.4%
20.5% 23.3%
Percent
20% 22.7%
19.2% 11.4%
17.0% 16.2%
10% 6.0%
0% 2.3% 2.4%
May-20 Jun-20 Jul-20 (97) Aug-20 Sep-20 Oct-20 Nov-20
(71) (88) (73) (74) (88) (83)
Month-Year (unique intakes)
All Downgrades Downgrades to PN
RCCI Intake Rates and Types of Abuse or Neglect Allegations
The 1,205 intakes by SWI that were reported by DFPS involved 1,533 children in licensed
placements between May 1, 2020 and November 30, 2020 and contained 1,646 allegations of child
abuse, neglect, or exploitation. Among those 1,646 allegations, Neglectful Supervision was the
most common allegation type at 59%, affecting 965 children; Physical Abuse allegations
constituted 23% of allegations, affecting 376 children; and Sexual Abuse allegations constituted
9% of all allegations, affecting 147 children.107 Other allegation types account for the remaining
ten percent of allegations; those include Medical Neglect, Emotional Abuse, and Physical Neglect.
The data may underrepresent the prevalence of alleged sexual abuse victimization among PMC
children due to the nature of Neglectful Supervision allegations. The Monitors found during
reviews of intakes and investigations that between one quarter to one third of allegations of
Neglectful Supervision involve child on child sexual contact, both in the First Report and during
107
If a child was the subject of the same type of allegation in two separate intakes, that child would be double counted
in this analysis.
64
this reporting period. DFPS’s data does not identify the type of harm underlying Neglectful
Supervision allegations.
Figure 4.7: Allegation Types for RCCI Intakes Involving PMC Children in Licensed
Placements, May 1, 2020 to November 30, 2020
Source: RCCI Intakes May - November 2020

n=1,646 allegations for 1,205 intakes
70%
59%
60%
50%
Percent
40%
30% 23%
20%
9%
10% 5% 3% 2%
0%
Neglectful Physical Sexual Medical Emotional Physical
Supervision Abuse Abuse Neglect Abuse (46) Neglect
(965) (376) (147) (85) (27)
Allegation (number of allegations)
B. Remedial Order 3: Screening and Intake Performance Validation
During this reporting period, DFPS reconfigured its policy and structure to better align its
screening process with child safety as discussed above.
Methodology
To evaluate DFPS’s performance associated with Remedial Order 3 and assess the
appropriateness of screening of referrals of abuse, neglect or exploitation involving PMC children
in licensed and unlicensed placements, the monitoring team conducted a qualitative review of
referrals received by SWI.
65
First, the Monitors assessed the appropriateness of DFPS’s secondary screenings and
reviewed all 275 referrals that SWI initially assigned to either RCCI or CPI108 for investigation
between May 1, 2020 and November 30, 2020, but were later downgraded in a secondary screening
process to non-abuse or neglect reports or for other reasons.109 A secondary screener at RCCI (and
later within SWI) or CPI110 reversed the original determination at SWI and assigned a Priority
None (PN) classification so that the State did not investigate the referrals for abuse, neglect or
exploitation.111
The DFPS data between May 1, 2020 and November 30, 2020 identified 1,205 intakes
involving PMC children in licensed placements that were assigned by SWI to RCCI for a Priority
One or Two abuse or neglect investigation. Secondary RCCI screeners downgraded 185 of these
intakes. The table below shows the number of intakes downgraded to PN for each of the seven
months reviewed by the Monitors. As of November 2020, the reasons for downgrade following
SWI’s decision to assign a referral for investigation by RCCI no longer included any determination
that the intake did not include abuse or neglect, consistent with the new policy.112
108
Referrals assigned to RCCI involve PMC children placed in licensed placements, while referrals assigned to CPI
involve PMC children placed in unlicensed placements and/or involve allegations of abuse or neglect related to a
child’s birth family or caregiver(s) often prior to entering DFPS custody.
109
On Sept 4, 2020, during a hearing regarding Plaintiffs’ motion to hold the state in contempt for failure to implement
certain Remedial Orders, the State agreed that Remedial Order 3 applies broadly to the PMC class and thereby
incorporates PMC children placed in licensed and unlicensed placements. See Contempt Hr’g Tr. 6:14 to 8:21, Sept.
4, 2020. Specifically, Kimberly Gdula, Assistant Att’y General, stated, “I do understand that Remedial Order Number
Three references the PMC class, not RCCI specifically.” Id. at 7:14-17. Child Protective Investigations, CPI, is the
investigative unit within DFPS charged with screening and investigating allegations of abuse or neglect involving
PMC children in unlicensed placements. Following the State’s agreement, the Monitors included a qualitative review
of CPI’s screening decisions of referrals involving PMC children placed in unlicensed homes in their assessment of
Remedial Order 3.
110
Referrals assigned to RCCI involve PMC children placed in licensed placements, while referrals assigned to CPI
involve PMC children placed in unlicensed placements and/or involve allegations of abuse or neglect related to a
child’s birth family or caregiver(s) often prior to entering DFPS custody.
111
The determination of non-abuse or neglect was the primary reason for the downgrades under the former policy.
Other reasons included “closed and reclassified,” “other agency/out-of-state,” “allegations addressed in previous
case,” and “too vague or general.” As described above, as of November 1, 2020, RCCI no longer conducts a secondary
screening of intakes assigned to abuse or neglect investigations by SWI. All screening decisions, including
downgrades, are now made internally by the newly created unit within SWI. As such, in its review of November 2020
referrals downgraded to PN, the Monitors assessed the screening decisions of SWI not RCCI. For CPI referrals, DFPS
has not made any policy changes and CPI continues to complete secondary screenings of those intakes assigned to an
abuse or neglect investigation by SWI.
112
The reasons for downgrade were permissible under the current policy in DFPS Child Care Investigations Handbook
§ 6211.1 as discussed above.
66
Table 4.1: Intakes Downgraded by RCCI between May 1, 2020 and November 30, 2020
Total No. of Intakes Percent of

Month Total No. of Intakes
Assigned for RCCI Downgraded
(2020) Downgraded
Investigation by SWI Intakes
May 178 53 29.8%
June 193 39 20.2%
July 142 32 22.5%
August 185 29 15.7%
September 188 24 12.8%
October 181 5 2.8%
November 138 3113 2.2%
Total 1,205 185 15%
The DFPS data between May 1, 2020 and November 30, 2020, identified 574 intakes
involving PMC children in unlicensed placements that were assigned by SWI to CPI for a Priority
One or Two abuse or neglect investigation. Secondary CPI screeners downgraded 90 of these
intakes, all of which the Monitors reviewed. The table below shows the number of intakes
downgraded by CPI for each of the seven months reviewed by the Monitors.114
Table 4.2: Intakes Downgraded by CPI between May 1, 2020 and November 30, 2020
Total No. of Intakes Total No. of Intakes Percent of

Month Assigned for CPI Downgraded by Downgraded
Investigation by SWI CPI Intakes
May 71 23 32.4%
June 88 15 17.1%
July 97 22 22.7%
August 73 14 19.2%
September 74 12 16.2%
October 88 2 2.3%
November 83 2 2.4%
Total 574 90 15.7%
113
For the three intakes downgraded in November 2020, SWI secondary screening staff made the determination to
reclassify these intakes as PN and not assign them for an abuse or neglect investigation.
114
For the months of October and November 2020, CPI downgraded a total of four intakes citing the following reasons:
“Allegations addressed in previous case;” “Doesn’t appear to involve abuse, neglect or risk;” and, “Other Agency/Out
of State.”
67
Second, the Monitors conducted a primary screening review of SWI’s decision-making.

The Monitors randomly selected 953 out of 7,829 referrals to SWI during the months of January
and February 2020; and October and November 2020, in order to assess SWI’s decision-making
at the beginning of the calendar year and then toward the end of the calendar year. The Monitors’
review focused on referrals where an intake specialist at SWI determined that the report did not
include an allegation of abuse, neglect, or exploitation and referred the matter to HHSC for further
assessment for a potential minimum standards investigation or administrative closure.115 For these
953 referrals, SWI determined that they did not contain an allegation of abuse or neglect and
assigned the referrals to RCCR within HHSC as an Information and Referral (I&R) for a potential
minimum standards investigation or administrative closure. The Monitors’ review focused on
whether SWI appropriately screened the referrals when it determined that they did not contain any
allegations of abuse or neglect.116
As the HHSC referral data does not provide child identifiers, the Monitors’ methodology
and analysis involved a preliminary two-step process to ascertain which referrals involve children
in PMC status. The monitoring team first undertook the effort of reviewing each individual report
to identify which child or children were the subject of the report. Next, the monitoring team
searched the IMPACT records of each child or children identified in each report to determine
whether a given report involved a child in PMC status by checking for the child’s legal status.
For the months of January and February 2020, HHSC identified 3,480 referrals involving
all children in licensed placements that SWI determined should not be assigned for a child abuse,
neglect, or exploitation investigation and were instead assigned to RCCR within HHSC for further
analysis. The Monitors randomly selected a sample of 599 of these referrals. Of those 599 referrals,
the monitoring team identified 241 that involved children with PMC status; the other 358 intakes
involved children in TMC status or children who were not then in the State’s custody and therefore,
those referrals are not included in these results.
For the months of October and November 2020, HHSC identified 4,349 referrals involving
all children in licensed placements that SWI assigned to RCCR for further analysis. The
monitoring team randomly selected a sample of 354 reports; of these, the monitoring team
identified 154 referrals that involved children with PMC status. The other 200 intakes involved
children in TMC status or children not then in the State’s custody and therefore, those referrals are
not included in these results.
115
When a report to SWI is assigned for investigation to RCCI or CPI, the Monitors receive the data from DFPS in a
separate report; therefore, these data are representative of the reports originally assigned to HHSC. HHSC referred
nine reports originally coded by SWI as non-abuse or neglect back to SWI and SWI staff reentered them as intakes
that warranted an abuse or neglect investigation.
116
The sample was selected using a 95% confidence level from monthly data reports provided by HHSC listing all
referrals it received related to children in licensed placements. For January and February 2020, the sample was created
independently using a 95% confidence level for each month; the Monitors selected referrals for October and November
2020 using a 95% confidence level on the total between the two months. In the October and November 2020 sample,
the Monitors oversampled for referrals that were sent to RCCR within HHSC with an intake of Priority One, Two, or
Three and then assigned for a minimum standards investigation.
68
Remedial Order 3 Secondary Screening Validation Results for RCCI and CPI
The Monitors’ secondary screening review focused on whether RCCI117 and CPI
appropriately downgraded a total of 275 referrals after SWI initially assigned them for a Priority
One or Two abuse or neglect investigation between May 1, 2020 and November 30, 2020.
RCCI Results
The Monitors’ review determined that of the 185 intakes that RCCI downgraded at
secondary screening, RCCI appropriately downgraded 162 (88%) intakes, and inappropriately
downgraded 23 (12%) intakes which contained allegations that warranted investigation for abuse,
neglect, or exploitation to ensure the safety of a PMC child(ren). In these 23 cases, summarized
in the Appendix, the Monitors agreed with the original SWI determination to assign the intakes for
abuse, neglect, or exploitation investigations and disagree with the secondary screeners’ final
determination not to do so. All of these cases arose prior to the effective date of the new DFPS
policy restricting secondary screening of RCCI intakes. The intakes with which the Monitors
disagreed primarily fell in the earlier months of the review period as follows: eight in May; eight
in June; two in July; three in August; and two in September 2020. The Monitors did not identify
any referrals to RCCI that were inappropriately downgraded in October or November 2020.
Because of the change in DFPS’s screening policy and practice in the months leading up
to the effective date of the new policy, for the current review period, the Monitors found significant
improvement in RCCI’s screening of abuse, neglect, or exploitation referrals involving PMC
children when compared with the review findings presented in the Monitors’ First Report. The
Monitors in the First Report found that of 174 intakes RCCI downgraded at secondary screening
between July 31, 2019 and October 31, 2019, RCCI inappropriately downgraded 57 intakes reports
(33%), which contained allegations that warranted investigation for abuse or neglect.118 Thus, the
Monitors’ rate of disagreement with RCCI’s downgrade determinations dropped by 21 percentage
points from 33% in the First Report to 12% in this Second Report.
CPI Intakes
For the review of SWI intakes involving PMC children referred to CPI, the Monitors
determined that of the 90 intakes that CPI downgraded at secondary screening, CPI appropriately
downgraded 88 (98%) of intakes, and inappropriately downgraded only two intake reports (2%),
which contained allegations that warranted investigation for abuse or neglect to ensure the safety
of children in the PMC class. In these two cases, summarized in the Appendix, the Monitors
agreed with the original SWI determination to assign the intakes for abuse or neglect investigations
and disagree with the CPI final determination not to investigate.
Remedial Order 3: SWI Original Screening Validation Results for

Referrals Assigned to HHSC
117
In November 2020, SWI performed this function internally.
118
Deborah Fowler and Kevin Ryan, First Report 73-75, ECF No. 869.
69
In the Monitors’ sample of 599 SWI referrals from January and February 2020 sent directly
to HHSC for RCCR assessment, the Monitors identified 241 reports that involved a child or
children with PMC status. Of these 241 referrals assigned to HHSC, 76 were assigned by HHSC
for a non-abuse or neglect investigation to determine whether there was a violation of statute,
administrative rules, or minimum standards and the other 165 intakes were administratively closed,
consistent with the distribution within the HHSC data.
Of these 241 reports, SWI appropriately determined that 98% (235 intakes) did not contain
an allegation of abuse or neglect of a PMC child and were properly assigned to RCCR. The
Monitors found six reports (3%) which SWI had inappropriately referred to RCCR and did not
assign for an abuse or neglect investigation. The Monitors concluded that these six reports
contained allegations that warranted an investigation for abuse, neglect, or exploitation to ensure
the safety and well-being of a child(ren) with PMC status. Of the six reports with which the
Monitors disagreed, five were assigned by RCCR for a Priority Two or Three minimum standards
investigation and one was administratively closed.
During the Monitors’ review of 175 SWI referrals from October 2020, the Monitors
identified 66 reports that involved children with PMC status. The Monitors found that SWI
appropriately determined that all 66 (100%) of these intakes did not contain an allegation of abuse
or neglect of a PMC child. Of the 66 reports assigned to HHSC that involved children with PMC
status, HHSC assigned 26 for a non-abuse or neglect investigation to determine whether there was
a violation of statute, administrative rules, or minimum standards and the other 40 intakes were
administratively closed.
During the Monitors’ review of 179 SWI referrals that were assigned to RCCR for a
Priority One, Two or Three minimum standards investigation in the sample for November 2020,
the Monitors identified 88 referrals that involved a PMC child. Of the 88 referrals, the Monitors
found that SWI appropriately determined that 94% (83 intakes) did not contain an allegation of
abuse or neglect of a PMC child and were properly assigned to RCCR. The Monitors found that
6% (5) had been inappropriately screened by SWI.
Remedial Order 3: Maltreatment in Care Investigations
In response to the Monitors’ First Report and its associated findings about investigations
of abuse, neglect, or exploitation of children in the PMC class, DFPS stated that under its new
leadership, DFPS “understands and recognizes the Monitors’ child safety concerns due to issues
with the investigations or the interpretation of various administrative code sections.”119 DFPS
confirmed that its review of the investigations included in Appendix 3.2 to the Monitors’ First
Report prompted the State to make changes to improve the quality of investigations. For the current
report, the Monitors subsequently undertook a similar and expanded method of review to assess
the State’s performance associated with Remedial Order 3.
119
Email from Audrey Carmical, DFPS to Kevin Ryan and Deborah Fowler (December 4, 2020) (on file with the
Monitors).
70
Overview of RCCI Maltreatment in Care Investigations
RCCI opened 851 new investigations involving at least one PMC child between May 1,
2020 and October 31, 2020. Foster parents and institutional staff accounted for 87% of the alleged
perpetrators.120 Institutional staff accounted for 908 (47%) of the alleged perpetrators; foster
parents accounted for 778 (40%) of the alleged perpetrators; relative/household members
accounted for 59 (3%); service providers accounted for 28 (1%); parents/guardians accounted for
four (less than 1%); and the perpetrator was unknown, not listed, or listed as other for 170 (9%) of
the alleged perpetrators. Some investigations recorded multiple perpetrators; therefore, the number
of perpetrators is greater than the number of investigations.121
Figure 4.8: Alleged Perpetrators in RCCI Involving PMC Children in Licensed Placements
Source: RCCI Open Investigations, May - October 2020 Investigations Data

n= 1,947 perpetrators in 851 investigations
50% 47%
40%
40%
30%
Percent
20%
10% 9%
3% 1% 0.2%
0%
Institutional Foster Parent Relative/home Service Parent/guardian Unknown/not
Staff (908) (778) member (59) Provider (28) (4) listed (170)
Perpetrator (number)
RCCI closed 768 investigations of maltreatment of a PMC child in licensed placements

between May 1, 2020 and October 31, 2020, and 7% (52) of the investigations resulted in a
disposition of Reason to Believe, thereby substantiating the allegations as abuse, neglect, or
120
The 851 RCCI investigations involved 1,947 allegations. In the data the Monitors received from DFPS, each
allegation has a perpetrator category, but not a unique identifier for each perpetrator. As a result, it is possible that
some perpetrators may be counted more than once in a single investigation or over time.
71
exploitation. RCCI Ruled Out 698 (91%), Administratively Closed 17 (2%), and closed one as
UTB.
Figure 4.9: Reason to Believe Findings in Closed RCCI Investigations Involving PMC
Children in Licensed Placements
Source: RO3.2 Closed Investigations Percent RTB, May - October 2020

n=768 Dispositions
12%
10% (13) 7% (6)
10% 9% (13)
8% (12)
8%
Percent RTB
6%
4% 3% (4) 3% (4)
2%
0%
May-20 (144) Jun-20 (127) Jul-20 (151) Aug-20 (124) Sep-20 (130) Oct-20 (92)
Month-Year (investigations closed)
Methodology
To validate DFPS’s performance associated with Remedial Order 3 and the appropriateness
of RCCI investigations of alleged maltreatment of PMC children, the monitoring team conducted
reviews on a randomly selected sample of 403 (out of 768) RCCI investigations closed between
May 1, 2020 and October 31, 2020.122
122
To evaluate dispositional results for the investigations included in the sample, the Monitors designed a review tool
for the case record review. To support consistency in scoring, both inter-rater reliability and secondary reviews were
tested and used. The sample was drawn from quarterly and monthly reports provided to the Monitors by DFPS during
the reporting period. During this time period, there were 768 investigations closed by RCCI, of which the Monitors
reviewed a random sample of 403 investigations using a 97% confidence level for the sample drawn from all
investigations closed from June through October 2020; and reviewed 133 or the 144 investigations closed in May
2020.
72
Remedial Order 3 Investigation Validation Results
Of the 403 (of 768) RCCI investigations analyzed by the monitoring team, 31 (8%) resulted
in a substantiation of at least one allegation with a disposition of RTB; in the review of those
investigations, the Monitors concurred with the State’s investigative conclusions to substantiate at
least one allegation with a disposition of RTB. However, the Monitors also identified that in three
of these investigations, RCCI either should have substantiated an additional allegation of abuse or
neglect (one investigation) or that it conducted a deficient investigation of other allegations of
abuse or neglect in order to render a disposition (two investigations). Six of the investigations (1%)
were administratively closed, and the Monitors disagreed with RCCI’s closure of one of these
investigations and one investigation resulted in a finding of UTB; the Monitors concurred with
those findings.
RCCI Ruled Out all the allegations in 365 (91%) of the investigations reviewed by the
Monitors. The Monitors found that of the 365 investigations where RCCI Ruled Out all of the
allegations, RCCI did so appropriately in 300 cases (82%); inappropriately in 18 cases (5%); and
conducted investigations with such substantial deficiencies in 47 cases (13%) that the Monitors
were prevented from reaching a conclusion. To appropriately reach a final disposition in these
investigations, additional information would have been required to determine whether children
were abused or neglected. Many of these RCCI child abuse or neglect investigations were deficient
because of long gaps in investigative activity and substantial delays in completion that
compromised access to relevant evidence and diminished the inability of witnesses to recall critical
information.
The Monitors’ summaries of these investigations are located in the Appendix. In sum, the
Monitors identified 65 cases (18%) among a sample of 365 investigations that RCCI assigned a
disposition of Rule Out to all allegations between May 1, 2020 and October 31, 2020 that had
substantial deficiencies or were inappropriately resolved by RCCI. In the First Report, the
Monitors determined 28.6% of sampled investigations had substantial deficiencies and/or were
inappropriately resolved, and the present results for this period reflect a significant improvement.
In addition, of the investigations that RCCI had assigned a RTB disposition to some
allegations or administratively closed, the Monitors identified four investigations that had
substantial deficiencies or were inappropriately resolved by RCCI, bringing the total to 69
investigations identified by the Monitors as having been inappropriately conducted or resolved
between May 1, 2020 and October 31, 2020.
73
C. Investigations with Substantial Time Delays and Gaps Contributing to Deficiency
Of the 69 investigations the Monitors determined RCCI inappropriately conducted or

resolved, the majority were not completed in a timely manner, in violation of Remedial Order 10.
Specifically, 38 (55%) were not completed within the 30-day timeframe;123 of the remaining
investigations, 28 were completed within the required 30-day timeframe (41%), and three (4%)
were completed outside of the 30-day timeframe but were completed in compliance with approved
extensions. The Monitors found that the significant delays in RCCI’s completion of investigations
resulted in substantial deficiencies that undermined the dispositional finding(s). The Monitors
observed that while the investigations were generally initiated timely and investigators frequently
interviewed alleged victims within the required timeframes of 24 or 72 hours, investigative activity
often stalled for many months or ceased entirely after these initial tasks were completed. Although
the deficiencies were not limited to the delays, the impact of the delays had a significant impact
on the quality of the investigations.
For example, in an investigation that remained open with RCCI for over 20 months, an
anonymous caller reported to SWI on October 1, 2018 that a few weeks prior to the call, a staff
member at Five Oaks Achievement Center, an RTC, choked a child (age 12), threw her on the bed,
and “jacked” her up. The reporter stated that a second staff member was present and witnessed the
incident but did not report it. Finally, the reporter stated that the shift supervisor at the RTC drinks
beer on campus and allows other staff to smoke marijuana. RCCI completed the investigation on
June 30, 2020, 20 months after intake. Between January 2019 and June 2020, the investigator
completed no activities related to this case. When the investigation was recommenced in June
2020, over a year and half after RCCI initiated the investigation, the investigator attempted for the
first time to interview the alleged perpetrators. Likely due to the investigative delay, the
investigator did not interview two of the alleged perpetrators and reported that the investigation
would be “closed without their input.”
In addition to significant gaps contributing to missed interviews with key individuals, the
Monitors also found that long delays impair the ability of investigators to gather pertinent
information from interviewees about the allegations to render an accurate disposition. In one
investigation, for example, which took over 10 months to be completed, the gap between the
alleged incident and the interviews with key individuals diminished these individuals’ ability to
recall the relevant allegations of abuse. On June 13, 2019, a DFPS staff person reported to SWI
that a staff person at Houston Serenity Place pushed a youth (age 15) down on her bed several
times for refusing to go to bed. The staff person allegedly grabbed the youth by her hair and pushed
the youth’s face into the mattress and, as a result, the youth struggled to breathe. The reporter also
stated that the staff person inappropriately restrained the youth by forcefully grabbing the youth’s
123
None of these investigations were compliant with any approved extensions.
74
arm and yanking it up toward her shoulder blades. The youth cried out in pain and yelled for the
staff person to stop.
The investigation was deficient due to a significant gap between the alleged incident and
interviews with key individuals and for a failure to follow-up with pertinent information. The
investigator interviewed the alleged perpetrator and collateral witnesses ten months after the
alleged incident occurred and, as a result, some individuals were unable to recall details of the
incident. The alleged perpetrator reported that on the day of the incident she was not working and
that she was not familiar with the alleged victim. The investigator did not review employee records
to corroborate whether this staff person was working on the day of the alleged incident, but instead
accepted this staff person’s denial ten months later. Because the investigator did not verify the
veracity of the staff member’s claim, it is unknown whether this staff member was working and
involved in the incident as the youth alleged. Moreover, the gap in time between the incident and
the interview with the perpetrator diminishes the reliability of the information.124
In another example from Houston Serenity Place involving an investigation that remained
open with RCCI for six months, a CPS staff member reported on January 29, 2020 that staff
observed a youth (age 16) with injuries to his face that appeared to be caused by “blunt force.” The
reporter stated the youth appeared scared and showed signs of “physical trauma/abuse” when he
explained the incident to the reporter. The youth reported another youth at Houston Serenity Place
caused the injuries. However, the youth also disclosed that his stepfather was “beating on him”
and threw all his belongings against a wall. The reporter stated that she believed the incident that
caused his injury occurred a few days prior to the report. Through their review, the Monitors found
that due to significant delays in the investigation, the investigator did not gather sufficient evidence
to Rule Out the allegations of Physical Abuse and Neglectful Supervision. The investigator did not
attempt to interview key individuals, including the alleged perpetrator, a child victim, and
collateral staff and residents, until approximately five months after RCCI initiated the
investigation. The investigator’s attempts to locate and interview the alleged perpetrator, some
collateral youth and staff and the children’s caseworkers were unsuccessful, likely because of the
delay. The youth witnesses who were interviewed late in the investigation were unable to recall
any specifics related to the alleged incident. Similarly, a staff member who could have provided
relevant information, also interviewed late in the investigation, was unable to recall the alleged
incident. Due to these numerous deficiencies, the Monitors found that a disposition cannot be
rendered on this investigation which took six months for RCCI to complete.
D. Deficient Investigations for Neglectful Supervision in the Context of Self-Harm by

Children
Of the 69 investigations that the Monitors identified as having incorrect dispositions or

deficiencies, nine (13%) included allegations of Neglectful Supervision involving a child who had
attempted or committed self-harm. In these investigations, the investigative record was often
124
The Monitors’ September 2, 2020 Update alerted the Court to the closure of Houston Serenity Place.
75
deficient in its inquiry and documentation about key issues related to supervision. The Monitors
repeatedly encountered lapses in supervision and treatment for children with serious emotional
disturbances in the Texas child welfare system that expose the children to a risk of serious harm,
as the Monitors discussed in the First Report in connection with the death of C.G., and more
recently in the Court Monitors’ Update to the Court Regarding Conditions at Devereux – League
City Residential Treatment Center.125
In eight of the nine investigations involving self-harm that were identified by the Monitors
for deficiencies or for incorrect dispositions, the children had been placed at inpatient psychiatric
facilities (6) or had been assessed by a psychiatric facility (2) during the year prior to the self-
harming incident that was the subject of the investigation under review. In at least two instances,
the self-harming incident occurred within weeks of the child’s psychiatric assessment or inpatient
psychiatric placement. The investigations raised common themes around child safety, the
children’s mental health needs and potential gaps in the preparedness of certain facilities to
appropriately address the needs of these children and ensure their safety.
For example, in one instance, an 11-year-old child was placed at an inpatient psychiatric
facility for a week from April 21 to April 27, 2020. One month after her discharge from psychiatric
care, in early June 2020, a DFPS staff member reported to SWI that the child attempted to cut her
wrist with a piece of glass and that the child had also attempted to hang herself during the previous
month while placed at The Tree House Center, a GRO. The DFPS staff member voiced concern
about inadequate supervision due to the child’s repeated self-harming incidents at the GRO.
During the investigation for Neglectful Supervision, staff members and residents told the
investigator that the child self-harmed “often” at the GRO. The investigator did not appear to
consider these statements in the decision to Rule Out the allegations of Neglectful Supervision.
Further, the investigator did not assess whether a child with a “history of suicidal thoughts and
psychiatric hospitalizations” as well as prior self-harming incidents at the GRO required greater
supervision to ensure her safety.
On another occasion, one of the Monitors reported two prior incidents involving a youth
(age 17) who the Monitor discovered had been documented by Hector Garza Residential Treatment
Center (Hector Garza), an RTC, in incident reports, but which the RTC never reported to SWI.
The Monitors’ First Report discussed DFPS’s decision to terminate its contract in 2020 with
Hector Garza. In the first incident, it was alleged that on August 11, 2019, the youth was observed
by a staff person to be tying her bra around her neck in an effort to commit suicide. Staff members
intervened and the youth had some redness on her neck from the action. In the second incident, it
was alleged that on February 7, 2019, the youth informed staff that she had swallowed laundry
detergent in an attempt to self-harm. Hector Garza documents stated that medical staff observed
the youth and reported no serious injury. The youth reportedly had an extensive history of self-
harming and suicide attempts. This investigation took five months to complete and there was no
approved extension. The youth had a history of self-harming, but the investigation was unable to
determine whether the youth was subject to heightened supervision at the time of the alleged
incidents. The investigator’s requests for documentation from the facility were not satisfied. In
125
Deborah Fowler and Kevin Ryan The Court Monitors’ Update to the Court Regarding Conditions at Devereux –
League City Residential Treatment Center at 36-58, (February 2, 2021), ECF No. 1027; Deborah Fowler and Kevin
Ryan, First Report 354-356, ECF No. 869.
76
fact, despite multiple information requests, the investigator documented the lack of cooperation by
the facility in its failure to provide requested documentation. The facility’s failure to timely report
the allegations, along with its failure to cooperate with the investigation, erected barriers that
contributed to the investigation’s deficiencies.
On another occasion, an administrator at a GRO, the Whataburger Center for Children and
Youth (Whataburger),126 reported that a youth (age 16) allegedly attempted suicide by ingesting a
metal bolt. The reporter stated that during the incident, staff were present and attempted to take
the object away from the youth. The youth had a history of suicidal ideation. Following the
incident, the youth was taken to the hospital for medical care and then to an inpatient facility.
RCCI’s Whataburger investigation was deficient for a failure to interview key individuals
and to follow-up on information disclosed during the investigator’s interviews. The investigator
did not interview two staff members who had pertinent information about the alleged incident of
self-harming as documented in the investigative record. Staff members reported that the youth
made a first attempt to self-harm earlier that same morning; however, the investigator did not
sufficiently investigate whether supervision was adequate during this incident nor whether the
shelter staff increased the youth’s level of supervision following the first self-harming incident.
Based upon evidence gathered during the investigation, it appears the shelter staff should have
placed the youth on a specialized level of supervision due to a history of self-harming. The case
reveals the gaps in the preparedness of certain facilities to appropriately address the needs of
children and ensure their safety.
E. Summary of Performance for Receiving, Screening and Investigating Allegation of

Maltreatment
Receiving Allegations
• Between February 1, 2020 and November 30, 2020, SWI received 533,471 calls. During
the period analyzed, 13% (69,468) of calls were abandoned, a decrease from 18% observed
in the previous report.127
• On average, callers waited for 2.3 minutes before their calls were handled or abandoned,
an improvement by almost two minutes from the data reported in the Monitors’ First
Report.128 Seventy percent (373,970) of callers waited on the queue for under one minute.
Screening Allegations
126
Whataburger relinquished its license on January 5, 2021. The Monitors include a detailed description of
the events leading up to the closure of this GRO, and the subsequent use of the facility by Family Tapestry,
an SSCC, in a concurrently filed but separate report.
127
The First Report found that 18% of calls were abandoned from August 1, 2019 to January 31, 2020. See Deborah
128
77
• The Monitors reviewed whether DFPS appropriately downgraded 185 referrals after SWI
initially assigned them to RCCI for a Priority One or Two abuse or neglect investigation
between May 1, 2020 and November 30, 2020. The Monitors determined 162 (88%) were
appropriately downgraded.
• Most of the 23 inappropriate downgrades arose prior to the effective date of the new DFPS
policy restricting secondary screening downgrade of intakes. The Monitors did not identify
any referrals involving maltreatment in licensed foster care that were inappropriately
downgraded in October or November 2020.
• In the First Report, the Monitors determined that of 174 intakes downgraded at secondary
screening between July 31, 2019 and October 31, 2019, DFPS inappropriately downgraded
57 intake reports (33%), which contained allegations that warranted investigation for abuse
or neglect. Thus, the Monitors’ rate of disagreement with downgrade determinations
dropped by 21 percentage points from 33% in the First Report to 12% presently.
• The Monitors reviewed whether DFPS appropriately downgraded 90 referrals after SWI
initially assigned them to CPI for a Priority One or Two abuse or neglect investigation
between May 1, 2020 and November 30, 2020. The Monitors determined CPI appropriately
downgraded 88 of these intake reports (98%).
• The Monitors also reviewed 241 referrals to SWI from January and February 2020, which
SWI sent directly to HHSC, involving a PMC child. Of these 241 referrals, 76 were
assigned to HHSC for a non-abuse or neglect investigation to determine whether there was
a violation of statute, administrative rules, or minimum standards and the other 165 intakes
were administratively closed. Of these 241 reports, the Monitors concurred with SWI’s
determination in 98% (235) of intakes.
• The Monitors also reviewed 66 referrals that SWI sent directly to HHSC for a minimum
standards investigation in October 2020 that involved children with PMC status. The
Monitors found that SWI appropriately determined that none of these intakes contained an
allegation of abuse or neglect of a PMC child and were properly assigned to HHSC for
follow up.
• The Monitors also reviewed 88 SWI referrals from November 2020 that involved children
with PMC status and concurred with SWI’s determination 94% of the time (83 intakes),
agreeing those referrals did not contain an allegation of abuse or neglect of a PMC child
and were properly assigned to HHSC.
Investigating Allegations
• Of the 768 RCCI investigations DFPS completed involving PMC children between May
1, 2020 and October 31, 2020, the Monitors evaluated 403 investigations. Of those 403
RCCI investigations, the Monitors concurred with the outcome of all 31 (8%) that resulted
in a substantiation of the allegations with a disposition of RTB.
• The Monitors found that of the 365 investigations where RCCI Ruled Out all of the
allegations, RCCI did so appropriately in 300 cases (82%); inappropriately in 18 cases
(5%); and conducted investigations with such substantial deficiencies in 47 cases (13%)
that the Monitors were prevented from reaching a conclusion.
78
• In addition to the 65 cases (18%) among a sample of 365 investigations that RCCI Ruled
Out between May 1, 2020 and October 31, 2020 that had substantial deficiencies or were
inappropriately resolved by RCCI, the Monitors also identified four investigations in which
RCCI assigned an RTB disposition to some allegations or administratively closed that had
substantial deficiencies or were inappropriately resolved by RCCI.
• In the First Report, the Monitors determined 28.6% of sampled investigations had
substantial deficiencies and/or were inappropriately resolved, and the present results for
this period reflect a significant improvement.
F. Timeliness of RCC Investigations: Remedial Orders 5 through 11; 16 and 18

Performance Validation (DFPS)
Remedial Order 5: Within 60 days and ongoing thereafter, DFPS shall, in accordance with existing
DFPS policies and administrative rules, initiate Priority One child abuse and neglect
investigations involving children in the PMC class within 24 hours of intake. (A Priority One is by
current policy assigned to an intake in which the children appear to face a safety threat of abuse
or neglect that could result in death or serious harm.)
Remedial Order 6: Within 60 days and ongoing thereafter, DFPS shall, in accordance with existing
DFPS policies and administrative rules, initiate Priority Two child abuse and neglect
investigations involving children in the PMC class within 72 hours of intake. (A Priority Two is
assigned by current policy to any CPS intake in which the children appear to face a safety threat
that could result in substantial harm.)
child victim(s) in Priority One child abuse and neglect investigations involving PMC children as
child victim(s) in Priority Two child abuse and neglect investigations involving PMC children as
Remedial Order 9: Within 60 days and ongoing thereafter, DFPS must track and report all child
abuse and neglect investigations that are not initiated on time with face-to-face contacts with
children in the PMC class, factoring in and reporting to the Monitors quarterly on all authorized
and approved extensions to the deadline required for initial face-to-face contacts for child abuse
and neglect investigations.
Remedial Order 10: Within 60 days, DFPS shall, in accordance with DFPS policies and
administrative rules, complete Priority One and Priority Two child abuse and neglect
investigations that involve children in the PMC class within 30 days of intake, unless an extension
has been approved for good cause and documented in the investigative record. If an investigation
79
Remedial Order 11: Within 60 days and ongoing thereafter, DFPS must track and report monthly
all child abuse and neglect investigations involving children in the PMC class that are not
timeframe, and the reason for the extension, must be documented and tracked. If an investigation
1. Recent Policy Changes
DFPS changed its policy defining the initiation of an investigation three times between May
1, 2020 and January 31, 2021. For investigations initiated from May 1, 2020 through August 31,
2020, the DFPS policy in effect required initiation to occur through face-to-face contact with all
alleged victims.129 In September 2020, DFPS revised its policy. This policy required investigators
to initiate investigations through face-to-face contact with one alleged victim, an adult involved in
the allegation, or through contact with a collateral source.130 DFPS stated that it made this change
because:
[D]ata intended to measure timeliness of initiations and face-to-face contact with

all alleged victims had the unintended consequence of double-counting the
timeliness of face-to-face contact with all alleged victims while excluding other
potential methods for initiating an investigation. The double-count occurs when
both the initiation measure and the measure of timeliness of face-to-face contact
with all alleged victims are defined identically.131
DFPS reported that the change was meant to eliminate the “total overlap and reflect that
timely initiation and face-to-face contact with alleged victims were two related but distinct
measures…”132 Moreover, DFPS communicated that it would employ these new measures
retrospectively to evaluate its performance due to its belief that this was a better representation of
performance.133 Soon thereafter, however, in December 2020, DFPS again changed its initiation
129
DFPS, Investigations Division Field Communication #008 (Mar. 11, 2019) (on file with the Monitors).
130
DFPS, Investigations Division Field Communication #26 (September 3, 2020) (on file with the Monitors).
131
Email from Heather Bugg to Kevin Ryan and Deborah Fowler, summarizing the reason for the September 2020
policy change and the December 2020 policy change (Dec. 1, 2020) (on file with the Monitors).
132
Id.
133
Email from Audrey Carmical to Kevin Ryan and Deborah Fowler (August 27, 2020) (on file with the Monitors).
“We will utilize this definition for the timeliness indicator we will add in Q4 reporting (for all investigations upon
which we are reporting, including those initiated prior to the policy change). We understand that the Monitors may
80
policy to require face-to-face contact with one alleged victim or through an attempted contact with
the victim.134
Subsequently, in January 2021, DFPS changed its initiation policy again to require
investigators to make face-to-face contact with each alleged victim to initiate an investigation.135
At that time, DFPS further stated that:
[e]ffective January 4, 2021 and thereafter, there will be no additional time added to
the required timeframes even if there is an approved exception. In the reports we
provide to you, however, we will continue to include information about approved
exceptions to face-to-face contact to provide context. As a result of these changes,
we anticipate that timely face-to-face and timely initiation in reports will likely be
lower than using the previous methodology.136
For reviews conducted for investigations opened under the January 2021 policy, the
Monitors will measure performance in association with this policy. During the period under
review, the Monitors measured performance in association with the effective date of the DFPS
policies.

To validate the State’s performance associated with Remedial Orders 5 through 11, 16 and
18, the Monitors requested from the State key data and information for all investigations conducted
by RCCI regarding any child in the PMC General Class.137
In the previous reporting period, the State notified the Monitors that it could not provide
some of the requested data relevant to its performance for these orders.138 Subsequently, the State
implemented updates to its data systems, particularly IMPACT, and began to submit data reports
with the relevant information to measure performance related to Orders 5 through 11, 16 and 18.
Remedial Orders 5 through 11; 16; and 18 Performance Validation (DFPS)

Methodology
For validation of orders measuring the timeliness of various aspects of RCCI
investigations, the monitoring team reviewed all RCCI investigations that were opened by the State
wish to continue measuring our timeliness of initiation by looking solely at FTF contact with all alleged victims but
we think tracking them as separate measures provides a more illustrative view of whether action is being taken quickly
at the outset of investigations.” Id.
134
See DFPS., Child Care Inv. Handbook § 6411-6413 (in effect December 1, 2020); see also, Email from Heather
Bugg, DFPS to Kevin Ryan and Deborah Fowler, Monitors (Dec. 1, 2020) (on file with the Monitors).
135
DFPS, Child Care Inv. Handbook § 6411 (in effect Jan. 2021); see also, Email from Heather Bugg, to Kevin Ryan
and Deborah Fowler, Monitors, alerting the Monitors of the January 2021 change in policy (Jan 4, 2021) (on file with
the Monitors). Email from Jane Burstain to Tim Ross et al. (April 29, 2021 8:55 ET) (on file with the Monitors)
(“Under current policy, timely initiation of an RCI investigation is only measured through face-to-face contact with
all alleged victims within the required timeframes.”).
136
Id.
137
Deborah Fowler and Kevin Ryan, First Report 102-103. ECF No. 869.
138
Id. at 104-105, ECF No. 869.
81
from May 1 to September 30, 2020.139 The monitoring team reviewed the data provided by DFPS
to validate performance for all 657 investigations opened by RCCI during this time period.140 The
monitoring team also independently performed corresponding case record reviews for all 657
investigations opened during this time period to validate the data as reported by DFPS. Through
these case record reviews, the Monitors were able to substantially validate the accuracy of the data
reports and thus, the results in this report reflect the data as reported to the Monitors by DFPS. The
monitoring team reviewed the 657 investigations for compliance with the Court’s orders relating
to timeliness of RCCI Investigations using the methodologies described below, by Order:
• Remedial Order 5: To measure initiation in Priority One Investigations within 24 hours,

the Monitors reviewed the data to determine whether the investigation was initiated within
24 hours in a manner consistent with the DFPS policy in effect at the time of the
investigation initiation, two of which are relevant to this time period under review. For
investigations initiated from May 1, 2020 through August 31, 2020, the DFPS policy in
effect required initiation to occur through face-to-face contact with all alleged victims.141
In September 2020, the revised DFPS policy in effect at the time required initiation to occur
through face-to-face contact with an alleged victim, an adult involved in the allegation, or
through contact with a collateral source.142 Therefore, for investigations initiated from May
1 through August 31, 2020, the Monitors reviewed the intake date and time, and the date
and time of the first face-to-face contact with each alleged victim; for September 2020
investigations, to measure initiation in Priority One Investigations within 24 hours, the
Monitors reviewed the intake date and time from IMPACT, and the initiation date, time,
and method of initiation to determine whether the investigation was initiated within 24
hours of intake in conformance with the effective policy.
• Remedial Order 6: To measure initiation in Priority Two Investigations within 72 hours,

the Monitors reviewed the data to determine whether the investigation was initiated within
72 hours in a manner consistent with the DFPS policy in effect at the time of the
investigation initiation. For investigations initiated from May 1 through August 31, 2020,
the DFPS policy in effect required initiation to occur through face-to-face contact with all
alleged victims.143 In September 2020, the revised DFPS policy in effect at the time
required initiation to occur through face-to-face contact with an alleged victim, an adult
139
To identify investigations opened between May 1, 2020 and September 30, 2020, the Monitors used the “Date
Investigation Stage Start” data field. The source files included: open investigations and closed investigations, as
reported in RO3.2 RCI Investigations Q3 FY 20 - July-15-20- 99217.xlsx; RO3.2 RCI Investigations Q4 FY 20 - Sept-
30-20- 99229-with provider dates.xlsx; RO3.2 RCI Investigations FY21-Sept 100165 with provider dates.xlsx; RO3.2
RCI Investigations - Oct 20 100489 with provider dates.xlsx, and RO3.2 RCI Investigations - Nov 20 101137 with
provider dates.xlsx.
140
The DFPS data included 13 investigations that were administratively closed and were, therefore, excluded from
the analysis. Another five investigations lacked Priority status indication and are not included in these results but were
reviewed manually. In addition, for Remedial Order 10, the Monitors reviewed DFPS’s report of the total number of
RCCI investigations involving children in the PMC class open longer than 30 days as of April 6, 2021, and the total
number of investigations with an extension approved for good cause documented in the investigative record as of
April 6, 2021.
141
142
143
82
involved in the allegation, or through contact with a collateral source.144 Therefore, for
investigations initiated from May 1 through August 31, 2020, the Monitors reviewed the
intake date and time and the date and time of the first face-to-face contact with each alleged
victim; for September investigations, to measure initiation in Priority Two Investigations
within 72 hours, the Monitors reviewed the intake date and time from IMPACT, and the
initiation date, time, and method of initiation to determine whether the investigation was
initiated within 72 hours of intake consistent with the effective policy.
• Remedial Order 7: To measure face-to-face contact with all alleged victims in Priority One
investigations within 24 hours, the monitoring team calculated performance using the
intake date and time in IMPACT and the date and time of the first face-to-face contact with
each alleged victim in IMPACT.145
• Remedial Order 8: To measure face-to-face contact with all alleged victims in Priority Two
investigations within 72 hours, the monitoring team calculated performance using the
intake date and time in IMPACT and the date and time of the first face-to-face contact with
each alleged victim in IMPACT.
• Remedial Order 9: To measure reporting of all child abuse and neglect investigations that
are not initiated on time with face-to-face contacts with children in the PMC class, the
Monitors assessed the quality and availability of data concerning the date and time of the
first face-to-face contact with each alleged victim in IMPACT.
• Remedial Order 10: To measure completion of Priority One and Priority Two
investigations within 30 days, the monitoring team calculated compliance using the intake
date and time in IMPACT and the date submitted for approval in IMPACT.146 In addition,
the Monitors reviewed the total number of investigations reported by DFPS as open as of
April 6, 2021, and the total number of those open longer than 30 days as of April 6, 2021.
The Monitors assessed whether the investigations reported by DFPS as open longer than
30 days included a current extension approved for good cause documented in the
investigative record as of April 6, 2021. If the investigation was extended more than once,
the Monitors assessed whether all extensions for good cause were documented in the
144
145
Investigations were only deemed timely if investigators met with each alleged victim associated with an
investigation individually, denoted by a timestamp of first face-to-face contact in IMPACT.
146
Email from Heather Bugg to Kevin Ryan and Deborah Fowler (Jan 4, 2021) (on file with the Monitors). DFPS
states the correct field to calculate completion of investigations is the final date submitted for approval in IMPACT.
“For reports due to you January 4, 2021 and after, the final date submitted for approval in IMPACT will be used to
calculate the completion of all investigations as we believe that this will better align with the Court’s Order and will
ensure consistency in reporting and ultimately ease verification efforts. When an investigator submits for closure an
investigation in IMPACT, the supervisor may determine that the case needs additional work or documentation to
ensure a quality investigation has occurred. If so, the supervisor will return the investigation and once the additional
tasks have been completed, the caseworker will submit it again. Because the IMPACT date is captured in an automated
way and the CLASS date is manually entered, the IMPACT date will provide a more accurate date and may ease
verification and as the agency moves forward in its efforts to improve the quality of its investigations, it believes it’s
important to capture the final submission rather than initial submission date.” Id.
83
• Remedial Order 11: To measure documentation of approved extensions to investigations,

the monitoring team reviewed the extensions for RCCI Investigations sections of the source
files. The Monitors also assessed whether the investigations reported by DFPS as open
longer than 60 days as of April 6, 2021 included a current extension approved for good
cause documented in the investigative record as of April 6, 2021. If the investigation was
extended more than once, the Monitors assessed whether all extensions for good cause
were documented in the investigative record.
• Remedial Order 16: The Monitors measured investigation completion using the date
documentation was submitted to the supervisor. Therefore, investigations are completed
only when the documentation has been submitted to the supervisor for the final time.147
• Remedial Order 18: To measure timeliness of mailing notification letters to the referents
and providers in Priority One and Two investigations, the Monitors calculated compliance
using the date of supervisor approval, the date of notification to the reporter from IMPACT,
and the date of notification to the provider from CLASS. In addition, beginning in
September 2020, the Monitors calculated DFPS performance with its newly added
IMPACT data field identifying the date of notification to the provider. To be considered
timely for this Order, the State must have notified both the referent and the provider within
five days of closing the investigation. If either the referent or the provider was notified
more than five days after the investigation was closed or was not notified at all, the
notification was counted as untimely. The Monitors used only the investigations that
opened and closed during the time period since the required action is only triggered by case
closure.
Remedial Order 5: Initiation within 24 Hours in Priority One

Investigations
Within 60 days and ongoing thereafter, DFPS shall, in accordance with existing DFPS
policies and administrative rules, initiate Priority One child abuse and neglect
investigations involving children in the PMC class within twenty-four hours of intake. (A
Priority One is by current policy assigned to an intake in which the children appear to face
a safety threat of abuse or neglect that could result in death or serious harm.)
The Monitors found that of 657 investigations opened by RCCI between May 1, 2020 and
September 30, 2020, 48 were assigned Priority One, requiring that DFPS initiate the investigation
within 24 hours of intake. DFPS initiated 79% (38) of Priority One investigations within 24 hours
of intake in a manner consistent with existing policy. Twenty-one percent (10) of investigations
were not initiated timely or did not have sufficient data to assess timeliness. DFPS’s rate of
initiating Priority One investigations through face-to-face contact with each alleged victim within
24 hours in the Monitors’ first report was 68%.148
147
Email from Heather Bugg, Dir. of Project Management, DFPS. to Kevin Ryan and Deborah Fowler, Monitors (Jan
4, 2021) (on file with the Monitors).
148
84
Figure 4.10: Initiation of Investigations within 24 Hours in Priority One Investigations per
Existing Policy
Source: Priority One Investigations Opened May -September 2020

n=48 investigations opened
10
21%
38
79%
Twenty-four hours Not timely
Of the 37 RCCI investigations opened between May 1, 2020 and August 31, 2020 that were
assigned Priority One, DFPS initiated 76% (28) of the investigations within 24 hours of intake
through face-to-face contact with each alleged victim (per the existing policy). An additional 5%
(2) of investigations had documentation of exceptions to initiation through face-to-face contact but
neither of the investigations with documented exceptions were initiated timely through an alternate
method. The remaining 19% (7) of investigations either did not include face-to-face contact with
each alleged victim within 24 hours or did not have sufficient data to assess timeliness.
During September 2020 when the DFPS policy changed and no longer required face-to-face
contact with each alleged victim in order to initiate an investigation, of the 11 Priority One
investigations opened in September 2020, 91% (10) of investigations were initiated within 24
hours of intake with face-to-face contact with at least one alleged child victim (consistent with the
policy in effect at the time). One investigation did not have sufficient data to assess timeliness.
Remedial Order 6: Initiation within 72 Hours in Priority Two

Investigations
Within 60 days and ongoing thereafter, DFPS shall, in accordance with existing DFPS
policies and administrative rules, initiate Priority Two child abuse and neglect
investigations involving children in the PMC class within seventy-two hours of intake. (A
Priority Two is assigned by current policy to any CPS intake in which the children appear
to face a safety threat that could result in substantial harm.)
85
DFPS disclosed 609149 Priority Two RCCI investigations requiring DFPS initiation within
72 hours of intake. DFPS initiated 81% (494) of Priority Two investigations within 72 hours of
intake in a manner consistent with existing policy. Eighteen percent (107) of investigations were
not initiated timely or did not have sufficient data to assess timeliness. One percent (8) of
investigations had a documented exception and were initiated timely. DFPS’s rate of initiating
Priority Two investigations through face-to-face contact with each alleged victim within 72 hours
in the Monitors’ first report was also 81%.150
Figure 4.11: Initiations of Investigations within 72 Hours in Priority Two Investigations per
Existing Policy
Source: Priority Two Investigations Opened May - September 2020

n= 609 investigations opened
8
1%
107
18%
494
81%
Within Seventy-two hours Not Timely Other
Of the 468 RCCI investigations opened between May 1 and August 31, 2020, that were
assigned Priority Two, DFPS initiated 78% (366) of the investigations within 72 hours of intake
through face-to-face contact with each alleged victim (per the existing policy). Of 16 investigations
with documented exceptions, 50% (8) of the 16 were initiated timely.151 The remaining 18% (86)
of investigations either did not include face-to-face contact with each alleged victim within 72
hours or did not have sufficient data to assess timeliness.
During September 2020 when the initiation policy did not require face-to-face contact with
each alleged victim, out of the 141 Priority Two investigations opened that month, 91% (128) of
investigations were initiated within 72 hours of intake consistent with the DFPS initiation policy
149
One investigation involved seven alleged victims, five who were classified as alleged victims of a Priority One
matter and two who were classified as alleged victims in a Priority Two matter. This investigation is only included in
the Priority One analyses.
150
See Deborah Fowler and Kevin Ryan, First Report 110, ECF No. 869. During the prior reporting period, the policy
required face-to-face contact with each alleged victim. Id.
151
Seven of the investigations with exceptions were initiated through face-to-face contact and one investigation was
listed as “Other.”
86
in effect during September. Four investigations were not initiated within 72 hours, and nine
investigations did not have sufficient data to assess timeliness. Ninety-three percent (131) of
investigations were initiated with face-to-face contact with at least one alleged child victim.152
Remedial Order 7: Timeliness of initial face-to-face contact with the

alleged victims in Priority One Investigations
Within 60 days and ongoing thereafter, DFPS shall, in accordance with DFPS policies and
administrative rules, complete required initial face-to-face contact with the alleged child
victim(s) in Priority One child abuse and neglect investigations involving PMC children
as soon as possible but no later than twenty-four hours after intake.
Of the 48 Priority One investigations opened by RCCI between May and September 2020,
the Monitors found that 79% (38) of the investigations included initial face-to-face contact with
each alleged child victim individually within 24 hours. An additional 4% (2) of investigations had
documentation of approved exceptions to face-to-face contact. DFPS’s rate of completing initial
face-to-face contact with each alleged victim in Priority One investigations within 24 hours in the
Monitors’ first report was 68%.153
Of the two investigations with exceptions for face-to-face contact, the data documented
that in one instance, the child’s whereabouts was unknown and in the other instance, the approved
exception was due to “other circumstances beyond the investigator’s control preventing the
interview or observation from taking place within the initiation time frame.”
The remaining eight investigations (17%) either did not include face-to-face contact with
each alleged victim individually within 24 hours of intake (7) or did not have sufficient data to
assess timeliness (1).
152
One investigation’s initiation type was listed as “Other,” and nine investigations did not have data available to
indicate the type of initiation. However, the case record reviews showed that the methods were consistent with policy.
153
87
Figure 4.12: Face-to-Face Contact within 24 Hours with All Alleged Child Victims in
Priority One Investigations
Source: Priority One Investigations Opened May - September 2020

2
8 4%
17%
38
79%
Twenty-four hours Not timely Other
Remedial Order 8: Initial Face-to-Face Contact with All Alleged

Victims in Priority Two Investigations within 72 Hours
Within 60 days and ongoing thereafter, DFPS shall, in accordance with DFPS policies and
administrative rules, complete required initial face-to-face contact with the alleged child
victim(s) in Priority Two child abuse and neglect investigations involving PMC children
as soon as possible but no later than seventy-two hours after intake.
Of the 609 RCCI investigations assigned Priority Two, the Monitors’ review found that
79% (484) of investigations included initial face-to-face contact with each alleged child victim
within seventy-two hours of intake. Twenty-two additional investigations (4%) had documented
exceptions to face-to-face contact. DFPS’s rate of completing initial face-to-face contact with each
alleged victim in Priority Two investigations within 72 hours in the Monitors’ First Report was
81%.154
Of the 22 RCCI investigations with documented exceptions for face-to-face contact, 27%
(6) were due to the unknown whereabouts of the child; 14% (3) were due to a prior interview with
alleged victim by CPS, law enforcement, or a child advocacy center before RCCI received the
report; 5% (1) were due to the alleged victim no longer living in Texas; and 55% (12) were due to
“other circumstances beyond the investigator’s control preventing the interview or observation
from taking place within the initiation time frame.”
154
88
The remaining 103 investigations (17%) either did not include individual face-to-face
contact with each alleged victim within 72 hours (59) or did not have sufficient data to assess
timeliness (44).
Figure 4.13: Face-to-Face Contact within 72 Hours with All Alleged Child Victims in
Priority Two Investigations
Source: Priority Two Investigations Opened May - September 2020

22
103 4%
17%
484
79%
Seventy-two hours Not timely Other
Remedial Order 9:
Within 60 days and ongoing thereafter, DFPS must track and report all child abuse and
neglect investigations that are not initiated on time with face-to-face contacts with children
in the PMC class, factoring in and reporting to the Monitors quarterly on all authorized
and approved extensions to the deadline required for initial face-to-face contacts for child
abuse and neglect investigations.
Overall, in 90% (590) of all 657 RCCI investigations (both single and multi-alleged victim
investigations) DFPS was able to track and report in its data whether face-to-face contact was
made with each alleged child victim within an investigation and the date and time that contact
occurred for each child.
In 97% (435) of the 450 investigations with one victim, DFPS was able to track and report
in its data reports to the Monitors whether face-to-face contact was made with the alleged child
victims within an investigation and the date and time the contact occurred.
In 75% (155) of 207 investigations with more than one victim, DFPS was able to track and
report in its data reports to the Monitors whether face-to-face contact was made with each of the
alleged child victims within an investigation and the date and time the contacts occurred.
89
Remedial Order 10: Completion of Priority One and Priority Two

Investigations within 30 Days
Within 60 days, DFPS shall, in accordance with DFPS policies and administrative rules,
complete Priority One and Priority Two child abuse and neglect investigations that involve
children in the PMC class within 30 days of intake, unless an extension has been approved
for good cause and documented in the investigative record. If an investigation has been
extended more than once, all extensions for good cause must be documented in the
Of the 657 Priority One and Priority Two RCCI investigations opened between May 1,
2020 and September 30, 2020, the data documented that 51% (337) were not completed within 30
days. Forty-two percent (273) of investigations were documented as completed within 30 days of
intake and 7% (47) had approved extensions and were completed within the extension timeframe.
DFPS’s rate of completing Priority One and Two investigations within 30 days in the Monitors’
first report was 19%.155
While 82 investigations had approved extensions, as noted above, only 47 of those

investigations were completed within the approved timeframe allotted by the extension; 24 were
not completed within the allotted extension timeframe; and 11 investigations were still open at the
time of review.
Figure 4.14: Completion of Priority One and Two Investigations within 30 Days
Source: Investigations Opened May - September 2020

n=657 Investigations opened
337
51%
47
7% 273
42%
Timely Timely with Extensions Not Timely
While over 50% of investigations opened in May, June, and July 2020 were completed
within 30 days, timely investigation completion dropped to 44% in August 2020 and to 35% in
September 2020.
155
90
Figure 4.15: Completion of Priority One and Two Investigations within 30 Days over Time

80%
65%
60% 57% 55% 56% 56%
43% 45% 44% 44%

40% 35%
20%
0%
May Jun Jul Aug Sep
Timely Not timely
DFPS made substantial progress complying with Remedial Order 10 by April 6, 2021. Of
the 151 Priority One and Priority Two RCCI investigations that remained open as of April 6, 2021,
the State’s data documented that 5% (8) were open for more than 30 days with an extension, and
1% (2) were open more than 30 days without an extension. The two oldest investigations that were
overdue as of April 6, 2021 without extensions were one and three days overdue.
The Monitors confirmed the eight investigations reported by DFPS as open longer than 30
days with a current extension had extensions that were approved for good cause documented in
the investigative record as of April 6, 2021. To achieve this level of performance, DFPS had to
close at least 465 RCCI investigations involving PMC children between the March 1, 2021 and
April 6, 2021. The average monthly rate of closure from August 1, 2019 through February 28,
2021 has been 120 closures per month and has ranged between 48 and 180 investigations per
month. The Monitors will review the quality of those investigations pursuant to Remedial Order 3
and will advise the Court.
Remedial Order 11: DFPS Track and Report Requirement
Within 60 days and ongoing thereafter, DFPS must track and report monthly all child
abuse and neglect investigations involving children in the PMC class that are not
timeframe, and the reason for the extension, must be documented and tracked. If an
91
investigation has been extended more than once, all extensions for good cause must be
documented in the investigative record.
The Monitors reviewed data and information provided by DFPS in association with
Remedial Order 11, which requires DFPS to track and report all investigations that are not
completed on time. Approved extensions to the standard closure timeframe, and the reason for the
extension, must be documented and tracked. If an investigation has been extended more than once,
all extensions for good cause must be documented in the investigative record.
Of the 337 investigations that were opened by RCCI between May and September 2020
and were not completed within 30 days, DFPS data included extensions approved for 82
investigations with the dates the extensions were approved, the reasons for the extensions, and the
number of additional days approved by each of the extensions.156
Each of these 82 investigations contained at least one extension approved for either seven,
14, 21, or 30 days each. Of those with extensions, 66% (54) included one extension, 27% (22)
included two, 6% (5) included four, and 2% (1) included six extensions. All extensions included
documented approval dates and all but two included documented reasons for the extension.
Figure 4.16: Number of Extensions in Priority One and Two Investigations
Investigations Opened May 1 - September 30, 2020

n=82 investigations with extensions
22 5
27% 6%
1
1%
54
66%
One Two Four Six
The total number of extension days approved for an investigation ranged from seven to
120. Twenty-one percent (17) of investigations with extensions were for 7-14 days; 49% (40)
were extended for 15-30 days; 7% (6) were extended 31-44 days; 16% (13) were extended 45-60
days; and 7% (6) were extended for more than 60 days.
156
These data matched to the investigations’ corresponding intake start date and original due date and therefore, the
Monitors were able to determine the due dates associated with the extensions to assess timeliness of completion within
the extension period.
92
For all open investigations as of April 6, 2021, the total number of extension days approved
for an investigation ranged from 14 to 60. Twenty percent (2) of investigations with extensions
were for 7 to 14 days; 60% (6) were extended for 15 to 30 days; and 20% (2) were extended 45 to
60 days.
Remedial Order 16: Timeliness of Completion and Submission of

Documentation in Priority One and Priority Two Investigations
Effective immediately, the State of Texas shall ensure RCCL investigators, and any successor
staff, complete and submit documentation in Priority One and Priority Two investigations on
the same day the investigation is completed.
DFPS advised the Monitors that the agency uses the date the investigation was submitted
to the supervisor as the investigation completion date. Therefore, according to DFPS,
investigations are considered completed when the documentation is finally submitted to the
supervisor in compliance with this Order.157
Remedial Order 18: Timeliness of Notification Letters to Referent and

Provider
Effective immediately, the State of Texas shall ensure RCCL investigators, and any successor staff,
finalize and mail notification letters to the referent and provider(s) in Priority One and Priority
Two investigations within five days of closing a child abuse and neglect investigation or completing
a standards investigation.
For the referent letter, of the 538 (out of 657) Priority One and Priority Two investigations
that were documented as closed at the time of the Monitors’ review, the notification letter to
referents was mailed within five days of closure in 40% (213) of investigations. Of the remaining
cases, in 1% (3) of investigations, notification letters to the referents were not mailed timely; 56%
(299) were mailed to the referent prior to supervisor approval; 3% (17) of investigations had an
anonymous reporter; and one percent (6) were unknown due to documentation deficiencies.
DFPS’s rate of mailing notification letters to referents within five days of investigation closure in
Priority One and Two investigations in the Monitors’ First Report was 78%.158
157
DFPS advised the Monitors, “When an investigator submits for closure an investigation in IMPACT, the supervisor
may determine that the case needs additional work or documentation to ensure a quality investigation has occurred. If
so, the supervisor will return the investigation and once the additional tasks have been completed, the caseworker will
submit it again. Because the IMPACT date is captured in an automated way and the CLASS date is manually entered,
the IMPACT date will provide a more accurate date and may ease verification and as the agency moves forward in its
efforts to improve the quality of its investigations, it believes it’s important to capture the final submission rather than
initial submission date. Finally, the final date submitted for approval in IMPACT will also be used as the one date to
determine compliance with Remedial Order 16 to ‘submit and complete documentation in Priority One and Priority
Two investigations on the same day the investigation is completed.’ The date complete in CLASS will no longer be
used to calculate compliance with any remedial order.” Email from Heather Bugg, to Kevin Ryan and Deborah Fowler
(Jan 4, 2021) (on file with the Monitors).
158
93
Figure 4.17: Notification Letter Sent to Referent within Five Days of Investigation Closure
in Priority One and Two Investigations

n= 538 closed investigations
Timely
299 17
56% 3% 6 Not Timely
1%
Mailed prior to supervisor
approval
Reporter anonymous
213
40% Unknown due to blank
3 date
1%
For the provider letter, HHSC mailed its notification letters to providers in abuse, neglect,
and exploitation investigations within five days of closure in 59% (317) of investigations.159 The
notification letters to providers were not mailed timely in 20% (106) of investigations. In addition,
1% (8) were mailed prior to supervisor approval; and 20% (107) did not have sufficient data to
assess timeliness. HHSC’s rate of mailing notification letters to providers within five days of
investigation closure in Priority One and Two investigations in the Monitors’ First Report was
65%.160
159
The Monitors were provided with three data sources regarding letters to providers. DFPS and HHSC use different
dates within their different systems to determine closure of an abuse and neglect investigation. The Monitors adhered
to the DFPS request that the CLASS closure date not be used to calculate compliance with the Remedial Orders
associated with RCCI investigations. DFPS instead requested the Monitors use the date of supervisor approval in
IMPACT. Email from Heather Bugg to Kevin Ryan and Deborah Fowler, Monitors (Jan. 4, 2021). The Monitors
assumed when DFPS made the request that it had conferred with HHSC, but the Monitors learned on April 30, 2021
that HHSC instead wants the Monitors to use a different date to measure compliance than the date requested by DFPS.
160
94
Figure 4.18: Notification Letter Sent to Provider within Five Days of Investigation Closure
in Priority One and Two Investigations
Investigations Opened May - September 2020

n= 538 closed investigations
107
8 20% Timely
1%
Not Timely
317
106 59% Mailed prior to
20% supervisor approval
Unknown due to
blank date
Beginning in September 2020, the Monitors also assessed whether notification letters to
providers were mailed by DFPS within five days of investigation closure using a new DFPS data
field provided for date of notification to provider in IMPACT. The letter to the provider is sent by
DFPS pursuant to its new policy effective for cases closed after September 1, 2020.161 The
Monitors identified 87 investigations opened between May 1, 2020 and September 30, 2020 and
closed between September 1, 2020 and September 30, 2020. Of these 87 investigations, the
notification letters were mailed within five days of investigation closure in 83% (72) of
investigations. In 17% (15) of investigations, the Monitors could not determine whether the letters
were sent timely due to documentation deficiencies.
Of the 538 (out of 657) investigations that were documented as closed at the time of the
Monitors’ review, 23% (123) included evidence that notification to the referent and provider
occurred within five days of closure of the investigation as required by Remedial Order 18.
Summary
Remedial Order 5:
• 79% (38) of RCCI investigations opened from May 1 to September 30, 2020 were initiated
within 24 hours of intake; and
• 21% (10) of RCCI investigations opened from May 1 to September 30, 2020 were not
initiated timely or did not have sufficient data to assess.
Remedial Order 6:
161
95
• 81% (494) of RCCI investigations opened from May 1 to September 30, 2020 were
initiated within 72 hours of intake;
• 18% (107) of RCCI investigations opened from May 1 to September 30, 2020 were not
initiated timely or did not have sufficient data to assess; and
• 1% (8) of RCCI investigations opened from May 1 to September 30, 2020 had a
documented exception and were initiated timely.
Remedial Order 7:
• 79% (38) of RCCI investigations opened from May 1 to September 30, 2020 included
initial face-to-face contact with all alleged victims within 24 hours of intake;
• 17% (8) of RCCI investigations opened from May 1 to September 30, 2020 did not have
timely face-to-face contact with all alleged victims or did not have sufficient data to assess;
and
• 4% (2) of RCCI investigations opened from May 1 to September 30, 2020 had an approved
exception to face-to-face contact.
Remedial Order 8:
• 79% (484) of RCCI investigations opened from May 1 to September 30, 2020 included
initial face-to-face contact with all alleged victims within 72 hours of intake;
• 17% (103) of RCCI investigations opened from May 1 to September 30, 2020 did not have
timely face-to-face contact with all alleged victims or did not have sufficient data to assess;
and
• 4% (22) of RCCI investigations opened from May 1 to September 30, 2020 had an
approved exception to face-to-face contact.
Remedial Order 10:
• 51% (337) of investigations were documented as completed within 30 days of intake;
• 42% (273) of investigations were not completed timely; and
• 7% (47) of investigations had an approved extension and were completed within the
extension timeframe.
• For RCCI investigations open as of April 6, 2021, 5% (8) of investigations still open as of
April 6, 2021 were open for more than 30 days and had an extension and 1% (2) of
investigations still open were open for more than 30 days and did not have an extension.
Remedial Order 16:
• Investigation completion is measured by the date the investigation is submitted for
approval. Therefore, all investigations are completed on the same day as submission.
Remedial Order 18 (Notification to Referent):

• 40% (213) of investigations included data that notification letters to referent(s) were mailed
within five days of investigation closure;
• Less than 1% (3) of investigations did not have timely notification to referent(s);
• 56% (299) of investigations were mailed prior to supervisor approval;
• 1% (6) of investigations were unknown due to documentation deficiencies; and
96
• 3% (17) of investigations had an anonymous reporter

Remedial Order 18 (Notification to Provider):
• 59% (317) of investigations included data that notification letters to provider(s) were
mailed within five days of investigation closure;
• 20% (106) of investigations did not have timely notification to provider(s);
• 1% (8) of investigations included letters that were mailed prior to supervisor approval; and
20% (107) of investigations were categorized as unknown due to documentation
deficiencies.
G. Remedial Order B5
Remedial Order B5: Effective Immediately, DFPS shall ensure that RCCL, or any successor entity,
promptly communicates allegations of abuse to the child’s primary caseworker. In complying
with this order, DFPS shall ensure that it maintains a system to receive, screen, and assign for
investigation, reports of maltreatment of children in the General Class, taking into account at
all times the safety needs of children.
1. Background
First Court Monitors’ Report Validation Findings
The Monitors’ First Report reviewed findings from the monitoring team’s independent case
reads, and found that in 57 of the 115 (50%) cases reviewed, investigators took longer than 72 hours
to notify the child’s caseworker of an abuse or neglect allegation, if the investigators notified the
caseworker at all.162 The First Report also included a review and summary of the State’s own case
read, which used the investigation priority timeframes as the measure for determining timeliness
of the notifications.163 Of the 1,282 caseworkers that the State identified as requiring notification,
710 (55%) were notified within priority time frames.164
Updates and Policy Changes Following the Monitors’ First Report
After the First Report was filed, the monitoring team asked the State to provide any policy
changes or field communications related to IMPACT enhancements of December 19, 2019, which
created an automated process to notify caseworkers when an abuse or neglect intake was received
for a child on their caseload.165 On July 9, 2020, DFPS provided the Monitors with Field
162
163
“DFPS determined that the highest rate at which investigators notified caseworkers within priority time frames
across all the case record reviews was 69%, leaving a substantial number of investigations for which the
investigator notified the caseworker at some point beyond the agency’s priority-based timeframe for initiating
an investigation. This rate of notification is much greater than the CPS Handbook’s requirement that investigators
notify caseworkers within 24-hours of receiving a report of abuse or neglect regardless of priority assigned.”
164
165
E-mail from Linda Brooke, Director, Monitoring Team, Texas Appleseed to Tara Olah et al., DFPS, June 30, 2020
(on file with Monitors).
97
Communication #017 (FC 17), and also provided a December 2019 Child Care Investigations Job
Aid related to IMPACT notifications.166
FC 17 outlines the RCCI process for entering information into IMPACT during intake to
ensure that the automated notification is sent.167 According to FC 17, the screener, supervisor, or
designee at SWI notifies the CPS caseworker and supervisor by completing a “Notifications”
section in IMPACT on the Priority/Closure page prior to stage progressing the intake report to an
investigation.168 The notification is generated during the intake stage once the investigation is
either progressed to an investigation or downgraded.169 According to the CCI Job Aid, once the
investigator follows the described process for generating the notification, “[a]n alert and event will
be sent to the Assigned Workload of the CVS Caseworker and Supervisor as well as an RCI intake
indicator.”170
September 2020 Contempt Hearing & December 18, 2020 Contempt

Order
The Plaintiffs’ July 2, 2020 Motion to Show Cause included an argument that the State
should be held in contempt for failing to comply with Remedial Order B5.171 The Plaintiffs’
argument was based on the finding in the Monitors’ First Report that caseworkers were timely
notified of ongoing abuse and neglect investigations in only 50% of cases reviewed.172 In response,
the State argued that DFPS was not in contempt of Remedial Order B5 but had, in fact,
implemented procedures that demonstrated compliance.173 The State argued that the Monitors’
case record review failed to account for the IMPACT enhancement it implemented on December
19, 2019, which automatically generates an alert that notifies the CPS caseworker when a child is
involved in an abuse or neglect intake.174 The State noted that in May 2020, caseworkers received
the automated notification of all abuse and neglect intakes.175
During the contempt hearing on September 3, 2020, the Court asked the State’s witness,
Ashland Batiste, the Director of RCCI, about the notifications that the IMPACT enhancements
automated on December 19, 2019:
[ASHLAND BATISTE]: During the screening process, if an Intake involves a

foster home and it’s downgraded to a Priority None, an automated IMPACT alert
is sent to the victim’s caseworker and that caseworker’s supervisor.
166
Email from Tara Olah to Deborah Fowler, re. RO B5 and RO37 (July 7, 2020) (on file with the Monitors).
167
DFPS, Field Communication #017, December 20, 2019 (on file with Monitors).
168
IT Automation in IMPACT 2.0 Roll Out, December 19, 2019, Field Communication #017
169
Id. at 10.
170
DFPS, Child Care Investigations Job Aid: Notifications in IMPACT 5 (December 2019).
171
Plaintiffs’ Motion for Order to Show Cause Why Defendants Should Not be Held in Contempt (Plaintiffs’ Motion
to Show Cause), ECF No. 901.
172
Plaintiffs’ Motion to Show Cause at 11-12, ECF No. 901.
173
Defendant’s Response in Opposition to Motion to Show Cause at 16 (July 24, 2020), ECF No. 911.
174
See Exhibit A (Batiste Declaration), 10 :32
175
See Exhibit A (Batiste Declaration), 15 57.
98
If there are non-victim children in the foster home, an automated alert

notification is also sent…[to] caseworkers and supervisors…The most recent data
indicates that in May, June and July, those automated alerts were sent 100 percent
of the time to caseworkers and those supervisors.
THE COURT: Okay. The notifications of the PNs, as well as Priority One and
Priority Two, do you send those to caseworkers and their supervisors?
THE WITNESS: Yes, Your Honor. For Priority One and Priority Two, Intake
notifications are also sent to the caseworker’s supervisor using the IMPACT
automated alert.
THE COURT: How quickly?
THE WITNESS: Those are done upon screening. And so the screening requirement
and priority decisions must be made the same day and no later than 24 hours from
Intake.
THE COURT: Okay. And what do you put in those notifications? Do you just say
that there was – according to the Monitors, there’s a little flag, but it doesn’t say –
it means the caseworkers have to go to IMPACT or CLASS to actually see what
the allegations is. Have you corrected that or can they actually – do they actually
get notification instantly of the – of the particular allegations?
THE WITNESS: So the notification, it is an alert that’s put on their to-do list or
work list in IMPACT…and they go into it and review the – they can go into
IMPACT and review the allegation and information.176
On September 4, 2020, the second day of the hearing, the Plaintiffs’ counsel asked the
DFPS Director of Field for CPI, Sherry Gomez, twice whether this notification process was in
place for all children in the General PMC Class who are placed in kinship homes. However, Ms.
Gomez appeared to misunderstand the question; her answers related to notification of CPI
caseworkers, rather than the child’s CVS caseworker.177 When Plaintiffs’ counsel asked DFPS
Commissioner Masters the same question, she was not able to provide a definitive answer, but she
said she “thought” CPI sent caseworkers for children in kinship placements a notification when an
abuse or neglect investigation is opened, but was unsure how the notification was sent or what it
looked like.178
In its December 18, 2020 order holding the State in contempt, the Court found that
Defendants failed to comply with Remedial Order B5.179 The Court wrote that in order to
implement Remedial Order B5 in a way that “ensure[s] that Texas’s PMC foster children are free
from an unreasonable risk of harm,” as required by the Court’s injunction, Defendants must do
176
Telephonic/Zoom Show Cause Hr’g Tr. (September 3, 2020) 30-31, ECF No. 964.
177
See Telephonic/Zoom Show Cause Hr’g Tr. (September 4, 2020) 32-33, 53, ECF No. 967.
178
Id. at 148-49.
179
Order at 155 (December 18, 2020) ECF No. 1017.
99
more than simply checking the boxes of (1) providing bare-bones notifications to caseworkers that
allegations of abuse occurred; and (2) implementing a system for receiving, screening, and
assigning such allegations for investigation.180
The Court found that Remedial Order B5 requires the State to ensure that it “promptly
communicates” the allegations, themselves, including their substance, to the caseworkers, and the
system that the State must put in place to comply with the Remedial Order must ensure that the
State is “taking into account at all times the safety needs of children.”181 The Court noted that in
testing for a “reasonable timeframe after initiation,” DFPS asked whether investigators notified
the caseworkers within the timeframe that is required for initiation of the investigation.182 The
Court found that this was not an appropriate measure:
Defendants need not wait for the initiation of an investigation in order to communicate an
allegation to the caseworker. Remedial Order B5 requires notification to the caseworker
of the receipt of the allegation of abuse, not the initiation of an investigation; therefore,
tying notification of an allegation under Remedial Order B5 to the timeframe for initiating
Priority One and Priority Two investigations is inconsistent with the remedial order.183
The Court noted that the Monitors’ case read showed that nearly a quarter of caseworkers in the
sample did not receive any notification of an allegation of abuse or neglect, and that “in numerous
additional cases, notifications did not occur in a timely manner.”184 The Court ordered the State
to submit sworn certification of its compliance with Remedial Order B5 within 30 days following
the date of the Order.185
In reviewing the State’s compliance with Remedial Order B5, the Court instructed the
Monitors to:
Determine whether Defendants are “promptly communicat[ing] allegations of

abuse to the child’s primary caseworker.” In order to implement the remedy to
ensure that PMC children are free from an unreasonable risk of serious harm,
compliance with Remedial Order B5 requires more than prompt communication to
the caseworker of the existence of an allegation. It requires that caseworkers receive
prompt communication of “allegations of abuse.” Therefore, the Court instructs the
Monitors that in their assessment of Defendants’ compliance with this Remedial
Order, they must assess whether Defendants “promptly communicate[]” the
substance of the “allegations of abuse” to “the child’s primary caseworker.186
180
Id.
181
Id.
182
Id.
183
Id. at 155-56.
184
Id. at 157.
185
Order at 326 (December 18, 2020), ECF No. 1017.
186
Order at 327 (December 18, 2020), ECF No. 1017.
100
Updates and Policy Changes Following the Contempt Hearing
On October 16, 2020, DFPS notified the Monitors of a policy change as a result of the
agency’s review of notifications made in accordance with Remedial Order B5: during DFPS’s
review of August 2020 data, DFPS discovered six instances in which notification was not sent.187
In each case, the six children were placed in an adoptive placement, but DFPS’s responsibility for
the children had not yet been terminated by the court.188 DFPS policy allowed for a child’s subcare
stage to be closed in IMPACT when an adoption stage was opened. A November 1, 2020, policy
change requires the caseworkers to keep the subcare stage open until DFPS responsibility is
terminated by a court.189
The monitoring team also asked the two SSCCs in Stage Two of CBC (therefore providing
casework services for children under their purview), questions related to compliance with
Remedial Order B5 during a January 7, 2021 virtual meeting with DFPS and the SSCCs. The
Monitors asked OCOK how their caseworkers receive notice that an abuse or neglect investigation
has been opened. OCOK responded that its caseworkers receive the automated notification in
IMPACT, and also receive an email from RCCI. According to OCOK, the SSCC has an internal
expectation that its caseworkers and supervisors read the investigation in CLASS. OCOK said
that its staff had received training on using CLASS, however, the SSCC noted that they had
experienced access problems with CLASS. 2INgage, the other SSCC providing case management
for PMC children during the period, reported that they follow the same procedure for compliance
with Remedial Order B5 that DFPS follows. Case mangers stay abreast of allegations, track them
in IMPACT, and share the information with the caseworker’s supervisor.
DFPS’ January 16, 2021 Certification of Compliance
On January 16, 2021, DFPS filed its sworn certifications, including an affidavit (Exhibit
F) from Clint Cox, DFPS Director of Residential Child Care Investigations (RCCI), that included
DFPS’s attempts to comply with Remedial Order B-5 prior to the contempt hearing and since.190
In the affidavit, Mr. Cox certified enhancements to the IMPACT 2.0 system were deployed on
December 19, 2019 and included automated notification to caseworkers of abuse and neglect
intakes. According to Mr. Cox, the notification is sent to the caseworker and supervisor at the point
in time the RCCI screener or supervisor makes the decision to stage progress to an investigation.191
Mr. Cox also certified dissemination of Field Communication #17 to RCCI staff related to the
deployed changes for Remedial Order B5.192 Mr. Cox certified the November 1, 2020 update to
CPS Policy Section 1411 that rectified the error of caseworker notification in instances of
caseworkers not receiving notice.193 The certification by Mr. Cox also documented the monthly
187
Email from Heather Bugg to Deborah Fowler and Kevin Ryan. (October 16, 2020) (on file with the Monitors).
188
Id.
189
Email from Heather Bugg to Deborah Fowler and Kevin Ryan Caseworker Notifications of Abuse/Neglect Intakes
– Remedial Order B5 (October 16, 2020) (on file with the Monitors).
190
Defendants’ Certification of Compliance, Exhibit F: Sworn Declaration for Remedial Order Nos 3, 5, 7, 10, and
B-5, ECF No.1021-6.
191
Id. at 153.
192
Id.
193
Id. at 154.
101
reporting for the automated notifications to CVS caseworkers; for the seven months of reporting
reviewed, DFPS found 100% of the notifications were received by the child’s caseworker during
four of the seven months, two months were documented at 99%, and one month at 97%. 194
A sworn certification by Erica Banuelos (Exhibit E), DFPS CPS Director of Field, was also
filed on January 16, 2021. In her affidavit, Ms. Banuelos attested to short- and long-term solutions
DFPS implemented in response to the Court’s requirement that prompt notice include the
substance of the allegations of abuse or neglect and account for the safety needs of children in
either a licensed or unlicensed placement.195 Ms. Banuelos’s affidavit states that beginning January
14, 2021, “Statewide Intake (SWI) will be creating Information and Referrals (I&R) and directly
assigning them to a caseworker's workload simultaneous to receiving a report of abuse and/or
neglect and creating the intake when a child in DFPS temporary or permanent managing
conservatorship is a principal in a Child Protective Investigation (CPI) or RCCI abuse or neglect
referral.”196 Ms. Banuelos’s affidavit states that this short-term solution will be created and
assigned on the worker’s caseload by SWI, will include the child’s IMPACT person ID,
information about the alleged victim[s] and perpetrator[s], and a narrative regarding the substance
of the allegations.197 The caseworker can click on the Information & Referral and launch a report
with the intake information and allegations.198 Furthermore, “[a]s a redundancy, when an RCCI
intake is screened by the SWI screeners, the screener will email the caseworker and supervisor.
This second notification will also include the allegations.”199 The certification also speaks to a
“long-term IT solution,” which will build on the December 19, 2019 IMPACT enhancements, and
has an implementation date estimated in Fall 202l. 200
Data and Information Production
The State continues to provide monthly Statewide Intake data of abuse and neglect referrals
received for all PMC children in the General Class in response to the Monitors’ first data and
information request. In a subsequent request sent by the Monitors on February 21, 2020, the
Monitors noted that DFPS had failed to provide the previously requested data for dates and manner
of caseworker notification.201 The State responded that it “anticipate[d] being able to provide
information as part of the DDS report once the data warehouse tables are built and functional. We
currently anticipate including the information for Q3 FY 20 reports.”202
194
Id. at 156.
195
Defendants’ Certification of Compliance, Exhibit E: Sworn Declaration for Remedial Order Number B-5 ¶5, ECF
No. 1021-5.
196
Id. at ¶5.
197
Id.
198
Id. The affidavit also speaks to what a caseworker is required to do when they receive an I&R. In addition to
reviewing the abuse or neglect report in IMPACT, CLASS, or both and discussing it with their supervisor, according
to the affidavit, they are also required to consult with the program director about the circumstances surrounding the
investigation “no later than 7 p.m. the next business day” and document the staffing in the child’s IMPACT record.
Id. at ¶ 8. They are also required to document any follow-up actions in IMPACT when they are completed. Id. at ¶
9.
199
Id. at ¶ 6.
200
Id. at ¶ 7.
201
Email from Kevin Ryan, to Andrew Stephens (Feb. 21, 2020) (on file with the Monitors).
202
Email from Tara Olah, DFPS to Kevin Ryan and Deborah Fowler, Monitors (March 24, 2020) (on file with the
Monitors).
102
Beginning in July 2020 (for May 2020 data) DFPS included two new variables in its
monthly RCCI intake data reports including “Notice to CVS worker and supervisor” and “Notice
within 48 hours (RO37).” DFPS defined “Notice to CVS worker and supervisor” as the date/time
that an automated notice about the intake was sent to the CVS caseworker and supervisor. DFPS
did not make changes to the data it provided for CPI intakes for PMC children in the General Class.
The monitoring team discovered limitations in the SWI data of abuse and neglect referrals
during the monitoring team’s case record reviews. Referrals to RCCI are assigned an IMPACT
case ID number which uniquely identifies the allegation and can be used to track investigations in
the State’s CLASS system. Allegations and their associated case ID numbers can be “linked” if
multiple calls are made for the same allegation, for the same child, or for a similar allegation at an
operation where an investigation is already underway. Linked allegations are grouped under a
single case ID number. The case ID used for an investigation usually relates to the first referral
related to the allegations that is received by SWI.
Data provided by the State included a case ID for all allegations. This case ID (IMPACT
Case ID) was used by the Monitors to identify a child’s case for both the automatic notification
and caseworker communication verification. During the automatic notification verification, the
monitoring team found that, for linked allegations, the case ID provided in the RCCI intake data
represented the “linked” case ID, not the ID originally assigned to that allegation at intake. The
automatic notification in the child’s IMPACT event list was found for the correct intake date
(usually the same or next day) but the case ID did not match the data for that date in the SWI intake
data of abuse and neglect referrals provided the State. The case ID matching the SWI intake data
was, in most cases, found in the child’s event list with automatic notification occurring prior to the
date of the selected intake. Questions posed to the State by the monitoring team verified that the
case ID included in the RCCI SWI intake data represented the linked case ID for all linked
allegations rather than the original Case ID assigned at intake.
Remedial Order B5 Performance Validation
Methodology
To validate DFPS’s compliance with Remedial Order B-5, the monitoring team conducted
three separate case reads for the months of April 2020 through October 2020. For each sample
period, all RCCI intakes received by SWI with a final Priority of One or Two were included in the
randomized sample. Cases meeting the selection criteria were randomly selected based on a 95%
confidence level for each month of data.203
The first case record review included 319 SWI intakes from April 2020 to June 2020. The
second case read included 226 SWI intakes from July 2020 through August 2020, and the third
case read included 270 SWI intakes from September 2020 through October 2020.
203
Duplicate cases were removed from the universe of cases prior to sample selection. A duplicate was defined as a
child with multiple intakes on the same day or a child with multiple intakes during the month for the same allegation
and same Case ID. For both the first intake for that child in the month was included in the universe of cases for the
sample.
103
To assess compliance with Remedial Order B5 regarding prompt communication of

allegations of abuse or neglect to a child’s primary caseworker, all three case reads included the
following methodology:
• Verification of Automatic Notification: The monitoring team reviewed child event
records in the State IMPACT system were reviewed to identify the date automatic
notification204 of an RCCI intake was sent to the child’s caseworker. The automatic
notification analysis calculated the number of days from the date of the SWI intake to
the date of notification. The exact time of notification was not available in IMPACT
and therefore, the monitoring team measured the notification time period using
calendar days.205
• Verification of Communication with Caseworker: The monitoring team reviewed
CLASS investigation contact log records were reviewed to identify the first
communication between the RCCI investigator and the child’s primary CVS
caseworker regarding the sample intake.206 The caseworker communication analysis
calculated the number of calendar days between the SWI intake and the first
communication and the method of communication.
Performance Validation Results, Remedial Order B5 Case Read

Results
For the three case reads conducted by the monitoring team, each sample consisted of RCCI
intakes from SWI with a final Priority of One or Two (excluding intakes that were downgraded to
PN). Over the course of the three case reads, the monitoring team evaluated a total of 815 intakes
alleging abuse or neglect.
The results of each case read found a high rate of timely automatic notifications from SWI
to CVS caseworkers. Of automatic notifications identified by the monitoring team, all automatic
notifications occurred within two days of RCCI intake. The table below documents the rate of
automatic notification identified and the timing of those notices.
204
Automatic notification refers to the IMPACT system generated alert that appears on a child’s event record and the
caseworker’s workload/To Do list when the SWI completes the Notifications section in IMPACT on the
Priority/Closure page before stage progressing the intake to an investigation (Child Care Handbook CCI Policy
6353.1).
205
Because State policy does not require an investigator to notify a caseworker of each intake linked to an existing
investigation, the time to first caseworker communication for linked cases was calculated using the date of intake for
the “primary” or first linked case rather than the date of intake found in the sample.
206
DFPS Policy requires after initial notification, the investigator must attempt to maintain contact with the child’s
CPS caseworker if a child is listed as an alleged victim. DFPS, Child Care Investigations Handbook §6353.2.
104
Table 4.3: Automatic Notification Found and Timing of Automatic Notification
Case Read No. 1: Case Read No. 2: Case Read No. 3:

Data Point Apr-Jun 2020 Jul-Aug 2020 Sept-Oct 2020
n=319 n=226 n=270
Automatic 100.0% 99.1% 100.0%
Notification (319) (224) (270)
Found
Timing of 48.3% (154) same day 61.5% (139) same day 57.8% (156) same day
Automatic 51.1% (163) next day 37.2% (84) next day 41.8% (113) next day
Notification 0.6% (2) 2 days 0.4% (1) 2 days 0.4% (1) 2 days
0.9% (2) no notification
In its analysis, the monitoring team compared the notification date provided by the State to
the date of notification identified by the monitoring team in the verification of automated
notification found in the child’s record in IMPACT.207 Of the 718 intakes sampled between May
and October, 2020 for which a notification was found, the monitoring team identified 16208 intakes
with notification dates that did not match the date provided in the State’s data. In almost all of
these intakes, the automated notification date the Monitors identified had occurred one day prior
to the automated notification date provided by the State.209 For two intakes, the monitoring team
identified an automatic notification, but the State did not report an automatic notification date.
Table 4.4: Automatic Notification Date Comparison of State Data and Case Read Data
Case Read #1: Case Read #2: Case Read #3:

Data Point May-Jun 2020 Jul-Aug 2020 Sept-Oct 2020
n=224 n=224 n=270
Automatic 98.7% 96.4% 98.1%
Notification Dates (221) (216) (265)
the Same
Although the monitoring team could not determine the quality of exchange of information in most
communications between RCCI investigators and the CVS caseworkers, the monitoring team
conducted a verification of the first contact documented between the two, using the contact log for
207
The state provided a variable “Notice to CVS worker and supervisor” in RCI intake data provided for May, 2020.
“Notice to CVS worker and supervisor” was defined as the date/time that an automated notice about the intake was
sent to the CVS caseworker and supervisor.
208
The monitoring team received notification on October 16, 2020 that August 2020 data provided by DFPS had seven
instances (four total children) in which notifications were not sent to caseworkers in accordance with RO B5.
According to the RCI intake data if “Notice to CVS worker and Supervisor” field is blank, this “generally indicates
that notice was not sent, usually because the child did not have an open SUB stage.”
209
The State provided data for the date and time of automated notification for RCCI intakes beginning in May 2020.
Time of automatic notification was not available to the monitoring team. On average, the State reported that automated
notification occurred within 12:27 to 12:31 hours of intake.
105
the selected investigation in CLASS, was conducted. Of the 815 investigations reviewed for the
sample period, a contact was documented in 728 or 89% of the investigations.
Table 4.5: Communication Between RCCI Investigator and CVS Caseworker Found
Case Read #1: Case Read #2: Case Read #3:

n=319 n=226 n=270
Communication 90.6% 92.0% 85.6%
Found in CLASS (289) (208) (231)
The timing of the contact and the method of contact was also documented. The time
between SWI intake and documented communication in CLASS between the RCCI investigator
and the CVS caseworker ranged from 0 days to 67 days.
Table 4.6: Timing and Most Common Method of Communication Between RCCI
Investigator and CVS Caseworker
Case Read No. 1: Case Read No. 2: Case Read No. 3:

n=289 n=208 n=231
Average Time of 5.17 4.36 4.45
Communication
from Intake (days)
Communication 70.2% 69.2% 80.5%
within three days (203) (144) (186)
of intake
Most Common Email Email Email
Method of 42.6% 44.7% 43.3%
Communication (123) (93) (100)
The most common methods of initial communication between RCCI investigators and
CVS caseworkers were via emails and phone calls. In 43% of cases (316 of 728), initial
documented communication between RCCI investigators and CVS caseworkers occurred via
email while in 36% of cases (264 of 728) initial documented communication occurred via phone
call.
For the case reads conducted for July-August 2020 and September-October 2020, the
monitoring team added an additional step to document a second communication between the RCCI
investigator and the child’s CVS caseworker for those instances where the initial documented
contact was not a phone call.210
210
The monitoring team included this additional inquiry due to concerns that an initial contact via e-mail or voicemail
might not allow the caseworker to ask questions about the allegations or clarify information received by the
investigator.
106
Between July and October 2020, communication between RCCI investigators and CVS
caseworkers was found in 89% of cases (439 of 496). This initial communication was via phone
in 34% of cases (149 of 439). For the majority of cases where initial contact was through
voicemail, email, or other type of contact (not phone), 76% of cases (219 of 290) had a subsequent
contact documented in CLASS. The most common method of the subsequent contact was made
via phone call (50%, 110 of 219).
Table 4.7: Subsequent Communication Between RCCI Investigator and CVS Caseworker
for Cases Where Initial Contact was NOT a Phone Call and Most Common Method
Case Read No. 2: Case Read No. 3:

Data Point Jul-Aug 2020 Sept-Oct 2020
n=135 n=155
Subsequent 78.5% 72.9%
Communication (106) (113)
Documented
Most Common Phone Phone
Method of 61.3% 39.8%
Communication (65) (45)
Summary
The Monitors’ case reviews reflect that the automated system of notification designed by
DFPS to promptly communicate allegations of abuse or neglect to the child’s primary caseworker
is working: notifications were observed to be occurring in almost all cases reviewed. While the
notification does not include the substance of the allegations, the monitoring team verified follow-
up communication between the RCCI investigator assigned to the case and the child’s caseworker
in most cases reviewed, but could not assess the quality of that communication.
The State’s January 2021 certifications indicate that changes in the intake process have
allowed SWI to create an Information and Referral report that gives caseworkers the ability to
access a report from IMPACT that includes intake information and the allegations associated with
the intake. Due to the timing of the new policy and the State’s data production, the Monitors did
not conduct case reviews testing for this new function in time for this report, and will do so for the
next comprehensive report to the Court.
107
H. Remedial Order 37
Remedial Order 37: Within 60 days, DFPS shall ensure that all abuse and neglect referrals
regarding a foster home where any PMC child is placed, which are not referred for a child abuse
and neglect investigation, are shared with the PMC child’s caseworker and the caseworker’s
supervisor within 48 hours of DFPS receiving the referral. Upon receipt of the information, the
PMC child’s caseworker will review the referral history of the home and assess if there are any
concerns for the child’s safety or well-being, and document the same in the child’s electronic case
record.
1. Background
First Court Monitors’ Report Findings related to Remedial Order 37
In the First Report to the Court, the Monitors found that the policy adopted by DFPS to
implement Remedial Order 37 failed to implement the timeline set out in the Order, which requires
notification to the child’s caseworker and the caseworker’s supervisor and the caseworker’s review
of the home’s history (home history reviews, or “HHRs”) within 48 hours. The results of the
Monitors’ case read detailed in the First Report showed HHRs were completed in 71% of the cases
reviewed, but only 27.2% were completed within 48 hours of the SWI referral. Even when there
was a timely HHR, the caseworkers failed to document any type of staffing with their supervisors
41.7% of the time. When there was documentation of a staffing, only 33% occurred within 48
hours. Where a staffing was documented, some failed to document any action taken despite
disturbing patterns of similar allegations for the child’s placement.
September 2020 Contempt Hearing & December 18, 2020 Contempt

Order
In their July 2, 2020 Motion to Show Cause, the Plaintiffs requested the Court sanction the
State for failing to comply with Remedial Order 37 based on the Monitors’ findings that the State
failed to timely conduct HHRs. 211 The State responded that the plain language of Remedial Order
37 required only a 48-hour timeframe for the notice to a child’s caseworker and the caseworker’s
supervisor, but that the remedial order did not include a timeline for the staffing by the caseworker
and supervisor and documentation of any safety concerns.212 The State replied that Remedial
Order 37 did not require reviews of an HHR and an assessment and documentation of concerns for
the child’s safety or well-being within any specified period.
In holding DFPS in contempt of Remedial Order 37, the Court found the amount of time
DFPS took to complete the full review, assessment, and documentation process inconsistent with
Remedial Order 37; DFPS failed to complete HHRs consistently for Priority None cases; and
DFPS failed to take action when there were disturbing patterns of similar allegations at the child’s
placement.213 The Court emphasized that the purpose of Remedial Order 37 was to quickly assess
211
Plaintiffs’ Motion to Show Cause Why Defendants Should Not Be Held in Contempt (July 2, 2020 ) ECF No. 901.
212
Defendant’s Verified Objections to Monitors’ Report at 17, ECF No. 903.
213
Order (December 18, 2020) at 258, ECF No. 1017.
108
and address potentially dangerous placements in cases in which the State has chosen not to conduct
an abuse or neglect investigation.214 For that reason, Remedial Order 37 requires caseworkers and
their supervisors to be notified within 48 hours of a case being screened out or downgraded to PN.
Then, “[u]pon receipt of the information” about the allegation, the home history review and
assessment of child safety must occur, which must be documented in the child’s electronic case
record.215
State witness testimony at the Contempt Hearing revealed that the State failed to implement
necessary processes and procedures to remedy urgent safety issues targeted by Remedial Order 37
The Court found that:
A timeframe that can stretch up to twelve days is not consistent with Remedial
Order 37’s requirement that “the PMC child’s caseworker will review the referral
history of the home and assess if there are any concerns for the child’s safety or
well-being, and document the same in the child’s electronic case record” “[u]pon
receipt” of the information that an allegation would not be investigated for abuse
or neglect.216
The Court concluded that the State failed to complete an HHR in 21% of the cases, and
had no explanation for this failure.217 For those HHRs that were completed, in 39% of the cases
there was no documentation indicating any discussion of concerns for children’s safety or well-
being based on the HHR.218 In addition, the Court noted that even when an HHR was completed
and there was a discussion, in some cases the caseworker failed to recognize and act on a pattern
of similar allegations of abuse and neglect from the same home.219
In finding the State in contempt, the Court found “that Defendants have continued to
expose PMC children to an unreasonable risk of serious harm in foster home placements… and
hence…failed to address the exact same problems occurring today in their system that were taking
place” at the time of trial.220 The Court ordered DFPS to file with the Court sworn certification of
compliance with Remedial Order 37 within 30 days of the date of the Order.221
The Court also instructed the Monitors to:
[A]ssess Defendants’ evidence and determine whether notification of reports

“which are not referred for a child abuse and neglect investigation, are shared with
the PMC child’s caseworker and the caseworker’s supervisor within 48 hours of
DFPS receiving the referral,” and whether “[u]pon receipt” of the information that
an abuse or neglect allegation was made but not referred for investigation, the
child’s caseworker has “review[ed] the referral history of the home[,] . . .
214
215
Id.
216
Id. at 262, ECF No. 1017.
217
Id. at 263-4, ECF No. 1017.
218
Id. at 265, ECF No. 1017.
219
Id. at 265-68, ECF No. 1017.
220
Id. at 268-9, ECF No. 1017.
221
Id. at 326, ECF No. 1017.
109
assess[ed] if there are any concerns for the child’s safety or well-being, and
document[ed] the same in the child’s record.”222
State’s Certification of Compliance
On January 15, 2021, DFPS filed its Certification of Compliance, attaching an affidavit
from DFPS Director for Conservatorship Services, Hector Ortiz, that outlined DFPS’s attempts to
comply with Remedial Order 37 prior to the Contempt Hearing and afterward.223 In the affidavit,
Mr. Ortiz certified that DFPS had changed its policies regarding the timeframe to complete all of
the steps required by Remedial Order 37, but also changed its policy related to downgrading abuse
or neglect investigations, as discussed, supra.
Mr. Ortiz averred that on October 1, 2020,224 DFPS policy changed and “solely allows
downgrades of intakes to a PN in two narrow circumstances: when the allegations were previously
investigated or when the allegation is not within RCCI jurisdiction. Additionally, sole screening
responsibilities were moved to Statewide Intake.”225 In addition, according to Mr. Ortiz’s
affidavit, as of January 2021, policies regarding the timeline for completion of the HHR and the
review and documentation by the caseworker now require:
• Statewide Intake screeners, upon making a decision to PN a case, create an HHR report
and email it to the caseworker and supervisor. Intakes received outside of regular business
hours go to a rotation of on-call SWI screeners who complete the HHR.226
• Caseworkers review and staff the HHR reports with their supervisors immediately upon
receipt from the SWI screener. If a report is received outside of business hours… it is also
sent to the on-call CPS caseworker for the region for an immediate safety review.227
Because policy changes did not go into effect until mid-January 2021, the State
Certification of Compliance did not provide any case record reviews showing how the new policy
translated into compliance with Remedial Order 37.228
222
223
Defendants’ Certification of Compliance Regarding RO-37, Exhibit D, Sworn Declaration for RO-37 at 4, ECF
No. 1021.
224
DFPS notified the Monitors that it instructed staff about the new downgrade practice effective October 1, 2020 and
that the policy would be finalized and published as of November 1, 2020. Email from Audrey Carmical, Associate
Commissioner for Compliance, Coordination, and Strategy, DFPS to Deborah Fowler and Kevin Ryan, Court
Monitors (October 1, 2020).
225
Defendants’ Certification of Compliance Regarding RO-37, Exhibit D, Sworn Declaration for RO-37 at 4:45, ECF
No. 1021.
226
Defendants’ Certification of Compliance Regarding RO-37, Exhibit D, Sworn Declaration for RO-37, -4, ¶ 48
227
Defendants’ Certification of Compliance Regarding RO-37, Exhibit D, Sworn Declaration for RO-37 at 4:49, ECF
No. 1021.
228
The Monitors reviewed Priority None intakes for January 2021, and determined that none involved foster homes.
Data provided by DFPS for the month of January 2021, included a total of five intakes, involving eight PMC children,
that were downgraded to Priority None. Review of each of these intakes revealed none of the five reports to SWI
occurred for a child residing in a foster home. Two intakes occurred for four children at Glenn Eden (an SSCC operated
location for children without placement), one intake with two victims occurring while at Have Haven RTC, one intake
with one victim while at an out of state facility called Capstone RTC, and the final intake involved one victim while
at Connections Emergency Shelter.
110
Remedial Order 37 Performance Validation
Methodology
To validate the State’s performance with respect to Remedial Order 37, the monitoring
team conducted independent case record reviews for intakes involving a PMC child occurring
between April 1, 2020 and October 31, 2020, which were subsequently downgraded to PN.229 The
Monitors reviewed all of the 129 intakes230 that were downgraded to Priority None for PMC
children in a licensed foster care setting between April 1, 2020 and October 31, 2020.
The case review examined:
• whether the caseworker received notification of the SWI allegation within 48 hours of the
referral;
• whether upon receipt of the notification, the child’s caseworker reviewed the HHR and
assessed any concerns for the child’s safety or well-being;
• and whether the caseworker documented this information in the child’s electronic case
record.231
The monitoring team also reviewed the State’s case reviews and analyzed the underlying
methodology. The State conducted quarterly case record reviews for a random sample of 34
intakes downgraded to PN from March 1, 2020 to November 30, 2020.
Performance Validation Results
Validation of Casework Notification
The monitoring team reviewed child event records in the IMPACT system to identify the
notification to a caseworker of an SWI RCCI intake downgraded to Priority None where the
229
DFPS formally changed the screening procedures on November 1, 2020, limiting the circumstances when a case
could be downgraded to a Priority None, resulting in a significant reduction in the percentage of Priority None intakes,
as discussed in Section III supra.
230
Duplicate cases were removed from the universe of eligible cases. A duplicate was defined as children with multiple
intakes on the same day or a child with multiple intakes during the same month for the same allegation and same Case
ID. Where duplicates were found, the first intake for the child in the month was included in the universe of cases.
231
In conducting the case record review, the monitoring team found the following data limitation:
• Data provided by the State included a case ID for all allegations. This case ID (IMPACT Case ID) was used
by the monitoring team to identify a child’s case for both the automatic notification and caseworker
communication verification. During the automatic notification verification, the monitoring team found that,
for linked cases, the case ID provided in the RCI intake data represented the “linked” case ID not the unique
ID assigned to that case originally at intake. The automatic notification in the child’s IMPACT event list
was found for the correct intake date (usually the same or next day) but the case ID did not match the data
for that date in the sample. The case ID matching the sample was, in most cases, found in the child’s event
list with automatic notification occurring prior to the date of the selected intake. Questions posed to the State
verified that the case ID included in the RCI intake data represented the linked case ID for all linked cases
rather than the original Case ID assigned at intake.
111
alleged victim was residing in a foster home. Because the exact time of notification is not available
in IMPACT, the notification analysis calculated the number of calendar days from the date the
case was referred232 to the date of the caseworker’s notification. The exact time of notification was
not available. The monitoring team found the system-generated notification for the Priority None
intakes occurred 100% of the time (129 of 129); additionally, 99% (128 of 129) of automatic
notifications to caseworkers occurred within two days of the SWI referral. Only one case had an
automatic notification that occurred three days after intake.233
Home History Reviews
The monitoring team analyzed HHRs completed by the HHR team234 to determine whether:
an HHR was found and completed for all foster homes in the sample; the accuracy of the HHR
information compared to intake and investigation history data in CLASS for the foster home in the
case; and the number of days from the date the case was referred to the date the HHR was
completed.
The monitoring team found that DFPS completed 86 HHRs of 129 intakes (67%).235 Of
the 86 cases where an HHR was found, 59 (69%) were completed within two days of the case
referral date. For the 33% of cases (43 of 129) that did not contain an HHR, the reason for its lack
of completion was found in 100% (43 of 43) of the cases, with most (95%) found through DFPS
documentation and two cases (5%) found through the monitoring team’s review.236 The most
common reasons that an intake did not have an associated HHR were that the foster home was
closed, or that the incident did not occur in a foster home (61%, 26 of 43).
232
Intake start date as provided in the SWI data.
233
The monitoring team also calculated the automatic notification from the PN disposition date. Three cases had
different notification timing in the State data compared to the monitoring team’ case read data. Two of the cases
reviewed by the monitoring team had a notification the day before for State data and the notification occurred same
day in the case read. The third case had a same day notification in the State data and a next day notification in the
monitoring team’s case record review. Starting in May 2020 RCCI intake data provided to the Monitors included a
variable “RCCI data notice within 48 hours flag,” which is defined as “an indicator for whether the automated notice
was sent within 48 hours of the intake date/time for intakes on a foster home with PN as a final priority. Ninety-four
percent (96 of 102) reported “Yes” to the notice happening within 48 hours.
234
The HHR Team is comprised by DFPS staff and is described more fully in the Monitors’ First Report. See Deborah
235
Home History Review documents were provided to the Monitors in PDF documents and named by foster parent
name. To locate the corresponding HHR to a case downgraded to Priority None, the Monitors searched the completed
home history reviews provided by the State for the child’s foster home.
236
On March 11, 2021, the Monitors sent a list of intakes not found in INT_07 reports and on the Home History
Review Not Completed log to the State. On April 3, 2021, the State produced three data files and provided 21 home
history review documents. The data files addressed those INT_07 cases not found, the No HHR log cases, and an
updated HHR log for FY 2020. Using the DFPS HHR log data provided information on 41 cases (95%) where no
HHR was completed and the monitoring team’s case record review identified the reason for two (5%) of the cases
where no HHR was found. In their updated data, the State reported that in one case there was an HHR provided for
the child, but the child is not listed on the HHR. In one case the state reported an HHR was completed, but it was not
provided until the State submitted its updated data on April 3, 2021
112
Figure 4.19: Reason Found for Home History Review Not Completed
Source: RO 37 April-October 2020 Monitors’ Case Review Data, Home

History Review Not Completed Log April-October 2020 State Data
n=43
Foster Home Closed 40% (17)

Incident not in Foster Home 21% (9)
Reason Found
Outside RCCI Jurisdiction 19% (8)

No Children in Foster Home 12% (5)
Allegation Prior to Placement 7% (3)
Previously Investigated 2% (1)
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Percent of Cases
The monitoring team reviewed the content of the HHRs and determined that they generally
listed a summary of all investigations (including deficiencies and any Reason To Believe (RTB)
findings), the CPAs under which the foster home had operated, a reason for leaving a prior CPA,
and a listing of all children in the home.
Figure 4.20: Home History Review Content237

Source: Remedial Order 37 April - October 2020 Monitor Case Read Data
n=86
Investigations Deficiencies RTBs
• 100% of HHRs • 98% of HHRs • 97% of HHRs

documented documented prior documented prior
investigations deficiencies RTBs
• Average: 2 • Average: 1 • Average: 0
• Range: 0-12 • Range: 0-8 • Range: 0-3
237
Averages are rounded (2.4 investigations, 0.9 deficiencies, and 0.05 RTBs).
113
Additionally, the monitoring team conducted an analysis to identify the proportion of foster
homes with a history of investigations, deficiencies, and confirmed allegations of abuse, neglect
or exploitation (“ANE”). If a home reported more than one investigation, deficiency and/or RTB,
they were considered to have a history of ANE:
• No foster home had a history of all three elements - investigation, deficiency, and/or RTB.
• 44% of foster homes (38 of 86) had more than one investigation, deficiency, and/or RTB
within the last five years.
• The majority of foster homes, 56%, (48 of 86) had no history of child abuse, neglect and
exploitation.
Verification of Home History Review Staffing
To determine whether the child’s caseworker (1) reviewed the HHR; (2) staffed the case
with their supervisor to assess whether there were any concerns for the child’s safety or well-being;
and (3) documented the same in the child’s record, the monitoring team reviewed the child’s record
in IMPACT.238 In 50% (43) of the 86 cases where the monitoring team identified an HHR in the
record, there was no documentation of a staffing.239
In those 43 cases, the monitoring team attempted to identify a reason for the lack of staffing.
The monitoring team was unable to identify a reason for the lack of a documented staffing in 53%
(23 of 43) of the cases. In 33% (14 of 43) of cases the incident that was the basis of the reported
allegation occurred prior to the child’s current placement.
238
For the case read, the monitoring team attempted to locate documentation of the staffing either on the Child event
record or in the contact record.
239
Of the total number of cases reviewed, 34% (44 of 129) had a staffing documented in IMPACT. One case with a
staffing documented did not have an HHR found.
114
Figure 4.21: Reason Found for Not Documenting a Home History Review Staffing
Source: RO 37 April - Ocotber 2020 Monitors' Case Read Data

n=43
Allegation Happened Prior to

Placement 33% (14)
Reason Found
Allegation Previously Investigated 9% (4)
Outside RCCI Jurisdiction 5% (2)
No Reason Found 53% (23)
0% 20% 40% 60% 80% 100%

Percent of Cases
Even where there was a documented reason for a lack of staffing in the record, the monitoring
team found cases in which staffings should still have occurred to ensure a child’s safety and well-
being. For example, a case was not staffed based on “allegation previously investigated.” The
allegation involved a 7-year-old child touching a 6-year-old foster sibling on his private parts while
they were riding the school bus. Yet, the case had not been previously investigated as abuse or
neglect, but instead was the focus of an RCCR standards investigation for which a caseworker
would not have received notification. This case should have been staffed by the caseworker to, at
a minimum, appropriately counsel the foster parent about how to address the situation with the
children and to create a safety plan for the children while on the school bus.
The monitoring team also analyzed the timing between the date the case was referred and
the date the staffing occurred by the caseworkers with their supervisors. In 91% (39 of 43) of the
cases where DFPS held a staffing, it took more than two days for the caseworker to complete all
the components of Remedial Order 37.240
240
The cases reviewed by the Monitors and the State all occurred before the State made several policy changes that
may impact the timing between the date a case is downgraded to PN and a documented staffing.
115
Figure 4.22: Time from Case Referral to Home History Review Staffing Documented
Source: RO 37 April - October 2020 Monitor Case Read Data

n=43
Next Day 4.7% (2)

Timing Category
Two Days 4.7% (2)
3-5 Days 48.8%

(21)
6-7 Days 20.9% (9)
GT 7 Days 20.9% (9)
0% 10% 20% 30% 40% 50%

Percent of Cases
Of the 44 cases in which a home history review staffing was documented, almost all (95%, 42 of
44) had a narrative description of the staffing in IMPACT. One staffing was documented for a case
where no HHR was found. Staffings were documented for 43 of the cases where an HHR was
completed. Of the 42 cases with a narrative description found in the staffing, 33 (79%) indicated
that the caseworker and supervisor discussed and considered the child’s safety and well-being in
the staffing. Almost half of those cases (48%, 16 of 33) indicated that some action was taken as a
result of the HHR staffing, and an additional 27% (9) reflected an action had been take prior to the
staffing.
116
Figure 4.23: Actions Taken as a Result of a Home History Review Staffing241
Source: RO 37 April - October 2020 Monitor Case Read Data

n=16
Placement Change 6
Additional Safety Measures/Plan 7
TA/Training for Caregivers 1
Respite Care 1
Other 2
0 2 4 6 8 10
During the monitoring team’s case review, the team flagged some cases that did not appear
to adequately address issues related to child safety and well-being. Examples of problems
identified in flagged cases include:
• The foster home had the same citations for the same ongoing issues over time.
• No discussion of runaway notification to the police or other measures to locate
runaway youth.
• No discussion of safety, training, therapy, next steps when the child was known to
be suicidal.
• No discussion of immediate safety precautions and delayed change of placement
• Foster parent not meeting medical, school, or therapy needs.
• No information about the staffing discussion, concerns, or next steps.
Two examples illustrating inadequately documented staffings are provided, below.
In the first example, SWI received an intake on July 3, 2020 made by the foster parent. The
intake was recorded as follows:
Last night, OV was taken to Hospital for suicidal ideations. After OV came to the hospital,
FP learned that OV was on the phone with his girlfriend when he got a knife from the
kitchen and threatened to kill himself. OV’s girlfriend was able to calm him down. It is
unclear at what point OV was talked down from killing himself as he did have the means
and method for causing his death. FP said she was asleep when this happened.
241
More than one action could have occurred in a single home history review staffing.
117
Yesterday, OV had a counseling session and afterwards, he came to FP and said that he
thought he was in danger. OV wanted to go to the hospital. It is unknown when OV will
be released. FP will accept OV back once he is released.
A couple of years ago, OV attempted to hang himself. FP had no instruction that OV would
need any special supervision because of his past suicidal attempt.
An HHR was completed on July 6, 2020 and the caseworker staffed the case on July 8,
2020 with the program director, five days after the intake. The caseworker documented in the
staffing notes that she was “unaware of this child's suicidal ideations in the past,” that she had read
through the child’s records and did not find any documentation related to this, and that she would
request the documentation from a previous placement to determine what happened.
The staffing did not meet the requirements of Remedial Order 37 in that the staffing
occurred five days after the intake was downgraded to Priority None, there was not a documented
review of the foster home’s history, and the staffing only stated that the child would remain in the
home. There was not a documented discussion regarding the safety and well-being of the child.
The HHR provided to the caseworker indicated a previous report to SWI was made on April 3,
2020, just three months prior to this incident, reporting that another child in the home had self-
harmed with a knife he had gotten from the foster home. The staffing should have addressed any
need for safety plans, training the foster parents on how to care safely for a child with suicidal
ideations and the need to secure knives in the home. The foster parents are verified for basic and
moderate services, treatment services for emotional disorders and specialized services.
The caseworker indicated a lack of oversight by Benchmark (a CPA currently under

heightened monitoring) and the lack of any suicide history in the CPS file. What is of even greater
concern is that the child had a psychological evaluation completed at the end of June 2020 and,
according the caseworker, the psychologist found that the child could be considered a suicide risk,
but had not alerted anyone to this finding until after the incident.
In the second example, SWI received an intake on June 2, 2020 made by the foster parent.
The intake was recorded as follows:
Yesterday, L. A. and N got into a fight. L.A. said that N climbed onto the bunk bed and
started throwing away L.A.’s possessions from the bed. L.A. and N started wrestling and
[Foster Parent] (72yo) told them to stop and they did. About 1 or 2 minutes later, L.A. and
N were standing about 20 feet apart, N had a broom, ran towards L.A. and struck L.A. in
the face with the broom on the right side of the face. L.A. was injured from the strike and
was taken to Texas Children’s Hospital for medical assistance.
LA was given 3 stitches for the cut on [the child’s] face.
While a Home History Review was developed on June 3, 2020, an HHR staffing was not
conducted until 23 days after the initial intake date. The HHR staffing was brief and lacked the
substantive discussion required by the Court. The staffing notes did not include information related
to the discussion regarding this incident, a summary of what was reviewed from the HHR, nor any
118
indication of what steps would be taken to ensure the safety of the youth. The HHR staffing notes
simply indicated:
“[Placement] was discussed and reviewed and we are not going to request a placement
change. The foster parents were not at fault and they provided immediate medical attention
for L.A. after the incident.”
In reviewing the HHR, the Monitors found that the foster home is verified to provide care
for six children, male or female, ages 0 – 17, with basic, moderate and specialized levels of care.
The foster home is also authorized to provide treatment services for children with emotional
disorders, pervasive developmental disorders and an intellectual disability. The foster home may
additionally provide special services for physically challenged children and youth, emergency care
services, and transitional living services.
The victim (L.A.) in this incident is documented as a moderate level of care while the
aggressor is at a specialized level of care. Specifically, the record states:
• Youth information indicates that each of the two youth are within separate levels of care in
which N (the aggressor) is at a Specialized level of care, diagnosed with Depressive
Disorder and Adjustment Disorder with mixed disturbance of emotions/conduct for which
he is prescribed psychotropic medication requiring supervision within visual and hearing
distance of the caregiver. N requires supervision within visual and hearing distance of his
caregiver.
• L.A. is at a Moderate level of care, having ADHD and Bipolar Disorder and requiring
supervision within visual and hearing distance of the caregiver.
A discussion regarding how to ensure the safety of both children given these distinctive
needs should have been documented. Additionally, the SWI allegation narrative included that
additional concerns, as reported during that call, indicated that the two youth ‘usually wrestle like
children.’ That statement indicates a pattern of physical contact between the youth could be present
and should be addressed.
By August 24, 2020, the victim in the case for which this HHR had been developed, was
released to a behavioral health hospital. Over the course of the investigations documented in the
HHR, there appears to be a pattern of transferring youth to behavioral health hospitals. While each
instance does include circumstances and may be appropriate, a discussion related to this foster
home’s current ability to continue to care for youth with specialized needs seems warranted.
The lack of detail in the HHR staffing is concerning. Given the level of care that the home
is licensed to offer, more thorough discussion should have been documented. The current
documentation does not indicate a thorough review of the HHR or the children’s safety was fully
taken into account.
119
State’s Remedial Order 37 Case Read Results
To assess its compliance with Remedial Order 37, the State conducted three quarterly case
reads of a sample of intakes downgraded to PN that involved a PMC child in a foster home. For
each quarter the State reviewed 30% of the total number of downgraded intakes. For the period
March to May 2020, 22 cases were reviewed and 17 HHRs were found, 21 cases were reviewed
for the period June to August 2020 with 13 HHRs found, and for September to November 2020,
10 cases were reviewed and four HHRs were found.242
The State’s case reads continued to test whether an HHR was completed within a two-
business day timeframe, rather than 48 hours. When using the two-business day timeframe, the
State found for all three quarters that in 100% of the cases the HHRs were completed timely.243
The State also reviewed whether there was an HHR staffing documented. Between March
and May 2020, the monitoring team found almost the same percentage of HHR staffings
documented as the State case read. The State, however, observed more HHR staffings documented
from June through November 2020 than the monitoring team.
242
RO37 Q1 FY 2021 Home History Review State Case Read Report, (Q1 State Case Read Report) p. 1.
243
Q3 (2020), Q4 (2020), and Q1 (2021) State Case Read Report p. 2.
120
Figure 4.24: Home History Review Staffing Contact Documented: Monitor Case Read
Compared to State Case Read
Source: RO 37 April-October 2020 Source: RO 37 Q3 2020-Q1 2021 Home

Monitor Case Read Data History State Case Read
n=86 n=34
No Yes No Yes
Case Read Months

Case Read Months
Apr-May 32% (10) 68% (21) Mar-May 29% (5) 71% (12)
Jun-Aug 8% 92% (12)

Jun-Aug 60% (25) 40% (17)
(1)
Sept-Oct 62% (8) 38% (5) Sept-Nov 100% (4)
0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%
Percent of Cases
Percent of Cases
For quarters June to August and September to November 2020, the State added a question
to its case read, “If the staffing was held, did it occur within 7 days of receipt of the Home History
Review report?”244 The State did not analyze for any shorter period. Because the Court indicated
in its contempt order that this timeframe does not comply with Remedial Order 37, the Monitors
have not included the State’s results here.
The State also reviewed the staffing narrative to determine if it contained an accurate
summary of the review of the HHR, but it does not appear that the State reviewed the narrative to
determine whether there was any consideration for the child’s safety and well-being.245 Even when
looking at whether there was an accurate summary of the HHR in the narrative, the State found
that for both June to August and September to November 2020, 25% of the cases246 did not contain
an accurate review of the HHR.247 This was a significant decline from earlier in the year, when
for the period March to May 2020, the State found that 11 out of 12 applicable cases (92%)
contained an accurate summary of the HHR report.248 The State also determined that through
244
Q4 (2020) and Q1 (2021) State Case Read Report, p. 2.
245
For all three case reads the question asked was “Did the narrative of that staffing contain an accurate summary of
the review completed by the Home History Review team?” Q3 (2020), Q4 (2020), and Q1(2021) State Case Read
Report p. 3.
246
25% of the cases for the June-August read equated to 3 of 12 cases. In September- November 2020, 25% of the
cases equated to 1 of 4 cases.
247
Q4 (2020) and Q1 (2021) State Case Read Report, p. 3.
248
Q3 (2020) State Case Read Report, p. 3.
121
each of the quarters, between 92% and 100% of the narratives contained details of any decision or
action taken by the caseworker or supervisor.249
Summary
The monitoring team’s case read confirms that, at least through October 2020, the State
was not complying with the timeliness required in Remedial Order 37. Although in 99% of the
cases the automatic notifications to caseworkers occurred within two days of the SWI referral, the
average total time from the date the case was received by SWI to the date the home history review
staffing occurred, as documented in IMPACT, was eight days with a range from one to 70 days.250
In addition to failing to comply with the timeliness requirement of Remedial Order 37, the
State frequently did not consistently document HHR staffings between the caseworker and the
supervisor. In cases in which an HHR was located, the monitoring team did not find any staffing
or a reason for failing to have a staffing in 27% (23 of 86) of the cases. Finally, the monitoring
team again found concerns with the quality of the caseworkers’ reviews of the HHRs and staffing
notes. The State’s case read confirmed the Monitors’ finding, having found in both its June to
August and September to November 2020 case reads that in 25% of the cases, the caseworker’s
narrative did not contain an accurate review of the HHR.
249
Q3 (2020), Q4 (2020), and Q1(2021) State Case Read Report, p. 4.
250
The average total time from the date of PN to date home history review staffing occurred, as documented in
IMPACT, was 7.51 days with a range of 1 day to 70 days.
122
V.ORGANIZATIONAL CAPACITY
A. Remedial Order 1: CPS Professional Development Training
Remedial Order One: Within 60 days, the Texas Department of Family Protective Services
(“DFPS”) shall ensure statewide implementation of the CPS Professional Development (“CPD”)
training model, which DFPS began to implement in November 2015.
1. Background
First Court Monitors’ Report Performance Validation Findings
For the First Report, the Monitors analyzed data produced by DFPS related to hiring and
training for staff employed to serve as a primary caseworker between September 1, 2018 and
September 30, 2019. The Monitors’ analysis indicated that almost all caseworkers who were hired
between September 1, 2018 and September 30, 2019 started and completed some CPD training.
While most caseworkers completed CPD training within the expected time frames, 22% of
those with a training cohort start date of September 2019 or later completed the training earlier
than the CPD training model timeframe.251 Similarly, of the caseworkers for whom the Monitors
recorded both a training cohort start date and a hire date, it was unclear whether they completed
the full CPD training program: 15% were newly hired with a training cohort start date that fell
prior to their hire date.252 The average length of training for these caseworkers was significantly
shorter than the average for those caseworkers who started and finished training with their
cohort.253
For caseworkers who were included in the sample for which the Monitors could cross-
match training and data, approximately 14% were newly hired staff who appeared to have become
case assignable prior to their completion of CPD training.254
Policy Changes Following the Monitors’ First Report
DFPS Updates to CPD Training
On December 18, 2020, DFPS alerted the Monitors to changes that the agency anticipated
making to CPD training:
251
Id. at 160.
252
Id.
253
Id.
254
Id. at 161.
123
We would like to apprise you of some upcoming improvements being made to the
CPS Professional Development (CPD) training model which was implemented in
2015. These improvements are designed to align the CPD curriculum with current
best practice and maximize proteges' hands on practical experience with case work
tasks. Although the ratio of classroom and field training will remain the same, the
distribution of this training across the 13-week period will shift to focus on practical
application of classroom content and case work decision-making under a mentor's
supervision. These improvements are scheduled to deploy by March 1, 2021, and
we will share the revised CPD modules with you as soon as they are finalized.
Meanwhile, attached is a document highlighting these scheduled improvements.
Please let us know if you have questions or need additional information.255
The three-page document attached to the e-mail described the anticipated changes to the
CPD model. The document described the existing timeline for the current CPD model, which
consisted of a mix of classroom and field-based training.256 The existing 13-week timeline requires
the trainee to begin with four weeks of “Specialty Field I” training, followed by two weeks of
“Core Class,” then two weeks of “Specialty Field II” training, followed by one week of “Specialty
Class,” and ending with four weeks of “Specialty Field III” training.257
The changes to the timeline would continue to require 13 weeks of training, but would
decrease the time spent in “Specialty Field I” training from four weeks to three weeks, reduce the
“Core Class” to one week, but increase “Specialty Class” to two weeks, and “Specialty Field III”
to five weeks.258 The document explained:
Looking at the models, time has been shifted from Specialty Field and Core.
1) A shift of one week of Core Class content into Specialty Class. This change is
updated curriculum to reflect current evidence based best practice and giving
more time to teaching the leaner [sic] how it applies to the Conservatorship
specialty.
2) Moving one week of Specialty Field I into Specialty Field III. This is to give
more time to taking lead on case work decision making under the supervision
of the mentor. This adjustment is aligned with the emphasis of increasing time
spent hands on engagement with casework.259
The document also described “a few other minor tweaks to the model” to be delivered across
classroom and field delivery:
255
E-mail from Tara Olah to Deborah Fowler and Kevin Ryan, CPS Professional Development Training
Improvements, December 18, 2020 (on file with Monitors).
256
The CPD model is described in more depth in the Monitors’ First Report. See Deborah Fowler and Kevin Ryan,
First Report 156-57, ECF 869.
257
DFPS, Summary of Improvements to the CPD model (undated) (on file with Monitors).
258
Id.
259
Id.
124
• More focus on specialty concepts;

• Updating individualized training plans to reflect field training tasks to be completed
with the caseworker’s mentor during field training;
• Increasing the number of knowledge assessments;
• More hands-on practice with IMPACT and assessment tools;
• Incorporating more demonstration of skills beyond the standard knowledge
assessments;
• Guided observation tools;
• Conversion of some computer-based trainings to instructor-led content.260
Because Remedial Order 1 explicitly requires implementation of the CPD training model, on
January 24, 2021, the Monitors asked DFPS for a detailed list of changes to the model, as well as
any associated material highlighting any substantive differences from the model in place at the
time the Fifth Circuit validated the remedial order.261
DFPS responded by email on February 23, 2021, attaching a side-by-side comparison of

the planned updates to CPD and the existing curricula, and a more detailed description of the
changes as follows:262
Per your request, we are providing a detailed list of all new changes to CPD and
associated material describing the enhancements. We have not yet implemented but
tentatively plan to begin delivering this content in May 2021.
The CPD model was implemented in a phased rollout beginning in January 2015,
and since that time, the only revisions to the curriculum have been made to reflect
changes in DFPS policy, legislative initiatives and updates to modernize content or
to improve processes, such as revising forms. Hence, the CPD model has not
changed since October 2018 when the Fifth Circuit affirmed Remedial Order One.
The CPD model is characterized by the following characteristics:
• Supports the adopted Practice Model;
• Includes 20% classroom instruction and 80% field instruction;
• Contains a mentoring component;
• Alternates sequence between classroom and field instruction; and
• A duration of 13 weeks.
The changes do not vary from these characteristics.263
260
Id.
261
E-mail from Kevin Ryan to Heather Bugg, Training Update (January 24, 2021) (on file with Monitors).
262
E-mail from Heather Bugg to Kevin Ryan & Deborah Fowler, Training Update (February 23, 2021) (on file with
Monitors). DFPS also sent an e-mail to the Monitors on January 24, 2021, describing updates to the CPD training
that were consistent with recommendations made by Praesidium, as part of its review of the agency’s policy and
trainings related to sexual abuse. This e-mail and the description of the changes are discussed in Section V, infra.
263
Id.
125
Some of the described changes to the curriculum included adding training in elements
consistent with other remedial orders or changes made as a result of concerns expressed by the
Court, including:
• The addition of an introduction to CLASS and the Black Bell IMPACT notification
for RCCI investigations to the “Intro to Tech”;264
• Increased content on Child Sexual Aggression in the “CPS Core Competencies
Training;”
Adding content regarding child sexual aggression, searching CLASS and “enhanced
discussion” on “assessing for safety” in the Specialty Classroom training.265
SSCCs Providing Case Management Services
Two SSCCs – OCOK and 2INgage – moved to Stage II of the Community Based Care
(CBC) model in 2020. Stage Two includes shifting case management services from DFPS to the
SSCC.266 The Monitors did not include data or information related to CPD training for OCOK
and 2INgage caseworkers in the First Report, because case management services were not
transferred to OCOK and 2Ingage until March 1, 2020 and June 1, 2020, respectively.267 While
this shift does not relate to a change in policy, it resulted in a significant change in practice for the
264
The Black Bell IMPACT notification was an IMPACT change made by DFPS in an effort to comply with Remedial
Order B-5.
265
DFPS, CPS Professional Development (CPD) Classroom Training Overview (undated)(on file with Monitors).
266
SSCCs contract with DFPS to provide services to foster children in DFPS regions that have transitioned to the
Community Based Care (CBC) model. CBC was formerly known as Foster Care Redesign. There are currently four
regions that have transitioned to the CBC model, or are in the process of doing so: Region 1 (Texas Panhandle);
Region 2 (30 counties in North Texas); Region 3b (seven counties around Fort Worth); and Region 8a (San Antonio
and Bexar County).
There are two stages to the transition to the CBC model: In Stage I, the SSCC “develops a network of services
and provides placement services. The focus in Stage I is improving the overall well-being of children in foster care
and keeping them closer to home and connected to their communities and families.” DFPS, Community-Based Care,
available at https://www.dfps.state.tx.us/Child_Protection/Foster_Care/Community-Based_Care/default.asp
According to DFPS, “In Stage II, the SSCC provides case management, kinship, and reunification services. Stage II
expands the continuum of services to include services for families and to increase permanency outcomes for children.”
Id.
DFPS has contracts with the following providers for CBC:
• Region 3b – Our Community. Our Kids. (OCOK) (Stage II)

• Region 2 – 2INgage (Stage II)
• Region 8a – Family Tapestry (Stage I)
• Region 1 – Saint Francis (Stage I)
Id.
267
See DFPS, Community-Based Care in Region 3b, available at
https://www.dfps.state.tx.us/Child_Protection/Foster_Care/Community-Based_Care/region3b.asp (noting that
OCOK began providing case management, kinship, and family reunification services to youth and families in
Region 3b on March 2, 2020); DFPS, Community-Based Care in Region 2, available at
https://www.dfps.state.tx.us/Child_Protection/Foster_Care/Community-Based_Care/region2.asp (noting that
2INgage began providing case management, kinship, and family reunification services to youth and families in
Region 2 on June 1, 2020).
126
two regions served by OCOK (Region 3b) and 2INgage (Region 2). Consequently, the monitoring
team met virtually with DFPS and the SSCCs to better understand the data provided by the SSCCs
and the caseworker training models they used. In addition, the Monitors requested data and
information related to OCOK and 2INgage caseworker training in a supplemental data and
information request sent to DFPS in November 2020, as described below.
2. Data & Information Request & Production
Monitors’ Data and Information Request
In October 2020, the monitoring team began to hold regular virtual meetings with DFPS
staff to discuss questions and issues related to the data provided by the State to the Monitors. The
data provided by DFPS for Remedial Order 1 was discussed during these meetings, after the
monitoring team sent DFPS a list of questions related to data provided for this remedial order on
October 28, 2020.268
In response to questions the monitoring team sent to DFPS, OCOK and 2INgage began
providing data to the Monitors related to Remedial Order 1, in January and March of 2020,
respectively. Staff from both OCOK and 2INgage joined one of three total meetings devoted to
discussing the data related to Remedial Order 1 to answer questions regarding the OCOK and
2INgage training data.269
Following these meetings, on November 16, 2020, the Monitors sent a supplemental data
request to DFPS and HHSC that included requests related to Remedial Order 1. The Monitors
asked DFPS to provide the following data:
• For DFPS CVS Caseworker hires:

o IMPACT personal identification;
o A flag to indicate if an individual is required to participate in partial CPD training
only;
o A flag to indicate if a DFPS employee transfers to an SSCC prior to completing
CPD training.
The Monitors also asked DFPS to include in reports of CVS caseworkers hired between
October 1, 2019 through September 30, 2020 additional information to support the Monitors’
validation work: the caseworkers’ IMPACT identification number; each individual’s case-
assignable date or an explanation as to why there is no date (e.g., worker still in training or left
agency before completing CPD); an indicator of whether the individual was a stipend student;270
268
E-mail from Nancy Arrigona to Jane Burstain, RO 1 data questions (October 28, 2020) (on file with Monitors).
269
The monitoring team met virtually with DFPS on November 5, 2020 to discuss questions related to the DFPS data;
on November 19, 2020, the monitoring team met with DFPS and OCOK to discuss questions related to OCOK data;
and on December 3, 2020, the monitoring team met with DFPS and 2INgage to discuss questions related to the
2INgage training data.
270
According to DFPS, a “stipend student” is “ an individual who is generally hired and completes CPD while they
are still in school and, after completing school, is hired as a caseworker. Generally, their graduated caseload starts
when they are hired as a caseworker.” DFPS, RO 1 Questions for State Call (undated)(on file with Monitors).
127
an indicator for whether the individual only had to complete part of CPD; and an indicator for
whether the individual transferred to an SSCC/CBC provider prior to completing CPD.
In addition, the Monitors asked for the following information related to the SSCCs’ caseworkers:
• Dates that reflect the employee’s total time in training;

• DFPS region and county;
• Separation of hire type and notes into two fields;
• A flag to indicate whether the employee transferred to the SSCC from DFPS; and
• A flag to indicate when an individual is only required to participate in partial training.
DFPS and SSCC Data & Information Production
Following the Monitors’ supplemental data request on November 16, 2020, beginning on
December 15, 2020, and monthly thereafter, DFPS provided the requested data, and also corrected
data for CVS caseworkers hired between October 1, 2019 and September 30, 2020. In addition,
DFPS compiled corrected data for CVS staff subject to graduated caseloads between May 1, 2020
and November 30, 2020 and provided it to the Monitors on January 4, 2021.
As was true of the data analyzed for the First Report, the Monitors again encountered
limitations with the data provided for CPD training validation. The data was limited in the
following respects:
• OCOK Training Dates and Case Assignable Dates: The training start and end dates
provided by OCOK represented the dates that OCOK’s Permanency Academy training
began and ended, not a caseworker’s total time in training.271 In addition, in a virtual
meeting between the Monitors, the State, and OCOK on November 19, 2020, OCOK
reported that the caseworker training end dates provided to the Monitors was the estimated
end date. The Monitors attempted to use the case assignable dates provided by OCOK as
training end dates, as all training must be completed prior to a caseworker becoming case
assignable. On January 15, 2021, during a virtual meeting among the Monitors, the State,
and the SSCCs, OCOK reported that the case assignable date provided to the Monitors was
the expected case assignable date, not the actual date. Without reliable dates of training
completion and case assignable dates for all OCOK caseworkers, the Monitors were not
able to validate training completion or time in training for OCOK caseworkers. Therefore,
the Monitors have not included analysis of training completion or time in training for
OCOK staff in this report, and cannot verify OCOK’s compliance with Remedial Order 1.
• DFPS Training Start and End Dates and Case Assignable Dates: The training start date
provided by DFPS is the “date the cohort to which the caseworker was assigned started.”
For some caseworkers this is the actual CPD training start date, but for staff who were
rehired or transferred, they may be placed in a cohort already underway. DFPS indicated
during a virtual meeting held on November 5, 2020, that the cohort start date for rehires
271
Expected CPD training for OCOK includes a seven-day new hire orientation, a possible two to six weeks of field
work prior to starting the Permanency Academy and the six-week Permanency Academy.
128
and transfers is “either the cohort start date or hire date, whichever comes later.” The
training end date provided by DFPS is the “Anticipated Cohort End Date”, the date the
cohort is expected to end. DFPS reported that “as the caseworkers in this report were newly
hired into their position, we cannot provide their actual CPD completion date.”272 Because
actual training completion dates were not provided, DFPS directed the Monitors to use the
case assignable date as a proxy for the actual training completion date. The State provided
the Monitors with case assignable dates in the graduated caseload data separate from the
caseworker hired data. The data defines the caseworker’s case assignable date as the “date
the caseworkers completed CPD training and became eligible to be assigned primary on
cases.”273 In the data dictionary, DFPS provided an additional note that there may be a
delay when the case assignable date is entered into CLOE Learning Management system,
in which case they enter the actual case assignable date and not the date the data is
entered.274
• DFPS Paper Records and Manual Notes on Training: Some CPD training is tracked through
paper forms that are manually entered and updated in the CLOE system. As a result, many
data entry and completeness issues can occur. Specifically, the “notes on training” are
entered into the data by hand and are not standardized and may be missing notes that would
support the understanding of staff CPD training requirements. For transfers and rehires
without training notes, DFPS directed the Monitors to assume full CPD was needed.275
• DFPS CVS Caseworkers Transferring to SSCCs: Caseworkers hired by DFPS in January,

February, and April 2020 were flagged as transferring to OCOK or 2INgage. Information
for these caseworkers was not consistent or thorough in initial hired data provided by the
State but was provided in corrected data.
• 2INgage Training End Dates: Data provided by 2INgage included the “anticipated cohort
end date” which was defined in the data dictionary as the anticipated date training will end.
The case assignable date provided by 2INgage was used as a proxy for training end date.
• OCOK and 2INgage Incomplete Hire Records (OCOK & 2INgage): For both SSCCs, not
all caseworkers hired during the period were included in initial data. For OCOK, six
additional caseworkers were included in the corrected data who were not accounted for in
272
Data dictionary for hired data, provided monthly by DFPS.
273
Data dictionary as provided monthly by DFPS in file RO2.4 and RO1.1 DFPS CVS Grand CL and CPD grads
"date".xls.
274
In an informal response to a draft of the Monitors’ First Report, the State also noted, “The monitors note that all
new hires (unless excepted) are enrolled in CPD. With regard to the report noting that 21.7% of the caseworkers in
their sample finished CPD early, the case-assignable date is manually entered after CLOE staff audits the employee’s
training record to verify completion of all requirements. This process can create a delay between the actual date
training was completed and when case assignability is recorded. Some supervisors assigned cases when the training
was completed instead of when CLOE verified the worker was assignable. Clarification has been sent to the field on
this point.” DFPS & HHSC, Agency Response to DR Texas Report 11-12 (June 15, 2020)(on file with Monitors).
275
DFPS assured the Monitors that there were quality assurances in all reports. However, paper records and manual
notes as text fields are subject to data errors. In addition, text notes did not provide quantifiable data for the Monitors’
analysis.
129
initial data provided to the Monitors. For 2INgage, 65 of 125 (52%) caseworkers were not
provided in initial hire data sent to the Monitors.
• OCOK and 2INgage Hire Types and Training Requirements: Hire type and training
information found in notes were, at times, mismatched in the data. Staff categorized by
hire type, who should have been required to participate in full CPD training, were found to
be exempted from training as recorded in other data or in the notes associated with that
caseworker. These mismatches in hire types and training time required that CPD
completion and timing had to be adjusted for analysis. Data provided also did not clearly
specify the reasons that some caseworkers were flagged as in need of “partial” or “no
training,” though training materials indicated they should have participated in full CPD
training. The same was true for staff who, according to training materials provided, should
not have been required to participate in training but who had cohort start dates.
In addition to providing data to the monitoring team, OCOK and 2INgage provided
information describing their training programs. The materials provided highlight what appear to
be significant differences in the length of training between the two SSCCs’ training programs and
the 13-week DFPS CPD training in place when the Fifth Circuit validated Remedial Order 1. For
example, the timeline provided by OCOK for training its caseworkers (referred to as “Permanency
Workers”), indicates that its training model could be as short as 11 weeks, depending on the lag
between a caseworker’s hire and the date of the next “Permanency Academy.”276
Figure 5.1: OCOK Training Timeline for New Permanency Workers
OCOK described the following timeline for its training in a written response to the questions posed
by the monitoring team:
Total training time before case assignability is 11-15 weeks, depending on when
the hire date falls in the monthly training cycle. This includes 7 business days of
276
OCOK, Training Timeline for New Permanency Workers (undated) (on file with Monitors).
130
new hire training, followed by 2-6 weeks of observation/field work, followed by 2

weeks of Academy training in the class room, followed by 2 weeks in the field,
followed by an additional 2 weeks of Academy training, followed by 2 weeks in
the field. At that time, the worker graduates from training and is assessed for
readiness to take on full case management responsibility. If they are not assessed
to be ready, their supervisor and mentor will continue to develop their skills until
such time as the worker is assessed to be ready. For this reason, the Case
Assignable date for a few workers will extend beyond graduation from the
Academy.277
2INgage materials describe a six-week “2INgage Academy” program for training

caseworkers (referred to as “Permanency Case Managers”), alternating one week in the classroom
with a week in the field for the six-week period. In an overview of professional development,
2INgage reported:
Training for Permanency Case Managers begins on the date of hire and includes a
minimum of six weeks to include 3 weeks of Classroom training and an additional
three weeks of other On-line and Field training outlined in the Individual Training
Plan.
2INgage Academy is structured by alternating one week of classroom training with

one week of training in the field. Each week’s curriculum is independent of the
other and allows new employees to begin Academy the week following hire date.278
This training curriculum was confirmed by 2INgage in the written responses the agency provided
to the monitoring team’s questions:
Total training time of six weeks includes both 3 weeks of classroom and 3 weeks
of [field training] and other online training requirements as documented in the
Individual Training Plan. This time starts on date of hire and ends when all
requirements of the classroom and Individual Training Plan are met.
Our model includes a total of 6 weeks [of training] with an additional 5 weeks of
Solution Based Casework provided after the staff are case assignable.279
3. Remedial Order 1 Performance Validation
Methodology
277
OCOK, OCOK Responses to RO1 Questions (on file with Monitors).
278
2INgage, 2INgage Professional Development Overview (undated)(on file with Monitors).
279
2INgage, RO1 Questions for State Call (undated)(on file with Monitors).
131
In order to validate DFPS’s performance for Remedial Order 1, the Monitors analyzed a cohort
of data consisting of all persons hired to perform the job of DFPS CVS caseworker during the
months of January 1, 2020 to July 31, 2020. A total of 440 persons were hired by DFPS as CVS
caseworkers during this time period. The cohort included caseworkers who were newly hired (new
hires), rehired after leaving the agency (rehires), or transferred to the caseworker position from
another position in the agency (transfers). The analysis included a review of:
• Time to leaving the CVS caseworker job and/or leaving DFPS, to allow the Monitors to
better understand incomplete training records, CVS staff turnover, and the timing of staff
turnover.
• Verification of Completion of CPD Training, by using the case assignable date as the date
of completion.
• Verification of Time to Complete CPD Training, analyzing caseworkers subject to full
training separately from partial training due to differences in requirements related to
training.280
• Expected CPD Completion, to determine whether CVS caseworkers required to complete
the full CPD training course completed within the expected timeframe of 13 weeks (91
days), based on the CPD curricula.
In order to validate performance for the two SSCCs, the Monitors analyzed two cohorts of
data consisting of 302 persons across the two SSCCs:
• OCOK hired 177 caseworkers between January 1, 2020 and July 31, 2020. Caseworkers
could have been newly hired with no previous experience (new hires), or transferred to the
position from DFPS or another SSCC (transfers).
• 2INgage hired 125 caseworkers between April 1, 2020 and July 31, 2020. Caseworkers
could have been newly hired with no previous experience (new hires), transferred to the
position from DFPS (transfers), or been hired with previous DFPS experience (previous
DFPS).
The analysis conducted for the SSCCs included the same elements as the DFPS analysis, described
above.
Caseworkers Hired and Trained by DFPS
DFPS hired 440 CVS caseworkers between January 1, 2020 and July 31, 2020. The majority
of caseworkers hired, 79% (347 of 440), were classified as new hires. Of new hires, 26 were
described as “stipend students,” interns who completed CPD training with the agency prior to
being hired as full-time caseworkers. Stipend students are fully case assignable on their hire date.
280
Transfers, rehires, and “student stipends” are not subject to full CPD training.
132
Figure 5.2: DFPS CVS Caseworkers Hired by Hire Type, January 1, 2020 to July 31, 2020
Source: DFPS CVS Hire Data, January - July 2020

n=440
7%
33
79% 14%
347 60
New Hire Rehired Transferred
Figure 5.3: DFPS CVS Caseworkers Hired by New Hire Type
Source: DFPS CVS Hire Data, January - July 2020

n=347
New Hire Type
New Hire 93%

(321)
Student Hire 7%
(26)
0% 20% 40% 60% 80% 100%

Percentage of Caseworkers
Student Hire New Hire
133
Out of these 440 caseworkers, 123 (28%) had left the agency as of December 1, 2020. Of
those that exited, 20 DFPS caseworkers transferred to an SSCC.
More than half of the caseworkers leaving the agency (51%, or 63 of 123) exited during
CPD training. Caseworkers who left the agency during the CPD program completed 71 days of
training on average.
Thirty-two percent (39 of 123) of caseworkers who left the agency exited after completing
CPD training. On average, caseworkers who completed training and left the agency did so within
83 days after completing training.
Figure 5.4: Hired DFPS CVS Caseworkers Who Left Position by December 1, 2020 Timing
of Exit*
Source: DFPS CVS Hire Data

n=123
17%
32% 21
Before Training 39
During Training
After Training
51%
63
*Analysis assumes left the agency or CVS, based on provided exit dates. Most left the agency entirely.
134
Figure 5.5: DFPS CVS Caseworkers Hired by Agency Status as of December 1, 2020

n=440
100%
Percentage of Caseworkers
80% 72%
60%
40%
23%
20%
5%
0%
Still with DFPS Left DFPS Left DFPS for SSCC
(317) (103) (20)
Agency Status
Still with DFPS Left DFPS Left DFPS for SSCC
Three DFPS regions – Region 7, Region 8, and Region 1 -- hired close to half (45%, or
196 of 440) of all caseworkers hired between January 1, 2020 and July 31, 2020. One region –
Region 2 – lost all 13 of the caseworkers hired during this time period, with four of those
transferring to an SSCC. Region 3W, in the Fort Worth area, also lost a high percentage of the
caseworkers hired (18 of 23, or 78%) during this time period.
135
Figure 5.6: Caseworkers Hired, Active, and Left Agency by Region

n=440
100 91
Number of Caseworkers
80 69
60 50 55
44 42
38 37 35 3632
40 30
23 24 22 26
21 18 1715
20 12 13 13 15 13
9 9 9
0
7 7
0
5 7 4 2 2 8 6 2 2 2 1 1 4 1 1 0
0
Re 11
12
gi E
6A
3W
Re B
1
Re n 3
Re 4
Re 5
Re n 6
Re 7
Re n 9
Re 10
3
6
n
on
on
on
on
on
on
on
io
io
io
o
on
on
on
on
gi
gi
gi
gi
gi
gi
g
gi
gi
gi
gi
gi
gi
Re
Re
Re
Re
Re
Re
Re
DFPS Region
Total Hired Active Caseworkers Left Agency
(440) (317) (123)
Of the 440 caseworkers hired by DFPS during the time period analyzed, 313 were subject to CPD
training requirements, and remained at the agency through training.
136
Figure 5.7: CVS Caseworkers CPD Training Completion Sample

n=313
All Caseworkers Hired between Total

Caseworkers
January 1, 2020- July 31, 2020 Hired
N=440 440
Caseworkers by CPD Training Caseworkers Caseworkers not

Level subject to CPD subject to CPD
N=440 397 43
Caseworkers Excluded* from CPD Remained at Left Agency Prior

Agency Through to/ During Student Hires Rehires/Transfers
Training Completion Analysis Training Training 26 17
N=127 313 84
Caseworkers included in CPD Caseworkers

included in
Training Completion Analysis Analysis
N=313 313
Of these 313 caseworkers, 78% (244 of 313) were newly hired subject to full CPD training,
and the remaining 69 caseworkers were rehired or transferred into the agency, subject to full or
partial CPD training. Of the 69 rehired and transferred staff subject to CPD training, 52% (36 of
69) were subject to full training, while 33 (48%) were subject to partial CPD training.
Of the 313 caseworkers required to complete full or partial CPD training, 97% (305 of 313)
had completed CPD training as of January 2021. The eight caseworkers who had not yet
completed training were noted as being “not case assignable yet” in the “Date Case Assignable
Notes” provided by DFPS. However, of these eight, one caseworker was identified in full caseload
data for November 2020 and December 2020. This caseworker was never included in graduated
caseload data.
137
Figure 5.8: DFPS CVS Caseworkers CPD Training Completion

n=313
3%
97% 8
305
Training Completed Training Not Completed
DFPS reported that, on average, CPD training takes 13 weeks (91 days) to complete. Of
the 304 caseworkers281 hired by DFPS who completed CPD training, 271 were subject to full
training. The average time to complete CPD training for these 271 caseworkers was 102 days.
The 33 caseworkers who were rehired or transferred into the agency completed their partial CPD
training in 65 days, on average.
The Monitors also analyzed training for the two SSCCs – OCOK and 2INgage – that
transitioned to providing casework services for the children in their regions in 2020. The results
of those analyses follow.
Caseworkers Hired by OCOK and 2Ingage
On March 1, 2020, OCOK took over all case management, kinship, and reunification
services in Region 3b, as part of the Community Based Care (“CBC”) plan.282 DFPS staff who
had been providing these services in the region were allowed to apply to transfer to OCOK, if they
preferred.283 Consequently, of the 177 staff OCOK hired as caseworkers during the time period
281
One caseworker was excluded from the time to complete analysis due to leaving on maternity leave during training.
282
While OCOK did not begin providing case management services until March 1, 2020, the Monitors began receiving
hiring data from OCOK in January 2020.
283
The Family Code requires the SSCC to give preference for employment to employees of DFPS who are
considered to be in good standing. Tex. Fam. Code §264.155(7). According to DFPS, the SSCCs have a goal of
modifying the process for hiring in order to expedite the process for CPS staff in good standing. See DFPS,
138
studied, most (114 of 177, or 64%) were hired as transfers from DFPS, and most of those
caseworkers transferred to OCOK on March 1, 2020 (106 of 114). One staff person hired by
OCOK as a caseworker transferred from ACH (the parent company for OCOK); the remaining
caseworkers hired (62, or 35%) were new hires.
Figure 5.9: OCOK Caseworkers Hired Type January 1, 2020 to July 31, 2020 by Hire Type
Source: OCOK Caseworker Hire Data, January - July 2020

n=177
35%
62
65%
115
New Hire Transfers
2INgage took over case management, kinship, and reunification services in Region 2 on
June 1, 2020. Between April 1, 2020 and July 31, 2020, 2INgage hired 125 staff to act as
caseworkers. In contrast to OCOK, most of 2INgage hires were new hires (85 of 125, or 68%)
rather than transfers from DFPS. Of the remaining 40 caseworkers hired by 2INgage, 30 (75%)
were transfers from DFPS, and another 10 (25%) had worked for DFPS at some point in the past
but were not working for the agency when they were hired by 2INgage.
Community-Based Care FAQs, Position Specific/Hiring Questions, available at

https://www.dfps.state.tx.us/Child_Protection/Foster_Care/Community-Based_Care/FAQ.asp.
139
Figure 5.10: 2INgage Caseworkers Hired April 1, 2020 to July 31, 2020 by Hire Type
Source: 2INgage Caseworker Hire Data, April - July 2020

n=125
24%
30
8%
68%
10
85
New Hire Previous DFPS DFPS Transfer
Of the 177 caseworkers OCOK hired between January 1, 2020 and July 31, 2020, 15% (26
of 177) had left the agency as of December 2020,. More than three-fourths of these caseworkers
(20 of 26, or 77%) had transferred to the agency from DFPS and were not required to complete
CPD training. Of the remaining OCOK caseworkers who were required to take CPD training but
left the agency, three (12%) left prior to completing CPD training and three (12%) left after
completing CPD training.
Figure 5.11: Caseworkers Leaving OCOK as of December 2020, Timing of Exit
Source: OCOK Caseworker Hire Data

n=26
12%
3
Before Completing Training 12%
3
After Completing Training
After Hired 77%

(No CPD Required) 20
140
The majority of caseworkers hired by OCOK served Tarrant County, which also had the highest
number of caseworkers leave the agency during the period analyzed.
Figure 5.12: Number of OCOK Caseworkers Hired, Active, and Left Agency as of
December 2020, by Work County
Source: OCOK Caseworker Hire Data

n=177
150 130
112
100
50
17 13 19 16 18
5 5 0 4 6 5 1 3
0
Hood Johnson Palo Pinto Parker Tarrant
Work County

(177) (151) (26)
Of the 125 caseworkers hired by 2INgage during the time period studied, 35 (28%) had left
the agency as of November 2020. Of the 35 caseworkers who left, 11 (31%) transferred from
DFPS and were not required to complete CPD training and 24 (69%) were required to complete
CPD training. Of those 24, four left prior to completing CPD training, and 20 left after completing
CPD training.
Figure 5.13: Caseworkers Leaving 2INgage as of November 2020, Timing of Exit
Source: 2INgage Caseworker Hire Data

n=35
11%
Before Completing 4
Training 31%
After Completing 11
Training
After Hired
(No CPD Required) 57%
20
141
Most of the caseworkers hired by 2INgage, and most who left the agency, served three
counties: Brown, Taylor, and Wichita.
Figure 5.14: Number of 2INgage Caseworkers Hired, Active, and Left Agency as of
November 2020, by Work County

n=125
80
60 54
40 37
29
23 20
17 18 19
20 15
11
3 4
0
Brown Taylor Wichita Other Counties
Work County

(125) (90) (35)
Of the 85 caseworkers hired by 2INgage who were required to complete CPD training and
who stayed with the agency through completion of the training, all (100%) had completed the
“2INgage Academy” training by November 2020. Though six of the caseworkers hired by
2INgage had prior DFPS experience, they were nevertheless required to complete the full CPD
training.
The average time to complete training for these 85 caseworkers was 43 days. However,
ten caseworkers completed CPD training within 28 days. 2INgage did not explain to the Monitors
why these caseworkers were case assignable four weeks after they started training.
142
Figure 5.15: 2INgage CPD Completion Time Compared to Expected, Caseworkers

Requiring Full Training

n=85
12%
10
Before expected
W/in week of expected 19%

16
On or after expected
69%
59
Summary
Ninety-seven percent (305 of 313) of DFPS caseworkers had completed CPD training as
of the time of the analysis. These caseworkers were hired by DFPS between January 1, 2020 and
July 31, 2020, did not leave the agency prior to or during training, and were subject to CPD training
requirements. Of the eight caseworkers who did not complete CPD training, one caseworker was
identified in the full caseload data, and was never included in graduated caseload data as would be
expected. On average, CPD training takes DFPS caseworkers 13 weeks (91 days) to complete.
Of the 85 caseworkers hired by 2INgage who were required to complete CPD training and
stayed with the agency through training, all (100%) had completed the “2INgage Academy”
training as of January 2021. Seventy-nine (93%) of those 85 caseworkers were newly hired and
subject to full CPD training. On average, caseworkers completed the 2INgage training in 43 days.
Ten of these newly hired staff completed 2INgage training in just 28 days.
OCOK did not provide reliable data to the Monitors in time for assessment of their
performance associated with Remedial Order 1. The failure to report reliable data about OCOK
suggests that neither OCOK nor DFPS was actively assessing OCOK’s conformance with training
completion requirements and case assignability prior to the Monitors’ efforts to validate the data.
B. Remedial Order 2: Graduated Caseloads
Remedial Order 2: Within 60 days, DFPS shall ensure statewide implementation of graduated
caseloads for newly hired CVS caseworkers, and all other newly hired staff with the responsibility
143
for primary case management services to children in the PMC class, whether employed by a public
or private entity.
DFPS Graduated Caseload Policy
According to its policy, DFPS’s newly hired conservatorship caseworkers, or “protégés,”

may be assigned primary case management responsibility on cases after completion of CPD
Training.284 Once protégé workers complete CPD Training, DFPS policy requires that their case
assignments are subject to the graduated caseload standard relevant to Remedial Order 2, which
the State calls “Advancing Practice.”285
Pursuant to the generally applicable, internal caseload standards, effective February 15,
2020, caseloads should not exceed 14 to 17 children per worker.286 Under that new standard,
therefore, in the first month following protégé worker eligibility for primary case assignment, per
DFPS’s policy, the protégé’s caseload may not exceed 6 children, one-third of the generally
applicable caseload standards. 287 In the second month of eligibility, the protégé’s caseload may
not exceed 12, or two-thirds of the caseload standards.288 In the third month of eligibility, the
protégé is eligible to be assigned a full caseload.289
As reported previously, DFPS informed the Monitors that it does not have the current
capacity to report on the total number of days during the month that new caseworkers’ caseloads
are not compliant with the graduated caseload standard.290 Instead, DFPS provided to the Monitors
compliance data on the 15th and 45th days after caseworkers’ eligibility for primary case
assignment.291 The Monitors also received data reporting on the dates that caseworkers become
284
DFPS, Graduated Caseloads Compliance Summary, at 1 (Nov. 1, 2019) [hereinafter Graduated Caseloads
Compliance Summary] (on file with the Monitors). In response to the Monitors’ Data and Information Request for
graduated caseload policies; field guidance; and information or directives describing to managers and/or supervisors
the graduated caseloads policy and schedule, the State produced various documents. See id., DFPS, Supervisor BSD
(Basic Skills Development) Information (Nov. 1, 2019) [hereinafter Supervisor BSD] (on file with the Monitors);
DFPS. CVS Individualized Training Plan July 19 (Nov. 1, 2019) (on file with the Monitors).
285
Graduated Caseloads Compliance Summary, at 1.
286
Order Regarding Workload Studies in the November 20, 2018 Order at 1-2, M.D. ex rel. Stukenberg v. Abbott, No.
2:11-CV-84, slip. op. (S.D. Tex. Dec. 17, 2019), ECF No. 772 (Workload Studies Order).
287
DFPS, Generally Applicable Caseload Standards – Guidelines for Conservatorship (CVS), at 8 (July 2020)
[hereinafter CVS Caseload Standards].
288
DFPS., Generally Applicable Caseload Standards – Guidelines for Conservatorship (CVS), at 8 (July 2020)
[hereinafter CVS Caseload Standards].
289
Id.
290
Deborah Fowler and Kevin Ryan, First Court Monitors’ Report 2020, at 163-164, ECF No. 869; Email from
Andrew Stephens to Kevin Ryan and Deborah Fowler (Oct. 18, 2019) (on file with the Monitors) (attaching DFPS
Information and Data Request Proposal in response to the Monitors’ Sept. 30, 2019 Data and Information request).
291
DFPS reported in March 2020 that it was unlikely it could report on the daily compliance data for graduated
caseloads in the near term. See Email from Tara Olah, to Kevin Ryan and Deborah Fowler (Mar. 24, 2020)
(attaching DFPS response to Feb. 21, 2020 Data and Information Request). There were no additional updates to
report. (on file with the Monitors).
144
eligible for primary case assignments, thus triggering the start date for calculation of graduated
caseload performance.
During this reporting period, DFPS began providing data reporting the caseloads for the
caseworkers employed by the two SSCCs that became responsible for case management in their
respective regions, along with the dates associated with primary case assignment eligibility.
However, DFPS did not provide data from OCOK that was sufficiently reliable to assess
performance associated with Remedial Order 2. In the data reporting on OCOK caseworkers, the
Monitors learned that many of the caseworkers’ case assignment eligibility dates were estimated
and, therefore, requested that the State, in conjunction with OCOK, provide the actual dates that
workers became eligible for case assignment.292 The State resubmitted the data from OCOK but
when the Monitors again reassessed the resubmissions in March 2021, the data did not appear
reliable. The Monitors sought clarity about the data that OCOK provided and DFPS confirmed
that the data did not include the actual eligibility dates that the Monitors requested but remained
the estimated dates for workers.293 DFPS indicated that, going forward, OCOK is implementing
technical improvements to ensure submission of the correct data for assessment.294 The failure to
report reliable data suggests that during this time period, neither OCOK nor DFPS was able to
assess accurately OCOK’s ongoing conformance with the graduated caseload policy and Remedial
Order 2 prior to the Monitors’ efforts to validate the data.
Remedial Order 2 Graduated Caseloads Results and Performance

Validation:
Methodology
The monitoring team evaluated the State’s performance associated with Remedial Order 2
through analysis of data provided by DFPS about its own caseworkers and the caseworkers
employed by the two SSCCs responsible for case management during this period, OCOK and
2Ingage.295 The Monitors used the standard that became effective on February 15, 2020 to assess
performance.296 The Monitors also interviewed 50 randomly selected caseworkers who were
subject to graduated caseloads and validated the data in the caseload reports.
292
Email from Megan Annitto, Monitoring Team, to Heather Bugg, (January 27, 2021) (attaching request for
resubmission of data in format conforming with DFPS caseworker data and requesting the SSCCs to confirm that
the date provided is the actual date the workers are eligible for case assignments) (on file with the Monitors).
293
Email from Heather Bugg to Kevin Ryan and Deborah Fowler, RO 2 (March 23, 2021) (on file with the Monitors).
294
Email from Heather Bugg, to Kevin Ryan and Deborah Fowler, RO 2 (March 24, 2021) (on file with the Monitors)
(stating that “as [its] reporting has begun to become more consistent, OCOK will be able to use [an analytic] server to
automate the reports, reducing the likelihood of human error and allowing for more advanced error handling.”).
295
DFPS, R02.4 and R01.1 DFPS CVS Grad CL and CPD grads mar 2020 - 4-15-20 99287 (May 18, 2020) (on file
with the Monitors); DFPS., R02.4 and R01.1 DFPS CVS Grad CL and CPD grads Apr 2020 - 6-15-20 98629 (June
16, 2020) (on file with the Monitors); DFPS., R02.4 and R01.1 DFPS CVS Grad CL and CPD grads May -Nov 2020
- 1-4-20 101199 (January 8, 2021) (on file with the Monitors); TEX. DEP’T OF FAMILY & PROTECTIVE SERVS., R02.4
and R01.1 DFPS CVS Grad CL and CPD grads Dec 2020 - 2-1-21 101040 (February 2, 2021) (on file with the
Monitors); DFPS., 2INgage Graduated caseload request to SSCCs through 02012021 (March 2, 2021) (on file with
the Monitors); DFPS, OCOK Graduate caseload request to SSCCs (March 2, 2021) (on file with the Monitors).
296
See Section IV.(C)(1), infra; Workload Studies Order.
145
For this report, the monitoring team examined the caseloads of caseworkers who became
eligible for case assignment between March 1, 2020 and December 31, 2020. The Monitors
verified whether staff subject to graduated caseloads conformed to the graduated caseload standard
at three points in time: the 15th day after eligibility, the 45th day after eligibility, and on the
calendar date at the end of the month after the 15th day of eligibility. To assess performance
associated with the graduated caseload standards, the monitoring team calculated the percentage
of workers who carried a number of children on their caseloads that was at or below the allotted
caseload limit by the total number of staff subject to graduated caseloads at each point in time.297
Remedial Order 2: Performance Validation Results
The monitoring team identified 665 caseworkers who became eligible for case assignment
and subject to graduated caseloads between March 1, 2020 and December 31, 2020. Of these 665
staff, 470 staff worked for DFPS, 64 worked for OCOK, and 131 worked for 2INgage.298 Most of
the caseworkers subject to graduated caseloads who worked for DFPS had the job title CPS CVS
Specialist I (408 of 470 or 86.8%). The other workers subject to graduated caseloads had the job
titles CPS CVS Specialist II (19 of 470 or 4.0%), III (24 of 470 or 5.1%), or IV (15 of 470 or
3.2%). Four caseworkers had other titles, including CPS CVS Specialist V (2), CPS Heightened
Monitoring IV (1), and CPS Master CVS V (1). The caseworkers subject to graduated caseloads
at 2INgage all had the title of Permanency Case Manager. The caseworkers subject to graduated
caseloads at OCOK all had the title of Permanency Specialist.
In the period from March 1, 2020 to December 31, 2020, 665 caseworkers were subject to
graduated caseloads and were in caseworker positions on their 15th day after becoming case
assignable. The Monitors confirmed that OCOK did not submit accurate data on their caseworkers
subject to the graduated caseload standards during the required timeframe299 and, therefore, the
297
For example, a worker who became case assignable on June 7, 2020 would be assessed on the worker’s caseload
on the 15th day after case assignability (June 22, 2020); the last day of the calendar month after the 15th day (June
30, 2020); and on the 45th day after case assignability (July 22, 2020). The monitoring team analyzed the data to
determine if the last day of the calendar month after the 15th day was in the first 30-day period after case assignability
with a standard of six children or the second 30-day period after case assignability with a standard of 12 children.
298
The monitoring team conducted quality checks on the data submitted by 2INgage. Of the 157 rows of data originally
submitted, the monitoring team removed 26 rows. Nine rows had caseworkers who became case assignable in January
or February 2021, as the Monitors requested but that were not in the timeframe for this analysis. Of the remaining 148
rows of caseworkers, six rows did not have a case assignability date for the case worker (each of these six rows had
termination dates), one row had a worker with the same termination and case assignability date, and two workers had
termination or transfer dates before their 15th day. These nine rows were eliminated from the analysis, as there was
no way to assess whether they complied with the graduated standard. Four rows had the same caseworker listed twice
with different case assignability dates and case counts and therefore, those four rows were removed from the analysis.
Three Person IDs appeared in two rows each with different caseworker names; the monitoring team kept the row
where the name and Person ID matched the name and Person ID that appeared in the monthly caseload data and
removed the other three rows form the analysis.
299
Email from Heather Bugg to Kevin Ryan and Deborah Fowler, RO 2 (March 24, 2021) (on file with the Monitors).
In the period from March 1, 2020 to December 31, 2020, OCOK reported 64 caseworkers who were subject to
graduated caseload standards. Because the monitoring team’s analysis suggested systemic data quality issues
concerning the dates of eligibility, the Monitors inquired with DFPS and OCOK. OCOK confirmed in March 2021
that the dates for 29 staff were incorrect.
146
Monitors eliminated the OCOK workers from this analysis and assessed the remaining 601
caseworkers at DFPS and 2INgage.
As shown in the table below, on the 15th day after becoming case assignable, 72% (432
workers) of the 601 workers conformed to the graduated caseload standard of six or fewer case
assignments. In the previous reporting period, 69% were in conformance.300 On the last day of the
month following the 15th day, 75% (449 workers) of the 470 workers were in conformance with
the graduated caseload standard.301 On the 45th day after becoming case assignable, 80% (473
workers) of the 588 workers still receiving case assignments on the 45th day conformed to the
graduated caseload standard. In the previous reporting period, 94.4% were in conformance.302
Table 5.1. Caseworkers Conforming to the Graduated Caseload Standards

at Three Points in Time
Texas Caseworkers Conforming to Graduated Caseload Standard

at Three Points in Time
Month Case New 15th Last Day 45th Average
Assignable Caseworkers Day of Month Day
March 31 29% 65% 74% 56%
April 49 47% 76% 80% 67%
May 37 81% 89% 94% 88%
June 142 35% 32% 55% 41%
July 51 86% 84% 98% 90%
August 54 94% 91% 92% 93%
September 70 96% 91% 96% 94%
October 67 91% 94% 92% 92%
November 36 97% 89% 83% 90%
December 64 97% 97% 77% 90%
Total 601 72% 75% 80% 76%
Over the three points in time, 76% of new caseworkers’ caseloads conformed with the
graduated caseload standard. The similarity of the rate of conformance to the graduated caseload
standard on the last day of the month compared to the rates for the other two points in time (the
15th and 45th days) is important, as that data was verified by the Monitors through interviews with
caseworkers.303
In general, workers who became case assignable in the first four months of the period
examined, March 1, 2020 to June 30, 2020, had lower rates of conformance with the graduated
caseload standard. Two factors likely contributed to the lower rates. First, March 2020 was the
300
301
The standard the Monitors used on the last day of the month after the 15th day of case assignability was either six
assignments or 12 assignments depending on when the worker became eligible to accept cases.
302
303
See infra, Section IV.C.
147
first full month of the new graduated caseloads standard and DFPS supervisors were in the process
of adjusting their practice. Second, June 2020 was the first month that 2INgage accepted
permanency cases. In June, 2INgage had many new workers who did not conform to the graduated
caseload standard, resulting in lower overall performance.
The monitoring team interviewed 50 caseworkers subject to graduated caseloads over two
time periods. On April 22, 2020, the monitoring team interviewed via videoconference a randomly
selected sample of 20 DFPS caseworkers assigned to 15 counties across the state who were hired
into a CVS caseworker position in November 2019 and became subject to graduated caseloads
between March 2, 2020 and April 21, 2020. All 20 caseworkers in the sample had the job title CPS
CVS Specialist I. The monitoring team reviewed with the workers’ their case assignment detail
reports dated April 20, 2020 generated from the DFPS INSIGHT system. The individual caseloads
of the sample of caseworkers interviewed ranged from three to 17 children. Fourteen of the
caseworkers were in the first month of eligibility; six of the workers were in the second month of
case assignability. A total of six caseworkers (30%) had caseloads that exceeded the caseload
guidance—five workers in the first month and one worker in the second month of case
assignability. The monitoring team compared the results of the interviews of these caseworkers
with the monthly caseload data submitted by DFPS in June 2020 to confirm the accuracy of the
graduated caseload data collected during the caseworker interviews.304
On December 2 and 3, 2020, the monitoring team interviewed by videoconference a

randomly selected sample of 30 DFPS caseworkers assigned to 20 counties across the state who
were hired into a CVS caseworker position between May 11, 2020 and August 1, 2020 and became
subject to graduated caseloads between October 1, 2020 and November 6, 2020. All 30 of the
caseworkers in the sample had the job title CPS CVS Specialist I. The monitoring team reviewed
with the workers case assignment detail reports dated December 1, 2020 generated from the DFPS
INSIGHT system. The individual caseloads of the sample of caseworkers interviewed ranged from
two to 11 children. One of the caseworkers was in the first month of eligibility to be assigned a
case; 29 workers were in the second month of case assignability. All caseworkers interviewed had
caseloads within the generally applicable graduated caseload standards. The monitoring team
compared the results of the interviews of these caseworkers with the monthly caseload data
submitted by DFPS in February 2021 to confirm the accuracy of the graduated caseload data
collected during the caseworker interviews. During the Monitors’ cross-data validation of the
INSIGHT reports of these 30 workers with the DFPS monthly caseload data, the monitoring team
found that 100% of the caseloads were a perfect match to those reported directly by caseworkers
interviewed who were subject to graduated caseloads.
304
During cross-data validation of the INSIGHT reports of the twenty workers interviewed with the monthly caseload
data, the monitoring team found that 65% of the caseloads in primary substitute and adoption stages were a perfect
match, 80% were within one case, and 95% were within two cases in the graduated caseloads reviewed. The date of
the INSIGHT reports requested by the Monitors for worker interviews was April 20, 2020 and were to be cross
validated with the monthly caseload data for April 30, 2020. The ten-day span between the two reports could
reasonably account for some of these discrepancies. Starting in August 2020, the monitoring team requested INSIGHT
reports and monthly caseload data with no more than a one-day gap between the two data sets.
148
Summary of Performance Validation
• For the 601 workers that the Monitors assessed at two points in time and the 588 workers
the Monitors assessed at three points in time, the State was in conformance with the
graduated caseload standards 76% of the time.
• On the 15th day, 28% of workers who became eligible for primary case management and
reached their 15th day between March 1 and December 31, 2020 had caseloads in excess
of the graduated caseload standard of six children.
• On the 45th day, 20% of workers who reached their 45th day between March 1 and
December 31, 2020 had caseloads in excess of the graduated caseload standard of 12
children.
• The agency’s compliance with Remedial Order 2 improved sharply during the period
reviewed. Just over half (56%) of the 31 caseworkers who became eligible for primary case
standard and less than half (41%) of the 141 such workers in June 2020 conformed to the
graduated caseload standard. But about nine in every ten caseworkers who became case
assignable on July 1, 2020 or later had case assignments that conformed to the graduated
caseload standard at three points in time.
• 2INgage submitted data that was sufficiently reliable to allow the monitoring team to
provide a performance assessment and are included in the analysis; OCOK did not provide
reliable data in time for assessment of their performance associated with Remedial Order
2.
• The failure to report reliable data about OCOK suggests that neither OCOK nor DFPS was
actively assessing OCOK’s conformance with the graduated caseload policy and Remedial
Order 2 prior to the Monitors’ efforts to validate the data.
C. Remedial Order 35, A-1, A-2, A-3, and A-4: Caseloads
services to children in the PMC class and their caseloads. In addition, DFPS’ reporting shall
149
Remedial Order A1: Within 60 days of the Court’s Order, DFPS, in consultation with and
supervision of the Monitors, shall propose a workload study to generate reliable data regarding
current caseloads and to determine how many children caseworkers are able to safely carry, for
the establishment of appropriate guidelines for caseload ranges. The proposal shall include, but
will not be limited to: the sampling criteria, timeframes, protocols, survey questions, pool sample,
interpretation models, and the questions asked during the study. DFPS shall file this proposal with
the Court within 60 days of the Court’s Order, and the Court shall convene a hearing to review
the proposal.
Remedial Order A2: Within 120 days of the Court’s Order, DFPS shall present the completed
workload study submission to the Court, how many cases, on average, caseworkers are able to
safely carry, and the data and information upon which the determination is based, for the
establishment of appropriate guidelines for caseload ranges.
Remedial A3: Within 150 days of the Court’s Order, DFPS shall establish internal caseload
standards based on the findings of the DFPS workload study, and subject to the Court’s approval.
The caseload standards that DFPS will establish shall ensure a flexible method of distributing
caseloads that takes into account the following non-exhaustive criteria: the complexity of the
cases; travel distances; language barriers; and the experience of the caseworker. In the policy
established by DFPS, caseloads for staff shall be prorated for those who are less than full-time.
Additionally, caseloads for staff who spend part-time in the work described by the caseload
standard and part-time in other functions shall be pro-rated accordingly.
is charged by DFPS to provide case management services to children in the General class. [The
Court modified the effective date of this Remedial Order to February 15, 2020.305]
Background
On December 16, 2019, the Court approved an agreed motion by the parties that provided
in lieu of conducting workload studies pursuant to Remedial Orders A1, A2, B1 and B2, DFPS
and HHSC would use as caseload guidelines:
• 14-17 children per conservatorship caseworker, for the purpose of satisfying State
obligations within Remedial Orders A-2, A-3 and A-4;
• 14-17 investigations per DFPS CCI investigator, for the purpose of satisfying State
305
Workload Studies Order, at 1-2. Supra 284.
150
obligations within Remedial Orders B-2, B-3 and B-4; and

• 14-17 tasks per RCCR inspector, for the purpose of satisfying State obligations within
Remedial Orders B-2, B-3 and B-4.
To assess the State’s compliance with Remedial Order 35, the Monitors requested
that DFPS comply with the following reporting schedule:
Provide a report by November 15, 2019 and on a monthly basis

thereafter, with caseloads for all staff, including supervisors, who
provide primary case management services to any child in the PMC
class, with name of employer (public or, as evolves, private), and
indicate whether full-time or part-time. The report will be a point in
time caseload for November 1 and is due by November 15, then for
December 1, 2019 due by December 15, 2019, and monthly
thereafter. The reports must include all staff who provide case
management services to children in the PMC General Class and their
caseloads; the number and percent of staff with caseloads within,
below and over the DFPS guideline once established, by office, by
county, by agency (if private) and statewide; the identification
number and location of all individual staff and the number of PMC
children and, if any, TMC children to whom they provide case
management; include caseloads for staff, as defined above, who
spend part-time in caseload carrying functions and part-time in other
functions. Identify all staff subject to a graduated caseload. Provide
individual fields for every type of case that the worker carries,
including those outside the child welfare domain, if any. Identify for
each staff all non-case carrying work, such as IV-E eligibility
determinations, that impacts their capacity. Identify all secondary
assignments for each staff. Identify at the bottom of the report the
total number of supervisors carrying a case.306
The Monitors subsequently wrote to the State and requested DFPS list “by staff member,
the names and identification numbers of all children assigned to all staff, including supervisors,
who provide primary case management services to any child in the PMC class.”307
306
Email from Deborah Fowler and Kevin Ryan to Andrew Stephens (Sept. 30, 2019) (on file with the Monitors)
(including Monitors’ Sept. 30, 2019 Data & Information Request in attachment).
307
Email from Kevin Ryan and Deborah Fowler to Andrew Stephens (Oct. 28, 2019) (on file with the Monitors).
151
The State provided point-in-time caseload data to the Monitors monthly, most recently at
a 30-day lag. The last point-in-time caseload data submitted by DFPS prior to the cut-off for
validation in this report was submitted on February 2, 2021 and reflected the point-in-time
caseloads for December 31, 2020. The information in the monthly caseload submissions for DFPS
and for OCOK and 2Ingage caseworkers included spreadsheets listing all caseload carrying staff,
details for the caseloads they carried and spreadsheets listing each child in the custody of DFPS
and their legal status. The information in the caseload submissions for the SSCCs did not contain
the information the Monitors requested for supervisors. On January 27, 2021, the Monitors notified
DFPS that it should “coordinate with all SSCCs, including those currently in Stage II and going
forward, so that all data are provided in the same format wherever possible” for data and
information requests as to all Remedial Orders.308
To validate the accuracy of the State’s caseload data submissions, the Monitors randomly
selected and interviewed 150 CVS caseworkers from 52 counties as described below. In advance
of the monitoring team’s interviews, DFPS provided caseload information from the State’s
INSIGHT reporting tool for each identified worker for a date selected by the Monitors.309 The
State also separately provided the INSIGHT reports for 317 workers to inform a comprehensive
analysis and comparison of INSIGHT reports and the State’s monthly caseload data
submissions.310
In this reporting period, the State has also provided to the Monitors and to the Court
information related to the development and implementation of a new caseload tracking tool for
supervisors.311
D. Remedial Orders 35 and A-4: Caseworker Caseloads
308
Memorandum from Kevin Ryan and Deborah Fowler to DFPS, at 1 (January 27, 2021) (on file with the Monitors)
(requesting information and instructing that DFPS ensure that the SSCCs provide information consistent with the
Monitors’ requests for all Remedial Orders).
309
DFPS describes INSIGHT as a tool to “manage critical case tasks and deadlines.” DFPS., Impact Modernization,
available at
https://www.dfps.state.tx.us/Doing_Business/IMPACT_Modernization/default.asp.
310
DFPS, RO2.1 CVS caseloads as of 7-31-20 - sept-1-20 - 99357 (002).xlsx
FINAL -List of workloads for a select group on 8-1 – 99647.xlsx; Copy of Caseload Verification Results April – Dec
2020.xlsx (on file with the Monitors).
311
The State provided several documents to the Monitors in association with its Affidavit filed in relation to Graduated
Caseloads that bear on supervisor management of caseloads. See generally Exhibit A Sworn Declaration for Remedial
Order No. 2 Related to Graduated Caseloads, ECF No. 1021-1 (supporting documentation on file with the State and
the Monitors).
152
services to children in the PMC class and their caseloads. In addition, DFPS’ reporting shall
is charged by DFPS to provide case management services to children in the General class. (The
Court modified the effective date of this Remedial Order to February 15, 2020.)
Methodology
The Monitors cross-checked the monthly data files provided by the State for DFPS
caseworkers, OCOK caseworkers, and 2INgage caseworkers and found the number of children
assigned to each worker in the listing table added to the number of children in the caseload table.
To analyze caseloads, the Monitors used the total number of children assigned to CPS CVS
Specialists (I-V) at DFPS; Permanency Specialists at OCOK, and Permanency Case Managers at
2INgage.312,313 The monitoring team also independently replicated caseload validation by
interviewing 150 CVS caseworkers,314 selected by the Monitors, about their caseloads between
August 2020 and January 2021 and by conducting a comparison of 317 caseworkers’ INSIGHT
reports with the State’s caseload data report for the corresponding month. Finally, the Monitors
met with the representatives from DFPS and HHSC to discuss DFPS’s new caseload tracking tool
on January 29, 2021.
For this report, the State reported the data as requested by the Monitors with respect to
DFPS supervisors who managed PMC children’s cases, but not for OCOK or 2INgage supervisors.
312
CVS Specialists I, II, III, IV, V staff account for over 95% of all the staff listed by DFPS carrying at least one PMC
child’s case in each of the ten caseload reports the Monitors received from March 2020 to December 2020. Supervisors
account for most of the remaining case carrying staff. For this report, the Monitors eliminated from the analysis staff
with other titles because they account for a relatively small number of staff carrying a small number of PMC children.
On December 31, 2020, for example, of the 1,337 DFPS carrying at least one PMC case, 1,302 (97%) are CVS
Specialists I-V and 14 are supervisors (1%). Program specialists (12), master CVS specialists (5), and staff with other
titles (4) account for the remaining 21 staff.
313
The Monitors did not weight secondary assignments in their assessment of conformity with the caseload guidelines
for this report and continue to collect information in interviews with caseworkers and assess the appropriate
methodology.
314
The Monitors also interviewed 50 additional workers who were subject to graduated caseloads and report on those
validation efforts separately in the corresponding section of this report under Remedial Order 2.
153
Remedial Order 35 and Remedial Order A-4: Performance

Validation results
As of December 31, 2020, the State reported there were 1,495 caseworkers who managed
at least one PMC child’s case, which includes caseworkers employed by DFPS, OCOK, and
2INgage combined.315 In ten months of caseload reports between March 2020 and December 2020,
the State reported the highest number of caseworkers managing at least one PMC child’s case on
October 31, 2020 (1,512) and the lowest number on April 30, 2020 (1,413). From the March 31,
2020 report to the December 31, 2020 report, the number of caseworkers managing at least one
case rose by 54 (4%).
Remedial Order A-4 became effective on February 15, 2020, requiring DFPS to ensure that
the caseload standard of 14 to 17 children is “utilized to serve as guidance for supervisors who are
handling caseload distribution” and is used to inform “hiring goals for all staff.” In ten months of
caseload reports starting on March 31, 2020 and ending on December 31, 2020, an average of 56%
of caseworkers managing at least one PMC child’s case were assigned to serve 17 or fewer children
and an average of 44% of these caseworkers served 18 or more children. The highest rate of
conformance with the guidelines among the ten caseload reports occurred in July (58%) and the
lowest rate occurred in March (52%).
As shown in the Table below, on December 31, 2020, of the 1,495 caseworkers who
managed at least one PMC child’s case, 846 (57%) caseworkers had 17 or fewer children on their
caseload. Two-hundred and 63 (18%) carried 18 to 20 children on their caseloads. Two hundred
and eighty-four workers (19%) carried 21 to 25 children on their caseloads. The remaining 102
workers (7%) carried more than 25 children on their caseloads, with 20 (1% of all workers)
carrying more than 30 children on their caseloads. Over one-quarter (386 workers, 26%) of all
caseworkers carried 21 children or more on their caseloads on December 31, 2020.
315
DFPS, RO2.1 CVS caseloads as of 12-31-20 - 2-1-21 - 101129 (Feb. 2, 2021) (on file with the Monitors).
154
Table 5.2: Caseworkers Managing at Least One PMC Child

March 2020 to December 2020
Serving at least one 17 Children or 18 Children or

Month PMC Child Fewer More
No. No. % No. %
Mar-20 1441 745 52% 696 48%
Apr-20 1413 756 54% 657 46%
May-20 1448 816 56% 632 44%
Jun-20 1473 841 57% 632 43%
Jul-20 1472 858 58% 614 42%
Aug-20 1474 822 56% 652 44%
Sep-20 1,496 869 58% 627 42%
Oct-20 1512 873 58% 639 42%
Nov-20 1487 825 55% 662 45%
Dec-20 1495 846 57% 649 43%
Average 1471 825 56% 646 44%
As of December 31, 2020, DFPS directly employed 1,302 (87%) of the 1,495 caseworkers
managing at least one PMC child’s case. The 1,302 caseworkers are a decline of 3% from the
1,349 DFPS caseworkers managing at least one PMC child in March 2020, caused in part by some
DFPS caseworkers transferring to OCOK or 2INgage. In the ten months of caseload reports
starting on March 31, 2020 and ending on December 31, 2020, an average of 57% of DFPS
caseworkers managing at least one PMC child’s case were assigned to serve 17 or fewer children
and an average of 43% of these caseworkers served 18 or more children. The highest rate of
conforming to the guidelines among the ten caseload reports occurred in October (59%) and the
lowest rate occurred in March (53%).
As shown in the Table below, on December 31, 2020, of the 1,302 DFPS caseworkers who
caseload. Two-hundred and twenty-six (17%) carried 18 to 20 children on their caseloads. Two
hundred and thirty-three workers (18%) carried 21 to 25 children on their caseloads. The remaining
93 workers (7%) carried more than 25 children on their caseloads, with 20 (2% of all workers)
carrying more than 30 children on their caseloads. One-quarter (326 workers, 25%) of all DFPS
case workers carried 21 children or more on their caseloads on December 31, 2020.
155
Table 5.3: DFPS Caseworkers Managing at Least One PMC Child

Serving at least 17 Children 18 Children or

Month one PMC Child or Fewer More
No. No. % No. %
Mar-20 1349 713 53% 636 47%
Apr-20 1317 722 55% 595 45%
May-20 1301 728 56% 573 44%
Jun-20 1292 733 57% 559 43%
Jul-20 1283 742 58% 541 42%
Aug-20 1286 728 57% 558 43%
Sep-20 1302 766 59% 536 41%
Oct-20 1319 780 59% 539 41%
Nov-20 1298 740 57% 558 43%
Dec-20 1302 750 58% 552 42%
Average 1305 740 57% 565 43%
On December 31, 2020, 14 DFPS supervisors managed at least one PMC child’s case. The
14 supervisors are a decrease of 48% from the 27 supervisors managing at least one case on March
31, 2020. In the ten months of caseload reports starting on March 31, 2020 and ending on
December 31, 2020, an average of 19 DFPS supervisors managed at least one PMC child’s case.
As of December 31, 2020, 106 (7%) of the 1,495 caseworkers who managed at least one
PMC child’s case were employed by OCOK. The 106 caseworkers are an increase of 15% for
OCOK from the 92 caseworkers managing at least one PMC child on March 31, 2020. In the ten
months of caseload reports starting on March 31, 2020 and ending on December 31, 2020, an
average of 44% of OCOK caseworkers managing at least one PMC child’s case were assigned to
serve 17 or fewer children and an average of 56% of these caseworkers served 18 or more children.
OCOK’s highest rate of conforming to the guidelines among the ten caseload reports occurred on
December 31, 2020 (53%) and the lowest rate occurred on March 31, 2020 (35%).
As shown in the table below, on December 31, 2020, of the 106 OCOK caseworkers who
caseloads. Fifteen (14%) carried 18 to 20 children on their caseloads. Twenty-nine workers (27%)
carried 21-25 children on their caseloads. The remaining six workers (6%) carried more than 25
children on their caseloads. No workers carried 31 or more children on their caseloads. One-third
(35 workers, 33%) of all OCOK caseworkers carried 21 children or more on their caseloads on
December 31, 2020.
156
Table 5.4: OCOK Caseworkers Managing at Least One PMC Child

Serving at Least 17 Children 18 Children

Month One PMC or Fewer or More
No. No. % No. %
Mar-20 92 32 35% 60 65%
Apr-20 96 34 35% 62 65%
May-20 100 42 42% 58 58%
Jun-20 102 48 47% 54 53%
Jul-20 105 50 48% 55 52%
Aug-20 101 42 42% 59 58%
Sep-20 105 49 47% 56 53%
Oct-20 103 44 43% 59 57%
Nov-20 100 43 43% 57 57%
Dec-20 106 56 53% 50 47%
Average 101 44 44% 57 56%
As of December 31, 2020, 87 (6%) of the 1,495 caseworkers managing at least one PMC
child’s case were employed by 2INgage. The 87 caseworkers are an increase of 85% from the 47
caseworkers managing at least one PMC child in May 2020 when 2INgage first started managing
cases. In the eight months of caseload reports for 2INgage starting on May 31, 2020 and ending
on December 31, 2020, an average of 63% of 2INgage caseworkers managing at least one PMC
child’s case were assigned to serve 17 or fewer children and an average of 37% of these
caseworkers served 18 or more children. The highest rate of conforming to the guidelines among
the ten caseload reports occurred in May (98%) and the lowest rate occurred in December (47%).
As shown in the Table below, on December 31, 2020, of the 87 2INgage caseworkers who
caseload. Twenty-two (25%) carried 18 to 20 children on their caseloads. Twenty-two workers
(25%) carried 21 to 25 children on their caseloads. The remaining three workers (3%) carried more
than 25 children on their caseloads. No workers carried 31 or more children on their caseloads.
Over one-quarter (25 workers, 29%) of all 2INgage caseworkers carried 21 children or more on
their caseloads on December 31, 2020.
157
Table 5.5: 2INgage Caseworkers Managing at Least One PMC Child

May 2020 to December 2020
Serving at least 17 Children 18 Children

Month one PMC Child or Fewer or More
No. No. % No. %
Mar-20 0 0 0 0 0
Apr-20 0 0 0 0 0
May-20 47 46 98% 1 2%
Jun-20 79 60 76% 19 24%
Jul-20 84 66 79% 18 21%
Aug-20 87 52 60% 35 40%
Sep-20 89 54 61% 35 39%
Oct-20 90 49 54% 41 46%
Nov-20 89 42 47% 47 53%
Dec-20 87 40 46% 47 54%
Average 82 51 63% 30 37%
*2INgage began caseworker performance in May 2020.
To validate the accuracy of the State’s monthly caseload data submissions from its
IMPACT system, which the Monitors most recently received on a 30-day lag, the monitoring team
examined the symmetry of the data within those reports with caseload data from the DFPS
INSIGHT database, which is available to caseworkers and their supervisors on a daily basis. The
monitoring team used the INSIGHT data DFPS provided for a sample of 317 caseworkers, selected
by the Monitors.316 The analysis compared the INSIGHT data report extracted at 8:00 a.m. CST
August 1, 2020 (reflecting July 31, 2020 caseloads) against the primary and secondary caseload
information in the DFPS monthly caseload data report extracted from the IMPACT database
reflecting July 31, 2020 caseloads. The analysis found that 98% of primary caseloads were a
perfect match and over 99% were within one case. For secondary caseloads, 88% were a perfect
match and 96% were within one case. Very few caseloads differed by more than three cases.
Next, the monitoring team interviewed individually 150 DFPS caseworkers and their
supervisors from 52 counties remotely by videoconference between August 5, 2020 and January
7, 2021. All 150 of the caseworkers in the sample had job titles of CPS CVS Specialist I, II, III,
IV, or V. In preparation for these interviews, the monitoring team asked DFPS to provide in
advance a caseload report from DFPS’s INSIGHT system for each individual interviewee
corresponding to a previous date near the time of the interview. The monitoring team then reviewed
the records with the caseworker, discussing each listed child by name and other work assignments,
if any, and observed whether the caseworker’s workload matched the DFPS records.
316
DFPS, RO2.1 CVS caseloads as of 7-31-20 - sept-1-20 - 99357 (002).xlsx;
FINAL -List of workloads for a select group on 8-1 – 99647.xlsx; Copy of Caseload Verification Results April – Dec
2020.xlsx (on file with the Monitors).
158
The monitoring team compared the results of the interviews of these caseworkers with the
monthly caseload data from IMPACT submitted by DFPS to confirm the accuracy of the caseload
data collected during the caseworker interviews. During cross-data validation of the INSIGHT
reports of the 150 workers interviewed with the monthly caseload data, the monitoring team found
that 94% of primary case assignments were a perfect match and 99% were within one case in the
caseloads reviewed. The individual caseloads of the sample of caseworkers interviewed ranged
from four to 34 children. The monitoring team found 84 (56%) of the 150 workers were within the
generally applicable caseload standards and 66 (44%) exceeded the caseload standards.
Summary
The parties agreed to, and the Court approved, a workload standard of 14 to 17 children
per caseworker, pursuant to Remedial Order A-3. To validate the State’s performance, the
Monitors reviewed and analyzed all data provided by the State. The Monitors’ analysis showed
that as of December 31, 2020, 57% of all caseworkers (846 of 1,495), including OCOK and
2INgage, had primary caseloads within or below the standard of 17 children per worker. From
March 2020 to December 2020, conformity with the standard remained within a narrow band
ranging from 52% to 58% of all State workers. Although supervisors carried only a small
percentage of PMC cases, those who did were rarely compliant with the workload standard.
The Monitors found that conformity with the caseload standard varied among DFPS,
OCOK and 2INgage. Of the 1,302 DFPS workers carrying at least one PMC case on December
31, 2020, 750 workers (58%) had primary caseloads within or below the standard of 17 children
per worker. As of December 31, 2020, the two SSCCs that are undertaking case management,
OCOK and 2INgage, had 53% and 46% of their workers within or below the standard, respectively.
In the data the Monitors received from March 31, 2020 to December 31, 2020, the rate of
caseworkers meeting the standard at OCOK was at its highest point on December 31, 2020; the
rate of caseworkers meeting the standard at 2INgage was at its lowest point on December 31, 2020.
The rates of caseworkers meeting the standard at both the SSCCs were lower than those at DFPS.
E. Remedial Orders B1 to B4:
Remedial Orders B1: Within 60 days of the Court's Order, DFPS, in consultation with and
under the supervision of the Monitors, shall propose a workload study to: generate reliable data
regarding current RCCL, or successor entity, investigation caseloads and to determine how much
time RCCL investigators, or successor staff, need to adequately investigate allegations of child
maltreatment, in order to inform the establishment of appropriate guidelines for caseload ranges;
and to generate reliable data regarding current RCCL inspector, or successor staff, caseloads and
to determine how much time RCCL inspectors, or successor staff, need to adequately and safely
perform their prescribed duties, in order to inform the establishment of appropriate guidelines for
caseload ranges. The proposal shall include but will not be limited to: the sampling criteria,
timeframes, protocols, survey questions, pool sample, interpretation models, and the questions
asked during the study. DFPS shall file this proposal with the Court within 60 days of the Court’s
Order, and the Court shall convene a hearing to review the proposal.
159
Remedial Order B2: Within 120 days of the Court’s Order, DFPS shall present the completed
to the Court, how many cases, on average, RCCL inspectors and investigators, or any successor
staff, are able to safely carry, and the data and information upon which that determination is
based, for the establishment of appropriate guidelines for caseload ranges.
Remedial Order B3: Within 150 days of the Court’s Order, DFPS, in consultation with the
Monitors, shall establish internal guidelines for caseload ranges that RCCL investigators, or
any successor staff, can safely manage based on the findings of the RCCL investigator workload
study, including time spent in actual investigations. In the standard established by DFPS,
caseloads for staff shall be prorated for those who are less than full-time. Additionally, caseloads
for staff who spend part-time in the work described by the RCCL, or successor entity, standard
and part-time in other functions shall be prorated accordingly.
Remedial Order B4: Within 180 days of this Order, DFPS shall ensure that the internal guidelines
for caseload ranges and investigative timelines are based on the determination of the caseloads
RCCL investigators, or any successor staff, can safely manage are utilized to serve as guidance
for supervisors who are handling caseload distribution and that these guidelines inform DFPS
hiring goals for all RCCL inspectors and investigators or successor staff.
1. Background
The court granted the Plaintiffs’ and Defendants’ agreed order, wherein the parties agreed
to include workload guidelines of 14 - 17 total assigned “tasks” per RCCR inspector and 14 -17
investigations per RCCI investigator,317 and extended the time for establishing internal guidance
for supervisors that administer caseload distribution until February 17, 2020.
2. Data & Information Request & Production
a. Monitors’ Data and Information Request
DFPS and HHSC provided data to the Monitors, which the Monitors used for validation of
caseloads. Data from DFPS represented RCCI investigations and investigator and supervisor
caseloads as of the last day of the month and data provided by HHSC represented RCCR tasks and
inspector and supervisor caseloads as of the first day of the month.
As part of its caseload verification work, the Monitors requested staffing and caseload
information to use in conducting interviews with RCCI investigators, RCCI supervisors, RCCR
inspectors, and RCCR supervisors. The Monitors requested a complete listing of RCCI and RCCR
investigators/inspectors and supervisors with information as follows: Position, Assigned Region,
Assigned Unit, City, Employee ID, and RCCR/RCCI Hire Date.318 319 The Monitors later requested
317
Order (December 17, 2019), ECF No. 722.
318
Email from Linda Brooke to Georgette Oden, RCCI Interviews (September 25, 2020 (on file with Monitors).
319
Email from Linda Brooke to Audrey Carmical, RCCI Interviews (October 28, 2020) (on file with Monitors).
160
that the State provide the inspectors’ and investigators’ caseload reports the day prior to the date
of each interview.
On November 16, 2020, the Monitors submitted a supplemental data and information
request to the State for DFPS caseworker caseload data asking the State to include the date of hire
for RCCI inspectors and supervisors, as well as the county where the staff assigned as the primary
investigator in at least one RCCI investigation during the month was housed or officed.320
b. DFPS and HHSC Data & Information Production
HHSC and DFPS both provided data and information to the Monitors. The following data
issues were noted:
• Data provided by DFPS did not include caseloads for special and master investigators or
staff working in the complex investigation unit.
• Data provided by DFPS did not include staff work location or hire dates. Date of hire was
found in data provided to validate CSA training requirements (RO32), though not all staff
were included in the data.
• Monthly data provided by HHSC varied both in content and structure. Data on supervisor
caseloads and administrative review cases was added to the monthly caseload data file in
May, 2020. However, the hire date data were incomplete: the field for that information
exists in the data but not all staff are recorded as having a hire date.321
c. Remedial Orders B-1 to B-4 Performance Validation
The methodology for validation of the State’s performance related to Remedial Orders B1
to B4, included analyzing the monthly caseload data submissions from both DFPS and HHSC for
inspector, investigator, and supervisor caseloads. The Monitors analyzed data for the months of
March through December 2020.
The monitoring team also conducted 70 interviews with both DFPS and HHSC staff via
videoconferencing between October 21, 2020, and December 9, 2020. The purpose of these
interviews was to assist the Monitors in better understanding the workloads of investigators and
inspectors.322 Approximately 50% of eligible staff were randomly selected for interview. The
320
E-mail from Deborah Fowler to Audrey Carmical, Data and Information Request (November 16, 2020) (on file
with Monitors).
321
The Monitors First Report to the Court identified similar data issues and limitations. Deborah Fowler and Kevin
Ryan, First Report 179 -182. ECF No. 869.
322
Because of the timing of the interviews, the list provided by the State prior to the scheduled interviews with RCCI
and RCCR investigators/inspectors and supervisors could not be independently verified or cross-matched to the State’s
monthly data production, as was done for the analysis of caseloads for CVS caseworkers. Going forward, the Monitors
will correct for this by changing the timing of interviews to coincide with the State’s data production, so that the
caseload information produced for interviews can be cross-matched to the State’s data as a method of validating the
State’s data production for RCCI and RCCR caseloads. DFPS caseload data includes RCI and non-RCCI staff assigned
161
monitoring team selected 28 RCCI investigators and supervisors from a list provided by DFPS of
all staff working as RCCI investigators and supervisors as of October 30, 2020.323 The monitoring
team also selected 42 RCCR inspectors and supervisors from a list provided by HHSC comprising
all staff working as RCCR inspectors and supervisors as of September 4, 2020.324
During the period reviewed for this report, three factors may have had an impact on RCCI
and RCCR caseloads: (1) the State’s response to the COVID-19 pandemic; (2) implementation of
Heightened Monitoring; and (3) the change in RCCI Priority-None screening procedures, as
described in Section III of this report.325
d. Remedial Orders B1 – B4 Performance Validation Results
RCCI Caseloads
The Monitors analyzed caseload data for RCCI investigators, supervisors and non-
investigator staff working on RCCI investigations. The total number of open RCCI
investigations declined between March and July of 2020, then steadily increased by month
through the end of the year.326 The number of open RCCI investigations increased from 807 in
March 2020 to 828 in December 2020, for a 3% increase.
to work as the primary staff on investigations and their supervisors. Staff were categorized based on job title with the
exception of supervisors. Staff were categorized as a supervisor in the month if they were assigned one or more
subordinates during the month. Supervisors working investigations and having no subordinates in the month were
considered to be “non-investigator” staff. DFPS reported that RCCI investigators and supervisors could be assigned
as the primary investigator on a case “in name only.” This is done so that investigations assigned to staff outside of
the RCCI program will continue to show up in RCCI caseload data. There was no data provided to identify those
cases where RCCI staff have investigations on their caseload that other DFPS staff were actually working.
Administrative review cases were included in RCCR data provided by HHSC as of July 2020 for the month of May
2020. The actual work of determining if a finding should be overturned or upheld in an administrative review case is
the responsibility of RCCR supervisors. Administrative review cases are then returned for closure to the inspector
who had been assigned to the case. These cases were not included in the inspector caseload analysis as the work for
the case was already completed and in order to have RCCR caseloads comparable to RCCI caseloads. RCCI
investigations appealed or/under administrative review were not included in the caseloads of investigators who have
been assigned that investigation.
323
Staff excluded from interviews were: (1) staff interviewed previously, in April 2020; (2) staff not yet case
assignable; and (3) staff that had been case assignable for one month or less.
324
Staff excluded from interviews were: (1) staff interviewed in April 2020, (2) staff not yet case assignable; and (3)
staff that had been case assignable for one month or less.
325
From mid-March through the end of May, 2020, on-site investigations and inspections were limited due to the
pandemic. At the end of June/early July 2020 the newly required Heightened Monitoring process began pursuant to
Remedial Order 20. Heightened Monitoring teams were recruited from existing staff, leading to reductions in the
number of RCCI investigators and, especially, RCCR staff available for investigations and inspections. Additionally,
on November 1, 2020, DFPS implemented new policies which changed the criteria for downgrading an ANE case to
Priority None. Screening procedures were changed as of November 1, 2020.
326
The decline in investigations may have resulted from on-site visit limitations imposed from March through May
2020 in response to the COVID-19 pandemic. Increases in RCCI investigations after October 1, 2020, may have
resulted from the change in criteria for SWI in downgrading to RCCI Investigations.
162
Figure 5.16: Number of RCCI Investigations by Month
Source: RCCI Caseload Data, March - December 2020

n=6,659
1000
Number of Investigations
800 807 828

826
743
617 611
600 595
573 551
400 508
200
0
Mar20 Apr20 May20 Jun20 Jul20 Aug20 Sep20 Oct20 Nov20 Dec20
Month/Year
RCCI Investigations
The majority of RCCI investigator caseloads were at or below the guidelines between
March and December 2020.327 The caseload for RCCI investigators during this time ranged from
9 to 14 cases, with 72%328 of investigators (389 of 541) having caseloads of fewer than 14
investigations per month during the period, and 14% of investigators (77 of 541) having caseloads
between 14 and 17 investigations. Secondary caseloads are not included in the caseload
calculations as the average number of secondary cases assigned to investigators was less than one
per month.329
327
In the First Report, the Monitors found that caseload data provided by DFPS showed that on December 31, 2019,
forty-three RCCI investigators and twelve non-investigators and supervisors carried a total of 1,011 cases. Of the
forty-three investigators, twenty (46.5%) had more than seventeen investigations.
328
Between March and December 2020, 76% of investigators experienced a caseload of 7 or fewer investigations for
one or more months; 17% of investigators had caseloads of 7 or fewer investigations for 6 or more months during the
March to December 2020.
329
Between March and December 2020, only 21 of 72 investigators carried one or more secondary cases in addition
to their primary cases. The average number of secondary cases for these investigators was less than 1 per month.
163
Table 5.6: RCCI Investigators330 with Caseloads within Guidelines March to December 2020
RCCI Investigators Conforming to Caseload Guidelines

Month Number Number within Percent within
Investigators Guidelines Guidelines
March 50 39 78%
April 50 45 90%
May 48 43 90%
June 58 53 91%
July 56 54 96%
August 55 53 96%
September 51 44 86%
October 59 47 80%
November 59 45 76%
December 55 43 78%
Although the majority of investigators had caseloads within the guidelines during the
period, large differences in the number of cases existed between investigators with the lowest and
highest caseloads: investigators with the highest caseloads were assigned as much as 40 times the
number of investigations than the number of investigations assigned to those investigators with
the lowest caseloads. Between March and December 2020, monthly RCCI investigator caseloads
ranged from one to 45 investigations, with 35% of investigators (25 of 72) experiencing a caseload
of 18 or more investigations for one or more months and 17% of investigators (12 of 72)
experiencing a caseload of 25 or more abuse, neglect, or exploitation investigations for one or
more months.
330
Investigations assigned to supervisors and non-investigators are not included in this analysis.
164
Figure 5.17: Low and High Caseloads for RCCI Investigators331

n=541 investigators and 5,993 investigations
50 45 44
Investigations on caseload
40 38 38
33
33 30
30
23 23
19
20
10
1 1 3 2 2 3 3
1 1 2
0
Month/Year
Caseload Low Caseload High
Investigator tenure, or length of employment, does not appear to be a factor in higher

caseload levels. RCCI investigators assigned seven or fewer investigations as of the end of
December had worked for DFPS an average of 4.7 years while investigators assigned 20 or more
investigations had worked for DFPS an average of 2.4 years. Overall, 28% of investigators (15 of
54) in December 2020 had been with DFPS less than one year while 26% of investigators (14 of
54) had been with DFPS for four years or more. The average time with DFPS for all investigators
was 3.5 years.
DFPS manages RCCI investigations and investigator caseloads in part by assigning RCCI
investigations to RCCI supervisors and non-investigator staff. 332 Between March and December
2020, the percent of investigations assigned to supervisors and non-investigator staff as the
primary investigator ranged from 24% to 3% of all investigations. Non-investigator caseloads
ranged from one to 14 during the period while RCCI supervisor caseloads ranged from zero to 77
investigations.
331
Includes only investigations assigned to investigators. Does not include investigations assigned to supervisors and
non-investigators.
332
Non-investigators include program specialists, RCCR administrative assistants, CPS investigative screeners, CPS
investigators, and CPS Special Investigations investigators. During our conversations with DFPS about caseloads,
the monitoring team was told that some investigators and supervisors may have been assigned an investigation even
though they are not acting as the primary investigator. The monitoring team was told that this occurs when DFPS
staff who do not report through the RCCI chain of command are assigned investigations in order to ensure that the
cases are counted under the RCCI program. Of the four RCCI supervisors interviewed, two reported having been
assigned as the primary investigator on the caseload report, though they were not acting as the primary investigator
on the case.
165
Figure 5.18: RCCI Investigations by Staff Type Acting as Primary Investigator

n=6,659
900
807 826 828
800
743
700
Number of Investigations
617 611
600 573 595
551
508
500
400
300
200
100
0
May2
Mar20 Apr20 Jun20 Jul20 Aug20 Sep20 Oct20 Nov20 Dec20
0
Non-Investigator Cases 30 14 12 9 3 10 4 9 8 8
Supervisor Cases 163 116 81 53 15 19 25 32 18 37
Investigator Cases 614 487 480 549 490 522 566 702 800 783
Month/Year
RCCI supervisors are expected to oversee the work of five to seven investigators, staffing
and providing assistance with cases as needed, reviewing investigation findings, and approving
completed cases. RCCI supervisors provided support on as many as 136 investigations per month
during March and December 2020. In addition to overseeing the work of their subordinates, RCCI
supervisors may be assigned as the primary investigator on a case. Between March and December
2020, xx RCCI supervisors were assigned an average of five investigations per month.
RCCI Interviews
The Monitors conducted 28 interviews with RCCI investigators and supervisors over the
course of four days during the month of December 2020. The interviews collected information
from investigators and supervisors on the following topics:
• Supervision of other staff (supervisors only)
• Training details
• Casework process and caseloads
• COVID process and challenges
• Two-year risk assessment
• Process for case closure
• Additional job responsibilities
166
All investigators and supervisors were asked to provide their caseload report from the day prior
to the date of their interview. For 12 investigators and two supervisors interviewed on December
1 and December 2, 2020, these caseload reports were compared to November 30, 2020, monthly
caseload data provided by DFPS. Of the investigators interviewed the first two days of December,
75% (9 of 12) had caseload reports that matched the November 30, 2020 caseload data provided.
For the three remaining investigators (25%), all had caseload reports showing one fewer
investigation than was found in the monthly caseload data.
On average, RCCI investigators reported being assigned nine new investigations per
month. The range of new investigation assignments per month was between two and 20.
Investigators who reported seven or more new investigations per month were all investigators who
had been working as an investigator for RCCI for over a year.
RCCI investigators reported an average of 17 investigations as the highest number of

investigations on their caseload in the past six months. The highest number of investigations
reported ranged from seven to 37 investigations. Twenty-nine percent of investigators (7 of 24)
reported having had 18 to 20 cases on their caseload as the highest number of investigations on
their caseload in the last six months, and 21% percent (5 of 24) reported having 21 or more
investigations as the highest number of investigations in the past six months. Two of those five
investigators had been an investigator for less than one year.
Supervisors reported assigning newly case assignable investigators an average of six

investigations while maintaining a “round robin” assignment method for investigations. The range
for investigations assigned to newly case assignable investigators was one to ten investigations.
Seventy-five percent of supervisors (3 of 4) reported giving investigators “courtesy”333

assignments. All supervisors reported conducting weekly staffings with investigators and indicated
they participate on visits with investigators in order to mentor new staff, conduct field assessments,
or when protocols change.
RCCR Caseloads
The Monitors analyzed caseload data for RCCR inspectors and supervisors. As shown in
the figure below, the total monthly number of RCCR tasks (investigations and inspections)
declined between March and May 2020 before increasing to approximately the same level by the
end of 2020.334
333
Investigators given courtesy assignments are most often asked to assist in an investigation by conducting interviews
with children or others associated with an investigation. Courtesy assignments are not considered secondary
assignments.
334
Total RCCR cases, as reported by HHSC, include investigations under administrative review. Cases under
administrative review are assigned to supervisors. Once the review is complete and a decision is made, the case returns
to the inspector for closure. Administrative review cases accounted for approximately five percent of total cases each
month but never less than three percent. Administrative review cases are included in the supervisor analysis only.
167
Figure 5.19: Number of RCCR Tasks
Source: RCCR Caseload Data, March - December 2020

n=14,075
1600 1,470 1,494 1,520 1,466 1,474
1,416
Number of Inspections/Investigations
1,329 1,322
1,272 1,312
1,427 1,447 1,395 1,400
1200
1,230 1,255 1,267 1,256
800
400
0
Month/Year
RCCR Total Cases RCCR Cases, No Admin Review
All RCCR inspectors are assigned specific operations as part of their caseload. On average,
caseload data showed each inspector was assigned an average of eight operations between March
and December 2020. All monitoring inspections in a specific operation are led by that inspector.
Assigned operations are usually monitored twice a year. Inspector caseloads reflect operations to
which they are assigned although they may not be actively conducting monitoring activities.335
Agency home sampling inspections, which are usually assigned to inspectors on a quarterly basis,
were completely suspended from mid-March to the end of May 2020 because of the pandemic.
Facility inspections336 accounted for more than half of the RCCR inspectors’ “tasks”337
reported for the period March to December 2020, ranging from 54% to 65% of total tasks assigned.
Investigations include abuse or neglect investigations reviewed by RCCR for minimum standards
violations (which may or may not involve an on-site inspection), and those assigned to RCCR by
SWI for an investigation of minimum standards compliance.
335
Call with HHSC and Monitors, September 24, 2020.
336
Facility inspections include inspections at assigned operations and agency home sampling inspections.
337
Tasks include monitoring and sampling inspections, ANE investigations, and non-ANE investigations. Does not
include administrative review cases.
168
Figure 5.20: RCCR Tasks by Type

N = 13,563
1600
Number of Inspections/Investigations
1200
54%
58% 65% 63% 60% 63%
65% 64% 62% 62%
800
400
46% 42%
38% 38% 35% 37% 40% 37%
35% 36%
0
(1,470) (1,416) (1,230) (1,255) (1,267) (1,256) (1,427) (1,447) (1,395) (1,400)
Month/Year
Investigations Facility Inspections
Between March and December 2020, the majority of RCCR inspectors had caseloads
within the guidelines (1-17 tasks assigned), although the proportion of inspectors with caseloads
within the guidelines sharply declined from a high of 92% in June 2020 to 58% in December
2020.338
338
By way of comparison, the Monitors’ analysis for the First Report indicated that caseload data provided by HHSC
showed that on January 1, 2020, ninety-two RCCR inspectors carried a total of 1,854 cases or “tasks.” Of the ninety-
two inspectors, fifty-four (59%) had caseloads above seventeen tasks.
169
Table 5.7: RCCR Inspectors with Caseloads339 within Guidelines, March to December 2020
RCCR Inspectors Conforming to Caseload Guidelines

Month Number Number within Percent within
(2020) Inspectors Guidelines Guidelines
March 85 48 57%
April 94 68 72%
May 94 85 90%
June 92 85 92%
July 90 76 84%
August 93 83 89%
September 92 64 70%
October 90 61 68%
November 87 52 60%
December 85 49 58%
During the period of March to December 2020, there was a fluctuation in the number of
inspectors who had one or more tasks assigned at the beginning of each month, beginning and
ending the period with 85 inspectors after reaching a high of 94 inspectors in May 2020.340 The
average tenure of RCCR inspectors in March 2020 was 4.9 years, with 5% (4 of 85) having less
than one year with the agency, and the average tenure of RCCR inspectors in December 2020 was
4.2 years, with 13% (11 of 85) having less than one year with the agency.
339
Includes monitoring and sampling inspections, ANE investigations, and non-ANE investigations. Does not include
administrative review cases.
340
The analysis did not include inspectors who were not yet case assignable or who were not assigned tasks at the
beginning of the month.
170
Figure 5.21: Caseload Lows and Highs for RCCR Inspectors*

40 n= 902 inspectors and 13,563 tasks
Tasks on Caseload
29
30 2
24 24 24 25
22 22 22 21
20
10 8 7 8
5 6
4
1 1 1 1
0
Month/Year
Caseload Low Caseload High
*Includes monitoring and sampling inspections, ANE investigations, and non-ANE investigations. Does
not include administrative review cases.
Between March and December 2020, monthly RCCR inspector caseloads ranged from one
to 29 tasks with 71% of inspectors (76 of 107) having one or more months with a caseload of 18
or more tasks. Fifty-eight percent of inspectors (62 of 107) experienced at least one month with a
caseload of 20 or more tasks. In December 2020, 25% of inspectors (21 of 85) had caseloads with
20 or more tasks assigned, while 14% of inspectors (12 of 85) managed caseloads of 13 or fewer.
The average tenure of inspectors with 20 or more tasks was 4.3 years and the average tenure of
inspectors with 13 or fewer tasks was 4.6 years.
The number of RCCR supervisors increased slightly between March and December 2020.
Supervisors of RCCR inspectors were responsible for providing support on as many as 149 tasks
a month during the period. In December 2020, RCCR supervisors oversaw an average of 64 tasks.
RCCR supervisors managed an average of four inspectors per month although the number of
inspectors supervised ranged from one to 14.341 RCCR supervisors are also responsible for
conducting administrative reviews on investigation findings appealed by operations. Between
341
Data on RCCR supervisors assigned cases and administrative reviews was not provided by HHSC until May, 2020.
Prior to that time, HHSC had informed the Monitors that RCCR supervisors did not carry a caseload and no breakout
of data for supervisors was necessary. HHSC indicated in a footnote provided in the May 2020, caseload data that
investigations assigned to an RCCR supervisor were pending assignment to an inspector. Between May and
December, RCCR supervisors had an average of three administrative review cases assigned as of the beginning of the
month.
171
March and December 2020, RCCR supervisors had an average of three administrative review cases
assigned as of the beginning of each month.
RCCR Interviews
The Monitors conducted 42 interviews with RCCR inspectors and supervisors over the
course of eight days during the months of October and November 2020.
All RCCR inspectors and supervisors were asked to provide their caseload reports from
the day prior to the date of their interview. The interviews conducted collected information from
investigators and supervisors on the following topics:
• Supervision of other staff (supervisors only)

• Training details
• Casework process and caseloads
• COVID process and challenges
• Extended Compliance History Review (ECHR) process
• Process for case closure
• Enforcement action decisions and process
• Heightened Monitoring operations
• Waivers and variances process
• Licensing approval and revocation
• Additional job responsibilities
Inspectors reported having an average of nine operations on their caseloads at the time of
the interview. The range of operations on the inspector caseloads was five to fifteen operations.
Two RCCR inspectors with less than a year of service reported having ten or more operations on
their caseloads at the time of the interviews.
The monitoring team’s interviews with inspectors gleaned the following data regarding
caseload assignments:
• 68% of inspectors (21 of 31) reported being assigned four to six new investigations per
month with a range of three to 15 investigations assigned. Inspectors who reported seven
or more new investigations per month had all been inspectors at RCCR for over a year.
• 52% of inspectors (16 of 31) reported having six to ten investigations as the highest number
of investigations on their caseloads in the past six months, with a range of four to 16
investigations.
• 81% of inspectors (25 of 31) reported that they work on inspections even when not the
primary inspector on the case. Twenty-three inspectors (74%) reported they work on
investigations where they are not the primary inspector on the case.
• 91% of inspectors (28 of 31) reported other ongoing job responsibilities with the most
common being courtesy assignments, enforcement team conferences, waiver/variance
reviews and new operation applications.
RCCR inspectors were asked to share the level of contact they have with RCCI
investigators when assigned a closed RCCI investigation for standards review. According to
HHSC policy, investigators are required to participate in risk assessments and to discuss
172
information related to regulatory responsibilities with DFPS investigators during an ANE

investigation.
Almost half of inspectors (45%, 14 of 31) reported having contact with the RCCI
investigator throughout an investigation. Nine inspectors (29%) reported having contact with the
investigator only at the beginning of the investigation. Three inspectors (10%) reported having no
communication or contact with the RCCI investigator during the investigation.
Figure 5.22: Timing of Communication Between RCCR Inspectors and RCCI Investigators
During an ANE Investigation
Source: RCCR Inspector Interviews Fall 2020

n=31
10%
3 29%
16%
5 9
45%
14
At Beginning Throughout At End None
RCCR supervisors reported assigning newly case assignable inspectors an average of nine
total cases. The range for total cases assigned to inspectors was five to 12 cases.
Summary
RCCI
The majority of RCCI investigator caseloads were within or below the guidelines between
March and December 2020. Although the majority of investigators had caseloads within the
guidelines during the period, large differences in number of cases existed between investigators
with the lowest and highest caseloads. Investigators with the highest caseloads were assigned as
much as 40 times the number of investigations than the number of investigations assigned to those
investigators with the lowest caseloads.
173
RCCR
The majority of RCCR inspectors had caseloads within the guidelines during the period, although
some inspectors had higher caseloads, outside of caseload guidelines. Between March and
December 2020, RCCR inspector caseloads ranged from one to 29 tasks. As of December 1, 2020,
inspectors and tasks per work county indicated that an additional eight inspectors are necessary to
achieve caseloads of 17 tasks per inspector
174
VI. PREVENTING SEXUAL ABUSE AND CHILD-ON-CHILD SEXUAL AGGRESSION
This section of the report discusses the remedial orders related to identifying, documenting,
and notifying caregivers of a child’s history of sexual abuse, sexual aggression, or sexual behavior
issues and to preventing child-on-child sexual abuse.
As of December 31, 2020, the most recent point-in-time data342 analyzed by the Monitors,
DFPS had identified 1,210 children with a confirmed history of sexual abuse or an indicator for
sexual aggression. These children represented approximately 12.3% of the 9,820 PMC children
in a placement on that day. DFPS flagged an additional 158 children with an indicator for a sexual
behavior problem, bringing the total number to 1,368.
Children with a history of sexual abuse or an indicator for sexual aggression were more
likely to be in a congregate care (GRO or RTC) placement than children with no sexual
characteristic flag: 380 (31%) of the 1,210 children identified, were in a congregate care placement
and 467 (39%) were in a foster home, while 13% of children (1,151 out of 8,610) with no sexual
characteristic flag were in a congregate care placement and 53% (4,533 of 8,610) were in a foster
home.343
Children whose case records are positively identified in IMPACT for either for a history
of sexual abuse or with an indicator for sexual aggression change placements more frequently than
children whose IMPACT records were not flagged. Of the total 16,326 children344 in PMC
between March and December 2020, 1,458 (9%) were children with an indicator for sexual
victimization, and 297 children (2%) had an indicator for sexual aggression.345
342
Unless otherwise noted, the data relied upon to produce the case read samples and analyses for this section of the
report are data the State has provided on PMC children in response to the Monitors’ Data and Information requests,
including sexual abuse and sexual aggression indicators, since November 15, 2019. Data was provided on a quarterly
basis but was changed to monthly with a 30-day lag for data received, beginning November 2, 2020. The last data
submitted by DFPS prior to the cut-off for validation for this report was submitted on February 2, 2021 and reflected
children in the PMC class and PMC child placements for December 2020. Data for the months of March through
December 2020 was used for the trend analysis while data for the months of March through October was used for the
case read samples. Data submitted monthly include a file of all children in the PMC class during the month (“List of
Children in PMC”) and a file of all placements for those children during the month (“List of Placements for Children
in PMC”). Both files include the following sexual history indicators: sexual victimization history, ever a confirmed
victim of sex trafficking, active child sexual behavior problem characteristic, date characteristic active, active child
sexual aggression episode, and date child sexual aggression episode started. The additional data element, “Confirmed
RCI Victim of Sex Abuse/Sex Trafficking After Removal” was added to the data submission as of November 30,
2020. A fuller discussion of the history of the Monitors’ data and information requests and the State’s responses can
be found in Section V of the Monitors’ First Report. Deborah Fowler and Kevin Ryan, supra note XX, at 197 – 260.
343
Kinship placements are not included in foster homes.
344
Data as reported by the State in “List of Placements for Children in PMC” data. Data as contained in the placements
data file does not exactly match “List of Children in PMC” data provided by the State for the same period. Excludes
137 children who were on runaway status the entire period.
345
Children with indicators for sexual abuse and sexual aggression are counted in both.
175
Children with an indicator for sexual aggression or sexual victimization were over three
times more likely than children with no sexual characteristic indicator to have a high frequency of
placement changes (four or more) during this time period. While only 5% of children without a
sexual characteristic indicator (736 of 14,653) had four or more placements during this period,
18% of children (53 of 297) with an indicator for sexual aggression and 18% of children (256 of
1,458) identified as victims of sexual abuse had four or more placements during this 10-month
period.
Table 6.1: Number of Placements for PMC Children by Sexual Indicator Type,346 March to
December 2020
(n=16,326)
Number of Sexual Abuse Indicator Sexual Aggression No Sexual Indicator

Placements Indicator
(n=1,458) (n=14,653)
(n=297)
Number Percent Number Percent Number Percent
One Placement 576 39% 99 33% 6,589 45%
Two to Three 626 43% 145 49% 7,328 50%
Four to Six 171 12% 37 13% 588 4%
Seven or More 85 6% 16 5% 148 1%
In addition to more frequent placement moves, the data revealed that runaway incidents
were more common among children with an indicator for sexual victimization or sexual aggression
than for children without a sexual characteristic indicator. Children who had an indicator for
sexual abuse victimization had more runaway incidents during the ten-months period than other
children, with 8% (123) having one or more runaway incidents compared to 7% of children (20)
with an indicator for sexual aggression, and 2% of children (322) with no sexual characteristic
indicator.
346
Eighty-two children had both a sexual abuse and sexual aggression indicator and so are counted in both indicator
categories.
176
Table 6.2: Number of Runaway Incidents for PMC Children by Sexual Indicator Type,
March to December 2020
(n=16,326)347
Number of Sexual Abuse Indicator Sexual Aggression No Sexual Indicator

Runaway Indicator
(n=1,458) (n=14,653)
Incidents
(n=297)
Number Percent Number Percent Number Percent
One 81 5% 17 6% 215 1.5%
Two or more 42 3% 3 1% 107 0.7%
A. Remedial Order 32: Policy Creation & Training of Staff Responsible for Making
1. Determinations
Remedial Order 32: Within 90 days of this Order, DFPS shall create a clear policy on what
constitutes child on child sexual abuse. Within 6 months of the Court’s Order, DFPS shall ensure
that all staff who are responsible for making the determinations on what constitutes child on child
sexual abuse are trained on the policy.
Background
Court Monitors’ First Report Performance Validation Findings
For the First Report, the Monitors reviewed the State’s policies related to child-on-child sexual
abuse, and the training modules used for staff who make determinations related to child-on-child
sexual abuse.348 The Monitors contracted with Praesidium, a Texas-based consulting firm that
works with organizations to prevent the sexual abuse of children.349 Praesidium analyzed the
State’s policies and training related to child-on-child abuse and provided a written report to the
Monitors.350 The Monitors outlined Praesidium’s recommendations in the First Report, as well as
the concerns it expressed regarding whether the training modules were sufficient to appropriately
347
A total of 16,463 children were in PMC placement between March and December 2020, including those who were
on runaway status the entire period. Of these, 1,488 children had a sexual abuse indicator, 298 children had a sexual
aggression indicator, and 14,759 children did not have either indicator. Children with an indicator for sexual abuse
and sexual aggression are counted in both categories.
348
Deborah Fowler and Kevin Ryan, First Report 202., ECF 869.
349
Id.
350
Id. at 202-203.
177
prepare investigators, CPS supervisors, and program administrators or directors to prevent or

appropriately respond to child-on-child sexual aggression.351
September 2020 Contempt Hearing
At the contempt hearing, the State’s witnesses were questioned about the State’s objections to
the Praesidium report. The State relied on testimony from Carol Self, the Director of Permanency
for DFPS (“Self” or “Carol Self”) to support its position that it was in compliance with the remedial
orders related to identification of, and caregiver notification for, children with a history of sexual
aggression or sexual abuse. During her cross-examination, Self admitted that DFPS is obligated to
ensure the safety of children while at the same time asserting that RO 32 does not specifically
require prevention of abuse, but only to provide documentation:
[MR. YETTER]: You may have seen this in the State’s papers in response to the
Monitors, but there is some suggestion by the State that the Remedial Orders are
not requiring that the State of Texas prevent sexual abuse of children in foster care.
Is that your understanding of what the Order does, or do you think it does
require the State to keep these children safe?
A: Well, absolutely, we’re required to keep the children safe. I think that the
question regarding prevention had to do with training.
And we train on ensuring that – that our staff know how to document that
we have the information, and through…ensuring that folks can recognize sexual
abuse and document it, then that will prevent future abuse and neglect.
THE COURT: How would that – how would that prevent it? Documenting it, how
would that prevent it?
THE WITNESS: Being aware of a child’s history is what helps.
….
THE COURT: What do you train your staff on preventing sexual abuse?
351
Id. at 203. The State filed written objections to the First Report, including an objection to the Praesidium
recommendations, “Defendants object to Section V(A) of the Report, related to Remedial Order No. 32, and Section
V(C) of the Report, related to Remedial Order No. 4, because it improperly attempts to redefine the requirements of
those Remedial Orders. Specifically, the Report references a third-party report commissioned by the Monitors to
examine Defendants’ training on child-on-child sexual abuse, which relates to Defendants’ efforts to “create a clear
policy on what constitutes child on child sexual abuse” and “ensure that all caseworkers and caregivers are
trained to recognize and report sexual abuse, including child-on-child sexual abuse,” as required by Remedial
Order Nos. 4 and 32 * * * However, the Report, in summarizing information from the third-party report, criticizes
Defendants for not focusing on prevention of child-on-child sexual abuse in the training. While Defendants
appreciate and take into consideration the recommendations provided by the Monitors, Defendants also object to the
Monitors’ disregard of the actual language in Remedial Order Nos. 4 and 32 and their failure to evaluate Defendants’
compliance with that actual language. Defendants’ Verified Objections to Monitors’ Report, ECF No. 903.
178
THE WITNESS: Our staff are trained on how to recognize sexual abuse, how to
speak to children and interview children, and assess child safety, and then document
any of that information so that a caregiver has that information so that they can keep
the children safe while they’re in their care.
THE COURT: Well, it is your position that the Remedial Orders do not address
DFPS’s attempt to order DFPS to try to prevent child sexual abuse?
THE WITNESS: My understanding of the Orders, as they’re written, is that we are

to train on sexual abuse, and not – I mean, I think that --
THE COURT: And not prevent it?
THE WITNESS: Well, I think ensuring that we appropriately document and capture
the information in our system and provide it to caregivers is how we prevent it.
Making caregivers a way to –
….
THE COURT: Do you think documenting a history of child abuse will prevent it in
the future without – especially, this is odd, since you don’t even give the
notification to caregivers. I’m not sure how it is you’re supposed to be preventing
child abuse.
Or do you consider that that’s part of your job, is to prevent child abuse –
sexual abuse?
THE WITNESS: Yeah. I absolutely feel like it’s our responsibility to ensure that
children are safe.
THE COURT: Okay. And that includes preventing child sexual abuse?
THE WITNESS: Yes.
THE COURT: What was the – what was the aspect of the Praesidium Study that
you objected to?
THE WITNESS: I don’t have it in front of me. I know that, specific to prevention,
we provide training as to caregivers and to our caseworkers on understanding
sexual abuse, recognizing sexual abuse, reporting –
THE COURT: Okay. This is my question. Listen to the question.
179
What was your objection to implementing the Praesidium Study?
THE WITNESS: I’m not certain I can answer without having it in front of me and
seeing what our objections are.
THE COURT: Do you know, Commissioner?
COMMISSIONER MASTERS: No, ma’am, I do not. But I’m already asking.352
Commissioner Masters was also asked about the State’s objection to the Praesidium report during
her testimony:
[MR. YETTER]: …It is among the most important issues that your group deal with
is simply keeping the children in the custody of the State safe. You’d agreed with
that. Wouldn’t you?
A: I would. I agree.
Q: And keeping these children safe in both body and mind includes keeping them
safe from sexual abuse, whether it is from caregivers or other children. Agree?
A: Agreed.
Q: It’s not enough for your department simply to document sexual abuse of children
in the custody of the State. Is it?
A: No.
Q: The purpose is to prevent abuse of these children whether it’s sexual or physical
or emotional. Right?
A: Yes. We make every effort to keep them safe.353
Updates Following the Contempt Hearing
On January 24, 2021, DFPS sent an email update to the Monitors regarding CPD
curriculum, noting that it had implemented some of Praesidium’s recommendations:
As you are aware from our correspondence on December 18, 2020, DFPS is
working to update CPD curriculum. While updating the curriculum, DFPS has
implemented some of the recommendations from Praesidium that could be
done within existing resources. In particular, the following recommendations
have been included in the new CPD training curriculum:
352
Telephone/Zoom Show Cause Hr’g Tr. (September 3, 2020) at 299 - 303, ECF No. 964.
353
Telephone/Zoom Show Cause Hr’g Tr. (September 4, 2020), at 130 - 131, ECF No. 967.
180
• Section B – CPS Professional Development Core Competencies

Training – Sexual Abuse, recommendation 1 has been partially
implemented where there are questions in the knowledge
assessment that address child sexual abuse and child sexual
aggression.
• Section B – CPS Professional Development Core Competencies
Training – Sexual Abuse recommendations 2–7 have been
incorporated into the training curriculum.
As our previous correspondence shared with you, DFPS plans to go-live with the
new CPD training curriculum in March 2021.354
1. Methodology
In addition to assessing DFPS policy changes following the Monitors’ First Report to the
Court, the Monitors analyzed training data for staff responsible for making the determination of
what constitutes child-on-child sexual abuse in order to validate the training requirement included
in Remedial Order 32. The Monitors analyzed a total of 4,853 staff records to assess completion
of Child Sexual Aggression (CSA) training for non-caseworker staff355 active with DFPS, OCOK,
or 2INgage between March 1, 2020 and November 30, 2020 (Q2 FY 20 -Q1 FY 21).356 The
monitoring team reviewed employee records provided by the State357 to identify the presence of
the most recent date supervisors and employees completed the CSA computer-based training.358
2. Results of Performance Validation
The State confirmed CSA training as complete if there was a date in the employee’s record of
the most recent date the employee completed the training. When records did not provide a
completion date for staff, the data noted the following reasons: employee left the agency; or
employee was still in training.
354
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, Training Update (January 24, 2021) (on file with
Monitors).
355
Non-caseworker staff include CVS supervisors, program directors, program administrators, screeners, and RCI and
CPI investigators, supervisors, and program administrators.
356
Data provided by DFPS, OCOK, 2INgage training data, Q2 FY 20 - Q1 FY 21.
357
Id.
358
The data provided indicated the CSA completion date as “the most recent date the individual completed the child
sexual aggression computer based training.” In some instances, this date preceded the most recent date of hire for the
staff person. Data provided by the State indicated that the most recent hire date provided was not necessarily “the
individual’s most recent date of hire in their current position.” CSA training, therefore, may have occurred prior to
the individual becoming a supervisor, program administrator, program director, investigator or other non-CVS
positions.
181
Figure 6.1: CSA Training by Position for Staff Active March to November 2020
Source: DFPS, OCOK, 2INgage training data, Q2 FY 20 - Q1 FY 21

n=4,853
2% 6% 3%
100% (19) (199) (13)
80%
60% 100% 98% 94% 97%
40% (223) (19) (3,078) (483)
20%
0%
Directors/ Supervisors Investigations Non-CVS Staff
Adminstrators Staff
CSA Completed CSA Not Completed
182
Figure 6.2: CSA Training Verification, Staff Active March to November 2020 by
Position
Source: DFPS, OCOK, and 2INgage CSA training data, Q2 FY 20 - Q1 FY 21

n=4,853
5% 10%
Non-CVS Staff 223 496
18%
857
Investigation Staff
Supervisors
68%
Directors/Adminstrators 3,277
Of the 4,853 staff active between March and November 2020, 95% (4,622 of 4,853) had
completed CSA training. All directors and administrators had completed CSA training and those
who did not complete training held staff supervisor, investigation, or non-CVS positions.
CSA training was documented as complete across regions at rates between 86% to 97% for
4,853 staff members.359
• Of the 4,622 staff that completed CSA training, 98% completed it after the hire date for
their current position.
• The average time from hire date to CSA completion date was four (4) years. Of the 96 staff
members with a CSA completion date prior to their hire date, the average time from CSA
completion date to hire date was two years.
• Thirty-two percent (1,498 of 4,462) of staff had a most recent CSA training date in 2020,
38% (1,760 of 4,462) had a most recent CSA training date in 2019 and 29% (1,364 of
4,462) had a most recent CSA training date between 2016 and 2018.
The most common reasons given for an individual’s failure to complete CSA training were
either that they left the agency or the individual was still in training at the time that data was
359
The lowest completion rate was in region 3B, OCOK staff, and regions 1, 2, 4, 7, 10, & 12 had the highest
completion rates of 97%, which included DFPS and 2INgage staff.
183
provided. Staff leaving the agency should have had a CSA training date unless their departure
occurred prior to completing training associated with hire. For staff stating the reason CSA was
not completed was due to leaving the agency, the Monitors calculated that 6% (13 of 231) should
have had enough time to complete CSA training before leaving the agency.360
Of the 231 staff members who did not complete CSA training, 19% (43/231) did not have a
reason for not completing training included in the data. An additional 13 staff who had not
completed CSA training reported it was due to leaving the agency, but they left the agency with
enough time to complete all training.
• A total of 4,789 staff were reviewed for CSA training completion from DFPS. Of DFPS
staff, 95% (4,564 of 4,789) completed CSA training.
• A total of 36 staff were reviewed for CSA training completion from OCOK. Of OCOK
staff, 86% (31 of 36) completed CSA training.
• A total of 28 staff were reviewed for CSA training completion from 2INgage. Of 2INgage
staff, 96% (27 of 28) completed CSA training.
3. Summary
The Monitors’ analysis of CSA training data for staff responsible for making
determinations regarding what constitutes child-on-child sexual abuse shows that almost all
(95%, or 4,622 of 4,853) have completed training. The entity with the lowest training
completion rate was OCOK, at 86% (31 of 36) of OCOK staff having completed CSA training.
Of the 231 staff across DFPS, OCOK and 2INgage who had not completed CSA training, 43
did not have a reason for failing to complete the training included in the data. Thirteen
additional staff reported they had not completed CSA training due to leaving the agency, but
they left the agency with enough time to complete all training.
B. Remedial Order 4: Caseworker and Caregiver Training on Sexual Abuse
Remedial Order 4 directs the State to ensure that it trains those who interact extensively
with PMC children, namely caseworkers and caregivers, to identify and report child sexual
abuse, including child-on-child sexual abuse:
Remedial Order 4: Within 60 days, DFPS shall ensure that all caseworkers and caregivers are
trained to recognize and report sexual abuse, including child-on-child sexual abuse.
1. Background
Policy
The Texas Family Code requires the adoption of “standards for persons who investigate
suspected child abuse or neglect at the state or local level,” which “must provide for a minimum
360
The average time in CPD or BSD training is 90 days. Analysis assumed that staff employed longer than 120 days
should be been working in their position prior to leaving the agency.
184
number of hours of annual professional training for interviewers and investigators of suspected
child abuse or neglect.”361 The implementing regulations provide that each such person must
receive at least 20 hours of training each year, including information pertaining to abuse and
neglect as defined by Texas statute and regulation (which includes sexual abuse) and law-
enforcement style-training regarding the investigative process.362 Applicable regulations
provide that DFPS can offer, require, and fund training, but the regulations do not specify
topics that have to be covered.363
For foster parents, DFPS requires that they complete pre-service training and annual
training thereafter.364 Pre-service training must include training “to recognize and report sexual
abuse, including abuse of a child by another child,” which must be repeated annually.365 As
such, DFPS developed an online training entitled “Recognizing and Reporting Child Sexual
Abuse: A Training for Caregivers”366 and in September 2020, DFPS assembled separate,
extensive training guides, called “Sexual Abuse Core Concepts Refresher,” for both instructors
and participants.
Like foster parents, GRO employees are required to complete pre-service training and
annual training thereafter.367 Pre-service training must include “[m]easures to prevent, identify,
treat, and report suspected occurrences of child abuse (including sexual abuse), neglect, and
exploitation.”368 GRO employees must also complete annual training that includes several
mandatory topics, none of which focus on child sexual abuse.369 However, annual training may
include “supervision and safety practices for children in care.”370
The Monitors’ Data Information Request
To validate the State’s performance with respect to Remedial Order 4, the Monitors
requested the following from the State:
• Due to the Monitors by November 15, 2019, and on a quarterly basis thereafter, provide a
list that includes the date of completion of sexual abuse training for all caseworkers and
caregivers (including the name and identification number of the caseworkers; and the
names, identification numbers, and addresses of the caregivers) assigned to serve children
in the PMC class as of September 30, 2019. For quarterly reporting beginning with
February 15, 2020 report, include all caseworkers and caregivers assigned to serve children
in the preceding period. Consistent with the Court’s order, training is required to include
information about how to recognize and report sexual abuse training, including child-on-
361
26 TEX. ADMIN. CODE § 261.310 (2017).
362
26 Tex. Admin. Code § 748.931(a-b).
363
See generally 40 TEX. ADMIN. CODE §§ 702.601 – 702.621.
364
26 Tex. Admin. Code § 749.863 (pre-service training); 26 Tex. Admin. Code § 749.931 (annual training).
365
DFPS, Child Protective Services Handbook, §§ 7330, 7521.
366
DFPS, Recognizing and Reporting Child Sexual Abuse for Caregivers Training (Nov. 15, 2019), available at
http://www.dfps.state.tx.us/Training/Child_Sexual_Abuse_for_Caregivers/index.html (last updated 2019).
367
26 Tex. Admin. Code § 748.863 (pre-service training); 26 Tex. Admin. Code § 748.931 (annual training).
368
Id. at § 748.881.
369
Id. at § 749.931.
370
Id. at § 748.943.
185
child abuse. For ongoing quarterly reporting, provide a single, unified list that includes the
date of completion of sexual abuse training for all caseworkers and caregivers (including
the name and identification number of the caseworkers; and the names, identification
numbers and addresses of the caregivers) assigned to serve children in the PMC class as of
the last date of the quarter.371
• Provide a copy of current sexual abuse training materials referenced above and, if changes
or updates are made, provide updated materials on a quarterly basis thereafter.
As detailed in the Monitors’ First Report to the Court, the State did not fully comply with
the above data and information request with respect to caseworkers and caregivers.372 Due to
the State’s limited compliance, the Monitors subsequently communicated the following
updated request during this reporting period:
• To the extent that such workers [caseworkers] completed the training(s) by different and
various methods, the Monitors request the State identify within a single, unified list the
methods by which each worker completed the training(s). For example, for a CVS worker
who completed the online training and CPS Professional Development (“CPD”) to satisfy
the requirements of Remedial Order 4, the list should identify the worker, the methods for
completion of the training, and the dates of completion for each method.373
• As this request had not been fulfilled by the State in a unified or complete manner as of
September 23, 2020, the State should provide to the Monitors by November 1, 2020 a
quarterly report that lists all caseworkers assigned to serve PMC children from May 1,
2020 through August 31, 2020. Training completion dates may go through October 31,
2020 to reflect the State’s efforts to ensure compliance.374
• Consistent with the Monitors’ original request for ongoing quarterly reporting after
November 1, 2020, the Monitors request that the State provide a single, unified list that
includes the methods and dates of completion of sexual abuse training for all caseworkers
assigned to serve children in the PMC class as of the last date of the quarter, whether
employed by DFPS or a private agency.375
371
For a complete discussion of this request and the State’s response, see Deborah Fowler and Kevin Ryan, First
Report 217-218, ECF No. 869. When DFPS responded that it was unable to provide the information due for caregiver
training, DFPS stated that it will instead provide attestations from operations serving PMC children certifying that
their caregivers serving PMC children have received sexual abuse training as required by the Court. In addition, DFPS
stated that operations will provide quarterly reports that include the following data for caregivers serving PMC
children: date caregiver completed Sexual Abuse Training, caregiver name, caregiver ID number, and caregiver
address. DFPS will aggregate these quarterly reports and submit them to Monitors. The attestations will include the
names of the caregivers serving PMC children who completed the training and the names of those who did not as of
the date of the attestation. Id.
372
See Deborah Fowler and Kevin Ryan, First Report 218-222, ECF No. 869, (describing the deficiencies in the data
provided by DFPS in response to the Monitors’ request).
373
Email from Kevin Ryan to Audrey Carmical, (Sept. 23, 2020) (on file with the Monitors).
374
Id.
375
Id.
186
• Consistent with the Monitors’ original request, the State shall provide a copy of current
sexual abuse training materials used to train caseworkers and caregivers and, if changes or
updates are made, provide updated materials within 30 days of implementation instead of
on a quarterly basis thereafter.376
• Provide the Monitors with all training records for the selected individuals who have served
as primary caseworkers for any PMC child(ren) and who were hired between October 2019
and September 2020. The State should include any and all documentation of training
completion, including competency-based test results, certificates of training, module
completion and other data and information demonstrating compliance with Remedial Order
4.377
DFPS Data and Information Production for Caseworker and

Caregiver Sexual Abuse Training
For validation of caseworker sexual abuse training completion, DFPS provided the Monitors
with three separate data files on November 2, 2020. The files contained a listing of all caseworkers,
including those employed by private entities conducting primary casework for PMC children,
OCOK and 2InNgage,378 and the respective date(s) these workers completed the training required
by Remedial Order 4.379 The State confirmed that for DFPS caseworkers, the requisite training is
generally completed in two parts. First, during the pre-service training, CPS Professional
Development (“CPD”), caseworkers receive training about child sexual abuse in the core
curriculum,380 and second, caseworkers complete a computer-based training (“CBT”) on
recognizing and documenting problematic sexual behavior and sexual abuse, including child-on-
child sexual abuse.381,382 OCOK and 2INgage each reported that in in this reporting period, its
376
Id.
377
Email from Deborah Fowler to Tiffany Roper (Jan. 11, 2021) (on file with the Monitors). A random sample of
caseworkers’ names was included with this request. Id.
378
DFPS, RO.4 and RO.32 CVS CW Training 5-1-20 to 8-31-20 - 100527 (Nov. 2, 2020) (on file with the Monitors).
DFPS, RO.4 and RO.32 2INgage CW Training 5-1-20 to 8-31-20 (Nov. 2, 2020) (on file with the Monitors).
DFPS, RO.4 and RO.32 OCOK CW Training 5-1-20 to 8-31-20 (Nov. 2, 2020) (on file with the Monitors). In addition,
DFPS produced for the third quarter on August 17, 2020, two separate files for CVS and OCOK permanency
caseworkers, supervisors, PA and PD staff who were active on May 31, 2020. DFPS, R0.4 CVS and RCI CW Sup, PD,
and PA CSA Training Q3 FY 20 – 8-17-20 - 98242 (Aug. 17, 2020) (on file with the Monitors); DFPS, OCOK CSA
Training Q3 FY 20 – 8-17-20 - OCOK (Aug. 17, 2020) (on file with the Monitors).
379
DFPS, OCOK and 2INgage document similar methodologies for reporting on caseworker training completion in
data files provided to Monitors.
380
DFPS reported that for caseworkers hired after November 2015, they receive pre-service training through CPD and
complete a course on child sexual abuse called Child Protective Services Professional Development Core
Competencies Training for Sexual Abuse. For caseworkers hired prior to November 2015, they received pre-service
training through Basic Skills Development (BSD) and completed training during BSD on recognizing and reporting
child sexual abuse.
381
Email from Audrey Carmical to Kevin Ryan (Sept. 17, 2020) (on file with the Monitors) (with some variations
depending on worker hire date).
382
Data on caseworkers’ completion of this course indicated that the date provided for course completion represents
the most recent time the employee completed the course. The data report stated that any blanks indicated that the
employee had no record of having completed the course. The file submitted for DFPS caseworkers included a “Date
CPD/BSD Core Complete,” which is described as “the most recent date the individual completed CPD/BSD core
curriculum which includes recognizing and reporting sexual abuse.” The file submitted for DFPS caseworkers also
included “Date CBT Complete,” which is described as “the most recent date the individual completed the computer-
187
caseworkers completed training with the same content as the DFPS CPD training and a course
with training content that addresses child-on-child sexual abuse. The agencies report that this
separate course will be incorporated into their respective pre-service training programs going
forward.383
DFPS reported that in some circumstances for staff who completed the new caseworker
training several years ago, documentation of the date they completed CPD or its predecessor, Basic
Skills Development (BSD), could not be located.384 For those staff, DFPS stated that it created,
and required completion of a comparable training course that had the same content on recognizing
and reporting sexual abuse as is contained in the current CPD training.385
For validation of caregiver sexual abuse training completion, DFPS is unable to track
independently whether all caregivers have completed child sexual abuse training. DFPS provided
the Monitors with data files on May 15, 2020, August 17, 2020, September 30, 2020, and
November 2, 2020. DFPS divided its reporting on caregiver child sexual abuse training completion
into three separate categories: 1) CPA; 2) CPS as a CPA; and 3) GRO.386
In May 2020, the State provided the Monitors with data files containing those caregivers who
completed sexual abuse training between January and March 2020. The data files include
individual logs of those foster parents and operation staff who reportedly completed training from
59 different CPA agencies and 240 different GROs respectively. The State also produced 11
separate certification forms for caregivers in foster homes who completed the training in the State’s
11 regions, as defined by DFPS. In its May 2020 reporting, DFPS did not provide the Monitors
with aggregate reporting that compiled the individual CPA and GRO logs into comprehensive
listings of caregivers and the respective date(s) they completed sexual abuse training.
In August 2020, the State provided the Monitors with an aggregate report listing all caregivers
who completed child sexual abuse training between April and June 2020 for both the CPA and
GRO categories. The data files include individual logs of those foster parents and operation staff
who reportedly completed training from 141 different CPA agencies and 241 different GROs
respectively. Finally, the State produced an electronic folder which includes 11 separate
certification forms by region, as defined by DFPS.
In September and November 2020, the State provided the Monitors with a separate aggregate
report listing all caregivers who completed child sexual abuse training for the months of July,
August, and September 2020 for both the CPA and GRO categories. For July and August 2020,
based training (CBT) on child-on-child sexual abuse and aggression.” DFPS, RO.4 and RO.32 CVS CW Training 5-
1-20 to 8-31-20 - 100527 (Nov. 2, 2020) (on file with the Monitors).
383
DFPS, RO.4 and RO.32 2INgage CW Training 5-1-20 to 8-31-20 (Nov. 2, 2020) (on file with the Monitors); DFPS,
RO.4 and RO.32 OCOK CW Training 5-1-20 to 8-31-20 (Nov. 2, 2020) (on file with the Monitors).
384
DFPS, R0.4 and RO.32 CVS CW Training 5- 1-20 to 8-31-20 - 100127 (Nov. 2, 2020) (on file with the Monitors).
385
Email from Audrey Carmical to Kevin Ryan, Monitor (Sept. 17, 2020, 22:09 EST) (on file with the Monitors).
See also Deborah Fowler and Kevin Ryan, First Report 218-222, ECF No. 869(describing the deficiencies in the data
provided by DFPS in response to the Monitors’ request).
386
The categories “CPA” and “CPS as CPA” contain data on foster parents serving PMC children who reportedly
completed the requisite training for Remedial Order 4. The category “GRO” contains data on caregivers serving PMC
children in congregate care settings who reportedly completed training in accordance with Remedial Order 4.
188
the data files include individual logs of those foster parents and operation staff who reportedly
completed training from 142 different CPA agencies and 232 different GROs respectively. For
November 2020, the State provided the Monitors with similar data as produced in September 2020.
The data showed the same number of CPA agencies and GROs as reported in September 2020.
With regard to the provision of content of training materials, DFPS provided to the Monitors
its current course materials related to child sexual abuse training in association with Remedial
Orders 4 and 32 during the prior reporting period.387 Pursuant to the requirement that the State
provide any updates to those materials ongoing, the State has subsequently provided refresher
training materials used for some DFPS caseworkers in September 2020.388 In addition, the State
has submitted the supplemental training materials used by 2INgage389 and OCOK.390 The State
also notified the Monitors that based upon the Monitors’ First Report to the Court, the State has
implemented some of the recommendations from Praesidium into its sexual abuse training course
included in the CPD curriculum.391
2. Remedial Order 4: Caseworker and Caregiver Sexual Abuse Training Performance

Validation
Caseworker Training Methodology
The methodology for validation of Remedial Order 4 on caseworker training included data
analysis, caseworker interviews, and meetings with training managers at SSCCs.392 The Monitors
analyzed data files produced by the State that contained names and identifiers of caseworkers and
separate dates for when each worker completed training on recognizing and reporting sexual abuse
and training on child-on-child sexual abuse. The Monitors cross-matched the caseworkers listed
in the training data provided by the State with lists of case-carrying caseworkers produced by the
State as part of the Monitors’ work verifying compliance with Remedial Order 35.
Based upon information from DFPS, the Monitors understand that completion of sexual abuse
training includes completion of a) either the CPD Core Competencies Training for Sexual Abuse
387
See Deborah Fowler and Kevin Ryan, First Report 201-202; 218-222, ECF No. 869 (describing the data and
information provided by DFPS in response to the Monitors’ request).
388
DFPS Sexual Abuse Core Concepts Refresher – Training Guide (Nov. 2, 2020) (on file with the Monitors); DFPS
Sexual Abuse Core Concepts Refresher – Instructor Guide (Nov. 2, 2020) (on file with the Monitors); DFPS Sexual
Abuse Core Concepts Refresher Training (Nov. 2, 2020) (on file with the Monitors).
389
DFPS, 2INGAGE Training Overview (Jan. 4, 2021) (on file with the Monitors).
DFPS, Academy Training Agenda November 2020 (Jan. 4, 2021) (on file with the Monitors).
DFPS, Child Sexual Aggression (Dec. 4, 2021) (on file with the Monitors).
390
DFPS., OCOK Peer to Peer Abuse Prevention Training Summary (Jan. 23, 2021) (on file with the Monitors); TEX.
DEP’T OF FAMILY & PROTECTIVE SERVS., OCOK PTP Abuse Prevention 2016-1 (Jan. 23, 2021) (on file with the
Monitors).
391
Email from Heather Bugg to Kevin Ryan and Deborah Fowler (January 24,) (on file with the Monitors). For the
Monitors discussion of the recommendations from Praesidium, see Deborah Fowler and Kevin Ryan, First Report
202-203, ECF No. 869.
392
The monitoring team met with representatives from OCOK on November 19, 2020 and from 2INgage on December
3, 2020 to discuss data on new workers’ training, including training related to recognizing and reporting sexual abuse,
including child-on-child sexual abuse. The Monitors then met with representatives from 2Ingage and OCOK on
January 15, 2021, to discuss their reporting on each order, including Remedial Order 4.
189
or relevant training under BSD, depending upon when a caseworker was hired; and b) four modules
of Child Sexual Aggression computer-based training.393 In addition, the Monitors completed
independent verification of the data through interviews with caseworkers to verify completion of
the required child sexual abuse training.
Caseworker Training Performance Validation Results
The State provided training completion data for DFPS CVS caseworkers, OCOK caseworkers,
and 2INgage caseworkers.394 The Monitors determined that between July 1, 2020 and August 31,
2020 there were 2,157 case-assignable caseworkers. Of those workers 98.1% (2,116) completed
the child sexual abuse training.395
Table 6.3: Child Sexual Abuse Training Completion by Caseworker Type, July 1, 2020 to
August 31, 2020
Child Sexual Abuse Training

Completion Categories Total Percent
Caseworker Type Completed Not Completed Caseworkers Compliant
DFPS CVS 1,894 6 1,900 99.7%
OCOK 127 17 144 88.2%
2INgage 95 18 113 84.1%
Total Caseworkers 2,116 41 2,157 98.1%
The monitoring team compared the list of caseworkers in the data provided by the State listing
caseloads for DFPS CVS, OCOK, & 2INgage caseworkers as of June 30, 2020, July 31, 2020, and
August 31, 2020 with the list of DFPS CVS, OCOK & 2INgage caseworkers in the data provided
by the State regarding completion of child sexual abuse training.396 Using the June 30, 2020, July
31, 2020 and August 31, 2020 caseload files, the Monitors matched all 1,900 (100.0%) CVS
caseworkers listed in the caseload data with CVS caseworkers listed in the DFPS child sexual
abuse training data set, matched all 144 (100.0%) OCOK caseworkers listed in the caseload data
with the OCOK caseworkers listed in the child sexual abuse training data set, and matched all 113
393
According to DFPS, the CBT portion of the training included either completion of (1) Child Sexual Aggression –
Course #0003632 or (2) Child Sexual Aggression FY19 – Course #0003805.DFPS, RO.4 and RO.32 CVS CW Training
5-1-20 to 8-31-20 - 100527 (Nov. 2, 2020) (on file with the Monitors).
394
This analysis included those workers identified in the files as caseworkers, consistent with Remedial Order 4,
DFPS, R0.4 and RO.32 2Ingage CW Training 5- 1-20 to 8-31-20 (Nov. 2, 2020) (on file with the Monitors).
DFPS, R0.4 and RO.32 CVS CW Training 5- 1-20 to 8-31-20 - 100127 (Nov. 2, 2020) (on file with the Monitors);
DFPS, R0.4 and RO.32 OCOK CW Training 5- 1-20 to 8-31-20 (Nov. 2, 2020) (on file with the Monitors).
395
Because DFPS could not locate training data for some workers with longstanding tenures, the Monitors agreed that
if those workers completed a refresher training course after August 31, 2020, they would count as compliant with
Remedial Order 4. A total of 271 workers (One hundred and seventy DFPS workers, 40 OCOK workers, and 61
2INgage workers) completed the training required by Remedial Order 4 after August 31, 2020.
396
DFPS, RO2.1 CVS caseloads as of 8-31-20 - sept-30-20 - 99667 (Oct. 8, 2020) (on file with the Monitors); DFPS,
RO2.1 CVS caseloads as of 7-31-20 - Sept-1-20 - 99357 (002) (Sept. 8, 2020) (on file with the Monitors); DFPS,
RO2.1 CVS caseloads as of 6-30-20 - Aug-1-20 - 99328 (Aug. 4, 2020) (on file with the Monitors).
190
(100.0%) 2INgage caseworkers listed in the caseload data with 2INgage caseworkers listed in the
child sexual abuse training dataset.
Finally, the Monitors interviewed a random sample of 180 caseworkers between August 2020
and January 2021 to further verify caseworker completion of sexual abuse training. Through
individual interviews with each caseworker, the Monitors found that all 180 caseworkers reported
having completed training about child sexual abuse.397
Caregiver Child Sexual Abuse Training
From May 2020 through November 2020, the State provided the Monitors with 1,351 separate
data files from its various operations attesting that caregivers completed child sexual abuse training
in accordance with Remedial Order 4. In addition, the State provided aggregate training logs for
both GROs and CPAs for the August 2020, September 2020 and November 2020 reporting
periods. The State did not produce an aggregate report showing that all its caregivers completed
child sexual abuse training and the date of completion. Because of the format of the data produced,
the Monitors are unable to verify that all caregivers have completed child sexual abuse
training.398,399
The Monitors determined that it was possible for a user to obtain a certificate of completion
for the caregiver training without completing the training.400 Therefore, the Monitors were unable
to rely on case record reviews as a reliable method of verifying training completion by caregivers
during this reporting period. The Monitors communicated the problem to DFPS upon discovery
and the State has subsequently notified the Monitors that they are addressing the technical issues
raised by the Monitors and plan to make additional technical improvements.401
397
In addition, each caseworker provided the dates on which they completed the child sexual abuse trainings. Of these
180 workers, 95.6% provided the same date for completion of the computer-based component on child sexual
aggression in their interview as was documented in the data file produced by the State for RO 4 training completion.
398
Additionally, DFPS alerted the Monitors that the caregiver compliance spreadsheets previously submitted did not
account for staff whose employment has been terminated. DFPS stated that future reports will be cumulative and will
not exclude any terminated staff, beginning with the next round of quarterly reports due on November 16, 2020. Email
from Audrey Carmical to Kevin Ryan (Sept. 25, 2020) (on file with the Monitors).
399
During a site visit to Devereux-League City, the monitoring team conducted on-site caregiver interviews, records
inspection and validation. Based on the results of this review, the Monitors reported to the Court concerns of
inexperience and lack of training among staff employed at the RTC Devereux – League City. Through interviews with
Devereux staff, the Monitors found that only three out of 18 caregivers interviewed stated that they would call SWI if
a child disclosed sexual contact with another child. This number was confirmed by the monitoring team’s employee
record review, which showed that 70% (28 out of 40) of the reviewed records of direct care staff and supervisors
included documentation showing they had completed the Child Sexual Aggression training. Deborah Fowler and
Kevin Ryan, The Court Monitors’ Update to the Court Regarding Conditions at Devereux – League City Residential
Treatment Center, (February 2, 2021) at 35-36, ECF No. 1027.
400
The Monitors were able to access the training and obtain a certificate of completion without completing the training
on February 19, 2021, without completing the training.
401
“As was mentioned in our March 18, 2021 email, we took note of your statement that you were ‘stuck’ on how to
verify compliance for RO 4 because of the computer glitches. To that end, we are in the process of adding an online
form in the training to gather information on who completed it, rather than relying on a printed certificate. At the
completion of the training, each person will be asked to type in his/her name, email address, name of the operation
they are associated with, and the Operation ID. This information can only be entered once and cannot be accessed
without taking the training all over again. This information will be securely stored in an online database so that DFPS
can sort the data and distribute a list to the various providers across the state advising them of who has completed the
191
Summary of Caseworker and Caregiver Sexual Abuse Training

Performance Validation
The State implemented the child sexual abuse training requirement in Remedial Order 4 by
providing a Child Sexual Aggression course and through pre-service training for new caseworkers.
The Monitors determined that State data indicates 98.1% of case-assignable workers between July
1, 2020 and August 31, 2020 had completed the training. All of the CVS caseworkers, OCOK
caseworkers and 2INgage caseworkers listed in the caseload data matched with the respective
caseworkers listed in the child sexual abuse data set. A random sample of 180 caseworkers
interviewed by the monitoring team between August 2020 and January 2021 resulted in all of the
caseworkers confirming their completion of sexual abuse training, though their reported
completion dates varied somewhat from the dates provided by the State.
Regarding caregiver sexual abuse training, the State does not maintain a list of all caregivers
serving DFPS children or their training completion date(s), and, therefore, the Monitors cannot
validate that all or most caregivers completed the full child sexual abuse training required by
Remedial Order 4.
C. Remedial Orders 23, 24, 28, and 30: Tracking and Documenting Sexual Abuse and
Child-on-Child Sexual Aggression
Four remedial orders issued by the Court relate to tracking and documenting sexual abuse and
child-on-child sexual aggression:
Remedial Order 23 : Within 60 days, DFPS shall implement within the child’s electronic
case record a profile characteristic option for caseworkers or supervisors to designate
PMC and TMC children as “sexually abused” in the record if the child has been confirmed
to be sexually abused by an adult or another youth.
Remedial Order 24 : Within 60 days, DFPS shall document in each child’s records all
confirmed allegations of sexual abuse in which the child is the victim
Remedial Order 28 : Effective immediately, DFPS shall ensure a child’s electronic case
record documents “child sexual aggression” and “sexual behavior problem” through the
profile characteristic option when a youth has sexually abused another child or is at high
risk for perpetrating sexual assault.
training. Each person who completes the training will receive a unique confirmation ID number. We anticipate that
this database solution will be up and running by April 12, 2021. Once the electronic form is operational, we will issue
a direction to the providers that we are requiring all caregivers to immediately retake the training, We will also set a
time deadline of May 1, 2021 for the retaking of the training course. While we truly believe most caregivers would
have honestly completed the course, we understand your dilemma with verification and trust these additional changes
will be viewed favorably by the Court.” Email from Corliss Lawson to Kevin Ryan and Deborah Fowler (March 25,
2021) (on file with the Monitors).
192
Remedial Order 30: Effective immediately, DFPS must also document in each child’s
records all confirmed allegations of sexual abuse involving the child as the aggressor.
1. Background
The Monitors’ First Report found that the State created pages within its IMPACT data system
that allow DFPS to record information related to sexual victimization, sexual aggression, or a
sexual behavior problem in a child’s electronic case record. The Monitors also determined,
through a case record review, that the IMPACT records for PMC children identified by the State
as having an indicator for sexual abuse or sexual aggression almost always had relevant
information included on the appropriate IMPACT page.402
During on-site reviews of children’s records, the Monitors found that approximately 9% of
the records reviewed revealed children who should have been flagged with a sexual characteristic
indicator but were not.403 In addition, the data analysis of trends in identification did not indicate
a notable change in the percentage of children identified with an IMPACT indicator for a sexual
characteristic, even when accounting for the children who were newly added to PMC and those
who left PMC. Finally, the Monitors’ review of case records for children with an indicator for
sexual victimization did not reveal a single child identified as a result of child-on-child abuse while
in care, though sexual-related behaviors between children formed the basis of one-third of all
Neglectful Supervision allegations for PMC children in care.
Policy Changes Following First Report
On July 24, 2020, DFPS sent the Monitors an e-mail update that included a policy update published
on July 15, 2020 related to caregiver notification:
CSA/SXAB documentation and caregiver notification – A CPS policy update

published on July 15, 2020 requires caseworkers to document sexually aggressive
behaviors and sexual victimization histories in the IMPACT CSA and Sexual
Victimization History (SVH) IMPACT pages, Child Sexual History Report
Attachment A and placement summary form.404
Several attachments to the e-mail included:
• An e-mail to CPS staff related to a “Q&A webinar” regarding the changes in policy and
the IMPACT pages.
• The sections of the CPS handbook that reflected the changes in policy; and
402
The Monitors found that of the 328 PMC children included in the case read identified as having a confirmed history
of sexual abuse, IMPACT records for 313 (95%) included information on the sexual victimization history page. For
the 56 children included in the case read flagged with an indicator for sexual aggression, 55 (98%) included
information on the child sexual aggression page.
403
Deborah Fowler and Kevin Ryan, First Report 212-214, ECF 869.
404
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, MD—updates, July 24, 2020 (on file with
Monitors).
193
• The updated Child Sexual Aggression Resource Guide.
In addition to updating the handbook, DFPS also updated the Child Sexual Aggression Resource
Guide to include the same requirements related to capturing information in IMPACT. 405
In their July 2, 2020 Motion to Show Cause, the Plaintiffs argued that the State should be held
in contempt for, in part, failing to comply with Remedial Orders 23, 24, 28, and 30.406 The
Plaintiffs based their argument on the Monitors’ findings that on-site file reviews revealed
confirmed findings of abuse in some children’s files, even though the children had not been flagged
with an indicator by the State. During their case record review, the Monitors did not find any case
records where children were flagged with an indicator for sexual abuse due to child-on-child abuse
endured while in care, despite the prevalence of the problem.407
On July 24, 2020, the State filed a response, attaching affidavits from DFPS and HHSC
staff relevant to each of the remedial orders at issue. The response included an affidavit from
Carol Self, describing the agency’s attempts to comply with Remedial Orders 24 through 31.408
The affidavit outlined the agency’s changes to policy and practice related to these remedial orders,
and pointed to the results of its own case record reviews to support its argument that DFPS should
not be held in contempt.409 The affidavit also referred to a July 15, 2020 update to its policies
related to documenting sexual victimization and aggression and caregiver notification, and to
updates to the Child Sexual Aggression Resource Guide, and referred to a plan to publish a Child
Victimization Resource Guide in September 2020.410
During the Contempt Hearing, Carol Self testified regarding DFPS’s attempts to comply
with Remedial Orders 24-31. Self’s testimony generally comported with the affidavits the State
filed in response to the Motion to Show Cause. However, when the Court questioned Self about
the Monitors’ findings that none of the children identified as victims of sexual abuse who were
included in the case review sample were identified as the result of abuse that occurred after entering
care, Self did not answer the Court’s questions directly:
THE COURT: Can you tell me how it is that not a single one of these child abuse victims
– all of them occurred before they came into foster care, nothing during the foster care? In
fact, we – just to remind you that the Monitors found 11 cases that were definitively
investigated involved child-on-child abuse, and none of those children were marked as
victims or as sexual aggressors.
Can you explain how you did not identify a single child that was sexually abused
while in care?
405
DFPS, Child Sexual Aggression Resource Guide 13-14 (updated June 2020).
406
Plaintiffs’ Motion to Show Cause Why Defendants Should Not Be Held in Contempt (July 2, 2020). ECF No. 901.
407
Id. at 14.
408
Defendant’s Response to Motion to Show Cause, Exhibit D, Declaration of Carol Self Regarding Compliance
Activities for Remedial Orders Nos. 24-31, ECF No. 916.
409
Id.
410
Id. at ¶¶ 43, 51, and 52.
194
THE COURT: What is your response to that? That you can’t – that you – that you
have not identified a single child that was abused in care –
…Now, there are some sexual aggressors that have been identified in care that were
not identified prior to care, but not sexual – child sexual abuse victims. And in fact,
as I said, the Monitors identified 11 cases of child-on-child sexual abuse that should
have been investigated that are not reported – that were not reported in your case
notes.
THE WITNESS: I am 100 percent onboard, and part of what I do regularly, almost
every day, is work with the field to ensure that we are appropriately documenting
this information in our system. And so, when we find out that something’s not
documented, that’s part of what we do, is we want to know so we can provide TA.
While we’ve been doing this for – you know, we had the update April of last
year. So we’re a year into it. You know, we…want to be able to continue to improve
our practice. And there may be instances where we want to do some one-on-one TA
with specific workers, with specific supervisors, or units, or Program
Administrators, so that we can help them perfect this practice.
During cross-examination, Self testified as to the extent of the State’s review of children’s
case records to determine whether their history indicated that an indicator for sexual abuse or
aggression should be added to their IMPACT electronic records:
[MR. YETTER]: The – since the Judge’s – since the Court’s Order, affirmed by
the Fifth Circuit a year ago came down, has DFPS made a comprehensive review
of all of the case records of PMC children to – that have been identified as – that
had not been identified as victims or aggressors – have you reviewed those records
to make sure that there wasn’t something missed because of the State’s prior history
of not keeping track of that sort of thing?
A: Are you asking if – I just want to make sure that I understand your question.
Are you asking if we went through every PMC child’s case record to review
if there is a history of aggression or victimization for every child in PMC?
Q: Correct.
A: No, we have not done that.
195
Q: * * * How did you expect to do that if you didn’t go back and check the
children’s records?
A: Well, we did check every PMC child’s record who had a confirmed
victimization record.
Those are the ones, because if they had an RTB, or if they were victim child
in a sexual abuse case, or they were the victim of a child sexual aggression incident,
those are the individuals that we ensured had the appropriate documentation marked
in our IMPACT system.
Q: And did you do that for – pardon me? Go ahead.
A: Well, and, as I mentioned, like when we first instituted this in 2016 with creating
the child sexual aggression indicator, reviewing, you know, the cases where we
previously had children who had been marked as sexually acting out – even though
we weren’t sure what exactly sexually acting out – why someone may have made
that determination – that we reviewed every one of those cases.
And then when we updated the system in 20 – December of 2019, any child
that had that – in the system, that was a victim of an RTB of sexual abuse, a
confirmed victim of sex trafficking – all that information pulled into the sexual
victimization page in IMPACT.
And a review of those cases was done. And there was roughly, I want to
say 4,000 or so of those cases that were reviewed. They weren’t necessarily all
PMC kids.
But it was – we reviewed over 4,000 cases to make sure that that information
that pulled over from their – the allegation detail of the investigation into the sexual
victimization page that was just created.411
Self was also asked whether the agency had conducted a review of Neglectful Supervision
cases involving child-on-child sexual abuse to determine whether an indicator should be added to
IMPACT records for any of the children involved, either as victims or as aggressors:
[MR. YETTER]: Okay, Ms. Self, my question was: In the past year, while the
Court’s order has been in effect, has DFPS reviewed all the cases of negligent
supervision involving child-on-child sexual abuse?
A: I can’t confirm that we’ve done that.
Q: To your knowledge, it hasn’t been done?
411
Telephonic/Zoom Show Cause Hr’g Tr. (September 3, 2020) 295 -297, ECF No. 964.
196
A: To my knowledge – it’s – it’s being done per policy of when the investigations
come in. They’re supposed to be reviewing them as the investigations come in.
But I can’t confirm that it’s happening.412
The Contempt Order & DFPS’ Certification of Compliance
In its Order of December 18, 2020, the Court did not find the State in contempt of Remedial
Orders 23, 24, 28, and 30. However, the Court noted:
It remains unclear whether sexual abuse and sexual aggression information

is documented somewhere in the record for every PMC child who was involved in
a confirmed allegation of sexual abuse as a victim or as an aggressor. Defendants
would have to conduct a thorough case review of every PMC child to be sure of
this, but [Carol] Self confirmed that DFPS has not reviewed every PMC child’s
record. The Court agrees with the Monitors that the lack of any child-on-child
sexual contact reported in confirmed allegations of sexual victimization is
“significant.” The fact that not a single child in a random sample of PMC children,
whom DFPS itself identified as confirmed victims of sexual abuse, had a confirmed
allegation of sexual abuse while in foster care is dubious. This absence raises
concerns that DFPS may not be properly investigating allegations of child-on-child
sexual abuse between PMC children in foster care, or that Defendants may not be
documenting confirmed allegations of such sexual abuse. Not enough information
has been provided for the Court to reach a conclusion. The Court therefore instructs
the Monitors to review allegations of child-on-child sexual abuse involving PMC
children while in State care that are (1) not investigated, (2) investigated and not
confirmed, and (3) investigated and confirmed, in order to determine the extent to
which Defendants are properly investigating and documenting such allegations.
This matter may be the subject of future contempt hearings.
Notwithstanding the issues and deficiencies mentioned, Defendants have

demonstrated sustained efforts to protect PMC children through the documentation
of sexual abuse and sexual aggression in compliance with Remedial Orders 24, 28,
and 30…However, more work needs to be done to ensure that every allegation of
sexual victimization or sexual aggression is properly investigated, and that every
confirmed allegation is properly documented in the appropriate Sexual
Victimization Page or Sexual Aggression Page in IMPACT for each PMC child.
These pages are particularly important for compliance monitoring because
Defendants updated their policy to require documentation in these pages, and
because these pages serve as consistent benchmarks for the Monitors to evaluate
whether complete information about a child’s history of sexual abuse and/or sexual
aggression is document and accessible. The Court instructs the Monitors to
continue investigating these matters.413
412
Id. at 299.
413
Order at 285-86, ECF No. 1017 (emphasis in original).
197
D. Remedial Orders 23, 24, 28, and 30 Performance Validation
1. Methodology
The Monitors’ First Report validated the State’s compliance with Remedial Orders 23 and
28, requiring the creation of profile characteristics in IMPACT that would allow DFPS to
document a child’s history of sexual abuse or an indicator for sexual aggression.414 For this report,
the Monitors’ method of validating the State’s compliance with Remedial Orders 24 and 30
included:
• A review of trends in identification for children flagged with an indicator for sexual
victimization or sexual aggression; and
• Independent case record reviews principally conducted for the remedial orders related to
caregiver notification (and described more fully below), but that included questions
regarding whether any incidents of sexual abuse or sexual aggression occurred after the
child was placed in care, and capturing information related to the perpetrator of abuse for
victims who endured abuse after entering care.
• Case Review of Sexual Victimization History in Dispositions with Reason to Believe: To

validate performance associated with Remedial Order 24, the Monitors reviewed all case
records for investigations with allegations of Sexual Abuse and/or Neglectful Supervision
involving child-on-child sexual contact that were substantiated with a disposition of
Reason to Believe between May 1, 2020 and October 31, 2020, which was a total of ten
investigations. The Monitors assessed whether the sexual victimization history pages for
the associated victims should have been positively indicated consistent with DFPS policy
when appropriate. Because DFPS is unable to separately identify which Neglectful
Supervision investigations involve child-on-child sexual contact, for allegations involving
confirmed allegations of Neglectful Supervision, the Monitors first determined whether the
allegations involved child-on-child contact in the 27 Neglectful Supervision investigations;
414
Deborah Fowler and Kevin Ryan, First Report 216, ECF 869. The case record reviews for the First Report, which
tested whether IMPACT records for children identified by the State as having an indicator for sexual aggression or
sexual abuse, included the relevant information in the children’s electronic records confirmed that the overwhelming
majority of records reviewed (95% - 98%) did so. Id. at 212. These case reads confirmed that the State’s IMPACT
enhancements allow it to develop a report of children identified as having a sexual characteristic indicator by relying
on the flag added to IMPACT, and did not need to be repeated for this report to the Court. This report does not include
a robust validation sample from on-site interviews with direct caregivers as the Monitors’ First Report did. The onset
of the COVID-19 pandemic in March 2020 severely curtailed the Monitors’ ability to make site visits. The monitoring
team visited one GRO, Devereux Advanced Behavioral Health – League City, in October 2020 after the media
reported a riot that resulted in the arrest of a number of children housed at the facility. That visit was the subject of a
separate report, filed by the Monitors on February 8, 2021. Deborah Fowler and Kevin Ryan, The Court Monitors’
Update to the Court Regarding Conditions at Devereux – League City Residential Treatment Center, ECF No.
1027.The Monitors are working toward identifying new methods to test for whether children who are not currently
flagged with an indicator should be. On-site reviews of children’s files are one method of testing for this, but, to date,
the case files kept on-site by placements visited by the Monitors have never been complete; at most, they may include
some records from a child’s last placement, but do not include all the child’s records. Thus, even this method of
identifying children who should be flagged with a sexual characteristic indicator likely misses important information.
198
they then reviewed the investigative record to examine the sexual aggression staffing
conclusion and associated documentation. (Remedial Orders 23 and 24).
Results of Performance Validation
Increase in Indicators for Sexual Abuse or Sexual Aggression
The number of children with an indicator for sexual abuse or sexual aggression increased
by 22% (from 991 to 1,210) between November 30, 2019 and December 31, 2020.
The Monitors analyzed data for the number of children identified with an indicator for
sexual victimization or sexual aggression on a given day between November 30, 2019 and
December 31, 2020 to determine trends in identification. The point-in-time analysis (using the
last day of the quarter for the first, second, third and fourth quarters of 2020, and December 31,
2020) shows a steady 22% increase (from 991 children on November 30, 2019 to 1,210 children
on December 31, 2020) in the number of children flagged with a sexual characteristic indicator.
Figure 6.3: PMC Children with a Sexual Characteristic Flag (Victim or Aggressor)
Active as of November 30, 2019 to December 31, 2020
Source: PMC child placement data

n=5,461
1,400
1,147 1,210
1,200 1,108
991 1,005
1,000
800
600
400
200
0
End of Q1 End of Q2 End of Q3 End of Q4 Dec 31
FY2020 FY2020 FY2020 FY2020 2020
The number of children’s records flagged with an indicator for sexual victimization
increased more significantly than the number of children’s records flagged with an indicator for
sexual aggression. The number of children’s records flagged with an indicator for victimization
increased 26% during this time period, from 832 on November 30, 2019, to 1,050 on December
31, 2020. Children’s records flagged with an indicator for sexual aggression increased 13% during
the same time period, from 197 on November 30, 2019 to 223 on December 31, 2020.
199
A trendline analysis beginning in January of 2019 and continuing through December 31,
2020, indicates that the monthly number of newly flagged placements for sexual victimization and
aggression415 increased in late 2019 and reached a peak in early 2020, but declined in late 2020.
Figure 6.4: Number of Newly Flagged PMC Children by Month,

January 2019 to December 2020
Source: PMC child placement data

n=242
New agg flag New victim flag
40
30
20
10
0
Jan 19 Mar 19 May 19 Jul 19 Sep 19 Nov 19 Jan 20 Mar 20 May 20 Jul 20 Sep 20 Nov 20
The number of newly flagged PMC children has averaged two per month for sexual
aggression and ten per month for sexual victimization since June 2019 (the first month for which
the Monitors received data).
Sexual Abuse After Children Enter Foster Care
Given the Court’s concerns related to DFPS’s compliance with the remedial orders for
children who were victims of abuse in care, or who engaged in incidents of child-on-child sexual
aggression after entering care, the Monitors adapted the case record review tool used to validate
caregiver notification to include questions related to whether children with a sexual abuse indicator
had been victimized while in foster care. These new questions were included in the monitoring
team’s review of new placements made from June 1, 2020, through October 31,2020 and will be
part of the Monitors’ case record reviews going forward.
Of the 304 children whose case records were reviewed and started a new placement
between June 1, 2020 and October 31, 2020416 and who had an indicator for sexual victimization,
415
Newly flagged placement is defined as a new placement start for a child with an indicator for sexual victimization
or aggression where the child’s previous placement did not have an indicator.
416
As discussed more fully in the next section, these case record reviews were conducted using a confidence interval
of 95 percent. PMC child placement data was initially provided by the State quarterly. As of November 2020, this
200
the information included on the IMPACT sexual history page indicated that the child had an abuse
incident that occurred after entering care for 21 percent (63 out of 304) of the children.
Figure 6.5: Percent of Children with a Sexual Abuse Indicator with Abuse After Entering
Care, June to October 2020417
Source: Case review data, abuse occurred

after entering care, June - October 2020
n=304
Yes Unable to Determine No
21%
63
7
2%
77%
234
Of the 63 children included in the case record review who had an indicator for sexual abuse
and had an abuse incident that occurred after the child entered care, the perpetrator was most
commonly an adult not associated with the placement where the abuse occurred (25 of 63, or 40%)
or another child in the placement (23 of 63, or 37%).418
data was received monthly, allowing the Monitors to review case records through October 2020. The collection of
data for children with an indicator for sexual victimization and whose sexual history page indicated that the abuse
incident occurred after entering care began with the Monitors’ second case read. Data is not available for children
sampled during the 3rd quarter case read (March – May 2020).
417
Abuse occurring after entering care was determined by reviewers as any identified abuse occurring in care for
children with a history of sexual victimization. Beginning in September 2020 and going forward, the State began
providing the Monitors a variable identifying confirmed RCCI victims after removal (i.e., while in care) which does
not include victims of abuse outside of RCCI investigations with confirmed findings.
418
It is possible for the cases involving an adult perpetrator not associated with the child’s placement that these
incidents occurred during a runaway episode. Thirty-eight percent (24 of 63) of children had been abused while on
runaway status.
201
Figure 6.6: Perpetrators Identified for Children with Abuse Occurring After Entering
Care
Source: Case review data, June to October

2020
n=63
Other child in 37% (23)
placement
GRO/RTC staff 8% (5)
Foster parent/home
staff 6% (4)
Adult not
associated with 40% (25)
placement
Child not associated 5% (3)
with placement
0% 10% 20% 30% 40% 50%
Percent of Cases
Of the 128 children whose case records were reviewed and started a new placement
between March 1, 2020 and October 31, 2020419 and whose IMPACT records included an indicator
for sexual aggression, 48% of children (61 out of 128) had a sexual aggression incident after being
placed in foster care.
419
Data provided by the State included the child’s sexual aggression indicator, the date child sexual aggression episode
started, and the child’s removal date.
202
Figure 6.7: Sexual Aggression Occurred After Entering Care for Children with a Sexual
Aggression Indicator
Source: Aggression occurred after entering care for

children in case review sample with aggression indicator,
March - October 2020
n=128
Yes No
48%
52%
61
67
More than one-quarter of the children (16 of 61, or 26%) whose records were reviewed
who were flagged with an indicator for sexual aggression and had a sexual aggression incident
after being placed in foster care were placed in congregate care settings at the time of the incident,
while more than one-third (21 of 61, or 34%) were placed in a foster home setting at the time of
the incident. Thirty-two percent (20 of 61) were placed in a kinship or adoptive placement at the
time of the incident.420
Case Review of Sexual Victimization History in Dispositions with

Reason to Believe
Of the 27 investigations involving Neglectful Supervision or Sexual Abuse that the monitoring
team reviewed, six included substantiated allegations of Neglectful Supervision and/or Sexual
Abuse; and four included substantiated allegations of Sexual Abuse only. The monitoring team
reviewed the documentation in those ten investigations and found seven of ten investigations
(70%) were properly documented:
• One child’s record should have had a positive indication for sexual victimization but did
not.
• Two of the confirmed child victims’ records already had a positive indication for sexual
victimization history prior to the confirmed allegation that was under review. In those
instances, the child’s record was not updated with the more recent victimization event in
the sexual victimization history page but was otherwise properly documented.
• In the remaining seven investigations, the record for sexual victimization history did not
contain omissions and the documentation was appropriate.
420
More than one type of placement could have been identified.
203
Summary
Both the Monitors’ analysis of trends and the case review show that the State is making
progress in identifying children with a confirmed history of sexual abuse or sexual aggression and
adding the required documentation to their IMPACT records. The number of children flagged
with an indicator for sexual abuse or sexual aggression increased by 22% (from 991 to 1,210)
between November 30, 2019 and December 31, 2020. Though a monthly trend analysis shows
increases peaked in February 2020 and have declined since then, the peak coincides with the
State’s launch of the IMPACT enhancements related to sexual victimization and would have been
expected to follow this change.
In addition, the Monitors’ case review showed that 21% of children with a sexual
victimization indicator had an abuse incident which occurred after entering care, and 48% of
children with a sexual aggression indicator had an aggression incident which occurred after the
child entered care. Of the children who endured sexual abuse after entering care, 37% were abused
by another child in their placement. A case record review of substantiated findings of Neglectful
Supervision or Sexual Abuse showed that 70% (7 of 10) of cases reviewed indicated that sexual
victimization was properly documented in the child’s electronic case record.
E. Remedial Orders 25, 26, 27, 29 &31: Caregiver Notification
As discussed in the Monitors’ First Report, three remedial orders speak directly to
caregiver notification of child sexual aggression or victimization:
Remedial Order 25: Effective immediately, all of a child’s caregivers must be apprised of
confirmed allegations at each present and subsequent placement.
Remedial Order 27: Effective immediately, all of the child’s caregivers must be apprised
of confirmed allegations of sexual abuse of the child at each present and subsequent
placement.
Remedial Order 31: Effective immediately, all of the child’s caregivers must be apprised
at each present and subsequent placement of confirmed allegations of sexual abuse
involving the PMC child as the aggressor.
Two additional remedial orders speak to caregiver notification indirectly, by requiring the state to
document child sexual aggression or victimization in forms that DFPS policy mandates staff
provide to caregivers before or upon a child’s placement:
Remedial Order 26: Effective immediately, if a child has been sexually abused by an adult
or another youth, DFPS must ensure all information about sexual abuse is reflected in the
child’s placement summary form, and common application.
Remedial Order 29: Effective immediately, if sexually aggressive behavior is identified

from a child, DFPS shall also ensure the information is reflected in the child’s placement
summary form and common application.
204
1. Background
For the First Report, the Monitors used several different methods to determine compliance
with the remedial orders related to direct and indirect caregiver notification, including a cross-
match of data provided by the State that identified children with a sexual characteristic flag. In
addition, the Monitors reviewed data the State provided for a mass notification of caregivers
ordered by the Court, on-site interviews of caregivers, on-site reviews of children’s files, and
multiple case record reviews.
Each of these methods revealed gaps in notification, but the gaps in communication were
particularly acute among CPS, Program Administrators, and the caregivers responsible for the day-
to-day supervision of children in the GROs visited by the Monitors. During on-site interviews
with caregivers, only 57% of the caregivers interviewed indicated they received notice when a
child had been identified as sexually aggressive, and 50% said they received notice when a child
had been identified as having a history of sexual abuse.421 Furthermore, the Monitors’ on-site
child file reviews frequently revealed that one or both of the forms used to notify caregivers were
missing. The Monitors’ case record reviews, which examined children’s records to determine
whether information related to sexual abuse or sexual aggression was included in Common
Applications and Placement Summaries’ Attachment A, also revealed gaps.
Policy Changes Following First Report
DFPS sent the Monitors an e-mail update related to several issues on July 24, 2020,
including a policy update related to caregiver notification published on July 15, 2020:
CSA/SXAB documentation and caregiver notification – A CPS policy update

published on July 15, 2020 requires caseworkers… must notify caregivers of new
information involving CSA/SVH by updating the relevant IMPACT page,
launching a new Attachment A and reviewing with the caregiver, obtaining the
caregiver’s signature, uploading a signed copy into OneCase, and documenting in
a contact that the information was provided to the caregiver. Also on July 15th, the
CSA Resource Guide was updated to reflect the IMPACT 2.0 enhancements and
CPS policy changes.422
The e-mail attached the updated sections of the CPS Handbook. In addition to outlining the
requirements for capturing information related to a child’s indicator for sexual abuse or sexual
421
In filed objections to the First Report, the State argued that the Monitors’ findings related to on-site interviews
“[i]mproperly restricts validation activities regarding caregiver interviews to General Residential Operations (GRO)
employees. As notifications of a child’s history of sexual victimization or aggression are made to GRO directors and
administrators and not GRO direct care staff, the Report fails to meet the requirements of the 2018 Order by wholly
failing to address notifications to GRO directors and administrators in evaluating compliance.” Defendants’ Verified
Objections to Monitors’ Report, ECF No. 903, paragraph 27.
422
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, MD—updates (July 24, 2020) (on file with
Monitors).
205
aggression on the relevant IMPACT pages, the updated CPS Handbook included the following
documentation requirement:
Notifying Caregiver of New Information Involving Child Sexual Aggression or

Sexual Victimization
If at any time during the course of the case the child is determined to have
a confirmed history of sexual victimization or sexual aggression that has not
previously been documented, the caseworker must update the relevant page
in IMPACT. The caseworker must launch a new Child Sexual History
Report Attachment A, review with the caregiver, obtain the caregiver’s
signature, and upload a signed copy into One Case. The caseworker must
also document in a contact that the information was provided to the
caregiver. The caseworker must also notify other individuals listed in
6151.3 Notification Requirements and Schedule.423
The updated handbook also noted that in Community-Based Care (CBC) catchment areas, the
caseworker “follows the placement process in the relevant CBC operations manual” and states that
the SSCC is contractually responsible for making sure caregivers are aware of a child’s history of
sexual aggression, sexual behavior problems, or sexual victimization.424
In addition to updating the handbook, DFPS also updated the Child Sexual Aggression
Resource Guide to include the same requirements related to reviewing the information with the
caregiver and uploading the signed copy of Attachment A in One Case.425
Contempt Hearing
The Plaintiffs also argued that the State should be held in contempt for failing to comply with
Remedial Orders 25, 26, 27, 29, and 31, and based their argument on the Monitors’ findings that
on-site interviews with caregivers showed that only half reported receiving information related to
sexual victimization, and just under half reported receiving information related to a child’s history
of sexual aggression.426 The State’s response included Carol Self’s affidavit as a supporting exhibit
and described DFPS’s attempts to comply with Remedial Orders 24 through 31 by updating policy,
improving practice through staff trainings, and conducting case record reviews.427
At the Contempt Hearing, Carol Self testified to the State’s efforts to comply with
Remedial Orders 25, 26, 27, 29 and 31. The Court asked questions related to caregiver notification.
Self demurred on the definition of “caregiver,” resulting in the following exchange:
423
DFPS, Child Protective Services Handbook §6241.11 (updated July 2020).
424
Id.
425
DFPS, Child Sexual Aggression Resource Guide 13-14 (updated June 2020).
426
Id. at 15-16.
427
Defendant’s Response to Motion to Show Cause, Exhibit D, Declaration of Carol Self Regarding Compliance
Activities for Remedial Orders Nos. 24-31 at ¶¶43, 51, and 52, ECF No. 916.
206
THE COURT: Are you notifying all of the caregivers of the sexual abuse and sexual
victimization and aggression history of these children, every single caregiver of
every single child that has been so identified in your records?
(Pause in the proceedings.)
THE WITNESS: I think my – my struggle in answering is, is because of the

definition of caregiver. And in a foster home –
THE COURT: What is – oh, my goodness. What is your definition of a caregiver?
THE WITNESS: Well, in a General Residential Operation, you have – you can
have multiple caregivers. And when we – when we place –
THE COURT: Do you have a definition from DFPS as to a caregiver?
THE WITNESS: It’s someone responsible for the day-to-day care of the child.
THE COURT: Okay. Are you notifying each of those individual caregivers?
THE WITNESS: We provide a Placement Summary Form to – at the time of

placement and it provides –
THE COURT: Are you notifying every –
THE WITNESS: I’m sorry.
THE COURT: -- are you notifying every single caregiver of the sexual history of
the child, abuse and victimization?
THE WITNESS: We make efforts to notify the caregivers (indiscernible) –
THE COURT: This is a yes or a no question. Are you notifying every single
caregiver of these children in the Common Application?
THE WITNESS: I can’t speak to what’s happening every single day at the time of
placement. I can speak to the policies and the processes that we put in place to
ensure that the caregiver is notified.
THE COURT: Well, the Monitors –
THE WITNESS: If the caregivers are found –
THE COURT: -- the Monitors’ Report – just a moment.
207
The Monitors’ Report says that you’re admin --- notifying the
administrators and not the individual caregivers. Is that true or not true?
THE WITNESS: That is true.
THE COURT: Now, does DFPS have a definition of a caregiver, so we can narrow
this down since there seems to be some confusion, years down the road, after my
Orders?
Commissioner, do you know if there’s a definition as to caregiver for

DFPS?
COMMISSIONER MASTERS: I would assume that there would be. I’ve asked
the same question and they are looking.428
The next day, Commissioner Masters testified and was asked about the agency’s definition of a
“caregiver” for purposes of complying with the remedial orders:
[MR. YETTER]: When the Court’s Order says that every one of a
child’s...caregiver [sic] should get notice, that’s not just the administrator of a
facility. Is it Commissioner?
A: Yes. That was clear.
Q: In other words, it’s not just the administrator of a facility, it’s every one of the
caregivers, the employees, the staff, the nurse, the caseworker, all of them. Right?
A: Yes. Yes.429
In addition to the definition of a caregiver, the Court asked the witness about settings that
a child could be placed in that would not receive notification of an indicator for sexual abuse or
aggression under the agency’s policy:
THE COURT: I also want to know, when I say that this must be given to all
caregivers, what placements does DFPS except from this Order?
(Pause in the proceedings.)
THE WITNESS: They’re – the only placements that we would not notify a
caregiver of a child’s sexual aggression or sexual victimization history would be –
428
Telephonic/Zoom Show Cause Hr’g Tr. (September 3, 2020) 254 -260, ECF No. 964.
429
Telephonic/Zoom Show Cause Hr’g Tr. (September 4, 2020) 146, ECF No. 967.
208
I mean, we notify every placement, we notify kinship caregivers, we notify non-

licensed placements, as well as licensed placement.
THE COURT: And you notify the psychiatric hospitals when you place them there?
THE WITNESS: We don’t consider a psychiatric hospital as placement.
THE COURT: Why is that?
THE WITNESS: Because it’s –
THE COURT: What would it be?
THE WITNESS: It’s a hospital stay. And so we haven’t –
THE COURT: Don’t you place them there yourselves? You’re the managing
conservator. Right?
THE WITNESS: They’re – we –
THE COURT: Are you the legal managing conservator of the PMC children?
THE WITNESS: Yes. Yes, ma’am.
THE COURT: So when you put them some place, you’re saying it’s not a
placement? What on earth is it? Don’t you place them in the psychiatric hospital?
Aren’t you the only people who have the authority to do that as managing
conservators?
THE WITNESS: If the child has – yes. I mean, if the child has needs, and they’re
in a foster home, and they’re placed in a psychiatric hospital, oftentimes the child
returns back to that foster home placement. So their placement is still with the
foster home. It’s just that they’re temporarily in the psychiatric hospital setting.
THE COURT: Okay. Well, let me tell you that not reporting this information to all
placements is not consistent with the Court’s Order. I’m going to give you a heads-
up on that because that’s a contempt issue.
And if you’re not telling the psychiatric hospitals, of all places, that these
children have sexual aggression and sexual victimization history, it’s actually
shameful.430
430
Hr’g Tr., supra note 426, at 262- 64.
209
Policy Updates that Followed the Contempt Hearing
After the Contempt Hearing, DFPS asked the Monitors for feedback regarding proposed
definitions of “caregiver” and “apprised,” initially looking to existing definitions within the Texas
Administrative Code (TAC) that could be referenced in policy related to the remedial orders.431
DFPS sent the Monitors the following proposed definitions:432
As we mentioned to you in our call on 9/28/2020, we propose for consideration the

following approach to caregiver notification as it relates to placement settings and
ROs 25, 27, and 31:
Definition of “Caregiver”
For purposes of Remedial Orders 25, 27, and 31, a caregiver is a person who is
counted in the child/caregiver ratio pursuant to 26 TAC §§ 748.43(5) or 749.43(8),
or, for a setting other than a foster home or General Residential Operation, a person
whose duties include direct care, supervision, guidance, and protection of a child in
care to the extent that they would be counted in the child/caregiver ratio in a setting
subject to Child-Care Regulation. This definition does not authorize DFPS to
direct or otherwise control how an entity housing a member of the PMC class
distributes the provided information if DFPS is not authorized by contract, statute,
or law to exercise such authority.”
The aforementioned TAC sections are as follows:
26 TAC Section 748.43 (Minimum Standards for GROs)
5) Caregiver--A person counted in the child/caregiver ratio, whose duties

include the direct care, supervision, guidance, and protection of a child. This
does not include a contract service provider who:
(A) Provides a specific type of service to your operation for a limited
number of hours per week or month; or
(B) Works with one particular child.
26 TAC Section 749.43 (Minimum Standards for CPAs)
(8) Caregiver--A caregiver:

(A) Is a person counted in the child/caregiver ratio for foster care
services, including employees, foster parents, contract service providers,
and volunteers, whose duties include direct care, supervision, guidance, and
protection of a child in care. This includes any person that is solely
responsible for a child in foster care. For example, a child-placement staff
431
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, Proposal for approach to caregiver notification,
(October 7, 2020) (on file with Monitors).
432
Id.
210
that takes a foster child on an appointment or doctor's visit is considered

a caregiver;
(B) Does not include babysitters, overnight care providers, or respite
child-care providers unless they are:
(i) Verified foster parents.
(ii) Licensed foster parents; or
(iii) Agency employees.
(C) Does not include a contract service provider who:
(i) Provides a specific type of service to your agency for a limited
number of hours per week or month.
(ii) Works with one particular child: or
(iii) Is a nurse being reimbursed by Medicaid; and
(D) Does not include a person left alone momentarily with a child in care
while the caregiver leaves the room.
The definition of caregiver in Texas Family Code Section 261.001(5) does not
define the term “caregiver” as such, though it does define the related concept of
“person responsible for a child’s care, custody, or welfare.” This definition,
however, is relevant to the agency’s authority to investigate child abuse and neglect
and may be too broad for application in licensed residential placement settings,
particularly where the definition includes entities for which DFPS may not exert
some control of the distribution of information. Also, the definition includes school
personnel or volunteers at a child’s school, an entity for which DFPS may not exert
some control over the distribution of information or limitations on the distribution
of history to persons who may not need to know the history. Considering potential
privacy or confidentiality concerns youth may have about sharing their background,
whether school personnel may need to know a youth’s history should be considered
on a case-by-case basis rather than across the board and possibly include
consideration of factors such as the nature of the youth’s history, the age of the
child, and whether the child will be in situations without supervision while in the
educational setting.
The term “caregiver” as defined above also excludes babysitters, overnight care
providers, and respite caregivers unless they meet certain criteria. DFPS construes
this exclusion to be consistent with obligations under state and federal law to
promote normalcy and apply the reasonably prudent parent standard. See 42 U.S.C.
§ 675(5)(B),(10), (11); Tex. Fam. Code §§ 264.001(1) and 264.125. So, for
example, a child who is allowed to go on a weekend camping trip with a friend
from school will not be required to have sensitive sexual victimization history
shared, presuming that such normalcy activity is already consistent with any service
planning, court orders and treatment plan in place.
Definition of “apprised”
DFPS acknowledges and agrees that in order to protect children from sexual abuse,
those individuals who meet the definition of caregiver above, i.e., who have day to
211
day responsibility over caring for children, should be aware of the information they
need to keep children safe. Given that staff of operations may fluctuate and given
the expectations DFPS will add and enforce in contracts regarding
administration/intake staff sharing this information with direct-care staff who need
it, DFPS proposes to define “apprise” as follows: “to direct information regarding
sexual abuse or sexual aggression history to (a) with regards to a foster home, the
individual foster parents, and (b) with regards to a GRO, the administrator,
receiving intake staff, and child’s case manager, all of whom DFPS must ensure
(through monitoring and contractual enforcement) share this information to those
staff who need it to protect children. The obligation to apprise also includes the
obligation to monitor and enforce contractual requirements and agency
expectations regarding provision of the information to those staff who need the
information to protect children.”
Once the definition of “caregiver” for the purposes of these remedial orders is
settled, DFPS is prepared to move forward with changes to policy, updating forms,
communicating to staff, and completing contract amendments within 30 days.
If you are open to continuing to discuss, perhaps we can discuss this on the
21st when we meet (invite forthcoming).433
The Monitors responded to the DPFS inquiry by asking additional questions about the
definitions.434 DFPS responded to the Monitors’ additional questions within the body of the
Monitors’ e-mail. (In the exchange below, the Monitors’ questions are featured in regular typeface,
and the agency’s response is shown in italicized typeface):
Your proposed definition of caregiver includes this sentence:
"This definition does not authorize DFPS to direct or otherwise control how an
entity housing a member of the PMC class distributes the provided information if
DFPS is not authorized by contract, statute, or law to exercise such authority."
Can you give some examples of entities that might house a member of the class but
that DFPS is not authorized by contract, statute, or law to exercise authority over?
Yes, we were thinking primarily of the situation where a child is admitted to an in-
patient psychiatric hospital or medical hospital or is adjudicated into a detention
setting. We would certainly have a practice to share the information but we are not
the regulator or contractor in those situations so would not have the same authority
to direct actions. In those scenarios we of course would want the child to get the
433
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, Proposal for approach to caregiver
notification (October 7, 2020) (on file with Monitors).
434
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, Proposal for approach to caregiver
notification (October 22, 2020) (on file with Monitors).
212
needed hospital services, or would lack the authority to determine the placement if
the child were adjudicated, respectively.
Next, I understand why you suggest incorporating the TAC definition by reference
into the definition, and I know that these definitions and the Family Code definition
came up during the hearing. However, I'm a bit concerned about using the TAC
definitions because they exempt contract service providers who work in an
operation for a limited number of hours per week/month or work with one particular
child.
While this makes abundant sense for purposes of limiting the people who can be
counted in the ratio - I worry that it may be problematic in this context. I'm thinking
in particular of the BCFS awake-night staff as just one example - you'd certainly
want those folks to know which kids have been flagged, and there may be other
similar examples.
Do you have any suggestions about how to address this - I suppose one option
would be to simply create a definition of caregiver for purposes of these ROs that
does not refer to any existing definition?
I think that sounds like a good option, and we could quickly take that back to come
up with something to propose that focuses on day-to-day supervision (or nightly
supervision in your example). I think you are right that BCFS was exempted from
the ratios, so maybe we could simply look at something to address-head on the issue
of contractors providing awake-night supervision. Where we struggled was also
wanting to preserve some normalcy, so for example if a child had a mentor or a
tutor, who would not be responsible for day-to-day care, the child could have some
privacy on that sensitive information with people who are there on a limited
basis.435
After this e-mail exchange, DFPS agreed that rather than using existing TAC definitions, it would
craft a definition specific to the remedial orders. On October 28, 2020, DFPS sent the Monitors
the following proposed definitions:
Definition of “Caregiver”
For purposes of Remedial Orders 25, 27, and 31, a caregiver is a person, including
an employee, foster parent, contract service provider, or volunteer, whose day to
day responsibilities include direct care, supervision, guidance, and protection of a
child/youth in care. This includes employees and contract staff who routinely
provide 24-hour awake night supervision in accordance with Remedial Orders A7
and A8.
This definition does not authorize DFPS to direct or otherwise control how an entity
housing a member of the PMC class distributes the provided information if DFPS
435
Id.
213
is not authorized by contract, statute, or law to exercise such authority. However,

DFPS is committed to partnering with the state agencies having such authority (e.g.,
HHSC, TJJD), and is assessing opportunities for collaboration related to the
provision and distribution of this information once it is determined that a
child/youth will be admitted to or detained in a psychiatric hospital or TJJD facility.
Generally, and in furtherance of a child/youth having as normal of a life experience

as possible while in substitute care, “caregiver” does not include individuals who
are not routinely responsible for direct care, supervision, guidance, and protection
of a child/youth in care, such as school personnel, mentors, tutors and chaperones.
Instead, determining what information to provide an adult involved with a
child/youth’s normalcy activity (e.g., extra-curricular activity, part-time job, church
activities, school field trip, visit to friend’s house) must be considered on a case-
by-case basis, keeping in mind the confidential nature of the information and the
need to balance the child/youth’s privacy concerns. Depending on the history, age
of the child/youth, and situation in which the child/youth may be when engaging in
a normalcy activity, the involved adult may not need to know of the child/youth’s
history, for example a tutor periodically at the child/youth’s placement or an adult
chaperone on a school field trip.
Definition of “apprised”
DFPS acknowledges and agrees that in order to protect children from sexual abuse,
those individuals who meet the definition of caregiver above, i.e. who have day to
day responsibility over caring for children, should be aware of the information they
need to keep children safe. Given that staff of operations may fluctuate and given
the expectations DFPS will add and enforce in contracts regarding
administration/intake staff sharing this information with direct-care staff who need
it, DFPS proposes to define “apprise” as follows: “to direct information regarding
sexual abuse or sexual aggression history to (a) with regards to a foster home, the
individual foster parents, and (b) with regards to a GRO, the administrator,
receiving intake staff, and child’s case manager, all of whom DFPS must ensure
(through monitoring and contractual enforcement) share this information to those
staff who need it to protect children. The obligation to apprise also includes the
obligation to monitor and enforce contractual requirements and agency
expectations regarding provision of the information to those staff who need the
information to protect children.”436
After conferring with the Court, the Monitors responded to DFPS’s proposed definitions,
striking the second paragraph in the caregiver definition that limited DFPS’s responsibility for
caregiver notification in certain settings. The Monitors also made small changes to the definition
of “apprised” to clarify that DFPS must ensure that information related to an indicator for sexual
436
(October 28, 2020) (on file with Monitors)
214
abuse or aggression is shared with all those who fall within the definition of a caregiver rather than
only “those staff who need the information to protect children.”437
The agency responded, asking:
With regard to the struck language pertaining to entities over which DFPS is not
authorized by contract, statute, or law to control how those entities operate their
facilities, we want to make sure we are on the same page as you—and the Court, of
course—regarding notification. For example, DFPS will not necessarily have
access to nurses or other employees who may provide care to a child in a psychiatric
hospital. In that scenario, DFPS would provide notification to the person doing
intake (or another appropriate staff person) and request it be placed in the child’s
file for others to view. Would that be your understanding as well? If a follow-up
call would be helpful, we are happy to set that up.438
In response, the Monitors advised DFPS, “The Judge expects the State to apprise caregivers
for PMC children of confirmed allegations wherever the children may be living, whether the
arrangement is temporary or longer term, and to be able to certify that it is doing so” and offered
to schedule a teleconference with the Court if further clarification was needed.439 DFPS responded
that a teleconference was not necessary.440
On November 25, 2020, DFPS sent a memorandum (“memo”) to all CPI and CPS staff and
SSCCs alerting them to changes that would become effective December 1, 2020 related to
caregiver notification.441 The memo noted that staff would be required to review the information
contained in the Placement Summary and Attachment A with caregivers at each initial and
subsequent placements, obtain the caregivers’ signatures, and provide a copy of the document per
the memorandum’s guidance.442 The memo included a chart setting out requirements and guidance
specific to unverified kinship homes, foster homes, GROs, and “Other Facilities” which includes
juvenile detention settings, psychiatric hospitals, state supported living centers, and medical
hospitals.443 The guidance for the “other facilities” specifies that the individual responsible for
admissions is required to sign the Placement Summary and Attachment A, and notes,
“Caseworkers must review the information with the staff who is admitting the child and make
efforts to have them sign the documents. If they refuse to sign, document who the information was
437
E-mail from Deborah Fowler and Kevin Ryan, Proposal for approach to caregiver notification (October 29, 2020)
438
October 31, 2020 (on file with Monitors).
439
E-mail from Deborah Fowler and Kevin Ryan to Audrey Carmical, Proposal for approach to caregiver notification,
(November 5, 2020) (on file with Monitors).
440
(November 8, 2020) (on file with Monitors).
441
Memo from Jim Sylvester, Association Commissioner for CPI & Deneen Dryden, Associate Commissioner for
CPS to All CPI and CPS staff and SSCC Contractors regarding Notification to Caregivers Regarding Sexual
Victimization and Sexual Aggression History of children in DFPS conservatorship (November 25, 2020) (on file with
Monitors).
442
Id.
443
Id. at 2.
215
provided to, their title, date, and indicate their refusal to sign. If the caregiver admits the child,
staff must review the information and obtain the signatures upon notification of the admission.”444
The DFPS memo answered the question “Must I obtain signatures for children who are
already placed?” as follows:
For children currently placed in General Residential Operations (GRO), State

office staff are coordinating with providers to obtain the required signatures for any
children who are identified in IMPACT as having a history of sexual victimization
and or sexual aggression. If a GRO attempts to give you copies of the Attachment
A they received from state office staff, please ask them to send it back to the
individual who provided it to them.
For children placed in foster homes and unverified kinship homes who have a
history of sexual victimization and or sexual aggression, at the workers next visit
with the caregiver, caseworkers should obtain the signature of any caregivers who
have not signed the Attachment A and upload it into One Case. If the child does
not have a history of sexual victimization or sexual aggression, there is no
additional action required.445
The memo also included a list of documents and policies that would be updated to reflect the
guidance.446
The Court’s Contempt Order & DFPS’s Certification of Compliance
The Court held DFPS in contempt of Remedial Orders 25, 26, 27, 29, and 31. In so doing,
the Court found gaps in and non-compliance with DFPS’s own policies:
In sum, the Monitors’ various methods for validating compliance with the Remedial
Orders related to caregiver notification revealed significant gaps in Defendants’
performance. Information frequently did not make it to the direct care staff who
are actually engaged in protecting children’s safety on a daily basis. Even if
Defendants were 100% compliant with their own policy of notifying GRO directors
or administrators, the Defendants’ obligation under the Remedial Orders is to
444
Id.
445
Id. at 2-3 (emphasis in original).
446
These documents and guidance included 14 sections in the CPS Handbook (4121.2 Prepare the Current and New
Caregivers for the Move; 4121.3 Complete the Placement Summary Form; 4133 Provide and Discuss the Placement
Summary Form; 4152.2 Meeting the Needs of a Child or Youth Until a Placement is Secured; 4220 Placements into
Facilities Regulated by the Health and Human Services Commission (HHSC); 4221 Abuse and Neglect Investigations
of Placements; 4221.1 RCCI Notifying CPS of Alleged Abuse or Neglect; 4221.2 CPS Responsibility and Procedure
after Receiving a Notification of Abuse or Neglect by either RCCI or CPI; 4221.3 CPS Protocol During an
Investigation Involving a Child in Conservatorship; 4230 Facilities Under the Authority of Other State Agencies; 4231
DFPS’s Continuing Responsibilities When a Child in Conservatorship is Placed in a Facility Regulated by Another
State Agency; 4231.1 Notifying a Facility Regulated by Another State Agency of a Child’s Sexual Victimization and
Sexual Aggression History; 4233 TJJD and JPD Facilities; 6241.11 Working with Children Who Are Sexually
Aggressive, Have Sexual Behavior Problems, or Are Victims of Sexual Abuse), the Placement Summary Form 2279,
the Kinship Caregiver Agreement Form 0695, and The Child Sexual Aggression Resource Guide. Id. at 3.
216
ensure that the caregivers “be apprised.” The Monitors’ Report demonstrates that
Defendants are not fulfilling this obligation. The Monitors’ interviews with a
sample of direct caregivers revealed that only 50% of these caregivers are notified
if a child under their care has a history of sexual abuse, and only 57% are notified
if a child under their care is sexually aggressive…These interviews further revealed
that 26% of these caregivers did not know if they were currently supervising a child
identified as having a history of sexual abuse…Based on the Monitors’ Report, and
by Self’s own admission, DFPS is not notifying “all of a child’s caregivers…at each
present and subsequent placement,” as required by the Remedial Orders. As the
Court stated during the Show Cause Hearing, the failure to notify caregivers at
hospitals when DFPS places PMC children in those hospitals is not compliant with
the Remedial Orders.447
The Court also expressed concerns about whether caregivers who did receive some information
received complete information, finding:
The Court notes that even the information communicated to caregivers may not
accurately reflect the reality of a child’s history of sexual abuse or sexual
aggression. As previously discussed, the Court is concerned that child-on-child
sexual abuse allegations may not be properly investigated and/or that confirmed
child-on-child sexual abuse allegations may not be properly documented…This
potential deficiency in investigating and/or documenting is exacerbated by the
failure to communicate information about confirmed allegations to the caregivers
responsible for the care and safety of PMC children. The Court therefore instructs
the Monitors to continue reviewing the investigation and documentation of child-
on-child sexual abuse allegations involving PMC children in foster care, as well as
the communication of information about such confirmed allegations to the primary
caregivers of these PMC children. These matters may be the subject of future
contempt hearings.448
The Court ordered DFPS to file with the Court sworn certification of their compliance with these
remedial orders within 30 days of the date of the Order.449
On January 16, 2021, DFPS filed its sworn certifications, including Carol Self’s affidavit
repeating much of what was included in the affidavit submitted in response to the Plaintiffs’
Motion to Show Cause, but adding information about the agency’s attempts to come into
compliance following the contempt hearing.450 The same day, DFPS sent the Monitors links to
their shared electronic database for the documents referred to in the supporting affidavits that had
not previously been provided.451 The documents in the database included:
447
Order (December 18, 2020) 298-99, ECF No. 1017 (emphasis in original).
448
Id. at 299-300.
449
Id. at 326.
450
Defendants’ Certification of Compliance Regarding Remedial Order Nos. 2, 3, 5, 7, 10, 25-27, 29, 31, 37 and B-5,
Exhibit C, Sworn Declaration for Remedial Order Nos. 25, 26, 27, 29 and 31, ECF No. 1021-3.
451
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, Remedial Order Sworn Declarations –
supplemental documents (January 16, 2021) (on file with Monitors).
217
• The updated 24-hour Residential Care Requirements, which added the caregiver
notification requirements, and definitions of “caregiver” and “apprised,” and a notification
sent to residential providers calling their attention to the revisions.
• Forms created by three SSCCs – 2Ingage, Family Tapestry, and OCOK – to comply with
the remedial orders’ requirements for notifying caregivers upon placement via the
Common Application and Placement Summary.
• The updated Child Sexual Aggression Resource Guide.
• Amendments made to child-specific contracts to include updates related to caregiver

notification.
• The updated kinship caregiver agreement.
• E-mail notifications sent to out-of-state providers on January 13, 2021, requiring that they
“provide notice to any temporary placement or alternate caregiver (psychiatric or medical
hospital, juvenile detention facility, respite care, both formal and informal babysitters, etc.)
of any associated child sexual aggression, behaviors or victimization noted in the
Attachment A of Placement Summary form 2279.”
• A unilateral amendment form for DFPS’ contracts with SSCCs, adding the definitions of
“caregiver” and “apprised,” and describing the notification requirements for caregivers,
including the requirement that they obtain caregiver signatures indicating they received
information related to a child’s history of victimization or aggression. This amendment
also required SSCCs to ensure that each CPA provider has a written process in place to
provide notice to a temporary placement. Examples of temporary placements that the
language includes are a psychiatric or medical hospital, a juvenile detention facility, and
respite care.452
• December and January updates to the CPS Handbook related to caregiver notification,
including notification that Foster and Adoptive Home Development (FAD) caseworkers
are required to provide to alternative caregivers or temporary placements.453
452
DFPS, Department of Family and Protective Services Unilateral Amendment No. X (undated)(on file with
Monitors).
453
The updated sections of the handbook require caseworkers to provide and discuss the Placement Summary form
and Attachment A with the new caregivers at the time of placement. For foster or kinship homes, section 4130
specifies that “all caregivers in the home” must sign the Placement Summary and Attachment A to acknowledge
receipt. The same section requires that if the placement is a GRO, the forms must be signed by the administrator for
the GRO, receiving intake staff (if applicable), and the child’s caseworker. DFPS, CPS Handbook §4133 (updated
December 2020). If the placement is an initial placement into foster care, the caseworker must provide the documents
to the new caregivers within 72 hours of the child’s placement; if it is a subsequent placement, the documents must
be provided and signed at the time of placement. Id. The signed forms are required to be uploaded to OneCase by 7
p.m. on the next calendar day after the day of the placement. This section of the handbook also specifies, “If any
caregivers are not present during the placement, the caseworker must review the information with those who were not
present and obtain signatures on Form 2279 and Attachment A within three business days. Required signatures for
those who were not present may be collected electronically.” Id. The section of the handbook related to an FAD
218
• A “Psychiatric Hospital Contact Protocol for Children/Youth in DFPS Conservatorship”

that includes language requiring the caseworker to notify the hospital of a child’s sexual
aggression and aggression history “[i]mmediately, but no later than 3 business days after
notification that a child/youth on your caseload has been admitted to a psychiatric
hospital.” The form requires the child’s primary CVS caseworker to provide a copy of the
Placement Summary Attachment A to the admissions staff or person responsible for the
oversight of the child, and “make every attempt to obtain a signature on the Attachment
A.” It notes that if the facility refuses to sign the document, the caseworker must note the
refusal on the form and upload the form into OneCase.454
• An Excel spreadsheet listing the children with an indicator for sexual abuse, a sexual
behavior problem, or sexual aggression for whom DFPS represented a mass caregiver
notification was completed in December 2020.455
In addition, in February 2021, DFPS provided the Monitors with more than 400 policies for
caregiver notification adopted by GROs.456
worker’s responsibilities requires the FAD worker to inform foster or foster/adoptive parents that they must provide
information about a child’s sexual history to alternate caregivers or temporary placements, stating that this “includes
when a child is placed in a psychiatric hospital or arrested and placed in juvenile detention.” It requires FAD workers
to “ensure that alternate caregivers or temporary placements have received the child’s sexual history information by
obtaining signatures of all caregivers” on a form created to certify receipt of the information. This section also
incorporates the definition of “caregiver” and requires that for “unplanned temporary placements, such as psychiatric
hospitals or juvenile detention, the FAD worker must” obtain signatures on the certification within 24 hours of
receiving a serious incident notification, and provide the signed certification to the child’s primary caseworker within
three business days. DFPS, CPS Handbook § 7911.
454
DFPS, Psychiatric Hospital Protocol For Children/Youth in DFPS Conservatorship (undated) (on file with
Monitors). One Case is the electronic database associated with IMPACT that allows for storage of external
documents.
455
In order to validate the list of children included in the mass caregiver notification, the Monitors matched children
identified in the State’s Excel caregiver notification spreadsheet with November 30, 2020 PMC child placement data
for children having a flag for sexual abuse, or an indicator for sexual aggression or sexual behavior problem, and
found few discrepancies for children identified as a victim of sexual abuse or with an indicator for sexual aggression,
but a higher number of discrepancies for children identified with an indicator for a sexual behavior problem. Eleven
children with a flag for a history of sexual victimization in the PMC child placement data were not included in the
caregiver notification list, and three children with a flag for sexual aggression in the PMC child placement data were
not included in the caregiver notification list. However, 154 children with a flag for a sexual behavior problem in the
PMC child placement data were not included in the caregiver notification list. While the Monitors were not able to
conduct a statistically significant case read of the IMPACT records of children included on the State’s mass caregiver
notification spreadsheet, the few records the Monitors have checked do not always include a signed “Attachment A”
in the child’s One Case file for the placement that the spreadsheet indicates should have been notified, per the
instructions given to the DFPS staff completing the mass notification.
456
These policies are referred to in paragraph 72 of Carol Self’s affidavit filed as an exhibit to the State’s certification
of compliance. Defendants’ Certification of Compliance Regarding Remedial Order Nos. 2, 3, 5, 7, 10, 25-27, 29,
31, 37 and B-5, Exhibit C, Sworn Declaration for Remedial Order Nos. 25, 26, 27, 29 and 31, at ¶ 72, ECF No. 1021-
3.
219
F. Remedial Orders 25, 26, 27, 29, and 31 Performance Validation
1. Methodology
The monitoring team conducted three case record reviews457 using a sample of new
placements for children with an indicator for sexual victimization or sexual aggression in each.458
The sample sizes for each were as follows:
• March – May 2020: a sample of 264 cases, out of a total of 779.

• June – August 2020: a sample of 265 cases, out of a total of 817.
• September – October 2020: a sample of 207 cases out of a total of 546.
The chart below captures the characteristics for the total sample of 736 case records reviewed
across all three quarters.
457
Several of the methods used by the Monitors to validate the direct caregiver notification requirements of Remedial
Orders 25, 31 and 37 for the First Report could not be replicated for this report. The cross-match of data included in
the First Report was based on a one-time mass notification of caregivers by DFPS ordered by the Court on November
5, 2019 that has not been repeated by the State. Similarly, the Monitors’ First Report included a robust dataset
compiled from on-site interviews with direct caregivers. As discussed, the Monitors’ ability to conduct site visits was
hampered by the onset of the pandemic.
458
The sample was taken from all children with a sexual characteristic flag who started a placement requiring a
Common Application or caregiver notification during each quarter. The confidence interval for each sample is 95/5.
Children who began more than one qualifying placement in the quarter may be in the sample more than once. Children
with an indicator for both sexual abuse and sexual aggression may be in both the abuse and aggression sample.
220
Figure 6.8: Case Record Review Sample Characteristics, March to October 2020
Source: Case review data

n=736
The 736 case records reviewed by the monitoring team across all three quarters involved
525 children (128 children flagged with an indicator for sexual aggression, and 408 children
flagged with an indicator for sexual abuse. Eleven children (2%) were flagged with both indicators.
The case record review tool asked questions related to:
• Which indicator the child’s records showed had been marked for the child (sexual
victimization, or sexual aggression).
• The placement name, the type of placement, and the start date for the placement.
• The date the child’s history page had last been updated.
• The date the caseworker documented in IMPACT for providing Attachment A to the
placement.
• Whether a Common Application corresponding to the placement could be found, and if so,
the date for the document and questions related to the information included.
• Whether a Placement Summary and Attachment A could be found corresponding to the
placement, and if so, dates they were completed, questions related to the information
included, who signed the Attachment A form, the dates of the signatures, and whether the
signature was made by hand or typed.
221
Common Application
The monitoring team found a Common Application that corresponded to the placement
under review which contained all known information related to a child’s history of sexual abuse
in 50% of the placements reviewed, and containing all information related to a child’s history of
sexual aggression in 57% of the placements reviewed. The rate of finding a Common Application
with complete information corresponding to the placement reviewed did not improve over time
for children with an indicator for sexual aggression, though it did improve for children with a
history of sexual abuse. DFPS slightly outperformed SSCCs when results were examined
according to the entity responsible for the child’s placement.
DFPS’s own case record reviews failed to consider whether the Common Application not
only included all known information related to a child’s history of sexual abuse or sexual
aggression, but also whether it was provided to the caregiver. There did not appear to be any
inquiry into whether the reviewers could find documentation indicating caregivers received the
Common Application. Similarly, the State’s case record reviews did not conjunctively consider
whether the Placement Summary and Attachment A were provided to a placement or caregiver
and whether they included all known information related to the child’s history of sexual abuse or
sexual aggression. The State’s case record reviews appeared to test for one or the other but did
not examine the percentage of cases in which they could confirm that the documents were both
provided to the caregiver and included all known information related to the child’s sexual
history.459
Consequently, the Monitors’ second series of case record reviews, completed for this
report, assessed whether a Common Application associated with the placement being reviewed
could be found in IMPACT, and if so, whether it included all known information related to a
child’s history of sexual abuse or sexual aggression. Whether a Common Application includes all
information related to the child’s history does not show that the caregiver received the Common
Application, particularly if there is no Common Application in IMPACT that clearly corresponds
with the placement under review.460
Determining whether a Common Application found in IMPACT corresponded to the

placement under review was challenging. Of the 145 placements reviewed by the monitoring team
involving a child who had an indicator for sexual aggression, 94 (65%) Common Applications
459
Deborah Fowler and Kevin Ryan, First Court Monitors’ Report 2020 at 239 -240.
460
The Monitors’ case reviews for the First Report asked only whether the child’s Common Application included
information about the child’s history of sexual abuse or aggression, similar to DFPS’s case reviews. While adding
the question related to whether a Common Application could be found corresponding to the placement under review
improves the case reads, it still does not guarantee that the caregivers at the placement received it or reviewed it. As
discussed in the Monitors’ First Report, on-site child file reviews showed the Common Application to be missing in
20% of files reviewed. Deborah Fowler and Kevin Ryan, First Report at 244. The monitoring team found a Common
Application in only 47% of children’s files reviewed during the only site visit the Monitors conducted since publication
of the First Report, to Devereux-League City. Deborah Fowler and Kevin Ryan, First Report at footnote 51.
222
clearly corresponded to the placement under review. In another 39 (27%), the Common
Application was found in IMPACT, but the monitoring team was unable to determine whether it
corresponded to the placement being reviewed. The monitoring team could not find any Common
Application in 12 cases (8%).461
Figure 6.9: Common Application in IMPACT with Children’s History of Sexual

Aggression
Source: Case review data, sexual aggression indicated
in common application, March - October 2020
n=145
Yes Unable to determine No
12
8%
39
27%
94
65%
Similarly, of the 465 placements reviewed for children who had an indicator for sexual
abuse, the monitoring team found a Common Application that was clearly associated with that
placement in 271 (58%) instances. The monitoring team found a Common Application but was
unable to determine whether it corresponded to the placement being reviewed in another 128 (28%)
cases and found no Common Application for 66 (14%) placements.
461
The Common Application was considered “not found” when no Common Application was found for the child in
IMPACT or when the date on the Common Application was prior to the placement and the child’s placement log had
not been updated.
223

Victimization
Source: Case review data, sexual victimization indicated

in common application, March - October 2020
n=465
Yes Unable to determine No
66
14%
128 271
28% 58%
The number of placements reviewed in which the monitoring team found a corresponding
Common Application that included all of a child’s sexual history was lower. For placements
involving a child with an indicator for sexual aggression, the monitoring team found a Common
Application corresponding with the placement under review that included all of the child’s history
in 57% (83 of 145) of placements. For placements involving a child with a history of sexual abuse,
a Common Application corresponding to the placement that included all of the child’s history of
sexual abuse was found in 50% (234 of 465) of those reviewed.
224
Figure 6.11: Common Application in IMPACT with Children’s Complete History of Sexual
Aggression or Sexual Abuse
Source: Case Review Data, Complete Sexual History Indicated in

Common Application, March - October 2020
n=610
Common App found - includes all sexual history
Common App found - incomplete or no sexual history
Common App not found or unable to determine
Sexual History Indicator
Sexual aggression 83 11 51
Sexual abuse 234 37 194
0 100 200 300 400 500

Number of Cases
The rate of finding a Common Application with complete information corresponding to

the placement reviewed did not improve significantly over time for children with an indicator for
sexual aggression, though it did improve for children with a history of sexual abuse:
225
Aggression or Sexual Abuse By Period
Source: Case Review Data, March - October 2020

n=610
Common App not found or unable to determine
Common App found – incomplete or no sexual history
Common App found – includes all sexual history
Sexual Aggression Indicator Sexual Abuse Indicator

n=145 n=465
100% 100%
23%
80% 32% 31%
80% 46% 46%
Percent of Cases
49%
13%
3% 6%
60% 60%
6% 4%
14%
40% 40%
64% 65% 63%
20% 46% 51%
20% 40%
0% 0%
Q3 Q4 Sep-Oct Q3 Q4 Sep-Oct
Case Read Case Read
As the Monitors assessed whether a Common Application corresponding to a child’s

placement could be found that included all known history, the Monitors also analyzed whether
differences emerged when the entity responsible for the placement was DFPS or an SSCC. The
analysis showed that DFPS out-performed the SSCCs for both placements involving children with
an indicator for sexual aggression and sexual abuse:
226
Aggression or Sexual Abuse By Entity Responsible for Placement

n=608

n=144* n=464*
DFPS (n=100) SSCC (n=44) DFPS (n=287) SSCC (n=177)
70% 66% 70% 65%

61% 60% 58%
60% 60%
50% 48%
50% 50%
38%
40% 40%
30% 30%
20% 20%
10% 10%
0% 0%
Common App Common App Common App Common App
found includes all history found includes all history
*The entity responsible for placement was unknown for two cases (one sexual aggression and one sexual abuse case).
Placement Summary
In addition to the Common Application, DFPS relies on the Placement Summary form and
Attachment A to provide caregivers with information related to a child’s history of sexual
victimization or aggression. The Placement Summary includes a section to guide the “Discussion
with the Receiving Caregiver” which includes “Needs Relative to History of Sexual Victimization,
Sex Trafficking, Sexual Behavior Problem, or Sexual Aggression.”462 This section allows the
caseworker to indicate, by checking a box, whether the child has any known sex trafficking or
sexual victimization history, has sexual behavior problems and a corresponding characteristic
marked in IMPACT, or has engaged in sexually aggressive behavior and a corresponding episode
documented on the sexual aggression page in IMPACT.463 The form notes:
“All information regarding a child’s history of sexual victimization, or sexual

aggression is documented on Child Sexual History Report (Attachment A).
Caregivers and Caseworker must sign Attachment A acknowledging that they have
reviewed and received/provided the document. For foster homes, this includes all
foster parents. For kinship homes, this includes all adults with unsupervised access
462
DFPS, Placement Summary, Form K-908-2279.
463
Id.
227
to the child living in the home. For placement in General Residential Operation,
this form must be signed by the administrator of the operation, the intake or
admissions staff, if applicable, and the case manager. Caseworkers must ensure
that this form is reviewed with any caregivers not present at the time of placement
and obtain their signatures on the form within three business days. Additional
required signatures on the form may be scanned and returned through e-mail.”464
During the Monitors’ case record review, in addition to determining whether a Common
Application could be found corresponding to the placement episode being reviewed, the
monitoring team also looked for a Placement Summary and Attachment A associated with the
placement. Reviewers found both a Placement Summary and Attachment A for placements
involving a child with an indicator for sexual aggression in 64% of placements reviewed (110 out
of 171) and found both forms for placements involving a child with an indicator for sexual abuse
in 54% (306 out of 565) of placements reviewed. The case record reviews also revealed that the
percentage of placements in which the reviewer found both a Placement Summary and Attachment
A associated with the placement increased over time.
Figure 6.14: Percent of Placements in which Both Placement Summary and Attachment A
Associated with the Placement was Found By Period
Source: Case Review Data, Attachment A and

Placement Summary Found, March - October 2020
n=736
Q3 (n=264) Q4 (n=265) Sep/Oct (n=207)
100%
80%
63% 65% 66%
Percent of Cases
59% 61%
60%
44%
40%
20%
0%
Sexual aggression Sexual abuse
Sexual History Indicator
The monitoring team also recorded how often the Placement Summary and Attachment A included
all information related to a child’s history of sexual abuse or sexual aggression, and whether the
464
Id.; DFPS began requiring the caseworker and caregiver to sign the Attachment A when the new IMPACT
enhancements were deployed on December 19, 2019, which automatically populate Attachment A with the
information included in the relevant IMPACT pages related to a child’s history of sexual abuse or aggression. See
Exhibit C, supra note 454, at paragraphs 26 – 29.
228
forms were hand-signed465 by the receiving caregiver. If the form was signed, the monitoring team
also determined whether it was signed on or before the placement start date. The charts below
show the results of the case record review.
Figure 6.15: Number of Placements with Both Placement Summary and Attachment A
Found, Includes Sexual History Information, and Signed by Receiving Caregiver on or
Before Start of Placement
Source: Case review Data, March - October 2020, n = 736
Results across all of the issues that the monitoring team reviewed improved over time, though
results for placements involving a child flagged with an indicator for sexual abuse lagged behind
those for placements involving a child flagged with an indicator for sexual aggression.
465
While it is possible that the ability to obtain hand signatures was affected by the onset of the pandemic, particularly
during the period when caseworkers were not making in-person visits to children’s placements, a typed “signature” is
problematic from the standpoint of validating caregiver receipt.
229
Figure 6.16: Percent of Placements with Hand Signed Placement Summary and
Attachment A On or Before Placement By Period

n=736
n=171 n=565
Both forms found Both forms found
Both forms include history Both forms include history
Both forms signed on or before placement start Both forms signed on or before placement start
63% 65% 66%

59% 61%
Percent of Cases
61%
Percent of Cases
54% 51%
54% 44%
40% 41% 46%
31% 34% 30% 37%
26%
Q3 Q4 Sep-Oct Q3 Q4 Sep-Oct
Case Read Case Read
Finally, the placements were analyzed according to the entity responsible for placement
(DFPS or an SSCC). The SSCCs outperformed DFPS in this analysis:
230
Figure 6.17: Percent of Placements with Hand Signed Placement Summary and
Attachment A On or Before Placement By Entity Responsible for Placement
Source: Case review data, March - October 2020

n=736
n=170 n=564
DFPS (N = 126) SSCC (N = 44) DFPS (N = 387) SSCC (N = 177)
100% 100%
80% 75% 80%

60% 59%
60% 60% 54% 55%
43% 43%
38%
40% 40%
20% 20%
0% 0%
Both forms found Hand signed by Both forms found Hand signed by
receiving caregiver receiving caregiver
on or before start on or before start
*The entity responsible for placement was unknown for two cases (one sexual aggression and one sexual abuse case).
Results were also analyzed according to placement type: foster home, congregate care
(GROs), and adoptive/kin. As the charts indicate, results were particularly poor for adoptive or
kinship placements.
231
Figure 6.18: Percent of Placements with Hand Signed Placement Summary and Attachment
A On or Before Placement By Living Arrangement
Source: Case review data, March - October 2020

n=736
n=171 n=565
Attachment A hand signed Attachment A hand signed
Placement Summary hand signed Placement Summary hand signed
77% Foster home 72%

Foster home
Living Arrangement
59% 52%
Living Arrangement
(34) (169)
80% Congregate care 71%

Congregate care 53%
(111)
62% (296)
Adoptive/kinship 42% Adoptive/kinship 51%

27% (100)
39%
(26)
Total 74% 68%

56% Total
(171) (565)
50%
0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Percent of Cases Percent of Cases
*Congregate care includes children in intensive mental health placements. Includes hand signatures only.
State’s Case Record Reviews
The Monitors reviewed the State’s case record reviews for the 3rd and 4th quarters of fiscal
year 2020, and the first quarter of fiscal year 2021. The review for the 4th quarter was an
“abbreviated” review that included a partial month of August 2020. In these case record reviews,
DFPS tested for:
• Whether the Common Application includes all known information about the child’s sexual
history.
• Whether the Placement Summary (or equivalent SSCC form) and Attachment A include
all known information about the child’s sexual history.
• Whether the caregiver received the Placement Summary and Attachment A.
o According to the case review reports, “Reviewers are confirming this either by
seeing the copy of the signed Placement Summary Form 2279 and Attachment A
or by speaking with the caregiver in a joint call with the caseworker during which
232
the caregiver confirms he or she received the child’s 2279 and Attachment A and
was aware of the child’s sexual victimization history.”466
In each of the three case record reviews reviewed, DFPS reported that almost all of the Common
Applications reviewed included all known information about a child sexual victimization history
or history of sexual aggression:
• Quarter 3, FY 2020: The Common Application included all known information related to
a child’s sexual victimization history in 86% (177 of 205) of cases reviewed, and included
all known information related to a child’s history of sexual aggression in 90% (47 of 52)
cases.
• Quarter 4, FY 2020: The Common Application included all known information related to
a child’s sexual victimization history in 93% (208 out of 224) of cases reviewed, and
included all known information related to a child’s history of sexual aggression in 83% (49
of 59) of cases.
• Quarter 1, FY 2021: The Common Application included all known information regarding
a child’s sexual victimization history in 92% (206 of 224) of cases reviewed, and included
all known information related to a child’s history of sexual aggression in 84% (52 of 62)
of cases.
The State did not verify that the caregiver received the Common Application, nor that the Common
Application found in IMPACT corresponded to a particular placement reviewed.
The State’s case reviews present mixed success related to the Placement Summary and
Attachment A. Though the reviewers found a high percentage of the forms included all known
information related to the child’s history of sexual victimization or sexual aggression, results
related to confirmation of caregiver receipt of the forms were problematic:
• Quarter 3, FY 2020: The State reported Attachment A included all known information
related to a child’s history of sexual victimization in 95% (162 of 170) of cases reviewed,
and included all known information related to a child’s history of sexual aggression in 98%
(42 of 43) cases reviewed. However, the reviewers could verify that the Placement
Summary form and Attachment A were provided to the caregiver in only 57% (129 of 228)
of cases reviewed for children with a history of sexual victimization. Similarly, the
reviewers verified that the Placement Summary form and Attachment A were provided to
466
DFPS, Child Sexual History Case Review Results Quarter 3 – Federal Fiscal Year 2020, at 3-4 (on file with
Monitors); DFPS, Child Sexual History Case Review Results Quarter 4 – Federal Fiscal Year 2020 (abbreviated), at
4 (on file with Monitors); DFPS, Child Sexual History Case Review Results Quarter 4 – Federal Fiscal Year 2020, at
3 (on file with Monitors). During the contempt hearing, Carol Self gave an example of the way that telephone calls
were used to verify caregiver receipt, “[I]f we contacted a caseworker and they said, ‘I don’t have the documents, but
I did tell the caregiver at the time that I placed,’ then the Quality Assurance Team will set up a joint call with the
caseworker and caregiver to talk to the caregiver to make sure that the caregiver can confirm that they were provided
the information.” Transcript, Testimony of Carol Self, supra note 174, at 289-90.
233
the caregiver in only 60% (35 of 58) of cases involving a child with a history of sexual
aggression.
related to a child’s history of sexual victimization in 91% (190 of 209) of cases reviewed,
and included all of a child’s history of sexual aggression in 88% (46 of 52) of cases
reviewed. However, the reviewers verified that the forms were provided to the caregiver
in only 67% (168 of 252) of cases reviewed for children with a history of sexual
victimization. Reviewers verified that the forms were provided to caregivers in 75% (46
of 61) of cases reviewed for a child with a history of sexual aggression.
related to a child’s history of sexual victimization in 93% (186 of 199) of cases, and
included all known information related to a child’s history of sexual aggression in 87% (47
of 54) of cases. However, reviewers verified the forms were given to the caregiver in only
66% (158 of 240) of cases involving a child with a history of sexual victimization and in
only 68% (44 of 65) of cases involving a child with a history of sexual aggression.
Summary
The monitoring team found a Common Application that corresponded to the placement
under review which contained all known information related to a child’s history of sexual abuse
in 50% of the placements reviewed, and contained all information related to a child’s history of
sexual aggression in 57% of the placements reviewed. The rate of finding a Common Application
with complete information corresponding to the placement reviewed did not improve over time
for children with an indicator for sexual aggression, though it did improve for children with a
history of sexual abuse. DFPS outperformed the SSCCs when results were examined according
to the entity responsible for the child’s placement.
The monitoring team found a Placement Summary and Attachment A for the placement
reviewed that included the complete history for children with an indicator for sexual aggression in
54% of placements reviewed and found a Placement Summary and Attachment A that included
the complete history for children with an indicator for sexual abuse in only 40% of cases. Of those,
the Placement Summary and Attachment A were hand-signed by the receiving caregiver on or up
to 30 days before the placement in only 30% of placements reviewed for children with an indicator
for sexual abuse, and only 40% of placements reviewed for children with an indicator for sexual
aggression. The SSCCs outperformed DFPS on this analysis.
While the State’s case reviews show that the Common Application, Placement Summary
(or equivalent SSCC document) and Attachment A almost always include all the known
information related to a child’s sexual history, the evidence indicates caregivers do not routinely
receive the information.
234
G. Remedial Orders A7 and A8: Awake-Night Supervision
Remedial Order A-7: The Defendants shall immediately cease placing PMC children housing
more than 6 children, inclusive of all foster, biological, and adoptive children, in licensed foster
care (LFC) placements that lack continuous 24-hour awaken-night supervision. The continuous
24-hour awake-night supervision shall be designed to alleviate any unreasonable risk of serious
harm.
Remedial Order A-8: Within 60 days of this Court’s Order, and on a quarterly basis thereafter,
DFPS shall provide a detailed update and verification to the Monitors concerning the State’s
providing continuous 24-hour awake-night supervision in the operation of LFC placements that
house more than 6 children, inclusive of all foster, biological, and adoptive children.
1. Background
Monitors’ First Report Performance Validation Findings
The Monitors’ First Report found that the State’s own certifications, as well as
placements’ self-reports, indicated ongoing issues related to Awake-Night supervision.
While the Monitors and the monitoring team did find Awake-Night staff at all GROs visited
prior to the First Report, during one visit the Awake-Night staff in one house appeared to
be sleeping and during another, a riot broke out and monitoring staff were left alone on a
wing with more than 20 children.467
During the September 2020 Contempt Hearing, the Court raised concerns revealed by the
Monitors’ review of the State’s Awake-Night certifications that the State’s list of children residing
in facilities did not match the children found in the residential facilities during on-site visits:
THE COURT: One other thing, just for the record. There were 91 certifications of 24-hour
awake-night supervision lists that were provided to the monitors that did not match the children
that were in the facility, including 13 repeat visits to those same facilities. And that is really
stunning. And when the monitors asked, I think they were, "Why you don’t have a current
list?”
467
At least two certifications documented failures to comply with the required staff-to-youth ratio. Certifications
indicated staff had not documented room checks as required by the facility’s Awake-Night policy, and one instance
in which the staff had pre-populated the room check document for the night. There was documentation of instances in
which Awake-Night staff were present in the facility but did not conduct frequent room checks (one example involved
room checks every two hours) or did not conduct any room checks during the night. Six certifications noted facility
staff did not have a listing of the children they were supervising and, in some of these cases, could not name the
children they were assigned to supervise. State staff notes from a visit to one placement indicated that the alarm on
the door of a child with a history of sexual aggression was not working and that the Awake-Night staff checked rooms
only three times each night.
235
I think we're told something vague like, "Well, that's just sort of a guideline.” And you’re
going, "Oh, no, this is not -- this is not actually happening.” Somebody needs to know where
these children are.468
Policy Changes Following the Monitors’ First Report
Beginning September 2020, DFPS instituted a number of progressive intervention contract

actions to address residential operations’ noncompliance with the continuous 24-hour Awake-
Night supervision requirement.
The new policy provided for a range of contract actions depending on the number,
frequency or both of any episodes of noncompliance as follows:
• Residential operations and DFPS staff are required to document and formally
notifying the operation of any violations in a final monitoring report.
• DFPS staff is to remain on the premises until compliance is achieved.
• DFPS staff and residential operation leadership conducting root cause analysis to
identify issues and barriers to implementing resolutions.
• The imposition of liquidated damages (withholding supplemental payments for
each episode of noncompliance), and a placement hold.469
On December 18, 2020, DFPS provided the Monitors with email correspondence between
DPFS and contracted residential providers that notified the providers of updates to the 24-Hour
Residential Child Care requirements. These updates are incorporated into the DFPS contract with
providers and include modifications to Section 1115 that define “Failure to Provide Supervision
and Failure to Provide Access” as follows:
Failure to Provide Supervision. Contractor’s Caregiver staff that fails to provide

continuous awake supervision for DFPS children. Examples of noncompliance
include, but are not limited to, Contractor’s Caregiver staff sleeping, have been
asleep, or awake staff that is not present at the location where DFPS children and
youth are located.
Failure to Provide Access. DFPS monitoring staff is unable to access the facility or
foster home. Examples of non-compliance include, but are not limited to monitoring
staff’s access that is denied, delayed by more than ten minutes, or there is no
response to DFPS monitoring staff’s attempt to obtain access to the placement.
Appendix V clarifies the contract action and liquidated process for contract
violations as follows:
Contract Actions and Liquidation Damages
468
Telephone/Zoom Show Cause Hr’g Tr., September 4, 2020 at 147- 148, EFC No 967.
469
Email from Audrey Carmical to Kevin Ryan and Deborah Fowler, Updates related to 24-hour supervision (Oct.
24, 2020) (on file with the monitors).
236
Contract Action #1. Four or fewer Non-Consecutive Violations of Section 1115.

• DFPS Staff will stay on the premises until Contractor complies;
• DFPS will contact the placement’s leadership (i.e., Director and/or Administrator)
to:
o Identify the cause for non-compliance, including challenges and barriers;
and
o Provide technical assistance as needed to assist in identifying a solution to
achieve compliance; and
• DFPS will provide written notification of a contract violation of the Continuous 24-
Hour Awake Supervision contract term in the form of a final monitoring report; and
• DFPS will require a Corrective Action Plan be submitted by the Contractor to
correct the concern(s) identified by DFPS.
Contract Action #2. Five Non-Consecutive Violations of Section 1115.

• The steps for Contract Action #1 will apply; and
• DFPS will contact the Contractor’s Board President or Executive Director, as
applicable, to address the pattern of violations and explain the Progressive
Intervention Steps.
Contract Action #3. At least one violation for non-compliance with Section 1115 in each
month for two consecutive months OR when there are two Consecutive Violations.
• The steps for Contract Actions #1 and #2 will apply;
• The DFPS Director of Placement will also participate when DFPS contacts the
Contractor to discuss the Contract Action and future plans for compliance; and
• Liquid Damages will be assessed. DFPS will withhold payments for one shift equal
to 415.46 x 8 hours - $123.68 for each instance of non-compliance beginning with
the second instance of non-compliance.
Contract Action #4. At least one violation for non-compliance with Section 1115 in three
consecutive months or when there are three consecutive Violations.
• The steps for Contract Actions #1 - #3 will apply;
• DPFS will suspend any further placements at the Contractor’s facility or operations;
and
• Liquidated Damages will be assessed. DFPS will withhold payments for ALL
shifts for each instance for non-compliance beginning with the third instance of
non-compliance.
o Liquidated Damages will continue until two unannounced visits within a
four week period show compliance with Section 1115.
Contract Action #5. At least one violation for non-compliance with Section 1115 in each
month in a consecutive five month period OR when there are five consecutive violations.
• The steps for Contract Actions #1 - #4 will apply;
• **DFPS will continue with placement hold;
• DFPS will proceed with the removal of children after taking appropriate next steps;
• DFPS will evaluate the need to terminate the Contractor’s contract; and
237
• Liquidated Damages will be assessed. DFPS will withhold supplemental payments

for ALL shifts for each instance of non-compliance beginning with the third
instance of non-compliance until all DPFS children have been removed from the
operation.
NOTE ON PLACEMENT HOLD FOR CPA. If a facility is a CPA, a placement hold will be
specific to the foster home that is in violation of Section 1115. The placement hold will continue
until, through attrition, the number of children in the foster home is six or fewer. Once a foster
home is reduced to six or fewer child because of noncompliance with Section 1115, DFPS
will not expand the number of children in the foster home.
EXCEPTIONS
• Kinship homes are excluded from placement changes.
• Contract Actins #3,4, and 5 are not applicable to CPA foster homes. 470
During a meeting on January 25, 2021, with DFPS and HHSC, the Monitors asked the
DFPS and HHSC what method the agencies used to follow-up on allegations raised during abuse
or neglect or RCCR investigations of failure to provide appropriate Awake-Night supervision. In
a follow-up to the conversation, the Monitors provided an example of a case that involved a child
who stated during an RCCI maltreatment investigation that staff slept at night and did not
appropriately check on residents. The Monitors asked DFPS whether “DFPS has a process in place
for investigators and caseworkers to relay information about gaps in Awake-Night supervision to
the unit/team responsible for overseeing compliance with Remedial Order A-7. If so, please detail
that process and indicate how the Monitors can find examples of that process at work.” 471
DFPS responded to the Monitors on March 11, 2021, reporting that it re-examined the
current process and identified gaps, explaining:
[W]e did not have a process for investigators to investigate those allegations when they
are unrelated to the allegations currently under investigation and not tied to a specific
allegation of abuse and/or neglect. We also did not have a process in place for Residential
Child Care Contracts and the 24-Hour Awake Monitoring Unit to communicate such
allegations or confirmed violations to RCCI so that it could investigate to determine
whether the circumstances rise to the level to constitute Neglectful Supervisions. 472
470
Email from Heather Bugg to Deborah Fowler and Kevin Ryan (December 18, 2020) 24-Hour Residential Child
Care Requirements, Residential Contracts (RCC). Available at
https://www.dfps.state.tx.us/Doing_Business/Purchased_Client_Services/Residential_Child_Care_Contracts/docum
ents/24_Hour_RCC_Requirements.pdf .
471
Email from Kevin Ryan to Heather Bugg, January 25, 2021 Meeting Follow-Up (February 2, 2021) (on file with
the Monitors.
472
Email Heather Bugg to Deborah Fowler and Kevin Ryan, ROA7 – Follow up from January 25, 2021 Meeting
(March 11, 2020) (on file with the monitors).
238
On March 16, 2021, DFPS provided the Monitors with details about “the new process being
implemented to address the identified gaps,” which had been communicated to staff through a
Field Communication:473
Field Communication #307:

Notifications Required When Residential Operation Does Not have 24-Hour Awake Night
Supervision, was issued on February 2, 2021 to Residential Child Care Staff. The Field
Communication provided notification to CCR staff of the procedures to take if during the
course of an inspection or investigation, “CCR staff become aware that staff are sleeping
on the job.” CCR staff are directed to report the information to DFPS Statewide Intake.474
DFPS followed the policy update with a flow chart detailing the updated reporting process.475
DFPS also provided details about the policy for 24-hour awake supervision:
In instances where operations are providing 24-hour awake supervision but are not
complying with the specifics of [its] 24-hour awake supervision policies and procedures,
effective December 15, 2020, DFPS contract managers making overnight visits were
instructed to continue monitoring whether operations are in compliance with [its] own 24-
hour awake supervision policies and procedures and provide technical assistance when
infractions are observed. These breaches, however, are not documented as violations and
will not be applicable to 24-Hour Residential Child Care Requirements, APPENDIX V:
24-Hour Awake Supervision Progressive Intervention and Liquidated Damages. However,
an operation’s failure to follow its 24-hour supervision policy is reported to the primary
DFPS contract manager, who will address the concern with the Provider through standard
contract management processes, including corrective action plans.476
In addition, DFPS reported that “by May 1, 2021, the agency plans to review all contracted
operations’ 24-hour supervision policies to determine if adjustments or refinements are needed.
Thereafter, each operation’s 24-hour policies will be reviewed annually beginning in FY 2022.”477
H. Remedial Orders A7 and A8 Performance Validation
1. Methodology
473
Id. Although HHSC did not directly respond to the Monitors’ question from the January 25, 2021 meeting or email,
on March 16, 2021, the Monitors received a transmittal email from HHSC indicating the agency had sent “CCR Policy
Updates,” which contained Field Communication #307.
474
HHSC, Field Communication #307 (Feb. 5, 2021), Notifications Required When a Residential Operation Does Not
have 24-Hour Awake Night Supervision.
475
Email from Heather Bugg to Deborah Fowler and Kevin Ryan, supplementing DFPS response dated March 11,
2021 (March 18, 2021) (on file with the Monitors)
476
Email from Heather Bugg to Deborah Fowler and Kevin Ryan, Progressive Intervention Plan (March 15, 2021)
(on file with the Monitors).
477
Id.
239
The Monitors’ validation of the State’s performance associated with Remedial Orders
A7 and A8 on 24-hour awake supervision included data analysis and review of information
from four primary sources:
• DFPS on-site Awake-Night verification documents;

• PMC child placement data;
• A list of foster homes with capacity greater than six children;
• Operations’ self-report violations; and
• Contract violations and progressive interventions required when an operation is found out
of compliance by DFPS.478
DFPS Certifications of Awake Night Supervision
Based on the placement data the State provided for PMC children, the Monitors determined
a total of 246 operation locations required Awake-Night supervision479 in at least one month from
March 2020 to October 2020. Of the 246 locations, 235 (96%) were GROs and 11 (4%) were foster
homes. Twenty-two of the operations480 (9%) were located outside the state.
The Monitors reviewed 1,667 DFPS Awake Night certifications provided by DFPS from
March 2020 to October 2020 and found that DFPS made overnight, unannounced visits to between
84% and 90% of the operation locations requiring Awake-Night supervision each month, and that
70% of the operations were visited in every month that they were required to have Awake-Night
supervision.481
478
The data was limited in the following respects:
• Data captured from Awake-Night certification documents were matched to PMC child placement data based
on Resource ID. For agency homes, both the CPA ID and the Placement Resource ID are included in the
child placement data and more than one Resource ID may be included in the certification document.
Additionally, multiple Resource IDs may be used for a single operation/location due to differences in
contracts and levels of care within a location. A number of attempts were made to match the Resource ID
contained in the certification documents to the PMC placement file, but there are some instances where
operation/location identified in the PMC data did not match to a certification due to conflicting Resource
IDs.
• DFPS onsite verification visits could have been conducted at operations/locations that do not require 24-hour
Awake-Night supervision (i.e., some operations have no PMC children present).
• DFPS noncompliance incident reports include the operation name, but do not include address or operation
number/ID for matching to other datasets.
479
Operations requiring Awake-Night supervision include GROs and foster homes with a total capacity greater than
6 children, and at least one PMC child placed or active in the month. The PMC child placement data has limitations
including, at times, gaps in updated placement dates. This could result in slight discrepancies in the number of PMC
children active or placed in a given month, and thus the total number of operations requiring Awake-Night supervision
each month.
480
Operation location was defined by street address. Operations with multiple addresses were counted for each address
and those operating different levels of care at the same address (e.g., emergency shelter and residential treatment)
were only counted once.
481
Eligible is defined as having at least one PMC child placed or active in the month and a total capacity greater than
6 children. Eligibility may change month to month for an operation depending on whether or not a PMC child is placed
there.
240
Figure 6.19: Number of Operation Locations Requiring Awake-Night Supervision Visited,

March to October 2020482
Source: PMC Child Placement Data and Awake Night Verification

Documents, n =1,642
Visit No visit
250
205 214
203 200 204 204 205 207
200 14%
16% 11% 12% 13% 15% 11% 10%
(30)
(33) (23) (25) (26) (31) (23) (21)
150
100 84% 89% 88% 87% 85% 89% 90% 86%

(170) (177) (179) (178) (174) (184) (184) (184)
50
0
Mar Apr May Jun Jul Aug Sep Oct
• 170 operation locations requiring Awake-Night supervision were visited in March (84%)
and 184 were visited in October (86%). Of the 30 locations with no visit in October 2020,
six were out of state and three were foster homes.
• 173 operation locations (70%) had visits in every month where that location had at least
one PMC child in placement. Of the 36 locations with no visits in any eligible month, eight
(22%) were out of state.
• Locations were visited multiple times in a month if an initial visit could not be completed
or if follow-up was needed. Between March and October 2020, 229 operation locations
accounted for a total of 1,667 visits.483 Of those, 1,462 (88%) involved an operation with
at least one PMC child present. The majority of locations requiring a visit were visited in
all eight months of the period examined.
• 13% of visits (209 or 1,667) lasted 15 minutes or less and 13% (214 of 1,667) lasted one
hour or longer. Visits lasting 15 minutes or less reported an average of 12 total children
present while visits lasting one hour or longer reported an average of 42 total children
482
Awake night certification visits conducted by DFPS continued to be made in person through spring of 2020 while
other in-person visits (i.e., licensing inspections) were suspended due to COVID-19. Of the operations without a visit
each month, some did have a visit (identified by operation name and address) but the Resource IDs provided on the
awake-night certification documents did not match the IDs provided in the PMC placement data. There were four such
cases in March, three cases in April, July, August, September, and October, and two cases each in May and June.
483
Multiple certification forms submitted for a single location with the same date and times (e.g., visits to an
emergency shelter and a residential care facility) were counted as a single visit. The total number of certification forms
DFPS provided to the Monitors was 1,744, eight of these were exact duplicates or otherwise in error.
241
present. Of all visits, a total of 20 children and seven PMC children were present on
average.
The monitoring team’s review of the certification reports revealed that DFPS documented
difficulty accessing sites in 5% (28 of 558) of visits that occurred between August and October
2020.484 In only 15 of 1,667 visits (1%), it was indicated that DFPS could not certify compliance
with the 24-hour Awake-Night requirement.
On October 13, 2020, DFPS conducted an Awake Night certification at the Hearts with
Hope – GRO – House B for which eight children were present. DFPS documented the following:
RCM arrived at House B at 2:45 am. RCM rang the doorbell and no one
answered. RCM knocked on the door and no one answered. RCM looked
through the window and saw someone laying on the couch with a blue, green
and white comforter. RCM called the facility number at 2:51, while still looking
in the window. The phone rang for 10 second and the person that was on the
couch answered the phone. RCM informed Ms. M, RCM was outside and please
open the door. Ms. M opened the door. RCM asked Ms. M if she was asleep.
Ms. M stated no. Ms. stated she did not hear the doorbell because she was in
the bathroom. While talking to Ms. M, she was stretching and seemed to be
tired.
Ms. M stated she was monitoring 8 kids. Ms. M stated she does 15 minute bed
checks. Ms. M stated she logs her bed check but she did not have copies of the
log. Ms. M found copies of the logs and stated she did not know she had copies.
She started the logs while RCM was standing at the facility.
During a case record review for another remedial order, the monitoring team reviewed an
RCCI abuse and neglect investigation of a child at the Kidz Safe Harbor Emergency Shelter.
During an interview, the child stated that staff were asleep during the night. In the review of the
State’s Awake-Night certifications, the monitoring team found that in follow-up to the child’s
statement, DFPS staff conducted an unannounced 24-Hour awake visit and documented the
following:
“I arrived at Kidz Safe Harbor Treatment Center Houston and rang the doorbell.
There’s a phone number listed outside to call to gain entrance. I called the phone
number twice and there was no answer. I could see someone looking through
the blinds. I called the phone number again no answer. Someone opened the
door and identified themselves as a resident. I asked was there a staff in the
house and the youth stated that he had just left and should return shortly. There
was another youth that came outside to observe. The youth were not able to go
outside the gate because it was locked, so they were talking to me through the
gate. I waited in the driveway for about 15 minutes until the night staff B
484
The monitoring team assessed in March – July whether the narrative reflected any issues. In August – October the
monitoring expanded consideration of the narrative to include whether there were any issues accessing the facility, as
well as whether the narrative reflected any issues with awake night supervision.
242
arrived. B arrived and stated that he was filling in for someone tonight. I asked
were the youth left alone after the previous shift and he stated no that he ran to
the store to use the restroom due to plumbing issues at the house. I inquired
about the youth being able to use the bathroom and he stated the plumbing was
fixed earlier and it just became an issue when he had to go to the bathroom. The
children were left in the home unattended and locked in the home with burglar
bars. B was asked was the supervisor notified that he would be leaving the youth
unsupervised and he stated no one was notified.
There are currently 10 boys total tonight in which 4 are PMC. B is the only staff
providing awake night supervision and he conducts room checks every 15
minutes. When B isn’t conducting room checks he sits in the middle hallway so
that he could hear and observe movement. When not doing room checks staff
is responsible for house chores.”485
DFPS Action Related to Contractual Violations of Awake-Night

Supervision Requirements
The Monitors reviewed self-reports of non-compliance made by operations to DFPS, and

reports provided by DFPS documenting violations found during awake night visits. Violations
documented included: staff sleeping or not present to provide awake supervision; not logging bed
checks as the operation’s policy requires; not complying with supervision ratio as the operation’s
policy requires; and DFPS not able to gain access to the operation for verification of awake
supervision.
DFPS reported 40 incidents of contractual violations reported by DFPS for Awake-Night

supervision requirements between March 1, 2020 and October 31, 2020. Some incidents had
multiple violations. Of the 40 incidents, 15 were self-reported by an operation, and 25 violations
were cited by DFPS following an unannounced visit.
485
DFPS, Certification of Awake Night Supervision, Kidz Safe Harbor Treatment Center Houston, January 21, 2021.
243
Figure 6.20: Incidents of Noncompliance with Awake-Night Supervision

Requirements
Source: DFPS Noncompliance Reports, March - October 2020
n = 40
14
12
12
10
10
8 7
6 5
5
4
2 1
0 0
0
Mar Apr May Jun Jul Aug Sep Oct
• 27 operations accounted for 40 incidents of noncompliance with Awake-Night

supervision requirements between March and October 2020.
• The 25 incidents cited as a result of unannounced visits represents approximately 1.5%
of the 1,667 visits conducted during the period.
• In 10% of incidents (4 of 40), COVID-19 was noted as an issue that affected staffing
and/or gaining access to facilities.
• 5 operations had more than one incident of noncompliance during the period. All of
these operations were subject to a corrective action.
The reasons noted for noncompliance were inconsistently documented in writing, ,

however a hand count performed by the monitoring team recorded the following violations:
Violation Noted Number of Violations*

Staff sleeping or not present 20
Not documenting bed checks per operation policy 11
Out of ratio per operation policy 9
Problem gaining facility access by DFPS staff 7
*More than one violation could have been found within a single incident.
More than half of noncompliance incidents did not have a corrective action plan requested
by DFPS following the finding of noncompliance.
244
Figure 6.21: Corrective Action Taken for Incidents of Noncompliance with Requirements
of Awake-Night Supervision
Source: DFPS Noncompliance Reports, March - October 2020

n = 40
No corrective action TA only CAP only Both TA and CAP
2
5%
14
35%
15
38%
9
22%
CAP is a Corrective Action Plan
Of the 14 incidents that did not result in a corrective action, four were later found to be
compliant with supervision requirements (reported as ratios found to be compliant or that there
were fewer than six children in placement) and one operation had their contract terminated (Prairie
Harbor). Two operations were documented as having failed to maintain bed check logs; these
facilities have contracts with the Community Based Care provider not with DFPS. In one instance,
the State documented that the CBC would address the issue with the provider to ensure compliance.
In a second instance, the State documented that the supervisor on duty would reiterate the
importance of maintaining accurate checks during shift briefings and would review random bed
log checks throughout the shift to ensure accuracy.
Five operations documented more than one incident of noncompliance during the period.
All of these operations were placed on a corrective action.486
486
According to the DFPS 24 Hour Residential Child Care Requirements, DFPS determines after a Monitoring Visit
or Self-Reported Violation that the Contractor is not in compliance with this Section. If a Contractor is not compliant
during a Monitoring Visit or a Self-Reported Violation, Progressive Contract Actions and Liquidated Damages may
be assessed against the Contractor (Appendix V). See DFPS 24-Hour Residential Child Care Requirements
https://www.dfps.state.tx.us/Doing_Business/Purchased_Client_Services/Residential_Child_Care_Contracts/docum
ents/24_Hour_RCC_Requirements.pdf .
245
Table 6.4: Number of Noncompliance Incidents for Operations with More Than One
Noncompliance Incident
Source: DFPS Noncompliance Reports, March – October 2020
n = 18
Operation Number of Incidents
Autistic Treatment Center 4
Bluebonnet Youth Ranch 3
Presbyterian Home 6
Sheltering Harbor 2
Whataburger Center* 3
*No longer in operation.
Summary
DFPS continues to document instances in which operations are failing to comply with the 24-
hour Awake-Night supervision requirements of Remedial Orders A7 and A8. Of the 40 instances
in which DFPS identified a violation of the Awake-Night requirement between March and October
2020, however, it required a corrective action plan in only 17 instances.
246
VII.REGULATORY MONITORING & OVERSIGHT OF LICENSED PLACEMENT
A. Remedial Order 22: Consideration of Abuse or Neglect/Corporal Punishment &

Obligation to Report Suspected Abuse or Neglect
Remedial Order 22: Effective Immediately, RCCL, and any successor entity charged with
inspections of childcare placements, must consider during the placement inspection all referrals
of, and in addition all confirmed findings of, child abuse/neglect and all confirmed findings of
corporal punishment occurring in the placements.487 During inspections, RCCL, and any
successor entity charged with inspections of childcare placements, must monitor placement
agencies’ adherence to obligations to report suspected child abuse/neglect. When RCCL, and any
successor entity charge with inspections of childcare placements, discovers a lapse in reporting,
it shall refer the matter to DFPS, which shall immediately investigate to determine appropriate
corrective action, up to and including termination or modification of a contract.
1. Background
As discussed in the Monitors’ First Report, Remedial Order 22 contains two distinct
requirements: First, the requirement that RCCR consider referrals and confirmed findings of abuse
or neglect and corporal punishment during inspections (which the State documents in CLASS in
“Extended Compliance History Reviews,” or ECHRs); and second, the requirement that RCCR
monitor obligations to report abuse or neglect and report any lapses to DFPS.
For the First Report, the Monitors conducted a case record review for the period of July
31, 2019 through January 31, 2020 to determine compliance with the remedial order’s first
requirement related to RCCR’s consideration of confirmed abuse, neglect or corporal punishment
findings during inspections. The case record review revealed that regardless of the period
reviewed, only 28% of the inspections/investigations completed an ECHR, and of those that had
an ECHR, only 58% were completed prior to or on the same day as the inspection/investigation.
487
In response to the State’s request for clarification regarding the timeframe for review and how to document RCCRs
consideration of the required elements during inspections, on October 7, 2019, the Monitors advised HHSC that the
Court, “directs with respect to the look-back period for considering all referrals of, and in addition, all confirmed
findings of, child abuse/neglect and all confirmed findings of corporal punishment, RCCL inspectors should assess
the previous 5 years. With respect to the request for clarification about how to document that the inspectors have
considered these referrals and findings, a check box is insufficient. The Court directs the agency to have inspectors
document in CLASS (1) the number of referrals of child abuse/neglect; (2) the number of confirmed findings of child
abuse/neglect; (3) the number of confirmed findings of corporal punishment; and (4) a narrative description of how
this data and information was considered.” Email from Kevin Ryan and Deborah Fowler to Andrew Stephens,
(October 17,2019)(on file with the monitors).
247
To validate compliance with the second requirement of Remedial Order 22, the Monitors
analyzed data provided by the State for citations related to failure to report abuse or neglect, and
interviewed caregivers during their on-site visits to GROs and RTCs. The State’s citation data for
the period between July 31, 2019 and March 20, 2020 indicated that RCCR issued very few (20)
citations for failure to report abuse or neglect. Yet, the interviews of direct care staff during the
on-site monitoring visits revealed that many staff were not aware of the policy and legal
requirements related to reporting abuse or neglect, and most said that they would not call SWI
themselves if they became aware of abuse or neglect. 488
Updates & Policy Changes Following the Monitors’ First Report
RCCR updated its Policy and Procedure Handbook in August 2020 (“Policy”), which
explicitly requires “Child Care Regulation (CCR) staff [to] conduct an extended compliance
history review prior to inspecting a residential child care operation, for all monitoring,
investigation, and monitoring/investigation inspections.”489 If a review of the extended compliance
history report reveals a confirmed finding of abuse or neglect or corporal punishment violation on
the RCCR SharePoint site, the inspector is required to consider: “the Explanation of the
Disposition Based on Preponderance narrative box located on the Investigation Conclusion page
(if applicable); the allegation narrative for the citation (if applicable); whether the allegations
involved a child under the age of 6; any follow-up activity that was completed; and any patterns
of investigations or the agency homes involved in the investigations.”490
The Policy also describes how RCCR staff are to document the ECHR. The inspector is
required to fill out in CLASS “the Extended Compliance History Review” section on the
“Inspection Details” page which includes the following data: the date the information was
reviewed; the number of abuse, neglect or exploitation intakes received; the number of confirmed
findings of abuse, neglect, or exploitation; the number of citations issued for corporal punishment;
and an assessment of the information reviewed, including any risk identified. In addition, within
one day of completing the inspection, the inspector is to document the steps taken during the
inspection to mitigate risk.491
488
The State responded to the Monitors’ findings in its written objections to the First Report, filed with the Court on
July 6, 2020. Defendant’s Verified Objections to Monitors’ Report, ECF No. 903. The State’s specific objections to
the section of the report detailing the Monitors’ findings related to Remedial Order 22 were: that the report incorrectly
stated that an ECHR is required prior to an investigation; that the report used an improper data timeframe as the basis
for its analysis; incorrectly concluded that failure to document the ECHR prior to the inspection date necessarily means
the reviews are not completed by the inspection date; incorrectly stated that HHSC had not adopted a formal policy
for ECHRs; criticizes defendants’ conduct based on case reviews without provided information regarding the cases
included in the sample or the process employed; and was based on the Monitors’ subjective assessments and
interpretations of inspectors’ responses during the interviews. Id. at ¶¶ 32, 33, 34, 36, 37, and 39. DFPS and HHSC
also provided the Monitors with an informal, unfiled response to the Report on June 15, 2020, which included many
of the same complaints raised in the objections.
489
HHSC, Policy and Procedures Handbook §4143.
490
Id. (emphasis in the original)
491
HHSC Policy and Procedures Handbook § 4143. (Emphasis in original).
248
September 2020 Contempt Hearing & The Court’s December 18, 2020
Contempt Order
Plaintiffs addressed Remedial Order 22 in their July 2, 2020 Motion to Show Cause,
arguing that the State should be held in contempt for failing to comply with the remedial order
based on the Monitors’ findings related to the low percentage of case reviews that showed an
ECHR had been completed.492 In response, the State pointed to the field communication to RCCR
inspectors issued in November 2019, and policy developed in May 2020 related to ECHRs as
evidence of compliance.493 The State also raised the same arguments regarding the flaws in the
Monitors’ case reviews that the State raised in its formal objections to the report.494
During the contempt hearing, Jean Shaw (“Shaw”), the Associate Commissioner for Child
Care Regulation within HHSC, testified to RCCR’s compliance with Remedial Order 22. Shaw
testified that RCCR began using ECHRs in December of 2019, and subsequently formalized the
process in policy in May 2020.495 Shaw also testified that, effective August 31, 2020 (four days
before the hearing started), RCCR began using a new field in CLASS to document ECHRs.496 The
Court asked the witness about RCCR’s inability to provide data indicating compliance with the
remedial order:
THE COURT: Why is it that you’re unable to provide any data as to completion or agency
review for the Extended Compliance History Review?
THE WITNESS: Prior to August 31st of 2020, we just did not have any mechanism in
CLASS to capture this information. We had staff document it through a…chronology, and
there’s not a way to track that data. But as of August 31, 2020, we now have the
components in our CLASS system that we will be able to track that information and provide
reports to the Monitors.
Shaw confirmed that RCCR did not do any case record reviews to verify compliance prior
to the August 31, 2020 CLASS enhancements becoming operational and could not offer any data
or information to rebut the Monitors’ findings in the First Report. 497
The Court held RCCR in contempt for failing to comply with Remedial Order 22, noting
HHSC made no efforts to verify whether its inspectors were conducting ECHRs for inspections
for more than a year after Remedial Order 22 went into effect, from July 30, 2019 through August
31, 2020. 498 The Court also rejected RCCR’s argument that Remedial Order 22 does not require
492
Plaintiffs’ Motion to Show Cause Why Defendants Should Not Be Held in Contempt (July 2, 2020), ECF No. 901.
493
Defendants’ Response in Opposition to Motion to Show Cause (July 24, 2020) 32-35, ECF No. 911.
494
Id.
495
Telephonic/Zoom Show Cause Hr’g, Tr. (September 4, 2020) 86-87, ECF No. 967.
496
Id. at 95-96.
497
Id. at 93:22 – 94:8; 100:13–101:5
498
HHSC attempted to shift blame for its inability to provide proof it was complying with RO-22, by arguing that the
Monitors did not provide HHSC with the sample of cases the Monitors reviewed. At the Show Cause Hearing, the
Court made clear that “the Monitors are not obligated to give HHSC-RCCL a list of every case included in their case
reads; HHSC-RCCL can conduct its own case reads to verify its own compliance with the court order to which they
are subject.” Id. at 106:9–13
249
its inspectors to document the ECHR before conducting an inspection. The Court found this
position to be inconsistent with the plain language of Remedial Order 22, which requires HHSC
to consider the ECHR during the placement inspection:
[I]f the extended compliance history reviews must be considered during an

inspection; it strains logic to argue that they need not be completed and
documented before that same inspection. Also, if a review is not
documented prior to or on the same day as the inspection, the Monitors have
no way of validating that the inspector considered the information during
the inspection, as required by the language of the Remedial Order.499
The Court also found HHSC’s argument disingenuous because its own Field
Communication #271 explicitly states “Effective December 1, 2019 [HHSC] Inspectors will be
required to conduct and document an extended compliance history review for each operation
before conducting an inspection.”500
Finally, the Court rejected HHSC’s argument that it exercised reasonable diligence in a
good faith effort to comply with Remedial Order 22, and that the Monitors’ case review did not
provide HHSC with any leeway for implementation after the date of the Court’s October 7, 2019
clarification of the remedial order. The Court reiterated that Remedial Order 22 was “effective
immediately” upon the Fifth Circuit’s Mandate on July 30, 2019, more than two months before
the Court’s clarification in October 2019. Yet, as the Court noted, HHSC did not inform its
inspectors of the requirements of the remedial order until December 1, 2019, did not implement a
formal policy until May of 2020, and did not make changes to its CLASS system that would allow
the agency to determine if it was in compliance with the remedial order until three days before the
Show Cause Hearing.501
Having rejected all of HHSC’s objections and arguments, the Court ordered DFPS to file
with the Court sworn certification of their compliance with RO-22 within 15 days of the date of
the Order.502
HHSC’s December 31, 2020 Certification of Compliance
On December 31, 2020, the State filed its sworn certifications related to Remedial Order
22. The certification attached as an exhibit an affidavit from Lana Estevilla (Estevilla) (Exhibit
A), HHSC Deputy Associate Commissioner for Regional Operations for Child Care Regulation,
outlining HHSC’s attempts to comply with RO-22 prior to the Contempt Hearing and after.503 In
the affidavit Estevilla certifies that HHSC has been running reports every weekday since
September 2, 2020 to “track the ECHR timeliness by staff. The reports are sent via email to each
regional director, who works with staff to ensure any overdue items are quickly entered.”504 Based
499
Order (December 18, 2020) 234-5, ECF No.1017.
500
Id. at 235. (Emphasis added).
501
Id. at 241-2
502
Id. at 250.
503
Defendants’ Certification of Compliance Regarding RO-22, Exhibit A, Sworn Declaration for RO-22, ECF No.
1019-1.
504
Id. at ¶16.
250
on this review, HHSC changed its policy regarding the timeframe to complete the documentation
for the steps taken to mitigate risk after the inspection from 24 hours to one calendar day after the
inspection is completed.505 In October 2020, 199 RCCR staff participated in a webinar informing
staff of the steps to be taken prior to the inspection, the steps to be taken after the inspection, and
what should be documented in the narrative boxes in CLASS.506
Estevilla’s affidavit indicates that in November 2020, HHSC conducted a case review to
certify that inspectors were timely and accurately entering the number of abuse or neglect intakes,
the number of confirmed findings of abuse or neglect, and the number of corporal punishment
deficiencies.507 The agency reviewed 33 cases, representing a 5% sample of inspections from
September 15, 2020 through October 31, 2020. 508 Although the review did find that inspectors
were entering the data points, the review also found that “inspectors may need further training to
ensure they properly document the assessment of the information reviewed, including any risk
identified.”509 To address this issue, Estevilla’s affidavit avers “an ECHR job aid was updated on
December 31, 2020, to provide additional information on completing the assessment of the
information reviewed, including examples of good documentation.”510
Estevilla’s affidavit also referred to the requirements in the remedial order related to abuse
and neglect reporting, reiterating RCCR policy that if during the course of an inspection or
investigation, an operation fails to report suspected abuse or neglect, a deficiency will be cited and
is contained in CLASS.511 When an operation fails to report suspected abuse or neglect, HHSC
has had an automated report that has been in place prior to July 2019 that pulls deficiency
information and sends it to DFPS.512
The State also filed an affidavit from William Walsh (Walsh) (Exhibit B), DFPS Director
of Purchased Client Services, in which he certified that when DFPS receives a notification from
RCCR of a Failure to Report Abuse/Neglect citation to its Residential Contracts mailbox, the
agency works to determine whether the facility cited is a DFPS provider; if it is, the course of
action may include providing the contractor with technical assistance, requiring a corrective action
plan, or modifying or terminating the contract.513 Walsh’s affidavit also addresses DFPS’s
amended investigation accounting procedures:
DFPS is also amending its procedures to account for investigations of Failure to

Report Abuse/Neglect citations that do not involve a child in DFPS
conservatorship. DFPS is also developing written guidelines that should be
505
Id. at ¶17.
506
Id. at ¶18.
507
Id. at ¶19.
508
Id. An additional 2 cases were read initially by the PMU team for consistency and case reading criteria validation.
PMU Case Reading Special Request - RC Extended Compliance History Review 2 (on file with Monitors).
509
Defendants’ Certification of Compliance Regarding RO-22, Exhibit A, Sworn Declaration for RO-22, ECF No.
1019-1, at ¶20.
510
Id.
511
Id. at ¶5(a).
512
Id. at ¶5(b).
513
Defendants’ Certification of Compliance Regarding RO-22, Exhibit B, Sworn Declaration for RO-22, ECF No.
1019-2, ¶10.
251
considered when determining a response. Additionally, DFPS will continue to

develop a more structured process for providing technical assistance and
documenting that technical assistance, as well as continuing to ensure timely action
is taken after receiving notice of a citation. Finally, DFPS is developing guidance
that will strengthen enforcement actions against operations with more than one
Failure to Report Abuse/Neglect citation.514
2. Data and Information Production
HHSC provided inspections data, pursuant to the Monitors’ September 2019 and February
2020 data and information requests to validate the Extended Compliance History Reviews
(ECHRs) required by Remedial Order 22. As of September 2020, data was provided monthly and
includes data for all inspections, investigations, assessment and monitoring conducted. For
September 2020 and thereafter, the data includes the ECHR review date and the date steps to
mitigate risk were entered in CLASS. Deficiencies data is also provided by HHSC and is used to
identify operations cited for failure to report.
For validation of the remedial order provisions related to abuse and neglect reporting, three
sources of information from HHSC and DFPS were utilized:
• HHSC provides data for all deficiencies cited, including corporal punishment, other
forms of prohibited punishment, failure to report, and failure to report within required
timeframes;
• HHSC produces a list of deficiencies cited for failure to report abuse or neglect each
month to DFPS; and
• DFPS provides the Monitors with a report on the failure to report notifications the
agency receives from HHSC
514
Id. at ¶21.
252
Methodology
ECHR Validation
To validate HHSC’s compliance with the Remedial Order 22 requirement that RCCR
consider referrals and confirmed findings of abuse or neglect and corporal punishment during
inspections, the monitoring team conducted a total of four case record reviews for the period from
March 1, 2020 through October 31, 2020.
Between March and August 2020, all RCCR inspections, with the exception of attempted,
application, and initial inspections, were included in the sample of cases reviewed. Two separate
case reviews were conducted for this time period:
• The first case reviews included a sample of 261 inspections out of a total of 803 from
March 1, 2020 to June 30, 2020; the second case reviews included a sample of 277, out of
a total of 980 inspections from July1, 2020 to August 31, 2020. Both case reviews included
95/5 samples.
• Inspections sampled included monitoring, investigation, monitoring and investigation,
follow-up, and “other” inspections.
• Both case reviews included identical questions regarding (1) whether or not an ECHR was
completed and the timing of completion; (2) the total number of intakes, ANE
investigations, and corporal punishment citations provided in the report; and (3) whether
or not the ECHR included a narrative description and if so, the extent to which the narrative
provided a discussion of how the information was considered (i.e., discussion of risk and
steps taken to mitigate risk).
RCCR inspections sampled for the case review between September 2020 and October
2020, were limited to monitoring, investigation, and monitoring and investigation inspections
since, as of August 2020, the State was no longer requiring ECHRs for any other type of inspection.
Because of this change, as well as the change in the method that ECHRs were being recorded in
CLASS,515 analysis of sampled cases between March 2020 and August 2020 are reported
separately from those sampled in September 2020 and October 2020. Two separate case reviews
were conducted for these two months:
• The first case review included a sample of 213 out of 436 inspections in September 2020
and the second case review included a sample of 196 out of 399 inspections in October
2020.
515
Starting September 1, 2020, a section was added to the Inspection Details page of CLASS, allowing ECHR data
entry directly into this page for each inspection. Prior to this date, ECHRs were documented by the inspector in the
CLASS chronological listing for the operation.
253
• Inspections sampled included monitoring, investigation, and monitoring and investigation

inspections. Monitoring and investigation inspections are counted under investigation
inspections.
Validation of Requirements Related to Reporting Abuse or

Neglect
To assess compliance with the Remedial Order 22 requirements related to the reporting of
abuse or neglect, the Monitors methodology included:
• Analysis of standards violations cited by RCCL against operations for failure to report, or
delayed reporting of, allegations of abuse or neglect; and
• Analysis of two state reports: – (a) HHSC list of deficiencies cited for Failure to Report
abuse or neglect provided each month to DFPS; and (b) DFPS report on the failure to report
notifications the agency receives from HHSC in a given time period – and comparison of
these reports with state deficiency data.
Though the Monitors’ methodology for the First Report included information from on-site
interviews conducted with direct care staff in GROs across the state, the onset of the COVID-19
pandemic significantly restricted the Monitors’ ability to conduct on-site visits to GROs during
this reporting period.
ECHR Validation
First Two Case Record Reviews (March 1, 2020 through August 31, 2020)
For the first two case record reviews, encompassing the period March 1, 2020 through
August 31, 2020, the Monitors sampled 538 of 1,783 HHSC inspections, a 95/5 sample, including
all types of inspections RCCR conducts as part of a minimum standards investigation, follow up
inspections, and inspections categorized as “other” in accordance with HHSC’s November 22,
2019, Field Communication #271.516 HHSC suspended on-site inspections due to the COVID-19
pandemic, other than those related to abuse or neglect investigations, for the period starting on
April 3, 2020, resuming inspections on June 11, 2020. This reduced the overall number of
inspections in the sample for this case review.
The Monitors conducted these case reviews prior to HHSC’s addition of a section to the
Inspection Details page in CLASS for ECHR data entry. To determine whether an ECHR was
associated with a given inspection, the Monitors examined the Operation’s chronological history
to identify a combination of the date the ECHR was completed, and the Inspection ID or
Investigation ID included in the report.
516
HHSC, Field Communication #271 (12/01/2019) at 2.
254
The Monitors sought to determine whether an inspector completed an ECHR for its
inspection, and whether an ECHR was clearly linked with that inspection during the period
examined. The Table below indicates how the Monitors made this determination.
Table 7.1: Definition for ECHR Found in Case Review
Case Review Definition Used

Response
An ECHR is found that explicitly indicates that it is for the inspection
Yes
or a linked investigation (i.e., the inspection ID is listed on the ECHR).
An ECHR cannot be located, there is an ECHR with no associated
inspection ID dated more than 5 days after the inspection begin date,
or there is an ECHR with a different inspection ID dated more than 5
No
days after the inspection begin date. An ECHR is found dated on or up
to 5 days after the inspection begin date, but the inspection ID is not
found in the report or a different inspection ID is listed.
The Monitors analyzed the results of the two case record reviews together. A majority of
inspections included in the two samples, 88%, (475 of 538) were monitoring or investigation
inspections.517 Only 5% (24) were follow up inspections and 7% (39) were considered “other”
inspections.
Of the 538 cases reviewed, 51% (273) of the inspections did not have an ECHR that was
clearly linked to the inspection. Monitoring inspections had an ECHR completed most often, with
a 55% completion rate followed by Investigations inspections with a 51% completion rate. Of
those inspections with an ECHR, 27% (72 of 265), were completed one or more days prior to the
inspection, 60% (159 of 265) were completed the same day as the inspection,518 and 13% (34 of
265) were completed one or more days after the inspection.
The monitoring team reviewed the completed ECHRs to determine if they contained all of
the Court required components and found that 235 of 538 (44%) had completed ECHRs containing
all of the required components. Of those with a completed ECHR:
• 93% (246 of 265) included all three required data elements (abuse or neglect intakes and
findings, and corporal punishment citations).
• 94% (250 of 265) included a narrative discussion:
517
"Monitoring and Investigation inspections” are counted as part of “Investigation inspections.”
518
During the monitoring team’s interviews with inspectors, of the 31 inspectors interviewed, 23 (74%) reported they
start the ECHR the day before the inspection, while eight (26%) reported they start the ECHR the day of the inspection.
All 11 supervisors interviewed reported that their expectation is that the ECHR should be completed no later than the
day before the inspection is to take place.
255
o 17% of ECHRs (43 of 250) did not include a discussion of the abuse or neglect
findings in the narrative.
o 17% of ECHRs (43 of 250) did not include a discussion of the corporal punishment
findings in the narrative.
• 62% (154 of 250) of inspections where an ECHR narrative was found had risk factors
identified, of these 31% (48 of 154) did not include a discussion of risk in the ECHR
narrative.
• 53% of completed ECHRs with a narrative and identified risk did not include a discussion
of steps to mitigate the risk identified.
• 45% of the 250 ECHRs with a narrative were assessed by the monitoring team as poor
quality, overall.519
• 7% of inspections with an ECHR found and a prior ECHR had either no change at all or
no change in the narrative from the prior to the current ECHR.
Third & Fourth Case Record Reviews (September through October 2020)
The third and fourth case record reviews were conducted for the time period of September
1, 2020 to October 31, 2020, and changed the methodology (as discussed, above) to account for
changes HHSC made to the Inspection Details page. The modification included data entry for
ECHR into CLASS for each inspection, instead of documenting the ECHR as a chronological entry
for the operation. The CLASS Inspection Details page was modified to include the following
sections related to ECHRs: Date ECHR Reviewed; Number of Abuse/Neglect/Exploitation Intakes
Received; Number of Confirmed Abuse/Neglect/Exploitation Findings; Number of Corporal
Punishment Citations; Assessment of Information Reviewed (a narrative box); and Steps Taken to
Mitigate Risk (also a narrative box).520
Additionally, on September 29, 2020, HHSC, through a new Field Communication #292,
instructed staff that RCCR would not require an ECHR to be completed for follow-up and “other”
inspections.521 These changes resulted in differences in findings across case record reviews before
and after Sept. 1, 2020.
For this case record review, the monitoring team sampled 49% (409 of 835, a 95/5 sample)
of monitoring, investigation, or monitoring and investigation inspections from September 1, 2020
through October 31, 2020. The majority of inspections included in the case review (75%, or 307
of 409) were investigation inspections and 25% (102 of 409) were monitoring inspections.522 With
the change to documenting the ECHR in CLASS in the Inspection Details page, complete ECHR
information was more consistently recorded. The number of inspections with completed ECHRs
dramatically improved to 100%, as did the inclusion of the required elements (abuse or neglect
519
In assessing ECHR narratives, the monitoring team considered the quality of information provided in the narrative
related to findings of abuse, neglect, and corporal punishment, and the potential implications for risk to child safety,
and whether the narrative included any discussion of steps taken to assess or mitigate identified risks.
520
HHSC guidance allows for the “Steps to Mitigate Risk” section to be completed up to one day after the inspections.
521
Field Communication #292, and HHSC Policy and Procedures Handbook § 4143 requires RCCR staff to conduct
an ECHR prior to conducting a monitoring, investigation, or monitoring/investigation inspection at a residential
childcare operation. HHSC did not base changes to state policy on changes in court requirements.
522
“Monitoring and Investigation” inspections are counted as a part of “Investigation” inspections.
256
intakes, abuse or neglect findings, and corporal punishment citations as well as a narrative
description), also found to be 100% (409 of 409).
In 33% (137 of 409) of the ECHRs reviewed, inspectors entered these elements one-to-five
or more days before the inspection, with the remaining ECHRs reviewed entered the day of the
inspection.523
Figure 7.1: Days from ECHR Review Date to Inspection Begin Date for Inspections with an
ECHR
Source: Case Review Data, September - October 2020

n=409
5 or more days prior to inspection 3%

(13)
2-4 days prior to inspection 5%

Timing
(21)
Day before inspection 25%

(103)
Day of inspection 67%

(272)
0% 20% 40% 60% 80% 100%

Percent Completed
Data elements reported by inspectors in the ECHRs regarding abuse or neglect intakes and
findings and corporal punishment citations were found to be largely consistent with the data
provided by the State to the Monitors for the operation, with the exception of abuse or neglect
intakes.
523
Though the inspection page includes the time the inspection began and ended, the ECHR box does not include a
time stamp; therefore, it is impossible to know whether it was completed prior to the start of the inspection, during the
inspection, or after the inspection concluded.
257
Figure 7.2: Comparison of ANE/Corporal Punishment Data Found in Extended

Compliance History Reviews and State Aggregate Data as of the First Day of the Month
Source: Case Review Data and ECH Intakes and Corporal Punishment
Citations as of First Day of the Month, September - October 2020
n=409
ANE Intakes 32% 11%

57% (233)
(132) (44)
Matched exactly
Category
6%<1%
ANE Findings 94% (385) (23) (1) Within +/-3 of state
numbers
Greater than +/-3 of
Corp Punish 3% state numbers
Citations 97% (395) (14)
0% 50% 100%
Percent of Cases
Accuracy improved slightly from the May 1, 2020 - August 31, 2020 time period524 for
abuse or neglect findings and corporal punishment citations. Abuse or neglect findings (160 of
175) and corporal punishment citations (165 of 182) matched exactly for 91% of ECHRs in the
May 1, 2020 - August 31, 2020 sample of cases reviewed, compared to 94% (385 of 409) of
ECHRs with matching information on abuse or neglect findings and 97% (395 of 409) of ECHRs
with matching information on corporal punishment citations in the September 1, 2020 – October
31, 2020 sample of cases reviewed. For abuse or neglect intakes, the proportion matching exactly
declined from 70% (121 of 174) in the May 1, 2020 -August 31, 2020 sample of cases reviewed
to 57% (233 of 409) in the sample of September 1, 2020 - October 31, 2020 cases reviewed.
There is no date field in CLASS that the Monitors could use to determine when inspectors
entered the “Steps Taken to Mitigate Risk” narrative in the Investigation Details page. Data
provided by HHSC indicates that 85% of inspections in the case record review sample (349 of
409) had the “Steps Taken to Mitigate Risk” entered on the same day or the day after the
inspection.
Although documentation of the completion of ECHR rose dramatically with the change in
CLASS, the discussion of abuse or neglect findings and corporal punishment citations in the
narrative decreased. For inspections with at least one abuse or neglect finding, 38% of ECHRs
524
Starting in May 2020, the State began providing the Monitors with aggregate data on the number of ANE intakes,
confirmed findings, and corporal punishment citations for each operation as of the first day of each month. This data
was matched to the case read data by operation for inspections conducted in May through August 2020, and September
through October 2020, to compare the numbers included in ECHRs.
258
(85 of 223) in September 1, 2020 – October 31, 2020 cases reviewed did not include a discussion
of the abuse or neglect findings in the narrative compared to 32% (43 of 135) of ECHRs reviewed
between March 1, 2020 and August 31, 2020. This was also true for inspections with at least one
corporal punishment citation: 42% of ECHRs (94 of 222) did not include a discussion of the
corporal punishment findings in the narrative in September 1, 2020 – October 31, 2020 cases
reviewed compared to 31% (43 of 139) of ECHRs reviewed between March 1, 2020 and August
31, 2020. Inspectors were more likely to include a discussion of the abuse or neglect findings and
corporal punishment citations in the narrative if the inspection was tied to monitoring instead of
an investigation inspection.525
Inspectors often listed abuse or neglect cases with an RTB outcome and/or corporal
punishment citations but included no synopsis of trends or patterns found. Inspectors were also
more likely to include a discussion of the abuse or neglect findings and corporal punishment
citations in the narrative when inspecting an RTC versus a GRO versus a CPA.526 When the ECHR
was linked to an investigation of a foster home, the ECHRs would often review the CPA’s
compliance history, without considering the history of the foster home that was the focus of the
investigation.
To determine whether the inspectors were analyzing identified patterns or trends, the
Monitors reviewed the narrative discussion to determine if identified patterns/trends were in the
inspection or investigation. Approximately 70% (290 of 409) of inspections were found to have a
pattern or trend to consider. However, as shown in Figure 7.3 only half of these ECHRs included
in the narrative a discussion incorporating an analysis of this pattern into the inspection.
525
For operations with at least one abuse or neglect finding, 73% of ECHR narratives for monitoring inspections (33
of 45) included a discussion of abuse or neglect findings compared to 59% of those for investigation inspections (105
of 178). For operations with at least one citation for corporal punishment, 75% of ECHR narratives for monitoring
inspections (36 of 48) included a discussion of citations compared to 53% of those for investigation inspections (92
of 174).
526
70% of ECHR narratives for inspections at RTCs (41 of 59) included a discussion of abuse or neglect findings for
operations with at least one finding compared to 60% of inspections at GROs (37 of 62) and 59% of inspections at
CPAs (33 of 45). 71% of ECHR narratives for inspections at RTCs (30 of 42) included a discussion of corporal
punishment citations for operations with at least one citation, compared to 53% of inspections at GROs (26 of 49) and
55% of inspections at CPAs (72 of 131).
259
Figure 7.3: Consideration of Identified Pattern, September to October 2020527
Source: Case Review Data, September - October 2020

n=290
10
3%
57
20%
137
86
47%
30%
Steps to Mitigate Risk Discussed

Inspector took Steps to Identify Pattern
No Narrative
Other
Specific examples of the failure to include discussion of patterns or trends in the ECHR narrative,
include:
• An ECHR for an investigation inspection, in which the foster parent who was the subject
of the underlying investigation had multiple intakes for inappropriate discipline, including
at least one substantiated allegation that involved pinching a child for wetting their pants.
None of this was mentioned in the narrative; the narrative simply listed the case numbers.
• An ECHR for an inspection of a GRO with a history of RTBs for Physical Abuse that did
not include a discussion of the abuse in the narrative.
• An ECHR in an investigation inspection in which the narrative noted that there had been
multiple citations and RTBs for corporal punishment for the CPA but did not look at the
history of the particular home under investigation. The foster parent had been investigated
for abuse or neglect seven times across two CPAs and had an RCCR investigation in a case
that had been downgraded from SWI and sent to HHSC. Review of the intakes shows a
527
“Other” cases cite the inspector taking some steps to discuss risk but not enough to qualify identification or
discussion of a pattern.
260
pattern of allegations of the foster mother hitting the children, but none of this is mentioned
in the narrative.
• An ECHR in an investigation inspection which failed to note that the home that was the
subject of the underlying investigation is one of the homes that had been cited for corporal
punishment. Though the allegations in the underlying investigation were not related to
corporal punishment, when the child was interviewed he said that the foster mother laid on
top of him during a restraint when he was on his stomach, and was verbally provoking him
to hit her. This allegation was discounted by the inspector/investigator after a cursory
investigation because the foster parents denied it happened.
• An ECHR for a GRO with a history of ANE for Physical Abuse and corporal punishment
noted that the operation had been cited 166 times over the previous five years, but did not
indicate the nature of the citations or if any pattern(s) were present.
• An ECHR in an investigation inspection for an operation that is currently under Heightened

Monitoring did not discuss any of the abuse or neglect or corporal punishment findings, or
make any attempt to determine whether there were patterns or trends that should be
considered.
The case record reviews also collected information regarding how well RCCR
inspectors/investigators updated the content of ECHRs from one inspection to the next. Of the
409 ECHRs reviewed between September 1, 2020 and October 31, 2020, 86% (353) had a prior
ECHR found for the associated operation; of these, the narrative and numbers had changed in 72%
(255 of 353). The narrative alone had changed in 21% (73 of 353); the numbers had changed but
the narrative had not in another 4% (13 of 353), and in 12 (3%), the ECHRs showed no change at
all.
When the associated inspection was a result of an investigation, the monitoring team
reviewed whether a current allegation for the underlying investigation was similar to a pattern or
trend identified in the ECHR. Of the 307 investigation inspections reviewed between September
1, 2020 and October 31, 2020, the Monitors found that 18% (56 of 307) of the allegations that
were the subject of the investigation were similar to a pattern or trend in the ECHR and of those,
only 43% (24) of the ECHRs discussed the similarity.
Finally, in assessing ECHR narratives, the monitoring team considered the quality of
information provided in the narrative on findings of abuse, neglect, or corporal punishment,
potential risk to child safety, and steps taken during inspection to mitigate and/or identify risk to
child safety. Nearly 40% of ECHR narratives reviewed by the monitoring team between
September 1, 2020 and October 31, 2020 were found to be of poor quality overall.
State Case Record Review on Extended Compliance History Reviews
HHSC provided the Monitors a case record review on compliance with ECHRs. The
State’s case record review sampled both investigation inspections and monitoring inspections
261
between September 15, 2020 and October 31, 2020 and included a sample size of 33.528 The
findings of the State’s case record review529 are reflected in the table, below.
Table 7.2: State Case Record Review on Extended Compliance History Reviews
Case record review questions % Responding “Yes”
Staff entered the correct data in the following field in ANE Intakes – 89%
CLASS:
ANE Findings – 97%
• ANE Intakes
Corporal Punishment
• ANE Findings Citations – 94%
• Corporal Punishment Citations
If staff included a reference to the number of ANE Overall – 96%
intakes, ANE findings, and/or corporal punishment
CPA – 100%
citations in the narrative field, was the data correct?
GRO – 90%
The steps taken to mitigate risk were in line with the Overall – 86%
assessment.
CPA – 95%
GRO – 73%
Validation of Requirements Related to Reporting Abuse or

Neglect
The first analysis utilized was to review the monthly deficiencies data provided by the State
including deficiencies cited in investigations, inspections, and assessments. The six standards
identified as Failure to Report abuse or neglect include:
• 748.303(a)(3)(A), related to a GROs obligation to report allegations of abuse, neglect, or

exploitation;
• 748.303(a)(4)(A) related to a GROs obligation to report allegations of physical abuse
committed by a child against another child;
• 748.303(a)(5)(A) related to a GROs obligation to report allegations of sexual abuse
• 749.503(a)(3)(A) related to a CPAs obligation to report allegations of abuse, neglect, or
exploitation;
528
An additional 2 cases were read initially by the PMU team for consistency and case reading criteria validation.
PMU Case Reading Special Request - RC Extended Compliance History Review 2 (on file with Monitors).
529
PMU Case Reading Special Request Summary of Findings.
262
• 749.503(a)(4)(A) related to a CPAs obligation to report allegations of physical abuse

• 749.503(a)(5)(A) related to a CPAs obligation to report allegations of sexual abuse
committed by a child against another child.
Citations for Failure to Report Abuse or Neglect make up a small proportion of overall
deficiencies cited, 0.8% or 29 out of a total of 3,669 citations issued during the period of March
2020 through October 2020.530 Deficiencies for Failure to Report abuse or neglect were steady
throughout the period with an average of 4 citations a month.531
Slightly more than half of citations, 15 of 29, were issued in connection with an abuse or
neglect investigation, while 12 of 29 were issued in connection with a non-abuse or neglect
investigation. One Failure to Report citation was issued in connection with a monitoring
inspection, and one was issued in connection with an assessment.
• 41% of the deficiencies cited for Failure to Report abuse or neglect, or 12 of 29, occurred
in CPA operations while the remainder were split between GROs (9 of 29) and RTCs (8 of
29).
• Regarding the standards cited, both CPAs and RTCs had a majority of their Failure to
Report citations around findings of abuse, neglect or exploitation (nine of 12 and six of
eight, respectively), while a majority of the Failure to Report citations for GROs concerned
findings of sexual abuse (five of nine).
• 26 operations accounted for the 29 deficiencies cited for Failure to Report during the time
period.
o 38% or ten of the 26 operations are currently on Heightened Monitoring.532
o Three operations had two deficiencies cited during the period.533
o 13 operations had a Failure to Report deficiency cited during the prior past five
years.
530
Deficiencies cited include waived, upheld, and pending administrative review.
531
RCCR suspended all on-site inspections, with the exception of those related to abuse or neglect findings
investigations, between April 3 and June 11, 2020 due to the COVID-19 outbreak.
532
Operations cited as of April 14, 2021 on Heightened Monitoring: A World for Children, Benchmark Family
Services, The Grandberry Intervention Foundation, Inc, Children’s Shelter, Connections Inc Emergency Shelter, Fred
and Mabel R Parks Youth Ranch, Freedom Place, Promise House, A Fresh Start Treatment Center, Texas Hill Country
School. An additional three operations cited were placed on Heightened Monitoring but as of January 4, 2021 no
longer had a contract with DFPS: Whataburger Center, Prairie Harbor LLC, and Hearts with Hope Foundation
533
Operations with two deficiencies: Benchmark Family Services, Presbyterian Children’s Home and Services, and
Promise House.
263
Figure 7.4: Number of Prior Failure to Report Deficiencies Between 9/30/2014 and
2/29/2020 for Operations with a Failure to Report Deficiency Between March 1, 2020 and
October 31, 2020
Source: Deficiencies Data, September 30, 2014 - October 31, 2020

n=13
Benchmark 11
Prairie Harbor 4
Whataburger Center 3
HMIH Cedar Crest 3
A World for Children 3
Texas NeuroRehab Center 2
Operation
Devereux 1
Texas Dept of FPS Reg 5 1
Presbyterian Children's Home & Services 1
Krause Children's Residential 1
Good Hearts Youth & Family Services 1
Freedom Place 1
Covenant Kids, Inc. 1
0 2 4 6 8 10 12
Number of Deficiencies
The second analysis completed by the Monitors was a comparison of the following three
sources of data:
• deficiencies data associated with RCCR inspections, investigations and assessments

provided to the Monitors monthly by HHSC;
• the HHSC report, submitted to the Monitors monthly, including only deficiencies cited for
Failure to Report abuse or neglect; and
• the DFPS report, provided monthly to the Monitors, including the failure to report
notification (i.e., citations issued) DFPS receives from HHSC.
The number of citations for failure to report abuse or neglect varied across the different
deficiencies data reported to the Monitors.
264
Figure 7.5: Number of Failure to Report ANE Deficiencies Cited Between March 1, 2020
and October 31, 2020 by Data Source
Source: Deficiencies Data, HHSC Report on Cited Deficiencies,

and DFPS Report on Failure to Report Notifications
n=67
35
29
Number of Deficiencies
30
25 20
20 18
15
10
5
0
Deficiencies Data HHSC Report DFPS Report
Data Source
• Sixteen citations for Failure to Report abuse or neglect were found in all three data sources.
• Three citations were found in both the deficiencies data and the HHSC report that were not
found in the DFPS report.
• One citation was found in the DFPS and the HHSC reports that were not found in the
deficiencies data.534
Citations included in the HHSC reports appear to be limited to the abuse or neglect standards and
exclude those specifically related to physical or sexual abuse.
534
This deficiency was later overturned following administrative review.
265
Figure 7.6: Citations for Failure to Report ANE in Deficiencies Data

Source: Deficiencies Data and HHSC Report on Failure to Report Deficiencies Cited
n=29
Summary
While HHSC has made improvement ensuring ECHRs are reviewed prior to or on the day
of the inspection and has created a consistent method for staff to document the ECHRs in CLASS,
improvement remains necessary in the documentation of trends and patterns, as well as in the
quality of how the information was considered during the inspection. The Monitors’ first case
review revealed that only 44% of cases reviewed had an ECHR containing all of the required
components.
While the Monitors’ third and fourth case record reviews showed that the changes to
CLASS dramatically improved ECHR completion rates, the quality of the narratives discussing
abuse or neglect and corporal punishment findings declined: in cases reviewed between September
1, 2020 and October 31, 2020, 38% of ECHRs did not include a discussion of the abuse or neglect
findings in the narrative and 42% did not include a discussion of the corporal punishment findings,
compared to 32% of ECHRs that did not include a discussion of abuse or neglect findings and 31%
that did not include a discussion of corporal punishment findings in cases reviewed between March
1, 2020 and August 31, 2020. Similarly, though 70% of cases included in the review revealed a
pattern or trend in abuse or neglect intakes or substantiated findings, or corporal punishment
findings, only half of those ECHRs discussed the pattern or trend in the narrative. The case review
also revealed a gap found in applying the ECHR to foster homes: often the data and the narrative
were reflective of the CPA and not the foster home where an investigation was occurring.
When comparing the three sources of data for Failure to Report, the number of citations
for failure to report abuse or neglect varied across deficiencies data. Citations included in the
266
HHSC reports appear to be limited to the abuse or neglect standards found in Title 26 of the Texas
Administrative Code §§748.303 (a)(3)(A) and 749.503(a)(3)(A)(which require a report of
allegations of abuse, neglect, or exploitation) and seem to exclude those specifically related to
child-on-child physical or sexual abuse, found Title 26 of the Texas Administrative Code
§§748.303(a)(4)(A) and 749.503(a)(4)(a) (which both relate to reporting an incident of physical
abuse of a child against another child) and §§748.303(a)(5)(A) and 749.503(a)(5)(A)(which relate
to reporting an incident of sexual abuse of a child against another child) . The Monitors could not
find an explanation for this variation.
B. Remedial Orders 12-19: Timeliness of Minimum Standards Investigations
1. Remedial Orders 12 through 19: Timeliness of Minimum Standards Investigations
Remedial Order 12: Effective immediately, the State of Texas shall ensure the Residential Child
Care Licensing (“RCCL”) investigators, and any successor staff, observe or interview the alleged
child victims in Priority One child abuse or neglect investigations within 24 hours of intake.
and any successor staff, observe or interview the alleged child victims in Priority Two child abuse
or neglect investigations within 72 hours of intake.
and any successor staff, complete Priority One and Priority Two child abuse and neglect
investigations within 30 days of intake, consistent with DFPS policy.
and any successor staff, complete Priority Three, Priority Four and Priority Five investigations
within 60 days of intake, consistent with DFPS policy.
and any successor staff, complete and submit documentation in Priority Three, Priority Four and
Priority Five investigations within 60 days of intake.
267
and any successor staff, finalize and mail notification letters to the referent(s) and provider(s) in
Priority Three, Priority Four and Priority Five investigations within 60 days of intake.
Background
HHSC is responsible for regulating child-care and child-placing operations in Texas and
for creating and enforcing minimum standards. Each set of minimum standards is based on a
particular chapter of the Health and Human Services title of the Texas Administrative Code; Title
26 Chapter 749 sets forth the minimum standards for CPAs, including those that serve PMC
children.535 The minimum standards establish basic requirements to protect the health and safety
of children in care and are weighted by HHSC based on the agency’s assessment of the risk that a
violation of that standard presents to children. RCCR, as part of HHSC, is responsible for
inspecting CPAs for compliance with these minimum standards and investigating reports of
standards violations. These investigations by RCCR, ordinarily known as minimum standards
investigations, are classified as Priority One, Two, Three, Four or Five.536
During the last reporting period, HHSC indicated to the Monitors its position that Remedial
Orders 12 through 14 did not apply to minimum standards investigations.537 While its policies
were consistent with Remedial Order 14, the policies conflicted with Remedial Orders 12 and 13.
As of November 1, 2020, HHSC has updated its policies to be consistent with Remedial Orders
12 and 13. HHSC policies now requires RCCR staff to initiate and make face-to-face contact with
all identified victims within 24 hours of intake in Priority One investigations and within 72 hours
in Priority Two investigations.538 The policy change requires staff to document the date and time
of each face-to-face contact with an alleged victim in Priority One and Two investigations at a
residential operation.539 The exceptions for making such contact with a victim outside of the
required timeframe include if the alleged victim’s whereabouts are unknown during the initiation
timeframe; or “the alleged victim was identified after the required time frame to conduct face-to-
face contact.”540 The previous policy for Priority One investigations did not require face-to-face
contact, although initiation was required within 24 hours.541 Similarly, in Priority Two
investigations, initiation did not require face-to-face contact with all alleged child victims;
535
See generally 26 TEX. ADMIN. CODE §§ 749.1 - 749.4267.
536
See generally HHSC, Child Care Licensing Policy and Procedures Handbook § 6240 (2021) available at
https://hhs.texas.gov/laws-regulations/handbooks/cclpph/6000-investigations#6240 (Child Care Licensing Policy and
Procedures). More information about the definitions of the priorities is also included in the first Monitors’ report to
the Court. See also Deborah Fowler and Kevin Ryan, First Report 273, ECF No. 869.
537
See Deborah Fowler and Kevin Ryan, First Report 274-275, ECF No. 869.
538
DFPS, RCCR Field Communication #294 (Jan. 29, 2021) (on file with the Monitors).
539
Id.
540
HHSC., RCCR Field Communication #294 (Jan. 29, 2021) (on file with the Monitors). An investigation may be
completed without making face-to-face contact with the victim only when the whereabouts of the victim were
unknown during the entire course of the investigations; the alleged victim is deceased; or the alleged victim no longer
lives in Texas. Id.
541
268
moreover, the initiation time frame permitted five days between intake and initiation instead of 72
hours.542 The current policies are now consistent with Remedial Orders 12 and 13.
Monitors Data and Information Request and Production

Monitors Data and Information Request
To validate the State’s performance with respect to Remedial Orders 12 through 19, the
Monitors requested from the State key data points for all investigations conducted by RCCR
regarding any child in the PMC General Class on a quarterly (now monthly) basis.543
HHSC produced data files for RCCR investigations on the Monitors’ requested timeline.
HHSC cannot distinguish between PMC and non-PMC child-related investigations in its data
production; therefore, the data does not include the PMC child identifier(s) linked to the referrals
or investigations as requested by the Monitors and rather include all investigations for the time
period contained in the report.544 HHSC also stated that it could not provide the following
requested data fields as to RCCR investigations:
• the time of the first face-to-face contact with an alleged victim, noting any and all
untimely face-to-face contacts and the reason for any approved extensions to the face-
to-face contact timeframe;
• the relationship(s) of the alleged perpetrator(s) to the alleged child-victim(s);
• the date the completed investigation was submitted to the supervisor for approval;
• the date the supervisor approved the investigation;
• the disposition of each allegation; the overall disposition of the investigation; and
• the date of any notification letters to parents.545
542
543
Monitors’ Data and Information Request (Sept. 30, 2019) (on file with the Monitors). The Monitors requested
certain identifying information to support validation, including: Intake stage ID number; Investigation stage ID
number; Person ID (for all alleged PMC victims); County where maltreatment is alleged; Most recent investigator
name and ID; Date and time investigation stage started; Program conducting investigation; Child’s placement type at
intake; Placement resource at time of intake; the manner of initiation (action taken by the investigator that triggered
the start of the investigation); the date/time of face to face contacts with alleged victim(s) as applicable noting any and
all untimely face to face contacts and the reason(s) for any approved extensions to the face to face contact timeframe;
the relationships of the alleged perpetrator(s) to the child-victims. Id.
544
According to HHSC: “[t]he agency is operations-centric not child centric. CLASS does not contain the PMC
identifier of children involved in a referral [or investigation]; the PMC identifier is only associated with referrals of
abuse or neglect in IMPACT.” Memorandum from Tex. Health & Human Servs. Comm’n to Kevin Ryan and Deborah
Fowler, Monitors, at 5-6 (Dec. 6, 2019) (on file with the Monitors) (responding to the Monitors’ Sept. 30, 2019 Data
and Information Request). See also, Deborah Fowler and Kevin Ryan, First Report 275, ECF No. 869.
545
Id.
269
In addition, consistent with the prior reporting period, HHSC did not provide the date and
time of face-to-face contact with all alleged child victims in cases that involve multiple alleged
victims; rather, it provided only the first face-to-face contact date with an alleged child victim in
cases where such contact occurred.546 As of December 2020, HHSC began to provide an additional
monthly report starting with cases initiated as of November 1, 2020. The report includes case
reviews by HHSC of its Priority One and Two investigations, reporting on timely face-to-face
contact performance. Those data will be reviewed in the next reporting period. Finally, in this
reporting period, HHSC added a data field to indicate which investigations did not require
notification to the reporter consistent with its policy.547
Remedial Orders 12 through 19 Performance Validation (HHSC)
Methodology
To validate the timeliness of the State’s performance associated with Remedial Orders 12
through 19, the Monitors assessed all 2,225 completed minimum standards investigations with an
intake date between April 1, 2020 through September 30, 2020. Because HHSC reported it does
not have the capacity to distinguish which investigations involve PMC children and instead
produced to the Monitors all of its minimum standards investigations in the period, the Monitors
evaluated all RCCR investigations included in the data HHSC produced with intake dates between
April 1 through September 30, 2020.548 The investigations fell into the priority levels described in
Table 7.3 below.
• Remedial Order 12: To measure timeliness of HHSC’s face-to-face contact with alleged
child victims in Priority One investigations, the Monitors calculated performance using the
data fields for intake date and “first face-to-face contact with victim date.” The “face-to-
face contact with victim date” provided by HHSC includes only a date, not a time-of-day
timestamp. The Monitors used a standard of one calendar day to approximate performance.
The calculation is based upon the intake date and the date of the first face-to-face contact
with the child victim.
• Remedial Order 13: To measure timeliness of HHSC’s face-to-face contact with alleged
child victims in Priority Two investigations, the Monitors calculated performance using
the data fields for intake date and “first face-to-face contact with victim date.” The “face-
to-face contact with victim date” provided by HHSC includes only a date, not a time-of-
day timestamp. The Monitors used a standard of three calendar days to approximate
performance. The calculation is based upon the intake date and the date of the first face-
to-face contact with the child victim.
546
See Deborah Fowler and Kevin Ryan, First Report 276. ECF No. 869.
547
HHSC, Child Care Licensing Policy and Procedures Handbook § 6640 (2021) available at
https://hhs.texas.gov/laws-regulations/handbooks/cclpph/6000-investigations#6640.
548
The data file used for this analysis was a listing of all non-abuse neglect investigations completed between
December 1, 2019 to December 31, 2020. HHSC AR TX 229 RO.15-19.2 12.01.2019-12.31.2020 RCCL.Inspec
1.14.2021.xlsx (on file with the Monitors).
270
• Remedial Order 14: To measure timely completion of Priority One and Priority Two
investigations, the Monitors calculated performance using the intake date and the date the
investigation was completed.
• Remedial Order 15: To measure timely completion of Priority Three, Priority Four, and
Priority Five investigations, the Monitors calculated performance using the intake date and
the date the investigation was completed.
• Remedial Order 16: To measure timeliness of completing and submitting documentation

in Priority One and Priority Two investigations, the Monitors calculated performance using
the date the investigation was completed and the date documentation was completed.
• Remedial Order 17: To measure timeliness of completing and submitting documentation

in Priority Three, Priority Four, and Priority Five investigations, the Monitors calculated
performance using the intake date and the date the documentation was completed.
• Remedial Order 18: To measure timeliness of mailing notification letters to the referents
and providers in Priority One and Two investigations, the Monitors calculated performance
using the date the investigation was completed; the date of notification to the reporter;
whether notification to the reporter was required;549 and the date of notification to the
provider. To be compliant with this Order, HHSC must have notified both the referent and
the provider within five days of completing the investigation. If either the referent or the
provider was notified more than five days after the investigation was completed or was not
notified at all, the notification was counted as untimely.
• Remedial Order 19: To measure timeliness of mailing notification letters to referents and
providers in Priority Three, Priority Four, and Priority Five investigations, the Monitors
calculated performance using the data fields for intake date; date of notification to reporter;
whether notification to the reporter was required; and date of notification to provider. To
be compliant, HHSC must have notified both the referent and the provider within sixty
days of the intake date. If either the referent or the provider was notified after more than
sixty days or were not notified at all, the notification was counted as untimely. Where
HHSC left data cells in the date of notification fields empty, the Monitors assumed that
notification had not occurred when calculating performance.
549
Pursuant to the Texas Health and Human Services Commission Child Care Licensing Policies and Procedures
Handbook, §6640, there are five exceptions to referent notification: “the reporter has indicated that he or she does
not want to be notified; there is a reasonable likelihood that notifying the reporter will jeopardize the reporter’s
safety; the reporter is the person in charge, director, administrator, applicant, permit holder, head of governing body
or designee and will receive notice in another capacity; the intake is identified as a Self Report on the Intake
Report page and the Investigation Main page; or the reporter is anonymous.” HHSC, Child Care Licensing Policy
and Procedures Handbook § 6640 (2021) available at https://hhs.texas.gov/laws-
regulations/handbooks/cclpph/6000-investigations#6640.
271
Table 7.3: Priority of RCCR Investigations
RCCR Investigations, April 1 to September 30, 2020

Source: HHSC RO12-RO19 data
Priority Number Percent
Priority One 2 0.1%
Priority Two 406 18.2%
Priority Three 1,288 57.9%
Priority Four 10 0.4%
Priority Five 519 23.3%
Total 2,225 100%
Remedial Order 12: Timeliness of Observations or Interviews

with Alleged Child Victims in Priority One Investigations
Effective immediately, the State of Texas shall ensure the Residential Child Care Licensing
(“RCCL”) investigators, and any successor staff, observe or interview the alleged child victims in
Priority One child abuse or neglect investigations within 24 hours of intake.
HHSC reported two Priority One investigations with intake dates between April 1 and
September 30, 2020. HHSC’s data submissions did not include time stamps for face-to-face
contact with the victims in Priority One investigations; therefore, the monitoring team used
calendar days to approximate performance with Remedial Order 12 with the data available.550
Using this methodology, the data confirm that 50% (1) of the Priority One investigations included
first face-to-fact contact with an alleged child victim within 24 hours of intake.
The data field provided by HHSC for the first face-to-face contact with an alleged child
victim was available for one of the two investigations; in that investigation, the contact was
completed within 24 hours of intake.551 In the second Priority One investigation, the data did not
indicate whether or not face-to-face contact was made with an alleged child victim and the data
field was blank.552
550
For example, if the intake date was August 1, 2020, and the face-to-face contact with victim date was August 4,
2020, the Monitors calculate three days between intake and initiation.
551
The Monitors also conducted a case record review and confirmed that the child was seen within twenty-four hours;
additionally, the Monitors confirmed that the alleged victim was a child with PMC status.
552
The Monitors conducted a case record review and confirmed that face-to-face contact did not occur with an alleged
child victim within twenty-four hours due to the child’s runaway status; that child was in TMC status. In the Monitors’
first report, there was only one Priority One investigation and it was related to a child fatality. Deborah Fowler and
Kevin Ryan, First Report 278, ECF No. 869.
272
Remedial Order 13: Timeliness of Observation or Interviews

with Alleged Child Victims in Priority Two Investigations
observe or interview the alleged child victims in Priority Two child abuse or neglect investigations
within 72 hours of intake.
HHSC reported 406 Priority Two investigations with an intake date between April 1, 2020
and September 30, 2020. HHSC’s data submissions did not include time stamps for face-to-face
contact with the victims in Priority Two investigations; therefore, the monitoring team used
calendar days to approximate performance for Remedial Order 13. Using this methodology, 41%
(167) of investigations included first face-to-face contact with an alleged child victim within three
days of intake; 26% (106) of investigations did not conduct face-to-face contacts within three days;
and data were not available for 33% (133) of investigations. The rate of first face-to-face contact
within three days declined from the rate in the Monitors’ first report (59%) due to low rates in the
first months of the pandemic.553
Figure 7.7: Timeliness of Face-to-Face Contact with Alleged Child Victims in Priority Two
HHSC Investigations
Source: HHSC Investigations April - September 2020

n=406 Priorty Two Investigations
70%
62%
60% 55%
49% 49%
50%
Percent Timely
40%
30%
20% 14%
11%
10%
0%
Apr-20 (63) May-20 (63) Jun-20 (71) Jul-20 (59) Aug-20 (77) Sep-20 (73)
Intake Month
553
273
Remedial Order 14: Completion of Priority One and Two

Investigations within 30 Days
complete Priority One and Priority Two child abuse and neglect investigations within 30 days of
intake, consistent with DFPS policy.
HHSC reported 408 Priority One (2) and Priority Two (406) investigations with an intake
date between April 1, 2020 and September 30, 2020. During this period, HHSC completed 96%
(392) of investigations within 30 days of intake. HHSC’s rate of completing Priority One and
Priority Two minimum standards investigations within 30 days was nearly the same as the rate in
the Monitors’ first report (95%).554
Figure 7.8: Completion of Priority One and Two Investigations within 30 Days

n=408 Priorty One and Two Investigations
100%
98% 98%
98% 97%
96% 95% 95%

Percent Timely
94%
94%
92%
90%
88%
86%
Apr-20 (63) May-20 (63) Jun-20 (71) Jul-20 (59) Aug-20 (78) Sep-20 (74)
Intake Month
Remedial Order 15: Completion of Priority Three, Four, and

Five Investigations within 60 Days of Intake
complete Priority Three, Priority Four and Priority Five investigations within 60 days of intake,
consistent with DFPS policy.
554
274
HHSC reported 1,817 Priority Three, Four, and Five minimum standards investigations
with an intake date between April 1, 2020 and September 30, 2020. The priorities assigned to these
investigations are as follows: Priority Three (1,288); Priority Four (10); and Priority Five (519)
investigations. During this period, HHSC’s performance improved by completing 98% (1,786) of
investigations within 60 days of intake. HHSC’s rate of completing Priority Three, Four, and Five
minimum standards investigations within 60 days in the Monitors’ first report was 96%.555
555
See Deborah Fowler and Kevin Ryan, First Report at 280, ECF No. 869.
275
Figure 7.9: Completion of Priority Three, Four, and Five Investigations within 60 Days of
Intake

n=1,817 Priorty Three, Four, and Five Investigations
100% 99% 99%
99% 98%
98% 98%
97%
Percent Timely
96%
94%
92%
90%
Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20
(288) (347) (301) (285) (306) (290)
Intake Month
Remedial Order 16: Completion and Submission of

Documentation on the Same Day the Investigation was
Completed in Priority One and Two Investigations
complete and submit documentation in Priority One and Priority Two investigations on the same
day the investigation is completed.
HHSC reported 408 completed Priority One (2) and Priority Two (406) completed
investigations with an intake date between April 1, 2020 and September 30, 2020. During this
period, in 93% (381) of the investigations, the documentation was completed on the same day the
investigation was completed. HHSC’s rate of completing documentation on the same day the
investigation was completed in Priority One and Priority Two investigations was close to the rate
in the Monitors’ First Report (96%).556
556
276
Figure 7.10
Priority One and Two RCCR Investigations Completed

n=408 Priority One and Two Investigations
100%
97% 97%
95%
95% 93%
Percent Timely
92%
90%
87%
85%
80%
(63) (63) (71) (59) (78) (74)
Intake Month
Remedial Order 17: Completion and Submission of

Documentation within 60 Days of Intake in Priority Three,
Four, and Five Investigations
complete and submit documentation in Priority Three, Priority Four and Priority Five
investigations within 60 days of intake.
HHSC reported completion of 1,817 Priority Three (1,288), Priority Four (10), and Priority
Five (519) investigations with intake dates between April 1, 2020 and September 30, 2020. During
this period, HHSC completed documentation within 60 days of the intake date in 97% (1,765) of
the investigations. HHSC’s rate of completing documentation on the same day the investigation
was completed in Priority Three, Priority Four, and Priority Five investigations was nearly the
same as the rate in the Monitors’ First Report (96%).557
557
277
Figure 7.11: Completion and Submission of Documentation within 60 Days of Intake in

Priority Three, Four, and Five Investigations

100%
99%
98% 98% 97%
97%
97%
Percent Timely
96%
96%
94%
92%
90%
(288) (347) (301) (285) (306) (290)
Intake Month
Remedial Order 18: Notification Letters Sent within Five Days

of Investigation Closure in Priority One and Two
Investigations
finalize and mail notification letters to the referent and provider(s) in Priority One and Priority
Two investigations within five days of closing a child abuse and neglect investigation or
completing a standards investigation.
HHSC reported completion of 408 Priority One (2) and Two (406) minimum standards
investigations with intake dates between April 1, 2020 and September 30, 2020. Of
those 408 investigations, 93% (380) of investigations included notification to the referent (or the
278
referent was anonymous);558 and notification to the provider was within five days of completion
of the minimum standards investigation.559 HHSC’s reported rate of notifying the referent and
provider within five days of completion of Priority One and Priority Two minimum standards
investigations was higher than the rate in the Monitors’ First Report (77%);560 previously, HHSC
did not report data indicating which investigations did not require notification to the reporter.
Figure 7.12: Notification Letters Sent within Five Days of Investigation Closure in Priority
One and Two Investigations

n=408 Priority One and Two Investigations
100% 98%
95%
95% 94%
Percent Timely
92%
90% 91%
90%
85%
80%
(63) (63) (71) (59) (78) (74)
Intake Month
Remedial Order 19: Notification Letters Sent within 60 Days of

Intake in Priority Three, Four, and Five Investigations
finalize and mail notification letters to the referent(s) and provider(s) in Priority Three, Priority
Four and Priority Five investigations within 60 days of intake.
558
The data showed that no letter was required in 35% (142) of Priority One and Two investigations.
559
In one Priority Two investigation, the notification to the referent was documented as sent before the investigation
was closed. This investigation was counted as non-compliant.
560
279
HHSC reported completion of 1,817 Priority Three (1,288), Priority Four (10), and Priority
Five (519) investigations with intake dates between April 1, 2020 and September 30, 2020. Of
the 1,817 investigations, 96% (1,753) of investigations included notification to the referent (or no
letter to the referent was required);561 and to the provider within 60 days of intake. HHSC’s rate of
notifying the referent when required and the provider within 60 days of intake of Priority Three,
Priority Four, and Priority Five investigations was higher than the rate in the Monitors’ First Report
(79%).562 Previously, HHSC did not report data identifying investigations that did not require
notification to the reporter.
Figure 7.13: Notification Letters Sent within 60 Days of Intake in Priority Three, Four, and
Five Investigations

100%
98%
98% 97%
97%
Percent Timely
96%
96%
96%
94%
94%
92%
90%
(288) (347) (301) (285) (306) (290)
Intake Month
C. Remedial Order 20: Heightened Monitoring
Remedial Order 20: Within 120 days, RCCL and/or any successor entity charged with inspections
of child care placements, will identify, track and address concerns at facilities that show a pattern
of contract or policy violations. Such facilities must be subject to heightened monitoring by DFPS
and any successor entity charged with inspections of child care placements and subject to more
frequent inspections, corrective actions, and as, as appropriate, other remedial actions under
DFPS’ enforcement framework.
Background
561
In 34% (619) of Priority Three, Four, and Five investigations, the data reported that notification was not required.
562
280
First Court Monitors’ Report Performance Validation

Findings
The State was not required to produce its list of operations identified for Heightened
Monitoring until June 5, 2020, just eleven days before the Monitors filed the First Report with the
Court. The First Report therefore reviewed the GROs and CPAs with the highest RTB and
minimum standard deficiency rates and detailed the lack of effective oversight and enforcement
by DFPS and HHSC for troubled facilities but did not include a validation of the State’s
implementation of Heightened Monitoring.
Updates and Policy Changes Following the First Report
a. The State’s List of Placements Subject to Heightened

Monitoring & Request to Implement in Phases
The State sent the Monitors the list of 98 operations it identified as subject to Heightened
Monitoring on June 5, 2020, along with a “triage proposal” to implement Heightened Monitoring
in three phases, arguing that the State lacked the capacity to immediately implement Heightened
Monitoring for the full list of operations.563 The State proposed using a “risk stratification”
analysis to determine which operations would be prioritized for the first and second phases of
implementation.564 The State’s proposal suggested immediately placing nine operations on
Heightened Monitoring during Phase One of implementation, then placing ten facilities with the
next highest risk scores on Heightened Monitoring “by the end of the calendar year.”565 The State
proposed placing the remaining facilities on Heightened Monitoring “no later than Spring
2022.”566
After conferring with the Court, on June 17, 2020, the Monitors asked the State to make
application directly to the Court to request implementation of Heightened Monitoring in phases,
and asked the State to file with the Monitors or the Court the steps it had taken to secure the
additional funding needed to fully implement Heightened Monitoring.567 On June 19, 2020, the
State filed its response to the Court’s request for information, describing its attempts to obtain the
563
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, List and Triage Proposal (June 5, 2020) (on
file with Monitors); DFPS, HM List – Risk Stratification Steps (undated) (attached to June 5, 2020 e-mail) (on file
with Monitors); Letter from Audrey Carmical to Deborah Fowler and Kevin Ryan, proposal for a staged roll out of
Heightened Monitoring (undated) (attached to June 5, 2020 e-mail) (on file with Monitors). See also The Court
Monitors’ Update to the Court Regarding the State’s COVID-19 Response and Implementation of the Court’s Order
Regarding Heightened Monitoring (September 2, 2020), ECF No. 955.
564
DFPS, HM List – Risk Stratification Steps, supra note 561.
565
Letter from Audrey Carmical to Deborah Fowler and Kevin Ryan, supra note 561.
566
Id.
567
See The Court Monitors’ Update to the Court Regarding the State’s COVID-19 Response and Implementation of
the Court’s Order Regarding Heightened Monitoring, supra note 561, at 26.
281
funding needed to fully implement Heightened Monitoring.568 On June 26, 2020, the State filed a
Motion to Modify the Court’s March 18, 2020 Order regarding Heightened Monitoring.569 In its
motion, the State requested that the Court modify the March 18, 2020 Order to allow it to have
until January 1, 2021 to fully implement Heightened Monitoring for the 98 operations identified
by the State on June 5, 2020.570 On August 13, 2020, the parties submitted an agreed order to the
Court, indicating that the Plaintiffs were not opposed to the relief requested in the State’s
motion.571 On August 31, 2020, the Court entered an order granting the State’s motion, giving the
State until January 1, 2021 to fully implement Heightened Monitoring for all the operations
identified.572
The Monitors completed the pattern analysis to validate the State’s list of operations subject
to Heightened Monitoring, and the State agreed to add several GROs identified by the Monitors
based on the Court-approved formula.573 The State also agreed to eliminate some elements of the
risk stratification analysis that the Monitors assessed did not take into account children’s safety
needs.574
On December 11, 2020, the State filed a notice with the Court indicating that, due to a
coding error, the foster care home count the State used to complete the “pattern” analysis for CPAs
“caused an overcount of some and an undercount of others.”575 According to the notice, the new
count resulted in a “change in status” for approximately nine operations.576 The State also noted
that it made changes to the list of operations qualifying for Heightened Monitoring in keeping with
the Monitors’ validated list.577 On December 14, 2020, the State sent an e-mail to the Monitors
with the revised list of CPAs required to be placed under Heightened Monitoring; the list added
two CPAs, based on the corrected analysis, and removed seven CPAs from the list.578 The Monitors
subsequently validated the corrected list, and the operations were notified.579
568
Defendants’ Response to Court’s Request for Information and Advisory Regarding Implementation of Heightened
Monitoring, June 19, 2020, ECF. No. 898.
569
Defendants’ Advisory Regarding Compliance with Heightened Monitoring Requirements and Motion to Modify
Order, June 26, 2020, ECF No. 900.
570
Id.
571
Submission of Agreed Order, August 13, 2020, ECF No. 942.
572
Order Granting Defendants’ Motion to Modify (August 31, 2020), ECF. No. 950. The order also allowed the State
to compile documentation related to heightened monitoring using a manual process until CLASS could be modified
to allow for electronic entries. Id.
573
The Court Monitors’ Update to the Court, supra note 256, at 27.
574
Id. at 27-28.
575
Defendants’ Verified Notice Regarding Proposed Amendment to List of Operations Subject to Heightened
Monitoring, December 11, 2020, ECF No. 1014. The State had notified the Monitors of the error prior to filing the
notice to the Court.
576
Id. at 2.
577
Id.
578
E-mail from Tiffany Roper, General Counsel, DFPS to Deborah Fowler and Kevin Ryan, Revised CPA report for
Heightened Monitoring, December 11, 2020 (on file with Monitors).
579
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, Heightened Monitoring Follow Up, March 11,
2020 (on file with Monitors) (indicating that the monitoring team verbally notified the State of its validation of the list
during a videoconference meeting).
282
b. The State’s Request to Modify the Court’s Order Regarding

Placement Approval
On October 25, 2020, DFPS sent an e-mail to the Monitors describing the challenges
associated with the requirement that the Associate Commissioner of CPS approve placements for
operations on Heightened Monitoring.580 DFPS proposed that Regional Directors, rather than the
Associate Commissioner, approve placements.581 The agency also proposed that “the Heightened
Monitoring team have the discretion to allow placements without review into branches of CPAs
that have not had a pattern of poor performance.”582
The Monitors responded with several questions related to the ability of Regional Directors
to document in IMPACT their review of the operation’s history, and justification for approval, as
part of the approval process.583 The Monitors also asked how many CPAs would be affected by
the proposed change related to placement approvals for CPA branches.584 DFPS confirmed that
the documentation proposed by the Monitors could be included in the Regional Directors’
approval. 585 In response to the Monitors’ question related to CPA branches, DFPS said that it was
“still in the process of considering as we review the data and look at specific issues for various
branches. In that vein, we would like to propose working with the monitoring team to look at
parameters around this distinction and in the meantime would not apply the distinction or seek the
modification.”586
580
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, Heightened Monitoring – Associate
Commissioner Approval (October 25, 2020) (on file with Monitors).
581
Id.
582
Id.
583
E-mail from Deborah Fowler and Kevin Ryan to Audrey Carmical, re: Heightened Monitoring – Associate
Commissioner Approvals (October 26, 2020) (on file with Monitors).
584
Id.
585
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, re: Heightened Monitoring – Associate
Commissioner Approvals (November 9, 2020) (on file with Monitors). The State also described the existing process
for approving placements, “We notify caseworkers if a prospective placement is on heightened monitoring.
Caseworkers alerted that a youth on their workload is in a facility on Heightened Monitoring must document the
notification email in IMPACT as a contact. Caseworkers of children placed in an operation on Heightened Monitoring
enter the notification into IMPACT as a contact in the FSU or SUB stage. For new placements, the caseworker
documents the Associate Commissioner’s approval in the placement section of IMPACT. The Associate
Commissioner for CPS must approve all placements into an operation on heightened monitoring before placing a
child. The State Office Placement Team will coordinate and notify the caseworker or SSCC designee upon approval.”
According to policy adopted by DFPS in October 2020, when a placement in an operation on Heightened Monitoring
was being proposed, the Regional Placement Team requested approval by sending an e-mail that included the child’s
name, age, and identification number, their common application, the placement name, the date the placement was
needed, any court orders regarding placement, and a statement outlining why it was in the child’s best interest to be
placed at the operation to the “DFPS HM Placement Approval mailbox.” DFPS, CPS Handbook §4211.2 (October
2020). The policy also required the caseworker to document the associate commissioner’s approval or denial in
IMPACT in the child’s placement detail under the “Appropriateness of Placement” question in the Discussion tab. Id.
586
Id.
283
The Monitors responded, asking for clarification related to the process SSCCs follow when
placing children into operations under Heightened Monitoring.587 DFPS indicated, “although the
SSCCs are generally authorized to make placement decisions independently of DFPS in Stage II,
there are requirements that still apply to them when they stand in our shoes. In this instance, given
the Court’s order, the requirement regarding associate commissioner approval is in place with
respect to SSCC placements in operations on HM as it is with DFPS placements.”588 After
conferring with the Court, the Monitors advised the State to include in any motion to modify the
Court’s order the language related to documenting justifications for approval in IMPACT.589
On December 4, 2020, the parties filed a joint motion to modify the Court’s order regarding
Heightened Monitoring.590 On December 7, 2020, the Court entered an order granting the parties’
motion, and ordering:
Direct approval for placement of a PMC child into a facility on Heightened

Monitoring will be done by the Regional Director, including placements made by
the Single Source Continuum Contractor. Approval will be made by the Regional
Director for that child’s legal county unless the Regional Director is unavailable.
Should the Regional Director be unavailable, the placement may be approved by
the CPS Director of Field or the CPS Associate Commissioner.
Before approving a PMC child’s placement into a facility on Heightened

Monitoring, the Regional Director must consider all required elements as set forth
in applicable DFPS policy, including but not limited to reviewing the facility’s
history over the previous five years. If the Regional Director approves the
placement, he or she will personally document approval of the placement in the
comment box within the placement section of IMPACT, will confirm that the
facility’s history was reviewed and considered for the past five years, and will
document the justification for the approval, which will constitute certification that
the Regional Director approved the placement and followed the required DFPS
policy.
Caseworkers are to receive notification from DFPS if a prospective

placement is on Heightened Monitoring, and caseworkers will ensure those email
notifications are documented in IMPACT as a contact.
587
E-mail from Deborah Fowler and Kevin Ryan to Audrey Carmical, Heightened Monitoring – Associate
Commissioner Approval s (November 9, 2020) (on file with Monitors).
588
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, Heightened Monitoring – Associate
Commissioner Approvals (November 9, 2020) (on file with Monitors).
589
E-mail from Deborah Fowler and Kevin Ryan to Audrey Carmical, Heightened Monitoring – Associate
Commissioner Approvals (November 16, 2020) (on file with Monitors).
590
Joint Motion to Modify Order Regarding Heightened Monitoring, December 4, 2020, ECF No. 1011.
284
If a child is placed in an operation on Heightened Monitoring, that child’s

caseworker will enter the notification of that placement into IMPACT as a contact
in the FSU or SUB stage.591
Data and Information Requests and State’s Production
On November 12, 2020,592 the Monitors requested any and all documentation and data utilized
and/or created as part of the Heightened Monitoring process to include, but not limited to:
• Any documentation and/or data used in the development and update of Heightened
Monitoring plans, contractual obligations (to include base contracts), decision making
processes, and/or risk analysis;
• Any documentation and/or data used to monitor and track operation progress and
compliance with Heightened Monitoring including all monitoring and tracking tools;
• A listing of all reportable qualitative data elements associated with Heightened

Monitoring;
• Any documentation and/or data related to operation reporting and the evaluation of an
operation during and at the close of Heightened Monitoring.
The Monitors also requested that all information for each operation be provided in a
designated “folder” which would be updated monthly and that data related to Heightened
Monitoring be provided in a specific data folder. Lastly, the Monitors requested that all files
related to the Heightened Monitoring process, policies and procedures, trainings, organizational
charts, points of contact, and FITS staffings and Heightened Monitoring team meetings covering
multiple operations be provided in a Heightened Monitoring General folder. The State notified
the Monitors that the requested Heightened Monitoring documents had been provided on
December 2, 2020.593
The Monitors also requested additional data related to Heightened Monitoring in the
November 16, 2020 supplemental data request. Beginning on December 15, 2020 and monthly or
quarterly thereafter, the Monitors requested from DFPS all policy violations, complaints and all
contract violations identified as part of the Heightened Monitoring process and from HHSC all
inspections and assessments conducted and all deficiencies cited as part of the Heightened
Monitoring process.
591
Order Modifying Order Regarding Heightened Monitoring, December 7, 2020, ECF No. 1012. The State amended
its policy in the CPS Handbook related to placements to reflect these changes in April 2021. DFPS, CPS Handbook
§4211.6 (April 2021).
592
Email from Linda Brooke to Audrey Carmical, Heightened Monitoring (November 15, 2020) (on file with the
Monitors).
593
Email from Heather Bugg to Linda Brooke, Heightened monitoring (December 2, 2020) (on file with the monitors).
285
Methodology
To validate the State’s performance with respect to Remedial Order 20, the monitoring
team reviewed Heightened Monitoring documents and analyzed monthly RCCI investigations,
RCCR non-ANE investigations, RCCR inspections, and deficiency data submissions from DFPS
and HHSC. To ensure the completeness of data used in the analysis, the monitoring team also
collected data related to Heightened Monitoring visits and ANE investigations from the CLASS
system.
The Monitors focused the analysis on those operations that began Heightened Monitoring
between June and September, 2020 and were still active as of January 15, 2021. This included
eight operations identified as presenting the most risk of harm for children and designated as
“Phase One” by the State.594 Each operation’s progress under Heightened Monitoring was tracked
through December 31, 2020. Analysis included a review of the following for each operation:
history of violations; trends and problems as identified by the State; Heightened Monitoring Plans
and Plan tasks; Heightened Monitoring visit documentation; placement authorization requests;
investigations, inspections, and deficiencies before and after commencement of Heightened
Monitoring; and requests for variances after beginning Heightened Monitoring.
The monitoring team undertook two case record reviews to validate placement approvals
for children sent to Phase One operations under Heightened Monitoring.595
594
Originally there were nine Phase One operations, but Whataburger Center closed on January 4, 2021, prior to the
Monitors’ analysis of Heightened Monitoring. The State proposed a phased in approach to heightened monitoring
using the stratified risk score developed by DFPS to identify those operations that posed the greatest risk to children.
595
For the first case record review, the monitoring team used all placement requests uploaded by the State to the shared
electronic database between June and December 2020 as the primary data source. Placement requests provided by the
State were PDFs of emails between caseworkers, the DFPS placement authorization “mailbox,” and DFPS staff
coordinating and approving placements. Emails did not always provide complete information. The monitoring team
then used the child’s personal identification number (PID) to match the requests to a list of children selected by the
Monitors from the DFPS data warehouse, and to PMC placement data. As discussed in the Data and Technology
Section of this report, the PMC child placement data has limitations including, at times, gaps in updated placement
dates. This could result in slight discrepancies in the number of PMC children placed in a given month. The children’s
PID numbers were then searched in IMPACT to retrieve the children’s electronic case records to identify placements
made and any discrepancies between the documentation. The analysis included: a) PMC/TMC status of children for
whom placement requests were made; b) number of requests associated with a placement found in IMPACT; c)
number of requests that were approved according to court requirements; d) documentation of approval in IMPACT;
e) request timing and content. In the second case record review, the monitoring team used PMC placement data as the
primary data source, and matched the data to placement requests using the children’s PIDs. Children’s PID numbers
that did not match to a placement request were then searched in IMPACT, and the children’s electronic case records
were reviewed to determine whether the placement was approved according to the Court’s requirements. The analysis
included: a) total number of placements post-Heightened Monitoring; b) number/percent of total placements that were
approved according to Court requirements; and c) average number of placements per month prior to and following
placement on Heightened Monitoring.
286
a. Overview of Operations Identified for Heightened

Monitoring in 2020
A total of 97 operations with an active DFPS contract596 were placed or met the criteria for
placement on Heightened Monitoring (HM) between June and December 2020. This included 45
CPAs, 41 GROs, and 11 GRO-RTCs. The number of operations that are currently active on
Heightened Monitoring includes 71 that were placed on Heightened Monitoring in 2020 and seven
that were placed on HM in 2021.597
• 87 operations were notified and placed on Heightened Monitoring between June and
December 2020. Of the 87 operations placed on HM in 2020, nine (10%) have since had
their DFPS contract terminated or the operation closed through April 16, 2021, and seven
(8%) were removed from HM due to a recalculation of capacity which resulted in the
operation no longer meeting the criteria for Heightened Monitoring.
• Three (3) operations met the criteria for placement on Heightened Monitoring, but had their
contract terminated or closed prior to notification of their HM status.
• Seven (7) operations met the criteria for placement on Heightened Monitoring in 2020, but
were notified and placed on Heightened Monitoring in 2021.
Figure 7.14: Operations Placed or Meeting Criteria for Placement on Heightened
Monitoring in 2020
97
Operations placed or meeting the criteria for placement on HM in 2020
71 7 9 3
Placed on HM Placed on HM in Placed on HM in Operation 7
in 2020 and 2020 and no 2020 and no closed or foster Identified as
currently longer active due longer active due care contract meeting HM
active to modified to closure or terminated prior criteria in 2020
capacity contract to HM but notified and
calculation termination notification placed in 2021
87 operations placed on HM in 2020

596
An additional 15 operations met criteria for Heightened Monitoring but did not have an active contract with DFPS
in 2020 when Heightened Monitoring was implemented.
597
Gulf Coast Trades Center, Willow Bend Center, and The Tree House Center are not counted in the 71 active
Heightened Monitoring operations. While they were actively on HM as of the end of 2020, their contracts were
terminated in 2021. Information on closures as of April 16, 2021. On April 2, 2020, the Monitors were notified that
Fostering Life Youth Ranch purchased Children’s Hope Residential, Levelland, and operation on Heightened
Monitoring. Fostering Life Youth Ranch will be subject to Heightened Monitoring.
287
b. Operations that Closed After or Just Prior to Being Placed

on Heightened Monitoring
Several operations closed598 after the State identified them for Heightened Monitoring, as
discussed in Section VII, infra, either as a result of DFPS’s decision to cancel its contract with the
operation due to ongoing safety concerns, RCCR’s decision to revoke or deny its final license for
the same reason, or the operation’s voluntary relinquishment of its license.599
598
The Monitors reported some of these closures in the September 2, 2020 Update to the Court regarding facility
closures. Deborah Fowler and Kevin Ryan, The Court Monitors’ Update to the Court Regarding Child Fatalities and
Congregate Care Facility Closures (September 2, 2020), ECF No. 956. Others are included in this report’s updates
regarding Remedial Order 21, infra.
599
The State also notifies the Monitors of placement suspensions for operations on Heightened Monitoring. One of
the recent notifications of a placement suspension was for Gulf Winds RTC. DFPS indicated the agency suspended
placements after the suicide of a TMC child. E-mail from Tara Olah to Deborah Fowler and Kevin Ryan, re: Child
Fatality in TMC, February 27, 2021 (on file with Monitors). The child, Z.A., hanged himself in the shower at the
facility, using a sheet from his bed. The bathroom was “not far” from Z.A.’s room but was not attached to Z.A.’s
bedroom. According to the investigation notes in CLASS, when Z.A. committed suicide, he was on “close watch,”
which (according to the staff member assigned to Z.A. when he died) means “to keep him in eyesight at all times.”
The child was being supervised by a female staff member and when Z.A. asked to use the restroom, the female staff
member unlocked the door and stood outside the male bathroom. She did not go into the bathroom until she knocked
on the door and called out to Z.A. and he did not respond, at which point the staff member found him and called for
assistance. During her interview, the staff member said that though Z.A. was on one-to-one supervision, she was also
supervising two other children the night that he died. Before he hanged himself, Z.A. posted a picture of himself on
Instagram in the bathroom, waving to the camera, with the sheet hanging from the shower bar in the background. Z.A.
was not supposed to have electronics, but children interviewed for the investigation said he was able to borrow a tablet
from a staff person to post on Instagram.
Z.A. had disclosed thoughts of suicide earlier in the week, to a staff member at Gulf Winds, who called the local
mental health authority (LMHA) to have him assessed by a counselor. The day of his suicide, Z.A. had confided to
someone at his high school that he was feeling suicidal, and a counselor with the crisis response team from the LMHA
again assessed Z.A. before he left school that day. The initial recommendation made by the LMHA professional was
that Z.A. be hospitalized, but after a discussion with the LMHA professional’s supervisor, Z.A.’s psychiatrist, and
Gulf Winds staff, the decision was instead to change Z.A.’s medication and return him to Gulf Winds with one-on-
one supervision. Notes in CLASS indicate, “This evaluation included that they believed that [Z.A.] wanted to demand
hospitalization whenever he wanted to and that was not a productive solution for this patient.” Z.A.’s psychiatrist
“did not want to reinforce behavior that the patient could just demand going to the hospital because he was mad or
depressed.” Staff at Z.A.’s high school objected verbally and in writing to the decision to return Z.A. to Gulf Winds
instead of hospitalizing him. After Z.A. returned to the facility, the serious incident report timeline indicates he had
a “rough call” with his girlfriend, prompting his case manager to speak to the supervisor and floor staff to ask them to
“keep an eye on him.” Two children interviewed indicated that Z.A. said he wanted to kill himself during group the
day that he died. Z.A. had a history of trauma and a diagnosis of major depression, and according to his service plan
had been hospitalized three times in 2020, once for attempting to hang himself, and twice for suicidal ideation.
288
Table 7.4: Operations Meeting the Criteria for Heightened Monitoring that Closed or with
Which DFPS Terminated Contracts
Source: State Heightened Monitoring List
Closed or
Operation Notified
Operation Terminated
Type of HM
Contract
Eckerd Youth Alternatives, Inc. CPA License Relinquished No
Panhandle Child Placement Svcs CPA License Relinquished Yes
The Payton Foundation CPA License Relinquished Yes
Contract Terminated
Gulf Coast Trades Center RTC Yes
by DFPS
RCCR Intent to
Prairie Harbor, LLC RTC Yes
Revoke
Houston Serenity Place, Inc. RTC License Relinquished Yes
Whataburger Center for Children RTC License Relinquished Yes
Foundation Contract
Hearts with Hope Foundation GRO No
Terminated by DFPS
Contract Terminated
The Tree House Center GRO Yes
by DFPS
Williams House GRO License Relinquished Yes
RCCR Intent to
Willow Bend Center GRO Yes
Revoke
Youth and Family Enrichment Centers GRO License Relinquished No
289
c. Operations that Reopened Under Another Name Following

Closure
When the State provided the Monitors with its initial list of operations that qualified for
Heightened Monitoring on June 5, 2020, the State indicated that nine of the CPAs on the list, and
six of the GROs, had already closed.600 On December 18, 2020, the Monitors sent an e-mail to the
State after determining that at least two GROs that were on the State’s original Heightened
Monitoring list, but that the State removed from the list because (according to the State) the GROs
were no longer operating, appeared to have reopened under a different name.601 The Monitors
noted:
The Care Cottage***which was located in Willis, TX is shown as having closed on

January 2, 2020. On the very same day, the same controlling persons opened
another RTC – HeartBridges – in Cypress, TX, with the Children who were in Care
Cottage moved to HeartBridges. This Care Cottage location had an RCCR
enforcement history, having been on probation from January 2, 2019 through
August 6, 2019. Our heightened monitoring analysis showed this operation’s
minimum standards violations and contract violations, in particular, placed it above
the State average in four out of five years of the analysis. Across all five years, the
operation was cited 96 times for a standards violation rated medium, medium-high,
or high, and had 12 contract violations. It had one “reason to believe” finding in
2018 related to the physical abuse of a child, after a child alleged that a staff
member “grabbed her by the shirt, slammed her to the ground, drug her to [a]
room…and put his knee in her throat.” Her allegation was substantiated by two
witnesses, and the staff person was charged with a felony offense.602
The Monitors’ e-mail noted that this was the second Care Cottage location to voluntarily
close, with the first having closed in 2018 after being raided by law enforcement due to reports of
physical and sexual abuse.603 The Monitors indicated that their review of the “new” operation
(HeartBridges) in CLASS showed that inspectors and investigators were not connecting the history
of The Care Cottage with HeartBridges, frustrating the intent of Remedial Orders 3 and 22, in
addition to Remedial Order 20:
In addition to frustrating the purpose of Remedial Order 20, this frustrates the
purpose of Remedial Order 22 and Remedial Order 3. Remedial Order 22 requires
inspectors to consider an operation’s history of referrals and substantiated findings
of abuse or neglect and citations related to corporal punishment during inspections,
600
According to the State, the following GROs qualified for Heightened Monitoring, but had already closed: Arrow’s
Endeavor Place, Carter’s Kids RTC, Five Oaks Achievement, Shoreline, Inc., The Care Cottage, and Visionquest
Residential. The following CPAs were included on the list, but were identified as closed: J. Elohim Inc., Jameson
Center, Kids at the Crossroads, Inc., Kingdom Kids Child Placing Agency, Respite Care of San Antonio, Strawberry
Creek Services, Trinity Foster Care, Houston Serenity Place CPA, Optimum Children’s Services.
601
E-mail from Deborah Fowler and Kevin Ryan to Tiffany Roper and Georgette Oden, Closure & Reopening of
Facilities (December 18, 2020) (on file with Monitors).
602
Id.
603
Id.
290
including inspections undertaken as part of an investigation of a minimum

standards violation. A review of the “extended compliance history review”
conducted most recently for HeartBridges shows that the inspector found only 18
abuse or neglect referrals, and no confirmed abuse or neglect findings and no
corporal punishment citations. This is because by changing the name of the entity,
the operators have erased the poor compliance history.604
Further, the Monitors found that this was not the only operation that had escaped
Heightened Monitoring by closing and reopening under a different name, noting that Carter’s Kids,
an RTC that had 10 substantiated findings of abuse or neglect and 158 minimum standards
deficiencies rated medium, medium-high, or high during the five-year period examined, reopened
under the name “Life’s Purpose,” with related owners and in the same location as the closed
Carter’s Kids.605 The Monitors advised the State that “[a]llowing operators of troubled entities to
avoid enforcement action and wipe their histories clean, simply by relocating or changing their
name (or both, as in the case of HeartBridges) is deeply problematic from the standpoint of child
safety. But it is also deeply problematic from the standpoint of allowing these troubled entities to
dodge enforcement of the Court’s order. Judge Jack spoke to these very problems at the recent
contempt hearing.”606 The Monitors asked the State to verify whether any of the other operations
that the State removed from the Heightened Monitoring list due to closure were operating under a
new name, or in a new location, with the same controlling persons, and also asked the State to
explain why HeartBridges and Life’s Purpose were not under Heightened Monitoring.607
On December 23, 2020, RCCR responded:
Like you, HHSC is very concerned about ensuring that the Heightened Monitoring
process takes into account operations that may maintain the same controlling
persons but move locations, change names, or otherwise operate under a new
license. We have been coordinating with DFPS and agree that HeartBridges and
Life’s Purpose should be added to the Heightened Monitoring list. We have
notified those operations and we began unannounced visits this week. The
Heightened Monitoring team is presently searching for other operations in a similar
situation as HeartBridges and Life’s Purpose, and we will keep you updated about
those findings.
HHSC recognizes the need to capture additional data and evaluate permutations of
other factors aside from controlling persons, such as different owners, staff
members, locations, and so on. HHSC, in coordination with DFPS, will work
together on a plan to address these circumstances and hope [sic] to share that with
you in January.608
604
Id.
605
Id.
606
Id.
607
Id.
608
E-mail from Georgette Oden to Deborah Fowler and Kevin Ryan, closure and reopening of facilities (December
23, 2020) (on file with Monitors). DFPS also sent an e-mail to the Monitors that was almost identical in content. E-
mail from Tiffany Roper to Deborah Fowler and Kevin Ryan, Closure & Reopening of Facilities (December 23, 2020)
291
RCCR filed an Emergency Rule, effective December 30, 2020 and posted in the Texas
Register on January 15, 2021, which addressed the problems raised by the Monitors. The
Emergency Rule requires RCCR:
[T]o consider the previous five-year compliance history of related operations when
evaluating an application for a new residential child-care operation license. The
rules require the review when an application has been operating in a different
location, has previously closed an operation, or has significant ties to another
operation. The new emergency rules also require the continuation of heightened
monitoring as a condition of a new license if a previous or related operation is on
heightened monitoring, met the criteria for heightened monitoring in the previous
five years, but was not placed on heightened monitoring, or was placed on
heightened monitoring in the previous five years and did not successfully complete
it.609
The agency also confirmed that HeartBridges and Life’s Purpose had been placed under
Heightened Monitoring.610 On January 20, 2021, the State sent an update to the Monitors
identifying nine GROs that would be placed on Heightened Monitoring as a result of the concerns
raised by the Monitors in December 2020.611 In addition to identifying operations “first licensed
in calendar year 2019 or 2020 which would have met the criteria for Heightened Monitoring if the
HHSC emergency rules effective on and after 12/30/20 had been retroactively applied,” the State
also noted that, for purposes of Heightened Monitoring, operations would be treated as one
continuous operation if they had the same controlling persons and location, received an initial
permit, but withdrew prior to being issued a full license on one or more occasions, then
subsequently received a full license.612 The e-mail also identified seven operations that were
reviewed but did not meet the State’s criteria for being placed on Heightened Monitoring as a
linked operation.613 The Monitors asked the State for an explanation of the seven operations that
it determined should not be placed on Heightened Monitoring, which the State sent to the Monitors
on February 10, 2021.614
609
Emergency Rule, 26 TAC §§ 745.10201, 745.10203, 745.10207, Tex. Reg., January 15, 2021.
610
E-mail from Georgette Oden to Deborah Fowler and Kevin Ryan, closure and reopening of facilities (January 12,
2021) (on file with Monitors).
611
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, RO 20 Heightened Monitoring (January 20,
2021)(on file with Monitors). The nine operations placed on Heightened Monitoring are: HeartBridges, Life’s Purpose
RTC, Children’s Hope Residential Services (Levelland), A Pathway 2 New Beginnings, Road to Wisdom, 1 Archangel
Foster and Adoption Agency, House of Shiloh Family Service, A Fresh Start RTC (a second campus), Hands of
Healing.
612
Id.
613
Id.
614
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, RO 20 Heightened Monitoring (February 10, 2021)
(on file with Monitors). On February 5, 2021, the State also sent the Monitors an update on RCCR’s efforts to link
current and closed operations for extended compliance history reviews, pursuant to Remedial Order 22. E-mail from
Taryn Lam to Deborah Fowler and Kevin Ryan, HHSC Linked Operations Information (February 5, 2021) (on file
with Monitors).
292
d. Location of Operations Placed on Heightened Monitoring

& Date of Notification
Sixty-two percent of active Heightened Monitoring operations (44 of 71) were located in
Regions 6, 7, and 8.615 In comparison, 62% of all operations (201 of 324) were in Regions 6, 7,
and 8.616 There were no operations on Heightened Monitoring in Regions 9 and 10, while 3% of
all operations were in Regions 9 and 10. Regions 6 and 8 had the highest numbers of GROs and
RTCs on Heightened Monitoring, while Regions 3 and 7 had the highest number of CPA’s on
Heightened Monitoring.
Figure 7.15: Operations Currently on Figure 7.16: Operations with an Active

Heightened Monitoring by Type of Residential Child Care Contract by
Operation and Region Region
Source: State Heightened Monitoring Soure: DFPS website,
List, n = 71 n = 324
CPA GRO
Region 1 1 3 4 (6%) Region 1 16 (5%)
Region 2 2 1 3 (4%) Region 2 9 (3%)
Region 3 9 1 10 (14%) Region 3 61 (19%)
Region 4 1 2 3 (4%) Region 4 11 (3%)
Region 5 2 2 (3%) Region 5 5 (2%)
Region 6 93
Region 6 5 11 3 19 (27%) (29%)
Region 7 7 3 10 (14%) Region 7 52 (16%)
Region 8 4 9 1 14 (20%) Region 8 56 (17%)
Region 9 0 Region 9 4 (1%)
Region 10 0 Region 10 5 (2%)
Region 11 3 3 6 (8%) Region 11 12 (4%)
Within five (5) days of identifying an operation for Heightened Monitoring, DFPS is
required to schedule an initial Facility Intervention Team Staffing (FITS).617 The date of the initial
FITS meeting is the Heightened Monitoring start date for the operation, and the day the operation
is notified.618 At that point, a Heightened Monitoring development team is formed and the
615
Includes active operations placed on Heightened Monitoring in 2020 but does not include Gulf Coast Trades Center,
Willow Bend Center, and The Tree House Center which had their contracts terminated in early to mid-2021.
616
Includes all active Child Placing Agencies, General Residential Operations, and Residential Treatment Centers
operating in-state.
617
FITS staffings are “multidisciplinary meetings between DFPS and HHSC to discuss operations that are licensed
by HHSC and serve children and youth in DFPS conservatorship” which were “[i]nitially…focused on operations
where there were concerns regarding child safety based upon a serious incident, a pattern of performance issues, or a
corrective action issued by HHSC’s CCR division.” HHSC & DFPS, Heightened Monitoring Process Overview
(undated) (On file with Monitors).
618
HHSC & DFPS, Heightened Monitoring Process Overview at 2 (undated).
293
development team has four weeks to develop a draft Heightened Monitoring Plan (HM Plan).619
Approval of the HM Plan occurs after the development team presents the draft plan to HM directors
in each division to review, discuss, and edit the plan.620
e. Date of Notification for Operations Placed on Heightened

Monitoring
Eighty-five percent of operations placed on Heightened Monitoring in 2020 (74 of 87)

received notification between October and December 2020. Of the nine operations notified
between June and September 2020, five closed after starting Heightened Monitoring (Whataburger
Center, Williams House, Houston Serenity Place, Inc., The Payton Foundation, and Prairie Harbor)
and one had its contract terminated in March 2021 (Gulf Coast Trades Center). November 2020
was the month with the highest number of Heightened Monitoring notifications.
The average time from notification to HM Plan start for operations notified in 2020 was 28
days.621 Eleven percent (11%) of operations notified (nine of 82) had a HM Plan start date that was
the same day as the notification date.622 CPAs had, on average, the shortest time between
notification and HM Plan start at 27 days, compared to 28 days for GROs and 40 days for RTCs.
The time to HM Plan commencement decreased over the year. For operations notified between
June and September 2020, the average time from notification to HM Plan start was 45 days, but
for operations notified between October and December 2020 the average time was 26 days.
Overview and Analysis of Phase One of Heightened Monitoring
The State’s implementation of Heightened Monitoring featured a three-phase roll-out,

prioritizing sites based on the identified risk of harm to children, with Phase One operations having
the highest scores according to the State’s risk stratification analysis.623 A total of nine (9)
operations were classified as Phase One Heightened Monitoring operations.624 Originally, those
operations included Williams House, Houston Serenity Place Inc., Prairie Harbor, and The Payton
Foundation. However, those operations closed soon after the start of Heightened Monitoring, as
discussed above, and were replaced in Phase One with A Fresh Start, Beacon of Hope, Connections
Emergency Shelter, and New Life.625
619
Id. 3.
620
Id. at 4.
621
One notified operation did not have a Heightened Monitoring plan start date in documents provided to the Monitors.
622
The Heightened Monitoring start date designated on the plan was the operation’s notification date rather than the
date the Heightened Monitoring plan was finalized.
623
DFPS developed a risk stratification scoring system which incorporates different data related to child safety and
incorporating both recent trends and historic pattern including acuity and volume of children placed, quality of
services, EBIs, minimum standards violations, ANE investigations and RTBs and corrective actions.
624
Assuring Love, Azleway Valley View, Benchmark, and Gulf Coast Trades Center were initially classified as Phase
One, while A Fresh Start Treatment Center, Beacon of Hope, and New Life Residential Treatment were originally
classified as Phase Two but moved to Phase One. Whataburger was classified as Phase One and began Heightened
Monitoring in June but closed in January 2021, prior to the Monitors’ analysis of Phase One Heightened Monitoring
operations.
625
Though Whataburger Center also closed, the facility closed later in the Heightened Monitoring process after all
other operations identified for Heightened Monitoring had already started the process, making it unnecessary to
replace Whataburger Center with another operation in Phase One.
294
Figure 7.17: Timeline for Starting Heightened Monitoring at Operations in Phase One
Analysis626
Source: State Heightened Monitoring List
HM Start Dates PMC placements and

Assuring Love placement requests through
Azleway Valley View December 2020 were
Benchmark analyzed.
Gulf Coast Trades Center
June 2020
A Fresh Start
Connections Inc Emergency Shelter
July 2020
Beacon of Hope
August 2020
New Life
September 2020
According to the Court’s March 18, 2020 Order627 adopting definitions for pattern and
Heightened Monitoring, the State is required to engage in a pattern analysis to identify operations
for Heightened Monitoring, then:
• Schedule a FITS staffing to review: trends identified as a result of the five-year pattern
analysis, and any monitoring plans or corrective actions for the operation and risk analyses
conducted by RCCR or DFPS in the last five years.
• Suspend placements to and create a safety plan for the operation if the FITS review reveals
events that implicate ongoing concern for the health and safety of children.
• Develop a Heightened Monitoring plan that:
o Outlines a coordinated response from RCCR & DFPS, including a list of staff from
both agencies who will serve on the Heightened Monitoring team for the operation;
o Describes a detailed and specific plan addressing: the pattern of policy violations
that led to Heightened Monitoring; any barriers to compliance identified during a
626
Whataburger Center was initially a Phase One Heightened Monitoring operation that closed on January 4, 2021,
prior to the Monitors’ analysis. The Payton Foundation, Williams House, Prairie Harbor, and Houston Serenity Place,
Inc. were initially Phase One operations that closed after Heightened Monitoring notification.
627
Order, ECF No. 837.
295
review of previous corrective or enforcement actions or risk analyses; any technical

assistance needed by the operation; and, the steps the operation must take to satisfy
the plan.
• Share responsibility between DFPS and RCCR for weekly unannounced visits to the
operation.
• Ensure all children’s placements to operations under Heightened Monitoring are directly
approved by the DFPS Associate Commissioner of CPS (or, following the Court’s
December 2020 Order, discussed above, the Regional Director).628
Phase One Operations’ Histories of Compliance Problems
Altogether, over the five-year period between 2016 and 2020, these eight troubled
operations accounted for 67 substantiated findings of child abuse or neglect (RTBs), and 2,002
citations for minimum standards deficiencies629. Broken out by operation:
• A Fresh Start Treatment Center (Fresh Start) had one RTB for Physical Abuse during this
period, and 174 citations for minimum standards deficiencies.
• Assuring Love CPA had five RTBs (two for Physical Abuse, two for Neglectful
Supervision, and one for Sexual Abuse), and 128 citations for minimum standards
violations.
• Azleway Valley View GRO had 12 RTBs (all for Neglectful Supervision), and 94 citations
for minimum standards deficiencies.
• Beacon of Hope CPA had three RTBs (all for Physical Abuse), and 205 citations for
minimum standards deficiencies.
• Benchmark CPA had 26 RTBs (14 for Neglectful Supervision, four for Sexual Abuse,
seven for Physical Abuse, and one for Medical Neglect), and 930 citations for minimum
standards deficiencies.
• Connections Emergency Shelter had six RTBs (two for Sexual Abuse, two for Physical
Abuse, and two for Neglectful Supervision), and 124 citations for minimum standards
deficiencies.
• Gulf Coast Trade Center had seven RTBs (four for Neglectful Supervision, two for Sexual
Abuse, and one for Physical Abuse), and 198 citations for minimum standards violations.
• New Life Children’s Treatment Center (New Life) had seven RTBs (three for Neglectful
Supervision, two for Medical Neglect, one for Sexual Abuse, and one for Physical Abuse),
and 149 citations for minimum standards deficiencies.
628
Id. at 1-2.
629
Deficiencies cited include all citations waived, upheld and pending.
296
All of the Phase One operations have had a prior risk analysis, monetary penalty, and/or
RCCR enforcement action prior to being placed on Heightened Monitoring. Phase One operations
have had, on average, two prior risk analyses and four prior monetary penalties. Three operations
had a prior Enforcement Evaluation, including Azleway, Beacon of Hope, and Gulf Coast. Two
operations had a prior Plan of Action (POA), including Connections and New Life. Two operations
had both a prior Enforcement Evaluation and a prior POA, including Assuring Love and
Benchmark Family Services. No Phase One operation had been previously placed on Probation.
One operation was on a POA at the time of starting Heightened Monitoring (Connections) while
another operation was placed on a POA after starting Heightened Monitoring (A Fresh Start).
Figure 7.18: Number of Prior Risk Analyses, Monetary Penalties, and Enforcement Actions
Since 2015 at Operations in Phase One Heightened Monitoring Analysis
Source: State Heightened Monitoring Documentation
Risk Analyses Monetary Penalties Enforcement Actions

25
21
20
15
10 9
6 6
5 4 3
1 1 2 2 22
1 11
0 0 0 0 0 1 0 0 1
0
A Fresh Assuring Azleway Beacon of Benchmark Connections Gulf Coast New Life
Start Love Valley View Hope Trades
For the five Phase One operations with a prior Evaluation, the operations were under
Evaluation for a total of 211 days on average. For the four operations with a prior POA, the
operations were under a POA for a total of 230 days on average.630 The minimum amount of time
an operation was under Evaluation or POA was a total of 181 days and the maximum amount of
time was a total of 552 days.631
The monitoring team reviewed Heightened Monitoring documents, compliance reports,

CLASS, and a summary of the operation’s history based on data provided to the Monitors by the
State. Based on this collective information, the Monitors analyzed trends in child safety and
630
Includes the three most recent enforcement actions since 2015 to the date of placement on Heightened Monitoring.
Benchmark was the only operation to exceed three enforcement actions during this time period.
631
Operations under both Evaluation and POA include the total time under both.
297
compliance problems within each Phase One operation. The Monitors compared the safety and
compliance problems from each Phase One operation’s historical review with the issues identified
by the State in the operation’s Heightened Monitoring Plan (HM Plan).
The monitoring team identified the three most serious issues632 at Phase One operations
from 2015-2019 (the period that the State reviewed to determine which operations would be
subject to Heightened Monitoring), and from 2019-2020. Poor supervision was the most prominent
serious issue from 2015-2019, identified in six of eight operations. Inadequate service planning
and poor supervision were most often identified as serious issues from 2019-2020. Two
operations, A Fresh Start and Beacon of Hope, had the same issues identified as most serious
between 2015-2019 and 2019-2020. At least one issue recurred in all but one operation, Assuring
Love, across both time periods.
Table 7.5: Most Serious Issues at Phase One Heightened Monitoring Operations as
Identified by the Monitors, 2015 to 2019
Three Most Serious Issues at Phase One HM Operations as

Identified by Monitors, 2015-2019
Operation Issue #1 Issue #2 Issue #3
Missing/
A Fresh Start Inappropriate Discipline Poor Supervision Incomplete
Records
Inadequate Medical Missing/No Administration
Assuring Love
Care/Meds Management Background Checks Gaps
Azleway Valley Inadequate Medical Physical Plant
Poor Supervision
View Care/Meds Management Problems
Inadequate Medical Inadequate Service Administration
Beacon of Hope
Care/Meds Management Planning Gaps
Benchmark Family Inadequate Medical Inappropriate Poor
Services Care/Meds Management Discipline Supervision
Connections Inc. Inadequate Service Physical Plant
Poor Supervision
Emergency Planning Problems
Gulf Coast Trades Administration
Inappropriate EBI Poor Supervision
Center Gaps
Inappropriate Poor
New Life Sexual Abuse
Discipline Supervision
632
Issues were identified by looking at patterns or trends in standard and contract violations, abuse or neglect
investigations, and other compliance issues.
298
Table 7.6: Most Serious Issues at Phase One Heightened Monitoring Operations as
Identified by the Monitors, 2019 and 2020
Three Most Serious Issues at Phase One HM Operations as

Identified by Monitors, 2019-2020
Operation Issue #1 Issue #2 Issue #3
Missing/Incomplete
A Fresh Start Inappropriate Discipline Poor Supervision
Records
Violations of Children’s Inadequate Poor Supervision
Assuring Love
Rights Service Planning
Azleway Valley Inadequate Medical Inadequate Physical Plant
View Care/Meds Management Service Planning Problems
Inadequate Medical Inadequate Administration
Beacon of Hope
Care/Meds Management Service Planning
Benchmark Family Inadequate Medical Inadequate Physical Plant
Services Care/Meds Management Service Planning Problems
Connections Inc. Inadequate
Poor Supervision --------
Emergency633 Service Planning
Gulf Coast Trades Inadequate Administration
Poor Supervision
Center Service Planning Gaps
Serious Incidents Harmful Lapses in Training
New Life Poor Supervision
to Children
The monitoring team identified other safety and compliance problems outside of those
deemed most serious. The number of other identified issues ranged from two (Assuring Love) to
11 (Connections). On average, operations had six other issues identified outside of the three most
serious from 2015-2019 and 2019-2020. In addition to the safety and compliance problems
identified above, the monitoring team noted staff turnover or retention as serious problems in four
of the eight operations: Azleway Valley View, Benchmark, Gulf Coast Trades Center, and New
Life.
Quality of Heightened Monitoring Plans for Phase One
Operations
The monitoring team compared the identification of serious safety issues and compliance
problems for the Phase One operations analyzed to those identified by the State in the operations’
HM Plans.
633
Connections Inc. Emergency Shelter had only two issues identified as most serious, but had several other issues
identified that did not meet the definitions used for most serious.
299
Figure 7.19: Number of Operations with Identified Issues in Monitors’ Review and the
Operations’ Heightened Monitoring Plan
Source: Monitors' Review of State Heightened Monitoring Documentation

Monitors' Review Operations' Heightened Monitoring Plan
10
9 8 8
8 7 7 7 7 7
7 6 6 6 6 6 6
6 5 5
5 4 4 4
4 3 3 3 3
3 22 2 2
2 1 1 11
1
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*Other issues identified by the Monitors include Failure to Report. Other issues identified in the HM plan include
Behavioral Health
Of the 14 possible categories,634 Phase One operations had, on average, 10 safety or

compliance problems identified during the monitoring team’s review, compared to an average of
seven problems identified by the State in the Heightened Monitoring Plans.
634
Categories include Child Rights, Discipline/Physical and Emotional Abuse, Emergency Behavior Interventions
(EBI), Serious Incidents, Supervision/Neglectful Supervision, Sexual Abuse/Exploitation, Medicine/Medical/Medical
Neglect, Health and Safety/Physical Neglect, Service Planning, Training, Records, Criminal Background Checks,
Administration, Physical Plant, and Other.
300
Table 7.7: Problems Identified at Phase One Operations by the Monitoring Team’s Review
of Heightened Monitoring Documentation and by the State in Heightened Monitoring
Plans
Source: State Heightened Monitoring Documentation and Heightened Monitoring Plans
Number of Problems Identified

Operation
Monitors’ Review HM Plan
A Fresh Start 9 6
Assuring Love 8 8
Azleway Valley View 8 5
Beacon of Hope 7 4
Benchmark Family Services 13 11
Connections Inc. Emergency Shelter 14 7
Gulf Coast Trades Center 7 7
New Life 11 8
In half of Phase One operations analyzed (four of eight), the monitoring team determined that
the safety or compliance problems identified through the monitoring team’s review of historical
documents were overall consistent with those identified in the Heightened Monitoring Plan. The
four operations for which the monitoring team determined that patterns of problems identified
during compliance history reviews were not comprehensively consistent with those identified in
their Heightened Monitoring Plan were A Fresh Start, Assuring Love, Azleway Valley View, and
Beacon of Hope.
Table 7.8: Phase One Operations with Inconsistencies Between their Historical
Trends and the Issues Identified on their Heightened Monitoring Plan
Description of Inconsistencies Across Historical Review and

Operation Heightened Monitoring Plan
A Fresh Start Most of the issues were captured in the HM Plan, but not
violations of Children’s Rights and Neglectful Supervision.
Assuring Love There are some issues identified in the history that are found in
the HM Plan, but not all. Issues identified but not found in the
Plan include violations of Children’s Rights, inadequate Service
Planning, and missing Criminal Background Checks for staff.
Azleway Valley View Inappropriate Discipline and Emergency Behavioral
Intervention EBI were identified in the historical review but
neither were addressed in the history described in the HM Plan.
Beacon of Hope Most of the issues in the HM Plan are related to administration,
home screening, verifications, service planning, and
supervisory visits. Additional issues found in the historical
review include Health and Safety and Physical Plant.
301
The State’s HM Plans feature tasks each operation must complete in order to reduce the
risk of harm to children. The monitoring team reviewed the tasks outlined in each operation’s HM
Plan to assess the quality of the tasks and whether they appropriately addressed the safety and
compliance problems identified in the HM Plan. The same categories used for issues were assigned
to tasks.635 The number of tasks in each operation’s HM Plan ranged from two (Assuring Love) to
15 (A Fresh Start and Gulf Coast Trades Center).
Operations had a range of four (Beacon of Hope) to 11 (Benchmark) safety or compliance
problems referenced in their HM plans. All but one operation, A Fresh Start, had at least one
problem area in the HM plan that was not also identified in a task. Half of operations (four of eight)
had two or more problem areas identified in the HM plan that were not also addressed in a task.
Figure 7.20: Categories Identified as Problems in Operations’ Heightened Monitoring

Plans
Azleway
A Fresh Assuring Valley Beacon of Connection
Start Love View Hope Benchmark s Gulf Coast New Life
Discipline Discipline Supervision Discipline Child Rights Discipline Discipline EBI
Serious Serious
EBI Medical Supervision Discipline Supervision EBI
Incidents Incidents
Health
Supervision Service Plan Medical EBI Medical Supervision Supervision
/Safety
Service Sexual Serious Sexual Sexual
Admin Admin Service Plan
Plan Abuse Incidents Abuse Abuse
Physical
Training Medical Supervision Training Service Plan Medical
Plant
Records Training Medical Admin Admin Training
Health/ Physical Physical
Admin Records
Safety Plant Plant
Other-BH Service Plan Admin
Training
Background
Checks
Admin
Not covered in HM tasks

*Sexual abuse was provided as an issue category but was not included as a task category.
Source: State Heightened Monitoring Documentation and Heightened Monitoring Plans
The Monitors’ review of the tasks also indicates that some may not fall within the Court’s
vision for a “specific and detailed” Heightened Monitoring Plan; similarly, some tasks did not
635
Tasks may have sub-tasks if there are separate compliance due dates for each sub-task. A primary and secondary
category was assigned to each task and sub-tasks, where applicable. Operations had, on average, nine tasks outlined
in their Plan.
302
seem measurable. Examples of tasks that the monitoring team highlighted during their review
include:
• Operation will explore the costs associated with obtaining video cameras with recording
capabilities.
• Operation will complete a self-evaluation to: Identify what issues led to the operation
breakdown; Identify areas of improvement implemented to ensure successful ramp up.
• Administrator will contact other RTC’s that serve the same age groups and ask what EBI
models they use, outcomes with their model, and any injuries related to the use of their EBI
model to determine which EBI model best fits this operation’s population.
• The operation must provide an updated organizational chart including staff that have
responsibilities over all operations.
Other tasks simply appear to require the operation to meet existing minimum standards,
something they are already obligated to do. Examples include:
• The operation will demonstrate and provide evidence that supervision and admission
policies are sufficient and in place. Operation will submit a copy of updated Supervision
and Admission Policies.
• Operation will create and deliver training for all staff on minimum standards with an
emphasis on physical site, fire safety and vehicle safety.
• The operation will develop policies and procedures to ensure supervision of staff during
supervisory visits to ensure quality.
• The Administrator must develop a plan to ensure that all records are maintained as per
minimum standards. This includes the development of a check list for personnel files and
child files to be used to train staff and conduct quality assurance record reviews.
Some tasks simply required the operation to comply with another enforcement action:
• The operation will provide documentation of improvements made during licensing

corrective action regarding supervision and discipline. The operation will provide
evidence as requested of continued compliance.
• The operation will ensure compliance with any enforcement of voluntary plan of action.
Some tasks require the Administrator of the operation to actually visit it, or – even more basic –
conduct a walkthrough. Examples include:
• The Administrator must develop a staff oversight and development plan that includes
specific strategies the operation will take to ensure that direct delivery staff interact safely
and appropriately with the children while ensuring that the children achieve their
therapeutic goals. The plan must include onsite and unannounced visits by Administrator.
• The operation will enhance supervision of direct care staff by having the Administrator
conduct unannounced onsite visits during evening and weekend hours. The Administrator
303
will observe staff/child interactions and document concerns during onsite visit. The
administrator will document how these concerns will be addressed.
• The Administrator will conduct a walkthrough of the dining hall and non-school grounds
on a daily basis to ensure physical site conditions meet minimum standards requirements.
And perhaps most troubling is a task that simply requires the Administrator of the operation to
talk to youth, something one would hope they would not have to be instructed to do:
• The Administrator must conduct interviews with the youth in care regularly and
consistently. The youth should be selected at random with a minimum of five (5) youth
being interviewed each month. The Administrator must interview the youth about the
following topics: (1) concerns with EBI; (2) discipline practices; (3) staff interactions; (4)
supervision.
Timeline for Completing Tasks Identified in Heightened

Monitoring Plans
The monitoring team reviewed the timeline in each HM Plan for completing tasks.
Expected compliance with tasks and sub-tasks for Phase One operations was, on average, due 50
days out from an operation’s HM Plan Start Date:
• 25% of the 80 tasks and sub-tasks, or 20, were due within two weeks (14 days) of the HM
Plan start date. Seven of 80 were due within five days. Nearly half (48%, 38 of 80) of tasks
and sub-tasks were due within 31 to 90 days of the HM Plan Start Date.
Figure 7.21: Proportion of Heightened Monitoring Tasks and Sub-Tasks Due Within Two
Weeks of the Heightened Monitoring Plan Start Date
Source: State Heightened Monitoring Documentation and Plans

n = 80
100% (2)
100%
80% 57%
(4) 50%
60% 38% (4)
(6)
40% 18% 20%
(2) (2)
20%
0% 0%
0%
Start Love Valley View Hope (10) (8) Trades (9)
(16) (2) (7) (11) (17)
304
The average time to the latest task compliance due date (i.e., full compliance) for all Phase
One operations was 111 days from the HM Plan start date. The time to full compliance from the
HM Plan start date was from 14 days (Assuring Love) to 203 days (Gulf Coast Trades Center).
Table 7.9: Time to Expected Compliance of All Tasks for Phase One Heightened
Monitoring Operations Analyzed
Number of Days from Heightened
Operation Monitoring Plan Start to Expected
Compliance of All Tasks
A Fresh Start 97
Assuring Love 14
Azleway Valley View 60
Beacon of Hope 105
Benchmark 92
Connections 75
Gulf Coast Trades Center 203
New Life 87
Total average 111
Although the HM Plan for Assuring Love contained only two tasks, they were broad in
scope, calling into question the 14-day timeline expected for compliance.
Tasks for Assuring Love

The operation will provide documentation of improvements made during licensing
corrective action regarding supervision and discipline. The operation will provide
evidence as requested of continued compliance.
The operation will develop policies and procedures to ensure Supervision of staff
during supervisory visits to ensure quality.
f. Comparison Between Prior Enforcement Actions and

Heightened Monitoring Plan
The monitoring team reviewed prior enforcement actions taken against each Phase One
operation based on the information provided in the HM Plan and documents. The issues and
requirements from prior enforcement actions were then compared with the identified safety and
compliance problems and tasks outlined in the operation’s HM Plan.
305
All but one operation (A Fresh Start) had previously been under enforcement action for
similar issues that led to Heightened Monitoring.636 Two operations – Benchmark and Gulf Coast
– had been under enforcement action for all of the same trends/issues identified in the operation’s
current HM Plan. The remaining five operations had been under enforcement action for some of
the same trends/issues identified in the current HM Plan.
Table 7.10: Prior Enforcement Actions at Phase One Heightened Monitoring Operations
and Similarities in Issues and Requirements to Current Heightened Monitoring Plan
Comparison of Prior Enforcement

Type(s) of Prior Action to Current HM Issues/Tasks
Operation Enforcement Action Similar Similar
Trends/Issues Requirements
A Fresh Start None N/A N/A
Assuring Love POA & Evaluation Yes, some No
Azleway Valley View Evaluation Yes, some Yes, some
Beacon of Hope Evaluation Yes, some Yes, some
Benchmark POA & Evaluation Yes, all Yes, all
Connections POA Yes, some Yes, some
Gulf Coast Evaluation Yes, all Yes, all
New Life POA Yes, some Yes, some
The monitoring team compared the tasks included in the HM Plan with tasks included
under prior enforcement actions, if any, and found that 31% of HM Plan tasks, or 22 of 71, were
similar to requirements included in prior enforcement actions. Six of eight operations (all but A
Fresh Start and Assuring Love) had at least one task that was similar to requirements in prior
enforcement actions.637
636
Enforcement action is defined as a Plan of Action, Enforcement Evaluation, or Probation since 2015 to the date of
placement on Heightened Monitoring.
637
A Fresh Start had not been placed under enforcement action prior to Heightened Monitoring. The prior enforcement
action requirements for Assuring Love were much more detailed while their Heightened Monitoring tasks are broad.
While the past requirements for Assuring Love were different – mostly due to their Heightened Monitoring tasks being
broad – they addressed similar issues.
306
Figure 7.22: Proportion of Heightened Monitoring Tasks with Similar Requirements to

Prior Enforcement Actions at Operations in Phase One Heightened Monitoring
Source: State Heightened Monitoring Documentation, Enforcment

Actions in CLASS
n = 54
100%
70% 67%
80% (7) (4)
50%
60% (4)
25% 27%
40% (4)
14% (2)
20% (1)
0%
Azleway Beacon of Benchmark Connections Gulf Coast New Life
Valley View Hope (10) (8) (15) (6)
(7) (8)
Review of Heightened Monitoring Visits to Phase One

Operations
The monitoring team reviewed Heightened Monitoring visit documentation provided by

the State and found in CLASS “other” monitoring inspection entries and Heightened Monitoring
chronological entries for the Phase One operations.638 The State’s monitoring visits were
conducted between June 17 and December 31, 2020.
Two hundred and fifty-three (253) Heightened Monitoring visits were documented
between June 17, 2020 and December 31, 2020 in the Phase One operations analyzed. Visits were
made to GROs,639 CPA branch offices, and agency homes. An additional 24 visits were attempted
during the period. Attempted visits were all associated with CPAs, with 92% of attempted visits
(22 of 24) occurring at foster homes.
638
This analysis is based on documentation as detailed in Residential Contracts Weekly Monitoring Visit, Child-Care
Inspection Form 2936, CPS Monitoring Visit, and CPS Safety Visit forms. Incomplete visit form information was
supplemented, where possible, with details found for a visit in the heightened monitoring chronology entry.
639
GROs include residential treatment centers (RTCs) and emergency shelters.
307
Table 7.11: Number of Heightened Monitoring Visits at Phase One Heightened Monitoring
Operations Analyzed
Operation Number of Visits Type of Operation

A Fresh Start 25 GRO
Assuring Love 33 CPA
Azleway Valley View 31 GRO
Beacon of Hope 22 CPA
Benchmark 52 CPA
Connections 28 GRO
Gulf Coast 47 GRO
New Life 15 GRO
Total 253 -----
The majority (58% or 146 of 253) of Heightened Monitoring visits at Phase One operations
were conducted at GROs. Visits to CPA branch offices accounted for 23% of visits (58 of 253)
while visits to agency homes accounted for 19% (49 of 253).
308
Figure 7.23: Heightened Monitoring Visits at Phase One Operations by Type of Operation
and Entity Conducting Visit, 640 June-December 2020
Source: Heightened Monitoring Visit Documentation in
SharePoint and in CLASS
n=253
160
146
120 57
Number of Visits
80
35 58 49
40 29 8
54 38
29
0 3
GRO CPA Branch Agency Home
RCM CPS RCCR
Twenty-one percent of Heightened Monitoring visits (52 of 253) at Phase One operations
occurred prior to the development of the operation’s Heightened Monitoring Plan. Operations
were, on average, visited for the first time within five days of being notified that they were being
placed under Heightened Monitoring. Two operations, Assuring Love and Connections
Emergency Shelter, were visited the day of notification, while Azleway Valley View was not
visited until 13 days after notification. On average, Heightened Monitoring visits lasted just under
three hours. The shortest visit documented was 10 minutes while the longest visit was over 7 hours.
Heightened Monitoring visits for Phase One CPAs occurred at the main CPA office, CPA
branch offices, and at agency homes associated with the CPA branches. Phase One CPAs with
branches and agency homes did not experience Heightened Monitoring visits equally. The State
indicated that visits to CPA branches and agency homes were determined based on risk scoring,
with those branches and homes with the highest risk visited more frequently.641 Benchmark
McAllen, however, received only five of the agency’s 52 visits (10%) even though they were under
a Plan of Action (POA) as of September 1, 2020.
640
The Heightened Monitoring team responsible for conducting visits includes RCCR Heightened Monitoring
Inspectors (HM Inspectors), DFPS Heightened Monitoring Specialists (HM Specialists), and DFPS Heightened
Monitoring Residential Contract Managers (HM Residential Contract Managers). Between June and December
2020, 37% of Heightened Monitoring visits (94 of 253) were conducted by RCCR HM Inspectors, 34% (86 of 253)
were conducted by DFPS HM Residential Contract Managers, and 29% (73 of 253) were conducted by DFPS HM
Specialists.
641
Virtual meeting between Monitors and State, January 25, 2021.
309
Table 7.12: Heightened Monitoring Visits Associated with Child Placing Agencies
Total
Branch Agency
Heightened
CPA Branch Office Office Homes
Monitoring
Visited Visited
Visits
Assuring Love-Desoto* 23 10 33
Beacon of Hope-Corpus Christi* 11 8 19
Beacon of Hope-Harlingen 3 0 3
Benchmark-San Antonio* 13 14 27
Benchmark-McAllen 3 2 5
Benchmark-Sugarland 0 0 0
Benchmark-Duncanville 1 2 3
Benchmark-Pflugerville 1 0 1
Benchmark-Longview 1 0 1
Benchmark-League City 0 7 7
Benchmark-Corpus Christi 0 0 0
Benchmark-Killeen 1 6 7
Benchmark-Ft Worth 1 0 1
Benchmark-Spring 0 0 0
Total 58 49 107
* Indicates CPA main branch.
Phase One CPA offices were visited more frequently than agency homes. Between June
and December 2020, CPA offices were visited 58 times (54%) while agency homes received 49
visits (46%). Eighty-one percent of CPA office visits (47 of 58) occurred at the main branch. Three
Benchmark branches received no Heightened Monitoring visits between June and December 2020.
Between June and December 2020, 15% of agency homes (42 of 271) associated with a
Phase One CPA642 were visited. The percent of homes visited per branch ranged from 3% of
associated homes (Benchmark Duncanville) to 50% of associated homes (Beacon of Hope Corpus
Christi). Six homes received two or more visits during the period.
Operations on Heightened Monitoring are required to receive weekly unannounced visits.
Between June and December 2020, only 1% of all unannounced visits to Phase One operations (3
of 253) did not meet this requirement.643 Eighteen percent of visits (46 of 253) occurred on the
same day as another visit at that operation. Same day visits were most often associated with agency
642
Number of agency homes associated with the CPA branch as of March 21, 2021. The actual number of homes
associated between June and December 2020 may have been different.
643
Three visits which occurred at Benchmark Family Services (9/3/20 to 9/17/20), A Fresh Start (11/12/20 to 11/22/20)
and Beacon of Hope (11/18/2020 to 12/1/2020) did not take place as part of a weekly cadence.
310
home visits. Sixty-five percent (32 of 49) of agency home visits occurred on the same day
compared to 7% of visits to GRO (10 of 146) and CPA branch offices (4 of 58).
Heightened Monitoring visit documentation was reviewed to identify what occurred during
the visit. This analysis is based on the details included in documents provided by the State, and in
CLASS “other” monitoring inspections, and Heightened Monitoring chronological entries.644
Four percent of visit documentation (9 of 253) included no details about what occurred during the
visit.
Heightened Monitoring visits conducted prior to Heightened Monitoring Plan development
are intended to support the development of the operation’s plan, engage operation leadership, and
identify improvement areas, while visits conducted after the plan is finalized are intended to
evaluate the operation’s compliance history and progress with Heightened Monitoring tasks.645
Between June and December 2020, 45% of visits (91 of 201) conducted after an operation’s plan
was finalized646 clearly identified the tasks monitored during the visit. On average, six (6) tasks
were monitored during visits, with the percent of total tasks monitored per visit ranging from 7%
to 100% of an operation’s heightened monitoring tasks.
Table 7.13: Number of Heightened Monitoring Plan Tasks per Operation and
Average Number of Tasks Reviewed During Visits
Average Number of
Number of
Operation Tasks Reviewed
Plan Tasks
During Visit
A Fresh Start 15 8.0
Assuring Love 2 1.5
Azleway Valley View 7 5.7
Beacon of Hope 8 2.2
Benchmark 10 1.9
Connections 8 4.7
Gulf Coast 15 8.8
New Life 6 5.0
Fifty-five percent of Heightened Monitoring visits (135 of 244) to Phase One operations
included a review of one or more documents. Documents most often reviewed included:
staff/foster parent training records, background checks, staffing plans, child service plans,
admission assessments, medication logs, and serious incident reports. Agency home visits were
the least likely to include a document review (15% or 7 of 46) while CPA branch office visits were
644
CLASS “other” monitoring inspections and Heightened Monitoring chronological entries were checked to ensure
that all heightened monitoring visits that occurred during the period were included in the analysis. Eight percent of
visits (20 of 253) were documented solely based in CLASS entries.
645
Heightened Monitoring Process Overview, HHSC and DFPS, November 30, 2020.
646
Fifty-two of the visits documented between June and December 2020 occurred prior to the finalization of the
operation’s Heightened Monitoring plan.
311
most likely to include a document review (69% or 38 of 55). DFPS or RCCR staff documented a
walk-through of the operation in 79% of visits conducted at GROs and agency homes. A walk-
through was not expected for visits conducted at CPA branch offices.
Figure 7.24: Percent of Heightened Monitoring Visits to Phase One Operations that
Included Document Review, Standards Review, a Walk Through, and Technical Assistance
Source: Heightened Monitoring Visit Documentation in SharePoint and

CLASS, June - December 2020
n= 244
Yes No
100%
79%
80%
Percent of Visits
66% 66%
60% 55%
45%
40% 34% 34%
21%
20%
0%
Documents Standards Walk Through TA Provided
Reviewed Reviewed* Conducted*
* Includes only applicable visits; standards were only reviewed during Heightened Monitoring inspector visits and
walk throughs were only conducted at GROs and agency homes.
Files of both staff/foster parents and children were reviewed during 24% (59 of 244) of
Heightened Monitoring visits at Phase One operations, while State representatives reviewed only
child files in 12% of visits (29 of 244) and only staff/foster parent files in 9% of visits. No files
were reviewed in 55% of visits (135 of 244). Children and/or staff or foster parents were
interviewed in 68% (166 of 244) of Heightened Monitoring visits. Both children and staff/foster
parents were interviewed in 35% of visits (86 of 244), while only staff/foster parents were
interviewed in 18% of visits (43 of 244) and only children were interviewed in 15% of visits (37
of 244).
312
Figure 7.25: Type of Files Reviewed and Interviews Conducted During Heightened
Monitoring Visits at Phase One Operations
Source: Heightened Monitoring Documentation

in SharePoint and in CLASS, June - December 2020
n=244
Both Staff and Child Staff Only Child Only None
60% 55%
40% 35%
32%
24%
20% 18%
15%
12%
9%
0%
Files Reviewed During Visits Interviews Conducted During Visits
RCCR Inspectors monitor an operation’s compliance with minimum standards during

Heightened Monitoring visits. Standards were reviewed in 66% (57 of 86) of all visits conducted
by RCCR Heightened Monitoring Inspectors at Phase One operations. During visits including a
standard review, an average of two standards were monitored. Thirty-eight percent of Heightened
Monitoring visits (33 of 86) conducted by Heightened Monitoring Inspectors resulted in one or
more deficiencies being cited. A total of 83 deficiencies were cited in Phase One operations
between June and December 2020.647
Technical assistance was provided to operations and agency homes in 34% (84 of 244) of
Heightened Monitoring visits at Phase One operations. RCCR Heightened Monitoring Inspectors
were the most likely to provide technical assistance during visits (64% of visits or 55 of 86) while
DFPS Heightened Monitoring Specialists were the least likely (1% of visits or 1 of 73).
DFPS and RCCR identified one or more allegations of abuse or neglect or other safety or
compliance problems in 23% (55 of 244) of visits, including 21 calls to Statewide Intake made as
a result of visits. Reasons for SWI calls included:
• Child touching another child inappropriately
• Two foster children were staying in another home because their foster home was
problematic, no meals prepared, problem with administering medications and
inappropriate documentation
• Staff member calling a child “fat ass”
647
Includes all standards cited during a Heightened Monitoring visit. Some standards cited during Heightened
Monitoring visits may have been overturned after administrative review or may be pending an administrative review
decision.
313
• Safety concern for a child who was threatened by a group of other children
• Child was attempting to self-harm with scissors and no staff was in close proximity
• Child reported staff asleep at night
• Child left alone while foster parents were out of town
• Child not being able to call caseworker
Other noted problems included:
• Foster parent reported that the turnover in CPA case managers is disconcerting
• Foster parent expressed concerns with the case manager: paperwork not timely, incident
reports are sent several months after the incident, recommendations are not followed-up
timely, agency not meeting needs of children or the caregivers. Discipline techniques not
provided by CPA. CPA not responsive when concerns are expressed
• One child interviewed stated that he did not know who to contact if he has complaints or
issues, and he had not heard of the Ombudsman
• Two youth were still not enrolled in a court-ordered GED program, and staff and Admin
stated that there was a plan in place to have them enrolled in regular school if the GED
program still had not responded by 10/30
• Three child service plans were reviewed. All three had a generic narrative to address the
child’s needs that the operation used for every child
• Monitor noted at 6:45 dinner was not being prepared for 7:00 service. Staff were not aware
what would be served as the cook was out. One staff obtained 3 frozen pizza for 8 children
Review of Placement Approvals for Phase One Operations
The Monitors engaged in two analyses to validate the Court’s requirement that the
Associate Commissioner for CPS, or, later, the Regional Director approve children’s placements
to operations on Heightened Monitoring prior to the child’s admission. The first analysis was
based on a review of placement authorization requests provided to the Monitors for June through
December 2020. The second analysis used PMC child placement data for the same time period.
A total of 133 placement authorization requests were provided to the Monitors by the State
between June and December 2020 for the eight operations in Phase One of Heightened Monitoring.
Of these, 99% were approved (131 of 133).
314
Figure 7.26: Placement Authorization Requests for Phase One Heightened Monitoring
Operations Analyzed
Source: Placement Authorization Requests in SharePoint, June – December

2020, n = 133
Approved Denied
100
77
80
60
37
40
20 8
0 1 3 1 3 0 3
0
Start Love Valley Hope
View
Of the 131 placement requests that were approved, only eight had conditions associated with
the placement, including:
• Child must be the only child in the home.

• Caregivers must be briefed on behaviors of the child.
• Child not allowed to room with another child with a history of child sexual aggression of
child sexual abuse and must be supervised when with another child with a history of sexual
abuse or aggression.
• No staff currently under investigation may supervise the child.
• Extra visits by worker are required to observe child and home environment.
Seven of the eight children whose placement approvals included conditions were ultimately placed
in the setting subject to Heightened Monitoring. Only one of the two denied placement approval
requests featured a reason provided in the denial: the children who would be sharing a bedroom
did not comply with agency policy around allowable age differences, as the child who would have
been placed was a four year-old, and the child who would have shared the bedroom was an 11
year-old.
Forty-seven of the 131 (36%) approved placement requests provided to the Monitors were
for placements of PMC children; the rest (84 of 131) of the approved requests were for TMC
children.
315
Figure 7.27: Legal Status of Children with Approved Placement Authorizations in Phase
One Heightened Monitoring Operations Analyzed
Source: Placement Authorization Requests in SharePoint, June – December 2020 and

pp_10slx report from Data Warehouse
n = 131
PMC TMC
60
52
50
40
30 25
22
20 15
10 6
3 2 1 2 0 1 2
0
0
A Fresh Start Assuring Love Azleway Beacon of Benchmark Connections Gulf Coast New Life
Valley View Hope
Of the 47 placement approvals for PMC children into a Phase One Heightened Monitoring
operation between June and December 2020, 34 resulted in placement in the operation. Overall,
the Monitors found 79% of approved placement requests (104 of 131) resulted in placements in
the operations.
316
Figure 7.28: Placement Requests at Phase One Heightened Monitoring Operations with an
Approved Placement by PMC Status
Source: Placement Authorization Requests in SharePoint, June –

December 2020, pp_10slx Report from data warehouse, IMPACT
n = 131
Placement No placement
PMC 13
34 (72%)
(28%)
14
TMC 70 (83%)
(17%)
0 20 40 60 80 100
Most of the placement approval requests were made prior to the Court’s December 7, 2020
order, which modified the placement approval process. Consequently, 97% of approved PMC
placements that resulted in placement in a Phase One operation (33 of 34) between June and
December 2020, were approved by the CPS Associate Commissioner.
The information included in placement requests was more robust following the Court’s
order of December 7, 2020. However, even before the modification, the placement requests almost
always included a “best interest” statement for the child, and a description of the child’s needs.648
648
All of the 17 placements made after the Court’s December 7, 2020 order through December 31, 2020 were for
TMC children, so a “before and after” comparison could not be made solely for PMC children.
317
Figure 7.29: Information Included in Approved Placement Requests that Resulted in

Placement by Timing of Request
Source: Placement Authorization Requests in SharePoint, June – December 2020

and IMPACT
n = 104
100% Before court order modification (n = 87)

94%
87% (17) After court order modification (n = 17)
100% (16)
(76) 75%
80% (65)
53% 53%
60% 39% (9) (9)
(34) 24%
40%
(21)
5%
20%
(4) 0%
0%
Operation history Statement of best Description of All three elements No elements
interest child's needs
Of the 34 PMC children with an approved placement request who were placed in a Phase
One operation, 62% (21 of 34) were placed after the request for approval was made. Six (18%)
were placed the same day as the approval, and seven (21%) were placed prior to the approval.
Figure 7.30: Timing of Placement Start for PMC Children with Approved Placement
Requests and Placement at Phase One Operations
Source: Placement Authorization Requests in SharePoint, IMPACT, PMC Child

Placement Data, June - December 2020
n = 34
Placed prior to approval 21% (7)
Placed same day as approval 18% (6)
Placed 1 to 7 days after approval 41% (14)
Placed more than 7 days after approval 21% (7)
0% 10% 20% 30% 40% 50%
318
The Monitors next used the PMC placement data provided by the State to identify
placements of PMC children in Phase One operations that occurred after the operation was notified
that it was placed on Heightened Monitoring. The monitoring team looked for documentation of
an approved placement request in IMPACT, based on the State’s description of the process for
approving placements prior to and after the Court’s order of December 7, 2020.
There were a total of 118 new placements of PMC children in the Phase One operations
analyzed after the operations were notified of being placed on Heightened Monitoring.649
Figure 7.31: Number of PMC Placements at Phase One Operations After Operation was
Placed on Heightened Monitoring, June – December 2020
Source: PMC Child Placement Data
n = 118
80 75
60
40
20 10 12 10
0 4 2 5
0
Start Love Valley View Hope
Of the 118 PMC placements at Phase One operations, the monitoring team was unable to
find a placement approval for 65% (77 of 118). The monitoring team also compared the 118 PMC
placements to the placement requests provided by the State and found that 71% (84 of 118) of the
children placed in a Phase One operation subject to Heightened Monitoring between June and
December 2020 did not match to a placement request provided to the Monitors by the State.
However, of those 84 placements, seven did have a placement approval by either the CPS
Associate Commissioner (6 of the 7), or Regional Director (1) documented in IMPACT.
649
New placement is defined as a child having a Placement Start Date after the date of notification of Heightened
Monitoring for that operation. Placement starts occurring within one day of a prior placement end at the same operation
location (e.g., a change in level of care) were excluded. Gulf Coast Trades Center was put on a placement suspension
on December 11, 2020. Of the 12 PMC placements made to Gulf Coast Trades Center, none occurred after the
placement hold was put in place.
319
Figure 7.32: PMC Placements at Phase One Heightened Monitoring Operations by

Approval
Source: PMC Child Placement Data and Placement Authorization Requests in

SharePoint, June – December 2020
n = 118
Approval found in placement request or IMPACT
No approval found in placement request or IMPACT
A Fresh Start 0
Assuring Love 10
Azleway Valley View 31
Beacon of Hope 2
Benchmark 23 52
Connections 2 3
Gulf Coast 12
New Life 1 9
0 20 40 60 80
Since the eight operations were placed under Heightened Monitoring, the number of PMC
placements has declined in all of them.
320
Figure 7.33: Average Monthly PMC Placements at Phase One Operations One Year Prior
to Heightened Monitoring and in the Months Following Placement on Heightened
Monitoring through December 31, 2020
Source: PMC Child Placement Data, June 2019 - December 2020

One year prior to HM Since HM
20 19
18
16
14 13
12
10
8
5
6
3 4 3
4 2 2 2 2
2 0.5 0.7 1 0.5 1
0
0
g. Analysis of Minimum Standards Citations and

Substantiated Abuse or Neglect Allegations for Phase One
Operations
The monitoring team analyzed the number of citations issued for minimum standards violations,
the number of intakes and substantiated allegations of abuse or neglect, and the number of
minimum standards waivers or variances granted after Phase One operations were placed on
Heightened Monitoring. The Monitors compared the average number of deficiencies per month
in the 12 months prior to the onset of Heightened Monitoring with the average number of
deficiencies per month from placement on Heightened Monitoring through December 2020 for
Phase One operations.
321
Figure 7.34: Average Number of Deficiencies Prior to and Following Placement on

Heightened Monitoring through December 31, 2020 for Phase One Operations Analyzed
Source: Deficiencies Data and State Heightened Monitoring Documentation

n = 662
One year prior to HM After HM
25
21
20
15 13
10
10
6
5 4 3 4 4 3 4 5
2 2 1
1 0.3
0
Five of the eight Phase One operations analyzed (63%) had a higher number of deficiencies per
month after placement on Heightened Monitoring than in the year prior to heightened monitoring.
In total, Phase One operations had 396 deficiencies cited in the year prior to placement on
Heightened Monitoring and 266 deficiencies cited in the months following placement on
Heightened Monitoring.650 Seven of the eight Phase One operations had a higher number of high
or medium-high deficiencies per month after placement on Heightened Monitoring than in the year
prior to Heightened Monitoring.
650
One year prior to placement on HM was calculated as 365 days prior to the HM notification date. The average
number of deficiencies per month following placement on HM was calculated by summing the number of deficiencies
cited after the HM notification date through December 31, 2020 and dividing the sum total by the number of months
each operation was on HM in 2020. If an operation was notified of HM toward the end of the month, that month was
not counted in the number of months placed on HM. Deficiencies include those with an administrative review status
of Waived, Upheld, or Pending.
322
Table 7.14: Total Number of Deficiencies Prior to and Since Placement on Heightened
Monitoring Through December 31, 2020 for Phase One Operations Analyzed
Total number of
Total number of deficiencies since Number of
deficiencies in year placement on months on
Operation prior to Heightened Heightened Heightened
Monitoring Monitoring651 Monitoring
A Fresh Start 47 48 5
Assuring Love 12 18 6
Azleway Valley View 4 14 6
Beacon of Hope 70 17 4
Benchmark 156 123 6
Connections Inc. 43 14 5
Gulf Coast Trades Center 44 29 6
New Life 20 3 3
Some of these citations were issued following an abuse or neglect investigation. A total of
113 allegations of child abuse, neglect, or exploitation were associated with 93 RCCI
investigations opened for Phase One operations subject to Heightened Monitoring between June
and December 2020. RCCI opened at least two investigations in every Phase One operation during
the time period. Benchmark had the highest number (61) and Connections had the lowest number
(2). Operations had a total of 66 citations652 for standards violations associated with investigations
during the period.
Half of the allegations at Phase One operations (56 of 113, 50%) were for Neglectful
Supervision, 21% (24 of 113) were for Physical Abuse, 12% (14 of 113) were for Sexual Abuse,
and the remaining 17% (19 of 113) were for Emotional, Medical, or Physical Neglect. All Phase
One operations had at least one Neglectful Supervision allegation and all but one operation
(Connections) had a Physical Abuse allegation. Five of eight Phase One operations had a Sexual
Abuse allegation.
Of the 113 allegations at Phase One operations, 104 (92%) were Ruled Out, seven (6%)
were substantiated with a finding of Reason to Believe (RTB),653 one was found UTB and one was
pending at the time of data collection.654 Three of the RTBs were for Neglectful Supervision, two
were Physical Abuse, one was for Sexual Abuse, and one was for Medical Neglect. A total of 121
perpetrators were identified in the 113 ANE allegations at Phase One operations. More than 90%
of perpetrators were caregivers or foster parents (114 of 121, 94%).
651
Deficiencies from the date of notification through December 31, 2020.
652
Includes all minimum standards violations as found in CLASS. Some citations may have been overturned.
653
Of RCCI investigations started between June and December 2020 with a disposition of RTB, 6 were completed in
2020 and one was completed in 2021.
654
Data was collected as of the week of April 5, 2021.
323
Table 7.15: ANE Allegation Dispositions for ANE Investigations Conducted at Phase One
Heightened Monitoring Operations
Allegation Disposition
Operation Reason to Unable to
Believe Ruled Out Determine Total
A Fresh Start 0 6 0 6
Assuring Love 0 6 0 6
Azleway Valley 0 3 0 3
Beacon of Hope 1 8 1 10
Benchmark 4 56 0 61655
Connections 0 2 0 2
Gulf Coast 1 15 0 16
New Life 1 8 0 9
7 104 1
Total
(6%) (92%) (1%) 113656
h. Analysis of Minimum Standards Waivers or Variances

Requested and Granted at Phase One Operations
Operations on Heightened Monitoring can request and be granted waivers and variances of
minimum standards. The Monitors first raised concerns related to RCCR’s approval of minimum
standards variances for troubled facilities in its updated review of the investigation of K.C.’s
fatality, filed September 2, 2020. During the research for the Update to the Court, the Monitors
discovered that Prairie Harbor LLC, the facility where K.C. died, had been granted a variance for
minimum standards related to staffing ratios, though the facility was on probation and had been
identified for Heightened Monitoring.657
During the September 2020 contempt hearing, the Court discovered that DFPS was
unaware that the variances had been granted by HHSC:
THE COURT: Do you know about this***Commissioner?
COMMISSIONER MASTERS: About the placements?
THE COURT: Yes. This is a place that has been identified by DFPS for heightened
monitoring, and yet, they have been approved, apparently, from – by HHSC for a
staffing variance, so they have even less staff per child than is required?
655
Benchmark had one allegation that was pending a disposition.
656
Id.
657
Deborah Fowler and Kevin Ryan, First Report, 25, ECF No. 869.
324
COMMISSIONER MASTERS: No, Your Honor. I was not aware.658
The next day, the Court asked Jean Shaw, the Director of RCCR, about the variances that were
granted for Prairie Harbor:
THE COURT: Who granted – who granted the variance for the***staff-to-child
after they were put on probation in February?
THE WITNESS: It was reviewed and approved by a supervisor.
THE COURT: In your department?
THE WITNESS: Yes, Your Honor.
THE COURT: And why was it approved knowing they were on probation?
***
THE WITNESS: The pandemic of COVID-19 has put quite a few operations at risk
of not having enough staff. *** So Prairie Harbor requested it, knowing that they
weren’t going to have enough staff. We did approve a variance, but we put
conditions on that variance, such as they could only – the normal ratio requires one-
to-five. We put – allowed them to go to a ratio of one-to-six. If any child was on
one-to-one supervision, that child was still required to be on one-to-one supervision
being supervised by somebody within their administration staff. We did put other
additional conditions on there as well.
Plaintiffs’ counsel also asked this witness about the variances:
BY MR. YETTER:
Q: There’s been a variance for several months after this child died in February.
You know that, Ms. Shaw. Don’t you?
A: Yes.
Q: And what – and this is a facility that’s had 145 citations and a recent child – very
preventable child’s death and your group is actually allowing them to have – get
out of ratio on the number of caregivers to children. That would – you just
explained to the Court?
A: Yes. I think that under normal circumstances, that would not be approved, but
we recognized that Prairie Harbor is not going to have enough staff. So we
658
Telephonic/Zoom Show Cause H’rg Tr, (September 3, 2020) 122-23, ECF No. 964.
325
implemented to *** to try to mitigate the risk to the fact that they are not going to
have enough staff whether we approve the variance or not.659
The Court instructed RCCR to provide DFPS and the Monitors with information related to
variances or waivers of minimum standards on a monthly basis going forward.660
Between June and December 2020, 360 minimum standards variances were requested by
operations on Heightened Monitoring,661 including 30 requests at Phase One operations. HHSC
granted requested variance to operations on Heightened Monitoring 163 times (of 323 requests,
50%).662
Phase One operations were granted variances in 57% of requests (17 of 30). Only one Phase One
operation (Gulf Coast Treatment Center) did not request a variance or waiver between June and
December 2020. On average, variances were effective for 66 days.
Table 7.16: Requested Variances at Phase One Heightened Monitoring Operations
Number of Number of Average

Operation Variances Variances Days
Requested Granted Effective
A Fresh Start 2 2 7
Assuring Love 1 1 365
Azleway Valley View 2 1 60
Beacon of Hope 2 2 62
Benchmark 11 4 84
Connections 4 1 0
Gulf Coast 0 0 0
New Life 8 6 30
Total 30 17 66
659
Telephonic/Zoom Show Cause Hr’g. Tr. (September 4, 2020) 113-15, ECF No. 967.
660
Id. at 120-21.
661
There were a total of 2,214 requests for variances and waivers between June 1,2020 and December 31, 2020, 360
of which were requested by operations on heightened monitoring (14%).
662
HHSC granted approval for variance waivers in operations not on Heightened Monitoring 85% of the time (1,668
of 1,968 requests). Calculations include only those requests for which data on decision was provided. Data on
requested waivers and variances provided by the State included missing supervisor decision information, with the
majority of missing information occurring for requests made in the month of August. Thirty-seven of Heightened
Monitoring requests and 246 of non-Heightened Monitoring requests did not have decision data.
326
Variances in Phase One operations were granted for the following minimum standards:
Table 7.17: Variances Granted to Phase One Heightened Monitoring Operations, June to
December 2020
Source: Variance and Waiver Data as Provided by DFPS, June – December 2020
Number of
Standard for Variance Variances Operation
Granted
748.1003(a)- Child/caregiver ratio-Caregiver may care for 5
children if any require treatment services, 8 children if not; Azleway Valley View
children under 5 years old count as 2 children 5 New Life
748.1007(b)(1)- Child/caregiver ratio-Awake caregiver may
care for 15 children if any child in group requires treatment
services 2 New Life
748.983(a)- First-aid-CPR renewal-Each caregiver must
complete any new first-aid training, as required to maintain
a current certification 2 A Fresh Start
749.1251(a)- Pre-placement visits-A child over six months
of age must visit the foster home at least once before
placement 1 Beacon of Hope
749.1291(a)- Contact between child placement staff and
children-except for child with primary medical needs,
monthly face-to-face contact; no longer than 60 days
without a visit 1 Beacon of Hope
749.2815(a)(1)- Supervisory Visits-must have supervisory
visits in the foster home at least quarterly 1 Benchmark
749.3021(a)- Space-Bedroom must have at least 40 square
feet of space per occupant; only four occupants per
bedroom 1 Benchmark
749.304- You must have a main or branch office in each
region of DFPS where you verify homes or within 150
miles of each verified home 1 Benchmark
749.673- Child placement staff qualifications-Employees
who perform child placement activities must meet
educational and professional qualifications 1 Assuring Love
New Life received variances related to child/caregiver ratios monthly, with effective dates from
July 3, 2020 to November 9, 2020.
327
Summary
The State’s list of operations to be placed under Heightened Monitoring changed twice
after the Monitors validated the list sent on June 5, 2020. First, the State added two CPAs and
removed seven after correcting a coding error that resulted in a miscount of CPA foster homes.
Second, the State added nine operations after the Monitors raised concerns regarding GROs that
were originally slated for Heightened Monitoring, but fell off the list after having “closed,” only
to reopen under a new name. The Monitors’ analysis for this report focused on the eight operations
prioritized for Phase One of Heightened Monitoring. Phase One operations had the highest scores
on a risk stratification analysis used by the State.
Between 2016 and 2020, the eight Phase One operations analyzed accounted for 67
substantiated findings of abuse or neglect, and more than 2,000 citations for minimum standards
deficiencies. All Phase One operations had been placed under some type of enforcement actions
at least once; some had been the focus of more than one type of enforcement action. A comparison
of tasks in the Phase One operations’ Heightened Monitoring Plans with those included in previous
enforcement actions showed that 31% (22 of 71) of the tasks included in Heightened Monitoring
Plans were similar to requirements included in the operations’ previous enforcement actions.
Heightened Monitoring visits in Phase One operations occur on a weekly basis, as required.
Thirty-eight percent of Heightened Monitoring visits (33 of 86) conducted by RCCR Heightened
Monitoring Inspectors between June and December 2020 resulted in one or more deficiencies
being cited; a total of 83 deficiencies were cited at Phase One operations during a Heightened
Monitoring visit. DFPS and RCCR identified one or more allegations of abuse or neglect or other
safety or compliance problems in 23% (55 of 244) visits, including 21 calls to SWI made as a
result of visits. After Phase One operations were placed on Heightened Monitoring, a total of 113
allegations of abuse or neglect were made; RCCI opened at least two abuse or neglect
investigations in every Phase One operations between June and December 2020.
A review of placement approval requests showed they were almost always approved: of
the 133 provided to the Monitors by the State between June and December 2020, 131 (99%) were
approved. However, the Monitors were unable to validate placement approval by either the
Associate Commissioner for CPA, or (later) the Regional Director, for the overwhelming majority
of PMC children placed in the Phase One operations after they were placed on Heightened
Monitoring. Of the 118 PMC placements made during that time period, the monitoring team was
unable to find approval for 65% (77 of 118) and could not find a placement approval request in
the documents provided by the State for 71% (84 of 118).
D. Remedial Order 21: Revocation of Licenses
Remedial Order 21: Effective immediately, RCCL and/or its successor entity, shall have the right
to directly suspend or revoke the license of a placement in order to protect children in the PMC
class.
328
Background
First Court Monitors’ Report Performance Validation

Findings
In the Monitors’ First Report, after a review of all the documents and information submitted
by the State, the Monitors determined that there had not been any license revocations for any
placement (foster home, CPA, or GRO) in the five-year period preceding September 30, 2019.663
HHSC had notified the Monitors of pending license revocations for two GROs – Children’s Hope
– Lubbock, and North Fork Educational Center –in December 2019 and February 2020,
respectively. The First Report discussed the history of RTBs leading up to the closure of these
facilities. 664 The Monitors’ First Report also discussed two GROs for which DFPS had terminated
its contract in 2020: Hector Garza RTC, and High Frontier Treatment Center.665 In the three years
between September 30, 2016 and September 30, 2019, DFPS had terminated only four contracts.666
The Monitors subsequently filed an update to the Court related to facility closures on
September 2, 2020, discussing the closure of Williams House, after DFPS removed all of the
children in the placement following the investigation of the death of C.G., discussed at length in
the Monitors’ First Report and updated in Section VIII of this report. 667 Williams House
voluntarily relinquished its license. The Monitors’ September 2, 2020 Update also alerted the
Court to the closure of three other GROs: Houston Serenity, Youth and Family Enrichment Center
(YFEC) and the YFEC Shelter, all of which surrendered their licenses. Had they not surrendered
their licenses, Williams House, Houston Serenity, and the YFEC Shelter would all have been
subject to Heightened Monitoring pursuant to Remedial Order 20 due to troubled child safety
histories involving violations of minimum standards and confirmed findings of child abuse and
neglect.668
The Monitors had not received any notifications from HHSC related to closure of an
agency foster home, though HHSC had indicated that it was developing a process for determining
when agency homes should be closed and expected a “full rollout of the new process by May 1,
2020.”669
663
664
Id. at 323-339.
665
Id. at 317.
666
Id.
667
Deborah Fowler and Kevin Ryan, The Court Monitors’ Update to the Court Regarding Child Fatalities and
Congregate Care Facility Closures (September 2, 2020), ECF No. 956.
668
Id.
669
Id. at 322. In addition, in an informal response to a draft of the First Report, HHSC indicated, “HHSC’s new
procedures for recommending closure of an agency home by RCCL inspectors rolled out on April 29, 2020, effective
May 1, 2020.” DFPS & HHSC, Agency Response to DR Texas Report 27 (June 15, 2020) (on file with Monitors).
329
Though Remedial Order 21 was not included in the Plaintiffs’ Motion to Show Cause, the
Court asked questions related to the issuance of license revocations and facility closures during
the testimony of Jean Shaw, the Associate Commissioner for Child Care Regulation at HHSC:
THE COURT: …[H]ow many licensed placements have you revoked in the past
five years?
THE WITNESS: I believe three.
THE COURT: And what are those – what are they?
THE WITNESS: One was for Five Oaks Achievement Center, one was for North
Fork, and the other one was for Children’s Hope…
THE COURT: So all of these placements that – you revoked their licenses?
THE WITNESS: We issue an Intent to Revoke. Throughout that process –
THE COURT: Which ones have you actually revoked?
THE WITNESS: Children’s Hope voluntarily relinquished their license after we

issued the Intent to Revoke. Five Oaks did the same thing. And North Fork is
under due process right now.
THE COURT: Okay, so of those three, which ones did you make it a stipulation
that they can’t reopen a – a facility in the future?
THE WITNESS: We have statutory requirements that guide us for that. So if –
THE COURT: How many? Just answer the question.
THE WITNESS: None at this time, Your Honor.
THE COURT: Okay. You know Five Oaks and North Fork are the same owners.
Right? And these are for profit organizations; is that right?
THE WITNESS: That is correct.
THE COURT: Same owners and for-profit, correct?
THE WITNESS: Yes, Your Honor.
330
THE COURT: So what is it you’ve licensed them for if DFPS won’t put children
there? These other places like Prairie Harbor and Hector Garza, what are they
licensed to do exactly?
THE WITNESS: I believe Prairie Harbor is licensed to be a residential treatment

center, which falls under a general residential license. It’s a service type. If they
no longer accept children from DFPS, they can look for other placement sources,
as long as they have a license.
THE COURT: Well that must be reassuring to the public generally.670
Policy Updates Following the Contempt Hearing
In October 2020, HHSC updated the Child Care Regulation Handbook to reflect the policy
changes for agency home closures that went into effect May 1, 2020.671 A new section was added
to the Handbook devoted to policies and procedures related to agency home closures.672
According to the Handbook, RCCR staff will recommend the closure of an agency home
when there is a high degree of risk to children and the risk cannot be mitigated.673 When RCCR
staff identifies risk at an agency home, the following criteria are used in assessing the home for
closure:
• patterns and repeated violation of high risk deficiencies;

• number of intakes and investigations; and
• whether the home was previously closed for deficiencies by another CPA.674
670
Telephonic/Zoom Show Cause Hr’g Tr. (September 4, 2020) 81-83, ECF No. 967 .
671
Despite HHSCs representation that the new policies were “rolled out” April 29, 2020, and would go into effect
May 1, 2020, HHSC did not provide the new policy or procedures to the Monitors, even after the Court instructed
both agencies to send the Monitors any policy changes related to the remedial orders during the September 2020
contempt hearing. The Monitors found the October 2020 changes in the Handbook during their own review. On
March 14, 2021, the Monitors e-mailed HHSC to ask the agency to send them any policy updates related to
Remedial Order 21, including Field Communications. E-mail from Deborah Fowler and Kevin Ryan to Taryn Lam,
Policy Updates, Field Communications, and Documents Related to RO 21 (March 14, 2021). The Monitors also
asked for any recommendations for an agency home closure made by RCCR staff, and the responses to the
recommendations. Id. In response, HHSC uploaded to the shared database redlined revisions to the Handbook
related to Remedial Order 21, as well as other remedial orders, and nine Field Communications, one of which was
related to Remedial Order 21 and eight related to other remedial orders, with effective dates ranging from May 1,
2020 to February 5, 2021. HHSC also uploaded five agency home closure recommendations and related documents,
which are discussed infra. E-mail from Taryn Lam to Deborah Fowler and Kevin Ryan, Policy Updates, Field
Communications, and Documents Related to RO 21 (March 16, 2021). Field Communication 284, the Field
Communication related to Remedial Order 21 that was provided to the Monitors on March 16, 2021, has an effective
date of May 1, 2020 and is almost identical to the updates made to the Handbook in October 2020.
672
HHSC, Child Care Regulation Handbook §4450 et seq. (October 2020), available at https://hhs.texas.gov/laws-
regulations/handbooks/ccrh/section-4000-inspections
673
Id. at §4450.
674
Id. at §4451.
331
The next section describes “Agency Home Compliance History Considerations,” instructing CCR
staff:
When evaluating the compliance history of the agency home, CCR staff considers
if there is a pattern or repeated violations of high risk deficiencies related to:
a. inappropriate discipline;
b. inadequate supervision;
c. unsafe living conditions;
d. safe sleep violations;
e. interference with an investigation; or
f. failure to report to the CPA a household member or frequent visitor for
background checks.675
When CCR staff “determines that an agency home has a high level of risk that cannot be
mitigated,” the staff person is to recommend closure within 24 hours of identifying the risk.676 The
procedure for submitting a recommendation for closure involves e-mailing a completed form and
supporting documentation to HHSC, and copying the staff person’s supervisor, program
administrator, and district director on the e-mail.677
The Handbook next describes a “Closure of Agency Home Meeting” that takes place:
If CCR state office accepts the recommendation for closure, CCR leadership and
HHSC legal hold an internal meeting to discuss the details of the recommended
closure.
If the recommendation for closure is approved during the meeting, the final
approval is requested from the HHSC Regulatory Services leadership.678
If HHSC RCCR leadership approves the closure during this meeting, the Handbook
indicates the RCCR regional director contacts the CPA to request closure of the home, and notifies
DFPS to assess for “placement disallowance.”679
675
Id. at §4451.1.
676
Id. at §4452.
677
Id.
678
Id. at §4453. Field Communication #284 indicates that within three days of a recommendation for closure form
being submitted, “the FCL project manager reviews the form for completion and, if warranted, schedules a closure of
agency home (CAH) review meeting” with the CCR Associate Commissioner, RCCR Director, RCCR field staff and
HHSC legal representative. HHSC, Child Care Regulation Field Communication #284 (April 29, 2020) (on file with
Monitors).
679
Id. at §4454. On March 19, 2021, the Monitors e-mailed RCCR to ask why a “placement disallowance” would be
necessary for an agency home that has been subjected to a forced closure. Email from Deborah Fowler and Kevin
Ryan to Taryn Lam, Policy Updates, Field Communications, and Documents Related to RO 21, March 19, 2021 (on
file with Monitors). RCCR explained, “Under applicable statutes and corresponding rules, the new CPA would be
required to review and consider background check determinations and other information from the previous CPA before
the new CPA can verify an agency foster home…With respect to transfer of an agency foster home from one CPA to
another, the home must notify the new CPA of all licensing violations cited during the preceding 3 years, and the
DFPS caseworker can provide input on whether the transfer is in the best interest of each child placed in the
332
Methodology
The Monitors reviewed all documents related to policy changes associated with agency
home closures, and documents submitted by HHSC to the Monitors related to the five agency
homes for which a closure recommendation was submitted. The Monitors also reviewed CLASS
to determine the history associated with each of the homes.
Since the Monitors’ last update to the Court related to congregate care facility closures,
RCCR issued letters to four additional GROs, notifying them of the agency’s intent to revoke their
license, and denied a license two GROs that were operating in an initial licensure period. In
addition, DFPS has notified the Monitors of its decision to cancel its contract with one GRO, and
one troubled GRO – Whataburger Center for Children – voluntarily relinquished its license. The
Monitors reviewed CLASS and data provided by the State regarding the history of these GROs.
Remedial Order 21 Performance Validation Results
a. Agency Homes Recommended for Closure by RCCR
Between the time that the new policy related to agency homes went into effect on May 1,
2020 and March 16, 2021, the date that the State responded to the Monitors’ request for
information related to agency home closures, five recommendations for closures had been
submitted by RCCR staff. Of those five recommendations, one was still pending at the time that
the information was provided to the Monitors, three had been approved for closure and closed, and
one recommendation for closure had been denied.
home…Additionally, where CCR’s closure recommendation is not related to a RTB finding, the disallowance
referenced in Tila’s e-mail to DFPS would prevent the agency home from receiving placements in the future. CCR
has initiated an IT change in CLASS to add “CCR Recommended Closure” as a reason that a CPA can select for any
agency home closure on the provider portal. Such change could deter reverification because the new CPA would be
able to see that the agency home was previously closed by another CPA at CCR’s recommendation.” E-mail from
Taryn Lam to Deborah Fowler and Kevin Ryan, Policy Updates, Field Communications, and Documents Related to
RO 21 (March 22, 2021) (on file with Monitors). For clarification, the Monitors responded by asking, “If the foster
parent has an RTB – would the background check come back showing them as ineligible?” E-mail from Deborah
Fowler and Kevin Ryan, Policy Updates, Field Communications, and Documents Related to RO 21 (March 22, 2021)
(on file with Monitors). RCCR responded, “If someone who requires a background check has a sustained finding for
Physical Abuse, Sexual Abuse, Labor Trafficking, or Sex Trafficking, the CPA would receive notification that the
person is Ineligible to be present at the operation. If the person has a sustained finding for Emotional Abuse or any
type of Neglect, the Centralized Background Check Unite would offer the subject of the background check a risk
evaluation. The CBCU would then evaluate the information obtained as part of the risk evaluation to determine
whether the person is ineligible to be present at the operation or eligible (with our without conditions placed on the
person’s presence).” E-mail from Taryn Lam to Deborah Fowler and Kevin Ryan, Policy Updates, Field
Communications, and Documents Related to RO 21 (March 22, 2021) (on file with Monitors).
333
b. Approved Closure Recommendations
Of the three homes that were closed, two were closed after abuse and neglect investigations arising
out of child fatalities resulted in RTBs:
• An investigation involving an 18-month old infant, E.C., discussed in Section VIII of this
report, who drowned in the foster family’s backyard swimming pool. An investigation of
the child’s death by RCCI led to a finding of Neglectful Supervision. CLASS shows the
CPA closed the home (by relinquishing its verification of the home) on December 8, 2020,
listing the relinquishment reason as “Voluntarily Closed with Deficiencies.”
• An investigation involving the April 13, 2020 death of a three-year-old foster child, R.M.680
The autopsy report revealed she had suffered blunt-force trauma to her head, trunk, and
extremities and that the injuries were “concerning” for inflicted trauma. However, the
child was also suffering from influenza when she died; therefore, the autopsy listed the
cause of death as “undetermined.” The investigation also revealed that R.M. had been
lethargic and had refused food for two days after the foster parent and other children in the
home said she fell off of her bike and hit her head. The February 10, 2021 RTB included
findings for physical abuse, medical neglect, and neglectful supervision. The child’s
sibling, who also lived in the home, had expressed homicidal ideation toward her, and had
injured her “multiple times,” resulting in a safety plan requiring her to sleep in a separate
room from the sibling, requiring the foster parent to install cameras in common areas of
the home, and requiring the child to be supervised when with her sibling. The foster parent
failed to follow the safety plan. This investigation was the first of this home, which had
opened less than a year before the child died. The recommendation for closure was made
February 23, 2021.681 RCCR also sent a background check letter to the CPA noting that
680
This child was not in PMC at the time of her death. The CPA responsible for oversight of the foster home where
the child died, Circle of Living Hope, is one of the CPAs subject to Heightened Monitoring pursuant to Remedial
Order 20.
681
An e-mail thread included in the materials that RCCR provided to the Monitors for this closure shows that the
RCCI investigation that resulted in the RTB was completed on February 10, 2021. The final report related to the
fatality was sent to DFPS leadership that day, indicating “Attached is the Confirmed Death Report for [R.M.]. [R.M.]
was found vomiting in her bedroom, became unresponsive, and was taken to the hospital and pronounced dead on
4/13/2020. During the investigation it was determined that [R.M.] had multiple unexplained bruises and injuries. The
autopsy was inconclusive but noted that she had suffered blunt force trauma concerning for inflicted child abusive
trauma. It was also determined that [R.M.] had been exhibiting symptoms of injury for multiple days prior to her
death and the foster mother…failed to obtain medical services. The investigation was closed with Reason to Believe
for Medical Neglect, Neglectful Supervision, and Physical Abuse of [R.M.] by [foster parent].” E-mail from Jonathan
D. Wilson, Lead Investigative Analyst, Complex Investigations Division, CCI, to Jillian Bonacquisti et al, Child
Death Final Report Region 07 (February 10, 2021) (on file with Monitors). The e-mail thread shows that DFPS sent
the fatality report to RCCR the same day, and the RCCR staff person who received it forwarded it to additional RCCR
staff, one of whom responded “This case is from April 2020 and has been back and forth with the autopsy cause of
death coming back as undetermined and LE stopped pursuing charges last August. The [Plan of Action] on several
other branches is coming to an end…Temple was not included in the PoA pending the outcome of this case.” E-mail
from Nicol Hoffer, Program Specialist, RCCR to Tila Johnson, et al, Child Death Final Report Region 07, (February
11, 202)1 (on file with Monitors). On February 22, 2021, Tila Johnson, the Director of Regional Operations for
RCCR, responded “Can you have someone complete the form to recommend closure of this foster home…Her home
is showing ‘inactive’ in CLASS. I’ll get a call set up once it’s submitted to me and to the mailbox. Todd – moving
forward with probation for all of the branches.” E-mail from Tila Johnson, Director of Regional Operations, RCCR,
334
the foster parent was ineligible to be a foster parent on February 25, 2021. CLASS shows
the CPA’s closure of the home was effective February 26, 2021 and lists the closure reason
as “Criminal History Match.”
The third closure involved a home that had been investigated for abuse or neglect seven
times, for minimum standards violations four times, and had received five citations related to
inappropriate discipline over its 11-year period of being licensed by two different CPAs (Beacon
of Hope and Benchmark Family Services).682 The foster home first operated under the McAllen
branch of Benchmark Family Services, from June 22, 2010 until September 23, 2013. During this
time, the home was the subject of four abuse and neglect investigations:
• An investigation opened January 3, 2011, alleging that when the nine-month old foster
child was on a visit with his parents, a diaper change resulted in the discovery of marks on
the child that appeared to be bruises, and a severe diaper rash. Abuse and neglect was
Ruled Out and the investigation was closed without any citations being issued.
• An investigation opened May 18, 2011, after a two-year old child made an outcry that the
foster parent hit her on the mouth. The child was observed by her CVS worker to have a
small circular bruise on her left cheek “possibly the size of a thumb.” During a follow-up
interview, the child recanted and said her sister hit her. Her sister said she got the bruise
when she fell. The foster parent also said the child had fallen, and a serious incident report
dated the day before the child’s outcry showed the foster parent had reported the fall and
the bruise. Abuse and neglect were Ruled Out and the investigation was closed.
• An investigation opened August 31, 2012, linking two intakes to SWI made by the same
reporter for two different sibling groups formerly in the foster parent’s care. Both intakes
alleged that the foster parent was physically abusive to the children while they were in her
care. However, the investigator discredited the reports when it was determined that the
reporter’s husband had left her and was romantically involved with the foster parent.
Though one of the children acknowledged that the foster parent hit him on the arm with a
water bottle, another child denied any physical abuse or discipline aside from time-outs.
The other children were too young to be interviewed. No concerns were expressed by any
of the other witnesses interviewed. The allegations of abuse were ruled out and the
investigation was closed.
• An investigation opened April 4, 2013, after a child made an outcry at school that the foster
parent put her younger sister, who was afraid of the dark, into a closet for time out and also
slapped her “for no reason.” The reporter, a staff person at the child’s school, also indicated
that the child said she does not have food at home and eats her best meal at school. The
child recanted the allegations during an interview with the investigator. The other foster
to Nicol Hoffer et al, Child Death Final Report Region 07 (February 22, 2021) (on file with Monitors). The next day,
the closure recommendation was sent from Nicol Hoffer to Tila Johnson and the e-mail address used for submitting
closure recommendations. E-mail from Nicol Hoffer to Tila Johnson, et al, Re: COLH King 2980e, February 23, 2021
682
Both of these CPAs are on Heightened Monitoring pursuant to Remedial Order 20.
335
children in the home were too young to be interviewed. A citation was issued for
inappropriate discipline because the foster parent acknowledged yelling at the children.
On September 24, 2013, Beacon of Hope CPA licensed the foster home. Between that date
and the date that RCCR recommended closure of the home, the home was the subject of three more
abuse or neglect investigations:
• An investigation opened May 2, 2014, after a three year-old foster child was observed with
marks under his arm on the right side of his body and made an outcry that the foster parent’s
boyfriend had hit him with a flyswatter. During the interview with the foster parent, she
said that the child obtained the injuries when he fell while he was playing and denied that
her boyfriend hit the children. During this interview, the investigator noticed a fly swatter
hanging on the wall, picked it up and asked the child with the injuries to come over to him.
The investigator lifted the child’s shirt and showed the foster parent that the handle of the
fly swatter aligned perfectly with the markings on the child’s body. This investigation was
closed with an RTB finding of Physical Abuse by the foster parent’s boyfriend but ruled
out Neglectful Supervision on the part of the foster parent. Three citations were issued: a
citation associated with the minimum standard for a child’s right to be free from abuse or
neglect; a citation issued related to inappropriate discipline due to the boyfriend’s use of
physical discipline; and a citation issued for inappropriate discipline related to the foster
parent’s admission during the investigation that she placed a toddler in a crib as a form of
discipline.
• An investigation opened June 6, 2017, when a five year-old foster child was found
wandering in the neighborhood. When law enforcement took the child back to the home,
the foster parent was in the bathroom and said she thought the child was asleep. The child
left the home twice the day before; the foster parent reported that she had new deadbolts
that she was planning to have installed on the doors. During the interview with the child,
he indicated that he left the home because he missed his family. However, he also said that
the foster parent hit him on his stomach “a lot,” that she hit the other kids “harder,” and
that she pushed him down to the floor from his neck when he didn’t go to sleep. He also
reported being spanked with a belt on his buttocks. Three other foster children were
interviewed and denied any physical abuse or discipline. Two children acknowledged that
the foster parent yelled at them. The investigation ruled out the allegation of neglectful
supervision and physical abuse. However, three citations were issued: one for inappropriate
discipline related to the foster parent yelling at the children; one due to the foster parent’s
admission that she left the door unlocked the day the child was found wandering in the
neighborhood, despite a safety plan requiring deadbolts on the doors (put in place after the
same child had left the house on a previous occasion); and a citation related to the foster
parent’s failure to appropriately supervise the foster child the day that he wandered out of
the house.
• An investigation opened December 12, 2019 after an eight year-old child who was formerly
in the foster parent’s care made an outcry of having been choked by the foster parent. The
same intake alleged that the foster parent would give a six year-old foster child and three
year-old foster child medications prescribed for older foster children who lived in the home
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to make them sleep. Though the child who made the outcry repeated the allegation when
she was interviewed, none of the other children reported physical abuse or discipline. One
child said that his sister’s allegation that she was choked was not true, that she was hitting
the foster parent and was never choked. None of the children reported being given
medication prescribed for another child. However, some of the children reported having
access to their medication and to medication prescribed for others in the home. The foster
parent acknowledged leaving medication in an unlocked drawer. The allegations related
to physical abuse were ruled out. However, four citations were issued related to the findings
related to the children’s access to medication.
Another four minimum standards investigations were opened after the foster parent was
licensed by Beacon of Hope:
• A Priority 3 minimum standards investigation initiated by RCCR on December 5, 2016,

after a foster child made an outcry that a five-year old child in the home was hit with a shoe
thrown by the foster parent. The child also alleged the child was “struck in other ways.”
When the child who was allegedly hit with the shoe was interviewed for the investigation
he said the other children in the home hit him. However, he also alleged that the foster
parent hit another foster child with a stick and “made his nose bleed.” This foster child
denied being hit with a stick during his interview. Another child interviewed stated that
the foster parent sometimes hit the five-year old foster child on the hand with a shoe. The
foster parent denied physically disciplining the children, but did admit that when the five-
year old misbehaved she redirected him by noting that if he “continued to make bad choices
that he may have to leave her home and could be separated from his sister” and also
threatened that he might not be able to visit his father. The foster parent also acknowledged
calling law enforcement for help deescalating the five-year old on one occasion. The
investigator ruled out any violation of minimum standards and no citations were issued.
• A Priority 3 minimum standards investigation initiated by RCCR on January 22, 2019 due
to allegations that the foster parent brought all five children in her care to a holiday party
in a car that was too small to transport the children. The intake also indicated that it “has
also been reported that FP repeatedly makes threats to call the police to remove the child
when that child cries, regardless of the reason the child is crying.” The children all denied
the allegations during their interviews. No citations were issued.
• A Priority 2 minimum standards investigation initiated by RCCR on June 18, 2020 after
three siblings had a Facetime visit with their father and one of the children told her father
that the foster parent hit her and her siblings. The child’s father asked her what she meant,
and she said that the foster parent hit them, repeating this twice. During her interview with
the investigator, the child recanted the allegations. The foster parent admitted using a
booster seat/high chair for time outs for one of the children during her interview, but denied
any physical discipline. A citation for inappropriate discipline was issued based on the use
of the booster/high chair as a form of discipline.
• A Priority 3 minimum standards investigation was initiated by RCCR on August 21, 2020,
involving the same sibling group, based on the following intake: “The children have video
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chat visits with their FA. FA had a video chat with the children last week (second week of
08/2020) and noticed [M] appeared to look scared. FA asked [M] what was wrong. [M]
said nothing. SBs indicated ‘they are hurting her.’ However, SBs did not provide specifics.
Unknown who they are or how they are hurting [M].” When the children were interviewed,
they denied any physical abuse or discipline. No citations issued. However, before the
investigation was closed on October 11, 2020, the recommendation was made to close the
home.
The recommendation for closure was submitted to RCCR on September 16, 2020 and
approved on September 25, 2020.683 The CPA was notified of the recommendation by letter on
September 29, 2020.684 DFPS was notified of the closure the same day via e-mail.685 CLASS lists
the closure reason as “Noncompliance.”
Pending Closure Recommendation
The closure recommendation that RCCR indicated remained pending on March 16, 2021
was made on October 26, 2020, at the same time that the closure recommendation was made for
E.C.’s home, discussed above. Both homes were licensed by the same CPA. The closure
recommendation form includes the following in the “Closure Recommendation Summary”:
683
An e-mail thread included in the materials submitted to the Monitors shows the submission was made via e-mail
by an RCCR Supervisor. E-mail from Erina Torres, RCCR Supervisor, CCR Agency Home Closure
Recommendation (September 16, 2020) (on file with Monitors). On September 25, 2020, an e-mail was sent in
response that said “The closure recommendation…has been approved. Tila please contact the CPA to discuss the
concerns and request closure, and coordinate with Jean to notify DFPS of the closure recommendation. Toni, no
further action is required by you or your team at this time. Tila will communicate with the CPA to request closure
of the home and we will work with DFPS to pursue a disallowance of placement preventing children from being
placed in the home in the event the CPA does not close the home. Thank you for your effort to get this one through
the process and doing our part to keep kids safe. Let me know if you have any questions.” The e-mail is signed
“Audrey” but does not include a last name or title. E-mail from HHSC RCCL Foster Care Litigation to Tila
Johnson, CCR Agency Home Closure Recommendation (September 25, 2020) (italics in original) (on file with
Monitors).
684
The letter notifying Beacon of Hope states, “As you may know, the federal district judge in M.D., et al, issued an
order effective July 31, 2019, concerning HHSC’s ‘right to directly suspend or revoke the license of a placement in
order to protect children in the PMC (permanent managing conservatorship) class.’ In line with that order, the Child
Care Regulation department of the Health and Human Services Commission (HHSC) recommends that your agency
close the following agency home [(home name and operation number listed)] HHSC’s recommendation is based on
a repetition of minimum standard deficiencies regarding discipline and medication at this foster home” and ends by
noting “Your failure to close the home may result in HHSC taking an enforcement action against your license if the
home continues to be deficient.” Letter from Tila Johnson to Jose Gomez, Beacon of Hope, September 29, 2020 (on
file with Monitors).
685
The e-mail to DFPS states, “This is to notify you that CCR has officially notified Beacon of Hope Child Placing
Agency by contacting Adriana Orozco, Executive Director, of our recommendation to close the…foster home, as a
result of a federal district court order to suspend or revoke the license of a placement in order to protect children in
the PMC class. This decision was made based on a determination that the home had a repetition of violations related
to discipline and medication. Ms. Orozco reported that she would take this information back to her team and
communicate back to CCR their decision to accept the recommendation to close the home or not. Please let me know
if you have additional questions.” E-mail from Tila Johnson to Kaysie Tacetta, et al., DFPS, Beacon of Hope – Foster
Home Closure (September 29, 2020) (on file with Monitors).
338
[Foster parents] have had two A/N investigations involving a lack of supervision.
The most recent investigation involved a [Primary Medical Needs] child with Down
Syndrome almost drowning in the above ground pool. This happened because
[Mrs. R], though in the pool, was making adjustments to the pool pump and was
not supervising the child. There are concerns regarding the story she gave about
the events that took place as she stated the child was in a life jacket but when the
child was discovered, she was not breathing and CPR had to be performed. During
the sampling visit on 10/7/20, [Mrs. R] brought up the incident and framed it as an
“accident” that just happened rather than a lack of supervision on her part. This
investigation was Ruled Out with a citation for supervision.
The other A/N investigation took place in May 2018. The allegations noted that
[Mr. R] took a newborn child in care into the CPS office in Abilene for a visit.
While [Mr. R] waited, he left another 10 month-old child in care in the vehicle in
the parking lot. The vehicle was running and unlocked. The child was left in the
car for approximately 3-5 minutes. The child was crying while in the vehicle. This
incident was observed by 2 CPS Investigation Program Directors, who spoke with
[Mr. R.] about the dangers of leaving a child unattended but [Mr. R.] felt this was
appropriate because he did not want to get both infants out of the vehicle. This
investigation was Ruled Out with a citation for supervision. On 6/4/18, during the
investigation inspection, a crib was observed with blankets and a stuffed toy in it
and ammunition was stored in the same locked safe with the hand guns. This
resulted in two High weighted citations by assessment and an Administrative
Penalty for the blanket and toy in the crib.
During the sampling visit on 10/7/20, it was noted that the two-car garage is so full
of belongings that it cannot be entered. The home was observed with large amounts
of clothing and toys all around the home. There was a garbage bag with garbage in
it on the kitchen table. There was a desk located in the kitchen with papers and
books stacked up and also cluttered. [Mrs. R] could not locate any of the pet
vaccinations because of the paper clutter. The home had six dogs plus a litter of
five puppies. Though the dogs appear clean, well care for, and friendly, there are
also six children living in the home. One adopted child was observed during the
visit to have a high level of need regarding interventions. This child was adopted
and had been shaken as a baby, resulting in low levels of emotional control and
frequent tantrums. There is a foster child currently placed that has Down Syndrome
and a heart condition. Another foster child placed has Autism Spectrum Disorder
and has a vocabulary of 15 words. Medication logs were unable to be viewed
during this sampling visit as [Mrs. R] stated that her husband completes this
documentation at work. While asking about unannounced visits, [Mrs. R] noted
she could not recall the agency ever completing one and stated it would be hard for
this to take place as she stays very busy and the agency office is so far from her
home. When reviewing the Quarterly documentation from 2019 it was documented
that all 4 Quarterly visits were unannounced. The foster home is not licensed for
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IDD Treatment Services though a current placement qualifies for this service.
When this was brought to the attention of the agency, their response was that YFT
and 2Ingage did not increase the child’s service level.
It appears that [Mrs. R] has a large amount of responsibility with all the needs of
the children and the large amount of animals in the home. There have been major
concerns about supervision. The two current placements in the home require a high
level of supervision and intervention due to their needs. It is concerning that the
agency does not appear to have spoken with the [Rs] about the near-drowning
incident, other than checking on [Mrs. Rs] emotional state.686
This document is the only one the Monitors received related to this home closure recommendation,
aside from the e-mail sent to the e-mail address that RCCR created for making closure
recommendations, attaching the recommendation form. RCCR offered no explanation for the
pending status of the recommendation, despite the fact that the recommendation was made almost
six months earlier.
Denied Closure Recommendation
One recommendation for closure was not approved by RCCR. This recommendation was sent to
the RCCR e-mail designated for closure recommendations on January 19, 2021. The “Closure
Recommendation Summary” in the recommendation stated:
In the past six months there have been 2 separate occasions in which the foster
mother’s home was found to be out of compliance with CBCU [background check]
requirements regarding household members and visitors.
The foster mother is deceptive and vague in confirming the individuals who reside
in her home.
The Administrators and Compliance Officer are adversarial in communicating with

the RCCR Representative to discuss identified deficiencies or concerns. The foster
mother receives disability payments and is unable to work outside of the home due
to serious injuries she sustained from a car accident back in 2008. There is concern
regarding her ability to meet her needs and supervision requirements for the
children in the home given her physical limitations. Failure to adhere to CBCU
requirements pose a high risk to the health, safety and welfare of the children placed
in the home. Furthermore, the foster placement is currently verified to care for
children with Autism Spectrum Disorder or Emotional Disturbances as well as
children under the age of 5. The children’s diagnosed disorders as well as their age
increase their overall vulnerability to potential risk of harm.687
686
HHSC, CCR Agency Home Closure Recommendation (Undated) (on file with Monitors).
687
HHSC, CCR Agency Home Closure Recommendation (Undated) (on file with Monitors).
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This home was verified by the Spring, Texas branch of the Youth in View CPA on June 29, 2018,
and since then has been the subject of nine minimum standards investigations and three
investigations of allegations of abuse or neglect. The three abuse or neglect investigations include:
• An investigation opened January 2, 2020, after the foster parent got into an argument with
a 16-year old foster child and called the police, alleging that the foster child had physically
assaulted her. According to the reporter, the foster child denied hitting the foster parent,
and the foster parent did not have any visible injuries. When the police called the foster
parent to pick the child up after determining the child would not be detained, the foster
parent refused, stating that she was getting ready to go on a cruise. The CPA was also
called and they refused to come and pick up the foster child. DFPS staff attempted to reach
the foster parent, and the foster parent refused to pick up the foster child. A 24-hour
discharge notice was issued. DFPS staff went to the foster parent’s home to pick up the
child’s insulin and psychotropic medications, and no one would answer the door.
Consequently, the foster child was without the medication for the entire weekend. A
neighbor told DFPS that the foster parents were abusive. During an interview with the
foster child, the foster child acknowledged hitting the foster parent when they argued over
whether she could have a laptop or tablet in her bedroom. Medical Neglect was ruled out
and no citations issued.
• An investigation opened February 3, 2021, after a 15 year-old foster child who stayed in
this home for a little over a week reported to her caseworker that the placement was “not
good,” that “there was a lot of alcohol in the house” and that she could smell alcohol on
the foster parent. The foster child reported that it was easy to steal cigarettes from the man
who lived in the home, that the foster children in the home had easy access to alcohol, and
that she was able to run away from the home because the back door was left unlocked and
unsupervised. The child also reported that there were unauthorized people in the home,
and that the adults in the home would throw parties at night, that included alcohol and
cigarettes. When she was interviewed by the investigator, the child also alleged that the
older foster youth had to take care of the younger children in the home because “no adult
was around most of the time.” She said that the adults in the home were gone from 8:00
a.m. to 5:00 p.m. and would check on the youth by logging into the camera that was in the
dayroom of the house. None of the collateral children or other witnesses substantiated the
allegations, and the investigation Ruled Out abuse and neglect.
• An investigation opened February 13, 2021, when the caseworker for an 11-year old foster
child and the child’s four year-old sibling, who were living in the home, requested they be
moved due to concerns related to a lack of supervision. The 11 year-old began self-harming
while living in the home and the caseworker was concerned that the child was not receiving
the assessment needed to address the behavior. None of the children reported a lack of
supervision when they were interviewed, and the 11-year-old’s therapist said she was
receiving treatment for the self-harming incidents. The investigation Ruled Out abuse and
neglect.
The nine investigations of minimum standards violations include:
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• An investigation was initiated July 16, 2018, after medical personnel from a hospital called
SWI to report that the foster parent “abandoned her foster child at the ER for hours at a
time and was unwilling to help the child get the mental/medical attention she needed after
having suicidal ideations. Foster mother was belligerent, aggressive toward the child and
all staff involved an uncooperative. Child was obviously frightened of this woman and
refused to speak with myself or her nursing staff.” Another report to SWI, made on July
31, 2018, was tied to this intake. That report came from a neighbor, who alleged that there
were “at least 13 people” living in the foster home, that “there are always at least 7 vehicles
parked there” and “other people and cars coming at all hours of the day and night.” The
caller also alleged that the adults smoked marijuana in the back yard. During the
investigation, the foster child who was hospitalized denied the allegation that the foster
parent abandoned her at the hospital, and none of the three other foster children interviewed
substantiated any of the allegations raised in either report. No citations were issued.
• An investigation was initiated on April 4, 2019, after a report to SWI that the foster parent’s
adopted child was sent to live with her father in California, though he had lost his parental
rights to the child due to abuse and neglect. The child’s father kicked her out and the child
called the foster parent, who pretended not to know the child. The caller alleged that the
foster parent still had the adopted child’s birth certificate, clothing, and money, and that
the foster parent never returned SSI money that she collected for the child. The caller said
that the foster parent sells her own pain medication, was abusive to the other children in
the home, and threatened children with putting in a notice to have them removed from her
home. The caller indicated the children lie for the foster parent, and that the foster parent
rewards the children. The intake indicates, “SWI Worker advised REP that this information
doesn’t meet definition of abuse or neglect that FPS would investigate. SWI Worker
advised that this information would be sent to RCL per standards compliance concerns.”
All four foster children were interviewed during the investigation; none of them
substantiated any of the allegations (though none appear to have been asked about the
allegations related to the adopted child). No citations were issued.
• An investigation was initiated on May 15, 2019, when a 16 year-old foster child’s high
school teacher reported that she was found vomiting in the school bathroom, and said she
was afraid because one of her foster siblings had threatened to kill members of the
household. The child recanted during her interview with the investigator, and said she was
not threatened, that the foster sibling had threatened the foster parent during an outburst.
None of the other children interviewed reported feeling unsafe in the home. No citations
were issued.
• An investigation was initiated on August 27, 2019, when a foster child (the same child who
reportedly threatened the foster parent in May 2019) reported being bullied by the foster
parent and the other foster children in the home. However, when she was interviewed by
the investigator, the child said she liked being in the home, but cut the interview short
because she did not feel like talking. During a later interview, the foster child said she was
not comfortable in the home, but did not feel unsafe. None of the other children
substantiated the allegation that the child was being bullied. No citations were issued.
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• A separate RCCR investigation was initiated on January 2, 2020, related to the allegations
that the foster parent refused to provide the medications for the child who was arrested
(discussed above). A citation was issued based upon the finding that the foster parent
refused to provide the foster child’s medication to the child’s caseworker, and the
caseworker was not able to obtain the prescriptions from the pharmacy because they had
just been filled by the foster parent.
• An investigation was initiated on October 12, 2020, when a six year-old foster child
reported to his caseworker that when he gets in trouble he gets a time out or a “whooping.”
When he was asked who “whoops” him, he confirmed that the foster parent did. When the
child was interviewed by the investigator he said that he was disciplined with a time out
and that “if a kid is super bad…maybe you’ll get a whipping.” However, the other foster
child interviewed denied corporal punishment being used in the home, and the foster parent
and caregivers denied using corporal punishment. A citation was issued related to the
failure to have an updated background check for a person (the foster parent’s daughter)
listed as a staff person, though the investigator acknowledged the foster parent may have
incorrectly characterized the daughter as staff.
• An investigation was initiated December 18, 2020, when an RCCR staff person called SWI
to report concerns related to the home. The RCCR staff who made the report is the licensing
representative for the CPA. The CPA contacted RCCR to discuss “whether or not the CPA
should continue to be affiliated with the…foster placement,” raising concerns about the
foster parent’s ex-husband, who the CPA suspected of having continued access to the
home. The ex-husband was ineligible to be present at the foster home, based on his DFPS
history. When the foster parent was interviewed, she said that she got married November
14, 2020 but had submitted her husband’s paperwork for a background check before they
married. She said that he does not reside in the home with her. When the background
check revealed that he was ineligible to be in the home, they decided to get an annulment.
The foster parent showed a receipt for the annulment to the investigator. However, though
the children agreed that the husband did not live in the house, three of the four children
interviewed said the foster parent’s husband did visit the home, and that they also saw him
outside the home. A citation was issued for the failure to complete the background prior
to allowing access to the children, and an administrative penalty was issued.
• An investigation was initiated on February 10, 2021, when a medical provider made a
report to SWI that when he called to let the foster parent know that a 16 year-old foster
child tested positive for chlamydia, the foster parent told him that the child had run away
from the home with her boyfriend. This report is linked with the foster parent’s report of
the runaway, made two days earlier. This case is still pending.
• An investigation was initiated February 22, 2021, after a foster child made an outcry that
the foster parent’s brother “goes to the foster home frequently and drinks at the foster
home.” The foster child reported that the foster parent’s brother talks to her about his past
abuse and “is very touchy, no[t] sexually touchy but invading space touchy.” The reporter
also noted that the foster child had self-harmed. This investigation is still pending.
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Prior to being verified by the Spring, Texas branch of Youth in View, the home operated
under the Desoto, Texas branch of the same CPA. During the time that the home operated under
the Desoto branch, the home was the subject of three abuse or neglect investigations, none of which
resulted in substantiated findings: once for allegations of Negligent Supervision related to child-
on-child sexual contact between a 13 year-old girl and 10 year old-boy (which the children agreed
occurred); once for Medical Neglect; and once for Physical Abuse and Neglectful Supervision.
While operating under the Desoto branch, the home was also the subject of three RCCR
investigations related to minimum standards violations; one of these investigations resulted in two
citations for inappropriate discipline after it was found that the foster parent instructed two foster
children in the home to pull another foster child who was hiding in the closet out of the closet and
to strip off her clothes, and after the child had refused to change her clothes to go to church.
The Monitors did not receive any information related to RCCR’s decision denying the
recommendation for closure, or any other documentation associated with this recommendation,
aside from the email sending the closure recommendation form to the e-mail address created by
RCCR for making closure recommendations.
Congregate Care Facility Closures & DFPS Contract

Terminations
As discussed in the Monitors’ First Report, there were no license revocations for any
placement (foster home, CPA, or GRO) in the five-year period preceding September 30, 2019.
Since then, RCCR has initiated revocation proceedings or denied a license for eight GROs, and
DFPS has notified the Monitors that the agency cancelled contracts with two GROs. Five other
GROs voluntarily relinquished licenses after being placed on Heightened Monitoring or another
type of RCCR enforcement action.
In the First Report, the Monitors discussed the first two GROs (Children’s Hope
Residential Services – Lubbock, and North Fork Education Center) against which RCCR initiated
license revocation proceedings, and two additional closures, one resulting from a voluntary
relinquishment (Children’s Hope – Levelland (Washington Campus), and another from DFPS’s
decision to cancel its contract with the operation (Hector Garza Residential Treatment Center).
In an update to the Court filed on September 2, 2020,688 the Monitors reported an additional
four closures, for Williams House, Houston Serenity, Youth and Family Enrichment Center
(YFEC) and the YFEC shelter, all of which voluntarily relinquished their licenses. Three of these
operations (Williams House, Houston Serenity, and the YFEC shelter) would have been subject to
Heightened Monitoring pursuant to Remedial Order 20 had they remained open. Williams House
closed after C.G.’s death, discussed in the First Report and in this report below, resulted in an RTB
for Neglectful Supervision that included the administrator of the facility. YFEC also was under a
corrective action plan relating to issues with 24-hour supervision and RTBs at the time that it
relinquished its license.
688
Deborah Fowler and Kevin Ryan, The Court Monitors’ Update to the Court Regarding Child Fatalities and
Congregate Care Facility Closures (September 2, 2020), ECF No. 956.
344
Since the Monitors’ September 2, 2020 Update, RCCR issued letters to four additional
GROs, notifying them of the agency’s intent to revoke their license, and denied a license to two
GROs that were operating in an initial licensure period. In addition, DFPS has notified the
Monitors of its decision to cancel its contract with two GROs, and one troubled GRO –
Whataburger Center for Children – voluntarily relinquished its license.689
Table 7.18: Congregate Care Facility Closures, September 2, 2020 – April 16, 2021
Operation Name Reason for ClosureDate of Notification to

Monitors
Prairie Harbor LLC RCCR Intent to Revoke 09/03/2020
The Landing at Corpus Christi RCCR Denial of Final License 09/16/2020
The Pillar of Progression for RCCR Intent to Revoke 12/15/2020
the Youth
Whataburger Center License Relinquished 01/05/2021
Merkabah RTC RCCR Denial of Final License 01/26/2021
Brave Hearts Children Center RCCR Intent to Revoke 02/06/2021
Gulf Coast Trades Center Contract Terminated by DFPS 02/23/2021
The Tree House Center Contract Terminated by DFPS 04/15/2021
Willow Bend Center RTC RCCR Intent to Revoke 03/02/2021
a. Prairie Harbor LLC
The Monitors’ First Report included a detailed description of the RCCI investigation of the
death of K.C., who died during her stay at Prairie Harbor LLC (Prairie Harbor), a residential
treatment center. The Monitors included an update of the investigation and discussion of the
689
E-mail from Corliss Lawson to Deborah Fowler and Kevin Ryan, The Treehouse (April 9, 2021) (on file with
Monitors). The Monitors review of the April 9, 2020 CLASS intake referenced in the State’s e-mail showed that a
first April 8, 2021 intake from the D.A.’s office was referred to RCCR as a Priority 3 investigation, and re-entered on
April 9, 2021 as a Priority 2 abuse or neglect investigation. The intake alleges that the CEO of the operation instructed
the manager of the facility not to run a background check on a staff person who “is a habitual felon and has a record
of aggravated assault and a history of possession of substances.” The intake goes on to allege that this staff person
“has keys which would allow access to the medication room and other rooms where [children] can be found.” The
intake also alleged that the CEO sent a text telling the facility manager to “get all the employees [sic] phones and
check to see who made a call to SWI.” It further alleged that the CEO “sent a text that has requested a list of all
employees so they can say people have been working so that they are not out of ratio compliance.”
The Monitors were notified on April 13, 2021 that all children had been moved from The Tree House Center, and
that “DFPS staff were present at the operation continuously since 04/09/21”. E-mail from Heather Bugg to Deborah
Fowler and Kevin Ryan, re: The Treehouse, April 13, 2021 (on file with Monitors). However, DFPS and RCCR have
not confirmed whether any action will be taken related to the contract with the operation or its license.
On April 15, 2021, the Monitors were notified that DFPS provide notice to Treehouse that DFPS is terminating their
contract. Email from Heather Bugg to Deborah Fowler and Kevin Ryan, re: The Treehouse (April 15, 2021) (on file
with Monitors). Also on April 15, 2021, HHSC notified the Monitors that on 4/27/2021, RCCR attempted to deliver
an “intent to involuntary suspend: letter to Treehouse. However, no one was at the location, a copy was left and a copy
was also subsequently mailed. Email from Katy Gallagher, HHSC Attorney to Kevin Ryan and Deborah Fowler, The
Treehouse (April 28,2021) (on file with the Monitors).
345
chronic systemic problems associated with the facility in the report filed with the Court on
September 2, 2020, and a further update on the investigation is included in this report in Section
VII.690
On September 3, 2020, during the hearing on the Plaintiffs’ Motion to Show Cause, DFPS
advised the Court that it was no longer placing children in Prairie Harbor and was in the process
of transitioning children out of the facility.691 The next day, the Court asked RCCR whether the
license for the facility would be revoked. RCCR testified that if an RTB finding was made
associated with the child fatality, the agency would issue an intent to revoke letter.692 On
September 9, 2020, RCCI completed its initial investigation, which resulted in RTBs for several
of the direct care staff who were with K.C. the night that she died.693
On September 11, 2020, the agency issued an intent to revoke letter to Prairie Harbor. The
letter cited the operation’s failure to successfully complete the probation on which RCCR placed
the facility just before the child’s death:
On February 5, 2020, your operation was placed on probation due to poor

compliance with minimum standards, requiring on-going adherence to minimum
standards and specific conditions of the probation…The probation sought to
address the risk to the health and safety of children in care created by the numerous
deficiencies related to caregiver responsibilities, judgment, punishment, discipline
and supervision. Further, the probation sought to address emergency behavior
intervention (EBI), as well as staff oversight and management. At the time of the
probation, investigations at the operation concluded that children in care were
sexually and physically abused by caregivers. Further, an investigation remained
on-going related to allegations of medical neglect related to the death of a child in
care. During the probation period, 4 inspections resulted in citations for 40
violations of minimum standards.694
The letter also referred to substantiated findings of Medical Neglect resulting from the
investigation of K.C.’s death, and to RCCI investigations substantiating allegations of Sexual
Abuse:
After the conclusion of an abuse and neglect investigation, numerous staff members
were found responsible for medical neglect related to the child death at your
operation. It was determined that the child had not received necessary medical
690
Deborah Fowler and Kevin Ryan, First Report, 1-27, ECF No. 869.
691
692
693
As discussed in Section VII, after this initial finding, RCCI re-opened the investigation to consider whether the
systemic issues related to K.C.’s death, identified by the Monitors, warranted RTBs for the facility’s administrators.
They were added as perpetrators to the investigation, and RCCI’s review resulted in RTB findings for the three
administrators of the facility. Of the eleven staff and administrators for whom the investigation of the fatality resulted
in an RTB, the RTBs have been upheld for all but two direct care staff; administrative review has been requested for
one of the two direct care staff and is pending for the second.
694
Letter from Tila Johnson to Anthony Hurst, Program Administrator, Prairie Harbor LLC (September 11, 2020) (on
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attention in the weeks prior to the child suffering a medical emergency in the weeks
prior to the child suffering a medical emergency. During the medical emergency,
staff failed to timely seek medical attention, and the child was denied timely
emergency medical assistance.
In addition to the child death detailed above, there were several investigations
related to the sexual abuse of children in care of your operation. Two staff members
were ultimately found responsible for the sexual abuse of children in care as a result
of those investigations.695
Finally, the letter referenced “numerous and repetitious deficiencies related to caregiver
responsibilities, caregiver judgment, inappropriate discipline and improper punishments,
inappropriate emergency behavior intervention (EBI), and improper supervision.”696
The operation requested administrative review of the revocation decision on September 14,
2020, and the decision was upheld on February 2, 2021.697
b. The Landing at Corpus Christi
The Monitors’ review of Prairie Harbor’s history and systemic problems revealed that the
same administrators and operators had opened a second RTC, The Landing at Corpus Christi (The
Landing), in August of 2019. During the September 2020 contempt hearing, the Court asked
whether RCCR reviewed Prairie Harbor’s history prior to issuing a license to The Landing:
THE COURT: …Back now to Prairie Harbor, they had 145 citations in the past
five years. The pictures that the Monitors have in their report is just – is disgusting.
And so you let these same people open a new place in Corpus Christi in
September of 2019. Did you review their history, the owners’ history, with Prairie
Harbor?
THE WITNESS: Our regulation related to – not to the same owners opening a new
operation. We can look to see if there’s been any adverse action as a reason to not
issue any license. If there has not been an adverse action and the applicant meets
all the requirements, then we move forward…
THE COURT: What would you consider an adverse action for Prairie Harbor with
145 citations in the past five years?
THE WITNESS: An adverse action…means a revocation.698
695
Id. at 2.
696
Id.
697
CLASS database, Prairie Harbor LLC, Provider Adverse Action (for Revocation/Denial), last accessed March 23,
2021.
698
Telephonic/Zoom Show Cause Hr’g. Tr (September 4, 2020) 80 -81, ECF No. 967.
347
On September 7, 2020, DFPS notified the Monitors that they had suspended placements
for The Landing, effective September 3, 2020.699 On September 21, 2020, DFPS notified the
Monitors that RCCR had issued a denial of license to The Landing on September 16, 2020, and
that all children had been removed from the facility on the same day.700
The letter to the administrator and operator of The Landing, notifying them of RCCR’s
intent to deny the license cited the revocation of Prairie Harbor’s license as one of the reasons for
the denial of the license for The Landing:
HHSC designated you as a controlling person when it revoked the license of Prairie
Harbor…This designation may be sustained once the revocation of that operation’s
license and your due process for the designation are final. Because of the pending
status of your designation as a controlling person, HHSC cannot issue you a permit
to operate a child-care operation.701
The letter also referred to an ongoing investigation into an allegation of sexual abuse,702
which has since been substantiated. In that case, a child made an outcry that she and a staff member
had sexual intercourse, and that she believed she might be pregnant. The investigation revealed
that the staff member had a habit of walking the grounds of the facility with children without other
staff present. He had sexual contact with the victim in a shed on the facility grounds. While a
pregnancy test was negative, interviews with other children and staff substantiated details of the
child’s outcry, and the investigation concluded with an RTB for Sexual Abuse and three citations:
one for a minimum standards violation related to a child’s right to be free from abuse or neglect,
another for the administrator’s violation of minimum standards by allowing staff to be alone with
children, and a third for the perpetrator’s failure to demonstrate “prudent judgment” by taking the
child outside and to the storage shed alone.703 The same staff member had been the subject of a
similar Sexual Abuse investigation while he was employed by another GRO after a report was
made to SWI by two adults to whom the child made an outcry, but Sexual Abuse was Ruled Out
when the alleged victim denied the allegations.
The letter also referred to a number of minimum standards violations during The Landing’s
initial licensure period, many of which were similar to the systemic problems associated with
Prairie Harbor’s history, including:
• A minimum standards violation related to the failure of the facility to timely report to
RCCR a child’s attempt to commit suicide by drinking disinfectant spray.
• A minimum standards violation associated with the operation’s inability to meet the needs
of the children, by “admitting too many children with behaviors caregivers were unable to
handle,” after six children damaged property while trying to break out of the facility, and
699
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, Updates – contracts and CPS (September 7,
2020) (on file with Monitors).
700
E-mail from Audrey Carmical to Deborah Fowler and Kevin Ryan, Updates on operations (September 21, 2020)
701
Letter from Tila Johnson to Jason Peeler, Administrator, The Landing at Corpus Christi (September 16, 2020) (on
702
Id. at 2.
703
An administrative review upheld the findings of the investigation on March 4, 2021.
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attacked and injured two other children. According to the findings, staff were unable to
bring the situation under control, resulting in the citation.
• A minimum standards violation related to caregiver responsibility, involving an allegation
of child-on-child sexual abuse, based on the failure to follow the safety plan for a child
who was alleged to have demonstrated sexual aggression.
• A minimum standards violation associated with the facility’s failure to follow a child’s
safety plan, which included provisions related to her history of running away, after she told
staff she wanted to run away prior to her attempt, and then injured herself when she jumped
out of a window while attempting to run away.
• Two minimum standards violations associated with the failure of the facility to seek
medical care for a child who reported being in pain and requesting to see a doctor. The
child had “landed wrong” while jumping on a trampoline and reported having a headache
to several staff for several days. When she was finally taken to the doctor, she was
discovered to have a mild concussion and neck injury.704
The letter also referred to a number of minimum standards violations found across a range of issues
during RCCR inspections.705
c. The Pillar of Progression for the Youth
On December 1, 2020, RCCR notified the Monitors of its intent to issue a revocation of
license letter to The Pillar of Progression for the Youth (Pillar of Progression), an RTC licensed
March 8, 2018.706 On December 15, 2020, RCCR sent the Monitors the letter notifying the RTC
of the agency’s intent to revoke its license.707
This enforcement action taken by RCCR against this RTC was not the first: Pillar of
Progression had been placed on a one-year probation, beginning on November 4, 2019, due to the
high number of minimum standards deficiencies for which it had been cited by RCCR during its
first 18 months of operation. The letter notifying the RTC of RCCR’s decision to place the facility
on probation listed more than 50 minimum standards violations between March 28, 2018, and
August 28, 2019. Of the 14 conditions associated with the probation, the facility does not appear
to have met a single one during its probationary period. According to the December 15, 2020
intent to revoke letter:
On November 4th, 2019 [Pillar of Progression] was placed on corrective action

probation due to poor compliance with minimum standards, which created a risk of
harm to the health and safety of children in care. On-going adherence to minimum
standards and specific conditions of the probation were required by the corrective
action probation. Specifically, the probation sought to address the risk to the health
and safety of children in care created by the numerous deficiencies related to
caregiver responsibilities, supervision, child’s rights, discipline, serious incident
reporting, staff records, frequent unauthorized absences and child records. As the
704
Id. at 3 -7.
705
Id.
706
E-mail from Georgette Oden to Deborah Fowler and Kevin Ryan (December 1, 2020) (on file with Monitors).
707
E-mail from Georgette Oden to Deborah Fowler and Kevin Ryan ( December 15, 2020) (on file with Monitors).
349
probation deficiencies progressed, an additional condition was required in order to

address a new pattern of deficiencies related to medical records and storage. At the
time the operation was placed on probation, there were three open investigations.
Those investigation concluded with disposition related to the physical abuse and
neglectful supervision of children in care by caregivers at the operation. During
the corrective action probation period, 10 inspections resulted in citations for 55
additional violations of minimum standards.708
The Monitors’ analysis of data related to minimum standards deficiencies confirms that
Pillar of Progression was a troubled facility. In the short time that this RTC was in operation, it
accumulated 150 minimum standards deficiencies. Of those, 69 were weighted high or medium-
high. In addition, three RCCI investigations of abuse or neglect resulted in substantiated findings
in 2020, as discussed in the intent to revoke letter.
Four RTBs were related to a single case reported to SWI on May 7, 2019, in which the
reporter, an RCCR staff person, alleged that a child made an outcry that a Pillar of Progression
staff member discussed details of her sex life with children. The child who made the outcry also
alleged that the staff member allowed him to drive her car to Walmart, though the child did not
have a driver’s license and “he was scared.” The child alleged that several other children were in
the car with them when this happened. The child also alleged that the staff member would take
children to unauthorized places when she was transporting them on outings or to visits with family,
and that she gave another child a cigarette. Several of the children confirmed the allegations that
the staff member allowed the child to drive her car, and the investigator obtained a video of the
incident recorded by one of the children who was a passenger in the car. The other allegations
were not substantiated, though one of the children interviewed said that the staff member “smokes
cigarettes around them and talks about nasty stuff.” RCCI made RTB determinations of neglectful
supervision by the staff person for the child who was allowed to drive the car, and each of the three
other children who were passengers in the car. RCCR issued three citations to the facility as a
result of the investigation: a citation related to the operation’s failure to maintain the staff
member’s employee records after terminating her; a citation related to the staff member’s failure
to demonstrate prudent judgment by allowing the child to drive her car; and, a citation related to
the staff member’s violation of the children’s right to be free of abuse or neglect. The investigation
was closed January 30, 2020.
Another RCCI investigation resulted in an RTB for Neglectful Supervision after a report
was made to SWI on September 11, 2019 alleging that a child tried to hang himself from a tree
outside the facility by putting a belt around his neck, and that staff saw the child and failed to
intervene.709 The investigation resulted in a RTB for Neglectful Supervision for one staff member.
According to the findings:
708
Letter from Todd Willis, Licensing Representative, RCCR, to Edwin Dearman, Administrator, The Pillar of
Progression for the Youth (December 15, 2020) (on file with Monitors).
709
A linked intake in CLASS appears to indicate that this case was initially not identified as a case involving abuse or
neglect. A September 12, 2020 intake shows that a DFPS staff member called SWI and reported that the earlier intake
“needs to be upgraded to abuse/neglect. Child tried to self-harm by tying a belt around his neck and hang himself
from a tree…The child was put on 1:1 supervision a few hours before the incident occurred because the child told
staff he wanted to harm himself. The staff member…who actually saw the child and got him down from the tree was
not the same staff member who was on 1:1 with the child.” The September 11, 2019 intake, reported to SWI by a
350
[J.F.], 13 year-old alleged victim, wrapped a belt around his neck and a tree branch
to try to self-harm. [J.F.] wanted to self-harm because he was bullied at school.
[J.F.] expressed suicidal ideations after returning home from school and was placed
on 1:1 supervision according to a safety plan implanted [sic] by the facility upon
[J.F.’s] arrival from school. [The staff member] was assigned to [J.F.] as his 1:1
staff to monitor his behavior. While [the staff member] was in another area of the
parking lot, [J.F.] had enough time to wrap a belt around his neck and a tree branch.
Additionally, [J.F.] dropped down from the tree branch once [J.F.] saw another staff
member in [J.F.’s] eyesight. [J.F.’s] suicide attempt was the result of lack of
supervision from [the staff member]. [The staff member] breached his duty as a
caregiver when he failed to adequately supervise and properly intervene during a
crisis.
This investigation also resulted in four citations for Pillar of Progression: a citation related
to the staff person’s failure to follow the safety plan for the child that required one-to-one
supervision; a citation related to the failure of the staff person to intervene; a citation related to the
facility’s failure to document the incident through a serious incident report; and, a citation related
to the violation of the minimum standard associated with a child’s right to be free from abuse or
neglect. The investigation closed on February 1, 2020; the staff member waived administrative
review.
The third investigation resulting in an RTB for Physical Abuse was opened after a report
was made to SWI on October 8, 2019, that a Pillar of Progression staff member physically abused
a child in care. The report was made by the child’s caseworker, after the child told her that he
punched a television, injuring his hand and told his attorney that a staff person at the facility pinned
him on the ground, put his knee in his throat, and “choked [him] out.” The child did not have any
injuries that required medical attention, but had a bloody nose as a result of the incident. Two
children and another staff person interviewed corroborated the child’s report that he was choked
after the child got into an argument with the staff person when the staff person attempted to redirect
him. RCCI’s investigation resulted in an RTB for Physical Abuse, and RCCR issued three
citations to the facility associated with the incident: a citation for the failure of the staff person to
demonstrate prudent judgment when he became physically aggressive with the child; a citation
associated with the discrepancies in the facility’s serious incident report; and a citation for the staff
member’s violation of the minimum standard associated with a child’s right to be free from abuse
or neglect. The investigation was closed February 20, 2020, and an administrative review was
pending as of March 24, 2021.
The intent to revoke letter sent to Pillar of Progression on December 15, 2020, concluded
with a finding that the facility posed an immediate risk to the children in the facility:
The determination that your operation poses an immediate risk to the health or
safety of children in care is supported by the multiple investigations with reason-
to-believe dispositions for neglectful supervision and physical abuse of a child in
Pillar of Progression administrator, indicates “[Victim] does have a history of self-harm but no history of one-to-one
supervision.”
351
care at your operation. Additionally, despite being placed on corrective action

probation to address the numerous and repetitious deficiencies that created a risk to
the children in care, your operation failed to meet the terms and conditions of the
implemented probation.
HHSC has concluded that you are unable or unwilling to ensure compliance with
minimum standards and other applicable laws as your operation has consistently
been cited for repeated high and medium-high deficiencies while on corrective
action probation. Further, the severity of the deficiencies, as well as the repetition
of deficiencies demonstrates that no other form of corrective action or conditions
could be implemented to avoid further deficiencies. HHSC asserts that the
deficiencies described above provide sufficient basis for revocation and the
deficiencies are evidence that your operation poses an immediate threat or danger
to the health and/or safety of children in care. For these reasons, the issued permit
is revoked.710
d. Whataburger Center for Children and Youth
The Court Monitors include a detailed description of the events leading up to the
closure of this GRO, and the subsequent illegal use of the facility by Family Tapestry
SSCC, in a separately filed report.711
e. Merkabah Residential Treatment Center
On January 19, 2021, the Monitors received an e-mail from RCCR indicating that the
agency would be issuing an intent to deny the application for Merkabah RTC “based on issues
related to maintaining compliance with standards.” RCCR noted, “The operation has patterns of
[deficiencies] related to children’s records, personnel records, and physical plant issues. In
addition, there have been two instances in which falsification of records has occurred.” RCCR
stated that DFPS had been notified and was working to move the children out of the RTC and into
new placements.
According to CLASS records, RCCR granted Merkabah RTC’s initial permit October 8,
2019, and the facility began operating soon after. The Monitors’ data analysis showed that in 2019
and 2020, the facility was cited for minimum standards deficiencies more than 80 times, with
almost all of those citations issued for standards weighted high, medium-high, or medium by
RCCR. The letter sent by RCCR to Merkabah RTC notifying the operators of the agency’s intent
to deny the final permit notes:
An investigation by Texas Department of Family and Protective Services (DFPS)

resulted in confirmation that direct care staff were allowed to work with residents
without having a cleared background check. In addition, several patterns of
deficiencies were observed at your operation during the initial permit phase, which
710
Letter from Todd Willis, supra note 706, at 18.
711
Deborah Fowler and Kevin Ryan, The Court Monitors’ Report to the Court Regarding Maltreatment in Care and
Unsafe Placements for Children Without a Placement, April 27, 2021, ECF No. 1066.
352
has placed children at risk of harm. On two occasions your operation was cited for
records issues, specifically records required to be kept by licensing were falsified.
One instance of falsification involved your Licensed Child-Care Administrator
(LCCA) providing answers to the Emergency Behavioral Intervention (EBI)
Training post-test for direct care staff. Direct care staff are charged with, and
responsible for executing techniques learned during the post-test phase. Because
your LCCA provided the answers to the post- tests, the results were inaccurate and
falsified. During the second citation for records issues, a different Licensed Child-
Care Administrator attempted to pass personnel records as Merkabah RTC records
when they were clearly marked as another operation’s personnel records.
Additionally, there were numerous deficiencies related to Child-Care

Administrator responsibility, caregiver responsibility, prohibited punishments,
record keeping and the physical site of the operation. Falsifying records related to
Emergency Behavior Intervention training creates a risk of harm to children in care
as it is required that direct care staff have the knowledge, skills and ability necessary
to interact and provide competent care for the children at the operation. Further,
staff engaging in repeated instances of prohibited punishments evidences a toxic
culture at the operation that is tolerated by management. There are clearly several
deficiencies that create an endangering situation, as well as a repetition or pattern
of deficiencies that create an overall immediate threat or danger to the health or
safety of children in care. As a result, your permit is denied.712
In addition to the minimum standards deficiencies cited by RCCR, three abuse and neglect
investigation resulted in three substantiated findings and five RTBs:
• An investigation opened after a September 24, 2020 report to SWI alleged that a child was
able to steal a vehicle from the operation twice: driving to Lubbock the first time, then,
when he was returned to the facility, stealing the vehicle again on the same night that he
was returned. Each time, the child who took the vehicle was accompanied by one other
child. The investigation resulted in three RTBs for Neglectful Supervision against the same
staff person for each of the children involved. RCCR issued three citations for violation
of minimum standards: a citation for violation of the minimum standards associated with
the child care administrator’s responsibilities, because the administrator “failed to properly
secure the keys to operation vehicles after children in care had stolen them and taken the
vehicle;” a citation for violation of the minimum standard associated with caregiver
responsibility; and a citation for violation of the minimum standard associated with a
child’s right to be free from abuse or neglect. An administrative review of the citations is
listed as “pending” in CLASS.
• An investigation resulted in an RTB for Physical Abuse, after a November 16, 2020, report
to SWI alleged that a child was “body slammed” on his head, causing the child to lose
consciousness. According to the findings, the staff member “lifted up” the child and
“slammed” him to the floor, causing injury to the child when he hit his head on the floor.
712
Letter from Todd Willis, District Director, RCCR to Byron Parker, Controlling Person, Merkabah RTC, January
29, 2021 (on file with Monitors).
353
RCCR issued four citations: a citation for violation of the minimum standard associated
with EBI implementation; a citation for violation of the minimum standard associated with
medical care, because the child did not receive immediate medical attention for the injury;
a citation associated with violation of the minimum standard associated with prohibited
punishment; and a citation for violation of the minimum standard associated with a child’s
right to be free from abuse or neglect. An administrative review of the citations is listed
as “pending” in CLASS.
• An investigation resulted in an RTB for Physical Abuse after a January 26, 2021 report to
SWI alleged a child was thrown to the ground by a staff member, causing a deep cut to the
child’s hand that required medical attention. Five citations were issued by RCCR in
connection with this investigation: a citation for violation of the minimum standard
associated with employee responsibility because “a child in care was assaulted by staff,
resulting in injury;” three citations related to violation of the minimum standards associated
with EBI implementation; and one citation for violation of the minimum standard
associated with a child’s right to be free from abuse or neglect. An administrative review
of the citations is listed as “pending” in CLASS.
f. Brave Hearts Children Center
On January 25, 2021, the Monitors received an e-mail from DFPS notifying them of an “evolving
situation concerning Brave Hearts Children Center” (Brave Hearts).713 Brave Hearts was an RTC
located in Houston, Texas that opened in June of 2020. According to the e-mail, DFPS and HHSC
State Office directors planned to make an unannounced visit to the facility the next day, and DFPS
was issuing an immediate placement suspension for the operation for DFPS and SSCCs.714
According to the e-mail:
As of 1/21/2021, there were 32 open investigations at Brave Hearts Children

Center, with an increase in intakes in January, including allegations of and concerns
relating to improper restraints, physical abuse, supervision issues, background
checks, employment of staff with negative history at other operations (including
Devereux), administrator appearing resistant to intervention, high acuity needs of
the children in placement, children’s educational needs, and lack of adequate
medical care.715
The e-mail indicated that DFPS held a standard contract with the facility, eight child-specific
contracts, and a contract for children who had tested positive for COVID-19. OCOK also
contracted with the operation for placements.716 The e-mail also noted, “HHSC CCR is currently
contemplating next steps related to the license, which will be informed by formal issuance of RTBs
713
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, re: Brave Hearts Children Center, January 25,
2021 (on file with Monitors).
714
Id.
715
Id.
716
Id.
354
for open CCI investigations. CCI is also contemplating whether the administrator will be
considered for abuse/neglect findings.”717
DFPS e-mailed the Monitors with an update later the same week, indicating that during the
unannounced visit the day before, “a number of supervision, leadership/organizational, physical
environment, and COVID issues were noted,” and advising that DFPS and OCOK were seeking
and obtaining new placements for the youth housed at the facility. 718 The e-mail noted that in
addition to the safety precautions that had already been put in place, as of January 26, 2021, DFPS
was making nightly visits to the facility, and sent “[a]beyance letters…to the operation to prevent
individuals who have a prior, concerning history from having contact with children.”719
On February 4, 2021, DFPS again e-mailed the Monitors with an update:
Since we first updated you, DFPS and OCOK have moved 26 youth from the
facility and have pending placements for an additional 7 youth. The 7 youth should
be moved by February 5. As of this communication, DFPS and OCOK continue to
work to locate placements for the remaining 17 youth who are still placed in Brave
Hearts Children Center and do not have a subsequent placement identified. Several
of these youth have complex behavioral health needs and it has been challenging to
locate placements that can safely care for the youth and meet their needs; however,
at this time, DFPS and OCOK plan to have all youth moved from the facility on or
by February 12, 2021. The daily visits to the operation and weekly staffings are
continuing as described in previous communications.720
Another e-mail update was sent February 6, 2021:
We wanted to provide you with an update relating to Brave Hearts Children Center,
which has continued to evolve throughout the day. As of yesterday afternoon, DFPS
made the determination that in order to ensure child safety in the operation, DFPS
and OCOK staff must be present at the operation 24/7.
Also yesterday, RCCI finalized a Reason to Believe Finding for physical abuse
against the owner of Brave Hearts Children Center. As a result, DFPS issued an
abeyance against her and a contract termination letter was sent. The contract
termination was to be effective the last day children were placed there, with the
goal of having all children moved out of the facility by February 12, 2021.721
On February 8, 2021, RCCR e-mailed the Monitors to notify them that the agency sent
Brave Hearts an intent to revoke letter, based on “patterns of deficiencies, abuse/neglect findings,
717
Id.
718
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, re: Brave Hearts Children Center, January 28,
2021 (on file with Monitors).
719
Id.
720
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, Brave Hearts Children Center (February 4, 2021)
721
355
and the operation’s inability to make corrections.”722 Finally, on February 16, 2021, DFPS e-
mailed with a final update:
As we previously shared with you, DFPS has terminated the contract with Brave
Hearts Children Center. DFPS and/or OCOK staff started having a 24/7 presence
at Brave Hearts Children Center beginning on Friday, February 5, 2021. As of
Saturday, February 6, 2021, all youth were moved from Brave Hearts Children
Center. DFPS and OCOK were able to locate placements for all but five of the
youth. Since then, DFPS has found placement for one of those children and the
remaining four are currently under staff supervision in CWOP. DFPS and OCOK
continue to actively look for placements that can meet the needs of these youth.723
According to the Monitors’ analysis of deficiencies data provided by the State, the
operation received 21 citations for minimum standards deficiencies in 2020, though it opened six
months into that year. Of those, 16 deficiencies were issued for standards that were ranked high,
medium-high, or medium by RCCR. A review of CLASS shows another 30 deficiencies cited in
2021 before the operation closed in February.
Four RCCI investigations resulted in eight RTBs for Physical Abuse, Sexual Abuse, and
Neglectful Supervision:
• An investigation opened after a report by an EMS staff member to SWI on December 5,

2020 alleged that a child “was assaulted by a facility staff member” and that this was “a
frequent occurrence at this facility, and EMS responds daily for similar incidents involving
staff members assaulting patients.” The reporter also alleged that “the staff is neglectful
and the children there are all at risk.” During his interview, the child said that he was
choked and punched by a staff member after he refused to turn off the television. Though
the staff member denied harming the child, video showed him place the child in a choke
hold, refusing to let the child go until another staff person pulled the remote out of the
child’s pocket. The investigation resulted in an RTB for Physical Abuse against the staff
person.
• An investigation opened after a December 8, 2020 report to SWI alleging that a child was
injured and required medical treatment after another child hit her over the head with a metal
bar that she had taken off of one of the facility’s bunkbeds. Two staff were present and
witnessed the altercation, but failed to intervene to stop it. The investigation resulted in
four RTBs: two RTBs for each staff member, for each of the two children. RCCR issued
three citations: two citations for violation of minimum standards associated with the failure
of staff to intervene to prevent the injury; and violation of the minimum standard associated
with a child’s right to be free from abuse or neglect.
722
E-mail from Taryn Lam to Deborah Fowler and Kevin Ryan, Brave Hearts RTC (February 8, 202)1 (on file with
Monitors).
723
356
• An investigation opened after a hospital social worker made a report to SWI on December
15, 2020 alleging that a 15 year-old child made an outcry of sexual abuse against a Brave
Hearts staff member when she was in the hospital. An investigation revealed the child first
told the owner of Brave Hearts about the alleged abuse five days before she was
hospitalized, and that multiple staff also told the owner of the sexual abuse; the owner did
not report the allegations to SWI and left the staff member on the facility schedule after the
child reported the abuse to her. The investigation resulted in an RTB against the staff
member who sexually abused the child, and an RTB against the owner for Neglectful
Supervision. Though the other staff members who reported the abuse to the owner were
aware of it and did not report it to SWI, RCCI ruled out Neglectful Supervision for those
staff because “they did report the allegation through their chain of command at Brave
Hearts Children Center and were told by [the owner/director of the facility] that she would
take care of it.” RCCR issued five citations in connection with the investigation: a citation
for violation of the minimum standards associated with caregiver responsibility due to the
owner/director’s failure to report the allegations and failure to remove the alleged
perpetrator from the shift schedule; a citation for violation of the minimum standard
associated with interference with an investigation because “3 different staff members made
attempts to question the victim about the allegation;” a citation for violation of the
minimum standard requiring the permit holder to ensure compliance with minimum
standards; a citation for violation of the minimum standard requiring employees to report
suspected abuse or neglect; and a citation for violation of the minimum standard associated
with a child’s right to be free from abuse or neglect.
• An investigation opened after a child’s probation officer made a report to SWI on January
22, 2021 alleging that a child reported being hit by a staff member, but also told the
probation officer that there were fights “all the time” at the facility, that staff “will watch
residents fight instead of intervening to protect them,” and that the facility did not wash
her clothes very often. Video captured the incident, showing that after the child tried to
make a phone call and the staff person twice disconnected the call by pushing the hang-up
button. The child became angry and “slapped” the phone off the wall. The phone hit the
staff person, and the staff person “went after” the child and “the two engaged in a wrestling
match, which included hair pulling, clawing with finger nails, and [the staff member’s]
glasses being pulled off her face.” The investigation resulted in an RTB for Physical Abuse
of the child by the staff member.
g. Gulf Coast Trades Center
On March 2, 2021, DFPS alerted the Monitors that it had terminated its contract with Gulf
Coast Trades Center (GCTC), a GRO in New Waverly, Texas.724 DFPS noted that all the foster
youth who were living in the facility were moved by January 19, 2021, with the exception of a
child for whom the placement was court ordered.725 That child was reunited with his father on
February 23, 2021.726
724
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, Gulf Coast Trade Center (March 2, 2021).
725
Id.
726
Id.
357
GCTC was one of the GROs prioritized for Heightened Monitoring by the State pursuant
to Remedial Order 20; the facility had the highest risk score of the more than 40 GROs placed on
Heightened Monitoring. DFPS instituted a placement hold for GCTC on December 11, 2020, just
six months after having notified the operation that it would be placed under Heightened
Monitoring.727
Prior to being placed under Heightened Monitoring, GCTC had twice been placed under
Evaluation by RCCR: once from October 4, 2016 through March 17, 2017 and again from January
9, 2019 through July 9, 2019. Prior to being placed under Evaluation, the operation had been
placed under a voluntary plan of action due to “the number and seriousness of the deficiencies
cited during the last two years and the overall noncompliance of the agency,” that lasted from
March 25, 2011 to June 25, 2011. The Monitors asked RCCR whether it intended to take any
action on the operation’s license; RCCR responded that it intended to place GCTC on probation,
but that the facility had not yet been informed of that decision.728 RCCR notified the Monitors on
April 12, 2021 that the only children remaining in the facility were Texas Juvenile Justice
Department (TJJD) placements, and that RCCR met with the operation to discuss placing Gulf
Coast Trades Center on probation on April 8, 2021, but that the operation “asked for some changes
to the Corrective Action Letter prior to finalization and that CCR is in the process of finalizing
that letter.”729
The Monitors’ analysis shows the troubled history of GCTC: the facility was cited by
RCCR for minimum standards deficiencies 198 times between January 1, 2016 and December 31,
2020. Of these citations, 161 were for standards weighted high, medium-high, or medium by
RCCR. During the same time period, GCTC was also the subject of five RCCI abuse or neglect
investigations, resulting in seven RTBs, with substantiated allegations of Neglectful Supervision,
Sexual Abuse, and Physical Abuse:
• An investigation opened after DFPS made a report to SWI on February 26, 2016 alleging
that a sleeping child was left behind by a GCTC staff member when the staff member and
other children evacuated a dorm during a fire. RCCI found that the staff member was the
first person out of the burning building, and failed to follow protocol to ensure all of the
children were safely evacuated. The child was “left in a burning building for at least five
minutes unaccounted for.” During his interview, the child said that he woke up twice
during the fire “after becoming hot” and that the second time, “he saw the smoke had filled
the room and he got up from bed and ran out.” The investigation resulted in an RTB finding
against the staff member for Neglectful Supervision of the child. Four citations were issued
727
Because DFPS did alert the Monitors that it had ended its contract with GCTC until March 2, 2021, GCTC was
included in the Heightened Monitoring reviews conducted by the monitoring team, discussed supra. Consequently,
the Monitors will not include a review of the Heightened Monitoring plan here.
728
E-mail from Taryn Lam to Deborah Fowler and Kevin Ryan, re: Gulf Coast Trade Center, March 2, 2021 (on file
with Monitors). RCCRs decision not to take any action against GCTC’s license has important implications, since
DFPS informed the Monitors, “The Texas Juvenile Justice Department (TJJD) has informed DFPS that they plan to
continue to use this facility for future placements. If TJJD recommends placement of a youth in DFPS conservatorship
into this facility, DFPS will discuss concerns with TJJD in the interest of child safety.” E-mail from Heather Bugg,
supra note 722.
729
E-mail from Katy Gallagher, Attorney, HHSC, to Deborah Fowler and Kevin Ryan, Gulf Coast Trade Center (April
12, 2021) (on file with Monitors).
358
by RCCR for minimum standards violations, but one citation (for a minimum standard
related to having an accessible fire extinguisher) was overturned. The three citations that
were upheld on administrative review were: a citation for the minimum standard associated
with fire drills (which were not being conducted during night shifts); a citation for violation
of the minimum standard related to caregiver responsibility; and a citation for violation of
the minimum standard associated with a child’s right to be free from abuse or neglect.
• An investigation opened after a report was made to SWI May 8, 2018, alleging that a 16
year-old child told his probation officer that a staff member at GCTC allowed children to
give each other tattoos, smoke cigarettes behind the building outside, and that staff allowed
children to go into the bathroom and fight and did nothing to intervene. The child had
several bruises on this arm; he said that other children at the facility hit him and staff did
not stop it from happening. The staff confirmed the child was getting bullied at the facility.
The investigation resulted in three RTB findings for Neglectful Supervision of the alleged
victim and two other children by the same staff member, based on the staff member’s
failure to intervene appropriately when he observed the children tattooing each other with
sharpened paper clips and ink from pens. RCCR issued two citations: a citation associated
with the minimum standard associated with child-to-caregiver ratio because a review of
staffing schedules showed that six staff were in charge of 13 -16 children during both shifts,
two days in a row; and a citation associated with the minimum standard associated with a
child’s right to be free from abuse or neglect.
• An investigation opened after a report was made to SWI on July 19, 2017, alleging a 17
year-old male youth had sexual contact with a female staff member. The child confirmed
during a forensic interview that the female staff member performed oral sex on him and
that they had sexual intercourse. The female staff member denied the allegations, but the
child was able to describe tattoos on the staff member’s back, lower arm, and chest. The
investigation resulted in an RTB for Sexual Abuse against the staff member. RCCR issued
two citations: a citation for violation of the minimum standard associated with employee
responsibilities; and a citation for violation of the minimum standard associated with a
child’s right to be free of abuse or neglect.
• An investigation opened after a report was made to SWI on October 10, 2017, alleging a
shift supervisor was involved in a physical altercation with a 17 year-old youth at the
facility. During his interview, the staff person acknowledged starting the fight when he
pushed the child who had “invaded his personal space” and hit the youth back after the
youth hit him. The investigation resulted in an RTB for Physical Abuse against the staff
member. RCCR issued three citations: a citation for violation of the minimum standard
prohibiting corporal punishment; a citation for violation of the minimum standard related
to caregiver supervision, due to the failure of the administrative staff to “provide the level
of oversight necessary to direct care staff;” and a citation for violation of the minimum
standard associated with a child’s right to be free from abuse or neglect.
• An investigation opened after a report was made to SWI on April 27, 2020, alleging that a
former GCTC staff person and a youth who had aged out of care two months earlier
announced on Facebook that the former staff person was pregnant with the youth’s child.
359
The reporter alleged that the former staff person “sexually exploited” the youth while he
was a resident at GCTC. During her interview, the former staff person admitted to engaging
in sexual contact with the youth while he was a resident at GCTC, stating that she was
suspended from GCTC for engaging in inappropriate behavior with the youth. She
acknowledged that her sexual contact with the youth during his stay at the facility resulted
in her pregnancy. The investigation resulted in an RTB finding for Sexual Abuse of the
youth by the staff member. RCCR issued three citations: a citation for violation of the
minimum standard associated with employee responsibilities; a citation for violation of the
minimum standard related to child-care administrator responsibilities, due to the failure to
protect the child from inappropriate contact by the staff member; and a citation associated
with the minimum standard associated with a child’s right to be free from abuse or neglect.
h. Willow Bend Center RTC
On March 2, 2021, RCCR notified the Monitors that the agency had decided to issue an
intent to revoke letter to Willow Bend Center RTC (Willow Bend Center), located in Tyler, Texas,
“based on ongoing patterns related to restraints, supervision, and recent reason to believe
findings.”730 RCCR indicated that DFPS was working to secure placements for the children at the
operation, and that the operation had not yet been notified.731 The Monitors asked RCCR to provide
them with the intent to revoke letter once it had been sent to the operation.
On March 24, 2021, RCCR notified the Monitors that the agency had delivered the letter
to the operation the day before, after confirming that all the children had been discharged from the
operation.732 The same day, DFPS notified the Monitors that on March 3, 2021, the agency
“immediately began working with the SSCCs who had children placed in the facility to find new
placements” and that on March 23, 2021, all children had been moved and DFPS had terminated
its contract with the facility.733
Willow Bend Center, which opened in 2009, had been subject to RCCR enforcement
actions prior to the agency’s decision to revoke the RTC’s license. The RTC was under
Heightened Monitoring when it was notified of RCCR’s intent to revoke its license. Prior to being
placed under Heightened Monitoring, Willow Bend Center had been placed on Evaluation by
RCCR from September 19, 2017 through March 19, 2018. The RTC had also twice been placed
on a voluntary Plan of Action: once from May 21, 2014 through August 21, 2014, and again from
June 5, 2020 through December 5, 2020. The 2020 POA was not successfully completed.
730
E-mail from Taryn Lam to Deborah Fowler and Kevin Ryan, Willow Bend Center RTC (March 2, 2021) (on file
with Monitors).
731
Id.
732
E-mail from Taryn Lam to Deborah Fowler and Kevin Ryan, re: Willow Bend Center RTC, March 24, 2021 (on
733
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, re: Willow Bend Center RTC, March 24, 2021 (on
360
According to RCCR’s letter notifying Willow Bend Center of its intent to revoke the
operation’s license, the decision was based on findings of abuse and neglect, as well as a pattern
and repetition of severe minimum standards deficiencies.734 The letter specified:
From 9/19/2017 to 3/19/2018, your operation, Willow Bend, was required to

complete an Evaluation to address concerns with emergency behavior intervention
(EBI), supervision, child’s right, discipline, medication, and physical site
deficiencies. On 6/5/2020, Willow Bend was requested to complete a Provider Plan
of Action to, again, address concerns related to EBI, child’s rights, and discipline.
The Plan of Action ended unsuccessfully on 12/5/2020 due to Reason to Believe
findings and the operation’s overall compliance during the Plan of Action period.
Since 12/2019, Willow Bend has had 6 Abuse/Neglect investigations, 5 of which

resulted in Reason to Believe findings of Abuse or Neglect. An investigation
completed on 12/12/2019 determined a child was physically abused during an
altercation with Willow Bend staff. An investigation completed on 8/7/2020
concluded that a child was physically abused during an altercation with Willow
Bend staff. On 11/4/2020, an investigation revealed that Willow Bend caregivers
neglectfully supervised two children by not accounting for their specific
supervision needs and they were able to engage in sexual misconduct.
Investigations completed on 1/22/2021 and 2/3/2021, respectively, found a Willow
Bend direct caregiver physically abused children by striking a child in the face
during an EBI and kicking a child in the stomach and slamming a door on the child’s
foot. In addition, a prior physical abuse investigation completed on 1/13/2020
resulted in a finding of UTB for the same caregiver.
In addition to the findings of abuse and neglect, there is an on-going pattern and
repetition of severe deficiencies for child’s rights, discipline, emergency behavior
intervention, medication, serious incidents, supervision, and physical site.
Between 1/9/2018 and 2/9/2021, 44 investigations or inspections of Willow Bend

resulted in citations for 73 deficiencies. Willow Bend was cited 29 times for
corporal punishment or other prohibited punishments, 11 times for child’s rights, 6
times for medication or medical care, 6 times for EBI or personal restraint
implementation, 7 times for physical site, 4 times for caregiver responsibility or
supervision, and 2 serious incident deficiencies.
Child Care Regulation has determined that your operation poses an immediate risk
to the health or safety of children in care. This is due to findings that numerous
staff have been found responsible for physical abuse and neglectful supervision of
children in care, as well as the patterns of deficiencies in multiple sections of
minimum standards.
734
Letter from Shellie Adetona, Program Manager, RCCR to Leslie Harrold, Administrator, Willow Bend Center,
March 23, 2021 (on file with Monitors).
361
Due to the severity, patterns, and repetitious nature of deficiencies, confirmed

findings of abuse and neglect, your operation’s demonstrated inability to implement
lasting corrections, and the threat to children that has created an endangering
situation, your permit to operate a residential operation is revoked.735
The Monitors’ analysis confirms RCCR’s findings. Between January 1, 2016, and
December 31, 2020, RCCR cited Willow Bend Center 137 times for minimum standards
deficiencies. Of those, 125 were standards weighted high, medium-high, or medium by RCCR.
During the same time period, seven RCCI investigations resulted in twelve RTBs for physical
abuse or neglectful supervision:
• An investigation opened after a report was made to SWI on May 10, 2016 alleging that an
I-See-You worker had learned that two 16 year-old children, who two days earlier had been
reported as having run away, had been taken to a hotel by a Willow Bend staff member,
who also paid for the hotel room. The RCCI investigation revealed that the staff member
encountered the two residents after they had run away from the facility, and rather than
reporting that she had found them and returning them to Willow Bend Center, she rented a
room at a motel for them for two nights, then drove one child to his birth mother’s home
in Houston and left the other child at a truck station. The investigation resulted in two RTB
findings for the staff person for Neglectful Supervision for each child. Though RCCR
issued three citations in connection with this investigation, two citations associated with
violation of minimum standards related to caregiver responsibilities were overturned after
an administrative review, because the staff person in question had been suspended prior to
taking the children to the motel. The remaining citation was issued for violation of the
minimum standard associated with a child’s right to be free from abuse or neglect.
• An investigation opened after a report was made to SWI on May 18, 2016, alleging that a
staff member slapped and hit a 15 year-old child, and kicked him in the head. The
investigation resulted in an RTB for Physical Abuse by the staff member, finding that the
staff member “punched [the child] in the head before taking him to the ground” and that
after taking the child to the ground, the staff member “punched [the child] in the head a
few more times.” The incident was witnessed by two other staff members. RCCR issued
three citations related to the investigation: a citation for violation of the minimum standard
associated with caregiver responsibilities; a citation related to EBI implementation; and, a
citation for violation of the minimum standard associated with a child’s right to be free
from abuse or neglect.
• An investigation opened after a report was made to SWI on June 3, 2016, alleging that a
13 year-old child made an outcry of having been choked by a staff member, another child
alleged having been kicked by a staff member, and a third child reported having been
shoved by a staff member. The investigation resulted in an RTB for Physical Abuse of the
13-year old child due to video showing the staff member “grabbing and choking” the child,
“sitting on top of the child with one hand around his neck.” RCCR issued three citations:
a citation for prohibited punishment; a citation for corporal punishment, and a citation for
735
Id. at 2-3.
362
violation of the minimum standard associated with a child’s right to be free from abuse or
neglect.
• An investigation opened after a report was made to SWI by RCCI on February 4, 2017 that
while an RCCI investigator was reviewing video at the facility as part of another
investigation, “[The investigator] ran across another incident with a staff using physical
force on a child. The staff took a chair and placed it over the child and squeezed the child
in between the legs of the chair. The staff forcefully put his forearm on the back of the
child’s neck while holding him up against the wall. He grabbed and push [sic] the child
several times by the back of his neck. The child was drug down the hall…The video
showed the staff kicking the child. The child had an accident in his clothes apparently and
the staff took the soiled underwear and hit the child several times with the dirty underwear.
The staff also sprayed the child twice with Lysol. There was another staff who stood by
and witnessed the incident but she did not report it.” The investigation resulted in two
RTBs: one for Physical Abuse of the child by the staff person who hit, kicked and dragged
him, and one for Neglectful Supervision of the child by the staff person who failed to
intervene. RCCR issued six citations in connection with the investigation: one citation for
failure to report the incident; one citation related to violation of the minimum standard
associated employee responsibilities; one citation for prohibited punishments; one citation
for violation of the minimum standards associated with appropriate disciplinary measures;
a citation for corporal punishment; and a citation for violation of the minimum standards
associated with a child’s right to be free from abuse or neglect.
• An investigation opened after a May 6, 2019, report to SWI alleging a child was injured
when he got into an altercation with a staff person. The investigation revealed that the staff
person took his hat off and his keys out of his pocked “to prepare for the altercation” and
returned the child’s punches when the child hit him. The investigation resulted in an RTB
for Physical Abuse by the staff person. RCCR issued two citations: one for corporal
punishment; and, one citation for violation of the minimum standard associated with a
child’s right to be free from abuse or neglect.
• An investigation opened after a July 9, 2020, report to SWI alleging a staff member injured
a 15 year-old child when he “used inappropriate force.” During the investigation, the staff
member. E.M., “admitted to grabbing, hitting, and kicking [the child]” E.M. was “unsure
how many times he hit or kicked [the child].” Another staff person who witnessed the
incident indicated that when the child refused to go back to his room after being told
repeatedly to do so, E.M. grabbed the child by the back of the neck and threw him to the
ground and that the child “kept trying to leave but [E.M.] kept coming for him.” The
investigation resulted in an RTB for Physical Abuse by E.M. RCCR issued three citations:
a citation for failure to follow EBI training; a citation for corporal punishment; and a
from abuse or neglect.
• An investigation resulting from an October 6, 2020, report to SWI alleging that two
children who had histories of sexually acting out engaged in sexual contact while they were
showering. Both children were flagged as having indicators for sexual aggression. Service
363
plans for both indicated they needed constant supervision. Despite this, they were allowed
to shower at the same time. The investigation resulted in four RTBs for two staff assigned
to supervise the two children at the time of the incident. RCCR issued three citations: a
citation for violation of the minimum standard associated with caregiver responsibility; a
from abuse or neglect; and, a citation for the minimum standard associated with the child-
care administrator’s responsibilities, because “[a]dministration was aware that there was
an ongoing concern about a child’s behavior but did not ensure there were enough staff on
duty to meet the supervision needs of the children in care.”
In addition to these RTBs, RCCR’s letter referred to two abuse or neglect investigations
resulting in substantiated findings in 2021:
• An investigation resulted in an RTB for Physical Abuse after an investigation substantiated

a December 24, 2020 report to SWI alleging that a staff member hit a child on the head
after the child bit his finger.
• An investigation resulted in two RTBs for Physical Abuse of two other children, by the
same staff member involved in the December 24, 2020 incident. An investigation of a
January 4, 2021 report to SWI substantiated allegations that the staff member slammed a
child’s foot in the door, as well as allegations made by another child that the same staff
member gave him a black eye during a restraint
i. The Tree House Center
The most recent e-mail from the State736 indicating that it would begin removing children from a
facility under due to safety concerns was sent to the Monitors on April 9, 2021, regarding The Tree
House Center, an operation that is under Heightened Monitoring:
DFPS and HHSC want to make you aware of an evolving situation at The
Treehouse Center, a General Residential Operation, in Conroe, TX. As of April 8,
2021, 10 youth in DFPS conservatorship reside at the operation, 3 of whom are in
PMC. The Treehouse Center is on Heightened Monitoring. As you are aware,
DFPS and/or HHSC CCR have been conducting weekly site visits; residents are
visited in-person monthly to assess their safety and well-being; and DFPS has been
conducting monthly, unannounced overnight visits to the operation to verify
compliance with 24-hour awake night supervision requirements. The Treehouse
Center had been on placement suspension from November 8, 2020 until March 12,
2020, when a corrective action plan and safety plan were lifted.
On April 5, 2021, [a District Court judge] issued a search warrant for property
located at The Treehouse Center. Law enforcement executed the search and seized:
736
Email from Corliss Lawson to Deborah Fowler and Kevin Ryan, The Treehouse (April 9, 2021) (on file with
Monitors).
364
• Computers and computer equipment

• Personnel records
• CPS documentation, including child records
• Licensing records
• Training guides
• Policies and procedures (including for restraints)
• Cell phones and other communication devices
• Photographs
• Video equipment
• Cameras, and all other devices used for the capture, taking, storing,
transferring developing and otherwise manipulating images
• Financial records
• Documents showing dominion or control over the operation.
CPI Special Investigators were present during the execution of the search
warrant***The search occurred during daytime hours. The DA’s office declined
to share a copy of the affidavit in support of the search warrant at that time.
In response thereto, DFPS began daily, unannounced safety checks*** on April 6,

2021 and overnight visits were increased to 2-3 visits per week. On April 7, 2021,
The Treehouse Center was formally notified that placements into the operation
have, again, been suspended. DFPS is working with Treehouse Center staff to
reconstruct the records of children in our conservatorship to support the operation’s
ongoing ability to appropriately care for these children. Treehouse Center staff
notified us that they received a subpoena ordering them to appear on April 13, 2021
before a grand jury.
Today, the DA phone in an intake to SWI***that asserts serious allegations against

the Administrator. Based on the seriousness of the allegations, DFPS has decided
to remove the children and has sent staff to provide 24/7 monitoring to ensure the
safety of the children until they are removed.
We will continue to monitor the situation closely and will update you as more
information becomes available.
The Monitors review of the April 9, 2020 CLASS intake referenced in the State’s e-mail showed
that a first April 8, 2021 intake from the D.A.’s office was referred to RCCR as a Priority 3
investigation, and re-entered on April 9, 2021 as a Priority 2 abuse or neglect investigation. The
intake alleges that the CEO of the operation instructed the manager of the facility not to run a
background check on a staff person who “is a habitual felon and has a record of aggravated assault
and a history of possession of substances.” The intake goes on to allege that this staff person “has
keys which would allow access to the medication room and other rooms where [children] can be
found.” The intake also alleged that the CEO sent a text telling the facility manager to “get all the
employees [sic] phones and check to see who made a call to SWI.” It further alleged that the CEO
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“sent a text that has requested a list of all employees so they can say people have been working so
that they are not out of ratio compliance.”
The Monitors were notified on April 13, 2021 that all children had been moved from The Tree
House Center, and that “DFPS staff were present at the operation continuously since 04/09/21”.737
DFPS notified the Monitors that it cancelled its contract with The Tree House Center on April 15,
2021;738 RCCR has not confirmed whether any action will be taken related to the contract with the
operation or its license.
Summary
Between May 1, 2020 (the date the new RCCR policy went into effect related to agency
home closures) and March 16, 2021, there have been only five recommendations made by RCCR
staff to close an agency foster home. Of those, only three were ultimately approved; one remains
pending, though the recommendation was made at the end of October 2020.
There were no license revocations for any placement (foster home, CPA, or GRO) in the
five-year period preceding September 30, 2019. Since then, RCCR has initiated revocation
proceedings or denied a license for eight GROs, and DFPS has notified the Monitors that the
agency cancelled contracts with two GROs. Five other GROs voluntarily relinquished licenses
after being placed on Heightened Monitoring or another type of RCCR enforcement action.
Each of the agency homes and GROs that have closed, regardless of whether the closure was the
result of a voluntary surrender of their license, RCCR action, or DFPS’s termination of a contract,
share deeply troubled histories that include not only a pattern of minimum standards deficiencies,
but in each case, multiple substantiated findings of abuse or neglect. Many had failed to come into
compliance despite previous enforcement action.
737
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, The Treehouse (April 13, 2021) (on file with
Monitors).
738
E-mail from Heather Bugg to Deborah Fowler and Kevin Ryan, Re: The Treehouse (April 15, 2021) (on file with
Monitors).
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VIII. CHILD FATALITIES
After learning through the Monitors of the death of a child in the PMC General Class, the Court
Ordered on February 21, 2020:
Within 24 hours of this order’s time and date, Defendants are ordered to report to the Monitors
the death of any PMC child occurring from July 31, 2019 forward until further order of this Court.
Defendants are further ordered to provide to the Monitors all records that the Monitors deem
necessary and relevant including, but not limited to, reports, interviews, witness statements, and
investigations from any and all said deaths that have occurred from July 31, 2019 forward until
further order of this Court.
Defendants have continued to provide notification to the Monitors of PMC child fatalities.
As discussed in the Monitors’ First Report, DFPS notified the Monitors that 11 children in the
PMC General Class died between July 31, 2019 and April 30, 2020. Since then, DFPS notified the
Monitors that 13 additional PMC children died between May 1, 2020 and April 10, 2021.
In less than 21 months since the Fifth Circuit issued the mandate in this matter (July 31,
2019 – April 10, 2021), 23 PMC children have died in State custody.739 These fatalities include
six children whose caregivers were determined to have abused or neglected them in connection
with their deaths or their care prior to their deaths. In addition, a seventh fatality, J.C., is strongly
suspicious for abuse. As of April 10, 2021, a DFPS investigation was underway in that case and
five additional child fatalities, which the Monitors will review and discuss in the next report to the
Court.
The fatalities that DFPS determined did not involve abuse or neglect include a teenager
who drowned; children with severe medical conditions; and a youth who had run away from care
and was found murdered on the side of the road. One child was in a placement in another state,
and DFPS did not investigate that fatality.
Of the six cases involving confirmed abuse or neglect and a seventh case strongly
suspicious for abuse, SSCCs were involved with five of the seven children. State records indicate
SSCCs directly managed care for four of the children; DFPS directly managed care for two of the
children and in the case of one child, C.G., whose death is discussed in the Monitors’ First Report
and within this Section, an SSCC was responsible for placement, while DFPS was responsible for
case management.
739
DFPS initially reported to the Monitors that L.B., whose death was discussed in the First Report, was a PMC child.
After DFPS confirmed an RTB finding for caregiver neglect in connection with the child’s death on February 18,
2021, the agency notified the Monitors on April 30, 2021, that L.B. was a TMC child at the time of death. L.B.’s
death is excluded from the total of 23 fatalities presented in this report
367
A. Child Fatalities Involving Abuse and Neglect (July 31, 2019 – Aril 10, 2021)
K.C., Born September 1, 2005; Died February 9, 2020
The Monitors’ First Report detailed the circumstances surrounding K.C.’s death, but the
RCCI investigation into her death remained open at that time. K.C. was living at Prairie Harbor,
an RTC, when she died after collapsing in the middle of the night on February 9, 2020. As the
Monitors noted in the First Report, “RTC staff waited thirty-seven minutes before calling 911 after
K.C. collapsed, because direct care staff believed they needed permission from administrators to
make the call.”740 The cause of death was a pulmonary embolism associated with a deep venous
thrombosis in her right calf.
As described in the First Report, RCCR had cited Prairie Harbor more than 60 times for
minimum standards violations between February 2017 and December 2019, and RCCR had placed
Prairie Harbor on probation just five days prior to K.C.’s death.741 DFPS Contract monitoring staff
had also identified concerns in 2017 and again in 2019 related to children missing psychiatric
appointments required by treatment plans, as well as problems associated with documentation of
administration of prescribed medications and failure to appropriately administer prescribed
medications.742, 743
During RCCI’s investigation into K.C.’s death, seven children (of the ten interviewed)
reported that K.C. had complained of leg pain in the weeks before she died, but the staff members
at the facility did not address her complaints. Only two staff (of eleven interviewed) advised RCCI
investigators that they were aware of K.C.’s complaints; however, the Monitors found
contemporaneous documentation of K.C.’s complaints of pain in her right calf dated January 19,
21, 22, 23, and 24 2020. Despite that documentation, K.C. did not receive medical attention.
On September 3, 2020, the Court convened the first day of a two-day hearing regarding the
Plaintiffs’ Show Cause motion. During that hearing DFPS announced that they would no longer
refer children to Prairie Harbor.744 RCCR issued a notification of revocation to the facility on
740
Report, at 13.
741
Id.
742
TEX. DEP’T OF FAMILY & PROTECTIVE SERVS., Fiscal Year 2017 Residential Child Care Program Contract
Monitoring Report Prairie Harbor LLC (July 17, 2017) (on file with the Monitors).
743
Id. at 5-7.
744
As discussed earlier in this report, the owner of Prairie Harbor had opened another RTC, The Landing at Corpus
Christi. That program had been issued an initial permit on September 27, 2019, which was renewed on March 26,
2020 for six months (or through September 27, 2020). The record at that time indicates that: “The permit will be
renewed due to the number of open investigations, similar investigative allegations, pattern of investigations involving
the same staff, and the operation transitioning EBI and practice.” (CLASS record, The Landing at Corpus Christi,
viewed November 29, 2020). On September 16, 2020, as the permit was again up for renewal (on September 27,
2020), the second renewal was denied: “Denial of permit based on revocation of permit issued to controlling persons
identified for this applicant. There is a pending sexual abuse case at this operation as well.” Id. The controlling person
identified in that note was also a controlling person for Prairie Harbor.
368
September 11, 2020. Prairie Harbor requested administrative review of that determination, which
has been upheld.745
Approximately one week after the Court hearing in September 2020, DFPS re-opened the
investigation into the death of K.C. in order to evaluate whether administrative staff were negligent
in their duties to provide oversight and management of Prairie Harbor. Based on that investigation,
RCCI substantiated the allegations with a disposition of RTB for Neglect by three Prairie Harbor
administrators. In total, including those administrative staff, the state investigation into K.C.’s
death resulted in eight findings of Neglectful Supervision and ten findings of Medical Neglect.
D.D., Born May 16, 2017; Died February 10, 2020
D.D. suffered from Methylmalonic acidemia, a metabolic disorder that prevented the
child’s body from breaking down proteins and fats. D.D.’s condition was terminal. On January 30,
2020, shortly before D.D.’s death, DFPS substantiated allegations of child maltreatment against
the child’s licensed foster mother for Neglectful Supervision with a disposition of RTB for
excessively leaving the child alone with nurses. D.D. was in the hospital in a pediatric Intensive
Care Unit at the time of death.
T.M., Born October 27, 2013; Died March 15, 2020
At the time of the Monitors’ First Report, T.M.’s death remained under investigation. T.M.
was non-verbal and relied on a tracheal tube to support breathing. The child’s caregivers reported
T.M. suffered a respiratory event that prompted the child’s licensed foster parents to call 911 and
request emergency medical aid. At the time, the child’s pulse oximeter, an electronic device that
measures the saturation of oxygen carried in the blood, indicated T.M. was experiencing
hypoxemia and the child’s breathing was shallow. The foster father reported he performed a
sternum rub and bagged the child for oxygen support. First responders transported the child to the
hospital and treating physicians observed multiple brain bleeds, some bruising on the left neck,
left ear, possibly both sides of the nose, both sides of the forearms, and on and under the chin.
T.M. also had a spinal fracture, and evidence of possible strangulation. The treating physicians
expressed concern for potential abuse. T.M.’s foster parents denied causing the child’s injuries.
The Medical Examiner conducted an autopsy and concluded that the cause of death was
blunt force trauma to the head from an undetermined source. The Forensic Assessment Center
Network (FACN) agreed and noted that the child sustained the injuries in the hours leading up to
his death.
Based on the Medical Examiner’s and FACN’s findings, RCCI issued a disposition of RTB
for Physical Abuse, but with an unknown perpetrator, and RTB for Neglect against both foster
parents.
745
Prairie Harbor’s “Operating Status” in CLASS is denoted as “No,” with an effective date of September 14, 2020.
Prairie Harbor does, however, continue to show as an active placement on the State’s residential child care website.
See
http://www.dfps.state.tx.us/Child_Care/Search_Texas_Child_Care/ppFacilityDetails.asp?ptype=RC&fid=1191339
(visited March 18, 2021) (“Temporarily Closed: No”).
369
The foster home was initially verified on October 16, 2018. There were two prior
investigations in the home. Both involved an 11-year-old with autism, intellectual disability, and
limited verbal ability. In the first incident, in July 2019, the foster father and a nurse confirmed the
child had fallen to the ground. The nurse had assessed him and did not believe he needed to see a
doctor, but the next day the foster parents realized he was in pain and sought medical attention,
which confirmed that he had broken his arm. RCCI Ruled Out abuse and neglect.
In the second investigation, in October 2019, the same child had broken his leg and an
RCCI investigator observed several faint bruises when she saw the child. His doctor advised that
he had a history of easily breaking bones and easily bruising. The doctor reportedly advised that
the medical condition that caused him to bruise easily was “unknown,” and that the child was a
“medical mystery.” RCCI again Ruled Out abuse and Neglect.
A.B., Born June 9, 2016; Died April 12, 2020
The Monitors’ First Report detailed the circumstances surrounding A.B.’s death but the
CPI investigation into his death remained open. On April 12, 2020, A.B., a three-year-old, was
found unresponsive on the floor, bleeding from his ear, with injuries suspicious for physical abuse.
SWI had received multiple referrals in the month leading up to A.B.’s death alleging Physical
Abuse and safety concerns. Those referrals sparked two investigations for abuse or neglect, neither
of which caused DFPS to remove the child from the placement. Those calls to SWI included
allegations that the caregiver’s domestic partner “beats [the children, including A.B. and A.B.’s
sibling, who also resided with the caregivers] really bad.”
In addition, the child’s OCOK caseworker on a visit to the home saw a bump on A.B.’s
forehead and scratches on A.B.’s face. The caregiver’s partner denied knowledge of the bump and
said that the scratches were from A.B.’s long nails. A.B.’s daycare had expressed numerous
concerns about changes in A.B.’s demeanor since the placement in the caregiver’s home, sporadic
attendance, and bruises and injuries. One of the referrals resulted in an evaluation by a pediatrician
at a hospital clinic that provides forensic child abuse evaluations, which expressed concerns for
“non-accidental trauma” based on the child’s injuries. And three days before A.B.’s death, the
daycare texted the OCOK caseworker a picture of A.B.’s eye, swollen shut; the caregiver
previously told the caseworker that the child’s eye was swollen due to allergies, which the
caseworker repeated to the daycare center staff. The CPI investigator did not interview anyone
from the daycare prior to A.B.’s death. A witness interviewed after the child’s death described
numerous injuries to A.B. over the prior several weeks including a hip injury, a black eye, and
facial bruising.
DFPS completed its investigation on October 29, 2020. DFPS substantiated the allegations
with a disposition of RTB for Physical Abuse of A.B. by both the caregiver and the caregiver’s
domestic partner, and for Neglectful Supervision by the caregiver and the caregiver’s domestic
partner for both A.B. and A.B.’s sibling. Investigators were UTB whether the caregiver and the
caregiver’s domestic partner also physically abused A.B.’s sibling. Both the caregiver and the
caregiver’s domestic partner were arrested and criminally charged in connection with A.B.’s death
in January 2021.
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C.G., Born December 29, 2005; Died April 26, 2020
The Monitors’ First Report detailed the circumstances of C.G.’s death, but the RCCI
investigation into her death remained open. Fourteen-year-old C.G. hanged herself in the bathroom
of a shelter, Williams House, where she was placed by DFPS following her third discharge from
a psychiatric hospital on March 4, 2020, where she had been treated for suicidal behavior and risk
of self-harm. C.G.’s treatment plan required that she be “monitored by staff at all times.” Despite
that requirement C.G. was left alone in the bathroom for thirty minutes before a staff person opened
the door and found her.
The shelter where C.G. died, Williams House, had a troubled history, including nine
investigations that substantiated abuse or neglect between late 2014 and March 2020. During her
stay at the shelter, C.G. presented as overwhelmed, tearful, “on edge,” and upset by the fighting
among other residents. Three weeks before her death she expressed sadness because a new policy
prohibiting phone calls with family after work hours meant that she was less able to talk with her
family. The day before her death staff took away an MP3 player she had been given to help manage
her anxiety, and immediately preceding her entry into the bathroom, she had been reprimanded
and brought to tears by a staff person for going into the staff person’s purse to look for a hair tie.
RCCI completed its investigation on November 16, 2020 and issued a disposition of RTB
for Neglectful Supervision against three staff arising from their failure to supervise C.G. while she
was in the bathroom for 30 minutes, and against one administrator for failing to ensure that the
staff provided the required level of supervision due to significant systemic issues.
E.C., Born December 12, 2018; Died June 22, 2020
E.C., an 18-month-old girl, drowned in an above-ground pool when her licensed foster
parents inadvertently left the ladder in place. According to the foster parents, each thought the
other was supervising the child. There were three foster children in the home – E.C., 13-year-old
M.R., (E.C.’s half-sister), and 7-month-old T.C., (E.C.’s birth sister), as well as the foster parents’
birth children.
The foster home had a handful of prior reports addressed by RCCR. One of the prior
reports, on April 24, 2019, pertained to E.C. when she was three months old. A report was made
to SWI that the child had a bruise on her temple. Based on the documents received, which included
medical reports and photographs, RCCR concluded that the child had a birthmark on her temple
and that there was no minimum standards violation or other concerns with the foster parents.
The remaining four reports involve M.R., who was E.C.’s half-sibling.
At the time of E.C.’s death, all three foster children in the home – E.C., M.R., and 7-month-
old T.C. - had goals of adoption with the foster parents. In the days after E.C.’s death, M.R. and
T.C. were placed in respite care until a court hearing regarding whether they could return to the
foster home. At that hearing, which occurred on July 2, 2020, the court permitted both to return to
the foster home. RCCI documented a safety plan, which it indicated was based on a court order
dated July 8, 2020, allowing M.R. and T.C. to return to the foster home.
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On July 31, 2020, RCCI entered a disposition of RTB against the foster parents for
Neglectful Supervision of E.C., noting:
Based on a preponderance of the information gathered, there is

sufficient evidence to support the documented circumstances to
meet the criteria of abuse/neglect as defined in the Texas Family
Code Section 261.001 and further defined in the Texas
Administrative Code 700.465.
[The foster parents] were not watching the child when she left the
home to enter the back yard, crawl up the ladder and fall into the 4
foot deep above ground swimming pool.
[E.C.] did not survive and was pronounced dead at 8:34 PM

06/22/2020.
[The foster mother] admitted to leaving the pool ladder accessible

to entry into the pool after attempting to clean the pool earlier in the
day.
While [the foster father] was feeding the animals and [the foster
mother] was cooking in the kitchen each thought the other was
watching [E.C.] when in fact neither was watching her and she fell
to a tragic accident.
This case will be ruled Reason To Believe for Neglectful

Supervision of [E.C.] due to neither parent noticing the child had
left the home and fallen into the pool.
That finding was not final. On August 18, 2020, the RCCI investigator requested and
received an extension request because E.C.’s death certificate had not yet been received. The
extension was to expire on September 19, 2020. Records in CLASS indicate that RCCI received
the death certificate and emailed it to the CPA supervising the foster home that same day.
Although the RCCI investigator received the death certificate on August 18, 2020, the next
set of entries in CLASS are dated October 27, 2020. On that date the RCCI investigator advised
one of the involved agencies of the case closure and RTB findings, sent the notification letters to
the referent and perpetrators, and documented a case transfer to HHSC that included concerns
RCCI identified to HHSC.
After that transfer, on October 28, 2020, HHSC notified the Centralized Background Check
Unit regarding the disposition of RTB for Neglectful Supervision with regard to the foster parents.
Next, on November 5, 2020, HHSC conducted an exit interview with an administrator from the
CPA supervising the foster home. HHSC advised the administrator regarding the “citations for
supervision, the pool being accessible to the children in care by the ladder being left in the pool,
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and Child right’s [sic] being free from abuse/neglect.” The administrator responded that she had
received a conditional check on the foster parents, and that she understood that the CPA could not
place additional children in the home. She indicated, however, that the CPA intended to leave the
home open until the adoption of M.R. and T.C. was finalized, which was scheduled to occur before
the end of November 2020.
B. Child Fatality Investigations Pending
A.F., Born September 6, 2003; Died November 30, 2020
Seventeen-year-old A.F. died by an overdose of acetaminophen on November 30, 2020.

On Saturday, November 28, 2020, F.D., a 24-year-old male, met A.F. through social media.
According to F.D., A.F. told him that she had been kicked out of where she was previously living
and did not have anywhere to go. He picked her up in Amarillo at a hotel and drove her to his
apartment in Lubbock. On Sunday, November 29, 2020, he saw that she had taken over-the-
counter pills and was acting “out of it.” She eventually vomited and, according to F.D., ultimately
began to act normal. He left for work at 2:00 p.m. and returned Monday morning, November 30,
2020. He noticed that the window of his apartment was broken and when he entered the bedroom,
he said he found A.F. unresponsive on the bed. He called 911, the authorities responded, and A.F.
was pronounced dead. The autopsy concluded that A.F. died by suicide by means of an overdose
of acetaminophen.
A.F. had experienced a total of 39 placements during the more than fifteen years that she
was in DFPS’s care. Within those placements, two were non-consecutive moves into the same
foster home with the goal of adoption (in the second placement at the same home); and two were
non-consecutive moves into a relative’s home with the hope of permanency (again in the second
placement at the same home). One placement change was into an unrelated adoptive home; two
were into relative homes; one was into a fictive kin home; seven were into foster homes; three
were foster group homes; six were RTCs; six were shelters; and one was a GRO. A.F. was
hospitalized four times; she was on runaway status twice; and she stayed in two unauthorized
placements, including her final placement, which was subsequently approved as a relative/fictive
kin placement.
In 2020, DFPS moved A.F. to a therapeutic foster home, where she stayed for less than two
months until she ran away and refused to return. She alleged that the foster mother called her
names and treated her differently from other children in the home. She went to stay with a friend’s
mother in an unauthorized placement, which DFPS subsequently approved as a fictive kin
placement in early November 2020. A few days later, A.F. left to stay with a friend, on the weekend
of November 6-7, 2020, and never returned.
During the next few weeks, A.F. was in occasional contact with the fictive kin caregiver,
her CASA worker, and her caseworker. She reported to her CASA worker that she was in Fresno,
California, but would not reveal her location to anyone else. She also indicated at some point that
she was in a relationship with a “boy” who could take care of her, and on at least two occasions,
she expressed suicidal ideation. According to the fictive kin caregiver, at one point, she asked to
return to the home with a boyfriend and the caregiver said no. At another point, she indicated that
373
they had been kicked out of where they were staying because her boyfriend had been selling drugs.
She also told the CASA worker that she was engaging in survival sex in order to eat.
DFPS’s fatality investigation included allegations of Sex Trafficking and Neglectful

Supervision against A.F.’s last fictive kin caregiver. The allegations arose after A.F. told her cousin
in November 2020 that the fictive kin caregiver had either allowed or facilitated her and another
girl to have sex with two of the caregiver’s adult relatives; as a result, A.F. contracted a sexually-
transmitted disease.
According to the investigation, on August 4, 2020, the caregiver, who was not yet approved
as a fictive kin caregiver for A.F., encountered A.F. and another girl in DFPS care, Z.C., age 14,
after they had run away from their placements. The caregiver indicated that she told the girls she
would provide them with a place to stay but that she was leaving for a trip to Denver. According
to the caregiver, she did not want to leave the girls in her home alone, so she placed them in a hotel
room for the night until she could return. She asked two of her fictive kin, both age 27, to go to the
hotel to check on the girls. She stated that she told them specifically not to go into the room. She
did not report to DFPS nor law enforcement that the girls were found and that she put them in a
hotel.
The caregiver said she learned in August 2020 that the two men she allegedly sent to check
on the girls instead had sex with them that night. The caregiver allegedly showed the investigators
documentation from her phone as proof that she confronted the two men via text message, telling
them that she found out about they had sex with the two teenagers and that she did not want them
coming to her home.
The DFPS investigator did not interview the two men, one of whom had allegedly
committed sexual assault of a minor, Z.C. The investigator interviewed Z.C., but never asked her
questions to probe whether the caregiver trafficked the girls for sex by arranging for them to have
sex with men. The investigator did not ask Z.C. whether she engaged in sexual activity with one
of the men, nor whether the caregiver had planned for them to have a sexual encounter with men
in the hotel while she was in Denver. The caregiver said that after A.F. moved in with her, she
discovered that the men had sex with the two girls in the hotel. According to the caregiver, A.F.
told her that she wanted to have sex with one of the men, but Z.C. reportedly would not admit to
the caregiver that she had sex with the other man. However, Z.C. ran away the same day that DFPS
placed A.F. with the caregiver, so it is unlikely the caregiver would have had an opportunity to
question Z.C. about the sexual assault by the 27 year-old man. This raised an inconsistency in the
timeframe reported by the caregiver which the investigator did not attempt to resolve. Finally, it is
undisputed the caregiver failed to notify law enforcement or DFPS about the sexual activity
between the two teenagers and the two men nor that she had located the girls before she left for
Denver.
Later in November, the caregiver failed to notify police and DFPS for a few days after A.F.
ultimately ran away again, which was inconsistent with the Kinship Agreement she signed. She
also left A.F. to care for her other fictive kin, a 14 old-boy, while she was out of town. Therefore,
when A.F. ran away, the boy was alone. Although A.F. left her home for the final time on
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November 6 or 7, 2020, the caregiver waited until November 9, 2020 to notify authorities that she
was missing.
CPI initially issued a disposition of Ruled Out as to all allegations. In concluding that there
was no abuse, neglect or exploitation involved in her death, the investigator did not discuss the
caregiver’s role in placing the girls unsupervised in a hotel; her failure to contact DFPS; her
decision to send two 27 year-old men to the hotel room to check on the girls; nor her failure to
contact DFPS or law enforcement upon learning the men had engaged in sexual activity with the
girls. The investigator concluded:
The allegations of Neglectful Supervision do not meet the

preponderance of evidence standard and is [in]sufficient to state that
[caregiver] neglectfully supervised [A.F.]. Neglectful Supervision is
defined as placing a child in or failing to remove a child from a
situation that a reasonable person would realize requires judgment or
actions beyond the child’s level of maturity, physical condition, or
mental abilities and that results in bodily injury or a substantial risk
of immediate harm to the child; placing a child in or failing to remove
the child from a situation in which the child would be exposed to a
substantial risk of sexual conduct harmful to the child; or placing a
child in or failing to remove the child from a situation in which the
child would be exposed to acts or omissions that constitute abuse
under Subdivision (1)(E), (F), (G), or (K) committed against another
child. [Caregiver] reported [A.F.] as a runaway. [Caregiver] was
meeting [A.F.’s] needs while she was in her home. [A.F.] left the
county and met up with random men from online dating sites. [A.F.]
was found to have died due to an overdose of Tylenol. [A.F.] was not
in [caregiver’s] care when her death occurred.
The allegations of Sex Trafficking do not meet the preponderance of

evidence standard and is [in]sufficient to state that [caregiver] sex
trafficked [A.F.]. The injuries/circumstances do not meet the
definitions of abuse/neglect as outlined in the Texas Family Code.
Sex trafficking is defined as knowingly cause, permit, encourage,
engage in, or allow a child to be trafficked in a manner punishable as
an offense under 20A.02(a)(7) or (8), Penal Code, fail to make a
reasonable effort to prevent a child from being trafficked in a manner
punishable as an offense under 20A.02(a)(7) or (8), Penal Code,
compel or encourage a child to engage in sexual conduct that is an
offense under 20A.02(a)(7) or (8), Penal Code (trafficking of
persons), 43.02(b), Penal Code (prostitution), or 43.05(a)(2), Penal
Code (compelling prostitution). [Caregiver] denied the allegations
and there has been no evidence in speaking with family members and
collaterals to support this allegation. Law enforcement is not
pursuing charges for sex trafficking of [A.F.] by [caregiver].
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On April 4, 2021, however, CPI entered new, tentative

findings in this investigation. DFPS appeared to reverse its earlier
decision and concluded there was Reason to Believe the allegation of
Neglectful Supervision of A.F. by the caregiver. That investigative
record notes:
[Caregiver] did place [A.F.] in a situation that the child would be

exposed to a substantial risk of sexual conduct harmful to the child.
[Caregiver] met [A.F.] while she was on runaway from a foster
home (8/3/20). [Caregiver] put [A.F.] and another runaway foster
child in a hotel room for the night while she left town. [Caregiver]
asked some male family friends who are in their 20’s to stay at the
hotel, allegedly outside, to ensure the girls did not run. [Caregiver]
set [A.F.] up in a situation that left her vulnerable and easily able to
be taken advantage of. Based on interviews completed, [A.F.] did
end up having sexual intercourse with one of these males that night
in the hotel; it is unclear if the sexual intercourse was consensual or
not. In addition, [Caregiver] failed to report [A.F.] as a runaway to
the authorities in a timely manner.
As of April 4, 2021, DFPS also entered a disposition of UTB as to allegations of Sex

Trafficking of A.F. and UTB as to allegations that the caregiver gave A.F. and the other child
marijuana the night they stayed in the hotel.
However, as of April 10, 2021, IMPACT records appeared to show that DFPS altered its
conclusion, again, and was poised to Rule Out or administratively close all of the allegations
against the caregiver. The documentation appeared to reframe the allegations of Neglectful
Supervision around the caregiver’s failure to notify the agency that A.F. ran away on November
6th or 7th. With respect to the allegations stemming from the night the caregiver hosted A.F. was
hosted at the hotel, DFPS appeared poised to administratively close the investigation into
allegations of Physical Abuse and Sex Trafficking, citing the agency’s lack of jurisdiction. The
IMPACT records noted the investigation was open as of April 10, 2021, and provide:
The allegations of Neglectful Supervision do not meet the

preponderance of evidence standard and thus it is not sufficient to
state that [caregiver] neglectfully supervised [A.F.] Neglectful
Supervision is defined as placing a child in or failing to remove a
child from a situation that a reasonable person would realize requires
judgment or actions beyond the child’s level of maturity, physical
condition, or mental abilities and that results in bodily injury or a
substantial risk of immediate harm to the child; placing a child in or
failing to remove the child from a situation in which the child would
be exposed to a substantial risk of sexual conduct harmful to the
child; or placing a child in or failing to remove the child from a
situation in which the child would be exposed to acts or omissions
that constitute abuse under Subdivision (1)(E), (F), (G), or (K)
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committed against another child. [A.F.] is not here to speak for

herself, however based upon the investigation there has been no
evidence found to state that [caregiver] was neglectful in her care of
[A.F.] [Caregiver’s] delay in reporting [A.F.] as a runaway appears
to have been based on her misunderstanding of the law, the fact that
[A.F.] was seventeen, and [caregiver’s] belief that law enforcement
would not consider [A.F.] a runaway at that age. There is insufficient
evidence to support [caregiver] was neglectful in her supervision
due to the delay in reporting [A.F.] as a runaway.
[A.F.] Physical Abuse
The Texas Family Code states Physical Abuse includes the

following acts or omissions by a person: physical injury that results
in substantial harm to the child, or the genuine threat of substantial
harm from physical injury to the child, including an injury that is at
variance with the history or explanation given and excluding an
accident or reasonable discipline by a parent, guardian, or managing
or possessory conservator that does not expose the child to a
substantial risk of harm; failure to make a reasonable effort to
prevent an action by another person that results in physical injury
that results in substantial harm to the child; the current use by a
person of a controlled substance as defined by Chapter 481, Health
and Safety Code, in a manner or to the extent that the use results in
physical, mental, or emotional injury to a child; or causing,
expressly permitting, or encouraging a child to use a controlled
substance as defined by Chapter 481, Health and Safety Code;
[Caregiver] was not an approved caregiver for [A.F.] at the time of
the alleged abuse and neglect, thus the Department does not have
jurisdiction to investigate this allegation.
[A.F.] Sex Trafficking
Sex trafficking is defined as knowingly cause, permit, encourage,

engage in, or allow a child to be trafficked in a manner punishable
as an offense under 20A.02(a)(7) or (8), Penal Code, fail to make a
reasonable effort to prevent a child from being trafficked in a
manner punishable as an offense under 20A.02(a)(7) or (8), Penal
Code, compel or encourage a child to engage in sexual conduct that
is an offense under 20A.02(a)(7) or (8), Penal Code (trafficking of
persons), 43.02(b), Penal Code (prostitution), or 43.05(a)(2), Penal
Code (compelling prostitution).The Department does not have
jurisdiction to investigate this allegation. [Caregiver] was not an
approved caregiver at the time of the alleged incident and was acting
as a good samaritan [sic] when the decision was made to secure a
hotel room for [A.F.] Moreover, [caregiver] had no duty or
377
obligation to [A.F.] but acted to remove [A.F.] from risk of harm

and provided shelter, food, and clothing.
D.H., Born May 17, 2006; Died January 30, 2021
D.H., a 14-year-old boy, was unresponsive when his foster mother found him in their home
upon her return from the restroom. D.H. resided in a foster home that cares for children with
Primary Medical Needs (“PMN”). According to DFPS, D.H. was diagnosed with involuntary
muscle movement, spastic quadriplegic cerebral palsy, seizure disorder, asthma, esophageal reflux,
GERD, tracheomalacia, reactive airway disease, bronchomalacia, osteoporosis, spasticity,
epilepsy, and unspecified brain abnormality. D.H. was fed via G-tube and required a wheelchair
and specialized bed. According to the intake regarding his death, because of his medical challenges
D.H. was not expected to live past two years old.
When D.H.’s foster mother found him unresponsive, she called EMS. First responders
managed to resuscitate D.H., but he stopped breathing again. The first responders tried to
resuscitate him again for an hour, but they were not successful. There was no autopsy after his
death. The Harris County Institute of Forensic Sciences conducted an inquest and determined that
the cause of death was complications from cerebral palsy and the manner of death was natural.
According to DFPS, D.H. had been in the same foster home since he entered care in 2006. An
RCCI investigator interviewed the foster mother, the adoptive children and the other foster child,
the CVS worker, the case manager, and several of D.H.’s treating physicians. None of them raised
any concerns about—and in fact were complimentary of—the foster mother’s care of D.H.
Although the investigation was not yet formally closed as of April 10, 2021, it appeared RCCI
intended to Rule Out the allegations of Neglectful Supervision.
J.C., Born July 1, 2019; Died February 15, 2021
J.C., was a one-year-old child who had been in DFPS care for the year prior to her death.
The child’s caregiver reported that she, the victim and an adolescent living in the home had taken
a nap. She stated that when she awoke two hours later, J.C. was unresponsive. The caregiver called
911 and first responders transported J.C. to the hospital, where the child was ultimately declared
dead after showing no signs of brain activity. Preliminary medical evidence is strongly indicative
of Physical Abuse. The investigation was pending as of April 10, 2021.
J.R., Born January 31, 2004; Died March 18, 2021
A caregiver found 17-year-old J.R. unresponsive in the home where he resided, which was
designed to meet his ongoing specialized medical needs. The caregiver called EMS but the
attempts by first responders to revive J.R. were unsuccessful. Adult Protective Services (APS), an
entity within HHSC, is conducting the investigation into J.R.’s death. While J.R. was 17 at the
time of his death, his placement was a specialized foster home for people with developmental
disabilities that operates under the auspices of a home and community-based services (HCS)
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provider. APS is responsible for investigations in those settings.746 An autopsy was pending and
the investigation was ongoing as of April 10, 2021.
C.S., Born July 31, 2019; Died April 3, 2021
C.S. was 21 months old when she died and was diagnosed with Zellweger syndrome, a rare
congenital disorder. Patients with Zellweger syndrome do not typically survive beyond one year
of age. On April 3, 2021, C.S.’s foster parent noticed she was not breathing and was unresponsive.
First responders unsuccessfully attempted to revive C.S. and transported her to the hospital, where
she was pronounced dead. An investigation into the child’s fatality was open and a determination
of the cause and manner of death remained pending as of April 10, 2021.
E.T., Born December 13, 2015; Died April 8, 2021
Five-year-old E.M. had been diagnosed with anoxic brain injury, feeding difficulty, failure
to thrive, sleep apnea, spastic quadriplegic cerebral palsy, global developmental delays, cortical
vision loss, hip dysphagia due to contractures and hypertonia. E.T. was also dependent on a g-tube,
had pneumonia in the past, as well as breathing issues. E.T. resided in a foster home that cares for
children with PMN.
On the morning of April 7, 2021, E.T. was having difficulty breathing and suction (a
method used for her care) was not improving her condition. The foster mother and a nurse were
both caring for E.T. at the time. The foster mother called 911 and EMS first responders transported
E.T. to the hospital. E.T. died the next day. RCCI reported that there would not be an autopsy
due to E.T.'s medical history. The RCCI investigation remained open as of April 10, 2021.
C. Abuse and Neglect Ruled Out/UTB; Possible Neglect (July 31, 2019 – April 10, 2021)
D.P., Born June 26, 2004; Died September 5, 2020
D.P., a 16-year-old male, went to a waterpark and then to a beach in Galveston with his
girlfriend and her parents. He and his girlfriend resided with her grandmother, where DFPS
recently assigned D.P. for placement. He went swimming at the beach between 9:00 and 9:30 p.m.
and never returned to shore. A passerby notified the beach patrol upon seeing the body in the water
the next day. The record indicates that his CPS worker had approved the trip to the waterpark but
had not—and would not have—approved the evening trip to the beach.
D.P. was diagnosed with behavioral challenges including adjustment disorder with mixed
disturbance of emotions and conduct, oppositional defiant disorder, and attention deficit
746
See 26 Texas Admin. Code § 711.1(2)(A)(ii) (stating that the regulations in the chapter are to “describe . . . Adult
Protective Services (APS) investigations of allegations of abuse, neglect, and exploitation involving . . . adults or
children” living in a home operated by a provider agency “in the home and community-based services (HCS) waiver
program”) (emphasis added).
379
hyperactivity disorder. As of August 21, 2020, he was prescribed Vyvanse, Quetiapine, Clonidine,
Escitalopram and Melatonin. D.P.’s episode in out-of-home placement began in June 2018 after
he was released from a juvenile detention facility. At the time of his release, his mother was
incarcerated and could not care for him and his other relatives declined to take physical custody of
him. DFPS initially placed him in a shelter. He then had six additional placements over two
years: (1) an RTC, which he left because it became all female; (2) another RTC, which he left at
the request of his attorney ad litem for a placement closer to Houston; (3) and (4) two different
contracts in the same RTC, where he lived for 18 months; (5) an RTC where he lived for six weeks;
and (6) the fictive kin placement with his girlfriend’s grandmother.
DFPS interviewed the adults and children who were present at the time of D.P.’s death.
According to the interviews, D.P. asked his girlfriend’s mother whether he could go in the water
at the beach, despite that it was dusk. She indicated that he could, as long as he agreed to sit on a
towel in the car on the way home so that he would not get the car seat wet. She and her husband
also told him that they would shine the lights on their phones to signal him to come back in to
shore, which acknowledged that, even if it was not already, soon it would be too dark for D.P. to
see them and for them to see him. D.P.’s girlfriend’s mother also acknowledged that she had been
primarily monitoring her son, D.P.’s girlfriend’s brother, who was also in the water. Finally, the
toxicology report confirmed that D.P., a sixteen-year-old, had a blood alcohol concentration of
.024. A witness reported that D.P.’s girlfriend’s father had provided D.P. with at least some amount
of an alcoholic beverage; the father denied it. DFPS also noted that there were signs posted near a
lifeguard stand warning “Danger/Rip Tide” and prohibiting swimming or wading near the rocks.
DFPS initially concluded that the allegations of Neglectful Supervision should be substantiated
with a disposition of Reason to Believe. DFPS subsequently revised that conclusion and instead
entered a disposition of UTB, though the record contains no new evidence to support the change.
DFPS closed the investigation on January 28, 2021.
On March 31, 2021, DFPS reported to the Monitors that a review of the case had initially
led the agency to decide in March 2021 to change the disposition “back to RTB based on the lack
of any analysis to support UTD.”747 However, in the same communication, DFPS reported that
“CPI determined it never had jurisdiction of this case in the first instance. CPI only investigates
parents, guardians, conservators, relatives/family member, household member, and paramours.”748
Because D.P.’s girlfriend’s parents were not D.P.’s caregivers, DFPS reported “the case will be
reopened and administratively closed.”749
Because the question of CPI’s jurisdiction was not well investigated in this matter750 and
D.P.’s death remains suspicious for neglect, the Monitors cannot determine whether the agency’s
final disposition is appropriate.
747
Email from Corliss Lawson to Kevin Ryan (March 31, 2021) (with attachment).
748
Id.
749
Id.
750
See Texas Family Code § 261.301 (requiring DFPS investigate allegations of abuse or neglect against a person
who is a member of a child’s “household.”) A “household” is defined as “a unit composed of persons living together
in the same dwelling, without regard to whether they are related to each other.” Texas Family Code § 71.005. The
Texas Administrative Code further defines “household” to include:
(A) A unit composed of persons living together in the same dwelling, whether or
not they are related to each other, when the dwelling consists of:
380
D. Child Fatalities, No Abuse or Neglect Determined (May 1, 2020 and April 10, 2021)
A.C., Born October 1, 2004; Died Unknown
A.C. was a 15-year-old girl with a significant history of running away. DFPS’s records also
indicate the victim may have been a sex trafficking survivor. A.C. had most recently entered into
DFPS’s care in June 2019. In February 2020, DFPS placed her back with her mother under a CPS
safety plan, but she ran away in mid-April 2020. Law enforcement located A.C. again on May 8,
2020 and turned her over to CPS; while the CPS worker was driving her to a new placement, A.C.
asked to use the restroom at a convenience store and ran away again. Nine days later, on May 17,
2020, she was found deceased on the side of the road. DFPS did not undertake an investigation. It
closed the intake concluding that it was a matter for law enforcement. Preliminary autopsy results
indicated that she suffered from multiple sharp force injuries (injuries caused by pointed or sharp
objects), and the death was classified as a homicide. Law enforcement officials have arrested an
individual who is suspected to have killed A.C.
N.M., Born March 29, 2003; Died May 9, 2020
N.M., a seventeen-year-old youth, had been placed with his aunt on March 30, 2020, about
five weeks prior to his death, following at least two dozen placements during the past several years.
On the day of his death, N.M. went to the lake with his aunt, uncle, cousins (one of whom was 13
years old), and a friend who was 18 years old. N.M., the 13 year-old cousin, and the 18 year-old
friend went swimming in the lake. His aunt made them take a flotation device and instructed them
not to go past the marked boundaries. The 13 year-old and the 18 year-old swam back to shore
because they could not touch the bottom, leaving N.M. with the float. The float apparently blew
away and N.M. swam further away from the shore in an attempt to try to get the float; the two
(i) The child’s family’s household, including the households of both

parents when the parents reside separately;
(ii) A household in which the parent has arranged for or authorized
placement of the child; or
(iii) A household in which the child is legally placed by a parent or a
court.
(B) During the receipt and investigation of reports of child abuse and neglect, we
treat an unrelated person who resides elsewhere or whose place of residence
cannot be determined as a member of the household if the person is at least 10
years old and either:
(i) Has regular free access to the household; or
(ii) When in the household dwelling takes care of or assumes
responsibility for children in the household.
Texas Admin. Code § 707.451(a)(8).
On its face, it appears that D.P.’s girlfriend’s parents are each an “unrelated person who resides elsewhere” and are
“at least 10 years old.” There is also information in the record that indicates that D.P.’s girlfriend’s parents had
“regular free access to the household” and/or had “take[n] care of or assume[] responsibility for children in the
household.” Whether D.P.’s girlfriend’s parents meet those definitions does not appear to have been well investigated
by DFPS as of March 31, 2021.
381
others called to him to come in and he attempted to swim back in, but the waves and the current
pulled him under the water. His uncle and other bystanders swam out to try to save him but he was
limp when they reached him. It took them ten minutes to bring him to shore, where they performed
CPR until EMS arrived. N.M.’s uncle and others who assisted also went to the hospital due to
intake of water. At the hospital the doctors advised that N.M. had been under the water for a
significant period of time and that his prognosis was poor. They ultimately removed him from life
support.
The Medical Examiner’s final report noted that there were reports of witnessed submersion
in a lake, there was fluid retention in the tissue, and there was no evidence of significant trauma
or acute toxicity, with the report indicating that alcohol and drugs were not detected. The Medical
Examiner concluded that N.M. died as a result of complications of drowning. DFPS subsequently
concluded that the cause of death was asphyxiation (drowning) and the manner of death was
accidental. As a result, DFPS concluded that there was no abuse or neglect involved.
J.G., Born June 26, 2013; Date of Death July 7, 2020
J.G., a 7-year-old girl, had significant health problems including end-stage renal failure
(she was in need of a kidney transplant and required daily dialysis), a feeding tube, developmental
delays, pulmonary issues, and was non-verbal and unable to walk. She did not have a do-not-
resuscitate order or a hospice nurse, but some of her medical caregivers indicated that she was
likely terminally ill. Because of her medical fragility, DFPS appeared to have classified her as
PMN.
J.G. had resided in a specialized foster home with other PMN children since November 20,
2019. The home included the foster mother, who was also a nurse, the foster father, two other
foster children, four adopted children, and three adult birth children. It appears that she had 24/7
one-to-one nursing care (in addition to the foster mother).
On the day J.G. died, the foster father, foster mother, and J.G.’s nurse were taking her to a
scheduled medical appointment which appeared to have been her regular dialysis treatment.
During the ride to her appointment, her pulse oximeter began to alarm and she appeared blue and
was unresponsive. Her caregivers pulled the car over and called 911. Her foster mother and the
nurse provided CPR until EMS and police arrived and took over. After a period of time, J.G. did
not respond and first responders discontinued CPR.
During the investigation into the death, the nurses and the foster mother indicated that J.G.
did not have any significant medical issues earlier on the day of her death. They also noted that
she had seen a physician, her ear, nose, and throat specialist, the day before her death and the
physician did not raise any concerns. During their interviews, the foster father and the adult
children did not appear to have extensive knowledge about J.G.'s medical conditions.
J.G.’s birth mother requested an autopsy, which concluded that the death was caused by
complications of chronic renal disease. An RCCI investigator interviewed the foster parents, the
nurse who was with them at the time of J.G.’s death, five other home nurses, J.G.’s primary care
provider and treating nephrologist, CPA staff, the CPS caseworker, and the foster parents’ adult
382
birth children. None raised any concerns regarding the foster parents’ care of J.G. The medical
providers also indicated that due to J.G.’s serious health conditions, J.G.’s death was not
unexpected. Based on those findings, RCCI Ruled Out abuse and neglect by the foster parents and
closed the investigation on January 8, 2021.
D.N., Born December 20, 2015; Died October 25, 2020
D.N., a four-year-old child with significant medical needs, resided in a specialty foster
home. His foster mother noticed that his pulse oxygen meter went off at 6:00 a.m. She went to
check on him and found that he had stopped breathing. She tried to call 911 unsuccessfully and
then eventually was able to call police. She tried to resuscitate him for 30 minutes before EMS
arrived at the home and took him to the hospital.
D.N. had been in the conservatorship of DFPS since 2017 based on findings of Medical
Neglect because his parents were not providing for his medical needs. According to DFPS, D.N.
had severe cerebral palsy, unspecified epilepsy, was nonverbal, used a standing wheelchair and a
specialized hearing aid, and had a tracheotomy tube, a G-tube, and, at time, used a ventilator. The
foster mother was a nurse, and D.N. and other children in the home also received in-home nursing
care.
RCCI Ruled Out abuse or neglect in the fatality investigation. According to the
investigation there was no physical evidence of maltreatment. Moreover, the other nurses in the
home and D.N.’s primary care provider, his treating pulmonologist for the last several years, and
the emergency room physician had no concerns regarding the fatality or the foster mother’s care
of D.N. The physicians attributed the death to D.N.’s significant health concerns. His treating
pulmonologist indicated that the foster mother had never missed an appointment and that her
excellent care had extended D.N.’s life. The Medical Examiner determined that there were no
circumstances to warrant an autopsy. Law enforcement also determined that an investigation was
not warranted.
RCCI completed the investigation on February 6, 2021, and reported the finding to the
provider on February 8, 2021. On February 9, 2021, the foster home voluntarily closed without
deficiencies.
383
I.R., Born March 15, 2012; Died December 28, 2020
In June 2017, DFPS was granted TMC over I.R., who had a number of medical conditions
including Down Syndrome, severe intellectual disability, seizure disorder, and encephalopathy.
I.R. could not walk and used a G-tube, suction machine, CPAP with ventilator, CPT vest,
nebulizer, pulse oximeter, and a VNS chip/magnet to help control seizures. DFPS took custody of
I.R. because he was severely malnourished and near death. DFPS substantiated allegations of
Physical and Medical Neglect against both his mother and father and was ultimately awarded PMC
over I.R., although without termination of parental rights. I.R.’s mother and father were arrested
for child neglect in July 2017. His mother was indicted in October 2017, apparently because she
had primary physical custody of I.R., and the charge against her was dismissed in July 2019. She
reported that the charge was dismissed because the hospital searched its records and it was
documented that she had, in fact, brought I.R. in for medical treatment.
According to DFPS, after the charge was dismissed, both I.R.’s mother and father were
complying with DFPS’s instructions to address the reasons for removal. As a result, on July 23,
2020, DFPS returned I.R. home to live with his mother and grandmother but he remained under
DFPS supervision. One of the conditions of the return home was the provision of 24/7 nurse
coverage, for which DFPS assumed a role to set up.
During the next few months I.R.’s mother and grandmother advised DFPS several times
that the nursing service was not consistently able to ensure 24/7 nursing coverage. In early October
2020, I.R.’s grandmother advised DFPS that I.R.’s mother was only able to care for I.R. with 24/7
nursing coverage. In addition, one of the nurses raised concerns about the care by I.R.’s mother,
as well as implicitly acknowledging that the agency was not covering all of the shifts. She indicated
that when she returned to care for I.R. after another nurse had not been at the home for a couple of
days, I.R. always seemed like he was not doing well and they would have to “build him back up.”
Around that same time, I.R.’s mother changed nursing services to attempt to address the staffing
challenges, but the issues continued with the new agency.
On November 1, 2020, DFPS noted that I.R.’s mother “struggles with getting nursing staff
daily to show up for their shifts; she has changed nursing companies and still has issues with
staffing.” On December 11, 2020, I.R.’s grandmother communicated to the DFPS worker who
had been conducting home visits that even the new nursing agency struggled to appropriately staff
the home with nurses on nights and weekends. “[Grandmother] stated that if we really wanted to
help them we would make sure there was always a nurse there.” Another DFPS worker responded
to the visiting worker: “I don’t know what to say, it’s challenging because those are things that are
beyond our control [having home health fully staffed and able to work shifts].”
On December 28, 2020, I.R.’s grandmother advised the caseworker that I.R. had passed
away. She said he had been having trouble breathing for a few weeks and had severe seizures, and
that earlier on the morning of the child’s death, I.R.’s mother had noticed he was not breathing
well and was turning purple. I.R.’s mother indicated that she had been monitoring him that night
and that she had left the room for two minutes to wash her hands so she could clean him. She stated
that when she returned, he was gasping for air and turning blue. She called out to her family who
called 911. The family tried to revive him with CPR before EMS arrived and attempted to revive
384
him as well. First responders transported I.R. to the hospital but he did not revive. On the morning
of his death, there was no nurse coverage at the home, although the records were not clear whether
nursing coverage was supposed to be 24/7 or 7 a.m. to 7 p.m. with the new agency.
DFPS issued a disposition of Ruled Out as to the allegations of Neglectful Supervision on

February 18, 2021, noting that no autopsy was done and that the attending physician indicated that
I.R. died of natural causes.
385
List of Tables
Table 2.1: Race for Children in PMC on December 31, 2020 and Estimates of Total
Population in Texas by Race for Children ages 0 to 17 years, July 1, 2019................................ 36
Table 2.2: Exits from PMC by Exit Outcome, March 1, 2020 to December 31, 2020................ 38
Table 2.3: Authorized Level of Care for Children in PMC as of December 31, 2020 ................ 39
Table 2.4: Top 5 Counties of Removal for Children in PMC on December 31, 2020 ............... 39
Table 2.5: PMC Children Living in Regions with Single Source Continuum Contractor
Presence on December 31, 2020 ................................................................................................. 40
Table 2.6: PMC Children Living in Regions with Single Source Continuum Contractor
Presence by Region on December 31, 2020 ................................................................................ 40
Table 4.1: Intakes Downgraded by RCCI between May 1, 2020 and November 30, 2020 ....... 67
Table 4.2: Intakes Downgraded by CPI between May 1, 2020 and November 30, 2020 ........... 67
Table 4.3: Automatic Notification Found and Timing of Automatic Notification ................... 105
Table 4.4: Automatic Notification Date Comparison of State Data and Case Read Data ........ 105
Table 4.5: Communication Between RCCI Investigator and CVS Caseworker Found ........... 106
Table 4.6: Timing and Most Common Method of Communication Between RCCI
Investigator and CVS Caseworker ............................................................................................ 106
Table 4.7: Subsequent Communication Between RCCI Investigator and CVS Caseworker
for Cases Where Initial Contact was NOT a Phone Call and Most Common Method ............. 107
Table 5.1. Caseworkers Conforming to the Graduated Caseload Standards
at Three Points in Time ............................................................................................................. 147
Table 5.2: Caseworkers Managing at Least One PMC Child March 2020 to December
2020............................................................................................................................................ 155
Table 5.3: DFPS Caseworkers Managing at Least One PMC Child March 2020 to December
2020 ........................................................................................................................................... 156
Table 5.4: OCOK Caseworkers Managing at Least One PMC Child March 2020 to December
2020 ........................................................................................................................................... 157
Table 5.5: 2INgage Caseworkers Managing at Least One PMC Child May 2020 to December
2020 ........................................................................................................................................... 158
Table 5.6: RCCI Investigators with Caseloads within Guidelines March to December 2020 .. 164
Table 5.7: RCCR Inspectors with Caseloads within Guidelines, March to December 2020 ... 170
Table 6.1: Number of Placements for PMC Children by Sexual Indicator Type, March to
December 2020 ......................................................................................................................... 176
Table 6.2: Number of Runaway Incidents for PMC Children by Sexual Indicator Type, March
to December 2020 ...................................................................................................................... 177
Table 6.3: Child Sexual Abuse Training Completion by Caseworker Type, July 1, 2020 to
August 31, 2020 ........................................................................................................................ 190
Table 6.4: Number of Noncompliance Incidents for Operations with More Than One
Noncompliance Incident ........................................................................................................... 246
Table 7.1: Definition for ECHR Found in Case Review ......................................................... 255
Table 7.2: State Case Review on Extended Compliance History Reviews .............................. 262
Table 7.3: Priority of RCCR Investigations .............................................................................. 272
Table 7.4: Operations Meeting the Criteria for Heightened Monitoring that Closed or with
Which DFPS Terminated Contracts .......................................................................................... 289
Table 7.5: Most Serious Issues at Phase One Heightened Monitoring Operations as Identified
by the Monitors, 2015 to 2019 .................................................................................................. 298
Table 7.6: Most Serious Issues at Phase One Heightened Monitoring Operations as Identified
by the Monitors, 2019 and 2020 ............................................................................................... 299
Table 7.7: Problems Identified at Phase One Operations by the Monitoring Team’s Review
of Heightened Monitoring Documentation and by the State in Heightened Monitoring Plans..301
Table 7.8: Phase One Operations with Inconsistencies Between their Historical Trends and
the Issues Identified on their Heightened Monitoring Plan ...................................................... 301
Table 7.9: Time to Expected Compliance of All Tasks for Phase One Heightened Monitoring
Operations Analyzed ................................................................................................................. 305
Table 7.10: Prior Enforcement Actions at Phase One Heightened Monitoring Operations and
Similarities in Issues and Requirements to Current Heightened Monitoring Plan ................... 306
Table 7.11: Number of Heightened Monitoring Visits at Phase One Heightened Monitoring
Operations Analyzed ................................................................................................................. 308
Table 7.12: Heightened Monitoring Visits Associated with Child Placing Agencies .............. 310
Table 7.13: Number of Heightened Monitoring Plan Tasks per Operation and Average
Number of Tasks Reviewed During Visits ............................................................................... 311
Table 7.14: Total Number of Deficiencies Prior to and Since Placement on Heightened
Monitoring Through December 31, 2020 for Phase One Operations Analyzed ....................... 323
Table 7.15: ANE Allegation Dispositions for ANE Investigations Conducted at Phase One
Heightened Monitoring Operations .......................................................................................... 324
Table 7.16: Requested Variances at Phase One Heightened Monitoring Operations Source:
Variance and Waiver Data as Provided by DFPS, June – December 2020 .............................. 326
Table 7.17: Variances Granted to Phase One Heightened Monitoring Operations, June to
December 2020 .............................................................................. 327
Table 7.18: Congregate Care Facility Closures, September 2, 2020 – April 16, 2021.............. 345
List of Figures
Figure 2.1: Age of Children in PMC on December 31, 2020 ...................................................... 35
Figure 2.2: Living Arrangements for Children in PMC on December 31, 2020 ......................... 37
Figure 2.3: Length of Stay in Care of Children in PMC on December 31, 2020 ....................... 38
Figure 4.1: Number of SWI Calls by Month .............................................................................. 56
Figure 4.2: Time Callers Waited before Calls were Handled or Abandoned ............................. 57
Figure 4.3: Duration of Handled SWI Calls ............................................................................... 58
Figure 4.4: Number of SWI Calls Handled and Abandoned by Day of the Week ..................... 60
Figure 4.5: RCCI Rate of Downgrades from May 1, 2020 to November 30, 2020 .................... 63
Figure 4.6: CPI Rate of Downgrades from May 1, 2020 to November 30, 2020 ....................... 64
Figure 4.7: Allegation Types for RCCI Intakes Involving PMC Children in Licensed
Placements, May 1, 2020 to November 30, 2020 ....................................................................... 65
Figure 4.8: Alleged Perpetrators in RCCI Involving PMC Children in Licensed Placements ... 71
Figure 4.9: Reason to Believe Findings in Closed RCCI Investigations Involving PMC Children
in Licensed Placements ............................................................................................................... 72
Figure 4.10: Initiation of Investigations within 24 Hours in Priority One Investigations per
Existing Policy ............................................................................................................................ 85
Figure 4.11: Initiations of Investigations within 72 Hours in Priority Two Investigations per
Existing Policy ............................................................................................................................. 86
Figure 4.12: Face-to-Face Contact within 24 Hours with All Alleged Child Victims in Priority
One Investigations ....................................................................................................................... 88
Figure 4.13: Face-to-Face Contact within 72 Hours with All Alleged Child Victims in Priority
Two Investigations ...................................................................................................................... 89
Figure 4.14: Completion of Priority One and Two Investigations within 30 Days .................... 90
Figure 4.15: Completion of Priority One and Two Investigations within 30 Days over Time ... 91
Figure 4.16: Number of Extensions in Priority One and Two Investigations ............................ 92
Figure 4.17: Notification Letter Sent to Referent within Five Days of Investigation Closure in
Priority One and Two Investigations .......................................................................................... 94
Figure 4.18: Notification Letter Sent to Provider within Five Days of Investigation Closure in
Priority One and Two Investigations .......................................................................................... 95
Figure 4.19: Reason Found for Home History Review Not Completed ................................... 113
Figure 4.20: Home History Review Content ............................................................................ 113
Figure 4.21: Reason Found for Not Documenting a Home History Review Staffing .............. 115
Figure 4.22: Time from Case Referral to Home History Review Staffing Documented ......... 116
Figure 4.23: Actions Taken as a Result of a Home History Review Staffing .......................... 117
Figure 4.24: Home History Review Staffing Contact Documented: Monitor Case Read
Compared to State Case Read ................................................................................................... 121
Figure 5.1: OCOK Training Timeline for New Permanency Workers ..................................... 130
Figure 5.2: DFPS CVS Caseworkers Hired by Hire Type, January 1, 2020 to July 31, 2020 .. 133
Figure 5.3: DFPS CVS Caseworkers Hired by New Hire Type ............................................... 133
Figure 5.4: Hired DFPS CVS Caseworkers Who Left Position by December 1, 2020 Timing
of Exit ........................................................................................................................................ 134
Figure 5.5: DFPS CVS Caseworkers Hired by Agency Status as of December 1, 2020 .......... 135
Figure 5.6: Caseworkers Hired, Active, and Left Agency by Region ...................................... 136
Figure 5.7: CVS Caseworkers CPD Training Completion Sample .......................................... 137
Figure 5.8: DFPS CVS Caseworkers CPD Training Completion ............................................. 138
Figure 5.9: OCOK Caseworkers Hired Type January 1, 2020 to July 31, 2020 by Hire
Type .......................................................................................................................................... 139
Figure 5.10: 2INgage Caseworkers Hired April 1, 2020 to July 31, 2020 by Hire Type ......... 140
Figure 5.11: Caseworkers Leaving OCOK as of December 2020, Timing of Exit .................. 140
Figure 5.12: Number of OCOK Caseworkers Hired, Active, and Left Agency as of December
2020, by Work County .............................................................................................................. 141
Figure 5.13: Caseworkers Leaving 2INgage as of November 2020, Timing of Exit ............... 141
Figure 5.14: Number of 2INgage Caseworkers Hired, Active, and Left Agency as of November
2020, by Work County .............................................................................................................. 142
Figure 5.15: 2INgage CPD Completion Time Compared to Expected, Caseworkers Requiring
Full Training .............................................................................................................................. 143
Figure 5.16: Number of RCCI Investigations by Month ........................................................... 163
Figure 5.17: Low and High Caseloads for RCCI Investigators ................................................ 165
Figure 5.18: RCCI Investigations by Staff Type Acting as Primary Investigator .................... 166
Figure 5.19: Number of RCCR Tasks ....................................................................................... 168
Figure 5.20: RCCR Tasks by Type ........................................................................................... 169
Figure 5.21: Caseload Lows and Highs for RCCR Inspectors ................................................. 171
Figure 5.22: Timing of Communication Between RCCR Inspectors and RCCI Investigators
During an ANE Investigation ................................................................................................... 173
Figure 6.1: CSA Training by Position for Staff Active March to November 2020 .................. 182
Figure 6.2: CSA Training Verification, Staff Active March to November 2020 by Position .. 183
Figure 6.3: PMC Children with a Sexual Characteristic Flag (Victim or Aggressor) Active
as of November 30, 2019 to December 31, 2020 ..................................................................... 199
Figure 6.4: Number of Newly Flagged PMC Children by Month, January 2019 to December
2020 ........................................................................................................................................... 200
Figure 6.5: Percent of Children with a Sexual Abuse Indicator with Abuse After Entering
Care, June to October 2020 ....................................................................................................... 201
Figure 6.6: Perpetrators Identified for Children with Abuse Occurring After Entering Care .. 202
Figure 6.7: Sexual Aggression Occurred After Entering Care for Children with a Sexual
Aggression Indicator .................................................................................................................. 203
Figure 6.8: Case Review Sample Characteristics, March to October 2020 .............................. 221
Aggression ............................................................................................................................... 223
Victimization ............................................................................................................................. 224
Aggression or Sexual Abuse ..................................................................................................... 225
Aggression or Sexual Abuse By Period .................................................................................... 226
Aggression or Sexual Abuse By Entity Responsible for Placement ......................................... 227
Figure 6.14: Percent of Placements in which Both Placement Summary and Attachment A
Associated with the Placement was Found By Period .............................................................. 228
Figure 6.15: Number of Placements with Both Placement Summary and Attachment A Found,
Includes Sexual History Information, and Signed by Receiving Caregiver on or Before Start
of Placement .............................................................................................................................. 229
Figure 6.16: Percent of Placements with Hand Signed Placement Summary and Attachment A
On or Before Placement By Period ........................................................................................... 230
On or Before Placement By Entity Responsible for Placement ............................................... 231
On or Before Placement By Living Arrangement .................................................................... 232
Figure 6.19: Number of Operation Locations Requiring Awake-Night Supervision Visited,
March to October 2020 ............................................................................................................. 241
Figure 6.20: Incidents of Noncompliance with Awake-Night Supervision Requirements ...... 244
Figure 6.21: Corrective Action Taken for Incidents of Noncompliance with Requirements
of Awake-Night Supervision .................................................................................................... 245
Figure 7.1: Days from ECHR Review Date to Inspection Begin Date for Inspections with an
ECHR ........................................................................................................................................ 257
Figure 7.2: Comparison of ANE/Corporal Punishment Data Found in Extended Compliance
History Reviews and State Aggregate Data as of the First Day of the Month ......................... 258
Figure 7.3: Consideration of Identified Pattern, September to October ................................... 260
Figure 7.4: Number of Prior Failure to Report Deficiencies Between 9/30/2014 and 2/29/2020
for Operations with a Failure to Report Deficiency Between March 1, 2020 and October 31,
2020 ........................................................................................................................................... 264
Figure 7.5: Number of Failure to Report ANE Deficiencies Cited Between March 1, 2020 and
October 31, 2020 by Data Source ............................................................................................. 265
Figure 7.6: Citations for Failure to Report ANE in Deficiencies Data ..................................... 266
Figure 7.7: Timeliness of Face-to-Face Contact with Alleged Child Victims in Priority Two
HHSC Investigations ................................................................................................................ 273
Figure 7.8: Completion of Priority One and Two Investigations within 30 Days ..................... 274
Figure 7.9: Completion of Priority Three, Four, and Five Investigations within 60 Days of
Intake ......................................................................................................................................... 276
Figure 7.10: Priority One and Two RCCR Investigations Completed ..................................... 277
Figure 7.11: Completion and Submission of Documentation within 60 Days of Intake in
Priority Three, Four, and Five Investigations ........................................................................... 278
Figure 7.12: Notification Letters Sent within Five Days of Investigation Closure in Priority
One and Two Investigations ...................................................................................................... 279
Figure 7.13: Notification Letters Sent within 60 Days of Intake in Priority Three, Four, and
Five Investigations ..................................................................................................................... 280
Figure 7.14: Operations Placed or Meeting Criteria for Placement on Heightened Monitoring
in 2020 ..................................................................................................................................... 287
Figure 7.15: Operations Currently on Heightened Monitoring by Type of Operation and
Region ........................................................................................................................................ 293
Figure 7.16: Operations with an Active Residential Child Care Contract by Region ............... 293
Figure 7.17: Timeline for Starting Heightened Monitoring at Operations in Phase One
Analysis...................................................................................................................................... 295
Figure 7.18: Number of Prior Risk Analyses, Monetary Penalties, and Enforcement Actions
Since 2015 at Operations in Phase One Heightened Monitoring Analysis .............................. 297
Figure 7.19: Number of Operations with Identified Issues in Monitors’ Review and the
Operations’ Heightened Monitoring Plan .................................................................................. 300
Figure 7.20: Categories Identified as Problems in Operations’ Heightened Monitoring
Plans ........................................................................................................................................... 302
Figure 7.21: Proportion of Heightened Monitoring Tasks and Sub-Tasks Due Within Two
Weeks of the Heightened Monitoring Plan Start Date............................................................... 304
Figure 7.22: Proportion of Heightened Monitoring Tasks with Similar Requirements to Prior
Enforcement Actions at Operations in Phase One Heightened Monitoring ............................. 307
Figure 7.23: Heightened Monitoring Visits at Phase One Operations by Type of Operation and
Entity Conducting Visit, June-December 2020 ......................................................................... 309
Figure 7.24: Percent of Heightened Monitoring Visits to Phase One Operations that Included
Document Review, Standards Review, a Walk Through, and Technical Assistance ................ 312
Figure 7.25: Type of Files Reviewed and Interviews Conducted During Heightened
Monitoring Visits at Phase One Operations............................................................................... 313
Figure 7.26: Placement Authorization Requests for Phase One Heightened Monitoring
Operations Analyzed.................................................................................................................. 315
Figure 7.27: Legal Status of Children with Approved Placement Authorizations in Phase One
Heightened Monitoring Operations Analyzed .......................................................................... 316
Figure 7.28: Placement Requests at Phase One Heightened Monitoring Operations with an
Approved Placement by PMC Status ........................................................................................ 317
Figure 7.29: Information Included in Approved Placement Requests that Resulted in Placement
by Timing of Request ................................................................................................................ 318
Figure 7.30: Timing of Placement Start for PMC Children with Approved Placement Requests
and Placement at Phase One Operations ................................................................................... 318
Figure 7.31: Number of PMC Placements at Phase One Operations After Operation was Placed
on Heightened Monitoring, June – December 2020 ................................................................. 319
Figure 7.32: PMC Placements at Phase One Heightened Monitoring Operations by
Approval .................................................................................................................................... 320
Figure 7.33: Average Monthly PMC Placements at Phase One Operations One Year Prior to
Heightened Monitoring and in the Months Following Placement on Heightened Monitoring
through December 31, 2020 ....................................................................................................... 321
Figure 7.34: Average Number of Deficiencies Prior to and Following Placement on
Heightened Monitoring through December 31, 2020 for Phase One Operations Analyzed ..... 322

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Case 2:11-cv-00084 Document 1079 Filed on 05/04/21 in TXSD Page 1 of 393

UNITED STATES DISTRICT COURT

CIVIL ACTION NO. 2:11-CV-00084

M.D.; bnf STUKENBERG, et al., Plaintiffs, v. GREG ABBOTT, et al., Defendants.

Janis Graham Jack Senior United States District Judge

SECOND REPORT OF THE MONITORS

Deborah Fowler and

Texas Appleseed Public Catalyst

Linda Brooke Lisa Alexander-Taylor

I. INTRODUCTION & EXECUTIVE SUMMARY ................................................................. 8

Summary ............................................................................................................................. 107

1. Background ............................................................................................................. 160

Results of Performance Validation ..................................................................................... 199

Remedial Order 22 Performance Validation....................................................................... 253

Summary ............................................................................................................. 328

I. INTRODUCTION & EXECUTIVE SUMMARY

permanent managing conservatorship (‘PMC’) to an unreasonable risk of serious harm.” On July

SUMMARY OF THE MONITORS’ FINDINGS

SUMMARY OF FINDINGS BY REMEDIAL ORDER

A. Section IV. Screening, Intake, And Investigation of Maltreatment In Care

B. Section IV. Organizational Capacity

A. Section V. Preventing Sexual Abuse and Child Sexual Aggression

Policy Creation and Training of Staff Responsible for Making Determinations

Tracking and Documenting Sexual Abuse and Child-on-Child Sexual Aggression

Caseworker and Caregiver Training and Notification on Child Sexual Abuse

• The monitoring team found Common Applications that corresponded to placements

• Though relatively infrequent, DFPS continues to document instances in which operations

B. Section VI. Regulatory Monitoring and Oversight of Licensed Placements

Timeliness of Minimum Standards Investigations

• A review of requests to approve placement of a child in a Phase One operation subject

Scope and Methodology of the Monitors’ Work

II. DEMOGRAPHICS OF CHILDREN IN PMC CARE

A. Age, Gender, and Race

Figure 2.1: Age of Children in PMC on December 31, 2020

Source: List of Children in PMC Dec 20

Ages 12-17 Ages 0-6

Estimates of Total Population in

B. Living Arrangements and Length of Time in Care

Source: List of Children in PMC Dec 2020

Missing Less than 1

Exit Outcome Frequency Percent

Authorized Level of Care Frequency Percent

County Name Frequency Percent

E. Single Source Continuum Contractor Presence and Placement Oversight

Regions PMC Children Percent

III. OVERVIEW OF STATE DATA AND DATA SYSTEMS CHALLENGES

A. Fragmented Data Systems

• Remedial Order 2 requires statewide implementation of graduated caseloads for newly

• Remedial Orders A7 and A8 require continuous 24-hour Awake-Night supervision for

• Remedial Orders 12 and 13 address the timeliness of initiation of HHSC investigations.

Documentation to verify heightened monitoring visits, communication, compliance, and

C. Limited VPN Capacity and Barriers to Accessing Information

IV.SCREENING, INTAKE AND INVESTIGATION OF MALTREATMENT IN CARE ALLEGATIONS

All intake reports require an evaluation to determine:

Change of Name for HHSC’s Residential Child Care Regulation

DFPS Investigation of Allegations of Abuse or Neglect

RCCI is charged with investigating allegations of abuse, neglect, or exploitation of children

Statewide Intake Performance

Statewide Intake Call Center Performance Analysis