Finding 1190827 (2025-009)

Recommendation The Department should strengthen controls over the retention and documentation of foster care records to ensure compliance with all applicable regulations. This includes ensuring all required documentation are properly collected, stored, and accessible for audits. Regular internal audits of foster care case files should be implemented to confirm compliance with internal controls and regulations. A system to track and follow up on outstanding documents will ensure timely collection of all required records. We also recommend that the files are stored electronically in one location, with appropriate access given to individuals. The Department should also review licensing processes for providers with disqualifying criminal histories and take corrective actions when necessary. Additionally, staff training on proper documentation and adherence to internal controls should be enhanced. Management Response Issue Missing and incomplete supporting documentation for Children placed in Children placed in Congregate Care Settings. Root Cause Lack of clear instruction or process. Direction and agreement on how to work with HCA and MCO to obtain needed documentation when a child is placed in a congregate setting. Corrective Action Create a supervisor checklist to ensure licensure documentation is complete and accurate. Supervisor will perform review at initial placement; checklist will include supervisor verification of complete and accurate placements agreements. Supervisors and Managers will address work performance with employees through corrective actions or employment evaluation. Work with CYFD Behavioral Health and NM Health Care Authority (HCA) to ensure CYFD has proper documentation for Medicaid licensed and approved congregate care facilities, to include certification of staff CRCs, licensure, and placement agreements. Issue a directive to CYFD licensing and placement staff that outlines the process for determining level of care, payment, placement agreements, and how this is documented for children in custody placed in all congregate care settings. The CYFD Office of Performance and Accountability in partnership with CYFD Protective Services Licensing and Support will incorporate annual Regional Placement Reviews into its annual case review schedule Issue Missing and incomplete placement agreements for children placed with foster families. Root Cause Lack of clear instruction or process. Need for more robust supervisory oversight. Corrective Action Create a supervisor checklist to ensure placement agreement documentation is complete and accurate. Supervisor will perform review at initial placement; checklist will include supervisor verification of complete and accurate placements agreements. Supervisors and Managers will address work performance with employees through corrective actions or employment evaluation. Provide FACTS Entry and Documentation Refresher training for all Licensing and Support Staff. The CYFD Office of Performance and Accountability in partnership with CYFD Protective Services Licensing and Support will incorporate annual Regional Placement Reviews into its annual case review schedule. Issue No documentation of Level of Care in hard file or entered into FACTS per agency procedures Root Cause Lack of clear instruction or process. Need for more robust supervisory oversight. Corrective Action Create a supervisor checklist to ensure level of care documentation is complete and accurate. Supervisor will perform review at initial placement; checklist will include supervisor verification of completed level of care documentation. Supervisors and Managers will address work performance with employees through corrective actions or employment evaluation. Provide FACTS Entry and Documentation Refresher training for all Placement and Licensing Staff. The CYFD Office of Performance and Accountability in partnership with CYFD Protective Services Licensing and Support will incorporate annual Regional Placement Reviews into its annual case review schedule. Issue Missing criminal records checks and no mitigation measures found. Root Cause Lack of clear instruction or process. Need for more robust supervisory oversight. Corrective Action Create a supervisor checklist to ensure criminal record check (CRC) documentation is complete and accurate. Supervisor will perform review at initial placement; checklist will include supervisor verification of completed CRC documentation. Supervisors and Managers will address work performance with employees through corrective actions or employment evaluation. Provide "cheat sheet" that outlines level of documentation needed to verify CRC’s have been completed for family foster homes, TFC homes, and congregate care settings. Provide guidance on when and how to mitigate criminal record checks histories, and how this is documented. Provide FACTS Entry and documentation refresher training for all Placement and Licensing Staff. The CYFD Office of Performance and Accountability in partnership with CYFD Protective Services Licensing and Support will incorporate annual Regional Placement Reviews into its annual case review schedule. Issue Missing Abuse and Neglect Checks Corrective Action Create a supervisor checklist to ensure abuse and neglect check documentation is complete and accurate. Supervisor will perform review at initial placement; checklist will include supervisor verification of completed Abuse and Neglect Check documentation. Supervisors and Managers will address work performance with employees through corrective actions or employment evaluation. Provide guidance on conducting abuse and neglect checks and documents that show checks are completed before a child is placed and in accordance with agency policy and procedure. Provide FACTS Entry and documentation refresher training for all Placement and Licensing Staff. The CYFD Office of Performance and Accountability in partnership with CYFD Protective Services Licensing and Support will incorporate annual Regional Placement Reviews into its annual case review schedule. Issue Missing Foster Care Licensure Corrective Action: Create a supervisor checklist to ensure licensure documentation is complete and accurate. Supervisor will perform review at initial placement; checklist will include supervisor verification of completed licensure documentation. The CYFD Office of Performance and Accountability New Mexico Children, Youth, and Families Department Reporting 30 in partnership with CYFD Protective Services Licensing and Support will incorporate annual Regional Placement Reviews into its annual case review schedule. Issue Missing Abuse and Neglect Petition and Ex-Parte Custody Orders Root Cause Need for more robust supervisory oversight in the Title IVE determination process. Corrective Action The Title IVE/Medicaid Manager will work with CYFD Children's Court Attorneys to ensure that Abuse and Neglect Petitions and Ex-parte Custody Orders are present when conducting initial and ongoing Title IVE determination. The CYFD Office of Performance and Accountability in partnership with CYFD Protective Services Licensing and Support will incorporate annual Regional Placement Reviews into its annual case review schedule. Due Date of Completion: June 30, 2026 Responsible Person(s) Protective Services Division Director, Behavioral Health Division Director, Director of Performance and Accountability, Policy Director