Since 2003, governors have had to provide an assurance that  states have in effect and are enforcing a state law or program that  includes policies and procedures to address the needs of infants affected  by prenatal substance abuse or displaying withdrawal symptoms at birth. Most States Reported Having Policies About Notification and Investigation of Substance-Affected Infants

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

In response to our survey, 42 states reported that state policies and  procedures require health care providers to notify CPS about substance- affected infants. Although one state reported in our survey that it does not require or  encourage health care providers to notify CPS about substance-affected  infants, in an interview, state officials explained that its policy requires that  health care providers notify CPS if, through an assessment, they  conclude that infants are at risk for abuse and neglect. Most States Reported Having Requirements to Develop Plans of Safe Care, but Officials We Interviewed Reported Challenges Meeting the Needs of All Families States Reported That CPS Agencies Develop Plans to Primarily Address Infants’ Immediate Safety and Medical Needs and Caregivers’ Substance Use

In response to our survey, 49 states reported that their CPS agency has  policies to develop a plan to ensure the safety and well-being of  substance-affected infants who meet the state’s criteria for investigation. Plans also  address other needs, such as infants’ immediate medical and longer-term  developmental needs, as well as caregiver’s substance use treatment  needs. Specifically, officials reported concerns about increased caseloads,  particularly if they are required to provide plans and services for infants at  low risk of abuse or neglect, the content of plans, and confidentiality  restrictions. Although HHS Has Provided Technical Assistance and Guidance to Assist States’ Efforts to Implement CAPTA, States Want More Help

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

In HHS’ role to assist states in the delivery of child welfare services, two  agencies—ACF and the Substance Abuse and Mental Health Services  Administration (SAMHSA)—provided technical assistance to states  through the National Center on Substance Abuse and Child Welfare  (NCSACW). States Reported the Need for Additional Guidance and Assistance from HHS to Address Implementation Challenges

Most states reported in our survey that additional guidance and  assistance would be extremely or very helpful (see figure 3). States’ suggestions ranged from  assisting in the development of substance abuse training curriculum for  staff to video conferences with other states to share information about  implementing CAPTA. ACF officials told us that states have flexibility with implementing the law  and the agency does not anticipate issuing additional written guidance on  the amendments to CAPTA made by CARA. These plans are expected to include  details on how the states are addressing the CAPTA requirements. While  ACF could not provide the number, officials reported that some of the  state plans submitted to date did not meet the requirements and those  states have been asked to develop program improvement plans. Undertaking these actions can enhance states’ understanding of CAPTA  requirements and better address known challenges such as the ones  described in this report. However, more specific guidance from HHS on  the issues which states have expressed confusion can assist them in  better understanding CAPTA requirements and providing more effective  protections and services for the children and families most in need. CAPTA  requires states to have policies and procedures to address the needs of  these infants and their families, including mothers with a substance use  disorder. Recommendation for Executive Action

The Secretary of HHS should direct ACF to provide additional guidance  and technical assistance to states to address known challenges and  enhance their understanding of CAPTA requirements, including the  requirements for health care providers to notify CPS of substance- affected infants and the development of a plan of safe care for these  infants. HHS did not concur with our recommendation. HHS stated that:  in January 2017, ACF clarified in guidance several of the issues  raised in the report, including the population of infants and families  covered by the provision and the state flexibility inherent in  determining which infants are “affected by” substance abuse, and the  terminology used in the federal law of what a “plan of safe care” is;
ACF believes it is necessary to allow states the flexibility to meet the  requirements in the context of their state CPS program; several of the challenges that the GAO notes are not specific to  CAPTA compliance with the safe care plan and notification  requirements; and  it does see the value in continuing to provide technical assistance to  states to address known challenges and to enhance their  understanding of CAPTA requirements. In  addition, as of October 2017, HHS confirmed that some state plans did  not meet CAPTA requirements and that the states were asked to develop  program improvement plans.
Why GAO Did This Study

Under CAPTA, states perform a range of prevention activities, including addressing the needs of infants born with prenatal drug exposure. The number of children under the age of 1 entering foster care increased by about 15 percent from fiscal years 2012 through 2015. Child welfare professionals attribute the increase to the opioid epidemic. GAO was asked to examine the steps states are taking to implement CAPTA requirements on substance-affected infants and related amendments enacted in 2016.
This report examines (1) the extent to which states have adopted policies and procedures to notify CPS of substance-affected infants; (2) state efforts to develop plans of safe care, and associated challenges; and (3) steps HHS has taken to help states implement the provisions.
To obtain this information, GAO surveyed state CPS directors in all 50 states and the District of Columbia and reached a 100 percent response rate. GAO also visited 3 states (Kentucky, Massachusetts, and Pennsylvania); reviewed relevant documents such as federal laws and regulations, and HHS guidance; and interviewed HHS officials. GAO did not assess states' compliance with CAPTA requirements.

What GAO Found

All states reported adopting, to varying degrees, policies and procedures regarding health care providers notifying child protective services (CPS) about infants affected by opioids or other substances. Under the Child Abuse Prevention and Treatment Act (CAPTA), as amended, governors are required to provide assurances that the states have laws or programs that include policies and procedures to address the needs of infants affected by prenatal substance use. This is to include health care providers notifying CPS of substance-affected infants. In response to GAO's survey, 42 states reported having policies and procedures that require health care providers to notify CPS about substance-affected infants and 8 states reported having policies that encourage notification. The remaining 1 state has a policy requiring health care providers to assess the needs of mothers and infants and if they conclude that infants are at risk for abuse or neglect, CPS is notified.
In response to GAO's survey, 49 states reported that their CPS agency has policies to develop a plan of safe care; 2 reported not having such a requirement. Under CAPTA, states are required to develop a plan of safe care for substance-affected infants. Although not defined in law, a plan of safe care generally entails an assessment of the family's situation and a plan for connecting families to appropriate services to stabilize the family and ensure the child's safety and well-being. States reported that plans typically address the infant's safety needs, immediate medical needs, and the caregiver's substance use treatment needs. However, officials in the 3 states GAO visited noted challenges, including uncertainty about what to include in plans and the level of intervention needed for infants at low risk of abuse or neglect.
The Department of Health and Human Services (HHS) has provided technical assistance and guidance to states to implement these CAPTA requirements. Most states reported in GAO's survey that additional guidance and assistance would be very or extremely helpful for addressing their challenges. Nevertheless, HHS officials told GAO that the agency does not anticipate issuing additional written guidance, but that states can access technical assistance through their regional offices and the National Center on Substance Abuse and Child Welfare—a resource center funded by HHS. However, of the 37 states that reported on the helpfulness of the assistance they have received, 19 said it was only moderately helpful to not helpful. States offered suggestions for improving the assistance, such as developing substance abuse training materials for staff and holding video conferences with other states to share information. In October 2017, HHS officials explained that some states have submitted plans that include details on how they are addressing the CAPTA requirements. HHS officials reported that some of the plans submitted to date indicated that states are not meeting the requirements and those states have been asked to develop program improvement plans. Without more specific guidance and assistance to enhance states' understanding of CAPTA requirements and better address known challenges such as the ones described in this report, states may miss an opportunity to provide more effective protections and services for the children and families most in need.

What GAO Recommends

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