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ARIZONA CITIZEN REVIEW
PANEL
Twelfth Annual Report
Prepared for
Arizona Department of Economic Security
Division of Children, Youth & Families
Phoenix, Arizona
Contract No: DE091156001
December 2010
Prepared by
Vicki Staples, M.Ed., Program Manager
Lisa Moen, B.A., Project Coordinator
Julie Sauvageot, M.S.W., Case Analyst
Judy Krysik, Ph.D., Principal Investigator
Michael Shafer, Ph.D., Co-Principal Investigator
Center for Applied Behavioral Health Policy
with
Arizona State University
School of Social Work
College of Public Programs
Arizona State University
500 North 3rd Street
Suite 200
Phoenix, Arizona 85004-2135
(602) 496-1470

This publication can be made available in alternative format. Please contact the Arizona Citizen
Review Panel Program at (602) 496-1470. Please visit www.cabhp.asu.edu for more information.
Permission to quote from or reproduce materials from this publication is granted when
acknowledgment is made.

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Acknowledgements
This report was prepared by the Center for Applied Behavioral Health Policy (CABHP), Arizona
State University. This project was supported by the Arizona Department of Economic Security,
Division of Children, Youth and Families through a grant awarded by the Child Abuse and
Prevention Treatment Act (CAPTA). Vicki Staples, Lisa Moen, and Julie Sauvageot were
responsible for the content, analysis and writing of the report. Drs. Judy Krysik and Michael
Shafer provided ongoing oversight to the project as well as contributed to this report.
The authors also wish to thank the members of the Arizona Citizen Review Panel and staff of
the Division of Children, Youth and Families for their continued commitment and cooperation
with this project. In particular, we would like to thank Linda Johnson, Sandra Lescoe, Karin
Kline, Minerva Gant, Katherine Guffey, Dani O’Connell, and Christie Kroger for their assistance.
Points of view represented in this report are those of the Arizona Citizen Review Panels and do
not necessarily represent the official position or policies of the Arizona Department of
Economic Security or Division of Children, Youth and Families.

©2010 by the Arizona Board of Regents for and on behalf of Arizona State University
and its Center for Applied Behavioral Health Policy.

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TABLE OF CONTENTS

Executive Summary..................................................................................................................... 4
Arizona Citizen Review Panel Overview ..................................................................................... 9
Arizona Citizen Review Panel Program Structure ..................................................................... 10
CAPTA Requirements of Citizen Review Panels ........................................................................ 13
Case Record Review Process..................................................................................................... 15
Summary of Citizen Review Panels’ Case Record Review Findings .......................................... 22
Areas of Focus for 2011 ............................................................................................................ 28
Appendix A: Agency Response To The 2009 Arizona Citizen Review Panels’ 11th Annual
Report Recommendations ........................................................................................................ 31
Appendix B: 2010 Agenda and Meeting Locations .................................................................. 34
Appendix C: Citizen Review Panel Members Central Region .................................................. 36
Appendix C: Citizen Review Panel Members Southern Region ............................................... 37
Appendix C: Citizen Review Panel Members Northern Region ............................................... 38
Appendix D: CABHP Case Record Summary and Presentation ................................................ 39
Appendix E: Citizen Review Panel Survey ................................................................................ 46

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Executive Summary
The Center for Applied Behavioral Health Policy at Arizona State University (CABHP), through an
interagency service agreement with the Arizona Department of Economic Security (ADES),
began administering the Arizona Citizen Review Panel (ACRP) Program in December of 2008.
The Arizona Department of Economic Security/Division of Children Youth & Families (DCYF) is
the state agency responsible for the provision of child protection services. Working in
conjunction, DCYF and CABHP are responsible for meeting all federal requirements specified in
the Child Abuse Prevention and Treatment Act (CAPTA) regarding Citizen Review Panels. Panels
develop recommendations for improvement of Arizona’s child welfare system, including Child
Protective Services (CPS), through independent, unbiased system reviews. The panels are
composed of citizens; social services providers; child advocates; adoptive and foster care
parents; legal, medical, education, and mental health professionals; and faith-based
representatives.
Citizen Review Panels review CPS state policies, current practices, pertinent data, and case
record information on child fatalities and near fatalities due to maltreatment. In addition, the
panels evaluate the CPS relationship with foster care, adoption, and other related agencies. The
panels make recommendations to CPS for system changes and improvements through the
submission of the annual report.
The 12th Annual Citizen Review Panel Report summarizes the accomplishments, activities,
findings, and recommendations of the three ACRPs (Northern, Central and Southern). Areas for
recognition included CPS Specialists’ positive qualities such as maintaining a good rapport with
families, linking families with helpful services, and taking actions early to establish permanency.
In addition, areas for improvements are included in both the case record review section and the
panel’s recommendations.

ACCOMPLISHMENTS
Throughout the past year the panels have continued to refine their operations as well as
observed the many strengths of the Arizona child welfare system. The panels witnessed the
dedication and many achievements of the CPS field staff, including a CPS Specialist who
substantiated an abuse finding despite the reluctance of law enforcement to move forward with
criminal charges against the perpetrator; and a CPS Parent Aide determination to obtain
medical records despite the medical provider’s reluctance to release the documents. In
addition, the panels observed system partners working collaboratively in order to quickly
establish permanency for child(ren) and provide a multitude of services from across various
organizations to support reunification.
Additional highlights identified over the past year are detailed below:
 The panels found that case record documentation indicated that reports taken by the
CPS Child Abuse Hotline were complete, accurate, and timely;
o the timeframe for the initial response by CPS, law enforcement, or other
emergency personnel were within the allotted times determined by levels of risk
(high, moderate, low, potential); and

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






o the investigative findings were supported in all 24 investigations reviewed;
The panels formally recognized and sent letters of acknowledgement to CPS staff who
exceeded expectations, and a community leader who exemplified collaboration efforts
across the child welfare, criminal justice, and service delivery systems;
The panels recognized the achievements of the Arizona Court Teams (“Best for Babies”)
as the cases reviewed showed CPS and the courts worked collaboratively to move the
case forward and achieve permanency for the child within nine months of custody;
Increased the number and expanded the diversity of panel membership, including
recruiting foster and adoptive families along with youth formerly served through the
child welfare system;
Augmented the orientation process provided to new members;
Enhanced the structured protocol for conducting case record reviews and the case
record presentations during panel meetings; and
Established a strong linkage with the National Citizens Review Panel Coordinating Center
at the University of Kentucky, and participated in the Ninth Annual National Citizen
Review Panel Conference.

PANEL’S RECOMMENDATIONS
Each of the three panels developed recommendations for improvement of the child welfare
system in Arizona based on policy review, case record reviews, presentations, materials
distributed and updated provided by representatives from the ADES/DCYF. Recommendations
are combined, prioritized, and then divided into four categories based on input from panel
members and DCYF. The first category (Recommendations for Agency Response) is the
recommendations that require a formal written response from DCYF as required by the CAPTA.
Recognizing the ongoing efforts of DCYF to improve practices and services, only those areas not
currently addressed, or those which panels identified as benefiting from additional
enhancements were included in this category.
The second category (Observations In Alignment With Current Performance Improvement Plans
Or Areas Being Addressed By The Child Welfare Training Institute) includes recommendations
that are currently being addressed through practice improvement activities. DCYF has
dedicated Practice Improvement Specialists in all regions. Practice Improvement Specialists in
each region lead case reviews, provide data and performance information to regional
management and the DCYF’s Quality Improvement Manager, facilitate regional action planning,
and monitor and lead regional practice improvement activities. The panels want to monitor
progress in these areas in the upcoming year. Updates on the result of these activities,
including new initiatives, are provided annually to panel members.
Recognizing that the child welfare system is not solely the responsibility of DCYF, the final
category (Recommendations for Child Welfare System Partners) includes recommendations for
systems improvement that are directed toward system partners. Panel members and DCYF
staff are encouraged to advocate and promote collaborative efforts with systems partners to
incorporate these recommendations.

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The following are the recommendations made by the regional panels in an effort to improve the
CPS system:

RECOMMENDATIONS FOR AGENCY RESPONSE
1. DCYF should seek opportunities with collaborative partners to evaluate outcomes and
systems collaboration, and explore expansion of the Arizona Court Teams (“Best for
Babies”) model throughout all regions of Arizona.
2. DCYF should review policies related to medically fragile children and their families/
caregivers and ensure that supervisors receive training related to this population (e.g.,
gathering, assessing and documenting key medical information; identification of high risk
medical conditions and identifying needed services; accessing consultation from CMDP;
expectations for service coordination with medical providers including Children’s
Rehabilitation Services; and providing clinical supervision to staff working with medically
fragile children). DCYF should encourage and assist families of children with complex
medical needs to invite their health care provider or an identified health care coordinator to
interdisciplinary meetings (e.g., case staffings, care plan coordination meetings, and/or
Child and Family Team Meetings) so they may assist with case planning, link families with
resources, educate families/caregivers on the child’s needs, and coordinate ongoing
services. Alternative methods for participating in these meetings that maximize the use of
technology should continue to be explored (e.g., teleconferencing and web-based
applications).
3. Expand to all regions the remedial training for proper documentation that was initially
piloted in one region of the state.
4. Clarification should be provided to CPS staff regarding the need to complete a safety
assessment when an infant is born to a parent with an open case.

OBSERVATIONS IN ALIGNMENT WITH CURRENT PERFORMANCE IMPROVEMENT PLANS OR
AREAS BEING ADDRESSED BY THE CHILD WELFARE TRAINING INSTITUTE
1. Child Safety Assessments must document all safety threats, not just those identified in the
report and case plans; should identify how each of the safety threats and risk factors are
being addressed in the case plan; documentation not meeting CPS policy standards for
quality and timeliness, including clearly indicating services offered to families, as well as
services declined; CPS investigations must include interviews with all members of the
household and/or other persons known to have knowledge of the abuse or neglect or could
confirm or deny a safety threat to the child victim, or any other child in the home where the
abuse or neglect occurred, such as school personnel, medical providers, child care
providers, relatives, other adults living in the non-custodial parents home, neighbors); and
joint investigations protocols not being adhered to.

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2. It is critical that CPS field staff have ample and timely clinical supervision to guide staff in
decision making process and to identify and address ongoing and emergent training needs;
enhance skills and improve documentation in the case record; ensure the quality of
assessments and services; and address performance issues.
3. Key areas that the panel identified for continuing education of supervisors are medically
fragile/complex youth, trauma and grief, identifying and addressing children’s safety threats
and risk factors.

RECOMMENDATIONS FOR CHILD WELFARE SYSTEM PARTNERS
1. It is critical that funding for DCYF and other Child Welfare partners not be reduced to ensure
safety and maintain services of our children. Arizona’s workforce continues to be challenged
as CPS Specialists were reportedly working 65.6% above caseload standards.1 The majority
of the cases reviewed involve complex problems including substance use, mental illness,
children who are medically fragile, parental criminal justice involvement, and inadequate
day care funding. Reductions to other health and human service agencies will negatively
impact the entire child welfare system.
2. The medical community needs to provide parents/caregivers with education and
instructions for care and medications in their primary language.
3. Children with complex medical needs should be assigned an advocate by the medical
community and would benefit from better coordination with medical services.
4. Emergency room physicians and other emergency personnel should continue to receive
training in identifying and reporting child abuse and neglect. DCYF records reviewed and
anecdotal reports from panel members identified several instances in which reports to CPS
should have been made. Education to clarify that it is not the medical personnel’s
responsibility to report only when they are able to determine abuse has occurred. They are
to report when there is a reasonable belief that a minor is or has been the victim of physical
injury, abuse, child abuse, not just when abuse is confirmed. Additional training could also
enhance the skills of medical staff to identify potential maltreatment such as when a child is
seen repeatedly or is taken to multiple medical providers for similar injuries.
5. As child protection and safety involves ongoing collaboration and coordination across
multiple systems, joint investigation protocols are crucial for clarifying expectations and
agency roles. The panels identified that delays in obtaining autopsy reports impeded
criminal investigations. Concerns were also expressed when the cause of death was
undetermined, yet there appeared to be injuries (e.g., old fractures) noted in the CPS report
that are highly suspect of maltreatment. Opportunities for all involved parties to improve
collaboration and timely exchange of information during the investigation process should be
examined, including expansion of joint protocols to include the Medical Examiner’s Offices.
1

Child Protective Services Bi-Annual Financial and Program Accountability Report (CPS Report), August 2010, Arizona
Department of Economic Security.

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6. AHCCCS and other medical facilities should continue to explore electronic medical records
that would allow access to and sharing of medical records. Emergency rooms do not always
have vital medical history information that would aide them in identifying children who are
being abused and neglected.
7. Criminal Justice Coordinators, who play an important role in ensuring that joint investigation
protocols are followed and resolve system issues that arise, are not available in every
region. Counties should apply for the Children’s Justice Grant funds available through the
Office for Children, Youth and Families, Division for Children. Based upon a review of a case
in Colorado City, the panel strongly recommends that the Criminal Justice Coordinator
position in Mohave County that has remained vacant for a significant time period be reestablished to address the concerns with investigation processes and joint investigation
protocols.
8. Hospitals throughout Arizona are providing education and information to mothers of
newborns on Shaken Baby Syndrome (SBS) prior to their discharge. The panels recommend
that both parents and other caregivers participate given the number of incidents involving
perpetrators of SBS who are fathers and caretakers. Pediatricians during well checks should
also provide information and education to families on SBS.

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Arizona Citizen Review Panel Overview
The ACRP was established in 1999 in response to the
1996 amendment to the Child Abuse Prevention and
Treatment Act (CAPTA) requiring states to develop and
establish Citizen Review Panels. The purpose of ACRP is
to determine whether state and local agencies are
effectively discharging their child protection
responsibilities. Panel members develop
recommendations for improvement of CPS through
independent, unbiased case record and data reviews.

“I think we should be really proud of
ourselves, all of us. It really shows that it’s
important for everybody to be involved,
to make recommendations and try to
stand behind them the best we can and
get them moving, because nobody will
get them moving for you… a lot has been
done (by the Panels).”

-Judy Gideon, Foster Parent
The creation of the ACRP Program is an
Northern Panel Member
acknowledgment that protection of our children is the
responsibility of the entire community, not a single
agency. Although the primary focus of oversight is ADES/DCYF, the ACRP takes into
consideration the impact of other entities and assesses whether they support or hinder the
state’s efforts to protect children from abuse and neglect.

CHILD ABUSE PREVENTION AND TREATMENT ACT
The Child Abuse Prevention and Treatment Act (SEC.106 [42 U.S.C. 5106a]) was enacted in 1974
to provide grants to states to support innovations in state child protective services and
community-based preventive services, as well as research, training, data collection, and
program evaluation. CAPTA requires states receiving a Basic State Grant to establish no less
than three Citizen Review Panels. Panels are comprised of volunteer members who are broadly
representative of their community, including members who have expertise in the prevention
and treatment of child abuse and neglect. Each panel must meet at least once every three
months and evaluate the extent to which the state agency is effectively fulfilling its child
protection responsibilities in accordance with the CAPTA state plan. In addition, panels are
required to review child fatalities and near-fatalities, and examine other criteria important to
ensure the protection of children (i.e., the extent to which the state child protective services
system is coordinated with the foster care and adoption programs).
Section 106(c)(5)(A) of CAPTA requires states to provide each Citizen Review Panel with access
to information on cases that the panel chooses to review if the information is necessary for the
panel to carry out its functions under CAPTA. Report language clarifies that congressional intent
was to direct states to provide the panels with necessary information to carry out these
functions.
Section 106(d) of CAPTA requires that Citizen Review Panels develop reports and make them
available to the public annually. These reports should contain a summary of the panel's
activities, as well as the recommendations of the panels based upon their activities and findings.

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Citizen Review Panel members are bound by the confidentiality restrictions in section
106(c)(4)(B)(i) of CAPTA. Specifically, members of a panel may not disclose identifying
information about any specific child protection case to any person or government official and
may not make public other information unless authorized by state statute.
The Keeping Children and Families Safe Act of 2003 amended CAPTA to include the following
requirements:
1. Each panel shall examine the practices (in addition to policies and procedures) of the
state and local child welfare agencies.
2. Panels shall provide for public outreach and comment in order to assess the impact of
current procedures and practices upon children and families in the community.
3. Each panel shall make recommendations to the state and public on improving the child
protective services system.
4. The appropriate state agency is required to respond in writing no later than six months
after the panel recommendations are submitted. The state agency’s response must
include a description of whether or how the state will incorporate the recommendations
of the panel (where appropriate) to make measurable progress in improving the state
child protective services system. The ADES response to the 2009 Citizen Review Panel
Report is included in Appendix A.

Arizona Citizen Review Panel Program Structure
At the state level, the CABHP administers and supports the three regional panels located in
Phoenix (Central), Tucson (Southern), and Flagstaff (Northern). Each of the panels represent
specific DCYF regions and counties, and CABHP staff are responsible for the coordination and
sharing of information across the three panels. In July of 2010, ADES/DCYF was realigned from
six districts to five regions.

QUARTERLY ACTIVITIES
The three ACRPs met quarterly in 2010 as required by CAPTA. Each meeting was scheduled for
three (3) hours. Panel members were sent agendas with case record summaries and other
meeting materials prior to each regional meeting. Orientation sessions were held one hour
prior to the start of each meeting for new and continuing panel members. All meetings were
digitally recorded and formal meeting minutes were prepared and emailed to respective panel
members for review and comment.
At the 4th quarter meeting of 2009, panel members suggested thematic areas of focus for 2010
(e.g., cultural diversity, foster care, team decision making, advocacy centers, safety planning,
Hotline process, and chronic child neglect). Based on these suggestions, the 2010 annual
schedule of meetings was developed and distributed to each ACRP member (Appendix B). This
structured meeting agenda included review of data collected from various sources, speakers,

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case record presentations, and policy reviews. Panels continue to have access to an intranet site
that contains meeting documents and other pertinent information (e.g., minutes, reports,
presentations, journals articles, and links). Additionally, CABHP routinely sent panel members
informative news items from the National Citizen Review Panel at the University of Kentucky,
and links to teleconferences and publications.
Monthly coordination meetings occurred between DCYF and CABHP staff. DCYF representatives
provided quarterly meeting program reports to ensure that the panels received information on
the status of ACRP recommendations, process improvement initiatives, new policies and
procedures, budget updates, and other relevant information. A focus on continuous formal
feedback mechanisms served to improve communication, facilitate collaboration, increase
panel member satisfaction, identified opportunities for innovation. CABHP and DCYF each
maintain internal tracking systems for monitoring the implementation of ACRP
recommendations. DCYF will continue to provide updates to the panels on a routine basis as
many of the proposed changes span across multiple years.
Below are highlighted topics from each of the quarterly meetings:
•

Quarter 1- Guest speaker presentations on Practices for Diverse Cultures
(Understanding Integration, Assimilation and Multiculturalism) and Team Decision
Making; reviewed the CAPTA Implementation Plan and Back to Basics (2010-2014
Activities); and the CPS policy on Special Immigrant Juveniles.

•

Quarter 2- Guest speakers presented on the Babies, Infants, and Toddlers in Foster Care
Program (Arizona Best for Babies Project); revisions to the Child Abuse Hotline; Safety
Planning and Safety Monitors were presented to the panel; and the CPS policy on
Voluntary Consent for Foster Care Placement for a Native American Child was reviewed.

•

Quarter 3- Guest speakers presented on Regional Advocacy Centers and highlighted the
multidisciplinary and collaborative approaches to case investigations. Arizona legislative
updates were discussed, including the impacts of the changes to the DCYF budgets
effective July 29, 2010. Information was distributed on the 9th Annual Arizona Citizen
Review Panel Conference. The CPS policy review was on SB 1091, which expands the
scope of CPS duties to include investigation of child abuse and neglect reports in
licensed behavioral health residential settings. The case record theme was on joint
investigation protocols.

•

Quarter 4- CABHP presented and discussed the draft of the 12th Annual Report of the
Arizona Citizen Review Panel, and identification of priorities and agenda topics for 2011.
Updates were provided to the panels on ADES/DCYF activities resulting from CRP
Recommendations from 2007-2009.

PANEL MEMBERSHIP
Panels are comprised of 9 to 26 volunteers of diverse backgrounds and experience. Below is a
chart of the panel membership from each region showing their agency or discipline
representation. During the past year significant efforts were made to expand not only the

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number of individuals on each panel, but also the composition of the panels’ membership to
ensure both community representation and diversity. The membership in two of the regional
panels, as well as the panel as a whole, increased again this past year. The Central and Northern
Regional ACRPs increased by 53% and 29% respectively, while the Southern Region ACRP
deceased slightly by 16%. (See Appendix C).
The panel members have a wealth of knowledge and experience in child and family serving
systems. Nine citizens who joined the panel in 2010 were involved, or have family members
who were involved with CPS in the past. Each panel has increased its diversity with members
representing a variety of schools, hospitals, faith-based organizations, non-profit organizations,
law enforcement, courts, government agencies, as well as private citizens and adoptive/foster
care parents (Figure 3).

Figure 1
Panel Member Representation
*Representational Area
Central Southern Northern
n=26
n=21
n=9
Private Citizens
4
2
1
Educators
4
6
1
Mental Health
4
2
1
Legal
5
5
1
Law Enforcement
2
2
2
Health Care
3
3
0
Social Services
5
7
4
Child & Family Advocates
8
2
2
Adoptive Parents
2
3
1
Adoptees
0
0
0
Foster Parents
3
3
1
Foster Care Alumni
1
0
0
Faith Based
0
1
0
Tribal
1
2
0
*n= as of December 2010. Members may belong to more
than one representational area.

PANEL MEMBER SURVEY
The annual survey of the panel members was conducted between November 19 and December
6, 2010, to provide CABHP staff with information on panel members’ level of satisfaction and
suggestions for improvement. Twenty-one (21) panel members completed the survey; 12
responses were from Central (57%), 6 from Southern (29%) and 3 from Northern (14%). Overall,
the majority of the respondents reported satisfaction as indicated by noting that they “agreed”
or “somewhat agreed” as indicated below:



71% indicated that their regional panel was comprised of members with diverse
community representation.
95% indicated that CABHP provides effective administrative support for the panel.

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



67% reported they were satisfied with the case record review presentation.
81% were satisfied with the content of information provided at panel meetings.
81% reported they shared information about the Citizen Review Panel with community
members and other organizations.

The survey also provided panel members with an opportunity to provide their suggestions or
comments on what type of training would be helpful to become more effective as a member,
meeting topics or themes for 2011, and ideas that would make meetings more productive. A
few examples of members’ suggestions included: shadowing a CPS Specialist to better
understand their responsibilities; adding a theme on adopted youth returning to the child
welfare system; and expanding the quarterly meeting times. The complete survey results with
all of the comments are included in Appendix E.

CAPTA Requirements of Citizen Review Panels
The ACRP program evaluates the degree that CPS is effectively fulfilling its child protection
responsibilities through several means including: the review of the state plan; examining
compliance with federal child protection standards; looking at coordination between agencies
and child welfare systems of care; conducting outreach to communities; and case record
reviews of child fatalities and near-fatalities. All of the findings and panel recommendations
were based on one or more of these activities.

Review of the State Plan
During the first quarter, the federal prescribed activities for which the CAPTA Basic State Grant
may be used were reviewed with each of the panels. The panels’ suggestions for utilizing the
funds were collected and are included in the recommendations section of this report.

Compliance with Federal Child Protection Standards
Compliance with federal child protection standards is examined through a review of the DCYF
semi-annual reports and information provided through DCYF updates or presentations.
Additionally, the ACRP case record review instrument (Appendix D) and process examine
compliance with federal child protection standards. The DCYF Practice Improvement Case
Review Instruments (PICR) and the ACRP case record review instrument were both modeled
after the Child and Family Services Review: Onsite Review Instrument and Instructions (2007).

Public Outreach and Soliciting Public Comments
The CABHP website hosts a link to the ACRP Program website to inform the community about
the ACRP Program and to solicit public comments. Questions regarding specific cases are
directed to the appropriate state agency for assistance. Over the past two years, only a few
comments have been received and the panels will need to explore alternative methods for
conducting public outreach and soliciting public comments. Information was collected from
other Citizen Review Panels across the country and this information was shared with the panels
to examine the initiatives currently underway and aids in identifying effective methods of
collaboration.

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The ACRP Program brochure continues to be distributed at events to inform the public,
stimulate interest in the ACRP program, and solicit volunteers. The brochure and CPR program
information have also been distributed throughout Arizona by multiple community and
advocacy email listservs (e.g., Arizona Association for Foster and Adoptive Parents, Arizona
Council for Human Services Providers, RBHAs, Governor’s Office of Children, Youth & Families,
and contacts in the faith-based community).

Case Record Reviews
Panel members reviewed twenty-four cases in 2010. Although the case record review process
addresses foster care and adoptions as related to the specific situation under review, further
examination of coordination across agencies was completed this year. The Court Teams for
Maltreated Infants and Toddlers project, known as Best for Babies in Arizona is focused on
improving collaboration between the courts, child welfare agencies, and related child-serving
organizations to work together, share information, and expedite services for young children age
zero to three who are placed in out of home care. The program relies on judicial leadership to
ensure that such infants and toddlers are receiving the resources and supports they need to
foster optimal physical and mental health.
Panel members were provided with information on the implementation and outcomes of the
Arizona Court Teams (“Best for Babies”) and a special sample was selected for case file reviews.
The case file review tool was modified and examined:
 Safety- protected from further maltreatment
 Well-being- received needed services including pediatric care and developmental
screening/services
 Reasons for removal
 Health needs at intake- exposed to parental substance abuse that contributed to poor
health and substance exposed newborn
 Services received to alleviate maltreatment and meet developmental needs
 Family contact
 Foster care placements and placement stability
 Absence of and repeat of maltreatment
 Achieving timely permanency
Even though there was a limited sample size and no specific conclusions or trends could be
drawn, several areas of interest were noted. The protocols for coordination and the checklists
completed appeared to aide in the assessment of the infants and ongoing service delivery. All
involved parties were held accountable by the courts and there were more frequent and
thorough reviews. Additionally the checklist was reviewed at court proceeding. Key areas of
interest were that permanency appeared to be achieved more rapidly, and evidence of
coordinated efforts by CPS, community providers, and juvenile courts were well documented in
the small sample of cases reviewed.

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Case Record Review Process
Throughout the past two years, CABHP staff has continued to refine the case record review
process with the assistance and input of DCYF staff and panel members. Feedback from panel
members continues to be an important part
Figure 2
of the design and quality of the case review
Case Record Sampling Parameters
tool. The standards for case reviews
1. Child fatality/near fatality cases were
established in 2009 (i.e., criteria for case
selected from those reported in 2009 –
selection, tool standardization, and
2010.
adherence to established instructions) have
resulted in a comprehensive and consistent
2. Established criteria for case selection
method for case review preparation,
require that CPS investigations must be
presentation, and a procedure for obtaining
completed. Cases with pending or
and organizing feedback from panel
incomplete investigations are not
members during the interactive case review
considered for review; however, cases
process at quarterly meetings.
which remain open for ongoing services
may be selected.
Twenty-four cases were selected for review
in 2010. Two cases were presented at each
3. Panels identified themes or particular
panel region (Northern, Southern, and
areas of concern they wanted to highlight
Central) quarterly. Reviews included cases
in 2010. DCYF staff worked with the
that involved allegations of fatalities and
CABHP to provide a list of cases
near-fatalities determined by CPS to have
representative of specific quarterly
resulted from child maltreatment (neglect
themes.
and/or physical abuse). Selected cases
included both in-home and out-of-home
placements of children. A CABHP staff member with a background in child welfare serves as the
primary case reviewer. The case reviewer is responsible for case selection, writing case reviews,
and presenting cases to the panels. The CABHP reviewer is authorized for access to the CPS
electronic records (CHILDS) system. The reviewer also works with CPS Practice Improvement
Specialists and other key persons in each region to obtain additional information, including
clarification regarding specific cases or policies, as necessary. A preliminary review of the case
summary is conducted by the case reviewer and Program Manager to ensure the information is
comprehensive and thorough. The CABHP staff are available one hour prior to each meeting,
affording panel members access to hard copies of the CPS case files.
DCYF provides the case reviewer with a list of all investigative reports involving allegations of
maltreatment that resulted in child fatality/near fatality. From this list, the CABHP case reviewer
selects cases for review that meet the sampling parameters (Figure 4) and are consistent with
the quarterly meeting themes. The case records are requested eight to ten weeks prior to the
first scheduled meeting each quarter. CPS staff provides a “hard” copy file to the CABHP that
contains additional information (e.g., autopsy reports, medical records, law enforcement
records, and service provider progress reports) that is not accessible through CHILDS. Cases
arrive at the DCYF Central Office and are transported by designated staff to the CABHP offices at
Arizona State University. Upon receipt of the cases, the case reviewer organizes the case record

15

information and documents the information in the review tool. If information relevant to the
case review is not in the case record, the case reviewer contacts a designated key contact
person at DCYF to request further assistance in obtaining the information.
In an effort to prepare and assist panel members for each case review, they are provided with
ACRP Case Summary Forms (Appendix D), a timeline of key events, and a genogram (a pictorial
display of family relationships and key information including ages and medical history) in
advance of each meeting. Panel members also receive redacted copies of the actual Child Safety
Assessments (CSA), Family Safety and Risk Assessments (SRA), case plans, and aftercare plans
(when applicable) completed by DCYF staff for each case. Key areas in which information is
examined and discussed by the panels include:
1) Timeliness of Initiating Investigation of Reports of Child Maltreatment-Information on
whether responses to every child maltreatment report received was initiated within
timeframes established by policy including: identification of risk level; allegation of
maltreatment; mitigated timeframes; accuracy of Hotline reporting procedures; whether
law enforcement or other emergency personnel was notified; CPS confirmation of child’s
safety; and CPS Specialist’s attempts at face-to-face contact with alleged victim(s).
2) Initial Child Safety Assessment-Information on whether the CPS Specialist made concerted
efforts to gather and analyze sufficient and relevant information to accurately assess child
safety including: decision whether any child in the home is unsafe due to present danger
was consistent with observations at initial contact with child and family; if concerted efforts
were made to interview or observe all relevant persons and to gather sufficient and relevant
information to identify potential safety threats. CPS Specialist made correct safety decisions
based on analysis of information gathered in the CSA.
3) Safety Planning to Protect Children in Home and Prevent Removal- Information on whether
the CPS Specialist took sufficient and least intrusive actions to: control present or impending
danger (through protective action and safety plan), ensure child(ren)’s safety in-home, and
prevent child(ren)’s entry into foster care or re-entry after reunification. The panel
determines if the actions taken by CPS to manage and control safety threats.
4) Family Strengths and Risk Assessment and Provision of Services to Reduce Risks-Information
on whether CPS Specialist made concerted efforts to assess the risks that were of sufficient
severity to necessitate CPS services including: gathering sufficient and relevant information
about each domain in the Family Strengths and Risks Assessment (SRA); identify consistency
of risk indicators and protective behaviors; necessity of intervention; and case opening and
closure with information gathered during the assessment and documented in the case
record. The SRA provides the panel with an overview of the number and type of risk factors
identified in the family/caregiver constellation. Identified risk factors include: parental
substance abuse; physical/mental/emotional limitations of caregivers; parental history of
abuse, family violence, and inter-partner violence; parental history of trauma and mental
illness; observed parental nurturing, bonding and empathy; recognition of the problem and
willingness to change; child vulnerability and special needs.

16

5) Determine Whether Maltreatment Occurred- An analytical and evidentiary process carried
out by the CPS Specialist which involves synthesizing pertinent case information and
applying the legal definitions of abuse and neglect to determine if maltreatment has
occurred. Panels utilize the evidence presented in the CPS case file, police investigation, and
medical and autopsy records to determine if the statement of maltreatment reflects the
severity and type of child maltreatment documented.
6) Aftercare Planning- Panels review information to determine if aftercare planning was
developed with input from family, and if parents/caregivers were provided adequate
information on services and supports to address whether the safety and risk factors
necessitating department involvement have been adequately addressed or needs that may
improve family functioning. When applicable, the panel determines if the CPS Specialist met
with parents/caregivers and the child; assessed their needs and preferences with regard to
aftercare services; and if parents/caregivers and children were provided with sufficient
information on community or other supports.
The ACRP case review instrument, adapted from the In-Home/Out-of-Home section of the DCYF
Practice Improvement Case Review Instrument, is completed on each case presented to the
panel. In 2010, the applicable information examined and criteria discussed by the panel
included:








ongoing safety and risk assessment
and management
permanency goal for child
concurrent permanency planning
visiting with parents and siblings in
foster care
relative placement







needs and services of child, parents
and foster parents
case plan development
worker visits with child
educational needs of child
mental/behavioral health of child
foster homes

The panel recommendations and comments section focuses on the following information:







precipitating events or triggers
family risk factors addressed and
resolved
factors that may have contributed to
death
joint investigation protocol




potential policy issues or issues not
addressed
exemplary CPS practices that should
be noted
CPS supervision and communication

In addition to cases of child fatalities/near fatalities, cases representing specific themes or particular
areas of interest were reviewed by the panels. As highlighted in the chart below, these topics
included: cultural diversity; potential barriers impacting families; coordination of services to meet
the unique needs of infants and toddlers placed in foster care; and the joint investigation process.

17

Figure 3
2010 ACRP Case Review Themes/Special Topics
Cases were selected for review based on identified issues related to diversity factors
and opportunities for culturally competent practices.
Example: A language barrier existed between healthcare providers and the parents
of a chronically ill teenager, resulting in medication non-compliance and subsequent
reports of neglect.
Quarter 1
Cultural
Diversity

Quarter 2
Infants in
Foster Care

Panel Recommendations and Comments: The panel recommended CPS to review
their policies related to medically fragile/complex children and their
families/caregivers and ensures that supervisors receive training related to this
population. The medical community needs to ensure that parents/caregivers receive
education and instructions for care and medications in their primary language.
Children with complex medical needs should be provided an advocate by the medical
community to improve coordination with medical and other services providers.
Interdisciplinary meetings for families of children with complex medical needs should
include a healthcare provider with training and background in disease management
to assist with identifying helpful resources.
Cases were selected from two regions that have implemented Best for Babies
procedures targeting children (ages 0 to 3) placed in foster care. In these regions,
teams comprised of CPS, health/developmental service providers, and the juvenile
court coordinate services to assure timely and thorough provided medical care,
developmental assessments and services, and other needed services within
established timeframes. Monthly status reviews are conducted by the juvenile court
to review the child’s health needs and to establish permanency for the child within
the shortest timeframe possible. The panel also reviewed cases selected from a
region that has not yet adopted a specific protocol coordinated for infants and
toddlers in foster care.
Example: An infant was removed from her family due to chronic neglect. The CPS
Specialist and service providers coordinated medical and developmental
assessments for the child, and follow-up appointments were documented in the CPS
case record. Attempts to engage the birth family in appropriate services were well
documented in the case record. Upon judicial review, it became evident that the
birth parents lacked the motivation to engage in services. The case goal was changed
from family reunification to adoption in order to establish permanency for the infant.
Panel Recommendations and Comments: The panel recognized that CPS and the
courts worked collaboratively to move the case forward and achieve permanency for
the child within nine months of custody.

18

Figure 3
2010 ACRP Case Review Themes/Special Topics
Cases that involved joint investigation by law enforcement and CPS were examined
for the following factors: adherence to written protocols; access and utilization of
forensic services for children; issues with jurisdiction; challenges faced; lack of
consensus in determining the presence of child maltreatment; and lack of resources
and/or training for law enforcement officers and CPS Specialists responsible for
conducting forensic interviews with children.
Quarter 3
Joint
Investigation

Example: An investigation was conducted related to the death of a toddler. The
toddler and his two sisters were in the care of Mom’s significant other when he
sustained a blow to his head by a blunt object and later died from his injuries. The
primary language of the siblings was Spanish, and an interpreter was used to assist in
the forensic interviews conducted with the young girls. No forensic physical exam
was conducted and the criminal investigation dropped.
Panel Recommendations and Comments: The panel believed that the siblings should
have had skeletal surveys to determine if they had any old or healing injuries. A
forensic specialist on the panel stated that the younger of the two siblings was still
within the age range for a full skeletal survey even though the injuries may have
occurred months earlier.

Quarter 4
Fatalities
and Near
Fatalities

Cases involving CPS investigation of fatalities and near fatalities were reviewed by
the panel. Panel members adhered to the established review processes: reviewing a
summary of the information reported to and documented by CPS; determining if all
risk factors were identified, assessed, and addressed; reviewing the joint
investigation conducted; noting clinical supervision and exemplary practices of CPS
staff; identifying potential policy issues; determining and documenting any action
that could have prevented the event; and recommendations related to policies,
services, and practices.
Example: The case described a family with multiple risk factors, including very young
parents and three children under the age of 5 with identified moderate to severe
developmental disorders. Multiple services were implemented; however,
coordination of needed services was left up to the overwhelmed parents. The
parents were very slow to respond to the assistance offered. A lack of family
resources and support were identified as potential barriers to parental engagement
to services.
Panel Recommendations and Comments: The panel proposed that the case be used
as a CPS training example for review by the National Resource Center for Child
Protective Services (NRCCPS). The National Resources Center provides onsite
training and technical assistance to local CPS offices.

19

Upon completion of each review, the panel asks the key questions of whether state and federal
policies were followed and whether the panel recommends any changes in policies and
procedures. Panels also comment on actions they believe could have been taken to prevent or
avoid the event and their overall recommendations on the case. The results of each review are
entered into a database that is maintained by the CABHP.
The case record reviews encompass all aspects of the child welfare system, and throughout the year
resulted in a variety of recommendations or actions taken by individual panel members, DCYF staff,
and system partners. The table below highlights some of the recommendations or actions which
resulted from the panel case reviews.

Southern Panel

Northern Panel

Figure 4
Actions Resulting from Case Record Reviews
Region
Issue
Action Taken
Family with three moderate to severely
Recommendation was made to use
developmentally disabled children under the the case as a training example with
age of three with multiple complex needs.
the National Resource Center for
Child Protective Services.
Investigation of potential neglect with an
infant whose sibling died from Shaken Baby
Syndrome approximately one year prior.

Based on the panel’s concerns, a new
investigation ensued and the child
was taken into CPS custody.

Conflicts concerning law enforcement
jurisdictions and investigation protocols
impeded the proper investigation of a child
maltreatment report. The child interview
was also not audio recorded as the
equipment was broken.

A critical incident review was
requested to examine the case,
review policy and procedures, and
identify barriers in the investigation.
DCYF administrators began holding
meetings with local law enforcement
to resolve issues with jurisdiction and
joint investigation protocols. New
recording equipment was purchased
for field staff. Panel members
researched the lack of a Mohave
County Criminal Justice Coordinator.

Case record documentation indicated that
CPS Specialist maintained their
professionalism when working with
antagonistic parents.

The panel sent a letter of
commendation to the CPS Specialist
involved in this case acknowledging
their professionalism in a difficult
situation.

A case that involved a parent taking his child
to the fire station to be “checked” led to
questions about how “walk-ins” at fire

Panel members visited their local fire
stations and/or discussed the issue
with EMT personnel and provided

20

Figure 4
Actions Resulting from Case Record Reviews

Central Panel

Region

Issue
stations are documented, and if non-medical
firemen receive mandatory reporter training.

Action Taken
information at the subsequent panel
meeting.

A new child was born to a mother who had
recently been substantiated for physical
abuse of her two year old. A safety
assessment had not been completed by CPS
on the newborn.

The panel requested that CPS conduct
a safety assessment with the
newborn. Policy requires new CSA is
completed when household
composition changes.

Hospital documents revealed that the child
had been treated only a few weeks prior for a
similar injury. No x-ray was taken, although
medical documentation indicated that the
child’s arm was swollen. Both times the child
was seen at the ER, he had multiple minor
injuries in addition to significant injuries.

The panel recommended that CMDP
Medical Director conduct an internal
review to determine whether
mandatory reporting requirements
were followed. DCYF also conducted a
critical incident review.

A toddler with cystic fibrosis was regularly
followed by a specialty clinic. When the child
was taken into CPS custody for nonaccidental blunt force trauma to her
abdomen, she was observed to have
decaying front teeth and her weight/height
rate was at the 10th percentile for her age,
yet no referral for neglect had been received.

A DCYF panel member who had been
attending a collaboration meeting
with the clinic volunteered to request
that a peer review of the case be
conducted, and also recommend that
Children’s Rehabilitation Services
(CRS) review their procedures for
mandatory reporting and obtaining
assistance from the CPS liaison for
CRS.

A juvenile court judge has worked toward
assuring that foster children ages 0 to 3 are
provided with all services necessary to reduce
vulnerability and promote health and
permanency.

The panel sent the juvenile court
judge a letter of support and
commendation for efforts to
implement the Best for Babies
guidelines in Maricopa County.

21

Summary of Citizen Review Panels’ Case Record Review Findings
During this reporting period, 24 cases of child maltreatment that occurred between June 25, 2008
and April 21, 2010 were reviewed. Each of the three ACRPs completed reviews of two cases each
quarter. Seven (7) of these cases were fatalities, seven (7) were near-fatalities, and ten (10) cases
had allegations of maltreatment (ranging from physical abuse/high risk to neglect/low risk).
Eighteen (18) cases selected for review were representative of specific themes; of these cases, five
(5) were fatalities and four (4) were near fatalities.
Case record review findings summarized below are consistent with the state’s process by which
reports of child abuse and neglect are received and addressed. Examination of the operations of
the CPS system at each of these stages as outlined below are also recommended in the Citizen
Review Panels for Child Protective System: Guidelines and Protocols (October 2001.)

PRIOR CHILD PROTECTIVE SERVICE HISTORY
Of the cases selected in 2010, 15 (63%) had no prior CPS reports. CPS received a total of 28 reports
in the nine (9) cases with prior report histories. Of the nine cases with prior reports, the number of
reports ranged from one (1) to six (6) with an average of four (4) reports per case. Of the nine (9)
cases with a total of 28 previous CPS reports, three (3) previous reports were substantiated; two of
the three substantiated prior reports were made on the same case.

INTAKE AND SCREENING
The panels identified the initial intake information gathering process as a strong component of the
child protection system. The panels found that reports taken by the CPS Child Abuse Hotline were
complete, accurate, and timely in all 24 cases (100%). The timeframe for the initial response by CPS,
law enforcement, or other emergency personnel were within the allotted times determined by level
of risk (high, moderate, low, potential).
A new CPS intake hotline process was put into effect in July, 2010. The new procedure was
implemented to align the report allegations received at hotline with the child safety assessment
completed in the field by CPS investigators. A primary goal of the new intake process is to use an
assessment tool to family functioning as opposed to incident-based data collection. Two major
changes to the hotline procedures include: 1) hotline staff have the option to contact collateral
resources in instances when the person making the report does not give adequate information to
determine the child’s safety; and 2) prioritizing report based on child safety.

CRISIS INTERVENTION AND INITIAL CHILD SAFETY ASSESSMENT
The panels concluded that CPS adequately fulfilled its role of assessing child safety in 14 (58%) of
the 24 investigations reviewed. This finding is similar to the finding of 61% in 2009. In ten (10)
cases, the panels found that various critical safety factors were not identified or thoroughly
addressed in Child Safety Assessments. The agency recognized that many of the cases had multiple
safety factors, as noted in the next section. However, panel members agreed that Child Safety
Assessments should reflect all identified safety factors, as this assessment process drives the
intervention for the removal of safety threats.

22

Of the ten (10) cases in which the panel identified the lack of action in response to a thorough
safety assessment:
 One (1) case no safety monitor was present in the home;
 Three (3) cases had prior substantiated reports that were not factored into the Child Safety
Assessment tool’s safety threats analysis;
 Four (4) cases the Child Safety Assessments were not thorough and/or were completed
outside of required timelines; and
 Two (2) cases the CPS staff did not document assessment of the safety of other children in
the home.
DCYF staff reported that CPS Specialists are provided Child Safety Assessment training at the time of
hire, and ongoing monitoring and training is provided through refresher training and clinical
supervision. The panels’ findings are consistent with the case record reviews completed by DCYF
practice improvement specialists, and the agency recognizes that this is a critical area for
performance improvement, and continues to be a primary key goal of ongoing performance
improvement activities.

FAMILY RISK FACTORS RELATED TO THE CASE RECORD REVIEW
Panel members review specific family risk factors addressed by CPS during the initial investigation.
Based on this information, panels determine if CPS adequately assessed, identified and resolved
risks contributing to child maltreatment. The most prevalent family risk factors identified during the
reviews were lack of parenting skills (87.5%), lack of motivation to provide care (75%), lack of anger
control (66.6%) and domestic violence (62.5%). Methamphetamines (33.3%), alcohol (33.3%), and
marijuana (16.6%) were the most prevalent types of drugs identified in case record reviews. The
predominant risk factors identified are consistent with the findings from 2009 case record reviews.
It is important to note that looking at individual risk factors does not take into consideration
cumulative risk. The number of risk factors per case ranged from 3 to 12 with an average of
approximately eight (8) risk factors identified per case. Three factors appeared to be prominent
issues in cases reviewed by the panel in 2010: the case had the death/ injuries occur to young
children while in the care of the mother’s significant other; the children had multiple caregivers;
and the children were medically fragile/medically complex.
Below are the risk factors identified in the 24 cases reviewed (Please note: More than one factor
may have been identified in a single case):

Figure 5
Risk Factors
Lack of parenting skills

Frequency
of cases
(n=24)
21 (88%)

Very young parents (19 to 22 years)

7 (29%)

Parental substance abuse

13 (54%)

Parental mental illness/trauma

14 (58%)

23

Figure 5

Frequency
of cases
(n=24)

Risk Factors
Domestic violence

15 (63%)

Lack of anger control

16 (67%)

Lack of physical/mental ability to provide adequate care

13 (54%)

Lack of willingness/motivation to provide adequate care

18 (75%)

Lack of resources for adequate food/shelter/medical/childcare

13 (54%)

Prior child death

1 (4%)

Prior removals by CPS/severance of parental rights

5 (21%)

Prior unsubstantiated reports

6 (25%)

Prior substantiated reports

5 (21%)

*Medically complex/medically fragile child

8 (33%)

Developmentally delayed child

6 (25%)

*Children with health issues including premature birth, physical and developmental disabilities,
failure to thrive, liver failure, cystic fibrosis, and substance exposed newborns.

In addition to the risk factors listed in the table, the CABHP staff started tracking the following risk
factors in 2010 as requested by the panels:
○
○
○
○
○
○

○ Parent did not seek medical treatment for
child
○ Multiple caregivers
○ Parent(s) who are developmentally
disabled
○ Household with 3 or more children under
the age of five
○ Lack of coordination/cooperation across
law enforcement jurisdictions

Language/cultural barriers
Child in the care of significant other
Parent in prison
Chronic neglect
Prior abuse not detected/
Lack of supervision reported by healthcare
provider

These additional risk factors will be compiled and incorporated into the 2011 annual report.

INVESTIGATION STAGE
When examining each case investigation process, the panel identifies the strengths of the
investigation and exemplary practice of CPS case staff. The panels noted CPS Specialists’ positive
qualities including, maintaining a good rapport with families, linking families with helpful services,
and taking actions early to establish permanency. For example, the Southern Panel recognized two
CPS Specialists for maintaining professionalism in difficult circumstances with a particular family.
Letters of commendation, signed by panel members, were sent to the Specialists and their
supervisors. The Southern Panel also noted the professionalism of a CPS investigator who

24

recognized and reported a foster care licensing violation. The Central Panel noted that a CPS
investigator substantiated findings of abuse and neglect in a fatality case in which law enforcement
did not pursue, despite evidence of child abuse. The Northern Panel recognized the professionalism
and diligence of a CPS case aide who obtained medical records, despite barriers confronted with a
healthcare provider who was reluctant to release the information.
Panels also identify aspects of the investigation process where barriers hindered investigation,
determination of findings, and/or case closure. Panels concluded that thorough investigations were
completed on 15 out of the 24 cases reviewed (63%). The following issues with case investigation
were identified:













previous medical issues/injuries were not addressed in five (5) cases;
no documentation of medical/development assessments in four (4) cases;
no immunization records were obtained in four (4) cases;
missing medical records (other than immunization records) in four (4) cases;
background checks on household members were absent in four (4) cases;
case information of interviews conducted with persons in the household were either
unclear or not documented in three (3) cases;
safety assessment documentation was incomplete in three (3) cases;
autopsy reports were missing in three (3) cases;
CPS did not interview all relevant persons in home in two (2) cases;
child victim interviews were not conducted according to CPS procedures in two (2) cases;
law enforcement reports were absent in two (2) cases; and
safety monitor agreements were missing in two (2) cases.

INVESTIGATIVE FINDING/DETERMINATION
The panels found that case record documentation supported the investigative findings in all of the
24 investigations reviewed. The Central Panel identified one case in which a finding of neglect, in
addition to the finding of physical abuse, should have been added post-investigation. In this case,
the juvenile court judge ruled that there was no persuasive evidence that the perpetrator identified
by CPS was responsible for the physical abuse (near fatality) of the child. The testimony of expert
witnesses concluded that the injury was due to non-accidental trauma, but stopped short of
identifying the perpetrator. The panel believed that the neglect had been disregarded as the
emphasis appeared to be on determining who caused the physical injuries.
Sound multidisciplinary forensic collaboration is critical to investigation and evidence gathering in
fatality/near fatality child maltreatment cases. Of the 24 cases reviewed by the panels, 15 cases
(63%) involved joint investigation. As noted previously in the chart on page 23, a subset (6) cases
involving joint investigation were reviewed by the panels, specifically to evaluate the following: 1)
adherence to protocol; 2) barriers to thorough investigations; 3) multidisciplinary (CPS, law
enforcement, medical, forensic experts) collaboration; and 4) factors that resulted in thorough,
investigation. The panel found that one-third of the cases reviewed in 2010 were jointly
investigated by CPS and law enforcement according to established protocols. A properly conducted
joint investigation includes the following elements: CPS case record documentation; police,
forensic, and/or autopsy reports; CPS observations; interviews conducted by law enforcement;
utilized forensic services, including audio/video recordings of child interviews; child interviews
conducted by a trained forensic interviewer in a child-friendly, safe environment; all evidence is

25

gathered by a multidisciplinary team; and CPS and law enforcement work cooperatively with county
attorneys and the juvenile court.
The panels cite the following issues concerning joint investigation in ten (10) cases: interviews by
CPS and law enforcement did not include all members of the household; law enforcement lacked
cooperation across jurisdictions; the county where the case was investigated does not have a
Children’s Justice coordinator; audio recorders were broken or had no spare batteries on hand;
child interview protocol was not followed; forensic services were appropriate, but not accessed;
police did not report a child death to CPS; police detective focused on child death, but not of
evidence of child abuse; CPS supervisor instructed CPS investigator not to attend police interview
because of budget cuts (staff shortage and fewer travel approvals for staff); inside of the home of
parents was not observed by responding officer; CPS was not allowed in the interview room during
parent interviews conducted by police; and documentation of forensic interviews with children was
provided to CPS by police.

CASE PLANNING AND IMPLEMENTATION
Seven (7) cases did not receive ongoing services because these cases were closed following
investigation. The panels determined that in nine (9) of seventeen (17) cases, case planning and
ongoing case management activities were appropriate and timely. Panels noted instances when
parents or guardians refuse to participate in services voluntarily; in such instances, CPS is unable to
enforce recommended case plans when safety concerns do not rise to the level that requires court
intervention. Concerns were raised by panels regarding the ongoing education training and support
needs of parents of children who were medically fragile and/or complex. The panels cited two
instances in which one parent was not addressed in the case plan. In addition, the panel expressed
concerns that siblings of a deceased child were not assessed for grief or trauma. In another case,
the CPS case worker discontinued daycare services for three young, developmentally disabled
children after only two weeks of service. A panel member from DCYF concluded the department
had the discretion to provide the family up to a maximum of six months of daycare services. Finally,
the panels voiced concern regarding the lack of services available to families who are
undocumented.

FOSTER FAMILY
There was one case involving physical abuse of a young child in foster care. The CPS Specialist
witnessed the abuse (a spank) while visiting the family, and immediately reported the incident, as
this was a licensing violation. The incident was investigated and it was determined that the foster
parents would attend additional training regarding appropriate behavioral techniques for
disciplining young children.

CASE CLOSURE
Eleven cases (46%) were receiving services provided by CPS ongoing case management workers at
the time of panel review. One (1) investigation remained open pending CPS’s receipt of autopsy and
medical record documentation. Three (3) cases had been transferred to the adoptions unit for
further services. Of the nine (9) cases that were closed prior to review, three (3) involved child
fatalities with no other children in the home.
Concerns noted by panels included: the lack of mental health services for persons who are
undocumented; incomplete CPS case record documentation in case plans; case closures with no
documented aftercare plan; minimal case record documentation of medical services for children;

26

referrals not made for needed services for child and family; a case plan that did not address the
needs of a medically fragile child; Medical Examiner’s findings that cause of death was
undetermined ended further investigation of the case; a case that did not undergo a thorough
investigation despite a prior child death and continued safety threats in the home; a safety plan not
signed by safety monitors due to a language barrier; and a family that moved out of state was not
linked with services to address the serious developmental needs of the child.

POLICY ISSUES
At the conclusion of case reviews, panel members determine if state and federal policies were
followed. In addition, panels evaluate the impact of policies/actions of community service and
healthcare providers as related to the identification, prevention, and treatment of child
maltreatment. The following are policy issues identified by the ACRP in 2010:

Figure 6
Issues Identified by Panels
Specific to CPS

Community/Healthcare Providers

Cases with medically fragile children require
intensive and frequent oversight in clinical
supervision.

Court Appointed Child Advocates (CASA’s)
assigned to work with medically fragile children
should have a background in pediatric
healthcare.

The protocol for interviewing child victims was
not followed.

A service provider conducted a developmental
assessment by phone rather than through
observation in the home, the protocol
prescribed by agency guidelines.

Properly maintained audio/video equipment for
recording interviews (when feasible) should be
available to field staff when necessary.

Law enforcement did not report a child death to
CPS.

Collateral informants were not interviewed
during investigation.

Multiple instances when healthcare providers
did not report suspected abuse/neglect.

The lack of a national database that interfaces
with State CPS agencies results in delays in
receiving and/or incomplete information during
the investigation phase, which could increase
the risk of further child maltreatment.

Multiple instances when prior injuries were not
detected in x-rays; frequent ER visits involving
serious injuries or multiple minor injuries are not
often diagnosed as child maltreatment by the
healthcare provider.

Workload negatively impacts the efficiency and
expediency with which child maltreatment cases
can be investigated and case managed.

Autopsy reports often delayed for months.

Case records and documentation not meeting
CPS policy standards for quality and timeliness.

Barriers to coordinated healthcare caused by a
lack of access to medical record across within
the healthcare.

27

Figure 6
Issues Identified by Panels
Specific to CPS
CPS needs access to resources which assist in
effective time management and increased
efficiency of workers in the field. The panel
recognized that a pilot project in one region
involves testing dictation software. If proven
successful, the panel supports the efforts of CPS
to expand and capitalize on this capability.

Community/Healthcare Providers
The homicide investigation concluded that an
unknown perpetrator caused an infant’s death.
Witnesses reported observations of abusive
behavior by the parent, and the Medical
Examiner’s report indicated that the infant had
multiple minor injuries. Law enforcement did
not pursue charges of child abuse against the
parent.

In addition to identifying policy issues, the panel works to identify the appropriate agencies or
persons for action. Such actions may be undertaken collaboratively or individually, immediately or
through another process, such as a work group. The panel seeks and considers pertinent
information about current CPS, law enforcement, and community provider policies. Actions are
underway to investigate and address the aforementioned policy issues identified by the ACRP in
2010.

Areas of Focus for 2011
CABHP continues to be committed to providing panel members with the information they need to
fulfill the program requirements as outlined in the CAPTA and to make certain the program is
functioning in an efficient manner. To ensure that practices are employed consistently with a
process for continuous quality improvement, several areas for enhancing the ACRP programs had
been identified in the 2010 report. Due to resource limitations, not all of the activities proposed
were able to be implemented. Below is an update on the suggestions identified by DCYF
representatives, CABHP staff and panel members in 2010:
o Request technical assistance from the National Resource Center for Child Protective
Services to sponsor a facilitator to conduct strategic planning with panel members to
facilitate the development of actions steps and strategies to meet program
requirements including:
 the examination and evaluation of the coordination between state and local
foster care and adoptions systems; and expansion of outreach activities.
Status: A technical assistance application was drafted by CABHP and will be submitted
by DCYF for consideration by Federal Children’s Bureau.
o CABHP will begin tracking areas of concern identified in several of the case record
reviews (e.g., perpetrators responsible for caretaking while mother working outside the
home in two of the cases reviewed, parent(s) co-sleeping with infants in four cases and
investigations completed by law enforcement and closed by CPS prior to safety factors
being resolved in two cases) to determine whether these may constitute a trend
requiring additional actions.
Status: Completed

28

o Explore opportunities to utilize technology for enhancing participation and
communication for panel members and across panels (e.g., video conferencing and
cross panel trainings).
Status Update: Due to changes in the CABHP video conferencing software/program
this was delayed and is planned to start during the second quarter of 2011.
o Continue to update the ACRP Program Manual and augment panel member orientation.
Status Update: The CABHP Program Manager is now providing orientations to panel
members face-to-face prior to their first panel meeting. Orientation materials continue
to be updated as needed.
o Identifying opportunities to recognize panel members and their contributions to the CPS
program.
Status Update: All panel members were provided sponsorship to attend a workshop
featuring David Conrad who is a national expert on secondary trauma.
o As recommended by the ACRPs, CPS and Arizona State University will explore how
graduate students can be utilized in the DCYF evaluation process.
Status Update: A Master’s level graduate student in the School of Social Work
completed a summer internship with ACRP Program.
Strategic planning with each of the panels did not occur in 2010; however, priority areas of focus in
2011 were identified during the fourth quarter meeting and through the panel member annual
survey. Areas identified by the panel members during panel meetings and in the survey results
included:



Presentations on: trauma informed care, the Never Shake a Baby program, and multiple
placements and disruptions in foster care;



Case record review samples that include: youth aging out of the CPS system; teen parents
including those in foster care; adopted youth returned to CPS;



Training for panel members on: the child welfare system, assessing strengths and risks;
impact of blended families on child welfare and domestic violence, additional trauma
training for foster parents and CPS supervisors and staff, shadowing CPS staff in the field,
observe Hotline, foster care services and ethics, criteria for child abuse prosecution, child
abuse prevention strategies/resources (healthy families, etc.);



DCYF staff to provide updates on: activities related to panel recommendations (e.g.
national registry, chronic child neglect) and impact of economic downturn (e.g. budgets,
referral and services);



Areas for further inquiry include: an examination of the child welfare system to identify
areas where child abuse victims are “falling through the cracks”; examine initiatives in other

29

states that intended to strengthen and support their child welfare system, child
maltreatment attributed to the economic downturn, educational services/supports for kids
in foster care, intergenerational child abuse and neglect, and opportunities to collaborate
with the Medical Examiner’s Offices;



Continue recruitment efforts targeting: juvenile court/judge, legislators, court-appointed
special advocates (CASA), concerned citizens, guardians ad litem, law enforcement, medical
providers, faith-based representatives, adoptees and foster children.

30

Appendix A: Agency Response To The 2009 Arizona Citizen Review Panels’ 11th
Annual Report Recommendations
The following is a summary of the findings and recommendations by the Regional Citizen Review
Panels in an effort to improve the CPS system:
Recommendation 1: DCYF should seek opportunities to work collaboratively with the
Arizona Attorney General’s Office to expand the Office of Drug Endangered Children’s
programs across counties.
Response: The Division of Children, Youth and Families (DCYF) agrees with this recommendation.
The Governor’s Office for Children, Youth and Families is now providing administrative support for
the Drug Endangered Children’s programs (DEC). DCYF will continue to be supportive of expanding
the DEC programs and will work collaboratively with Drug Endangered Children’s Alliance to achieve
expansion of this program statewide. DCYF will continue to be an active participant in the Alliance,
which includes the Governor’s Office for Children, Youth and Families, Attorney General’s Office,
the Law Enforcement Community, County Attorneys, and other key stakeholders. The focus of the
Alliance is to:
 develop a statewide safety assessment tool for use by the law enforcement communities;
this tool will be congruent with the Division’s Child Safety Assessment model;
 develop and enter into a Memorandum of Understanding with all Alliance partners;
 review and revise as necessary existing DEC protocols; these protocols will be expanded to
include children of incarcerated parents and Level 2 drug endangered children; and
 review, revise and expand current training.

Recommendation 2: DCYF should explore opportunities to work in partnership with
the Federal Regional Office to advocate for a national registry and central depository
that would aid CPS efforts to access information in a timely manner on adults who
have a history of maltreatment reports in other states, especially those with multiple
allegations of chronic abuse and neglect.
Response: The Division of Children, Youth and Families (DCYF) agrees with this recommendation.
The Adam Walsh Child Protection and Safety Act of 2006 required that the U.S. Department of
Health and Human Services conduct a study to assess the feasibility of establishing a national child
abuse and neglect registry and present the results in a report to Congress. The Interim Report to the
Congress on the Feasibility of a National Child Abuse Registry (May 2009) describes key issues
regarding the feasibility of establishing a national child abuse registry and concludes that
implementation is not feasible under statutory limitations of the authorizing legislation. It would
also require enabling state legislation including funding for a project of this magnitude.
It should be noted that department policy provides guidance to staff regarding obtaining and use of
prior CPS history in assessing child safety. Policy states that the CPS supervisor “will complete the
review of prior reports and case history in the Child Protective Services Central Registry including
out-of-state reports.” Information (such as when CPS history was requested, whether records exist,
barriers in obtaining the information, and a summary of the information, etc.) is documented in the

31

automated Child Safety Assessment. CPS staff are also required to contact other states when they
learn a parent may have history in that state.

Recommendation 3: Additional guidelines should be provided to assist DCYF staff in
strengthening and assessing the appropriateness of safety monitors. Provide staff
with the types of charges on the Department of Public Safety background checks that
would preclude someone from being a safety monitor. Currently, DCYF staff is
expected to conduct background checks, but there is some discrepancy in how
decisions are made and what type of criminal arrest, charge and/or convictions
would prevent a person from becoming a safety monitor.
Response: The Division of Children, Youth and Families (DCYF) agrees with this recommendation.
Current department policy provides guidance to assist CPS Specialist in identifying appropriate
safety monitors. The CPS Specialist must consider the following in assessing the appropriateness of
a safety monitor:
 current or prior CPS history;
 criminal history;
 whether the home is physically safe (if child will be staying there);
 an understanding of the safety threats and that the threats must be controlled;
 ability to prevent contact with those who pose threats;
 availability at times needed to ensure child safety;
 accessible when threats are or are likely to be present;
 ability to meet the child’s basic needs;
 is physically able to protect child;
 is aligned with CPS in carrying out the safety plan; and
 any substance abuse, mental health or personal issues that may interfere with keeping the
child safe.
The DCYF will ensure that the criminal history requirements for safety monitors are more closely
aligned with the criminal history guidelines for unlicensed caregivers. These guidelines note the
following:
 If the prospective relative caregiver including a person who has a significant relationship
with the child or any adult household member is awaiting trial on or has been convicted of
committing, attempting to commit, soliciting or facilitating or conspiring to commit one or
more specific criminal offenses prescribed in A.R.S. § 41-1758.03, he/she is precluded from
placement.
 If a criminal records background check or a self-disclosure statement reveals a conviction or
indictment of any other criminal offense, the decision to place a child in that home will be
based upon the safety threats presented by that crime. In assessing the safety threats, the
CPS Specialist, in consultation with the CPS Supervisor, must consider the following:
 the extent of the person’s criminal record including whether the criminal offense
was an isolated incident or indicative of a pattern of criminal activity;
 the length of time that has elapsed since the offense was committed;
 the nature of the offense;
 any applicable mitigating circumstances including whether the victim was child or a
vulnerable adult;
 the degree to which the person participated in the offense;

32



the extent of the person’s rehabilitation, including:
completion of probation, parole or community supervision,
evidence of positive action to change criminal behavior, such as completing
of drug treatment program or counseling, and
personal reference attesting to the person’s rehabilitation;
 The vulnerability of the child needing placement including the child’s age and special needs.
Recommendation 4: The Arizona Citizen Review Panels recommended that DCYF
reinforce current policy and documentation requirements on cases involving criminal
conduct allegations. The Arizona Citizen Review Panels are concerned about the lack of
adequate information gathered and/or documented which indicate a thorough safety
assessment was completed for children remaining in the home when a criminal
investigation has ended and a determination to close the case was made.
Response: The Division of Children, Youth and Families (DCYF) agrees with this recommendation.
The DCYF will continue to reinforce compliance with the policy and documentation requirements
for completing a thorough investigation including the assessment of child safety in all cases
including reports alleging criminal conduct behavior through:
 instructional tips and model examples:
 of documentation, and
 on who to interview, what documents to review, review of criminal history
information, and obtaining and reviewing court orders that restrict or deny custody,
visitation or contact;
 case record reviews that evaluate whether or not the required interviews occurred,
whether required documents were obtained and reviewed, whether sufficient relevant
information was gathered to confirm the presence or absence of each of the 17 safety
threats, and whether there is documentation of an analysis of the information in relation to
17 safety threats and the safety threshold;
 real-time feedback to staff about their documentation following each case review to clarify
and reinforce the practice standards for staff at all levels in the district and to improve
consistency and accountability;
 employee performance evaluation; and
 Case Manager and Supervisor CORE training, and refresher and advance training
opportunities including development of seven-hour documentation training which focuses
on the fundamental foundation for documentation (e.g., the importance of documentation,
how to record important tasks and events in the life of a case, and
who/what/when/where/how).

33

Appendix B: 2010 Agenda and Meeting Locations

1st Quarter
2nd Quarter
3rd Quarter
4th Quarter

Northern Panel
Monday (1:00 – 4:00)
March 29
June 7
August 30
November 1

Southern Panel
Monday (1:00 – 4:00)
March 15
June 21
September 20
November 15

Central Panel
Friday (9:00 – 12:00)
March 19
June 25
September 24
November 19

1st Quarter Meeting Agenda
Welcome and Introduction
Presentations: Practices for Diverse Cultures and Team Decision Making (TDM)
CPS Policy Review Related to Case Record Presentation
Case Record Review #1
DES Program Report: CAPTA Implementation Plan and Back to Basics
Case Record Review #2
Recommendations from 1st Quarter Meeting
Review Agenda and Identify Requests for 2nd Quarter Meeting
2nd Quarter Meeting Agenda
Welcome and Introduction
Review of 1st Quarter Meeting Minutes
Presentation: Babies, Infants, and Toddlers in Foster Care
CPS Policy Review Related to Case Record Presentation
Case Record Review #1
DES Program Report: Hotline Process; Safety Planning & Safety Monitors
Case Record Review #2
Recommendations from 2nd Quarter Meeting
Review Agenda and Identify Requests for 3rd Quarter Meeting
3rd Quarter Meeting Agenda
Welcome and Introduction
Review of 2nd Quarter Meeting Minutes
Presentations: Regional Advocacy Centers; Multidisciplinary Approach to Case Investigations
CPS Policy Review Related to Case Record Presentation
Case Record Review #1
DES Program Report: Legislative Updates
Case Record Review #2
Recommendations from 3rd Quarter Meeting
Review Agenda and Identify Requests for 4th Quarter Meeting
4th Quarter Meeting Agenda
Welcome and Introduction
Review of 3rd Quarter Meeting Minutes
Presentation: Annual Report
CPS Policy Review Related to Case Record Presentation
Case Record Review #1
DES Program Report: Agency Responses to CRP Recommendations 2007-2009
Case Record Review #2
Recommendations from 4th Quarter Meeting
Review Agenda and Identify Priorities for 2011

34

2010 Meeting Locations
Arizona Citizen Review Panel

Southern Region
La Paloma Family Services
870 West Miracle Mile
Building A
Tucson, AZ 85705
(520) 750-9667
http://www.lapalomakids.org

Central Region
School of Social Work
Arizona State University
Downtown Phoenix Campus
University Center (UCENT)
411 North Central Avenue
Suite 822A, 8th Floor
Phoenix, AZ 85004-0698
(602) 496-0800
http://ssw.asu.edu/portal/

Northern Region
United Way of Northern Arizona
1515 East Cedar Avenue
Suite D-1
Flagstaff, AZ 86001
(928) 773-9813
http://www.nazunitedway.org/

If you have questions or need additional information,
please contact:
Lisa Moen
Program Coordinator
Phone: (602) 496-1480
Email: lisa.moen@asu.edu

35

Appendix C: Citizen Review Panel Members Central Region
Allison Thompson
Maricopa County Adult Probation

Linda Madrid
Arizona State University
Southwest Interdisciplinary Research Institute

Bernadette Chambers
Arizona State University
Prevention Research Center

Lisa Barrientos
Mesa Police Department, Homicide Unit

Beth Rosenberg
Children’s Action Alliance

Marcia Stanton
Phoenix Children’s Hospital

Cindy Copp
DES/DCYF/CPS Southwestern Region

Minerva Gant
DES/DCYF Child Protective Services

Darryl Bailey
DES/DCYF/CPS Central Region

Nancy Logan
Office of Disability Adjudication, SSA

Diana Yazzie Devine
Native American Connections

Natalie Miles Thompson
Crisis Nursery

Gary Brennan
Quality Care Network

Pamela Fitzgerald
Citizen/Former Teacher

Gloria Sesma
Isaac Middle School

Pamela Ruzi
Hospice of the Valley

Janet Cornell
Scottsdale City Court

Princess Lucas-Wilson
Citizen

Janice Waggoner
Maricopa County Justice Court

Roy Teramoto, M.D.
Indian Health Services

Jennifer Mullins
Arizona State University
School of Social Work

Samantha Nordvold
Madison School
Simon Kottoor
Sunshine Group Home

Jo Fuhrmann
CHEERS, Inc.

Stephanie Zimmerman, M.D.
Phoenix Children’s Hospital

Joelle Minitti
DES/DCYF Child Protective Services

Tracy Sloat
Maricopa County Dept. of Public Health

Kara VanHise
Arizona Ombudsman’s Office, Citizen’s Aid

Yariet Camarena
DES/DCYF Practice Improvement Specialist

Kim Leggio
Maricopa County Justice Court
Kris Jacober
Arizona Association for Foster and Adoptive Parents

36

Appendix C: Citizen Review Panel Members Southern Region
Anna Binkiewicz, M.D.
Retired Professor/Medical Director
Casa de los Niño’s Crisis Nursery

Joan Mendelson
Citizen/Attorney

Barbra Quade
Jewish Family Services

Joy Subrin
Northwest Medical Center, Social Work
Department

Carla Hinton, Ph.D.
Amphitheater Public Schools

Karen Harper
Southern Arizona Children’s Advocacy Center

Cheryl Brown
Pima County Attorney’s Office
Juvenile Unit

Karen Kelsch
Pilot Parents of Southern Arizona
Laurie San Angelo
Office of the Arizona Attorney General

Christie Kroger
DES/DCYF Practice Improvement Specialist

Linda Johnson
DES/DCYF Child Protective Services

Comel Belin
Tucson Unified School District
Cynthia Killion
Amphitheater Public Schools

Martha McKibben
Northwest Medical Center, Social Work
Department

Darlene Moten
Amphitheater Public Schools

Marty Fuentes
Tohono O’Odham Police Nation Department

David Reynolds
Citizen/Special Education Teacher

Robin Gerard
Casa de los Niños Crisis Nursery

Gloria Bernal
Sycamore Elementary School

Sandy Guizzetti
Foster Care Review Board

Jaymie Jacobs
Office of Pima County School Superintendant

Susan Peacock
Foster Care Review Board

Scott Gamble
Tohono O’Odham Police Nation Department

37

Appendix C: Citizen Review Panel Members Northern Region
Beya Thayer
Northland Family Help Center
Carli Moncher
Safe Child Center/Flagstaff Medical Center
Cindy Trembley
DES/DCYF Child Protective Services
Dani O’Connell
DES/DCYF Practice Improvement Specialist
Erin Callinan
Northland Family Help Center
Dustin Wagner
Child and Family Support Services
Gene Shantz
Flagstaff Police Department
Jill Sanchez
Juvenile Court Services
Coconino County Superior Court
Judy Gideon
Citizen/Retired Foster & Adoptive Parent
Julie Wood
Arizona’s Children Association
Kathi Raley
Victim/Witness Services for Coconino County
Sandra Lescoe
DES/DCYF Child Protective Services
Suzette Vigil
DES/DCYF Child Protective Services

38

Appendix D: CABHP Case Record Summary and Presentation
Arizona Citizen Review Panel
___ Quarter, ____, 20__
_____Region, Case # ___
Purpose: Highlight key data and findings extracted from CPS CHILDS system and other documentation to provide information to the
regional Citizen Review Panels so that recommendations can be developed and areas of exemplary practice identified. Panel members will
receive a copy of this document with copies of the Practice Improvement Case Review Instrument and the In Home or Out of Home (if
applicable). All personal identifying information will be redacted from the materials before distribution. The period under review will be the
last 12 months except for items that are related to history of CPS involvement and /or may be relevant to the current case being reviewed (e.g.
substance use, criminal history, etc.)
A. Narrative Overview of Case Description - allegation(s)/what trigger the call, age, gender and race/ethnicity of victim(s), reporter,
perpetrator(s), summary of history of CPS reports and findings, relevant factors (e.g. substance use, mental illness, physical health,
developmental disability), manner and cause of death (specify per medical report, autopsy and/or death certificate), relevant toxicology
testing performed including results and any charges filed, summarize services received and/or needed but not received.

B. DES Practice Improvement Case Review Instrument Summary - review should use the directions in the tool also refer to the DCYF
Quality Improvement System Procedures, Training Manual and any relevant DCYF policies and procedure. Significant information summary of information reviewed in the copy of the DES record and/or collected from CHILDS. Key Findings-document findings of
safety & risk assessment and investigations, plus any relevant decisions made by DES and the courts. Comments- additional information

Item

Significant Information, Key Findings & Comments

that would be beneficial to share with CRP members, DES Administration and/or CABHP staff.

39

Item 1
Timeliness of Initiating
Investigation of Reports of
Child Maltreatment
Consider also the relevance
and sufficiency of the
information gathered during
current or prior CPS
investigations and case
planning
Item 2
Initial Child Safety
Assessment
Item 3
Safety Planning to Protect
Child(ren)
in Home and Prevent
Removal
Item 4
Initial Strengths & Risk
Assessment and Provision
of Services to Reduce
Risks

-ATTACHED COPY OF CSA FROM CHILDS-

-ATTACHED COPY OF CSA FROM CHILDS-

-ATTACHED COPY OF SRA FROM CHILDSDocument whether services offered and/or provided addressed the identified safety threats and risk factors and any
outcomes as a result of services received. Also need to consider whether actions were taken in a timely manner to
ensure the safety of other children remaining in the home.

Item 5
Determining Whether
Maltreatment Occurred
Item 6
Aftercare Planning

40

C. DES Practice Improvement Case Review Instrument-In Home or Out of Home- review - should use the directions in the tool and any
relevant DCYF policies and procedure. Key Finding- should include information that justifies the rating. Comments- additional
information that would be beneficial to share with CRP members, DES Administration and/or CABHP staff.

Item
Item 1
Ongoing Safety and Risk
Assess. And Safety
Management

Significant Information, Key Findings & Comments

-ATTACHED UPDATES OF SRA FROM CHILDS-

Item 2
Permanency Goal for
Child
Item 3
Concurrent Permanency
Planning
Item 4
Independent Living
Services
Item 5
Visiting with Parents &
Siblings in Foster Care
Item 6
Relative Placement
Item 7
Needs &Services of Child,
Parents and foster
Parents

41

Item 8
Case Plan Development
Item 9
Worker Visits with Child
Item 10
Worker Visits with
Parents
Item 11
Educational Needs of the
Child
Item 12
Physical Health of the
Child
Item 13
Mental/Behavioral Health
of the Child
Foster Homes
Complete only if
allegations involve foster
family placement. Identify
any findings from foster
care review board on their
barriers.
D. Panel Recommendations and Comments
Precipitating Events and/or Suspected Triggers:
Disobedience
Feeding Difficulty
Toilet Training
Other:

Commission of Another Crime
Family Violence
Revenge
Crying

42

Family Risk Factors:
Substance Use
Mental Health Problems
Domestic Violence
Sexual Abuse
Violence Outside the Home
Lack of Physical or Mental Ability to Provide Adequate Care
Lack of Motivation to Provide Adequate Care
Prior Removals by CPS or Severance of Parental Rights
Lack of Resources for Adequate Food/Shelter/Medical/Child Care
Child(ren) with special needs:
Medical
Developmental
Emotional/Behavioral Health
Were all identified risk factors addressed and/or resolved?

Yes

Lack of Parenting Skills
Teen Parent
Prior Child Death
Lack of Anger Control
Co- sleeping with Infant
Prior Substantiated Reports
Other:
Were all risk factors identified in the record?

Yes

No

If not, specify additional risk factors identified by the panel
members:

No If No, describe:

Joint Investigation: reference the joint investigation protocol for the applicable region and note any areas in which the protocol was not
followed.
Was a thorough investigation completed?

Yes

No

If No, describe:

Supervision: note any instances or documentation that indicates that there was inadequate communication (e.g. reporting facts, clear
instructions) between the CPS worker and their supervisor. Also specify any decisions/findings were overturned.
Potential Policy Issues: indicate whether there are any specific policy issues, concerns or recommendations. 1) Areas where policy not
followed or quality concerns; 2) Policy followed but still bad outcome or concern identified (may need to re-evaluate or modify the policy); 3)
Issue not addressed in the policy.
Exemplary Practices: note any practices that should be shared to encourage the continued practice.

43

Other: note any known circumstances that you believe may have impacted the outcome (e.g. lack of services, support services, case load size,
training). Document any barriers outside the CPS agency that impacted the agency's ability to ensure a continuity of consistent, timely and
adequate services.
What actions does the panel believe could have been taken to prevent/avoid this event?
Recommendations:

Demographics
Age of Child:

Race:

Prior CPS involvement:

Hispanic/Latino:

Yes

Number of prior complaints:

Age of Parents/Gender (e.g. 43F 51M):

No

Number of substantiated complaints:

Marital Status:

Father History of Abuse:

Yes

No

Check Type:

Physical

Sexual

Mental/Emotional

Neglect

Mother History of Abuse:

Yes

No

Check Type:

Physical

Sexual

Mental/Emotional

Neglect

Does mother work out of the home?

Yes

No

If Yes, was perpetrator primarily responsible for caring for Target Child during mother’s absence?
Birth Order of Target Child:

Number of Children Under Age 5:

Was substance abuse a risk factor for this family:

Yes

No

Identify substance(s):

Was Target Child identified as having a behavioral health disorder?

44

Yes

No

If Yes, specify:

Yes

No

Time Line
Date

Significant Events for the Target Child

45

Notes

Appendix E: Citizen Review Panel Survey
On November 19, 2010, Panel members received an email request from the Citizen Review Panel Program Coordinator requesting them to
complete a 10 question survey by December 6, 2010 as a means to provide information on the level of satisfaction and suggestions for
improvement of the program.

Question 1: I am a Citizen Review Panel member for (check one): Central, Southern or Northern Region. Twenty-one (21) Panel
members completed the survey with 12 responses from Central, 6 from Southern and 3 from the Northern Panels.
Question 2: I have served on the Citizen Review Panel for: ___month(s) or ___year(s). Members who responded indicated they had
served on Panels from 1 month to 8 years. The majority of the respondents were satisfied with the performance of CABHP administrative
support, community diversity of Panel members, CPS case record presentations, and content of the meetings, e.g. guest speakers, policy
reviews, and DES program reports. Panel members were asked for suggestions on areas of additional training or topics that they would
like to learn more about, in addition to ideas on ways that Panel meetings could improve in the upcoming year. Panel members’
comments generally reflect more confidence and enthusiasm about the program and their roles compared with last year’s survey. The rest
of the 2010 survey questions and results are summarized as follows:
Question 3: My regional Panel is comprised of members with diverse community representation.
Comments:








Need law enforcement, former foster child,
someone from the GAL/legal advocate office, a
CASA; how about a judge? (Southern)
I think that juvenile probation needs to send a
worker. (Southern)
Law enforcement not present.
I know there is considerable effort put into
finding people from diverse backgrounds.
Panel has great diversity.
Diversity can always be enhanced.
I have previously stated that the citizen review
panel seems more like the 'professional' review
panel and that the opinions of the CPS members often make it feel like the "CPS reviewing CPS panel." We need more 'off the street'
citizens to review the cases with an outsider’s view. (Central)

46

Question 4: The ASU Center for Applied Behavioral Health Policy provides effective administrative support.
Comments:





I am VERY impressed with the administrative/ organizational aspect of this panel. The meetings are very well facilitated.
They are great.
The work of the ASU Center is thorough and
informative.
Exceptionally strong support and direction. It is
very much appreciated.

Question 5: I am satisfied with case record review presentations.
Comments:







The content of the reviews is good and the
discussion is really good, but we often run out of
time and have to move on from discussions to
keep on schedule.
Due to my newness, I am still learning best
methods to review the case materials.
There are times when reports from providers are
given to panel members as part of the case
history. These reports can be critical if the
provider is not assisting the family in the way
that CPS is requesting.
Sometimes the rules and processes that are used by CPS and other institutions are unknown to a Board member. It takes time on the
Board to pick up information about laws and regulations that are built into the process.

47






The panel still tends to go off on tangents. This is to be expected with such a large group and Vicki does a great job of politely and
diplomatically keeping us on task.
Always seems like we do not have much time for the case reviews. The agenda is always very full.
Not enough time!
They are well synopsized and easy to work through.

Question 6: I am satisfied with the content of information provided at Panel meetings.
Comments:


I think it is very difficult to go through files that have extensive information and that are dated. Problems with the information provided
come from the originating source. Many of the
questions the caseworkers fill in are cut and
pasted; following dates and any changes over
time becomes difficult.

Question 7: What information or training would be helpful for you to become more effective in your role as a Panel member?
Comments:






I think a little more upfront information about the role/responsibilities of the panel would have been helpful as a new member. Maybe
being paired with a seasoned member, to act as a mentor or someone to ask questions would be helpful.
CPS policy and procedures for removal/investigations. Maybe not the 'whole book' but a flow sheet or some tool they use to guide their
work.
No specific training recommended. Suggest my continued panel participation will assist in becoming more effective.
As meeting results are processed, I would like to know about follow-ups for information requested from the panel.
Have been satisfied with the information provided.

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It may be helpful for a panel member to shadow a Case Manager to better understand the types of hurdles they must overcome to make
the best decision possible to assist a family in need. It would also be helpful to learn how a family can be so inundated with services that
they are set up to fail.
You have already helped with offering training one hour prior to quarterly meetings and provided a listing of acronym definitions.
Maybe training that includes how the various institutions that are typically involved with CPS work together. Flow chart form. That might
be an overwhelming task. Unless you are already a little familiar with the relationships between institutions, it will be very confusing to
figure out what each part plays to the whole.
Over a period of time, it might be good to review the policies and processes for the various organizations from CPS to law enforcement
to forensic pediatrics, etc.
Trainings held in Tucson.
Information provided at the end of each meeting on what recommendations/suggestions will be made to DES regarding the cases
reviewed that day.
It might help if non-DCYF staff had a strengthened understanding of CPS policy in determining child safety/risk, reasons for removal, and
conditions for return/reunification.
Agency policies and protocols.
Case worker ride-along to understand the role of CPS caseworkers.
The use of all the acronyms is sometimes frustrating when you don't know what they all stand for.
An update on how CPS categorizes a child's case when it is presented to the agency.
Update on the joint protocols between CPS and law enforcement, including a response from the police leadership and the County
Attorney’s Office.

Question 8: What additional themes or topics would you like to explore at Panel meetings in 2011?
Comments:
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Foster Care Ethics.
Ineffective safety plans.
Blended family dynamics and review of family history as risk factors.
Domestic violence.
The determining factors as to whether the case should be forwarded to the Attorney General's Office for a Dependency action.
How information is able to flow or not flow between institutions, police, schools, hospitals, doctors, courts, etc.
There was a good list of topics presented at the most recent meeting, but I would repeat the recommendation for general training on
"systems."
Discussion of follow up services arranged for families who have had a child removed from their care.
Lack of good behavioral health services for the children and families.

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I'm wondering if the incidents of child fatalities and level of severity of child abuse in Arizona is increasing since the economic downturn
and legislative budget cuts. I have an impression that it is, but I do not know if anyone is collecting data and/or reporting findings to
citizens regarding this possible trend.
Chronic neglect; prevention strategies; adopted youth returning to the system; and how lack of resources is affecting agency
effectiveness.
More information about what we need to do to get this state to improve CPS. What we need to do to make them able to do their jobs
better! The idea is to save lives!
Criteria for child abuse prosecution (seems as though few cases are actually pursued and prosecuted); child abuse prevention
strategies/resources (Healthy Families, etc.); cases involving youth; -educational services/supports for kids in foster care;
intergenerational child abuse.
We need to comment on other state and public agencies that must interface with and coordinate with ADES/CPS, so we can better
protect children, families and our communities.
Information regarding prevention programs available in the community specific to cases evaluated.
How does the educational system, including Arizona Department of Education, school districts, and schools (e.g., charter) support
and/or participate in child protection?

Question 9: My Regional Panel meetings would be more productive if (please specify):
Comments:
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All members should attend.
No suggestions - it is quite productive as is.
It appears that not everyone on the panel understands the criteria involved in the decision making process as to the services that are
provided to each family. It may appear on the outside that each family presented to CPS needs services, but once the process is
understood, the panel will then see that it is what is on the inside that CPS must work with to help the family.
I believe adding more time to the quarterly meetings would not make things so rushed. We are rarely able to follow the agenda schedule
because of so much discussion, which is beneficial and should occur.
I think our panel and the ASU support does a great job and that we are unusually productive for such a diverse group.
Less time was taken on "extraneous" topics. On the other hand, these are often valuable ideas/topics, and it is difficult to measure the
value in terms of "productivity."
They are well organized and they run very smoothly--staff support is excellent.
I made more time to prepare between meetings.
A Mohave DCYF representative could attend the Mohave case reviews.
Members should not go off on tangents or philosophical ranting on parenting, the system, etc., and instead focus on what our objectives
are.

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There should be more 'off the street' citizens and less professionals from the field, who sometimes can't look at cases as an outsider
could.
The meetings are very productive.
Case overviews seem to be heavy in investigation and little information about the rest of the case. For example, more information is
needed about what services were offered, completed, opinions, reports of those involved in order to get the full picture; who else was
involved in the case, etc.
I am wondering if others would agree that the number of meetings should be increased to 5 or 6 annually?

Question 10: In the past year I have shared information about the Arizona Citizen Review Panel with community members and/or
other organizations.
Comments:
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Many people were not aware that there is such
a panel and were very pleased to hear of its
existence.
I am working with the Pima County Juvenile
Court Committee on education. Some of the
areas of interest and concern overlap.
Yes, with respect to confidentiality.
I invited people from Pima County Juvenile
Court.

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To obtain further information, contact:

Arizona Citizen Review Panel Program
Center for Applied Behavioral Health Policy
School of Social Work
College of Public Programs
Arizona State University
500 North 3rd Street
Suite 200
Phoenix, Arizona 85004-2135
Tel: (602) 496-1470
Fax: (602) 496-1494
Information about the Arizona Citizen Review Panel Program can be found on the Internet through the
Center for Applied Behavioral Health Policy at:
http://www.cabhp.asu.edu/

This publication can be made available in alternative format.
Please contact the Arizona Citizen Review Panel Program at (602) 496-1470.

CENTER FOR APPLIED BEHAVIORAL HEALTH POLICY
SCHOOL OF SOCIAL WORK
COLLEGE OF PUBLIC PROGRAMS
ARIZONA STATE UNIVERSITY
500 North 3rd Street, Suite 200
Phoenix, Arizona 85004-2135
(602) 496-1470
Printed on Recycled Paper
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