Title page 1

Contents 3

Highlights 2

Letter 6

Background 9

Trends in Congregate Care Placement 9

Title IV-E Foster Care Program 12

Family First Prevention Services Act 12

Federal Monitoring 13

States Continue to Use Congregate Care and Increasingly Use State Funds to Support Youth in These Facilities 14

The Majority of States Have Not Reduced the Use of Congregate Care in Recent Years 14

The Majority of States Have Adopted Qualified Residential Treatment Programs (QRTP) 16

The Majority of States Have Increased Their Own Spending on Congregate Care as Federal Funds Have Diminished, Shifting Child Welfare Spending Priorities 19

Almost All States Experienced Capacity, Service, and Staffing Challenges, but Many Reported Benefits from Family First's Congregate Care Provisions 21

All States Reported Challenges Obtaining Enough Foster Care Placements 21

Almost All States Reported Challenges Related to Providing Services to Youth and Staffing Congregate Care Facilities 26

Many States Reported Family First's Congregate Care Provisions Helped Reduce the Use of Congregate Care or Had Other Benefits 29

Many States Did Not Know Whether More Dually Involved Youth Had Been Placed in Juvenile Justice Placements Since Family First Implementation 31

ACF Monitors the Use of Federal Funds for Congregate Care, But Some States Interpret Title IV-E Claiming Rules Differently 35

Conclusions 38

Recommendations for Executive Action 39

Agency Comments and Our Evaluation 39

Appendix I: Objectives, Scope, and Methodology 42

Appendix II: Online Questionnaire of Young Adults and Selected Responses About Experience in Congregate Care 46

Appendix III: Comments from the Department of Health and Human Services 53

Appendix IV: GAO Contact and Staff Acknowledgments 56

Tables 3

Table 1. Number of States That Reported Sufficient Foster Care Capacity, by Placement Type 22

Table 2. Number of State Child Welfare Agencies Reporting Placement and Length of Stay Changes for Dually Involved Youth Since October 1, 2021 32

Table 3. Number of State Juvenile Justice Agencies Reporting Increased Number of Placements or Length of Stay for Dually Involved Youth Since October 1, 2021 32

Table 4. Selected States' Interpretations of Whether to Individually Assess Youth to Be Eligible for Title IV-E Funds for Congregate Care Beyond 14 Days 37

Figures 4

Figure 1. Youth in Foster Care by Setting (fiscal years 2002-2023) 9

Figure 2. Youth in Foster Care by Placement Type (fiscal years 2002-2023) 10

Figure 3. Youth in Juvenile Justice Residential Placements by Selected Facility Type (2003-2023) 11

Figure 4. Changes in Placements and Time in Congregate Care Since October 2021 14

Figure 5. Number of States with Qualified Residential Treatment Programs (QRTP) and Percentage of Congregate Care Facilities in Those States That Are QRTPs 17

Figure 6. State-Reported Challenges Meeting Family First Requirements for Qualified Residential Treatment Programs (QRTP) 18

Figure 7. State-Reported Challenges Placing Youth in Congregate Care 23

Figure 8. State-Reported Challenges Placing Specific Populations of Youth in Congregate Care 25

Figure 9. State-Reported Challenges Related to Services for Youth in Child Welfare 26

Figure 10. Examples of GAO Survey Responses About Young Adults' Feelings on Staff in Congregate Care 28

Figure 11. State-Reported Benefits of Family First Congregate Care Provisions 30