Out-of-state PRTFs: an interview with Joonu Coste

In our #BringNCKidsHome campaign, DRNC has been bringing you stories of traumatized NC kids who are bearing the brutal impact of NC’s over-reliance on institutional care in facilities called psychiatric residential treatment facilities (PRTFs). Recently, a team of investigative reporters with Gannett/USA Today examined this broken system in a series of articles called Locked Away. The series is gaining national attention and includes a look into NC’s practice of shipping our children to out-of-state PRTFs.

DRNC has been looking into that dangerous practice too.

Joonu Coste is a DRNC attorney who has spent the past two years focusing on NC kids in PRTFs, on the NC systems that send our children to these institutions, and what happens to our kids when they are #LockedAway. What she discovered is shocking.

Each year, NC ships hundreds of kids to out-of-state PRTFs, some hundreds of miles from home, where they stay for months on end. Some of these kids come home damaged, traumatized and needing care to heal from their “treatment.” Yet NC spends hundreds of dollars per day, per child on these facilities, including some with documented histories of (and ongoing) abuse and neglect.

How can this be? In this interview, we asked Coste to tell us more.

NC says they know the facilities where these kids are sent.  But you learned that this isn’t exactly true. Why doesn’t NC know where our kids are?

There is a law called the Interstate Compact on the Placement of Children, that has been adopted in all 50 states. It is supposed to prevent kids from falling through the cracks when they are sent across state lines. But it doesn’t work. Even though it looks like there is a procedure for states to track children, there is no enforcement. Quite simply, it is an honor system.

So, for instance, if an LME/MCO (one of the state’s organizations that manages and pays for these services), or a county department of social services, or a juvenile court doesn’t report that they sent a child out of state, then the state will not have any record of it. They will not know that the child left NC, or where the child is. There is also nothing the state can do to hold agencies accountable for failing to report when they send children out of state. Even if the state knew an agency was sending children out of state without reporting it, there is no way for the state to punish the agency for failing to comply with the law.

Likewise, if the receiving state itself fails to notify NC that they received a child from NC, there is nothing NC can do. The same is true if the PRTF receiving the child doesn’t notify its own state that they have a child from NC. Under current law and procedures, North Carolina has no way to know about these kids and no way to hold the other state accountable for them.

Bottom line, NC loses children. NC law and policies must change.

You did a lot of digging to get an idea of where NC children are sent.  How many places did you learn are actively accepting children from NC?  And in how many states?

I have confirmed that NC’s LME/MCOs currently refer our kids to at least 23 facilities across at least 12 states. These states include Alabama, Arkansas, Georgia, Illinois, Indiana, Missouri, New Mexico, Pennsylvania, South Carolina, Tennessee, Utah, and Virginia.

Bottom line, NC loses children. NC law and policies must change.

There are “sending states” – those that export kids to other states. There are “receiving states” – states that receive kids into their facilities.

North Carolina is a sending state.

I learned about this practice by reviewing client records, talking with guardians, and representing kids stuck in out-of-state placements.

Does anyone check on our children when they are sent to out-of-state PRTFs?

When I visited a facility in South Carolina in 2020, I asked NC to provide a list of the NC kids who were there so I could check in on them. The list they gave me did not include the name of the specific child I was going to visit. It also listed children who had been discharged up to 6 months prior. Once at the facility, I asked the facility for a list of the NC children present that day or the names of their guardians. They promised to send that list. I never received it.

Under law, when agencies send kids from NC to another state, that receiving state has no obligation to provide oversight for the child.

In NC, if a child is in the care of a child welfare agency, NC’s laws require the public guardian to check on the child periodically. However, it is unclear if social workers keep track of a child once the child is out of state. Caseloads are large. Funding is limited.

What are the dangers in sending a NC child out of state to these locked institutions?

There are so many dangers.

We know many kids are slipping through the cracks, becoming stranded in other states with no way home. We know kids are abused and neglected with no NC oversight.

The laws of many other states are less protective than NC law governing the institutional care of children. NC law promises the right to live as usual as possible, to have individualized treatment, to be free of corporal punishment, to call a parent or guardian at any reasonable time in private, to be free of restraint, seclusion, and overmedication. In NC, kids also have the right to a sound, basic education, the right to special education and vocational training, and the right to appointed counsel. Still, even with these protective laws on the books, DRNC often learns of children’s rights being violated when we visit NC PRTFs to monitor them. Because there are laws in place, DRNC can advocate for the enforcement of the child’s rights and is often successful in doing so.

However, in most of the states that NC sends children to, kids do not have any of these rights in law. They can be stripped of these basic human rights and left to the mercy of the facility without anyone knowing about it. Even though these facilities may have written policies about how kids are treated, there is often no enforcement. It is a chilling thought. The facility controls all flow of information in and out. They can create a totalistic environment for the children living there…Too often, abuse is the treatment. The child has no way out. In many cases, no one even knows they are there. Many of the stories I have heard from children sent to out-of-state facilities involve situations where the child was being abused, neglected and deprived of education with no way to communicate with the outside world. Remember, these facilities are locked 24 hours a day, 7 days a week. Many times, not even law enforcement or child welfare can go into these places. Unlike DRNC, many states’ P&As can’t engage in routine facility motioning due to lack of personnel and funds.

It is a chilling thought. The facility controls all flow of information in and out. They can create a totalistic environment for the children living there. This situation is ripe for exploitation of young lives. Too often, abuse is the treatment. The child has no way out. In many cases, no one even knows they are there.

Why does NC do this to begin with?  Isn’t there a better way to help our kids?

North Carolina must provide disability services under Medicaid to anyone 21 and under who is eligible. When there are no services in the community, the LME/MCO or insurance provider will then look for residential placement. If residential placement is not available in state, they will look out of state.

The better way to help kids is to make sure the right community-based services are available to our kids and families so they get the help they need in their communities before they reach a crisis state. That will drastically reduce the need for residential services and will comply with federal requirements that kids are entitled to have mental health services they need in their communities, not in institutions.

NC must put an end to sending our kids out of state, full stop. NC must invest in community-based behavioral health supports and stop relying on institutions. Community-based care is both more effective and less expensive.

Does NC still pay these facilities for NC kids even when there has been documented abuse or neglect? And does the state ensure the child gets the help they need when this happens?

Yes. Even if abuse or neglect is documented by a state or local agency, the child’s stay in the institution will still be paid for through NC Medicaid. The facility will still be paid according to the contract and the billing for services.  NC does not, to my knowledge, have a system to identify these traumatized children in order to ensure they receive treatment to help them heal from the abuse they experience in a PRTF.

When NC learns an out-of-state institution has harmed children, does it stop sending children to that institution?

No.  Under current law, as long as a facility is operating, there is no legal mechanism by which NC can prohibit NC agencies from sending children to facilities that are known to hurt kids – in state or out of state. The LME/MCOs defer to the state licensing body. If a facility is operating, the LME/MCO will typically continue to send a child to that facility.

However, the State can make a policy decision regarding when to stop sending a child to any facility – in state or out of state. It can also decide to stop sending our children out-of-state under any circumstance.

I have observed occasions where a particular LME/MCO has not renewed a contract with a facility. However, in one instance, the facility sued the LME/MCO over that action and the LME/MCO created a new contract with the facility.

I have observed individual child welfare agencies decide to stop sending children under their guardianship to certain PRTFs due to ongoing allegations of abuse and neglect. However, those are generally individual decisions made by individual agencies and they are not widely shared.NC must immediately stop sending our children out of state.

We need to #BringNCKidsHome. Tell Governor Roy Cooper and the Secretary for the NC Department of Human Services, Kody Kinsley, that NC must do better. Our children deserve care and treatment in our NC communities, not #LockedAway in institutions. Learn more.