Offic e o f the I nspe c to r Ge ne ra l o f Ne b ra ska Child - - PowerPoint PPT Presentation
Offic e o f the I nspe c to r Ge ne ra l o f Ne b ra ska Child We lfa re Julie L . Rog e r s, Inspe c tor Ge ne r a l of Ne br a ska Child We lfa r e Sta te Ca pito l P.O. Bo x 94604 L inc o ln, NE 68509-4604 402-471-4211 T o
Julie L . Rog e r s, Inspe c tor Ge ne r a l of Ne br a ska Child We lfa r e
Sta te Ca pito l P.O. Bo x 94604 L inc o ln, NE 68509-4604 402-471-4211 T
re e - 855-460-6784
Pho to b y Mic ha e l Sa ue rs, lic e nse d b y CC 2.0
Cre a te d b y the L
e g isla ture in 2012
One o f 18 re c o mme nda tio ns o f a study o f c hild we lfa re priva tiza tio n - L
R 37 (2011)
“…to e nha nc e a c c o unta b ility a nd fa c ilita te re fo rm in the c hild we lfa re syste m.”
Ove rsig ht o f DHHS e mplo ye e s a nd c o ntra c to rs
Ho use d in the le g isla tive b ra nc h, within the Omb udsma n’ s o ffic e Jurisdic tio n e xpa nde d in 2015 to inc lude juve nile justic e a g e nc ie s a nd c o ntra c to rs:
Juve nile Pro b a tio n Ne b ra ska Co mmissio n o n L
a w E nfo rc e me nt a nd Crimina l Justic e
Juve nile De te ntio n Juve nile Dive rsio n
c hild we lfa re a nd juve nile justic e o pe ra tio ns
I
nve stig a te de a ths a nd se rio us injury to c hildre n
L
a g e nc ie s se rving c hildre n a nd fa milie s
I
de ntify syste mic issue s a nd ne e de d po lic y c ha ng e s
Assist in impro ving a g e nc y a nd syste m o pe ra tio ns a nd o utc o me s
Ho ne sty I
nte g rity
T
rustwo rthine ss
I
nde pe nde nc e
Co nfide ntia lity Pro mo ting :
Ac c o unta b ility T
ra nspa re nc y
Go o d Go ve rnme nt Hig h Pe rfo rma nc e “...T he pub lic e xpe c ts OI Gs to ho ld g o ve rnme nt
ide ntify, e xpo se and e liminate fraud, ...ille g al ac ts and ab use . T his pub lic e xpe c tatio n is b e st se rve d b y inspe c to rs g e ne ral whe n the y fo llo w the b asic princ iple s o f inte g rity, o b je c tivity, inde pe nde nc e , c o nfide ntiality, pro fe ssio nalism, c o mpe te nc e , c o urag e , trust, ho ne sty, fairne ss, fo rthrig htne ss, pub lic ac c o untab ility and re spe c t...”
Asso c ia tio n o f Inspe c to rs Ge ne ra l
nc ide nt Re vie ws
nve stig a tio ns
I
ndividua l I nve stig a tio ns
Annua l Re po rt Juve nile Ro o m Co nfine me nt
I n F Y 2015-2016, the OI G re c e ive d 577 c a se s:
385 c ritic a l inc ide nts (22 de a ths,
20 se rio us injurie s)
155 c o mpla ints 24 re po rts o r re q ue sts fo r
info rma tio n
13 g rie va nc e re po rts fro m DHHS
he OI G c o mple te d:
I
nve stig a tio ns into 22 de a ths o r se rio us injurie s o f syste m-invo lve d c hildre n a nd 4 de a ths in lic e nse d c hild c a re fa c ilitie s;
Se rio us I
njury a fte r 11 Re po rts o f Physic a l Ab use
De a th o r Se rio us I
njury a fte r a Child Ma ltre a tme nt I nve stig a tio n (11 c hildre n)
Sudde n Une xpe c te d I
nfa nt De a ths (11 c hildre n)
Suic ide s o f Sta te Wa rds (2 c hildre n) De a th o f Yo uth Jo intly Se rve d b y DHHS & Pro b a tio n
An inve stig a tio n into de te rio ra ting c o nditio ns a nd vio la tio ns o f la w a t YRT
C- K e a rne y
T
he OI G issue d 30 re c o mme nda tio ns – 26 to DHHS, 4 to Pro b a tio n – re la te d to :
Ca se lo a d a nd Wo rklo a d fo r Ca se wo rke rs a nd Othe r Sta ff Stre ng the ning the Wo rkfo rc e – Spe c ia liza tio n a nd T
ra ining
Co o rdina tio n b e twe e n Ag e nc ie s Se rving Childre n E
nha nc e me nts to I nte rna l a nd E xte rna l Pe rfo rma nc e Mo nito ring
Ca se Sc e na r io: A 4-ye a r-o ld , who se fa mily ha d re c e ntly a g re e d to pa rtic ipa te in a vo lunta ry c hild we lfa re c a se ,
wa s a d mitte d to the ho spita l with a skull fra c ture a nd b ruising a ll o ve r his b o d y. T he sub se q ue nt inve stig a tio n re ve a le d tha t his fa the r wa s re spo nsib le a nd ha d re pe a te d ly physic a lly a b use d
ye a r-o ld b y his fa the r, five o f whic h we re inve stig a te d b y DHHS, la w e nfo rc e me nt, o r b o th.
T he OIG’s Inve stig a tion F
T he Ho tline ma d e e rro rs tha t e ithe r d e la ye d o r pre ve nte d injurie s fro m b e ing a sse sse d .
Me d ic a l info rma tio n wa s re pe a te d ly misinte rpre te d b y DHHS a nd la w e nfo rc e me nt, le a d ing the m to d ismiss the c hild ’ s re c urring injurie s.
Inve stig a tio ns into the po ssib le a b use we re fla we d . K e y e vid e nc e wa s no t g a the re d , inc lud ing pho to g ra phs
DHHS sta ff d id no t fully re ly o n the ir a sse ssme nt to o l to g uid e d e c isio ns a b o ut c hild sa fe ty.
A slo w tra nsitio n to o ng o ing c a se ma na g e me nt me a nt tha t e ve n tho ug h a c a se wa s o pe n whe n the c hild ’ s se rio us injury o c c urre d , no suppo rts o r se rvic e s we re b e ing pro vid e d to the fa mily.
Ba se d o n the finding s in its inve stig a tio n, the OI G re c o mme nde d:
Imple me nt tra ining o n the me d ic a l a spe c ts o f c hild a b use .
Ad o pt po lic y o n pho to g ra phing injurie s d uring Initia l Asse ssme nt.
De ve lo p a d d itio na l, spe c ia lize d tra ining fo r Initia l Asse ssme nt sta ff.
F urthe r d e fine pro c e ss fo r utilizing c hild a d vo c a c y c e nte rs b y Initia l Asse ssme nt.
Upd a te a nd pro vid e a d d itio na l d e ta il o n re spo nse prio rity d e finitio ns a t the Ho tline .
Co nd uc t a n a na lysis to d e te rmine whe the r supe rviso ry sta ffing a t the Ho tline is a d e q ua te .
E xpa nd q ua lity a ssura nc e a nd c o ntinuo us q ua lity impro ve me nt (CQI) a t the Ho tline . DHHS a c c e pte d a ll re c o mme nd a tio ns.
Case Sc e nario: Be twe e n July 2013 a nd June 2015, 2 de a ths a nd 9 se rio us injurie s fo llo wing a
c hild ma ltre a tme nt inve stig a tio n we re re po rte d to the OI G. Afte r e a c h o f the DHHS inve stig a tio ns (a lso c a lle d I nitia l Asse ssme nts), no c a se wa s o pe ne d to o ffe r o ng o ing se rvic e s to the fa milie s. I n a ll o f the c a se s, the injurie s we re c a use d b y a b use
he OI G e xa mine d e a c h c a se a nd a lso ide ntifie d tre nds a nd la rg e r issue s.
T he OIG’s Inve stigation F
Childre n a g e 3 a nd unde r we re the vic tims in e ve ry c a se . T he OI G fo und spe c ific c ha lle ng e s whic h limite d the e ffe c tive ne ss o f I nitia l Asse ssme nts with ve ry yo ung c hildre n.
Physic a l a b use b y the c hild’ s fa the r o r mo the r’ s ma le pa rtne r wa s the c a use o f injury in the ma jo rity o f c a se s. Asse ssme nt o f the pe rpe tra to rs wa s o fte n limite d b e fo re the de a th o r se rio us injury.
Ha lf o f the fa milie s sc o re d a s hig h risk fo r future a b use o r ne g le c t b y DHHS. Ho we ve r, e ve n tho se tha t sc o re d a s mo de ra te risk ha d sig nific a nt risk fa c to rs fo r a b use a nd ne g le c t pre se nt.
Mo st c hildre n injure d live d in rura l c o mmunitie s, whic h impa c te d I nitia l Asse ssme nt pra c tic e a nd fa milie s’ a c c e ss to re so urc e s.
I n ha lf o f the c a se s, the Ho tline re c e ive d a n a dditio na l c a ll b e twe e n the I nitia l Asse ssme nt c lo sing a nd the de a th o r se rio us injury. E rro rs we re ma de tha t limite d DHHS’ a b ility to a ppro pria te ly sc re e n c a lls.
E ve ry inve stig a tio n c o nduc te d b e fo re a de a th o r se rio us injury invo lve d la w e nfo rc e me nt, me dic a l pro fe ssio na ls, o r b o th. Po o r c o o rdina tio n with o r po o r pra c tic e b y the se e ntitie s c o ntrib ute d to b a d o utc o me s in ma ny c a se s.
I nitia l Asse ssme nt po lic y a nd pro c e dure we re no t c o nsiste ntly fo llo we d. Re q uire d do c ume nta tio n wa s no t g a the re d a nd inte rvie ws with ke y c o lla te ra l c o nta c ts did no t o c c ur.
I nitia l Asse ssme nt a nd mixe d c a se lo a ds do no t c o mply with sta te la w. Hig h c a se lo a ds ne g a tive ly impa c t the a b ility to do tho ro ug h, q ua lity wo rk a nd fo llo w DHHS po lic y.
Ba se d o n the finding s in its inve stig a tio n, the OI G re c o mme nde d:
Inc re a se the Initia l Asse ssme nt wo rkfo rc e to c o mply with Ne b ra ska la w o n c a se lo a d sta nd a rd s.
T a ke ste ps to wa rd g re a te r Initia l Asse ssme nt wo rkfo rc e spe c ia liza tio n a nd e xpe rie nc e .
Co ntra c t with a n ind e pe nd e nt e ntity to pe rfo rm a va lid a tio n stud y o f Ne b ra ska ’ s SDM Risk Asse ssme nt instrume nt.
Ga the r a nd a na lyze a d d itio na l d a ta o n the pre va le nc e o f pe d ia tric a b usive he a d tra uma a nd upd a te sha ke n b a b y synd ro me ma te ria ls d istrib ute d b y the Divisio n o f Pub lic He a lth.
Inc re a se the c a pa c ity fo r the CF S wo rkfo rc e to pa rtic ipa te in pe d ia tric a b usive he a d tra uma pre ve ntio n e ffo rts.
Inc re a se the numb e r o f supe rviso rs a t the Child Ab use a nd Ne g le c t Ho tline a nd a sse ss Ho tline wo rklo a d a nd o ng o ing tra ining a nd supe rvisio n.
E nha nc e d a ta a va ila b le o n Initia l Asse ssme nt a nd mixe d c a se lo a d s a t Ce ntra l Offic e a nd ma ke this info rma tio n pub lic a lly a va ila b le o n a mo nthly b a sis.
Co lle c t d a ta o n hig h a nd ve ry-hig h risk c a se s tha t d o no t a c c e pt se rvic e s a nd imple me nt mo re pro mising a ppro a c he s to fa mily e ng a g e me nt.
Re struc ture the Child re n’ s Justic e Ac t (CJA) ta skfo rc e to e nsure the re is a wo rking g ro up fo c use d o n impro ving c hild a b use inve stig a tio ns, e spe c ia lly multid isc iplina ry inve stig a tio ns. E nha nc e mo nito ring o n ho w CJA fund s a re spe nt to e nsure the y a re a d d re ssing syste mic g a ps in c hild a b use inve stig a tio ns. DHHS a c c e pte d a ll re c o mme nd a tio ns.
Case Sc e nar io: During the 2015-16 fisc a l ye a r, the OI
G e xpe rie nc e d a mo re tha n 300 pe rc e nt inc re a se in c o mpla ints a nd c ritic a l inc ide nts re la te d to the Yo uth Re ha b ilita tio n a nd T re a tme nt Ce nte r-K e a rne y (YRT C-K ), Ne b ra ska ’ s re side ntia l fa c ility fo r b o ys in the juve nile justic e syste m. T he inve stig a tio n fo c use d o n the a dministra tive o ve rsig ht a nd de c isio n-ma king tha t a llo we d a de te rio ra tio n o f c o nditio ns a nd vio la tio ns o f sta te la w a t YRT C-K to g o unc he c ke d while the fa c ility wa s witho ut a full-time a dministra to r.
T he OIG’s Inve stig a tion F
K
e y da ta me a sure s sig nific a ntly wo rse ne d while YRT C-K wa s witho ut a full-time a dministra to r;
T
he de c isio n to re mo ve the prio r fa c ility a dministra to r wa s ma de ha stily a nd unde r o utside pre ssure , witho ut a de q ua te c o nside ra tio n fo r the impa c t it mig ht ha ve o n the yo uth a nd fa c ility;
T
he re wa s no a ppro pria te pla n in pla c e fo r ho w YRT C-K wo uld o pe ra te unde r inte rim a dministra tio n;
T
he Offic e o f Juve nile Se rvic e s (OJS) Administra to r wa s no t a b le to fulfill jo b dutie s re la te d to YRT C-K , le a ving the fa c ility witho ut a ppro pria te o ve rsig ht;
Ce ntra l Offic e a dministra to rs we re una wa re o f the spe c ific s o f pro g ra ms a nd pla nning a t YRT
C- K tha t we re unla wful a nd pro duc ing ne g a tive o utc o me s fo r yo uth; a nd
Yo uth a t YRT
C-K , e spe c ia lly tho se living fulltime in the Dic kso n Unit, we re c o ntinua lly sub je c t to c o nditio ns tha t we re no t c o mplia nt with Ne b ra ska la w.
Ba se d o n the finding s in its inve stig a tio n, the OI G re c o mme nde d:
Ma ke the OJS Administra to r a F
ull-time Po sitio n
Clo se o r Appro pria te ly Re struc ture F
ull-time Se c ure Ca re Pro g ra m in Dic kso n, D5
De ve lo p Co ntinuo us Qua lity I
mpro ve me nt Pro c e ss L e d b y Ce ntra l Offic e
De ve lo p a nd imple me nt a c o mpre he nsive Stra te g ic Sta ffing Pla n a t YRT
C-K
Dig ita lize Re c o rds
DHHS a c c e pte d 4 o f 5 re c o mme nda tio ns.
Wa lk-I
ns o r Appo intme nts
E
ma il: OI G@ le g .ne .g o v
Online c o mpla int fo rm: o ig .le g isla ture .ne .g o v Pho ne : 402-471-4211 o r 855-460-6784
Co nta c t o ur o ffic e : I nspe c to r Ge ne ra l o f Ne b ra ska Child We lfa re 1327 H St, Suite 306 402-471-4211