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 ll F re e - 855-460-6784 o ig .le g islature .ne .g o v o ig @ le g .ne .g o v Pho to b y Mic ha e l Sa ue rs, lic e nse d b y CC 2.0

Ove rvie w of the OIG  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

Role of the OIG  Co nduc t c o nfide ntia l, inde pe nde nt inve stig a tio ns a nd re vie ws o f 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 o o k into a lle g a tio ns o f misc o nduc t a nd vio la tio ns o f la w b y individua ls a nd 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

Assoc ia tion of Inspe c tors Ge ne ra l Co Va lue s  Ho ne sty  I nte g rity “...T he pub lic e xpe c ts OI Gs to ho ld g o ve rnme nt o ffic ial ac c o untab le ...and to pre ve nt, de te c t,  T rustwo rthine ss ide ntify, e xpo se and e liminate fraud, ...ille g al  I nde pe nde nc e 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  Co nfide ntia lity the b asic princ iple s o f inte g rity, o b je c tivity,  Pro mo ting : 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,  Ac c o unta b ility fo rthrig htne ss, pub lic ac c o untab ility and  T re spe c t...” ra nspa re nc y  Go o d Go ve rnme nt -- Sta te me nt o f Princ iple s fo r Offic e s o f Inspe c to r Ge ne ra l, Asso c ia tio n o f Inspe c to rs Ge ne ra l  Hig h Pe rfo rma nc e

OIG Ope ra tions  Critic a l I nc ide nt Re vie ws I n F Y 2015-2016, the OI G re c e ive d 577 c a se s:  Co mpla int Re vie ws  385 c ritic a l inc ide nts (22 de a ths,  I nve stig a tio ns 20 se rio us injurie s)  Re po rts  155 c o mpla ints  I  24 re po rts o r re q ue sts fo r ndividua l I nve stig a tio ns info rma tio n  Annua l Re po rt  13 g rie va nc e re po rts fro m DHHS  Juve nile Ro o m Co nfine me nt

OIG Ope ra tions, F Y 15- 16  T 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

OIG Ope ra tions, F Y 15- 16  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

Inve stigation: Se r ious Injur y Afte r 11 Re por ts of Physic al Abuse 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 him. In the six mo nths b e fo re the injury, the Ho tline ha d re c e ive d 11 re po rts o f a lle g e d physic a l a b use o f the 4- 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 ound:  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 o f the c hild ’ s injurie s. Inte rvie ws we re no t a ppro pria te ly c o nd uc te d .  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.

Re c omme ndations: Se r ious Injur y Afte r 11 Re por ts of Physic al Abuse 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.

Inve stig a tion: De a th a nd Se rious Injury F ollowing Child Ma ltre a tme nt Inve stig a tions 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 o r ne g le c t. T 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.

F indings: De ath and Se r ious Injur y F ollowing Child Maltr e atme nt Inve stigations T he OIG’s Inve stigation F ound:  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.