Overview

The Department of Children and Families (DCF) does not ensure that it is aware of all incidents of abuse, neglect, and injury involving children that it serves. If DCF does not effectively monitor the medical services provided to children in its care, unreported critical incidents may go undetected. This can put children at risk of further abuse, neglect, and bodily injury.

Using the information in the Medicaid Management Information System (MMIS), we analyzed the medical information related to a sample of 566 children in DCF care and found 617 occurrences that appeared to involve serious bodily injury to a child, based on the description of the medical treatment provided. For 260 of these occurrences, DCF had no record of their ever being reported to the department or of DCF identifying them as incidents that should be followed up to determine whether they were critical incidents that should have been reported and possibly investigated. Examples of these occurrences include a 15-year-old with brain damage from a firearm injury, a 1-year-old with first- and second-degree burns on multiple body parts, and a 12-year-old with multiple head contusions that the treating physician determined were a result of an assault.

Serious Medical Incidents Involving Children in DCF Care

 

Assault

Weapon

Drug Overdose or Poisoning

Suicide Attempt with Injury

Fire-Related Injury or Severe Burn

Bone Fracture

Total*

Not Reported to DCF

147

26

96

101

30

150

547

Vendor Major Incident Report

10

2

2

25

0

12

44

51A or Institutional Abuse Report

8

0

2

14

0

4

26

 

165

28

100

140

30

166

617

*    The sum of the individual columns will not equal the Total column because there are incidents classified in multiple categories (e.g., assault with a weapon would be classified under both Assault and Weapon). The Total column represents unique incidents, which means that the same incident can only be counted once no matter how many categories it is found in.

†    A vendor major incident report is a written report filed by a licensed individual (i.e., someone who has been approved by DCF to care for children in its custody) detailing an incident that occurred. Some examples of major incidents are incidents that require emergency room visits; suicide ideation or attempts that require medical attention; and injuries resulting from use of weapons.

Authoritative Guidance

Section 1.02 of Title 110 of the Code of Massachusetts Regulations (CMR) states, “In delivering services to children and families the Department shall . . . seek to ensure the safety of children.” To meet this responsibility effectively, DCF should use all the information and resources available to it to monitor all incidents involving the health and safety of children in its care, even those that are not reported by mandated reporters, to determine whether any actions are necessary.

Reasons for Noncompliance

DCF has not implemented policies, procedures, or processes for routinely monitoring MMIS to identify types of medical services provided to children in DCF’s care and to investigate cases that might indicate abuse or neglect. Further, DCF relies on mandated reporters to notify it of critical incidents involving children in its care. However, there are certain types of serious bodily injury that mandated reporters are not required to report to DCF, including ones that occur in homes, institutions, and other settings such as schools, but were not caused by the child’s caretaker/s.

Recommendation

DCF should establish policies and procedures that require its staff to routinely monitor MMIS data to ensure that it can identify, and investigate as necessary, medical occurrences that appear to be critical incidents involving children in its care.

Auditee’s Response

DCF provided overall comments on this report as well as comments specific to each finding. DCF’s overall comments are as follows.

Since September 2015, DCF has been engaged in significant system-wide reforms that are fundamentally changing the way we do our work. Among these reforms are the development and implementation of seven new policies, including a new Protective Intake Policy and the Department’s first-ever Supervision Policy. The new Intake Policy provides a comprehensive set of procedures that guide DCF’s review and investigation of reports of abuse or neglect. The Supervision Policy strengthens supervisory support of social workers and improves decision-making by bringing special attention to practice areas including parental history, the parent’s ability to care safely for the child and factors such as substance use, mental health challenges or domestic violence that may impact child safety.

More than $100m in new resources has been added to increase the number of social workers on the front lines, to add specialty social workers in the fields of mental health, domestic violence, medical and addictions, to hire the first medical director and create a medical services unit, and to strengthen management and supervisory processes. A strengthened field structure provides consistent management and supervisory oversight while the Department’s completely new Continuous Quality Improvement program provides a means of routinely reviewing and improving clinical practice and decision making so that children served by DCF achieve the best outcomes. While the progress continues, the social work caseloads are the lowest in many years and almost 97% of social workers are licensed.

Recognizing the importance of collaborating closely with our community partners as child welfare is not the work of one person or one agency, the Department remains committed to engaging in learning opportunities in order to improve upon our work.

DCF’s comments specific to this audit finding are as follows.

M.G.L. ch. 119, sec. 51A requires certain individuals, such as doctors, to file reports with DCF when they have reasonable cause to believe that a child is being abused or neglected. These mandated reporters are subject to financial penalties should they fail to file a report. Additionally the law requires all licensed mandated reporters to take training to “recognize and report suspected child abuse and neglect.” The Department regularly conducts trainings for mandated reporters across the state as well on-line trainings developed by local District Attorneys are available on the Internet. While the responsibility to report remains with mandated reporters, DCF will determine the feasibility of accessing MassHealth claims data in its MMIS system to identify medical treatment that may indicate a child was abused or neglected and should have been reported to DCF (either by our providers or by mandated reporters such as doctors and hospital staff). Given the fact that this data is claims data and likely several months old by the time it might be available to DCF, any process will serve as an “after-the-fact” quality indicator.

Auditor’s Reply

Although there is a statutory requirement for mandated reporters to provide DCF with information regarding children who have been abused or neglected, based on the data we reviewed, for a variety of reasons this does not always appear to happen, in which case some children may be at a continued risk of abuse and/or neglect. Therefore, the Office of the State Auditor (OSA) believes that DCF, as the state agency charged with overseeing the protection of children, is responsible for taking whatever measures it has available, including reviewing the MassHealth data regularly to ensure that it is aware of all potential instances of neglect or abuse of a child and can act on these situations appropriately. In its response, DCF asserts that “given the fact that this data is claims data and likely several months old by the time it might be available to DCF, any process will serve as an ‘after-the-fact’ quality indicator.” We do not agree with this assertion. In fact, based on OSA’s use of MassHealth data in this and other audits, claim information is typically available to be viewed in MMIS within 2 to 14 calendar days from the date the medical procedure was provided. Moreover, although there may be some lag time between the date of a potential critical incident and the time this information would be available to DCF, we believe it is better to receive this information late and act on it than not to receive it at all.

Based on its response, DCF is taking measures to address our concerns in this area.

Date published: December 7, 2017
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