he Commonwealth of Massachusetts Department of Early Education and Care 1250 Hancock Street Suite 120-3, Quincy, Massachusetts 02169 Date: May 10, 2012 IN ESTIGATION REPORT Incident 61686 Facility 4904129 Name of Facility: Massachusetts Mentor Lawrence Address: 12 Methuen St, Floor, LAWRENCE, MA 01840-1866 Intake Date: 01/24/2012 Report Date: 04/3/2012 Facility Description: A specialized foster care program. Reason for Investigation?: On Saturday, January 21, 2012 at about 11:00 am, a 2 months old child died While in foster care. The cause of death is unknown. Investigation Activities: This investigator had telephone contacts with the DCF investigator, the program manager, and a state trooper. This investigator reviewed the DCF 51 A report and a draft police report. On February 2, 2012 this investigator and the DCF investigator made a scheduled visit at the program. The licensee?s quality assurance manager was present. Interviews were conducted with 2 supervisors and one social worker (coordinator). The foster mother?s record and the child?s record were reviewed. This investigator, the DCF investigator, and quality assurance manager visited the foster home on February 2, 2012. Interviews were conducted with the foster mother and foster father. Telephone interviews were conducted with 2 DCF supervisors and the previous DCF foster mother. This investigator had a telephone contact with a representative of the medical examiner?s of?ce. Determinations: This investigation revealed serious violations of the child placement regulations. On January 21, 2012 a 2 months old child died while in foster care. The cause of death is ?sudden unexplained death,? noting maternal substance abuse. Although the foster mother and the foster father reported that they are aware that infants need to sleep on their backs, safe sleep practices were not followed by the foster parents. The child was dressed in ?eece pajamas, over a ?Onesie,? swaddled in a receiving blanket, placed on her side in a port?a?crib, with a crocheted blanket on top of her, and a blanket rolled up on each side to prevent the child from moving. The foster mother found the child sweating, and not breathing. The foster father was found to have neglected the infant, as evident in the DCF 51 report. The licensee reported that safe sleep information is not given to foster parents who care for infants. Although this investigator discussed with the program manager the need to immediately inform foster parent of the safe sleep procedures, 12 days after this child's death, aworker responsible for supervising the caseworkers did not have knowledge ofthe safe sleep practices for infants. The licensee failed to obtain any medical information on the child. The foster mother reported that the child was in her care for 8 days, but she did not have the child's Mass Health information or any medical information. Although DCF supervisors could not locate any medical information in the nap records, the licensee failed to followup with her once the child was placed in the foster home. The child was placed in the licensee's foster home on January 13, 2012, but the coordinator was not informed she was assigned to the home until January 20, 2012. The coordinator never visited the foster home or saw the child, The program failed to follow the licensee's own procedures which require weekly visits to the foster home. During this investigation, it was revealed that coordinators assigned to foster homes are not reading the foster parent's record. Information is lac in the record without being reviewed by the worker assigned to the home, then, a supervisor was aware ofa letter written by a previous foster parent and given to the foster parent, but she failed to read the letter or obtain a copy for the child's record The letter contained significant information concerning the child's temperament and sleeping habits. The licensee failed to have procedures to ensure communication between previous coordinators assigned to the home and a new coordinator assigned to the home. The foster patents involved in this investigation did not have a current CPR and first aid certification. The placement history found in the foster parent's record was incomplete, not listing all children placed in the home and it did not include dates of transfer or reason for transfer for the most recent children placed in their home. An individual child's placement agreement was not found in the foster parent's record. Other violations ofthc regulations included entries in records not signed and dated. evidence of completed trainings not found in foster parent's records and in personnel records, an incomplete orientation checklist for one staff member, and inconsistent information found in records. The licensee failed to immediately notify EEC ofthe death ofthe infant. Investigation Findings: 11 As a result ol'reviewing the DCF 51 A report, this learned that at time of her death, a 2 months old child (LM was in tem urary 1)le custody. LM was placed in the licensee's foster home of nd Francisco Eloise, located in Beverly, MA, On Saturday, January 21, 2012, at 11:08 am, LM was transported via to Beverly Hospitalr LM was pronounced dead at 11:59 am. The faster mother informed the hospital that at 9:35 am the foster father put the infant to sleep on her side, in her crib. The foster mother checked LM at about 11:00 am and found her on her stomach, not breathing. The foster mother immediately called 911. 2. During the initial contact with the program manager - this investigator learned that although LM had no known medical condition at the time of her death, the biological mother tested positive for heroin during her re nancy. He reported that LM did not test positive at the time of her birth. eported that there was a prior issue with LM's umbilical cord, but at the time of her placement it appeared to be healing well. -explained that initially LM was placed with her 9 years old sibling at a DCF foster home. The foster mother requested that LM be moved because she was so "fussy." Once moved to the Mentor foster home, LM continued to be "fussy." -reported that the foster mother attended MAPP training in 2003, but he is not aware ofthe training given at that time about infant care. He stated that there is no one in his office that was working for the program in 2003. _reported that the foster mother attended additional trainings, but he is not aware of her being trained in safe sleep practices for infants. . As a result (if telephone contacts, this investigator learned that the cause nf death is noted as "sudden unexplained death." The medical examiner also noted maternal substance abuse as a possible condition. The state trooper informed this investigator that the medical examiner informed him that the cause of death may be due to positional The trooper reported that there is no evidence of abuse and he described the foster parents as "appropriate," and "very attached" to LM. The trooper reponed that the foster parents have been cooperative during the investigation. He explained that LM was placed on her side to sleep and a red blanket or towel was rolled up on both sides of LM, to prevent LM from moving. . As a result of interviews with the foster parents _nd Francisco Bloise), this ator learned about the details surrounding the death ofLM on January 21, 2012. served as a translator for her husband due to her husband's En lish language being limited (Spanish is the foster parents' primary language). recalled that LM woke up at about 7:00am. She gave LM 4 ounces of formula and then changed her diaper. -reported that at about 7:25am she burped LM and then laid her down in a parka-crib, which was located in the dining room. -rccalled placing the infant on her back and tuming on the television. At about 3:35am, -Jegan to get ready for work. She is currently employed at the local hospital as a translator in the labor and delivery unit. Francisco picked up LM and was holding her at that time. He then placed the infant back in the port-a-crib so that he could go outside to remove snow. eponed that she lefi for work between 9:00 and 9:10 am and LM was in the port-arerib and Francisco was sitting in the ehair next to the p011>>a-crib. . Francisco reported that aner-lett, LM began to cry. He picked her up and carried her to the kitchen. He then gave her a bottle. she only ate about one ounce of formula Francisco reported that he burped LM and then swaddled her in arcceiving blanket. He demonstrated a traditional swaddle with the infant's arms wrapped inside the blanket. - later informed this investigator that LM was wearing fleece pajamas over a "Onesie." Francisco reported that at about 9:303m he laid LM on her side in the portra-erib. He placed a crocheted blanket on top ofLM. Francisco recalled also having a "thmw" blanket (described as thicker than a receiving blanket) in the port-n-crib, under LM. He rolled up each side of the blanket, securing LM in her side position (creating a wedge on the back and the front ofLM). Upon invesfigatots' request, using a doll, Francisco demonstrated the position of the baby between the rolled up edges oftbc blanket. He showed that the rolls extended up to the infant's chin. later in the visit, Francisco reported that he also gave LM her pacifier and placed LM's bottle, containing the remaining formula, inside the port-a-crib. Francisco denied that he propped the bottle for LM to drink. He explained that he stored it in the crib in case he needed to feed LM latcr. Francisco reported that he then went to clean the kitchen, but walked in and out orthe dining room and obsewed LM sleeping. 6. "reported that she arrived back home between 10:40 am and 10:45 am. she reca ed Francisco saying that eve ing was Francisco left the home to go to Waigreens to buy diapers. $513th that she sat in the kitchen and had a cup of coffee-reported that her 4 years old daughter (w peeial needs) cried for her after hearin her mother on the telephone. then sat her daughter at the kitchen table. eported that at about 10:50 am she went to check on LM and saw her on her stomach, with her face to the side. She immediately observed that LM was "all sweaty." then placed her hand on back and discovered that LM was not breat mg. he immediately called 91 1, using her cell phone. -mted that she continually pet-fonncd CPR while speaking to the dispatcher. Francisco then entered the home and-sent him downstairs (the home is a second floor apartment) to wait for the emergency responders. 7. During their interview, -and Francisco reported that they are aware that infants are to sleep on their back. They confirmed knowing this prior to LM's death. -could not recall where she learned this information, stating that she has been to different trainings. In response to questions,- stated, was more comfortable on her that she never received any medical information on LM. She also stated that at the time of placement she was not given any written information, including LM's date of birth, with the exception of a letter from the previous foster mother. According to - this was the first time a child was placed in her home without information. 3. During interviews with the licensee's staff members, this investigator was informed that LM was placed in the foster home on Friday, January 13, 2012. The intake occurred at the foster home, with the DCF worker and a Mentor supervisor -. During the intake, the DCF worker gave the foster mother a letter, which was written by the previous DCF foster mother. -errplained that she did not read the letter at that time because she thought it was only an explanation afLM's feeding and sleeping schedule. -stated that no one at the program read the letter. After LM's death, the foster mother gave - a copy of the letter as she requested. -reponed that the letter contained information regarding the child being a restless baby. This investigator received a copy ofthe letter, which described LM as being "intense at times," noting that she can be "particularly fictful" in the evening. The DCF foster mother wrote, are times the only thing that calms her is the vacuum or white noise. . .0verall 10. 11. would not call her a content baby." The DCF foster mother explained that she usually and rocked LM to sleep, noting that she sleeps better when she is swaddled. She noted, "Unfortunately I could not get her to lay in her crib so she only has slept in her car (LM's) perfect world she would like to be carried around and held all day." During this investigation, the supervisor - and the program manager reported that no one at the program had a "safe sleep" discussion with the foster arenl prior to placing an infant. After LM's death, the foster mother informed ihat LM slept better on her side. The licensee's quality assurance manager eportcd that the agency is now talking about training the start and foster parents in "safe sleep" practices for infants. This investigator gave the quality assurance manager written information regarding "safe sleep" practices. This investigator and the DCF investigator interviewed the supervisor - for the coordinator assigned to LM and the foster home. During that interview, stated that she knows that an infant needs to sleep on their back, but she also Stated that pillows should be placed on each side of the infant to keep them in place. This investigator and the DCF investigator again reviewed the "safe sleep procedures," emphasizing that pillows are not to be used with infants. The quality assurance manager reported that a coordinator was delivering the written information to a foster parent who is now caring for infants. During a telephone Contact, this investigator informed the program manager about the concern that 12 days after the LM's death, his staff members were still not trained in "safe sleep" practices. As a result of interviewing the licensee's staff members, this investigator learned that the coordinator, who was assigned as caseworker and the worker for the foster home. was not informed about her assignment until one Week afier LM was placed in home. The supervisors explained that LM was placed on Friday, January 13, 2012. Monday, January 16. 2012 was a holiday. A managers' meetin occurred on Tuesday, January 17, 2012, so the eoordinator's supervisor did not have the opportunity to inform the coordinator. On Wednesday, January 18. 2012, the supervisor did not have supervision with the coordinator and she was bu during the day. In response to this investigator's questions, the supervisor-reported that there was no emergency on Wednesday, but it was "just a busy day." so she cancelled supervision with the coordinator. '1 he supervisors reported that on Thursday, January 19, 2012, there was all day training. On Friday, January 20, 2012, the coordinator was informed about the assignment. This investigator and the DCF investigator interviewed the coordinator. - She explained that she was informed by her supervisor, prior to LM's placement, that she was the next worker up for a new client. She recalled seeing her supervisor -- at the copy machine at about 2:00 pm on Friday, January 20, 2012, and she asked her when she would get a new case -then told her that she forgot to inform her about LM's placement. --xplained that new cases are assigned to whoever has the least number 0 cases at the time and she 12. 13. 14. 15. usually is informed ahout new cases during supervision meetings, but cancelled the scheduled supervision on Wednesday, January is, 2012. insiructe to Contact the foster mother at the Iimc 5116 was informed about the new case, which she did. - reponed that-was not home, so she Ianned on seeing LM on Monday, January 23, 2012. According to have her an update on LM, stating that she had a supervised visit with the biological parent on Thursday, January 19, 2012, Although the licensee's "Coordinator/Mentor Contact Record" noted that the visit occurred on January 19, 2012, a weekly contaet sheet, whieh was completed by the supervisor during the intake, noted that the visit was scheduled for Friday, January 20, 2012. The tester mother continned that the visit with the biological mother happened on Friday, January 20, 2012, During her interview, eponed being assigned 8 children, which are placed in 5 different foster homes Along with being the 0 children's coordinator, she is also assigned to supervise foster homes, where these children are placed. Interviews revealed that the coordinator assigned to the foster child is always the same worker as the one assigned to the foster home, In the event that a child is removed from the foster home, then the coordinator moves with the child and a new placement's worker will be assigned to the foster home. The licensee did not have procedures in place to ensure communication hetween workers. The last foster care review occurred in January 2012, prior to placement by a worker. The foster mother had no children in care at the time ofthis review and the worker did not communicate with any previous worker assigned to the home. The licensee did not have a system orcommunieation in place to ensure information is relayed to a person completing a review. This investigator reviewed the foster parent's record. The recent history of placements noted in the record did not include LM. In addition, the history of placements did not include the dates a child was transferred from the home or the reason for transfer. The foster parent's record did not contain LM's individual service agreement. This investigator did not find any trainings completed by the foster father (Francisco) in the foster mother's record, hut the supervisor reported that he did attend a "reservice training in 20 I 1 which should have been documented by the coordina assigned to the hom tthat time. The roster parent's record eluded were om leted 2009 a program director and worke were not aware ofthis notation made by the The foster parent's record adso contained an "Addendum to Narrative." This addendum is not dated and not signed. It refers to the foster parents heing "mentors" since February 2003, which shows that it is not an addendum to the original home study. A review of the child's record revealed that the licensee never obtained any medical information on the child. The child's placement agreeman dated 16. 17. 18. 19. January 10, 2012, included the dates of mother's positive drug screens. but noted that upon LM's delivery both mother and baby tested negative. The placement agreement included that there are no special medical needs. he individual service agreement was located in the child's record and noted that the information for the child's physician is "unknown 7 information requested." This investigator reviewed the "Coordinator/Mentor Contact Record," which included that on Janu 25 2012 the program manager had a telephone contact with the foster mothek. In response to his questions, the foster mother reported that her CPR certification had expired and she did not recall why she did not attend the classes offered in the summer of 201 1. During this investigator's and the DCF investigator's interview with she reported that she is certified in CPR and first aid but she and her husband cannot locate any evidence of their certification During this investigation, the program manager reported, "There is no practice for coordinators to review (foster parent's) files" when assigned to a foster home. He also reported that training of staff occurs on a "crises basis," which resulted in staff members not being thoroughly trained. During her interview, the coordinator stated that she did not complete her orientation prior to her case assignments. This investigator reviewed the licensee's orientation checklist for LM's coordinator, titled, "Training New Coordinators. The checklist was incomplete, failing to show any dates of completion for any portion of the orientation. This investigator discussed with the program manager the need to immediately notify EEC about a death of a child. The program manager sent the EEC licensor an email on Monday, January 23, 2012, asking her to call him and he also noted, need to update you about a situation that occurred." The licensor returned his call on Tuesday, January 24, 2012. This investigator instructed the program manager to speak to the EEC lieensor on duty and not to leave messages or emails for a Licensor. Aficr learning that the licensee has no medical records or medical information in LM's record, this investigator contacted 2 DCF offices, which managed LM's ease. DCF could not locate any medical records and explained that there were errors with the activation of LM's Mass Health. This investigator conducted a telephone interview with the LM's previous DCF foster mother, who had a copy of the discharge summary from the hospital. The summary noted that the biological mother tested positive on 3 occasions during her pregnancy; 8/22 positive for opiates. 9/6 positive for oxycodone, and 10/24 positive for benzodiazephines. At time of birth, LM started on protocol," (which is an assessment tool used for infants at risk of narcotic withdrawal). The summary included that LM's urine and meconium screens were negative. A follow>>up appointment was scheduled for 1/25/2011. 20. The DCF foster mother identified a pediatrician who saw LM twice while in her home. The foster mother recalled that LM was seen by the pediatrician one week after being placed at her home for 8 well baby check. LM was seen a second time because die umbilical cord was not healing correctly. The DCF foster mother reported that at the time she took LM to the pediatrician for her first round of immunizations, she ws sent away because of outstanding bills. She then leamed that there was a problem with the Mass Health, Although not noted in LM's record, the DCF foster mother reported that a visiting nurse came to the foster home every Week for the first 6 weeks to assess risk of withdrawal due to LM being exposed to drugs in mere. 21. The DCF foster mother reported that she made a referral for LM to have an early intervention (ED evaluation. This investigator reviewed the El evaluation, which noted that the referral earne from DCF due to the foster mother reporting concerns about LM's sleeping patterns. It is also noted that the foster mother observed some stiffness in IrM's upper extremities. The evaluation's summary noted that LM is a one month old inf scored within age expeetations in all the developmental domains Therefore she is not eligible for early intervention services," It was also noted that the El team mailed sleep information to LM's foster parent, 22. During her interview, the DCF foster mother reported that l/M was moved to the Mentor foster home because she could not manage an infant with her own 4 children and 2 other foster children. stated that LM did not sleep well and was fussy. She stated that LM slept in a car seat because LM would not get to sleep when place flat in a crib. The DCF foster mother reported that she never informed the DCF worker about LM sleeping in a car seat because no one ever asked about it. 23. This investigator reviewed the licensee's policies and procedures that were submitted to EEC licensing unit. A procedure, 3 dated May 22, 2009, Show that Visits are made to the foster home on a weekly basis. A manager must approve a visit to be missed and contact the DCF worker for approval. Also, a corrective action plan submitted to EEC in 2005 in response to a serious investigation, noted that Mentor will obtain "prior to placement of a child" the most recent medical examination. 24. EEC ms informed that DCF determined that the foster father neglected the infant, due to the unsafe position. Non-cumpliances: See attached. .mi .angnu :96" E: 2,5 Eo ESE 9 355% was 9; .2. as: .2 was $155 .maom .mEa; 538 335 m5 Sana Egg .5 .c m5 2 95%. 853.0%950 28553 a ?38 5 $2 a. . :33is; 3322: ES 52.; $89 5 Emma mm; co 2:98 Ewe. ES .2 9a 3333:" Em ?2.65 .uom 2 59.3.5? . mite m2: m5. .4 ?86 3.2. :8 <.2522 mocflano 21:9:me The licensee failed to establish a system of business management to assure that the agency maintains complete and accurate records, as evident by children's records and foster parents record missing signi?cant information and having incomplete information. In addition, at least on personnel record did not contain evidence of a completed orientation. The licensee failed to immediately notify EEC about a death of a child. There was no evidence to show that an employee completed the agency's orientation. An orientation checklist for the employee was incomplete and not dated. At the time of this investigation, this employee was the assigned caseworker for 8 children and supervising 6 foster homes. The employee reported that she did not complete all sections of the orientation. A supervisor failed to adequately supervise a social worker (coordinator) ?to ensure continuity of planning for a child and the family. The social worker was not aware that she was assigned to an infant and her foster family until seven days after the placement. A child's record did not contain any medical information, including the date ,of the child's most recent medical examination, health history, and recommendations concerning future examinations, care and treatment, and immunizations. .. 17 Kmv?ch-?t MA . u, rh? mm? Print Date: 9I2012012 Page 2 on; $5.25559: mm 528 . 8 Eu 2950 9,2 .2 23:23 .232 .mmsumuoa Sac we a. BEE. mm .532 5 Emma 25 5.5.2 mEizu .u 2% 9: 9:2 .8 ?238; $3.239 y: .33 2 a: 6: mm; EUR82 ?ng 53 252 3.32 22.8% 9: eon! .8.qu 2. $9 6: 3 SEE ?533 95 3:93 .33 m: 32>> En EmEmaaEm. m. Eu m5 EEBCS gauge; 28.235 323:8 5:2 2: .989 5.5. 89 a: 2:83.83 2: imzmfia .23. 30:53 52:32 .53 5.3. mama is; non E035 $53,233 $35 @352 .55 m5 m;me .mzussg 2. Ezmm ea 3% 6: ea: $289 9323 E: 5 8.82 mtoae Sass .<