OFFICE OF INSPECTOR GENERAL flE\ASi-( L\iiii i & It \i\N SERVICES Co\INIISSK IN FINAL REPORT Bate: January 26, 2015 OIG Case: 14876-15 Investigation Category: Texas Penal Code, Sec. 37.10. Tampering with Governmental Record Allegation: On October 12. 2014. this investigation was initiated by the 0111cc of Inspector General based on information received that a UPS Investigator Child Protective Services. Department of Family and Protective Services, Dallas. Texas. mishandled her work files and falsitied the lnlbrmation Management Protecting Adults and Children in Teas (IMPACT) system. . Summary of Activities: The Internal AtYairs Division conducted an investigation during the period of November 17. 2014. to January 26. 2015. The allegation UPS Investigator mishandled her work tiles and litisifed IMPACT is substantiated. These results arc based upon the following: • Interview with UPS Investigator Ill, who stated she documented- making lace—to-face contact in IMPA(’ I when she had only made telephone contact on cases she deemed not ‘serious” without any expressed concern. • Review of UPS investigator Hi’s records of transportation disclosed she (lid not claim travel in relation to the false entries made into IMPACT. • Interview with UPS Program Administrator, Dallas. who stated she was notified UPS investigator Ill falsified documentation in IMPAC’l’ in DFPS eases. UPS Program Administrator stated clients in this case confirmed UPS Investigator Ill did not complete a face-to-face visit that she documented in IMPACT. • Interview with UPS Investigations Supervisor, who stated clients confirmed UPS Investigator lii did mit complete a face-to-face visit as documented on IMPACT. UPS Investigations Supervisor stated client was unaware UPS had opened a ease on the family in 2014. UPS Investigations Supervisor staled UPS Investigator III admitted to copying inlbrmation from a DIPS case from 2Ol3and pasting it into the 2014 DFPS case to include the fitce to face contact with parents. • Interview with UPS Investigations Supervisor, who slated UPS investigator III also falsified entries in DIPS cases. UPS Investigations Supervisor stated the healthearc Iàcilitv reported UPS Investigator Iii did not complete fltce-to-faee visits with the child at the hospital UPS Investigations Supervisor stated UPS Investigator IH admitted to copying inlormation from a DIPS. from 201 3and pasting it into the 2014 DIPS case to include the face to flice contact with parents. • Interview ith UPS Program Director. DIPS. Dallas. (‘PS Program Director stated UPS investigator III falsified entries in DFPS eases. UPS Program Director stated UPS Ineesligator III did not make contact Reviewed By: 01G0002 (10/21/2014) Date: ,4?—22._-.c QIG Case: 14876-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL fIv\s IIFALNI & tit.AiAN SLRvWtSCt )\V\USSV)N FINAL REPORT with parent as documented in IM PACt. (PS Program Direcior stated CPS Investigator Ill also did not make a faeeto-face contact with clients that CPS Investigator Ill documented in IMPACT • • Interview 4ith CPS Special. Investigator, who stated a client conhrrned CPS Investigator HI interviewed. her over the telephone and did mft visit the residence. ( PS In; tsiigatot Ill icsigntd horn thc Ikpaltnknt ot Famib. and Protctti; Scrwccs on Noem&r 6 2014. _ ACtions raken Referred to Cynthia 0’ KeetIe, General Counsel, Department of’ Family and Protective Services. Austin. Texas; Tarrant County District Attorneys Office. Fort Worth, Texas. Reviewed By: OG0002 (10121/2014) Date: OIG Case: 14876-15 Page 2 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES COMMISSIoN FINAL REPORT Date: February 12. 201.5 OIG Case: 14954-15 Investigation Category: Child Protective Services Child Death Allegation: On December 8, 20 14, this investigation, was initiated by the Office of Inspector General upon receipt of infonnation that a child, whose family had Child Protective Services history, died due to co-sleeping, neglectful supervision, and substance abuse. The child death is being investigated by the Clebume Police Department. The medical examiner has conducted an autopsy; the cause of death is suspected co-sleeping, pending toxicology, histology, and cultures. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of December 8,2014 February 12,2015. The allegation that an Investigator Ill, Child Protective Services, failed to tollow CPS Handbook policies in CPS case is substantiated based on the following • Reviewed DFPS case pertaining to the death of a child which :dentihcd the actions and entries of CPS Investigators taken in the death investigation, such as adhering to established timelines, coordinating with law enforcement, making mandatory notification, historical data review, and conducting background checks of every member of the family. The case review indicated CPS Investigators followed established policies and procedures pursuant to the CPS Handbook. Other children were removed from the home and placed in foster care. • Review of historical DFPS case opened for physical neglectlunknown victim. The review showed actions taken by an Investigator III did not comply with established policies, procedures, and protocols pursuant to i:he CPS Handbook. The Investigator 111 did not initiate the case, did not interview and examine each alleged victim, did not interview- each of the alleged victims parents, did not interview collaterals with relevant information, did not check the criminal background of each alleged perpetrator. did not complete a safety or risk assessment, and did not document the case in iMPACT. The case has been merged with the death investigation case. • Interview with a Program Director, Child Protective Services, who said actions taken by the investigator III during the historical investigation, were not consistent with established CPS policies, procedures. and protocols. The Investigator HI failed to initiate the case within the 72-hour. did not document contacts within 24 hours, or complete the safety assessment or risk assessment on this Case. The Program Director stated these inactions by the Investigator III, might have caused the family to not receive proper services or have the children in the home being removed. — — Reviewed By: 01G0002 Revised 11-2014 Dale: OIGCase; 14954-15 Page lof2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SER\tcES CoMitssIoN FINAL REPORT The Investigator Ill was placed on a Level I Reminder on November 24, 2014 and resigned the same day from her position with Child Protective Services. Actions Taken: Referred to Trevor Woodruff, Acting General Counsel, Department of Family and Protective Services, Austin, Texas. fleviewed By 01G0002 Revised 11-2014 Date: 010 Case: 14954-15 Page2of 2 OFFICE OF INSPECTOR GENERAL rEx.’_s Hu:izni & HUMAN SURVICES COMMISsION FINAL REPORT Date: February 17, 2015 010 Case: 14957-15 Investigation Category: Texas Penal Code. Title S. Chapter 37. Section 37.10, Tampering with Govern mental Record Allegation: On December 9,2014. this investigation was initiated by the Office of Inspector Genera l, upon receipt of information, alleging a former CPS Family Based Safety Services caseworker reported false information in the Child Protective Services reporting system, Information Management Protecting Adults and Children in Texas (IMPACT). Summary of Activities: The Internal Affairs Division conducted an investigation during the period of December 9, 2014. to Fehruaiy 17, 2015. The allegations that a former CPS Family Based Safety Services caseworker reported false information in the Child Protective Services reporting system. IMPACT, and reported false information on state travel vouchers submitted for reimbursements are substantiated, based on the following: • Review of .DFPS case. in which the CPS caseworker documented she met fitce to face with family members in a CPS case tell times during the period May 13. 2014 November 7,2014. • interview with the caseworker’s CPS Family Based Safety Services Supervisor, who said she questioned witnesses in the case who did not confirm He information made by the CPS caseworker in IMPAC T regarding visits with the family members. • Interview with the director of the child’s daycare who said the child had not been visited by the CPS caseworker during the time the child attended their davcare. • Interview with family members in this CPS case who denied three of the visits the CPS casewo rker documented in IMPACT or claimed mileage for on travel vouchers. One family member said she no longer lived at the address on the date of one of the documented visits. • Review of the CPS caseworkers travel vouchers showed there were three instances in which reimbursements for travel were submitted tbr visits that could not he supported by witness testimony or additional evidence • interview with the CPS caseworker who admitted she may have made entries into IMPACT that were not factual. Actions Taken: This case has been referred to Trevor Woodruff, Acting General Couns el, Department of Family and Protective Services and Gail Falco Leyko, Assistan.t District Attorney, Collin County District Attomey Office, MeKinney. Texas. s 1 Reviewed By: 01G0002 (10/21/2014) Date: 12 2t-/i OIG Case: 14957-15 Page 1 of I OFFICE OF INSPECTOR GENERAL TEXAS hEALtH & RLM?J SER%lcEs COMMISSR)N FINAL REPORT Date: February 2, 201 5 OIG Case: 14958-15 Investigation Category: Texas Penal Code. See. 37.10, Tampering with Governmental Record Allegation: On December 9. 2014, this investigation was initiated by the OFfice of inspector General, based on information received, that an Investigator III, Child Protective Services. Department of Family and Protective Services, Dallas, Texas. falsified the Inthrmation Management Protecting Adults and Children in Texas (IMPACT) system. Summary of Activities: The Internal Affairs Division conducted an investigation (luring the period of December 9, 2014. to Febnary 12. 2015. The allegation that Investigator Ill made false entries in IMPACT is substantiated. These results are based upon the following: Interview with CPS Program Administrawr, Clehume. CPS Prow-am Administrator stated she was notified Invcsngator III talsihed documentation in IMPkCT on DFPS -J and DFPS CPS Program Administrator stated parties to these cases confirmed Investigator Ill did not complete face-to-face visits as documented in IMPACT Interview with CPS Program Director, Fort Worth. (‘PS Program Director stated Investigator III made an entry in LMPACT on DFPS ,stating contact was made with the thmily on October 29, 2014. Program CPS Director stated client confirmed Investigator III did not complete a face to face visit as documented in IMPACT. Interview with a CPS Investigator, DFPS, Cleburne. CPS investigator stated she responded to a subsequent report on DFPS involving the death of a child. The family reported having called Investigator III multiple times and never received a call back from the her. • Interview with CPS Investigations Supervisor, DFPS, Cleburne, CPS Investigations Supervisor stated Investigator Iii did not complete a face to face visit with DEPS t as documented in IMPACT. CPS Investigations Supervisor stated the family was unaware CPS had opened a case on the family in May 2014. CPS Investigations Supervisor also stated investigator III documented in IMPACT she traveled to the familVs residence on May 16, 2014, and met with the oldest child in school on May 18, 2014. CPS Investigations Supervisor stated Investigator lii’s travel did not reflect a trip to the client’s home on May 16, 2014, or a school on May IS, 2014. CPS Investigations Supervisor stared Investigator III Falsified her signature on the Safety Plan put in place on DFPS — — Reviewed By 01G0002 Revtsed 11-2014 Oate QIG Case: 14958-IS Page 1 of 2 • • • Interview with a CPS Investigator. DEPS. Clehurne. CI’S Investigator stated she was the primary worker CPS Investigator stated family on an alleged called in on November21. 2014 for DEPS reported not being aware a CI’S case had been opened on the family in May 2013. Investigator Ill refused to meet with the 010 investigator and would not Provide specifics to any cases in question. She stated too much time had elapsed since her resi1ation and she handled too many cases. Investigator Ill resiied from the Department of Family and Protective Services on November 24, 2013. Actions Taken: This case will be referred to Trevor Woodruff, Acting General Counsel. Department of Family and Protective Services, Austin; Johnson County District Attorneys Office, Tarrant, Texas. Rev)ewed By: 01G0002 Revsed 11-2014 Date: ,ç_J_ c DIG Case: 14958-15 Page 2 of 2 OFFICE OF INSPECTOR GENERAL [UxAS HEALtH & HUMAN SERVICES CoMMIssIoN FINAL REPORT Date: February 6, 2015 OlGCase: 15011.15 Investigation Category: Texas Penal Code, TitleS. Chapter 37, Section 37.10- Tampering with Governmental Record; Texas Penal Code. Title 7, Chapter 32 Section 31 .03 Theft Allegation: On December 12, 2014, this investigation was initiated by the Office of Inspector General, upon receipt of infbrmation, that a Child Protective Services (CPS) Investigator, Fort Worth, Texas. reported false inthrrnation during September 2014, and October 2014, in the CI’S reporting system, Information Management Protecting Adults and Children in Texas (IMPACT). Further, infonnation on travel vouchers regarding home visits niay have also been falsified.. The CPS Investigator resigned from employment on December 30, 2014. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of December 12, 2014. to February 6, 2015. The allegation that a tbrmcr CPS Investigator falsified inthrmation in IMPACT and on travel vouchers for October 2014 and November 2014 is substantiated. These results are based upon the following: Interview with an investigation Supervisor, Child Protective Services, Fort Worth, Texas. The Investigation Supervisor said she confronted the thrmer CPS Investigator regarding alleged falsified IMPACT entries as well as travel vouchers related to assicd cases. The Investigation Supervisor said the former CPS Investigator denied making false entries in his reports and travel vouchers; describing mistakes were made by “cutting and pasting” while preparing the documents. • Interviews were conducted with a grandmother of a Child Protective Service client, and a Child Protective Service client, regarding Department of Family and Protective Services (DFPS) ease The two interviewed said the former CPS investigator did not make contact with them on September 22. 2014, October 17, 2014, or November 26, 2014. IMPACT records indicated the ibnner CPS Investigator documented he visited those interviewed on September 22, 2014, October 17, 2014, and November 2c5, 2014, Further, the tbrmer (78 Investigator claimed travel to their residence in Grand Prairie, Texas to which travel reimbursement was made. • interview was conducted with a second CPS client, regarding DFPS case ‘The client said the fonner CPS Investigator did not make contact with her on October 28, 2014. IMPACT records indicated the former CPS Investigator documented he visited with the client’s children on October 28, 2014. Further, the Former CPS Investigator claimed travel to the client’s residence in on November 26, 2014. • Interview was conducted with a third CPS client, regarding DFPS case The client said she and her famil.y were home during the Thanksgiving 201 4holiday period, and the former CPS Investigator did not appear at her residence in The fhrmer CPS investigator claimed he travelled to thehome on November 26, 2014. in his travel voucher, Reviewed By: /C” fllflflflfl’)Qa,.tc.A1’I fl1A Date: OFFICE OF INSPECTOR GENER\L TExas HE\LIII & IIIAIAS Sl-RVI(rSCOMMN,tO\ FINAL REPORT • The Interview was conducted with a tztndfatlier ota CI’S client, regarding DEl’S case as the grandfather said the former CI’S Investigator did not appear at his residence in Ibrmer CPS Investigator claimed in his travel voucher for travel on November 25, 2014. The Firmer CPS Investigator refused to he interviewed and indicated lie wanted to speak with his attorney regarding ihis investigation. — • Actions Taken: Referred to Tnvor Woodruff. Acting General Counsel. Department of Family and Protective Services, Austin. Texas: Sharen Wilson, District Attorney. Tarraur County Texas. Reviewed By: OtGflflO2 RvcM il.Dnia Date: 22-cr’” nit’ ,“,.,,.,.,,. •cn.• r n,,.,,. ‘i ,.e . OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES CoMMssIoN FiNAL REPORT Date: June 24, 2015 OIG Case: 15014-15 Investigation Category: Child Protective Services Child Death Allegation: On December 12, 2014, this investigation was initiated by the Office of Inspector General upon receipt of information that a 4½-year-old died on November 25, 2014. The suspected cause of death was neglectful supervision. The involved family had Child Protective Services (CPS) history. The child’s death was investigated by the Harris County Sheriffs Office. The Harris County Medical Examiner has listed manner of death “homicide”, with cause of death pending. During the course of this investigation, it was discovered that four CPS employees involved in the casework of the deceased child and his family failed adhere to to established CPS Handbook policies by failing to properly document their case work, abide by timelines, failing to interview principal adults, and failing to evaluate a child prior to a safety plan. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of December 12, 2014, to June 24, 2015. Administrative violations discovered, however no violati contrib on uted to the death of the child. The allegations that four CPS eriployees failed to adhere to established CPS Handbook Polices in their casework involving the deceased child’s family are substantiated. These results are based upon the following: • Review of historical data of the deceased child and his family. All cases with the except ion of one occurred prior to the deceased child’s birth. One case involved allegations of physical abuse, which had a disposition of “unable to determine” based on a lack of evidence to support the allegation and an allegation of physical neglect with a disposition of “ruled out” based on a lack of evidence suppor to t the allegation and the children having food, clothing, and shelter. The historical data review of all the above cases indicated procedural actions taken by caseworkers did not comply with established policies, procedures, and protocols as outlined in the CPS Handbook Policy. These inactions included not properly documenting theii case work, not abiding by established tirnelines, failing to interview principal adults, and failing to evaluate a child prior to a safety plan. • Interview with a Child Safety Specialist, Houston, Texas, The Child Safety Specialist said she reviewed the historical DFPS cases involving the deceased child’s mother. She indicated one of the allegations was physical abuse, which had a disposition of “unable to determine” based on a lack of evidence to support the allegation and an allegation of physical neglect with a disposition of “ruled out”, based on a lack of evidence to support the allegation and the children having food, clothing, and shelter. The Child Safety Specialist said the actions taken by caseworkers during the historical investi gations were not consistent with established CPS policies, procedures, and protocols. The caseworker failed intervi to ew 8$ 0IG0002 Revised 11-2014 Date, /1- a-,r OIG Case: 15014-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALW&HUMAN SERVICES COMMISSION FINAL REPORT • • principals, and upload documents into IMPACT. The Child Safety Specialist said there was no CPS policy that required caseworkers to photograph or physically inspect weapons in a home. Interview with a CPS Investigator who said the DFPS Intake Report did not includ allegat e ions of weapons in the home and gun disclosure was not developed during the course of the investi gation therefore was not addressed. Interview with a second CPS Investigator, who said the DFPS Intake Report did not include allegations of weapons in the home and gun disclosure was not developed during the course of the investigation therefore was not addressed. CPS has no policy that required caseworkers to photograph or physically inspec weapo t ns in a home. Caseworkers are trained to inquire about weapons, where they are stored and if they are safe from reach of children. Three of the four employees involved in this case were not interviewed in this investi gation; due to being terminated from CPS employment. Actions Taken: Referred to Trevor Woodruff, Acting General Counsel, Department of Family and Protective Services, Austin, Texas. RM.ndBy: 01G0002 Revised 11-2014 Date: /i —‘2’-r ( 010 Case: 15014-15 Page 2 of 2 ‘OR OFFICE OF INSPECTOR GENERAL 1 EXAS Ht-.i Th & HUM \\ SLRVflS CoMwssio\ FINAL REPORT Date: January 20, 2015 OIG Case: 15025-15 Investigation Category: HHS, Human Resource Manual, Chapter 4, Employee Conduct, Section B, Standards of Conduct; ElKS, Human Resource Manual, Chapter 4, Employee Conduct, Section B, Work Rules (7)(8)( 18) Department of Family and Protective Sen ices, KR-2 104, Code of Ethics. Section 2.0, Section 6 1, Section 6.2, Section 66, ,Department of Family and Piotective Sauces, Child Care Licensing Manual. Section 3311, Section 3313, Section 3313 1. Section 1313 2, Section 3313.3, Section 1243 1 Allegation: On December 18, 2014. this insestigation was initiated by the Office of Inspector General upon receipt of infoimation that a Childcare Licensing lnspectoi. Department of Family and Protectis-e Scnices, entered into a business partnership with a childcare prouder to open a child care center in the area she teguhited. and issued the initial pci inn fin the operation on an incomplete Daycare Licensing Application. Summary of Activities: The Internal Affairs Disision condutted an investigation during the period of December 14.2014, to January 20,2015 The allegation that Child Licensing Ii spector entered into a daycare business partnership with a childcaie provider is substantiated based on the following Interview conducted with a Distuct Dizcctor, DFPS, who stated DFPS investigated a pros ider regarding a separate incident Dining the ins esti2ation, the prouder alleged she entered into a partnership with the Childcare Licensing Inspector to open a childcare center. The center subsequent]) closed • Interview conducted with the Childcare Licensing inspector, who denied entenng into a partnership with provider to open a childcaie center The Childcare Licensing Inspector denied paying the deposit fot the building where the childcare centei was operating, and denied her husband signed a lease for the building. The Childcaie Licensing Inspector saic the application submitted by pros ider for the chfldcaic center permit was incomplete, hut she only issued an initial permit for the Facility • Inteniew conducted with a provider, who stated she went into a partnership with the Childcare Licensing Inspector to open a childeare centei The provider said the Chtldcare Licensing Inspector paid $2,500 of the deposit tot the building whew the childcare center was located, and that the Childcare Licensing Inspector’s husband signed the lease agieement with provider [‘he Prouder stated the Chi[dcare Ucensing Inspector wanted her to care for her iwo small cousins in exchange for the licensing inspector’s asetance in open&ng the chililcare center The proudet said there were complications with the building. o the licensing inspector paid three days in a hotel so the providet could care for her children • Interview with the Program Adniinistrator, DFPS. who said she met with the prouder and obtained a copy of the lease agreement for the chtldcaie center The Program ‘\dnnnistiator stated the application Reviewed fly zi 01G0002 Revised 1 1-2014 Date _4L 4tzrs’ 010 Case- 15025-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL Thx s F1lAL1I1 & IRNI A SRvKES Cos1MLssto, FINAL REPORT • • • for the childcare center permit stihniitted by the provider was not complete, and the permit should not have been issued. It contained incomplete sections. the fee was not paid, operational forms for the wrong facility were arached. it did not contain a floor plan. and there was no proof of liability insurance Review of the lease agreement for the property, which indicated it was rented to the Childcare Licensiniz Inspector’s husband and the provider for the building, indicated the Childcare Licensing Inspector’s husband and the provider agreed to rent the location for a term of five years. for 53.000 a month rent and a 53,0(0 deposit. Interview with owner of property, who stated she rented the property for a term of five years to the Childcare Licensing Inspector’s husband and the provider. The owner said she met with Chi.ldcare Licensing Inspector. who identified herself as a Childcare Licensing Inspector for the State of Texas and was the person who paid the deposit for the building. Interview with a childcare center employee, who said she was hired by the Childeare Licensing Inspector and the provider to work at the childcare center. Actions ‘taken: Referred. to Trevor WoodrufL Acting General Counsel, Department of Family and Protective Services. Austin, Texas. Reviewed By: 01G0002 Revised 11-2014 Date: OIG Case: 15025-15 Page2of2 __________ OFFicE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERvIcES COMMISSION FINAL REPORT Date: February 2, 2015 OIGCase: 15132-15 Investigation Category: Health and Human Services Human Resources Manual, Chapter 4, Employee Conduct, Section B, (1) (2); Child Protective Services Handbook, Sections 1922, 2254, 23112,2377.2, 2388 Allegation: On January 8, 2015, this investigation was initiated by the Office of Inspector General, upon receipt of information, that a Special Investigator, Department of Family and Protective Services, has been showing personal involvement on an assigned case, has not been following policies in the investigation, and assaulted the mother and her boyfriend. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of January 8, 2015 February 2, 2015. Insufficient evidence was developed to support the allegation that the Special Investigator was personally involved with the mother or assaulted her and her boyfriend. The allegation that the Special Investigator failed to complete the safety assessment within 7 days. failed to document contacts within 24-hours and failed to upLoad photographs of the child into IMPACT, failed to drug screen the mother and boyfriend, and failed to obtain medical records or a medical release for the child as required by Child Protective Services Handbook is substantiated. These results are based upon the following: • Review of CPS case opened on November 11, 2014, for neglectful supervision of a child. The case was assigned to Special Investigator on November 12, 2014. The Special Investigator initiated the case on November 14.2014, and did not complete a safety assessment, did not document the case within 24 hours, and did not upload photographs taken of the child into IMPACT. The case was reassigned to another investigator on December 8, 2014, and is currently open. • Review of CPS case opened on May 17, 2014, for sexual abuse and neglectful supervision of child. The Special Investigator initiated the case on May20, 2014, and closed the case on October 31, 2014. The allegation of sexual abuse was administratively closed and neglectfifl supervision ruled out with factors controlled. The case was approved to be closed by a former CPS Supervisor. The Special Investigator completed the safety assessment on June 6, 2014, after the 7-day requirement, did not document the case within 24 horns, and did not upload photographs taken of the child into IMPACT. • Interview conducted with the Program Director, Department of Family and Protective Services, Child Protective Services, who said the Special Investigator did not follow CPS Handbook policies. He failed to complete the safety assessment within 7 days per policy, failed to document contacts within 24 hours per policy, failed to upload photographs of the child into IMPACT, failed to drug screen the mother and her boyfriend, and failed to obtain medical records or a medical release for the child on two CPS cases. — Reviewed By 01G0002 Revised 11-2014 Date: QIG Case: 15132-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HE.Lm & HUMAN SERVICES COMMISSION FINAL REPORT • • Interview conducted with the Special Investigator, who admitted he did not complete the safety assessments per policy, did not document contacts within 24 hours per policy, and did not upload photographs of the child per policy, due to personal health reasons and being overwhelmed by his large workload. The Special Investigator denied having a personal relationship with the family in question, and denied the family came to his residence. Interview conducted with the mother who denied that Special Investigator assaulted her or her boyfriend, denied she went to Special Investigator’s residence to borrow money from him, and denied she had a personal relationship with Special Investigator. Actions Taken: Referred to Trevor Woodruff, Acting General Counsel, Department of Family and Protective Services, Austin, Texas, -, , Roytewed By: 0lG0002 Revised 11-2014 Data: /€.Z 22-,f QIG Case: 15132-15 Page2of2 OFFICE OF INSPECTOR GENERAL UXAS HEALTH& HUMAN SERVICES COMMISSION FU4AI REPORT Date: April 17,2015 OIG Case: 15153-15 investigation Category: Texas Penal Code, Title 8, Chapter 37, Section 37.10, Tampering with Governmental Record Allegation: On January 15, 2015, this investigation was initiated by the Office of Inspector General, upon receipt of information that a 14 year old committed suicide on December 30, 2014 There was CPS History under Department of Family and Protective Services Summary of Activities: The Internal Affairs Division conducted an investigation during the period of January 15, 2015 to April 17, 2015. The investigation revealed that a former CPS Investigator, Department of Family and Protective Services, falsified entries into the Information Management Protecting Adults and Children in Texas system (IMPACT). The allegation is substantiated and based upon the following: • Review of historical data under Department of Family and Protective Services filed under DFPS indicated the former CPS Investigator failed to comply with CPS Handbook section 2210 General Provisions and 2241 Interview with Children which is corroborated with the following interviews: O The deceased child’s mother reported she was •never contacted, had telephone conservation, or received a business card” at her residence from the former CPS Investigator, as indicated in IMPACT entries. O A CPS Supervisor said she did not have a face to face staffing in with the former CPS Investigator as indicated in IMPACT entries. o The deceased child’s mother’s neighbor said he did not meet with the former CPS Investigator at his residence as indicated in IMPACT entries. O A Counselor from said she never met with the former ,,Jj, CPS Investigator regarding file deceased child’s suicide attempt as indicated in IMPACT entries. O A Lead Counselor from said the school safeguards provided no evidence the former CPS Investigator visited the school as indicated in LMPACT entries. • Interviews with a CPS Investigator 11, a Fatality Unit Supervisor, DFPS, Angleton, Texas and a Lead Counselor, ‘LIEjJ Texas. Those interviewed said that although, the former CPS Investigator did not comply with established CPS Handbook policies and procedures -2210 General Provisions Uncooperative Principal and 2241 Interview with Children. while handling the historical investigation, her inactions did not impact, nor were they, a contributing factor in death of the child. The casework indicated services were being provided to the family and revealed that the deceased child’s mother was proactive in addressing the childs depression and previous suicide attempt by providing immediate psychiatric care, — - . — - - - - - —. This ease was staffed with Adam Muldrow, Assistant District Attorney, Public Integrity Division, Harris County Reviewed By: 01G0002 Revised 11-2014 Date: /2- e&->-r OIG Case: 16153-15 Paae 1 of 2 OFFICE OF INSPECTOR GErtERAL TEXAS HEALTH & HUMAN SERVICES COMMISSION FINAL REPORT District Attorney’s Office, Houston, Texas. Muldrow agreed to pursue charges for Tampering with a Governmental Record against previous Melody the former CPS Investigator involving her actions in this case. Actions Taken: Referred to Trevor Woodrufl Acting General Counsel, Department of Family and Protective Services, Austin, Texas; Adam Muldrow. Assistant District Attorney, Public Integrity Division, Harris County District Attorney’s Office, Houston, Texas. Reviewed By tsr 01G0002 Revised 11-2014 Oa: /Z 22-> OIG Case: 151 sa-i 5 Prio 2 nf 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES COMMISSION FINAL REPORT Date: February 19, 2015 OIGCase: 15159-15 Investigation Category: HFIS Human Resources Manuel, Chapter 4, Section B, Work Rules (I) (2) (12); Child Protective Services Handbook, Section 3324, Making Face-to-Face Contact Allegation: On January 20, 2015, this investigation was initiated by the Office of Inspector General upon receipt of information that a. Family Based Safety Specialist, Department of Family and Protective Services, Child Protective Services, Hereford, Texas did not follow up on a home visit for the month of December 2014, as entered in the information Management Protecting Adults and Children in Texas system (IMPACT). The Family Based Safety Specialist was terminated from employment on January 17,2015 Summary of Activities: The Internal Affairs Division conducted an investigation during the period of January 20, 2015 to February 19, 2015. The allegation that a Family Based Safety Specialist did not follow up on a home visit thr the month of December 2014, as entered iii IMPACT is substantiated and based upon the following: in which the Family Based Safety Specialist indicated • A copy of the IMPACT report (DFPS December 18, 2014. This entry was later determined the children at their foster visited with home on he to be false. • Interview with a Supervisor, Department of Family and Protective Services, Child Protective Services, Amarillo, Texas. The supervisor said she questioned the Family Based Safety Specialist after receiving information that he did not visit a foster family, which housed children during the month of December 2014. The Family Based Safety Specialist documented he visited the children; however, the children were in school during the documented home visit. The supervisor said the Family Based Safety Specialist originally said he might have entered the wrong date. Ultimately, the Family Based Safety Specialist said he (lid not visit the children although he documented that he did. The supervisor said that. the children were not placed in harm’s way as a result from the non-visit. • Interview with the Family Based Safety Specialist, Department of Family Services, Child Protective Services, Hereford, Texas. The Family Based Safety Specialist admitted he did not visit the children at their foster home on December 18. 2014, even though he documented he did visit them, The Family Based Safety Specialist reason for the false documentation was “because he was behind on my paperwork”. The Family Based Safety Specialist said he was already on a level 2 disciplinary action for not keeping up with his papenvork. • Training records indicated Adcox had been trained in ethics permanency value training and IMPACT family plan of service training. Actions Taken: Referred to Trevor Woodruft Acting General Counsel, Department of Family and Protective Services, Austin Texas. Reviewed By: fliflriflfl9 Pawcc.el 11..2ri14 Date: 1-U-fl---. OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES CoMMISSIoN FiNAL REPORT Date: March 2.2015 O1G Case; 15180-15 Investigation Category: Texas Penal Code. Title 8, Chapter 37.02. Perjury Allegation; On January 21, 2015. this investigation was initiated by the Office of Inspector General upon receipt of information alleging that an Investigator, Department of Family and Protective Services. livalde, Texas, provided false information during a court hearing. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of January 21. 2015 March 2.2015. The allegation that Investigator provided false information in an affidavit and a court proceeding is substantiated. These results are based LlOfl the following: • Copy of certificate of completion for Parenting Education Certification for client, dated September 3, 2014. • Copy of certificate of completion for Anger Management Certification for client, dated October 15, 2014. • Copy of tile sign-in log for front desk of the Child Protective Services office, which indicated on October 15. 2014. client visited at 11:30a.m. and met with the Investigator. The log also indicated that at 3:25 p.m. client left copies of certificates with the Investigator. • Statement from an Administrative Tech, Department of Family and Protective Services, Uvalde, Texas, who verified the copy of the sign-in log, was from the front desk at the office. • Copy of affidavit prepared by the Investi ator. On page 14. the top paragraph stated that client “has stated she has completed the parenting and anger management classes but has not provided the caseworker with certificates of completion7 • Copy of the court transcript, which stated, on page 5, from the Investigator’s testimony given in the hearing November 6, 201.4, “The client is participating in her services and has initiated all of them. She ha.s stated to me that she had completed the domestic violence and the anger management classes hut had not provided me certificates of completion at this time.” • Statement from client, in which she stated she gave the certificates of completion for the anger management and parenting courses on October 15, 2014. to Investigator. She stated he lied in court about not having them. • Statement from a Supervisor, Depar ment of Family and Protective Services, Uvalde, Texas, who stated there was no policy as to timelines for updating case files when receiving documents, but they should be done as documents arrive. She stated that if client met with Investigator, he would have made an entry into IMPACT. Supervisor pulled tile IMPACT case for client and found the entry of the meeting indicating the Investigator met with client and obtained training certificates. Remewe By: d’ 01G0002 (10/21/2014) Date: 010 Case; 15180-15 Page I of 2 OFFICE OF INSPECTOR GENERAL tEXAS IIE\ETF{ & llr\t.\c SERVICES COMNUSSION FINAl. REPORT • • Copy of the IMPACT entry by the Investigator, which indicated on October 15, 2014. he met with the client. The final sentence of the entry suited. Client lelt copies of the parenting and anger management completion certificates with the Department.” Statement from Investigator. in hich lie stated that he wrote the affidavit and he testified to the information in couru He acknowledged the sign-In log was from the front desk, and acknowledged the certificates belonged to client. FTc stated he did not have the certificates when he wrote the affidavit and testified in court, but acknowledged the entry into the IMPACT that lie received the certificates. F-Ic theti stated he had made a mistake and told. client he had not updated his tile before court hut would fix his mistake. He adniitted lie received the certificates prior to writing the affidavit or testifying in court. Actions Taken: Referred to Trevor Woodruff. Acting General Counsel, Department of Family and Protective Services, Austin, Texas; John Dodson. County Attorney, Uvalde County Attorney’s Office. U aldc, Texas, Reviewed By: 0160002 (10/21/2014) Date: Z7 0IGCase: 15180-IS Page2ot2 OFFICE OF INSPECTOR GENERAL TEXAS (([Al.. [II & [U MAN SlRvaFs COMMISSIL tx FINAL REPORT Date: March 12. 2015 010 Case: 15i84-l5 Investigation Category: Texas Penal Code, Title S. Chapter 37. Section 37.10. Tampering with Governmental Record Allegation: On Januaty 22. 20[5. this investigation was initiated by the Office of Inspector General, internal Affairs Division. based on a referral from Supervisor. Child Protective Services. Department of Family and Protective Services. Dallas. who alleged: Falsified Documentation, It was reported Child Protective Services Family Based Safety Service Specialist lii, Department of Family and Protective Services, Dallas falsified her documentation in the lnfbrmatIon Management Protecting Adults and Children iii Texas (IMPACT) system and her travel vouchers. Summary of Activities: The Internal Affairs Division conducted an investigation during the period ofJanuaiy 22, 2015 to March 12.2W 5, The allegation Family Based Safety Service Specialist [TI falsified documentation in the Information Management Protecting Adults and Children in Texas (IMPACT) system and her travel vouchers is substantiated. These results arc based upon (he thilowint,: • Interview with (‘PS FBSS Supervisor. Dallas. CPS FBSS Supervisor stated she received a complaint from caregivers on several DFPS cases slating Family Based Safety Service Specialist Ill had never visited their home or the children in their care. CPS FI3SS Supervisor reviewed documentation in the Information Managemen.t Protecting Adults and Children in Texas system for DiPS cases and determined Family Based Safety Service Specialist Ill falsified the fltce— to- lace contacts with the caregivers. CPS FRSS Supervisor slated she reviewed additional cases assigned to Family Based Safety Services Specialist Ill and confirmed with the clients Family Based Safety Service Specialist ill did not complete the number of ftice-to—fttee visits as Family Based Safety Services Specialist ill documented in IMPACT. CPS FI3SS Supervisor further determined Family Based Safety Service Specialist Ill Iltisified her travel records for the above listed cases. • Interviews were conducted with Caregivers. Caregivers staled that during the timeframe they cared for children placed in their home. Family Based Safety Service Specialist lH never made face to face visits to their home. • An. interview was conducted with Client. DFPS. Dallas. Client stated she met with Family Based Safety Service Specialist ill once, in September 2014 or October 2014. Client stated subsequent contacts with RevieweU By 01G0002 Revised 11-2014 Date: J 2 2 2-s DIG Case: 15184-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TEXAS RPM it! & Hi MAN Si:RVKES Ct)MMISSI(j\ FINAL REPORT • • • • Family Based Safety Service Specialist 1K were done over the telephone to obtain updates on client’s daughters. An interview was conducted with another Client DFPS, Irving. Client stated he met with Family Based Safety Service Specialist Ill once, in September2014. Client assumed his case had been closed as he received a letter stating the case would he closed. An interview with another Client. DFPS. Dallas. Client stated Family Based Safety Service Specialist Ill made face to flhce contact approximately three times and missed Family Based Safety Service Specialist Ill ‘s visit in October 2014 when Family Based Safety Service Specialist (II delivered baby item. Family Based Safety Service Specialist Ill refused to meet. with the DIG Investigator stating she would be consulting an attorney for advice. Analysis of travel records Thr Family Based Safety Service Specialist Ill disclosed Family Based Safety Service Specialist Ill fraudulently filcd for reimbursement of 474.78 iiles- at .56 cents per mile for a total of $265.88. Family Based Safety Service Specialist Ill was terminated from the Department of Family and Protective Services on Fehruaiy 11,2015. Actions Taken: This case will be referred to Trevor \Voodruft Acting General Counsel, Department of Family and Protective Services. Austin; The Dallas County District Attorneys Office, Dallas, Texas. Reviewed By: 01G0002 Revised 11-2014 Date: 010 Case: 15184-15 Page 2 of 2 ________________ OFFIcE OF INSPECTOR GENEL TUXA5 [IE.\LFH & fl1,3MAN SERVICES COMMISSION FINAL REPORT Date: March 26. 2015 OEG Case: 15275-15 Investigation Category: FIHS Human Resources Manual Chapter 4, Employee Conduct. Section B, Work Rule I and 2; Child Protective Services Handbook section 6130 and 6131. Allegation: On February 2, 2015, this investigation was initiated by the Office of Inspector General upon tcceipt of informatton that a Child ProtectIve Scrvtce Spcc:alist, Department of Family and Protecthe Serwccs, Arlington, Texas, withheld important information from a mother, after her child, was voluntarily placed with relaiives. The relatives moved to Maryland. taking the child without the mother’s knowledge or consent, The Child Protective Service Specialist had knowledge of the child’s move to Maryland and did not advise the mother. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of February 2, 2015 March 26, 2015. The allegation that a Child Protective Service Specialist failed to advise a mother that her child, was moving out of state failed to properly document her case is substantiated. These results are based upon the following: Review of email correspondence from a Program Specialist, dated January 21., 2015, in which a CPS and that a policy Supervisor, Jacksonville. Texas. expressed concerns regarding DPI’S case violation may have occurred regarding the a child being moved out ofstate and the mother not being notified. indicated the Child Protective Sen-ices Specialist was made aware on • Review of DFPS ease November 26, 2014, that the child’s relatives, who had custody of her, were planning to move to Maryland. Further, the Child Protective Services Specialist had phone contact with the child’s mother on December 3.2014, hut did not discuss the move to Maryland, nor did she document it in her IMPACT report. • Interview with a €75 Program Director, Arlington, Texas. The CPS Program Director said that the Child Protective Sen-ices Specialist was placed on a First Level Reminder on February., 2015, for her violating 1*15 Work Rules I and 2 thr failing to document that she had engaged the families regarding the child moving to Maryland by relatives. • Interview with the Child Protective Sen-ices Specialist, Arlington. Texas. The Child Protective Services Specialist said that she was placed on a First Level Reminder, on February 9,2015, for her violating HHS Work Rules I and 2. She admitted that she failed to clearly document that she had engaged the families regarding the child moving to Maryland with relatives. The Child Protective Services Specialist admitted she should have advised the child’s mother of the move. • Attempts to interview the child’s mother at her last known address yielded negative results. — — , Actions Taken: Referred to Trevor Woodruff’, Acting General, Counsel, Department of Family and Protective Date: 42— &3 ‘vS RevIewed By: 01G0002 Revised 11-2014 010 Case: 15275-15 Page 1 of 2 OFFICE OF INSPECTOR GENER4L TEXAS tJEALr[c & HUMAN SERVICES COMMrnS{ON FINAL REPORT Services, Austin. Texas. Reviewed By: 01G0002 Revised 11-2014 Date: /J--a2.--cf OIG Case: 15275-15 Page2of2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES COMMISSION FINAL REPORT Date: April 7,2015 OIGCase: 15316-15 Investigation Category: Child Protective Services Handbook, sections 3412, 3412.1, 3412.2 Allegation: On February 10,2015, this investigation was initiated by the Office of Inspector General, based on referral from a Manager, Consumer Affairs, Department of Family and Protective Services, who alleged on February 8, 2015, that a Parent contacted his State Representative about the inappropriate behavior of the Child Protective Services. Parent stated a Program Administrator along with a Program Manager had been handling his Child Protective Services case (family plan) Parent feels that the laws have been violated Program Administrator and Program Manager have informed parent that Child Protective Services was not an agency to determine custody of the child, but to ensure the child safety. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of February 10, 2015, to April 7, 2015. The investigation revealed that Program Administrator and Program Manager did not adhere with Department of Family and Protective Services policy and procedure in the development of a family plan of service for Father by not involving or meeting him. This allegation is substantiated. These results are based upon the following: Department of Family and Protective Services case involved the parents of child. Both did not reside in the same household and were currently participating in Family Based Safety Services. An initial Family Service Plan was written which included both parents in the same plan, however, due to residing in separate households, separate Family Service Plans were required per Child Protective Services handbook 3412. A review of Department of Family and Protective Services case disclosed Program Administrator and Program Manager did not adhere to Child Protective Services policy 3412 by creating a Family Service Plan for Father without his participation. • Interview with Program Manager who stated a second family plan was then developed for the parent, however, he was not involved in the creation of it. • An interview was conducted with Program Administrator, Child Protective Services, Department of Family and Protective Services. Program Administrator said the second family plan created for Father was written by her and Program Direptor after their review of Father’s history with the department. • An interview was conducted with a Manager, Consumer Affairs, Department of Family and Protective Services. Manager said this service plan was not developed with parents and staff did not meet with Father, which was a policy violation of CPS Handbook Policy 3412 Developing the Family Service Plan forFBSS Case. Reviewed B 01G0002 (10/21/2014) Data: QIG Case: 15316-15 Page 1 of 2 OFFICE OF INSPECTOR GENE1tkL TEXAS HEALTH & HUMAN SERVICES ColMlssIoN FINAL REPORT • An interview was conducted with Father. Father said he was not involved with the creation of his separate Family Service Plan, which was written, by Program Manager and Program Administrator. Father stated he complained the Family Service Plan violated his rights because it said he couldn’t contact his representative. Actions Taken: Referred to Trevor Woodruff Acting General Counsel, Department of Family and Protective Services, Austin, Texas. Reviewed By - 01G0002 (10/21/2014) Date: zJ 22—A OGCase: 15316-15 Page2of2 OFFICE OF INSPECTOR GENERAL TEXAs HE;s[;[H & HuMAN SERVICES COMMISSION F[NAi REPORT Date: March 12. 2015 on; Case: 15335-15 Investigation Category: Child Protective Services Child Death Allegation: On February 12, 2015, this investigation was initiated by the Office of Inspector General upon receipt of information that a child in Hidalgo County died due to a blunt force trauma to the head. The family had CPS history Summary of Activities: The Internal Affairs Division conducted an investigation during the period of February 12. 2015 to March 12. 2015. This allegation is dosedlCPS Child Death based on the following: This cased pertained to the • Review of Department of Family and Protective Services case were taken in the death which caseworkers, (‘PS of a entries child death and identified actions and n.otitications and mandated investigation. Actions such as adhering to established timelines. making historical. data reviews, indicated the caseworkers followed established policies and procedures pursuant to the CR5 Handbook. • Review of Department of Family and Protective Services cases merged under ease number which involved allegations of medical neglect. neglectful supervision. and physical neglect with dispositions ot ‘ruled out, factors controlled” and ‘ruled out. The investigations determined that all children in the household were provided with appropriate. methcal care and supervision. The review indicated the actions taken by caseworkers were compliant with established policies, procedures. and protocols while handling the historical investigations. • Interviews with three CPS Investigation Supervisors, three CPS Investigators, a CR5 Special All those interviewed said Investigator, and a Chil.d Safety Specialist concerning DFPS case the actions taken such as reporting, notifications, and previous case reviews, were conducted timely and in accordance with CPS Handbook. policies. — . Actions Taken: Referred to Trevor \VoudrulI, Acting General Counsel, Department of Family and Protective Services. Austin. Texas. Reviewed By: Date: I., ‘c, - OFncE OF INSPECTOR GENERAL TExAs HEALTh & HUMAN SERvIcES COMMISSION FINAL REPORT Date: April 7, 2015 OLG Case: 15400-15 Investigation Category: HHS Human Resources Manual, Chapter 4, Employee Misconduct, Work Rules (1) (13) Allegation: On February 19, 2015, this investigation was initiated by the Office of Inspector General based on a referral that a Conservatorship Specialist 1, Department of Family and Protective Services, Child Protective Services, Dallas, Texas, falsified travel documents for December 2014. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of February 19, 2015, through April 7, 2015. The allegation that a Conservatorship Specialist I falsified her December 2014 travel records is substantiated based on the following: • Review of copies of travel records and corrected travel records for December 2014, which indicated the Conservatorship Specialist I listed she returned to her office after each home visit, but she had not. The Conservatorship Specialist I corrected the travel records and resubmitted them after being counseled on the requirements for providing true and correct travel records. There was no financial loss to the state. • Review of Supervisor / Employee Conference Notes dated January 26, 2014, reflecting that the Conservatorship Specialist I was counseled by the Conservatorship Supervisor II for falsifying travel records, which reflected the Conservatorship Specialist I admitted to falsifying her travel records. • Review of email dated January 26, 2015, from the Conservatorship Specialist Ito the Program Director, in which she admitted to falsifying travel records. • Interview with the Program Director, who stated the Conservatorship Specialist I’s employment with Child Protective Services was terminated on February 25, 2015, because of the falsified records, mid further stated that the records were corrected by the Conservatorship Specialist I and verified by the. Program Director prior to submission for travel expenses. • A review was conducted of the Conservatorship Specialist I’s prior travel records. Contacts with clients were verified. A comparison in travel patterns with those of other Conservatorship Specialists working in the same office found no other falsified travel record, or any indication of overpayment for travel. The Conservatorship Specialist l’s employment with CPS was terminated on February 25, 2015. Actions Taken: Referred to Trevor Woodruff, Acting General Counsel, Department of Family and Protective Services, Austin, Texas. ReV$ .dBr. ?I% Date: 3/ nD /Lc-’ cU; -J 0130002 (10/21/2014) 013 Case: 15400-15 Page 1 of 1 OFFICE OF INSPECTOR GENEL&L TbxAs HUALItI & HUMAN SERVICr5 CoMitssioN FINAL REPOWF Date: MayI.2015 016 Case: 15487-15 Investigation Category: HI-IS Human Resource Manual, Chapter 4, Section [3. Employee Rules, , 2. 25; Adult Protective Services Handbook, Section 1340, 2350, 2410 and 2511. Conduct, Work Allegation: On March 12, 2015, this investigation was initiated by the Office of Inspector General upon receip of information of physical and emotional abuse on an Adult Protective Services (APS) client. An APS Specialist II. Texas City, Texas, inlet-viewed the client on October 10, 2014, at his nursing home. No further action was taken by the Al’S Specialist. The APS Specialist did not address the physical abuse allegations. There are several discrepancies in her docurncnmtion regarding verbal abuse. Although, the client was on hospice and later on respite care, the ,\PS Specialist did not make any contact during the months of November. December. or .lanuarv. February. The client’s certificate of death indicated his manner of death was natural an i that he died on \ovep’ber 9.2014. This case was not investigated by law enlbrcement. On April I. 2015 the APS Specialist was terminated from employment with the Department of Family and Protective Services. Summary of Activities: The Internal AIThirs Division conducted an investigation during the period of March 12, 2015 to May I, 2015. The allegation an z\PS Specialist failed to make contact with and an Adult Protectiv. Services client, properly document her casework and follow-up with suspected abuse is substantiated, These results are bused upon the following: Review of DFPS case disclosed an APS Specialist II. Texas City. Texas, did not address reported physical abuse allegation in her casework. The intake report indicated bruising and redness II the client’s hack, however, the APS Specialist did take any photographs. The APS Specialist did not complete the required initial interview with the client after she received the allegation ot’physical abus::. The APS Specialist had no contact with the client fOr approximately 90 days while case remained opened. Interview with an APS Program Administrator, Houston. Texas. The APS Program Administrator sai. that the client was under the nursing home’s care when the allegation of physical and emotional abuse wa.s received. The client was on hospice and eventually died due to natural causes. The allegation wa not a contributing factor in his death. The APS Program Administrator said her office detected that thc APS Specialist tidied to properly conduct her casework and was subsequently terminated. , Actions Taken: Referred to l’revor Woodruji General Counscl, Department of Family and Protective Services, Austin. Texas. Re9iewod By: :d)c’ 01G0002 Revised 11-2014 Date: .es::l_2:s, nit—. I-’——., 4r4r,—,... —‘ OFFICE OF INSPECTOR GENERAL fEXA5 HEALrH & hUMAN SERvICESCOMMISStON FINAL REPORT Date: May 8. 2.015 OlOCase: 15541-15 Investigation Category: liFTS Human Resources Manual, Chapter 4, Employee Misconduct, Work Rules (l)(2)(28) Dcpartm’_nt of faimlv and Protcunc Scructs \dult Protcctnc Servicts ln—flomt lntstigauons Handbook. Sections; 2310 Procedures for Evidence Collection, 2333 Documentation of Investigation Contact*, 25 10 Safety Contacts, 2511 Procedure thr Safety Contacts. Allegation: On March 18, 201 5, this investigation was initiated by the Office of Inspector General based on a 1 referral from Managcr Ill, Adult Protectne Structs Dcpartmtnt of Family and Piotcctnc Strviccs Htalth ant thorough a (lid not complete Human Services Commission. Houston. Texas. who alleged In-Home Specialist II investigation and did not make the required safety contacts tbr November of 2014, January of 201 5, and February of 2015. The case was reassigned on March 10, 2015 and APS discovered the client had died on December 26, 2014. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of March 1.8, 2015, to May 8. 20! 5. The allegation that In-Home Specialist II, APS, failed to complete a thorough investigation and failed to make the required safety contacts is substantiated. These results are based on the following: Review of APS case. The case pertained to the allegation of abuse and neglect of client and identified actions and entries made by In—Home Specialist II, which was taken in the investigation, such as adhering to established timelines, determining the validity of the allegation, documenting evidence, completing safety assessments every 30 days, and identifying the need for protective services. The review determined established policies and procedures pursuant to the Al’S Handbook Section 231.0 Procedures [hr Evidence Collection, Section 2333 Documentation of investigation Contacts, Section 2510 Safety Contacts, and Section 2511 Procedure for Safety Contacts were not tbllowed by In-Home Specialist Ii. • An interview with Manager lIT, APS, in which she detailed her discovery of In-Home Specialist II work performance issues and the incomplete investigation In-Home Specialist II performed with the clients case. Manager 111 said In-Home Specialist II failed to follow Al’S policy and procedures. • A review of Manager HI recommendation icr termination memorandum to In—Home Specialist II which documented In-Home Specialist Ii work perthrmance issues and the steps taken by Al’S to address her continued failure to follow policy and procedure related to tack of ease documentation, collection of evidence, completion of required safety contacts, and implementation of services to APS clients. • A review of medical records disclosed that client had received continuous medical care from the time C Reviewed By: .. 01G0002 (10/21/2014) Date: /—2- 7 t_ GIG Case: 15541-15 Page 1 of .1 OFFICE OF INSPECTOR GENERAL TEAks HEALTH & HLMAN SERVICESCOM\IISSION FINAL REPORT • • the allegation to the time of his death. Review of Texas Department of State Health Service Vital Statistics state tile disclosing client died while admitted to Cornerstone Hospital. In-Home Snecialist II was terminated on March 23. 2015. and attempts to interview her were unsuccessful. The investigation also revealed that the substantiated work rules violations did not contribute to the death of the client as he had received ongoing medical care lbr the duration of the investigation. Actions Taken Referred to Trevor Woodruff. General Counsel. Department of Family and Protective Services. Austin. Texas Reytewed By: QlG0002 (10/2112014) Date: /‘—22 QIG Case: 15541-15 Page 2 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTh & HUMAN SERvICES CoMMissioN FINAL REPORT Date: May 27, 2015 OIG Case: 15599-15 Investigation Category: HHSC Human Resources Manual, Chapter 4, Employee Conduct, Work Rules 1, 2, and 28; Children Protective Services, Policy, Section 2411 Thorough Investigations; Section 2310 Assessing Safety Allegation: On March 31, 2015, this investigation was initiated by the Office of Inspector General upon receipt of information that a 2 year old child whose family had previous Child Protective Services history died due to blunt force trauma on March 19, 2015. The child’s death investigated by the Arlington Police Department have arrested the mother’s boyfriend and charged him with capital murder of a child under 10 years old against mother’s boyfriend. The Medical Examiner report list the cause of death as “blunt force trauma of head” and the manner of death as “homicide”. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of March 31, 2015, to May 27, 2015. Evidence was developed to support CPS investigator failed to follow policy and procedures while performing her duties, therefore the allegation is substantiated, These results are based upon the following: • Review of DFPS case that pertained to the death of a 2-year-old identified actions and entries of CPS investigators, which were taken in the death investigation, such as adhering to established timelines, making mandated notification, and historical data review. The case review indicated CPS staff followed established policies and procedures pursuant to the Child Protective Handbook. • Interviews conducted with CPS Investigative Supervisor II, CPS Investigator IV, CPS Special Investigator said the reporting, documentation and notifications in the child death investigation were conducted timely, required notifications were made, and previous case history reviews were conducted in accordance to CPS policy. • Review of historical DPFS cases involved allegations of physical abuse and neglectful supervisor with a disposition of “ruled out”. The review indicated primary worker did not conduct a thorough investigation as established by CPS Handbook Section 2411 and did not complete the Safety Assessment within the seven-day timeframe established by CPS Handbook section 2310. • Interview with CPS Investigator assigned to historical DFPS case stated the case was staffed and conducted as directed by Investigations Supervisor. CPS Investigator stated in some instances, investigations supervisors directions were different from those learned in Basic Skills Development Training. Reviewed By: 01G0002 (10/21/2014) Date: /i7- s2E OIG Case: 15599-15 Page 1 of 2 OFFICE OF INSPECTOR GENER4L TEXAS HEALTH & HUMAN SERVICES CoMMtssloN FiNAL REPORT • Interview with Investigations Supervisor. Investigations Supervisor stated policies were clarified because of this investigation but Investigations supervisor does not remember providing CPS Investigator with directives contradicting to those taught in Basic Skills Development Training. Actions Taken: Referred to Trevor Woodmti General Counsel, Department of Family and Protective Services, Austin, Texas. Reviewed By: 1f 0lG0002 (10/21/2014) Date /2- Z2-( - OIG Case: 15599-15 Page2of2 OmcE OF INSPECTOR GE?aAL TExAS HE4Lm & HUMAN SERvIcES COMMISSION FINAL REPORT Date: May 19,2015 OIG Case: 15687-15 Investigation Category: fillS, Human Resources Manual, Chapter 4, Employee Conduct, Section B, (1) (2); Child Protective Services Handbook Sections 2311.2, 2321.1, 2241,2242, and 2291 Allegation: On April 17, 2015, this investigation was initiated by the Office of Inspector General upon receipt of information that a 17-month-old child died on April 7, 2015, and the family had Child Protective Services history. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of April 17, 2015 May 19, 2015. The allegation that an Investigator IV, former Investigator, and Investigator I failed to follow CPS Handbook policies during the historical cases is substantiated. • Review of the Department of Family and Protective Services case pertaining to the death of the child, which identifIed the actions and entries CPS Investigators took m the death investigation such as adhering to established timelines, coordinating with law enforcement, making mandatory notification and historical data review, and conducting background checks of every member of the family. • Review of historical DIPS case involving the allegation of neglectful supervision and physical neglect for the child with the disposition of “unable to determine’. The mother was drug tested and the results were positive for marijuana. The Investigator I said that the child was healthy and did not show any signs of being delayed. The child had appropriate food, water, clothing, and shelter. The allegation of physical neglect for three siblings was closed with disposition of “unable to complete” because the children were unable to be located by the department. The review indicated all actions taken by caseworkers were compliant with established policies, procedures, and protocols pursuant to the CPS Handbook in the investigation. • Review of historical DFPS case for the allegations of neglectful supervision and physical abuse with dispositions of “ruled out”. The children did not appear malnourished. The mother submitted to three drug tests, and the results were negative. The review indicated the Investigator I, CPS, completed the safety assessment and risk assessment but not within timeframes required per CPS Handbook Section 2311.2 and 2321; and did not submit the case within 45 days for approval per CPS Handbook Section 2291. • Review of historical DIPS case involving the allegation of physical neglect with disposition of “ruled out”. The review indicated the former CPS Investigator interviewed the children involved in the case but not within timeframes per CPS Handbook Section 2241. • Revi of historical DFPS case for neglectful supervision with disposition of “ruled out”. Maternal — Rd 01G0002 (10/21/2014) iif lt\zo(s OIG.Case: 15719-iSPagel of 2 OFFicE OF JNSPECTOR GENna TEXAS HEALTh & HuMkN SERvIcES CoMMissioN FINAL REPORT a • grandmother was drug tested. The results were negative. The children appeared to be clean. A safety plan issued indicated children could not be cared for by maternal grandmother unsupervised. No concerns noted with residence belonging to the mother. The review indicated the Investigator IV, CPS, did not submit the abbreviated investigation within 30 days per CPS Handbook Section 2291. Review of historical DFPS cases for the allegation of neglectful supervision and physical neglect with dispositions of “ruled out”. The review indicated all actions taken in the investigation by caseworkers were compliant with established policies, procedures, and protocols pursuant to the CPS Handbook. Interview with a Kinship Development Specialist IV, Child Protective Services, Department of Family and Protective Services, who said she was the previous supervisor who approved historical cases for closure. She said none of the policy violations noted in the DR’S historical cases contributed to the death of the child. Actions Taken: Referred to Trevor Woodruff, General Counsel, Department of Family and Protective Services, Austin, Texas. Date: 01G0002 (10/21/2014) ,2122(7Cqc OlOCase: 15719-l5Page2of2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTh & HUMAN SERVICES COMMISSION FINAL REPORT Date: May 20, 2015 OICCase: 15717-15 Investigation Category: l-IHS Human Resource Manual, Chapter 4, Section B, Employee Conduct, Work Rules, 1, 2, 28; Child Protective Service Handbook: 2241 Interviews with Children, Audio and Visual Documentation and 2250 Home Visits. Allegation: On April 17,2015, this investigation was initiated by the Office of Inspector General upon receipt of information that a 3 ½ year old child with a date ofbirtht , died on April 3, 2015. The suspected cause of death was neglectfUl supervision The father had a Child Protective Service history that was merged into the current case. The Forney Police Department investigated the child death. The Dallas County Medical Examiner conducted an autopsy, which was rendered inconclusive because there were no obvious signs of foul play. A final autopsy report is pending toxicology examination. During the course of this investigation, it was discovered that a CPS Investigator ill, hued to follow established policies and procedures pursuant to the CPS Handbook. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of April 17, 2015 to May 20,2015. The allegation that a CPS Investigator Ill failed audio record an interview or take photographs of a home substantiated: Review of a DFPS case which pertained to the death of a 3 ½ year old child identified actions and entries of CPS investigators taken in the death investigation, such as adhering to established timelines, making mandated notifications, and historical data review. The case review indicated that a CPS Investigator III did not audio record an interview nor photograph the sibling of the deceased child during a face-to-face interview Further, the CPS Investigator III did not take photographs of the home environment on Apnl 3, 2015, during a home visit. The deceased child’s sibling was removed from the father’s home during the child death investigation, under a Parental Custody Safety Plan, and placed with her maternal grandparents’ home in Previous DFPS case dated April 3,2015, involved the same allegation of NeglectfUl Supervision of the deceased child and was merged with another DFPS case. • Interview with a CPS Investigative Supervisor II, Kaufman, Texas, who said the reporting, documentation, notifications in the child death investigation and required notifications were conducted timely; however, the CPS Investigator ifi did not take a photo of the deceased child’s sibling, nor did he conduct a home environmental assessment with photographs his home visit interviews, as required by CPS policy. • Interview with the CPS Investigator ill, Kaufman, Texas, who said he failed to conduct an audio recorded interview arid take photos of the sibling of the deceased child; failed photograph the home environment and did not document why he failed to do so in his report. He was aware that his actions were not consistent Reviewed By: 01G0002 Revised 11-2014 Date: OIG Case: 15717-l5Pagel of 2 OFFICE OF INSPECTOR GENEL TEXAS HEALTh & HUMAN SERVICES COMMISSION FINAL REPORT with established CPS policies, procedures, and protocols, The caseworker failed to interview principals, and upload documents into IMPACT. Actions Taken: Referral to Trevor Woodruff, General Counsel, Department of Family and Protective Services, Austin, Texas. Reviewed By: Aj< t1 01G0002 Revised 11-2014 Date: 016 Case: 15717-15 Page 2 of 2 OFFICE OF INSPECTOR GENERAL & HUMAN SERVICES COMMISSION FINAL REPORT TEXAS HEALTH Date: July 1, 2015 016 Case: 15730-15 Investigation Category: HHS Human Reso urces Manual, Chapter 4, Employee Misconduct, Work Rules (1 )(2); Department of Family and Protective Services, Child Protective Services Handbook , sections 6131.25. Allegation: On April 17. 2015, this investigation was initiated by the Office of Inspector Gene ral, upon receipt of mformation that a two-year-old child died on March 27, 2015, the cause of death was med icall y fragile This child and family had a history with the Depa rtment of Family and Protective Services, Child Protective Services. During the course of this investigation, it was discovered Conservatorship Specialist II, CPS, failed to follow established policies and procedures purs uant to the CPS Handbook. Summary of Activities Tht Internal Affairs Divi sion conducted an tn’v estigatron during the perio d of Apnl 17 2015, to July 1,2015. The allegation that Conserva torship Specialist Ii did not comply with HHS Hum an Resources policies and CPS Handbook policies is substantiated and based on the following: • Review of DFPS case disclosed, Conservatorsh ip Specialist II did not complete Monthly Eval uations for the months of September 2014 and October 2014 as required by CPS Handbook section 6131.25 Entering Contacts and Submitting the Monthly Evaluation/Assessment for Supervisory Approva l. • Review of DFPS case involving the Resi dential Child Care Licensing (RCCL) portion of this case. The RCCL. case pertained to the placement of child in specialized foster care and identified the actio ns and entries of RCCL investigators. DFPS/RCCL case disclosed RCCL followed established polic ies and procedures pursuant to the RCCL Handbook section 6000 Investigations and DFPS Minimum Standards for Child-Placing Agencies Chapter 749. • Search of historical data under Departme nt of Family and Protective Services revealed CPS did not have conservatorship or historical investigations relat ed to child before the near drowning. There was a recent DFPS history involving mother, the biological mother of child, dated September 4. 2013. This case was closed at intake by the screener and not assigned to be investigated. A review of DFPS case indic ated the actions taken by CPS complied with establishe d policies, procedures and protocols while closi ng investigations at intake and was not a contributing factor in the death of the child. • Interview conducted with Conservatorship Supe rvisor II, CPS, DFPS, who acknowledged she supervised the casework of Conservatorship Specialist II and that there was a failure to complete the required Monthly Evaluations for September 2014 and October 2014. • Interview conducted with Conservatorship Specialist II, CPS, DFPS, who acknowledge she was assigned to the conservatorship stage in August of 2014 and that she failed to complete the required Mon thly Evaluations for the months of September 2014 and October 2014. Actions Taken: This case was referred to Trev or Woodruff, Genera] Counsel, Departme nt of Family and Protective Services. Reviewed By: 0lG0002 (10/21/2014) Date: /2 -J2- ,tC - OFFICE OF INSPECTOR GENERAL TEXAS REALm & HUMAN SERVICES COMMISSION FINAL REPORT Date: May26, 2015 016 Case: 15732-15 Investigation Category: HHS Human Resources Manual, Chapter 4, Emplo yee Conduct, Work Rules 1, 2, and 20; Information Security Standard 1.1.1.7 Allegation: On April 22, 2015, this investigation was initiated by the Office of Inspector Genera l upon receipt of information alleging Administrative Assistant, Children Protective Servic e, Wichita Falls, released confidential information to a fonter Children Protective Service employee, who was not entitled to receive the confidential information. Summary of Activities: The Internal Affairs Division conducted an investi gation during the period of April 22, 2015— May 26, 2015. No evidence was developed to support the allegat ion Administrative Assistant disclosed confidential information. However, during the course of the investi gation, evidence was that Administrative Assistant accessed IMPACT files for personal reasons, therefore the allegation is substantiated. These results are based upon the following: • Interview with Program Specialist Data Support Supervisor, who stated an IMPACT audit trail report discloses Administrative Assistant accessed files on May 16, 2014, and June 4,2014, for contacts entered on May 12, 2014. Administrative Assistant also conducted person searches on March 10, 2015 that were unauthorized. • Interview with Region 2 Program Administrator, Children Protec tive Services. Davis stated the IMPACT audit trail disclosed Administrative Assistant, CPS Investigation Unit Administrative Assistant, Wichita Falls, accessed IMPACT. Administrative Assistant did not have work related reasons to access the CPS investigation. Program Administrator stated Administrativ e Assistant denied accessing case for non-work related reasons. • Interview with Administrative Assistant, CPS Investigation Unit Admin istrative Assistant, who denied she disclosed any confidential information to a non-CPS employee and thither denied she has accessed IMPACT and viewed CPS cases for non-work related reasons. Admin istrative Assistant also denied she has released confidential information to unauthorized persons. Admin istrative Assistant however admitted to leaving her workstation without locking her computer. • Interviews with CPS Investigations Supervisor. CPS Investigations Supervisor stated Administrative Assistant told her, called and asked her to access IMPACT and provide informaon on a CPS case. CPS Investigations Supervisor stated Administrative Assista nt told her she decline? request but had accessed IMPACT and searched the case out of curiosity. r Reviewed By: OlG0002 (10121/2014) Data: - QlGCase: 15372-15 Pagelof2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES COMMISSION FINAL REPORT Interview with Former CPS employee who denied she asked anyone to access IMPACT and provide information to her. Former CPS employee stated she researched CPS records while working for a Foster Care Re-Direct contractor. Investigator verified Foster Care Re-Direct no longer has a contract with DFPS and is no longer in operation Actions Taken: Referred to Trevor Woodruff, Assistant General Counsel, Health and Human Services Commission, Austin, Texas Reviewed ay: 01G0002 (10/2112014) Date: QIG Case: 15372-15 Page 2 of 2 OFFICE OF INSPECTOR GENERAL TFX45 HEALTH & HUMAN SiRvicts COMMIssION FINAL REPORT Date. July 1, 2015 OIG Case: 15962-15 Investigation Category’ HHS Human Resource Manual, Chapter 4 Section B Employee Conduct, Work Rules, 1, 28; Department of Family and Protective Services, APS Handbook l631 Procedure for Priority III Allegations Allegation: On May 8, 2015, this investigation was initiated by the Office of Inspector General upon receipt of information regarding an APS Adult Death. Emergency Medical Services responded to the home of an Adult Protective Services client and found him with low cardiac output, confused, disonented and heart was not working properly. The client had congestive heart failure; EMS and law enforcement responded to his home two weeks prior to incident. Law enforcement and APS reported that the client lost weight, had spoiled food, was wearing soiled underclothes and the home was filthy. During the course of this investigation, it was discovered that a former APS In Home Specialist failed to adhere to APS Handbook policy, 1631 Procedure for Priority ifi Allegations, by failing to make client face-to-face contact within required seven calendar days following initial assignment of case. Summary of Activities: The Internal Affairs Division conducted an investigation dunng the period of May 8, 2015 through July I, 2015 The allegation that a former Adult Protective Services, In-Home Specialist failed to make face-to-face contact with a client as indicated in the Adult Protective Services Handbook is substantiated These results are based upon the following • Review of DFPS case involving the client and allegations of Medical and Physical Neglect disclosed no historical data. On January 23, 2015, the case was initially assigned to a former In-Home Specialist and on February 4,2015, reassigned to an In-Home Specialist IV. IMPACT review disclosed the former InHome Specialist failed to make face-to-face contact with the client prior to reassignment of case. The review indicated procedural actions taken by former In-Home Specialist did not comply with established policies, procedures, and protocols as outlined in the APS Handbook Policy. The inaction included not making face-to-face contact within seven calendar days following initial assignment of case. • Review of Texas Certificate of Death for the client disclosed manner of death was natural with respiratory failure listed as the immediate cause. • Interview with the complainant, a Program Administrator, APS, Houston, Texas, The Program Administrator said the DFPS case involving the client was initially assigned on January 23, 2015, to the former In-Home Specialist, and she failed to make face-to-face contact with the client within the required seven calendar days following initial assignment date. The Program Administrator said on February 2, 2015, the former in-Home Specialist resigned. The Program Administrator said on February Reviewed B 0130002 Revised 11-2014 Date At 27 xS CR3 Case: 15962-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES cOMMISSION FINAL REPORT a a 4, 2015, the case was reassigned to an in-Home Specialist IV, APS, Houston, Texas. The Program Administrator said the required contact period expired prior to reassignment. The Program Administrator said the In-Home Specialist IV was not in ‘.iolation of policy and both the former InHome Specialist and In-Home Specialist IV actions did not contribute to the death of the client Interview with an In-Home Specialist IV, Adult Protective Services, Houston, Texas The In-Home Specialist IV said on January 23,2015, the client’s case was initially assigned to a former In-Home Specialist The Tn-Home Specialist IV said on February 2,2015, she was reassigned the case and the required client contact face to face seven calendar days period had expired. The fomier In-Home Specialist was terminated prior to this investigation and was not interviewed. Actions Taken; Referred to Trevor Woodruff, General Counsel, Department of Family and Protective Services, Austin, Texas. Reviewed By: — 01G0002 Revised 11-2014 Data: OIG Case: 15962-15 Page 2 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN -SERVICES COMM SSIOM FiNAL REPORT Date: July 7,2015 OTC Case: 15964-15 Investigation Category: HHS Human Resource Manual, Chapter 4 Section 3 Employee Conduct, Work Rules, 1, 28; Department of Family and Protective Services, APS Handbook 2410 Procedure for Safety Assessments and 2511 Procedure for Safety Contacts Allegation: On May 8, 2015, this investigation was initiated by the Office of Inspector General upon receipt of information regarding an APS Adult Death. The client was found dirty and in a weakened state in her home. Adult Protective Services visited client at her home and provided the client with a walker to assist with ambulation and made referrals for Community Care for Aged and Disabled. The client became ill and was admitted into the hospital due to shortness of breath and generalized swelling. The client died while in the hospital on March 7, 2015. During the course of this investigation, it was discovered that APS In Home Specialist, failed to adhere to established APS policy, APS policy, 241 0 Safety Assessments, start at case initiation and complete with the alleged victim during the initial face to face contact; and 2511 Procedure for Safety Contacts, by thilure to complete the number of required contacts between the APS specialist and alleged victim or collaterals every 30 calendar days during the investigation stage. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of May 8, 2015 through July 7,2015. The allegation that an Adult Pmtective Services, In-Home Specialist failed to make required safety contacts between the APS specialist and alleged victim or collaterals every 30 calendar days during the investigation stage as directed in the Adult Protective Services Handbook is substantiated. These results are based upon the following: • Review of DFPS involving the client and allegations of Physical self-neglect disclosed no historical data. On December 17, 2014, the case was assigned to In-Home Specialist and a face to face contact was made on December 19, 2014. On April 14, 2015, In-Home Specialist made a safety contact, IMPACT review disclosed In-Home Specialist failed to complete the required safety assessment during initial client contact and safety contacts were not conducted every 30-calendar days following initial contact. The review disclosed actions taken by the In-Home Specialist did not comply with established policies, procedures, and protocols as outlined in the APS Handbook. • Interview with the complainant, a Program Administrator, APS, Houston. Texas. The Program Administrator said the DFPS case involving the client was assigned on December 17, 2014 to In-Home Specialist and made contact with the client on December 19, 2014. The Program Administrator said the Tn-Home Specialist next made contact with the client on April 14, 2015. The Program Administrator Revewd By: 01G0002 Revised 11-2014 Pate: 4.? c22 - 01(3 Case: 15964-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTh & HUMAN SERVICES COMMISSION FINAL REPORT • • said the In-Home Specialist was in violation of safety assessments and safety contac directed ts by the APS Handbook, however, the hi-Home Specialist actions did not contribute to the death of the client. Interview with [n-Home Specialist 111, Adult Protective Services, Houston, Texa& The In-Home Specialist ill, said on December 19, 2014, she initiated contact with the client and a safety assessm ent was not completed; and a safety eontact was not completed until April 14, 2015 in violation of established policies, procedures, and protocols as outlined in the APS Handbook, Review of Texas Certificate of Death for the client disclosed manner of death was natural with end stage cardiomopathy listed as the immediate cause. Actions Taken: Referred to Trevor Woodruff, General Counsel, Department of Family and Protective Services, Austin, Texas. Reviewed By: AZ— 1’ 01G0002 Revised 11-2014 Date: - Q-.2- ,.s QIG Case: 15964-15 Page 2 of 2 OFFicE OF INSPECTOR GENERAL TEXAS REALm & HUMAN SERVICES COMMISSION FINAL REPORT Date: July 7. 2015 OIG Case: 15963-IS Investigation Category: HHS Human Resource Manual, Chapter 4 Section B Employee Conduct, Work Rules, I, 28; Department of Family and Protective Services, APS Handbook 2511 Procedure for Safety Contacts Allegation: On May 8, 2015, this investigation was initiated by the Office of Inspector General upon receipt of information regarding an APS Adult Death. The client was on hospice care and had 24-hour care. It was reported that the client’s husband was in denial regarding client’s prognosis. The husband believed hospice was doing the client no justice and was killing her. It was reported to Adult Protective Services that the husband wanted the client to sit up in her chair not in bed and to complete home exercises. The husband’s children were telling their father he was hurting the client instead of helping her. During the course of this investigation, it was discovered that APS In-Home Specialist failed to adhere to established APS policy, 2511 Procedure for Safety Contacts, by failure to complete the number of required safety contacts between the APS specialist and alleged victim or collaterals every 30-calendar days during the investigation stage. Sununary of Activities: The Internal Affairs Division conducted an investigation during the period of May 8, 2015 through July 7, 2015. The allegation that an Adult Protective Services, In-Home Specialit failed to make required safety contacts between the APS specialist and alleged victim or collaterals every 30 calendar days during the investigation stage as directed in the Adult Protective Services Handbook is substantiated. These results are based upon the following: Review of DFPS case involving the client and allegations of Physical Abuse disclosed no historical data. On November 6,2014, the case was assigned to Tn-Home Specialist and a face-to-face contact was made on the same date. On April 2, 201.4, In-Home Specialist made a safety contact. IMPACT review disclosed In-Home Specialist failed to complete the required safety contacts every 30-calen dar days following initial contact. The review disclosed actions taken by the In-Home Specialist did not comply with established policies, procedures, and protocols as outlined in the APS Handbook. • Interview with the complainant, a Program Administrator, APS, Houston, Texas. The Program Administrator said the DFPS case involving the client was assigned on November 6, 2014 to In-Home Specialist and made contact with the client on the same date. The Program Administrator said the InHome Specialist next made contact with the client on April 2, 2015 in violation of safety contacts directed by the APS Handbook, however, the In-Home Specialist actions did not contribute to the death of the client. Reviewed 8 r 0100002 Revised 11-2014 Date: 010 Case: 15963-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTh & HUMAN SEtvcEs CoMMISsoN FINAL REPORT • Interview with an InHome Specialist Ill, Adult Protective Services, Houston, Texas. The In-Home Specialist lit said on November 6, 2014, she initiated contact with the client and a safety contact was not completed until April 2. 2015 in violation of established policies, procedures, and protocols as outlined in the APS Handbook. Review of Texas Certificate of Death for the client disclosed, manner of death was natural with cerebrovascular event listed as the immediate cause. Actions Taken: Referred to Trevor Woodruff, General Counsel, Department of Family and Protective Services, Austin, Texas. RvmwodBy 01G0002 Revised 11-2014 Date: OIG Case: 15963-15 Page 2 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTh & HUMAN SERvICESCOMMiSSION FiNAL REPORT Date: August 24, 2015 01Cr Case: 1.6026-15 investigation Category: CPS Handbook Policies 2253, 2332, 2337.1, 2388, 2345, 2348, 2814, 2463, 3211, 3232, 3415. Allegation: On .May 20, 2015, this investigation was initiated by the Office of inspector General upon receipt of information that child, whose family has previous Child Protective Services (CPS) history, died due to Physical Abuse. The ease is being investigated by Harris County Sheriff Office with criminal charges pending. The Hams County Medical Examiner conducted an autopsy, which found internal and external bruising throughout the child’s body. Internal trauma found to intestinal areas and tear on colon caused by blunt force trauma. The final autopsy report is pending toxicology. Medical Examiner reported that manner of death is pending histology and toxicology results. During the course of this investigation, it was discovered that the CPS Investigator and the Family Based Safety Services (FBSS) caseworker failed adhere to the following policies and procedures pursuant to the CPS Handbook during theft casework with the family. Summary of Activities; The Internal Affairs Division conducted an investigation during the period of May 20, 2015, to August 24, 2015. The allegation that CPS Investigator and FBSS caseworker failed to adhere toCPS Policies and procedures is substantiated based on the following: Review of previous historical cases of the family revealed the caseworkers failed to adhere to CPS Handbook policies as follows: o CPS Investigator was assigned the family and failed to follow CPS Handbook policies: 2253- to initiate case timely within 72 hours for priority 2; 2348- to properly follow up when contact is not made within timeframe for Priority 2 every 72 hours and document an action plan to get this accomplished; 2332- to address all allegations alleged at intake or during investigation which was not done when specific information about the injuries was not obtained; 2345- to contact reporter prior to initiating the case, instead the CPS Investigator interviewed the family prior to obtaining relevant and critical information from the reporter relating to the injuries :2337,1-to obtain all documentary evidence to support the allegations when the CPS Investigator failed to explore information pertaining to the injuries after viewing the photographs; 2388- to request then store photos taken by persons who are not DFPS employees; 2814-document all information and contacts made in the investigation in the contact detail narrative when the CPS investigator failed to document vital information throughout the investigation. Anlewed By: 01G0002 Revised 11-2014 Date: OIG Case: 16026-15 Page 1 of S OrncE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERvns CoMMissioN FINAL REPORT • • o CPS Investigator was again assigned a new case on the family and failed to follow CPS Handbook Policies 2253 to initiate case timely when she missed the timeframe 2332- to address all allegations alleged at intake or during investigation when the CPS Investigator tailed to fully explore the information on why the mother carted the gun due to her ex-paramour making threats, 2814- to document all information and contacts made in the investigation tn the contact detail narrative when the CPS Investigator failed to document all the information provided and did not request a Family Team Meeting as noted below, and 2463-to attend the family assessment with the FBSS casewoiker when the CPS Initstigator failed to coordinate with the FI3SS sorker o FBSS casewoiker was assigned the FI3SS ongoing servjces case but failed to follow CPS Handbook policies 3211 conduct joint assessment with CPS Investigator when the FI3SS casewoi ker faded to cooidinate the assessment with the CPS Investigator 3232-conduct an assessment of the family the Ff355 caseworker admitted an assessment was not done prior to initial contact with lamily 3415-parental invohement in sen’ice plannmg ensuring the involvement of fathers when the Ff355 caseworker did not contact either biological father ot mother’s children to involve them in the sen ices process as required Interview of the biological father of the victim who stated the CPS Investigator was shown 4 photographs of the injuries taken of the victim of her face neck and arms during the first investigation The father stated the CPS Investigator did not ask for a copy of the photographs The father stated a referral was made because this was not the first time his daughter was seen with bruises. The father stated during the second investigation the CPS Investigator discussed having a Family Team Meeting (PPM) but he was never contacted again about the FTM. Interview of CPS Investigator who claimed durin.g the first investigation she could not remember if she saw the photographs mentioned in the intake. The CPS investigator admitted she did not document her attimpt to locate the family and initiate the case in a timely manner. The CPS investigator admitted she did notcontact the reporter prior to initial contact to obtain all relevant information relating to the injuries. The CPS investigator admitted she did not address the different injuries noted in the intake, The CPS Investigator admitted she did not document all the information obtained during the investigation. The CPS investigator admitted she did not attend the assessment with the FBSS caseworker. The CPS investigator admitted she discussed having a Family Team Meeting (FTM) with the father but she did not document this information nor can she remember why an PPM was not held. Interview of the Ff355 caseworker who admitted she did not conduct an assessment of the family prior to the initial contact, The FBSS caseworker admitted she did not coordinate with the CPS investigator to conduct a joint assessment. The FBSS caseworker admitted she did not contact the biological father’s and involve them in the services Interview of the Lead hil.d Safety Specialist who stated she reviewed the DFPS cases and stated that CPS faileçl this family. The department could have been more aggressive in working with this family, Relewed By: 01G0002 Revised 11-2014 Oats: 1-2 --a& /S’ OIG Case: 16026-15 Page 2 of 3 OFFicE OF INSPECTOR GENERAL ‘rEx.As HEALTH & HUMAN SERvIcEs CoMMissioN FINAL REPORT fully considered all the history. completely explored the allegations, and conducted more thorough investigations. The Lead Child Safety Specialist stated if the truth about the injuries had been discovered in the previous cases safety measures would have been taken to prevent ongoing abuse of the child and proper services been provided to the mother and her paramour. The Lead Child Safety Specialist stated proper inten’ention with the family could have possibly prevented the death of the child. Actions Taken: Referred to Trevor Woodruff, Acting General Counsel, Department of Family and Protective Services, Austin, Texas Reviewed By OGOOO2 Revised 11-2014 Date: 01(3 Case: 1602&15 Page 3 of 3 OFFICE OF INSPECTOR GENERAL TEXAS 1-{EALTII & HUMAN SERVICES COMMISSION FINAL REPORT Date: August 24, 2015 OIGCase: 16024-15 Investigation Category: HHS Human Resource Manual, Chapter 4, Section 8, Employee Conduct, Work Rules, 1, 2; Child Protective Service Handbook: 6131.25 Entering Contacts and Submitting the Monthly Evaluation/Assessment for Supervisory Approval, 6311 Contact With the Child, 6412.1 Contact With the Family, 6420 Services to the Substitute Caregiver, 6250 Child Service Plait Allegation: On May 20, 2015, this investigation was initiated by the Office of Inspector General, upon receipt of information that a child died in 2015; the cause of death was undetermined. This child and family had a history with the Department of Family and Protective Services, Child Protective Services, During the course of this investigation, it was discovered Conservatorship Specialist 11, CPS, failed to follow established policies and procedures pursuant to the CPS l-landbook. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of May 20, 2015. to August 24, 2015. The allegation that Conservatorship Specialist 11 did not comply with HHS Human Resources policies and CPS Handbook policics is substantiated and based on the following: • Review of DFPS case con.servatorship stage disclosed Conservatorship Specialist did not complete Monthly Evaluations for the months of September 2014, October 20141 November 2014, December 2014, February 2015. March 2015, and May 2015. Conservatorship Speci.alist,did not complete any Face-to-Face contacts during the month of November 2014 and did not document the face-to-face contacts for the month of April 2015. Conservatorship Specialist failed to complete the Child service plans within 45 days from the date of removal, • Review of IMPACT system data disclosed Conservatorship Specialist updated the Face-to-Face contacts for the months of December 2014, January 2015, February 2015, and April 2015, on the day the child died. • Interview conducted with Conservatorship Supervisor II, CPS, DFPS, who acknowledged she supervised the casework of Conservatorship Specialist and said Conservatorship Specialist failed to complete all the required Monthly Evaluations, monthly face-to-face contacts, and documentation of monthly contacts. Conservatorship Supervisor said the family received the services available to them and no services were missed or delayed due to the worker’s failure to complete casework and documentation in a timely manner. • Interview conducted with Conservatorship Specialist II, CPS, DFPS, who acknowledge she was assigned to the conservatorship stage in 2014 and that she failed to complete all the required Monthly Evaluations, monthly face-to-face contacts, and timely documentation of monthly contacts. Conservatorship Specialist also admitted to adding the narratives to the blank face-to-face contacts on the day she learned of the child’s death. • Review of current and historical CPS investigation stages which were merged under case with investigations initiated on 2008, 2012,2013, 2014, and 2015 revealed CPS followed established Rev+ewed By, r” flhf’flflfl9 f1flflhI9rMA Date; fljf” IAfl9&1 Qesna n 9 OFFICE OF INSPECTOR GENERAL & HUMAN SERVICES COMMISSION FINAL REPORT TEXAS HEALTH timelines, made notifications to appropriate parties, and. documented their activities pursuant to policies and procedures detailed in the CPS Handbook. Actions Taken; This case was referred to Trevor Woodruff General Counsel, Department of Family and Protective Services. Reviewed Br flIflflflfl2 (1fl/21!2fl14 Date: /2 .22 -C flIflINssn. tfl)A ‘IC 0-,.,. OFFICE OF INSPECTOR GENERAL TExAS HEALTH & HUMAN SERVICES COMMISSION flNAL REPORT Date: July2, 2015 OIG Case; 1604415 Investigation Category: HHS, Human Resources Manual, Chapter 4, Employee Conduct, Section 13, (1) (2); Child Protective Services Handbook Section 2310 Allegation: On May 28, 2015, this investigation was initiated by the Office of Inspector General, upon receipt of information, that a I-year-old child whose family had Child Protective Services history died on May 19, 2015. The child death is being investigated by a Police Department. An autopsy has been conducted; the cause of death was pending toxicology. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of May 28, 2015— July 2, 2015. The allegation that Investigator IV, CPS, violated a Child Protect Services policy in DFPS historical case by thiling to get program director approval to close the case administratively as per CPS Handbook Policy Section 2310 is substantiated based on the following: • Review of the DFPS case that pertained to the death of a child and identified the actions and entries CPS Investigators took in the death investigation, such as adhering to established timelines, coordinating with law enforcement, making mandatory notification and historical data review, conducting background checks of every member of the family. The review indicated the staff followed established policies and procedures pursuant to the CPS Handbook. The mother has no other children. The death case is still currently open and pending the final autopsy report, and the department is going to forward the case to the Family Based Safety Services unit for further monitoring. • Review of historical DFPS, which involved the allegation of neglectful supervision with the case being closed administratively. The allegation included the mother was using drugs and had been kicked out of school, The department interviewed several collaterals and disproved the allegation. During the investigation, the mother and child moved to an unknown address. The review indicated the Acting Supervisor, Investigator IV, Child Protective Services failed to get the Program Director’s approval to close the case administratively as per CPS Handbook Policy Section 2310. All other actions taken by caseworkers were compliant with established policies, procedures, and protocols pursuant to the CPS Handbook in the investigation. The case was subsequently closed on March 14, 2014. RevIewed B 4Z’ 01G0002 Revised 11-2014 Date: 22 GIG Case: 1604415 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES COMMISsioN FINAL REPORT • • Interview with the Supervisor 11, Child Protective Services, who stated that established policies, procedures, and protocols pursuant to the CPS Handbook, were followed by CPS Investigators in the child death investigation. No concerns were noted in the death investigation or the historical case. Interview with the Program Director, Child Protective Services, who stated Investigator IV should have assigned him as secondary on the historical case to allow for his approval of the administrative closure, and that this did not occur as per CPS Handbook Policy Section 2310. The Program Director sai.d he had no concerns with closing the ease administratively. No concerns were noted in the investigation. Actions Taken: This matter has been referred to Trevor Woodmft General Counsel, Department of Family and Protective Services. Austin, Texas. Reviewed By: 01G0002 Revised 11-2014 Date: /2 22-/C OIGCase: 16044-15 Page2of2 OFFICE OF INSPECTOR GENERAL. TEXAS HEALTH & HUMAN SERvicEs C0MM!ssloN FDAL REPORT Date: July 23, 2015 OIG Case: 16095-15 Investigation Category: HIIS Human Resources Manual, Chapter 4. Employee Misconduct, Work Rules (lX2)(28); Department of Family and Protective Services, Child Protective Services Handbook, sections 6131.23, 6131.26, 2272 and 2230 Allegation: On June 4,2015, this investigation was initiated by the Office of Inspector General, upon receipt of information that a child died on May 22. 2015; (lie cause of death was from neglectful supervision, Sudden Infant Death Syndrome (SIDS) This child and tamily had a history with the Department of Family and Protective Services, Child Protective Services The child’s death was initially intestigated as possible SIDS by the Ector County Sheriff Department. An autopsy was performed by Tarrant County Medical Examiner’s Office, who reported that, the manner of death could not be determined and the cause of death was “Sudden Unexplained Infant Death with Unsafe Sleep Environment”. During the course of this investigation, it was discovered that a Child Protective Services Investigator II, and a Supervisor, failed to follow established policies and procedures pursuant to the CPS Handbook Policy. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of June 4, 2015 July 23, 2015. The allegation that Child Protective Services Investigator and Supervisor failed to follow established policies and procedures pursuant to the CPS Handbook Policy by not completing timely evaluations and as well as permitting extensions without vering documentation in IMPACT, are substantiated. These results are based on the following: • Review of a DFPS case disclosed CPS Investigator did not complete required evaluation and visits in the initial investigation task stage for the month of April 2015, or May 2015, within 10 days as required for a Priority 2 in accordance with CPS policy 6131.1 and 2230. • Interview conducted with a CPS Investigator II, CPS, DFPS, who acknowledged she was assigned to a DFPS case in April 2015, and that she failed to complete the required evaluation and visit for the months of April 2015 and May 2015. The CPS Investigator said her documentation was in a Word Document and her computer “crashed” so she did not have information on her case. The CPS Investigator also said she was in a car accident, which prevented her from checking on her cases. • Review of a DFPS case, which disclosed a CPS Supervisor did not complete required caseworker assessments in IMPACT for documentation and visits in the initial investigation task stage and gave two — Reviewed By: OlG0002 (10/2112014) Date: CIG Case: 16095-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL rExAs HEALTH & HUMAN SERVICES CoMMissioN FINAL REPORT the month of May2015 without reading the case within 15 days as required for a Priority 2 in accordance with CPS policy 6131.26 and 2272. • Interview conducted with the Investigations Supervisor, CPS, DFPS, who acknowledged he supervised the casework of CPS Investigator and said she failed to complete the required evaluations and visits for April 2015 and May 2015. CPS Supervisor said there was no documentation in the ease so he “probably granted extensions because CPS Investigator had no documentation after her computer crashed and he assumed this is one of the cases she may have lost”. CPS Supervisor said there was nothin to g read in IMPACT and it was a “catch 22” and that either way he would be held accountable. • Interview with Regional Administrator, CPS, DFPS, who acknowledge she disciplined CPS Investigator and CPS Supervisor for their inactions involving DR’S case • Interview with Child Safety Specialist, CPS, DFPS, who acknowledge a Quality Review Team (QRT) was held on May 26, 2015, concerning the death of the child. CPS Child Safety Specialist acknowledged the lack of documentation and timely visits did not prohibit the family from receivi ng further services as prescribed by policy. extensions for — Actions Taken: Referred to Trevor Woodwff General Counsel, Department of Family and Protective Services, Austin, Texas. Reviewed By; 0100002(10(21/2014) Data: 010 Case: 16095-15 Page2of2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERvicEs CoMMissioN FINAL REPORT Date: Julyl7,2015 OIG Case: 16126-15 Investigation Category: Texas Penal Code 37.10 Tampering with a Government Record; Department of Family and Protective Services, Child Protective Services Handbook, sections 6131.1 Allegation: On June 10,2015, this investigation was initiated by the Office of Inspector General, upon receipt of information, alleging Child Protective Services (CPS) Conservatorship Division did not follow established procedures for Conservatorship within the foster care program. During the course of this investigation, it was reported that IMPACT documentation entered by a CPS Conservatorship Specialist and travel might have been falsified. In addition, the CPS Conservatorship (CVS) Specialist was alleged to have not complied with HHS Human Resources and CPS Handbook policies during casework involving several foster care families. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of June 10, 2015, to July 17, 2015 The allegation that a CVS Specialist falsified his travel and entnes into LMPACT are substantiated and based on the following: Review of IMPACT records revealed the following: o One DFPS case indicated the CVS Specialist documented he traveled to Lcvelland, Texas for a monthly-required visit of a foster child at her home. o A second DFPS case indicated the Ct’S Specialist documented he traveled to Plainview, Texas for a monthly-required visit of a foster child at his home. o A third DFPS case indicated the CVS Specialist documented be traveled to Slaton, Texas for a monthly-required visit of a foster child at his home. [nterview of Conservatorship Supervisor. Department of Family and Protective Services, Child Protective Services, Lubbock, Texas, who said the CVS Specialist entered travel documentation, which showed visits to a foster home in Plainview. Texas, (100 mile round tripl times 700 miles) on September 1 and 14, 2014, October 17, 2014, November 18, 2014, December 8, 2014, January 29, 2015, February 27, 2015, and March 20,2015, for a DFPS case. The Conservatorship Supervisor said the CVS Specialist documented seeing the foster child in the foster home in Plainview, 50 miles from Lubbock where the CVS Specialist is based, and spoke with the foster parent. • interview of foster parent in Slaton, Texas (30 Miles round trip 7 fimes=210 miles) said no one in the foster home has seen the Conservatorship Specialist since sometime “late last summer” (2014) and they saw the CVS Specialist once at the Lubbock Child Protective Services office, Foster parent said the CVS Specialist never came to their home to visit the foster child. Foster parent said foster child was Reviewed By: Date: 22.. /C 01G0002 (10/21/2014) QIG Case: 16126-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TExAs HEALTh & HUMAN SERVICES CoMMISsION FINAL REPORT • • placed with them on August 5,2014, but the CVS Specialist has not called about foster child since January 2015. Interview of foster parent who said the CVS Specialist has not been to their home in Levelland, Texas (48 mile round trip 7 times338 miles) except once during the fall of 2014, for a DFPS case. Foster parent said the CVS Specialist took over foster child’s case on October 7, 2014. Foster parent said Conservatorship Specialist has only seen foster child when they brought the child too court on October 28,2014, and February 24,2015, and once at a meeting at the Briercroft office in Lubbock, Texas on March 25, 2015. Interview of the former CVS Specialist who said visits were conducted with clients in the community, parks, fast food restaurants, and/or daycare. The CVS Specialist said no travel documents were falsified because travel was to the cities in question but not to the homes as required by CPS Handbook Policy 6130-6131I. Conservatorship Specialist admitted not seeing any of the foster children or foster parents when allegedly traveling to Plainview, Lcvelland or Slaton at the foster home per Child Protective Services Policy 6131.1, “Documentation of Monthly Contacts and Visits.” Actions Taknn: Referred to Trevor Woodruff; General Counsel, Department of Family and Protective Services, Austin, Texas. Referred to Matthew D. Powell, Lubbock County District Attorney, Lubbock, Texas Reviewed By: 01G0002 (10121/2014) Dale: 2?22 z5 QIG Case: 16126-15 Page2of 2 OFFICE OF INSPECTOR GENERAL ThxAs HEALTh & HuMAN Sas VICES CoM1nssIoN FINAL REPORT Date: July 23, 2015 OIG Case: 16190-15 Investigation Category: Child Protective Services Child Death Allegation: On June 24, 2015 this investigation was initiated by the Office of Inspector General upon receipt of information that child, whose family has previous Child Protective Services (CPS) history died due to Physical Abuse on June 21, 2015. Child was rushed to hospital due to complaining of blindness. Medical staff worked on child, but the child died. Live-in Boyfriend initially reported that a trampoline fell on the child but later admitted to hospital staff that he hit the child. Law enforcement initially investigated the death as a possible homicide and later arrested the live-in boyfriend for capital murder. The Medical Examiner reported that child had internal injuries and bruising on the face and blunt trauma to the torso and abdomen area. Medical Examiner reported that manner of death is pending histology and toxicology results. During the course of this investigation, it was discovered that CPS Specialist II, failed to follow established policies and procedures pursuant to the CPS Handbook by not developing a family plan of service within 21 calendar days, as required by CPS Handbook. Futhermore, CPS Specialist 11, failed to follow established policies and procedures pursuant to the CPS Handbook by not documenting all contacts with principals and children in the case within 24 hours, as required by CPS Handbook. Summary of Activities: The Internal Affairs Division conducted an investigation during the period of June 24, 2015, to July 23, 2015. The allegation that CPS Specialist II failed to develop a family plan of service within 21 calendar days. and not documenting all contacts with principals and children in the case within 24 hours, is substantiated based on the following: • Review of DFPS case disclosed CPS Specialist 11 failed to develop a family plan of service in a timely manner, and failed to document monthly contacts in a timely manner. In DFPS case, CPS Specialist II, was required to develop a family plan for the family due to concerns of ongoing Family violence and risk to the children. The plan explained to the family the reason for the requested services, and tasks and goals needed to successfully complete the plan. CPS Specialist II failure to complete the family in a timely manner did not delay the family from receiving services. CPS Specialist II completed a request for services for the family in a timely manner. • Interview conducted with CPS Specialist II, who acknowledged that she was assigned to the Family Based Services (FBSS) portion of case in October 2014, and that she failed to develop a family plan and documenting contacts in a timely manner due to overwhelming caseload. CPS Specialist II reported that her faiiure to document her contacts in a timely manner did not prevent the family from receiving family Re.lewed By: 01G0002 Revised 11-2014 Date.%.? -22 — - DIG Case: 16190-15 Page 1 of 2 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES COMMIsSIoN FINAL REPORT because she did complete request for services in a timely manner. Interview conducted with C.P.S. Family Based Supervisor 11, who acknow ledged she supervised the casework of CPS Specialist II and that the CPS Specialist II failed to develop a family plan and document monthly contacts in a timely manner. FBSS Supervisor II reporte d that the family plan is a contract between DIPS and the family outlining the concerns and tasks and goals needed to reduce or eliminate risk to the children. FBSS Supervisor II reported that although CPS Specialist II failed to develop the family plan in a timely manner, she did complete request for services for the family and no services were missed or delayed. • Interview conducted with CPS Child Safety Specialist, who reported that during review of family history, no contact was made in the month of January 2015, and that no documented contact was for the months of March and May 2015. CPS Child Safety Speciaiist also reporte d that the case was documented for contact for March and May 2015, but no narrative was compl eted. CPS Child Safety Specialist reported that no monthly contact was made with the family Januar in y 2015. CPS Child Safety Specialist reported that worker failure to complete a family plan in a timely manner could cause delays in services if the worker did not request services in a timely manne r, CPS Child Safety Specialist reported that the family did receive services while in EBBS. CPS Child Safety Specialist reported that the worker failure to complete documentation in a timely manner did not contribute to the death of the child. • • • Review of CPS Handbook state that caseworker must document all contac ts with principals and children in the case within 24 hours. Review of CPS Handbook state that the caseworker must develop a family plan of service within 21 calendar days of opening a family preservation stage. Although there were administrative violations identified, they did not contrib ute to the death of the child. Based on the information gathered and statement taken, the allegation that CPS Specialist II failed to develop a family plan. of service within 2 i calendar days, and not documenting all contac ts with principals and children in the case within 24 hours, is substantiated. Actions Taken: Referred to Trevor Woodruff, Acting General Counsel, Department of Family and Protective Services, Austin, Texas fleviawed By: OlG0002 Revised 11-2014 oste: J_2 u22 -zr OIG Case: 16190-15 Page 2 of 2 OFFICE OF INSPECTOR GENn&AL Ti ‘