The Ethical Challenges in Case Management

Transcription

1 Sheryl Steckler, Inspector General Jerry Chesnutt, Director of Internal Audit Audit Report OFFICE OF INSPECTOR GENERAL INTERNAL AUDIT Enhancing Public Trust in Government The Ethical Challenges in Case Management Project C February 27, 2008 Purpose and Objective The purpose of this audit is to explore the circumstances surrounding Office of Inspector General investigations of employees who falsify home visits to children. This audit was conducted as part of our FY audit plan. The objective of this audit is to identify recurring issues and shed light on additional information common to these investigations. Scope and Methodology The scope of this audit focuses primarily on twenty-three 1 Inspector General investigations (cases) of falsification of home visits with children that were completed from July 2006 to September Our methodology included reviewing regulations for home visits and examining case reports with supporting documents. In an effort to delve into underlying issues and extenuating circumstances, we interviewed supervisors, and in some cases, the investigation s subject. Background The Department faces the primary challenge of ensuring the safety and well-being of abused, neglected, and abandoned children. Protective supervision is provided through contracts between the Department and Community-based care lead agencies. Lead agencies usually employ subcontractors who provide case management and direct care services to children and their families. Section 65C , Florida Administrative Code (FAC), explains case management responsibilities and required contacts with children under supervision. It states in part, The Services Worker 2 shall make face-to-face contact with children under supervision and living in Florida, with the custodial parents of any child under in-home supervision, and with the child s caregiver if the child is in an out-of-home placement no less frequently than every thirty days. 1 Sample included all cases concerning only falsification of home visits to at-risk children from 7/06 through 9/07. Resulting breakdown of 23 sampled cases by District: District 7 = 1, District 8 = 1, District 9 = 8, District 11 = 4, District 13 = 1, District 14 = 2, SunCoast = 6. 2 Per Family Safety Program staff, the following position titles are interchangeable: services worker, case manager and case worker. 1

2 Section (2)(c), Florida Statutes (FS) on falsifying records states: Any person who knowingly falsifies, alters, destroys, defaces, overwrites, removes, or discards records of the Department of Children and Family Services or its contract provider with the intent to conceal a fact material to a child abuse protective investigation, protective supervision, foster care and related services, or a protective investigation or protective supervision of a vulnerable adult, as defined in chapter 39, chapter 409, or chapter 415, commits a felony of the third degree, punishable as provided in s , s , or s Nothing in this paragraph prohibits prosecution for a violation of paragraph (a) or paragraph (b) involving records described in this paragraph. Some challenges faced by case managers were described in OPPAGA report number 06-50: Lead agencies reported that case managers are in high stress, emotionally draining jobs that require long work hours. Case management organization and lead agency administrators said that additional job frustrations that lead to case manager turnover are documentation requirements that limit time spent with clients, and applicants not understanding the demanding nature of the job prior to accepting the position. 3 Several interviews during OIG investigations and during this audit corroborated this description and provided a glimpse into the nature of this work. the (case manager) told the (foster parent) that his caseload was too high and that he did not have the time to go to her home for the visit..had case management responsibility for about 63 children was required to conduct monthly visits with these children in their current placements. was an impossible job requirement. (There were) many vacant positions in the office. felt the high caseload was a form of punishment for being the most seasoned employee. As a result, he was becoming ill, working to 8:00 p.m. or 9:00 p.m. most nights, unable to see his children, and fighting with his wife over the long work hours. felt his employment termination might be a blessing in disguise for his personal life (OIG Case ). (case manager) resigned due to the stress of working long hours, weekends and holidays (OIG Case ). We can t retain staff because of high caseloads (OIG Case ). due to being the longest serving case manager, he had a caseload of 54 children to visit each month.always being rushed to complete his high caseload each month and travel to meet visitation targets (OIG Case ). care manager stated "due to her heavy caseload, had been unable to visit" (OIG Case ). (case manager s) caseload was somewhat excessive for an inexperienced case manager. (supervisor) was unable to assist him a great deal due to being overloaded herself by working a 30 child caseload in addition to being a new supervisor. He was further overloaded with cases when another employee s caseload was transferred to him after her resignation because he was the only 3 The Office of Program Policy Analysis and Government Accountability report number 06-50, Child Welfare System Performance Mixed in First Year of Statewide Community-Based Care, issued in June

3 Spanish speaking case manager.... (caseloads) slowly rose when positions were cut (OIG Case ). Turnover creates caseload issues (OIG Case ). case managers have until the 20th of each month to complete all visits but she allows until the 25th at max due to emergencies (OIG Case ). was very upset about the size of her caseload (OIG Case ). (The organization) recently cut positions, including case managers and one supervisor position, resulting in an increase in caseloads and supervisory responsibilities (OIG Case ). he had a caseload of 33 children and claimed it was the highest of any case manager in his unit. He said that it was very frustrating working in his unit because he had no support, there was a high turnover of staff and low morale in the unit. She said (case manager staff) was down by nine due to staff turnover (OIG Case ). He said he had a lot of cases and he was doing the best he could. (case manager) appeared hopeless at times (OIG ). Case work is hard and getting the right person is hard. Stress on the job may have caused her to do the job improperly. (OIG Case ). supervisors have to work their own caseloads and make the same deadlines as the case managers. Sometimes case managers work twice as many hours as they are paid for (OIG Case ). During interviews, supervisors commented that some case managers chose to perform their jobs incorrectly by using shortcuts giving the appearance that home visits were conducted appropriately. Some case managers indicated in HomeSafenet 4 (HSn) that face-to-face home visits occurred even though the case manager: only contacted clients by telephone or left a business card after finding no one home (OIG Case ) spoke to clients at the residence and never entered the home (OIG ) submitted timesheets and travel logs that were inconsistent with HSn notes (OIG Case ) visited the home and had foster parents sign an additional Monthly Child Visit form, then back-dated it to reflect a visit that did not occur (OIG Case ) neglected to provide and sign the Child Resource Book/visitation log (OIG Case ) forged signatures of caregivers, children, and supervisors (OIG Case ) requested that the foster parent sign the home visit form after a supervised parental visit at service center (OIG Case ) filed home visit forms that were unsigned and not dated (OIG Case ) Many of these instances are unethical and essentially fraudulent under section , FS. Case managers falsified documents to deceive supervisors that believed they had complied with procedures in completing home visits. 4 HomeSafenet (HSn) was Florida s federally funded Statewide Automated Child Welfare Information System (SACWIS) for providing information to support community-based organizations, in partnership with the State of Florida, in identifying victims of abuse and neglect. In July 2007, HSn was converted to Florida Safe Families Network. 3

4 ISSUES While there may be many reasons why case managers falsified home visits, the following reasons were prevalent in case reports and interviews. Many case managers were overwhelmed by large caseloads. Large caseloads were common in 18 of 23 (78%) cases. Caseloads ranged from 21 to 63 children where case managers were required to visit each month. We noted that when overwhelmed with cases, case managers chose to do as many as possible, resign, or take short cuts that entailed falsification. One case manager admitted a case note was false and that he created it so it could count as a monthly visit; that he conducted a quick home visit; that the notes were false because he did not go to the foster home on that date; and, that he admitted his actions were inappropriate, but said he had no other choice due to an excessive caseload. In his opinion, this was an impossible job requirement (OIG Case ). A co-worker commented that one case manager was so overwhelmed he appeared hopeless at times and became defensive. 5 OPPAGA reported that the statewide average caseload was 24 children per case manager in fiscal year The caseload ratio recommended by the Child Welfare League of America (CWLA) is foster children per case manager. Caseload standards help to ensure that case managers have enough time to adequately serve each child and family. 7 To assist with acquiring resources to comply with the CWLA, 20.19(5)(c), FS directs the Department each fiscal year to request a specific appropriation for funds and positions for the next fiscal year to provide an adequate number of full-time equivalent child protection case workers so that caseloads do not exceed CWLA standards by more than two cases. The statute essentially established caseload standards as children, 8 two cases more than CWLA standards based on the condition that the Department acquires an adequate number of full-time case workers through the legislative budget request. Compliance with (5) (c), FS was evident in the legislative budget request, as funding was requested for 400 case manager positions based on a proposal the Department accepted from the Florida Coalition for Children. 9 The Office of the Assistant Secretary for Programs stated that the Department does not track average caseload per case manager. The Family Safety Program Director stated the Department had not mandated the requirement for lead agencies or their subcontracted providers to adhere to CWLA standards or caseload ratios. The Assistant Secretary for Programs stated that, in his opinion, it was not advisable to include caseload standards in CBC contracts for the following reasons: 5 Department of Children and Families Inspector General Investigation , issued April See footnote 2 and when contacted OPPAGA staff indicated the ratio was calculated through surveys and interviews. 7 United States Government Accountability Office Report GAO T, Additional Federal Action Could Help States Address Challenges in Providing Services to Children and Families, May 15, The Office of Program Policy Analysis and Government Accountability report number 06-50, Child Welfare System Performance Mixed in First Year of Statewide Community-Based Care, issued in June Department of Children and Families Intranet, Budget Office website, Legislative Budget Request , Exhibit D-3A, page 198. Per the Office of the Assistant Secretary for Programs, the Department does not track average caseload per case manager. The budget request was based on a proposal submitted by Florida Coalition for Children. 4

5 The Department has not established a standard for child welfare caseloads. The lead agency average caseload correlates with the level of funding to the agency per child served. There is an inadequate understanding of how other factors (e.g. workplace environmental factors, salary, federal and state requirements, and public perception) interrelate to shape case manager compliance and performance. As a result, focusing only on caseloads in CBC contracts could potentially yield unintended negative consequences. The Assistant Secretary recommended that the Department should ensure compliance with the provisions of subsection 20.19(5)(c), FS and analyze available data to improve the ability to identify situations where case manager compliance is at elevated risk. The Inspector General commented that high caseload levels identified in this investigation (OIG Investigation ) may have a direct correlation to case manager s ability to perform their required monthly visits. It was recommended, and we concur, that they consider alternative options to reducing caseloads and sharing best practices statewide. We also recommend that caseload data be evaluated statewide so that the Department is better able to manage Florida s child protection system. By doing so, potential pitfalls and problems can be readily identified. This would be the starting point for understanding workload and can be used as a basis for determining the number of case manager positions needed to adequately serve each child and family. Large caseloads driving high turnover rates. High turnover was pointed out in seven of 23 (30%) cases. During interviews, one case manager supervisor commented that excessive caseloads drive turnover and vice versa. Another said high caseload is a contributing factor to retaining staff. When a case manager leaves, remaining case managers must absorb the workload until the position is filled. She said it is hard to retain case managers because the job is so demanding and exhausting. Some case managers do not realize what the job requires initially, and when they get overloaded with work, they see no outlet except job resignation. Several case managers had health conditions that made it difficult to keep up with the work that sometimes led to poor performance, resignation or termination. In one investigation, the case manager stated that she began having health problems that were stressed-induced and her ability to keep up with the documentation became difficult; she resigned due to the stress of working long hours, weekends, and holidays (OIG Case ). Supervisors indicated that high turnover was caused by resignations due to large caseloads, low salaries, long work hours, overall job dissatisfaction, and terminations due to inappropriate case management. Internal lead agency position cuts to cover other costs contributed to turnover as well. 10 A former case manager said there are not enough case managers to adequately handle cases. As a result, case managers reported experiencing stress from performance pressure to complete numerous home visits, paperwork, and data input to HSn within prescribed timeframes. We recommend that the Department and Community-Based Care organizations establish a workgroup to focus on finding ways to retain case management staff. The attached letter from 10 OIG Case : Lead Agency Child & Family Connections cut case manager positions of subcontractor Family Preservation Services of Florida, Inc. in District 9. 5

6 an anonymous case manager provides insight and information that should be considered by the workgroup. 11 Case management oversight needs improvement. We noted several situations where more oversight or supervision was needed. Several case managers stated that they never got the help they requested. During interviews, some supervisors commented that some case managers could not effectively organize their work and manage time. Supervisors noticed: discrepancies between time and travel records (OIG Cases and ) tardiness in completing face-to face sheet contact notes, entering data in HSn, and late submission of legal documents (OIG Case ) overlapping visits or visits that occurred at the same date and time as other visits or attempted visits (OIG Case ) We reviewed several cases where supervisory assistance was needed, but not provided for various reasons. One case manager indicated that his supervisor was unable to assist him due to management of her own caseload (OIG Case ). This was consistent with another supervisor (OIG Case ). Another case manager said he was very frustrated working in his unit because he had no support; there was high staff turnover and low morale in the unit (OIG Case ). Yet another said he had impossible job requirements that led him to take shortcuts until his caseload became manageable. He indicated he was overwhelmed by his caseload and insufficiently trained in some areas (OIG Case ). Another said she was required to have her 32 children seen before the 15th of each month, conduct judicial reviews, participate in staffing, in addition to a myriad of other activities. She started having problems keeping up with everything and requested a lower caseload from her supervisor. Her supervisor could not be relied upon to help and her caseload was not lowered. (OIG Case ) One supervisor said the case manager should have been monitored more closely, but she was experienced and had proven to be a good employee in the past (OIG Case ). Another said she was too trusting. A couple of case managers held second jobs. Job hours conflicted with case management work hours and could have interfered with their case management duties. Supervisors acknowledged they did not approve dual employment (OIG Cases and ). Personal issues were noted in eight of the 23 (35%) cases examined. Such issues included family illnesses, stress, personal illness, extended sick leave, relocation, attending graduate school, planning a wedding, fear of dogs, and problems working long hours and weekends. Supervisors were aware of some of these issues. Communication and monitoring should be improved to handle these situations with minimal adverse effects on the job. To improve case management oversight, we recommend that management consider implementing a Customer Care Call Policy. This policy was initiated by KHU (Kids Hope United, Inc.) in response to a falsification investigation. It requires each supervisor to make random calls to families to determine if case managers are making required home visits. We also recommend considering implementation of a Staff Shadowing Program that would involve 11 Source: DCF Office of Operations. 6

7 supervisors accompanying case managers on home and field visits to monitor the quality of services (OIG Case ). Supervisors and case managers are not satisfied with the training provided by the Department. Training dissatisfaction was expressed in eight of 23 (35%) cases. Several case manager supervisors echoed that the certification training was insufficient and ineffective. One case manager claimed he made mistakes because he was insufficiently trained in some areas (OIG Case ). Supervisors said case managers expressed that training is just theory and should include more hands-on exercises. In addition, more fieldwork training is needed (OIG Cases , and ). Training should not stop at theory, but extend to more hands-on case walk-throughs to help convey a better understanding of the job (OIG Case ). One supervisor indicated mock cases should be included so that case managers can carry out actual steps in processing a case (OIG Case ). Department management indicated mock cases are part of the curriculum; however, the Department does not continually monitor to know if they are being conducted. Supervisors said Kids Hope United case managers had complained that training was horrible and that once training was over they did not know how to work a case (OIG Case ). However, in July 2007, their lead agency, Heartland for Children, provided much better training that guided them more thoroughly through case processing. Case managers received a notebook of forms and better step-by-step instructions and illustrations, including redacted judicial reviews using successful cases. Supervisors from Children s Home Society (OIG Case ) said the Hillsborough Kids training group was hired to provide additional training to their case managers. They stated that case managers were very satisfied because the training was more hands-on and provided better reference tools. We recommend the Department and Community-Based Care organizations establish a workgroup to survey case managers evaluating the effectiveness of the training, implement best practices statewide, and enhance the training curriculum if necessary. We also recommend that the Department ensure that mock cases are conducted as required. Conclusion Challenges of case management have, for some, turned into poor ethical choices. Regardless of job conditions, the individual case manager is first and foremost responsible for the accuracy of visitation information. Supervisors also must be alert for indicators that may lead to falsification of home visits. Management should address the recommendations noted above to improve the case management environment for the benefit of staff and clients. While studying the work environment of case managers and the factors that led some to falsify client records, we recognized a need for behavioral guidance in the form of a code of ethics. This code of ethics should describe organizational expectations and be included as part of the case management training curriculum. This code would benchmark acceptable behavior and 7

8 foster an environment that does not force child welfare professionals to choose between their livelihood and the protection of children. Management Response The attached response from the Office of the Assistant Secretary for Programs and the Office of Family Safety indicated that they concurred with our findings and that appropriate corrective action will be taken. The complete report and response are available on our web site at the following address: This project was conducted in accordance with the International Standards for the Professional Practice of Internal Auditing, published by the Institute of Internal Auditors. This report is also available on our website: Project conducted by Renea Alexander under the supervision of Jerry Chesnutt, Director of Auditing (850) Sheryl G. Steckler, DCF Inspector General 8

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