OFFICE OF INSPECTOR GENERAL

fxAs FIt ALE II & Fit \IA SLR\ RI S CO\IulSsIO\

FINAL REPORT
Date: October 9. 2014
OIG Case: 13310-14
Investigation Category: HHS Human Resources Manual. Chapter 4. Employee Misconduct. Vork Rules
(l)(2)(28): Department of Family and Protecwe Services. Child Protective Services Handbook. sections 2345.
2364.2377.2397,3111.3324,3329.34l1, 3419
Allegation: On March 12. 2014. this investigation was initiated by the Office of Inspector General alleging
Child Protective Services ((PS) did not follow established procedures in the child death case of an S-yearold
Bexar County child who died of appendicitis. The child and family had prior (PS history under Department of
Family and Protective Services (DFPS) cases 38704081 and 29922909. The Schertz Police Department
investigated the death under case 2009-05731. During the course of this investigation, it was reported that
IMPACT documentation entered by caseworkers may have been altered. In addition. a former CPS Family
Based Safety Services (FBSS) Specialist, two (PS Investigators, and a (PS Kinship Specialist Ill were alleged
to have not complied with FIHS Human Resources and CPS Handbook policies during their casework inolving
the deceased childs family. Further allegations were rna(le that a (PS Program Director, and a former (PS
Program Director, did not comply with established (PS Handbook policies during the referral process involving
the child. The Internal Afihirs Division conducted an investigation during thc period of March 12. 2014. to
September 30, 2014.
Summary of Activities: [here was no evidence to support the allegation that the (PS Program I)irector or
former (PS Program Director did not comply with established (PS Handbook policies in their handling of the
famil referral and documentation process. There was no evidence to indicate that any policy violations were to
blame for the appendicitis shich is the listed cause oidcath. The allegation that a former (PS Family Based
Safety Services Specialist, a (PS Kinship Specialist IlL and two (PS Investigators did not comply with HHS
Human Resources policies and (PS Handbook policies is substantiated and based on the following:
The Program Director and former Program Director fbllo\ed established (PS Handbook policy in
sections 21 51. 21 52. 2 154. 2155, 2156. and 21 56.1 regarding Statewide Intake referrals involving the
childs family on March 3. 2(109. The fbrmer Program Director followed established CPS Handbook
policy in sections 1433 and 1481 when she requested a (PS Investigator make corrections to
documentation into IMPACT. When the changes were not made as directed by the fdrmer Program
Director, she made the corrections herself and the case was submitted for closure.
Interview of the former (PS FBSS Specialist. DFPS. ihe FBSS Specialist said she did not provide a
timely service plan in her casework involving the deceased child. The FBSS Specialist said she failed to
contact and inform the biological mother of DFPS case 29922909. which involved medical neglect
involving her three children. The FBSS Specialist said she failed to tollow up with professional
Reviewed By:
________
Date:
01G0002 (06/01/201 3)
OlGCase: 13310-14 Pagelof2
OFFICE OF INSPECTOR GENERAL
rExAs Hr.i.nt & lit %IA\ SItRvrFs (OSNISSK)N
FINAL REPORT
collateral sources to gauge the success of services in DFPS case 29922909, and failed to conduct visual
contact with the children in September 2008. and January 2009. The FBSS Specialist said she failed to
conduct a home assessment, which would have made her aware of provisions tbr the children and the
conditions in which they lived, and did not document in IMPACT within thc required timelines specified
in CPS Handbook policy The FBSS Specialists statement was corroborated by a review of IMPACT
records.
Interview of a CPS Investigator. DFPS. on April 30.2014. The CPS Investigator said she did not
contact the reporter of DFPS ease 29922909. the Supervision Monitor for Kid Share Family Services, as
required per (PS Handbook Section 2345. The CPS Investigator said the Supervision Monitor alleged
possible neglectful supervision and sexual abuse of three of the children. including the deceased child.
The CPS Investigators statement was corroborated by a review of IMPACT records.
Interview of a (PS Investigator. DFPS. on April 30, 2014. The CPS Investigator said she fiuiled to
notit!,
the biological mother of DFPS ease 29922909. which involved her children, as required per CPS
Handbook Section 2364. The CPS lnvestigators statement was corroborated by a review of IMPACT
records.
Interview of the CPS Kinship Specialist ill. DIPS. The CPS Kinship Specialist Ill said he failed to
contact a Laurel Ridge Hospital physician. as required per CPS Handbook Section 2397. The Laurel
Ridge Physician had reported one child appeared undernourished. The CPS Kiumhip Specialist III said he
also failed to respond to an outcry the children made that they were always hungry and not fed. The CPS
Kinship Specialist Ills statement was corroborated by a of IMPACT records.
Interview of the biological mother of the deceased child and two sons. The biological mother said she
was not contacted by an FBSS Specialist to inform her that her children were seen as part of a CPS
investigation, and that she was never contacted by an FBSS Specialist as a collateral source during the
open FBSS case.
Interviews of the Watts Elementary School nurse. counselor, and vice principal, and the Jordan Middle
School counselor. School employees are mandatory reports as specified in the Texas Family Code, Title
5. Subtitle E. Subchapter A, Subchapter B. Report Section 261.101. All interviewees said they reported
that during the 2008-2009 school year they had concerns regarding the deceased child and her brothers.
During the interviews, all independently said they were not informed of an open CPS case involving the
children, and were not contacted by any caseworker regarding their observations and subsequent
concerns for the children.
Actions Taken: Referred to Cynthia OKeeffe. General Counsel. I)epartment of Family and Protectite
Services, Austin Texas.
RremdBy
0IG0002 (0610112013)
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