YELLOW SHEET Office of the State Auditor of Missouri Claire McCaskill

Our office began auditing the hotline system run by the Division of Family Services after two boys died from abuse, despite at least 11 hotline calls about possible neglect - including an incorrectly categorized call just before their deaths. Our staff focused on determining how the system received, reviewed and resolved hotline calls. The audit tested decision making processes, tracked actions taken and studied the outcomes. 

Our review showed that while many calls are properly handled, ineffective oversight by top managers leaves many children in danger of further mistreatment.� Our findings fall into two major issues: overall quality control and investment in field staff. Without an adequate monitoring system, managers could not detect problems when they occurred and, in some cases, ignored detected problems. Managers also did not adequately support their field staff, which contributed to low morale and high turnover.� The following highlights our findings: 

Inconsistent decision making 

Our tests showed that field staff did not make consistent decisions about hotline calls. We presented a series of calls to several workers and received varying responses. The workers were requested to decide if the calls met abuse or neglect criteria and if so to classify them for either investigation or family assessment.� In our test, we included two calls made on behalf of three children who died and found 83 percent of those tested chose a different action than was chosen by the workers who originally handled those cases.� In a call of a mother forcing an 8-year-old to breast feed which was not accepted by the original call taker, all those tested said it should have been accepted as a child abuse and neglect report or referral for services rather than an unable to investigate case, which it was. �We proposed a decision making model that leaves less room for inconsistencies and worker judgment. (See page 4)�

Calls incorrectly classified 

Of the 95,000 calls received in 1999, call takers determined one quarter of them could not be investigated, which means no action occurred. But our audit showed many calls are incorrectly classified. In our small sample, we found 50 incorrectly categorized calls. We presented these cases to DFS officials in May 2000 to give the children another chance at protection, but officials only agreed with our reassessment on one case and took no action on the rest. One of our examples included an inadequately clothed boy locked outside his home on a cold day. The hotline manager defended the decision with: �Let�s face it, 38 degrees isn�t going to kill anyone.� (See page 6) 

Our review of these uninvestigated calls showed hotline workers did not always indicate if they checked for previous reports of abuse and did not fully document the call on the manual worksheet. In addition, supervisors approving the categorization of these calls never listened to the taped calls to monitor a call taker�s judgment. Finally, once a call is considered unable to investigate, usable records of the call are destroyed within two months. (See page 9)

Reports of abuse ignored

There is no assurance that the county offices will act on calls referred to them by the hotline unit. We found 33 calls in three months that received no action because the county staffs never pulled the call off the automated referral system. We could not determine the historical magnitude of this problem because the automated system only displays calls for a 3-month period. DFS officials have since tried to correct this issue. (See page 11) 

Nearly half substantiated calls overturned 

During 1999, the child abuse review board overturned on appeal 40 percent of all investigations substantiating probable abuse. �The review board cited poor case management as the reason for 26 percent of the overturned cases. �DFS has known of the high overturn rate for at least four years and hired an employee to create a better case-management plan, but then ignored the employee�s suggestions. (See page 13) 

More investment in staff needed 

The DFS Central office has not fully supported the field staff which suffers from low morale and high staff turnover and as a result cannot complete tasks within deadlines or have confidence in their decision-making. We attribute these problems to low pay, inadequate equipment, and training. 

Missouri ranks 45^th in the nation on basic pay and offers only a 4 percent raise for promotion to supervisor, which is nearly one third less than what four surrounding states offer. There is also no pay differential for staff obtaining a Master�s degree or professional licensing. (See page 26) Workers are inefficient due to inadequate equipment, such as some workers having to type or handwrite their reports due to a lack of computers. (See page 29) And all employee levels, from workers to supervisors, shared concerns about the adequacy of training and lack of guidance. In fact some directors, with background in Income Maintenance not Children Services, said they were uncomfortable supervising social workers. (See page 31) 

We realize that the role of DFS staff in receiving and processing hotline calls and cases is very difficult.� We also realize that no one in DFS wants a child at risk to remain at risk.� For this realization to remain true, senior managers need to take a more proactive role in managing the organization and institute effective quality controls. Our recommendations offer some simple mechanical steps to meet this goal.  

Complete Audit Report

---

Missouri State Auditor's Office
moaudit@mail.auditor.state.mo.us
Webmaster: auditor@mail.auditor.state.mo.us

---