Mass. Auditor Discusses Child Abuse Findings, Past Audits Of COVID-19-Stricken Soldiers’ Homes
Massachusetts State Auditor Suzanne Bump says an audit of the Department of Early Education and Care found a number of shortcomings in the agency — from inconsistent investigation and reporting of child abuse to a failure to properly conduct background checks on its staff. Bump’s audit – which ran from 2016 to 2018 – has produced a number of recommendations to the EEC. WAMC spoke with Bump about her investigation, as well as her department’s past examinations of the soldiers’ homes in Chelsea and Holyoke. The horror has garnered national headlines, with more than 100 coronavirus-related deaths at the state-run nursing facilities for veterans in Massachusetts since March. Bump says audits in 2016 and 2017 indicated issues with the facilities years before the pandemic.
BUMP: EEC has a number of responsibilities that go beyond what people think of as its primary function of overseeing daycare facilities. They also license group residential homes and temporary shelters. In this audit, we looked at their activities with regard to group homes. And we particularly focused on the safety of individuals residing in those group homes. They can be children, they can be young adults. We focused on a population that was 18 and younger and looked at the coordination between the Department of Children and Families, which is responsible for investigating claims of child abuse, abuse of minors, whether they're in their home or whether they're in a group setting, to see if then EEC was fulfilling its responsibility to investigate the overall safetiness and conditions of the group homes where abuse had been reported.
WAMC: And what did you find with that inquest?
Well, we found a number of instances where there was a lack of communication between DCF and EEC, as to certain incidents of abuse that had been reported to DCF. Some cases never were, apparently, reported to EEC for their investigation. And in other cases, there had been reports, but that they have not been followed up on by EEC. This is of course a concern. We have done a number of audits relative to the safety of minors in state custody, whether it is at DCF or other agencies. And it is unfortunate that in some respects, this is almost typical of the difficulties that agencies have in collaborating across agency programs. They are often hindered by technological deficiencies and the agency getting focused on its particular mission without regard to those requirements of interaction with another state agency, a sister agency, if you will.
So, I'm interested - what kind of structures can you put in place to better foster those relationships moving forward?
Well, actually, in its response EEC indicated, and, along with DCF, that they would better collaborate, and in fact, use new technology to ensure that it is not a matter of mailing reports or emailing reports, that there is a more seamless approach to reports being forwarded from DCF to EEC for their investigation as to whether the facility's license should be pulled, or if there should be sanctions against the group facility. So we, the purpose here of all of our audits isn’t just to wave a finger at an agency saying you did something wrong. It's to convince them to collaborate and fix the problem. And so we regard the a positive thing: their acknowledgement that they can, should, and will address the problem.
One of the findings of your audit that I found particularly striking was the information that 40 of 50 closed investigations into child abuse from the EEC were turned in well after establish due dates, on average 61 days after a 30 day deadline. Moving forward, what can happen to make the EEC pursue these investigations in a more timely manner, given the delicacy of its subject?
Well, the timeliness is of critical importance. So, there are reasons why there are deadlines. And it's because the sooner you act, the more potential harm that you can head off. You want a quick resolution of problems, whether it stems from an individual behavior or a more systemic problem within the organization that they're not providing sufficient oversight or resources or training to their staff on, and so that that is going to require EEC to establish new and stricter timeframes and do more policing of itself in order to ensure that the follow up is prompt and that there aren't more residents who are being exposed to potential harm.
These findings talk about a failure to review or initiate investigations of reports of suspected abuse and neglect of children in programs, and that background checks have not been happening as thoroughly on employees. On issues like that, what are the moves that need to happen to make sure that these are happening in the EEC?
Really the administration of the EEC, which in fact, has a new, fairly new administrator really have to, to take this to heart and establish this as a priority. We've seen over the past couple of years a number of the deficiencies in this area by EEC, for instance, in its oversight of daycare programs, and so I think that the new director at EEC needs to create a new culture at the organization, really look strategically at how their resources are being used so that they can fulfill its mission. Which is not to suggest that there has been an historic indifferent to these matters, but we've seen in investigations of daycare facilities as well, that there hasn't been a great attention to thoroughness and to timeliness of the investigative work there.
So outside of that culture shift, are there any sort of things that your office can do to institute changes? Or is it mostly an advisory capacity?
Yes. Agencies have to decide on their own whether and how they will react to our findings. We don't have independent authority to force solutions upon agencies. But I think I think that what we heard back from the agency overall is some recognition of the issues that need to be resolved and in fact, with regard to background checks, there was a change that, in policy, that was that resulted not from this audit but from changes in state and federal law. And there are new requirements around background checks that occurred after our audit period. So we have not opined and we did not examine the changes to background checks, which is an area where we saw deficiencies.
I understand that your audit is largely qualitatively about how exactly this system operates and how the EEC was carrying out these procedures. Is there any way of gauging the impact on the actual people in these group homes, to the children who are under the care of these programs? Is there any way to actually understand what this means to them?
Well, I think that, unfortunately, time will tell of all in in future 51-8 reports that, there are reports of abuse that gets filed. And perhaps in other audits when we look at other facets of the program to see how well the young people with behavioral issues or mental health issues who are residents in these facilities are faring. So I get a frequency of reports, whether they are coming from, possibly, you have school teachers and the like. Unfortunately, it's only time will tell whether changes get made and whether they are effective.
Now, I understand your audit was strictly for this particular period of time. But, I'm interested, do you have any sense of how the COVID-19 pandemic might impact some of the agency's abilities to adopt these changes? Obviously, the extraordinary time makes it seem that it's going to be difficult for sweeping changes to happen at an agency like the EEC.
Many state employees, including my own are working from home. And a number of them, although not us, are actually greatly hindered in their ability to affect system changes. They don't have good access to data. And in fact, right now, when you're talking about direct care services, the priorities, understandably, are on physical space and protecting against intrusion of the virus. So I think that it's probably safe to say that COVID-19 is going to be throwing a wrench into a lot of government activities, ongoing and as well as those planned for the for the future. So if there is a slow uptake in this regard, it is unfortunate but it is also understandable.
One of the biggest stories in Massachusetts during the pandemic has been that of the Holyoke Soldiers’ Home. I'm interested, what's your office's history with the Soldiers’ Home? Had you audited it prior to the pandemic? Was this on your radar at all before the crisis there broke out?
Within the past few years, we had first audited the Soldiers’ Home in Chelsea, where we found a number of health and safety issues. And we had also more recently been to the Holyoke Soldiers’ Home where again, we saw problems with staffing, and also with health and safety issues in that facility. It has been a couple of years and we actually have underway another investigation into Soldiers’ Homes. So we did not foresee all of the ills that have befallen Holyoke, but we saw that there had been a number of problems there. Both from a staffing perspective and operational perspective.
Looking at the Chelsea home and the Holyoke home, what were some of those operational issues that you recommended be changed?
A lot of it had to do with inspections of facilities, upkeep, exposure of the residents there to unhealthy and dangerous conditions, unsanitary conditions in kitchens, and crumbling infrastructure, matters of mold. We also saw at the Holyoke facility that there was a lot of what we perceived as abuse of overtime by some members of the nursing staff there, unauthorized overtime there, which cramped the ability of the agency to fund other services there. You know, if folks are not having overtime approved and potentially receiving compensation for unauthorized overtime, it means that another part of the budget is being sacrificed. And so, I think from a personnel management as well as an operational management point of view, there were deficiencies at Holyoke.
There's already a number of investigations into the Holyoke Soldiers’ Home. Do you think that your office is also going to launch an investigation to what happened?
We generally do not go into a facility where there is ongoing criminal investigation and with the involvement of the attorney general as well as the United States attorney, in addition to the consultants that the governor himself has brought in, I think that the most useful thing we can do is stay out of the way.