NC child welfare leader says system is 'in crisis' and state could be sued 'at any point'
The state's child welfare system "is in crisis," and "at any point there could be a massive class-action lawsuit," the N.C. Department of Health and Human Services told county directors of social services departments during a presentation earlier this month.
The speaker, Susan Osborne, said she was referring to local DSS offices boarding children in their offices or leaving children with emotional and behavioral health needs in emergency rooms after hospitals have released them because there was nowhere else to place them. Osborne is the assistant secretary for county operations at NCDHHS.
"We average about 50 children in emergency rooms on any given day, who have been discharged, but their appropriate level of placement has not been located," Osborne said in an interview with Carolina Public Press.
However, Corye Dunn, director of public policy for Disability Rights North Carolina, said the state cannot "foster its way out of this crisis."
"Children don't need to be put somewhere, they need to be parented and cared for and in many cases, to receive clinical treatment," Dunn said. "The very least we can do is give kids better outcomes if we are going to disrupt their families and their lives."
In an interview with CPP, Osborne said the state is concerned about the lack of qualified beds for children in psychiatric residential treatment facilities and reiterated North Carolina's last-place rank among seven states in the Southeast in per-child investment in child welfare.
"At this point, every year since I've been here, which is four years, we've asked for additional funding to support more child welfare workers in counties," Osborne said. "We haven't been successful."
Osborne gave the presentation to DSS directors around the state at the behest of county DSS directors who asked about the state's takeover of Bertie County's child welfare office.
The Bertie County office takeover by the state was the second time the state had taken over a child welfare office since the state legislature granted that ability in 2017 with the passage of Rylan's Law.
Directors around the state had questions about what the state had done and why, Osborne said.
Osborne said that the state would not take over a DSS agency over one case where policies weren't followed. But she did plead with agency directors to work with the state.
"We need each and every director's partnership, cooperation and willingness to critically look at feedback and engage in improvement as identified," Osborne's presentation notes said. "We have learned that this level of engagement of a director is a main predictor of avoiding intensive corrective action and leads to improving outcomes for children and families.
"At the end of the day, any failure is ultimately on the state."
Bertie parent separated from child for more than a year
In the Bertie County case, state officials found that the agency's former director may have acted unlawfully when she, instead of a judge, signed temporary custody orders to separate families.
Osborne said during the presentation to directors that the county office did not make "reasonable efforts" to keep children out of foster care, and once they were there, there was no clear plan to help the children find a permanent home.
In one case, "child and parent were separated for more than a year without court intervention," according to the presentation.
Five months after NCDHHS stepped in to take over the child welfare office, Osborne said there are two full-time state employees working in Bertie County every day. The county has also hired some contractor staff to help with training and coaching workers.
State officials found Bertie's social workers also did not properly record their interactions with parents, which is required to receive proper funding from federal and state sources. As it stands, the county may have to pay back an undetermined amount, Osborne said.
At times, court reports had inaccurate or missing information, and the county lacked several custody orders because it had filed the orders in a neighboring county, the presentation said.
Deficiencies at county levels can cost taxpayers millions of dollars.
The first NCDHHS child welfare office takeover was Cherokee County's in 2018. This year, the county settled nearly two dozen cases for $42 million, after losing a federal lawsuit for $4.6 million and settling three separate cases related to the same actions for a combined $4.7 million.
Emotional and behavioral needs of NC children can go unmet
When asked why Osborne thought the state might be sued, she said she was referring to issues with how officials are taking care of the behavioral health needs of children.
"We are continuing to have children in emergency rooms and in DSS offices while we are awaiting appropriate placement," Osborne told CPP. "Appropriate treatment placements for kids is probably the biggest focus."
An investigation earlier this year by USA Today showed more than 1,000 North Carolina children were placed in psychiatric residential treatment facilities during fiscal year 2020-21. It costs the state $423 per day to house a child there, the USA Today report said, and yet there is no evidence the treatment facilities are effective in helping children, researchers told the publication.
Some children were shipped out of state, as far as 1,000 miles away, due to a lack of beds here in North Carolina.
Disability Rights NC also says psychiatric residential treatment facilities "fail to provide mental health treatment" and instead control children through "strict rules and routines."
"They are not considered a best practice in treating mental health issues in youth," the organization says on its website. "Yet, North Carolina has increased its reliance on PRTFs at a rate of 119% since 2010."
The number of children staying the night in DSS offices or other "unsuitable locations" is increasing, said Sharnese Ransome, executive director of the N.C. Association of County Directors of Social Services. She was not able to provide an estimate. Children can be discharged from a hospital or other medical placement "without appropriate discharge plans."
"With no appropriate placements available, these youth may languish in county offices, emergency departments or other unsuitable settings," Ransome said in an email to CPP.
Behavioral issues can escalate in situations like these, "which in turn can create higher demands for psychiatric residential treatment facilities or other high-level placements. We have examined this population and find that they generally have experienced significant trauma and are disproportionately marginalized," Ransome said.
Dunn said the state needs to provide more resources for families to thrive.
"The bare minimum for success is the outcomes for kids removed from their families of origin should be better off than if we had left them in a situation where they were subjected to abuse and neglect," Dunn said. "And I'm not sure we're there."
NCDHHS spokeswoman Kelly Haight Connor said that before removing a child from a family, DSS offices sometimes refer the family for "in-home services, which are intended to help strengthen and stabilize families."
Only families who qualify — those under 44% of the federal poverty level — are able to access some of these services through Medicaid.
"Medicaid expansion would help more parents be able to afford in-home services to treat substance use disorders or mental health issues, enabling more children to safely remain with their families and removing the need for them to enter foster care," Haight Connor said.
Lawmakers are debating whether to expand Medicaid in the state. Other states that expanded Medicaid had reduced child neglect by improving parents' financial stability, research showed.
She said that many families who earn too much to currently qualify for Medicaid will become covered by the federal program if that expansion happens.
High workplace vacancies at state and county levels
The crisis in providing adequate medical placements to children with emotional and behavioral health needs also comes amid nationwide low unemployment and inflation not seen in a generation. Workers have far more employment options than just a few years ago, and it is challenging to recruit social workers due to the low pay, demanding schedules and emotionally difficult work, a CPP investigation found.
Osborne told CPP that the state's Division of Social Services, which oversees county DSS offices, has almost 1-in-5 positions vacant.
She also said some counties in North Carolina have more than 1-in-3 positions vacant, and many counties also have high turnover rates.
In counties, the hiring crisis has only grown more strained as the pandemic forced workers with decades of experience toward retirement, with few or no replacements coming in. One-in-four of North Carolina's 100 counties has a turnover rate higher than 40% — and high turnover is linked to longer stays in foster care, according to information from NCDHHS.
"Vacancies continue to be an ongoing problem for us," said Lenoir County DSS Director Jeff Harrison last week. "Across the state we are all pulling from the same social work applicant pool for qualified applicants."
A previous investigation by CPP showed that some county child welfare offices are forced to hire unqualified workers because their low wages and high-stress jobs often mean a qualified social worker will pass over county employment.
The investigation showed that a short commute from one county to another can equate to a $10,000 raise for a social worker. This leaves counties with fewer resources scrambling to fill positions.
Earlier this year, Harrison told CPP the turnover rate in his child welfare office was 61%. At the time he was down by 10 workers in his 20-person child welfare office. Today that number is the same, with three of those being supervisors.
The Lenoir County Board of Commissioners approved a 5% salary increase for all its workers in July, but that may not be enough when surrounding counties are raising wages by 10% or more.
However, even if counties were fully staffed with their current budgets, Osborne said the state needs to do more to fund county services for child welfare.
"We are trying to increase state participation in county salaries and not be 100% county funded," Osborne said.
Osborne said the department is working on ways to recruit more people to the field and entice those who have worked in child welfare in the past to return by potentially offering reduced retraining requirements.
A CPP investigation earlier this year showed North Carolina ranks ninth among nine states that have a state-supervised, county-administered system like ours. And of the seven Southeast states, North Carolina ranks last in state funding per child, at $52. Kentucky, Tennessee, Georgia, Mississippi, Alabama and South Carolina all pay more.
Dunn said low staffing can be disastrous for children and families.
"If we don't have enough hands on deck to do that work, the people these systems are designed to serve will pay the price," Dunn said.