Deep within the Oregon Secretary of State's 85-page audit report on the state's Office of Child Welfare is an account from caseworker Bridget Rayburn, 24.
"I love my job, but I feel like it's not sustainable," Rayburn said.
Rayburn said she and her colleagues receive up to 23 new cases a month — six new cases is the recommended amount.
She described feeling "desensitized" and that her "whole perspective on what constitutes abuse has shifted."
Rayburn described "unreal" staff turnover; she and just one other person in her unit had been there for more than a year.
And the emotional toll?
"Someone cries at their desk every day," Rayburn said.
"Not because of trauma. Because they're overwhelmed with work."
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The Secretary of State's scathing audit took aim at every aspect of a critical agency responsible for the safety of neglected and abused children, from receiving complaint calls to certifying foster homes and investigating families.
The audit reviewed more than a decade of legislative changes aimed at helping some of Oregon's most vulnerable children. It found the Office of Child Welfare, within the state's vast Department of Human Services, has failed to keep up with legal mandates and the increased demand for state intervention.
At the same time, the Office of Child Welfare has faced scandals, like the discovery in 2015 that the Give Us This Day foster home in Portland was running "substandard facilities" and using "improper ... force against foster children." On top of potential harm to children, the audit calculated $39 million in state legal settlements since 2006 over the state's poor protection of neglected and abused kids.
According to the audit, the problems start at the top. It found management at the Office of Child Welfare to be “disorganized, inconsistent” and a "high risk for children." The audit pointed out the office's tendency to constantly restructure and re-brand, rather than make substantive changes needed to improve services.
The audit dug into four initiatives that never delivered promised improvements:
1.) The 2006 "Oregon Safety Model" was supposed to instill "a best-practice method of managing child safety throughout the life of a case," according to the audit. But staff didn't receive consistent training and management resisted. "Some openly refused the change," the audit said. "The resistance was tolerated [by upper management]."
2.) An initiative called "Differential Response" was meant to enable caseworkers to allow more children to stay with their biological parents. But "management turnover" and the agency's decentralized implementation across 13 different communities "stalled" the effort, the audit said. Even its abandonment was botched: Auditors found when that was announced, central office staff responsible for the rollout were "caught by surprise."
3.) A years-in-the-making change to the OR-Kids computer system was supposed to improve data collection of complaints and other data critical to managing child welfare cases. Many staff said using OR-Kids took more time and was no more reliable than the previous data system. Auditors heard from staff who "report lost data, inconsistent and inaccurate search results, and inaccurate information displayed." OR-Kids was problematic across the state, but around Portland, problems were so acute that the district office contracted with the Multnomah Education Service District for a separate database. Implementation of the MESD system proved little better, even after spending $20 million on it. Elsewhere in the state, auditors said rather than use the software, caseworkers posted sticky notes to their cubicle walls to track appointments with families.
4.) The audit also looked at an unofficial effort to complete more child abuse investigations in 2016, which the audit agreed did produce "big improvements," as reported to the legislature. But auditors concluded the improvements were short-lived, about three months, and were based on questionable management decisions, such as shifting caseworkers away from other work to focus on investigations and attempting to motivate employees by threatening to deny them scheduled vacations.
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The audit also questioned the agency's lack of a central screening center for reports of child abuse and neglect — an initiative the audit said could help coordinate efforts statewide. The audit counted 15 different hotlines throughout Oregon, serving 16 district offices throughout the state. Centralizing the complaints is a recommendation dating back to previous reviews of Child Welfare — as far back as 2006. But the audit found it's only now being seriously considered.
But managing attempts at improvement were far from the only problems the audit uncovered.
In terms of day-to-day operations at the Office of Child Welfare, the audit found a persistent shortage of foster homes due to lack of support and failure to recruit new foster parents.
The audit stated starkly that the state has no plan to recruit new foster families and no data on how many foster parents are needed. And once people become foster parents, the audit found that rather than support, the parents are frequently asked to take on work that should fall to caseworkers and may be called upon to accept "emergency" foster children who suddenly need homes.
"DHS does not know the true capacity in current foster homes, what homes have openings, and what behavioral and special needs the family is trained and equipped to accept," the audit said.
The audit found reimbursements for foster families are falling short.
At the same time, the audit noted forces putting stress on the broader system of support for the state's most vulnerable children: shrinking capacity at both Department of Human Services in its residential treatment program and in the Oregon Health Authority's Children's Mental Health Services program.
The audit highlights several successful models for recruiting and retaining foster families, including the Utah Foster Care Foundation, a mentoring program run by the state of Florida, and an effort from the Annie E. Casey Foundation called "Family to Family," used in eight states.
As the Office of Child Welfare struggles to maintain foster families — particularly those who aren't related to the children they're parenting — the audit found staff turnover at shocking levels. It found burnout had led to a 23 percent turnover rate in 2016, and that roughly one-third of Child Welfare staff had been on the job less than 18 months.
Again, the audit faulted welfare officials for lacking reliable data, but auditors concluded the state was short 769 child welfare workers — more than twice the 307 staffers that welfare workers quoted to state lawmakers. The audit found only 11 field staff had been added since 2013.
The enormous holes in welfare staffing are sometimes filled by passing duties off to foster families — or by piling up overtime. Willamette Valley caseworker Bridget Rayburn told auditors she worked about 20 hours of overtime a month; others said they worked up to 100 hours.
Related: With Foster Care System 'Crisis,' Oregon Puts Kids In Hotel Rooms
Some of that overtime involved filling a hole related to the lack of foster homes: a September 2016 lawsuit against DHS over housing foster children in hotels and in offices. The audit found overworked and inexperienced caseworkers often had to spend nights with foster children because they couldn't find an available space with foster families. The audit found in a little less than a year — from mid-2016 to mid-2017 — Child Welfare spent about $2.5 million on hotel rooms for foster children and caseworkers.
The audit concluded with 24 recommendations. The first one asks officials to address previous recommendations, from a previous report that required regular progress reports.
The remainder of the recommendations cover the vast array of problems the audit verified or uncovered, from instituting an improved computer system, to improving the management culture, to improving transparency with lawmakers.
Child welfare officials agreed to implement all of them and provided some details on progress to date. Part of the problem at DHS and in the Child Welfare office is turnover at high levels of management. The response to the audit is signed by DHS Director Fariborz Pakseresht, who's been in his job five months, after running juvenile corrections for the Oregon Youth Authority. Pakseresht hired the new head of the Office of Child Welfare, Marilyn Jones, who has spent 20 years at DHS.