Critical Incident Rapid Response Team Love Gatewood

Florida Department of Children and Families May 04, 2015

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 2 | P a g e

Critical Incident Rapid Response Team

Love Gatewood Northeast Region

Circuit 7 St. Johns County, Florida

FSFN Report #2015-013121

Table of Contents Executive Summary 3 Introduction 5 Case Participants 6 Child Welfare Summary 6 System of Care Review 7 Practice Assessment 7 Organizational Assessment 9

Service Array 10 Immediate Operational Response 11 Attachments

Summary of Service Providers 12

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 3 | P a g e

Executive Summary Early on the morning of October 30, 2014, 3-month-old Love Dondre Gatewood was found wedged between his mother’s legs and the armrest, while positioned face down on the couch. Love was unresponsive, and 911 was called to the home. Love was resuscitated by emergency medical service personnel, taken to Flagler Hospital and later transferred to Wolfson Children’s Hospital in Duval County. Love remained at the hospital on life support until January 14, 2015, when he passed away. Prior to the fatal incident, Love resided with his parents, Angela Tomazovich and Andre Gatewood along with his half-siblings. Following Love’s birth on July 9, 2014, due to issues the Angela’s substance misuse, in-home, non-judicial services were initiated by St. Johns County child protective investigations. The family was engaged in Intensive Family Intervention Services (IFIS), provided by Family Integrity Program, the Community-Based Care Provider. Because there had been a verified report of abuse and/or neglect within 12 months of Love’s death, the Department of Children and Families deployed a Critical Incident Rapid Response Team (CIRRT) to complete a review and assess potential systemic issues within the local system of care. The CIRRT completed a review of case records involving Love and his family. In addition, interviews were conducted with child protective investigations staff, case management and legal staff, and as well as local service providers and other key stakeholders involved with the family. The review team identified opportunities for system improvements and to further strengthen the local system of care. The following is a summary of those findings: Practice Assessment

A. A Safety Plan was not developed with the family to clearly communicate the expectations of all parties and, despite a new incident of maltreatment and evidence of continuing and increasing concerns for the safety of the children, no further action was taken to assess and increase the level of intrusiveness.

B. Safety Services Specialist positions were created to support the new practice methodology. The Safety Services Specialist participates in staffings, family team conferences and assists with managing safety plans.

C. St. John County Child Protective Investigations (CPI) and Case Management do not

have the capacity to conduct urinalyses or breathalyzers for alcohol use. Organizational Assessment

A. Challenges were identified in the working relationship between Investigations staff and the Children’s Legal Services staff around role clarification and agreement in safety decisions.

B. St. Johns Service Center has collocation of several disciplines serving the child welfare

population.

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 4 | P a g e

Service Array

A. There are insufficient substance abuse and mental health services and transportation to those services in St. Johns County, resulting in lengthy waiting lists and difficulty in obtaining appropriate assessments.

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 5 | P a g e

Introduction Early on the morning of October 30, 2014, 3-month-old Love Dondre Gatewood was found face down on the couch wedged between his mother’s legs and the armrest. Love was unresponsive, and 911 was called to the home. Love was resuscitated by emergency medical service personnel, taken to Flagler Hospital and later transferred to Wolfson Children’s Hospital in Duval County. Love remained at the hospital on life support until January 14, 2015, when he passed away. The mother to Love, 25-year-old Angela Tomazovich, admitted to ingesting “Cisco” alcoholic beverage, marijuana and at least three Klonopin pills, prior to falling asleep with Love on the couch.

At the time of the incident, Love resided with his mother (Angela Tomazovich), father (Andre Gatewood), two half-sisters and brother

The family was being served through Intensive Family Intervention Services (IFIS), following a verified report of substance misuse due to the mother’s abuse of prescription drugs and cocaine.

In response to Love’s death, Secretary Mike Carroll of the Florida Department of Children and Families (Department) deployed a Critical Incident Rapid Response Team (CIRRT) to the Northeast Region, St. Johns County. The review team consisted of representatives from the Department’s Office of Child Welfare, Northwest Regional Management, Children’s Legal Services, Devereux Community Based Care, Brevard Family Partnership and Community Drug and Alcohol Council, Inc.

On January 20, 2015, the review team met at the Family Integrity Program’s main office in St. Johns County, where participants reviewed non-redacted case information, including child protective history, case management services and service provider reports. The team conducted face-to-face interviews with Child Protective Investigations staff from St. Johns County, Children’s Legal Services for the area, the Family Intervention Specialist and Case Management staff.

This report presents the review team’s findings with regards to a system-of-care analysis (including practice assessment, organizational assessment, and an assessment of service array/intervention), as well as child welfare history and the case participants.

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 7 | P a g e

Angela and Andre resided together with Love and Andre two (2) daughters from a previous relationship. Andre was described as protective, and the paternal grandmother was checking on Angela daily to ensure she was not under the influence while caring for the children. Angela and Andre . agreed to diversion services through Intensive Family Intervention Services (IFIS) and began receiving services on August 28, 2014. IFIS enabled Angela to re-engage in medication management services through Azalea Health Clinic, so there was not a lapse in her medications. IFIS also assisted the family in placing in daycare, obtaining clothing and other essentials for the family, and was working with Angela to reinstate her driver’s license.

Angela had several prior criminal issues, Andre had criminal history as well,

; however, his last charge was nine years ago.

System of Care Review

This review is designed to provide an assessment of the child welfare system’s interactions with the Tomazovich/Gatewood family and to identify issues that may have influenced the system’s response and the quality of the decision-making.

Practice Assessment

PURPOSE: This practice assessment examines whether the child welfare professionals’ actions and decision-making regarding the family were consistent with the Department’s policies and protocols.

FINDING A: A Safety Plan was not developed with the family to clearly communicate the expectations of all parties and, despite a new incident of maltreatment and evidence of continuing and increasing concerns for the safety of the children, no further action was taken to assess and increase the level of intrusiveness.

There were at least three opportunities when assessments to determine the appropriate level of intervention would have been appropriate.

A. The July 2014 Child Protective Investigation was closed as verified with the mother as the Caregiver Responsible and referred to IFIS, a diversion program. It was determined that Love was not safe in the sole care of Angela due to her ongoing and chronic substance abuse issues. There was no staffing with Children’s Legal Services (CLS)

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 8 | P a g e

despite the initial guidance from the CPI Supervisor that a staffing occur. When Love was released from the hospital, he and Angela moved in with Andre , and Andre . became responsible for ensuring that Angela was never caring for Love when she was impaired due to substance use. CPI staff reported that this expectation was clearly communicated to Andre ; however, there was never a formal written safety plan outlining everyone’s role in this plan.

B. On October 8, 2014, the father reached out to the IFIS worker for assistance with the

mother’s ongoing substance use in the home and requested that the IFIS worker come see the mother intoxicated. Since the child was not with the mother at the time, the IFIS worker responded the following day with a Safety Services Specialist. They discussed the concerns with the mother; however, they did not implement any additional safety services and did not increase the level of intrusiveness with the safety plan.

C. Finally, on October 14, 2014, the IFIS worker found wandering outside of the

home and in the road alone. The mother reported that she went back into the home for just a minute and he wandered off. There is no follow-up with CPI or CLS following this incident and no indication that this new incident of maltreatment was reported to the Florida Abuse Hotline to initiate an investigation.

Case file documents verified that Safe Sleep information was provided by the CPI to both parents, including a video on safe sleep environments. The Intensive Family Intervention Specialist observed Love sleeping in a “nest of blankets” on the bed during one visit and observed the child not securely fastened into the car seat on two occasions. The mother was counseled about the dangers associated with these actions at each incident.

It appears that both the CPI and IFIS worker were sensitive to the mother’s prior history and her negative experiences however, this also seemed to

limit their willingness to address her behaviors for fear of jeopardizing the rapport that had been developed.

FINDING B: Safety Services Specialist positions were created to support the new practice methodology. The Safety Services Specialist participates in staffings, family team conferences and assists with managing safety plans.

Family Integrity Program created a Safety Services Specialist position in order to support the implementation of the new practice model. The Safety Services Specialist’s role is to participate in staffings and family team conferences, and assist with managing safety plans to help other child welfare professionals in ensuring fidelity to the practice model. This position is a strength and asset to St. Johns County.

FINDING C: St. John’s County Child Protective Investigations and Case Management do not have the capacity to conduct urinalyses or breathalyzers for alcohol use.

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 9 | P a g e

Local child welfare professionals report high alcohol abuse/dependence among families served within St. Johns County. However, there are no means for anyone to field test for alcohol. Investigations does not have field or lab alcohol-testing, and if a lab test is requested by case management, the case manager is only given positive or negative results, never the levels so that they can be monitored. The Family Intervention Specialist reports that they rely on the client to inform as to whether they have been drinking. Therefore, clients may successfully complete a treatment program and continue to drink while testing negative for other substances.

Organizational Assessment

In St. Johns County, DCF is responsible for conducting child protective investigations for reports alleging child abuse, neglect and/or abandonment. Family Integrity Program provides child welfare services in Circuit 7, overseen by the St. Johns County Board of County Commissioners as the Community-Based Care Lead Agency. Legal representation is provided by DCF’s Children’s Legal Services.

FINDING A: Challenges were identified in the working relationship between Investigations and Children’s Legal Services around role clarification and agreement in decision making.

The local investigators reported that they had significant difficulties making contact with CLS when needed. Often, they would be told that the attorneys were unavailable to staff cases, even in the event of an emergency child safety concern. Additionally, they were under the impression that they were not able to make a decision to remove a child from an unsafe environment without the approval of CLS. This would cause them, at times, to delay making prompt safety decisions until they could get approval from an attorney. More often than not the staff had to escalate to management for assistance with legal staffings.

Conflicts during legal staffings around reaching agreement on the sufficiency of information was identified as a stressor and blamed for several CPIs “burn out” and additional challenge of being a CPI in this area. The relationship was clearly strained from having multiple different CLS attorneys assigned to this area over a very short period of time, resulting in lack of an established professional working relationship and understanding of roles. Prior to this time period there had been a stable attorney handling St. Johns County for well over five years. As a result of the above-mentioned issues, the St. Johns Office, during the time of the July 2014 investigation, was in turmoil with high turnover and stress leading to burnout. Shortly after the July 2014 investigation was closed, the CPI who had been assigned the investigation resigned via email without any notice and severed all ties with the investigation staff.

Case management and child protective investigations described caseloads as manageable with an average caseload of 15. Diversion reported an average caseload of 4-5. The investigative staff did not report any issues with high caseloads, which was supported by a review of data from FSFN (the child welfare database). Review of the removal rate in St. Johns County also supports that the removal numbers were significantly higher in fact than they had been in previous years and Diversion referrals were lower.

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 10 | P a g e

At the time of the CIRRT review, there had been significant leadership changes in St. Johns County. There was a new Program Administrator for Investigations, a new Program Director for Family Integrity Program and a new Managing Attorney for CLS. Everyone interviewed reported these as positive changes and expressed optimism for the future.

FINDING B: St. Johns Service Center has collocation of several disciplines serving the child welfare population.

An organizational strength of St. Johns County is the agency’s plan to collocate Child Protective Investigations, Children’s Legal Services, Community Based Care/ Case Management in the next several months. In addition to core child welfare disciplines being collocated, the diversion program, a domestic violence victim advocate and substance abuse specialist will all be located in the same office. This has been demonstrated in other areas of the state to improve communication and collaboration between all disciplines.

Service Array

FINDING A: There are insufficient substance abuse and mental health services and transportation to those services in St. Johns County, resulting in lengthy waiting lists, and difficulty in obtaining appropriate assessments.

The Family Intervention Specialist (FIS) program is new to the area (however present in other areas of the state) that conducts substance abuse screenings and connects clients with appropriate treatment services. This service is less than a year old in St. Johns County, and it is being utilized regularly. There is a gap in the specialist’s ability to assess and provide treatment as she is unable to test for alcohol. Additionally, there is one FIS worker who covers St. Augustine and Daytona; so, often it is unclear to staff when the FIS worker will be on site.

FIS is reported to have an average caseload size of 8-12 clients on a consistent basis, which allows for FIS services to be initiated in a timely manner. FIS reports that most referrals are related to cases with newborns. Once FIS services are initiated, a client who received a recommendation for treatment is either in treatment or has an appointment with the treatment provider within 10 days. This is notable since treatment providers are limited in the area, and the closest non-Marchman and Baker Act programs are in Daytona. It was reported that several other entities are vying for the limited bed space that is available. The majority of the clients participate in out-patient services and can participate in walk-in services without a referral from FIS. FIS attends multi-disciplinary team meetings and provides input related to client progress.

Additional substance abuse treatment services, provided by EPIC Behavioral Healthcare and Stewart-Marchman Act Behavioral Healthcare, are unable to meet the demand needed in St. Johns County, and often times, the families who are in need of services do not have the transportation or a way to access these services.

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 11 | P a g e

The SAMH Department in NE Region and Operations are working with the Managing Entity and providers to prioritize child welfare families, which has resulted in some improvements made to secure needed treatments. St. Johns also opened a detox facility and has access to inpatient programs in not only Daytona but in Duval County as well. The staff in St. Johns County has been advised that if they have any issue with getting the service they need in a timely manner there is an escalation process through SAMH and staff are now aware of this process. In addition the St. Johns County Department of Transportation does provide a Sunshine Bus which while a smaller scale transportation system, does provide bus transport throughout the county, The Family Integrity Program provides clients with free passes as well as transportation from their workers internally to get to appointments.

Immediate Operational Response

At the time of this review, DCF leadership in the Northeast Region had already made some management changes, and staff was expressing more support regarding their safety decisions from all levels, including Children’s Legal Services. There was a new Investigations Program Administrator, new Director at FIP, new CLS Managing attorney as well as experienced line attorney staff appointed to remedy the prior issues identified. At the time of the CIRRT there were no longer issues with accessing timely CLS input and clarity of roles had been established. The CPI Program added another Supervisor to their Team so there are three Supervisors with five (5) CPIs each which provides for more than manageable workload for each, with an average intake assignment of 8-9 per CPI when fully staffed. There is a Program Administrator, Field Specialist, or a Super Safety Practice Expert on site each day of the week to provide immediate consultation and support to staff. In addition programs have moved into their collocated office, which supports a stronger working relationship and access to one another for staffings. The CBC, CPI, CLS, domestic violence advocate, and FIS are all located on the same floor of a new building. Staff has been provided with field alcohol screens so they can test for alcohol during investigation and services provision and the FIS has an established schedule to serve St. Johns County needs, which is working very well and assisting in connecting timely services interventions. The escalation process for accessing timely Substance Abuse and Mental Health services has been established and communicated to staff.

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 12 | P a g e

Attachment I

Summary of Service Providers

St. Johns County

EPIC Behavioral Healthcare is a substance abuse detoxification, residential and outpatient treatment provider with 16 residential beds available to those who have gone through EPIC’s Detox program already. EPIC provides outpatient services, but only to those who have gone through the residential program.

Family Intervention Specialist Case Management (FIS) is a community-based intervention program for families who are involved in the child welfare system when substance abuse is a contributing factor to the abuse and/or neglect. FIS provides a link between the family and the treatment provider and will provide transportation to treatment.

Stewart-Marchman-Act Behavioral Healthcare is a substance abuse and mental health provider that provides crisis and detoxification, residential, outpatient, prevention, and community outreach and education services. Its residential facility, Project Warm, is in Flagler County and has limited residential beds that are shared between several counties. Outpatient services are provided in St. Johns County; however, transportation assistance is not available.

MediMD is a Family Medicine Practice and provides medication management services.

Florida Department of Children and Families Critical Incident Rapid Response Team Report – Love Gatewood 13 | P a g e