In the second-floor cubicles and offices of D.C.’s child welfare agency, on 2nd and I streets SE, small clusters of social workers watched, mute with shock, as Christian Greene spoke.

Sneaking furtive glances at their phones, which streamed live video of the Child and Family Services Agency’s Feb. 26 performance oversight hearing before the D.C. Council, they listened to the agency’s former ombudsman talk about how she was fired for refusing to downplay the severe and troubling trends so many of them had witnessed. They listened to her berate agency leadership for gutting the ombudsman’s office of its investigatory responsibilities, and for manipulating workers’ caseload data to make the agency appear more functional than it was.

The social workers were, in a word, thrilled. Finally, they thought, someone will know about us. Someone will have to listen to what they make us do.

“We are really in a crisis of integrity,” said Greene, who worked for CFSA in a number of roles—including as a contractor, frontline social worker, supervisor, and ombudsman—between 2005 and 2017. Greene wore an agency-issued shirt that reads “social workers STAND UP,” her commanding voice sometimes betraying a quiver. “We are failing our children,” she said. “During my tenure I saw the agency consistently make child safety decisions based on liability rather than legal validity or the welfare of the children.”

It’s been 30 years since a New York-based civil rights organization, Children’s Rights, Inc., filed a federal class-action lawsuit against the District on behalf of the abused and neglected children in its care. The same judge, Thomas F. Hogan, has ruled over the case since its inception, when he wrote that D.C.’s child welfare system was in “shambles.” The case, LaShawn A. v. Barry—now LaShawn A. v. Bowser, as it has been renamed for each successive mayor—has reshaped how the city identifies and responds to allegations of child abuse. In 1993, Hogan appointed a court monitor, the D.C.-based nonprofit Center for the Study of Social Policy, to oversee reforms at the agency.

The District’s administration of its foster care system was “deficient and inept,” a federal appeals court ruled, and violated both D.C. Code and federal law, including the U.S. Constitution. And in 2001, a Washington Post investigation found that nearly 230 children whose families came to the attention of CFSA between 1993 and 2000 had died.

In the years since, CFSA has effectively become a new agency. It has met 74 standards of the 88 required for it to exit the LaShawn suit. CSSP has noted its positive strides in providing better access to health care for foster children, fewer and shorter emergency shelter placements, and better oversight of licensed group homes and other facilities. CFSA has “seen a lot of changes, and I’m proud of having led a lot of those changes,” agency director Brenda Donald says.

In this, Donald has the support of Mayor Muriel Bowser. On May 16, 2018, City Paper attended a hearing in the LaShawn case, held biannually, where CSSP employees testify in front of Judge Hogan about CFSA’s progress in meeting LaShawn’s exit standards. Bowser attended this particular hearing with Donald. (Rachel Joseph, a former CSSP employee, is now Brenda Donald’s chief of staff.)

“I wanted to be here with Brenda and the team to thank you for helping us improve the agency,” Bowser said, emphasizing “how involved I’ve been with Brenda to ensure she has the resources she needs. […] With these reforms, with Brenda’s leadership, we’re confident.” She added that D.C. is “making unprecedented investments in CFSA.” (The mayor’s proposed fiscal year 2020 budget recommends cutting funds to the agency, to levels lower than it has received each of the last three years.)

“I want to thank you for your work,” said Bowser, “but say unequivocally that while we’re appreciative, the government can move forward [without the court monitor].”

Since Hogan appointed the court monitor, the now-$220 million agency has cycled through at least four different court-sanctioned adaptations of a strategy to satisfy LaShawn. Four different directors have led CFSA since it exited receivership in 2001; Donald is currently in her third separate stint as the agency’s director. In between, she was also the Deputy Mayor for Health and Human Services, the mayoral office with oversight of CFSA.

For more than two years, City Paper has spent dozens of hours interviewing 12 current and former CFSA employees, as well as legal advocates, child welfare experts, and court-appointed guardians. In extensive interviews, CFSA staff say that the agency has exaggerated its successes, and that the biannual court monitor reports under-emphasize its failures. This article reflects the contents of those interviews, hundreds of pages of reports produced by CFSA’s court monitor, CSSP, and internal agency documents obtained through Freedom of Information Act requests.

These social workers describe an agency where caseloads are often so high, and the pressure to close them so immense, that both children and workers suffer devastating consequences. Despite cherishing their jobs and responsibilities, they characterize the agency culture as one of “fear.” Unsupported by a weak union and paranoid that they’ll be fired—or “walked out,” in agency parlance—social workers say they’re afraid to flag life-threatening mistakes with supervisors and afraid to push back on decisions they don’t believe are in the best interests of children. Because of their fear of professional and personal retaliation, City Paper granted anonymity to the social workers quoted in this story.

Greene’s recent public testimony matches their accounts. In June of 2018, she filed a whistleblower suit against the District, alleging that CFSA’s upper management “whitewashed” an agency trend report her office was tasked with publishing, and terminated her without cause.

Their primary allegations revolve around the intentional manipulation of caseload data, a charge that the court monitor has substantiated in previous reports but that Donald insists the agency has resolved.

Social workers report that their higher-ups routinely encourage them to prematurely close referrals and investigations so that they meet the court monitor’s exit standards. Among the statutory requirements CFSA has yet to meet are the timely initiation and completion of CPS investigations, and the quality of its investigations, according to the November 2018 CSSP report.

“When clinicians act in fear, children die,” Greene says. Another social worker tells City Paper: “This culture is going to leave a lot of kids unsafe. How can you take care of someone else when you can’t take care of yourself?”

The children CFSA serves are overwhelmingly low-income black children from wards 7 and 8—three-quarters of CFSA’s clients live in these districts—nearly half of them under 6 years old.

At a Feb. 21, 2018, oversight hearing, Donald not-so-subtly threw a punch at critics of the agency. “I know it’s easy to sit outside of CFSA and point to examples and anecdotes about cases and children whose futures and situations are not that great,” she said pointedly from her seat. “I can do that every day. I can [also] do that 10-for-one on those that are doing well.”

But Judith Sandalow, executive director of Children’s Law Center—the largest pro-bono legal organization in D.C. representing low-income youth—calls the agency’s “public persona” both “Pollyannaish and not transparent.”

“Rather than acknowledging [CFSA’s] problems, there’s, ‘Oh no, we’re doing great. Oh no, we’re headed in a great direction,’” Sandalow says. “But in the past couple of years, we’ve seen things get worse, not better.”

Credit: Darrow Montgomery

I. “Double talk and misleading court numbers”

To understand how quickly social workers have to act, there are a few key numbers to know: They must initiate investigations of alleged child abuse and neglect within 48 hours of the report to the hotline, or make documented “good faith efforts” to initiate the investigation. They must complete these investigations, which require contact with five designated parties but frequently include many more sources, within 30 to 45 days of the hotline report, depending on which branch of Child Protective Services they work in.

CPS-I is the department’s investigative unit, where a team of about 50 social workers substantiate serious allegations of child neglect and abuse. Case workers in Family Assessment, the second branch of CPS, don’t substantiate abuse allegations; instead, they conduct “safety assessments,” initiating contact with families within 72 hours of the hotline call. They connect families with social, housing, health, or other necessary services, like making electricity payments or buying a crib for a new parent. Families’ engagement with FA workers is, beyond the safety assessment, voluntary.

Between January and June of 2018, the number of calls to CFSA’s hotline—the 24-hour emergency phone line residents can call to report abuse or neglect—ranged from between 1,761 and 2,064 a month, according to data culled by CSSP, with a total of 11,095 calls during the six month monitoring period. Of those, about 21 percent, or roughly 400 cases per month, were accepted for an investigation; about 20 percent of calls were accepted for a family assessment. At the time, there were fewer than 45 social workers in each department handling those cases.

The court’s “implementation and exit plan” for CFSA requires that each caseworker have no more than 12 cases. Last June, 84 percent of Family Assessment workers carried more than 12 cases, and 13 percent of investigation workers did so, according to the court monitor’s most recent LaShawn report, which analyzed caseload data from January to June of 2018. These figures represent a mere 1 percent improvement in Child Protective Services workers’ caseload burden since June of 2016.

“The effect of caseloads on quality practice is an important factor to consider with regard to assessing for safety, connecting families with supports and services and ensuring children’s safety and well-being,” the monitor wrote in a 2017 report.

“I’ve had up to 24 referrals at one time,” says one family assessment worker, who City Paper will call Michelle. “I contacted the court monitor because I was like, ‘Hey, I have 24 referrals. I don’t know if I’m comin’, I don’t know if I’m going, I can’t remember who I’ve talked to, can’t remember who I didn’t talk to.’ Twenty-four referrals doesn’t mean 24 children, it means 24 families. One family could have one kid, one family could have 13 kids. I had two moms who had 13 kids one time.”

And while the agency requires that supervisors skip social workers who recently connected to clients with eight or more children in the referral rotation, the dearth of trained caseworkers often leaves assigning officers to ignore that rule, social workers say. “You just keep getting them and getting them and getting them,” Michelle says.

Taylor, a former CFSA employee who worked her way up from social worker to supervisor in seven years, says that the timely completion of referral closures depends on the individual’s willingness to put in extra hours, like coming into the office three hours early and leaving four hours late, or working weekends. She calls the dynamic “overwhelming” for caseworkers, who routinely take extended medical leave (colloquially, “taking FMLA,” after the Family and Medical Leave Act), making the agency short-staffed.

She also describes an empathy gap between social workers and the supervisors managing their caseloads, sometimes slipping into the cadence of an army officer: “I do think sometimes we don’t have enough bodies to load those cases,” she says of caseworkers. Being a manager “is challenging, but it’s not as hard” as working directly with families, because some managers “have never even done the frontline work.”

One social worker is particularly blunt about the stakes of a large caseload. “If I call somebody and I’m not able to close because there’s an issue, there’s pressure for me from my supervisor, who is getting pressure from her supervisor, to close it—it might be kind of questionable, it might not be the best thing, but you need to close it. Because if you don’t close it then you’re going to get penalized and your job’s going to be on the line, and who are you going to choose? You or that client? And that’s just the realistic part of it.”

“They don’t only bully us, as workers,” she says, “but we also bully our clients.”

Donald maintains that CFSA has adequately addressed the issue, testifying during the agency’s February oversight hearing that it has “resolved issues with caseload levels.” City Paper texted one Family Assessment worker currently employed by CFSA, who we will call Maia, with this quote, and asked how she reacted to it. She sent back an emoji crying with laughter.

Greene says that caseloads are “heavy, even if on paper they’re not.” (Donald disagrees with the characterization that D.C.’s caseload numbers are high; she says that administrators in other jurisdictions are “astonished that our caseloads are so low.”)

Frontline workers say that data from FACES, the electronic system used to store social workers’ notes and case information for clients, does not reflect the full scope of their caseloads. “The truth is being buried in double talk and misleading court numbers,” Greene wrote in written testimony submitted to the D.C. Council.

The court monitor has also acknowledged problems with CFSA’s caseload data. In its most recent LaShawn report, published last November, CSSP notes that “the Monitor’s validation identified concerns about the accuracy of caseload data” due to an unusually high number of referrals that were classified as “in transfer” from the hotline staff to frontline workers. The monitor was able to validate only two months of data reported by CFSA in this period, in May and June. It notes later that a then-newly appointed Deputy Director of Entry Services “put appropriate corrective measures in place.”

Social workers continue to allege that supervisory staff manipulate caseload data through a practice they call “hiding cases.” CFSA supervisors, and occasionally program managers, assign case referrals to frontline social workers through FACES. As Greene explains in her written Council testimony, FACES has historically recorded the data in its system at midnight on the last day of the month. It is then sent to the court monitor.

But to avoid the inclusion of data that reflects poorly on agency performance—that is, data showing the existence of caseloads higher than the statutory maximum—social workers say that their supervisors will only distribute paper copies of some case referrals and notify social workers verbally without formally assigning the case in FACES. This practice “is 100 percent what they do,” one Family Assessment worker tells City Paper.

During the May 16, 2018, LaShawn hearing, Marcia Lowry, a child welfare attorney and the former executive director of Children’s Rights, Inc., reported that “for the second time in two years, we’ve been unable to validate caseload standards. It appears there has been an effort to keep cases unassigned, or merely assigned in the supervisor’s box. There is a problem with caseload standard in entry level services. That’s wrong, and it’s not the way things should be working at this stage in the case.”

In response, Donald says that she was “surprised” to hear City Paper ask her questions about the practice, since “it was an issue that LaShawn identified three or four years ago,” and that, to her knowledge, CSSP “no longer had any concerns about” the practice, which “is no longer occurring.” (CSSP now pulls caseload data daily instead of monthly in an effort to better track them.) “Certainly if someone believed that we’re still doing that, then we would take that very seriously, because we have to stand behind our data,” she says.

Family Assessment worker Maia tells City Paper that, within the last month, FACES reflected that she had only 15 referrals; in practice, she carried 18. She says that CFSA administrators and program managers will also encourage employees to fudge case notes, to make it appear as though social workers made contact with families earlier than they did. “They’ll ask if that’s really the time you saw the family, and suggest that perhaps you saw them at another time instead,” she says. “Just to make the good faith efforts, so as to meet court monitor standards.”

City Paper asked a former CFSA employee who served in a supervisory role, James, about this practice, and couldn’t finish the question before he cut in with a sarcastic laugh. “‘Oh, you sure you got there at that time?’” he mimics administrators at the agency.

CSSP noted that the apparent failure to make early contact with families has affected case outcomes. The most recent monitor report shows that the agency has reversed its progress on meeting the good faith effort standard. Ninety percent of investigations met the monitor’s exit standard in September of 2017, but that number ticked down to 79 percent in June of 2018. The court monitor says it could not validate the documentation of good faith efforts for the January to June 2018 monitoring period.

Social workers also express concern that superiors will overrule their clinical assessments.

“When a social worker’s notations say ‘per the directive,’ this should strike fear in the reader. A directive from management is a veto of the social worker’s clinical decision, absent of the qualifications or intimate clinical knowledge of the family,” Greene wrote in her D.C. Council testimony. She tells City Paper that the practice occurs frequently.

Often, social workers say, these decisions hedge on the side of keeping a child in the home after allegations of abuse have been made against the guardian; in some cases, social workers say they’re in the untenable position of justifying a superior’s clinical recommendation, which they might not agree with, in front of a child custody judge. (“If you’ve never experienced [what it’s like to be a social worker], you don’t get to tell me how to do my job,” Greene says. “And when you impede on their assessment, you run the risk of a child dying.”)

CFSA staff and legal advocates worry that the confluence of these factors—limited time with children and administrators making clinical decisions—harms caseworkers’ investigations and interactions with troubled families.

“Just that volume of referrals—you can’t put out quality,” says James, the former supervisor. “We can’t think about quality. There’s very limited information because they don’t have enough time to do the work.”

James tells City Paper that he once wrote up a social worker for “verbatim, copy-pasting” notes from an old investigation referral into a new case. When he went back and audited her body of work, he says he found six instances in the span of 12 months where the worker had done the same thing. James says he believes the worker did so to “close [the referrals] more quickly.” The agency suspended another frontline worker for 15 days for “saying she saw some kids she didn’t see,” James says.

Sandalow from the Children’s Law Center says that her organization has “had social workers express frustration that senior folks, senior agency staff, overrule them and their clinical judgment, and we’ve witnessed that in ways that raise concerns for us, that senior staff is feeling the pressure to close cases or make their statistics, and they are not listening to the line staff … who actually know the child and are spending time with the child.”

In response to criticisms that CPS investigations suffer from poor quality, Donald says the agency has “made great improvements in the last report period,” and that “obviously we want the investigations to be high quality, we want them to be consistent, we want them to be well documented, but I think we have fail-safe measures to ensure that we’re doing proper investigations.” She adds: “No agency can pretend to get it perfectly every time.” In January of 2019, only 73 percent of CPS investigations were considered “acceptable” by LaShawn standards, up from 66 percent in January of 2018.

In 2017, the agency slashed its training timeline for new employees by nearly half. James, who was privy to discussions about creating the new employee training manual, tells City Paper that newly hired employees would enter a training period of only seven weeks. (He compares the way D.C. has managed the agency to a foreman “running a warehouse.”) Donald acknowledges that CFSA “used to have a much longer pre-service training,” which she compared to learning in a classroom versus completing field work.

The shortage of workers is only exacerbated by employees taking medical leave. One family assessment worker, who City Paper will call Tina, says that employees “take FMLA left and right just so they can maintain their job and have some peace of mind.” Maia says that, at any given time, there could be 10 or more Child Protective Services caseworkers on medical leave. On Aug. 15, 2018, alone, the court monitor reported, there were 22 entry services staff members absent on medical leave. One Family Assessment worker who has been at the agency for over three years says that it has “never been fully staffed in the time that I’ve been there.”

While not a silver bullet, hiring more caseworkers has already proven effective in reducing individuals’ caseloads. In September of 2018, CSSP reports, there were 50 social workers assigned to the investigations unit and 49 working in FA. Caseload data “show that the additional hiring and deployment of workers, in addition to the seasonal decline in new referrals over the summer months, have led to reductions in caseloads,” CSSP wrote.

Only two legal organizations in D.C. perform pro-bono work on behalf of D.C. Superior Court’s high-conflict branch as guardians ad litem. These guardians are appointed by judges to independently assess a child’s family and medical history and make recommendations about their placement to the court.

One of these is the Children’s Law Center, which represents the majority of these youths—about 500 foster children annually. The other is the DC Volunteer Lawyers Project, which represents about 100 D.C. children annually, about half of which have come in contact with CFSA at some point in their lives.

Sara Tennen is DCVLP’s deputy director, and oversees the legal team’s child advocacy program. “There was a time,” Tennen says, “where we were keeping a documented list of all the cases where CFSA was not doing what they were supposed to be doing then.”

And over the years, though the type and severity of cases referred to DCVLP has changed, one thing hasn’t. It is “still seeing the same problems in them, which is CFSA is closing the cases prematurely without doing a thorough investigation,” Tennen says.

Tennen emphasizes that her job is “to make recommendations to a court on what is a safe and appropriate place for my child client to live.” In doing so, she says, she has to rely on experts like mental health professionals and teachers who are familiar with her client’s behavior. The other expert Tennen relies on, she says, is the CFSA social worker involved in the case.

But doing that “is hard,” Tennen adds, because she has to “rely on this information that I don’t have a great level of confidence in.” Part of Tennen’s concern stems from the belief that frontline workers don’t have the time to interrogate the claims of a guardian who has been accused of violence––that they “take what the alleged abuser said just at face value.” And while she doesn’t believe it’s malicious, “the information, the level of investigation is not done to a degree that ensures the kid’s safety. I have yet to see a case where CFSA has investigated it and I have felt really, really confident in the investigation as a guardian ad litem.”

“When there are reports on the news like, you know, a child was found murdered, a child was found dead, believed to have been murdered by a parent, mom’s boyfriend, whoever it is,” Tennen says, “Every single time I hear it on the news or I see it on WTOP on the internet, I brace myself and I’m like, ‘Please don’t be one of our kids.’”

Credit: Stephanie Rudig

II. “Who are you going to choose? You or that client?”

It was in late 2016 that Michelle had 24 cases at one time. She was, in her words, “struggling.”

She decided to email the court monitor and report her caseload after her supervisor proved unwilling to reduce it. (The supervisor’s response was “‘figure it out,’” Michelle says.)

Social workers say that their often-limited time with clients disproportionately affects the health of children with chronic medical conditions. One of Michelle’s 24 cases involved a young mother who had recently given birth to a child with a heart defect. As the hospital prepared to discharge the baby, Michelle was bogged down with other cases and knew she couldn’t transport the baby home herself. So she requested the help of a family support worker—agency employees who provide administrative case assistance, but are not required to have a license in social work.

Under even the best circumstances, it is difficult to care for a newborn with a persistent medical issue. But the difficulty of Michelle’s case was compounded by the youth and inexperience of the mother, who didn’t completely understand the baby’s discharge paperwork.

“Driving home from the hospital doesn’t sound bad, but if the parent is young, the parent doesn’t understand all of the instructions the doctor is telling them, you know, it’s a lot[.] Learning how to read a machine that’s going to help your child’s heart, there’s a lot that goes along with it,” she says.

Eleven days after the baby assigned to Michelle came home from the hospital, the baby died at home.

“I feel like, if there would have been someone else, if I would have had more time to be like, ‘Hey Mom, I’m going to come with you to discharge the child [and] sit with you,’ or, if that family support worker would’ve had more time to be like, ‘Hey, let me make sure I understand this so I can show her and not be ‘Hurry up and get this done,’ it could have saved a life in my opinion,” Michelle says. “It also could have been [that] nothing could have saved this child. But I really don’t know, because I wasn’t able to do it myself. Because I had too many cases. … I bawled, I cried. I have no other words to describe it. And it took me some time to even get over that, and I remember that situation because it was around the holidays. I’m trying to get my own self together to go home for the holidays, and this family isn’t going to have part of their family for the holidays.”

Three or four hours after she got the news, she says, a case manager called her into their office. They asked her why she wasn’t closing her cases faster.

Alicia, another Family Assessment worker, tells City Paper about a particularly busy stretch in the spring of 2017, when she received 18 referrals in just two weeks. In two days, she received six. “Within [that time], a child dies,” the worker says. “Even within [the child’s] medical issues, it was still like, ‘Hurry up and close.’ … Of course I didn’t get any help. There’s no support.”

Rumors about Michelle’s involvement in the baby’s death began circulating around the office. Social workers are not permitted to sit in on the fatality review unit’s assessment of the case, so it began to “trickle down” from upper management that “it could have been a preventable death.”

“We hear stuff about ourselves,” she says.

D.C. has historically had one of the country’s highest child fatality rates. In 2008, 182 children died in the District; by 2013, it dropped to 91. Child fatality statistics show that total deaths have increased steadily again since 2013, rising to 100 in 2014 and 124 in 2015, though the city’s overall rate of child deaths decreased from 2008 to 2015.

Brenda Donald has testified repeatedly, including during the agency’s most recent February performance oversight hearing, that there were “no deaths due to child abuse or neglect” in calendar and fiscal year 2018. (She tells City Paper that there were two such fatalities in 2017.)

It’s thus unclear how she’s classifying, say, Aceyson Aizim Ahmad, a 2-year-old Southeast D.C. boy. He died from blunt force injuries last April; his mother’s 24-year-old boyfriend was charged with beating him to death. And how do city records classify Carter Sanders, a 1-year-old boy killed last May in a Benning Road SE apartment? His mother’s then-28-year-old boyfriend, who watched Carter the day he died after attending a domestic violence training session, was charged with first-degree murder. “An incredible amount of force was used against this infant,” the medical examiner wrote of Carter, who suffered skull fractures, brain hemorrhages, and damage to his colon, liver, and kidneys. And what of Brooklynn Zakiyaa Hill-Davis, a 6-month-old girl from Valley Terrace SE, who was murdered last September by a 21-year-old D.C. man? The Office of the Chief Medical Examiner ruled all of the deaths as homicides.

Donald tells City Paper she would not have included cases like these in her count because they were not known to CFSA before their deaths. City Paper attempted to confirm this statement by submitting a FOIA request for records of any first responders dispatched to their addresses in the months before they died; the Office of United Communications, which handled this request, denied it in full, arguing that it constituted an unwarranted invasion of privacy.

It is close to impossible for the public to assess the veracity of Donald’s claims—there are no independent investigatory agencies in D.C. with unfettered access to FACES case data—but current and former CFSA staff say her statement is misleading at best. “I can say that, with the cases I’ve reviewed within my tenure, there were clear times children experienced harm that could have been prevented by the agency taking action,” Greene says. Maia, the family assessment worker, says that CPS gets fatality reports “all the time,” and that it is not uncommon to link those reports to closed CFSA referrals.

When a child in D.C. dies, two different groups review the case. The first is D.C.’s Child Fatality Review Committee, a group of about two dozen District employees and community representatives who meet monthly to discuss the circumstances leading to deaths of minors in D.C., a practice authorized by a 2001 law. More often than not, Greene says, these children have come in contact with CFSA. The second is CFSA’s own Child Fatality Review Unit.

In her two-year tenure as the agency’s ombudsman, Greene sat on both the Child Fatality Review Committee, which Greene says would review an average of three to four cases per month, and CFSA’s Child Fatality Review Unit. (A 2017 report from the office of Kathy Patterson, the D.C. Auditor, shows that the number of cases analyzed by the CFRC dropped from 122 in 2010 to 35 in 2015. This change “partly reflects budget and staff cuts, and must be reversed for the CFRC to fulfill its duty to review all child deaths in D.C.,” the report says.) Between 2011 and 2015, only 17 of the child fatalities it reviewed were the result of abuse or neglect.

The CFRU’s case studies, meanwhile, don’t include a determination about the agency’s culpability in the death of children in its care. The final pages of their cases contain lists with the diplomatically titled subheads “strengths of case practice” and “findings and issues.” The committee did not issue any recommendations during a review of 21 fatalities in the first half of 2018, CSSP notes in its November 2018 report. Greene tells City Paper that the committees are “hesitant to issue recommendations” and “don’t want to be held to something they already do” because there’s “a fear of getting deeper into LaShawn.”

City Paper obtained a copy of one of the CFRU’s case studies, which are typically confidential; frontline workers whose clients die are not privy to the review.

The report details eight incidents of abuse or neglect that CFSA was able to substantiate, all perpetrated by a mother of seven between 2003 and 2011. The woman, who City Paper will call Cynthia, was a chronic user of PCP and gave birth to three children who tested positive for that drug, or for marijuana. CFSA was also able to confirm that the mother gave her then-4-year-old daughter, who City Paper will call Denise, a black eye. Among other instances of abuse or neglect, CFSA also recorded instances of Cynthia’s infants sleeping in unsafe environments. By 2009, the agency received a call that Cynthia was high on PCP and wandering around naked outside. The home, according to CFSA’s report, “was in deplorable condition with minimal food,” and had 11 cats.

It wasn’t until three days after this incident, the seventh substantiated case of abuse, that her children were removed from her care. Denise eventually went to live with her aunt, and later her maternal grandmother in a home her social worker described to a court as infested with pests.

Just over two years later, she began living with her paternal grandparents. In March of 2012, Denise reported that her cousin raped her in her paternal grandparents’ home. She was 13 years old at the time. It was not, according to Denise, their only sexual encounter. Her cousin would later be charged with first-degree sex abuse.

Despite this history, Denise’s supervisory social worker “reported that [her cousin’s] behavior was not deemed abuse, but rather inappropriate,” according to the CFRU report. Denise would be placed with at least seven different foster parents over the next two years, before being “reunified” with her mother, who had beaten Denise upon learning of the assault.

It was not the only flagrant error Denise’s social workers would make. “The ongoing social worker reported that her client, [Denise], a teen mother, had given birth to [a baby] on Aug. 14, 2014, at Howard University Hospital. The ongoing social worker reported that [the baby] was transferred to Children’s Hospital due to his medical issues where he expired on September 14, 2014. The ongoing social worker reported that at the time that [the baby] died, [Denise] was in foster care,” the CFRU report says.

But Denise never gave birth to a child. The baby referenced in this report was Denise’s little brother. “It should be noted that [the baby] was the child of [Denise’s mother] and not [Denise],” the report says.

The “issues” with CFSA’s management of Denise’s case, the Child Fatality Review Unit concluded, were numerous: At multiple points, social workers misidentified basic family relationships; ignored reports from Denise’s siblings that they felt unsafe around their mother’s sexual partners; did not provide evidence that they addressed the infants’ dangerous sleeping environments; and mischaracterized Denise’s rape as “inappropriate rather than seen as a more serious crime.”

Denise’s case highlights the consequences of a failure to connect abused or neglected children with support services. For years, for example, Denise’s social worker reported that she maintained a solid academic performance and did not exhibit significant behavioral issues. That would change as she grew up and bounced from home to home.

Advocates emphasize that CFSA’s poor record of placing minors in stable foster homes with prepared guardians is one of its greatest outstanding failures.

Sandalow refers to the shortage of foster parents trained to manage children’s health and behavioral concerns as “a placement crisis.” The organization represented a 4-year-old, for example, who has been moved to at least four different foster homes. “Let me be really clear that the most devastating thing you can do to a child is have them move from home to home,” Sandalow says, with that harm exacerbated the younger the child is.

In written testimony she submitted to the D.C. Council’s Committee on Human Services, Greene wrote that half of the families “at the attention” of her office complained “that their children were being abused and neglected while in the care of CFSA.” WAMU reported this month that the agency is looking to add 40 beds to its foster system. Ten children slept overnight in CFSA headquarters between January and June of 2018 because of the lack of foster beds, up from two children who did so in the prior reporting period, CSSP noted in its most recent report.

Sandalow says that Children’s Law Center attorneys routinely encounter children placed in foster care whose foster parent was “not told about the child’s medical needs.” Other times, prescription medication is missing, and CLC’s lawyers “pick up the medication and bring it to them,” she says. “We’ve repeatedly had children released from psychiatric hospitalization without adequate medication, that’s an ongoing problem. That’s not just in the foster system, but that generally is an issue in the city.” (CLC also reports issues connecting trauma survivors to support services, with some who have suffered serial sexual abuse waiting three to six months for services, Sandalow says.)

The most recent CSSP report reflects these concerns. “CFSA leaders had identified resource parent support as an area for improvement, determining that its current Resource Parent Support unit provided inconsistent and frequently inadequate support to foster parents,” the report says.

Credit: Stephanie Rudig

III. “I’m just so relieved he’s out of this.”

Orlando Marshall turned down a promotion multiple times before he agreed to be a supervisor.

Ask any social worker at the agency whether they want the upward mobility, and they’ll likely say “no.” If there are few legal protections for frontline workers, there are none for those in management positions, who are all employed at-will.

One Family Assessment worker tells City Paper that she personally cycled through seven different supervisors in a span of three years.

Marshall, then 45 years old, worked at CFSA for years. Beloved by his wards, some took to calling him “Uncle O.” Colleagues like Maia remember him as a kind, whip-smart, passionate music lover who would blast the speakers in his cubicle.

City Paper spoke with Marshall’s mother, Justine Marshall. “He didn’t like the supervisor position because he said that they wanted him to write people up for every little thing, things that were not important. And before he would do that, he stepped down,” she says. Orlando only filled the post for three months before he returned to serving as a frontline worker.

He saw some of the worst years in the agency’s history. Orlando was one of the first social workers to respond to the home of Banita Jacks, a D.C. woman convicted in 2009 of killing her four daughters and leaving their bodies in her home for months to decompose. (“I said, ‘How do you live with that?’ He goes, ‘You just see that all the time, and it doesn’t bother you anymore,’” Justine says. “I said, ‘You need to go talk to someone. How do you [see] dead children, the skeletons of children—and it not bother you?’”)

“He was al-ways working. And somebody was al-ways calling,” Justine says. She knew not to expect him home on Christmas Eve until 10 p.m. or later—“He’d always let the ones who had children go home, and he would stay there so they could get their holiday going”—and when he did show up, he’d be there with his laptop and three cell phones.

Justine says that Orlando suffered from a pinched nerve in his back, and wouldn’t take the time to see a primary care physician or “go through no hassle to properly take care of himself.” In October of 2015, months shy of two decades at the agency, Orlando’s back gave out on him when he was at work, and he fell to the ground. His colleague called an ambulance.

“They took him from his job to the emergency room,” Justine says. “His back just totally gave out on him.” He was discharged with pain medication. Days later, Justine says, he began to complain of shortness of breath and leg pain. And less than two weeks after being discharged from the hospital, Orlando died. A blood clot formed in his leg and traveled to his lung.

Justine still thinks about how her son couldn’t stop himself from working. She tells everybody that “the job wore him out.”

“So that I can be at peace, I say, ‘That’s why God took him home.’ Because he didn’t know how to stop himself, on his own. So God gave him rest. So he’s at rest now. That’s how I look at it,” she says. “I miss him with every breath I take, but I’m just so relieved he’s out of this. He’s out of it. It was his calling because he has helped many a people. So he did what he was supposed to do. But he still didn’t have to be treated like he was. It didn’t have to be like it was.”

Social workers compare their jobs at CFSA to wearing “golden handcuffs,” Greene says: D.C. pays its social workers some of the highest salaries of any major metropolitan area, and recruits many of its frontline workers straight from graduate school, many of them from Howard University’s prestigious social work master’s programs.

They depart school for a notoriously challenging profession. The Bureau of Labor Statistics ranks social work as one of the 20 most fatal jobs in the country, with roughly one death per 100,000 workers. The American Federation of State, County, and Municipal Employees found that 70 percent of frontline child welfare workers have been victims of violence or threats of violence in the line of duty.

Greene and another social worker independently tell City Paper that merely walking into the CFSA office would cause them to break out into hives; one worker took medical leave for this reason. Another social worker who gave birth to a premature baby had a supervisor call after the birth to berate her for not closing her existing cases on time. There is the social worker who contracted scabies from a baby while removing it from its home. There is the social worker who fell down a flight of stairs, dislocating her shoulder, after an angry father threw PCP at her during a removal. There is the social worker who got into a car accident while on duty and needed months of physical therapy—and who continues to live with chronic pain.

“You have an institutionally traumatized workforce,” Greene says.

One social worker filed a complaint against CFSA in August of 2016 with the Equal Employment Opportunity Commission after the agency declined to immediately make a handicapped parking space available. The agency’s position was that it “maintained that her reasonable accommodation will be provided once it becomes available,” according to a partially redacted copy of the complaint obtained by City Paper through FOIA. The employee waited at least 10 weeks for the accommodation, according to the documents.

Donald says that, recognizing how stressful the job can be, employee “health, financial well-being and physical well-being” have been among her priorities. She says that CFSA headquarters boast a “serenity room, for employees who have been exposed to trauma on the job.” An agency slide presentation says that it offers “meeting-free middays” on Wednesday afternoons, when workers are encouraged to participate in activities like meditation, line-dancing, and Spanish classes.

In April of 2018, according to internal agency emails obtained through a Freedom of Information Act request, the agency launched an “employee feedback committee,” so that “all team members could voice their opinions, concerns, suggestions … [with] our pledge that their feedback will remain confidential and will not be used against them in any way.”

Yet the social workers City Paper spoke with say they know of few ways to receive material support from the agency. The city’s Employee Assistance Program provides counseling, but social workers say they don’t trust its confidentiality and are encouraged, regardless, to take medical leave to cope with stress. They are not entitled to paid time off to attend funerals.

Richard, a former CFSA employee who worked at the agency for two years, says that he missed “a lot of big things in my life at that time,” including his grandmother’s 80th birthday. “I was very depressed,” he says. “It was just toxic. The environment was toxic. I didn’t like myself. I didn’t feel good about who I was as an individual. I used to see people and how it would literally drain the life out of them. And I couldn’t stand that to happen to me.”

He notes that when he first started working at the agency, “people were dropping like flies. Back to back to back to back.” Richard and other frontline workers, including Michelle and Maia, express sadness that supervisors dissuaded them from taking time off to attend coworkers’ funerals.

“You try to process [the deaths] by yourself, but then if you miss a day of work, your work doesn’t stop,” Michelle says. Referring to supervisors’ attitudes toward former colleagues who died, she says, “They were like, ‘If you want to go to the funeral, you have to use your personal leave. We’re not going to let you go to the funeral to honor your fallen comrade because you need to get these referrals closed.’”

In February, Donald told the D.C. Council’s human services committee that CFSA “is increasingly being recognized around the country as a high-performing agency that other states want to emulate.” (Of this claim, Sandalow says: “If that’s true, I think it’s sad.”)

In the two weeks since March 30, three children went missing on the 200 block of I Street SE, where CFSA is headquartered. In 2018 alone, according to a review of the Metropolitan Police Department’s missing persons bulletins, at least 12 missing children were last seen at that address, outside CFSA.

Two weeks before the publication of this article, CFSA dissolved the Family Assessment and Investigation units, removing the distinction between clients whose families need more thorough investigating and those who need support services.

By the time this article publishes, CFSA will have also disbanded the special abuse unit, which was staffed with experts trained in sexual assault trauma, post-traumatic stress disorder, and victims services. Frontline workers will receive only one four-hour training session to fill this gap in expertise.

The agency is also creating a new unit of social workers who will specialize in educational neglect, and who CFSA will station at schools around the city. Caseworkers already employed by the agency will fill these positions.

“There’s a problem when you’re chasing the cutting edge and you never implement anything fully, so you don’t see the rewards of it,” Greene tells City Paper. “Child welfare, just like being a parent, is about consistency. If you establish a core set of ethics and standards for all your social workers, you don’t have to keep on chasing the new thing.”

For Donald, the “innovative practices” are a sign that the agency is on the up. “At this point, we know what we’re doing. We monitor ourselves, we have strong quality assurance practices. We have a data system we can rely on.” She tells City Paper that it is the agency’s position that there is “no value added” by the court monitor. She notes that the agency is in conversation with the plaintiff to exit the LaShawn lawsuit.

Creating, breaking, building up again—from the perch where Brenda Donald sits, it feels like movement. It could even be mistaken for progress.

City Paper produced this article with support from the Reporter’s Committee for Freedom of the Press.