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C16‐94‐1265.0

This case was written by Pamela Varley for Julie Wilson, director of the Malcolm Wiener Center for Social Policy, and Christine Letts, lecturer in public policy, at the John F. Kennedy School of Government, Harvard University. (1194)

Copyright © 1994 by the President and Fellows of Harvard College. No part of this publication may be reproduced, revised, translated, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the written permission of the Case Program. For orders and copyright permission information, please visit our website at www.ksgcase.harvard.edu or send a written request to Case Program, John F. Kennedy School of Government, Harvard University, 79 John F. Kennedy Street, Cambridge, MA 02138

High Stakes and Frightening Lapses: DSS, La Alianza Hispana and the Public‐Private Question

in Child Protection Work (A)

Introduction

On February 12, 1994, acting on an anonymous tip, police in Boston’s Roxbury neighborhood went to the home of 26‐year‐old Clarabel Ventura, where they reportedly found six hungry children, ages nine months to seven years, confined to a room strewn with human feces. According to the Boston Globe account, the children had gone without food for several days. More gruesome, police found Ventura’s five‐year old son, Ernesto Lara, lying on a mattress soaked with his own blood, urine and feces, his hands scalded from wrists to fingertips, “virtually burned down to the bone,” according to Boston Police Sergeant David Aldrich. Someone, it appeared, had plunged the child’s hands into boiling liquid.1 Lara’s second and third degree burns had become infected, according to reports from the Boston Children’s Hospital, as they had gone untreated for an estimated two to four weeks.2

Over the next few days, disturbing details of the Ventura family situation were reported in the Boston press, embellishing the initial lurid account. Former neighbors of Ventura—a single parent, four months pregnant—reported that she frequently screamed at her children, locked them in their bedrooms, and sent them out into their housing project late at night to bum cigarettes, food, and money from the neighbors. They also reported that Ventura had sold food stamps and the family washing machine to buy crack‐cocaine. And, they said, she had a violent boyfriend who had beaten her and burned her with an iron. Ventura’s children had been in and out of her custody

1 Ventura was charged by the Suffolk County district attorney with scalding her son’s hands, but

members of Ventura’s family claimed that Ventura’s boyfriend was to blame. 2 Boston Globe, February 13 and 14, 1994 and March 24, 1994.

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since 1987, as she made repeated efforts to overcome her drug addiction, secure a high school‐ equivalency diploma, and set her life aright.3

In Boston, the Ventura case quickly became a lightning rod for champions of all kinds of social causes and political agendas: the horrors of crack‐cocaine, the inadequacy of family planning, and the need to track down absent fathers (none of the four men who had fathered Ventura’s children paid child support). Advocates of welfare reform, including Massachusetts Gov. William Weld, used the case to illustrate “the cycle of welfare dependency,” as Ventura, her mother, and nearly all of her 13 siblings received welfare or another form of government income assistance.4

The Ventura scandal also focused a hard light of scrutiny both on the Department of Social Services (DSS), the arm of Massachusetts state government responsible for delivering child protective services, and on La Alianza Hispana, the community‐based agency under contract to DSS to provide protection to Ventura’s children. It soon came to light that La Alianza had not followed a key protocol in the regulations governing child protective work: case workers from the agency had failed to conduct monthly home visits to see Ventura and her children. Records from the agency indicated that, although the case worker had made several attempts, she had not seen Ventura since October 1993, four months before the incident, and no one from La Alianza had seen Ventura’s children since April 1993, ten months before the incident.

DSS publicly “blasted” La Alianza in the press5 for its handling of the Ventura case, alleging a history of problems with the agency. But critics of DSS questioned why the state agency was not doing a better job of monitoring its private contractors. And why, some added, was DSS contracting out such difficult, high stakes work to a community‐based agency in the first place? In addition to addressing these broad questions, DSS had to make an immediate decision in the wake of the Ventura incident either to continue, or to sever, its contracting relationship with La Alianza Hispana.

La Alianza Hispana

La Alianza Hispana, a Roxbury‐based non‐profit organization serving an estimated 5000 Latinos a year, was founded in a small storefront building in 1969 by a group of Hispanic activists who wanted to serve and empower Boston’s Hispanic residents. La Alianza gradually expanded over the next 15 years, and by 1986, when Luis Prado became its executive director, the agency had

3 Boston Globe, February 16, 1994 and March 24, 1994. 4 Boston Globe, February 20, 1994. 5 Boston Globe, February 15, 1994.

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an annual operating budget of $800,000 and was running 10 programs—from teen pregnancy prevention and after school day care to English as a Second Language and employment placement. Under Prado’s leadership, La Alianza expanded rapidly. By the time of the Ventura incident in 1994, the agency had an operating budget of $2.5 million, ran 25 programs, and was the largest Latino organization in Boston.

As part of that larger expansion, La Alianza Hispana began, under DSS contract, to provide child protective services to Hispanic families in 1989. By contrast with many of its other new programs, however, La Alianza had not sought out child protective work; child protective work had sought out La Alianza. Early in 1989, DSS administrators had approached the agency’s board of directors to ask La Alianza to provide child protective services under a new DSS initiative called “PAS,” or Partnership Agency Services program.

The history of private involvement in child protective work

When DSS introduced the PAS program, the Department of Social Services, itself, had been up and running fewer than 10 years. In fact, the involvement of the public sector in the child protection arena was a relatively recent phenomenon. Until the 1960s, child protective work in the state had been almost exclusively the domain of private charitable organizations—in particular, the Massachusetts Society for the Prevention of Cruelty to Children (MSPCC). Gradually during the 1960s and 1970s, in response to changing federal laws, the state Department of Public Welfare (DPW) had assumed ultimate responsibility for child protective services. Some of this work was provided directly by DPW social workers and some was contracted out to the private charitable organizations. During these years, the relationship between the state and the private agencies was a testy one, marked by divergent views of child protective work and also by ethnic snobbery—a vestige of the old Yankee‐Irish power battles in Boston, according to Loretta Kowal, former MSPCC director. Some of the charitable organizations had been run by Yankee society women, Kowal says, and they criticized the state—staffed mostly by uncredentialed, poorly paid white ethnic and minority social workers—for high case loads and unsophisticated work. The state workers, for their part, regarded the private agencies as soft and spoiled, with an inflated view of their own talents. They thought the private agencies served an easier, more middle class population on the whole, and noted that because the private contractors carried smaller case loads, they had the luxury to do less case management and more psychotherapy.

The Massachusetts legislature created DSS in 1980, partly due to a national trend to decouple welfare assistance and child protective work, and, recalls former DSS Commissioner Marie (Sandy) Matava, partly in response to public outcry over the discovery of a young girl who had been murdered and dumped in a trash can during a blizzard in 1978. The new DSS inherited from DPW contracts with the private charitable organizations, but the state also used the

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opportunity, along with some newly available federal funds, to “upgrade” its child protective work, hiring social workers with better training for better salaries. Though it was created with the primary aim of protecting children from abuse and neglect, the DSS leadership at once began to define the agency’s mission more broadly—not simply to protect children in an immediate sense, but to support families in trouble and keep them intact whenever possible. To this end, DSS not only investigated complaints and managed the custody and care of each child in the system6, it also funded a host of ancillary services, from day care and family counseling to parent training and programs for teenagers. In the early to mid 1980s, about two thirds of DSS’ overall budget was contracted out to private providers. The bulk of this funding went to foster parents and group homes for the children. DSS also contracted out all of its day care service and most other ancillary services. In addition, the department contracted out about 10 percent of actual case management services, according to Matava. By the late 1980s, however, the contracting out of case management services had become problematic for several reasons.

The origins of the PAS program: A convergence of woes

During the mid 1980s, public awareness of sexual abuse and the upsurge of crack‐cocaine abuse in inner cities resulted in a dramatic increase in reports of child abuse and neglect—from 36,258 in 1983 to 61,506 in 1988. In the same period, DSS’ load of open cases7 increased from 12,518 to 18,957. The state, however, was struggling with financial troubles and DSS’ budget appropriations did not keep pace with the burgeoning demand. Case loads for DSS social workers increased above the contractual limit of 18 into the twenties, prompting union protests and law suits.

At the same time, public social workers were often resentful that their colleagues in private agencies—under contract to DSS to manage cases—were still working with much smaller case loads, in some agencies as low as six or eight cases. (And in some instances, even fewer. In one notorious situation, a private agency had assigned four social workers to a single difficult case.) Indeed, the disparity in case loads between private and public sectors was the symptom of widespread confusion and inequity in DSS’ contracting practices. Thus, different agencies were

6 Case management entailed taking overall responsibility for a case—deciding whether a child should

remain at home or be placed in foster or group care, determining what services the family and child required and arranging for the delivery of those services, monitoring the progress of the parents in resolving their problems (for example, drug addiction or domestic violence), shepherding cases through the legal system, keeping detailed records for each case, and, all the while, monitoring the health and safety of the child, whether he or she was living at home, in a foster home, or in group care.

7 An open case at DSS was one in which allegations of child abuse and neglect had been filed, investigated, and supported; one that resulted from a voluntary request for services; or one that responded to a court order to provide services.

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paid different rates for the same services. There was a lack of clarity about who was “in charge” of the cases, and what the lines of authority between public and private sectors were. As a result, some cases fell through the cracks altogether. What’s more, case practice—how often clients were visited, for instance, and how cases were documented—varied widely from agency to agency.

Private contractors, meanwhile, had a gripe of their own. Across the state, social workers in the private agencies under contract to DSS were paid less than their counterparts in the public sector. As a result, employees of private agencies began to demand “parity.”

Devising the PAS program

Despite the problems, Matava believed there were several advantages to contracting out the management of some DSS cases. For one, she believed that such a partnership made the system more flexible. It created a community of practitioners who could share insights, compare notes, and, to some extent, share the blame when things went wrong. It gave parents and children in the system some choices. In some cases, it simplified the coordination of cases, by allowing the same agency delivering most of the services to a family also to manage the case. It gave DSS a way to handle conflict of interest situations—for instance, when a state legislator or DSS employee was accused of child abuse. It allowed DSS to send a case with specific kinds of problems to an agency with particular expertise—for instance, agencies that specialized in helping troubled teenagers or mentally retarded children. On particularly explosive cases—allegations of sexual abuse at a day care center, for instance—it allowed DSS to split up the investigative work among private and public social workers, which tended to reinforce the credibility of the findings.

At the same time, however, child protective services was becoming increasingly bound up with the courts and governed by legal requirements. It was therefore important, from Matava’s point of view, to standardize case practice across the system. Thus, the commissioner set out to transform the system of contracting out case management services from a chaotic and inequitable system into a fair and rigorous one. Under her “PAS,” or Partnership Agency Services initiative, all agencies providing case management services would receive the same set rate to manage a standard case load of 15 to 20 cases—about $63,000, including legal and administrative overhead— the same amount DSS itself spent to carry an average case load. In addition, PAS social workers were expected to use the same forms, follow the same procedures, and use the same central computer system as their counterparts at DSS. To perform these new functions, the private contractors would be given computer terminals compatible with DSS’, and they would have access to all DSS training and information. In fact, under the PAS scheme, private agencies were to be treated just like DSS’ own “area” offices. (The DSS organization at the time consisted of a central office, six regional offices and 40 area offices, where the actual case management work took place.)

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Deficits in service to racial and ethnic minorities. Matava decided to use the new PAS program to address an additional problem as well. During its short life, DSS had come under heavy criticism for failing to work effectively with racial and ethnic minorities, and Matava was sympathetic to the complaint. Racial minorities and political refugees tended to harbor a distrust for government, making it difficult for social workers to obtain the information necessary to make responsible decisions about protecting children or assisting families. In addition, cultural differences made it hard for some social workers to interpret the severity of family distress. Under Matava’s leadership, DSS recruited social workers of different racial and cultural backgrounds. But she also believed that minority agencies with strong community ties were in many ways better positioned to correctly interpret the complex family troubles in their neighborhoods, to win the trust of families in crisis, and to intervene effectively. What’s more, as a matter of state policy under the Dukakis administration, all the state’s social service agencies were encouraged to contract with minority‐run, community‐based agencies whenever possible—with the intention both of improving services to minority clients and of developing the capacity of the minority‐run agencies, themselves. Thus, Matava was determined to include community‐based minority contractors in the new PAS program. DSS therefore deliberately recruited La Alianza Hispana as an agency to work with families and children in Boston’s Latino population.

Approaching La Alianza

Like most of the minority‐based contractors, La Alianza had no experience delivering soup‐to‐nuts child protection and case management services. But DSS had, in fact, contracted with La Alianza to help find foster and adoptive homes for Hispanic children and to provide Latino families with “soft” services—those designed to strengthen families and prevent child abuse and neglect in the first place. Due to a rapidly burgeoning statewide case load and diminishing state resources, however, Gov. Michael Dukakis directed DSS to emphasize the primary, child protective role of the agency and de‐emphasize its broader family‐preservation agenda.8 As DSS began cutting back on soft services in the 1980s, DSS came to La Alianza and other like contractors with a take‐it‐or‐leave‐it proposition. DSS no longer had the funding to contract with La Alianza for soft services. On the other hand, DSS was prepared to contract with La Alianza for a much larger sum of money—if the agency agreed to deliver direct child protection and case management services.

La Alianza Director Luis Prado and the agency board of directors viewed DSS’ proposition with an uneasy mix of excitement and worry. On the one hand, most La Alianza board members

8 This was a controversial move, both within DSS and within the broader social service community. In

fact, child protection experts talk of the “pendulum swing” between narrow emphasis on protection and a broader effort to bolster families.

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knew first hand of cases in which DSS had dealt inappropriately with families in their community. One La Alianza board member recalled a case in which the children of a woman who spoke no English were placed with foster parents who spoke no Spanish. When the children were eventually reunited with their biological mother, the mother and children could no longer communicate with one another at all, and, after some dispute, DSS had to provide the children with tutoring in Spanish to make the reunion viable. The board was confident that La Alianza would do a better job than DSS with Latino families. What’s more, to lose its DSS funding would be a serious blow to La Alianza. Conversely, most board members believed the additional funds would be good for the agency, helping it build capacity in other ways.

Some board members, however, were deeply skeptical about the proposal. Gary Mena—a former DSS attorney and the La Alianza board member most uneasy about accepting the DSS contract—distrusted the DSS rate, questioning whether it would adequately cover La Alianza’s legal and other overhead expenses. Even more worrisome to Mena—and, indeed, the central concern of the rest of the board—was the fact that child protective work was inherently punitive and unpleasant. It always involved the threat—and sometimes the reality—of taking children out of their biological homes, anathema in the Latino community. To take on such a “policing” role might damage the comfortable, trusted position La Alianza occupied in the community. In addition, child protection work was difficult and litigious, full of rules and regulations utterly foreign to the La Alianza staff. Did La Alianza want to wrench itself around to meet DSS’ standards? And how much support would DSS really provide? Mena was so concerned over these issues that, during one board meeting, he threatened to resign from La Alianza’s board over the issue. In the end, however, DSS administrators won over Mena and other skeptics on La Alianza’s board by making several promises. First, they promised that La Alianza would not have to conduct investigations of families or remove children from their biological homes; La Alianza would inherit the cases after the initial assessments had been made. In addition, provision was made for additional money to cover legal costs, if it proved necessary. What’s more, DSS representatives promised that they would supply La Alianza with all the training and technical assistance the agency needed to do the job.

1989‐1990: The start‐up of the PAS program

During the first two years of the PAS program, Boston Regional Director William Warren recalls, the DSS Regional Office in Boston kept tabs on La Alianza and some 20 other PAS agencies, and supplied their employees with on‐site training, technical assistance, and informal advice.

All the PAS agencies undertaking child protective work for the first time—La Alianza included—struggled to meet their contractual obligations, Warren says. In part, this was due to the extraordinary difficulty of the work. For example, if an agency was managing a case involving a

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mother and five children living, say, in three different foster homes, the social worker had to check on each child each month, make sure each child was receiving appropriate health and other services, drive the children to appointments if the foster parents could not do so, arrange for visits between the children and their biological parents, monitor the efforts of the parents to solve the problems that caused them to lose their children, keep up with documentation for the case, and shepherd the case through various legal hearings along the way. This, multiplied by a case load of 18‐20 families, was a daunting work load, especially when other time‐consuming problems were factored in: parents that failed to show up for appointments, families without telephones, families that moved with no notice, court procedures that might take all day, crises (a runaway child, for example) that had to be handled immediately and might take several days. While DSS had a good reputation for case work by national standards, the agency had trouble meeting its own protocols. For instance, figures gathered in the first half of 1994 showed that in only about half of all cases did DSS social workers make the required monthly home visits, and in 13 percent of all cases, they did not make a home visit during any of three consecutive months. “The mandate is unrealizable,” declared a DSS social worker, profiled in a Boston Globe article. “We’re not doing quality interventions. We’re just running around in a panic.”9

What’s more, at many of the small PAS agencies—paying each social worker in the low $20,000 range—case workers tended to be young and inexperienced, often without the seasoning to recognize when someone was lying, for example, or abusing drugs, or suffering from a psychological disorder. They also found it hard to weigh their sympathy for a “nice” but erratic parent and their antipathy for turning their clients over to the legal apparatus of the state against the imperative to keep children safe. At a more pedestrian level, the small PAS agencies also found DSS’ protocols and paperwork requirements onerous and time consuming, given the overall workload.

Though many of the PAS agencies were falling short of DSS regulations and protocols in the early days of the program, the philosophy at DSS central headquarters was to support the agencies on the one hand, and to cut them some slack. This was doubly true for minority contractors. “They were seen as a real vital resource, and one which was almost irreplaceable for a population which DSS was not reaching,” says Nathan Thompson, DSS Director of Program Analysis. “There has been an inclination from Sandy [Matava]’s time on to work with particular minority agencies that are in trouble, rather than just pulling their money.”

The impetus at the time was—if we can shore them up, we’ll do that. If we need to put more money into it, we’ll do that. If we need to help them restructure, we’ll do that. If we have to replace a board, we’ll do that. If we have to outpost people there, we’ll do that. If we have to go in there and monitor them for six months and look at their case records and see how

9 “The Impossible Job,” Boston Globe, February 5, 1989.

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they’re doing—we’ll do what we have to do in order to try to get them back up to snuff.

Early relationship with La Alianza under PAS. As with the other PAS agencies, the actual monitoring of La Alianza at the Boston regional office was a relatively informal affair, based on information gleaned in the course of dispensing training and advice. In addition, the regional office received a steady stream of complaints about La Alianza from the courts, parents, foster parents, and others, says Boston Regional Office Director Warren. “Frankly, we didn’t need to put anybody in to monitor Alianza. We knew on a daily basis there were major problems,” says Warren. The basic difficulty, he continues, was that La Alianza had trouble hiring and retaining competent staff. In a program with a small staff to begin with, Warren says, poor hiring decisions and rapid turnover conspired to ensure that the remaining case workers were perpetually overburdened; it thus became impossible for La Alianza to stabilize and establish a lasting understanding of child protection service protocols and regulations. To the frustration of the regional office, it was therefore necessary to repeat its basic training to La Alianza personnel every few months as new case workers and supervisors cycled in and out of the agency. Regional staff urged La Alianza to increase pay levels to staff in order to attract and retain more qualified case workers and supervisors, but La Alianza administrators argued that they could not afford to do so under the rate the agency was paid by DSS.10 Administrators at the Latino agency also complained that no sooner did La Alianza hire and train young Hispanic social workers than DSS, itself, hired them away for more money and the promise of advancement.

Cutbacks at the Boston Regional Office. The first two years of PAS represented a high‐ water mark in terms of DSS’ support for and oversight of La Alianza and other PAS agencies, but even during these years, the efforts were never as extensive as they should have been, according to Warren—partly because the introduction of the PAS program coincided with major budget cutbacks at the regional level of DSS. In 1989—the first year of PAS—the state’s six regional offices were consolidated into four, and staffing in the Boston office decreased significantly. (That same year, the 40 area offices in Massachusetts were consolidated into 26 offices, adding to the general atmosphere of flux.) The following year, the four regional offices were cut back further, and renamed “field support” offices. In this context, the PAS agencies represented additional and time‐ consuming work for an already‐overburdened regional staff. Once responsible to monitor only the five area offices, each with a case load of 500 to 1200, the Boston regional office now also had to monitor some 20 PAS agencies, each with a case load of anywhere from 10 to 75. “I’ll be very honest—I think for a large number of us, we hated PAS. Because of the added work load,” says Warren. To their exasperation, regional staff found themselves drawn into disputes, particularly with the courts, over the handling of a host of individual cases contracted out to the PAS agencies.

10 Although DSS paid its contractors the same amount, per case load, that it cost the state to manage a case

load, overhead and other expenses were variable, and private contractors were free to divide up the money as they saw fit.

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“[The courts] didn’t deal with the private agencies. They came after us. In the end, we still ended up having to deal with the politics, with the courts, and all the rest of it,” Warren says. What’s more, says Warren, “You’re asking those PAS agencies to do things that they’ve never done before.... You’re talking training [at a level of] ABC. We were at Dick and Jane—‐that’s how fundamental it was.” And, while the administrators of private agencies had willingly entered into the child protection contracts with DSS, their own staff were often far less enthusiastic about the arrangement and were not, from the region’s perspective, eager students of DSS’ rules and regulations. At the staff level, says Warren, “This was a grudging marriage on both sides.”

1991‐1993: The situation deteriorates

Radical cutback of PAS. DSS’ admittedly quixotic support and oversight of La Alianza and other PAS agencies during the first two years of the program disappeared almost entirely in June 1991. That year, the PAS program was drastically cut back by a state legislature convinced— in part by the DSS social workers union11—that it was more cost‐effective and legally responsible to deliver direct child protection services in‐house. Under the legislative cutback, the statewide PAS case load shrank from 3500 cases (about 15 percent of DSS’ total case load) to 630 cases (about 3 percent of the DSS case load). The number of PAS agencies decreased from 63 to 18.

There were several reasons for the lack of political support for PAS. For one, the program’s two chief advocates—DSS Commissioner Matava and MSPCC Director Kowal—both left their positions in the spring of 1991, a few months before the legislative action. In addition, most PAS agencies, themselves, did not rally to rescue the program—partly due to the simultaneous availability of new kinds of social service funding and perhaps a lack of familiarity with the legislative process, but also due to their basic ambivalence about the PAS program. Private agencies new to child protection work disliked having to abide by DSS protocols and case loads, arguing that, by becoming “DSS clones,” they lost their special advantages as an alternative to the state system.

Under the legislature’s cutback of PAS, however, three groups of PAS agencies were spared the ax: those serving mentally retarded youngsters, those carrying DSS’ conflict of interest cases, and those serving racial and ethnic minorities. Contracts with the minority‐based agencies were retained due to a general agreement, inside DSS, the legislature, and the minority community, that DSS still did not have the internal capacity to serve minority populations well.12

11 Local 509 of the Service Employees International Union. 12 Most, by far, of minority children and parents in the protective service system were served by DSS,

however. In Boston alone, 70 percent of the 4600 families in the system were nonwhite.

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In addition, many of the smallest minority agencies, having become reliant on the PAS money during the prior two years, would probably have gone out of business had they been cut off.

Elimination of the regional offices. That same year, the state legislature—which had cut back DSS’ regional offices in each of the two previous years—eliminated the regional layer of the agency altogether. In the chaos and confusion of the DSS consolidation, Warren suspects that the monitoring of the remaining 18 PAS agencies “just ended—completely.” Thus, although DSS had made promises to the PAS agencies at the start of the program, the agency was unable to fulfill them, he adds.

What happens is that we are, by virtue of being public agencies, subject to the vagaries of politics. These [PAS] agencies—unless you’ve got an incredibly savvy exec—quite often operate with a lot more trust and faith in us than probably they should.

There were still some piecemeal oversight functions in place at the central level of DSS— for example, an annual “prequalification” review of contract agencies, to look at their financial status and stability; a biannual review of each child in a foster home placement; and a detailed, individual investigation of the case of any child under DSS supervision who died—no matter what the cause. But the collection of information about any single PAS agency was not routine or methodical.

It was not only the PAS agencies that lost monitoring attention. The area offices, too, were left much more to their own devices. Still, the position of the area offices was qualitatively different from that of the PAS agencies. “They were still connected to the department,” says DSS’ Thompson. “They were still getting all the mailings. If they had problems, they had a deputy commissioner to go to. If there was a hot case coming up, they would know who to call. The place hadn’t disappeared, there was a structure there—certainly not the kind of support they were used to, but there was something. So it went from 100 percent to 50 percent for the area offices, and from 100 percent to zero for the PAS guys.”

What goes around comes around. DSS operated without regional offices for two years. In February 1993, as part of a report prepared by a blue ribbon panel—the Special Commission on Foster Care, commissioned by Massachusetts Gov. William Weld—a firm called Andersen Consulting submitted an assessment of DSS’ organizational structure that specifically criticized the elimination of the regional offices. (The consultants described DSS, in a memorable phrase, as “a head and a body with no neck.”) The special commission report also criticized DSS, in general, for a lax and haphazard system of monitoring outside contractors—not just the PAS agencies, but all private contractors.

In June 1993, the regional offices were reinstated. DSS Commissioner Linda Carlisle, imported from New York by Gov. Weld to run the agency in January 1993, also began to gather

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information about the agency’s disparate monitoring activities and to think about how to better coordinate them.

Investigating La Alianza

During the two years without DSS regional offices, La Alianza and DSS had minimal contact. La Alianza Director Prado says he made repeated unsuccessful attempts to reduce the agency’s case load, arguing that a case load of 20 families per social worker was too high, especially at La Alianza, where the families tended to be large and complicated. He also says that, to his dismay, DSS announced that La Alianza would no longer be exempt from conducting investigations—presumably an effort on DSS’ part to standardize the contract.

DSS’ scrutiny of La Alianza resumed early in the summer of 1993. As part of its routine practice of reviewing the death of any child in the system, DSS investigated the death of a seven‐ year‐old girl in DSS custody. The bulk of that investigation centered on errors made by the DSS staff, but the child had been living in a foster home monitored by La Alianza. She had died in an auto crash with her mother at the wheel, though the youngster was not supposed to have had any unsupervised contact with her mother, who had lost custody due to a drug abuse problem. A review of La Alianza’s part in the case revealed some questionable case practices, DSS Commissioner Carlisle says, and informal scuttlebutt reinforced the perception that La Alianza was performing poorly. Thus Carlisle took the unusual step of ordering a more general review of La Alianza’s case files.

This review, conducted in August 1993, turned up a host of deficiencies in La Alianza’s case practices. In the majority of its 71 cases, La Alianza case workers were failing to make their monthly home visits, according to the report. In a number of cases, there had been no documented contact for months—even years—between La Alianza case workers and some of the families they were paid to serve. Cases frequently went unassigned to any social worker for months. The documentation of case work was “seriously inadequate in both quantity and quality” and “in the majority of cases the focus of case work activities could not be determined.” The process of finding permanent placements for children who could not return home was confused and full of delays.

The report detailing La Alianza’s deficiencies was not completed for some six months after the initial investigation, however. La Alianza Director Prado says he made several attempts to learn the results of the investigation during this period. He says DSS personnel gave him the name of “10 or 12” cases that needed immediate attention (the Ventura case was not among them, he adds), but he did not receive a full report of the findings until mid January, 1994. The reason for the delay, according to DSS Commissioner Carlisle, was that DSS had no dedicated monitoring

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staff. Thus, the members of the investigative team completed the report in and around other responsibilities.

The perspective of La Alianza’s newly hired social services director

The month DSS had begun its investigation—August 1993—La Alianza had hired a new social services director, Ann Grimaldi, a recent graduate of the Boston University School of Social Work. Like the DSS investigators, Grimaldi came to believe—soon after her arrival—that the state of affairs in La Alianza’ child protection program was dire. The best case workers were overwhelmed and—far from being on top of their caseloads—were scrambling, day by day, to cope with crises. The worst caseworkers were undisciplined in the extreme, failing even to show up for work reliably. Most of the workers had received no training in DSS child protection procedures. None had standard DSS social work manuals—a key resource. Some workers were unfamiliar with the standard battery of forms necessary to document their cases. They did not know how to write up simple legal reports. They had developed a reputation, in the court system, for failing to show up at hearings or arriving unprepared. They lacked, in fact, even a basic concept of what their job responsibilities were, Grimaldi says. What’s more, the program was understaffed and case loads were unworkably high. Overwhelmed by the magnitude of the problem before her, Grimaldi questioned how La Alianza could have allowed things to deteriorate to such a state. But she also wondered how DSS could have allowed things at La Alianza to deteriorate to such a state. “This is their business. This is what they do. They’re the ones who provide us the cases, they’re the ones who we’re supposed to be working with, they’re supposed to know every single thing we’re doing. And if they’re not getting that information, why weren’t they here saying, ‘Hey, wait a minute, the Jones case has been [in limbo] for three years, what’s going on?’” she says. Grimaldi commenced what she calls an exercise in “detective work” to find out who her DSS contacts were, what DSS resources were supposed to be available to her, and what DSS meetings she was supposed to attend.

According to Grimaldi, while some DSS personnel were helpful to her, key DSS administrators were cool and unhelpful, and communication was poor. “I started to have meetings with people at DSS, and the reaction from DSS was very weird. People appeared to be listening— but not. It seemed like everybody knew that things were really bad at La Alianza. And I’m wondering, why don’t they give us support? Or close us down?”

What I started to figure out was that DSS was very angry. Apparently they were tired of people coming and going, no organization, no anything. And I said, it would really be helpful if you could come in maybe once a week and help me sort out through these cases, help me [get a computer and modem] and someone from DSS to come out and train us on it.

High Stakes and Frightening Lapses ___________________________________________C16‐94‐1265.0

“We were drowning,” says Grimaldi. “We had cases that had not been worked on in three years.” DSS provided advice in dribs and drabs, but not enough assistance for the overhaul La Alianza needed, she says. It took months, for example, for DSS to help Grimaldi set up her computer system. “DSS expected that we would have had it all along,” Grimaldi says. “They didn’t understand what happened.”

From DSS’ point of view, La Alianza kept insisting that the bad old days were gone, and that things were really going to change at La Alianza, yet things did not appear to change. On January 31, 1994, about two weeks after the formal completion of the DSS report about La Alianza’s deficiencies, top level DSS officials, including Deputy Commissioner Michael Weekes, met with top‐level La Alianza officials, including the board president and executive director, to review the findings. At that meeting, La Alianza agreed to design a “corrective action plan” within 30 days, subject to DSS approval. DSS personnel were to return to La Alianza in April 1994 to review progress in complying with the corrective action plan. The agreement stipulated that DSS would make a decision about whether to re‐contract with La Alianza based on the results of the April investigation. But according to DSS Commissioner Carlisle, La Alianza’s administrators were full of reassurances that most of these problems had already been corrected, or were well on their way to being corrected.

Two weeks later, the Ventura case, in all its misery, was blasted across Boston’s TV screens and local newspapers.