The Rhode Island Department of Children, Youth and Families (DCYF) reported on Friday that it is committed to making widespread systemic changes and continuing ongoing reforms in order to better serve vulnerable children and families and prevent future tragedies from occurring.
The announcement came more than three months after Zha-Nae Rothgeb, a 9-year-old child with cerebral palsy, was found unresponsive by Warwick Police after being left alone in a bathtub for hours at the Oakland Beach home of Michele Rothgeb, her adoptive mother, on January 3 and was pronounced dead shortly afterwards. Zha-Nae was one of eight special needs children that were under Rothgeb’s care.
DCYF’s investigation confirmed that neglect and departmental deficiencies both contributed to her death, and that the department is reforming three specific areas – the process for licensing of prospective foster families and adoptive families; the placement of children; and how they conduct child safety investigations of adoptive and foster homes.
“Through the course of our investigation, what we discovered was a series of lapses in policy and in judgment that failed to detect significant changes in the ability of this mother to care for her children,” said Trista Piccola, director of DCYF. “It’s a painful conclusion that was confirmed by the state medical examiner’s office, which has determined that the child’s death was caused by complications of cerebral palsy, including her seizures, and as a result of neglect.”
Piccola said that the case involving Rothgeb spanned over a decade and that over a dozen people at DCYF interacted in the case directly or indirectly, so it was impossible to point to singular actions or inactions by DCYF personnel that resulted in Zha-Nae’s death.
Regardless, three DCYF employees, including the department’s Chief of Operations, no longer work for the state as a result of the case, and five more were facing disciplinary action – two of which Piccola said she was recommending for suspensions.
Another five employees have been issued “improvement plans and ordered retraining,” along with all frontline staff and supervisors undergoing additional training to be able to better assess foster and adoptive families’ abilities to care for children.
“Accountability in this situation is very important, as it is in all cases where we believe we’ve made mistakes,” Piccola said of the personnel decisions. “So, we’re going to take responsibility for this.”
However, Piccola cautioned that DCYF could not simply “discipline your way out of longstanding system deficiencies,” and that a more comprehensive, system-wide change was necessary.
“While not representative of DCYF, this case demonstrated that our state safety net is not touching every single child, and that’s unacceptable,” Piccola said. “And it’s exactly why we’ve been working to change, through our ongoing reform efforts, to reflect a more prevention-focused, public health response to child welfare.”
That reform, she reported, includes working more collaboratively with other state agencies – such as the Executive Office of Health and Human Services, the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) and the state Veterans Affairs Office – as well as outside, private nonprofits, to provide a “holistic” approach to child welfare – aiming for better screening of prospective adopters, more effectively identifying at-risk households and providing more support to families who are struggling.
“Children and families don’t live in isolation. They don’t live in a bubble. They live in homes, they live in neighborhoods, they live in communities,” said Craig Gordon, president of the Coalition for RI Children and Families, an agency encompassing 40 member organizations across the state tasked with assisting vulnerable families and children. “It takes all of us, it’s not simply one state agency that helps protect children from abuse and neglect. Preventing child abuse and neglect takes everybody in every community – we all have a legal and moral obligation to report any suspicions.”
Ben Weiner, vice present of Family Service of Rhode Island, said that they would be providing clinical support to DCYF to “better assess and manage risk in terms of some of the highest-need families in Rhode Island.”
“This really is a team approach,” added Lisa Vura-Weis, Acting Secretary Executive Office of Health and Human Services.
In terms of concrete policy changes, Piccola said that DCYF would no longer allow more than five children to be placed in a single home without her direct approval, or the approval of a designee of the director. Similarly, no unrelated children will be allowed to be placed in the same home without direct approval from the director.
Going forward, all adoptive home study reports must be approved by a DCYF administrator before being submitted to the Family Court, and a “multidisciplinary team” consisting of senior managers, legal counsel and caseworkers will review all child protection investigation cases of licensed homes.
“If we’ve had a child abuse and neglect investigation of a licensed family, I want people sitting in a room together talking about that investigation, talking about the outcome of it and talking about what the plan is moving forward,” Piccola said.
A Beacon report revealed in January that Rothgeb had racked up over $15,000 in settled and unsettled debt between December of 2017 and March of 2018, despite receiving around $4,500 a month in subsidies from the state to help provide for her adopted children.
Piccola said that from now on, all child safety investigations would include a “comprehensive assessment of a family’s ability to care for a child,” including a review of financial constraints, family supports, employment situation and “other outside factors.”
“We need to make sure we’re implementing an assessment in child protective investigations that assesses the full family and not just the incident that the investigator is going out on,” she said.
Piccola stressed that many of these reforms were already being put in place prior to the Rothgeb incident, and that they were not a “kneejerk” reaction to Zha-Nae’s death.
“That’s why the review took so long,” she said. “Because we wanted to analyze every decision along the way so that whatever reform efforts we had put into place – the ones we had already started and the new ones that we were going to put into place – would make sure our guardrails around keeping this from ever happening again were significant enough.”
She said that by May 1, revised regulations for DCYF will be submitted to the state for review, and that a newly-created “Division of Performance Improvement” will submit work plans to “ensure complete integration of these department-wide practice changes.”
“We know that reform efforts take several years, and we have to stay committed to those reforms, because they are working, and they are producing the outcomes that are strong, and as strong as we would want for our own families,” she said.
An ongoing challenge for the department is the availability of foster families. Piccola said that the number of licensed foster families has increased by 25 percent in the state over the past year, but that they must continue to focus efforts on increasing that number.
Piccola didn’t rule out the possibility that caseworkers being overloaded with cases could have contributed to the tragedy, but that her review led her to believe it wasn’t a contributing factor. She mentioned reducing the vacancy rate of frontline DCYF caseworkers from 20 percent when she assumed the directorship two years ago to being steady at 5 percent for the past five months.
“This is a frontline-fueled business,” she said. “We have to make sure our workers always have manageable caseloads. We’re always looking at the structures across the different departments to make sure that they’re resourced well enough to do the work we’re asking them to do.”
Rothgeb is awaiting trial on child neglect charges. DCYF spokesman David Levesque confirmed on Friday that the other children who had been placed with Rothgeb have since been placed with other families. Piccola said that an independent report from The Child Advocate on the case had not yet been received by the department.