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Will dental ruling send ripples through health care industry?

Georgia's 9,500 nurse practitioners include Dian Evans (left), specialty coordinator for the Emergency Nurse Practitioner Program at Emory University's Nell Hodgson Woodruff School of Nursing.

Georgia’s 9,500 APRNs include Dian Evans (left), specialty coordinator for the Emergency Nurse Practitioner Program at Emory University’s Nell Hodgson Woodruff School of Nursing. Photo credit: Bryan Meltz with Emory Photo/Video

A recent U.S. Supreme Court ruling about teeth-whitening services may have long-term implications for health care professionals and their practices across the country.

The dispute involves the right of dental hygienists to perform such services in North Carolina. The Federal Trade Commission brought a major anti-competition case on the matter. The high court did not settle the case, but rejected the state dental board’s claim that its actions were immune from FTC scrutiny.

“In this case, the North Carolina dental board’s members, primarily dentists, were drawn from the very occupation they regulate. They barred non-dentists [in this specific case, dental hygienists] from offering competing teeth-whitening services to consumers,” said FTC Chairwoman Edith Ramirez in a press release.

The American Nurses Association says the dental board case may have “far-reaching implications beyond dentistry.”

In Georgia, the experts are divided on how, or if, the case could affect professional practice laws.

What doctors and nurses say

Debbie Bartlett, CEO of the Georgia Nurses Association, says her organization “will utilize the Supreme Court’s ruling to help inform Georgia legislators about the need to support federal antitrust laws [as well as] avoid unduly suppressing pro-consumer competition.”

Georgia state practice and licensure law restrict the ability of nurse practitioners — nurses trained to perform many tasks often left up to doctors — to engage in at least one element of practice. Georgia nurse practitioners, also known as advanced practice registered nurses (APRNs), cannot write prescriptions for Schedule II medications. And their ability to order specific diagnostic tests is also limited.

The state requires supervision, delegation or team management by licensed physicians in Georgia in order for any nurse practitioner to provide patient care.

Donald J. Palmisano Jr.

Donald J. Palmisano Jr.

Donald J. Palmisano Jr., executive director of the Medical Association of Georgia, sees little reason for concern about the high court ruling, because the kind of situation cited in North Carolina does not exist here.

“The North Carolina case is drastically different than the way the licensing boards work in Georgia.” says Palmisano. Here, a board’s proposed actions are reviewed by the state attorney general’s office and released for public comment, he notes.

“The ruling in North Carolina never rose to the level where the Medical Association needed to contact the Georgia Nurses Association,” Palmisano says.

“The two organizations [in Georgia] have a fairly strong relationship. I don’t foresee [a big impact from the Supreme Court ruling] here,” he adds.

Atlanta nurse practitioner Mary Perloe agrees. “I actually think nurse practitioner collaborative agreements with physicians and using evidenced-based protocols make sense,” she says.

“I also believe that the nurse practitioners should bear responsibility for their practice. As NPs gain more authority, accountability needs to follow, and physicians need to be relieved of this liability,” says Perloe.

Rebecca Wheeler, the GNA past president, suggests the ruling may be a mixed blessing for those in the nursing profession.

“I think the decision is great for APRNs, but I am a little worried about what this means in order to protect our own RN scope of practice from medical technician or nursing assistant roles,” Wheeler says. “I feel like this is a bit of a double-edged sword for nursing.

“I’m not saying it’s necessarily a bad thing [referring to the Supreme Court decision]. We probably need to be prepared to ‘give a little’ if we want APRNs to be able to practice to the full extent of their training in Georgia.”


The issue of dentistry


The American Dental Association (ADA) said it was “extremely disappointed” at the U.S. Supreme Court decision.

The group said the decision “constitutes a dramatic departure from the Supreme Court’s established law, and throws into question the regulatory, licensing and disciplinary authority of thousands of professional boards across the county.”

“The ruling creates a quandary for professional boards . . . with no explanation as to what level of ‘active supervision’ is necessary to invoke immunity for each board,” ADA stated.

The association said it is planning to work with other organizations to provide some kind of guidance in view of the Supreme Court’s decision.

But among Georgia dentists, as among physicians in general, there seems to be less alarm about the ruling. Frank J. Capaldo, the Georgia Dental Association’s executive director, says there are a number of important distinctions between the dental licensing boards in Georgia and North Carolina.

“In Georgia, members are appointed to the Board of Dentistry by the governor, but in North Carolina they are elected to the board by other licensed dentists,” Capaldo says. “This difference in and of itself shows significant state oversight in Georgia.”


Some see more opportunities


Scope of practice limitations for nurses exist alongside a shortage of health care providers in Georgia, especially in rural areas.

The consumer group Georgia Watch recently reported that the number of licensed APRNs in Georgia has reached more than 9,500. With the physician shortage in the state, which is expected to get worse, APRNs could help fill this primary care gap, the group’s report says.

NP Photo with manA total of 129 of Georgia’s 159 counties have a shortage of health care professionals. In fact, about 80 percent of Georgia’s counties contain substantial populations without a consistent source for primary care, according to the Georgia Watch report.

Georgia Watch and others continue to urge state policymakers to consider using more advanced practice nurses and physician assistants in health care shortage areas.

Many Georgia physicians, however, traditionally support the restrictions on the duties of nurse practitioners. They’re concerned about whether people who are not doctors — working on their own — have the training to safely diagnose and treat patients, refer them to specialists, admit them to hospitals and prescribe medications for them. These doctors think the NPs should continue to work under the oversight of physicians.

The right of Georgia nurse practitioners to prescribe medications didn’t come until 2006. Georgia was the 50th state to grant NPs prescribing ability.

Many health care experts say that with the influx of thousands of Georgians into the health care system under the Affordable Care Act, the time may be right for the state to review its scope of practice laws, especially in rural areas.

“There are, after all, cost realities here. We just need to be prepared,” says Wheeler, referring to NP restrictions.

“This [Supreme Court] ruling seems to open up the door for everyone, including medical technicians or nursing assistants, as much as it does for APRNs,” she says.


Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.


Understaffing among Georgia’s school nurses: A quiet crisis

School nurse Sally Boswell examines a Greene County student

School nurse Sally Boswell examines a Greene County student.

Sally Boswell is the first person many low-income families in Greene County call when their child gets sick.

She hears about everything from acute ear infections to chronic conditions such as diabetes. Boswell helps parents, grandparents or guardians decide whether their child needs to see a doctor.

She is the only school nurse for the county’s 2,300 public school students. Despite the long economic downturn and resulting budget cuts, she has stuck with her passion for nursing.

Greene County

Greene County

Thanks to Lake Oconee, built in 1979, historically rural Greene County has attracted tourists and some very affluent residents in recent decades. Today it is listed as one of the wealthier counties in the state, with a median income of about $42,500. But poverty remains, and the number of Boswell’s students who are on Medicaid or are uninsured is high.

School funding for nurses and health care workers in Georgia varies by locale. Georgina Howard, director of the School Health Nurse Program at the Georgia Department of Education, says, “In Georgia, we’ve made some progress, but we aren’t fully staffed.  It’s left up to the district how they want to do their staffing.”

The current recommendation from the National Association for School Nurses is to have 1 nurse per 750 students. Georgia’s 2,264 public schools serve 1.7 million students, so the recommended number of nurses for the state is 2,267.

But as of October 2014, there were only 1,555 licensed nurses who work in the state’s schools, Howard said. That leaves a shortage of more than 700.

Problems to confront

In neighboring Morgan County, with a median income at about $47,700, there are four nurses for about 3,200 students. “Morgan County has a school nurse at every school; primary, elementary, middle, and high school,” says Leah Ainslie, who worked in Greene County before she became the nurse manager for the local public health department in Morgan.

Many students at Union Point STEAM Academy have asthma or diabetes.

Many students at Union Point STEAM Academy have asthma or diabetes.

“[The] purpose of the school nurse is to keep children well, so the children can learn.  If you don’t have anyone there to do that, then the kids aren’t learning,’’ says Ainslie.

Being the only school nurse in Greene County, Boswell barely has time to drive 10 minutes between the county’s one pre-school, two elementary schools, one middle school and one high school. The constantly shifting medical needs of students dictate what she does from one day to the next.

“When I started, we had four registered nurses and we ran a program, a true comprehensive nursing program,’’ Boswell says. “We did things like CPR classes for the bus drivers, we were able to do certain programs for not just the students, but for the faculty.”

Now, her attention is solely focused on the health of the students.  In early February, the hot spot was Union Point STEAM Academy, a K-7 elementary school that focuses on science, technology, engineering, the arts and mathematics.

“I’ve got little kindergartners who are horrible asthmatics, and all of the diabetics at the elementary level are here,” Boswell says.  “I have to be here to do insulin every day.”

Every day is different, but busy

Between administering breathing treatments and monitoring insulin levels, Boswell uses her qualifications as a pediatric nurse practitioner.  She catheterizes a wheelchair-bound student, diagnoses an ear infection in another student, and lines up a doctor’s appointment for a third.

Boswell’s job has become much more than keeping kids well.

When a family member can’t come to pick up a sick child, she will even give the youngster a ride home (with parental permission,  of course).

On a recent morning at 8:30, students swarmed in and out of her small office.  One child’s arms were covered with what appeared to be insect bites, and an itchy and swollen rash was forming. Another was reporting for his asthma inhaler treatment, and two hovered over a single toilet for fear they were going to vomit.

“I am certainly the child’s advocate” on medical issues, says Boswell. “With 2,300 students and knowing their families, and where they come from . . . I think that I help the continuity of care.”


Ansley Stewart is pursuing her master’s degree in journalism at the University of Georgia.  She is a freelance writer, musician, and also works full time at UGA.  


Will your hospital change hands? Partnerships, purchases on the rise

West Georgia Health in LaGrange is seeking a buyer or partner.

West Georgia Health in LaGrange is seeking a buyer or partner.

The hospital partnership dance continues in Georgia. Given the pressures of the health care economy, nobody apparently wants to be a wallflower.

Last week, St. Mary’s Health Care System in Athens said it is talking with financially ailing Ty Cobb Regional Medical Center about a possible acquisition of the Lavonia hospital.

That announcement reverberated in northeast Georgia, but it was overshadowed by news of a much bigger potential merger in metro Atlanta, between mega-systems WellStar and Emory Healthcare.

This week, West Georgia Health in LaGrange said it hopes to announce a possible partner or buyer soon.

A special panel has narrowed the candidate list for such a deal to two organizations, Jan Nichols, marketing director for the LaGrange health system, said Wednesday.

But sometimes there are fears that the dance is moving a little too fast. A former state lawmaker is concerned about a lack of transparency in the West Georgia situation.

Jeff Brown

Jeff Brown

“When you hire J.P. Morgan [to help explore potential deals], you’ve made a decision to sell or to merge,’’ Jeff Brown, former chairman of the House Health Appropriations panel, told Georgia Health News this week.

He said if West Georgia Health chooses the wrong partner, it could devastate Troup County taxpayers, who are guarantors of a $46 million bond.

Meanwhile, St. Francis Hospital in Columbus, rocked by an accounting misstep that left it financially less secure than it had believed, is talking with Atlanta-based Piedmont Healthcare about a possible alliance. And Tenet Health, a chain based in Texas,  is looking for a partner or buyer for its five metro Atlanta hospitals.


A rapidly changing landscape


The moves are coming fast as the whole U.S. health care system undergoes a transformation, at least partly because of the Affordable Care Act.

Hospitals are being squeezed financially by changes in the way they are reimbursed,  and by federal cuts and penalties.

Health insurers and Medicare are moving more toward paying for bundling of medical services, rather than paying for individual procedures or tests separately. The goal is to end the dominance of  fee-for-service medicine, in which hospitals and doctors are reimbursed based on the amount — not the quality — of care they deliver.

In addition, federal money for hospitals that deliver a “disproportionate share’’ of care for the poor and uninsured is being cut. Georgia hospitals will lose hundreds of millions of dollars.

Ty Cobb Regional Medical Center

Ty Cobb Regional Medical Center

It was the intent of the ACA that states would expand Medicaid to make up for these eliminated funds. But the U.S. Supreme Court ruled that states didn’t have to do that. Georgia is one that has declined to expand Medicaid, saying it would cost too much. Meanwhile, some already vulnerable hospitals are facing a further revenue crunch. (Here’s an article on how  Medicaid expansion has worked out in Kentucky.)

The hospital consolidation drive is moving forward rapidly, in Georgia and nationally. Hospitals of every size, in cities, suburbs and rural areas, have been affected.

Some of the hospitals in the mix are clearly struggling financially. Ty Cobb Regional, a 56-bed rural hospital, is relying on Franklin County to make its bond payments, according to the Independent Mail newspaper.

“Smaller community hospitals are having a real hard time,’’ said Greg Charleston of the consulting firm Conway MacKenzie in Atlanta. “Hospitals are struggling, they don’t know what to do, and they look for a buyer.’’

Part of the consolidation wave, he said, comes from a sense that “it’s the thing to do.  Sometimes it makes sense, sometimes it doesn’t.”

“If you’re a small community hospital, you probably need to team up with someone,” he said.

Larger health systems get patient referrals for their specialist services and solidify their territorial reach through such deals, which can yield economies of scale, eliminate duplication of services, and reduce overall costs, Charleston added.


Problems can add up


In LaGrange, West Georgia Health has been working on a potential deal for months.

A recent LaGrange Daily News article noted that from 2010 to 2013, West Georgia Health’s Medical Center listed revenue deficits each year, with the highest being $6.2 million dollars as in 2013.

Gerald Fulks

Gerald Fulks

Meanwhile, in fiscal 2012, West Georgia CEO Gerald Fulks received what is listed on an IRS 990 form as a $1.6 million “payout.”

Fulks told the Daily News that the payout was accumulated retirement benefits over a 10-year period. His total compensation in fiscal year 2012 was just over $2 million, IRS data show.

Nichols of West Georgia told GHN that the overall compensation package, including Fulks’ retirement benefits, was developed by a compensation committee of the WGH Board of Trustees. “It is based on a number of factors, including comparative health system CEO compensation and health system performance goals,” she said.

When asked why a merger is being considered, Fulks told the Daily News: “Because with the changes that are coming down from the Affordable Care Act, we are simply not big enough to take on the risk of bundled payments from patients, taking the risk of an entire population.

“We don’t have the information technology that is necessary to manage population health and we believe that we can lower our operating costs by participating in the overhead of a larger provider organization, and still provide the kind of care and support that our community expects.”

West Georgia says the hospital is currently operating in the black. Its current cash on hand of $55 million is 121 days, an amount it says is twice the figure required by its current bond covenants of 60 days.

Yet over the past five years, West Georgia Health has faced a rising bad debt and charity care burden, which has jumped from $39.5 million in fiscal 2010 to $64.4 million in fiscal 2014.

Brown, the former state legislator, said that beyond his concerns about the dealmaking process, he believes the LaGrange community will still have a medical facility after the dust settles. “They’ve been here for 75 years,’’ he said.

The hospital is the only one in Troup County, home of the massive Kia automotive plant, one of the economic showplaces of the state.


Medicaid physicians back in same spot after long-awaited raise expires

Dr. Jaquelin Gotlieb examines a new patient, Jada Smith, 5, at her Stone Mountain office

Dr. Jaquelin Gotlieb, shown examining a patient, says that the Medicaid pay bump is a matter of valuing children.

Dr. Michelle Zeanah is getting a big pay cut this month.

It’s not that the Statesboro pediatrician is seeing fewer patients. Just the opposite.

The 12 rural counties surrounding Bulloch County, where Statesboro is located, have no pediatrician. So Zeanah is very much in demand.

Forty percent of her patients have driving distances of 45 minutes or more. A few come from more than 50 miles away.

Dr. Michelle Zeanah

Dr. Michelle Zeanah

Her pay cut involves the Medicaid program. Reimbursements to primary care doctors under Medicaid just went down in Georgia and many other states.

The Affordable Care Act had awarded primary care doctors treating Medicaid patients a two-year pay increase. It was funded entirely with federal money, and pushed their Medicaid pay to the level of Medicare reimbursement.

But that additional Medicaid reimbursement, which went to family physicians, pediatricians and internists, ended Jan. 1. And doctors will be missing it.

“It allowed us to hire more staff so we could serve more patients,’’ Zeanah says. Without it, she adds, “I will have to work 70 hours a week’’ instead of the current 60.

About 70 percent of her patients are covered by Medicaid or PeachCare (the Georgia version of the child health insurance program).

Medicaid, the federal/state program for the poor and disabled, serves more than 1.5 million Georgians. Most are children.

Before the increase, Georgia primary care doctors had gone more than a dozen years since the last Medicaid pay hike.

A few states, including Alabama and Mississippi, have continued giving their primary care doctors the pay hike by using state dollars to fund it.

But Georgia political leaders, on the eve of the 2015 General Assembly, have shown no signs they’ll appropriate money to reinstate the pay hike. The money that would be needed – an estimated $62 million for a year – is not in the Department of Community Health budget being proposed to Gov. Nathan Deal.

Sasha Dlugolenski, a spokeswoman for the governor, said in an email to GHN in September that Deal was aware of the issue. She called the pay hike expiration “one of the early, blatantly obvious examples of Obamacare unloading costs onto the states. This was a short-term Band-Aid to a long-term problem, and now the states are left holding the bag.”

The federal health law required that the raise be paid for two years, 2013 and 2014. The money actually did not arrive till 2014, but when it did, eligible doctors received the pay hike retroactively to Jan. 1, 2013.

Such delays in the payments occurred in many states, including Georgia, that use managed care in their Medicaid programs.

Practices feel the pinch

The end of the federally funded raise means that Medicaid fees in Georgia will now be reduced by 34.8 percent, according to a recent Urban Institute study.

Some pediatricians describe the pay bump as a children’s health issue. They say children on Medicaid generally have greater health and social needs.

“It’s a matter of valuing children as the future of the state,’’ says Dr. Jaquelin Gotlieb, who practices along with her pediatrician husband, Edward Gotlieb.

“I believe primary care doctors feel a significant responsibility to their patients,” adds Jaquelin Gotlieb, who is 68 and has practiced in Stone Mountain for almost four decades. “That’s why we have hung in there.”

If the pay isn’t restored, she says, “This is going to take some of them and push them over the edge.’’

Dr. Eugene Cindea

Dr. Eugene Cindea

Roughly two-thirds of the Gotliebs’ patients are covered by Medicaid or PeachCare, she says.

Dr. Eugene Cindea, a pediatrician at the Longstreet Clinic in Gainesville, says the extra money “allowed us to expand offerings to patients.”

“It felt good for physicians who were seeing a considerable number of Medicaid patients,” he says.

The goal of the pay hike, Cindea notes, was to increase the number of physicians who accept Medicaid patients.

Without the money, he says, it’s more difficult to devote staff to manage the chronic diseases of children. “It decreases the likelihood that we’ll expand in an underserved area,” he adds.

OB/Gyns were not eligible for the two-year federal pay bump that just ended. Pat Cota, of the Georgia Obstetrical and Gynecological Society, says her organization is asking the state to revive the pay increase and expand it to include OB/Gyns.

The majority of children born in Georgia are covered by Medicaid.




An incentive for doctors

In Alabama, physician participation in Medicaid is a concern. The state says about 22 percent of enrolled primary care physicians now receive 90 percent of all claims payments. The other problem is that Alabama has shortages of health professionals in 62 of its 67 counties.

Niko Corley of the Alabama Medical Association says that “for Medicaid to be as efficient as possible, you’ve got to have physicians managing that care.”

The federal pay hike was supposed to increase doctor participation in Medicaid. But Kaiser Health News has reported that most states say they’ve seen no evidence that it did so — mostly because it was a temporary measure.

“The Medicaid pay boost was never meant to be a silver bullet,” Leonardo Cuello, director of health policy at the National Health Law Program, an advocacy group for low-income Americans, told KHN. Still, he worries about the provider fee cuts. “It won’t sink the ship but . . . I’m concerned it will contribute to access problems.”

Statesboro pediatrician Zeanah notes that many physicians have limited their numbers of Medicaid patients. That’s why her pediatric practice continues to see more patients.

Having the pay hike meant that the practice stopped losing money on delivering vaccines to kids on Medicaid. “We made a tiny profit,’’ Zeanah says.

Not having the pay hike, though, means more hours and less reimbursement. It means Zeanah and her pediatrician partners can’t build an office building to accommodate the growing practice.

Medicaid patients require more work, and are more often late or no-shows due to reasons such as lack of transportation, she says. “We have no social worker available to us. I am the social worker.”

Georgia desperately wants to recruit new physicians, Zeanah notes. “When you don’t have Medicaid payment parity, it makes it hard.”


DFCS disciplinary records show child safety challenges

A DFCS worker last year failed to inspect the living conditions in a Gwinnett County home where children under state supervision lived. The home was later found “in a deplorable condition [with] drugs and drug paraphernalia in the home and the water was off,” state records say. “The children were not being supervised.”

The worker received “a memorandum of concern and expectations” from the state Division of Family and Children Services.

A second DFCS worker failed to make timely contact with a couple who lived with their grandchildren in Newton County. “An infant included in this sibling group passed away on November 5, 2013,’’ state records show. “The children still had not been seen in this placement at the time of the child’s death.”

The DFCS worker received a “written reprimand and final warning.”

A third DFCS worker also received a written reprimand after failing to make contact with a Glynn County child who was reportedly not being properly fed by her teenage mother. The child was taken to the hospital “due to serious injury.’’

The three cases were among state records of disciplinary actions against Georgia DFCS workers in 2013. The records were obtained by GHN through an Open Records request.

A GHN analysis of disciplinary actions around the state found many employees received multiple chances – through strongly worded criticisms –to improve their performance before facing termination. They were given conferences, work plans, attendance plans and memoranda of concern before being handed a written reprimand and final warning.

The disciplinary records show many children in a variety of potentially dangerous situations. They also show DFCS workers juggling many cases simultaneously.


Child deaths shocked state


For years, DFCS has been an agency under pressure, burdened by high caseloads, stagnant pay, and low morale among its workers.

In recent months, though, Georgia’s child welfare system has drawn tougher scrutiny and harsher criticism, particularly after the gruesome deaths of 10-year-old Emani Moss and 12-year-old Eric Forbes in 2013.

The resulting fallout helped lead to increased state hiring of caseworkers and Gov. Nathan Deal’s creation of a council to review the child welfare system, as well as a legislative effort to privatize child welfare services.

A Department of Human Services spokeswoman last week said through an email statement that the current disciplinary process improves DFCS worker performance.

dhslogo“Working with an employee through additional training or monitoring after identifying a performance issue has proven to be an effective way to increase an employee’s skill level and influence future decision-making,” said the spokeswoman, Ravae Graham, in an email to GHN.

Human Services also acknowledged there are fewer caseworkers now handling a surge in the number of child abuse reports.

DFCS currently has 1,962 frontline workers and 409 supervisors working in child welfare. Five years ago, Georgia had 2,228 frontline workers.

The demand for state help, meanwhile,  is growing. DFCS said last week that since a 24-hour central intake line debuted, the agency has received significantly more referrals of abuse and neglect of children. In September 2013, the agency received 5,124 reports of child abuse in Georgia. This past September, that number was 8,572.

Earlier this year, a state report found the deaths of children whose families had DFCS involvement rose to 180 in 2013 from 152 the year before, an 18 percent increase.

(State officials and others, though, have urged caution in making direct comparisons with the figures. Most states are seeing increases, and are attributing the higher totals to better data collection, improved collaboration among agencies, better reporting on deaths, and increased interest from the community.)


Complaints over pay, conditions

Starting pay for entry-level DFCS workers is about $28,000 a year, for work in such categories as child abuse and neglect investigations, foster care, and family support.

A recent survey of workers found that about 90 percent with less than six months of tenure said they were somewhat or extremely satisfied with their jobs. But for workers with more tenure, just 40 percent said they were satisfied.

Bobby Cagle

Bobby Cagle

One major complaint involved a lack of raises – or even cost-of-living adjustments – for many years, the survey showed.

And two-thirds said they were sometimes concerned for their personal safety when working in the field.

The same percentage said that they were at least somewhat likely to look for a job outside of DFCS in the coming year.

This past summer, Gov. Deal authorized the hiring of an additional 103 DFCS staff statewide, beyond the 175 additional positions included in the state budget. The agency says it has a commitment from Deal to hire several hundred more staff over the next three years, with the goal of case managers having no more than 15 cases each.

Earlier this year, GHN reported some workers had caseloads of up to 100 or more in metro Atlanta counties – an extremely high number, experts said.

And just last week, DFCS chief Bobby Cagle ordered mandatory overtime for DFCS child protective services investigators to prevent a major backlog of child safety investigations.

Child Protective Services “was in a state of crisis” at the beginning of 2014, says Karl Lehman, CEO of Childkind, a nonprofit that serves children with complex medical challenges or developmental disabilities.

The crisis atmosphere followed a media and public firestorm in 2013 over the deaths of Emani Moss and Eric Forbes, two cases that led to criminal charges against relatives.


Disturbing lapses


State records of disciplinary actions in DFCS in 2013 include the firing of a Gwinnett County worker and the demotion of two others; and the termination of two Cobb County employees and the demotion of two others.

Emani died in Gwinnett, and Eric was under DFCS supervision in Cobb.

The records of disciplinary actions, including the firings and demotions, did not name any of the children involved in the cases.

childrenplayA total of seven employees were fired or terminated in 2013, the state records show.

Inadequate documentation – occasionally to the point of no documentation – was the most often cited problem among DFCS worker disciplinary actions.

The accuracy of workers’ records of home visits is essential when dealing with the court system, says Lehman of Childkind, which supervises some caseworkers. The documentation also ensures that children are getting services they need and that the state is focused on their well-being, he adds.

Many DFCS employees were cited for failure to make regular contact with families, or for not completing visits as assigned.

Others were cited for unprofessional behavior or chronic absenteeism. At least two were disciplined for misrepresenting facts in cases. Violations included not coming to work on time and aggressive behavior in the office.

In several cases, DFCS caseworkers did not complete quick follow-ups when there were alarming reports of abuse. One case involved a child who suffered a cigarette burn, another a child who had a black eye.

A caseworker in Houston County failed to follow through with an October interview and exam with a child who reported possible sexual abuse. As of Oct. 25, no contact has been made with the child, state records show.

An Effingham County home chosen as a “safety resource’’ for children was discovered to be the same home where DFCS had removed children from an adult caregiver on two separate occasions and had to transfer permanent custody of the children to a relative.

DFCS workers closed a case without observing a family in their Richmond County home. “There were present dangers identified due to domestic violence against the birth father and a ‘no contact’ order,’’ state records say. “The birth father was placed back in the home without services to assist the family or proper assessment to ensure the children were safe.”


Making workers better


Through the steps of the disciplinary process, a caseworker “can learn valuable lessons and become a valuable caseworker,’’ Lehman says.

With all that a caseworker is asked to do, he says, “it’s a very challenging job even in the best of circumstances.”

Lehman adds that high DFCS turnover and low worker morale should concern the Georgia General Assembly. Funding the program properly is critical, he says. Child protection has suffered, he says, “because Georgia has not invested sufficient resources.”

Gov. Deal has created a council to study Georgia’s child welfare system and come up with ways to protect children better from neglect and abuse.

Gov. Nathan Deal

Gov. Nathan Deal

That committee is creating recommendations to deal with the morale of DFCS caseworkers, large caseloads, stagnant salaries and potential exposure of workers to violence, among other issues.

Stemming the high rate of turnover is vital,  children’s advocates say.

“Personal recognition from inside and outside the department could help reinforce the promise of better things to come,’’ says Pat Willis of Voices for Georgia’s Children, who notes the challenge of reducing caseloads amid high worker turnover.

Georgia’s DFCS measures required by the feds generally compare favorably with other states, Willis adds.

“I am so sympathetic to that DFCS professional who has withstood a social and economic beating while trying to protect children and promote strong functional families,’’ she says. “It’s hard to ask them to hang on a little longer, but we need their leadership to implement the strategies of the commissioner and the recommendations of the Child Welfare Reform Council.”







Hyacinth Empinado is a freelance journalist in Athens. She is currently pursuing a master’s degree in health and medical journalism at the University of Georgia.

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