Systemic Fracture: A Comprehensive Analysis of the 2025 Federal Audit of West Virginia Child Protective Services
1. Introduction: The Convergence of Crisis and Transition
In November 2025, the fragile architecture of West Virginia’s child welfare system was laid bare by a scathing federal inquiry. The United States Department of Health and Human Services Office of Inspector General (HHS-OIG) released a compliance audit that was not merely a critique of bureaucratic inefficiency but a documentation of systemic collapse. The report, formally issued on September 26, 2025, but withheld from public view until mid-November, detailed a failure rate of 91% in the handling of child abuse and neglect cases during the 2024 fiscal year.1 This finding indicated that for every ten children whose potential abuse was reported and "screened in" for investigation, nine cases were mishandled in violation of federal safety requirements.1
The release of these findings occurred at a singular moment in the state's political history.
The audit period—October 1, 2023, through September 30, 2024—encompassed the final year of Governor Jim Justice’s tenure, a period characterized by mounting operational distress and the tragic, high-profile death of 14-year-old Kyneddi Miller.1 However, the burden of response fell to the newly inaugurated administration of Governor Patrick Morrisey, who took office in January 2025.5 The Morrisey administration was immediately placed in the position of defending a system it had just inherited, deploying a narrative that the audit represented a "snapshot of the past" that did not account for aggressive remediation efforts undertaken throughout 2025.5
This report offers an exhaustive examination of the HHS-OIG audit. It analyzes the operational mechanics of the failure, the specific human tragedy that catalyzed federal intervention, the subsequent legal and political fallout, and the tentative signs of workforce stabilization. By synthesizing data from federal reports, state responses, legal filings, and legislative actions, this analysis seeks to understand how a system designed to protect the most vulnerable could fail so completely, and whether the current corrective trajectory is sufficient to prevent future tragedies.
2. The Catalyst: The Death of Kyneddi Miller
To understand the 2025 audit, one must first understand the event that precipitated it. Federal audits are often routine, but the HHS-OIG’s decision to target West Virginia was explicitly driven by a risk assessment triggered by the death of Kyneddi Miller in April 2024.4 The Miller case served as a grim stress test for the state's child protective infrastructure, revealing fatal gaps in communication, intake procedures, and cross-agency collaboration.
2.1 The Discovery and Condition of the Victim
In April 2024, Kyneddi Miller was found deceased in her home in Boone County, West Virginia.4 First responders and investigators described her condition as "emaciated to a skeletal state," a physical manifestation of prolonged, severe neglect that raised immediate questions about how a child could deteriorate to such a degree without state intervention.4 The sheer horror of the discovery—a 14-year-old reducing to a skeleton within a populated community—galvanized public outrage and attracted the attention of federal overseers.2
Following the discovery, criminal charges were brought against the primary caregivers. Miller’s mother, Julie Miller, and her grandparents, Jerry and Donna Stone, were charged with murder by a parent, guardian, or custodian by failure or refusal to provide necessities, as well as child neglect resulting in death.1 As of late 2025, they were awaiting separate trials.6
2.2 The Administrative Void: The Referral Dispute
The most contentious aspect of the Miller case—and the one most relevant to the subsequent audit—was the dispute over prior knowledge. In the aftermath of the death, a conflicting narrative emerged between law enforcement and social services. West Virginia State Police officials asserted that troopers had visited the home in March 2023, a full year prior to Kyneddi's death.6 Law enforcement claimed that referrals had been made to Child Protective Services (CPS) alerting them to the precarious situation within the household.7
However, the West Virginia Department of Human Services (DoHS) initially maintained that they had "no record" of any referral that would have triggered an investigation.4 This administrative denial created a disturbing dichotomy: either law enforcement failed to transmit the referral, or the CPS intake system—the "front door" of the child welfare apparatus—was so dysfunctional that it swallowed a life-or-death warning without leaving a digital trace. The OIG audit would later confirm that intake and screening processes were, in fact, a primary point of failure across the system, lending credence to the possibility that the Miller referral was lost in the administrative noise of a collapsing bureaucracy.4
2.3 The Educational Loophole
The Miller case also highlighted the intersection of educational neglect and child welfare. Kyneddi Miller had been withdrawn from public school and was ostensibly being homeschooled from 2021 until her death.8 West Virginia law requires homeschooling parents to submit documentation tracking a student's academic progress. In Miller's case, her mother failed to turn in the required assessments to the local school board.4
This failure to report should have been a red flag. In a functioning system, a truancy or educational neglect report from the school board would cross-reference with CPS data. However, despite Governor Justice and various lawmakers calling for a tightening of homeschool reporting requirements in the wake of the tragedy, no substantial legislative changes were enacted to close this loophole.4 A bill passed by the House, which would have paused a parent's right to homeschool if a teacher reported suspected abuse, died in the Senate, leaving the structural blindness that hid Kyneddi Miller largely intact.4
3. The 2025 HHS-OIG Audit: Anatomy of a Failure
Against this backdrop of tragedy, the HHS-OIG launched its audit. The objective was to verify compliance with the Child Abuse Prevention and Treatment Act (CAPTA), specifically focusing on intake, screening, assessment, and investigation.1 The auditors utilized the state's "People's Access to Help" (PATH) computer system to review data.1
3.1 Methodology and Sampling
The audit universe consisted of 23,759 screened-in family reports of child abuse and neglect filed between October 1, 2023, and September 30, 2024.1 From this population, the OIG selected a random sample of 100 reports for detailed forensic review.1
While a sample size of 100 might appear small to a layperson, in federal auditing standards, it allows for a statistically valid projection of error rates across the entire population. The findings from this sample were extrapolated to estimate that 21,621 of the 23,759 total reports were likely non-compliant with one or more federal requirements.3
3.2 The Primary Finding: 91% Non-Compliance
The headline metric of the report is undeniable: 91% of the reviewed reports did not follow requirements.1 This is not a marginal failure rate; it is indicative of a system where compliance had become the exception rather than the rule. The audit found that the state’s Bureau for Social Services (BSS) failed to comply with fundamental procedural safeguards in 91 of the 100 cases.8
The implications of a 91% failure rate are profound. It suggests that during the final year of the Justice administration, the standard operating procedure for a child abuse investigation in West Virginia violated federal law nine times out of ten. This systemic deviation creates a liability vacuum, where the state is unable to prove that it took the necessary steps to ensure the safety of a child, regardless of the actual outcome of the case.
3.3 Detailed Breakdown of Deficiencies
The non-compliance was not monolithic; it fractured across three specific operational domains: notification, timeliness of assessment, and the conduct of investigations.
Table 1: Operational Deficiencies Identified by HHS-OIG (FY 2024)
Data Sources: 1
3.3.1 The Notification Collapse (74%)
The most prevalent failure was administrative: in 74% of cases, the state failed to send required notification letters.7 BSS officials defended this as a strategic choice, stating they "prioritized conducting child interviews over administrative functions such as sending out notification letters" due to staffing shortages.6
While this defense appeals to a triage logic—prioritizing the child over the paperwork—it ignores the systemic consequences of silence. Mandated reporters, such as pediatricians and school counselors, rely on these notifications to know that the system is working. When 74% of referrals result in silence, reporters may assume that their input is valueless or that the threshold for intervention is impossibly high. This degradation of trust can lead to a chilling effect on future reporting, effectively shrinking the system's radar.6
3.3.2 The Assessment Lag (61%)
More critical to immediate safety was the 61% failure rate in completing initial assessments on time.7 West Virginia policy and federal guidelines mandate that an initial assessment be completed within 30 days.6 In the majority of cases, this deadline was missed.
A delayed assessment is, functionally, an unassessed risk. If a report of physical abuse is screened in, but the assessment is not completed for 45 or 60 days, the child remains in the environment of alleged abuse without a formalized safety determination. The audit found that supervisors were not effectively utilizing system reports to track these delays, allowing cases to drift past deadlines without intervention.6
3.3.3 The Investigation Failure (41%)
The most damning statistic regarding physical safety is the 41% failure rate in completing required interviews.7 The state's defense of "prioritizing interviews over paperwork" collapses in the face of this data point. If the strategy was to sacrifice notification letters to ensure interviews happened, then the strategy failed, because nearly half of the required interviews also did not happen (or were not documented).7
An investigation without an interview is a contradiction in terms. It implies that caseworkers were closing or processing cases without speaking to the alleged victim or the perpetrator. In the context of the Miller case, where the state claimed no record of a referral, this 41% gap suggests a porous investigation layer where information could easily be discarded or ignored without the fail-safe of a mandatory interview.
4. Workforce Dynamics: The Crisis of Capacity
The HHS-OIG audit findings are inextricably linked to the workforce crisis that engulfed the West Virginia Department of Human Services during the audit period. The collapse in compliance was a direct downstream effect of a collapse in personnel.
4.1 The Vacancy Abyss (2023–2024)
The audit period (October 2023–September 2024) coincided with the nadir of CPS staffing in West Virginia. In 2023, the statewide vacancy rate for CPS positions hit a peak of 27.3%.3 However, statewide averages concealed the catastrophic shortages in specific rural jurisdictions.
In a five-county region comprising Doddridge, Pleasants, Upshur, Lewis, and Ritchie counties, the vacancy rate reached 44% by January 1, 2025.9 In these areas, nearly half of all authorized CPS desks were empty. This effectively doubled the caseload for the remaining workers, making the 30-day assessment windows and notification requirements mathematically impossible to meet.
4.2 Judicial Intervention: The Ritchie County Order
The severity of the shortage led to an unprecedented collision between the judicial and executive branches. In February 2024, Third Judicial Circuit Court Judge Tim Sweeney issued a court order compelling the leadership of the DoHS to personally report for duty. Judge Sweeney appointed Cabinet Secretary Alex Mayer, Deputy Commissioner Laurea Ellis, and other high-ranking officials to report to the Ritchie County Courthouse to receive assignments as CPS workers.10
This was not a symbolic gesture; it was a desperate attempt by the judiciary to manufacture capacity where none existed. It underscored the reality that in parts of West Virginia, the child protective system had ceased to exist as a functional entity. The officials were ordered to man shifts to cover the massive gaps left by the 44% vacancy rate.10
4.3 The Turnaround: 2025 Recruitment Metrics
Following the transition to the Morrisey administration and the focused efforts of Secretary Mayer, the workforce data began to show significant improvement throughout 2025. The administration launched a "Backlog Strike Team" in March 2025 to clear overdue cases and implemented aggressive retention strategies.6
Table 2: CPS Workforce Metrics Trend (2021–2025)
Data Sources: 3
By September 2025, the statewide vacancy rate had dropped to 8.5%, with only 69 vacancies out of 810 authorized positions.3 The turnover rate, which had been over 34% in 2021, was reduced to 15%.9
4.4 The "Snapshot" Defense and the Competence Gap
DoHS leadership utilized these improving metrics to contextualize the OIG audit. Secretary Mayer argued that the audit was a "snapshot of the past" and did not reflect the "significant reforms and modernization efforts already underway" in 2025.5
However, a critical distinction must be made between staffing and compliance. While the vacancy rate has dropped to 8.5%, the OIG audit showed a 91% non-compliance rate. Filling a position does not immediately rectify compliance failures. New caseworkers require training, mentorship, and experience to navigate the complex PATH system and conduct forensic interviews. The administration has introduced a mentorship program pairing new hires with seasoned workers for nine months 9, but the lag between hiring and full competency means that the risk of procedural error remains high even as the vacancy numbers improve.
5. The Legal Landscape: Jonathan R. v. Morrisey
The findings of the 2025 audit reverberated immediately within the legal sphere, specifically impacting the long-running class-action lawsuit Jonathan R. v. Morrisey (formerly v. Justice). This lawsuit, filed in 2019 by the advocacy group A Better Childhood, alleges that the West Virginia foster care system violates the constitutional rights of the children in its custody.12
5.1 The Dismissal: "The Ballot Box is the Remedy"
In early 2025, U.S. District Judge Joseph Goodwin dismissed the lawsuit. His dismissal was not an exoneration of the state’s performance; rather, it was an indictment of it, coupled with a refusal to intervene. Judge Goodwin wrote that the state was to blame for "inaction, bureaucratic indifference, shocking neglect, and temporary fixes".12 However, he concluded that "Constitutional limits prevent the court from crafting public policy... When elected officials fail, the ballot box is the remedy".12
This ruling placed the burden of reform squarely on the executive and legislative branches. However, the plaintiffs, led by Marcia Lowry, argued that this abdication left children with no recourse. "The court itself decided that it was just not going to protect these kids... So where are the kids supposed to turn?" Lowry stated.12
5.2 The Impact of the Audit on Appeal and Summary Judgment
The release of the audit in November 2025 provided powerful ammunition for the plaintiffs as they fought the state’s motion for summary judgment. In July 2024, the DoHS had filed a motion arguing that 3.2 million pages of documents proved that the plaintiffs could not win and that the trial was "costly and unnecessary".13 They cited improvements in community-based mental health spending and vacancy reductions.13
The OIG audit shatters the state's narrative of improvement. A 91% non-compliance rate flatly contradicts the assertion that the system is functioning constitutionally. Marcia Lowry highlighted this discrepancy, noting that despite the state's claims of "planning this and planning that," the basic facts—such as children being maltreated and workers having high caseloads—remain in dispute.14 The audit confirms that the state's internal metrics may have been masking a total procedural collapse.
5.3 The Institutionalization Crisis
A core component of the lawsuit involves the unnecessary institutionalization of children. The state had agreed to reduce the number of children in residential treatment facilities. However, data shows that despite setting a goal of no more than 712 children in such facilities by the end of 2024, the number had actually risen to 819 by December 2024.15
Furthermore, the state successfully amended the settlement agreement to remove the requirement for an independent subject matter expert to assess progress.15 This removal of independent oversight, combined with the OIG's finding of internal compliance failure, suggests a system that is becoming less transparent and more insular, even as it claims to be modernizing.
6. Political and Legislative Response
The audit has become a focal point for the West Virginia Legislature, which has struggled to exert oversight over the sprawling Department of Human Services.
6.1 The "Backyard Brawl" Economics vs. Social Safety Net
Governor Patrick Morrisey, sworn in during January 2025, has focused his administration on economic competitiveness, using the metaphor of the "Backyard Brawl" to describe competition with neighboring states.16 His priorities have included cutting red tape, auditing state agencies for efficiency, and promoting school choice.16
In August 2025, Morrisey announced a contract with BDO USA, P.C. to conduct a performance audit of the DoHS, Homeland Security, and Transportation departments.18
The Governor framed this as an effort to "root out all inefficiencies." The HHS-OIG audit likely reinforces Morrisey’s mandate for the BDO audit, providing federal justification for aggressive restructuring. However, the HHS audit points to under-resourcing (staffing shortages) as a cause, whereas Morrisey’s rhetoric often targets inefficiency and spending. This tension—between the need for more resources to achieve compliance and the political desire to cut government spending—will define the legislative battles of 2026.
6.2 Legislative Interims and SB 919
During the November 2025 Interim meetings at Pipestem Resort State Park, legislators grappled with the audit's findings.20 Senator Amy Grady, Chair of the Senate Education Committee, expressed continued frustration with the lack of progress on issues overlapping education and child welfare, such as student discipline.22
One legislative response to the verification crisis (the 41% interview failure) is Senate Bill 919, introduced in 2025. This bill mandates audio recording during Child Protective Services investigations and interactions.23 The logic is that if caseworkers are required to create an audio record, the "missing interview" problem identified by the OIG would be solved—or at least, the absence of a recording would be irrefutable proof of non-compliance.
6.3 The Legislative Dilemma
The legislature finds itself in a bind. They have authorized 810 positions for CPS.6 The executive branch claims vacancies are down to 69 positions. Yet, the federal government says the system is failing 91% of the time. The disconnect implies that the problem is no longer just about "funding positions" but about management, culture, and training—areas where legislative levers are less effective than executive action.
7. Recommendations and Future Outlook
The HHS-OIG made four specific recommendations to the West Virginia DoHS, all of which the state concurred with 2:
Enforce Procedures: Take steps to ensure workers perform all required intake and assessment procedures.
Supervisor Training: Train supervisors on the requirement to notify mandated reporters.
System Controls: Develop a new system edit in PATH to prevent incorrect safety assessment decisions.
Monitoring Policies: Develop written policies for supervisors to monitor interview progress and aging reports weekly.
7.1 The Path Forward: Remediation or Recidivism?
The state's response relies heavily on the "Backlog Strike Team" to clear the historical debt of casework and the new mentorship program to retain the influx of new hires.6 The DoHS has also revised policies to include "supervisor logs" to track face-to-face contacts.6
However, the structural risks remain acute. The reliance on a "system edit" to fix safety assessments 6 points to a technological dependency that is currently unfulfilled due to "competing elements within the system".6 If the software allows workers to bypass safety checks, and high caseloads encourage speed over precision, the 91% failure rate will likely persist despite the new hires.
7.2 Conclusion
The 2025 HHS-OIG audit is a foundational document in the history of West Virginia’s child welfare system. It provides empirical validation for the claims of families, activists, and legal challengers that the system collapsed during the post-pandemic years. The death of Kyneddi Miller serves as the human face of this statistical failure—a tragedy born of a missed referral, a loophole in education law, and an overburdened workforce.
While the Morrisey administration has achieved a statistical victory in reducing vacancies to 8.5%, the "compliance gap" remains the true measure of safety. Until the 91% error rate is reversed, the state’s child protective services will remain a system that exists on paper but fails in practice, leaving the state's most vulnerable children dependent on a safety net that catches only one in ten.
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