Responses to the Audit
Use the links below to skip to the specific response you wish to view:
- California Department of Social Services
- California State Auditor's Comment on the Response From the California Department of Social Services
- Department of Health Care Services
- Medical Board of California
- Los Angeles County
- Riverside County
- Sonoma County
California Department of Social Services
June 6, 2016
Ms. Elaine M. Howle, State Auditor
California State Auditor
555 Capitol Mall, Suite 300
Sacramento, CA 95814
Dear Ms. Howle:
SUBJECT: CALIFORNIA'S FOSTER CARE SYSTEM: THE STATE AND (REDACTED) HAVE FAILED TO ADEQUATELY OVERSEE THE PRESCRIPTION OF PSYCHOTROPIC MEDICATIONS TO CHILDREN IN FOSTER CARE 2015‑131
This letter provides the California Department of Social Services' (CDSS) initial response to the California State Auditor's Office draft of the above entitled report.
If you have any questions concerning the enclosed CDSS response, please contact me at (916) 857-2598 or Cynthia Fair, Audits Bureau Chief, at (916) 651-9923.
Sincerely,
WILL LIGHTBOURNE
Director
Enclosure
California Department of Social Services (CDSS)
RESPONSES TO AUDIT RECOMMENDATIONS
California State Auditor (CSA)
Audit #: 2015‑131
Audit Title: The State and (redacted) Have Failed to Adequately Oversee the Prescription of Psychotropic Medications to Children in Foster Care
Recommendations for Social Services
Recommendation 1:
To better ensure that counties only use parental consent in place of court authorization when it is appropriate, Social Services should assess _(redacted)_ County's practice of advocating to the juvenile court that it delegate to parents the authority to administer psychotropic medications to foster children.
CDSS Initial Response:
CDSS will commit to the following activities to assess the issue of reliance on parental consent regarding psychotropic medication usage:
- Meet with the county's Child Welfare Director and other relevant county staff to discuss their current practice of advocating to the Juvenile Court that parents be given the authority to retain their rights to make final decisions about their child's usage of psychotropic medication;
- Determine mutually agreed upon protocols for determining appropriateness of recommending parental consent versus court authorization for psychotropic medication prescriptions;
- Provide support and technical assistance to the county as they implement new protocols;
- Explore with county partners the option to extend psychiatric review (if available) of psychotropic medication prescriptions for youth whose parent(s) retain rights to consent to its usage; and
- If it is determined to be necessary, assist in the development of procedures to ensure parent(s) are provided with feedback from the psychiatrist conducting the review so that they may make informed decisions about their child's use of these medications.
Recommendation 2:
To better ensure that all caregivers are informed and educated regarding the use of psychotropic medications and the court authorization process, Social Services should develop instructions regarding these topics and provide them to caregivers that do not operate group homes, such as foster family agencies.
CDSS Initial Response:
Anticipated Implementation Date: Summer 2016. The Department developed a Medication Guide for Group Home providers to be aware of best practices as well as statutory and regulatory requirements through applicable scenarios and additional recommendations regarding the use of psychotropic medications and the court authorization process. This Medication Guide was published on December 31, 2015. A similar guide, specific to the Foster Family Agencies, is currently under review and an additional guide, for Foster Family Homes, will soon be under development.
The Department strives to promote improvement and efficiency throughout the licensing system, and while the guides cannot be used as a substitute for understanding and complying with the laws governing a licensee's license to operate, they do offer assistance in clarifying good practice for additional safeguards for medications within the providers' facilities and homes.
Recommendation 3:
To improve the State and counties' oversight of psychotropic medications prescribed to foster children, including the accuracy and completeness of its data system and foster children's health and education passports, Social Services should collaborate with counties and other relevant shareholders — such as Health Care Services, as applicable — to develop and implement a reasonable oversight structure. This structure should include at least the following items:
- Identification of the specific oversight responsibilities to be performed by the various state and local government agencies.
- An agreement on how county staff — including social workers, probation officers, and public health nurses — will use printed health and education passports to obtain foster children's necessary mental health information — including psychotropic medications and mental health services — for inclusion in Social Services' data system.
- A plan to ensure that counties have sufficient number of staff available to enter foster children's mental health information into Social Services' data system, and the resources to pay for those staff.
- An agreement on the specific information related to psyhchotropic medication — including but not limited to medication name, maximum daily dosage, and court authorization date — and mental health services information that county staff must enter into Social Services' data system for inclusion in foster children's health and education passports.
- Specific directions from Social Services regarding the correct medication start dates and court authorization dates to include in its data system and foster children's health and education passports.
- An agreement on the training or guidance Social Services should provide to ensure that county staff members working with Social Services' data system know how to completely and accurately update foster children's health and education passports.
- An agreement that the counties will implement the new forms that the Judicial Council approved regarding the authorization of psychotropic medications for foster children.
- An agreement regarding how counties will implement, use, or disseminate the educational and informational materials the Quality Improvement Project produced including the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care, Questions to Ask About Medications, and the Foster Youth Mental Health Bill of Rights.
- An agreement on the specific measures the State and counties will use to assess outcomes related to psychotropic medications prescribed to foster children.
- An agreement on how the State and counties will oversee psychotropic medications prescribed to foster children by those fee‑for‑service providers not affiliated with county Medi‑Cal mental health plans.
- An agreement on the extent of information related to psychotropic medications prescribed to foster children that counties will include in their self assessments, system improvement plans, and annual progress reports developed as part of Social Services' California Child and Family Services Reviews.
- An agreement on the extent of the information related to psychotropic medications prescribed to foster children that counties will include in their responses to Health Care Services' reviews, including county Medi‑Cal mental health plan compliance reviews and external quality reviews.
CDSS Initial Response:
CDSS agrees that improvements can be made to the quality and accuracy of mental health information documented in the Child Welfare Services/Case Management System (CWS/CMS). CDSS also recognizes that counties may provide this information to caregivers, health providers, and mental health clinicians via other documents in addition to the Health Education Passport (HEP).
CDSS will employ the following strategies to develop and implement a statewide oversight structure to ensure improved data entry into the CWS/CMS system and more efficient oversight and monitoring of psychotropic medication use by foster youth at both the state and local level:
- Utilize existing and ongoing meetings with the California Child Welfare Director's Association (CWDA) to collaborate with the Department of Health Care Services (DHCS), county child welfare and probation agencies, and relevant stakeholders to:
- Identify roles and responsibilities at the state and local level;
- develop collective guidance and best practices between CDSS and counties to address:
- data entry challenges
- appropriate use of the HEP for conveying information regarding the child's health, mental health and education information,
- appropriate documents to be provided in addition to the HEP,
- optimal training for social workers, probation officers and public health nurses regarding data entry for health and education notebooks in CWS/CMS
- implementation of new Judicial Council court authorization forms,
- dissemination and use of Quality Improvement Plan (QIP) educational materials, California Guidelines for the Use of Psychotropic Medications With Children and Youth in Foster Care, and the Foster Youth Mental Health Bill of Rights/ Questions to Ask About Medications (PUB 488) brochure,
- oversight of prescriptions to foster children served by providers outside of the county Medi‑Cal mental health plans,
- how information will be included by counties in their responses to Health Care Services reviews including Medi‑Cal mental health compliance reviews and external quality reviews,
- Meet with counties to explore additional funding options, repurposing of current funding streams, and/or increasing efficiency among current staff resources to ensure children's mental health information is entered into CWS/CMS;
- Issue guidance and instructions to counties via an All County Information Notice regarding entry of medication data into CWS/CMS specifically outlining the importance of medication name, medication start date, court authorization date, and mental health information;
- Explore with DHCS the development of a report, for signatory counties to the Global Data Sharing Agreement, to identify children receiving a paid claim for a medication in a dosage that exceeds the recommended maximum daily dosage recommended in the state guidelines;
- Revise methodology for reconciliation reports which are currently being provided to counties to add medication start date as a way to ensure non‑emergency prescriptions are not being filled prior to court authorizations;
- Add a medication/mental health information data entry focus to training being developed to meet the mandates of Senate Bill 238 (Chapter 534, Statutes 2015) which requires CDSS in consultation with stakeholders to develop and make available training for social workers, probation officers, court staff, children's attorneys, children's caregivers, and Court Appointed Special Advocates;
- Training will address authorization, uses, risks, benefits, assistance with self‑administration, oversight, and monitoring of psychotropic medications, trauma and substance use disorder treatments, and how to access those treatments.
- Encourage counties to include psychotropic medication oversight in their self‑assessments and system improvement plans; and
- Require counties to include psychotropic medication oversight in their California Child and Family Services Review (C‑CFSR) annual progress reports.
SB 238 outlined a set of measures the state and counties will use to assess outcomes related to psychotropic medications. In addition to the Youth Authorized for Psychotropic Medication (Measure 5f) cited in the report, CDSS provided the Auditor with the seven child welfare psychotropic medication measures that were developed through the Quality Improvement Project.
This audit report cited that one of the limitations of Measure 5f was that the measure does not identify the number of children actually prescribed medications. However, the report failed to acknowledge that CDSS has been regularly publishing two of the seven measures noted above since October 2015, Use of Psychotropic and Antipsychotic Medications (Measure 5a.1 and Measure 5a.2) on the California Child Welfare Indicators Project website Using matched DHCS and CDSS data, these measures identify youth in foster care who received a Medi‑Cal paid.
The remaining five measures are: Use of Concurrent Psychotropic Medications (Measure 5c). Ongoing Metabolic Monitoring for Youth in Foster Care on Antipsychotic Medication (Measure 5d),Use of First-Line Psychosocial Care for Youth in Foster Care on Psychotropic Medication (Measure 5e), Follow-Up Visit for Youth in Foster Care on Psychotropic Medication (Measure 5g), and Metabolic Screening for Youth in Foster Care Newly on Antipsychotic Medication (Measure 5h).
As of May 25, 2016, CDSS staff was granted access to a shared data environment to identify the full population of children in foster care within DHCS' data system. This shared data environment will facilitate the development and publication of the remaining measures.
Recommendation 4:
To ensure that the Medical Board can complete promptly its analysis to identify physicians who may have inappropriately prescribed psychotropic medications to foster youth, Social Services and Health Care Services should continue to work with the Medical Board and its consultant to meet its data needs. To the extent that the Medical Board's analysis is able to identify these physicians, Social Services and Health Care Services should enter into a future agreement with the Medical Board to continue providing information for the Medical Board's data needs.
CDSS Initial Response:
In April 2015, CDSS, DHCS, and the Medical Board of California (MBC) entered into a data use agreement in order for the MBC to acquire the necessary data to exercise its statutory authority as an oversight entity. As of May 4, 2016, CDSS has transmitted the additional data requested by the MBC to DHCS to be included in the dataset provided by DHCS to MVC.
To the extent that the MBC is successful in its analysis, CDSS agrees to extend, and amend as necessary, the existing data use agreement in order to ensure data is provided promptly and on a regular basis.
Comment
CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
To provide clarity and perspective, we are commenting on the response from the California Department of Social Services (Social Services) to the audit. The number below corresponds to the number we have placed in the margin of its response.
Our audit report did not “fail to acknowledge” measures 5a.1 (use of psychotropic medications by foster children) and 5a.2 (use of antipsychotic medications by foster children) as Social Services asserts; we intentionally omitted them. In Chapter 2 of our report, we indicate that only one measure—5F—published on the website for the California Child Welfare Indicators Project addresses the number of foster children authorized to receive psychotropic medications. Despite Social Services' statement that measures 5a.1 and 5a.2 have been published since October 2015, Social Services waited until April 2016 to inform counties of their availability through an all‑county letter. In an all‑county letter to county child welfare directors and other county officials dated April 28, 2016, Social Services mentioned that county child welfare and probation agencies could view the results of these two measures at the California Child Welfare Indicators Project website. Because the contents of the all‑county letter had no direct bearing on our report’s findings, conclusions, or recommendations, we opted to not mention the two new measures.
Department of Health Care Services
Ms. Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle:
The California Department of Health Care Services (DHCS) hereby provides response to the draft findings of the California State Auditor's (CSA) report entitled, California's Foster Care System: The State and [redacted] Have Failed to Adequately Oversee the Prescription of Psychotropic Medications to Children in Foster Care. The CSA conducted this audit and issued two (2) findings and two (2) recommendations.
DHCS agrees with the recommendations and has prepared corrective action plans to implement them. DHCS appreciates the work performed by CSA and the opportunity to respond to the findings. If you have any questions, please contact Ms. Sarah Hollister, Audit Coordinator, at (916) 650‑0298
Sincerely,
Jennifer Kent
Director
Enclosure
cc: Ms. Karen Johnson
Chief Deputy Director
Policy and Program Support
1501 Capitol Avenue, MS 0000
P.O. Box 997413
Sacramento, CA 95899-7413
cc: Ms. Mari Cantwell
Chief Deputy Director
Health Care Programs
1501 Capitol Avenue, MS 0000
P.O. Box 997413
Sacramento, CA 95899-7413
cc: Rene Mollow
Deputy Director
Health Care Benefits and Eligibility
1501 Capitol Avenue, MS 0000
P.O. Box 997413
Sacramento, CA 95899-7413
cc: Dr. Linette Scott, MD, MPH
Deputy Director, Chief Medical Information Officer
Information Management Division
1501 Capitol Avenue, MS 0000
P.O. Box 997413
Sacramento, CA 95899-7413
Department of Health Care Services Response to: The California State Auditor’s Report entitled, California’s Foster Care System: The State and [redacted] Failed to Adequately Oversee the Prescription of Psychotropic Medications to Children in Foster Care
Finding #1: Fragmented oversight and poor data hamper state and county efforts to ensure appropriate prescribing of psychotropic medications.
Recommendation 1: To ensure the Medical Board can complete promptly, its analysis to identify physicians who may have inappropriately prescribed psychotropic medications to foster youth, CDSS and DHCS should continue to work with the Medical Board and its consultants to meet its data needs.
Response: DHCS agrees with the recommendation.
DHCS and CDSS are providing additional data to the Medical Board by mid-June, 2016 as requested by the Medical Board under an existing Data Use Agreement. DHCS will provide data, to the extent that it is data that DHCS has, to the Medical Board beyond the initial evaluation if the Medical Board requests it.
Finding #2: DHCS does not ensure pharmacists obtain its approval before they dispense psychotropic medications to foster children for off-label uses.
Recommendation 2: To increase the State’s assurance that foster children do not receive medically inappropriate or unnecessary psychotropic medications, DHCS should devise and implement within six months, methods to better enforce its prior authorization requirements for off label use of psychotropic medications.
Response: DHCS agrees with the recommendation.
DHCS will research the FDA approved age limitations on all psychotropic medications and implement edits within the claims system that will alert the dispensing pharmacy that the age of the patient requires that an approved Treatment Authorization Request (TAR) be obtained prior to billing for the requested medication. The necessary research into the FDA approved age limitations for all dosage forms and strengths of all psychotropic medications will take approximately 3 months before the edits can then be appropriately implemented in the claims processing system approximately 3 months later.
As part of the notification process for all changes in benefit, pharmacy and medical providers will also be reminded in the provider bulletin publications that all off-label use of drugs requires a TAR and that, in particular, psychotropic medications used in the juvenile population should be verified to be FDA approved and age appropriate prior to dispensing the medication. Pharmacy Benefits staff will work with Audits and Investigation staff to explore possible onsite inspection protocols specific to off-label utilization of medications. DHCS estimates implementation of these corrective actions within the six-months.
Medical Board of California
June 6, 2016
Elaine M. Howle
California State Auditor
Bureau of State Audits
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Re: Draft Audit Report 2015-131 — California's Oversight of Psychotropic Medications Prescribed to Children in Foster Care
Dear Ms. Howle:
The Medical Board of California (Board) is in receipt of your draft audit report regarding California’s oversight of psychotropic medications prescribed to children in foster care. The Board received the portions of the draft audit related to the Medical Board. I would like to thank the Bureau of State Audits for conducting this audit and for allowing the Board to respond to the issues presented in the audit report. The Board agrees that a proactive approach to this issue is essential in order to ensure appropriate prescribing to foster children. The Board has been working on this issue and, as stated in the report, is currently under a data usage agreement (DUA) with the Department of Health Care Services (DHCS) and the Department of Social Services (DSS) to obtain specified prescribing information for foster children. The Board is currently waiting for additional information that is necessary for the Board’s consultant to perform the desired data analysis assessment. This additional information was originally requested from DHCS and DSS by the Board in February 2016.
In addition, the Board has been working closely with Senator McGuire on his bill, SB 1174. This bill would add to the Board’s priorities, repeated acts of clearly excessive prescribing, furnishing, or administering psychotropic medications to children without a good faith prior exam and medical reason. This bill would require the Board to confidentially collect and analyze data submitted by DHCS and DSS, related to physicians prescribing psychotropic medications to children. The data that will be required to be submitted to the Board pursuant to this bill will ensure that the Board can review prescribing data on an on-going basis to help identify physicians who may be inappropriately prescribing. The data the Board has received under the existing DUA is only a snapshot in time, for a six-month time period in 2014. Any information that can help the Board identify inappropriate prescribing can be utilized as a tool for the Board to use in its complaint and investigation process. Once a possible inappropriate prescriber is identified, the Board will still have to go through its normal complaint and investigation process. The Board believes this bill responds to the draft audit recommendations to the Legislature.
The Board would like to respond to the recommended steps the draft report suggests that the Board should take:
Recommendation: Within 60 days, obtain and analyze the data from DHCS and DSS to identify physicians who may have inappropriately prescribed psychotropic medications for foster children.
Response: The Board does plan on having the Board’s consultant analyze the additional data that has been requested from DHCS and DSS as soon as it is received. The Board will commit to requiring the Board’s consultant to perform an analysis of the data within 60 days of receipt.
Recommendation: Following the completion of its analysis, take the appropriate follow-up actions, including the investigation of physicians identified in its data analysis, that it deems necessary.
Response: Once the Board’s consultant identifies physicians that need further review, the Board will begin its complaint and investigation process. The first step will involve asking assistance from DSS, as the data provided to the Board does not include names of foster children. Per the DUA, DSS will provide technical assistance, which includes, but is not limited to, facilitating contact with county child welfare agencies, the juvenile courts, county counsel, children’s attorneys and other relevant entities to assist the Board in securing a court order authorizing it to obtain child-specific information, including relevant medical records. Once the child-specific medical records are obtained, the Board will follow its normal complaint and investigation process, which is confidential.
Recommendation: To the extent that its analysis is able to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, the Medical Board should enter into an agreement with DHCS and DSS within six months of completing its initial review to periodically obtain the data necessary to perform the same or similar analysis.
Response: If SB 1174 passes and is signed into law, similar prescribing data will be provided to the Board on an on-going basis. If SB 1174 is not signed into law, the Board will work with DHCS and DSS to revise the existing DUA to ensure that the Board receives the most current data and that the Board receives this data on an on-going basis. However, this revised DUA will have to be agreed upon by all parties involved.
The Board greatly appreciates the opportunity to respond to the draft report and its recommendations. The Board takes the recommendations in the draft report very seriously and believes that the issues raised are very important, as consumer protection is the Board’s primary mission. If you have any questions regarding this response, please contact me at (916) 263-2389.
Sincerely,
Kimberly Kirchmeyer
Executive Director
cc: Alexis Podesta, Acting Secretary, Business, Consumer Services and Housing Agency
Awet Kidane, Director, Department of Consumer Affairs
Los Angeles County
June 8, 2016
Ms. Elaine Howle, CPA
State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle:
DRAFT REPORT – AUDIT OF CALIFORNIA’S OVERSIGHT OF PSYCHOTROPIC MEDICATIONS
Thank you for allowing Los Angeles County the opportunity to review your redacted draft report on the audit of California’s oversight of psychotropic medications prescribed to children in foster care as requested by the Joint Legislative Audit Committee. Given the nature of redacted drafts, we were unable to review the report in its entirety; hence, our comments are confined to the content that was generally specific to Los Angeles.
Los Angeles County agrees with the four recommendations made in the report:
- Counties should implement procedures to more closely monitor requests for authorizations for psychotropic medications for foster children that exceed state guidelines for multiple prescriptions or excessive dosages.
Our Juvenile Court Mental Health Services agrees that they have not always, until this point, systematically monitored those proposed maximum dosage requests when reviewing requests for Psychotropic Medication Authorization prior to the court’s ruling. Based on observations shared by the auditors during their review of our cases, Juvenile Court Mental Health Services agreed to always consider and give significant weight to the maximum dosage information in their review of proposed Psychotropic Medication Authorization requests and has been doing so since it was brought to their attention approximately three months ago. - Ensure that prescribing physicians follow up within 30 days with all foster children to whom they prescribed new psychotropic medications.
Los Angeles County agrees that all youth prescribed psychotropic medications should have follow up appointments with the prescriber within 30 days and we strive to do so for all foster youth. Los Angeles County has limited authority regarding the scheduling practices of state licensed physicians and is unable to mandate prescribers to follow up with their patients within 30 days. Although we believe that the vast number of prescribers intend to follow up with foster youth within 30 days, we are aware that there are several barriers that can prevent this from occurring. Additionally, there are a limited number of credentialed prescribers who accept Medi‑Cal in Los Angeles County and demand for those services often exceeds capacity.
We will increase surveillance efforts by child welfare in an attempt to prioritize these youth within the healthcare system in hopes that the number of youth with no follow-up psychiatry services will be reduced. - Implement a process to ensure that foster children receive any needed mental health, psychosocial, behavioral health or substance abuse services before and concurrently with receiving psychotropic medications.
We recommend that the language of this recommendation be changed to: “Implement a process to ensure that foster children receive clinically indicated mental health, psychosocial, behavioral health, or substance abuse services associated with receiving psychotropic medications.”
We believe that this language would avoid creating a situation whereby foster children’s access to appropriate care would be compromised. For example, your report indicated on page 43 that “randomized controlled trials suggest that medication management for Attention Deficit Hyperactivity Disorder (ADHD) is the first-line treatment, while medication combined with behavioral treatment may be necessary for optimal outcomes in children with more complex problems”. This statement recognizes the value of individualized treatment planning based on empirical data, while continuing to support the value of psychosocial interventions in addition to medication for the majority of foster youth.
As to the specific findings of this report, we would like to remind the State that there was no available data regarding psychosocial interventions that were not billed to Medi‑Cal prior to and that occurred in association with psychotropic medication use. This absence of data would lead the reader to assume that fewer youth received psychosocial interventions than actually did when in fact, many youth access psychosocial interventions through their schools, private insurance, contracted group homes, foster family agencies and Wraparound agencies that may not have billed their services to Medi‑Cal. - Implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as required.
We believe that several strategies need to be implemented to address this recommendation.
In order to improve the rates in which Los Angeles County’s foster youth receive renewed consent by the court for psychotropic medication within 180 days, we created an electronic alert system that began on April 1, 2016. This system notifies the youth’s social worker and public health nurse on the first day of the month in which the current psychotropic medication authorization is due to expire. If information regarding an updated psychotropic medication authorization is not entered into the Child Welfare Services/Case Management System (CWS/CMS), the social worker and public health nurse will receive a second reminder. DCFS continues to provide training to all caregivers which explains and clarifies the need for court authorization for psychotropic medications prior to administering the medications. The Los Angeles County contracts with foster family agencies and group homes specify that the contracted agencies must maintain current psychotropic medication authorization for all youth on psychotropics in their care. Failure to comply with this contractual obligation results in corrective action plans with the violating contractor. However, strictly local efforts are limited in their ability to comprehensively address these issues.
This is an area in which State intervention would be helpful. Los Angeles County feels that the issue of youth receiving psychotropic medications prior to authorization by the court could most effectively be addressed at the pharmacy level. Youth are receiving medications prior to consent for treatment because prescribers are writing prescriptions prior to obtaining the court’s consent despite clear directives not to do so. Caregivers then fill the prescriptions prior to the court’s approval despite clear directives not to do so. Los Angeles County recommends that the State create an electronic Psychotropic Medication Authorization system and link it to the Medi‑Cal authorization process so that pharmacies are not approved to fill prescriptions for psychotropics that have not been approved by the court. We believe that this is the best way to ensure that no youth is administered psychotropic medication without parental or court consent.
Los Angeles County also suggests that the State, as part of its redesign of the CWS/CMS electronic data system, allow for greater interoperability with other data systems that store health information for the youth we serve. Given the prevalence of electronic record keeping in the medical disciplines, we feel that the opportunity to collect more accurate and timely health information from providers who treat foster youth would effectively address this report’s concerns regarding the lack of information in foster youth’s Health and Education Passport. Although we welcome the suggestion that Los Angeles County needs more Public Health Nurses to collect and manage this information, we also value their ability to manage the foster youth’s medical needs. It would be significantly more efficient if child welfare agencies receive updated health care information on a flow basis regarding the youth we serve so that our Public Health Nurses can focus their unique skills to help our Children’s Social Worker staff to interpret the information and follow up on medical needs appropriately.
Thank you for the opportunity to respond to your thoughtful report. If you have any questions, please call me or your staff may contact Lisa Sorensen, Division Chief at (213) 351-5724.
Sincerely,
PHILIP L. BROWNING
Director
PLB:HB:ls
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Comments
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM LOS ANGELES COUNTY
To provide clarity and perspective, we are commenting on Los Angeles County's response to the audit. The numbers below correspond to the numbers we have placed in the margin of its response.
Although we appreciate Los Angeles County’s suggested wording change, we believe that it does not differ substantially from the current wording of our recommendation.
The page numbers on Los Angeles County’s redacted draft copy of the audit report do not correspond to the page numbers of the final audit report. The content Los Angeles County refers to appears here in our final report.
Los Angeles County appears to restate one of the key points from Chapter 2 of our report; namely, certain psychosocial services provided to foster children are not included in the State’s information, including the Health and Education Passports. As we mention in Chapter 2, all 80 of the Health and Education Passports we reviewed were missing information about the corresponding psychosocial services foster children should have received for at least one psychotropic medication. Furthermore, Figure 4 summarizes the process for providing updated information, including psychosocial services, for the Child Welfare Services/Case Management System operated by the California Department of Social Services (Social Services) and the resulting Health and Education Passports. A key source of that updated information is the health care provider, regardless of where that provider works. In fact, state law states that caregivers are responsible for obtaining and maintaining accurate and thorough information from physicians to be included as part of Health and Education Passports. Therefore, Los Angeles County’s statement underscores the need for counties to ensure that caregivers and county staff are properly updating Health and Education Passports with mental health information to give counties a more accurate and up‑to‑date picture of foster children’s mental health treatments.
We appreciate Los Angeles County’s acknowledgement of the concern regarding unauthorized psychotropic medications for foster children and its idea for a longer‑term solution, a concern that can be included as part of the discussions during the collaboration between Social Services and the counties as we recommend in Chapter 2. However, because it is not yet clear whether or when such a solution may be implemented, counties need to take steps in the near term to better ensure that foster children receive appropriate court authorizations or parental consents for their psychotropic medications, as we recommend in Chapter 1.
We appreciate Los Angeles County’s acknowledgement of the concern regarding weaknesses in Social Services’ data system and its idea for a longer‑term solution. We anticipate that Los Angeles County can include this longer‑term solution as part of the discussions during the collaboration between Social Services and the counties as we recommend in Chapter 2.
Los Angeles County appears to not fully understand our point regarding public health nurses. We agree fully that public health nurses should focus their unique skills on more pressing duties and not on entering data into Social Services’ data system. That is why we point out in Chapter 2 that the federal government will cover 75 percent of the costs for necessary support staff for skilled professional medical personnel like public health nurses. These support staff could enter information into the Health and Education Passports, freeing public health nurses to oversee the support staff’s work and to perform other, more pressing responsibilities.
Riverside County
June 2, 2016
Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle,
Thank you for your thorough and insightful examination into the oversight of psychotropic medicine prescribed to children in foster care. Riverside County welcomes the opportunity to improve on our services to this very vulnerable and important population. We appreciate the time and attention you have given to our county in pursuit of quality improvement. Below is our response to your report for your consideration.
Counties
Recommendation: Implement procedures to more closely monitor requests for authorizations for psychotropic medications for foster children that exceed the state guidelines for multiple prescriptions or excessive dosages. When requests for authorizations exceed the state guidelines, counties should follow-up with providers about the medical necessity of the prescriptions and should document their follow-up in the foster children’s case files. In instances in which counties do not believe that a provider has adequate justification for exceeding the state guidelines, counties should relay their concerns and related recommendations to the court or parent.
Riverside County Response: Agree with recommendation. To ensure that the recommendation is met, Riverside County staff will immediately review existing policies and protocols related to requests for authorization that exceed the state guidelines as well as communication of concerns surrounding the prescriptions and dosages to the court and the parent. Protocols will be updated to address these issues.
Recommendation: Ensure that prescribing physicians follow up within 30 days with all foster children to whom they prescribed new psychotropic medications.
Riverside County Response: Agree with recommendation. Riverside County supports the guidelines that prescribing physicians follow up within 30-day for all newly prescribed medications, and it is done whenever possible and as appropriate. The lack of available psychiatrists in the workforce is the largest barrier. Riverside County is already aggressively pursuing child psychiatrists to fill vacancies. The County is looking at a variety of recruitment strategies and service delivery models to more consistently meet the 30 day standard.
Recommendation: Implement a process to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.
Riverside County Response: Agree with recommendation. Riverside County believes in attempting to provide non-medical interventions prior to, during and/or after medications are begun. The County further recommends that the Audit team consider including Rehabilitation and Case Management services as services that also meets this recommendation. Additionally, it is important to note that there are many behavioral health services provided to foster youth that are invisible to the County and to the State. Examples are those provided through private insurance or services at a Group Home.
Recommendation: Implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed with 180 days as required. The process should also ensure that the counties better document these authorizations in the foster children’s case files.
Riverside County Response: Agree with Recommendation. Riverside County has recently adopted a new process for this purpose. The County will re-examine the process to ensure it supports the recommended guidelines.
Develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are approved before administering medications. This process should also ensure that the counties obtain accurate medication start dates from the caregivers.
Riverside County Response: Agree with Recommendation. Many of the elements of this recommendation are in place in Riverside County, much of it performed by the Public Health nurses in the program. Social Services and Behavioral Health also meet twice monthly to discuss operations. Communication with providers and caregivers is a topic they address.
Riverside County:
Recommendation: Immediately adopt the state guidelines for its physicians use when prescribing psychotropic medications and county’s review of court authorization requests.
Riverside County response: Agree with Recommendation. Our County is committed to adopting the state guidelines for the use of psychotropic medications in foster youth. As we respect the need for immediacy, our county will immediately distribute the guidelines to all prescribers and instruct them to use them in their practice.
Further training for psychiatrists regarding the guidelines, development of concrete protocols, and full implementation of these processes will follow. Moreover, the Riverside University Health System – Behavioral Health will be adopting an internal data driven program improvement plan to monitor the prescriptions of psychotropic medication to foster youth.
Recommendation: Continue to use its new tracking process to better ensure that court authorizations are renewed within 180 days.
Riverside County response: Agree with Recommendation. Riverside County will continue to use the new tracking system to better ensure that court authorizations are renewed within 180 days.
Also, for consideration, Riverside County would like to highlight a few of the important improvements made for treatment services to foster youth in the past year:
- Increase in mental health services to foster youth by 34.8% from fiscal year 13/14 to fiscal year 14/15, including Trauma Focused Cognitive Behavioral Therapy.
- Services provided to foster youth which fall outside of the auditor’s definition of mental health services including: Intensive Care Coordination, In Home Based Services, assessments, unbilled services provided by group home providers or foster family agencies, Wraparound services, and broad based services to families.
- Implementation of an extensive joint Child Welfare and Behavioral Health data tracking system.
- Analysis of barriers to recruitment and retention of child psychiatrists including the competition with the private sector. Resultant activities include an innovative partnership with the University of California at Riverside medical school and planned implementation of telemedicine practices.
The above enhancements to our system of care will serve to further our success as we fully implement the state guidelines for the prescription of psychotropic medication to foster youth.
Thank you again for the opportunity to respond to the audit.
Sincerely,
Steve Steinberg
Director, RUHS-Behavioral Health
Susan von Zabern
Director, DPSS
Comments
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM RIVERSIDE COUNTY
To provide clarity and perspective, we are commenting on Riverside County’s response to the audit. The numbers below correspond to the numbers we have placed in the margin of its response.
Riverside County recommends in its response that we include rehabilitation and case management services as services that also meet our recommendation regarding the provision of psychosocial services before or concurrent with foster children receiving psychotropic medications. We, in fact, included psychosocial rehabilitation in our analysis. As we mention in Chapter 1, we based this analysis on the definition of psychosocial services contained in the Healthcare Effectiveness Data and Information Set (HEDIS), a set of health care performance measures used by more than 90 percent of the health plans in the United States. Although the HEDIS definition includes psychosocial rehabilitation, it does not include case management. We therefore stand by our methodology and the results we present in our report.
Riverside County appears to restate one of the key points from Chapter 2 of our report; namely, some quantities of psychosocial services provided to foster children are invisible to the county and the State. As we mention in Chapter 2, all 80 Health and Education Passports we reviewed were missing information about the corresponding psychosocial services foster children should have received for at least one psychotropic medication. Furthermore, Figure 4 summarizes the process for providing updated information, including psychosocial services, for the Child Welfare Services/Case Management System operated by the California Department of Social Services and the resulting Health and Education Passports. A key source of that updated information is the health care provider, regardless of where that provider works. In fact, state law states that caregivers are responsible for obtaining and maintaining accurate and thorough information from physicians to be included as part of Health and Education Passports. Therefore, Riverside County’s statement underscores the need for counties to ensure that caregivers and county staff are properly updating Health and Education Passports with mental health information to give counties a more accurate and up‑to‑date picture of foster children’s mental health treatments.
Riverside County states that certain types of services fell outside our definition of psychosocial services. As we mentioned earlier under Comment #1, we analyzed those types of psychosocial services included within the HEDIS definition. We included within our analysis any HEDIS psychosocial service regardless of the source—whether provided by group homes, foster family agencies, or other provider types—when we saw evidence of those services in the county’s or the State’s records. Furthermore, we did not include services such as intensive care coordination and assessments within our analysis because they are not mentioned in the HEDIS definition of psychosocial services. We therefore stand by our methodology and the results we present in the report.
Sonoma County
June 6, 2016
To the State Auditor:
On behalf of the County of Sonoma Human Services Department, Health Services Department and the Probation Department, attached is the response to the recent draft of the State Auditor report on California’s Foster Care System received on May 31, 2016.
We’re happy to answer any questions or comments you might have. Please contact us at any time.
The County of Sonoma’s Response to
the California State Auditor Report on California’s Foster Care System
The County of Sonoma appreciates the opportunity to respond to the draft of the State Auditor report on California’s Foster Care System received on May 31, 2016.
The County was asked to respond to both the report’s statewide recommendations as well as those specific to Sonoma County. These responses can be found in the pages that follow this introduction.
INTRODUCTION
Sonoma County is dedicated to protecting and promoting the safety, health and well-being of children and teens in foster care. The County continues to develop and implement high-quality, responsive programs that support foster youth. This vulnerable population can enter the foster care system for many reasons, including physical or sexual abuse in the home, neglect, abandonment, or mental health needs that are beyond the ability of caregivers to properly manage. Youth in the Juvenile Probation system may also be placed in out-of-home care. Due to their experiences and the subsequent trauma those experiences generate, these youth often need significant mental health support and treatment. Providing effective services to these youth is a primary concern in Sonoma County and statewide.
In 2013, two years prior to the Auditors’ visit, Sonoma County identified that data showed higher numbers of local foster children authorized to take psychotropic medications than the statewide average. Addressing that issue became a high priority, as reflected the County’s 2014-19 System Improvement Plan (SIP). Since then, the County has made system-wide changes to ensure that foster youth receive clinically appropriate psychotropic medication. Among these changes, in July 2015, the Sonoma County Human Services Department used prioritized funding to contract with an independent psychiatrist who reviews the recommendations of the treating psychiatrist prior to the social worker seeking court authorization for administration of psychotropic medication. It has been the County’s intent to add this review to cases in which the court has delegated the authority to consent to psychotropic medication to the child’s parent.
As another example, ongoing training for social work staff regarding best practices for psychotropic medications, side effects and options treatment continues. Two areas of focus also include how to clearly and effectively communicate with prescribing physicians and with foster youth regarding their experience with those medications and their use and monitoring for potential side effects. Sonoma County is proud of the services it provides to foster youth, including necessary mental health treatment. Nonetheless, it welcomes outside reviews and input on ways to improve. The County intends to implement all the recommendations of the State Auditor, as discussed more fully below. At the same time, the County takes issue with some of the narrative in the audit report, and would like to address those before turning to the recommendations.
The audit report has underscored the need for a high-level of detail in documentation. Systematic and consistent documentation is important to monitor and evaluate data, as noted in the audit report, and Sonoma County has focused on improving this since 2014. Sonoma County acknowledges the deficiencies in documentation described in the audit report and is working to improve its documentation.
However, as the audit report notes, missing information does not mean that, in fact, foster children were taking psychotropic medications in excessive doses or multiple medications in the same category. Mental health treatment information is maintained by the treatment provider, and in order to understand the treatment received by an individual foster youth, one must review the actual mental health treatment record. We are concerned that many of the cases referred to in the report did not reference the actual treatment decisions of the providers and the data for the audit was based less on chart review and more on claims data.
In addition, these medications can only be prescribed to foster youth by medical professionals who have standards to which they must adhere. Furthermore, the judicial system provides oversight, including providing these foster youth with legal counsel, who meet frequently with the youth and advocate on behalf of their client’s best interests.
We are confident that if the auditors had an opportunity to look deeper into each child’s records, they would have found that Sonoma County foster youth receive clinically appropriate amounts and types of psychotropic medication.
The audit report also gives the incorrect impression that Sonoma County foster youth are not provided non-pharmacological interventions. This is untrue. Foster youth are provided mental health, substance and other alternative services to pharmacological interventions before and/or concurrent with the prescription of psychotropic medication as clinically indicated. This information is often documented in contract, authorization and payments systems of the Human Services Department. The audit report findings do not take these documentation realities into account. Information is also required to be kept by licensed residential treatment providers and individual private practice psychiatrists. An audit of these records would have supplemented the audit report with additional specific information.
In addition, the audit report gives the false impression that Sonoma County does not follow generally accepted professional standards when prescribing psychoactive medication to foster care youth. In fact Sonoma County prescribers (who treat serious and severe mental illnesses through the County Mental Health Plan to youth in and outside the foster care system), are bound by and adhere to the prescribing standards established by federal and state law governing county mental health plans. As the audit report points out, Sonoma County’s policies were in need of updating, and the County has made those updates. County policies now incorporate the most current version of the Los Angeles Department of Mental Health, Parameters 3.8, for Use of Psychotropic Medication in Children and Adolescents and the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care (including appendices A-D). If the recommended prescribing guidelines are not met, or if medications are prescribed outside the recommended parameters, the prescribers will be urged to seek peer consultation and/or clinical review with the Sonoma County Behavioral Health Medical Director.
Finally, the County has some questions and suggestions about the methodology of the report. First, it would have been helpful to have a clear breakdown between the departments involved with foster youth: Family, Youth and Children’s Services Division and Probation. Children in each of these areas have differing needs for mental health interventions and care. A further description of the methodology in general and case review selection process would help the County understand how these cases relate to the child welfare population taking psychotropic medications, as well as the general child welfare population as a whole. In addition, the data reporting would be enhanced by hypothesis and proportions testing.
We note also that some statewide and Sonoma County recommendations, such as those calling for better documentation, are similar, which reinforces our belief that many issues highlighted in the report affect counties across the state. We hope that the State will offer additional guidance and resources to all counties to enhance consistency and clarity of implementation of these recommendations.
Therefore, with some caveats, Sonoma County finds the audit report recommendations for 1) all counties statewide and 2) Sonoma County are reasonable and constructive measures that will advance our mission of promoting the well-being of foster children in our care.
RESPONSE TO THE STATEWIDE RECOMMENDATIONS:
Recommendation 1. Implement procedures to more closely monitor requests for authorizations for psychotropic medications for foster children that exceed the state guidelines for multiple prescriptions or excessive dosages. When request for authorizations exceed the state guidelines, counties should follow-up with providers about the medical necessity of the prescriptions and should document their follow-up in the foster children’s case files. In instances in which counties do not believe that a provider has adequate justification for exceeding the state guidelines, counties should relay their concerns and related recommendations to the court or parent.
RESPONSE: Sonoma County supports this recommendation.
Recommendation 2. Ensure that prescribing physicians follow up within 30 days with all foster children to whom they prescribed new psychotropic medications.
RESPONSE: Sonoma County supports this recommendation.
Recommendation 3. Implement a process to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.
RESPONSE: Sonoma County already ensures that foster children receive these services before or concurrently with medication, but will work on putting systems in place that better track and document these services, and therefore Sonoma County supports the recommendation.
Recommendation 4. Implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as required. The process should also ensure that the counties better document these authorizations in the foster children’s case files.
RESPONSE: Sonoma County supports the recommendation.
Recommendation 5. Develop and implement a process for county staff and caregivers to work together to ensure that psychotropic medications are approved before administering medications. This process should also ensure that the counties obtain accurate medication start dates from caregivers.
RESPONSE: Sonoma County supports the recommendation.
RESPONSE TO THE SONOMA COUNTY RECOMMENDATIONS
Recommendation I. Immediately adopt the state guidelines for its physicians’ use when prescribing psychotropic medications and the county’s review of court authorization requests.
RESPONSE: Sonoma County supports this recommendation. The County was aware of a need to update policies around psychotropic medication before the auditors began their review and have been working on those updates. We have already completed the policy revision necessary to adopt the current state guidelines for physicians’ use when prescribing psychotropic medications and for review of court authorization requests.
Recommendation 2. Within six months, implement a process to review psychotropic medications that parents, rather than courts, are able to approve for children.
RESPONSE: Sonoma County supports the recommendation.
Recommendation 3. Update its policies to describe an acceptable method for obtaining and documenting parental consent for psychotropic medications.
RESPONSE: Sonoma County supports the recommendation.
Comments
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM SONOMA COUNTY
To provide clarity and perspective, we are commenting on Sonoma County’s response to the audit. The numbers below correspond to the numbers we have placed in the margin of its response.
Sonoma County apparently misunderstands the scope of our audit. Namely, we were directed to examine state and county oversight of psychotropic medications prescribed to foster children, as we state in the Introduction. As such and contrary to its statement, we did not need to review provider health records or charts for each foster child to understand the treatment received by individual foster children nor to determine whether each foster child received clinically appropriate amounts and types of psychotropic medication. Rather, to review Sonoma County’s oversight we examined its records, and when necessary, records maintained by relevant state oversight agencies. We did this to understand, analyze, and assess the processes Sonoma County used to oversee such prescriptions, including whether and how Sonoma County ensured that foster children under its charge received psychosocial services in advance of or concurrent with their prescribed psychotropic medications as recommended by relevant guidelines. We stand by the methodology and the results we present in our report.
As we stated in the previous comment, we stand by the methodology we used and the results attained by our implementation of that methodology. To identify information relevant to the audit, we examined available records at Sonoma County, such as documents from foster children’s welfare case files and behavioral health files. We also examined records within certain of the State’s data systems, including the Paid Claims and Encounters System operated by the Department of Health Care Services (Health Care Services) for each foster child. Contrary to Sonoma County’s assertion, reviewing provider records or charts for each foster child was not only unnecessary, it was not within the scope of our audit. Furthermore, we provided Sonoma County opportunities during our audit to provide additional records for every potential Sonoma County exception we identified.
Finally, as we indicate in Chapter 1, we understand that medically appropriate reasons may exist to explain why a provider requests psychotropic medications for foster children in amounts and dosages that exceed the state guidelines. However, if counties do not follow up with providers to obtain assurance that such instances are medically appropriate, counties miss opportunities to better protect their foster children from inappropriate psychotropic medication prescriptions.
Sonoma County is incorrect; we do not state, nor do we imply, that it does not follow generally accepted professional standards when prescribing psychoactive medication to foster children. The methodology we followed enabled us to examine Sonoma County’s oversight to determine whether it was ensuring whether provider’s prescribed psychotropic medications were within academy and state guidelines and whether it reasonably questioned those prescribers when they prescribed psychotropic medications outside these guidelines. As we mention in the Introduction, the California Department of Social Services (Social Services) and Health Care Services stated that the prescribing standards within the state guidelines are current best practices, and that they serve as a foundation for review to ensure that children receive the appropriate amounts and dosages of psychotropic medications. The academy and state guidelines are appropriate yardsticks to use for our analysis of the counties, and we stand by our conclusion that we often found little indication that counties followed up with providers to ensure the appropriateness of psychotropic medications prescribed in excess of the state guidelines.
Sonoma County’s statement that its providers “are bound by and adhere to the prescribing standards established by federal and state law governing mental health plans” is irrelevant to this audit; we did not assess such compliance. As stated in earlier comments, the scope of our audit was to examine the State and county oversight of psychotropic medications prescribed to foster children. Furthermore, as we mention in the Introduction, Social Services and Health Care Services stated that their prescribing standards are current best practices, and that they serve as a foundation for review to ensure that children receive the appropriate amounts and dosages of psychotropic medications. The academy and state guidelines are appropriate yardsticks to use for our analysis of the counties, and we stand by our conclusion that we often found little indication that counties followed up with providers to ensure the appropriateness of psychotropic medications prescribed in excess of the state guidelines.
Sonoma County only recently adopted the state guidelines. Sonoma County informed us on June 3, 2016, that it had adopted the state guidelines the previous day.
We acknowledge Sonoma County’s statement that children entering foster care through the child welfare system may have different mental health needs than children entering through the probation system. However, this point is not relevant for purposes of our audit. The methodology we used to assess Sonoma County’s oversight of psychotropic medications prescribed to foster children and its adherence to relevant academy and state guidelines is applicable to children entering foster care through either system.
Implementation of the recommendations we make to Social Services in Chapter 2 should address Sonoma County’s comment regarding additional guidance and resources from the State. We recommended that Social Services collaborate with counties and other relevant stakeholders to develop and implement a reasonable oversight structure.
Despite its assertion that Sonoma County already ensures that foster children receive psychosocial services before or concurrently with psychotropic medications, our audit demonstrates that Sonoma County’s records cannot provide such assurance. As we show in Table 11, Sonoma County was unable to provide evidence showing that some of the foster children whose case files we reviewed had received corresponding mental health services in the six months before starting at least one psychotropic medication. We look forward to reviewing Sonoma County’s future updates on the implementation of our recommendation and its efforts to put systems in place to better track and document these services.