Report 2019-105 Recommendation 11 Responses

Report 2019-105: Childhood Lead Levels: Millions of Children in Medi-Cal Have Not Received Required Testing for Lead Poisoning (Release Date: January 2020)

Recommendation #11 To: Public Health, Department of

To better ensure that children with lead poisoning are identified and treated, CDPH should prioritize meeting legislative requirements related to these issues, including doing the following by March 2020: Finish developing the lead risk evaluation regulations and include in them multiple risk factors, such as those used in lead risk evaluation questionnaires in other states. It should also commence the formal rulemaking process.

Annual Follow-Up Agency Response From September 2024

CDPH is updating financial estimates to reflect implementation of the new, October 2021 Centers for Disease Control and Prevention (CDC) blood lead reference value. Additional meetings will be held in the fall to confirm language addresses stakeholder concerns. CDPH is commencing the formal rulemaking process. It has drafted lead risk evaluation regulations, and expects to publish the notice of regulatory action in Spring 2025. In recognition of delays in the regulation package development, updated screening guidelines will be posted on the CDPH website (https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/prov.aspx) in September 2024.

In addition, CDPH has updated provider outreach materials and case management practices for consistency with CDC guidelines.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Since we first made this recommendation, successive responses that CDPH has provided have changed the dates by which it expected to provide formal notice of rulemaking. It initially expected to do so in fall 2020, then in March 2021, in March 2022, in January 2023, and in spring 2024. Now it states that it expects to publish the notice of regulatory action in the spring of 2025. It has extended this timeline by more than four years since its initial response, and it currently projects that it will accomplish this task five and a half years after the statutorily required deadline of July 1, 2019. Because of the potential effects of lead poisoning on younger children, CDPH's years of delays may have resulted in severe and lasting detrimental health effects for children who are now well past the ages of 1 and 2, the period when lead testing is most critical.

As of October 2024, the website CDPH indicated in its response still includes an assessment of only the single risk factor of whether children live in, or spend a lot of time in, a place built before 1978 that has peeling or chipped paint or that has been recently remodeled.

Annual Follow-Up Agency Response From September 2023

CDPH has completed a draft regulatory package which is currently going through the internal review process. CDPH expects to publish the notice of regulatory action in Spring 2024.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Since we made this recommendation, successive responses that CDPH has provided have described later dates by which it expected to provide formal notice of rulemaking. It initially expected to do so in Fall 2020, then in March 2021, in March 2022, and in January 2023. Now it states that it expects to publish the notice of regulatory action in Spring 2024. It has extended this timeline by more than three years since its initial response, and it currently projects that it will accomplish this task three and a half years after the statutorily required deadline of July 1, 2019. Given CDPH's struggle to conduct this process in a timely manner, it should consider implementing the changes described in the recommendation and separately pursuing the other regulatory changes it wishes to make.

Annual Follow-Up Agency Response From October 2022

CDPH is updating the regulatory package to incorporate the U.S. Centers for Disease Control and Prevention's new blood lead reference value, which was updated in October 2021. This inclusion will significantly impact the CLPP Program's number of cases and the estimated cost of the regulatory change. The estimated cost of the package is over $50 million and meets the definition of a major regulation; a Standardized Regulatory Impact Assessment (SRIA), which requires additional analysis of economic impact, is being prepared. The regulation package will have to be reviewed in its entirety due to the changes. CDPH anticipates providing formal notice of rulemaking in January 2023.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Since we made this recommendation, CDPH has stated in successive responses that it would provide formal notice of rulemaking in the Fall of 2020, in March 2021, in March 2022, and now in January 2023. It has extended this timeline by more than two years since its initial response, and it currently projects that it will accomplish this task three and a half years after the statutorily required deadline of July 1, 2019. Given CDPH's struggle to conduct this process in a timely manner, it should consider implementing the changes described in the recommendation and separately pursuing the other regulatory changes it wishes to make.

Annual Follow-Up Agency Response From October 2021

CDPH's internal review of the regulations package identified necessary revisions. While enabling CLPPB to produce a more accurate and defensible regulations package, with a cost estimating methodology based on more up-to-date base data, the revision and review process created additional delays. CDPH anticipates providing formal notice of rulemaking for this regulations package by March 2022, as outlined in the Administrative Procedures Act (APA).

California State Auditor's Assessment of Annual Follow-Up Status: Pending

CDPH's response indicates that it has delayed beginning the formal rulemaking process once again.

1-Year Agency Response

The regulations package is undergoing internal review and approval. There have been some delays due to the COVID-19 pandemic. The regulations package is anticipated to formally notice the rulemaking by March 2021, as outlined in the Administrative Procedures Act (APA).

California State Auditor's Assessment of 1-Year Status: No Action Taken

CDPH's 60-day response indicated that it would provide formal notice of rulemaking in the Fall of 2020. It stated in its 6-month response, and in this response, that it anticipates the formal notice of rulemaking will occur in March 2021. This indicates that its schedule has been extended by an additional 4-6 months since its 60-day response, and that it currently plans to accomplish this task almost two years after the July 1, 2019 deadline.

6-Month Agency Response

The regulations package is in the final stages of development and will undergo internal review and approval. The regulations package is anticipated to formally notice the rulemaking by March 2021, as outlined in the Administrative Procedures Act (APA).

California State Auditor's Assessment of 6-Month Status: No Action Taken

CDPH's 60-day response indicated that it would formally notice the rulemaking in the Fall of 2020. It now states that will occur in March 2021, which indicates that its schedule has been extended by an additional 4-6 months since its 60-day response.

60-Day Agency Response

CDPH is currently drafting regulations expanding the risk factor criteria to incorporate multiple additional risk factors. CDPH conducted extensive fact finding and analysis in consultation with experts, and public stakeholder meetings for input were held in both Richmond and Sacramento. Input meetings with medical providers were also held. CDPH is on track to formally notice the rulemaking as outlined in the Administrative Procedures Act (APA) in the fall of 2020.

California State Auditor's Assessment of 60-Day Status: No Action Taken

CDPH's response provides no information on any actions taken beyond those it already reported to us during the audit.

All Recommendations in 2019-105

Agency responses received are posted verbatim.