Report 2015-131 Recommendation 30 Responses

Report 2015-131: California's Foster Care System: The State and Counties Have Failed to Adequately Oversee the Prescription of Psychotropic Medications to Children in Foster Care (Release Date: August 2016)

Recommendation #30 To: Social Services, Department of

To improve the oversight of psychotropic medications prescribed to foster children, Social Services should collaborate with the counties and other relevant stakeholders—including Health Care Services, as necessary—to develop and implement a reasonable oversight structure that ensures the coordination of the State's and counties' various oversight mechanisms as well as the accuracy and completeness of the information in Social Services' data system. 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 such as 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 psychosocial services—for inclusion in Social Services' data system.
- A plan to ensure that counties have sufficient 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 psychotropic medication—including but not limited to the medication name, maximum daily dosage, and court authorization date—and psychosocial services and medication follow-up appointment 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 counties should 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 county staff members working with Social Services' data system to ensure that they know how to completely and accurately update foster children's Health and Education Passports.
- An agreement on how the counties will use information on the new authorization forms that the Judicial Council approved to better oversee the prescription of psychotropic medications to foster children.
- An agreement regarding how counties will implement, use, or disseminate the educational and informational materials the Quality Improvement Project has 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 and the best available sources of data the State and counties will use to oversee foster children prescribed psychotropic medications, including psychosocial services and medication follow-up appointments.
- An agreement on how the State and counties will oversee psychotropic medications prescribed to foster children by fee-for-service providers who are 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 the self-assessments, system improvement plans, and annual progress reports they develop 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 its county Medi-Cal mental health plan compliance reviews and external quality reviews.

Annual Follow-Up Agency Response From November 2020

Will not implement, and recommend this issue be closed. As detailed in responses to all other sub recommendations, substantial work has been done in this area, including the provision of key data to counties for case-level work, as well as recurring state-level data matches between the departments, among other activities and reporting

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From November 2019

No changes to 2018 responses.

30.02 - Will Not Implement

30.06 - Will Not Implement

30.10 - Will Not Implement

30.11 - Will Not Implement

30.12 - Will Not Implement

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From December 2017

See emailed response.

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

Based on its responses dated December 5, 2017 and earlier, Social Services has fully implemented several of this recommendation's components; other components remain partially implemented.

We will continue to monitor Social Services' implementation as part of our annual follow-up process.

1-Year Agency Response

CDSS has implemented all but one of the recommendations. The one recommendation which remains partially completed is the development of the Child Welfare Psychotropic Medication Measures. The following three measures are still under development and are anticipated to be completed by Spring 2018:

- 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).

In the time since the six-month audit response was provided in February 2017, CDSS has continued to provide oversight and monitoring of psychotropic medications to Child Welfare and Probation agencies through engagement with CWDA, Chief Probation Officers of California (CPOC), County Directors, DHCS, and County Public Health Departments. CDSS continues to provide frequent verbal and written updates regarding the training for social workers, probation officers and public health nurses (PHNs), implementation of the new JV-220 forms, data entry and data reports, and ongoing dissemination efforts for the materials created by the Quality Improvement (QI) Project. Additionally, information has been shared regarding increased oversight activities occurring in congregate care facilities and many more counties have signed data sharing agreements (more specifics are described in detail below).

The development of classroom training curriculum and an E-learning module has been completed to address the authorization, uses, risks, benefits, assistance with self-administration, oversight and monitoring of psychotropic medications including data entry, trauma and substance use disorder and mental health treatments, as well as how to access those treatments. Both trainings were piloted in late February 2017 and are now available statewide. Additionally, California Social Work Education Center (CalSWEC) has created an online Toolkit http://calswec.berkeley.edu/toolkits/psychotropic-medication-toolkit which provides information regarding the psychotropic medication training resources and curriculum as well as the Guidelines, resources, latest news and upcoming events.

Dissemination of the youth-friendly brochure containing the Youth Mental Health Bill of Rights and suggested Questions to Ask has continued, and All County Information Notice (ACIN) I-07-17 (Attachment A) was issued on February 28, 2017 to reiterate the importance of these materials and provide a streamlined mechanism to receive additional brochures. Additional health and wellness information for youth, including information about psychotropic medication treatment, continues to be updated and is available on the Department website.

CDSS has continued to provide information and technical assistance to counties regarding use of the new JV-220 forms. The Judicial Council sought feedback from CDSS, counties and other stakeholders and made some minor modifications. On June 21, 2017, CDSS issued follow-up All County Letter (ACL) 17-45 (Attachment B). This ACL provides counties with extensive instructions regarding the new Rules of Court and forms, documentation of psychotropic medication information, including clarification about entry of the medication start date for the Health Education Passport (HEP), and a summary tool for ongoing reference.

On February 13, 2017, DHCS issued Child Health and Disability Prevention (CHDP) Program Letter 01-2017 (Attachment C) that distributed the $1.65 million State General Fund (SGF) to local CHDP Programs for the purpose of utilizing PHNs for psychotropic medication oversight and monitoring activities. The letter described the allocation and claiming process in more detail. Upon release of this letter, counties began utilizing PHNs to conduct the new activities related to psychotropic medications. Counties will soon receive the 2017-2018 allocation letter.

Since February 2017, CDSS has been publically posting the Use of Multiple Concurrent Psychotropic and Antipsychotic Medications Measure (Measure 5c). Additionally, test data for the fourth of seven Child Welfare Psychotropic Medication Measures, Ongoing Metabolic Monitoring for Children in Foster Care on Antipsychotic Medication (Measure 5d), was provided to county child welfare and probation departments July 27, 2017. The measure is on schedule for public release by August 31, 2017. After a one-month county review period, this measure will be publically released. Measure 5d will display the number of children who had two or more dispensing events of the same or different antipsychotic medications during a 12-month period who also had a test for both blood glucose and cholesterol. Development of the fifth measure, Metabolic Screening for Children in Foster Care Newly on Antipsychotic Medication (Measure 5h), will begin in September 2017.

As of July 17, 2017, 28 counties have opted into the Global Data Sharing Agreement (GDSA) and 19 counties have opted into the Psychotropic Medication Data Sharing Agreement (PMDSA). CDSS continues to collaborate with the remaining 11 counties to assist with the memorandum of understanding (MOU) processing.

On May 4, 2017, ACIN I-27-17 (Attachment D) was issued which describes how CDSS implemented the monthly reports for Medi-Cal paid claims data for psychotropic medications required in Senate Bill 238 for counties that are signatory to one of two data sharing agreements. On May 15, 2017, CDSS hosted a webinar to all county child welfare and probation departments that described the process for accessing data matched between CWS/CMS and Medi-Cal paid claims for psychotropic medications using the SafeMeasures data analytic and case management platform.

Counties now have access to county-aggregate and client-level psychotropic medication-specific reports in SafeMeasures for all children under the county's care and supervision. These data are being provided to counties with the intent that it will assist county staff with their health oversight responsibilities.

Counties have access to all medication-specific details such as paid claim dates, medication brand and generic name, national drug code, strength, units, days' supply, prescriber name, specialty, and address, and pharmacy name and address. The reports available in SafeMeasures include Use of Psychotropic and Antipsychotic Medications (Measure 5a.1 & Measure 5a.2) and Use of Psychotropic Medication for Children Five Years old and younger. Although counties have data available to them in order identify children in the remaining indicators, CDSS is also working with the Children's Research Center to make these indicators are available in SafeMeasures for easy identification.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

6-Month Agency Response

CDSS has partially implemented these recommendations. CDSS has continued to engage in ongoing discussions with CWDA and County Directors to ensure improved oversight and monitoring is occurring at the state and local levels. During these discussions, CDSS has provided updates regarding the training for social workers, probation officers and public health nurses (PHNs), implementation of the new JV-220 forms, data entry and data reports, and ongoing dissemination efforts for the materials created by the QI Project. Additionally, information has been shared regarding increased oversight activities occurring in congregate care facilities and a new data sharing agreement, which is described in detail below.

In the time since the 60-day responses were provided to the auditor's report, development of classroom training curriculum and an E-learning module has been completed to address the authorization, uses, risks, benefits, assistance with self-administration, oversight and monitoring of psychotropic medications including data entry, trauma and substance use disorder and mental health treatments, as well as how to access those treatments. Both trainings are currently being piloted in several counties and will be available statewide in Spring 2017.

Dissemination of the youth-friendly brochure containing the Youth Mental Health Bill of Rights and suggested Questions to Ask has continued, and the All County Information Notice (ACIN) to reiterate the importance of these materials and provide a streamlined mechanism to receive additional brochures is in the final approval stages and will be issued in March 2017. Additional health and wellness information for youth, including information about psychotropic medication treatment, has been developed and is available on the Department website.

(The rest of the response could not fit in the textbox and will be emailed to the lead auditor.)

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Social Services' complete response is available from our office.

60-Day Agency Response

CDSS is in the process of making corrections to fully implement these recommendations. Please see the attachment for details.

California State Auditor's Assessment of 60-Day Status: Partially Implemented

In the hard-copy response it provided our office, Social Services mentioned that it had partially implemented this recommendation and that it was taking several actions, including engaging other stakeholders in ongoing discussions to ensure improved oversight and monitoring is occurring at the state and local levels; developing training for parties that work with children in foster care; issuing an all-county information notice regarding data entry procedures for its data system (CWS/CMS); and providing information and technical assistance regarding the use of the Judicial Council's new court forms.

All Recommendations in 2015-131

Agency responses received are posted verbatim.