Report 2019-105 All Recommendation 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 #1 To: Health Care Services, Department of

Because of the severe and potentially permanent damage that lead poisoning can cause in children, DHCS should ensure that all children in Medi-Cal receive lead tests by finalizing, by December 2020, its performance standard for lead testing of one- and two-year-olds. DHCS should use its existing data to assess the progress of managed care plans in meeting that performance standard and impose sanctions or provide incentive payments as appropriate to improve performance.

Annual Follow-Up Agency Response From December 2023

- Effective measurement year 2022, DHCS is holding Medi-Cal MCPs to the national 50th percentile for the Lead Screening HEDIS measures, which the list of measures including lead screening can be found here.

o MCPs performing below the national median will subject to Enforcement action such as monetary sanctions, and additional QI and HE projects to better support higher screening rates. DHCS is currently reviewing measurement year 2022 quality score results for blood lead screening and anticipates issuing Enforcement actions in the coming months.

- DHCS will continue to work with the EQRO to produce the annual Preventive Services Report, which reports on Title 17 and HEDIS Blood Lead Screening indicators. The report is located here.

- DHCS will also continue to monitor the Preventive Services Report and work on implementing report recommendations. The recommendations are updated annually, and the report is published and presented to external partners. We track all of EQRO's recommendations in our annual report found here. Throughout the report recommendations are made, and the report addresses how the previous year's recommendations were addressed.

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

DHCS has not yet demonstrated that it has implemented this recommendation. It asserts that it will use the Lead Screening HEDIS measure to assess managed care plans' performance in providing lead tests to children in Medi-Cal and that it will conduct enforcement actions for plans that do not meet the 50th percentile for lead screening. However, it did not provide evidence that it has begun doing so, nor did it provide documentation of its communication of these expectations upon our request that it do so. We will reassess DHCS's response to this recommendation after it provides All Plan Letters or worksheets showing that its expectations have been communicated to the MCPs, its assessment of MCPs progress toward meeting the performance standard, and evidence that it has imposed sanctions or provided incentive payments as appropriate to improve MCP performance in meeting the standard. In addition, although the implementation of this performance standard is an improvement in measuring whether children have received lead tests, it is important to recognize that it will not measure compliance with state law. The measure that DHCS describes assesses only whether a child has had one or more lead tests by their second birthday. With limited exceptions, state law requires that a child enrolled in Medi-Cal receive a lead screening test at 12 months of age and at 24 months of age.

Annual Follow-Up Agency Response From October 2021

DHCS released the Preventive Services Report Addendum in February 2021 which provided statewide and MCP-level rates for Title 17 and HEDIS Blood Lead Screening indicators using 2019 data. The Addendum presented findings and analysis related to the Blood Lead indicators which DHCS used to develop the Blood Lead Screening Approach Proposal. In July 2021, DHCS released the Proposal for stakeholder feedback and recommended to utilize the HEDIS Lead Screening in Children (LSC) measure as a proxy for Title 17 age stratifications. DHCS is reviewing the feedback and continuing internal discussions with a goal to release the finalized performance standard by the end of the year. Please see the attached Blood Lead Screening Approach Proposal document for further details on DHCS' recommendation.

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

DHCS's continued failure to implement this recommendation is troubling. A year has passed since the date we suggested for implementing this recommendation, and DHCS's own estimate of when it will implement this recommendation has been extended by a year since its 6-month response. However, it has not provided an explanation for this delay. The delay is especially troubling because its failure to implement this performance measure prevents the public from holding DHCS accountable for meeting the legal mandate to ensure children in Medi-Cal receive lead tests. If children are not receiving these tests they may suffer additional damage from continued lead poisoning.

1-Year Agency Response

DHCS is finalizing efforts to calculate the rate of Blood Lead Screening for each MCP per National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set technical specifications. The use of nationally-recognized technical specifications allows DHCS to compare California's performance to the performance of other Medicaid plans nationally and will assist DHCS in establishing adequate performance standards.

In addition, DHCS is finalizing the development of a California specific indicator and benchmarks with stratifications consistent with California's Title 17 CCR section 37100. The stratifications will be used in the metric including screening rates for one-, two-, and six-year-old members with no record of a screening, in alignment with Title 17 requirements. Options for benchmarking a Minimum Performance Level will be included in the Preventative Services Report Addendum scheduled for release in February 2021. Stakeholder engagement will occur in early 2021 so DHCS can finalize benchmarks/performance standards. MCPs not meeting the established benchmarks will be placed under a CAP. DHCS will impose sanctions and/or penalties on MCPs not complying with the CAP.

DHCS implemented a Value Based Payment Program which incentivizes providers to conduct various activities relating to care for Medi-Cal beneficiaries. Providers receive a payment for completion of a measure relating to said activities. Blood Lead Screening is one of the measures. Incentive payments are to be issued to plans upon DHCS' receipt of encounter data demonstrating lead screening, subject to federal approval. CMS approved DHCS' proposal for the Value Based Payment Program on May 5, 2020.

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

We will review DHCS' performance standard and its implementation of that standard once DHCS implements and provides documentation of the activities described.

6-Month Agency Response

DHCS released proposed measures, including Blood Lead Screening, for the 2020 Report for public comment on January 17, 2020. The public comment period ended February 3, 2020. DHCS is continuing to evaluate feedback to determine which measures need modifying to provide accurate and relevant information for the Report with the External Quality Review Organization, and continuing to move forward with production of the Report.

DHCS will utilize MCP administrative data to calculate the rate of Blood Lead Screening for each MCP per National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set, technical specifications. The use of nationally-recognized technical specifications will allow DHCS to compare California's Medi-Cal MCP rates to the performance of other Medicaid plans nationally, assisting DHCS with establishing a performance standard for DHCS to utilize in driving quality improvement. MCPs not meeting the established benchmark will be placed under a CAP. DHCS will impose sanctions and/or penalties on MCPs not complying with the CAP.

In addition, DHCS is in the process of developing a metric for Blood Lead Screening for infants up to age one. A Minimum Performance Level will also be developed. The metric will be included in the first version of the Report to be completed by December 2020.

DHCS implemented a VBPP which incentivizes providers to conduct various activities relating to care for Medi-Cal beneficiaries. Providers receive a payment for completion of a measure relating to said activities. Blood Lead Screening is one of the measures. Incentive payments are to be issued to plans upon DHCS' receipt of encounter data demonstrating lead screening, subject to federal approval. CMS has not yet approved the DHCS proposal for the VBPP.

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

We will review DHCS' performance standard and its implementation of that standard as soon as DHCS provides documentation of, and implements, the activities described.

60-Day Agency Response

DHCS released proposed measures, including Blood Lead Screening, for the 2020 Report for public comment on January 17, 2020. The public comment period ended on February 3, 2020. DHCS is reviewing the comments received, and determining any feasible adjustments to the performance measures for the Report with the External Quality Review Organization (EQRO), and continuing to move forward with production of the Report.

DHCS will utilize Medi-Cal MCP administrative data to calculate the rate of Blood Lead Screening for each MCP per National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set, technical specifications. The use of these nationally-recognized technical specifications will allow DHCS to compare California's Medi-Cal MCP rates to the performance of other Medicaid plans nationally. This will assist DHCS with establishing a performance standard that DHCS will utilize to drive quality improvement. MCPs that do not meet the established benchmark will be placed under a CAP. Should they not come into compliance with the CAP, DHCS will impose sanctions and/or penalties.

In addition, DHCS is in the process of developing a metric for Blood Lead Screening for infants up to age one. A Minimum Performance Level will also be developed. The metric will be included in the first version of the Report to be completed by December 2020.

Of note, DHCS has already implemented a VBP Program which incentivizes providers to conduct various activities relating to care for Medi-Cal beneficiaries. Providers receive a payment for completion of a measure relating to said activities. Blood Lead Screening is one of the measures. Incentive payments are to be issued to plans upon receipt by DHCS of encounter data demonstrating lead screening, subject to federal approval. The Centers for Medicare & Medicaid Services (CMS) has not yet approved the DHCS proposal for the Value Based Payment Program.

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

We will review the performance standard and DHCS' implementation of the standard after it has been implemented.

Recommendation #2 To: Health Care Services, Department of

To ensure that families know about the lead testing services that their children are entitled to receive, DHCS should send a reminder to get a lead test for children who missed required tests. It should send this reminder in the required annual notification it is developing to send to families of children who have not used preventive services over the course of a year.

Annual Follow-Up Agency Response From December 2023

DHCS released All Plan Letter (APL) 23-005 on March 16, 2023. The APL details the purpose, background, and policy for coverage of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services for Medi-Cal Members Under the Age of 21. The APL states MCPs must use the current AAP Bright Futures periodicity schedule and guidelines when delivering care to any Member under the age of 21, including but not limited to health and developmental screening services, physical examination, dental services, vision services, and hearing services. All Members under the age of 21 must receive EPSDT preventative services, including screenings, designed to identify health and developmental issues as early as possible. The APL details MCPs' responsibilities regarding EPSDT in the following areas:

- Behavioral Health Treatment,

- Case Management and Care Coordination,

- Transportation and Member Information, Certain Carved-Out Services,

- California Children's Services Program, Dental Services,

- Outreach and Education Materials, Provider Training, and

- Coordinating with Other Outside Entities Responsible for Providing EPSDT Services.

DHCS worked with the Center for Health Literacy to develop various written member materials for either posting or distribution to members. The materials (referred to as "Medi-Cal for Kids & Teens") included social media and website content, a Know Your Rights letter, and brochures. The materials describe the importance of checkups and screenings, which includes lab tests, including blood lead testing, as a covered service. The materials were finalized in 25 threshold languages and were shared with MCPs on July 3, 2023 and posted on the DHCS website.

Per APL 23-005 MCPs were instructed to:

- Post the materials on the MCP websites and mail the materials for the one-time mailings by no later than July 31, 2023.

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

DHCS' response fails to fully address this recommendation in several respects. First, it asserts that it generated materials for communicating information to Medi-Cal beneficiaries, but instead of sending the communication itself it delegated this task to the managed care plans. In its response it does not describe whether it took action to ensure the managed care plans provided these materials to all relevant beneficiaries. Second, instead of identifying those beneficiaries that have not received a required lead test and informing them or their families of the importance of obtaining such a test, according to DHCS's response the materials it is disseminating are sent to all beneficiaries and describe the services to which they are entitled and the importance of those services. Expecting beneficiaries to determine what services their child has or has not received, instead of informing them that their child has not received an important test, is likely less effective at motivating families to get their children tested. Finally, it is unclear how often this information will be communicated to beneficiaries. The All Plan Letter DHCS sent to managed care plans indicates that they are required to send materials annually, but DHCS's response indicates that this was a one-time mailing, unlike the annual communication that we recommended.

Annual Follow-Up Agency Response From October 2021

Phase 1 of the outreach campaign, which was completed in March 2020, resulted in sending a letter to all eligible Medi-Cal beneficiaries under age 21, not just those that had missed a preventative service such as blood lead screening.

Phase 2 involved working with the CHL to review and assess current preventive care outreach materials, as well as interview stakeholders and survey MCPs on current outreach efforts.

In addition to providing MCP's with outreach materials to use to communicate with their members about preventative services, including blood lead screening, the DHCS has also updated its MCP contracts to require MCP's to identify, at least quarterly, all children with no record of receiving a required lead test, and remind the responsible health care provider of the requirement to test children.

Lastly, in addition to the initial outreach letter, the outbound call campaigns, and updates to the MCP contract, MCPs were also required to submit policies and procedures to DHCS regarding blood lead screening.

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

The letters DHCS sent do not serve as a sufficient reminder to obtain a lead test for those children who missed tests. Specifically, they contain general information, are sent to all beneficiaries, and do not specify whether the child in question has missed a test.

The outreach efforts, MCP contracts, and MCP policies and procedures that DHCS describe are related to health care providers--not the families of children who have missed tests--and thus do not relate to this recommendation.

1-Year Agency Response

DHCS continues to work on a two phase targeted outreach campaign to inform beneficiaries about the availability of, and how to access, American Academy of Pediatrics/Bright Futures services under Medi-Cal. Part of the outreach will include highlighting the availability of lead testing services children are entitled to in Medi-Cal.

DHCS mailed 4,950,510 Preventative Care Outreach Notices in April 2020. Notices were sent to all beneficiaries under the age of 21 with full scope Medi-Cal eligibility. DHCS planned to direct MCPs to conduct a call campaign to follow-up with children and their families who have not used preventive services over the course of a year, including lead testing services for children younger than six years old. The MCP call campaign was scheduled to begin as early as March 2020 for some MCPs.

However, the MCP Outbound Call Campaign was delayed due to the COVID-19 pandemic. The calls were paused in recognition of the State of California's stay-at-home order and state and federal guidance to delay non-essential medical services; to avoid confusion with other communications from public health agencies and MCPs around the pandemic; and to avoid an increase in unscheduled in-person visits to health systems which may be impacted by high volume, stricter infection control procedures, or temporary closures.

After close collaboration with MCPs, DHCS was able to restart the MCP Outbound Call Campaign in November 2020 with modifications which allowed the Plans to not only make outbound calls, but also allowed MCPs to use other modalities for outreach such as member outreach materials, social media platforms, information shared on partnering websites, member portals, and other media. As of the time of this 12 month update, all MCPs have a DHCS approved Preventive Care Outreach proposal and are targeting completing phase I by December 31st, 2020 and phase II by March 31st, 2021 per the required due dates provided by DHCS to the MCPs.

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

The notices DHCS sent do not serve as a sufficient reminder to obtain a lead test for those children who missed tests. Specifically, they contain general information and do not specify whether the child in question has missed a test.

The call campaign DHCS has delegated to the managed care plans may meet the intent of the recommendation; however, DHCS must provide evidence that the calls include a reminder to get a lead test for those children who missed required test, that it has established a procedure to implement the campaign each year, and that it has a documented method to ensure the plans are fulfilling this responsibility.

6-Month Agency Response

DHCS continues to work on a two phase targeted outreach campaign to inform beneficiaries about the availability of, and how to access, American Academy of Pediatrics/Bright Futures services under Medi-Cal. Part of the outreach will include highlighting the availability of lead testing services children in Medi-Cal are entitled to receive.

DHCS completed mailing 4,950,510 Preventative Care Outreach Notices in April 2020. Notices were sent to all beneficiaries under the age of 21 with full scope Medi-Cal eligibility. DHCS had planned to direct MCPs to conduct a call campaign to follow-up with children and the children's families who have not used preventive services over the course of a year, including lead testing services for children younger than six years old. The MCP call campaign was scheduled to begin shortly after the mailing of the outreach notices, as early as March 2020 for some MCPs.

However, the MCP Outbound Call Campaign was delayed due to the COVID-19 pandemic. The calls were paused in recognition of the State of California's stay-at-home order and state and federal guidance to delay non-essential medical services; to avoid confusion with other communications from public health agencies and MCPs around the pandemic; and to avoid an increase in unscheduled in-person visits to health systems which may be impacted by high volume, stricter infection control procedures, or temporary closures. DHCS is closely monitoring the changes in local conditions regarding stay-at-home and other public health guidance, as well as provider reopening and capacity, and is consulting with MCPs and providers regarding local provider readiness and public health conditions to permit the MCP outreach call campaign to begin a narrower, locally appropriate outreach call campaign.

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

DHCS provided a copy of the notice it sent. Although the notice states that "Preventive Care includes things like... lab tests (including blood lead testing)," it does not serve as a reminder to get a lead test for children who missed tests because it does not indicate whether the beneficiary or their child has missed a test. In addition, DHCS did not provide evidence that the notices were sent, or that it has a written policy to conduct this mailing annually.

60-Day Agency Response

DHCS continues to work on a two phase targeted outreach campaign to inform beneficiaries about the availability of AAP/Bright Futures services under Medi-Cal and how to access them. Part of this outreach will include highlighting the availability of lead testing services that children in Medi-Cal are entitled to receive.

DHCS is targeting March of 2020 to mail its first outreach notice to all beneficiaries. This notice will be sent to all beneficiaries under the age of 21 with full scope Medi-Cal eligibility. It will be followed by a call campaign by the MCPs to follow-up with children and their families who have not used preventive services over the course of a year, including lead testing services for children younger than six years old. An evaluation of the existing preventive care outreach materials (with stakeholder and beneficiary involvement) will take place throughout 2020.

Please note the MCP call campaign was scheduled to begin shortly after the mailing of the outreach notices, as early as March 2020 for some MCPs. DHCS has instructed the MCPs to pause or delay initiation of these calls in March and potentially subsequent months, due to the emerging Coronavirus (COVID-19) situation. These calls will be paused to avoid confusion with other communications from public health agencies and MCPs around COVID-19, and to avoid an increase in unscheduled in-person visits to health systems that may be impacted by COVID-19 in the coming weeks, such as hospitals, clinics and physician offices. DHCS is closely monitoring the COVID-19 situation, and will instruct MCPs to begin or resume their call campaigns as soon as it is appropriate given public health and health care system conditions.

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

DHCS is delaying implementation of this recommendation to focus on COVID-19 issues. Upon implementation we will review documentation of DHCS' policy and the notices it has sent.

Recommendation #3 To: Health Care Services, Department of

To increase California's lead testing rates and improve lead test reporting, DHCS should, by no later than June 2020, incorporate into its contracts with managed care plans a requirement for the plans to identify each month all children with no record of receiving a required test and remind the responsible health care providers of the requirement to test the children. DHCS should also develop and implement a procedure to hold plans accountable for meeting this requirement.

Annual Follow-Up Agency Response From October 2021

DHCS continues to maintain the position that quarterly notifications are sufficient and align with the spirit and intent of CSA's recommendation. Further, at this time the California Department of Public Health (CDPH) does not have the capacity to transmit laboratory screening data to DHCS on a monthly basis, which is needed by the MCPs to ensure an accurate accounting of child members that have received or missed a blood lead test. Additionally, AB 2276 added Section 14197.08 to the Welfare and Institutions Code which requires that MCPs, on a quarterly basis, identify every enrollee who is a child without a record of completing the blood lead screening tests. To remain consistent with AB 2276 as well as APL 20-016, DHCS believes maintaining a quarterly identification process aligns with other supplemental data that DHCS provides to MCPs. Further, the quarterly identification requirement is also included in the CY 2021 Base Contract Amendment that DHCS has submitted to CMS. DHCS agrees that timely notification and accountability are critical to early intervention. Therefore, DHCS intends to add formal reporting of the LSC measure to its MCAS. MCAS MCPs that do not take steps to ensure blood lead screenings are completed timely in order to meet the MCAS standards will be subject to a CAP and/or sanctioned. As mentioned earlier, to assist MCPs with accurately identifying children who have not received a blood lead screening, DHCS has begun transmitting laboratory blood lead test data from the CDPH Blood Lead Screening Registry on a quarterly basis. This data, combined with DHCS' blood lead claims and encounter data, is distributed to each MCP and provides them with data files that aid in most accurately identifying which child members have received a screening and which child members may be missing the test so that MCPs and Providers can conduct appropriate outreach.

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

DHCS describes several reasons for its assertion that quarterly notifications are sufficient; however, it has not demonstrated whether its quarterly notifications have sufficiently improved testing rates. Until it demonstrates that the quarterly notifications have had the intended effect, we stand by our recommendation to send monthly notices to communicate the importance of providing lead tests and encourage providers to proactively provide these tests. Because children at the ages of one and two are especially vulnerable to the effects of lead, and testing delays can result in increased damage for those children with elevated lead levels, it is vital that children with elevated lead levels are identified as soon as possible and that steps are taken to prevent further exposure.

1-Year Agency Response

The contract amendment was submitted to CMS in December 2020. The contract submission includes a requirement for MCPs to identify each quarter all children with no record receiving a required lead test, and remind the health care provider of the requirement to test children. As documented in the previous response, requiring a monthly notification process is not feasible because after an initial notice is sent to a provider, the provider needs time to outreach, schedule, and provide services before another notice is sent to the provider for the same enrollee. In addition, providers may not immediately submit encounter/claims data to contracted health plans, possibly resulting in plans unnecessarily noticing providers for services already rendered. DHCS believes quarterly noticing provides the minimum opportunity for interventions and data submission before follow-up notices are sent.

DHCS released a draft APL for public comment on July 29, 2020, and subsequently issued APL 20-016: Blood Lead Screening of Young Children on September 29, 2020 which established requirements for the MCPs. At the time of APL release, the governor signed AB 2276: "Childhood Lead Poisoning: Screening and Prevention" into law. In order to align with the newly enacted legislation and additional stakeholder feedback, DHCS released a revised version of APL 20-016 on November 2, 2020. The revised APL added the authority of DHCS to implement procedures and sanctions as well as some clarifications for age range and voluntary refusal requirements. DHCS will begin reviewing health plan policies and procedures within 90 days after APL 20-016 release to ensure MCP compliance with the policy. DHCS will also review the MCP process related to the contractual requirement during the annual medical audit, and impose a CAP if non-compliance is identified. Since the DHCS annual medical audit is a one-year retrospective audit, DHCS will begin auditing the policy in 2021.

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

DHCS provided documentation to substantiate the actions it indicated it has taken; however, those actions are not completely aligned with our recommendation. Specifically, DHCS has required managed care plans to provide notices on a quarterly basis rather than a monthly basis, as we recommended. Although DHCS stated that it is not feasible to provide these notices on a monthly basis, we question the accuracy of this statement. DHCS has not presented any information regarding why it is not feasible to provide these notices; rather, it's comments address the feasibility of physicians providing and reporting the missing tests. However, even if it is not feasible for physicians to provide and report such tests within one month, sending additional notices will communicate the importance of providing these tests and encourage providers to proactively provide lead tests when they are due to avoid receiving notices in the first place.

Children at the ages of one and two are especially vulnerable to the effects of lead, and testing delays can result in increased damage for those children with elevated lead levels. Thus, it is important that children with elevated lead levels are identified as soon as possible and that steps are taken to prevent further exposure. If a one year old child is not tested after receiving the first two quarterly notices, they will be closer in age to their second required test than the first. Therefore, we stand by our recommendation that DHCS require monthly notices.

6-Month Agency Response

Due to the pandemic's impact on DHCS workload, the submission of the contract amendment to CMS for approval is targeted to be submitted by August 2020. The contract submission will include a requirement for MCPs to identify each quarter all children with no record of receiving a required lead test, and remind the responsible health care provider of the requirement to test children. As documented in the previous response, requiring a monthly notification process is not feasible because after an initial notice is sent to a provider, the provider needs time to outreach, schedule, and provide services before another notice, for the same enrollee, is sent to the provider. In addition, providers may not immediately submit encounter/claims data to contracted health plans, possibly resulting in plans unnecessarily noticing providers for services already rendered. DHCS believes quarterly noticing provides the minimum opportunity for interventions and data submission before follow-up notices are sent.

Also due to the pandemic's impact on DHCS workload, DHCS plans to release a draft APL for public comment no later than July 2020, and issue the final APL in the 3rd Quarter of 2020, establishing the MCP policy. DHCS will review health plan policies and procedures to ensure MCP compliance with the policy. DHCS will also review the MCP process related to the contractual requirement during the annual medical audit, and impose a CAP if non-compliance is identified. Since the DHCS annual medical audit is a one-year retrospective audit, DHCS will begin auditing the policy in 2021.

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

We look forward to reviewing DHCS' implementation of this recommendation upon the completion of the efforts it describes. However, children at the ages of one and two are especially vulnerable to the effects of lead. If they have elevated lead levels it is important that they are identified as soon as possible and that steps are taken to prevent further exposure. With a quarterly notice, a child could be up to 90 days past-due for their required lead test before the MCP sends the first notice and, as DHCS indicates, the provider would still need additional time to outreach, schedule, and provide services to the child. Implementation of this recommendation on a monthly basis could address DHCS' concerns by reinforcing the requirement to provide these tests on time, and encouraging more timely submission of lead test claims to managed care plans. Testing delays can result in increased damage for those children with elevated lead levels. Therefore, we stand by our recommendation that DHCS require monthly notices and our review of its implementation of this recommendation will assess whether the contractual requirement with managed care plans specifies monthly reminders.

60-Day Agency Response

DHCS continues to be on track to submit a contract amendment to CMS for approval by June 2020 that will include a requirement for MCPs to identify each quarter all children with no record of receiving a required lead test and remind the responsible health care provider of the requirement to test the children. It is not feasible to require a monthly notification process because after an initial notice is sent to a provider, the provider needs time to outreach, schedule, and provide services before another notice, for the same enrollee, is sent to the provider. In addition, providers may not immediately submit encounter/claims data to contracted health plans. This may result in plans unnecessarily noticing providers for services already rendered. DHCS believes that quarterly noticing provides the minimum opportunity for interventions and data submission before follow-up notices are sent. Given CMS has a contract review and approval process, DHCS plans to release an All Plan Letter no later than July 2020 establishing the MCP policy. DHCS will review heath plan policies and procedures to ensure MCP compliance with the policy. DHCS will also review the MCP process related to this contractual requirement during its annual medical audit, and impose a CAP if non-compliance is identified. Since the DHCS annual medical audit is a one year retrospective audit, DHCS will begin auditing this policy in July 2021.

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

We look forward to reviewing DHCS' implementation of this recommendation upon the completion of the efforts it describes. However, children at the ages of one and two are especially vulnerable to the effects of lead. If they have elevated lead levels it is important that they are identified as soon as possible and that steps are taken to prevent further exposure. If a quarterly notice is overlooked a child's next test may be shortly due by the time the missed test is provided, resulting in further damage for those children with elevated lead levels. Therefore, we stand by our recommendation that DHCS require monthly notices and our review of its implementation of this recommendation will assess whether the contractual requirement with managed care plans specifies monthly reminders.

Recommendation for Legislative Action

To provide sufficient information to homebuyers and renters, the Legislature should require CDPH, by December 2021, to provide an online lead information registry that allows the public to determine the lead inspection and abatement status for properties. To accomplish this task, CDPH should use the information it already maintains only to the extent that it can ensure that it does not make personally identifying information, including medical information, public.

Description of Legislative Action

As of January 7, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken

Description of Legislative Action

As of January 7, 2021, the Legislature has not taken action to address this specific recommendation.

AB 2422 (Grayson, 2020) would have required CDPH to develop and maintain on its website a public registry of lead-contaminated locations reported to the department pursuant to the provisions relating to lead hazards in buildings. The bill would have required CDPH to ensure that personally identifiable information, including medical information, is not disclosed or ascertainable from the information available on the registry. This bill failed passage due to adjournment of the 2019-20 Regular Legislative Session.

California State Auditor's Assessment of 1-Year Status: Legislation Proposed But Not Enacted

Description of Legislative Action

AB 2422 (Grayson) would, in part, require CDPH to develop and maintain on its website a public registry of lead-contaminated locations reported to the department pursuant to the provisions relating to lead hazards in buildings. The bill would require CDPH to ensure that personally identifiable information, including medical information, is not disclosed or ascertainable from the information available on the registry. As July 7, 2020, this bill was pending in the Assembly Health Committee.

SB 1008 (Leyva) would require CDPH to design, implement, and maintain an online lead information registry on its website that enables the public to determine the lead inspection and abatement status for properties, and to use information it maintains for the registry to the extent that CDPH ensures that personally identifying information is made unavailable to the public. As July 7, 2020, this bill was pending in the Senate Health Committee.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced

Recommendation #5 To: Public Health, Department of

To identify the highest priority areas for using resources to alleviate lead exposure among children, CDPH should immediately complete and publicize an analysis of high-risk areas throughout the State.

Annual Follow-Up Agency Response From October 2021

CDPH has completed the analysis of high-risk areas and published it on the CDPH website. https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/data.aspx

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

1-Year Agency Response

The geographic areas at high risk for childhood lead exposure identified in the biennial report are those zip codes with one or more geospatial risk factors which put children at increased risk of lead exposure. Additional maps to identify various levels of environmental risk areas have being developed at the census tract level and will be published on the CDPH website by January 2021.

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

The report CDPH published in its 2020 biennial report did not include sufficient information for its users to identify the highest priority areas for using resources to alleviate lead exposure among children. Its analysis of local health jurisdictions presented a number of blood lead related factors for certain jurisdictions, but did not describe how the rankings in the various categories relate to each other or what the overall risk determination is for each health jurisdiction. Further, its assessment of geographic areas and populations at risk for lead exposure identified essentially the entire State as a risk, making it unclear which geographic areas represented a higher risk than others.

The maps that CDPH submitted as examples of the information it intends to publish in January 2021 appear to better address our recommendation, and we look forward to reviewing the full report.

6-Month Agency Response

CDPH released the Biennial Report, "California's Progress in Preventing and Managing Childhood Lead Exposure" on June 9, 2020. The report is posted on the Childhood Lead Poisoning Prevention Branch website (https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/CDPH%20Document%20Library/CLPPBReport2020.pdf). The report provides statewide data and maps of the number of children with elevated blood lead levels, information about exposure sources and progress in lead exposure prevention and management, and identifies geographic areas at high risk for childhood lead exposure.

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

CDPH's report does not clearly indicate what areas present a high risk. Its analysis of local health jurisdictions presents a number of blood lead related factors for certain jurisdictions, but does not describe how the rankings in the various categories relate to each other or what the overall risk determination is for each health jurisdiction.

Further, its assessment of geographic areas and populations at risk for lead exposure is of limited value. It's analysis identified 99.3 percent of the State's zip codes as areas of risk for childhood lead poisoning. Because it identifies essentially the entire State as a risk, it is unclear which geographic areas represent a higher risk than others. As a result, this analysis is not useful for the purpose of identifying which parts of the State represent the highest priority for the limited resources available to address lead hazards.

60-Day Agency Response

CDPH prepared the Biennial Report, "California's Progress in Preventing and Managing Childhood Lead Exposure" and expects to release the report in Spring 2020. This report will be posted on the CDPH CLPPB website as well. The report identifies geographic areas at high risk for childhood lead exposure throughout the State. As of March 2, 2020, CDPH has posted the map outlining the high-risk areas on CDPH website. It is available here on the CDPH website: https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/CDPH%20Document%20Library/2018_BLL_Maps_Tables.pdf

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

We will review implementation of this recommendation after CDPH publicizes its biennial report.

Recommendation #6 To: Public Health, Department of

To ensure that local prevention programs' outreach results in a reduced number of children with lead poisoning, CDPH should, by December 2020, require local prevention programs to demonstrate the effectiveness of their outreach in meeting this goal. If the local prevention programs are unable to demonstrate the effectiveness of their outreach in reducing the number of children with lead poisoning, CDPH should analyze the cost-effectiveness of other approaches, including proactive abatement, and require the local prevention programs to replace or augment outreach to the extent resources allow.

Annual Follow-Up Agency Response From November 2022

To evaluate the effectiveness of outreach activities in preventing lead exposure in California children, in 2020 the Childhood Lead Poisoning Prevention Branch (CLPPB) created an Evaluation Toolkit (attached) with survey tools for multiple target audiences and provided it to local Childhood Lead Poisoning Prevention Programs (CLPPPs) for this purpose. The toolkit was used by CLPPPs with available capacity to evaluate their outreach activities. CLPPB conducted an analysis of blood lead level (BLL) data to determine whether CLPPPs' outreach has been effective in preventing lead exposure in the local health jurisdictions (LHJs). CLPPB compared the BLLs in the LHJs that fulfilled outreach requirements (i.e., rigorous outreach) with those that did not (i.e., limited outreach)1, with the goal of understanding whether lead poisoning prevention outreach activities may be impacting BLLs in California children. Based on our analysis, we found that children who lived in LHJs with rigorous outreach efforts were statistically less likely to have an elevated BLL defined at or above either 4.5 µg/dL or 3.5 µg/dL2 when compared to children living in LHJs with limited outreach efforts. CLPPB's analysis, results, and next steps are further described in the attached CLPPP Outreach Evaluation Fact Sheet and policy document.

1Unfulfilled outreach requirements were due to COVID-19 pandemic impacts on CLPPP staffing.

2As of October 2021, the Centers for Disease Control and Prevention (CDC) defined the blood lead reference value (BLRV) of 3.5 µg/dL to identify children with BLLs that are higher than most children's levels; the previous CDC BLRV was 5 µg/dL (CDPH used 4.5 µg/dL).

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

CDPH performed an evaluation of the effectiveness of local programs' outreach in reducing the number of children with lead poisoning. It also implemented a policy to conduct that evaluation annually, and if it determines that a local program's outreach is ineffective in reducing lead levels, it will require the local program to increase other efforts to reduce lead levels, such as proactive abatement. CDPH's discussion of its toolkit is not relevant to this recommendation because the toolkit measures knowledge gains rather than reductions in the number of children with lead poisoning.

Annual Follow-Up Agency Response From October 2021

To determine the effectiveness of local prevention program outreach, CDPH will analyze the association between local health jurisdiction blood lead level trends and the quantitative results of outreach activities reported by local prevention programs in progress reports. Because the Scope of Work timeline for completion of outreach activities is annual, CDPH requires a full year of local prevention program progress reports to conduct the analysis. Progress reports covering outreach activities for the first full year of the contract were due July 30, 2021. Many local prevention programs were unable to comply with this deadline due to impacts from local states of COVID-19 and wildfires emergency and were granted extensions to mid-August. Once CDPH receives local prevention program progress reports for the first year of the contract, CDPH will begin conducting the analysis of local prevention program outreach activities with respect to blood lead levels. If outreach is determined to be ineffective, CDPH will explore corrective action measures and/or other approaches to prevention.

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

CDPH has described actions that could lead to implementation of this recommendation. It indicates that it has not yet completed its analysis, and it did not provide documentation, so it remains to be seen whether the data it uses for outreach activities and local lead levels is sufficient to demonstrate the effectiveness of that outreach.

1-Year Agency Response

Local prevention programs are in the process of implementing their new Scope of Work requirement to evaluate the effectiveness of program outreach activities. CDPH has developed the attached outreach evaluation toolkit and held training sessions in July 2020 to assist local programs with this requirement and is working with them to evaluate the effectiveness of outreach activities in reducing the number of children with lead poisoning. The new evaluation toolkit provides outreach evaluation guidance and survey tools that local programs can use to assess changes in target population knowledge and behavior resulting from outreach activities. In February 2021, CDPH will receive the results of local program outreach activities in progress reports covering the first six months of the new contract cycle (July-December 2020). Upon receipt of the progress reports, CDPH will review the quantitative results of local program outreach activities, provide feedback to local programs, and begin assessing the effectiveness of outreach activities in reducing the number of children with lead poisoning. To help examine the impact of outreach activities on reducing blood lead levels in children, CDPH is in the process of analyzing blood lead level changes resulting from the lead education packets that CDPH has been mailing since July 2016 to the families of children with blood lead levels of 4.5-9.4 mcg/dL in California health jurisdictions that do not contract with CDPH. Because the Scope of Work timeline for completion of outreach activities is annual, CDPH will perform a complete assessment of outreach effectiveness after the end of the first contract year (June 30, 2021). If outreach is determined to be ineffective, CDPH will explore corrective action measures and/or other approaches to prevention.

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

CDPH's description of the steps taken to address this recommendation do not differ significantly from the condition we reviewed during the course of our audit. The toolkit it describes addresses whether outreach resulted in an increase in participants' knowledge, but does not address whether the outreach resulted in a reduced number of children with lead poisoning, as we recommended. CDPH states that it will begin assessing the effectiveness of outreach activities in reducing the number of children with lead poisoning as it receives progress reports, and that it has begun analyzing blood lead level changes resulting from the lead education packets that it has mailed since July 2016; however, this does not address our our recommendation. Specifically, our recommendation pertains to local programs demonstrating the effectiveness of their outreach in reducing the number of children with lead poisoning.

6-Month Agency Response

From December 2019-April 2020, CDPH completed its review of all 49 local health jurisdiction scopes of work received for the new contract cycle (FY 2020-21 through FY 2022-23), which included the new outreach evaluation requirements. Local program implementation will begin July 1, 2020. CDPH is currently updating the progress report template to link reporting requirements to the new scope of work. CDPH will communicate reporting expectations and offer training opportunities for local programs at the beginning of the new contract cycle.

In February 2021, CDPH will receive local program outreach evaluation results in progress reports covering the first six months of the new contract cycle (July-December 2020). At that time, CDPH will review reports for evaluation progress, continue to provide technical assistance as needed, and begin assessing the effectiveness of outreach activities in reducing the number of children with lead poisoning. Because the scope of work timeline for completion of outreach activities is annual, CDPH will perform a complete assessment after the end of the first contract year (June 30, 2021). CDPH will explore other approaches to prevention if outreach is determined to be ineffective.

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

CDPH provided updated contracts with local prevention programs that include scopes of work requiring them to demonstrate the effectiveness of their outreach. However, these contracts do not require the local programs to assess whether their outreach has reduced the number of children with elevated lead tests, as we recommended. Further, CDPH has not yet begun the process it describes of assessing local programs' progress in reducing the number of children with lead poisoning. We will review CDPH's progress after it has implemented this process.

60-Day Agency Response

CDPH has updated local prevention programs' scope of work requirements beginning in FY 2020-21 through FY 2022-23 to include the evaluation of outreach for purposes of demonstrating its effectiveness. The scope of work template with the new evaluation requirement was disseminated to local prevention programs in November 2019, and completed scopes of work are currently undergoing review by CDPH CLPPB. CDPH will provide technical assistance to local programs on outreach evaluation and check on evaluation progress every six months. CDPH will receive for review local programs' evaluation results to assess whether outreach activities are effective in reducing the number of children with lead poisoning. CDPH will explore other approaches to prevention if outreach is determined to be ineffective.

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

We will review CDPH's new scope of work requirements, CDPH's analysis of the effectiveness of local programs' outreach, and any corresponding evaluation of other approaches once CDPH has implemented this recommendation.

Recommendation #7 To: Public Health, Department of

To offset the cost of mitigating lead exposure in the highest-risk areas of the State, CDPH should seek out and apply for additional lead prevention funding as funding opportunities become available from CDC, the Department of Housing and Urban Development, and CMS. To the extent necessary, CDPH should enter into a memorandum of understanding with DHCS to apply for and obtain this funding

Annual Follow-Up Agency Response From October 2021

CDPH applied for CDC funding (CDC-FRA-EH21-2102: Childhood Lead Poisoning Prevention and Surveillance of Blood Lead Levels in Children) on May 14, 2021. This grant consists of two components; Component A would enhance blood lead surveillance and improve linkages to recommended services. Component B would pilot targeted, population-based interventions aimed at primary prevention of lead exposure with a focus on community-based approaches for lead hazard elimination in housing. As of August 17, 2021, CDPH has been awarded grant funding by the CDC for Component A.

CDPH applied for HUD funding (FR-6500-N-13: Lead Hazard Reduction Grant Program) on July 9, 2021, which was awarded on August 30, 2021. This grant will provide funding for lead hazard reduction to low-income households in two high-risk areas of the state and increase CLPPB's capacity for primary prevention.

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

1-Year Agency Response

CDPH has been collaborating with DHCS to identify CMS funding opportunities for lead abatement. CDPH plans to apply for new CDC funding that will become available in February 2021. The funding supports primary and secondary prevention strategies for childhood lead poisoning including: ensuring blood lead testing and reporting, enhancing blood lead surveillance, improving linkages to recommended services, and developing policies for targeted, population-based interventions (https://www.grants.gov/web/grants/view-opportunity.html?oppId=329557).

From April through October of 2020, CDPH posted eight funding opportunities for which local jurisdictions may qualify, including five from HUD. CDPH continues to update its website with and notify local jurisdictions of newly identified grants available to help eligible entities reduce lead hazards (https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/Grants.aspx).

CDPH is currently collaborating with HUD in preparation for applying for a lead hazard reduction grant in 2021.

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

As CDPH described, its efforts are ongoing and it has not yet applied for funding from any of the agencies we identified in our recommendation.

6-Month Agency Response

CDPH is currently collaborating with DHCS to identify CMS funding opportunities, which could be accessed via an MOU. On March 18, 2020, DHCS indicated that CMS guidance directs that Medicaid funds must be used for direct patient care and could not be used for "broader social or environmental concerns." However, DHCS is currently looking into the possibility of using Medicaid Children's Health Insurance Program (CHIP) Health Service Initiatives (HSIs) for lead abatement.

CDPH prepared an application for a CDC grant (CDC-RFA-EH20-2001) for blood lead surveillance in three high-risk areas. CDC notified CDPH that the Notice of Funding Opportunity was cancelled with COVID cited as the reason. CDPH will continue to apply for CDC funding opportunities as they become available in the future.

CDPH continues to search for lead abatement grant opportunities to abate lead hazards in California. CDPH has posted on its website a list of identified grants available to help eligible entities reduce lead hazards (https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/Grants.aspx). Some of the federal grant offers have recently been removed due to resources directed to COVID-19.

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

As CDPH described, its efforts are ongoing and it has not yet obtained funding from any of the agencies we identified in our recommendation.

60-Day Agency Response

On January 16, 2020, the Centers for Disease Control and Prevention (CDC) informed CDPH that their grant funding is not available for lead abatement. Thus, CLPP will research grant opportunities on an ongoing basis to seek out other possible funding opportunities, create a list of these funding opportunities and share with local health jurisdictions (LHJs) on-going. In addition, CDPH will continue to provide technical assistance to LHJs to apply for these additional resources, when applicable.

CDPH will work with DHCS to explore the process of using CMS funds to pay for mitigation of lead exposure and the possibility of a memorandum of understanding to achieve this purpose. CDPH will continue to encourage use of federal Department of Housing and Urban Development (HUD) funding by state and local jurisdictions to abate lead hazards in California.

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

Recommendation #8 To: Public Health, Department of

To better hold local prevention programs accountable for performing required activities, CDPH should, by June 2020, conduct direct oversight through site visits for each of the local prevention programs, and it should ensure that it continues to do so at least once per contract cycle. In addition, CDPH should use the local prevention programs' biannual progress reports to assess local prevention programs' performance and provide feedback on their strengths and shortcomings.

Annual Follow-Up Agency Response From October 2021

On April 23, 2021, CDPH completed site reviews for the contract cycle that ended in June 2020. CDPH is now conducting monthly site reviews for the current contract cycle, which began July 1, 2020. A schedule is in place to ensure completion of all 49 local prevention program site reviews by June 30, 2023, the end of the current contract cycle. Additionally, CDPH has implemented its improved process of using local prevention programs' biannual progress reports to assess performance and provide feedback on strengths and shortcomings. Attached is the template CDPH used to provide feedback to each local prevention program on progress reports submitted for the first reporting period of the current contract cycle (July 1, 2020-December 30, 2020), populated with feedback to Calaveras County Childhood Lead Poisoning Prevention Program for Scope of Work Objective 2-I for purposes of example. For each Scope of Work objective, the template includes performance measures (i.e., local prevention program performance with respect to Scope of Work performance goals); a comments column for strengths and shortcomings; and an action items column for requesting additional information. Any actions items requested are due within 30 days. CDPH will continue this feedback process for all subsequent reporting periods, further refining the process as needed.

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

1-Year Agency Response

By January 1, 2021, CDPH will have completed 43 of 50 local prevention program site reviews for FY 2017-18 through FY 2019-20. CDPH will review the remaining seven local prevention programs by the end of April 2021, continuing to observe site review safety modifications and working around reductions in local program and CLPPB staffing due to COVID-19 impacts.

In July 2020, CDPH disseminated new progress report templates to local prevention programs for the July-December 2020 reporting period. These reporting templates are Excel workbooks that facilitate tracking of program activities in real-time and will provide CDPH with more robust program performance data. The attached Performance Tracking Fact Sheet describes the components of the report and the next steps. Training sessions, videos, and a guidance document were provided to assist local prevention programs with completing the new progress report templates.

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

CDPH has not yet completed site reviews for the contract cycle that ended in June 2020. In addition, although it describes tools that may result in more consistent and streamlined evaluations of local programs, it did not provide documentation to demonstrate that it performed evaluations using those tools, nor is it clear that the new evaluation process results in an assessment of local prevention programs' performance and feedback on their strengths and shortcomings.

6-Month Agency Response

CDPH had planned to conduct up to three site visits each month to hold local prevention programs accountable for performing required activities. However, all March-April 2020 site reviews had to be cancelled due to local health jurisdiction impacts from COVID-19, including office closures and local health jurisdiction staff redirection to response activities. CDPH is planning to conduct six site reviews from June-July 2020, with social distancing strategies. CDPH remains committed to completing all FY 2017-18 through FY 2019-20 site reviews by April 2021.

Additionally, CDPH developed internal guidance for progress report feedback that will be piloted for the remainder of the current contract period.

For the new contract cycle, CDPH is updating the progress report template to link reporting requirements to the new scope of work. Once the updated template is finalized, the internal guidance for progress report feedback will be updated to include new requirements. The updated report template and updated guidance for report feedback will be implemented for the first reporting period of the new contract cycle, to commence January 2021, covering work performed July-December 2020.

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

CDPH was behind its schedule for visiting all local program sites before the COVID-19 pandemic, and it did not complete site visits for all local programs before the end of the most recent contract cycle on June 30, 2020. We will review CDPH's new process for providing feedback on progress reports once CDPH has implemented the process.

60-Day Agency Response

CDPH will continue to conduct up to three site visits each month to hold local prevention programs accountable for performing required activities. By April 2021, CDPH will complete all 50 local prevention program site reviews for the current contract cycle (FY 2017-18 through FY 2019-20). CDPH will continue to visit each local program to review work activities for each new contract cycle. CDPH also reaches out on a regular basis to provide technical assistance to these local programs. CDPH will continue to assess local program performance through biannual progress reports by cross walking progress report data against scope of work requirements. CDPH will provide more specific feedback on strengths and opportunities for improvement pertaining to the implementation of contractual activities.

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

CDPH's expected implementation date indicates that it remains behind schedule on its site visits, and it will not complete all site reviews for the current contract cycle. We will review implementation of this recommendation, including its feedback on strengths and shortcomings in biannual progress reports, once CDPH has begun implementation.

Recommendation for Legislative Action

To support CDPH's efforts to efficiently monitor lead test results, the Legislature should amend state law to require that laboratories report Medi-Cal identification numbers or equivalent identification numbers with all lead test results.

Description of Legislative Action

As of January 7, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken

Description of Legislative Action

As of January 7, 2021, the Legislature has not taken action to address this specific recommendation.

AB 2278 (Quirk, 2020) would have required a laboratory that performs a blood lead analysis to report to CDPH, among other things, the Medi-Cal identification number and medical plan identification number, if available, for each analysis on every person tested. This bill failed passage due to adjournment of the 2019-20 Regular Legislative Session.

AB 2422 (Grayson, 2020) would have added the Medi-Cal identification number, or other equivalent medical identification number of the person tested to the information that a laboratory is required to provide regarding blood lead level tests. AB 2422 also would have required, if the person tested is a minor, the laboratory to include the person's contact information and a unique identifier, in a form to be determined by CDPH.

California State Auditor's Assessment of 1-Year Status: Legislation Proposed But Not Enacted

Description of Legislative Action

AB 2278 (Quirk) would require a laboratory that performs a blood lead analysis to report to CDPH, among other things, the Medi-Cal identification number and medical plan identification number, if available, for each analysis on every person tested. As of July 7, 2020, this bill was pending in the Assembly Health Committee.

AB 2422 would add the Medi-Cal identification number, or other equivalent medical identification number of the person tested to the information that a laboratory is required to provide regarding blood lead level tests. AB 2422would require, if the person tested is a minor, the laboratory to include the person's contact information and a unique identifier, in a form to be determined by CDPH.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced

Recommendation for Legislative Action

To ensure that CDPH can contact the families of children with lead poisoning and has alternative information to match lead tests to the children's records that do not have unique identification numbers, the Legislature should amend state law to require laboratories to report phone numbers and addresses with all lead test results.

Description of Legislative Action

As of January 7, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken

Description of Legislative Action

As of January 7, 2021, the Legislature has not taken action to address this specific recommendation.

AB 2422 (Grayson, 2020) would have required, if the person tested is a minor, a laboratory to include the person's contact information and a unique identifier in a form to be determined by CDPH .

California State Auditor's Assessment of 1-Year Status: Legislation Proposed But Not Enacted

Description of Legislative Action

AB 2422would require, if the person tested is a minor, a laboratory to include the person's contact information and a unique identifier in a form to be determined by CDPH.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced

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 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.

Recommendation #12 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: Provide guidance to health care providers about the risks of childhood lead exposure and statutory requirements related to lead testing.

60-Day Agency Response

CDPH developed a revised Standard of Care Guidelines document which incorporates the California Health and Safety Code Section 105286 requirements. This same document also includes "Potential Sources of Lead: Educating Families to Prevent Childhood Lead Exposure," which was updated to include additional multiple lead risk factors cited in statute and risk factors identified during case investigations of lead-poisoned children. These updated documents were posted on the department website on August 15, 2019. (Documents attached)

In August 2019, CLPPB submitted an article notifying physicians of the updated version of "Standard of Care Guidelines on Childhood Lead Poisoning for California Health Care Providers" and "Potential Sources of Lead: Educating Families to Prevent Childhood Lead Exposure." for inclusion in the Fall 2019 California Medical Board Newsletter. The article is titled "Updates on the Childhood Lead Poisoning Prevention Program" and also provides information for California physicians regarding childhood lead poisoning prevention, screening, and management, including mandated requirements, information updates, and resources. The California Medical Board Newsletter is sent to all California physicians, and is expected to be published in a combined Fall 2019/Winter 2020 issue which will include the CLPPB-authored article.

CLPPB will continue to identify opportunities to provide guidance to medical providers throughout California about the risks of childhood lead exposure and statutory requirements related to lead testing. For example, CLPPB will be directly distributing the new guidelines and source information (along with a listing of free educational materials available for patients) to medical providers caring for children in California, beginning in March 2020.

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

CDPH met the requirements to provide health care providers with guidance about the risks of childhood lead exposure and statutory requirements related to lead testing based on the California Medical Board Newsletter article published for Fall 2019/Winter 2020.

Recommendation #13 To: Public Health, Department of

To ensure a more equitable distribution of resources for treating children with lead poisoning, CDPH should, by June 2020, update its methodology for allocating funds to local prevention programs, including accounting for the most recent annual count of children with lead poisoning in each jurisdiction. CDPH should revise the allocations before each contract cycle.

1-Year Agency Response

CDPH updated the local prevention program funding methodology allocations based on the most recent case data available, including the count of children with lead poisoning in each jurisdiction in June 2020. As a result, CDPH has awarded a total of $2.0 million additional funding to 16 counties. CDPH will assess the burden of cases across counties before each contract cycle to ensure the funding allocations are equitable. The CDPH policy memorandum attached describes the protocols for equitable distribution of resources to contracted local prevention programs.

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

6-Month Agency Response

CDPH updated the local prevention program funding methodology allocations based on the most recent case data available, including the count of children with lead poisoning in each jurisdiction. CDPH will assess the burden of cases across counties before each contract cycle to ensure the funding allocations are equitable.

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

CDPH updated the data used in its allocation of funds for local programs; however, it has not yet provided evidence of a policy to update the allocations before each contract cycle.

60-Day Agency Response

In October 2019, CDPH conducted an analysis for allocating funds to local prevention programs and included accounting of the most recent annual count of children with lead poisoning in each jurisdiction. CDPH is currently exploring fiscal mechanisms to increase its funding allocation for local prevention programs based on this analysis. CDPH will annually review the number of children with lead poisoning and ensure funding allocations remain equitable based on burden.

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

All Recommendations in 2019-105

Agency responses received are posted verbatim.