August 23, 2016 2015-131
The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
Sacramento, California 95814
Dear Governor and Legislative Leaders:
As requested by the Joint Legislative Audit Committee, the California State Auditor presents this audit report concerning the oversight of psychotropic medications prescribed to California’s foster children. This report concludes that the State and counties have failed to adequately oversee the prescribing of these medications. Specifically, some counties have yet to adopt the State’s prescribing guidelines (state guidelines), a valuable tool that counties should use to ensure that foster children do not receive inappropriate or unnecessary psychotropic medications. Consequently, when we reviewed the case files for a total of 80 foster children at Los Angeles, Madera, Riverside, and Sonoma counties, we found that many foster children were authorized psychotropic medications in quantities and dosages that exceeded the state guidelines. Although exceeding the state guidelines may be medically appropriate in some cases, we found no evidence that the counties had followed up with the health care providers to ensure the safety and necessity of the medications. When counties do not follow up with providers about prescriptions that exceed the state guidelines, the counties cannot ensure that they are reducing foster children’s exposure to potentially inappropriate medication interventions.
Further, the counties have not always ensured that they follow best practices relating to the health services that foster children should receive in conjunction with their psychotropic medications. Specifically, one-third of the foster children whose records we reviewed did not receive follow‑up appointments with their prescribers or other healthcare providers within 30 days after they began taking new psychotropic medications, thus increasing the risk that any harmful side effects would go unaddressed. Further, our review of the 80 case files indicates that foster children did not always receive corresponding psychosocial services before or while they were taking psychotropic medications. Additionally, and in violation of state law, counties did not always obtain required court authorizations or parental consents before foster children received prescriptions for psychotropic medications.
Finally, we found that the fragmented structure of the State’s child welfare system contributes to the problems we identified. Oversight of psychotropic medications prescribed to foster children is vested among different levels and branches of government, leaving us unable to identify a comprehensive plan that coordinates the various mechanisms in place. Although the different public entities involved have made efforts to collaborate, the State’s overall approach has exerted little system‑level oversight to help ensure that these entities’ collective efforts actually work as intended and produce desirable results. For instance, the fragmented oversight structure has contributed to the State’s failure to ensure it and other stakeholders have the reliable information necessary to monitor the prescription of psychotropic medications to foster children. Even when combined, the results from data systems operated by two state departments still contain inaccurate and incomplete data related to foster children who are prescribed psychotropic medications. Consequently, neither of the two departments can completely identify which foster children statewide are prescribed psychotropic medications or which medications those children are prescribed. We recommend that the State collaborate with counties and other stakeholders to develop and implement a reasonable oversight structure for psychotropic medications prescribed to foster children.
ELAINE M. HOWLE, CPA