Report 2015-131 All Recommendation 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 #1 To: Los Angeles County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children's case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.

1-Year Agency Response

As noted in our report of February 23, 2017, Los Angeles County's efforts with respect to psychotropic medications are being coordinated by the Psychotropic Medication Workgroup (Workgroup) convened by the Los Angeles County Office of Child Protection in July 2016. The Workgroup has met monthly since that time, and has recently been joined by representatives from the California Youth Connection (CYC).

On April 15, 2017, Los Angeles County implemented revised protocols for the approval process and the monitoring process of the use of psychotropic medications for children and youth involved in both the child welfare and juvenile justice systems. These revised protocols incorporate the new forms mandated by the Judicial Council last year. We believe that the new forms and protocols, along with practice changes, are implementing the recommendations made by the State Auditor in its August 2016 report.

At the Workgroup's monthly meetings, the various member entities—including the departments of Children and Family Services, Probation, Mental Health, and Public Health, along with the Juvenile Court—report on how the protocols and practices are being followed and properly documented. While implementation is still a work in progress, we are satisfied that compliance is steadily improving.

(Please see supporting documentation. The revised approval and monitoring protocols were submitted as attachments to our February 23, 2017, response. Attached to this response are newly revised policies and procedures from the Department of Children and Family Services regarding psychotropic medication, and newly revised policies and procedures from the Department of Public Health on the role of public health nurses in the new approval and monitoring protocols.)

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

6-Month Agency Response

As mentioned in our 60-day response, most if not all of Los Angeles County's efforts in relation to the prescription and administration of psychotropic medications for child-welfare and juvenile-justice youth——including those in response to the State Auditor report——originate from a Psychotropic Medication Workgroup (Workgroup) convened by the Los Angeles County Office of Child Protection (OCP) in July 2016.

In addition to OCP staff, the Workgroup consists of representatives from the departments of Children and Family Services, Probation, Mental Health, and Public Health, the Board of Supervisors, the Juvenile Court, Children's Law Center, Los Angeles Dependency Lawyers Inc., the Public Defender, the Alternate Public Defender, Court Appointed Special Advocates, the Commission for Children & Families, the Alliance for Children's Rights, Public Counsel, the Association of Community Human Services Agencies, and L.A. Care.

In its monthly meetings, the Workgroup's primary focus has been the implementation of the new forms mandated by the California Judicial Council to be used during the process of prescribing and administering psychotropic medication for the above-mentioned children and youth. The Workgroup has redrafted protocols for the approval and monitoring of the use of psychotropic medications, and has attached these protocols to this submission.

(Please see supporting documentation.)

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

60-Day Agency Response

Most, if not all, of Los Angeles County's efforts in relation to the prescription and administration of psychotropic medications for child-welfare and juvenile-justice youth—including those in response to the State Auditor report—will originate from a Psychotropic Medication Workgroup (Workgroup) convened by the Los Angeles County Office of Child Protection (OCP) in July 2016. In addition to OCP staff, the Workgroup consists of representatives from the departments of Children and Family Services, Probation, Mental Health, and Public Health, the Board of Supervisors, the Juvenile Court, Children's Law Center, Los Angeles Dependency Lawyers Inc., the Public Defender, the Alternate Public Defender, Court Appointed Special Advocates, the Commission for Children & Families, the Alliance for Children's Rights, Public Counsel, the Association of Community Human Services Agencies, and L.A. Care.

Over the next year, this Workgroup will develop strategies to more closely monitor and follow up on authorizations for prescriptions that exceed the state guidelines. Its initial focus has been the implementation of new forms developed by the California Judicial Council that are designed to: enhance the quality/quantity of information presented to judges tasked by law with decisions on approving the administration of psychotropic medications; enhance the engagement of youth, parents, caregivers, and agencies involved in the process; ensure that alternatives to medication are appropriately considered; ensure that other mental health services accompany the use of the medications; and help monitor the effects of the medications.

Discussions have focused on clarifying which persons or agencies will be responsible for completing each form and the timelines for doing so. Similar decisions are being made with respect to the optional forms for youth and those that can be completed by parents, caregivers, attorneys for the parties, and others.

(Please see supporting documentation.)

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

Recommendation #2 To: Los Angeles County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

1-Year Agency Response

The Juvenile Court now orders a 45-day progress report for every new medication or increased dosage on a previously approved medication. Among other things, that report requires information on whether or not the child was seen by the prescribing physician within the 30-day timeframe recommended by the State Auditor.

(Please see supporting documentation. The revised approval and monitoring protocols were submitted as attachments to our February 23, 2017, response. Attached to this response are newly revised policies and procedures from the Department of Children and Family Services regarding psychotropic medication, and newly revised policies and procedures from the Department of Public Health on the role of public health nurses in the new approval and monitoring protocols.)

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

The documents that Los Angeles County mentions are available from our office.

6-Month Agency Response

Los Angeles County protocols now require 30-day follow-ups to be documented in progress reports ordered by Juvenile Court judges 45 days after they approve any new medication or an increase in dosage of a previously authorized medication.

Our next progress report for the State Auditor will include our efforts at the complete implementation of the new procedures outlined in our response to Recommendations 1 and 2.

(Please see supporting documentation.)

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

60-Day Agency Response

Over the next year, the Workgroup detailed in our response to Recommendation 1 will develop strategies to ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

The Workgroup's agenda will also focus specifically on issues raised in the report of the State Auditor to the extent that the implementation of its recommendations is not being met by our ongoing work. For instance, in 2009, Los Angeles County implemented monitoring protocols for both the dependency court and the delinquency court. Those protocols require the court to set a progress report 40 days after it approves any new medication or an increase in dosage of a previously authorized medication. Among other things, that report is required to include the date of the follow-up visit with the prescribing physician. We will need to revisit this issue to ensure that the follow-up visits occur within the timelines stated in the State Auditor report.

(Please see supporting documentation.)

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

Recommendation #3 To: Los Angeles County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

1-Year Agency Response

The forms mandated by the Judicial Council require assurances that proper mental health services are being received along with the medication, and also that alternatives to medication are being considered.

(Please see supporting documentation. The revised approval and monitoring protocols were submitted as attachments to our February 23, 2017, response. Attached to this response are newly revised policies and procedures from the Department of Children and Family Services regarding psychotropic medication, and newly revised policies and procedures from the Department of Public Health on the role of public health nurses in the new approval and monitoring protocols.)

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

The documents that Los Angeles County mentions are available from our office.

6-Month Agency Response

While the new Judicial Council forms provide more information than previous forms——specifically with respect to enhancing input from multiple partners, ensuring that alternatives to medication are considered, and ensuring that other mental health services accompany the use of the medications——the Workgroup has focused on articulating that process.

Protocols now mandate agency input and specify how youth, caregivers, parents, tribes, attorneys, and others can provide input during the approval and administration phases. Notable changes include the inclusion of public health nurses (PHNs) in working with social workers and caregivers to assist with follow-up appointments, advising caregivers and social workers, monitoring medication effects, and recording activities.

(Please see supporting documentation.)

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

60-Day Agency Response

Over the next year, the Workgroup detailed in our response to Recommendation 1 will develop strategies for processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

As mentioned previously, the Workgroup's initial focus has been the implementation of the new forms developed by the California Judicial Council to improve the process for the administration of psychotropic medications. The forms, which became effective on July 1, 2016, are designed (among other things) to enhance the quality and quantity of information presented to judges who are tasked by law with deciding whether or not to approve the administration of psychotropic medications; to enhance the engagement of youth, parents, caregivers, and agencies involved in the process; to ensure that alternatives to medication are appropriately considered; to ensure that other mental health services accompany the use of the medications; and to help monitor the effects of the medications.

In addition, on September 13, 2016, the Los Angeles County Board of Supervisors voted to instruct the Office of Child Protection to collaborate with the Department of Children and Family Services (DCFS) and the Department of Public Health (DPH) to consolidate the public health nurse (PHN) programs of DCFS and DPH within DPH. The Board of Supervisors also instructed the relevant entities to determine how to most effectively use the PHN program, a discussion that will necessarily include the issue of how best to use PHNs with respect to psychotropic medications.

(Please see supporting documentation.)

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

Recommendation #4 To: Los Angeles County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children's case files.

1-Year Agency Response

We are also working with the Department of Children and Family Services, Probation, and other stakeholders (constituting the proverbial "village") to routinely inquire of children and caregivers on the use of medications and to fully document their answers. Our goal is to ensure that we are aware of every child involved in our systems who is being administered psychotropic medications, and to ensure that every one who is being medicated has in fact been the subject of the approval process designed to make sure that the use of these medications is appropriate.

(Please see supporting documentation. The revised approval and monitoring protocols were submitted as attachments to our February 23, 2017, response. Attached to this response are newly revised policies and procedures from the Department of Children and Family Services regarding psychotropic medication, and newly revised policies and procedures from the Department of Public Health on the role of public health nurses in the new approval and monitoring protocols.)

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

The documents that Los Angeles County mentions are available from our office.

6-Month Agency Response

Our 60-day response filed in October 2016 referenced a standing order issued by the Presiding Judge of the Juvenile Court requiring the Department of Mental Health's credentialing of prescribers of psychotropic medications for children and youth in group homes. That process has been implemented, and the blanket order is attached to this submission.

The October response also referenced the development of an electronic system to track the use of psychotropic medications. Los Angeles County has been actively involved with the California Department of Social Services in its efforts to accomplish this through the state's development of its new CWS/NS, currently being built to replace the CWS/CMS case management option.

(Please see supporting documentation.)

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

60-Day Agency Response

Over the next year, the Workgroup detailed in our response to Recommendation 1 will develop strategies to implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications, that court authorizations for psychotropic medications are renewed within 180 days (as state law requires), and that Los Angeles County better documents the court authorizations and parental consents in foster children's case files.

In addition to the Workgroup's efforts regarding forms and responsibilities, we most importantly want to ensure that we are aware of every child in our system who is being administered a psychotropic medication. We also want to know other things, including but not limited to what medications they are taking and why, where they live, who prescribed the medication, who authorized the medication, and much more. Los Angeles County is also engaged in developing a system to track the use of psychotropic medications electronically.

(Please see supporting documentation.)

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

Recommendation #5 To: Los Angeles County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.

1-Year Agency Response

We are also working with the Department of Children and Family Services, Probation, and other stakeholders (constituting the proverbial "village") to routinely inquire of children and caregivers on the use of medications and to fully document their answers. Our goal is to ensure that we are aware of every child involved in our systems who is being administered psychotropic medications, and to ensure that every one who is being medicated has in fact been the subject of the approval process designed to make sure that the use of these medications is appropriate.

(Please see supporting documentation. The revised approval and monitoring protocols were submitted as attachments to our February 23, 2017, response. Attached to this response are newly revised policies and procedures from the Department of Children and Family Services regarding psychotropic medication, and newly revised policies and procedures from the Department of Public Health on the role of public health nurses in the new approval and monitoring protocols.)

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

The documents that Los Angeles County mentions are available from our office.

6-Month Agency Response

The Workgroup has redrafted protocols for the approval and monitoring of the use of psychotropic medications, and has attached these protocols to this submission.

(Please see supporting documentation.)

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

60-Day Agency Response

Over the next year, the Workgroup detailed in our response to Recommendation 1 will develop strategies to implement a process for county staff and caregivers to work together to ensure that psychotropic medications are authorized before being provided to foster children, and to ensure that Los Angeles County obtains accurate medication start dates from caregivers.

The Workgroup's discussions on the California Judicial Council's new forms have focused on clarifying which persons or agencies will be responsible for completing each form and the timelines for doing so. We have also focused on these issues with respect to the new optional forms for youth and the new optional forms that can be completed by parents, caregivers, attorneys for the parties, and others.

It is also important to note that it is the Workgroup's intent to ensure training for all segments of the community who interact with our children with respect to all of the initiatives developed by the Workgroup.

(Please see supporting documentation.)

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

Recommendation #6 To: Madera County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children's case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.

6-Month Agency Response

Madera County revised the JV220 Psychotropic Medication Policy and Procedure Guidelines (PPG) to ensure that foster children only receive psychotropic medications that are appropriate and medically necessary. While our 6 month response only included recommendation "6", we agreed with the entire list of recommendations included in the Auditor's report and incorporated our compliance efforts into the PPG.

Documentation will be emailed to dalec@auditor.ca.gov under separate cover.

Training was provided to all CWS staff on May 3,2017.

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

60-Day Agency Response

This is included in our current policy and procedure guide, but will be an ongoing training process as new staff are hired and have children recommended/placed on psychotropic medication.

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

Recommendation #7 To: Madera County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

6-Month Agency Response

Madera County revised the JV220 Psychotropic Medication Policy and Procedure Guidelines (PPG) to ensure that foster children only receive psychotropic medications that are appropriate and medically necessary. While our 6 month response only included recommendation "6", we agreed with the entire list of recommendations included in the Auditor's report and incorporated our compliance efforts into the PPG.

Documentation will be emailed to dalec@auditor.ca.gov under separate cover.

Training was provided to all CWS staff on May 3,2017.

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

Recommendation #8 To: Madera County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

6-Month Agency Response

Madera County revised the JV220 Psychotropic Medication Policy and Procedure Guidelines (PPG) to ensure that foster children only receive psychotropic medications that are appropriate and medically necessary. While our 6 month response only included recommendation "6", we agreed with the entire list of recommendations included in the Auditor's report and incorporated our compliance efforts into the PPG.

Documentation will be emailed to dalec@auditor.ca.gov under separate cover.

Training was provided to all CWS staff on May 3,2017.

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

Recommendation #9 To: Madera County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children's case files.

6-Month Agency Response

Madera County revised the JV220 Psychotropic Medication Policy and Procedure Guidelines (PPG) to ensure that foster children only receive psychotropic medications that are appropriate and medically necessary. While our 6 month response only included recommendation "6", we agreed with the entire list of recommendations included in the Auditor's report and incorporated our compliance efforts into the PPG.

Documentation will be emailed to dalec@auditor.ca.gov under separate cover.

Training was provided to all CWS staff on May 3,2017.

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

Recommendation #10 To: Madera County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.

6-Month Agency Response

Madera County revised the JV220 Psychotropic Medication Policy and Procedure Guidelines (PPG) to ensure that foster children only receive psychotropic medications that are appropriate and medically necessary. While our 6 month response only included recommendation "6", we agreed with the entire list of recommendations included in the Auditor's report and incorporated our compliance efforts into the PPG.

Documentation will be emailed to dalec@auditor.ca.gov under separate cover.

Training was provided to all CWS staff on May 3,2017.

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

Recommendation #11 To: Riverside, County of

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children's case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.

6-Month Agency Response

Fully Implemented - DPSS, RUHS-Behavioral Health and Public Health Nursing continue to meet to address oversight of the prescribing of psychotropic medications for dependent children and youth. Behavioral Health's Quality Improvement (QI) Department has dedicated staff psychiatrists to oversee psychotropic medication. Any request for court approval for psychotropic medication that does not align with standards is returned to the provider for additional information and review. Currently, this process has resulted in a decrease in requests being returned by the court. The interagency protocol has been updated and is implemented.

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

60-Day Agency Response

The DPSS, RUHS-Behavioral Health and Public Health Nursing meet regularly to address the process for oversight of the prescribing of psychotropic medications for dependent children and youth. Behavioral Health's Quality Improvement Department now has dedicated staff overseeing psychotropic medications, and has initiated a new process: if a request for psychotropic medication does not align with standards, the QI staff return it to the provider for additional information and review. Many of those concerns then get resolved and do not involve the court. Any concerns noted are also relayed to the provider. The interagency protocol has been updated and will be implemented.

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

Recommendation #12 To: Riverside, County of

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

1-Year Agency Response

Riverside University Health System - Behavioral Health (RUHS-BH) informed psychiatrists of these requirements by letter from the Medical Director dated April 5, 2017. To track compliance, RUHS-BH created a report, MHS 8029, to track the 30-day follow up requirement.

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

6-Month Agency Response

Fully implemented - Riverside County has hired additional child psychiatrists and has communicated the expectation of a 30 day follow-up to prescribing doctors. County Behavioral Health is recommending to their Psychiatrists that they schedule appointments for foster children every four weeks which is in process. Behavioral Health is continuing to address increasing appointment availability to ensure more flexibility for 30 day appointments.

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

Riverside County has not yet fully implemented this recommendation. Riverside County stated that it communicated the state guidelines and the results of the audit, including the expectation of a 30-day follow up, in psychiatrist staff meetings. However, it further stated that it commissioned a performance improvement project regarding its "medication declaration process/medication monitoring" of foster children and that to assess how it is doing in regards to the 30-day follow up, it has been internally developing a new report. Finally, Riverside County stated that it plans to formalize the verbal directions it provided to psychiatrists and will provide this information in its next update.

60-Day Agency Response

Riverside County has improved on thirty-day follow-up appointments by hiring additional child psychiatrists, communicating the expectation as part of the psychotropic medication package distributed to prescribing doctors, and developing innovative ways to build the pool of available child psychiatrists.

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

Recommendation #13 To: Riverside, County of

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

1-Year Agency Response

Both RUHS-BH and Department of Public Social Services - Children's Services Division (DPSS-CSD) have adopted these guidelines. RUHS-BH informed psychiatrists of these requirements through a letter from the Medical Director dated April 5, 2017 and DPSS-CSD within the Authorization for Psychotropic Medications Policy dated July 19, 2017. In addition, this is also part of the Child and Family Team Policy, Attachment 1: CFTM Matrix dated 7/17/2017.

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

6-Month Agency Response

In addition to giving psychiatrists guidelines requiring that treatment options be provided when psychotropic medications are used, Riverside County is including this recommendation wherever psychotropic medications are discussed or reviewed. Treatment options could be further explored when child's mental health concerns are the focus of the Child and Family Team Meetings. DPSS has also developed an e-learning training for social workers on psychotropic medication that stresses the importance of mental health, psychosocial, behavioral health, or substance abuse services both before and concurrently with psychotropic medication. A new Psychotropic Medication Policy is being drafted that will include this recommendation. The Child and Family Team (CFT) meetings will also have this as a regular topic at CFTs with those children on psychotropic medication.

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

60-Day Agency Response

. The County workgroup has been discussing how best to use child and family teaming (CFT) to ensure appropriate services are provided prior to or in conjunction with psychotropic medications. The package with the guidelines psychiatrists receive explains that treatment options are to be provided when psychotropic medications are used, and only when necessary.

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

Recommendation #14 To: Riverside, County of

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children's case files.

1-Year Agency Response

Both RUHS-BH and DPSS-CSD have adopted these guidelines. Behavioral Health informed psychiatrists of these requirements through a letter from the Medical Director dated April 5, 2017 and DPSS-CSD within the Authorization for Psychotropic Medications Policy dated July 19, 2017. DPSS-CSD has three Public Health Nurses funded by SB 319 to assist with ensuring, documenting and tracking compliance.

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

6-Month Agency Response

Once funding from SB319 is available, the county expects to hire two Public Health Nurses to oversee the administration of psychotropic medications. The scope of practice will include: ensuring that court consents are obtained and documented, tracking their renewal within 180 days, and improving documentation of the above in the foster children's case files. In addition, the Children's Services Psychotropic Medication policy which is in development will have a monthly medication log for caregivers to use, allowing for tracking of the start date of when children began taking their medication. However, one of the barriers that currently prevents DPSS from implementing this process is pending clarification from the State on whether the start date entered in CWS/CMS is reflective of the medication administration, or the date of court approval.

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

60-Day Agency Response

DPSS sent a letter to all caregivers as a reminder not to start administering the child/youth psychotropic medications until they have received permission due to emergency placement or court/parental authorization. The County workgroup continues to develop the protocol to account for and document parental consent, and where to document the consent.

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

Recommendation #15 To: Riverside, County of

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.

1-Year Agency Response

Both RUHS-BH and DPSS-CSD have adopted these guidelines. RUHS-BH informed psychiatrists of these requirements through a letter from the Medical Director dated April 5, 2017 and DPSS-CSD within the Authorization for Psychotropic Medications Policy dated July 19, 2017. The three Public Health Nurses working at DPSS-CSD are also in contact with caregivers.

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

6-Month Agency Response

In progress - a process has been developed. The Children's Services Psychotropic Medication policy is being drafted to include guidance for social workers, and will have a monthly Medication Administration Log for caregivers to use, which will allow for tracking of the start date of when the child began taking the medication(s). However, Riverside County is still awaiting the State's direction on how to determine and document the medication start date.

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

60-Day Agency Response

In the absence of State direction on how to determine and document the medication start date, the County team is developing a working date to use. DPSS sent a letter to caregivers as a reminder not to start administering medications without parental consent or court authorization. Agency policies and procedures are being updated to provide workers guidance as to informing caregivers on: general uses for and side effects of psychotropic medications, how to document frequency and dosage, and behavioral observations while the youth is receiving medication. The social worker is to review this process for psychotropic medication administration with caregivers upon placement, and reinforce at each visit.

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

Recommendation #16 To: Riverside, County of

To improve its oversight of foster children who are prescribed psychotropic medications, Riverside County should immediately adopt the state guidelines for its physicians' use when prescribing psychotropic medications and for the county's use when reviewing court authorization requests.

60-Day Agency Response

Riverside County distributed the guidelines to all prescribing psychiatrists. The date of the mailing was June 30, 2016 with the notice that the process change was effective July 1, 2016. The date of full implementation was August 23, 2016.

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

Recommendation #17 To: Riverside, County of

To improve its oversight of foster children who are prescribed psychotropic medications, Riverside County should continue to use its new tracking process to better ensure that court authorizations are renewed within 180 days.

1-Year Agency Response

Both RUHS-BH and DPSS-CSD have adopted these guidelines. RUHS-BH informed psychiatrists of these requirements through a letter from the Medical Director dated April 5, 2017 and DPSS-CSD within the Authorization for Psychotropic Medications Policy dated July 19, 2017. DPSS-CSD has three Public Health Nurses to ensure and track compliance. DPSS-CSD staff receives monthly reports on JV220 status that includes expiration dates.

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

6-Month Agency Response

With the additional State funding from SB319, Riverside County will hire an additional two Public Health Nurses to track and ensure court authorizations are renewed within 180 days.

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

60-Day Agency Response

The County continues to use and look for ways to improve tracking mechanisms. With additional State funding to support the hiring of more Public Health Nurses, a more inclusive monthly report will be developed.

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

Recommendation #18 To: Sonoma County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children's case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.

1-Year Agency Response

Sonoma County Department of Health Services, Behavioral Health Division: Mental Health Services (DHS MH) uses the Department of Social Services Foster Care Improvement Project, Guidelines for Use of Psychotropic Medication with Children and Youth in Foster Care. In Spring of 2017, Sonoma County's Family, Youth and Children's (FY&C) Division instituted a secondary review process of all psychotropic medications prescribed to foster children by a reviewing psychiatrist. When prescribed medications, client ages, or dosage amounts exceed guidelines, the reviewing psychiatrist consults with the prescribing physician and documents their rationale for exceeding the guidelines. If the psychiatrist does not consider the prescribing physician's rationale for exceeding the guidelines to be adequate or justified, she will document that opinion for Human Services Department (HSD) and the information is passed on to the court or parent.

FY&C developed policies and procedures to ensure that the reviewing psychiatrists' concerns are documented. In the early summer of 2017, 2 Public Health Nurses filled vacancies in HCPCFC program and working directly with the reviewing psychiatrist to monitor clients taking psychotropic medications. The nurses and psychiatrist have begun a monitoring committee that oversees and reviews all foster children taking psychotropic medications. The Psychotropic Medication Oversight Committee (PMOC) meets regularly and reviews cases—the first goal is to address and monitor complex cases and follow up with prescribing physicians, social workers, and caregivers as needed. As a note, FY&C's percentage of foster youth prescribed psychotropic medications, according to Medi-Cal claims data for the 4th Quarter of 2016, was 9.65%.

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

6-Month Agency Response

County of Sonoma Department of Health Services, Behavioral Health Division: Mental Health Services (DHS MH) is using the Department of Social Services Foster Care Improvement Project, California Guidelines for Use of Psychotropic Medication with Children and Youth in Foster Care. When numbers of prescribed medications, specific age groups, or dosage amounts exceed the guidelines, the reviewing psychiatrist consults with the prescribing physician and documents the physician's rationale for exceeding the guidelines. If the reviewing psychiatrist does not consider the prescribing physician's rationale for exceeding the guidelines to be adequate or justified, she will document that opinion for the Human Services Department and the information will be passed on to the court or parent.

County of Sonoma Human Services Department, Family, Youth & Children's (FY&C) Division is in the process of developing policies and procedures to ensure that the reviewing psychiatrist's concerns and opinions are documented in each youth's case file. In addition, FY&C has recently received approval from the Board of Supervisors to add 2 Public Health Nurses and a psychiatric nurse effective in first quarter 2017. It is expected, at this time, that these nurses will likely be hired in Summer 2017. We anticipate that psychiatric nurse will be assigned the task of monitoring psychotropic medication prescriptions including, but not limited to, follow-up with physicians to monitor prescriptions including those that exceed the state guidelines and to ensure 30-day follow-up with prescribing physicians when new medications are being taken by a foster youth. As a note, Sonoma County's percentage of foster youth prescribed psychotropic medications, for the 3rd Quarter of 2016, was 12.4%, a one year decrease of 18.9% and a five year decrease of 48.6%.

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

60-Day Agency Response

County of Sonoma Department of Health Services, Behavioral Health Division: Mental Health Services (DHS MH) is using the Department of Social Services Foster Care Improvement Project, California Guidelines for Use of Psychotropic Medication with Children and Youth in Foster Care. When numbers of prescribed medications, specific age groups, or dosage amounts exceed the guidelines, the reviewing psychiatrist consults with the prescribing physician and documents the physician's rationale for exceeding the guidelines. If the reviewing psychiatrist does not consider the prescribing physician's rationale for exceeding the guidelines to be adequate or justified, she will document that opinion for the Human Services Department and the information will be passed on to the court or parent.

County of Sonoma Human Services Department, Family, Youth & Children's (FY&C) Division is in the process of developing policies and procedures to ensure that the reviewing psychiatrist's concerns and opinions are documented in each youth's case file. In addition, FY&C has recently received approval from the Board of Supervisors to add 3 Public Health Nurses and a psychiatric nurse effective in first quarter 2017. We anticipate that psychiatric nurse will be assigned the task of monitoring psychotropic medication prescriptions including, but not limited to, follow-up with physicians to monitor prescriptions including those that exceed the state guidelines and to ensure 30-day follow-up with prescribing physicians when new medications are being taken by a foster youth.

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

Recommendation #19 To: Sonoma County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

Annual Follow-Up Agency Response From October 2018

In early summer of 2017, FYC and DHS filled 2.0 FTE Public Health Nurse (PHN) positions that now work in collaboration with FYC/Probation staff and the Psychiatrist who reviews prescriptions to ensure that clients are also receiving case management and monitoring of appointments and visits with providers—including their required 30 day follow up if they begin a new medication. The PHNs are following up with Social Workers/Probation Officers as needed for clients that are in need of a 30 day follow up. In some cases, PHNs are also following up directly with caregivers to inquire if 30 day follow up visits are needed and being completed. The reviewing Psychiatrist has also contacted and followed up directly with prescribing physicians to let them know that there must be a follow up within 30 days for prescribed medications.

In September of 2017, a new Psychiatric Nurse position was filled and started at FYC. Her primary responsibilities are to monitor psychotropic medications in collaboration with the Psychiatrist. The Psychiatric Nurse also ensures that 30 day follow up visits are being made and tracked. She is continuing to refine and improve this tracking process to ensure full implementation of this recommendation. In addition, caregivers are being educated around their responsibilities during the Resource Family Approval (RFA) process related to prescriptions and support for youth taking psychotropic medication.

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

Annual Follow-Up Agency Response From November 2017

Please refer to our one year response

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

1-Year Agency Response

In early summer of 2017, FYC and DHS filled 2.0 FTE Public Health Nurse (PHN) positions that now work in collaboration with FYC/Probation staff and the Psychiatrist who reviews prescriptions to ensure that clients are also receiving case management and monitoring of appointments and visits with providers—including their required 30 day follow up if they begin a new medication. Currently the PHNs are following up with Social Workers/Probation Officers as needed for clients that are in need of a 30 day follow up. In some cases PHNs are also following up directly with caregivers to inquire if 30 day follow up visits are needed and being completed. The reviewing Psychiatrist has also contacted and followed up directly with prescribing physicians to let them know that there must be a follow up within 30 days for prescribed medications.

In September of 2017, a Psychiatric Nurse will start at FYC and some of their primary responsibilities will be to monitor psychotropic medications in collaboration with the Psychiatrist. The Psychiatric Nurse will also ensure that 30 day follow up visits are being made and tracked. In addition, caregivers are being educated around their responsibilities during the Resource Family Approval (RFA) process related to prescriptions and support for youth taking psychotropic medication.

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

6-Month Agency Response

FY&C has recently received approval from the Board of Supervisors to add 2 Public Health Nurses and a psychiatric nurse effective in first quarter 2017. It is expected these nurses will likely be hired in Summer 2017. We anticipate that the psychiatric nurse will be assigned the task of monitoring psychotropic medication prescriptions including, but not limited to, follow-up with physicians to ensure each youth has a 30-day follow-up appointment with prescribing physicians when new medications are being taken by a foster youth.

FY&C will send letters to all known prescribing physicians advising them of the requirement to see youth within 30 days of a foster youth beginning to take a new psychotropic medication. Additionally, all foster caregivers, including residential treatment centers, will be sent letters advising them that they should ensure that 30-day follow-up appointments are scheduled at the time a new psychotropic medication is prescribed. It is expected these letters will be sent by July 1, 2017. Caregiver responsibilities regarding foster youth and psychotropic medication is being added to the Resource Family training curriculum. Caregivers will be provided responsibility and communication information during the Resource Family Approval (RFA) process and with each placement of a foster youth in their home/facility.

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

60-Day Agency Response

FY&C has recently received approval from the Board of Supervisors to add 3 Public Health Nurses and a psychiatric nurse effective in first quarter 2017. We anticipate that the psychiatric nurse will be assigned the task of monitoring psychotropic medication prescriptions including, but not limited to, follow-up with physicians to ensure each youth has a 30-day follow-up appointment with prescribing physicians when new medications are being taken by a foster youth.

FY&C will send letters to all known prescribing physicians advising them of the requirement to see youth within 30 days of a foster youth beginning to take a new psychotropic medication. Additionally, all foster caregivers, including residential treatment centers, will be sent letters advising them that they should ensure that 30-day follow-up appointments are scheduled at the time a new psychotropic medication is prescribed. Caregiver responsibilities regarding foster youth and psychotropic medication is being added to the Resource Family training curriculum.

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

Recommendation #20 To: Sonoma County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

Annual Follow-Up Agency Response From October 2018

Since the addition of PHNs in Summer of 2017, they have spent time providing case management and review of the foster youth taking medications. Part of this review is ensuring that psychosocial, behavioral health or substance use services are also being provided concurrently with medication. In addition, each foster youth's case carrying social worker is required to ask the youth and caregiver about the mental health, psychosocial, behavioral health and/or substance abuse services the youth is involved or engaged in before and concurrently with taking psychotropic medications at each monthly visit. A guide and template has been created within the monthly contact notes to assist social workers with including this information. FY&C social workers were trained on how to use the new contact note template in Fall 2017.

In addition to practice changes, FY&C began reviewing cases for adherence to Safety Organized Practice standards for all social workers in September 2017.

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

Annual Follow-Up Agency Response From November 2017

Please refer to our one year response

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

1-Year Agency Response

Since the addition of PHNs in Summer of 2017, they have spent time providing case management and review of the foster youth taking medications. Part of this review includes finding out if the psychosocial, behavioral health or substance use services are also being provided concurrently with medication. In addition, each foster youth's case carrying social worker is required to ask the youth and caregiver about the mental health, psychosocial, behavioral health and/or substance abuse services the youth is involved or engaged in before and concurrently with taking psychotropic medications at each monthly visit. A guide and template has been created within the monthly contact notes to assist social workers with including this information. While the template has been created, FY&C must still train social workers on how to use the new contact notes. It is expected this training will be complete by December of 2017.

In addition to practice changes, FY&C is reviewing cases for adherence to Safety Organized Practice standards process for all social workers which will start Sept 1, 2017. Every social worker in a unit will have a case randomly selected to be reviewed by a Supervisor to ensure that standards were met or exceeded—this will include the review of how social workers update and provide accurate information in contact notes about psychotropic medications.

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

6-Month Agency Response

As the auditor's office is probably aware, the new JV-220(A) includes this question. If the prescribing physician does not provide an answer to the question or checks the "I don't know" box on the JV-220(A), the FY&C Social Worker and/or the Public Health Nurse will contact the caregiver and/or the prescribing physician to acquire the information and will assist the caregiver to define, locate, and engage services needed for each foster youth. Since the psychotropic medication monitoring Public Health Nurse has not been hired and all FY&C Social Workers have not yet been trained on this specific question, this recommendation is not yet fully implemented.

Each foster youth's case-carrying social worker will inquire, at each monthly visit with the youth and the caregiver, about the mental health, psychosocial, behavioral health, and/or substance abuse services the youth was/is involved or engaged in before and concurrently with taking psychotropic medication. The new guide for documenting monthly contacts, which will include the information addressed herein, will be effective March 2017. In addition, when JV-220(A) or (B) forms are received from doctors and the doctor has not completed the information, social workers will contact youth, caregivers, parents, etc. to obtain the information necessary to advise the reviewing psychiatrist and the court of other measures preceding or in tandem with medication.

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

60-Day Agency Response

As the auditor's office is probably aware, the new JV-220(A) includes this question. If the prescribing physician does not provide an answer to the question or checks the "I don't know" box on the JV-220(A), the FY&C Social Worker and/or the Public Health Nurse will contact the caregiver and/or the prescribing physician to acquire the information and will assist the caregiver to define, locate, and engage services needed for each foster youth. Since the psychotropic medication monitoring Public Health Nurse has not been hired and all FY&C Social Workers have not yet been trained on this specific question, this recommendation is not yet fully implemented.

Each foster youth's case-carrying social worker will inquire, at each monthly visit with the youth and the caregiver, about the mental health, psychosocial, behavioral health, and/or substance abuse services the youth was/is involved or engaged in before and concurrently with taking psychotropic medication.

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

Recommendation #21 To: Sonoma County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children's case files.

Annual Follow-Up Agency Response From October 2018

FY&C has updated and implemented policies and procedures that require renewed authorizations to be documented in CWS/CMS within 180 days of the preceding authorization. Social Workers and Supervisors are able to access which clients have current authorizations and those who are missing or have an expired authorization in Safe Measures reports. The PHNs and the Psychiatric Nurse are also following up directly with Social Workers when they see that a client's authorization has or is expiring, and tracking those due dates. Probation developed similar lines of communication with the PHNs and the Delinquency Court has already developed protocols to memorialize parental consent/court authorizations via judicial minute orders. Probation developed protocols for documenting authorizations in CWS/CMS through an MOU with Health Services through PHN staff.

FY&C sends letters to caregivers informing them that a child in their care has a medication or medications expiring within 75 days. A list of expiring authorizations is generated monthly and reviewed with the PMOC—including the Psychiatric Nurse who started in fall 2017, they review this list and follow up with Social Workers and Caregivers directly to ensure they are aware that an authorization is coming due.

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

Annual Follow-Up Agency Response From November 2017

Please refer to our one year response

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

1-Year Agency Response

FY&C has updated and implemented policies and procedures that require renewed authorizations to be documented in CWS/CMS within 180 days of the preceding authorization. Social Workers and Supervisors are able to access which clients have current authorizations and those who are missing or have an expired authorization in Safe Measures reports. The PHNs are also following up directly with Social Workers when they see a client's authorization has or is expiring and tracking those due dates. Probation is developing similar lines of communication with the PHNs and the Delinquency Court has already developed protocols to memorialize parental consent/court authorizations via judicial minute orders. Probation is in the process of developing protocols for documenting authorizations in CWS/CMS.

FY&C is also working to draft letters to caregivers informing them that a child in their care has a medication or medications expiring within 75 days. A list of expiring authorizations will be generated monthly and reviewed with the PMOC—it is expected that when the Psychiatric Nurse starts in fall of 2017, they will review this list and follow up with Social Workers and Caregivers directly to ensure they are aware and authorization is coming due.

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

6-Month Agency Response

FY&C has convened a Psychotropic Medication Monitoring Workgroup that is developing, among other monitoring issues related to use of psychotropic medications by foster youth, policies and procedures to ensure that court authorization and parental consents are obtained before foster youth begin taking any prescribed psychotropic medications as well as to ensure that all psychotropic medication authorizations (whether by court order or parent consent) are renewed and documented in CWS/CMS within 180 days of the preceding authorization. It is anticipated this policy and procedure, as well as practice, will be updated and in effect by August 1, 2017. In the meantime, measures have been implemented to assist social workers to effectively track due dates: social workers and supervisors are routinely provided lists of authorization due to expire in 30 days, 60 days, 90 days and 120 days; and, caregivers will be sent a letter 75-60 days prior to the expiration of authorizations advising them of steps they need to take to schedule an appointment with the prescribing doctor, obtain a new JV-220(A) or (B), submit to the social worker, etc.

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

60-Day Agency Response

FY&C has convened a Psychotropic Medication Monitoring Workgroup that is developing, among other monitoring issues related to use of psychotropic medications by foster youth, policies and procedures to ensure that court authorization and parental consents are obtained before foster youth begin taking any prescribed psychotropic medications as well as to ensure that all psychotropic medication authorizations (whether by court order or parent consent) are renewed and documented in CWS/CMS within 180 days of the preceding authorization. It is anticipated this policy and procedure, as well as practice, will be updated and in effect by March 1, 2017.

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

Recommendation #22 To: Sonoma County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.

1-Year Agency Response

FY&C policy requires that any foster youth receive authorization before taking a medication. A JV220 must be approved before medication is provided. In addition to the PMOC that monitors and tracks clients taking medications—a .5 PHN has been tasked with ensuring accurate data around start and end dates of medications in CMS/CWS. The PHN is reviewing all JV220s for accuracy in start date. Case managing PHNs are following up directly with Social Workers and Caregivers to obtain and verify the accurate medication start date in CMS/CWS. FY&C and Probation have implemented policies and procedures that require authorization by the court and parental consent be obtained before any foster child starts a medication.

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

6-Month Agency Response

FY&C has convened a Psychotropic Medication Monitoring Workgroup that is developing, among other monitoring issues related to use of psychotropic medications by foster youth, policies and procedures to ensure that court authorization and parental consents are obtained before foster youth begin taking any prescribed psychotropic medications as well as developing practices with caregivers to ensure that the actual date that foster youth begin taking medication is accurately known and accurately documented in CWS/CMS. It is anticipated this policy and procedure, as well as practice, will be updated and in effect by August 1, 2017. In the meantime, measures have been implemented to assist social workers in obtaining and accurately documenting this information: caregivers will be sent a letter 75-60 days prior to the expiration of authorizations advising them of steps they need to take to schedule an appointment with the prescribing doctor, obtain a new JV-220(A) or (B), submit to the social worker, etc.; and a guide for content of and documenting monthly contacts between social workers and foster youth has been developed that includes topics related to psychotropic medication and entry into CWS/CMS. This new guide for documenting monthly contacts will be effective March 2017.

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

60-Day Agency Response

FY&C has convened a Psychotropic Medication Monitoring Workgroup that is developing, among other monitoring issues related to use of psychotropic medications by foster youth, policies and procedures to ensure that court authorization and parental consents are obtained before foster youth begin taking any prescribed psychotropic medications as well as developing practices with caregivers to ensure that the actual date that foster youth begin taking medication is accurately known and accurately documented in CWS/CMS. It is anticipated this policy and procedure, as well as practice, will be updated and in effect by March 1, 2017.

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

Recommendation #23 To: Sonoma County

To improve its oversight of foster children prescribed psychotropic medications, Sonoma County should immediately adopt the state guidelines for its physicians' use when prescribing psychotropic medications and the county's use when reviewing court authorization requests.

Annual Follow-Up Agency Response From October 2018

DHS MH has revised its policy "Psychoactive Medication Utilization Policy for Children and Adolescents", effective September 13, 2016 to include adoption of both the Department of Social Services Foster Care Quality Improvement Project, California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care and the Los Angeles County Department of Mental Health, Parameters 3.8 For Use of Psychotropic Medication in Children and Adolescents, September 13, 2015.

FY&C developed the content for training all its foster care case-carrying social workers on the Department of Social Services Foster Care Quality Improvement Project, California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care. The training regarding psychotropic medication for all court case carrying social workers and supervisors (in the Court Services, Family Reunification/Court Family Maintenance and Permanency Planning programs) was completed in May 2018.

The Probation Placement Supervisor received the training entitled "Psychotropic Medication in Foster Care" through UC Davis. This day long training included legislative updates, court processes and forms, the State Auditor's report regarding psychotropic medication use in foster care, guidelines for prescribing (including the California Guidelines currently in use), and related topics such as informed consent and limits on the use of medication in foster care. Probation had scheduled for line staff to attend this training in October 2017 through UC Davis; however, the local wildfires forced the department to cancel attendance. Nevertheless, we continue to work closely with UC Davis for ongoing training opportunities relative to psychotropic medication use/oversight in the foster care population.

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

Annual Follow-Up Agency Response From November 2017

Please refer to our one year response

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

1-Year Agency Response

DHS MH has revised its policy "Psychoactive Medication Utilization Policy for Children and Adolescents", effective September 13, 2016 to include adoption of both the Department of Social Services Foster Care Quality Improvement Project, California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care and the Los Angeles County Department of Mental Health, Parameters 3.8 For Use of Psychotropic Medication in Children and Adolescents, September 13, 2015.

FY&C has developed the content for training all its foster care case-carrying social workers on the Department of Social Services Foster Care Quality Improvement Project, California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care. The training for social workers and supervisors will be complete by October 31, 2017. Probation is currently working with UC Davis in training its foster care case-carrying probation officers on these guidelines.

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

6-Month Agency Response

DHS MH has revised its policy "Psychoactive Medication Utilization Policy for Children and Adolescents", effective September 13, 2016 to include adoption of both the Department of Social Services Foster Care Quality Improvement Project, California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care and the Los Angeles County Department of Mental Health, Parameters 3.8 For Use of Psychotropic Medication in Children and Adolescents, September 13, 2015.

FY&C will, by June 2017 train all its foster care case-carrying social workers on the Department of Social Services Foster Care Quality Improvement Project, California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care.

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

60-Day Agency Response

DHS MH has revised its policy "Psychoactive Medication Utilization Policy for Children and Adolescents", effective September 13, 2016 to include adoption of both the Department of Social Services Foster Care Quality Improvement Project, California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care and the Los Angeles County Department of Mental Health, Parameters 3.8 For Use of Psychotropic Medication in Children and Adolescents, September 13, 2015.

FY&C will, by March 2017 train all its foster care case-carrying social workers on the Department of Social Services Foster Care Quality Improvement Project, California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care.

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

Recommendation #24 To: Sonoma County

To improve its oversight of foster children prescribed psychotropic medications, Sonoma County should within six months, implement a process to review psychotropic medications that receive parental consent rather than court authorization.

Annual Follow-Up Agency Response From October 2018

FY&C and the County of Sonoma DHS MH Division have an existing contract that requires a review by psychiatrist of all JV220 applications regarding psychotropic medication prescriptions that are an order of the court. The contract also includes the review of JV220 A and B for any medication with parental consent. This policy has been in effect for over 18 months.

Probation implemented a contract with DHS MH in 2018 that also requires review by psychiatrist of all JV220 applications and/or "Non Court-Ordered Foster Youth Medication Statement" for parental consent cases. Probation implemented a Psychotropic Medication Policy which outlines procedures regarding the administration of psychotropic medication to wards of the court. Additionally, in 2017 Probation implemented protocols to conduct monthly audit updates of foster care wards on psychotropic medication which are forwarded to the PHNs for monitoring purposes.

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

Annual Follow-Up Agency Response From November 2017

Please refer to our one year response

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

1-Year Agency Response

FY&C and the County of Sonoma DHS MH Division have an existing contract that requires a review by psychiatrist of all JV220 applications regarding psychotropic medication prescriptions that are an order of the court. The contract also includes the review of JV220 A and B for any medication with parental consent. This policy has been in effect for over 6 months.

Probation is developing a contract with DHS MH that also requires review by psychiatrist of all JV220 applications and/or "Prescribing Physician Statements" for parental consent cases. Probation is also drafting a Psychotropic Medication Policy which will outline procedures regarding the administration of psychotropic medication to wards of the court. Additionally, Probation is developing protocols to conduct monthly audit updates of foster care wards on psychotropic medication which will be forwarded to the PHNs for monitoring purposes.

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

6-Month Agency Response

FY&C has an existing contract with County of Sonoma DHS MH for review of all JV-220 applications regarding psychotropic medication prescriptions that require order of the court for administration. This contract was enhanced effective December 5, 2017 to include review of all JV-220(A) and (B) applications for prescriptions for which a parent can consent. Effective that date, all prescriptions for psychotropic medications provided to foster youth monitored by Family, Youth & Children's Services are being reviewed by an additional psychiatrist.

However, prescriptions for foster youth monitored by Juvenile Probation are not yet undergoing this same secondary review. Discussion toward development of a process to make this review occur are now underway. It is expected that a process will be in place by July 1, 2017.

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

60-Day Agency Response

FY&C has an existing contract with County of Sonoma DHS MH for review of all JV-220 applications regarding psychotropic medication prescriptions that require order of the court for administration.

Board of Supervisors approval was required before enhancement of the existing contract could occur to include review of all parental consent prescriptions. That approval has been granted and an amendment to the existing contract is underway. Effective December 5, 2016, a child and adolescent psychiatrist will begin reviewing all psychotropic medication prescriptions for FY&C foster youth that are authorized via parental consent.

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

Recommendation #25 To: Sonoma County

To improve its oversight of foster children prescribed psychotropic medications, Sonoma County should update its policies to describe methods for obtaining and documenting in the foster children's case files parental consents for psychotropic medications.

6-Month Agency Response

FY&C has convened a Psychotropic Medication Monitoring Workgroup that is developing, among other monitoring issues related to use of psychotropic medications by foster youth, policies and procedures to obtain and document parental consents for psychotropic medication. FY&C has developed a practice for obtaining parent signatures on JV-220(A) and (B) form for those prescriptions for which parents are able to consent. If the parent is physically available to provide a written consent, he or she will do so on the bottom of page 1 of the JV-220(A) or (B). If only available via telephone, the parent will be asked to give verbal consent and the social worker will document the consent in both the delivered service log in CWS/CMS and will note the verbal consent on the bottom of page 1 of the JV-220(A) or (B).

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

60-Day Agency Response

FY&C has convened a Psychotropic Medication Monitoring Workgroup that is developing, among other monitoring issues related to use of psychotropic medications by foster youth, policies and procedures to obtain and document parental consents for psychotropic medication. It is anticipated this policy and procedure, as well as practice, will be updated and in effect by March 1, 2017.

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

Recommendation #26 To: Social Services, Department of

To better ensure that counties only use parental consent in place of court authorization when it is appropriate, Social Services should assess Sonoma County's practice of advocating to the juvenile court that it delegate to parents the authority to administer psychotropic medications to foster children.

6-Month Agency Response

CDSS met with representatives from Sonoma County Human Services and Probation Departments, Sonoma County Superior Court Juvenile Division including the judge, county counsel, minor's attorney and parents' attorney, Behavioral Health Division and the consulting Child & Adolescent Psychiatrist on December 2, 2016. The discussion included the following topic areas:

- Mental Health Services Screening and Referral Procedures

- Psychotropic Medication Court Authorization and Parental Consent Protocols

- Use of the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care

- Talking with Children, Youth and Families about Psychotropic Medications

- Documentation

Prior to this audit, Sonoma County identified strategies to improve the oversight of Psychotropic Medication for children in Foster Care as part of the California Child and Family Services Review (C-CFSR) Self Improvement Plan. Psychotropic medications are now a standing item on all team meeting agendas if applicable, social workers received additional training on the topic, social workers are asked to maintain up-to-date client records on all psychotropic medication related issues, all JV-220 applications are reviewed by supervisors prior to court submission and a contract was executed for a consulting psychiatrist to review all JV-220 applications.

Sonoma County has now implemented a more efficient process for mental health referrals which are now processed by a centralized administrative unit to increase timeliness for the provision of services and increased follow-up to ensure children and youth are being taken for mental health treatment. Barriers to treatment are identified more promptly and staff are able to identify solutions expeditiously.

(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: Fully Implemented

Social Services' complete response is available from our office.

60-Day Agency Response

CDSS has made partial corrections to this recommendation. CDSS staff has met with Sonoma County staff to discuss the availability of mental health services to the children in foster care as well as their progress towards the implementation of California Pathways to Mental Health. Initial conversations have been held with the Sonoma County leadership to make arrangements for an in-person meeting. During the meeting, CDSS will discuss the county's practice of advocating to the Juvenile Court that parents be given the authority to retain their rights to make final decisions about their child's usage of psychotropic medication. It is anticipated that a meeting with the Director and key staff will take place in November 2016.

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

Recommendation #27 To: Social Services, Department of

To better ensure that all caregivers are informed and educated regarding the use of psychotropic medications and the court authorization process, Social Services should develop instructions regarding these topics and provide them to caregivers, such as foster family agencies, that do not operate group homes.

1-Year Agency Response

The Medications Guide for Certified and Licensed Foster Families and Resource Families has been posted on CDSS' website (http://www.cdss.ca.gov/Portals/9/FFA-CFH-RFH%20Meds%20033017.pdf?ver=2017-04-06-092732-473). It is the Department's vision that this resource will serve to educate families, foster family agencies and licensing staff on how to ensure compliance with licensing laws and regulations as well as provide technical assistance and best practice related to medication management. This resource is available online at http://www.cdss.ca.gov/inforesources/Community-Care/Resource-Guide-for-Providers.

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

6-Month Agency Response

Resource Family Approval, which is a new streamlined approval process for individuals applying to provide care for a foster child, became effective January 1, 2017. This new standard is being implemented by Foster Family Agencies (FFAs) and counties. The guide that has been under development for all licensed and certified families is now being updated to include resource families approved by the FFAs and counties. Publication is now anticipated on or before March 1, 2017.

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

60-Day Agency Response

Partially Implemented. The guide for Foster Family Agencies is undergoing revisions and the guide for the Foster Family Homes is almost complete and will be forwarded for review and approval within the Department. Publication is now anticipated on or before January 1, 2017.

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

Recommendation for Legislative Action

To improve the State's and counties' oversight of psychotropic medications prescribed to foster children, the Legislature should require Social Services to collaborate with its county partners and other relevant stakeholders to develop and implement a reasonable oversight structure that addresses, at a minimum, the concerns identified in this audit report.

Description of Legislative Action

The Legislature did not take action in the 2021-2022 legislative session to address this specific recommendation.

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

Description of Legislative Action

As of August 22, 2021, the Legislature has not taken action to address this specific recommendation.

SB 528 (Jones) would require Social Services to create an electronic health care portal, through which health care providers will be able to access health information included in a foster child or youth's health and education summary, and would include completed and approved forms developed by the Judicial Council relating to the administration of psychotropic medication for specified dependent children and wards of the juvenile court.

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

Description of Legislative Action

As of August 23, 2020, the Legislature has not taken action to address this specific recommendation.

It should be noted, however, that SB 377 (Chapter 547, Statues of 2019) requires Social Services, by January 1, 2020, to convene a working group to consider various options for seeking informed consent from a dependent child or ward, or their attorney, for medical information regarding psychotropic medication prescribed between January 1, 2017 and July 1, 2020, and to report to the Legislature by April 15, 2020 on those options and on any recommendations to best reach those children and their attorneys to seek consent.

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

Description of Legislative Action

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

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

Legislation has not been introduced to address this specific recommendation.

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

Recommendation for Legislative Action

To improve the State's oversight of physicians who prescribe psychotropic medications to foster children, the Legislature should require the Medical Board to analyze Health Care Services' and Social Services' data in order to identify physicians who may have inappropriately prescribed psychotropic medications to foster children. If this initial analysis successfully identifies such physicians, the Legislature should require the Medical Board to periodically perform the same or similar analyses in the future. Further, the Legislature should require Health Care Services and Social Services to provide periodically to the Medical Board the data necessary to perform these analyses.

Description of Legislative Action

SB 1174 (Chapter 840, Statutes of 2016), until January 1, 2027, requires Health Care Services and Social Services, pursuant to a data-sharing agreement, to provide the Medical Board with information regarding Medi-Cal physicians and their prescribing patterns of psychotropic medications and related services for foster children. Every 5 years, the Medical Board, Health Care Services, and Social Services must consult and revise the methodology. Further the Medical Board is required to contract for consulting services from, if available, a psychiatrist who has expertise and specializes in pediatric care for the purpose of reviewing the data. The Medical Board is required to report annually to the Legislature, Health Care Services, and Social Services the results of the analysis of the data. Until January 1, 2027, the Medical Board is required to review the data in order to determine if any potential violations of law or excessive prescribing of psychotropic medications inconsistent with the standard of care exist and, if warranted, conduct an investigation and take disciplinary action.

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

Description of Legislative Action

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

Legislation has not been introduced to address this specific recommendation.

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

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.

Recommendation #31 To: Social Services, Department of

To ensure that the Medical Board can promptly complete its analysis to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, Social Services and Health Care Services should continue to work with the Medical Board and its consultant to meet their data needs. If the Medical Board's analysis is able to identify these physicians, Social Services and Health Care Services should enter into an agreement with the Medical Board to provide the information the Medical Board needs to perform similar analyses in the future.

6-Month Agency Response

The Medical Board of California (MBC), California Department of Social Services (CDSS) and Department of Health Care Services (DHCS) have agreed to amendments to improve the existing data sharing agreement between the agencies and to ensure optimal data sharing in accordance with SB 1174. Data for 2015 will transfer from DHCS to the MBC by the end of February 2017.

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

60-Day Agency Response

Fully Implemented/Date Implemented: October 5, 2016. CDSS continues to collaborate with the Medical Board of California (MBC) to support the MBC's review of multiple concurrent psychotropic medications prescribed to children and youth in foster care. As noted in CDSS's response on June 6, 2016, CDSS transmitted additional data to be included in the dataset provided by DHCS to the MBC. In addition, a summary analysis was shared and discussed with MBC. CDSS is also currently providing technical assistance to the MBC to obtain necessary authorizations for additional child-specific information.

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

The Medical Board of California confirmed the receipt of additional data from the Departments of Health Care Services and Social Services to further its current analysis. The enactment of SB 1174 (Chapter 840, Statutes of 2016) addresses future data sharing among these entities. SB 1174's provisions become effective January 1, 2017.

Recommendation #32 To: Health Care Services, Department of

To ensure that the Medical Board can promptly complete its analysis to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, Social Services and Health Care Services should continue to work with the Medical Board and its consultant to meet their data needs. If the Medical Board's analysis is able to identify these physicians, Social Services and Health Care Services should enter into an agreement with the Medical Board to provide the information the Medical Board needs to perform similar analyses in the future.

6-Month Agency Response

DHCS has worked with CDSS and the Medical Board of California (MBC) to extend the Data Use Agreement. DHCS will have provided 2015 data to the MBC by February 28, 2017.

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

60-Day Agency Response

DHCS and CDSS provided additional data to the Medical Board as requested by the Medical Board under an existing Data Use Agreement. DHCS will provide data, to the extent that it is data that DHCS has, to the Medical Board beyond the initial evaluation if the Medical Board requests it.

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

The Medical Board of California confirmed the receipt of additional data from the Departments of Health Care Services and Social Services to further its current analysis. The enactment of SB 1174 (Chapter 840, Statutes of 2016) addresses future data sharing among these entities. SB 1174's provisions become effective January 1, 2017.

Recommendation #33 To: Health Care Services, Department of

To increase the State's assurance that foster children do not receive medically inappropriate or unnecessary psychotropic medications, Health Care Services should devise and implement within six months methods to better enforce its prior authorization requirement for the off-label use of psychotropic medications. For example, Health Care Services should revise its claims system to automatically prompt pharmacists to submit treatment authorization requests when filling prescriptions for Medi-Cal beneficiaries under age 18 when the prescribed psychotropic medications have no FDA-approved pediatric uses. Furthermore, as part of its collaboration with Social Services and the counties to develop and implement a reasonable oversight structure, Health Care Services should determine whether information from the Judicial Council's revised court authorization forms would help it better enforce its prior authorization requirements.

Annual Follow-Up Agency Response From October 2019

DHCS has reviewed the information fields on the Judicial Council's revised court authorization forms and determined that the information provided does not meet the prior authorization requirements for approval of diagnosis related, off-label prescriptions as mandated in Title 22, California Code of Regulations (CCR), Section 51313(c)(4), which states, in part:

"Authorization for unlabeled use of drugs shall not be granted unless the requested unlabeled use represents reasonable and current prescribing practices. The determination of reasonable and current prescribing practices shall be based on:

(A) Reference to current medical literature.

(B) Consultation with provider organizations, academic and professional specialists."

Medi-Cal providers requesting "off-label" approval are required to submit documentation supporting the claim that the request meets generally accepted medical standards. Standards of care changes over time and new literature may alter the landscape of what constitutes "reasonable and current prescribing practices." In order to satisfy the requirements of 22 CCR Section 51313(c)(4), the supporting documentation must come from credible, unbiased sources and be based on sound clinical reviews or studies. Anecdotal and/or personal experiences of the requesting provider would not be adequate documentation for purposes of meeting regulatory requirements.

While information contained on the Judicial Council's revised court forms is provided by the prescribing physician, it does not include credible studies and/or reports from current medical literature, nor does it provide clinical guidelines for off-label use adopted and published by child psychiatric provider organizations or academic/professional specialists. It would fail to meet 22 CCR Section 51313(c)(4) standards, and so cannot be utilized.

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

Annual Follow-Up Agency Response From November 2018

In March 2017, DHCS posted a second provider bulletin noting the age-based restrictions imposed on all psychotropic drugs as of January 1, 2017 (which was originally published in the December 2016 provider bulletin). These restrictions enforce the requirement of a TAR when the beneficiary's age is below the approved age recognized by the FDA. The link to this bulletin: http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/ph201703r.asp

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

Although Health Care Services addressed age-related off-label prescriptions, it did not provide information regarding whether information from the Judicial Council's revised court authorization forms would help it better enforce its prior authorization requirements regarding diagnosis-related off-label prescriptions.

1-Year Agency Response

In March 2017, DHCS posted a second provider bulletin noting the age-based restrictions imposed on all psychotropic drugs as of January 1, 2017 (which was originally published in the December 2016 provider bulletin). These restrictions enforce the requirement of a TAR when the beneficiary's age is below the approved age recognized by the FDA. The link to this bulletin: http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/ph201703r.asp

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

Although Health Care Services addressed age-related off-label prescriptions, it did not provide information regarding whether information from the Judicial Council's revised court authorization forms would help it better enforce its prior authorization requirements regarding diagnosis-related off-label prescriptions.

6-Month Agency Response

In the December 2016 provider bulletin (published 12/30/16), DHCS informed providers that, effective January 1, 2017, age restrictions would be implemented on all non-antipsychotic psychotropic drugs according to their FDA approved ages. The bulletin included links to specific pages within the Medi-cal provider manual listing those drugs effected by this change and informs providers that claims for non-antipsychotic psychotropic drugs that fall outside of these approved ages require an approved treatment authorization request (TAR) with medical justification.

DHCS will publish a 60-day reminder of this policy change in the February 2017 provider bulletin. The bulletin will also remind providers that, in addition to psychotropic medications, unlabeled use of all medications requires an approved TAR.

Using system edits which prevent claims for psychotropic medications that fall outside of FDA approved age guidelines from processing, DHCS feels that the risk of foster children receiving off-label psychotropic medications is adequately mitigated. The system edit will require a Treatment Authorization Request for the medication be submitted for review and approval prior to the claim being processed. Because of this, no additional enforcement actions will be taken at this time.

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

Health Care Services has partially implemented our recommendation. Our recommendation "to better enforce its prior authorization requirement for off-label use" pertained to the need to better ensure that pharmacists submitted TARs for both AGE-RELATED off-label prescriptions of psychotropic medications and DIAGNOSIS-RELATED off-label prescriptions, as we discussed on pages 70 through 74 of our report.

Based on the evidence it provided and the actions Health Care Services states it has taken, we conclude that Health Care Services implemented a new system edit to better ensure that pharmacists submit TARs for age-related off-label prescribing of psychotropic medications. However, Health Care Services does not address the steps it will take to better ensure that pharmacists submit TARs for diagnosis-related off-label prescriptions.

In addition, as our recommendation states, as part of its collaboration with Social Services and the counties to develop and implement a reasonable oversight structure, Health Care Services should determine whether information from the Judicial Council's revised court authorization forms would help it better enforce its prior authorization requirements.

Recommendation #34 To: Medical Board of California

To ensure that physicians do not inappropriately prescribe psychotropic medications to foster children, the Medical Board within 60 days should obtain and analyze the data from Health Care Services and Social Services to identify physicians who may have inappropriately prescribed psychotropic medications for foster children.

60-Day Agency Response

The Medical Board of California's (Board's) consultant has analyzed the additional data that has been requested from the Department of Health Care Services (DHCS) and the Department of Social Services (DSS) and has identified physicians who may have inappropriately prescribed psychotropic medications to foster children. The Board provided DSS with a listing of the patient de-identifiers on August 8, 2016. Per the DUA, the Board requested assistance from DSS in obtaining authorizations for medical records for these foster children. DSS is currently working on obtaining feedback from each county in order to determine the best process to get the authorizations the Board needs to continue its investigations.

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

Recommendation #35 To: Medical Board of California

Following the completion of the analysis (described in Recommendation 34), the Medical Board should take the appropriate follow-up actions that it deems necessary, including the investigation of physicians identified in its analysis.

Annual Follow-Up Agency Response From October 2021

The Board continues to place a high priority on these cases, pursuant to Business and Professions Code Section 2220.05. As the Board receives additional evidence, including medical records, related to existing complaints, or new complaints, the Board will investigate and take appropriate disciplinary action, when warranted. The Board views this recommendation as "Fully Implemented" because the Board taking is appropriate action.

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

To the extent that the Medical Board performs investigations and takes other appropriate follow-up actions when it becomes aware of physicians who may have inappropriately prescribed psychotropic medications for foster children, it has resolved this recommendation.

Annual Follow-Up Agency Response From October 2020

While the Board places a high priority on these cases, the Board has only received five cases for possible investigation since 2017. Three cases were fully investigated and departures from the standard of care were not identified. The other two matters did not provide enough information to locate medical records or a response for a release was not provided.

Further, on January 9, 2020, Board staff participated in the workgroup meeting required by SB 377 (Chapter 547, Statutes of 2019). The Board is hopeful that the updated procedures required by SB 377 will facilitate its access to these records so the Board can continue to conduct investigations, and take appropriate disciplinary action, when warranted.

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

Annual Follow-Up Agency Response From October 2019

The Medical Board of California (Board) is currently still in the same position as it was last year when the update was provided. However, SB 377 (McGuire, Chapter 547, Statutes of 2019) was signed into law and this bill will change the process for the Board to obtain authorizations for medical records for foster youth cases. SB 377 requires judicial council forms to be revised, by September 1, 2020, to include a request for authorization by the foster youth or the foster youth's attorney to release the foster youth's medical information to the Medical Board of California (Board), in order to ascertain whether there is excessive prescribing of psychotropic medications that is inconsistent with the standard of care. SB 377 also requires the California Department of Social Services (CDSS), by January 1, 2020, to convene a working group consisting of specific stakeholders, including the Board, to consider various options for seeking authorization from a foster youth or their attorney, for release of the foster youth's medical information regarding psychotropic medication prescribed between January 1, 2017, and July 1, 2020, and CDSS must report to the Legislature by April 15, 2020, on those options and on any recommendations to best reach those children and their attorneys to seek authorization. This bill will allow the Board to get authorizations to release medical records for foster youth as part of the judicial council process, so when the Board's expert identifies cases of potential inappropriate prescribing, the Board can obtain the medical records, investigate, and take disciplinary action, if appropriate. Once this bill becomes effective, the Board anticipates that the process to investigate past and future cases will be significantly improved.

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

Annual Follow-Up Agency Response From October 2018

The Medical Board of California (Board) is in the same position it was in a year ago when the last update was provided. The Board needs to obtain the appropriate authorizations for medical records so it can move forward to investigate physicians. Although the Board continues to work with the Department of Social Services, the Board is not receiving these authorizations. At this point, it appears that a legislative change may be necessary in order for the Board to obtain the necessary patient records so it can investigate these cases.

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

Annual Follow-Up Agency Response From October 2017

The Medical Board of California (Board) requested assistance from the Department of Social Services (DSS), since the data provided to the Board did not include the names of the foster children receiving the prescriptions. Per the data use agreement, DSS is to facilitate contact with county child welfare agencies, the juvenile courts, county counsel, children's attorneys and other relevant entities, to assist the Board in obtaining child-specific information, including relevant medical records. The Board and DSS worked with the relevant entities to create an authorization letter to send to current and former foster children and their guardians, as appropriate, to receive authorization to obtain the medical records of the foster children. DSS staff sent out 33 letters to last known addresses of foster children who had transitioned out of foster care. Unfortunately, some of those letters came back as undeliverable/returned. DSS staff also reached out to the counties on * children to see if there was a medical rights holder who could authorize the release of information. Of those children, * had a legal guardian with medical rights who were sent the letter and authorization form. The remaining * children in those counties will require court orders to obtain the release and the medical records. The Board will work with DSS on the process to move forward on seeking court orders. DSS staff are also preparing the letters and authorization forms for the children in the remaining counties to be sent out. The Board has received * releases from individuals who have agreed to allow the Board to look into the care and treatment provided. The Board is working to obtain authorization for the medical records. This will then begin the Board's normal complaint and investigation process to determine if discipline is warranted. It is important to note, that without the authorization for the medical records, the Board cannot move forward with investigating these matters.

* We redacted the number here because of its small size.

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

1-Year Agency Response

The Medical Board of California (Board) has requested assistance from the Department of Social Services (DSS), as the data provided to the Board does not include the names of the foster children. Per the DUA, DSS is in the process of providing technical assistance, which includes, but is not limited to, facilitating contact with county child welfare agencies, the juvenile courts, county counsel, children's attorneys and other relevant entities to assist the Board in obtaining child-specific information, including relevant medical records. The Board and DSS worked with the relevant entities to create an authorization letter to send to current and former foster children and their guardians, as appropriate, to receive authorization to obtain the medical records of the foster children. The first round of letters has gone out to foster children who have transitioned out of foster care, and the next round of letters will go out this week to the guardians of foster children still in the foster care system. Once authorizations to obtain the records are received by the Board and the child-specific medical records are obtained, the Board will follow its normal complaint and investigation process to determine if discipline is warranted.

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

6-Month Agency Response

The Medical Board of California (Board) has completed the first step of requesting assistance from the Department of Social Services (DSS), as the data provided to the Board does not include the names of the foster children. Per the DUA, DSS is in the process of providing technical assistance, which includes, but is not limited to, facilitating contact with county child welfare agencies, the juvenile courts, county counsel, children's attorneys and other relevant entities to assist the Board in securing a court order authorizing it to obtain child-specific information, including relevant medical records. Once the child-specific medical records are obtained, the Board will follow its normal complaint and investigation process to determine if discipline is warranted.

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

60-Day Agency Response

The Medical Board of California (Board) has completed the first step of requesting assistance from the Department of Social Services (DSS), as the data provided to the Board does not include names of foster children. Per the DUA, DSS will provide technical assistance, which includes, but is not limited to, facilitating contact with county child welfare agencies, the juvenile courts, county counsel, children's attorneys and other relevant entities to assist the Board in securing a court order authorizing it to obtain child-specific information, including relevant medical records. Once the child-specific medical records are obtained, the Board will follow its normal complaint and investigation process to determine if discipline is warranted.

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

Recommendation #36 To: Medical Board of California

To the extent that its analysis (described in Recommendation 34) is able to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, the Medical Board should enter into an agreement with Health Care Services and Social Services within six months of completing its initial review to periodically obtain the data necessary to perform the same or similar analyses.

6-Month Agency Response

Pursuant to SB 1174 (McGuire, Chapter 840, Statutes of 2016), the Medical Board of California (Board) is required to receive data on an on-going basis from the Department of Health Care Services (DHCS) and the Department of Social Services (DSS). This data is required for all foster children who are or have been on three or more psychotropic medications for 90 days or more. For each foster child that falls into this category, the following information is required to be submitted to the Board: the start and stop dates, if any, for each psychotropic medication prescribed; the prescriber's name and contact information; the child or adolescent's year of birth; the unit and quantity of the medication and the number of days' supply of the medication; and any other information that is de-identified and necessary to the Board to allow the Board to exercise its statutory authority as an oversight entity. The data required to be received is the same data that is in the existing DUA. The Board worked with DHCS and DSS on an updated DUA that conforms with the requirements of SB 1174, and this DUA was finalized on February 15, 2017.

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

60-Day Agency Response

Although the Medical Board of California (Board) has not entered into a new agreement with the Department of Health Care Services (DHCS) and the Department of Social Services (DSS), however, this is no longer necessary as SB 1174 (McGuire, Chapter 840, Statutes of 2016) was signed into law by the Governor.

SB 1174 requires DHCS and DSS to provide data to the Board on an annual basis, pursuant to a data-sharing agreement, including, but not limited to, pharmacy claims data for all foster children who are or have been on three or more psychotropic medications for 90 days or more. For each foster child who falls into this category, the following information shall be submitted to the Board: a list of the psychotropic medications prescribed; the start and stop dates, if any, for each psychotropic medication prescribed; the prescriber's name and contact information; the child or adolescent's year of birth; the unit and quantity of the medication and the number of days' supply of the medication; and any other information that is de-identified and necessary to the Board to allow the Board to exercise its statutory authority as an oversight entity.

This bill requires the Board to review this data on a quarterly basis to determine if any potential violations of law or excessive prescribing of psychotropic medications inconsistent with the standard of care exist and, if warranted, conduct an investigation. If the Board investigates a physician for inappropriate prescribing and concludes that there is a violation of law, the Board must take appropriate disciplinary action. This bill requires the Board to report this data annually to the Legislature in its annual report.

Since SB 1174 has been signed into law, this prescribing data will now be provided to the Board on an on-going basis.

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

The enactment of SB 1174 (Chapter 840, Statutes of 2016) addresses future data sharing by the Departments of Health Care Services and Social Services to the Medical Board of California for purposes of monitoring physicians who prescribed psychotropic medications to foster children. SB 1174's provisions become effective January 1, 2017.

All Recommendations in 2015-131

Agency responses received are posted verbatim.