(1)The California Community Care Facilities Act provides for the licensure and regulation of community care facilities, including foster family homes and group homes, by the State Department of Social Services. A violation of this act is a misdemeanor.

Under existing law, a child in a group home may receive mental health services, as deemed necessary by the placing agency and under the case management of that agency. Under existing law, only a juvenile court judicial officer may make orders regarding the administration of psychotropic medications to a child adjudged a dependent or ward of the court and removed from the physical custody of the parent. Existing law requires that the order be based on a request from a physician, indicating the reasons for the request and a description of the childs diagnosis and behavior, among other requirements.

This bill would provide that psychotropic medications may be used at a group home, other than at a runaway and homeless youth shelter, only in accordance with the written directions of the physician prescribing the medication and as authorized by the juvenile court. The bill would require the group home to maintain in the childs records specified information regarding the administration of those medications.

(2)Existing law requires the Director of Social Services, at least annually, to publish and make available to interested persons a list covering all licensed community care facilities, except as specified, and the services for which each facility has been licensed or issued a special permit.

This bill would require the department to compile specified information regarding the administration of psychotropic medications to children in group homes and to post that information on the departments Internet Web site. The bill would require the department, in consultation with the State Department of Health Care Services and stakeholders, to establish a methodology to identify those group homes that have levels of psychotropic drug utilization warranting additional review, as specified. The bill would also require the department, for the facilities identified by the methodology that it establishes, to visit those facilities at least once a year to examine specified factors. The bill would authorize the department, following that inspection, to share relevant information and observations with county placing agencies, social workers, probation officers, the court, dependency counsel, or the Medical Board of California, or share relevant information and observations with the facility and require the facility to submit a plan to the department, within 30 days of receiving the departments information and observations, to address any identified risks within the control of the facility related to psychotropic medication. The bill would require the department to approve the plan and verify the plans implementation to determine whether those identified risks have been remedied. Because the failure of the facility to comply with these provisions would be a misdemeanor, the bill would impose a state-mandated local program.

(3)Existing law requires the department, on or before January 1, 2016, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts with minors in group homes or under supervision of group home staff.

This bill would require the department, on or before January 1, 2017, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement alternative programs and services, as specified. The bill would make related changes.

(4)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Community Care Facilities Act provides for the licensure and regulation of community care facilities, including foster family homes and group homes, by the State Department of Social Services. A violation of this act is a misdemeanor.

Under existing law, a child in a group home may receive mental health services, as deemed necessary by the placing agency and under the case management of that agency. Under existing law, only a juvenile court judicial officer may make orders regarding the administration of psychotropic medications to a child adjudged a dependent or ward of the court and removed from the physical custody of the parent. Existing law requires that the order be based on a request from a physician, indicating the reasons for the request and a description of the childs diagnosis and behavior, among other requirements.

This bill would provide that psychotropic medications may be used at a group home, other than at a runaway and homeless youth shelter, only in accordance with the written directions of the physician prescribing the medication and as authorized by the juvenile court. The bill would require the group home to maintain in the childs records specified information regarding the administration of those medications.

(2)Existing law requires the Director of Social Services, at least annually, to publish and make available to interested persons a list covering all licensed community care facilities, except as specified, and the services for which each facility has been licensed or issued a special permit.

This bill would require the department to compile specified information regarding the administration of psychotropic medications to children in group homes and to post that information on the departments Internet Web site. The bill would require the department, in consultation with the State Department of Health Care Services and stakeholders, to establish a methodology to identify those group homes that have levels of psychotropic drug utilization warranting additional review, as specified. The bill would also require the department, for the facilities identified by the methodology that it establishes, to visit those facilities at least once a year to examine specified factors. The bill would authorize the department, following that inspection, to share relevant information and observations with county placing agencies, social workers, probation officers, the court, dependency counsel, or the Medical Board of California, or share relevant information and observations with the facility and require the facility to submit a plan to the department, within 30 days of receiving the departments information and observations, to address any identified risks within the control of the facility related to psychotropic medication. The bill would require the department to approve the plan and verify the plans implementation to determine whether those identified risks have been remedied. Because the failure of the facility to comply with these provisions would be a misdemeanor, the bill would impose a state-mandated local program.

(3)Existing law requires the department, on or before January 1, 2016, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts with minors in group homes or under supervision of group home staff.

This bill would require the department, on or before January 1, 2017, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement alternative programs and services, as specified. The bill would make related changes.

(4)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Community Care Facilities Act provides for the licensure and regulation of community care facilities, including foster family homes and group homes, by the State Department of Social Services. A violation of this act is a misdemeanor.

Under existing law, a child in a group home may receive mental health services, as deemed necessary by the placing agency and under the case management of that agency. Under existing law, only a juvenile court judicial officer may make orders regarding the administration of psychotropic medications to a child adjudged a dependent or ward of the court and removed from the physical custody of the parent. Existing law requires that the order be based on a request from a physician, indicating the reasons for the request and a description of the childs diagnosis and behavior, among other requirements.

This bill would provide that psychotropic medications may be used at a group home, other than at a runaway and homeless youth shelter, only in accordance with the written directions of the physician prescribing the medication and as authorized by the juvenile court. The bill would require the group home to maintain in the childs records specified information regarding the administration of those medications.

(2)Existing law requires the Director of Social Services, at least annually, to publish and make available to interested persons a list covering all licensed community care facilities, except as specified, and the services for which each facility has been licensed or issued a special permit.

This bill would require the department to compile specified information regarding the administration of psychotropic medications to children in group homes and to post that information on the departments Internet Web site. The bill would require the department, in consultation with the State Department of Health Care Services and stakeholders, to establish a methodology to identify those group homes that have levels of psychotropic drug utilization warranting additional review, as specified. The bill would also require the department, for the facilities identified by the methodology that it establishes, to visit those facilities at least once a year to examine specified factors. The bill would require a facility, for which authorize the department, based on following that inspection, finds a risk to the health, safety, or personal rights of clients in care, to share relevant information and observations with county placing agencies, social workers, probation officers, the court, dependency counsel, or the Medical Board of California, or share relevant information and observations with the facility and require the facility to submit a plan of correction to the department department, within 30 days of receiving notice of the departments findings. information and observations, to address any identified risks within the control of the facility related to psychotropic medication. The bill would require the department to monitor the facilitys approve the plan and verify the plans implementation of that plan of correction to determine that the concerns identified during the inspection have been addressed. whether those identified risks have been remedied. Because the failure of the facility to comply with these provisions would be a misdemeanor, the bill would impose a state-mandated local program.

(3)Existing law requires the department, on or before January 1, 2016, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts with minors in group homes or under supervision of group home staff.

This bill would require the department, on or before January 1, 2017, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement alternative programs and services, as specified. The bill would make related changes.

(4)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Community Care Facilities Act provides for the licensure and regulation of community care facilities, including foster family homes and group homes, by the State Department of Social Services. A violation of this act is a misdemeanor.

(2)Existing law requires the department director, Director of Social Services, at least annually, to publish and make available to interested persons a list covering all licensed community care facilities, except as specified, and the services for which each facility has been licensed or issued a special permit.

This bill would require the department director to compile specified information regarding the administration of psychotropic medications to children in those facilities group homes and to post that information to on the departments Internet Web site. The bill would require the department department, in consultation with the State Department of Health Care Services and stakeholders, to establish a methodology to identify those group homes that have disproportionately high and inappropriate levels of psychotropic drug usage, based on specified criteria. utilization warranting additional review, as specified. The bill would also require the department, for the facilities identified by the methodology that it establishes, to visit those facilities at least once a year to examine specified factors. The bill would require a facility that is found to have disproportionately high and inappropriate levels of psychotropic drug usage, which may be caused by inadequate alternative and less invasive psychosocial services, crisis management, and other services, facility, for which the department, based on that inspection, finds a risk to the health, safety, or personal rights of clients in care, to submit a plan of correction to address steps the facility shall take to reduce inappropriate prescribing and treatment regimens the department within 30 days of receiving notice of the departments determination. findings. The bill would require the department to monitor the facilitys implementation of that plan of correction and make a report, as provided. to determine that the concerns identified during the inspection have been addressed. Because this bill would create a new crime, the failure of the facility to comply with these provisions would be a misdemeanor, the bill would impose a state-mandated local program.

(3)Existing law requires the department, on or before January 1, 2016, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts with minors in group homes or under supervision of group home staff.

This bill would require the department, on or before January 1, 2017, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement alternative programs and services to reduce utilization of psychotropic medications for children in group homes. The bill would also delete an obsolete provision. services, as specified.

(4)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Community Care Facilities Act provides for the licensure and regulation of community care facilities, including foster family homes and group homes, by the State Department of Social Services. A violation of this act is a misdemeanor.

Existing law requires the department director, at least annually, to publish and make available to interested persons a list covering all licensed community care facilities, except as specified, and the services for which each facility has been licensed or issued a special permit.

This bill would require the department director to compile specified information regarding administering the administration of psychotropic medications to children in those facilities and to post that information to the departments Internet Web site. The bill would require the department to establish a methodology to identify those group homes that have disproportionately high and inappropriate levels of psychotropic drug usage. usage, based on specified criteria. The bill would also require the department, for the facilities identified by the methodology that it establishes, to visit those facilities at least once a year to examine specified factors that contribute to the high utilization of psychotropic medications. factors. The bill would require a facility that is found to have a high utilization of dangerous psychotropic medication regimens and disproportionately high and inappropriate levels of psychotropic drug usage, which may be caused by inadequate alternative, alternative and less invasive psychosocial, psychosocial services, crisis management, and other services, to submit a plan to address steps the facility shall take to reduce inappropriate prescribing and treatment regimens within 60 30 days of the visit. receiving notice of the departments determination. The bill would require the department to monitor the facilitys implementation of that plan and make a report, as provided. Because this bill would create a new crime, the bill would impose a state-mandated local program.

(2)Existing law requires the department, on or before January 1, 2016, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts with minors in group homes or under supervision of group home staff.

This bill would require the department, on or before January 1, 2017, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce utilization of psychotropic medications for children in group homes. The bill would also delete an obsolete provision.

(3)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Community Care Facilities Act provides for the licensure and regulation of community care facilities, including foster family homes and group homes, by the State Department of Social Services. A violation of this act is a misdemeanor.

Existing law requires the department director, at least annually, to publish and make available to interested persons a list covering all licensed community care facilities, except as specified, and the services for which each facility has been licensed or issued a special permit.

This bill would require the department director to compile specified information regarding administering psychotropic medications to children in those facilities and to post that information to the departments Internet Web site. The bill would require the department to establish a methodology to identify those group homes that have disproportionately high levels of psychotropic drug usage. The bill would also require the department, for the facilities identified by the methodology that it establishes, to visit those facilities at least once a year to examine specified factors that contribute to the high utilization of psychotropic medications. The bill would require a facility that is found to have a high utilization of dangerous psychotropic medication regimens and inadequate alternative, less invasive psychosocial, crisis management, and other services, to submit a plan to address steps the facility shall take to reduce inappropriate prescribing and treatment regimens within 60 days of the visit. The bill would require the department to monitor the facilitys implementation of that plan and make a report, as provided. Because this bill would create a new crime, the bill would impose a state-mandated local program.

(2)Existing law requires the department, on or before January 1, 2016, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts with minors in group homes or under supervision of group home staff.

This bill would require the department, on or before January 1, 2017, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce utilization of psychotropic medications for children in group homes. The bill would also delete an obsolete provision.

(3)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Community Care Facilities Act provides for the licensure and regulation of community care facilities, including foster family homes and group homes, by the State Department of Social Services. A violation of this act is a misdemeanor.

Existing law requires the department director, at least annually, to publish and make available to interested persons a list covering all licensed community care facilities, except as specified, and the services for which each facility has been licensed or issued a special permit.

This bill would require the department director to include in that list compile specified information regarding administering psychotropic medications to children in those facilities and to post that information to the departments Internet Web site. The bill would require the department to establish a methodology to identify those group homes that have disproportionately high levels of psychotropic drug usage. The bill would also require the department, if it determines based on that information that a facility is administering psychotropic medications to children at a rate exceeding the average authorization for all group homes, to inspect that facility for the facilities identified by the methodology that it establishes, to visit those facilities at least once a year to examine specified factors that contribute to the high utilization of psychotropic medications. The bill would require an inspected facility to submit to the department, within 60 days of that inspection, a facility that is found to have a high utilization of dangerous psychotropic medication regimens and inadequate alternative, less invasive psychosocial, crisis management, and other services, to submit a corrective action plan including to address steps the facility shall take to reduce the utilization of psychotropic medications. inappropriate prescribing and treatment regimens within 60 days of the visit. The bill would require the department to monitor the facilitys implementation of that plan and make a report, as provided. Because this bill would create a new crime, the bill would impose a state-mandated local program.

(2)Existing law requires the department, on or before January 1, 2016, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts with minors in group homes or under supervision of group home staff.

This bill would require the department, on or before January 1, 2017, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce utilization of psychotropic medications for children in group homes. The bill would also delete an obsolete provision.

(3)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Community Care Facilities Act provides for the licensure and regulation of community care facilities, including foster family homes and group homes, by the State Department of Social Services. A violation of this act is a misdemeanor.

Existing law requires the department director, at least annually, to publish and make available to interested persons a list covering all licensed community care facilities, except as specified, and the services for which each facility has been licensed or issued a special permit.

This bill would require the department director to include in that list specified information regarding administering psychotropic medications to children in those facilities. The bill would also require the department, if it determines based on that information that a facility is administering psychotropic medications to children at a rate exceeding the average authorization for all group homes, to inspect that facility at least once a year to examine specified factors that contribute to the high utilization of psychotropic medications. The bill would require an inspected facility to submit to the department, within 60 days of that inspection, a corrective action plan including steps the facility shall take to reduce the utilization of psychotropic medications. The bill would require the department to monitor the facilitys implementation of that plan and make a report, as provided. Because this bill would create a new crime, the bill would impose a state-mandated local program.

(2)Existing law requires the department, on or before January 1, 2016, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts with minors in group homes or under supervision of group home staff.

This bill would require the department, on or before January 1, 2017, in consultation with specified associations and other stakeholders, to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce utilization of psychotropic medications for children in group homes. The bill would also delete an obsolete provision.

(3)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

 UNFINISHED BUSINESS  

Bill No: SB 484

Author: Beall (D), et al.

Amended: 9/3/15

Vote: 21

SENATE HUMAN SERVICES COMMITTEE: 5-0, 4/21/15

AYES: McGuire, Berryhill, Hancock, Liu, Nguyen

SENATE HEALTH COMMITTEE: 9-0, 4/29/15

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15

AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

SENATE FLOOR: 40-0, 6/3/15

AYES: Allen, Anderson, Bates, Beall, Berryhill, Block, Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall, Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner, Stone, Vidak, Wieckowski, Wolk

ASSEMBLY FLOOR: 79-0, 9/8/15 - See last page for vote

SUBJECT: Juveniles

SOURCE: National Center for Youth Law

DIGEST: The bill requires California Department of Social Services (CDSS) to establish a methodology for identifying group homes that have levels of psychotropic dug utilization warranting additional review, and to inspect identified facilities at least once a year, as specified. Additionally, this bill permits CDSS to share information and observations with the facility and to require the facility to submit a plan within 30 days to address identified risks, as specified.

Assembly Amendments add licensing provisions stating that psychotropic medications shall only be used in accordance with the written directions of the prescribing physician and as authorized by the juvenile court. Amendments further add licensing provisions requiring facilities to maintain specified information in the child’s records regarding psychotropic medication. Additionally, amendments narrow the scope of the information and measurements required to be considered in establishing the methodology for identifying group homes and strikes specified components to be included in a corrective plan submitted by a facility. Further, amendments strike specific components to be determined by CDSS in monitoring of the facilities implementation of the plan.

ANALYSIS:

Existing law:

1. Establishes the Community Care Facilities Act, which provides for the licensure and regulation of community care facilities, including group homes, by CDSS, and requires that licensed facilities be subject to unannounced inspections under specified circumstances. (HSC 1500 et seq, and 1534)

2. Requires CDSS to establish a rate classification level (RCL) structure for group homes with a corresponding rate structure according to the level of care and services that will be provided, as specified. (WIC 11462)

3. Permits a group home to be classified as an RCL 13 or 14 if the program only accepts children with special treatment needs and meets other requirements. Additionally, requires the California Department of Health Care Services (DHCS) to annually certify group homes seeking classification as RCL 13 or 14 and permits such facilities to accept minor dependents who are seriously or emotionally disturbed if certain conditions are met. (WIC 11469, WIC 4096.5 and HSC 1502.4)

4. Requires CDSS to publish and make available to interested persons a list or lists covering all licensed community care facilities, other than foster family homes and certified family homes, to include specified information regarding group homes, transitional housing placement providers, community treatment facilities or runaway and homeless youth shelters including complaints, citations, fines and the number of law enforcement contacts made by group homes. (HSC 1536)

This bill:

1. Requires CDSS to compile, to the extent feasible and based on information provided by the California Department of Health Care Services (DHCS), specified child welfare psychotropic medication measures developed by CDSS and specified Healthcare Effectiveness Data and Information Set (HEDIS) measures related to psychotropic medication, pertaining to each group home, in order to review and evaluate the use of psychotropic medication in group homes.

2. Requires CDSS to establish a methodology for identifying group homes that have levels of psychotropic dug utilization warranting additional review, in consultation with DHCS.

3. Requires CDSS to inspect a facility identified as appearing to have levels of psychotropic medication utilization warranting additional review at least once a year, and requires the inspection to include, but not be limited to, a review of the facilities plan of operation, child-to-staff rations, staff qualifications and training, implementation of children’s needs and services plan, confidential interviews of residents, and availability of psychosocial and other alternative treatment to the use of psychotropic medication.

4. Permits CDSS to include confidential discussions with former residents, and confidential discussions with physicians prescribing medications to residents.

5. Permits CDSS to do either or both of the following after an inspection:

1. Share relevant information and observations with county placing agencies, social workers and probation officers, the court, dependency counsel, or the Medical Board of California.

2. Share relevant information and observations with the facility and require the facility to submit a plan, within 30 days, to address any identified risks within the control of the facility. Requires CDSS to approve and monitor implementation of the plan.

1. Provides that psychotropic medications shall only be used in accordance with the written directions of the prescribing physician and as authorized by the juvenile court.

2. Requires facilities to maintain specified information in the child’s records regarding psychotropic medication including a copy of any court order authorizing psychotropic medications and a separate log for each medication, as specified.

3. Permits CDSS to implement this bill through all-county letters or similar instructions until regulations are filed and requires emergency regulations to be adopted on or before January 1, 2017 and final regulations to be adopted on or before January 1, 2018.

4. Requires CDSS to monitor the facility’s implementation of the plan to determine whether the facility has reduced the rate that psychotropic medications are administered, and the percentage decrease; whether and to what extent alternative less invasive treatments are being provided to residents, and the percentage increase; whether and to what extent

5. Requires CDSS and DHCS in consultation with specified stakeholders to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce the utilization of psychotropic medications in group homes, including behavioral management programs, emergency intervention plans, and conflict resolution processes.

6. Requires CDSS to post on its internet website a statewide summary of information gathered pursuant to this bill and requires such information be de-identified and aggregate, and does not violate the confidentiality of a child’s identity and records.

Background

Group Homes. Group homes are 24-hour residential facilities licensed by CDSS to provide board and care to foster youth from both the dependency and delinquency jurisdictions. Group home facilities are organized under a system of rate classification levels (RCLs) ranging from 1-14 that are based on levels of professional training and adult-to-child ratios. In practice, the majority of group homes are at or above RCL 10 with nearly 50 percent of group homes at RCL 12. There is wide variation in group home size from as few as six children to more than 100.

Group Home Program Statement. Group homes are required to establish a “group home program statement” that includes a training plan that is appropriate for the client population and the training needs and skill level of child care staff. Through regulation, existing law provides that newly hired staff complete at least 24 hours of training within 90 days of being hired, and 40 hours within 12 months, as specified, with all existing staff receiving 20 hours annually. Regulations provide for the minimum topics that must be included (e.g. discipline policies and procedures, behavior problems / psychological disorders, and mental health / behavioral interventions). Social work staff is required to establish a "needs and services plan" for each child that identifies the specific needs of an individual child, and delineates those services necessary in order to meet the child's identified needs.

Group homes are required to submit to the department an emergency intervention plan, identifying how the facility will use emergency interventions to address aggressive or assaultive behavior of residents. The plan is required to be designed by the licensee and a qualified behavior management consultant and must be appropriate for the client population served by the group home, and for the staff qualifications and staff emergency intervention training.

Psychotropic Medication Use in Children. Concern over the use of psychotropic medications among children has been well-documented in research journals and the mainstream media for more than a decade. The category of psychotropic medication is fairly broad, intending to treat symptoms of conditions ranging from ADHD to childhood schizophrenia. Some of the drugs used to treat these conditions are FDA-approved, including stimulants like Ritalin for ADHD, however only about 31 percent of psychotropic medications have been approved by the U.S. Food and Drug Administration (FDA) for use in children or adolescents. It is estimated that more than 75 percent of the prescriptions written for psychiatric illness in this population are “off label” in usage, meaning they have not been approved by the FDA for the prescribed use, though the practice is legal and common across all manner of pharmaceuticals.

Anti-psychotic medications, used to treat more severe mental health conditions, include powerful brand-name drugs such as Haldol, Risperdal, Abilify, Seroquel and Zyprexa. They have very limited approval by the FDA for pediatric use beyond rare and severe conduct problems that are resistant to other forms of treatment, such as Tourette’s syndrome, behavioral symptoms associated with autistic disorder, childhood schizophrenia, and bipolar disorder. However, the off-label use of these anti-psychotics among children is high, particularly among foster children. According to a study published in 2011, children who took antipsychotic medications were likely to suffer ill health effects including “cardiometabolic and endocrine side-effects” as well as significant weight gain. The authors recommended that collaboration between child and adolescent psychiatrists, general practitioners and pediatricians is essential to “reduce the likelihood of premature cardiovascular morbidity and mortality.”

Compounding the potential for unintended side effects is the use of combinations of psychotropic medications, which foster youth are particularly likely to be prescribed, despite limited evidence of clinical efficacy.

Prescribing rates in California. A recent series of stories published in the San Jose Mercury News detailed significant challenges in accessing pharmacy benefits claims data held by the DHCS, and demonstrated that prescribing rates were far higher than had been anticipated by child welfare system experts. Specifically, the data revealed that nearly 1 in 4 youth, and 56 percent of all youth residing in group homes were prescribed at least one psychotropic medication. Furthermore, for those youth prescribed psychotropic medications, nearly 60 percent were prescribed an anti-psychotic – the powerful drug class most associated with debilitating side effects, and 36 percent were prescribed multiple medications, also referred to as “polypharmacy.”

Increases observed in California mirror those across the nation - children in foster care represent only three percent of children covered by Medicaid, yet, a study of pharmacy claims in 16 states showed that foster children enrolled in Medicaid were prescribed antipsychotic medications at nearly nine times the rate of other children receiving Medicaid.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

The Assembly Appropriations Committee states this bill may incur ongoing costs in the range of $300,000 to $600,000 (GF) per year to CDSS to conduct annual site visits at group homes identified as having disproportionately high and inappropriate levels of psychotropic medication use by foster youth. Additionally, the analysis estimates one-time costs of approximately $250,000 (GF) to CDSS to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny and ongoing costs of $130,000 ($65,000 GF) to DHCS to identify, evaluate and collate claims data packages to be used for the purposes of this bill.

SUPPORT: (Verified 9/8/15)

Advokids

Alameda County Foster Youth Alliance

All Saints Foster Care Project

California Court Appointed Special Advocates

California Department of Justice

California Youth Connection

Children’s Advocacy Institute

Children’s Defense Fund – California

Children’s Law Center of California

Children’s Partnership

Consumer Watchdog

Dependency Legal Group of San Diego

East Bay Children’s Law Offices

East Bay Community Law Center

First Focus Campaign for Children

First Place for Youth

Humboldt County Transition Age You Collaboration

Legal Advocates for Children and Youth

Legal Services for Prisoners with Children

Mockingbird Society

National Association of Social Workers

National Center for Youth Law

Peers Envisioning and Engaging in Recovery Services

Public Counsel’s Children’s Rights Project

Santa Clara Board of Supervisors

Youth Law Center

10 individuals

OPPOSITION: (Verified 9/8/15)

None received

ASSEMBLY FLOOR: 79-0, 9/08/15

AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins

NO VOTE RECORDED: Chávez

Prepared by: Sara Rogers / HUMAN S. / (916) 651-1524

9/8/15 19:24:28

**** END ****

SENATE THIRD READING

STR Bill Id:SB 484

Author:(Beall)

As Amended Ver:September 3, 2015

Majority vote

SENATE VOTE: 40-0

SUMMARY: Requires the collection of information on the administration of psychotropic medications to foster youth placed in group homes, and adopts measures aimed at reforming the practices of those group homes with levels of psychotropic medication utilization that warrant additional review. Specifically, this bill:

1. Requires that psychotropic medications for youth in group homes be used only in accordance with the written directions of the prescribing physician and as authorized by the juvenile court, as specified.

2. Requires group home facilities to maintain in a child's records a copy of any court order authorizing psychotropic medication, as well as a separate log for each prescribed psychotropic medication that contains information about that medication and its administration, as specified.

3. Clarifies that the Department of Social Services (DSS), and not its director, is responsible for publishing and making available a list or lists covering all community care facilities and the services for which they are licensed, as specified.

4. Adds short-term residential treatment centers to the list of community care facility types for which DSS must annually publish information related to licensing complaints and law enforcement contacts, as specified.

5. Includes professional organizations educating foster parents among entities authorized to have disclosed to them, upon request, the names and addresses of foster homes, as specified.

6. Requires DSS to compile, at least once per year and to the extent feasible, Health Effectiveness Data and Information Set (HEDIS) data, as specified and to include:

   1. Follow-up care for children prescribed attention deficit hyperactivity disorder medication;

   2. Use of multiple concurrent antipsychotics in children and adolescents;

   3. Use of first-line psychosocial care for children and adolescents on antipsychotics; and

   4. Metabolic monitoring for children and adolescents on antipsychotics.

7. Requires DSS to post the list of data to be collected pursuant to this bill on its Internet Web site.

8. Requires DSS to consult with the Department of Health Care Services (DHCS) and stakeholders to establish a methodology, by July 1, 2016, for identifying group homes that have levels of psychotropic drug utilization warranting further review. Further, requires periodic review of this methodology if necessary.

9. Requires DSS to inspect annually any facility found to have levels of psychotropic drug utilization warranting additional review. Further, requires this annual inspection to include, but not be limited to, the following:

   1. A review of the facility’s: plan of operation, policies, procedures, and practices; child-to-staff ratios; staff qualifications and training; implementation of children's needs and services plans; availability of psychosocial and other alternative treatments to the use of psychotropic medications; other factors that the department determines contribute to levels of psychotropic drug usage warranting additional review; and

   2. Confidential interviews with children living in the facility at the time of the inspection.

10. Permits the inspection to also include, but not be limited to, confidential interviews of children who resided in the facility within the last six months and confidential discussions with prescribing physicians.

11. Allows DSS, following an inspection and as it deems appropriate, to do either or both of the following:

    1. Share relevant information and observations with specified entities; and/or

    2. Share relevant information and observations with the facility and require the facility to submit a plan of correction, within 30 days of this information being shared, to address any identified risks within the control of the facility related to psychotropic medication. Further, require the department to approve the plan and verify its implementation to determine whether identified risks have been remedied.

12. Requires DSS to adopt emergency regulations by January 1, 2017, to implement this bill, as specified, and to adopt final regulations by January 1, 2018. Further, permits DSS to implement this bill through all-county letters or similar instructions until emergency regulations are filed with the Secretary of State.

13. States that nothing in this bill is intended to:

    1. Replace or alter other requirements regarding group home complaints, inspections, or visits; or

    2. Prevent or preclude DSS from taking any other action permitted under any other law, as specified.

14. Requires DSS, by January 1, 2017, and in consultation with specified entities, to develop additional performance standards and outcome measures that require group homes to implement alternative programs and services for children in group homes, as specified.

15. Exempts runaway and homeless shelters, as specified, from the bill’s data collection and reporting and inspection requirements.

16. Requires DSS to, at least once per year, post a statewide summary of the information gathered pursuant to this bill on its Internet Web site, as specified.

EXISTING LAW:

1. Establishes the California Community Care Facilities Act to provide for the licensure and regulation of community care facilities. (Health and Safety Code (HSC) Section 1500 et seq.)

2. Requires DSS to conduct unannounced visits of each licensed community care facility, except for foster family homes, and requires that no facility or center be visited less frequently than once every five years. Further requires DSS to conduct annual unannounced visits of licensed facilities under specified circumstances, such as when a license is on probation. Additionally requires annual visits of a random sample of at least 20% of facilities and centers not subject to annual inspections for specified circumstances and states that, should the total citations for this 20% of facilities and centers exceed the previous year’s by 10%, the random sample subject to annual inspection shall increase in the next year by 10%. Because of this trigger, 30% of eligible facilities and centers are now randomly sampled each year for inspection. (HSC Section 1534)

3. Requires DSS, in consultation with group home providers and other stakeholders, to develop performance standards to measure group home program performance. (Welfare and Institutions Code (WIC) Section 11469)

4. Defines "psychotropic medication" or "psychotropic drugs" as those medications administered for the purpose of affecting the central nervous system to treat psychiatric disorders or illnesses. Further states that these medications include, but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, anti-Parkinson agents, hypnotics, medications for dementia, and psychostimulants. (WIC Section 369.5 (d))

5. States that only a juvenile court judicial officer has the authority to make orders for the administration of psychotropic medications for a minor who has been adjudged a dependent of the court. (WIC Section 369.5)

FISCAL EFFECT: According to the Assembly Appropriations Committee, this bill may result in the following costs:

1. Ongoing costs in the range of $300,000 to $600,000 (General Fund (GF)) per year to DSS to conduct annual site visits at group homes identified as having disproportionately high and inappropriate levels of psychotropic medication use by foster youth. There are about 1,000 group homes in the state. The costs above assume that DSS identifies the top 10% to 20% of group homes for additional scrutiny.

2. One time costs of approximately $250,000 (GF) to DSS to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny.

3. Ongoing costs of $130,000 ($65,000 GF) to DHCS to identify, evaluate and collate claims data packages to be used for the purposes of this bill.

COMMENTS:

Psychotropic medications and foster youth: Psychotropic medications include drugs prescribed to manage psychiatric and mental health disorders or issues including depression, obsessive-compulsive disorder, attention deficit hyperactivity disorder, bipolar disorder, schizophrenia, and others.

There continues to be significant concern over the use of psychotropic medications for children, due to a vast array of side effects (which can include aggressive behavior, hostility, seizures, significant weight gain, and more) and due to the fact that the long-term effects for children using these drugs are largely unknown. Research has repeatedly indicated that children and youth in foster care face higher levels of inappropriate or excessive medication use, and that those foster youth placed in group home settings are particularly vulnerable to over-prescription and misuse of psychotropic medications. Data shared by the author's office indicate that, in fiscal year 2013-14, almost 15% of all foster youth in California ages zero to 20 years old were prescribed at least one psychotropic medication; looking specifically at all foster youth ages 12 through 20, this rate was almost 25% and for youth placed in group homes, it was 50%.

Need for this bill: According to the author:

More than half of the children in our state's institutions for foster children ('group homes') are medicated with powerful psychotropic drugs. Resistance to taking the drugs can be, and is, punished by expulsion from the facility. The most problematic of the medications are the 'antipsychotic' drugs designed to suppress the most uncontrollable behavior of schizophrenics. As a witness at last year's Congressional hearing said, 'these drugs are too often misused as "chemical straitjackets." This is a haphazard attempt to simply control and suppress undesirable behavior, rather than treat, nurture and develop these treasured young people.' Causes of overmedication include: poorly trained staff; sedated children allow for reduced staffing ratios; lack of therapeutic intervention alternatives; energetic promotion by manufacturers; and lack of state oversight.

Analysis Prepared by: Daphne Hunt / HUM. S. / (916) 319-2089 FN: 0002056

SENATE THIRD READING

STR Bill Id:SB 484

Author:(Beall)

As Amended Ver:August 28, 2015

Majority vote

SENATE VOTE: 40-0

SUMMARY: Requires the collection of information on the administration of psychotropic medications to foster youth placed in group homes, and adopts measures aimed at reforming the practices of those group homes with levels of psychotropic medication utilization that warrant additional review. Specifically, this bill:

1. Requires that psychotropic medications for youth in group homes be used only in accordance with the written directions of the prescribing physician and as authorized by the juvenile court, as specified.

2. Requires group home facilities to maintain in a child's records a copy of any court order authorizing psychotropic medication, as well as a separate log for each prescribed psychotropic medication that contains information about that medication and its administration, as specified.

3. Clarifies that the Department of Social Services (DSS), and not its director, is responsible for publishing and making available a list or lists covering all community care facilities and the services for which they are licensed, as specified.

4. Requires DSS to compile, at least once per year and to the extent feasible, Health Effectiveness Data and Information Set (HEDIS) data, as specified and to include:

   1. Follow-up care for children prescribed attention deficit hyperactivity disorder medication;

   2. Use of multiple concurrent antipsychotics in children and adolescents;

   3. Use of first-line psychosocial care for children and adolescents on antipsychotics; and

   4. Metabolic monitoring for children and adolescents on antipsychotics.

5. Requires DSS to post the list of data to be collected pursuant to this bill on its Internet Web site.

6. Requires DSS to consult with the Department of Health Care Services (DHCS) and stakeholders to establish a methodology, by July 1, 2016, for identifying group homes that have levels of psychotropic drug utilization warranting further review. Further, requires periodic review of this methodology if necessary.

7. Requires DSS to inspect annually any facility found to have levels of psychotropic drug utilization warranting additional review. Further, requires this annual inspection to include, but not be limited to, the following:

   1. A review of the facility’s: plan of operation, policies, procedures, and practices; child-to-staff ratios; staff qualifications and training; implementation of children's needs and services plans; availability of psychosocial and other alternative treatments to the use of psychotropic medications; other factors that the department determines contribute to levels of psychotropic drug usage warranting additional review; and

   2. Confidential interviews with children living in the facility at the time of the inspection.

8. Permits the inspection to also include, but not be limited to, confidential interviews of children who resided in the facility within the last six months and confidential discussions with prescribing physicians.

9. Requires DSS to share relevant information or observations from inspections with specified parties.

10. Requires facilities to submit a plan of correction, as specified, if DSS finds a risk to the health, safety or personal rights of clients in care, and requires the department to monitor the implementation of this plan, as specified.

11. Requires DSS to adopt emergency regulations by January 1, 2017, to implement this bill, as specified, and to adopt final regulations by January 1, 2018. Further, permits DSS to implement this bill through all-county letters or similar instructions until emergency regulations are filed with the Secretary of State.

12. States that nothing in this bill is intended to replace or alter other requirements regarding group home complaints, inspections, or visits.

13. Requires DSS, by January 1, 2017, and in consultation with specified entities, to develop additional performance standards and outcome measures that require group homes to implement alternative programs and services for children in group homes, as specified.

14. Exempts runaway and homeless shelters, as specified, from the bill’s data collection and reporting and inspection requirements.

15. Requires DSS to, at least once per year, post a statewide summary of the information gathered pursuant to this bill on its Internet Web site, as specified.

EXISTING LAW:

1. Establishes the California Community Care Facilities Act to provide for the licensure and regulation of community care facilities. (Health and Safety Code (HSC) Section 1500 et seq.)

2. Requires DSS to conduct unannounced visits of each licensed community care facility, except for foster family homes, and requires that no facility or center be visited less frequently than once every five years. Further requires DSS to conduct annual unannounced visits of licensed facilities under specified circumstances, such as when a license is on probation. Additionally requires annual visits of a random sample of at least 20% of facilities and centers not subject to annual inspections for specified circumstances and states that, should the total citations for this 20% of facilities and centers exceed the previous year’s by 10%, the random sample subject to annual inspection shall increase in the next year by 10%. Because of this trigger, 30% of eligible facilities and centers are now randomly sampled each year for inspection. (HSC Section 1534)

3. Requires DSS, in consultation with group home providers and other stakeholders, to develop performance standards to measure group home program performance. (Welfare and Institutions Code (WIC) Section 11469)

4. Defines "psychotropic medication" or "psychotropic drugs" as those medications administered for the purpose of affecting the central nervous system to treat psychiatric disorders or illnesses. Further states that these medications include, but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, anti-Parkinson agents, hypnotics, medications for dementia, and psychostimulants. (WIC Section 369.5 (d))

5. States that only a juvenile court judicial officer has the authority to make orders for the administration of psychotropic medications for a minor who has been adjudged a dependent of the court. (WIC Section 369.5)

FISCAL EFFECT: According to the Assembly Appropriations Committee, this bill may result in the following costs:

1. Ongoing costs in the range of $300,000 to $600,000 (General Fund (GF)) per year to DSS to conduct annual site visits at group homes identified as having disproportionately high and inappropriate levels of psychotropic medication use by foster youth. There are about 1,000 group homes in the state. The costs above assume that DSS identifies the top 10% to 20% of group homes for additional scrutiny.

2. One time costs of approximately $250,000 (GF) to DSS to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny.

3. Ongoing costs of $130,000 ($65,000 GF) to DHCS to identify, evaluate and collate claims data packages to be used for the purposes of this bill.

COMMENTS:

Psychotropic medications and foster youth: Psychotropic medications include drugs prescribed to manage psychiatric and mental health disorders or issues including depression, obsessive-compulsive disorder, attention deficit hyperactivity disorder, bipolar disorder, schizophrenia, and others.

There continues to be significant concern over the use of psychotropic medications for children, due to a vast array of side effects (which can include aggressive behavior, hostility, seizures, significant weight gain, and more) and due to the fact that the long-term effects for children using these drugs are largely unknown. Research has repeatedly indicated that children and youth in foster care face higher levels of inappropriate or excessive medication use, and that those foster youth placed in group home settings are particularly vulnerable to over-prescription and misuse of psychotropic medications. Data shared by the author's office indicate that, in fiscal year 2013-14, almost 15% of all foster youth in California ages zero to 20 years old were prescribed at least one psychotropic medication; looking specifically at all foster youth ages 12 through 20, this rate was almost 25% and for youth placed in group homes, it was 50%.

Need for this bill: According to the author:

More than half of the children in our state's institutions for foster children ('group homes') are medicated with powerful psychotropic drugs. Resistance to taking the drugs can be, and is, punished by expulsion from the facility. The most problematic of the medications are the 'antipsychotic' drugs designed to suppress the most uncontrollable behavior of schizophrenics. As a witness at last year's Congressional hearing said, 'these drugs are too often misused as "chemical straitjackets." This is a haphazard attempt to simply control and suppress undesirable behavior, rather than treat, nurture and develop these treasured young people.' Causes of overmedication include: poorly trained staff; sedated children allow for reduced staffing ratios; lack of therapeutic intervention alternatives; energetic promotion by manufacturers; and lack of state oversight.

Analysis Prepared by: Daphne Hunt / HUM. S. / (916) 319-2089 FN: 0001728

Date of Hearing: August 19, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

SBPCA Bill Id:SB 484

Author:(Beall) – As Amended Ver:July 8, 2015

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY: This bill requires the Department of Social Services (DSS) to collect data on the administration of psychotropic medications to foster youth placed in group homes, and develop a methodology to identify those group homes that have disproportionately high and inappropriate levels of psychotropic drug usage. The bill requires DSS to perform inspections of identified group homes and require plans from those facilities to reduce inappropriate use of psychotropic medications. Specifically, this bill:

1. Requires DSS to compile specified information for group homes regarding the administration of psychotropic drugs, by age of the foster youth, the types of medications administered, the length of administration of psychotropic drugs, the provision of other services to those foster youth, and other information;

2. Requires DSS to develop the information above through existing data sources, including information from the Department of Health Care Services (DHCS);

3. Requires DSS to consult with stakeholders and develop a methodology to identify group homes with disproportionately high and inappropriate levels of psychotropic drug usage;

4. Requires at least annual visits to identified group homes to review policies and practices and to have confidential discussions with foster youth and prescribing physicians;

5. Requires an identified group home to submit a plan of correction to DSS, as specified, and requires DSS to monitor these plans.

6. Requires DSS’s Community Care Licensing Division (CCLD) to provide a report to specified entities following an inspection and to report certain concerns to the Medical Board of California and/or to conduct appropriate investigations;

7. Requires DSS to adopt implementing regulations, but also authorizes DSS to begin implementation before regulations are adopted.

FISCAL EFFECT:

1. Ongoing costs in the range of $300,000 to $600,000 (GF) per year to DSS to conduct annual site visits at group homes identified as having disproportionately high and inappropriate levels of psychotropic medication use by foster youth. There are about 1,000 group homes in the state. The costs above assume that DSS identifies the top 10% to 20% of group homes for additional scrutiny.

2. One-time costs of approximately $250,000 (GF) to DSS to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny.

3. Ongoing costs of $130,000 ($65,000 GF) to DHCS to identify, evaluate and collate claims data packages to be used for the purposes of this bill.

COMMENTS:

1. Purpose. This is one of four bills proposing a set of reforms aimed at curbing excessive and inappropriate authorization and administration of psychotropic medications among foster youth. The National Center for Youth Law, states that, “This bill addresses a longstanding crisis in many of the group homes in which California foster children are living – the medication of children and youth, often with powerful antipsychotic drugs, to sedate and control behaviors that are natural responses to grief, suffering, and trauma.

2. Background. Under current law, DSS licenses and regulates community care facilities, including group homes for foster youth. The licensing requirements include specific requirements and standards for group homes that accept children with special needs.

Under current law, only a juvenile court judicial officer may order the administration of psychotropic medications for a minor who is a dependent of the court (i.e. a foster youth). Foster youth are categorically eligible for Medi-Cal benefits and hence Medi-Cal provides coverage for those psychotropic medications.

Psychotropic medications are intended to treat a variety of mental health conditions. While many patients benefit from the use of psychotropic medications, there are often serious side effects, particularly when taken in combination. In general, the use of psychotropic medications on children and adolescents is “off label” meaning that those drugs have not been specifically approved for use in children or adolescents. According to DSS, about 11% of foster youth under age 17 are authorized to receive psychotropic medications. Concerns have been raised by advocates for foster youth that many foster youth are being prescribed these medications to sedate them, rather than to appropriately address their mental health and behavioral health needs.

In response to concerns regarding the high rate of psychotropic drugs administered to foster youth, DHCS expanded its existing policy requiring treatment authorization requests for psychotropic drugs for Medi-Cal beneficiaries. Previously, DHCS required a prior treatment authorization request before Medi-Cal would authorize psychotropic drugs for Medi-Cal beneficiaries under age six. In October 2014, DHCS expanded this requirement for children and adolescents up to age 17. The treatment authorization request process allows for emergency prescriptions while the request is under review. In addition, in April 2015, DHCS and DSS released guidelines for the use of psychotropic medications in foster youth.

3. Related Legislation. The following bills are part of a four-bill package (including this bill) regarding the use of psychotropic medication for children in foster care. All are before this Committee today.

1. SB 238 (Mitchell), 2015, requires DSS to develop expanded training for foster parents, social workers, group home administrators, and others involved in the care and oversight of dependent children on issues related to psychotropic medications.

2. SB 253 (Monning), 2015, modifies juvenile court practices and requirements regarding the authorization of psychotropic medications for foster youth by, among other things, requiring clear and convincing evidence that administration of the medication is in the best interest of the child and, in specified circumstances, prohibiting the authorization of psychotropic medication administration for a child unless a second opinion is obtained from a child psychiatrist or behavioral pediatrician.

3. SB 319 (Beall), 2015, adds to the duties of foster care public health nurses, including monitoring each child in foster care who is administered one or more psychotropic medications.

Analysis Prepared by: Jennifer Swenson / APPR. / (916) 319-2081

Date of Hearing: July 14, 2015

ASSEMBLY COMMITTEE ON HUMAN SERVICES

Kansen Chu, Chair

SBPCA Bill Id:SB 484

Author:(Beall) – As Amended Ver:July 8, 2015

SENATE VOTE: 40-0

SUBJECT: Juveniles.

SUMMARY: Requires the collection of data on the administration of psychotropic medications to foster youth placed in group homes, and adopts measures aimed at reforming the practices of those group homes with high and inappropriate levels of such administration.

Specifically, this bill:

1. Requires the director of the Department of Social Services (DSS) to compile, at least once per year, data from existing data systems, as specified, on the number of children in each facility:

   1. to whom psychotropic medications were administered;

   2. ages 6 to 11 to whom psychotropic medications were administered;

   3. ages 12 to 17 to whom psychotropic medications were administered;

   4. for whom the juvenile court preauthorized the administration of psychotropic medication;

   5. to whom psychotropic medications were administered on an emergency basis;

   6. to whom antipsychotic, mood stabilizing, or antidepressant medications were administered;

   7. who received two or more drugs from the same class, as specified;

   8. who received two or more psychotropic medications concurrently, as specified;

   9. who received one or more medications for more than 90 days;

   10. who received psychosocial services alongside psychotropic medication, as specified;

   11. who received a dosage of a psychotropic medication that exceeded the maximum dosage approved by the Food and Drug Administration (FDA);

   12. who received metabolic monitoring, as specified, while they receive psychotropic medication; and

   13. who were prescribed antipsychotic medications for a use not approved by the FDA.

2. Requires DSS to consult with the foster care ombudsman and the Quality Improvement Project Clinical Workgroup to establish a methodology, by July 1, 2016, for identifying group homes with disproportionately high and inappropriate levels of psychotropic drug usage, per specified criteria. Further, requires periodic review of this methodology.

3. Requires DSS to inspect annually any facility found to have potentially high and inappropriate levels of psychotropic drug usage. Further, requires this annual inspection to include, but not be limited to, the following:

   1. A review of the facility’s: plan of operation, policies, procedures, and practices; child-to-staff ratios; staff qualifications and training; implementation of children’s needs and services plans; availability of psychosocial and other alternative treatments to the use of psychotropic medications; other factors that the department determines contribute to disproportionately high and inappropriate levels of psychotropic drug usage; and

   2. Confidential interviews with youth currently and recently living in the facility and confidential discussions with prescribing physicians, as specified.

4. Requires any facility found through the inspection to have disproportionately high and inappropriate levels of psychotropic drug usage to submit a plan of correction to DSS, as specified, that may include, but not be limited to:

   1. An improved crisis management plan, as specified;

   2. An overall behavioral management plan which shall be trauma-informed;

   3. A quantifiable goal to decrease the use of antipsychotic medications for behavioral control, multiple prescriptions, and pro re nata (“as needed”) medications; and

   4. A quantifiable goal for improving appropriate metabolic monitoring, as specified.

5. Requires DSS to monitor a facility’s implementation of its plan of correction to determine progress, as specified.

6. Requires DSS’s Community Care Licensing Division (CCLD) to provide a report to specified entities following an inspection. Further, requires CCLD, under specified circumstances, to report certain concerns to the Medical Board of California and/or to conduct appropriate investigations.

7. Requires DSS to adopt emergency regulations by January 1, 2017, to implement this bill, as specified, and to adopt final regulations by January 1, 2018. Further, permits DSS to implement this bill through all-county letters or similar instructions from the director until emergency regulations are filed with the Secretary of the State.

8. States that nothing in this bill is intended to replace or alter other requirements regarding group home complaints, inspections, or visits.

9. Requires DSS, by January 1, 2017, and in consultation with specified entities, to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce the utilization of psychotropic medications for children in group homes, as specified.

10. Requires DSS to, at least once per year, post a statewide summary of the data gathered pursuant to this bill on its Internet Web site, as specified.

EXISTING LAW:

1. Establishes the California Community Care Facilities Act to provide for the licensure and regulation of community care facilities. (HSC 1500 et seq.)

2. Defines “community care facility” to mean any facility, place, or building that is maintained and operated to provide nonmedical residential care, day treatment, adult day care, or foster family agency services for children, adults, or children and adults, including, but not limited to, individuals with physical disabilities or mental impairments and abused or neglected children. Includes within this definition, among a number of other facilities: group homes, foster family homes, small family homes, full-service adoption agencies, noncustodial adoption agencies, and transitional shelters. (HSC 1502)

3. Requires community care facilities operating in California, as specified, to have a valid license. (HSC 1503.5)

4. Requires DSS to conduct unannounced visits of each licensed community care facility, except for foster family homes, and requires that no facility or center be visited less frequently than once every five years. Further requires DSS to conduct annual unannounced visits of licensed facilities under specified circumstances, such as when a license is on probation. Additionally requires annual visits of a random sample of at least 20% of facilities and centers not subject to annual inspections for specified circumstances and states that, should the total citations for this 20% of facilities and centers exceed the previous year’s by 10%, the random sample subject to annual inspection shall increase in the next year by 10%. Because of this trigger, 30% of eligible facilities and centers are now randomly sampled each year for inspection. (HSC 1534)

5. Requires DSS, in consultation with group home providers and other stakeholders, to develop performance standards to measure group home program performance. (WIC 11469)

6. Establishes a state and local system of child welfare services, including foster care, for children who have been adjudged by the court to be at risk or have been abused or neglected, as specified. (WIC 202 et seq.)

7. Allows a juvenile court to adjudge a child a ward or a dependent of the court for specified reasons, including but not limited to if the child has been left without any provision for support, as specified. (WIC 300)

8. Defines “psychotropic medication” or “psychotropic drugs” as those medications administered for the purpose of affecting the central nervous system to treat psychiatric disorders or illnesses. Further states that these medications include, but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, anti-Parkinson agents, hypnotics, medications for dementia, and psychostimulants.
   (WIC 369.5 (d))

9. States that only a juvenile court judicial officer has the authority to make orders for the administration of psychotropic medications for a minor who has been adjudged a dependent of the court. (WIC 369.5)

FISCAL EFFECT: According to the May 28, 2015, analysis by the Senate Appropriations Committee, this bill may result in the following costs:

1. One-time costs of about $250,000 to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny (Technical Assistance Fund).

2. Ongoing costs of $300,000 to $600,000 per year to conduct annual site visits at group homes identified as having disproportionately high levels of psychotropic medication use by foster youth (Technical Assistance Fund).

COMMENTS:

Continuum of Care Reform: There has been growing consensus in the field of child welfare, at both the national and state levels, that institutionalized settings for foster youth should be used sparingly. The placement of maltreated children in group home settings has been increasingly viewed as a temporary solution in instances where emergency or crisis treatment is warranted. Yet, as of January 2015, 48% of youth placed in group homes in California via the Child Welfare Services (CWS) system had been there over two years, and 23% had been there over five years.

Prior to placement in a group home, it is common for a child to have multiple foster care placements. This type of history can be interpreted as the child being difficult-to-place. However, the Legislature has worked, and continues to work, with various entities in and around the CWS system to focus on family reunification and permanency by seeking ways to best address the needs of foster youth through less restrictive, more supportive placements and services.

SB 1013 (Senate Budget and Fiscal Review) Chapter 35, Statutes of 2012, realigned CWS to counties, established a moratorium on the licensing of new group homes, and required DSS to convene a workgroup. This workgroup was charged with examining the use of group homes in California and providing recommendations to the Legislature and the Governor on how to reform this use. In January 2015, DSS submitted the Continuum of Care (CCR) workgroup report to the Legislature, which included general and fiscal recommendations, alongside recommendations on home-based family care, residential treatment, and performance measures and outcomes. The report reinforced the view that group home settings are best used sparingly and temporarily, stating that:

“The foundation of [these] recommendations is that all children, including those in out-of-home care, deserve to grow up in families and develop a sense of community. Their families, including foster families, also at times need assistance and support to address stressors to avert crises. For those children and youth in crisis or whom otherwise initially cannot safely get the appropriate breadth and/or intensity of services they require in a family based setting, they can access high quality, short term, treatment oriented congregate care (which includes planning for a move to home-based family care as soon as reasonably possible).”

AB 403 (Stone), currently set to be heard in the Senate Human Services Committee, seeks to implement many of the changes proposed in the CCR workgroup report.

Psychotropic medications and foster youth: Psychotropic medications include drugs prescribed to manage psychiatric and mental health disorders or issues including depression, obsessive-compulsive disorder, attention deficit hyperactivity disorder, bipolar disorder, schizophrenia, and others. These medications include antipsychotics such as Seroquel, antidepressants like Prozac, mood stabilizers including Lithium, and stimulants like Ritalin.

There continues to be significant concern over the use of psychotropic medications for children, due to a vast array of side effects (which can include aggressive behavior, hostility, seizures, significant weight gain, and more) and due to the fact that the long-term effects for children using these drugs are largely unknown. Additionally, many psychotropic medications are prescribed to children “off label” – that is, they are used to treat symptoms other than those for which the FDA originally approved each drug. While off-label use is not illegal, there are concerns about how well-understood these medications and their uses are by prescribers and patients. Over 75% of psychotropic drug use among children and adolescents is believed to be off-label. One class of psychotropic medications, antipsychotics, raises particular concern; these are potent drugs with a high potential for side-effects, and there is little known about their impact on growth, development, and children’s neurological systems.

Research has repeatedly indicated that children and youth in foster care face higher levels of inappropriate or excessive medication use, and that those foster youth placed in group home settings are particularly vulnerable to over-prescription and misuse of psychotropic medications. Data shared by the author’s office indicate that, in fiscal year 2013-14, almost 15% of all foster youth in California ages 0 to 20 years old were prescribed at least one psychotropic medication; looking specifically at all foster youth ages 12 through 20, this rate was almost 25% and for youth placed in group homes, it was 50%.

In late 2011, the U.S. Department of Health and Human Services issued a letter to states encouraging them to coordinate with partners who worked with foster youth to address enhanced efforts to appropriately prescribe and monitor psychotropic medication among children placed in out-of-home care. As a result, the Department of Health Care Services (DHCS) and DSS developed the Quality Improvement Project to strengthen the state’s Medicaid and child welfare services system by, among other things, improving safe and appropriate prescribing and monitoring of psychotropic drugs; this project has enabled the state to access the knowledge and perspectives of various experts, and has continued to hold various workgroup meetings and set and accomplish objectives related to its mission. Additionally, this Spring, DHCS and DSS released state guidelines for the use of psychotropic medication with children and youth in foster care.

Need for this bill: This is one of four bills proposing a set of reforms aimed at curbing excessive and inappropriate authorization and administration of psychotropic medications among foster youth. Institutionalized settings for foster youth like group homes have come to be seen as placements that should be used sparingly, and only for short periods of time. The concerns raised by group home placements are compounded when considering that one-half of all foster youth placed in them are prescribed psychotropic medications. California is working to reform the continuum of foster care to better serve youth through, among other things, reducing reliance on group homes. However, such reform is involved and complex and therefore will take time. This bill provides a more immediate solution in the interim, aiming to redress the particular problem of high and inappropriate administration of psychotropic medications to youth living in group homes.

According to the author:

“More than half of the children in our state’s institutions for foster children (‘group homes’) are medicated with powerful psychotropic drugs. Resistance to taking the drugs can be, and is, punished by expulsion from the facility. The most problematic of the medications are the ‘antipsychotic’ drugs designed to suppress the most uncontrollable behavior of schizophrenics. As a witness at last year’s Congressional hearing said, ‘these drugs are too often misused as “chemical straitjackets.” This is a haphazard attempt to simply control and suppress undesirable behavior, rather than treat, nurture and develop these treasured young people.’ Causes of overmedication include: poorly trained staff; sedated children allow for reduced staffing ratios; lack of therapeutic intervention alternatives; energetic promotion by manufacturers; and lack of state oversight.”

The sponsor of this bill, the National Center for Youth Law, states that:

“This bill addresses a longstanding crisis in many of the group homes in which California foster children are living – the medication of children and youth, often with powerful antipsychotic drugs, to sedate and control behaviors that are natural responses to grief, suffering, and trauma.

Nearly four thousand children and adolescents are placed in more than one thousand group homes throughout California. On average, fifty-six percent of the children in group homes are given one or more psychotropic medications, often in lieu of counseling and appropriate care. In contrast, approximately five percent of children placed with relatives and twelve percent of children in foster family homes are administered psychotropic drugs. These psychotropic drugs can cause crippling sedation, morbid obesity, memory loss, diabetes, heart disease, irreversible tremors, other long-term disabilities, and in extreme cases, death.

[This bill] requires the identification of group homes suspected of using psychotropic medications inappropriately and specifies the factors to be used in pinpointing those facilities. Those group homes identified will be inspected to determine what policies or practices within the facility contribute to the misuse of psychotropic medications. A corrective action plan must be prepared by the facility and its implementation monitored by the Department to determine the extent to which the plan has led to reductions in the use of psychotropic medications and the provision of alternative treatments to children. The state is working on long-term solutions to the problem of group homes but overmedicated children and youth in group homes need action now.”

RELATED LEGISLATION:

SB 238 (Mitchell), 2015, requires DSS to develop expanded training for foster parents, social workers, group home administrators, and others involved in the care and oversight of dependent children on issues related to psychotropic medications. Further requires Judicial Council to, in consultation with other entities, update court forms related to the authorization of psychotropic medications, and requires DSS to establish an individualized monthly report and other tools for use by county welfare agencies to monitor the administration of psychotropic medications to foster youth.

SB 253 (Monning), 2015, modifies juvenile court practices and requirements regarding the authorization of psychotropic medications for foster youth by, among other things, requiring clear and convincing evidence that administration of the medication is in the best interest of the child and, in specified circumstances, prohibiting the authorization of psychotropic medication administration for a child unless a second opinion is obtained from a child psychiatrist or behavioral pediatrician.

SB 319 (Beall), 2015, adds to the duties of foster care public health nurses, including monitoring each child in foster care who is administered one or more psychotropic medications.

AB 403 (Stone), 2015, implements Continuum of Care Reform recommendations to better serve children and youth in California’s child welfare services system.

REGISTERED SUPPORT / OPPOSITION:

Support

Abode Services

Accessing Health Services For California’s Children In Foster Care Task Force

Advokids

California Department of Justice

California Youth Connection (CYC)

Children Now

Children’s Defense Fund – California (CDF-CA)

Children’s Law Center of California

Citizens Commission on Human Rights (CCHR)

Consumer Watchdog

Dependency Legal Group of San Diego

Family Voices of California

First Place for Youth

Humboldt County Transition Age Youth Collaboration

John Burton Foundation for Children Without Homes

Legal Services for Prisoners with Children (LSPC)

National Association of Social Workers, CA Chapter (NASW-CA)

National Center for Youth Law, sponsor

North American Council on Adoptable Children (NACAC)

Santa Clara County Board of Supervisors

The Children’s Partnership

The Jamestown Community Center

The Mockingbird Society

Youth Law Center (YLC)

4 individuals

Opposition

None on file.

Analysis Prepared by: Daphne Hunt / HUM. S. / (916) 319-2089

 THIRD READING  

Bill No: SB 484

Author: Beall (D)

Amended: 6/2/15

Vote: 21

SENATE HUMAN SERVICES COMMITTEE: 5-0, 4/21/15

AYES: McGuire, Berryhill, Hancock, Liu, Nguyen

SENATE HEALTH COMMITTEE: 9-0, 4/29/15

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15

AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

SUBJECT: Juveniles

SOURCE: National Center for Youth Law

DIGEST: This bill requires the California Department of Social Services (CDSS) to identify group homes in the foster care system that may be inappropriately administering psychotropic medications to foster youth. The bill requires CDSS to inspect identified group homes and to require the submissions of plans from those facilities to reduce inappropriate use of psychotropic medications, as specified.

ANALYSIS:

Existing law:

1. Establishes the Community Care Facilities Act, which provides for the licensure and regulation of community care facilities, including group homes, by CDSS, and requires that licensed facilities be subject to unannounced inspections under specified circumstances. (HSC 1500 et seq, and 1534)

2. Requires CDSS to establish a rate classification level (RCL) structure for group homes with a corresponding rate structure according to the level of care and services that will be provided, as specified. (WIC 11462)

3. Permits a group home to be classified as an RCL 13 or 14 if the program only accepts children with special treatment needs and meets other requirements. Additionally, requires the California Department of Health Care Services (DHCS) to annually certify group homes seeking classification as RCL 13 or 14 and permits such facilities to accept minor dependents who are seriously or emotionally disturbed if certain conditions are met. (WIC 11469, WIC 4096.5 and HSC 1502.4)

4. Requires CDSS to publish and make available to interested persons a list or lists covering all licensed community care facilities, other than foster family homes and certified family homes, to include specified information regarding group homes, transitional housing placement providers, community treatment facilities or runaway and homeless youth shelters including complaints, citations, fines and the number of law enforcement contacts made by group homes. (HSC 1536)

This bill:

1. Requires CDSS to compile, at least annually, specified information in order to identify group homes in which psychotropic medications may be inappropriately administered to children.

2. Requires CDSS to develop the information above through existing data sources it has access to, including information from DHCS.

3. Requires CDSS to consult with the foster care ombudsman and stakeholder quality improvement workgroups (currently in existence) to establish a methodology to identify group homes with disproportionately high levels of psychotropic drug usage warranting additional review of the facility.

4. Requires, on or after January 1, 2020, CDSS to consult with the foster care ombudsman and stakeholder quality improvement workgroups and revise, if necessary, the above methodology.

5. Requires CDSS to inspect identified facilities once a year to review specified information and factors that may contribute to high utilization of psychotropic medication regimens and low utilization of monitoring and psychosocial services. Requires CDSS to perform inspections with input from specified stakeholders.

6. Requires CDSS to include confidential discussions with current and former residents, and confidential discussions with physicians prescribing medications to residents, and requires DHCS and CDSS to identify the prescribers’ names, addresses and contact information using existing data systems.

7. Requires a facility found to have a high utilization of dangerous psychotropic medication regimens and inadequate alternative services, to develop and submit to CDSS a plan to reduce inappropriate prescribing of psychotropic medications and treatment regimens within 60 days of the visit.

8. Requires the plan to include the following:

   1. An improved crisis management plan, including de-escalation techniques and procedures for staff training;

   2. An overall trauma-informed behavioral management plan;

   3. A quantifiable goal to decrease the use of antipsychotic medications for behavioral control, to decrease polypharmacy and to decrease the use of pro re nata medications.

   4. Identify a quantifiable goal of appropriate metabolic monitoring, as specified.

9. Requires CDSS to monitor the facility’s implementation of the plan to determine whether the facility has reduced the rate that psychotropic medications are administered, and the percentage decrease; whether and to what extent alternative less invasive treatments are being provided to residents, and the percentage increase; whether and to what extent appropriate metabolic monitoring is being conducted, and the percentage increase.

10. Requires CDSS to submit a report to the Children and Family Services Division of the department and to any public agency that has certified any component of the facility’s program, including DHCS.

11. Requires CDSS to adopt implementing regulations, but permits CSSS to begin implementation through all-county letters or similar instructions before regulations are adopted, and to adopt emergency regulations prior to receiving formal approval from the Office of Administrative Law. Requires final regulations to be adopted on or before January 1, 2018.

12. Requires CDSS and DHCS in consultation with specified stakeholders to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce the utilization of psychotropic medications in group homes, including behavioral management programs, emergency intervention plans, and conflict resolution processes.

13. Requires CDSS to post on its internet website a summary progress report, with data that excludes personally identifiable information, of the information gathered pursuant to this bill.

Background

Group Homes. Group homes are 24-hour residential facilities licensed by CDSS to provide board and care to foster youth from both the dependency and delinquency jurisdictions. Group home facilities are organized under a system of rate classification levels (RCLs) ranging from 1-14 that are based on levels of professional training and adult-to-child ratios. In practice, the majority of group homes are at or above RCL 10 with nearly 50 percent of group homes at RCL 12. There is wide variation in group home size from as few as six children to more than 100.

Group Home Program Statement. Group homes are required to establish a “group home program statement” that includes a training plan that is appropriate for the client population and the training needs and skill level of child care staff. Through regulation, existing law provides that newly hired staff complete at least 24 hours of training within 90 days of being hired, and 40 hours within 12 months, as specified, with all existing staff receiving 20 hours annually. Regulations provide for the minimum topics that must be included (e.g. discipline policies and procedures, behavior problems / psychological disorders, and mental health / behavioral interventions). Social work staff is required to establish a "needs and services plan" for each child that identifies the specific needs of an individual child, and delineates those services necessary in order to meet the child's identified needs.

Group homes are required to submit to the department an emergency intervention plan, identifying how the facility will use emergency interventions to address aggressive or assaultive behavior of residents. The plan is required to be designed by the licensee and a qualified behavior management consultant and must be appropriate for the client population served by the group home, and for the staff qualifications and staff emergency intervention training.

Psychotropic Medication Use in Children. Concern over the use of psychotropic medications among children has been well-documented in research journals and the mainstream media for more than a decade. The category of psychotropic medication is fairly broad, intending to treat symptoms of conditions ranging from ADHD to childhood schizophrenia. Some of the drugs used to treat these conditions are FDA-approved, including stimulants like Ritalin for ADHD, however only about 31 percent of psychotropic medications have been approved by the U.S. Food and Drug Administration (FDA) for use in children or adolescents. It is estimated that more than 75 percent of the prescriptions written for psychiatric illness in this population are “off label” in usage, meaning they have not been approved by the FDA for the prescribed use, though the practice is legal and common across all manner of pharmaceuticals.

Anti-psychotic medications, used to treat more severe mental health conditions, include powerful brand-name drugs such as Haldol, Risperdal, Abilify, Seroquel and Zyprexa. They have very limited approval by the FDA for pediatric use beyond rare and severe conduct problems that are resistant to other forms of treatment, such as Tourette’s syndrome, behavioral symptoms associated with autistic disorder, childhood schizophrenia, and bipolar disorder. However, the off-label use of these anti-psychotics among children is high, particularly among foster children. According to a study published in 2011, children who took antipsychotic medications were likely to suffer ill health effects including “cardiometabolic and endocrine side-effects” as well as significant weight gain. The authors recommended that collaboration between child and adolescent psychiatrists, general practitioners and pediatricians is essential to “reduce the likelihood of premature cardiovascular morbidity and mortality.”

Compounding the potential for unintended side effects is the use of combinations of psychotropic medications, which foster youth are particularly likely to be prescribed, despite limited evidence of clinical efficacy.

Prescribing rates in California. A recent series of stories published in the San Jose Mercury News detailed significant challenges in accessing pharmacy benefits claims data held by the DHCS, and demonstrated that prescribing rates were far higher than had been anticipated by child welfare system experts. Specifically, the data revealed that nearly 1 in 4 youth, and 56 percent of all youth residing in group homes were prescribed at least one psychotropic medication. Furthermore, for those youth prescribed psychotropic medications, nearly 60 percent were prescribed an anti-psychotic – the powerful drug class most associated with debilitating side effects, and 36 percent were prescribed multiple medications, also referred to as “polypharmacy.”

Increases observed in California mirror those across the nation - children in foster care represent only three percent of children covered by Medicaid, yet, a study of pharmacy claims in 16 states showed that foster children enrolled in Medicaid were prescribed antipsychotic medications at nearly nine times the rate of other children receiving Medicaid.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to an analysis by the Senate Appropriations Committee, this bill would result in one-time costs of about $250,000 to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny (Technical Assistance Fund). Additionally, there are expected ongoing costs of $300,000 to $600,000 per year to conduct annual site visits at group homes identified as having disproportionately high levels of psychotropic medication use by foster youth (Technical Assistance Fund). There are about 1,000 group homes in the state. The costs above assume that CDSS identifies 10% to 20% of group homes for additional scrutiny.

SUPPORT: (Verified 6/1/15)

National Center for Youth Law (Source)

Advokids

Alameda County Foster Youth Alliance

California Court Appointed Special Advocates (CASA)

California Department of Justice

California Youth Connection

Children’s Advocacy Institute

Children’s Law Center of California

Children’s Partnership

Dependency Legal Group of San Diego

East Bay Children’s Law Offices

East Bay Community Law Center

First Focus Campaign for Children

Humboldt County Transition Age Youth Collaboration

Legal Advocates for Children and Youth

Legal Services for Prisoners with Children

National Association of Social Workers

Peers Envisioning and Engaging in Recovery Services

Public Counsel’s Children’s Rights Project

Youth Law Center

10 individuals

OPPOSITION: (Verified 6/1/15)

None received

ARGUMENTS IN SUPPORT: According to the author, more than half of the children in California group homes are medicated with powerful psychotropic medications. The author states that these medications are misused to control and suppress undesirable behavior, rather than treat, nurture and develop the young people residing in the facility. The author states that this bill identifies those group homes that appear to rely on psychotropic medication as the first-line or only treatment and requires those with the highest rates of medication to reduce those rates and to adopt alternative, less invasive, treatment approaches.

Prepared by: Sara Rogers / HUMAN S. / (916) 651-1524

6/2/15 13:22:04

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

SB 484 (Beall) - Juveniles

SUSPENSE FILE. AS AMENDED.

Bill Summary:

SB 484 would require the Department of Social Services to identify group homes in the foster care system that inappropriately administer psychotropic medications to foster youth. The bill would require the Department perform inspections of identified group homes and require plans from those facilities to reduce inappropriate use of psychotropic medications.

Fiscal Impact (as approved on May 28, 2015):

• One-time costs of about $250,000 to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny (Technical Assistance Fund).

• Ongoing costs of $300,000 to $600,000 per year to conduct annual site visits at group homes identified as having disproportionately high levels of psychotropic medication use by foster youth (Technical Assistance Fund). There are about 1,000 group homes in the state. The costs above assume that the Department of Social Services identifies the top 10% to 20% of group homes for additional scrutiny.

Background:

Under current law, the Department of Social Services licenses and regulates community care facilities, including group homes for foster youth. The licensing requirements include specific requirements and standards for group homes that accept children with special needs.

Under current law, only a juvenile court judicial officer may order the administration of psychotropic medications for a minor who is a dependent of the court (i.e. a foster youth). Foster youth are categorically eligible for Medi-Cal benefits and hence Medi-Cal provides coverage for those psychotropic medications.

Psychotropic medications are intended to treat a variety of mental health conditions. While many patients benefit from the use of psychotropic medications, there are often serious side effects, particularly when taken in combination. In general, the use of psychotropic medications on children and adolescents is “off label” meaning that those drugs have not been specifically approved for use in children or adolescents. According to the Department of Social Services, about 11% of foster youth under age 17 are authorized to receive psychotropic medications. Concerns have been raised by advocates for foster youth that many foster youth are being prescribed these medications to sedate them, rather than to appropriately address their mental health and behavioral health needs.

In response to concerns about the high rate of psychotropic drugs administered to foster youth, the Department of Health Care Services expanded its existing policy requiring treatment authorization requests for psychotropic drugs for Medi-Cal beneficiaries. Previously, the Department required a prior treatment authorization request before Medi-Cal would authorize psychotropic drugs for Medi-Cal beneficiaries under age six. In October 2014, the Department expanded this requirement for children and adolescents up to age 17. The treatment authorization request process allows for emergency prescriptions while the request is under review. In addition, in April 2015 the Department of Health Care Services and the Department of Social Services released guidelines for the use of psychotropic medications in foster youth.

Proposed Law:

SB 484 would require the Department of Social Services to identify group homes in the foster care system that inappropriately administer psychotropic medications to foster youth. The bill would require the Department to perform inspections of identified group homes and require plans from those facilities to reduce inappropriate use of psychotropic medications.

Specific provisions of the bill would:

• Require the Department to compile specified information for group homes regarding the administration of psychotropic drugs, by age of the foster youth, the types of medications administered, the length of administration of psychotropic drugs, the provision of other services to those foster youth, and other information;

• Require the Department to develop the information above through existing data sources it has access to, including information from the Department of Health Care Services;

• Require the Department to consult with stakeholders and develop a methodology to identify group homes with disproportionately high use of psychotropic drugs;

• Require at least annual visits to identified group homes to review policies and practices and to have confidential discussions with foster youth and prescribing physicians;

• Require a group home to develop a plan to reduce inappropriate prescribing of psychotropic medications, if the Department finds high utilization and inadequate alternative services;

• Require the Department to monitor the plans submitted by identified group homes;

• Require the Department to adopt implementing regulations, but also authorize the Department to begin implementation before regulations are adopted.

Related Legislation:

• SB 319 (Beall) would require counties to contract with local Child Health and Disability Prevention programs to provide foster care public health nursing services. The bill would expand the duties required of foster care public health nurses. That bill will be heard in this committee.

• SB 238 (Mitchell) would require additional training regarding psychotropic drugs and mental health issues for a variety of groups who have responsibility for foster youth. That bill is on this committee’s Suspense File.

• SB 253 (Monning) would modify the judicial requirements and practices for authorizing psychotropic drugs for foster youth. That bill will be heard in this committee.

Staff Comments:

The only costs that may be incurred by a local agency relate to crimes and infractions. Under the California Constitution, such costs are not reimbursable by the state.

Committee amendments (as adopted May 28, 2015): require the Department to consult with stakeholders and reevaluate the methodology in four years.

-- END --

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

SB 484 (Beall) - Juveniles

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

SB 484 would require the Department of Social Services to identify group homes in the foster care system that inappropriately administer psychotropic medications to foster youth. The bill would require the Department perform inspections of identified group homes and require plans from those facilities to reduce inappropriate use of psychotropic medications.

Fiscal Impact:

• One-time costs of about $250,000 to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny (Technical Assistance Fund).

• Ongoing costs of $300,000 to $600,000 per year to conduct annual site visits at group homes identified as having disproportionately high levels of psychotropic medication use by foster youth (Technical Assistance Fund). There are about 1,000 group homes in the state. The costs above assume that the Department of Social Services identifies the top 10% to 20% of group homes for additional scrutiny.

Background:

Under current law, the Department of Social Services licenses and regulates community care facilities, including group homes for foster youth. The licensing requirements include specific requirements and standards for group homes that accept children with special needs.

Under current law, only a juvenile court judicial officer may order the administration of psychotropic medications for a minor who is a dependent of the court (i.e. a foster youth). Foster youth are categorically eligible for Medi-Cal benefits and hence Medi-Cal provides coverage for those psychotropic medications.

Psychotropic medications are intended to treat a variety of mental health conditions. While many patients benefit from the use of psychotropic medications, there are often serious side effects, particularly when taken in combination. In general, the use of psychotropic medications on children and adolescents is “off label” meaning that those drugs have not been specifically approved for use in children or adolescents. According to the Department of Social Services, about 11% of foster youth under age 17 are authorized to receive psychotropic medications. Concerns have been raised by advocates for foster youth that many foster youth are being prescribed these medications to sedate them, rather than to appropriately address their mental health and behavioral health needs.

In response to concerns about the high rate of psychotropic drugs administered to foster youth, the Department of Health Care Services expanded its existing policy requiring treatment authorization requests for psychotropic drugs for Medi-Cal beneficiaries. Previously, the Department required a prior treatment authorization request before Medi-Cal would authorize psychotropic drugs for Medi-Cal beneficiaries under age six. In October 2014, the Department expanded this requirement for children and adolescents up to age 17. The treatment authorization request process allows for emergency prescriptions while the request is under review. In addition, in April 2015 the Department of Health Care Services and the Department of Social Services released guidelines for the use of psychotropic medications in foster youth.

Proposed Law:

SB 484 would require the Department of Social Services to identify group homes in the foster care system that inappropriately administer psychotropic medications to foster youth. The bill would require the Department to perform inspections of identified group homes and require plans from those facilities to reduce inappropriate use of psychotropic medications.

Specific provisions of the bill would:

• Require the Department to compile specified information for group homes regarding the administration of psychotropic drugs, by age of the foster youth, the types of medications administered, the length of administration of psychotropic drugs, the provision of other services to those foster youth, and other information;

• Require the Department to develop the information above through existing data sources it has access to, including information from the Department of Health Care Services;

• Require the Department to consult with stakeholders and develop a methodology to identify group homes with disproportionately high use of psychotropic drugs;

• Require at least annual visits to identified group homes to review policies and practices and to have confidential discussions with foster youth and prescribing physicians;

• Require a group home to develop a plan to reduce inappropriate prescribing of psychotropic medications, if the Department finds high utilization and inadequate alternative services;

• Require the Department to monitor the plans submitted by identified group homes;

• Require the Department to adopt implementing regulations, but also authorize the Department to begin implementation before regulations are adopted.

Related Legislation:

• SB 319 (Beall) would require counties to contract with local Child Health and Disability Prevention programs to provide foster care public health nursing services. The bill would expand the duties required of foster care public health nurses. That bill will be heard in this committee.

• SB 238 (Mitchell) would require additional training regarding psychotropic drugs and mental health issues for a variety of groups who have responsibility for foster youth. That bill is on this committee’s Suspense File.

• SB 253 (Monning) would modify the judicial requirements and practices for authorizing psychotropic drugs for foster youth. That bill will be heard in this committee.

Staff Comments:

The only costs that may be incurred by a local agency relate to crimes and infractions. Under the California Constitution, such costs are not reimbursable by the state.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 484

SUBJECT: Juveniles

SUMMARY:

Requires Department of Social Services’ (DSS) director to compile specified information to identify group homes that inappropriately administer psychotropic medications to children. Requires DSS to consult with specified entities to establish a methodology to identify group homes that have disproportionately high levels of psychotropic medication usage. Requires DSS to perform inspections on identified facilities and to require a plan from those facilities to reduce inappropriate prescribing and treatment regimens, as specified. Requires DSS to monitor the implementation plans of identified facilities, and to submit reports to specified entities.

Existing law:

1. Establishes the Community Care Facilities Act, which provides for the licensure and regulation of community care facilities, including group homes, by DSS, and requires that licensed facilities be subject to unannounced inspections under specified circumstances.

2. Requires DSS to establish a rate classification level (RCL) structure for group homes with a corresponding rate structure according to the level of care and services that will be provided, as specified.

3. Permits a group home to be classified as an RCL 13 or 14 if the program only accepts children with special treatment needs and meets other requirements. Additionally, requires the Department of Health Care Services (DHCS) to annually certify group homes seeking classification as RCL 13 or 14, and permits such facilities to accept minor dependents who are seriously or emotionally disturbed if certain conditions are met.

4. Requires DSS to publish and make available to interested persons a list or lists covering all licensed community care facilities, other than foster family homes and certified family homes, to include specified information regarding group homes, transitional housing placement providers, community treatment facilities, or runaway and homeless youth shelters, including complaints, citations, fines, and the number of law enforcement contacts made by group homes.

This bill:

1. Requires the director of DSS to compile, at least annually, the information below concerning group homes to identify those in which psychotropic medications may be inappropriately administered to children. Specifically, the information is required to include the number of children who:

1. were administered psychotropic medications;

2. for ages six to 11, were administered psychotropic medications;

3. for ages 12 to 17, were administered psychotropic medications;

4. were preauthorized by the juvenile court to be administered psychotropic medications;

5. were administered psychotropic medications on an emergency basis;

6. were administered antipsychotic, mood stabilizing, or antidepressant medications;

7. received two or more drugs from the same class, including, but not limited to, antidepressants, antipsychotics, and antianxiety medications;

8. received two or more psychotropic medications concurrently, and whether those children received two, three, four, or more than four psychotropic medications concurrently;

9. received one or more medications for more than 90 days;

10. received psychosocial services while in a group home placement while they received a psychotropic medication;

11. received a dosage of a psychotropic medication at a dosage above the maximum dosage approved by the federal Food and Drug Administration (FDA);

12. received metabolic monitoring in accordance with professional standards of care while they received a psychotropic medication; and,

13. prescribed antipsychotic medications for a use not approved by the FDA.

2. Requires the data required in 1) above concerning psychotropic medications, mental health services, and placement to be drawn from existing data systems, including, but not limited to, the Medicaid Management Information System’s medical and pharmacy claims data and the Child Welfare Services/Case Management System through the data sharing agreement between DHCS and DSS.

3. Requires DSS, based on the information required in 1) above, to consult with the foster care ombudsman and stakeholder quality improvement groups to establish a methodology to identify group homes that have disproportionately high levels of psychotropic medication usage that warrants additional review of the facility.

4. Requires DHCS to post, at least annually, on its Internet Web site a summary progress report with data of the information required in #1 above that excludes personally identifiable information.

5. Requires DSS to visit facilities with high levels of psychotropic medication usage at least once a year to review the facilities’ plans of operation, policies, procedures, practices, child-to-staff ratios, staff qualifications and training, implementation of children’s needs and services plans, and other factors that DSS determines contributes to the high utilization of dangerous psychotropic medication regimens and low utilization of monitoring and psychosocial services. Requires DSS to seek input for these visits from stakeholders, including, but not limited to, the foster care ombudsman and foster care mental health ombudsman, foster youth and advocates, county welfare departments, and county mental health departments.

6. Requires DSS to include in each visit confidential discussions with current and former foster youth placed in a particular facility and confidential discussions with physicians who prescribe the medications to those individuals. Requires DHCS and DSS to use existing data systems that identify prescribers’ names, addresses, and contact information in order to facilitate interviews with physicians.

7. Requires a facility identified as having high utilization of psychotropic medications and inadequate alternative, less invasive psychosocial, crisis management, and other services to submit to DSS a plan to address steps that the facility is required to take to reduce inappropriate prescribing and treatment regimens within 60 days of DSS’s visit to the facility. Requires the facility’s plan to:

1. include an improved crisis management plan, including de-escalation techniques and procedures in which facility staff will be trained;

2. include an overall behavioral management plan that is a trauma-informed plan;

3. identify a quantifiable goal to decrease the use of antipsychotic medications for behavioral control, to decrease polypharmacy, and to decrease the use of pro re nata (or “as needed”) medications; and,

4. identify a quantifiable goal of appropriate metabolic monitoring as set forth in state prescribing guidelines and psychosocial, physical, mental, behavioral, and nutritional services for children previously or currently prescribed psychotropic medications while placed in that facility.

8. Requires DSS to monitor a facility’s implementation of the plan to determine whether:

1. the facility has reduced the rate at which residents are administered pro re nata, multiple, and off-label psychotropic medications, and, if so, the percentage decrease in the administration of those medications;

2. alternative, less invasive treatments are being provided, and to what extent, to residents, and, if so, the percentage increase in the provision of those services; and,

3. appropriate metabolic monitoring is being conducted, and to what extent, and, if so, the percentage increase in the provision of appropriate monitoring.

9. Requires DSS’s Community Care Licensing Division, following DSS’s inspection of a facility, to provide a report to DSS’s Children and Family Services Division and to any other public agency that has certified the facility’s program or any component of the facility’s program, including, but not limited to, DHCS.

10. Provides DSS the authority to implement the provisions in this bill through all-county letters or similar instructions from the department’s director until emergency regulations are adopted. Requires DSS to adopt final regulations on or before January 1, 2018.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, more than half of the children in our state’s group homes for foster children are medicated with powerful psychotropic medications. Refusal to take the drugs can be, and is, punished by expulsion from the facility. The most problematic of the drugs are antipsychotic medications designed to suppress the most uncontrollable behavior of schizophrenics. As a witness at last year’s Congressional hearing said, “These drugs are too often misused as ‘chemical straitjackets.’ This is a haphazard attempt to simply control and suppress undesirable behavior, rather than treat, nurture, and develop these treasured young people.”

The more-than-1,000 group homes throughout California vary widely in size, staffing, and quality of care. Some are accredited, but many are not. In 2011, the state’s foster care ombudsman rated more than a third of the group homes unsatisfactory. Causes of overmedication include: poorly trained staff, sedated children allow for reduced staffing ratios, lack of therapeutic intervention alternatives, energetic promotion by drug manufacturers, and lack of state oversight.

2. National Institute of Mental Health (NIMH) on psychotropics. According to NIMH, psychotropic medications are substances that affect brain chemicals related to mood and behavior. In recent years, research has been conducted to understand the benefits and risks of using psychotropic medications in children, but more needs to be learned about the effects of psychotropics, especially in children under six years of age. NIMH states that while researchers are trying to clarify how early treatment affects a growing body, families and doctors should weigh the benefits and risks of medication. Each child has individual needs, and each child needs to be monitored closely while taking medications. Psychiatric medications treat mental disorders. Sometimes called psychotropic or psychotherapeutic medications, they have changed the lives of people with mental disorders for the better, according to NIMH. Many people with mental disorders live fulfilling lives with the help of these medications. Without them, people with mental disorders might suffer serious and disabling symptoms.

3. San Jose Mercury News exposé. A 2014 series published in the San Jose Mercury News, entitled “Drugging Our Kids,” reported that nearly one of every four adolescents in California's foster system is receiving psychotropic medications, which is 3 1/2 times the rate for all adolescents nationwide. Over the last decade, almost 15 percent of the state's foster youth of all ages were receiving the medications. Long-term effects, particularly in children, have received little study, but for some psychotropics, there is evidence of persistent tics, increased risk of suicide, and brain shrinkage. The report stated that over the past decade, nearly 60 percent of foster youth received antipsychotic medications, which is a class of psychotropic medications with the highest risk. The federal Food and Drug Administration (FDA) authorizes antipsychotics for children only with the most severe mental health conditions, but evidence showed that doctors were prescribing them to foster youth with behavioral problems. In 2013, 12.2 percent of foster children who were prescribed these medications were on up to four or more medications at the same time, up from 10.1 percent in 2004, with even more cases of foster youth being on up to eight or nine different psychotropic medications at a time. In another case highlighted, a nine-year-old was on a medication dose ten times higher the amount recommended for a psychotic adult. Hundreds of children aged five and younger have also been prescribed psychotropic medications even though federal health officials warn about the safety for use by children, and some states actively discourage it. According to the report, over the last decade, Medi-Cal spent more than $313 million on the ten most expensive drugs for foster youth, of which 72 percent was for psychotropic medications and 50 percent was for antipsychotics. According to the report, California was not the only state with this problem: in 2009, one study showed that some states, including Texas, Colorado, and Missouri, prescribed antipsychotics at a higher rate than California.

4. DHCS Treatment Authorization Request (TAR) policy for Medi-Cal beneficiaries. Effective October 1, 2014, the Department of Health Care Services (DHCS) extended its TAR policy for children ages six to 17 in order to review the appropriateness and safety of the requested medication for all juvenile beneficiaries. TARs are required for certain medications and must be submitted by prescribing health care professionals to DHCS for approval before a medication can be dispensed to a beneficiary. A TAR requirement for all antipsychotic medications has existed for children from birth through age five since 2006 without known reports of detriment to access. Adjudication of TARs is done on a case-by-case basis based on the clinical information included in the TAR and on the compliance with corresponding regulations. Adjudicators review the information to check if the request is for an FDA-approved indication, reflects the age-appropriate dose, avoids duplication of medication in the same therapeutic class and/or adverse interaction with other medications the beneficiary is taking, and falls within reasonable treatment parameters in respect to frequency and duration of therapy.

While some advocates and providers have been critical of DHCS's new TAR policy, claiming long wait times (from weeks to up to a month) for beneficiaries to receive needed medications, DHCS states that, when submitted accurately, TAR adjudication typically takes 24 hours. In addition, DHCS states that there are options to ensure that beneficiaries have access to needed psychotropic medications while a TAR is being adjudicated, such as requesting an emergency 72-hour supply, which can be requested twice for up to six days’ worth of medications.

5. California guidelines. DHCS and DSS have the shared responsibility for the oversight of mental health services provided to children and youth involved with county child welfare and probation agencies. In early April 2015, the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care were released specific to those children and youth who are: (a) involved with child welfare services and/or probation services, and (b) are placed in foster care. According to DHCS’s Web site, the Guidelines are a statement of best practice for the treatment of children and youth in out-of-home care, who may require psychotropic medications, which may be considered only after appropriate psychosocial interventions are employed (as with moderate anxiety/depression), or may not be indicated at all (as with learned defiance and predatory aggression). When psychotropic medication is indicated, it should be used in conjunction with psychosocial interventions. The exception is when psychosocial interventions have been effective and are therefore terminated, but continued use of medication is necessary to prevent the recurrence of symptoms.

DHCS notes that the Guidelines represent the first comprehensive effort at the state level to address the use of psychotropic medication in children and youth in out-of-home care being served by the child welfare and/or probation system. DHCS expects that the Guidelines, which will be reviewed annually, will evolve over time in response to updated research and the evolution of best practices, and in response to feedback from youth, families, prescribers, other providers, and additional community stakeholders.

6. Double referral. This bill was heard in the Senate Human Services Committee on April 21, 2015, and passed out with a vote of 5-0.

7. Related legislation. SB 319 (Beall), requires counties to contract with the community child health and disability prevention program established in the county to provide services by a foster care public health nurse (PHN). Requires the foster care PHN to consult and collaborate with a child’s social worker, as specified. Expands the duties of a foster care PHN, as specified, related to a foster youth’s prescription for psychotropic medications. SB 319 is scheduled for hearing in the Senate Health Committee on April 29, 2015.

SB 238 (Mitchell), requires specified certification and training programs for group home administrators, foster parents, child welfare social workers, dependency court judges and court appointed council to include training on psychotropic medication, trauma, and behavioral health, as specified, for children receiving child welfare services. SB 238 requires the Judicial Council to update court forms pertaining to the authorization of psychotropic medication and requires DSS to develop an individualized monthly report, a form to share information, and an alert system, used by county child welfare agencies, regarding the administration of psychotropic medication for a foster youth. SB 238 is scheduled for hearing in the Senate Judiciary Committee on April 28, 2015.

SB 253 (Monning), requires an order of the juvenile court authorizing psychotropic medication to require clear and convincing evidence of specified conditions. SB 253 also prohibits the authorization of psychotropic medications without a second independent medical opinion under specified circumstances; prohibits the authorization of psychotropic medications unless the court is provided documentation that appropriate lab screenings, measurements, or tests have been completed, as specified; and requires the court, no later than 45 days following an authorization for psychotropic medication, to conduct a review to determine specified information regarding the efficacy of the child’s treatment plan. SB 253 is scheduled for hearing in the Senate Judiciary Committee on April 28, 2015.

8. Support. Supporters of this bill, which include consumer advocates and legal aid organizations, argue that it addresses a longstanding crisis in many of the group homes in which California’s foster youth are living: the medicating of children and youth, with powerful antipsychotic medications, to sedate and control behaviors that are natural responses to grief, suffering, and trauma. Supporters state that, on average, 56 percent of the children in group homes are given one or more psychotropic medication, often in lieu of counseling and appropriate care. They further state that, in contrast, approximately five percent of children placed with relatives and 12 percent of children in foster family homes are administered psychotropic medications. Supporters note that such medications can cause crippling sedation, morbid obesity, memory loss, diabetes, heart disease, irreversible tremors, and other long-term disabilities, and, in extreme cases, death.

9. Support if Amended. The Children’s Law Center of California, which supports this bill if amended, writes that some group homes specifically serve youth with the highest level of mental health needs where medications may indeed be an important part of a comprehensive treatment plan. They would like to see an amendment to take into consideration group homes that treat this population so that such facilities are not unnecessarily subjected to corrective action plans.

SUPPORT AND OPPOSITION:

Support: National Center for Youth Law (sponsor)

Advokids

Alameda County Foster Youth Alliance

California Chapter of the National Association of Social Workers

California CASA Association

California Youth Connection

Children Now

Children’s Advocacy Institute

Dependency Legal Group of San Diego

First Focus Campaign for Children

Humboldt County Transition Age Youth Collaboration

John Burton Foundation

Legal Advocates for Children and Youth

Legal Services for Prisoners with Children

Peers Envisioning and Engaging in Recovery Services

Public Counsel’s Children’s Rights Project

The Youth Law Center

Five individuals

Oppose: None received.

-- END --

SENATE COMMITTEE ON HUMAN SERVICES

Senator McGuire, Chair

2015 - 2016 Regular

Bill No: SB 484

Subject: Juveniles

SUMMARY

This bill requires the California Department of Social Services (CDSS) to publish and make available to interested persons specified information regarding individual group homes, transitional housing placement providers, community treatment facilities, and runaway and homeless youth shelters regarding the administration of psychotropic medication to children residing in each facility. Additionally, this bill requires CDSS to inspect facilities at least once per year, as specified, if the facility is determined to have a higher than average rate of psychotropic medication authorization for children residing in the facility and requires CDSS to monitor corrective action plans, as specified.

ABSTRACT

Existing law:

1. Establishes the Community Care Facilities Act, which provides for the licensure and regulation of community care facilities, including group homes, by CDSS, and requires that licensed facilities be subject to unannounced inspections under specified circumstances. (HSC 1500 et seq, and 1534)

2. Requires CDSS to establish a rate classification level (RCL) structure for group homes with a corresponding rate structure according to the level of care and services that will be provided, as specified. (WIC 11462)

3. Permits a group home to be classified as an RCL 13 or 14 if the program only accepts children with special treatment needs and meets other requirements. Additionally, requires the California Department of Health Care Services (DHCS) to annually certify group homes seeking classification as RCL 13 or 14 and permits such facilities to accept minor dependents who are seriously or emotionally disturbed if certain conditions are met. (WIC 11469, WIC 4096.5 and HSC 1502.4)

4. Requires CDSS to publish and make available to interested persons a list or lists covering all licensed community care facilities, other than foster family homes and certified family homes, to include specified information regarding group homes, transitional housing placement providers, community treatment facilities or runaway and homeless youth shelters including complaints, citations, fines and the number of law enforcement contacts made by group homes. (HSC 1536)

This bill:

1. Requires CDSS to add to the information contained in the above-mentioned lists the following information:

• The number of children administered psychotropic medication in the facility.

• The number of children for whom the juvenile court authorized the medication.

• The number of children administered a psychotropic medication on an emergency basis.

• The number of those children who are between the ages of 6 and 11 years.

• The number of those children who are between the ages of 12 and 17 years.

• The number of children administered an antipsychotic, mood stabilizing or antianxiety medication.

• The number of children administered two, three, four, or more psychotropic medications concurrently.

• The number of children administered one or more medications for longer than 90 days.

• The number of children terminated from the program due to the child’s refusal to take psychotropic medication.

2. Requires CDSS to inspect facilities once a year if the facility is determined to administer psychotropic medication at a rate exceeding the average authorization for all group homes in order to examine the factors that the department determines contribute to the high utilization of psychotropic medications, as specified.

3. Requires a facility that is inspected to submit a corrective action plan within 60 days of the inspection, and in the plan to address the steps the facility shall take to reduce the utilization of psychotropic medication among residents.

4. Requires CDSS to monitor the facility’s implementation of the corrective action plan to determine whether the facility has reduced the rate that psychotropic medications are administered, and whether and to what extent alternative less invasive treatments are being provided to residents.

5. Requires CDSS to submit a report to the Children and Family Services Division of the department and to any public agency that has certified any component of the facility’s program, including the state Department of Health Care Services (DHCS).

6. Requires CDSS and DHCS in consultation with specified stakeholders to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce the utilization of psychotropic medications in group homes, including behavioral management programs, emergency intervention plans, and conflict resolution processes.

FISCAL IMPACT

This bill has not been analyzed by a fiscal committee.

BACKGROUND AND DISCUSSION

Purpose of the bill:

According to the author, more than half of the children in California group homes are medicated with powerful psychotropic medications. The author states that these medications are misused to control and suppress undesirable behavior, rather than treat, nurture and develop the young people residing in the facility.

The author states that this bill identifies those group homes that appear to rely on psychotropic medication as the first-line or only treatment and requires those with the highest rates of medication to reduce those rates and to adopt alternative, less invasive, treatment approaches.

Group Homes

Group homes are 24-hour residential facilities licensed by CDSS to provide board and care to foster youth from both the dependency and delinquency jurisdictions. Group home facilities are organized under a system of rate classification levels (RCLs) ranging from 1-14 that are based on levels of professional training and adult-to-child ratios. In practice, the majority of group homes are at RCL 10 and above with nearly 50 percent of group homes at RCL 12. There is wide variation in group home size from as few as six children to group homes that house more than 100 children.

Existing law requires that children removed from their homes and made dependents of the court be placed in the most family-like and “least restrictive” setting. Existing law requires counties to seek timely permanent placements, such as guardianship or adoption, for dependent youth that are removed from their homes. Group homes, which provide an institutional type of care as opposed to a family like setting, are not intended to be long term placements, however in practice many children placed in group homes remain in that setting for the duration of their time in foster care, and many age out of the system while residing in group home placements. While in a group home program, it is intended that children receive services and treatment designed to eliminate or reduce the conditions, behaviors and characteristics that led to their group home placement, and to teach new, adaptive skills and behavior.¹

Group Home Rate Classification

Existing law provides for the classification of group home programs for the purpose of establishing AFDC-FC rates. Through regulation, CDSS implemented the Rate Classification Level (RCL) point system in which the hours of child care and supervision, social work activities, and mental health treatment services provided to children, are weighted to take into consideration experience, education, training, and professional qualifications of the staff. These are calculated and then divided by an adjusted expected capacity of the group home program.  Every year, CDSS issues an updated rate structure based on required increases associated with the California Necessities Index.

Group homes classified as RCL 13 and 14 are permitted to accept a child assessed as seriously emotionally disturbed as long as the child does not need inpatient care in a licensed health facility.² To receive this classification, a facility may only accept children who have been assessed as seriously emotionally disturbed through an interagency placement committee, or by a licensed mental health professional. These group homes must be both licensed by CDSS and certified by DHCS as a program that provides mental health treatment services for seriously emotionally disturbed children.

Group Home Program Statement

Group homes are required to establish a “group home program statement” that includes a training plan that is appropriate for the client population and the training needs and skill level of child care staff. Through regulation, existing law provides that newly hired staff complete at least 24 hours of training within 90 days of being hired, and 40 hours within 12 months, as specified, with all existing staff receiving 20 hours annually. Regulations provide for the minimum topics that must be included (e.g. discipline policies and procedures, behavior problems/psychological disorders, and mental health/behavioral interventions). Social work staff is required to establish a "needs and services plan" for each child that identifies the specific needs of an individual child, and delineates those services necessary in order to meet the child's identified needs.

Group homes are required to submit to the department an emergency intervention plan, identifying how the facility will use emergency interventions to address aggressive or assaultive behavior of residents. The plan is required to be designed by the licensee and a qualified behavior management consultant and must be appropriate for the client population served by the group home, and for the staff qualifications and staff emergency intervention training.³

Psychotropic Medication Use in Children

Concern over the use of psychotropic medications among children has been well-documented in research journals and the mainstream media for more than a decade. The category of psychotropic medication is fairly broad, intending to treat symptoms of conditions ranging from ADHD to childhood schizophrenia. Some of the drugs used to treat these conditions are FDA-approved, including stimulants like Ritalin for ADHD, however only about 31 percent of psychotropic medications have been approved by the U.S. Food and Drug Administration (FDA) for use in children or adolescents. It is estimated that more than 75 percent of the prescriptions written for psychiatric illness in this population are “off label” in usage, meaning they have not been approved by the FDA for the prescribed use, though the practice is legal and common across all manner of pharmaceuticals.⁴

Anti-psychotic medications, used to treat more severe mental health conditions, include powerful brand-name drugs such as Haldol, Risperdal, Abilify, Seroquel and Zyprexa. They have very limited approval by the FDA for pediatric use beyond rare and severe conduct problems that are resistant to other forms of treatment, such as Tourette’s syndrome, behavioral symptoms associated with autistic disorder, childhood schizophrenia, and bipolar disorder.⁵ However, the off-label use of these anti-psychotics among children is high, particularly among foster children. According to a study published in 2011, children who took antipsychotic medications were likely to suffer ill health effects including “cardiometabolic and endocrine side-effects” as well as significant weight gain.⁶ The authors recommended that collaboration between child and adolescent psychiatrists, general practitioners and pediatricians is essential to “reduce the likelihood of premature cardiovascular morbidity and mortality.”

Compounding the potential for unintended side effects is the use of combinations of psychotropic medications, which foster youth are particularly likely to be prescribed, despite limited evidence of clinical efficacy.⁷ Protecting the health and well-being of children who are taking one or more psychotropic medication requires extensive and ongoing health and metabolic screenings to identify potential adverse effects quickly, however in practice many children many fail to receive ongoing screenings and adverse effects may go undetected causing permanent injury or death.

Drugging our Children Media Series

A recent series of stories published in the San Jose Mercury News⁸ and most recently in the Los Angeles Times, highlighted growing concerns that psychotropic medications have been relied on by California’s child welfare and children’s mental health systems as a means of controlling, instead of treating, youth who suffer from trauma-related behavioral health challenges. The series detailed significant challenges in accessing pharmacy benefits claims data held by the California Department of Health Care Services (DHCS), eventually overcome through a Public Records Act request and lengthy negotiations, and it demonstrated that prescribing rates were far higher than had been anticipated by child welfare system experts.

Related legislation:

SB 238 (Mitchell, 2015) requires specified certification and training programs for group home administrators, foster parents, child welfare social workers, dependency court judges and court appointed council to include training on psychotropic medication, trauma, and behavioral health, as specified, for children receiving child welfare services. This bill additionally requires the Judicial Council to update court forms pertaining to the authorization of psychotropic medication, and requires CDSS to develop an individualized monthly report, a form to share information and an alert system, used by county child welfare agencies, regarding the administration of psychotropic medication for a foster youth.

SB 253 (Monning, 2015) provides that an order of the juvenile court authorizing psychotropic medication shall require clear and convincing evidence of specified conditions. This bill also prohibits the authorization of psychotropic medications without a second independent medical opinion under specified circumstances. It also prohibits the authorization of psychotropic medications unless the court is provided documentation that appropriate lab screenings, measurements, or tests have been completed, as specified. Finally, it requires the court, no later than 45 days following an authorization for psychotropic medication, to conduct a review to determine specified information regarding the efficacy of the child’s treatment plan.

SB 319 (Beall, 2015) expands the duties of the foster care public health nurse to include monitoring and oversight of the administration of psychotropic medication to foster children, as specified. It also requires counties to provide child welfare public health nursing services by contracting with the community child health and disability prevention program established by the county.

COMMENTS

Staff notes that this bill appears to make personally identifiable information available on a public website regarding the administration of psychotropic medication to foster youth residing in group homes. In response to these concerns, the author proposes the following amendments to instead require CDSS to provide oversight of facilities deemed to have disproportionately high rates of psychotropic medication use, based on an evaluation methodology developed by existing quality improvement stakeholder work groups held by CDSS and DHCS.

POSITIONS

Support:

Advokids

Alameda County Foster Youth Alliance

California Court Appointed Special Advocates (CASA)

California Youth Connection

Children’s Advocacy Institute

Children’s Partnership

Dependency Legal Group of San Diego

East Bay Children’s Law Offices

East Bay Community Law Center

First Focus Campaign for Children

Humboldt County Transition Age You Collaboration

Legal Advocates for Children and Youth

Legal Services for Prisoners with Children

National Association of Social Workers

National Center for Youth Law

Peers Envisioning and Engaging in Recovery Services

Public Counsel’s Children’s Rights Project

Youth Law Center

10 individuals

Oppose:

None.

Amendments Mock-up for 2015-2016 SB-484 (Beall (S))

*********Amendments are in BOLD*********

Mock-up based on Version Number 99 - Introduced 2/26/15

The people of the State of California do enact as follows:

SECTION 1. Section 1536 of the Health and Safety Code is amended to read:

1536. (a) (1) At least annually, the director shall publish and make available to interested persons a list or lists covering all licensed community care facilities, other than foster family homes and certified family homes of foster family agencies providing 24-hour care for six or fewer foster children, and the services for which each facility has been licensed or issued a special permit.

(2) For a group home, transitional housing placement provider, community treatment facility, or runaway and homeless youth shelter, the list shall include both all of the following:

(A) The number of licensing complaints, types of complaint, and outcomes of complaints, including citations, fines, exclusion orders, license suspensions, revocations, and surrenders.

(B) The number, types, and outcomes of law enforcement contacts made by the facility staff or children, as reported pursuant to subdivision (a) of Section 1538.7.

(C) The number of children administered psychotropic medications in the facility, and all off the following information pertaining to those children:

(1) The number of children for whom the juvenile court preauthorized the administration of the psychotropic medication.

(2) The number of children administered psychotropic medication on an emergency basis.

(3) The number of those children who are 6 to 11 years of age, inclusive.

(4) The number of those children who are 12 to 17 years of age, inclusive.

(5) The number of children administered an antipsychotic, mood stabilizing, or antidepressant medication.

(6) The number of children administered two or more drugs from the same class, including, but not limited to, antidepressants, antipsychotics, antianxiety medications.

(7) The number of children administered two, three, four, or more psychotropic medications concurrently.

(8) The number of children administered one or more medications for longer than 90 days.

(9) The number of children terminated from the program due to the child’s refusal to take psychotropic medication.

(b) Subject to subdivision (c), to encourage the recruitment of foster family homes and certified family homes of foster family agencies, protect their personal privacy, and to preserve the security and confidentiality of the placements in the homes, the names, addresses, and other identifying information of facilities licensed as foster family homes and certified family homes of foster family agencies providing 24-hour care for six or fewer children shall be considered personal information for purposes of the Information Practices Act of 1977 (Chapter 1 (commencing with Section 1798) of Title 1.8 of Part 4 of Division 3 of the Civil Code). This information shall not be disclosed by any state or local agency pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), except as necessary for administering the licensing program, facilitating the placement of children in these facilities, and providing names and addresses only to bona fide professional foster parent organizations upon request.

(c) Notwithstanding subdivision (b), the department, a county, or a foster family agency may request information from, or divulge information to, the department, a county, or a foster family agency, regarding a prospective certified parent, foster parent, or relative caregiver for the purpose of, and as necessary to, conduct a reference check to determine whether it is safe and appropriate to license, certify, or approve an applicant to be a certified parent, foster parent, or relative caregiver.

(d) The department may issue a citation and, after the issuance of that citation, may assess a civil penalty of fifty dollars ($50) per day for each instance of a foster family agency’s failure to provide the department with the information required by subdivision (h) of Section 88061 of Title 22 of the California Code of Regulations.

(e) The Legislature encourages the department, when funds are available for this purpose, to develop a database that would include all of the following information:

(1) Monthly reports by a foster family agency regarding family homes.

(2) A log of family homes certified and decertified, provided by a foster family agency to the department.

(3) Notification by a foster family agency to the department informing the department of a foster family agency’s determination to decertify a certified family home due to any of the following actions by the certified family parent:

(A) Violating licensing rules and regulations.

(B) Aiding, abetting, or permitting the violation of licensing rules and regulations.

(C) Conducting oneself in a way that is inimical to the health, morals, welfare, or safety of a child placed in that certified family home.

(D) Being convicted of a crime while a certified family parent.

(E) Knowingly allowing any child to have illegal drugs or alcohol.

(F) Committing an act of child abuse or neglect or an act of violence against another person.

(f) At least annually, the Department shall post to its Internet Web site a summary progress report with non-identifiable data, of the information gathered pursuant to 1538.8.

SEC. 2. Section 1538.8 is added to the Health and Safety Code, to read:

1538.8. (a) In order to identify group homes in which psychotropic medications may be inappropriately administered to children the director shall compile, at least annually, the following information concerning each home:

(1) The number of children in the facility to whom psychotropic medications were administered.

(2) The number of children in the facility who are 6 to 11 years of age, inclusive, to whom psychotropic medications were administered.

(3) The number of children who are 12 to 17 years of age, inclusive, to whom psychotropic medications were administered.

(4) The number of children for whom the juvenile court preauthorized the administration of the psychotropic medication.

(5) The number of children to whom psychotropic medications were administered emergency basis.

(6) The number of children to whom antipsychotic, mood stabilizing, or antidepressant medications were administered.

(7) The number of children who received two or more drugs from the same class, including, but not limited to, antidepressants, antipsychotics, and antianxiety medications.

(8) The number of children who received two or more psychotropic medications concurrently, and whether those children received two, three, four, or more than four psychotropic medications concurrently.

(9) The number of children who received one or more medications for more than 90 days.

(10) The number of children who received psychosocial services while in a group home placement while they received a psychotropic medication.

(11) The number of children who received a dosage of a psychotropic medication at a dosage above the maximum dosage approved by the federal Food and Drug Administration.

(12) The number of children who received metabolic monitoring in accordance with professional standards of care while they received a psychotropic medication.

(13) The number of children who were prescribed antipsychotic medications for a use not approved by the federal Food and Drug Administration.

(b) The data in subdivision (a) concerning psychotropic medication, mental health services, and placement shall be drawn from existing data systems, including but not limited to, the Medicaid Management Information System’s medical and pharmacy claims data, and the Child Welfare Services/Case Management System, through the data sharing agreement between the State Department of Health Care Services and the State Department of Social Services.

If the department, based upon the information gathered pursuant to Section 1536, determines that the children and adolescents in a facility are administered psychotropic medications at a rate that exceeds the average authorization for all group homes, the department shall inspect the facility at least once a year to examine the policies, procedures, practices, child-to-staff ratios, staff training, and other factors that the department determines contribute to the high utilization of psychotropic medications.

(b) A facility inspected pursuant to subdivision (a) shall submit to the department a corrective action plan within 60 days of that inspection. The plan shall address the steps that the facility shall take to reduce the utilization of psychotropic medications among residents.

(c) The department shall monitor a facility’s implementation of its corrective action plan to determine both of the following:

(1) Whether the facility has reduced the rate at which residents are administered psychotropic medications, and, if so, the percentage decrease in the administration of those medications.

(2) Whether and to what extent alternative, less invasive treatments are being provided to residents.

(d) Following an inspection pursuant to subdivision (a), the Community Care Licensing Division shall provide a report to the department’s Children and Family Services Division and to any other public agency that has certified the facility’s program or any component of the facility’s program, including, but not limited to, the State Department of Health Care Services, which certifies group homes pursuant to Section 4096.5 of the Welfare and Institutions Code.

SEC. 3. Section 1538.9 is added to the Health and Safety Code to read:

1538.9 (a) (1) The department, based upon the information compiled pursuant to Section 1538.8, shall consult with the foster care ombudsman and existing stakeholder quality improvement workgroups to establish a methodology to identify those group homes that have disproportionately high levels of psychotropic drug usage warranting additional review of the facility.

(2) The department shall visit facilities identified in paragraph (1) at least once a year to review the facilities plan of operation, policies, procedures, practices, child-to-staff ratios, staff qualifications and training, implementation of children’s needs and services plan, and other factors that the department determines contribute to the high utilization of dangerous psychotropic medication regimens and low utilization of monitoring and psychosocial services.

(3) The department shall perform visits pursuant to paragraph (2) with input from stakeholders, including but not limited to, the foster care ombudsman and foster care mental health ombudsman, foster youth, foster youth advocates, county welfare departments, and county mental health departments.

(4) The department shall include in each visit confidential discussions with current and former foster youth placed in the facility’s care and confidential discussions with physicians identified as prescribing the medications. The State Department of Health Care Services and the State Department of Social Services shall use existing data systems, identify prescribers’ name, addresses, and contact information in order to facilitate interviews with providers.

(b) If, during a visit pursuant to subdivision (a), the department finds that the facility has a high utilization of dangerous psychotropic medication regimens, based on measures established pursuant to Section 1538.9, and inadequate alternative, less invasive psychosocial, crisis management, and other services, the facility shall submit to the department a plan to address the steps that the facility shall take to reduce inappropriate prescribing and treatment regimens within 60 days of the visit. The plan shall do the following:

(1) Include an improved crisis management plan, including de-escalation techniques and procedures in which their staff will be trained.

(2) Include an overall behavioral management plan which shall be a trauma-informed plan.

(3) Identify a quantifiable goal to decrease the use of antipsychotic medications for behavioral control, to decrease polypharmacy, and to decrease the use of pro re nata medications.

(4) Identify quantifiable goal of appropriate metabolic monitoring as set forth in the state prescribing guidelines and psychosocial, physical, mental, behavioral, and nutritional services for children previously or currently prescribed psychotropic medications while placed in that facility.

(c) The department shall monitor a facility’s implementation of the plan submitted pursuant to (b) to determine all of the following:

(1) Whether the facility has reduced the rate at which residents are administered pro re nata, multiple, and off-label psychotropic medications, and, if so, the percentage decrease in the administration of those medication regimens.

(2) Whether and to what extent alternative, less invasive treatments are being provided to residents, and, if so, the percentage increases in the provision of those services.

(3) Whether and to what extent appropriate metabolic monitoring is being conducted and, if so, the percentage increases in the provision of appropriate monitoring.

(d) Following an inspection pursuant to subdivision (a), the Community Care Licensing Division shall provide a report to the department’s Children and Family Services Division and to any other public agency that has certified the facility’s program or any component of the facility’s program, including, but not limited to, the State Department of Health Care Services, which certifies group homes pursuant to Section 4096.5 of the Welfare and Institutions Code.

(e) (1) Notwithstanding the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until emergency regulations are filed with the Secretary of State, the department may implement the amendments made to this section by the act that added this subdivision during the 2015-16 Regular Session of the Legislature through all-county letters or similar instructions from the director.

(2) On or before January 1, 2017, the department shall adopt regulations to implement the amendments to this section made by the act that added this subdivision during the 2015-16 Regular Session of the Legislature. The initial adoption, amendment, or repeal of a regulation authorized by this subdivision is deemed to address an emergency, for purposes of Sections 11346.1 and 11349.6 of the Government Code. After the initial adoption, amendment, or repeal of an emergency regulation pursuant to this section, the department may twice request approval from the Office of Administration Law to readopt the regulation as an emergency regulation pursuant to Section 11346.1 of the Government Code. The department shall adopt final regulations on or before January 1, 2018.

SEC. 4. Section 11469 of the Welfare and Institutions Code is amended to read:

11469. (a) The department, in consultation with group home providers, the County Welfare Directors Association of California, the Chief Probation Officers of California, the California Mental Health Directors Association, and the State Department of Health Care Services, shall develop performance standards and outcome measures for determining the effectiveness of the care and supervision, as defined in subdivision (b) of Section 11460, provided by group homes under the AFDC-FC program pursuant to Sections 11460 and 11462. These standards shall be designed to measure group home program performance for the client group that the group home program is designed to serve.

(1) The performance standards and outcome measures shall be designed to measure the performance of group home programs in areas over which the programs have some degree of influence, and in other areas of measurable program performance that the department can demonstrate are areas over which group home programs have meaningful managerial or administrative influence.

(2) These standards and outcome measures shall include, but are not limited to, the effectiveness of services provided by each group home program, and the extent to which the services provided by the group home assist in obtaining the child welfare case plan objectives for the child.

(3) In addition, when the group home provider has identified as part of its program for licensing, ratesetting, or county placement purposes, or has included as a part of a child’s case plan by mutual agreement between the group home and the placing agency, specific mental health, education, medical, and other child-related services, the performance standards and outcome measures may also measure the effectiveness of those services.

(b) Regulations regarding the implementation of the group home performance standards system required by this section shall be adopted no later than one year prior to implementation. The regulations shall specify both the performance standards system and the manner by which the AFDC-FC rate of a group home program shall be adjusted if performance standards are not met.

(c) Except as provided in subdivision (d), effective July 1, 1995, group home performance standards shall be implemented. Any group home program not meeting the performance standards shall have its AFDC-FC rate, set pursuant to Section 11462, adjusted according to the regulations required by this section.

(d) A group home program shall be classified at rate classification level 13 or 14 only if all of the following are met:

(1) The program generates the requisite number of points for rate classification level 13 or 14.

(2) The program only accepts children with special treatment needs as determined through the assessment process pursuant to paragraph (2) of subdivision (a) of Section 11462.01.

(3) The program meets the performance standards designed pursuant to this section.

(e) Notwithstanding subdivision (c), the group home program performance standards system shall not be implemented prior to the implementation of the AFDC-FC performance standards system.

(f) On or before January 1, 2016, the department, in consultation with the County Welfare Directors Association of California , the Chief Probation Officers of California, the California Mental Health Directors Association, research entities, foster youth, advocates for foster youth, foster care provider business entities organized and operated on a nonprofit basis, Indian tribes, and other stakeholders, shall develop additional performance standards and outcome measures that require group homes to implement programs and services to minimize law enforcement contacts and delinquency petition filings arising from incidents of allegedly unlawful behavior by minors occurring in group homes or under the supervision of group home staff, including individualized behavior management programs, emergency intervention plans, and conflict resolution processes.

(g) On or before January 1, 2017, the department, in consultation with the County Welfare Directors Association of California, the Chief Probation Officers of California, the California Mental Health Directors Association, research entities, foster youth, advocates for foster youth, foster care provider business entities organized and operated on a nonprofit basis, Indian tribes, and other stakeholders, shall develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce the utilization of psychotropic medications for children in group homes, including individualized behavior management programs, emergency intervention plans, and conflict resolution processes.

SEC. 5. No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.

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