BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 484|
|Office of Senate Floor Analyses | |
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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:
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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.
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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:
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a) An improved crisis management plan, including
de-escalation techniques and procedures for staff
training;
b) An overall trauma-informed behavioral management
plan;
c) 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.
d) 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.
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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
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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
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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.:YesLocal: Yes
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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: (Verified6/1/15)
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: (Verified6/1/15)
None received
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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
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