BILL ANALYSIS Ó
SB 484
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Date of Hearing: July 14, 2015
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Kansen Chu, Chair
SB
484 (Beall) - As Amended 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:
a) to whom psychotropic medications were administered;
b) ages 6 to 11 to whom psychotropic medications were
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administered;
c) ages 12 to 17 to whom psychotropic medications were
administered;
d) for whom the juvenile court preauthorized the
administration of psychotropic medication;
e) to whom psychotropic medications were administered on an
emergency basis;
f) to whom antipsychotic, mood stabilizing, or
antidepressant medications were administered;
g) who received two or more drugs from the same class, as
specified;
h) who received two or more psychotropic medications
concurrently, as specified;
i) who received one or more medications for more than 90
days;
j) who received psychosocial services alongside
psychotropic medication, as specified;
aa) who received a dosage of a psychotropic medication that
exceeded the maximum dosage approved by the Food and Drug
Administration (FDA);
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bb) who received metabolic monitoring, as specified, while
they receive psychotropic medication; and
cc) 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:
a) 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
b) 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
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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:
a) An improved crisis management plan, as specified;
b) An overall behavioral management plan which shall be
trauma-informed;
c) A quantifiable goal to decrease the use of antipsychotic
medications for behavioral control, multiple prescriptions,
and pro re nata ("as needed") medications; and
d) 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.
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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
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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.)
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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).
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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
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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
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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
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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'
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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
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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.
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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
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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)
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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
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