Grassley Receives Response from HHS on Foster Youth Recommendations
WASHINGTON – U.S. Sen. Chuck Grassley received a letter from Assistant Secretary for Family Support Lynn Johnson in response to an October 15 inquiry urging Johnson to implement recommendations from a Health and Human Services (HHS) Office of Inspector General (OIG) report that would help foster children who are prescribed psychotropic medications.
“Ensuring children in the foster care program are safe and receiving the proper treatments and support is critical. Iowa has a particularly high rate of foster children being treated with psychotropic medication and it’s imperative the state and federal government monitor treatments to make sure they are receiving the proper care. I appreciate Assistant Secretary Johnson’s timely response and will continue to closely monitor further actions taken.”
Iowa was one of five states studied by the OIG. More than 35 percent of Iowa’s foster youth are being treated with psychotropic medication, one of the highest rates in the country. The OIG found that 30 percent of these children did not receive a treatment plan, which is required by law in Iowa. Additionally, 48 percent of children in foster care did not receive medication monitoring by a prescribing professional.
Grassley is the co-founder and co-chair of the Senate Caucus on Foster Youth and has been working to improve the lives of foster children and families for more than two decades. In 2008, Grassley introduced the Fostering Connections to Success and Increasing Adoptions Act, which provided additional federal incentives for states to move children from foster care to adoptive homes. That legislation also made it easier for foster children to be permanently cared for by their own relatives, and to stay in their home communities.
The Tax Cuts and Jobs Act, which passed late last year, preserved the Adoption Tax Credit, making it easier for families who want to adopt children in foster care to do so. Also last year, Grassley introduced the Strong Families Act of 2017, legislation to prevent child abuse and improve maternal and child health.
In 2011, Grassley worked to reauthorize grants that support families who struggle with substance abuse, and that improve the well-being of children who are not in their homes or are likely to be removed because of parental substance abuse. His bill, the Building Capacity for Family Focused Residential Treatment Act, was recently signed into law as part of a bipartisan, bicameral effort to reduce opioid addiction.
The full text of the letter is available here and below.
The Honorable Charles E. Grassley
United States Senate
Washington, DC 20510
Dear Senator Grassley:
Thank you for your letter concerning the Office of Inspector General (OIG) report entitled: Treatment Planning and Medication Monitoring were Lacking for Children in Foster Care Receiving Psychotropic Medication.
The Children’s Bureau within the Administration on Children and Families provides oversight of states’ compliance with the requirements related to the use of psychotropic medications with children in foster care through the ongoing administration of the program and monitoring. It also provides technical assistance to states to promote best practices. The Children’s Bureau is taking a number of factions to support states in their oversight of prescription of psychotropic medications to children in foster care. In my responses to your questions below, I describe those actions as well as detail how the Children’s Bureau plans to address the OIG’s recommendations.
- Does the ACF intend to implement all of the recommendations of the OIG report?
- If ACF does not intend to implement all recommendations, please provide a detailed explanation as to what recommendations ACF will implement and why. Please also provide a detailed explanation of what recommendations will not be implemented and why ACF has reached this decision.
Response: The Children’s Bureau has developed and will implement a three-pronged approach to respond to the OIG’s recommendations:
- On June 30, 2019, states and tribes will be required to submit a new five-year Child and Family Services Plan (CFSP) for fiscal years (FYs) 2020-2024 and a final report on their progress implementing the previous five-year CFSP. In a program instruction to states regarding this upcoming submission, the Children’s Bureau will ask states to report on success and challenges in addressing this requirement over the previous five years, and will emphasize the importance of strengthening the development and implementation of protocols for the appropriate use and monitoring of psychotropic medications for children and youth in foster care.
- This fiscal year, the Children’s Bureau concluded the on-site portion of the Child and Family Services Review (CFSR) in the remaining states for Round 3. We will assess the findings for this round related to the use of psychotropic medications and make determinations about whether the approach should be amended for Round 4.
- The Capacity Building Center for States hosts “constituency groups” for professionals who perform the same functions across the state programs. The foster care managers oversee the casework staff. Oversight of psychotropic medications will be a topic to be addressed in the foster care managers’ constituency group.
- ACF noted that there is already a “well-established approach to program implementation.” However, the OIG report indicates that this approach is not sufficient to ensure state compliance with requirements related to treatment planning and medication monitoring. What steps does ACF intend to take to improve compliance with these requirements?
Response: The Health Care Coordination and Oversight Plan is one requirement of the Stephanie Tubbs Jones Child Welfare Services Program (title IV-B, subpart 1). To encourage integrated planning across the continuum of child welfare services and child welfare funding sources, ACF requires states to submit a five-year Child and Family Services Plan (CFSP) and then Annual Progress and Services Report (APSRs) for the intervening years to address the requirements of title IV-B, subparts 1 and 2; the Chafee Foster Care Program for Successful Transition to Adulthood and the Chafee Educational and Training Vouchers Program. (Requirements for the Child Abuse and Neglect State grant authorized by the Child Abuse Prevention and Treatment Act (CAPTA) are also addressed in conjunction with the annual submissions.) Each year, the Children’s Bureau issues a Program Instruction outlining the information that states must report to receive annual funding under these programs. Information pertaining to the Health Care Oversight and Coordination Plan is included as part of these submissions.
Staff in the regional offices of the Children’s Bureau engages in joint planning with state staff around the development of their CFSPs and APSRs prior to submission. States are then required to submit the CFSP or APSR to the regional office by June 30 each year. Once regional offices receive the plans, staff review them to ensure that all requirements for all programs have been adequately addressed, responding to the requirements as outlined in law and in the annual Program Instruction. In the even that a requirement (including a requirement pertinent to the Health Care Coordination and Oversight Plan) is not fully addressed, the regional office will ask the state to revise the plan prior to recommending approval of the annual APSR or CFSP submission.
We monitor state compliance with titles IV-B and IV-E of the Social Security Act through the CFSR. CFSRs allow us and the states to look at a sample of cases to determine whether the agency is providing appropriate oversight of a child’s psychotropic medications, such as whether the agency is:
- Ensuring that a child is seen regularly by a physician to monitor the effectiveness of the medication, assess any side effects and/or health implications, consider any changes need to dosage or medication type and determine if medication is still necessary and/or if other treatment options would be more appropriate;
- Regularly following up with foster parents/ caregivers and administering medications appropriately and about the child’s experience with the medication(s), including any side effects;
- Following any additional state protocols that may be in place related to the appropriate use and monitoring of medications
We ask states, prior to the review, to confirm our understanding of its state protocols articulated in its CFSP/IVB plan for medication oversight to support rating these items. We do not stratify our sample to generate a large number of children in foster care on such medications, so the number of cases reviewed varies per state. States are responsible for conducting further analysis on their results to determine the specific strengths of breakdowns in monitoring of psychotropic medications.
- ACF noted that the OIG’s recommendation would require statutory and regulatory changes to implement. What changes to law or regulation would be required to implement the OIG’s recommendations to improve states’ compliance with treatment planning and medication monitoring requirements?
Response: The OIG recommended that ACF strengthen its annual review of states’ protocols to confirm that state requirements incorporate professional practice guidelines related to treatment planning and medication monitoring. However, title IV-B does not require states’ health care coordination and oversight plans to incorporate professional practice guidelines. Also, ACF does not have authority to require state compliance with professional practice guidelines.
- What additional statutory authorities or monetary resources does ACF need to implement all of the OIG’s recommendations?
Response: The OIG recommended that ACF require states to report data on treatment planning and medication monitoring to the extent they can provide reliable and consistent data, and then compile national data to use as a benchmark for their progress in meeting requirements. However, the data is not appropriate for collection through the Adoption and Foster Care Analysis and Reporting System because it cannot be reported reliably and consistently.
- Are there other changes to law that would allow ACF to be more effective in improving states’ compliance with treatment planning and medication monitoring requirements?
Response: Each year, the Children’s Bureau issues a Program Instruction outlining the information that states must report to receive annual funding under these programs. Information pertaining to the Health Care Oversight and Coordination Plan is included as part of these submissions. Staff in the regional offices of the Children’s Bureau engages in joint planning with state staff around the development of their CFSPs and APSRs prior to submission. Once regional offices receive the plans, staff review them to ensure that all requirements for all programs have been adequately addressed, responding to the requirements as outlined in law and in the Program Instruction. In addition, we monitor state compliance with titles IV-B and IV-E of the Social Security Act through the CFSR. CFSRs allow us and the states to look at a sample of cases to determine whether the agency is providing appropriate oversight of a child’s psychotropic medications. Regulations allow the title IV-E agency to develop and complete a program improvement plan prior to withholding funds. Outside of the CFSR process, if it comes to our attention that a state is not complying with the Health Care Oversight and Coordination Plan, regulations allow ACF to initiate a partial review and subsequent program improvement plan.
- The recommendation to assist states in developing monitoring requirements that incorporate professional practice guidelines recommends publishing a memorandum with specific mechanisms for child-level treatment planning and monitoring. Does ACF intend to publish this memorandum, and if not what does ACF intend to do to assist states in implementing child-level monitoring consistent with professional practice guidelines?
Response: In 2019, ACF will publish a program instruction for submitting a new five-year Child and Family Services Plan (CFSP) for fiscal years (FYs) 2020-2024 and a final report on their progress implementing the previous five-year CFSP. In our program instruction to states regarding this upcoming submission, ACF will ask states to report on success and challenges in addressing this requirement over the previous five years, and will emphasize the importance of strengthening the development and implementation of protocols for the appropriate use and monitoring of psychotropic medications for children and youth in foster care.
- Does ACF intend to provide additional training or technical assistance for states related to incorporating professional practice guidelines beyond what is already available?
Response: The Children’s Bureau funds an array of technical assistance. The Child Welfare Information Gateway (Information Gateway) develops, disseminates and maintains publications, website pages, general information and guidance on a variety of child welfare topics, including those focused on effectively addressing ongoing challenges related to ensuring the appropriate use of psychotropic medications for children in foster care. The Capacity Building Center (the Center) for States seeks to support state and territorial child welfare agencies in building capacity to better serve youth by undertaking efforts and promoting best practices, including those related specifically to psychotropic medication use for children in foster care and accompanying topics such as health and mental health, well-being, continuity of care, and successful transitions to adulthood.
The Center is funded to provide tailored services to address the specific requests of states. The Center hosts “constituency groups” for professionals who perform the same functions across the state programs. The state foster care managers are one such constituency group. The foster care managers oversee the casework staff. Oversight of psychotropic medications will be a topic to be addressed in the foster care managers’ constituency group. In addition, both the Information Gateway and the Center have an extensive library of products available for state use.
I appreciate your concerns about the health and well-being of children in the public foster care system. I share your concerns and am dedicating to address the OIG recommendations.
I hope this information is helpful to you. Please feel free to contact me if I can be of further assistance. I will provide a copy of this response to your co-signers.