| Organization: | Office of the State Auditor |
|---|---|
| Date published: | November 7, 2024 |
Executive Summary
In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of the Department of Children and Families (DCF) for the period July 1, 2019 through December 31, 2023.
In this performance audit, we examined DCF’s process related to psychotropic medications1 prescribed to children in its protective custody. Specifically, we determined the following:
- whether DCF obtained the required court approval for antipsychotic medications and documented its consent for psychotropic medications prescribed to children in its protective custody as required by Sections 11.14(3)(a), (4)(a), and (6)(a) of Title 110 of the Code of Massachusetts Regulations and DCF Policy 2010-001: Medical Examinations for Children Entering DCF Placement or Custody;
- whether children in DCF’s protective custody received follow-up visits and recommended psychosocial services in conjunction with prescriptions for psychotropic medications in accordance with the American Academy of Child and Adolescent Psychiatry’s 2005 “Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline” and the American Academy of Child and Adolescent Psychiatry’s 2015 Recommendations about the Use of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems;
- whether DCF maintained medical passports2 for children in its protective custody who received psychotropic medications according to DCF Policy 85-003: Health Care Services to Children in Placement, DCF Policy 86-011: Ongoing Casework and Documentation, DCF Policy 2010-001, and Section 475 of the Social Security Act; and
- whether DCF provided oversight to children in its protective custody who received psychotropic medications that exceeded the US Food and Drug Administration’s (FDA’s) recommended maximum dosages.
In addition to examining DCF’s process related to psychotropic medications prescribed for children in its protective custody, we determined the following:
- whether DCF updated its internal control plan to address the COVID-19 pandemic as required by the Office of the Comptroller of the Commonwealth’s “COVID-19 Pandemic Response Internal Controls Guidance”;
- whether DCF ensured that employees who had access to COVID-19 funds completed cybersecurity awareness training in accordance with the Executive Office of Technology Services and Security’s Information Security Risk Standard IS.010; and
- whether DCF made outreach efforts to ensure that it reached eligible youths who aged out of DCF care to allocate funds from the John H. Chafee Foster Care Independence Program grant as required by the grant agreement ACYF-CB-PI-21-04.
Below is a summary of our findings, the effects of those findings, and our recommendations, with links to each page listed.
| Finding 1 | DCF did not always obtain or renew court approval before children in its protective custody were administered antipsychotic medications. |
| Effect | If DCF does not obtain or renew court approvals for antipsychotic medications, which includes presenting treatment plans to the courts, it cannot ensure that these treatment plans are safe and appropriate for the children. In addition, this is removing the courts’ oversight of children in DCF protective custody, who are too young to consent to their treatment plans and need a neutral, third party to ensure that any prescribed medications are in the children’s best interest. |
| Recommendation | DCF should add monitoring controls to its policies and procedures to ensure that any Rogers guardianship orders are approved and renewed by the court. |
| Finding 2a | DCF did not document and/or update psychotropic medications listed in children’s medical passports. |
| Effect | Without accurate and complete information, DCF and health providers may make decisions that conflict with existing medical treatments or do not reflect children’s best interests, such as overprescribing psychotropic medications, which can lead to adverse side effects. |
| Finding 2b | DCF did not document follow-up doctor appointments and recommended psychosocial services in iFamilyNet (iFN) for children in its protective custody receiving psychotropic medications. |
| Effect | If DCF does not of not keep accurate and complete medical records in iFN, then children in DCF’s protective custody may not receive the services needed to treat their conditions. This may delay the growth, development, or recovery of the children who did not receive needed care. Failure to keep accurate and complete medical records may also prevent DCF from determining which medical treatments or providers are most effective or cost-efficient for serving the medical needs of children in its care. |
| Finding 2c | DCF did not document its consent in iFN for children in its protective custody to receive psychotropic medications. |
| Effect | Without documentation of consent or court approval for prescriptions of psychotropic medications, DCF cannot ensure that its social workers and/or medical social workers are providing children in DCF protective custody with medical treatment that is legally required. |
| Recommendation | DCF should establish sufficient monitoring controls to ensure that children in its protective custody have up-to-date and accurate health records in iFN and that its social workers prevent these children from receiving medical care without approval, including the following:
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| Finding 3 | DCF did not ensure that children received recommended psychosocial services in conjunction with their prescriptions for psychotropic medications. |
| Effect | If children do not receive the recommended therapy and psychosocial services with psychotropic medications, treatment effectiveness can be negatively affected. Further DCF cannot monitor the effectiveness of these medications and cannot identify and mitigate any side effects that these children may experience. For example, 28 children from both our samples had suicidal ideations. |
| Recommendation | DCF should ensure that all children in its protective custody who are prescribed psychotropic medications receive psychosocial services and DCF should implement sufficient monitoring controls to ensure that these services are provided and that the efficacy of these services is evaluated. |
| Finding 4 | DCF did not ensure that all employees with access to COVID-19 funds received annual refresher cybersecurity awareness training. |
| Effect | If DCF does not ensure that all its employees complete cybersecurity awareness training, then it is exposed to a higher-than-acceptable risk of cyberattacks and financial and/or reputational losses. |
| Recommendation | DCF should develop and implement policies, procedures, and controls to ensure that all its employees complete cybersecurity awareness training. |
In addition, we identified an issue regarding DCF oversight of children in its custody receiving psychotropic medication in amounts that exceeded the FDA’s recommended doses. For more information on this issue, see the “Other Matters” section of this report.
During our audit, additional areas of concern that were outside the original scope of our objectives came to our attention. Given the high-risk nature of these areas, we examined them while we were still engaged with the auditee. These areas include human trafficking prevention measures, as well as DCF’s implementation of recommendations by the Massachusetts Commission on LGBTQ Youth. The results of this work are included within the “Other Matters” section of this audit report.
1. Psychotropic medications are used to treat mental health disorders such as schizophrenia, depression, bipolar disorder, anxiety disorders, and attention deficit / hyperactivity disorder.
2. A medical passport is a record of healthcare services that a child receives or has received, including their current medications, relevant mental health history, known mental health conditions, treatment programs, and appointments.