Overview
DCF did not properly maintain healthcare records in for children in its protective custody who received psychotropic medications. During the audit period, 117 of the iFN 118 children who were prescribed at least one psychotropic medication in our FFS sample had incomplete or missing mental health and psychosocial service information. In addition, 49 of the 50 children who were prescribed at least one psychotropic medication in our MCO sample had incomplete or missing mental health and psychosocial service information.
As a result of not updating iFN to reflect up-to-date healthcare records, DCF cannot provide adequate oversight and ensure that the health and mental health needs of all children in its protective custody are being met. In addition, DCF and providers could be creating a treatment plan that is not safe or effective for a child, because there is important information missing that would affect this child’s healthcare (for example, a history of depression or scheduled follow-up appointments to check the dosage of a new medication).
Below is a summary of the specific issues we identified in iFN.
| Specific Healthcare Records | Number of Documentation Issues—FFS Plan | Number of Documentation Issues—MCO |
|---|---|---|
| Medical passports | 104 out of 118 | 43 out of 50 |
| Follow-up doctor appointments and psychosocial services | 116 out of 118 | 46 out of 50 |
| Rogers guardianship order / department consent for psychotropic medications | 109 out of 118 | 47 out of 50 |
a. The Department of Children and Families Did Not Document and/or Update Psychotropic Medications Listed in Children’s Medical Passports.
DCF did not list and/or update the psychotropic medications prescribed to children in their medical passports in iFN. Specifically, 104 of the 118 children who were prescribed at least one psychotropic medication in our FFS sample had medical passports that did not list any of their psychotropic medication prescriptions or had incomplete information about their prescriptions. In addition, 43 of the 50 children in our MCO sample had medical passports that did not list any psychotropic medication prescriptions or had incomplete information about their prescriptions.
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.
Authoritative Guidance
According to DCF Policy 86-011: Ongoing Casework and Documentation,
It is the policy of the Department that the Social Worker documents casework activity for each family, in the family’s case record in FamilyNet. Each client and collateral contact is documented in dictation and entered into FamilyNet as soon as possible. It is expected that dictation will be entered into FamilyNet no later than one month following the contact.
According to DCF Policy 85-003: Health Care Services to Children in Placement,
All children in placement will have a medical passport containing pertinent and available medical, dental, mental health and developmental information prior to or at the time of placement. . . . This information contained in the medical passport will be reviewed in conjunction with the Service Plan every 6 months at Foster Care Review and will be updated when warranted. . . .
PROCEDURES SUBSEQUENT TO PLACEMENT. . . .
- 3. Encounter Form. The Social Worker ensures that the medical and dental appointments are documented by use of the encounter form. . . . Upon receipt of the second page of the encounter form, from either the physician or substitute care provider, the Social Worker completes the form and submits it for data entry or directly enters information into FamilyNet. . . . After data entry into FamilyNet, the encounter form should be placed in the special document section envelope with the copy of the passport. . . .
- 6. Case Review. In preparing for a case review the Social Worker reviews the child(ren)’s current health care status by identifying any recent medical/dental problems and whether the child(ren) has received any necessary routine care and follow-up treatment. The Social Worker ensures that current medical information is available in the case record. This includes:
- an up-to-date copy of the medical passport in the case record by either copying the substitute care providers medical passport or adding to the case record medical passport;
- current encounter forms in the case record and up to date information in FamilyNet;
- current evaluation, test, and treatment results in the case record.
According to DCF Policy 2010-001: Medical Examinations for Children Entering DCF Placement or Custody,
The information that the Social Worker documents in the medical sections of FamilyNet includes, but is not limited to:
- Name, address and telephone number of the primary medical practitioner;
- Names and dates of medical or oral health examinations or tests, the practitioner who completed the examinations or tests and any recommendations, findings or treatments;
- Medical, oral health and behavioral health conditions that have been observed or diagnosed;
- Medications that are prescribed;
- Known allergies;
- Immunizations that have been given; and
- Health-related equipment that is being used.
According to Section 475 of the Social Security Act,
(1) The term “case plan” means a written document . . . and includes at least the following: . . .
(C) The health and education records of the child, including the most recent information available regarding . . .
(v) the child’s known medical problems;
(vi) the child’s medications; and
(vii) any other relevant health and education information concerning the child determined to be appropriate by the State agency.
Auditee’s Response
DCF agrees with the recommendation for additional monitoring controls to ensure up-to-date and accurate documentation of a child’s health care in iFN. DCF is working to address controls around these documentation issues, and will review the existing policy, purpose, and guidelines for the medical passport as well as the documentation requirements for all medical visits.
DCF agrees with the OSA's broad concern that children in DCF custody must not receive medications that are contraindicated based on other medications they are taking. Sometimes, providers do have access to the child's complete electronic medical record. For continuity of care, DCF makes every effort to keep a child with their medical provider of origin. If a child’s medical provider changes, DCF requests that record to transfer immediately to a new provider.
While the medical passport was never intended to be a substitute for the child’s office medical record, DCF recognizes the importance of maintaining up to date records regarding psychotropic medications and other medical treatment in a child's iFN record and is exploring how we can make better use of technology to do so. In February 2024 and monthly thereafter, the Department began batch loading medication data based on MassHealth pharmacy claims. MassHealth Pharmacy Claims Data is used to create medication records for children in custody. The information can be viewed on the Medical/Behavior Info page which is available in the Person Demographics for the child. In addition, we are exploring ways to use MassHealth claims to capture other data such as visit dates and diagnoses.
Auditor’s Reply
We commend DCF for taking steps to improve its recordkeeping practices. We will follow up on this issue in approximately six months as part of our post-audit review.
B. DCF Did Not Document Follow-Up Doctor Appointments and Recommended Psychosocial Services in iFamilyNet for Children in Its Protective Custody Receiving Psychotropic Medications.
DCF did not document follow-up doctor appointments and recommended psychosocial services in iFN for children in its protective custody who received psychotropic medication. For 116 of the 118 children in our FFS sample and 46 of the 50 children in our MCO sample, we were unable to determine the type and frequency of therapy provided to the children or whether they received follow-up doctor appointments at all.
If DCF does 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.
Authoritative Guidance
According to the American Academy of Child and Adolescent Psychiatry’s (AACAP’s) 2015 Recommendations about the Use of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems,
All youth with complex behavioral needs, including youth in foster care, should receive a combination of evidence-based psychosocial interventions and psychotropic medication when indicated, not just psychotropic medication alone.
Auditee’s Response
DCF agrees with the recommendation for additional monitoring controls to ensure up-to-date and accurate health records in iFamilyNet and medical passports. DCF is working to address controls around these documentation issues, and will review the existing policy, purpose, and guidelines for the medical passport as well as the documentation requirements for all medical visits.
As one of DCF’s critical objectives is continuous improvement, there is an opportunity for the Department to review the existing policy regarding health care services for children in placement, the purpose, use and contents of the medical passport, and the utility of the current, paper based, encounter form. This will allow for a review of updated medical recommendations and any [information technology] enhancements that may be necessary.
In addition, DCF would like to note some additional circumstances and barriers continuously being worked on by the agency: Many children receive services via Family Support Services (“FSS”) . . . and will not be captured in claims. There are children who are stable on the ADHD medications, for example, who receive school supports through an IEP or 504, which also may not be clear in iFN. That child may not need additional outside support such as individual therapy.
Review of Medicaid claims data does not encompass the breadth of psychosocial services a child may be receiving.
Auditor’s Reply
We commend DCF for taking steps to improve its recordkeeping practices. We agree that DCF cannot rely solely on MassHealth claims to determine whether children in its custody received recommended psychosocial services, and we did not recommend this in our audit. We reiterate our recommendation that DCF should ensure that children in its protective custody have up-to-date and accurate health records in iFN.
c. The Department of Children and Families Did Not Document Its Consent in iFamilyNet for Children in Its Protective Custody To Receive Psychotropic Medications.
DCF did not properly document its consent or court approval for the prescribing of psychotropic medications16 for children in its protective custody. Specifically, 109 (92%) out of 118 of the children who were prescribed at least one psychotropic medication from our FFS sample did not have required documentation of DCF’s consent or court approval for psychotropic medications. In addition, 47 (94%) out of 50 of the children who were prescribed at least one psychotropic medication from our MCO sample did not have the required documentation of DCF’s consent or court approval for psychotropic medications.
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.
Authoritative Guidance
According to Section 11.14(4)(a) of Title 110 of the Code of Massachusetts Regulations,
When any individual, organization, facility, or medical provider seeks the Department’s consent to medicate with antipsychotic drugs a child, who is a ward of the Department or who is in Department custody, the Department shall seek prior judicial approval for administration of such drugs even if the child’s biological parents have consented to the medication.
According to the “Roles of Foster/Pre-Adoptive Parents or Other Substitute Care Providers and Social Workers” section of DCF Policy 2010-001, “The foster/pre-adoptive parent (or other substitute care provider) . . . arranges for the child to receive medical, behavior health and oral health care that is recommended by the medical practitioner and consented to by the Department.”
According to DCF Policy 86-011: Ongoing Casework and Documentation,
It is the policy of the Department that the Social Worker documents casework activity for each family, in the family’s case record in FamilyNet. Each client and collateral contact is documented in dictation and entered into FamilyNet as soon as possible. It is expected that dictation will be entered into FamilyNet no later than one month following the contact.
AACAP’s 2005 “Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline” states,
State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, should create a website to provide ready access for clinicians, foster parents, and other caregivers to pertinent policies and procedures governing psychotropic medication management, psychoeducational materials about psychotropic medications, consent forms, adverse effect rating forms, reports on prescription patterns for psychotropic medications, and links to helpful, accurate, and ethical websites about child and adolescent psychiatric diagnoses and psychotropic medications.
Reasons for Issues
DCF did not have sufficient monitoring controls in place 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.
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:
- DCF should review medical passports for children in its protective custody and update them at least every six months or when there are changes to a child’s prescription, whichever comes first (e.g., new prescriptions, dosage changes, or discontinued prescriptions).
- DCF should update iFN with all follow-up doctor appointments and psychosocial services for children in its protective custody, including the type and frequency of these appointments and services.
- DCF should document its consent for psychotropic medication for children in its protective custody in iFN and store that consent in the same location in iFN for quick and accurate reviews.
Auditee’s Response
DCF agrees with the recommendation for additional monitoring controls to ensure that the Department is documenting a child’s health care in a timely and accurate way in iFN.
The iFN system is the Commonwealth’s SACWIS (statewide automated child welfare information system), which supports the states’ child welfare business needs and is used primarily to document the activities and services that DCF social worker staff provides to the families and children it serves. DCF also utilizes iFN to document the health care a child receives in conjunction with policy, but in no way does the iFN health care record serve as a substitute for a child’s medical record kept by medical providers.
The OSA response combines both antipsychotic and non-antipsychotic medications under the heading of “psychotropic medications”. Different consent procedures exist for both: Antipsychotic medication consent is provided by the court and consent is indicated by the Rogers order, which is uploaded into iFN.
Substitute caregivers are authorized to provide consent for medical treatment, including non-antipsychotic medication, per DCF policy “Health Care Services to Children in Placement”. . . When a child is placed in a foster home, the foster parent signs both a Foster Parent Agreement and Child Placement agreement where they agree to manage the child’s routine health care, dental care, and emergency medical treatment when necessary. While the health care services policy requires foster parents to provide documentation of health care events, it does not require DCF to document consent for routine health care, which includes the administration of non-antipsychotic psychotropic medication.
DCF currently has multiple pathways for oversight to ensure safety and the judicious use of psychotropic medications for youth in state custody including: DCF nurses and [its] child psychiatrist are always available for consultation about the appropriate dosing and effectiveness of medications. . . .
DCF entered into an information sharing agreement with MassHealth, which enabled the documentation of psychotropic medication in the child’s electronic case record.
DCF has piloted and implemented the Antipsychotic Monitoring Program (AMP), overseen by the DCF child psychiatrist. The purpose of AMP is to provide a medical review of initial requests for antipsychotic medications for youth in state custody to help inform the court and Rogers Process around the appropriateness of the use of the antipsychotic medication in that child.
DCF collaborates with the MassHealth Pediatric Behavioral Health Medication Initiative (PBHMI) to provide further expert review when there are concerns about appropriateness of psychotropic medication for youth in state custody.
DCF will continue to collaborate with other child & family serving agencies around continuous quality improvement efforts of the state’s current psychotropic oversight program PBHMI as well as DCF’s internal oversight systems.
Auditor’s Reply
DCF states that it is not required to document consent for routine healthcare (for example, psychotropic medication, not including antipsychotics). The “Authoritative Guidance” section of this finding outlines best practices that, while not required, reflect best practices developed by healthcare professionals and experts. The AACAP 2009 “Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents” goes into detail about “documenting the assent of the child and consent of the parent.” In addition, iFN contains social worker notes and other references to seeking or documenting consent.
We appreciate that DCF shared its use of multiple oversight pathways to ensure safety for the use of psychotropic medications. However, we maintain our concern that DCF cannot provide proper oversight without accurate documentation of these medications and will follow up with DCF in approximately six months for our post-audit review.
| Date published: | November 7, 2024 |
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