The1st meeting of the Subcommittee on Families and Children of the Interim Joint Committee on Health and Welfare was held on Tuesday, August 24, 2004, at 10:00 AM, in the Brown and Williamson Room of Papa John's Cardinal Stadium in Louisville, Kentucky . Representative Tom Burch, Chair, called the meeting to order, and the secretary called the roll.
Members:Senator Katie Stine, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Richard Roeding, Elizabeth Tori, and Johnny Ray Turner; Representatives Bob DeWeese, Joni Jenkins, Mary Lou Marzian, Stephen Nunn, Ruth Ann Palumbo, Ancel Smith, and Kathy Stein.
Guests: Undersecretary Dr. Eugene Foster, Commissioner Mike Robinson, Barbara Carter, Sandra Wilson, Joel Griffith, Jeff Wright, Ruth Hebner, Robyn Zapp, Elizabeth Caywood and Gayle Yocum for the Department for Community Based Services; Susan Vessels and Janet Masterson for 4-C; Kathy Buskill, Joanne Maamry and Dan Shaw for Caritas Peace Center; Bill Heaton for St. Joseph Children's Home; M. Kelli Robinson for Woodlawn Children's Campus; Carolyn Robbins for the Department for Public Health; Mary Gwen Wheeler for the Louisville Metro Cabinet for Health and Family Services; Monique Jones for the University of Louisville; Bryan Sunderland and Frank Willis for the Legislative Research Commission; Patrick Yewell for the Administrative Office of the Courts; David Graves for Brooklawn; Marla Montell for the Cabinet for Health and Family Services; Sarah Nicholson for the Kentucky Hospital Association; Sheila Schuster for the Kentucky Mental Health Association; Jo Wilden for Holly Hill; and Steven Spaulding for the LMCDC.
LRC Staff: DeeAnn Mansfield, Murray Wood and Cindy Smith.
The first item on the agenda was a discussion about the child protective services process and the federal Child Abuse Prevention and Treatment Act (CAPTA) of 2003 discussed by Commissioner Robinson, Department for Community Based Services, Barbara Carter, Director, Protection & Permanency, Elizabeth Caywood, Supervisor, Division of Policy & Development, Saundra Wilson, Jefferson County Service Region Administrator, and Joel Griffith, Northern Kentucky Service Region Administrator. Ms. Caywood said that CAPTA from 1974 provides states with flexible funds to improve the child protective service system in one or more of the following areas: (1) the intake, assessment, screening, and investigation of reports of abuse and neglect; (2) protocols to enhance investigations, and improving legal preparation and representation; (3) case management and delivery of services provided to children and their families; (4) risk and safety assessment tools and protocols; (5) automation systems that support the program and track reports of child abuse and neglect; (6) training for agency staff, service providers, mandated reporters; and (7) developing, strengthening, and supporting child abuse and neglect prevention, treatment, and research programs in the public and private sectors. She said that states must submit a five-year plan and assurances that the state is operating a statewide child abuse and neglect program that includes specific provisions and procedures. The assurances require: the establishment of citizen review panels; expungement of unsubstantiated and false reports of child abuse and neglect; preservation of the confidentiality of reports and records of child abuse and neglect, and limited disclosure to individuals and entities permitted in statute; provision for public disclosure of information and findings about a case of child abuse and neglect that results in a child fatality or near fatality; the appointment of a guardian ad litem to represent a child's best interests in court; expedited termination of parental rights (TPR) for abandoned infants; not requiring reunification of a child with parents who have committed certain crimes; and provisions that make conviction of certain felonies grounds for TPR. New requirements include the mandatory reporting of infants born exposed to drugs, mandatory training for guardians ad litem, referrals to early intervention programs for children under age 3 who have been a victim of child abuse or neglect, and notification of reports to interested parties.
Senator Stine asked if the training for guardians ad litem was mandatory in Kentucky. Ms. Caywood said it is offered by the Administrative Office of the Courts for all guardians ad litem, but she did not know if it was mandatory. Sen. Stine said she wanted to discuss guardians ad litem in more detail at a subsequent meeting.
Ms. Caywood said they adopted 922 KAR 1:330 in June, 2004 and this assured their compliance with CAPTA and continued eligibility for the CAPTA state grant. Ms. Caywood said Kentucky receives $289, 852 from the CAPTA grant and commented this amount is not that big in comparison with other federal grants. Two states, Pennsylvania and Indiana, do not apply for the funds.
Ms. Caywood stated that the department has been making referrals to First Steps to address the needs of drug exposed infants and these referrals are consistent with federal initiatives to link Child Protective Services and developmental early intervention and health services related to evaluation and treatment of maltreated children. These new state eligibility requirements are intended to improve state practices so at risk children have greater access to supportive services.
Representative Jenkins asked about the investigative portion that requires notice to a parent before an investigation is begun. She asked if there is a procedure for interviewing the child before the parent has access to them. Ms. Caywood said there are three situations where the investigation can be initiated prior to notification: if the parent gives consent, if it is an emergency situation, or if it is a situation where executing a warrant is not feasible.
Representative Burch asked if health care providers are aware of requirements to refer cases of infants born exposed to alcohol and drugs to Child Protective Services, and asked if that was in place now. Ms. Caywood said that was in placement prior to the CAPTA amendments in Kentucky, and it is in statute, but she is not sure when the law was amended. Representative Burch stressed that he would like to see treatment for the mothers instead of punishment. Ms. Caywood said treatment is based on the extensiveness of the case, and the willingness for treatment on the part of the parent. Representative Burch asked what are the considerations for not prosecuting a parent if they have a child born with a drug or alcohol addiction. Ms. Caywood said Jefferson County has a protocol or an agreement with Jefferson County hospitals.
Next, Robin Zapp, from Child Protective Services in Jefferson County described the arrangements with Jefferson County hospitals. They formed a workgroup that included hospital staff and doctors to develop protocol for assessment of drug abused infants. All hospitals that deliver infants in Jefferson County are encouraged to test infants for drugs or alcohol if one of the following conditions exist: (1) the mother received late or no prenatal care: (2) abruptio placenta; (3) the mother has a history or there is evidence of current drug or alcohol usage; (4) the infant's birth weight is less than the 10th percentile; (5) there is an unplanned home delivery; (6) the total labor is less than three hours; or (7) the infant's head circumference is less than the 10th percentile.
Senator Tori asked what happens if the allegation of abuse or neglect are not substantiated. Ms. Caywood said there are requirements under the CAPTA amendment that if the allegations are not substantiated, social workers can provide links and referrals to other services. Senator Tori asked how many reports of child abuse there were last year. Ms. Caywood said there were 50,000 reports of child abuse and neglect last year. Rep. Burch asked for more information about the number, source, and disposition of child abuse and neglect reports at the next meeting.
Senator Stine asked how all the players in Child Protective Services work together. Commissioner Robinson said one of the approaches the Department has taken is getting everyone together in a "Family Team Meeting". Essentially the Department tries to bring everyone involved in the situation to the table to discuss needs and future plans.
Next, Joel Griffith, Service Region Administrator from Northern Kentucky said not all situations work perfectly, but they do try to get all the players to get together. A safety plan is developed to protect the child. The plan often looks different in different counties. Commissioner Robinson added that they work very closely with the court system in most situations, and the Judge has the ultimate decision as to what happens in each case.
Next, Barbara Carter, Director, Protection and Permanency reviewed a flow chart that demonstrated the CPS process from intake to achieving timely permanency. She said the average case should be open for about 90 days.
Senator Stein asked how frequently are discussions held with families. Ms. Carter said at least monthly as long as the case remains open.
The next item on the agenda was an update on Foster Care, Resource and Private Child Care Homes by Eugene Foster, Ed.D., Undersecretary, Office of Families and Children, Cabinet for Health and Family Services. Dr. Foster said there are 6,300 children any day committed to state custody. He discussed the census achievement and goals. He said it was initiated in the summer of 2002, and was completed in 2003. One hundred percent of over 6,000 children were seen and met in their homes and between 75 percent and 85 percent of foster care providers were interviewed. Safety and placement were validated and it was verified that children were being seen by their social workers as required by policy. All children were identified and found. Over ninety percent of foster care providers rated the services to meet the special needs of the foster child as "at least adequate." Over seventy percent of care providers rated visits by social workers as just right. Ninety percent had a physical within 12 months, and 83 percent had a dental exam within 12 months. He said they are working on developing detailed lists to send to the Service Regional Administrators of children who had not been visited, children needing physical or dental exams, children listed as not in school, or other child-related concerns. Other ideas to improve the system included establishing a hot line for foster parents to contact for visits or permanency issues. A system to validate visits by social workers through phone calls by regional staff was developed. Also a program improvement plan provides an incentive for and systems to monitor visits to children. An opportunity to improve the system would be to increase the use of hand-held technology to verify the child's location, enter contact information, track the child's needs in a more timely manner, and enter updated information directly into the TWIST system. Digital cameras that attach to a pocket PC could function like a web camera and be uploaded directly into the TWIST system. He said another opportunity to improve the system would be to identify each move for every child and their current foster home address. In summary he said that the Kentucky Foster Care Census reassured the Cabinet that every child was located in their placement. The census also identified gaps that posed risks to losing children. These gaps are being addressed through changes in the system. The census as completed will not be needed again, but did provide important information for system improvement.
Representative Nunn asked about the discrepancies of data in the TWIST system, particularly the number of children who had received a physical examination, and the "unable to determine" category of race of children. Commissioner Robinson said some data fields were not mandatory and workers did not complete all screens. He said many fields would be added and made mandatory and the TWIST system does need a lot of improvement.
Representative Nunn asked if the children in private child care (PCC) foster care are moved more often than children in agency foster homes. Dr. Foster said there is not good data on that at this time, but they have no reason to believe that there is more frequent movement in the PCC's than with other foster children who have equivalent levels of acuity.
Representative Palumbo asked if the physical exams are occurring. Dr. Foster said 90 percent of them are occurring, and they need to work on the other 10 percent.
The last item on the agenda was a presentation on the Investigation of Caritas Peace Center for Alleged Misuse of Medications with Youth by Protection and Advocacy Division, conducted by Heidi Schissler Lanham, Supervising Attorney, Department of Public Advocacy, Division of Protection and Advocacy and JoAnne Maamry, Vice-President, Caritas Peace Center. Ms. Lanham said 19 patients agreed to talk about their experience at Caritas. They all spoke about the use of PRNs, which are medications which are given as needed, not on a set schedule. Five of nineteen of the children said they felt they were required to take medicines before becoming agitated. Caritas staff did not acknowledge that this was an issue. They said the Office of Inspector General did investigate, but they found no inappropriate PRN use. The staff said they had concerns about their ability to work effectively with children with dual diagnoses. Protection and Advocacy staff conducted record reviews and did intensive reviews on the records of five of the children. They looked at the Medication Administration Record (MAR) and the flow sheets. Protection and Advocacy suggest that with PRNs, there should be appropriate reasons and documentation for PRNs to be given to control behavior. They noted that the reasons given for the PRNs were missing in half of the cases. In the charts, many times the flow sheets said the child was asleep while at the same time the MAR showed they were being given a medication. Both of these are filled out by different people and many discrepancies were found. There was a single nurse that was found to be inappropriately giving PRNs by the Office of Inspector General. There was also a systemic issue found in regard to lack of treatment plans. Protection and Advocacy did note that Caritas changed their documentation beginning in June, with a one sheet PRN administration form. This report was published in May of 2004, long after the investigation was completed.
Representative Palumbo asked if all these issues were resolved in June, 2003, and if, to their knowledge, they continue to be resolved. Ms. Lanham said they were resolved and things appear ok now.
Representative Burch asked if there had been visits this year. Ms. Lanham said they visited in late April and things were okay, and they will continue to monitor things. The Office of Inspector General was there in August of 2003 and things were okay then.
Next, JoAnne Maamry from Caritas said that Caritas provided a written response to the Protection and Advocacy report, and they do disagree with several of the Protection and Advocacy findings and comments. She said they have fully cooperated. She did say that one nurse was behaving improperly and she was disciplined, and then terminated. They did have a documentation issue, but they now have a new medical record system. She said they were never cited in regard to using PRNs improperly. She said every PRN medicine is not for behavior control. She said a nurse comments on flow chart every 15-30 minutes with notes of every patient. It is not completely accurate, as it is not documented constantly, but instead every 15-30 minutes.
Dr. Moore, Medical Director, pointed out two of the key problems he had with the report. One, there were non-medical people struggling to do a medical review and medication evaluation. It would be useful in the future if Protection and Advocacy armed their investigative teams with a psychiatrist if they are going to attempt to do that type of evaluation. The second issue is the PRN- restraint issue. In the report, they constantly equated psychotropic PRNs with chemical restraints, and he stated they are not the same thing.
Dr. Sullivan, Clinical Director, said the children at Caritas are violent and aggressive. About 85 percent of these children have suffered from physical and sexual abuse, and many come from broken homes. Many have psychiatric disorders, including bipolar, mood disorders, personality disorders, and require medications for mood and/or behavior problems, and these medications are very effective. He noted that the Protection and Advocacy report would have been better suited if a physician had been involved with the investigation.
Representative Marzian asked about the number of beds in relation to the number of nurses. Ms. Maamry said there are 20 beds in the unit. The ratio on the unit is about one nurse to three patients. There are between one and two nurses, chemical dependency counselors, and mental health workers on each shift. The nurse would chart the PRN and administer the medications and there may be one to nurses per shift for 20 patients.
The meeting was adjourned at 12:15 p.m.