U.S. Department of Health and Human Services 
Office of Inspector General 
 
Treatment Planning 
and Medication 
Monitoring Were 
Lacking for Children 
in Foster Care 
Receiving 
Psychotropic 
Medication 
OEI-07-15-00380 
OEI-00-00-00000 
 
MSeopnttehm 2b0e1rY 2 018 
Daniel R. Levinson 
 
Inspector General 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
September 2018 
Office  of Inspector General 
OEI-07-15-00380 
 
 
Treatment Planning and Medication Monitoring 
Why OIG Did This Review 
Were Lacking for Children in Foster Care 
Up to 80 percent of children enter 
foster care with significant mental 
Receiving Psychotropic Medication  
health needs.  For children with 
  mental health needs, psychotropic 
What OIG Found
Key Takeaway  medications (i.e., medication used 
In five States, one in three children in foster care who 
The five States we  to treat clinical psychiatric 
were treated with psychotropic medications did not 
reviewed partially  symptoms or mental disorders 
receive treatment planning or medication monitoring as 
required by States.  Additionally, the Administration for  complied with their own  such as depression, bipolar 
Children and Families (ACF) has suggested that States  State requirements for  disorder, and schizophrenia) may 
consider practice guidelines from professional  treatment planning and  be effective treatments.  However, 
organizations, including the American Academy of Child  medication monitoring for  these medications can have serious 
side effects and, as ACF suggests 
and Adolescent Psychiatry, (AACAP) related to treatment  children in foster care 
and the five States in our sample 
planning and medication monitoring.  We found that  receiving psychotropic 
require, should be used in 
State requirements for oversight of psychotropic  medication.  Improved 
conjunction with treatment 
medication did not always incorporate these professional  compliance and stronger 
planning mechanisms and effective 
practice guidelines.    State requirements will 
medication monitoring.   
help protect children who 
Treatment planning is critical to enhancing continuity of 
 
are at risk for 
care; improving coordination of services between health 
A 2015 OIG report foundbased 
and child welfare professionals; and reducing the risk of  inappropriate treatment 
on review of medical records
harmful side effects.  Effective medication monitoring  and inappropriate 
serious quality-of-care concerns in 
can reduce the risk of inappropriate dosing and  prescribing practices.   
the treatment of children with 
inappropriate medication combinations.   
psychotropic medications.  
 
How OIG Did This Review 
 
We selected a sample of 
 
625 children in foster care from the 
 
5 States that had the highest 
 
utilization of psychotropic 
 
medications in their foster care 
  populations.  On the basis of foster 
  care case file documentation and 
What OIG Recommends   Medicaid claims data, we 
To ensure coordinated care for children in foster care who receive psychotropic  determined the extent to which the 
medications, we recommend that ACF develop a comprehensive strategy to  children in our sample were 
improve States compliance with requirements related to treatment planning and  treated with psychotropic 
medication monitoring for psychotropic medications.  ACF should assist States in  medications in a manner consistent 
strengthening their requirements for oversight of psychotropic medications by  with their respective States 
incorporating suggested professional practice guidelines for monitoring children  requirements.  Additionally, we 
at the individual level.  ACF stated that it concurred with some of our  compared the five States 
recommendations but not others; it did not specify which of the two formal  requirements for psychotropic 
recommendations it agreed with, and which it did not.  OIG continues to  medication oversight with 
recommend additional action by ACF as actions to date have not led to the  treatment planning and medication 
needed outcomes. monitoring practice guidelines 
from the American Academy of 
Full report can be found at oig.hhs.gov/oei/reports/oei-07-15-00380.asp  Child and Adolescent Psychiatry.   
TABLE OF CONTENTS 
BACKGROUND  1 
Objectives  1 
Methodology  4 
   
FINDINGS  6 
One in three children in foster care who were treated with psychotropic medications did not  6 
receive required treatment planning or medication monitoring 
State requirements for psychotropic medication oversight did not always incorporate  9 
suggested professional practice guidelines for treatment planning and medication monitoring  
   
CONCLUSION AND RECOMMENDATIONS  12 
Develop a comprehensive strategy to improve States compliance with requirements related to  12 
treatment planning and medication monitoring for psychotropic medication 
Assist States in strengthening their requirements for oversight of psychotropic medication by    13 
incorporating professional practice guidelines for monitoring children at the individual level   
Agency Comments and Office of Inspector General Response  14 
   
APPENDICES   
A: Five Required Elements for Monitoring the Appropriate Use of Psychotropic Medications   16 
B: Detailed Methodology   17 
C: State-by-State Compliance With Psychotropic Medication Requirements  20  
D: Statistical Estimates and Confidence Intervals  26 
E: State Demographics Regarding Children in Foster Care Treated With Psychotropic  30 
Medications 
F: Agency Comments  33 
   
ACKNOWLEDGMENTS  35 
 
ENDNOTES  37 
 
   
BACKGROUND 
Objectives 
For the five States with the highest percentages of children in foster care 
treated with psychotropic medications: 
1.  to assess the extent to which children in foster care who were 
treated with psychotropic medications received treatment 
planning and medication monitoring consistent with States 
requirements; and 
2.  to assess the extent to which States incorporate suggested 
professional practice guidelines for treatment planning and 
medication monitoring into their requirements for treatment of 
children with psychotropic medications.  
In 2012, nearly 30 percent of the 400,000 children in foster care in the 
United States were taking at least one psychotropic medication.1  
Psychotropic medications are often used to treat clinical psychiatric 
symptoms or mental health disorders such as depression, bipolar disorder, 
schizophrenia, attention deficit/hyperactivity disorder (ADHD), 
post-traumatic stress disorder (PTSD), and anxiety disorders.2, 3  
Psychotropic medications can be effective treatments for children who have 
mental health needs, including children in foster care.4  However, these 
medications can have serious side effects, such as drowsiness, weight gain, 
nausea, headaches, involuntary movements, and tremors, among others.5  
There is limited research to guide the use of psychotropic medications in 
children.6  Therefore, psychotropic medications are to be used with care and 
as part of a comprehensive treatment plan.7  
Many factors related to foster care can complicate efforts to provide 
appropriate mental health treatment.  Up to 80 percent of children in foster 
care enter State custody with significant mental health needs.8  Unlike 
children from intact families, children in foster care often do not have a 
consistent interested party to coordinate treatment planning or to provide 
continuous oversight of their mental health treatment.9  Further, 
responsibility for children in foster care is shared among multiple people
foster parents, birth parents, and caseworkerswhich creates risk of 
miscommunication, conflict, and lack of followup.10  Children in foster care 
may also experience multiple changes in placement and in physicians, which 
can cause health information about these children to be incomplete and 
spread across many sources.11  Therefore, children in foster care may be at 
risk for inappropriate prescribing practices (e.g., too many medications, 
incorrect dosage, incorrect duration, incorrect indications for use, or 
inappropriate treatment).12   
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Effective ongoing oversight of childrens care and monitoring of prescribing 
patterns has several potential benefits, such as enhanced continuity of care, 
increased placement stability, reduced need for psychiatric hospitalization, 
and decreased incidence of adverse drug reactions and dangerous 
drug-to-drug interactions.13  Ineffective monitoring may increase the risk for 
inappropriate dosing, frequent medication switches, or the use of 
inappropriate medication combinations.14  For example, if a prescriber is 
unaware that medications are not being taken as ordered, the prescriber 
may conclude that the existing medication regimen is inadequate and 
increase a dose or add another medication.15   
A March 2015 Office of Inspector General (OIG) report found that children 
enrolled in Medicaidincluding children in foster careexperienced 
quality-of-care issues related to their treatment with antipsychotic 
medications, which are a type of psychotropic medication.  Two of the 
common quality-of-care issues that we identified through reviewing medical 
records were related to treatment and monitoring.16 
Medicaid pays for a majority of the healthcare services that children in foster 
care receive, including psychotropic medications.17  In 2013, State Medicaid 
programs paid approximately $366 million for psychotropic medications for 
nearly 240,000 children in foster care up to age 21.18   
The Administration for Children and Families (ACF) Oversight of 
State Foster Care Program Requirements  
ACF is responsible for awarding Federal funding to States child welfare 
programs and for overseeing those programs.   
ACF Requirements for State Plans.  ACF requires the State agency that 
administers the States child welfare program to submit a State plan every 
5 years, which outlines how it will comply with Federal requirements.  As 
part of its State plan submission, each State must include a healthcare 
coordination and oversight plan.  The State child welfare agency develops 
this plan with the State Medicaid agency, pediatricians, other healthcare 
experts, child welfare service experts, and recipients of these services.  The 
plan addresses the oversight of prescription medicines, including 
requirements for monitoring the appropriate use of psychotropic 
medications.19, 20  The plan must address five elements (listed in Appendix 
A).21  Annually, ACF requires each State child welfare agency to describe in 
its Annual Progress and Service Report its protocols (official procedures 
used to accomplish the State plan) related to each of the five elements and 
provide additional information on how the child welfare workforce and 
providers are trained with regard to these requirements.22  Hereinafter, we 
refer to State agency as State and protocols as State requirements.  
As noted earlier, previous OIG work has identified (through review of 
medical records) issues with children receiving inappropriate treatment and 
monitoring.  Two of the five elements ACF requires to be part of a States 
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OEI-07-15-00380   
plan include: (1) screening, assessment, and treatment planning mechanisms 
to identify childrens mental health needs and trauma-treatment needs, 
including a psychiatric evaluation, as necessary, to identify whether children 
need psychotropic medications; and (2) effective medication monitoring at 
both the client level and agency level.23  Client-level monitoringin this 
case, child-level monitoringrefers to monitoring an individual who 
receives medication.  Child-level monitoring can include practices such as 
employing nurses to ensure that individual children receive necessary 
services or requiring review of individual prescriptions.24  Agency-level 
monitoringin this case, State-level monitoringrefers to activities that 
support and inform decisions for all clients of an agency.  State-level 
monitoring could involve a States monitoring the rate at which children in 
foster care receive psychotropic medication, monitoring the types of 
psychotropic medications children receive, or establishing an advisory 
committee to oversee its medication formulary.25 
ACF Oversight of State Compliance.  ACF oversight includes periodic 
reviews of each States child welfare system, known as Child and Family 
Services Reviews, to assess whether a State complies with its State plan 
requirements.26  In this report, we refer to these reviews as compliance 
reviews.  ACF determines compliance (i.e., substantial conformity) based on 
a number of factors, including the States ability to meet criteria related to 
outcomes for children and families.27  In making its assessment, ACF uses a 
compliance review instrument that assesses particular criteria and makes a 
determination based on the entirety of the review.  
If ACF finds that a State is not in substantial conformity with its State plan, it 
requires that the State develop a program improvement plan.28, 29  If the 
State fails to successfully complete a program improvement plan, ACF has 
the authority to withhold a certain amount of Federal funding.30 
The mental/behavioral health section of the compliance review instrument 
includes an assessment of needs, and services that the State provided to 
meet those needs, for a sample of children in foster care.  The instrument 
includes criteria such as (1) ensuring the child was seen regularly by the 
physician to monitor the effectiveness of medication, assess side effects, and 
consider any changes needed in dosage; (2) regularly following up with 
foster parents/caregivers about administering medications appropriately 
and outcomes and side effects.31  
Guidance on Oversight of Psychotropic Medications for Children in 
Foster Care 
ACFs instruction to States regarding development of requirements related 
to screening, assessment, treatment planning, and effective medication 
monitoring is broad.  For example, ACF has not established requirements 
defining the periodicity of the screening, the assessment tools that should 
be used, or the details that should be included in the treatment plan.   
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ACF has suggested that States consider practice guidelines from 
professional organizations related to treatment planning and medication 
monitoring in efforts to improve their monitoring and oversight 
requirements of psychotropic medications.  These organizations include the 
American Academy of Child and Adolescent Psychiatry (AACAP), the 
American Academy of Pediatrics, and prescription parameters developed by 
the State of Texas, which detail mechanisms that may be used to 
accomplish the broad requirements.32  ACF highlighted the AACAP 
guidelines as particularly relevant to States when developing their 
psychotropic medication oversight and monitoring requirements.  However, 
ACF instruction acknowledges that States are unique and does not mandate 
States to incorporate professional practice guidelines in their requirements. 
Professional practice guidelines highlight the importance of treatment 
planning and medication monitoring for children prescribed psychotropic 
medications.33  Treatment planning should include collaboration among 
caregivers to discuss symptoms, behaviors, and potential benefits and side 
effects of treatment options.34  This allows all parties to understand why 
medication is being used and the plan for followup.35  Medication 
monitoring visits should occur regularly to enhance patient and guardian 
confidence in the treatment, and to promote effective management of 
longer term treatment and safety issues.36  Specifically, medication 
monitoring enables prescribing professionals, patients, and guardians to 
establish a plan for followup and reduce the risk for an unidentified relapse 
or recurrence of symptoms.37   
Methodology 
Scope 
For five States, we determined whether children in foster care were treated 
with psychotropic medications consistent with their States requirements 
related to: (1) screening, assessment, and treatment planning mechanisms, 
including (as necessary) psychiatric evaluations; and (2) medication 
monitoring.  This study focuses on these two elements because of the 
quality-of-care concerns that we identified in previous OIG work.   
We also determined the extent to which these State requirements were 
consistent with suggested professional practice guidelines focused on 
treatment of children with psychotropic medications. 
In the States we reviewed, requirements related to screening and 
assessment applied only to children entering foster care.  There was not a 
significant number of sampled children who entered foster care during the 
review period.  Therefore, we were not able to project results related to 
screening and assessment requirements in the study. 
Further, according to the States requirements, psychiatric evaluations are 
required only as necessary, or if recommended.  Because case files did 
not consistently document the need for psychiatric evaluation, we could not 
Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication  4 
OEI-07-15-00380   
assess compliance with this conditional requirement.  Therefore, we were 
not able to project results related to psychiatric evaluation requirements. 
State and Sample Selection 
We selected the five States with the highest percentages of children in 
foster care who were treated with psychotropic medications in FY 2013, the 
most recent year for which there was complete data available in the 
Medicaid Statistical Information System (MSIS).38  They were Iowa, Maine, 
New Hampshire, North Dakota, and Virginia. 
We combined foster care eligibility data and Medicaid claims data obtained 
from the five States to determine the population of children in foster care 
treated with psychotropic medication during the review period, 
October 1, 2014, through March 31, 2015.  From that population, we selected 
a simple random sample of 125 children from each of the 5 States, for a 
total of 625 children.  We excluded 36 children for various reasons, such as 
the childs not having been in foster care for a sufficient time (see Appendix 
B). 
Collection and analysis of documentation and data.  For each child in our 
sample, we requested documentation from foster care case files and 
Medicaid claims data representing services received during the review 
period.  We determined whether any services represented evidence that a 
required elementscreening, assessment, treatment planning, psychiatric 
evaluation, and/or medication monitoringoccurred.  For each instance of 
a requirement that the State appeared to have not met, we invited the State 
to provide additional evidence. 
Comparing States Requirements to Practice Guidelines 
Recommended by AACAP 
ACF suggested States consider professional practice guidelines for 
improving their monitoring and oversight of psychotropic medications.39  
We selected professional practice guidelines from AACAP guidance 
documents for comparison with the five States requirements for oversight 
regarding psychotropic medication.40  See Appendix B for a detailed 
description of our methodology. 
Limitations 
Our estimates cannot be generalized beyond the five selected States. 
It is possible that some children in our sample received healthcare services 
that were not paid for by Medicaid or were not included in the data 
submitted; therefore, this study may have underestimated the provision of 
required health services for these children.41   
Standards  This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency.   
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FINDINGS 
One in three  Thirty-four percent of children in foster care who were treated with 
psychotropic medications, in the five States we reviewed, did not receive 
children in foster 
either treatment planning or medication monitoring (see Exhibit 1).  Eight 
care who were 
percent of these children received neither treatment planning nor 
treated with  medication monitoring.  Treatment planning and effective medication 
monitoring are imperative because of the risks of inappropriate treatment 
psychotropic 
and inappropriate prescribing practices (e.g., too many medications, 
medications did not 
incorrect dosage, incorrect duration, incorrect indications for use).  See 
receive required 
Appendix C for more information regarding States compliance with each 
treatment planning  requirement we reviewed.   
or medication 
Exhibit 1: One in three children in foster care who were treated with 
monitoring 
psychotropic medications did not receive required treatment 
planning or medication monitoring 
See Appendix D for all point estimates and corresponding 95-percent 
confidence intervals. 
Twenty percent of children in foster care did not receive treatment 
planning 
In the five States reviewed, 20 percent of children did not receive treatment 
planning, as States required.  Effective treatment planning provides a 
mechanism for caseworkers, foster parents, and prescribers to be aware of 
medications the child is receiving.  For children in foster care, effective 
treatment planning is critical to enhancing continuity of care, improving 
coordination of services between health and child welfare professionals, and 
reducing the risk of harmful side effects. 
   
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In the following example,  there was  no evidence that a treatment plan was  
developed before  starting  the medication  of a child in foster care.   However,  
the child  did receive a retrospective review of the four psychotropic 
medications prescribed.  This  review  indicated  concerns regarding the 
medical necessity of  the childs drug regimen that should  have been 
considered and documented in a treatment plan.   Without  a treatment plan,  
there is  no evidence that the childs caregivers  understood  important 
concerns  before  medicating this  child,  such as  (1)  the rationale for each  
medication,  (2) the  potential benefits  and side  effects of each medication, 
and  (3)  the  plan for followup.    
 
  Child Description6-year-old child diagnosed with ADHD, behavior  
disorder, learning  disability, tic disorder, dysarthria (speech disorder), 
oppositional defiant disorder, PTSD, trichotillomania (hair-pulling disorder).  
Prescribed four  psychotropic medications.  
Case NarrativeThe State-employed nurse coordinator noted her  opinion  
that the medications were quite a bit for a child of  his age, and  initiated a  
referral for a medication review.  The medication review  indicated that the 
psychiatrist reviewer had  questions regarding two of the four medications  
prescribed to this child.  He acknowledged that current medication use 
could  have been within the standard of  care.  However, there were 
questions concerning the following: (1) medical necessity for one of the  
medications; (2) side effects of one medication that could  be exacerbating  
one of the childs conditions; and (3) a dosage increase in one medication 
that could have  negated the need for the fourth medication.  The medical 
review resulted in correspondence with the prescribing  professional 
regarding the medical necessity for two of the childs four medications.   
Subsequent to this review, the childs drug regimen was changed.  
In three of five States, over half of the children who received treatment  
planning  did not have a  complete treatment plan.   Three  of the five States  
have specific  criteria for treatment plans.  In those States, 52 percent of  
children who received treatment planning had  plans that did  not meet all  
State criteria.  See Appendix  C for each of the States specific  criteria for 
treatment plans, as well as the percentage of children  for whom treatment 
plans did  not meet all State-required criteria.  Examples of  State criteria for  
treatment plans  in those three States  include  documentation of:  diagnoses,  
assessment summaries, interventions, treatment progress, information  
about  prescribed medications, and  evidence  of collaboration by a 
multidisciplinary team. Including these criteria  in treatment plans  helps  
caregivers  to understand  why medication is being  used and the plan for  
followup.  Further, treatment planning provides a mechanism for caregivers  
Treatment Planning and Medication Monitoring  Were Lacking  for Children in Foster Care Receiving Psychotropic Medication   7  
OEI-07-15-00380    
to collaborate to assess target symptoms, behaviors, potential benefits, and 
adverse effects of treatment. 
Twenty-three percent of children in foster care did not receive 
medication monitoring   
In the five states we reviewed, 23 percent of children did not receive 
medication monitoring during the review period.  Effective medication 
monitoring can reduce the risk of inappropriate dosing or inappropriate 
combinations of medications.  For example, if a prescriber is unaware that 
medications are not provided as planned, the prescriber may unknowingly 
increase a dose or add another medication.   
Medication monitoring is essential for children in foster care to promote 
communication among prescribing professionals, patients, and guardians, 
and to establish a plan for followup.  Further, medication monitoring can 
reduce the risk for an unidentified recurrence of symptoms and promote 
effective management of longer term treatment and safety issues. 
States acknowledged challenges in providing required services 
related to oversight of psychotropic medication for children in 
foster care 
In the five States we reviewed, officials reported challenges in State plan 
implementation that can pose barriers to providing required services for 
children in foster care.  These challenges included a lack of data for 
measuring outcomes and limited access to mental health services.  
Additionally, States noted that some gaps in meeting their requirements are 
related to transitions in the case-management workforce, developing 
effective accountability measures for caseworkers, and appropriate training 
for new caseworkers.  Officials reported a need for additional guidance and 
technical assistance from ACF related to oversight of psychotropic 
medications prescribed to children in foster care. 
States proposed some guidance and assistance that would be helpful to 
mitigate barriers to providing required services, including:  
  national data for States to use as benchmarks in measuring their 
progress toward meeting the requirements;  
  successful policy and practice strategies that have been used by 
other States to meet requirements; and 
  assistance in improving communication between Medicaid and child 
welfare systems to facilitate the tracking of services provided to 
children in foster care and measure progress in meeting 
requirements. 
   
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State requirements  In the five States we reviewed, State requirements did not always 
incorporate professional practice guidelines regarding oversight of 
for psychotropic 
psychotropic medications for children in foster care, as suggested by ACF.  
medication 
Although ACF requires State plans to protect children by including 
oversight did not  treatment planning mechanisms and effective medication monitoring, it 
always incorporate  allows States flexibility in implementation.  ACF suggests that States 
consider practice guidelines from professional organizations, including 
suggested 
AACAP, to improve their treatment planning and medication monitoring 
professional 
requirements.   
practice guidelines 
The five States' requirements did not consistently incorporate 
for treatment 
professional practice guidelines for child-level monitoring  
planning and 
Our review of five States found that State requirements did not always 
medication  incorporate these recommendations related to child-level treatment 
monitoring  planning and medication monitoring (see Exhibit 2).  For example, none of 
the five States we reviewed included requirements to document medication 
dosages or potential adverse effects of medications within childrens foster 
care case files.    
Exhibit 2: States requirements did not consistently incorporate 
elements of suggested professional practice guidelines for child-level 
oversight of psychotropic medication  
Among five States, number that included suggested case file documentation 
requirements for child-level monitoring of psychotropic medications: 
Specifically, State child-level requirements did not include elements such as 
information on potential adverse effects or assessment of risk for 
nonadherence to the treatment plan.  These elements provide essential 
information to accomplish effective oversight, to monitor prescribing, and 
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to enhance continuity of care.  Without these child-level requirements, there 
is no mechanism to ensure that caregivers are consistently collaborating to 
assess target symptoms, behaviors, potential benefits, and adverse effects of 
treatment.  
Child-level practice guidelines promote a coordinated strategy in oversight 
of individual childrens psychotropic medication use.  This guidance is 
critical due to known concerns in the foster care population, such as 
complex mental healthcare needs and changes in foster home placement.  
These concerns increase the risk of miscommunication among caregivers 
and ineffective and inappropriate medications or medication combinations.   
Additionally, previous work by the Government Accountability Office (GAO) 
concluded that States that do not incorporate AACAPs recommended 
elements limit their ability to identify potentially risky prescribing practices.42 
The following example highlights the importance of State child-level 
requirements.  In this State, there is no requirement for caseworkers to 
follow up with foster parents about medication and the childs outcomes or 
assess the risk for medication nonadherence.  The child was without 
prescribed medication for a time and experienced adverse effects.  There 
was no evidence in the case file that the caseworker was aware of the 
nonadherence and the impact on the childs outcome. 
 
Child Description11-year-old child diagnosed with reactive attachment 
   
disorder, conduct disorder, anxiety, and ADHD.  Prescribed two psychotropic 
medications. 
Case NarrativeThe child experienced a 3-month period during which the 
foster mother stated she had difficulties obtaining medication refills for the 
child.  Two prescribing professionals said the child needed to be seen first by 
a psychiatrist.  One prescriber agreed to provide a refill because the child was 
unmanageable without medications.  The child was seen by a psychiatrist 
during the fourth month, at which time the notes indicated the child was 
without medications, had lost the ability to maintain normal psychological 
function, and had experienced a decline of his overall situation.  The decline 
included increased stealing, lying, bullying, poor interactions with other 
children, and in-school suspension. 
The five States' requirements generally incorporated suggested 
professional practice guidelines for State-level monitoring  
Unlike States child-level requirements, States State-level requirements 
generally incorporated suggested professional practice guidelines (see 
Exhibit 3, on the next page).  For example, States included a requirement to 
monitor the rates and types of psychotropic medication usage and rates of 
adverse reactions.  These aggregate mechanisms can improve States ability 
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OEI-07-15-00380   
to identify potentially risky prescribing practices and to improve oversight of 
psychotropic medications for children in foster care. 
Exhibit 3: States requirements generally incorporated suggested 
professional practice guidelines for State-level oversight of 
psychotropic medication 
Among five States, number that included suggested practice guidelines within 
their requirements for State-level monitoring of psychotropic medications: 
 
 
   
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CONCLUSION AND RECOMMENDATIONS 
The five States that we reviewed partially complied with their own 
State-established requirements for treatment planning and medication 
monitoring for children in foster care receiving psychotropic medications; 
further, State requirements did not always include suggested professional 
practice guidelines designed to protect these children.  Specifically, 
34 percent of children in foster care who were treated with psychotropic 
medications did not receive treatment planning or medication monitoring 
as required.  Additionally, States requirements did not consistently 
incorporate suggested professional practice guidelines, such as requiring 
assessment strategies and documenting information on potential adverse 
effects.  Improved compliance and strengthened State requirements are 
imperative to provide protections for children who are at risk for 
inappropriate treatment and inappropriate prescribing practices.   
To ensure coordinated care for children in foster care receiving psychotropic 
medications, we recommend that ACF:  
Develop a comprehensive strategy to improve States 
compliance with requirements related to treatment planning 
and medication monitoring for psychotropic medication 
ACF must ensure that States coordinate care for children in foster care with 
regard to oversight of psychotropic medication.  To do this, ACF should 
develop a comprehensive strategy that identifies methods for States to 
improve compliance with requirements for treatment planning and 
medication monitoring.  The strategy should guide ACF in strengthening 
compliance and identifying gaps that need to be addressed.  This will 
improve transparency and accountability, and assist States in doing the 
same.  The strategy should include, at a minimum: 
  providing enhanced training and technical assistance, through 
collaboration with professional provider organizations, for States 
related to implementing treatment-planning mechanisms and 
effective medication monitoring (e.g., continued education for 
caseworkers and supervisors). 
Also, ACF may consider: 
  helping States develop effective accountability measures and 
mechanisms for internal quality review;  
  requesting that States report data on treatment planning and 
medication monitoring to the extent they can provide reliable and 
consistent data, and then providing the compiled national data to 
States to use as a benchmark for their progress in meeting 
requirements; and  
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  placing increased weight on treatment planning and medication 
monitoring when determining a States substantial conformity with 
plan requirements, changing the assessment instrument as 
necessary, and following up with enforcement actions when 
appropriate (e.g., mandating program improvement plans, and, 
where appropriate, withholding Federal funds). 
Assist States in strengthening their requirements for oversight 
of psychotropic medication by incorporating professional 
practice guidelines for monitoring children at the individual 
level   
ACF must help States strengthen their requirements by incorporating child-
level protections for children in foster care who are treated with 
psychotropic medications.  To do this, ACF should: 
  strengthen its annual review of States protocols to confirm that 
State requirements incorporate professional practice guidelines 
related to treatment planning and medication monitoring,  
  publish an Information Memorandum regarding specific 
mechanisms for child-level treatment planning and methods to 
achieve effective medication monitoring, and 
  provide enhanced training and technical assistance for States related 
to incorporating professional practice guidelines in State protocols 
through collaboration with professional provider organizations. 
Also, ACF may consider: 
  providing standardized protocols or templates that include 
child-level recommendations and implementation strategies that 
States could adapt to meet local needs. 
 
   
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AGENCY COMMENTS AND OFFICE OF 
INSPECTOR GENERAL RESPONSE 
ACF stated that it concurred with some of our recommendations but not 
others; it did not specify which of the two formal recommendations it 
agreed with, and which it did not.  ACF comments addressed various 
subsections of each of these recommendations.  We ask that ACF clarify in 
its Final Management Decision its concurrence or non-concurrence for each 
formal recommendation. 
OIG recommended that ACF develop a comprehensive strategy to improve 
States compliance with requirements related to treatment planning and 
medication monitoring for psychotropic medication.  In response, ACF 
noted that it already has a well-established approach to program 
implementation that includes a regulated mechanism to identify and correct 
compliance issues.  However, OIG found that one in three children were not 
receiving treatment planning or medication monitoring, as required in their 
respective States, which suggests the current approach to identifying and 
correcting compliance issues is insufficient and more needs to be done.  
ACF did agree to assess opportunities to continue to provide technical 
assistance in this area as well as ensure States are reporting on this 
requirement through Child and Family Services Plans and annual updates.  If 
ACF does conduct such technical assistance and training activities, in 
collaboration with professional organizations, this would fulfill the intent of 
our first recommendation. 
However, we encourage ACF to further consider our additional suggestions 
toward improving States treatment planning and medication monitoring for 
children in foster care.  We note that ACF disagreed with one of these 
suggestions related to reporting data on treatment planning and 
medication monitoring.  ACF views this data reporting to be outside the 
scope of what can be reliably and consistently reported to an administrative 
data set.  ACF notes that, by law, its administrative data set must be both 
reliable and consistent across the reporting population.  OIG agrees that 
data reporting must be reliable and consistent.  We continue to encourage 
ACF to consider innovative approaches to promote State reporting of basic 
information on treatment planning and medication monitoring that will be 
reliable and consistent.  Likewise, ACF could actively assist States to develop 
effective accountability measures and mechanisms for internal quality 
review and consider placing increased weight in its review of treatment 
planning and medication monitoring during its compliance reviews of 
States. 
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With respect to the second recommendation, OIG recommended that ACF 
assist States in strengthening their requirements for oversight of 
psychotropic medication.  In response, ACF stated that it is amenable to 
assessing what additional technical assistance and best practice guidance to 
provide to States regarding the monitoring of psychotropic medication.  
ACF described the mechanisms through which it makes technical assistance 
available to States and noted that, to date, no States have reached out 
around this area of need.  ACF also stated that the Child Welfare 
Information Gateway will include a new article on improving the use of 
psychotropic medication for children in foster care.  This article may 
represent a step toward providing technical assistance for States related to 
incorporating professional practice guidelines in State protocols, one aspect 
of OIGs recommendation.  However, overall, ACFs response did not 
address the substance of OIGs recommendation.  OIG continues to 
recommend that ACF actively engage with States through various actions.  
In addition to providing technical assistance, these actions should include 
strengthening its annual review of States protocols to confirm that State 
requirements incorporate professional practice guidelines related to 
treatment planning and medication monitoring for children at the individual 
level.   
 
The full text of ACFs comments can be found in Appendix F. 
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APPENDIX A: Five Required Elements for 
Monitoring the Appropriate Use of Psychotropic 
Medications 
ACF program instruction directs States to include the following elements in 
their protocols:  
1.  comprehensive and coordinated screening, assessment, and treatment 
planning mechanisms to identify childrens mental health and trauma-
treatment needs, including a psychiatric evaluation, as necessary, to 
identify needs for psychotropic medications; and  
2.  informed and shared decision making and methods for ongoing 
communication between the prescriber, the child, the childs caregivers, 
and other stakeholders (e.g., healthcare providers and child welfare 
worker); 
3.  effective medication monitoring at both the client level and agency 
level; 
4.  availability of mental health expertise and consultation regarding both 
consent and monitoring issues by a board-certified child and adolescent 
psychiatrist; and  
5.  mechanisms for sharing accurate and up-to-date information related to 
psychotropics with clinicians, child welfare staff, and consumers 
(e.g., children and caregivers), including both data sharing mechanisms 
(e.g., integrated information systems) and methods for sharing 
educational materials.43 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX B: Detailed Methodology 
State Selection 
We selected the five States with the highest percentages of children in 
foster care who were treated with psychotropic medications in FY 2013.  Our 
assessment of Medicaid eligibility and claims data determined they were 
Iowa, Maine, New Hampshire, North Dakota, and Virginia.  Appendix E 
contains further details on demographics and Medicaid fee-for-service (FFS) 
expenditures in all States. 
Exhibit B-1: State Demographics Regarding Children in Foster Care 
Treated with Psychotropic Medications and Related Medicaid 
Expenditures 
Number of  Percentage of  Total Medicaid 
Children in  Children in  FFS Expenditures 
Population of 
State  Children in  Foster Care  Foster Care  for Psychotropic 
Foster Care  Treated with  Treated with  Medications for 
Psychotropic  Psychotropic  Children in Foster 
Medications  Medications  Care 
Iowa  13,951  4,981  35.7%  $7,135,849 
Maine  3,527  1,155  32.7%  $1,600,692 
New Hampshire  2,614  944  36.1%  $1,741,581 
North Dakota  2,734  1,021  37.3%  $1,184,934 
Virginia  14,999  5,584  37.2%  $11,959,404 
Source: OIG analysis of MSIS eligibility and prescription drug claims data, 2016. 
Collection of States Data and Requirements 
We sent a letter to the administrator of each selected States foster care 
agency and to each Medicaid director to request a point of contact to 
respond to our requests for information.  From the points of contact, we 
requested: (1) foster care eligibility data representing all children enrolled in 
foster care at any time during the review period; (2) a copy of the States 
selected foster care requirements; (3) any supporting documentation 
accompanying those requirements (such as State policies or required 
forms); (4) State responses to questions that the team developed regarding 
how the State has implemented the requirements and any related guidance 
and technical assistance ACF has provided; and (5) all Medicaid-paid claims 
for psychotropic medications prescribed to children up to 21 years old 
between October 1, 2014, and March 31, 2015, from the States Medicaid 
Management Information Systems (MMIS). 
Sample Selection 
We selected a simple random sample of 125 children from each State for a 
total of 625 children.  A total of 36 children were determined to be ineligible 
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for the sample for one of the following reasons: the child was not in foster 
care during the review period, the child did not receive a Medicaid-paid 
psychotropic drug claim during their foster care eligibility or during our 
review period, the child was not in foster care for at least 30 days of our 
review period, or other limitations prevented review of the case file.  
Therefore, the overall weighted response rate was 92 percent.  In total, 
589 children were analyzed for this review.  See Exhibit B-2 below regarding 
the population and sample sizes for the five States.  
Exhibit B-2: Population of Children in Foster Care Enrolled in 
Medicaid Treated with Psychotropic Medications at Any Time 
Between October 1, 2014, and March 31, 2015 
Ineligible  Final Analyzed 
Population 
State  Sample Size  Sampled  Sampled 
Size 
Children  Children 
Iowa  2,166  125  9  116 
Maine  566  125  5  120 
New Hampshire  244  125  1  124 
North Dakota  280  125  7  118 
Virginia  2,156  125  14  111 
   Total  5,412  625  36  589 
Source: OIG analysis of State foster care case files and Medicaid claims for children in foster care, 2017. 
Case File Documentation and Medicaid Claims Data Review 
We developed criteria based on the States selected requirements related to 
screening, assessment, treatment planning, medication monitoring, and 
psychiatric evaluation.  Using the foster care case file documentation and 
Medicaid claims data, we reviewed each childs treatment with psychotropic 
medications according to the States requirements.  For our study period, 
October 1, 2014 to March 31, 2015, we identified the case file documentation 
and healthcare services received by each child during the childs foster care 
eligibility.  We then determined whether any of those services represented a 
required element.   
For medication monitoring with a prescribing professional, any Medicaid 
claim for an evaluation and management visit with a mental health 
diagnosis was considered to fulfill this requirement.44  Any documentation in 
the case file stating that an appointment occurred was considered to have 
fulfilled this requirement so long as we could determine it was with a 
prescribing professional or the childs psychotropic medication(s) were 
discussed. Caseworker notes, narrative, or emails that summarized changes 
in medication were also considered medication monitoring. 
Because States gave minimal definition of treatment plans, we considered 
any case file documentation that was labeled treatment plan, case plan, 
or care plan to have fulfilled the treatment plan requirement.45  Plans 
developed by prescribing professionals and/or by foster care caseworkers 
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were considered to have fulfilled this requirement.  Documents developed 
by schools were not considered to have fulfilled treatment plan 
requirements.  
Analysis of Results 
We reviewed foster care case file documentation and Medicaid claims data 
for each sampled child.  If either foster care case file documentation or the 
Medicaid claims demonstrated receipt of a particular required element by a 
sampled child, that element was counted as received.  If neither the foster 
care case file documentation nor the Medicaid claims demonstrated receipt 
of a particular required element by a sampled child, that element was 
counted as not received. 
We followed up with foster care program officials in the five States 
regarding every child for whom we determined at least one required 
element was missing.  State officials either provided additional 
documentation showing that the child did receive the element(s) in 
question, or declined to submit additional documentation.  If additional 
documentation showed that the element(s) were received, we counted 
those element(s) as received.      
Comparing States Protocols to Professional Practice Guidelines 
We selected professional practice guidelines from AACAP guidance 
documents for comparison with the five States requirements for oversight 
regarding psychotropic medication.  Specifically, we selected professional 
practice guidelines related to (1) screening, assessment, psychiatric 
evaluations, and treatment planning; and (2) medication monitoring.  We 
then assessed the extent to which State requirements incorporated these 
professional practice guidelines.  For example, regarding treatment planning 
and medication monitoring, we assessed whether States protocols required 
inclusion of elements such as assessment for risk of nonadherence, 
information on adverse effects, assessment strategies, starting dose and 
timing of dose changes in the medication list. 
   
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APPENDIX C: State-by-State Compliance With 
Psychotropic Medication Requirements 
This appendix contains five State-by-State summaries of compliance for 
selected foster care requirements regarding psychotropic medications. 
We reviewed foster care case file documentation and Medicaid claims data 
representing healthcare services and mental health services received by the 
sampled children during the review period.  We determined whether any of 
those documents or claims represented evidence that a State-required 
criteria of treatment planning and medication monitoring was provided. 
Each State establishes its own foster care requirements (i.e., protocols) for 
oversight of psychotropic medications.  Each States requirements are 
unique; therefore, the criteria that we used to assess consistency with the 
requirements in each selected State is unique to that State.  Additionally, we 
included a determination for each State of whether each sampled child 
received medication monitoring by a prescribing professional. 
   
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APPENDIX D: Statistical Estimates and 
Confidence Intervals 
Exhibit D-1 contains: 
  sample sizes (the number of sample children where we obtained 
useable outcomes);  
  point estimates (made using the outcomes determined on the basis 
of the number of sample children reviewed, or the sample size); and 
  95-percent confidence intervals (estimates of the error in the point 
estimates; 95 percent is a strong level of confidence). 
Exhibit D-1: Point Estimates, Sample Sizes, and Confidence Intervals 
Sample  Point  95-Percent 
Estimate Description 
Size  Estimate  Confidence Interval 
Five States combined statistics 
Percent of children in foster care treated with 
psychotropic medications that did not receive  589  33.9%  29.8%38.3% 
treatment planning or medication monitoring 
Percent of children who did not receive a  589  19.5%  15.9%23.6% 
treatment plan 
Percent of children who did not receive  589  22.9%  19.2%27.0% 
medication monitoring 
Percent of children who did not receive  589  8.4%  6.0%11.7% 
treatment planning and medication monitoring 
In States with specific treatment plan 
requirements, percent of children who received  308  52.0%  44.4%59.6% 
a treatment plan that did not receive all State-
required treatment planning criteria  
Iowas specific requirements 
Percent of children who did not receive a  116  30.2%  22.7%38.9% 
treatment plan 
Percent of children who did not have evidence 
that the caseworker documented whether the  116  40.5%  32.2%49.5% 
child was receiving necessary medical care in 
their case files 
Percent of children who did not have evidence 
that the caseworker documented whether the  116  32.8%  25.0%41.6% 
program plan was providing appropriate and 
sufficient services in their case files 
continued on next page 
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OEI-07-15-00380   
Exhibit D-1: Point Estimates, Sample Sizes, and Confidence Intervals 
(continued) 
95-Percent 
Sample  Point 
Estimate Description  Confidence 
Size  Estimate 
Interval 
Iowas specific requirements 
Percent of children who did not have evidence 
that the caseworker inquired of the foster family 
116  82.8%  75.0%88.5% 
the effectiveness of the medications in their case 
files 
Percent of children who did not have evidence 
that the caseworker documented the reason the  116  83.6%  76.0%89.2% 
medication was prescribed 
Percent of children who did not have evidence 
that the caseworker documented whether the  116  72.4%  63.8%79.6% 
medication was meeting the childs needs 
Percent of children who did not receive 
medication monitoring by a prescribing  116  48.3%  39.5%57.1% 
professional 
Maines specific requirements 
Percent of children who did not receive a 
120  27.5%  21.0%35.1% 
treatment plan 
Percent of children who did not have their 
medication plan reviewed quarterly by their  120  25.8%  19.5%33.4% 
treatment provider 
Percent of children prescribed antipsychotic 
medication who had no evidence that the 
caseworker participated in medical or psychiatric 
appointments where medications were initially  39  59.0%  44.9%71.7% 
discussed and a determination is made to 
proceed or not, and then at least every 3 months 
following* 
Percent of children who did not receive 
medication monitoring by a prescribing  120  10.8%  6.8%16.8% 
professional 
New Hampshires specific requirements 
Percent of children who did not receive a 
124  23.4%  18.6%29.0% 
treatment plan 
Percent of children who did not receive all 
95  75.8%  69.2%81.3% 
State-required treatment planning criteria 
Percent of children who did not have an 
95  6.3%  3.6%10.8% 
assessment summary in their treatment plan 
Percent of children who did not have a diagnosis 
95  37.9%  31.3%44.9% 
in their treatment plan 
Percent of children who did not have goals or 
95  3.2%  1.4%6.8% 
desired outcomes in their treatment plan 
continued on next page 
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OEI-07-15-00380   
Exhibit D-1: Point Estimates, Sample Sizes, and Confidence Intervals 
(continued) 
95-Percent 
Sample  Point 
Estimate Description  Confidence 
Size  Estimate 
Interval 
New Hampshires specific requirements 
Percent of children who did not have incremental 
95  7.4%  4.4%12.0% 
steps to goal achievement in their treatment plan 
Percent of children who did not have 
95  6.3%  3.6%10.8% 
interventions in their treatment plan 
Percent of children who did not have the 
evaluators name/signature/date in their  95  56.8%  49.8%63.7% 
treatment plan 
Percent of children who did not receive 
medication monitoring by a prescribing  124  21.8%  17.1%27.3% 
professional. 
North Dakotas specific requirements 
Percent of children who did not receive a 
118  6.8%  4.1%11.1% 
treatment plan 
Percent of children who did not receive all 
110  38.2%  31.7%45.2% 
State-required treatment planning criteria 
Percent of children who did not receive goals or 
110  1.8%  0.6%5.0% 
objectives in their treatment plan 
Percent of children who did not receive action 
steps for meeting specified goals in their  110  8.2%  5.1%12.9% 
treatment plan 
Percent of children who did not receive 
information about prescribed medications in their  110  10.9%  7.3%16.1% 
treatment plan 
Percent of children who did not receive 
documentation of treatment progress in their  110  10.9%  7.3%16.1% 
treatment plan 
Percent of children who did not receive a 
treatment plan developed by a multidisciplinary  110  27.3%  21.5%33.9% 
team 
Percent of children who did not receive 
medication monitoring by a prescribing  118  1.7%  0.6%4.7% 
professional 
continued on next page 
 
 
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OEI-07-15-00380   
Exhibit D-1: Point Estimates, Sample Sizes, and Confidence Intervals 
(continued) 
95-Percent 
Sample  Point 
Estimate Description  Confidence 
Size  Estimate 
Interval 
Virginias specific requirements 
Percent of children who did not receive a 
111  7.2%  3.7%13.6% 
treatment plan 
Percent of children who did not receive all 
103  51.5%  42.1%60.7% 
State-required treatment planning criteria 
Percent of children who did not receive strengths 
103  11.7%  6.8%19.2% 
or needs of the child in their treatment plan 
Percent of children who did not receive a health 
status, including any allergies or health  103  25.2%  17.9%34.3% 
conditions in their treatment plan 
Percent of children who did not receive the 
names and addresses of child's medical and  103  41.7%  32.8%51.2% 
mental health providers in their treatment plan 
Percent of children who did not receive a list of 
the child's medications including psychotropic  103  29.1%  21.3%-38.4% 
drugs in their treatment plan 
Percent of children who did not receive 
medication monitoring by a prescribing  111  2.7%  0.9%7.8% 
professional 
Source: OIG analysis of State foster care case files and Medicaid claims for children in foster care, 2017. 
*We are unable to reliably project the frequency estimates for this item because of the small number of 
sample occurrences. 
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APPENDIX E: State Demographics Regarding 
Children in Foster Care Treated With Psychotropic 
Medications 
For each State, Exhibit E-1 represents the population of children in foster care,46 the 
number and percentage of children in foster care who were treated with psychotropic 
medications,47 and total Medicaid FFS expenditures for psychotropic medications for 
children in foster care in FY 2013.  These figures are based on MSIS eligibility and 
prescription drug claims data.  For States that cover medications through managed care, 
the exhibit does not reflect the amounts the managed care organizations (MCOs) paid for 
psychotropic medications for children in foster care.48  States such as Arizona and Hawaii 
do not have FFS expenditures for these drugs because they were all covered through 
managed care.    
Exhibit E-1: State Demographics Regarding Children in Foster Care Treated with 
Psychotropic Medications and Related Medicaid Expenditures* 
Total Medicaid FFS 
Number of Children  Percentage of 
Expenditures for 
Population of  in Foster Care  Children in Foster 
Psychotropic 
State  Children in  Treated with  Care Treated with 
Medications for 
Foster Care  Psychotropic  Psychotropic 
Children in  
Medications  Medications 
Foster Care 
Alabama  11,709  2,897  24.7%  $4,851,356 
Alaska  4,175  672  16.1%  $1,204,665 
Arizona  24,731  4,257  17.2%  $0 
Arkansas  9,857  2,470  25.1%  $3,415,546 
California  147,806  20,064  13.6%  $44,581,405 
Colorado  21,155  4,871  23.0%  $9,116,770 
Connecticut  5,674  1,532  27.0%  $3,345,982 
Delaware  2,254  719  31.9%  $1,465,037 
District of Columbia  4,671  613  13.1%  $1,026,092 
Florida  65,198  11,228  17.2%  $16,510,753 
Georgia  33,033  9,408  28.5%  $12,021,956 
Hawaii  5,912  571  9.7%  $0 
Idaho**  5,024  1,102  21.9%  $1,515,443 
Illinois  53,898  10,109  18.8%  $10,733,426 
Indiana  23,912  6,844  28.6%  $14,371,841 
Iowa  13,951  4,981  35.7%  $7,135,849 
continued on next page 
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OEI-07-15-00380   
Exhibit E-1: State Demographics Regarding Children in Foster Care Treated with 
Psychotropic Medications and Related Medicaid Expenditures* (continued) 
 
  Number of Children  Percentage of  Total Medicaid FFS 
Population of  in Foster Care  Children in Foster  Expenditures for 
  State  Children in  Treated with  Care Treated with  Psychotropic 
Foster Care  Psychotropic  Psychotropic  Medications for 
 
Medications  Medications  Foster Children 
 
Kansas  18,319  4,292  23.4%  $3,230,278 
Kentucky  18,257  5,657  31.0%  $494,659 
Louisiana  13,407  4,017  30.0%  $5,584,262 
Maine  3,527  1,155  32.7%  $1,600,692 
Maryland  16,030  4,450  27.8%  $9,441,087 
Michigan  18,884  4,190  22.2%  $10,193,641 
Minnesota  12,446  3,597  28.9%  $4,094,907 
Mississippi  7,294  1,891  25.9%  $3,187,730 
Missouri   34,817  9,847  28.3%  $26,130,684 
Montana  4,861  1,249  25.7%  $2,336,576 
Nebraska  13,606  3,882  28.5%  $7,118,577 
Nevada  12,100  1,829  15.1%  $3,431,784 
New Hampshire  2,614  944  36.1%  $1,741,581 
New Jersey  27,856  3,871  13.9%  $387,902 
New Mexico  6,450  1,189  18.4%  $53,857 
New York  54,099  9,068  16.8%  $9,671,915 
North Carolina  23,121  7,004  30.3%  $16,393,851 
North Dakota  2,734  1,021  37.3%  $1,184,934 
Ohio  35,029  9,196  26.3%  $23,575,138 
Oklahoma  11,120  2,267  20.4%  $3,150,116 
Oregon  23,331  4,468  19.2%  $4,812,840 
Pennsylvania  54,349  11,387  21.0%  $1,377,212 
Rhode Island**  4,875  979  20.1%  $178,257 
South Carolina  14,087  3,630  25.8%  $3,794,339 
South Dakota  4,709  1,304  27.7%  $2,480,728 
Tennessee  24,455  6,418  26.2%  $11,017,546 
Texas  88,609  23,991  27.1%  $35,762,195 
Utah  10,862  3,212  29.6%  $7,954,880 
Vermont  2,950  933  31.6%  $1,915,196 
continued on next page 
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Exhibit E-1: State Demographics Regarding Children in Foster Care Treated with 
Psychotropic Medications and Related Medicaid Expenditures* (continued) 
 
Number of Children  Percentage of  Total Medicaid FFS 
  Population of  in Foster Care  Children in Foster  Expenditures for 
State  Children in  Treated with  Care Treated with  Psychotropic 
  Foster Care  Psychotropic  Psychotropic  Medications for 
Medications  Medications  Foster Children 
 
Virginia  14,999  5,584  37.2%  $11,959,404 
 
Washington  27,538  5,035  18.3%  $7,008,379 
 
West Virginia  10,950  3,138  28.7%  $4,163,156 
Wisconsin  18,290  4,557  24.9%  $7,289,062 
Wyoming  3,805  875  23.0%  $1,542,474 
     Total:  1,073,340  238,465  22.2%  $365,555,960 
Source: OIG analysis of MSIS eligibility and prescription drug claims data, 2016. 
*Massachusetts is not included in this exhibit because its MSIS eligibility files for FY 2013 were incomplete.  The 
Massachusetts eligibility data included only approximately 1,500 unique identifiers for children in foster care.  The 
population of children in foster care in Massachusetts is known to be significantly higher than 1,500. 
**Indicates that complete FY 2013 data was not available in MSIS at the time of data collection; therefore, FY 2012 data was 
used. 
 
 
 
 
 
 
 
 
 
   
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APPENDIX F: Agency Comments 
 
 
 
 
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ACKNOWLEDGMENTS 
Jamila Murga served as the team leader for this study, and Dana Squires 
and Abbi Warmker served as lead analysts.  Others in the Office of 
Evaluation and Inspections who conducted the study include Cody Johnson, 
Katie Fry, Lesta Newberry, Anna Pechenina, and Andrea Staples.  Office of 
Evaluation and Inspections central office staff who provided support include 
Althea Hosein and Seta Hovagimian.  
This report was prepared under the direction of Brian T. Whitley, Regional 
Inspector General for Evaluation and Inspections in the Kansas City regional 
office, and Jennifer E. King, Deputy Regional Inspector General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
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ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public 
Law 95-452, as amended, is to protect the integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and 
welfare of beneficiaries served by those programs.  This statutory mission is 
carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
work done by others.  Audits examine the performance of HHS programs 
and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency 
throughout HHS. 
Office of Evaluation  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports 
also present practical recommendations for improving program operations.   
Office of  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  With investigators working in all 50 States 
and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and 
local law enforcement authorities.  The investigative efforts of OI often lead 
to criminal convictions, administrative sanctions, and/or civil monetary 
penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
OCIG represents OIG in all civil and administrative fraud and abuse cases 
involving HHS programs, including False Claims Act, program exclusion, and 
civil monetary penalty cases.  In connection with these cases, OCIG also 
negotiates and monitors corporate integrity agreements.  OCIG renders 
advisory opinions, issues compliance program guidance, publishes fraud 
alerts, and provides other guidance to the healthcare industry concerning 
the anti-kickback statute and other OIG enforcement authorities. 
36 
   
 
ENDNOTES 
1 ACF, Managing Psychotropic Medications for Children and Youth in Foster Care, 2012.  Accessed at 
http://www.acf.hhs.gov/blog/2012/08/managing-psychotropic-medications-for-children-and-youth-in-foster-care on April 1, 
2016.   
2 Centers for Disease Control, Psychotropic Medication Use Among Adolescents: United States, 2005-2010, 2013.  Accessed at 
https://www.cdc.gov/nchs/data/databriefs/db135.pdf on July 5, 2017. 
3 National Institute of Mental Health, Mental Health Medications, 2016.  Accessed at 
http://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml on March 31, 2016. 
4 ACF, Information Memorandum ACYF-CB-IM-12-03, 2012.  Accessed at https://www.acf.hhs.gov/sites/default/files/cb/im1203.pdf 
on August 24, 2017. 
5 National Institute of Mental Health, Mental Health Medications, 2016.  Accessed at 
http://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml on March 31, 2016. 
6 ACF, Managing Psychotropic Medications for Children and Youth in Foster Care, 2012.  Accessed at 
http://www.acf.hhs.gov/blog/2012/08/managing-psychotropic-medications-for-children-and-youth-in-foster-care on April 1, 2016. 
7 Ibid. 
8 American Academy of Pediatrics (AAP), Health Care Issues for Children and Adolescents in Foster Care and Kinship Care, 
Pediatrics, Vol. 136, No. 4, 2015.  Accessed at http://pediatrics.aappublications.org/content/136/4/e1142 on October 26, 2017. 
9 Michael Naylor, et al, Psychotropic Medication Management for Youth in State Care: Consent, Oversight, and Policy 
Considerations, Child Welfare, Vol. 86, No. 5, 2007, pp. 175-192.   
10 AAP, Fostering Health: Health Care for Children and Adolescents in Foster Care 2nd Edition, 2005.  Accessed at 
https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Fostering-Health.aspx 
on September 15, 2017. 
11 Ibid. 
12 ACF, Information Memorandum ACYF-CB-IM-12-03, 2012.  Accessed at https://www.acf.hhs.gov/sites/default/files/cb/im1203.pdf 
on August 24, 2017. 
13 Michael Naylor, et al, Psychotropic Medication Management for Youth in State Care: Consent, Oversight, and Policy 
Considerations, Child Welfare Vol. 86, No. 5, 2007, pp. 175-192.   
14 AACAP, Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents, J. Am. Acad. Child Adolesc. 
Psychiatry, Vol. 48, No. 9, 2009, pp. 961-973.  Accessed at http://www.jaacap.com/article/S0890-8567(09)60156-8/pdf on March 9, 
2016. 
15 Ibid. 
16 OIG, Second-Generation Antipsychotic Drug Use Among Medicaid-Enrolled Children: Quality-of-Care Concerns (OEI-07-12-00320), 
March 2015.  Accessed at https://oig.hhs.gov/oei/reports/oei-07-12-00320.pdf on October 31, 2017. 
17 In all States, nearly all children in foster care are eligible for Medicaid services.  According to section 1902(a)(10)(A)(i)(I) of the 
Social Security Act (the Act), children in foster care who are eligible for assistance payments through Title IV-E of the Act are 
mandatorily eligible for Medicaid.  Children in foster care who are not eligible under Title IV-E usually qualify for Medicaid through 
other eligibility categories established by each State.  Because most children in foster care are eligible for Medicaid, Medicaid pays 
for healthcare services for almost all children in foster care. 
18 These expenditures only reflect fee-for-service (FFS) Medicaid payments reflected in Medicaid Statistical Information System 
(MSIS) data for fiscal year (FY) 2013.  This was the most recent complete data available at the time of State selection. 
19 The Act,  422(b)(15)(A)(1)(v). 
20 Each State is required to submit its health services oversight and coordination plan as part of its CFSP to ACF every 5 years 
(45 CFR  1357.15).  The most recent plans available during the period of our review cover FYs 2015 through 2019. 
21 ACF, Program Instruction ACYF-CB-PI-12-05, 2012.  Accessed at http://www.acf.hhs.gov/sites/default/files/cb/pi1205.pdf on  
July 30, 2015. 
22 Ibid. 
23 Ibid. 
24 Michael Naylor, et al, Psychotropic Medication Management for Youth in State Care: Consent, Oversight, and Policy 
Considerations, Child Welfare Vol. 86, No. 5, 2007, pp. 175-192.   
25 Ibid. 
 
37 
   
 
26 The compliance reviews assess State compliance with Federal requirements and the outcomes of the child welfare system.  
These reviews do not specifically determine whether children in foster care received treatment consistent with States 
requirements.  ACF, Child and Family Service Reviews Fact Sheet. Accessed at https://www.acf.hhs.gov/sites/ 
default/files/cb/cfsr_general_factsheet.pdf on September 15, 2017. 
27 Substantial conformity is determined by the State agencys ability to meet various standards and criteria, including its capacity 
to deliver services leading to improved outcomes for children and families.  45 CFR  1355.34. 
28 45 CFR  1355.34. 
29 45 CFR  1355.35(a). 
30 If the State fails to successfully complete a program improvement plan, ACF has the authority to withhold a certain amount of 
Federal funding for the year under review and each subsequent year until the State either successfully completes a program 
improvement plan or is found to be operating in substantial conformity.  45 CFR  1355.33  1355.36.  
31 ACF, CFSR Round 3 Onsite Review Instrument and Instructions, 2016.  Accessed at 
https://www.acf.hhs.gov/sites/default/files/cb/cfsr_r3_osri.pdf on November 14, 2017. 
32 ACF, Information Memorandum ACYF-CB-IM-12-03, 2012.  Accessed at https://www.acf.hhs.gov/sites/default/files/cb/im1203.pdf 
on August 24, 2017. 
33 The recommendations described in this evaluation are not an exhaustive list of all professional recommendations.  We have 
selected recommendations that are relevant to the scope of this study. 
34 AACAP, A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents, 2012.  
Accessed at http://www.aacap.org/app_themes/aacap/docs/press/guide_for_community_child_serving_agencies_on_ 
psychotropic_medications_for_children_and_adolescents_2012.pdf on October 30, 2017. 
35 Ibid. 
36 AACAP, Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents, J. Am. Acad. Child Adolesc. 
Psychiatry, Vol. 48, No. 9, 2009, pp. 961-973. 
37 Ibid. 
38 We used eligibility and prescription drug files from the MSIS to calculate the total children enrolled in foster care in each State, 
and the total children who had at least one Medicaid-paid claim for a psychotropic medication in FY 2013.  We used FY 2012 data 
for Idaho and Rhode Island because complete FY 2013 files were not available. 
39 ACF, Program Instruction (ACYF-CB-PI-12-05), April 11, 2012, p. 13.  Accessed at 
http://www.acf.hhs.gov/sites/default/files/cb/pi1205.pdf on July 30, 2015. 
40 States are not mandated to establish requirements consistent with AACAP guidance.  Therefore, our analysis does not conclude 
that States are in error, or have failed to meet requirements, where their requirements are not consistent with AACAP guidance. 
41 Children may receive healthcare from sources such as schools, free health clinics, or a parents private insurance.  Additionally, 
some of the Medicaid claims data provided for our review included Medicaid Managed Care capitated payments, which did not 
consistently provide detail regarding the services received by those children. 
42 GAO, HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions (GAO-12-270T), 2011.  Accessed at 
http://www.gao.gov/new.items/d12270t.pdf on October 31, 2017.  
43 ACF, Program Instruction (ACYF-CB-PI-12-05), April 11, 2012, p. 13.  Accessed at 
http://www.acf.hhs.gov/sites/default/files/cb/pi1205.pdf on July 30, 2015. 
44 We define evaluation and management services as office visits, hospital visits, and consultations provided by qualified 
healthcare professionals authorized to perform such services within the scope of their practice. 
45 States are required to develop a case plan for each child in foster care.  The case plan must include information such as the 
childs health records, medical problems, and medications.  The Act,  422(a)(8)(A)(ii),  475(5), and  475(1)(C). 
46 The figures for the population of children in foster care in each State represent the total unique children that were eligible for 
Medicaid because of their foster care status at any point during FY 2013. 
47 We considered any child who had at least one Medicaid-paid claim for a psychotropic medication while in foster care to have 
been treated with psychotropic medications.   
48 Medicaid managed care is a type of healthcare delivery system that provides Medicaid health benefits and services to enrollees 
through contracted arrangements between State Medicaid agencies and MCOs.  MCOs receive a set payment per member per 
month from the State Medicaid agency for these services.  FFS is a type of healthcare delivery system in which healthcare 
providers are paid for each service provided to Medicaid enrollees. 
38