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- California Health and Human Services Agency
- Department of Health Care Services
- California Department of Public Health
November 25, 2019
Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle:
Thank you for the opportunity to respond to your draft report entitled, Childhood Lead Levels: Millions of Children in Medi-Cal Are Not Receiving Required Testing for Lead Poisoning. The California Health and Human Services Agency and its departments are committed to children’s health, including providing required lead tests.
Enclosed are the departments’ responses to your draft report.
We appreciate the work performed by your office. If you have any questions, please contact Sarah Aguirre, Audit Coordinator, at (916) 538-7112.
Mark A. Ghaly, MD, MPH
Finding 1: Department of Health Care Services’ (DHCS) Failure to Ensure Timely Lead Testing of Children in Medi-Cal Places Them at Risk for Permanent Health Problems
Because of the severe and potentially permanent damage lead poisoning can cause in children, DHCS should ensure that all children in Medi-Cal receive lead tests by finalizing, by December 2020, its performance standard for lead testing of one- and two-year-olds. DHCS should use its existing data to assess the progress of managed care plans in meeting that performance standard and impose sanctions or provide incentive payments as appropriate to improve performance.
Current Status: Will Implement
Estimated Implementation Date: December 2020
DHCS will release the first version of its Preventive Services Utilization Report (Report) by December 2020. DHCS will seek public comment on measures that should be included in the Report. However, it has already been determined that the Blood Lead Screening measure will be included.
DHCS will utilize Medi-Cal managed care plan (MCP) administrative data to calculate the rate of Blood Lead Screening for each MCP per National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set, technical specifications. The use of these nationally recognized technical specifications will allow DHCS to compare California’s Medi-Cal MCP rates to the performance of other Medicaid plans nationally. Furthermore, it will assist DHCS with establishing a performance standard and utilize them to drive quality improvement. MCPs that do not meet the established benchmark will be placed under a Corrective Action Plan (CAP). Should they not come into compliance with the CAP, DHCS will impose sanctions and/or penalties.
Of note, DHCS has already implemented a Value Based Payment (VBP) Program which incentivizes providers to conduct various activities relating to care for Medi-Cal beneficiaries. Providers receive a payment for completion of a measure relating to said activities. Blood Lead Screening is one of the measures.
To ensure that families know about the lead testing services their children are entitled to receive, DHCS should send a reminder to get a lead test for children who missed required tests. It should send this reminder in the required annual notification it is developing to send to families of children who have not used preventive services over the course of a year.
Current Status: Will Implement
Estimated Implementation Date: March 2020
DHCS is working on a targeted outreach campaign to inform beneficiaries about the availability of American Academy of Pediatrics (AAP)/Bright Futures services under Medi-Cal and how to access them. Part of this outreach will include highlighting the availability of lead testing services that children in Medi-Cal are entitled to receive.
DHCS is targeting March of 2020 to mail its first outreach notice to all beneficiaries. This notice will be sent to all beneficiaries up to the age of 21. It will be followed by a more targeted outreach notice which will be mailed to beneficiaries who have not accessed preventive services during the prior twelve months. Medi-Cal MCPs will also conduct a call campaign to follow-up with children and their families who have not used preventive services over the course of a year, including lead testing services for children younger than six years old.
To increase California’s lead testing rates and improve lead test reporting, DHCS should, no later than June 2020, incorporate into its contracts with managed care plans a requirement for the plans to identify each month all children with no record of receiving a required test and remind the responsible health care providers of the requirement to test the children. DHCS should also develop and implement a procedure to hold plans accountable for meeting this requirement.
Current Status: Will Implement
Estimated Implementation Date: June 2020
By June of 2020, DHCS will submit a contract amendment to the Centers for Medicare and Medicaid Services (CMS) for approval that will include a requirement for MCPs to identify each quarter all children with no record of receiving a required lead test and remind the responsible health care provider of the requirement to test the children. Given CMS has a contract review and approval process, DHCS will release an All Plan Letter establishing the MCP policy pending contract approval from CMS. DHCS will review heath plan policies and procedures to ensure MCP compliance with the policy. DHCS will also review the MCP process related to this contractual requirement during its annual medical audit, and impose a CAP if non-compliance is identified. Since the DHCS annual medical audit is a one year retrospective audit, the DHCS will begin auditing this policy in July 2021.
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE
RESPONSE FROM THE DEPARTMENT OF
HEALTH CARE SERVICES
To provide clarity and perspective, we are commenting on DHCS’ response to our audit. The numbers below correspond to the numbers we have placed in the margin of DHCS’ response.
DHCS’ plan does not address our recommendation to finalize its performance standard for lead testing of both one‑ and two‑year‑olds. The technical specifications it refers to measure only the percentage of two‑year‑olds who had at least one test by their second birthday. As we state in the audit results, state regulations, with few exceptions, require health care providers to administer tests for elevated lead levels for both one‑ and two‑year‑old children. Thus, the plan DHCS describes will not be effective in determining whether children have received the tests required by the regulations.
DHCS’ statement that it has already implemented a value‑based payment program for lead testing contradicts information it provided during the audit. Specifically, as we state in the audit results, as of September 2019 DHCS had not yet determined when it would begin making payments for lead testing. We look forward to DHCS informing us when it begins making payments for reported lead tests under this program.
Although DHCS’ plan for notifying health care providers would be an improvement from its current practice, we believe that it should include in its contracts the requirement to identify these children and remind the responsible health care providers each month, rather than each quarter. As we describe in the audit results, state regulations generally require children in Medi‑Cal to be tested at ages one and two. Further, as we explain in the Introduction, children at this age are especially vulnerable to lead exposure. Because delays in testing may result in additional exposure for children who have lead poisoning, and due to the relatively limited age range during which these tests should be conducted, we believe that providing this information on a monthly basis is in the best interests of a child’s health.
November 25, 2019
Ms. Elaine M. Howle
1621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle:
The California Department of Public Health (CDPH) has reviewed the California State Auditor’s draft report titled, “Childhood Lead Levels: Millions of Children in Medi-Cal Are Not Receiving Required Testing for Lead Poisoning.” The Childhood Lead Poisoning Prevention Program serves a vital role in protecting the health of children in California. We appreciate the opportunity to respond to the report and offer responses to the specific findings as we strive to protect California’s children.
Finding 1: CDPH has not sufficiently identified areas of the state that are high risk for childhood lead exposure, nor has it met its obligations to reduce the lead risks in those areas.
The Childhood Lead Poisoning Prevention Branch (CLPPB) agrees that a geographic analysis to identify areas of high risk is important and has completed such an analysis to identify areas of the state that are at high risk for childhood lead exposure. Information that is publically reportable (in accordance with Data De-identification Guidelines, to avoid disclosing protected health information), has been included in the draft 2019 biennial report, “Update on California’s Progress in Preventing and Managing Childhood Lead Exposure” which will soon be released.
CDPH has implemented a program of medical follow up and environmental abatement and follow up that has reduced the incidence of excessive childhood lead exposures in California.
CDPH has updated statutes and regulations so local enforcement agencies address lead hazards, including abatement, which prevent exposure to children. CDPH also has a program that trains and certifies individuals to identify and abate lead-based paint and lead hazards, resulting in thousands of abatements annually. CDPH does target areas of high risk for childhood lead exposure, and will continue to refine and improve targeting as more data is received and analyzed regarding high-risk areas.
Recommendation to Public Health
To identify the highest priority areas for using resources to alleviate lead exposure among children, CDPH should immediately complete and publicize an analysis of high-risk areas throughout the state.
CDPH agrees. CLPPB has drafted the 2019 biennial report, “Update on California’s Progress in Preventing and Managing Childhood Lead Exposure,” and the report is currently going through the approval process and will be released soon.This report includes information identifying high-risk areas that is reportable in accordance with the DDGs.
Finding 2: CDPH, nor the local prevention programs, measure the effectiveness of their outreach activities in reducing the number of children with lead poisoning, and CDPH does not require local prevention programs to perform such analyses.
CDPH and many local prevention programs do measure the effectiveness of individual outreach activities with respect to increasing knowledge and changing behavior. CDPH and many local prevention programs also analyze trends in website traffic following outreach campaigns to help determine campaign reach. CDPH will work with local partners to develop a mechanism to assess their impact on reducing the number of children with lead poisoning.
Recommendation to Public Health
To ensure local prevention programs' outreach results in a reduced number of lead-poisoned children, CDPH should, by December 2020, require local prevention programs to demonstrate the effectiveness of their outreach in doing so. If the local prevention programs are unable to demonstrate the effectiveness of their outreach in reducing the number of lead-poisoned children, CDPH should analyze the cost effectiveness of other approaches in reducing the number of lead-poisoned children, including proactive abatement, and require the local prevention programs to replace or augment outreach to the extent resources allow.
CDPH agrees with the importance of evaluating outreach activities for effectiveness and will work with local partners to develop a process for evaluation. CDPH has updated the local prevention program Scope of Work template to strengthen evaluation requirements for outreach activities. They will be reporting on evaluation related to the effectiveness of outreach activities by measuring changes in knowledge and behavior (e.g., increased hand washing, increased screening). CDPH will also measure trends in childhood lead poisoning.
Finding 3: CDPH can better ensure existing funding is used effectively and apply for additional funding to perform abatement activities in the highest risk areas.
CDPH agrees that existing funding could be used to better ensure that property owners abate lead hazards in the highest risk areas. However, CDPH does not agree that CDPH should apply for currently available funding to perform abatement. CDPH believes local jurisdictions are better suited to address local needs, as they have the authority to enforce local laws. Health and Safety Cose 105255 and 105256 provides permissive authority to enforce clean up of lead hazards, but that is enforced at the local level. CDPH continues to support local jurisdictions in applying for lead abatement grants and utilizing other funding, such as through legal settlements. We will explore additional opportunities to promote local application to abatement funding sources.
Recommendation to Public Health
To offset the cost of mitigating lead exposure in the highest-risk areas of the state, CDPH should seek out and apply for additional lead prevention funding from the CDC, the Department of Housing and Urban Development, and CMS as funding opportunities become available. To the extent necessary, CDPH should enter a memorandum of understanding with the Department of Health Care Services to apply for and obtain this funding.
CDPH does not agree. CDPH believes it is better for local jurisdictions to continue to apply for and receive these limited federal funds so the abatement work can be done at a local level with well-trained teams. It would be impractical to have an abatement team travel about the state or for CDPH to contract with multiple private business about the state, especially when there is significant effort to train teams about grant requirements. CDPH believes resources are better spent through enforcement of lead hazard laws, and education and outreach (see response to finding 2 about cost effective outreach to many people). Locals are still required to enforce State Housing Law, which includes lead, to require property owners to address lead hazards.
The auditor also suggested federal CMS funding opportunities, but CDPH notes that only three states have used the CMS funding for lead abatement, and one of those, Ohio, had not actually performed any abatements after two years, as they were still working through the onerous approval process. The most successful of those three, Michigan, had only completed 31 abatements in one year.
Finding 4: CDPH collects lead inspection and abatement information but does not make this information available to the public.
CDPH does make some inspection and abatement information public when requested by the public. However, CDPH does not publicly post information about all lead hazard evaluations, since doing so would reveal confidential medical information, specifically the addresses of lead-poisoned children.
CDPH has determined that it cannot post these addresses with redacted information, since such publicly posted information combined with information already produced in Public Record Act requests would also reveal the confidential homes of lead-poisoned children.
CDPH also notes that many abatements in California are not permanent, but short-term and require ongoing monitoring and maintenance. A record that a home has been abated in the past does not necessarily mean that there is no lead on the property, and that it is possible that lead hazards could exist on the property in the future.
The auditor suggested other states that post addresses that have been inspected for lead, but CDPH has determined that these other states’ processes and data are not comparable to that of CDPH. Specifically, lead hazard evaluations, including those done for lead-poisoned children, are not posted by these registries. Massachusetts does post all lead hazard evaluations. However, their forms are such that they can mask which are done for lead-poisoned children, but CDPH cannot.
Recommendation to Public Health
To provide sufficient information to homebuyers and renters, the Legislature should require CDPH, by December 2021, to provide an online lead information registry that allows the public to determine the lead inspection and abatement status for properties.
CDPH partially agrees. Rather than create a new mandated and funded program, CDPH will provide enhanced guidance to the public about how to request information about lead hazard evaluations and abatements for the specific addresses in which they are interested. The auditor noted that renters and buyers are already legally provided lead inspection and abatement information about homes they plan to buy or rent, and that California is unique in that properties built before 1978 are legally presumed to have lead-based paint unless a certified inspector shows otherwise. If, as the auditor suggests, the renter or buyer would like to compare their options prior to receiving a lease or contract, the individual may contact CDPH to inquire about the specific properties.
Finding 5: CDPH delegates responsibility for addressing lead risks to local prevention programs, the county or city agencies, but it does not sufficiently assess their performance.
CDPH assesses local prevention program performance through site visits and biannual progress reports, and provides written feedback and recommendations in response to both. In addition to written feedback on progress report submissions, local prevention programs may also receive requests for clarification and additional information via telephone or email. These requests are not reflected in the formal feedback reports from CDPH. CDPH is modifying its protocol for progress report feedback and will incorporate any “offline” follow-up into the formal progress report feedback document moving forward.
Recommendation to Public Health
To better hold local prevention programs accountable for performing required activities, CDPH should, by June 2020, conduct direct oversight through site visits for each of the 50 programs, and ensure that it continues to do so at least once per contract cycle.
CDPH agrees that a site visit for each local prevention program should be conducted each contract cycle. Due to vacancies in several key positions, CDPH is behind in meeting this goal for contract cycle 2017-20. Now that many of these vacancies are filled, CDPH will be conducting at least two local prevention program site visits each month. At this rate, 30 of 50 site visits will be completed by the end of contract cycle 2017-20 (June 2020). Local prevention programs that do not receive a site visit in contract cycle 2017-20 will be prioritized for a site visit in contract cycle 2020-23, and work for both contract cycles reviewed. Review of local prevention program work completed for contract cycle 2017-20 will be completed for all 50 local prevention programs by April 2021.
Finding 6: CDPH has failed to meet several legislative requirements that could improve the identification of children who need treatment for lead poisoning.
CLPPB has drafted the mandated 2019 biennial report, “Update on California’s Progress in Preventing and Managing Childhood Lead Exposure,” and the report is currently going through the approval process and will be available soon.
CLPPB is promulgating regulations expanding the risk factor criteria via the process outlined in the Administrative Procedures Act (APA). Promulgating regulations is generally a three-year process for non-emergency regulations. To date, CLPPB has drafted regulations documents, held public stakeholder meetings for input on March 22, 2019, in Richmond, California, and on April 22, 2019, in Sacramento, California, and held meetings for input from medical providers in June and July 2019. CDPH is on track to formally notice the rulemaking in the fall of 2020 after all approvals have been secured.
Recommendations to Public Health
To better ensure that lead-poisoned children are identified and treated, CDPH should prioritize meeting legislative requirements related to these issues, including doing the following by March 2020:
- Finish developing the lead risk evaluation regulations and include in them multiple risk factors such as those used in lead risk evaluation questionnaires in other states, and commence the formal rulemaking process.
- Provide guidance to health care providers about the risks of childhood lead exposure and statutory requirements of lead testing.
CDPH partially agrees. CLPPB is promulgating regulations expanding the risk factor criteria via the process outlined in the APA. CDPH is on track to formally notice the rulemaking in the fall of 2020 after all approvals have been secured.
Although there is more we can do, CDPH has provided guidance to health care providers about the risks of childhood lead exposure and statutory requirements of lead testing. CDPH informs providers of the risks of childhood lead exposure and California mandated lead testing requirements on an ongoing basis.
- Medical providers caring for children with blood lead levels at or above 4.5 mcg/dL receive reminder letters and additional follow up as needed, regarding the need for follow-up lead testing. Some families may not return for follow-up care, may choose not to have the testing done, or may delay going to the laboratory.
- Medical provider presentations covering lead poisoning health effects, risks, prevention, management, and California provider mandates are given by a CDPH Public Health Medical officer at grand rounds, hospitals, and clinics throughout the state. CDPH incorporated information about the new Health and Safety Code (HSC) Section 105286 requirements into its medical provider presentations beginning in January 2019.
- Local prevention programs provide presentations, mailings, and direct medical provider outreach. For example, in 2018, approximately 3,500 copies the Standards of Care/Sources of Lead fact sheet (shown as Figure 12 in the auditor’s report) were requested and sent to the local prevention programs for direct distribution to medical providers in their jurisdictions.
- CDPH developed a revised Standard of Care Guidelines document that incorporates the HSC Section 105286 requirements. This document is posted on the CLPPB website at: https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/CDPH%20Document%20Library/CLPPB-care%20guideline_sources%20of%20lead.pdf
- This same document also includes “Potential Sources of Lead: Educating Families to Prevent Childhood Lead Exposure.” This source list was updated to include additional lead sources cited in statute, along with additional sources based on CLPPB source review and analysis, and CLPPB analysis of additional sources identified during the AB 1316 fact-finding process including input from stakeholder feedback sessions.
- A program letter has been sent to the local prevention programs informing them of the new Standard of Care/Source of Lead document and advising them to include this information in provider materials.
- The new Standard of Care/Sources of Lead document is currently being printed and will be distributed to providers throughout the state when it is available.
CLPPB wrote an article for the California Medical Board Newsletter notifying providers of the new statutory requirement, the revised Standard of Care Guidelines and the revised Potential Sources of Lead. This has been submitted to the Medical Board for inclusion in the next quarterly newsletter. (The Winter 2019 issue of the Medical Board Newsletter contained information about new legislation affecting medical providers, including Childhood Lead Poisoning Prevention – Senate Bill 1041.) CDPH will continue to provide guidance to health care providers about the risks of childhood lead exposure and statutory requirements of lead testing.
Finding 7: CDPH’s inequitable methodology for allocating funds to local prevention programs has led to significant differences in the level of services provided to children diagnosed with lead poisoning.
CDPH introduced several different allocation methods based on program changes since the fiscal year (FY) 2011-14 contract cycle. For FY 2011-14, the base total for local assistance allocations was $11 million. CLPPB then increased the base to $17 million for local prevention programs, due to the change in the CDC case definition. CDPH will revist the funding allocation mechanism with specific attention to equity, and will report back to you with our findings. To our knowledge, however, no children with elevated lead levels have gone without case management due to funding. We are aware of cases where lead abatement has not been successful due to parental refusal.
All children with blood lead levels at or above 4.5 mcg/dL are required to receive specified services. Children with blood lead levels meeting the criteria for full case management services are required to receive a home visit. CDPH provides oversight and technical assistance to ensure those case management services are provided, and is not aware of required services not being provided due to lack of resources. The audit report references identifying home visits in only six out of the 10 cases reviewed by the auditor in the Humboldt program. The auditor did not provide CDPH with information identifying these cases. CDPH reviewed Humboldt cases and did identify cases where home visits and environmental investigations did not occur due to persistent, documented parental refusal. Parents do have the right to refuse services. CDPH will work with local jurisdictions to identify concrete actions they can take to address cases where parents are uncooperative or where records may be incomplete.
In addition, CLPPB works with the medical provider, continues to maintain contact with the family by phone and mail, provides educational information about lead and lead hazards, and monitor the blood lead levels (BLLs). If the BLLs remain high CDPH and local jurisdictions may take further steps. It would be an extreme case to utilize Child Protective Services to remove a child from their family. State Housing Law can be used to enter a home and make corrections without consent, but that would only be done in an extreme situation.
Recommendation to Public Health
To ensure a more equitable distribution of resources for treating lead-poisoned children, CDPH should, by June 2020, update its methodology for allocating funds to local prevention programs, including accounting for the most recent annual count of lead-poisoned children in each jurisdiction. CDPH should also revise the allocations prior to each contract cycle.
CDPH agrees. CDPH will update the local prevention programs’ funding allocations using recent data in the next contract cycle by June 2020.
We appreciate the opportunity to respond to the audit. If you have any questions, please contact Monica Vazquez, Chief, Office of Compliance at (916) 306-2251.
Sonia Y. Angell, MD, MPH
State Public Health Officer & Director
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE
RESPONSE FROM THE CALIFORNIA DEPARTMENT
OF PUBLIC HEALTH
To provide clarity and perspective, we are commenting on CDPH’s response to our audit. The numbers below correspond to the numbers we have placed in the margin of CDPH’s response.
CDPH has organized its response by summarizing the findings and conclusions described in our report. Its descriptions of the findings do not precisely correspond to the text of the report.
CDPH responded to several issues in our report by citing actions it asserts are reported in its draft biennial report. As we describe in the audit results, CDPH informed us during the audit that it completed the draft report in March 2019 but had not approved the report as of October 2019. CDPH asserts that its draft report is confidential, and because we cannot discuss this draft report we are unable to verify or dispute CDPH’s claims.
CDPH overgeneralizes in its assertion that it has implemented a program of medical follow‑up and environmental abatement that has reduced the incidence of excessive childhood lead exposures in California. As we state in Appendix A, CDPH assesses the progress it has made toward eliminating lead poisoning by tracking the percentage of children tested who had elevated lead levels over time. Although the number of children with elevated lead levels has varied from year to year, as Table 1 in the Introduction shows, from calendar years 2015 to 2017 the number of children with elevated lead levels has increased. Further, as we reference in Appendix A, during the past five years these percentages have not consistently decreased.
CDPH did not provide evidence to support its assertion that it targets areas at high risk for lead exposure. Specifically, as we state in the audit results, although state law requires annual analysis to identify geographic areas at high risk for lead exposure, CDPH’s most recent update to its list of high‑risk geographic areas was based on 2015 data. Thus, it follows that it does not have up‑to‑date information to use in targeting areas of high risk for reducing lead exposure. As we describe in the audit results, CDPH’s lead hazard reduction chief stated that CDPH’s approach to abating lead in high‑risk areas is to monitor abatement activities in the homes of children who have already been poisoned.
CDPH’s response does not address our concern that it does not know whether its outreach has reduced instances of lead poisoning. As we state in the audit results, neither CDPH nor the local prevention programs we reviewed measure the effectiveness of their outreach activities in reducing the number of children with lead poisoning. Evaluating the effectiveness of outreach by measuring changes in knowledge and behavior such as increased handwashing and increased screening, as CDPH suggests it will do, will not establish whether these efforts have reduced the number of children with lead poisoning.
We disagree with CDPH’s perspective that it is more effective for local agencies to apply for funding to perform abatement. As we describe in the audit results, CDPH stated that one of the reasons it has not applied for these funds is that it would be competing with local jurisdictions for the funding. CDPH’s branch chief also told us that it is inefficient for multiple agencies to apply for the same funds. However, as we state in the audit results, we believe that CDPH could more efficiently facilitate the distribution of such funding if it were to apply for the funds and pass them on to local programs, rather than have the local prevention programs expend resources competing against each other. Further, we did not recommend that CDPH perform abatement work directly, as CDPH implies. Nevertheless, because of its role in providing oversight of the statewide lead prevention program, and because a state agency is better equipped to apply for these federal funds, CDPH is best suited to seek out and apply for additional lead prevention funding to offset the cost of mitigating lead exposure in the highest‑risk areas of the State, identify areas of the State with the highest need for such funds, and allocate them to the local prevention programs as appropriate.
CDPH’s response is confusing. We do not suggest that CDPH is better suited to address local needs, enforce local laws, or enforce the cleanup of lead hazards. Rather, we are suggesting that CDPH obtain funds from federal sources and make them available to local prevention programs to use for lead abatement activities.
Notwithstanding CDPH’s description of the experiences of other states using CMS funding, we believe that any opportunity to prevent lead poisoning without cost to the State is of value. Therefore, we stand by our recommendation that CDPH should seek out and apply for additional lead prevention funding.
CDPH misinterprets our recommendation. As we state in the audit results, CDPH should report information only to the extent that it can ensure that it does not make personally identifying information, including medical information, public. Thus, development of an online lead information registry in this manner would not result in the disclosure of confidential information. As we describe in the audit results of our report, CDPH will need to take steps to ensure that it does not make information available to the public that could be used to identify individuals in its case management system. Therefore, it is unclear why CDPH asserts that implementing this recommendation would result in the disclosure of confidential information related to the addresses of children with lead poisoning. Further, as we state in the audit results, CDPH indicates that it receives lead inspection and abatement information on tens of thousands of properties every year. CDPH’s lead hazard reduction chief also informed us that only 1 percent of these records are related to the addresses of children with lead poisoning. As a result, CDPH could make public the majority of the abatement and inspection information it has collected without risk of disclosing confidential health information.
CDPH’s statements are irrelevant to our conclusions and recommendations. Our report does not suggest that a record of an abatement means that there is no lead on the property, or that it represents a guarantee that lead hazards could not exist in the future. Specifically, we state in the audit results that such registries can provide information on whether and when a property was inspected for lead, and the status of any identified lead hazards. Therefore it is unclear why CDPH implies that reporting such information as a short‑term abatement status would limit the usefulness of providing this information to the public.
CDPH’s suggestion that it cannot mask forms related to children with lead poisoning is not relevant to our recommendation. Our recommendation does not suggest that CDPH post forms in the registry. Rather, as we recommend on page 33, CDPH should make public the information it already maintains to the extent it can ensure that it does not make personally identifiable medical information public.
CDPH did not present the full text of this recommendation. As the audit results shows, our recommendation includes the following text: “To accomplish this task, CDPH should use the information it already maintains only to the extent that it can ensure that it does not make personally identifying information, including medical information, public.”
CDPH chose to respond to this recommendation even though we directed it to the Legislature. Nevertheless, CDPH’s proposal to provide guidance to the public on how to request information for specific addresses instead of reviewing an online registry would be inconvenient and time‑consuming. Further, as we describe in the audit results, state regulations already require CDPH to collect lead inspection and abatement information. Moreover, creating such a registry should not be an overly burdensome process. As we described to CDPH during the course of our audit, our office was able to create a working model of such a registry in less than a day using a copy of CDPH’s database that contains this information.
CDPH asserts that it assesses local prevention programs’ performance through site visits and biannual progress reports, but it has not done so for all local prevention programs. As we describe in the audit results, CDPH has failed to perform a majority of the site visits in its current contract cycle as its existing policy requires. Further, as we describe in the audit results, we have concerns that CDPH is not sufficiently addressing performance when reviewing the progress reports.
CDPH has not presented the full text of this recommendation. As the audit results show, our recommendation includes the following text: “In addition, CDPH should use the local prevention programs’ biannual progress reports to assess local prevention programs’ performance and provide feedback on their strengths and shortcomings.”
The activities that CDPH describes in its response are not specific to the legislative requirements our recommendation addresses. As we state in the audit results, the Legislature passed a law effective January 1, 2019, requiring CDPH to notify all health care providers who perform periodic health assessments of children of the risks and effects of childhood lead exposure, as well as the testing requirements. None of these efforts that CDPH describes, which we reviewed during the course of our audit, ensures that all health care providers who perform periodic health assessments for children received this information, as the law requires. Further, as we state in the audit results, CDPH already had resources it could have used to communicate the required information directly to providers when the law was passed in 2018.
CDPH’s statement that it introduced different allocation methods is inaccurate. Despite increasing the amounts paid to local prevention programs, CDPH allocated the amounts using the same proportions as before. We look forward to reviewing the information that CDPH provides regarding the equity of its funding allocation mechanism in its follow‑up responses to the audit.
We do not suggest in the report that children with elevated lead levels have gone without any case management due to unavailable funding. Rather, as we describe in the audit results, the level of services provided by the local prevention programs that we reviewed differ because of different funding levels. Specifically, we found that the annual funding CDPH allocated to local prevention programs using its current methodology varied from about $3,000 per child with lead poisoning to more than $30,000 per child with lead poisoning. These dramatic differences in funding levels highlight the effect of CDPH’s use of its current funding methodology.
We discussed our conclusions about the Humboldt program with CDPH on multiple occasions, but CDPH did not request information about the cases we reviewed.
CDPH’s statement that parents have the right to refuse services does not change our conclusion that CDPH’s inequitable method of allocating funds has led to differences in the level of services provided. As described in the audit results, we determined that the amount of funds allocated to local prevention programs did not align with the numbers of children with lead poisoning for which the programs are responsible. Further, the Humboldt County local prevention program explained that its ability to provide home visits is limited by the amount of funding it receives. As we state in the audit results, our review determined that in those cases where it performed a home visit, the Humboldt program provided fewer visits on average than the Fresno County local prevention program, which received the equivalent of twice the funding per child with lead poisoning.
CDPH’s statement regarding removing children from their families and entering homes without consent is unrelated to the text of our report and the nature of our recommendations. At no point did we recommend that CDPH should remove children from the homes of their parents, nor did we advocate for or against parents’ right to refuse services.