CASE RECORD REVIEW CHECKLIST TO ENSURE COMPLIANCE WITH REQUIREMENTS RELATED TO THE ADMINISTRATION OF PSYCHOTROPIC MEDICATIONS

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1 Date: Case Management Agency (CMA): Child Name: Date of Removal: Child Age: Date of Arraignment: Note: This review checklist is regarding children ages 0 through 17 who are in out-of-home care and have been identified as being prescribed psychotropic medications. Evidence of each requirement must be located in the Florida Safe Families Network (FSFN) system and copies placed the case file. (This section applies to children who enter out-of-home care ALREADY prescribed psychotropic medication) Has the child evaluated by a physician within 28 days of removal or no later than the arraignment hearing on the petition for dependency, whichever occurs first to determine whether it was appropriate to continue the medication? Date Completed: If this has not happened: you MUST IMMEDIATELY contact the physician to setup an appointment to have the child evaluated as required by the aforementioned timeframe (ie within 28 days of removal or no later than the arraignment hearing). Proceed to STEP #1 and follow the remaining steps in order to begin this process. (This section applies to children who enter out-of-home care and WERE NOT prescribed psychotropic medication UPON ENTRY but it has since been determined that psychotropic medication may be necessary) During the course of the Family Care Counselor setting up an appointment for the child to see a physician, it is critical that the below-mentioned steps be followed to ensure compliance leading up to and including expressed and informed parental consent or obtaining a Court Order. #1 The Physician s Report (PSF-173) should be provided to the physician prior to the child s evaluation UNLESS the child is in a crisis stabilization unit, residential treatment facility, or hospital, in which case the referral may be filled out after the child receives medication based on information received from the hospital/statewide inpatient psychiatric program (SIPP). The Family Care Counselor should do the following: 1. Complete and provide the original of the Physician s Report (PSF 173) to the physician (i.e. Prescribing Practitioner). 2. Provide the physician (i.e. Prescribing Practitioner) with a copy of the reports/information (i.e. CBHA, previous psychological evaluations, current health physical exam or recent well child exam, referral information including all medications currently prescribed, health status, health services and therapy currently receiving, and current school records, including functional behavioral assessments) needed to document other treatment options/alternatives used to avoid the use of psychotropic medication. 3. Provide a copy of the completed Physician s Report (PSF-173) to the parent, Children s Legal Services (CLS), and GAL or Attorney Ad Litem (if appointed) and place a copy in the case file. PSF-138C Revised 04/13/2015 Page 1 of 6

2 4. Document the efforts made to coordinate the evaluation and the reports/information that was provided in FSFN and place a copy of the FSFN note in the case file. STEP #1 completed? YES NO; Status of completion/comments: If the parents rights have been terminated then skip to STEP #3. If not, proceed to STEP #2. #2 To ensure the case record documents efforts to encourage and assist the parents/legal Guardian to participate in decision making regarding the need for psychotropic Medication(s), the Family Care Counselor should do the following: 1. Complete and provide the original of the Physician s Report (PSF-173) to CLS. NOTE: There must be some efforts to engage the parent even if there is a current court order, and there must be evidence of providing all written information about the prescription to the parent directly or at the parent s last known address. 2. Place a copy of the completed Psychotropic Medication Informed Consent Facilitation form (PSF - 173) in the case file. 3. Document in FSFN the efforts made to encourage and facilitate the parents/legal guardians participation in the expressed and informed consent process and place a copy of the FSFN note in the case file. STEP #2 completed? YES NO; Status of completion/comments: #3 Prior to and/or during the child s appointment, the Family Care Counselor should do the following: 1. Provide the physician (ie Prescribing Practitioner) with the blank Physician s Report (PSF 173). 2. The physician (i.e. Prescribing Practitioner) completes pages 2-4 of the Physician s Report (PSF 173) IT IS IMPERATIVE THAT THE PHYSICIAN (i.e. PRESCRIBING PRACTITIONER) FULLY COMPLETE ALL LISTED SECTIONS OF THE PHYSICIAN S REPORT. NOTE: Ensure a direct (telephone or face-to-face) conversation occurs between the physician (i.e. Prescribing Practitioner), caregiver, child (if age appropriate), and the parent to obtain informed consent. The Family Care Counselor must attend the appointment and if the caregiver cannot attend, the Family Care Counselor must convey the information to the caregiver. PSF-138C Revised 04/13/2015 Page 2 of 6

3 3. The parent (if parental rights have not been terminated) should complete the last page of the Physician s Report (PSF-173). NOTE: Psychotropic medications may be administered in advance of a court order or parental authorization under two circumstances: (1) EITHER the physician (ie Prescribing Practitioner) certifies delay could cause harm (ie the last section on page 4 of the report) OR (2) the child is in a hospital, Crisis Stabilization Unit (CSU), or psychiatric residential treatment. FOR EMERGENCY ADMINISTRATION OF PSYCHOTROPIC MEDICATION: If the child is in a hospital, Crisis Stabilization Unit (CSU), or psychiatric residential treatment, the Family Care Counselor must assist the physician in obtaining express and informed consent from the parent OR submit a completed Physician s Report (PSF-173) to CLS in time for a motion to be filed within three (3) business days after the medication is initiated or resumed. The FCC must call the CLS attorney, call the paralegal and then follow up with an to ensure receipt of the Physician s Report. 4. If the physician (i.e. Prescribing Practitioner) notifies the Family Care Counselor that the parents can't or won't consent, the Family Care Counselor must consult with the physician (i.e. Prescribing Practitioner) within one (1) business day. 5. Upon completion of the Physician s Report (PSF-173) provide the original to CLS WITHIN TWO (2) BUSINESS DAYS OF RECEIVING THE REPO RT. 6. Provide a copy of the Physician s Report (PSF-173) to the parent and caregiver (to be placed in the Child s Resource Record (i.e. Blue Folder) and place a copy in the case file. 7. Document in FSFN the direct conversation that occurred and the information communicated or shared with the physician (ie Prescribing Practitioner), parent, caregiver, and child and the efforts made to accomplish this. Place a copy of the FSFN note in the case file. STEP #3 completed? YES NO; Status of completion/comments: #4 Ensure the case file contains a copy of the court order authorizing the administration of the psychotropic medications currently prescribed if unsuccessful in obtaining informed parental consent. STEP #4 completed? YES NO; Status of completion/comments: IMPORTANT REMINDER: The Family Care Counselor will be responsible for securing a new parental express and informed consent OR court order if there are any changes in medication (including dosage or dosage range) that go beyond the existing authorization. The Family Care Counselor shall inform CLS of any changes in medication, and shall provide CLS a copy of the amended Physician s Report (PSF-173). PSF-138C Revised 04/13/2015 Page 3 of 6

4 Step #5 only applies to children ages 0 through 10 who are prescribed TWO or MORE Psychotropic Medications #5 Family Care Counselors are required to begin ON-LINE submission of pre-consent review forms for children ages 0 through 10 years on TWO or more psychotropic medications ONLY who were placed into Out-of- Home Care within 24 hours of the child being prescribed the medication. The Family Care Counselor should log into and follow these instructions: a. Click on the SUBMIT REVIEW FORM OPTION which is located on the top left-hand side of the page. b. Click on the CLICK TO OPEN A NEW PRECONSENT FORM link in the center of the page. c. Complete ALL sections of the new pre-consent form (psychotropic medication treatment plan review form). The Family Care Counselor should be able to use the information from the Physician s Report (PSF-173) to complete the new pre-consent form. The Family Care Counselor should also ensure he/she inputs a fax numbers for the physician (i.e. Prescribing Practitioner) and the Family Care Counselor on the form. d. Once the Family Care Counselor has completed the new pre-consent form, click on the SUBMIT button. e. The Family Care Counselor will see a print version of the submission and receive a job number confirming the submission; please print a paper or electronic version of the submission for your records. f. Afterwards, a UF MedConsult Psychiatrist will review the submission, complete the pre-consent form (psychotropic medication treatment plan review form), and fax the form back to the fax numbers the Family Care Counselor provided in the beginning of the online pre-consent form. Next, the Family Care Counselor should do the following: 1. Provide copies of the completed pre-consent form (psychotropic medication treatment plan review form) to CLS, the parent, caregiver (to be placed in the Child s Resource Record (i.e. Blue Folder)), physician (i.e. Prescribing Practitioner), and place a copy in the case file. 2. Document in FSFN the completion of these activities and place a copy of the FSFN note in the case file. STEP #5 completed? YES NO; Status of completion/comments: NOTE: The resource for person-to-person consultation about ANY use of psychotropic medication STILL EXISTS via the UF MedConsult Line regardless of the number of psychotropic medications a child has been prescribed. Using the MedConsult Line, a Family Care Counselor, judge, parent, GAL, or doctor can schedule an appointment to talk PSF-138C Revised 04/13/2015 Page 4 of 6

5 with a UF child psychiatrist and have their questions answered about side effects, contraindications, etc. This service is FREE OF CHARGE. The UF MedConsult can be reached at #6 Ensure the information for each psychotropic medication prescribed is entered on the FSFN Medication Screens and accurately reflect the following: Name of Prescribing Practitioner Name of Prescribed Medication Type/purpose - Is Medication for psychotropic purposes (the box must be checked) Date medication prescribed and/or stopped dates Prescription quantity and number of refills Dosage of prescribed medication Reason the medication was prescribed (also include the precautions and warnings) Instructions/Additional Comments (If the pre-consent review is waived by the parent or legal guardian then document this information in this section) Date of Expressed and Informed Parental Consent (must involve direct communication between the parent and Prescribing Practitioner) OR Date court authorized the use of psychotropic medication 1. Print and place a copy of the FSFN Medication Screens in the case file. STEP #6 completed? YES NO; Status of completion/comments: #7 Ensure the psychotropic medication information is accurately reflected in the following tabs: FSFN Medical Profile FSFN Mental Health Profile (also include date of the most recent CBHA and Disability tab is completed.) STEP #7 completed? YES NO; Status of completion/comments: #8 (Applies to children who decline to assent or request discontinuation of Psychotropic medications only.) Ensure that if a child of sufficient age, understanding, and maturity declines to assent to the psychotropic medication or requests the discontinuation of the psychotropic medication, AND the prescribing physician refuses to order the discontinuation, the Family Care Counselor must: 1. Request that CLS request an attorney be appointed for the child. 2. If applicable, document this information in FSFN, provide a copy of the FSFN note to CLS, and place a copy in the case file. PSF-138C Revised 04/13/2015 Page 5 of 6

6 STEP #8: Is the child currently refusing or requested discontinuation of the psychotropic meds? YES NO N/A; Status of completion/comments: Family Care Counselor Signature Date Family Care Counselor Supervisor Signature Date PSF-138C Revised 04/13/2015 Page 6 of 6