REVIEW OF DAYSTAR PROGRAM FEBRUARY 21, 2005 OFFICE OF THE MEDICAL DIRECTOR FOR BEHAVIORAL HEALTH TEXAS DEPARTMENT OF STATE HEALTH SERVICES OFFICE or MEDICAL DIRECTOR FOR BEHAVIORAL HEALTH TEXAS DEPARTMENT OF STATE HEALTH SERVICES OVERVIEW Steven P. Shon, M.D., Medical Director for Behavioral Health, Texas Department of State Health Services, and staff Cindy Hopkins and Linda Logan, met with the invited clinician reviewers at the conference center of the MHMRA of Harris County, Texas, on February 21, 2005. The 12 volunteer reviewers were: M. Crismon, Pharm. D, Professor, Pharmacy Program, University of Texas at Austin Sara R. Flick. MD, Medical Director-MR Services, MHMRA of Harris County R. Andrew Harper, MD, University of Texas Medical School at Houston, Medical Director, UT-Harris County Center Tot Harris, MD, Chairperson, Medical Executive Committee, Texana MHMR Alice Mao, MD, Director, Community Training, MHMRA of Harris County Robin Mallett. MD, Medical Director, Gulf Coast Center, Associate Professor of Child and Adolescent UTMB Galveston Cit/ion McGee, MD, MHMRA of Harris County Sylvia Muzquiz, MD, Medical Director, MHMRA of Harris County Valerie Robinson, MD, Texas Tech University Health Science Center Dept. of Santos, MD, Associate Professor, University of Texas Medical School at Houston Ann E. Saunders, MD, Chief,_AdoIescent Division, University of Texas Health Science Center Linda Schmalstieg, MD, MHMRA of Harris County Tommy Keto, R.N., presented the group with the medical records of children and adolescents receiving services at the Daystar Residential Treatment Center, Houston, Texas. Ms. Keto told the group that there were 68-70 charts for review. She stated that the medical recOrds were complete. Dr. Shon provided reviewers with a review tool that was based on the Medication Utilization Parameters for aster Children (Attachment A). Reviewers were instructed on how to use the two parts of The Individual Assessment and Medication Monitoring Review Instrument Version 1.0 1 8/02): . . Rcvzewer Records - Clinician Scoring Tool (Attachment B), and 1 4 Clinician Reviewer Recommendations (Attachment C). i 4 3 To ensure the anonymity of reviewers and the con?dentiality of 5 6 the children and adolescents whose charts were reviewed, 3 i identifying numbers were used for both reviewers and charts. 3 7 A count found that the number of charts totaled 59, of which 49 190 i were reviewed in the ?ve-hour period from approximately 12 5 noon until 5:00 pm. The time each reviewer was able to spend Ti?! 4; varied as did the numbers of records reviewed, ranging from one ??be Number of to seven per reviewer. Raw Clinician Scoring Tool results are Mullen! Records shown in Attachment D. Renewed by Revuewcr. IQ OFFICE OF MEDICAL DIRECTOR FOR BEHAVIORAL HEALTH TEXAS DEPARTMENT OF STATE HEALTH SERVICES REVIEW RESULTS Section Assessment Admitting mental status exams and physical exams were documented in almost all records. Old records from prior treatment were available in the chart. However, the- often did not document a history in the admitting assessment, or document that the old records had been reviewed, and this information incorporated into the current assessment. Medication histories typically were not documented as a part of- the admitting assessment. Section Diagnosis Most diagnoses appeared to meet DSM IV criteria. Rule-out diagnoses were used uncommonly, and when used, they were usually resolved Within a reasonable time period. Section Informed Consent The majority of records contained general consent forms for medical and treatment. However, there was no evidence of documented, informed consent for prescribed medications. All records reviewed for informed consent to treatment with medication received a ?no? score. Section The review indicates that regarding diagnosis, course of illness, treatment options, and prognosis is not being routinely provided to the legally authorized representative of the child or to parents of children who have visitation rights. is a critical element of informed consent. Additionally, the review indicates that residents are not being routinely provided regarding diagnosis, course of illness, or treatment being provided. Medical evidence clearly demonstrates that when these elements are provided, outcomes improve. isnecessary for engaging residents in treatment and for ongoing adherence to treatment. Section Pharmacotherapy regimen is consistent with diagnosis and/or target Positive ?ndings were that children were typically seen by a once which appeared to be an appropriate interval in nearly all of the cases. Additionally a review of medication regimens did not suggest a signi?cant potential for potentially toxic drug interactions. . OFFICE OF MEDICAL DIRECTOR FOR BEHAVIORAL HEALTH TEXAS DEPARTMENT or STATE HEALTH SERVICES On the negative side, target for which medication were being prescribed were often not documented in the records, and it was uncommon for response of target to treatment to be documented. It was rare for the absence or presence of potential medication related side effects to be documented in the records, and vital signs were almost never recorded at visits. Medication administration records were not provided, so it was not possible to evaluate the frequency of administration of pm medications. Nurses? notes did not appear to be present in the provided records so it was not possible to evaluate the nurses? assessment of the response to treatment. Laboratory tests were frequently obtained in children, but abnormal laboratory tests were frequently not addressed or followed-up. For example, most of the children were prescribed medications known to cause dyslipidemias and elevated blood glucose determinations. Several of these children had elevated serum cholesterol and LDL cholesterol, including children as young as ten years of age. In almost none of these children were the elevated laboratory tests addressed, the potential of it being drug induced addressed, or were any appropriate laboratory test follow-up performed, or changes in pharmacotherapy made in response to these lipid abnormalities. Lastly, it was unusual that the rationale for long-term maintenance pharrnacotherapy was addressed in the medical record. Of signi?cant concern was the fact that minimal evidence existed that care was integrated into the overall care of the patient. ,Based upon the documentation, care appeared to occur in a parallel and independent fashion compared to the remainder of treatment. print-outs of current medications contained ?canned diagnoses or indications? that often were not correct for the individual patient. Mention of care in the comprehensive treatment plan appeared ?canned?, was almost identical from patient to patient, and did not appear individualized for particular patient needs. Section Medication follow up Documentation of appropriate was rarely documented. A number of these children had signi?cant mental retardation that admittedly would make for the patient dif?cult. However, no documentation of for the legally authorized representative was documented either. In those children and adolescents who appeared capable of participating in there was no documentation of this occurring. CONCLUSIONS 0 Records were incomplete. Medication administration records were not included. Nursing notes were not included. Some progress notes were missing. a Laboratory follow-up was generally poor. The instrument will need to be modified to better score this. OFFICE OF MEDICAL DIRECTOR FOR BEHAVIORAL HEALTH TEXAS DEPARTMENT OF STATE HEALTH SERVICES Metabolic appeared to be developing in many/most of these children, abnormal labs (lipids), increased weight, etc. Many of these children started as normal. . . Informed consent was not accomplished. The consent form was not speci?c to medications or changed when new medications were added. did not occur. Evidence of discussions with the child or legally authorized representative was not found. Diagnoses were not revisited. Even when multiple treatments were not successful, diagnosis was not questioned. Use of PRN (as needed) medications could not be evaluated. Standing blanket orders for pm and emergency medications were in medical records but because of missing elements in charts, usage could not be evaluated. Treatment plans were uniformly the same (?canned?). Uniform statements did not always conform to assessment information. thrapyramidal (EPS) medications were uniformly ordered for atypical cogentin. EPS is signi?cantly less with atypical and therefore these medications are seldom necessary. EPS medications also have side effects themselves. The handwriting in notes and the related signature often were not the same.