Audit Report on the Tracking of Children with Elevated Blood Lead Levels by the Lead Poisoning Prevention Program of the New York City Department of Health

EXECUTIVE SUMMARY

The New York City Department of Health (DOH) promotes and protects the health and quality of life of City residents by enforcing compliance with the City’s Health Code and providing a broad range of public health programs and services. The mission of DOH’s Lead Poisoning Prevention Program (LPPP) is to reduce the incidence and severity of childhood lead poisoning.

Lead is a poison that affects virtually every system in the body. It is particularly harmful to the developing brain and nervous system of young children. Blood lead levels as low as 10 micrograms per deciliter (mcg/dL), which do not cause distinctive symptoms, are associated with decreased intelligence and impaired neurobehavioral development.

LPPP’s staff work with families affected by lead poisoning by providing general information about lead poisoning, counseling parents or guardians on reducing children’s blood lead levels, conducting environmental risk assessments, providing medical consultation through LPPP’s Medical Director, and providing case management. Lead poisoning exists when a child (under 18 years) has a venous blood lead level of 20 mcg/dL or has blood lead levels of 15 to 19 mcg/dL, for each of two tests performed at least three months apart. When reports received by LPPP confirm these levels, LPPP staff members designated as Public Health Advisors (PHAs) contact the child’s medical provider and family. The advisors visit the child’s home to educate the parents about the sources of contamination and the importance of continued monitoring of the child and siblings. The PHAs monitor children with elevated blood lead levels until their blood lead levels have been reduced below 15 mcg/dL.

DOH classifies its cases and prepares its reports based on the blood lead levels (bll) of each child. The classifications are as follows:

• blood lead levels between 15 and 19 mcg/dL for each of two tests performed at least three months apart;
• one blood lead level between 20 and 44 mcg/dL;
• one blood lead level between 45 and 69 mcg/dL; or
• one blood lead level greater than or equal to 70 mcg/dL.

DOH has criteria for follow-up procedures that differ, depending on the blood lead levels. Any blood lead level that is equal to or greater than 45 mcg/dL is classified as a three-star case and requires immediate (same day) follow-up by LPPP staff and shorter timeframes for initial contact and visits to the family. Children with blood lead levels in this range must begin medical treatment immediately.

The objective of this audit was to determine whether the Department of Health has adequately followed up on children who have elevated blood lead levels of 20 mcg/dL and above or have blood lead levels of 15-19 mcg/dL for each of two tests performed at least three months apart.

The primaryscope of our audit was a review of LPPP’s monitoring of cases involving children with elevated blood lead levels identified in fiscal year 2000. We also randomly selected and reviewed eight cases identified in fiscal year 2001, the period during which we conducted the audit. We reviewed various guidelines and codes, including DOH’s Lead Poisoning Prevention Program Protocol (Protocol),New York City Health Codes, and the Centers for Disease Control and Prevention: Guidance for State and Local Public Health OfficialsWe also reviewed fiscal year 2000 quarterly reports and the reports for the first two quarters of fiscal year 2001 prepared by LPPP staff for the Centers for Disease Control (CDC)In addition, we interviewed LPPP staff to obtain additional information about the program.

We randomly selected a sample of 28 out of 923 cases for fiscal year 2000 to determine whether the cases were appropriately monitored by LPPP staff. We analyzed the initial 28 cases and an additional randomly selected 105 cases to determine whether initial contacts were made with the family and medical provider and whether initial field visits were made within the required timeframe. For the 28 cases, we further reviewed each case to determine whether there was appropriate follow-up after the initial visit and whether the child had the necessary follow-up blood tests as required in the LPPP Protocol.

In addition, we conducted an in-depth review of eight fiscal year 2001 cases to determine whether they were addressed promptly, whether the initial contacts and field visits were made in a timely manner, and whether there was adequate back-up documentation to support the steps taken.

The New York City Department of Health’s Lead Poisoning Prevention Program is generally doing a good job of addressing childhood lead poisoning. LPPP staff monitor children with elevated blood lead levels by making initial and follow-up calls and visits to the families of these children and providing information about lead poisoning to the parents.

However, LPPP staff did not always comply with the procedures of the LPPP Protocol. For example, in 8 percent of the 133 cases we reviewed, initial contacts to the families of children with elevated blood lead levels were not made within the required timeframe of one to three business days; and in 11 percent of the 133 cases, visits to the families were not made within the required timeframe of one to five business days. An in-depth review of 28 of the 133 cases found that in 18 percent of the cases of children who required follow-up blood tests, LPPP staff did not send a reminder letter to parents reminding them to take their children for the follow-up blood tests.

In addition, LPPP is operating under a Protocol that does not reflect all of the current practices that LPPP officials say exist. Also, LPPP staff did not follow some relevant requirements in the existing Protocol. For example, required reports were not prepared, and many case folders lacked required documentation. There were also discrepancies in the data produced by LeadQuest when compared with the data submitted by LPPP to CDC for the same time frame.

This audit makes 12 recommendations, which are listed below. LPPP officials should ensure that its staff:

1. Make initial contacts and visits within the prescribed timeframes specified in the Protocol.
2. Establish alternative procedures and/or work hours to contact or visit working parents who are not at home during the weekdays.
3. Send reminder letters to parents of children who have not received a follow-up blood test within a three-month period.

LPPP officials should:

4. Prepare an updated Protocol that reflects current procedures to be followed by PHAs and other personnel.
5. Ensure that their managers and supervisors adequately supervise the LPPP staff and document their supervisory review in LeadQuest.
6. Prepare and document progress reports, change of data/status forms and supervisory reviews, as required by the LPPP Protocol.
7. Ensure that information reported in the quarterly CDC reports is accurate and compatible with the information in the supporting documentation.
8. Ensure that the back-up documentation used to prepare the quarterly reports to CDC is maintained.
9. Ensure that data used as the basis for the quarterly reports to CDC are reviewed by LPPP supervisors and submitted for entry into LeadQuest on a timely basis.
10. Generate and maintain reports, as required by the LPPP Protocol. This would enable LPPP to have easy access to critical information regarding children with elevated blood lead levels.
11. Report information on contacts and visits made by Public Health Advisors in the Mayor’s Management Report.
12. Consider reporting the number of active cases in the Mayor’s Management Report.

The matters covered in this report were discussed with officials from DOH during and at the conclusion of this audit. A preliminary draft report was sent to the DOH officials and discussed at an exit conference held on February 25, 2002. On March 11, 2002 we submitted a draft report to DOH officials with a request for comments. We received a written response from DOH on March 27, 2002. The response stated in part:

"Where appropriate, LPPP will incorporate the audit findings into its on-going efforts to improve its quality of service. In areas where the auditor had identified problems, LPPP has already begun to implement changes to address these concerns."

DOH agreed with most of the 12 audit recommendations. Specifically, DOH agreed with eight recommendations and has implemented five. DOH disagreed with recommendations #3 and #6 and is considering whether or not to implement recommendations #11 and #12.