BILL ANALYSIS Ó AB 2399 Page 1 Date of Hearing: April 17, 2012 ASSEMBLY COMMITTEE ON HEALTH William W. Monning, Chair AB 2399 (Allen) - As Amended: April 9, 2012 SUBJECT : Mental health: state hospitals: injury and illness prevention plan. SUMMARY : Requires each of the five state hospitals under the jurisdiction of the Department of Mental Health (DMH) to update its injury and illness prevention plan (IIPP) at least once a year and establish an IIPP committee to provide recommendations for updates to the plan. Specifically, this bill : 1)Requires each state hospital to update its IIPP at least once a year to include necessary safeguards to prevent workplace safety hazards related to workplace violence associated with patient assaults on employees. 2)Requires updated plans to at least address all of the following: a) Control of physical access throughout the hospital and grounds; b) Alarm systems; c) Presence of security personnel; d) Training; e) Buddy systems; f) Communication; and, g) Emergency responses. 3)Requires DMH to submit the updated plans to the Legislature every two years. Specifies that the requirement for submitting the updated plans is inoperative four years after the date the first report is due, as specified. Indicates that the plans must comply with existing reporting requirements. 4)Directs each state hospital to establish an IIPP committee comprised of hospital management and employees designated by the hospital's director in consultation with the employee bargaining units. 5)Makes the IIPP committee responsible for providing recommendations to the hospital director for updates to the AB 2399 Page 2 IIPP. Requires the committee to meet at least four times per year. 6)Requires each state hospital to develop an incident reporting system that can be used, at a minimum, to report patient assaults on employees and report identified risks of patient assaults on employees. 7)Provides that the reporting system must be widely accessible to staff and be designed to provide hospital management with immediate notification of reported incidents and identified risks. 8)Requires each state hospital to provide for timely and efficient responses and investigations to incident reports made under the reporting system. Requires the incident reports to be forwarded to the IIPP committee. EXISTING LAW : 1)Charges DMH with managing the care and treatment of mentally ill patients at California's five state mental hospitals: Atascadero (ASH); Coalinga (CSH); Metropolitan (MSH); Napa (NSH); and, Patton (PSH). 9)Designates NSH and MSH to only treat low-to-moderate risk patients and requires high-risk patients to only be treated at ASH or PSH, a correctional facility, or other secure facility. 10)Establishes, within the Department of Industrial Relations, the Division of Occupational Safety and Health, known as Cal/OSHA, to conduct inspections of California workplaces in response to a report of an industrial accident; a complaint about an occupational safety and health hazard; or, in conjunction with an inspection program targeting high-risk industries. 11)Requires, in regulations, every employer to establish, implement, and maintain an effective injury and illness prevention program that includes methods and procedures for correcting unsafe or unhealthy conditions, work practices, and procedures in a timely manner, based on the severity of the hazard when observed or discovered; and, when an imminent hazard exists, as specified. AB 2399 Page 3 FISCAL EFFECT : This bill has not yet been analyzed by a fiscal committee. COMMENTS : 1)PURPOSE OF THIS BILL . The author asserts that an increasing forensic population, insufficient staff levels, and facilities that were not originally designed or maintained for forensic patients are the major causes of increases in violent incidents at state hospitals. The author maintains that creating a safer environment has a significant impact on the well-being of both patients and staff and can reap significant financial benefits associated with reductions in overtime, fewer missed work days, and fewer workers' compensation claims from staff injuries relating to patient aggression. The author states that this bill seeks to improve worker safety by requiring state hospitals to update their IIPPs annually with important safeguards against workplace hazards posed by patient assaults and establishing a formal process, through an IIPP committee, to enable employees to work with management to make improvements. 2)BACKGROUND . DMH oversees the operation of the five state hospital campuses as well as two acute psychiatric programs that provide treatment to a combined patient population of over 5,000. There has been a dramatic shift in the patient population at state hospitals in the last decade as the number of patients committed by way of the criminal justice system has risen while the number of patients referred by counties under civil commitments has declined. DMH reports that the forensic population now comprises 92% of the state hospital system. 3)PROPOSED DEPARTMENT OF STATE HOSPITALS . DMH commissioned a report released in December 2011 to assist in the proposal for a new Department of State Hospitals to be included in the 2012-13 Governor's Budget and provide recommendations related to this new department's administrative structure. The Governor's Administration states that a new and separate department is needed to administer these facilities in order to comprehensively focus on mitigating significant health and public safety issues, centralize administrative functions, and address core patient population management and fiscal administration. According to the DMH report, the primary issues affecting clinical services are patient aggression AB 2399 Page 4 management with the related concern of a safe working environment. The report notes that central staffing directors and hospital administrative staff expressed serious concern regarding the need to enforce consequences for assaulting medical staff as threats from patients make it difficult for medical staff to provide effective care. 4)INCIDENCES OF VIOLENCE . Due to the increased forensic population, incidences of violence towards patients and staff have increased. Since the death of psychiatric technician, Donna Gross, at NSH in October 2010, much attention has been focused on the level of assaults on state hospital staff and patients. According to data that DMH reported to the Assembly Budget Subcommittee on Health and Human Services, patients at NSH committed 75 physically aggressive acts against staff in 2010-11 and there were nearly four times as many patient-on-staff assaults, and twice as many patient-on-patient aggressive incidents, than in 2009. DMH reports that there were almost 4,600 aggressive acts against staff and nearly 9,400 aggressive acts against others system-wide in 2010. 5)Cal/OSHA . Cal/OSHA is charged with enforcing occupational safety and health laws, orders, and standards and investigating alleged violations. Cal/OSHA issues a citation when an employer causes an employee to suffer or potentially suffer, among other things, serious injury or illness or serious physical harm. According to a March 2012 article in the Los Angeles Times, Cal/OSHA has issued nearly $100,000 in fines against PSH and ASH for their alleged failure to protect staff from patient assaults and deficient employee alarm systems. These latest citations are similar to those issued last year against NSH and MSH. According to the citations, the most serious violations were for inadequate IIPPs that contributed to an average of 20 patient-caused staff injuries a month at PSH from January 2006 to September 2011, and an average of eight a month at ASH between January 2007 and October 2011, all involving severe head trauma, fractures, contusions, lacerations, and bites. The citations indicate that corrective measures, such as a buddy system, adequate alarms, sufficient security personnel and sufficient back-up staffing, were not taken to improve conditions. Cal/OSHA also cited ASH for failing to adequately staff patient units on swing and AB 2399 Page 5 overnight shifts, and PSH for an employee alarm system that was not capable of being detected at all on hospital grounds, while ASH's did not work in a number of areas, including restrooms and stairwells. Additionally, Cal/OSHA levied more than $20,000 in fines against CSH last month for safety lapses related to an ineffective IIPP, inadequate employee alarm systems, and failure to implement corrective actions to prevent serious physical assaults to staff and identify the unsafe conditions created by privacy curtains, blankets and other means to conceal individuals from employees. DMH reports that each hospital campus has its own individual IIPP. Each hospital's IIPP contains policies regarding a variety of health and safety topics including health and safety policies of each hospital, inspection procedures, disaster responses, patient interventions, hazard assessment and correction, emergency responses, injury reporting, return to work policies, and violence in the workplace. DMH states that it is working with Cal/OSHA and patient and employee groups to revise the IIPPs, per Cal/OSHA's recommendations and findings. DMH indicates that this is an ongoing process that involves numerous changes to policies and procedures, as well as physical infrastructure changes, some of which may be implemented in the short term and some of which will be implemented over the long term. DMH has reached an agreement with Cal/OSHA to establish workgroups, with employee representation, to address the identified deficiencies. The workgroups are charged with, among other things, developing instructions for each hospital to assess the adequacy of policies regarding current alarms, both personal and facility-wide; developing safety assessments to identify the areas, activities, and factors that present increased risk of violence, including buildings and grounds, in order to abate the hazards of assaults and other unsafe workplace conditions; and, developing a tool or instrument to be used by all the hospitals to capture and identify the greatest risks of serious injury in a format that can be readily analyzed to identify both geographic and programmatic risk factors in each facility. According to DMH, there has been discussion about an overarching settlement agreement that would require DMH to adopt measures based on these workgroup recommendations and other discussions between DMH and Cal/OSHA relating to larger structural changes governing health and safety at the hospitals. Both sides AB 2399 Page 6 believe a settlement agreement is preferable to DMH litigating appeals of each hospital's citations because the citations are similar and, as a result, resolution and abatement would also be similar and more effective if it encompassed system-wide changes. 6)CURRENT HOSPITAL SAFETY EFFORTS . According to DMH's Strategic Plan for Statewide Aggression Reduction that was provided to the Assembly Budget Subcommittee on Health and Human Services, DMH has already completed a number of administrative steps to reduce aggression system-wide. Specifically, DMH reports that the transfer of 30 high aggression risk patients out of NSH to other state hospitals is complete; analyses from the Executive Directors of each facility regarding clinical and physical resources and subsequent ideal patient populations for each facility have been submitted; implementation of new personal duress alarm systems is currently 60% completed at NSH and approved for roll-out at the remaining four facilities; and efforts are ongoing with regard to evaluating resource needs for specialized units and making improvements to ground safety at NSH, PSH, and MSH. With regard to clinical steps, DMH reports that an auditing tool to monitor for appropriate assessment and treatment has already been developed; a statewide curriculum for treatment of aggression is in the process of being developed; a pre-admission violence risk screening tool has already been developed and is in the process of being implemented; and two specialized treatment units have been opened at ASH and CSH for the treatment and containment of psychotic, impulsive, and predatory aggression. 7)SUPPORT . The California Association of Psychiatric Technicians writes in support that this bill will provide the swift action that is needed to rectify safety concerns identified by Cal/OSHA that affect staff and the patients who depend upon them to provide a secure, therapeutic environment. The California Psychiatric Association supports a prior version of this bill, stating that it provides a more comprehensive approach to addressing the violence in state hospitals. The California Statewide Law Enforcement Association notes that this bill will ensure that safety procedures and other changes at state hospitals are implemented in a manner that evolves with the forensic nature of the patient population. AB 2399 Page 7 8)RELATED LEGISLATION . AB 2397 (Allen) requires state hospitals to have, at a minimum, an ancillary clinical staff-to-patient ratio of 1-to-25 for each applicable staff classification, based on the facility's licensed bed capacity with a specified shift relief factor. AB 2397 is scheduled to be heard in this committee on April 17, 2012. 9)DOUBLE-REFERRAL . This bill is double-referred. Should it pass out of this committee, it will be referred to the Assembly Labor and Employment Committee. REGISTERED SUPPORT / OPPOSITION : Support California Association of Psychiatric Technicians California Psychiatric Association (prior version) California Psychological Association California Statewide Law Enforcement Association Opposition None on file. Analysis Prepared by : Cassie Royce / HEALTH / (916) 319-2097