BILL ANALYSIS Ó
SB 1228
Page 1
Date of Hearing: August 28, 2012
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 1228 (Alquist) - As Amended: August 27, 2012
SENATE VOTE : 36-0
SUBJECT : Small house skilled nursing facilities.
SUMMARY : Establishes, until January 1, 2020, within the
Department of Public Health (DPH) the Small House Skilled
Nursing Facilities (SHSNFs) Pilot Program to allow DPH to
authorize the development and operation of up to 10 SHSNFs.
Specifically, this bill :
1)Establishes within DPH the SHSNFs Pilot Program to allow DPH
to authorize the development and operation of up to 10 SHSNFs.
2)Defines SHSNFs as a health facility that provides skilled
nursing care and supportive care in a small, homelike,
residential setting in an apartment, cottage, house, or
similar residential unit, to patients whose primary need is
for the availability of skilled nursing care on an extended
basis. Permits a SHSNF to consist of a group or cluster of
such residential homes, each home having 12 or fewer beds, or
a distinct area within an existing skilled nursing facility
(SNF) that otherwise meets the definition of a SHSNF, is
physically separate and distinguishable from the remainder of
the SNF, and has a distinct entry with no traffic of staff,
residents, or visitors not affiliated with the SHSNF. Permits
a SHSNF to also be a distinct part of a general acute care
hospital or an acute psychiatric hospital.
3)Defines "home" as an apartment, home, or other similar unit
that serves 12 or fewer residents.
4)Establishes characteristics for facilities that are eligible
for the SHSNF pilot program.
5)Permits a facility to be licensed by DPH as a SHSNF pilot
facility if the facility meets both of the following
requirements:
a) The facility has been determined by DPH to comply with
SB 1228
Page 2
all provisions necessary to be certified to participate as
a provider of care either as a SNF in the federal Medicare
Program or as a nursing facility in the federal Medicaid
Program; and,
b) The facility has been determined by DPH and the Office
of Statewide Health Planning and Development (OSHPD) to
fully comply with all pilot program requirements.
6)Requires each SHSNF pilot facility to be subject to the same
licensing enforcement provisions, in existing law, that apply
to other SNFs.
7)Requires each SHSNF pilot facility to be subject to DPH's
Licensing and Certification program fee for SNFs.
8)Requires each SHSNF pilot facility to receive a peer group
weighted average Medi-Cal reimbursement rate as calculated by
the Department of Health Care Services.
9)Requires DPH to permit the formulation of new standards for
long-term care that may extend beyond, or vary from,
traditional long-term health care facility models, including
but not limited to, facility layout and design consistent with
newly adopted revisions to the California Building Standards
Code, nursing care levels, staffing levels, infection control,
sanitation, dietary services, and other personal care and
habilitation provisions that may be more flexible than those
currently required in California for SNFs and continuous
nursing facilities.
10)Requires DPH, together with OSHPD and the State Long-Term
Care Ombudsman, in developing the standards for the SHSNF
pilot program to consult long-term care providers, health
advocacy organizations, health care employees organizations,
consumer advocates, elder care advocates, and others
identified as having a vested interest in long-term health
care.
11)Requires DPH to issue, by July 1, 2013, one or more All
Facilities Letters that provide the standards to be used by
providers accepted into the pilot program for the development
and operation of all pilot facilities.
12)Establishes several additional definitions, including
SB 1228
Page 3
defining: a) "versatile worker" which means a certified
nursing assistant who provides personal care, socialization,
activity aid services, meal preparation services, and laundry
and housekeeping services; b) "supportive care" which includes
the provision of socialization, activity aide services, and
homemaker services; and, c) "homemaker services" which means
food preparation, housekeeping, laundry, and maintenance
services.
13)Requires each pilot facility to provide for consistent staff
assignments and self-managed work teams of direct care staff,
including staff working as versatile workers. Requires
licensed nursing staff to direct versatile workers in all
activities delegated under the licensed nurses' scope of
practice. Permits a versatile worker to be supervised by
nonclinical staff when performing nonclinical duties, at the
discretion of the facility.
14)Requires DPH to establish criteria to measure the benefits
and successes of SHSNFs, as a whole, and to compare the
results achieved by each model variant. Requires DPH to
evaluate and analyze the emerging concepts in long-term SNFs
developed pursuant to the pilot program for purposes of
considering future regulatory modification.
15)Requires DPH to prepare and submit a report to the
Legislature on the results of the SHSNF pilot program.
Requires the report to be submitted to the Legislature at
least 24 months prior to the termination of the pilot program,
and requires the report to include an evaluation of the pilot
program's cost, safety, and quality of care.
16)Sunsets the SHSNF pilot program on January 1, 2020.
17)Makes conforming changes to avoid chaptering out problems
with SB 135 (Ed Hernandez) of 2012 regarding free standing
hospice facility licensure.
18)Makes other technical and clarifying changes.
EXISTING LAW :
1)Provides for the licensure of health facilities, including
SNFs, by DPH.
SB 1228
Page 4
2)Defines "SNF" as a health facility that provides skilled
nursing care and supportive care to patients whose primary
need is for availability of skilled nursing care on an
extended basis.
3)Requires OSHPD, under the Alfred E. Alquist Hospital
Facilities Seismic Safety Act, to assume responsibility for
the enforcement of all building standards related to hospital
buildings, including SNFs.
EXISTING REGULATIONS :
1)Further define "SNF" as a facility providing 24-hour inpatient
care and, at a minimum, includes physician, skilled nursing,
dietary, and pharmaceutical services and an activity program.
2)Require each SNF licensed for 59 or fewer beds to have at
least one registered nurse or a licensed vocational nurse,
awake and on duty, in the facility at all times, day and
night.
3)Require each SNF to employ sufficient nursing staff to provide
a minimum of 3.2 nursing hours per patient day. Require this
staffing ratio to only include direct caregivers, which is
defined to include registered nurses, licensed vocational
nurses, psychiatric technicians, or certified nurse
assistants, who are performing nursing services.
4)Specify that while all SNFs are required to maintain
compliance with licensing requirements, these requirements are
not to prohibit the use of alternate concepts, methods,
procedures, techniques, equipment, personnel qualifications,
or the conducting of pilot projects, as long as such
exceptions have prior written approval of DPH.
FISCAL EFFECT : This bill, as amended has not yet been heard by
a fiscal committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, SHSNFs
implementing the core practices outlined in this bill are an
important development in long-term care options that many
consumers, family, and staff prefer to traditional settings.
The author states that they also deliver better clinical
SB 1228
Page 5
outcomes, more direct-care time, and greater resident
engagement at the same operating cost as traditional nursing
homes. The author asserts that this deep culture change model
of small house nursing homes is proliferating in many states
and meets all federal nursing home certification requirements.
Unfortunately, these homes are difficult to develop in
California under current state requirements, and California's
current statutory and regulatory framework did not anticipate
this significant innovation.
According to the author, SHSNFs following the practices outlined
in this bill currently require multiple agency interpretations
and waivers to move forward in California. These
interpretations and waivers add a great deal of time and
expense to implementation - both for the provider
organizations and the state agencies involved. This
additional time and expense discourages their development and
deprives California residents of this important option.
The author states that this bill would create a SHSNF pilot
program to assist the development of SHSNFs in California
implementing the core practices that research has shown to
reliably deliver improved satisfaction, quality, and cost
outcomes.
The August 24, 2012 floor amendments changed this bill from
establishing a new licensing category for SHSNFs to a pilot
program. The Assembly Health Committee is hearing these
substantive changes as well as the August 27, 2012 amendments
which do the following:
a) Limit the SHSNF pilot facility license to 12 beds;
b) Establish a definition of "home" for purposes of this
bill;
c) Clarify that a SHSNF pilot facility kitchen may be open,
but must allow for separation in accordance with building
standards; and,
d) Make various technical changes.
2)PERSON-CENTERED CARE IN NURSING HOMES AND THE CULTURE-CHANGE
MOVEMENT . According to the Commonwealth Fund, in the 1980's
consumer groups exposed substandard care in some nursing
homes, as well as instances of even more dire problems like
abuse and neglect. These revelations led the Institute of
Medicine to issue a report recommending major regulatory
SB 1228
Page 6
changes and, in 1987, Congress passed a sweeping set of
nursing home reforms that required facilities to provide
individualized, or "person-centered," care. As a result, some
providers began to move away from the institutional model of
nursing home care and toward a more home-like environment in
which residents could have a say in their day-to-day lives.
According to the Commonwealth Fund, proponents of culture
change do not recommend a specific model or set of practices.
Instead, they support principles governing resident care
practices; organizational and human resource practices; and
the design of the physical facility. According to these
principles, an ideal culture change facility would feature:
a) Resident direction. Residents should be offered choices
and encouraged to make their own decision about personal
issues like what to wear or when to go to bed;
b) Homelike atmosphere . Practices and structures should be
more homelike and less institutional. For instance, larger
nursing units with 40 or more residents would be replaced
with smaller "households" of 10 to 15 residents, residents
would have access to refrigerators for snacks, and overhead
public address systems would be eliminated;
c) Close relationships . To foster strong bonds, the same
nurse should always provide care to a resident;
d) Staff empowerment . Staff should have the authority, and
the necessary training, to respond on their own to
residents' needs. The use of care teams should also be
encouraged;
e) Collaborative decision-making . The traditional
management hierarchy should be flattened, with frontline
staff given the authority to make decisions regarding
residents' care; and,
f) Quality improvement processes . Culture change should be
treated as an ongoing process of overall performance
improvement, not just as a superficial change or provision
of amenities.
According to the California HealthCare Foundation (CHCF),
recent literature shows that nursing homes embracing culture
change have improved quality outcomes and offer preliminary
evidence of positive business impacts. However, CHCF
indicates that California has lagged behind other states in
culture change.
3)THE GREEN HOUSE CONCEPT . This bill is sponsored by NCB
SB 1228
Page 7
Capital Impact (NCB), which has established The Green House
Project, funded by the Robert Wood Johnson Foundation, to help
spur replication of The Green House concept. NCB describes
The Green House concept as an innovative model for residential
long-term care that involves a total rethinking of the
philosophy of care, architecture, and organizational structure
normally associated with long-term care.
According to NCB, a Green House home is an independent,
self-contained home for six to 12 people, designed to look
like a private home or apartment in the surrounding community.
NCB states that Green House homes are typically licensed as
SNFs and meet all applicable federal and state regulatory
requirements. Each home is staffed by a team of universal
workers, who have core training as Certified Nurse Assistants
(CNA), plus extensive training in the Green House philosophy,
the self-managed work team structure of the Green House home,
culinary skills, and household management. These CNAs provide
personal care, meal preparation, and light housekeeping and
laundry, among other duties.
Preliminary studies have suggested that care in Green
House-model SNFs may lead to small improvements in certain
outcomes, such as more direct care time per day in Green House
models as compared to similar residents in traditional nursing
homes. Studies are ongoing to attempt to tease out whether
Green House offers better care than traditional nursing homes
and, if so, which specific elements and practices are making
the difference.
According to the author, Green House homes are currently
operating in 21 states. The author states that one California
nursing home provider has been working for three years to
implement the Green House model, but the provider has
experienced significant delays and added costs because the
Green House model does not fit well with California's current
law.
REGISTERED SUPPORT / OPPOSITION :
Support
None on file.
Opposition
SB 1228
Page 8
None on file.
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097