BILL ANALYSIS Ó
AB 40
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Date of Hearing: April 30, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 40 (Mansoor) - As Amended: April 17, 2013
SUBJECT : Substance abuse: recovery and treatment facilities.
SUMMARY : Requires alcoholism and drug abuse recovery or
treatment (ADART) program licensees to report deaths and other
unusual events to the Department of Alcohol and Drug Programs
(DADP) and requires licensees that provide medical
detoxification services to provide those services under the
supervision of a medical doctor. Specifically, this bill :
1)States that the death investigation policy of DADP is designed
to ensure that a resident's death is reported by the licensee
and addressed by DADP in a timely manner.
2)Requires the licensee to make a telephonic report to DADP
within one working day for any of the following events or
incidents: a) death of any resident for any cause, even if the
death did not occur at the facility; b) any facility-related
injury of any resident that requires medical treatment; c) all
cases of reportable communicable disease, as specified; d)
poisonings; e) natural disasters that affect the facility
premises; f) fires or explosions that occur in or on the
facility premises; and, g) unusual events or incidents that
affect the physical or emotional health or safety of any
resident.
3)Requires the licensee to make a written report to DADP, in a
form prescribed by DADP, within seven days of any of the
events or incidents listed in 2) a) through f) above.
4)Requires both of these reports to include a description of the
event or incident, including the time, location, and nature of
the event or incident, a list of immediate actions that were
taken, including persons contacted, and a description of the
followup action that is planned, including steps taken to
prevent a recurrence of the event or incident.
5)Requires drug and alcohol program licensees offering medical
detoxification services to provide those services under the
supervision of a medical doctor.
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6)Requires DADP to confirm that appropriate licensing is in
place for medical doctors providing medical detoxification
services, and confirm that appropriate licensing and
monitoring is in place for health care providers who provide
any intravenous medication or detoxification medication.
7)Requires DADP to establish a formal procedure for obtaining
information about any disciplinary proceedings against health
care providers from the boards that license those providers.
EXISTING LAW :
1)Gives DADP sole authority in state government to license adult
ADART facilities.
2)Defines ADART facility as any premises, place, or building
that provides 24-hour residential nonmedical services to
adults who are recovering from problems related to alcohol,
drug, or alcohol and drug misuse or abuse, as specified.
3)Prohibits the operation of an ADART program without first
obtaining a current valid license issued by DADP pursuant to
current law, as specified.
4)Requires ADART licensees to provide at least one of the
following nonmedical services: recovery services, treatment
services, or detoxification services.
5)Prohibits an ADART licensee from operating an alcoholism or
drug abuse recovery or treatment facility beyond the
conditions and limitations specified on their license.
6)Gives DADP sole authority in state government to determine the
qualifications of personnel working within alcoholism or drug
abuse recovery and treatment programs, as specified.
7)Requires DADP to implement a voluntary program certification
procedure for ADART services and to develop standards and
regulations for ADART services that describe the minimal level
of service quality required of the service providers to
qualify for and obtain state certification. Exempts the
certification standards from the rulemaking requirements of
the Administrative Procedure Act and makes these standards
voluntary.
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8)Current state regulations (California Code of Regulations,
Title 9, Division 4, Chapter 5, Section 10561(b)) contain
nearly identical requirements to the reporting requirement in
this bill: telephone reports within one working day; a written
report within seven working days; reports required for deaths
and injuries that require treatment; reportable communicable
diseases; poisonings; catastrophes (natural disasters); and,
fires/explosions.
9)Eliminates DADP as of July 1, 2013, and transfers its
functions to other departments within the state Health and
Human Services Agency (CHHSA).
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . A report published September 4, 2012,
by the California Senate Office of Oversight and Outcomes
(SOOO) identified two serious problems in DADP's regulation of
ADART programs: a) troubling gaps in the Department of Alcohol
and Drug Program's regulation of residential programs: failure
to pursue evidence of problems, slow responses to deaths and
other serious incidents, and reluctance to use the full
spectrum of its statutory powers to shut down programs that
pose a danger to the public; and, b) widespread flouting of
the state's ban on medical care at residential drug and
alcohol programs.
The author states this bill seeks to implement the recommended
reforms in the SOOO report to improve the quality of care
provided in residential facilities and to ensure that proper
oversight is established.
2)BACKGROUND . The state's residential ADART facilities are
authorized to provide nonmedical services to individuals
recovering from alcohol and drug addiction. ADART programs
must be licensed by DADP, with licensing criteria that are
focused on health and safety rather than treatment program
content. DADP conducts site visits every two years to check
for compliance with regulations, including: staff tuberculosis
tests; health questionnaires for residents; staff First Aid
and cardiopulmonary resuscitation (CPR) training; and,
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adequate food for residents.
Licensing of ADART programs was shifted from the Department of
Social Services (DSS) to DADP in the 1980s because ADART
programs required less intensive services than other
facilities licensed by DSS. At the time, the dominant model
of treatment for substance abuse recovery was the social
model, a peer-oriented program based on the 12th step in the
Alcoholics Anonymous process: reaching out to help other
alcoholics as a way of sustaining sobriety. The social model
is essentially nonmedical; accordingly, the ADART programs
were defined in statute as programs that provide nonmedical
services.
3)SOOO REPORT . In September 2012, the SOOO published a report
titled "Rogue Rehabs: State failed to police drug and alcohol
homes, with deadly results." The report focuses on two key
problems in DADP's oversight of ADART programs. First, the
report identifies a pattern, over the past decade, of DADP
failing to identify potentially dangerous problems and, when
it does, neglecting to follow up to assure that they have been
corrected. Second, the report found evidence of the
widespread provision of medical treatment by ADART programs,
in direct violation of state law.
The SOOO report investigates several incidents where DADP's
enforcement and investigation activities following resident
deaths at ADART facilities were inconsistent. At one facility
where four patient deaths occurred over a span of two and a
half years, DADP was slow to respond: one death was only
investigated a year and a half after the fact, upon DADP
learning of another death in the same facility. By the time
DADP suspended the facility's license, the home had already
been closed due to foreclosure. At other facilities, patients
who were too sick to receive care at an ADART facility died
after being admitted with the expectation that they would
receive medical care.
According to the report, DADP says it is now being more
aggressive in halting practices that could lead to injury or
death, and the record shows that it is indeed revoking and
suspending licenses more frequently. DADP has implemented new
policies intended to focus limited resources on cases that
pose the greatest risk to the public. According to the report,
this new approach, however, may be a function of the current
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leadership and subject to change, especially when the
department's duties are shifted to another state operation in
July 2013. The report recommends that DADP's recent death
investigation policy be used as a template for statutory death
investigation requirements, if the policy is found to be
effective.
The second major problem identified by the SOOO report is that
DADP interprets its mission as overseeing non-medical care in
residential homes, yet the industry routinely offers services
that include medications and care by doctors and other medical
professionals. Though many programs continue to adhere to the
"social model," much of the industry has abandoned that model
in favor of a "comfortable" model that provides medicine to
help with detoxification. The report's survey of websites,
press releases, and non-profit tax returns identified 34
programs that made claims that appeared to violate state law
and regulations barring medical care.
The report notes that California is unusual among populous
states in prohibiting medical care in residential treatment
programs, and the report recommends that the Legislature
consider approving a bill allowing medical care in residential
treatment facilities, given that many experts believe that
medical care is an integral part of successful treatment.
However, the report adds that it would not be enough to simply
lift the ban; the state may have to strengthen other laws and
regulations to make sure that medical care is safe and
effective.
4)SUPPORT . In support, one individual physician argues that
the bill appropriately focuses strictly on detoxification
services and increases the emphasis on proper licensure,
oversight, reporting of poor outcomes, and enforcement.
5)OPPOSITION . In opposition, Promises Treatment Centers
(Promises) objects to the provision of the bill requiring
medical detoxification services to be provided under the
supervision of a medical doctor. Promises argues that this
provision adds unnecessary new requirements and a new level of
regulatory compliance that would place both a qualification
and operational burden on the residential alcohol and drug
treatment center business model.
6)RELATED LEGISLATION . AB 395 (Fox), pending in the Assembly
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Appropriations Committee, would expand the types of facilities
licensed by DADP to also include any facility that does not
require a health facility license and has a nationally
accredited program that uses a multidisciplinary team to
provide 24-hour residential medical services to adults
recovering from alcohol and drug abuse problems.
7)PREVIOUS LEGISLATION .
a) SB 1014 (Committee on Budget), Chapter 36, Statutes of
2012, was a 2012-13 Budget trailer bill. SB 1014
eliminates DADP and transfers the administrative and
programmatic functions of DADP to departments within CHHSA.
b) AB 972 (Butler) of 2011 would have expanded ADART
licensing to facilities that provide limited medical
services using a multidisciplinary team. AB 972 was held
on the Senate Appropriations Suspense File, then amended to
address a different subject.
c) AB 2221 (Beall) of 2010 would have expanded ADART
licensing to facilities that provide limited medical
services using a multidisciplinary team. AB 2221 died on
the Senate Appropriations Committee Suspense File.
d) AB 1055 (Chesbro) of 2009 would have allowed ADART
facilities to include, at the sole discretion of the
facility, detoxification services assisted by licensed
physicians. AB 1055 died on the Assembly Appropriations
Committee Suspense File.
e) AB 396 (Committee on Budget), Chapter 709, Statutes of
1992, requires that DADP, in administering the licensing of
those ADART programs, issue new licenses for a period of
two years, and that onsite program visits for compliance be
conducted at least once during the license period. AB 396
also authorizes DADP to conduct unannounced onsite program
visits.
f) SB 990 (Watson), Chapter 919, Statutes of 1989, excludes
ADART facilities from the California Community Care
Facilities Act and instead requires that these facilities
and programs be licensed by DADP, as specified.
8)SUGGESTED AMENDMENTS .
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a) The bill as drafted leaves the current law limiting
treatment in ADART facilities to nonmedical services in
place. At the same time, it requires facilities that
provide "medical detoxification" services to provide those
services under the supervision of a medical doctor. There
is currently a proposal, AB 395, pending in the Legislature
to make it legal to provide some medical services in ADART
facilities, but it may be premature for this bill to impose
requirements on facilities that provide these not-yet-legal
services. Therefore, the committee may wish to consider
striking Section 3 of this bill.
b) In addition, the bill requires DADP to establish a
formal procedure for obtaining information from boards that
license health care providers as to any potential
disciplinary proceedings against those providers by the
board. This requirement is drawn from a recommendation in
the SOOO report that the department that takes over
residential licensing should also establish a formal
procedure for sharing information with boards that license
medical professionals. However, as noted above, it is not
yet legal for ADART programs to provide medical services,
so health care providers should not be working at ADART
facilities, regardless of the status of their license.
Therefore, the committee may wish to consider striking
Section 2 of the bill.
c) Another key problem identified by the SOOO report is
that DADP is slow to respond to residents' deaths.
However, this bill's current language does not directly
require DADP to adopt a policy that allows for timely
investigation. This bill states: "The death investigation
policy of the department is designed to ensure that a
resident's death is reported by the licensee and addressed
by the department in a timely manner." This is a statement
of fact, not the creation of a requirement. Therefore, the
committee may wish to amend the bill to read: "The death
investigation policy of the department is shall be designed
to ensure that a resident's death is reported by the
licensee and addressed by the department in a timely
manner."
REGISTERED SUPPORT / OPPOSITION :
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Support
Four individuals
Opposition
Narconon Western United States
Promises Treatment Centers
Analysis Prepared by : Ben Russell / HEALTH / (916) 319-2097