Amended in Senate June 18, 2013

Amended in Assembly May 24, 2013

Amended in Assembly April 10, 2013

Amended in Assembly April 1, 2013

California Legislature—2013–14 Regular Session

Assembly Bill No. 1340

Introduced by Assembly Member Achadjian

February 22, 2013

An act to begin insert amend Sections 1180.1 and 1180.2 of, and to add Section 1255.9 to, the Health and Safety Code, and to amend Sections 4100 and 7200 of, and to end insert add Sections begin delete 4142 and end delete begin insert 4142, end insert 4143 begin delete to end delete begin insert , and 4144 to, end insert the Welfare and Institutions Code, relating to mental health.

LEGISLATIVE COUNSEL’S DIGEST

AB 1340, as amended, Achadjian. State Hospital Employees Act.

Existing law establishes state hospitals for the care, treatment, and education of mentally disordered persons. These hospitals are under the jurisdiction of the State Department of State Hospitals, which is authorized by existing law to adopt regulations regarding the conduct and management of these facilities. Existing law requires each state hospital to develop an incident reporting procedure that can be used to, at a minimum, develop reports of patient assaults on employees and assist the hospital in identifying risks of patient assaults on employees. begin insert Existing law provides for the licensure and regulation of health facilities, including acute psychiatric hospitals, by the State Department of Public Health. A violation of these provisions is a crime. end insert

This begin delete bill, as of July 1, 2015, end delete begin insert bill would establish an Enhanced Treatment Facility and specified programs within the State Department of State Hospitals, end insert and subject to available funding, would require each state hospital to establish and maintain an enhanced treatment unit begin insert (ETU) end insert as part of its begin delete facilities and end delete begin insert facilities. The bill would authorize an acute psychiatric hospital under the jurisdiction of the department to be licensed to offer an ETU that meets specified requirements, including that each room be limited to one patient, and would authorize the department to adopt and implement policies and procedures, as specified. Because the bill would create a new crime, it imposes a state-mandated local program. end insert

begin insert The bill end insert would also require any case of assault by a patient of a state hospital, as specified, to be immediately referred to the local district attorney, and if, after the referral, the patient is found guilty of a misdemeanor or a felony assault, the local district attorney declines to prosecute, or the patient is found incompetent to stand trial or not guilty by reason of insanity, the bill would require the patient to be placed in the begin delete enhanced treatment unit end delete begin insert ETU end insert of the hospital until the patient is deemed safe to return to the regular population of the hospital.

begin insert

The bill would authorize a state hospital psychiatrist or psychologist to refer a patient to an ETU for temporary placement and risk assessment upon determining that the patient may pose a substantial risk of inpatient aggression. The bill would require a forensic needs assessment panel (FNAP) to conduct a placement evaluation to determine whether the patient meets the threshold standard for treatment in an enhanced treatment program (ETP). The bill would require, if the FNAP determines that the ETU placement is appropriate, that the FNAP certify the patient for 90 days of ETP placement and provide the determination in writing to the patient and the patient’s advocate. The bill would also require a forensic needs assessment team (FNAT) psychologist to perform an in-depth clinical assessment and make a treatment plan upon the patient’s admission to an ETP. The bill would require the FNAP to meet with specified individuals to determine whether the patient may stay in the ETP placement or return to a standard security treatment setting and provide the determination in writing to the patient’s advocate. If the FNAP determines the patient is no longer appropriate for ETP placement, the FNAP may refer the patient to the 7-day step down unit, as defined, or a standard security setting in a department hospital.

end insert begin insert

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

end insert begin insert

This bill would provide that no reimbursement is required by this act for a specified reason.

end insert

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program:  begin delete no end delete begin insert yes end insert .

The people of the State of California do enact as follows:

SECTION 1.  

This act may be known and cited as the State
Hospital Employees Act.

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 1180.1 of the end insert begin insert Health and Safety Code end insert begin insert is
amended to read: end insert

1180.1.  

For purposes of this division, the following definitions
apply:

(a) “Behavioral restraint” means “mechanical restraint” or
“physical restraint” as defined in this section, used as an
intervention when a person presents an immediate danger to self
or to others. It does not include restraints used for medical
purposes, including, but not limited to, securing an intravenous
needle or immobilizing a person for a surgical procedure, or
postural restraints, or devices used to prevent injury or to improve
a person’s mobility and independent functioning rather than to
restrict movement.

(b) “Containment” means a brief physical restraint of a person
for the purpose of effectively gaining quick control of a person
who is aggressive or agitated or who is a danger to self or others.
begin insert ”Containment” does not include admission into an enhanced
treatment unit end insert begin insert or end insert begin insert enhanced treatment facility, end insert begin insert as defined in
subdivision (k) of Section 4144 of the Welfare and Institutions
Code. end insert

(c) “Mechanical restraint” means the use of a mechanical device,
material, or equipment attached or adjacent to the person’s body
that he or she cannot easily remove and that restricts the freedom
of movement of all or part of a person’s body or restricts normal
access to the person’s body, and that is used as a behavioral
restraint.

(d) “Physical restraint” means the use of a manual hold to restrict
freedom of movement of all or part of a person’s body, or to restrict
normal access to the person’s body, and that is used as a behavioral
restraint. “Physical restraint” is staff-to-person physical contact in
which the person unwillingly participates. “Physical restraint”
does not include briefly holding a person without undue force in
order to calm or comfort, or physical contact intended to gently
assist a person in performing tasks or to guide or assist a person
from one area to another.

(e) “Seclusion” means the involuntary confinement of a person
alone in a room or an area from which the person is physically
prevented from leaving. “Seclusion” does not include a “timeout,”
as defined in regulations relating to facilities operated by the State
Department of Developmental begin delete Services. end delete begin insert Services, nor does
”seclusion” include admission into an end insert begin insert enhanced treatment unit end insert
begin insert or end insert begin insert enhanced treatment facility, end insert begin insert as defined in subdivision (k) of
Section 414 end insert begin insert 4 of the Welfare and Institutions Code. end insert

(f) “Secretary” means the Secretary of California Health and
Human Services.

(g) “Serious injury” means significant impairment of the
physical condition as determined by qualified medical personnel,
and includes, but is not limited to, burns, lacerations, bone
fractures, substantial hematoma, or injuries to internal organs.

begin insert

begin insert SEC. 3. end insert   

end insert

begin insert Section 1180.2 of the end insert begin insert Health and Safety Code end insert begin insert is
amended to read: end insert

1180.2.  

(a) This section shall apply to the state hospitals begin insert , the
enhanced treatment units, and the enhanced treatment facility end insert
operated by the State Department of State Hospitals begin insert , as listed in
Section 7200 of the Welfare and Institutions Code, end insert and facilities
operated by the State Department of Developmental Services that
utilize seclusion or behavioral restraints.

(b) The State Department of State Hospitals and the State
Department of Developmental Services shall develop technical
assistance and training programs to support the efforts of facilities
described in subdivision (a) to reduce or eliminate the use of
seclusion and behavioral restraints in those facilities.

(c) Technical assistance and training programs should be
designed with the input of stakeholders, including clients and direct
care staff, and should be based on best practices that lead to the
avoidance of the use of seclusion and behavioral restraints,
including, but not limited to, all of the following:

(1) Conducting an intake assessment that is consistent with
facility policies and that includes issues specific to the use of
seclusion and behavioral restraints as specified in Section 1180.4.

(2) Utilizing strategies to engage clients collaboratively in
assessment, avoidance, and management of crisis situations in
order to prevent incidents of the use of seclusion and behavioral
restraints.

(3) Recognizing and responding appropriately to underlying
reasons for escalating behavior.

(4) Utilizing conflict resolution, effective communication,
deescalation, and client-centered problem solving strategies that
diffuse and safely resolve emerging crisis situations.

(5) Individual treatment planning that identifies risk factors,
positive early intervention strategies, and strategies to minimize
time spent in seclusion or behavioral restraints. Individual treatment
planning should include input from the person affected.

(6) While minimizing the duration of time spent in seclusion or
behavioral restraints, using strategies to mitigate the emotional
and physical discomfort and ensure the safety of the person
involved in seclusion or behavioral restraints, including input from
the person about what would alleviate his or her distress.

(7) Training in conducting an effective debriefing meeting as
specified in Section 1180.5, including the appropriate persons to
involve, the voluntary participation of the person who has been in
seclusion or behavioral restraints, and strategic interventions to
engage affected persons in the process. The training should include
strategies that result in maximum participation and comfort for
the involved parties to identify factors that lead to the use of
seclusion and behavioral restraints and factors that would reduce
the likelihood of future incidents.

(d) (1) The State Department of State Hospitals and the State
Department of Developmental Services shall take steps to establish
a system of mandatory, consistent, timely, and publicly accessible
data collection regarding the use of seclusion and behavioral
restraints in facilities described in this section. It is the intent of
the Legislature that data be compiled in a manner that allows for
standard statistical comparison.

(2) The State Department of State Hospitals and the State
Department of Developmental Services shall develop a mechanism
for making this information publicly available on the Internet.

(3) Data collected pursuant to this section shall include all of
the following:

(A) The number of deaths that occur while persons are in
seclusion or behavioral restraints, or where it is reasonable to
assume that a death was proximately related to the use of seclusion
or behavioral restraints.

(B) The number of serious injuries sustained by persons while
in seclusion or subject to behavioral restraints.

(C) The number of serious injuries sustained by staff that occur
during the use of seclusion or behavioral restraints.

(D) The number of incidents of seclusion.

(E) The number of incidents of use of behavioral restraints.

(F) The duration of time spent per incident in seclusion.

(G) The duration of time spent per incident subject to behavioral
restraints.

(H) The number of times an involuntary emergency medication
is used to control behavior, as defined by the State Department of
State Hospitals.

(e) A facility described in subdivision (a) shall report each death
or serious injury of a person occurring during, or related to, the
use of seclusion or behavioral restraints. This report shall be made
to the agency designated in subdivision (i) of Section 4900 of the
Welfare and Institutions Code no later than the close of the business
day following the death or injury. The report shall include the
encrypted identifier of the person involved, and the name, street
address, and telephone number of the facility.

begin insert

begin insert SEC. 4. end insert   

end insert

begin insert Section 1255.9 is added to the end insert begin insert Health and Safety Code end insert begin insert ,
to read: end insert

begin insert

begin insert 1255.9. end insert   

(a) On and after January 1, 2018, an acute psychiatric
hospital that is operated by the State Department of State Hospitals
may be licensed by the State Department of Public Health to offer,
as a special service, an enhanced treatment unit (ETU) to provide
treatment to the most violent patients.

(b) An ETU shall meet all of the following requirements:

(1) Maintain a staff-to-patient ratio of one-to-five.

(2) Limit each room to one patient.

(3) Each patient room shall allow visual access by staff 24 hours
per day.

(4) Each patient room shall have a private bathroom in the
room.

(c) Each patient room may have the capacity to lock the door
externally.

(d) An acute psychiatric hospital that has an approved ETU on
its license shall adopt and implement policies and procedures that
provide for all of the following:

(1) A definition of patients considered to be “most violent.”

(2) A process for a clinical assessment and review focused on
behavior, history, dangerousness, and clinical need for patients
who have been designated to receive treatment in an ETU.

(3) A process for a risk for violence assessment that meets the
criteria for treatment in an ETU.

(4) A process for a continuum of care with an ETU appropriate
for each patient’s need.

(5) A process for a phased treatment plan with regular clinical
review and reevaluation of placement back into an appropriate
unit for less violent patients that includes discharge planning
designed to achieve a quick and safe transition out of an ETU.

(6) A process for continual oversight and enhanced treatment
focused on the individual physical and psychiatric care and
assessment of a patient.

(7) Emergency egress of ETU patients and staff.

(e) Regulations defining an ETU that is operated by the State
Department of State Hospitals that are in effect prior to January
1, 2014, shall be inoperative until January 1, 2018. Regulations
adopted on and after January 1, 2014, shall not become effective
until January 1, 2018, and until that time, the enhanced treatment
units and facility are exempt from any licensing requirements.

end insert

begin insert

begin insert SEC. 5. end insert   

end insert

begin insert Section 4100 of the end insert begin insert Welfare and Institutions Code end insert begin insert is
amended to read: end insert

4100.  

The department has jurisdiction over the following
begin insert programs and end insert institutions:

(a) Atascadero State Hospital.

(b) Coalinga State Hospital.

(c) Metropolitan State Hospital.

(d) Napa State Hospital.

(e) Patton State Hospital.

begin insert

(f) State Department of State Hospitals Enhanced Treatment
Facility, subject to funding be made available in the annual Budget
Act.

end insert begin insert

(g) Vacaville Psychiatric Program of the State Department of
State Hospitals.

end insert begin insert

(h) Salinas Valley Psychiatric Program of the State Department
of State Hospitals.

end insert begin insert

(i) Stockton Psychiatric Program of the State Department of
State Hospitals.

end insert

begin delete SEC. 2. end delete
begin insert SEC. 6. end insert   

Section 4142 is added to the Welfare and Institutions
Code, to read:

4142.  

Commencing July 1, 2015, and subject to available
funding, each state hospital shall establish and maintain an
enhanced treatment unit as part of its facilities for the placement
of patients described in begin delete Section 4143. end delete begin insert Sections 4143 and 4144. end insert
The hospital administrator of each state hospital shall establish
procedures to provide an increased level of security for the
enhanced treatment unit.

begin delete SEC. 3. end delete
begin insert SEC. 7. end insert   

Section 4143 is added to the Welfare and Institutions
Code, to read:

4143.  

(a) Subject to available funding, any case of assault by
a patient of a state hospital that causes injury to or illness of, or
has the potential to cause future illness of, a state hospital employee
or another patient of the state hospital rising to the level of a
misdemeanor or felony shall be immediately referred to the local
district attorney.

(b) If, after referral to the local district attorney, the patient is
found guilty of misdemeanor or felony assault, the local district
attorney declines prosecution, the patient is found to be
incompetent to stand trial, or the patient is found not guilty by
reason of insanity, the patient shall be placed in the enhanced
treatment unit of the state hospital begin insert pursuant to Section 4144, end insert until
the patient is deemed safe to return to the regular population of
the hospital.

(c) This section shall become operative on July 1, 2015.

begin insert

begin insert SEC. 8. end insert   

end insert

begin insert Section 4144 is added to the end insert begin insert Welfare and Institutions
Code end insert begin insert , to read: end insert

begin insert

begin insert 4144. end insert   

(a) A state hospital psychiatrist or psychologist may
refer a patient to an enhanced treatment unit (ETU) for temporary
placement and risk assessment upon determining that the patient
may pose a substantial risk of inpatient aggression and the
patient’s care and treatment may not be possible in a standard
security treatment environment. The referral may occur at any
time after the patient has been admitted to a hospital or program
under the jurisdiction of the department.

(b) Within three business days of placement in an ETU, a
dedicated forensic evaluator, who is not on the patient’s treatment
team, shall complete a full clinical evaluation of the patient that
shall include an analysis of diagnosis, past violence, and any
instances of an offense, and a valid and reliable violence risk
assessment.

(c) (1) Within seven business days of placement in an ETU and
with 72-hour notice to the patient and patient’s advocate, the
forensic needs assessment panel (FNAP) shall conduct a placement
evaluation meeting with the referring psychiatrist or psychologist,
the patient and patient’s advocate, and the dedicated forensic
evaluator who performed the full clinical evaluation. A
determination shall be made as to whether the patient meets the
threshold standard for treatment in an enhanced treatment program
(ETP).

(2) (A) The threshold standard for treatment in an ETP may
be met if a doctor, utilizing standard forensic methodologies for
clinically assessing violence risk, determines that a patient poses
a substantial risk of inpatient aggression and the patient’s care
and treatment cannot be provided in his or her present
environment.

(B) Factors used to determine a patient’s substantial risk of
inpatient aggression may include, but are not limited to, an analysis
of past violence, delineation of static and dynamic violence risk
factors, and utilization of valid and reliable violence risk
assessment testing.

(3) If a patient has shown improvement during his or her
placement in an ETU, the FNAP may delay its decision for another
seven business days. The FNAP’s determination of whether the
patient is appropriate for continued or longer term ETU placement
and treatment shall be based on the threshold standard for
treatment in an ETP as specified in paragraph (1).

(d) (1) After consideration of discussion and reviewed materials,
the FNAP shall either certify the patient for 90 days of treatment
in an ETP or direct that the patient be returned to a standard
security treatment environment in the hospital.

(2) After the FNAP makes a decision to provide an ETP on a
longer term basis and if the ETP will be provided at a hospital
other than the referring hospital, such as an enhanced treatment
facility (ETF), the transfer may take place as soon as
transportation may be reasonably arranged.

(3) The FNAP determination shall be in writing and provided
to the patient and patient’s advocate as soon as possible, but if
the ETP will be provided at a state hospital other than the referring
hospital, then no later than prior to transfer. The determination
shall also be included in a quarterly report to the State Department
of Health Care Services.

(e) (1) Upon admission to an ETP, a forensic needs assessment
team (FNAT) psychologist who is not on the patient’s treatment
team shall perform an in-depth clinical assessment and make a
treatment plan for the patient within 14 business days of placement
in the ETP. Formal treatment plan reviews shall occur on a
monthly basis, which shall include a full report on the patient’s
behavior while in the ETP.

(2) An ETP patient shall receive treatment from a team of
psychologists, a psychiatrist, a nurse, and a psychiatric technician,
who shall meet as often as necessary, but no less than on a weekly
basis, to assess the patient’s need for continued placement in an
ETP.

(f) Prior to the expiration of 90 days from the date of placement
in an ETP and with 72-hour notice provided to the patient’s
advocate, the FNAP shall convene a treatment placement meeting
with a psychologist from the treatment team, a patient advocate,
the patient, and the FNAT psychologist who performed the in-depth
clinical assessment. The FNAP shall determine whether the patient
may return to a standard security treatment environment or
whether the patient is appropriate for continued ETP placement.
If after consideration of the discussion and documentation, the
FNAP determines that the patient requires continued ETP
placement, the patient shall be certified for further treatment. The
FNAP determination shall be in writing and provided to the
patient’s advocate within 24 hours of the meeting. The report shall
also be included in a quarterly report to State Department of
Health Care Services.

(g) The FNAP shall review the patient’s treatment summary
every 90 days after the first FNAP meeting and determine if the
patient requires continued ETP placement. If the FNAP determines
that the patient is no longer appropriate for ETP placement, the
FNAP may refer the patient to the seven-day step down unit or to
a standard security treatment environment in a state hospital. The
FNAP report shall also be included in a quarterly report to State
Department of Health Case Services.

(h) If a patient continues to remain in an ETP placement, prior
to the expiration of one year from the date of certification to an
ETP and with 72-hour notice provided to the patient’s advocate,
the FNAP shall convene a treatment placement meeting with a
psychologist from the treatment team, a patient advocate, the
patient, and the FNAT psychologist who performed the in-depth
clinical assessment. The FNAP shall determine whether the patient
may return to a standard security treatment environment or
whether the patient is appropriate for continued ETP placement.
If after consideration of the discussion and documentation, the
FNAP determines that the patient requires continued ETP
placement, the patient shall be certified for further treatment for
an additional year. The FNAP determination shall be in writing
and provided to the patient’s advocate within 24 hours of the
meeting. The report shall also be included in a quarterly report
to State Department of Health Care Services.

(i) At any point during an ETP placement, if a patient’s
treatment team determines that the patient no longer requires
treatment at the ETU or ETF, a recommendation to transfer the
patient out of the ETU or ETF shall be made to the FNAT and
FNAP. After a determination that an ETP placement is no longer
necessary, the patient shall be transferred to a step down unit for
seven business days for transitioning and evaluation of the patient’s
stability at the step down unit. After completing the seven-day step
down placement, the FNAT shall meet to recommend either
continued evaluation at the step down unit, a return to ETP
placement, or a transfer to a standard security treatment
environment in a state hospital. If the FNAT recommends that the
patient be transferred to a standard security treatment
environment, the department shall identify a state hospital and
appropriate placement, and transfer the patient within 30 business
days of the recommendation.

(j) The process described in this section may continue until the
patient is no longer appropriate for ETP placement or until the
patient is discharged from the state hospital.

(k) As used in this section, the following terms have the following
meanings:

(1) “Enhanced treatment environment” means an enhanced
treatment unit, an enhanced treatment facility, or a step down unit.

(2) “Enhanced treatment facility” or “ETF” means a state
hospital that is part of the enhanced treatment program designed
and dedicated to house and treat patients who have been assessed
to pose a substantial risk of inpatient aggression which cannot be
contained in a standard treatment program.

(3) “Enhanced treatment program” or “ETP” means
supplemental treatment provided in an acute psychiatric hospital
or facility under the jurisdiction of the department for patients
who have been assessed to pose a substantial risk of inpatient
aggression which cannot be contained in a standard treatment
program.

(4) “Enhanced treatment unit” or “ETU” means a unit in a
hospital under the jurisdiction of the department that is part of the
enhanced treatment program designed to house, treat, and evaluate
patients who have been assessed to pose a substantial risk of
inpatient aggression which cannot be contained in a standard
treatment program.

(5) “Forensic needs assessment panel” or “FNAP” means a
panel that consists of the placement hospital medical director, the
referring hospital medical director if the patient will be transferred,
and the ETF hospital medical director or their designee, who all
evaluate the placement of a patient into an ETP, and conduct ETP
placement evaluation meetings.

(6) “Forensic needs assessment team” or “FNAT” means a
panel of psychologists with expertise in forensic assessment and/or
violence risk assessment, each of whom are assigned an ETP case,
or group of cases, to conduct an in-depth violence risk assessment,
ensure the treatment plan encompasses the elements delineated
by that assessment, and follow the patient through placement in
the ETP.

(7) “In-depth violence risk assessment” means the utilization
of standard forensic methodologies for clinically assessing the
risk of a patient posing a substantial risk of inpatient aggression.

(8) “Standard security treatment environment” means a state
hospital or facility, or a portion of a state hospital or facility, that
is not part of an enhanced treatment environment.

(9) “Step down unit” means a unit in an enhanced treatment
unit or enhanced treatment facility that is part of the enhanced
treatment program designed to help assess a patient’s readiness
to return to a standard security treatment environment.

end insert

begin insert

begin insert SEC. 9. end insert   

end insert

begin insert Section 7200 of the end insert begin insert Welfare and Institutions Code end insert begin insert is
amended to read: end insert

7200.  

There are in the state the following state hospitals for
the care, treatment, and education of the mentally disordered:

(a) Metropolitan State Hospital near the City of Norwalk, Los
Angeles County.

(b) Atascadero State Hospital near the City of Atascadero, San
Luis Obispo County.

(c) Napa State Hospital near the City of Napa, Napa County.

(d) Patton State Hospital near the City of San Bernardino, San
Bernardino County.

(e) Coalinga State Hospital near the City of Coalinga, Fresno
County.

begin insert

(f) State Department of State Hospitals Enhanced Treatment
Facility at a location to be determined by the State Department of
State Hospitals and subject to available funding.

end insert

begin insert

begin insert SEC. 10. end insert   

end insert begin insert

No reimbursement is required by this act pursuant
to Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.

end insert