BILL ANALYSIS Ó Senate Appropriations Committee Fiscal Summary Senator Kevin de León, Chair AB 1340 (Achadjian) - Enhanced treatment programs. Amended: July 2, 2014 Policy Vote: Health 8-0, PS 7-0 Urgency: No Mandate: Yes Hearing Date: August 14, 2014 Consultant: Brendan McCarthy SUSPENSE FILE. AS AMENDED. Bill Summary: AB 1340 would authorize the creation of enhanced treatment programs within the state hospital system, to provide enhanced treatment to patients with histories of violent behavior. Fiscal Impact (as approved on August 14, 2014): One-time costs likely in the low hundreds of thousands to develop policies and regulations by the Department of State Hospitals (General Fund). One-time costs likely in the tens of millions for the construction of new enhanced treatment program facilities (General Fund). The Department intends to renovate existing units of state hospitals to create units for the new enhanced treatment programs, rather than to construct new buildings. Most state hospital facilities are very old and do not meet current building standards. The costs to significantly renovate portions of state hospital facilities are likely to be significant. Increased staffing costs of about $2.5 million per year to comply with the higher staff-to-patient ratio required in the bill (General Fund). Under current law and practice, state hospitals have a nursing staff-to-patient ratio of one-to-six on acute units (with a lower ratio during the night shift). This bill requires a staff-to-patient ratio of one-to-five at all times. Based on the Department's plan to create four enhanced treatment programs with either eight or twelve patients and the need for 24-hour per day coverage, staff estimates that the Department will need about 16 additional nursing positions at a cost of about $2.5 million per year. AB 1340 (Achaddjian) Page 1 Ongoing costs of $800,000 per year for a contracted patient advocate for each enhanced treatment program (General Fund). Minor additional costs for licensing of enhanced treatment programs by the Department of Public Health (Licensing and Certification Fund). Background: The Department of State Hospitals manages five state hospitals: Atascadero, Coalinga, Metropolitan, Napa, and Patton. Over time, the patient population of the state hospital system has shifted to almost entirely comprise "forensic" patients who have a history of violent behavior and/or criminal behavior. Forensic patients committed to state hospitals include individuals found incompetent to stand trial, not guilty by reason of insanity, mentally disordered offenders, and sexually violent predators. As the patient population has shifted to a more forensic population, incidents of violence against state hospital staff and other patients have increased significantly. According to the Department, in 2013 there were 2,586 patient-on-staff assaults and 3,344 patient-on-patient assaults. Because the state hospital system was not initially designed as a system to accommodate mostly forensic population, the state hospital system often lacks the physical infrastructure to handle violent patients. Since December 2011, the Department has operated a pilot enhanced treatment unit at Atascadero State Hospital. That pilot unit does not allow for locked doors, but is otherwise the model for the proposal in this bill. A review by the Department indicates that the pilot program is likely effective at reducing violence. In the recently adopted Budget Act, the Department was appropriated $2 million for planning for the development of facilities to accommodate enhanced treatment programs (conditional on the enactment of authorizing legislation). Proposed Law: AB 1340 would authorize the creation of an enhanced treatment program within the state hospital system, to provide enhanced treatment to patients with histories of violent behavior. AB 1340 (Achaddjian) Page 2 Specific provision of the bill would: Require the enhanced treatment pilot program to meet the licensing requirements for acute psychiatric hospitals, unless otherwise specified; Authorize the Department of State Hospitals to create a pilot enhanced treatment program, from July 1, 2015 to January 1, 2018; Authorize the Department to adopt emergency regulations to implement the bill; Specify criteria for the enhanced treatment program, including staff-to-patient ratios and requirements for the patient rooms; Authorize patient room doors to be locked by staff when clinically indicated; Require the adoption of policies and procedures for admission criteria, clinical assessment of patients, and other issues; Require ongoing evaluation of the program and reporting to the Legislature; Specify the process for referral to an enhanced treatment program and periodic reviews of the appropriateness of the placement. Related Legislation: AB 2399 (Allen, Statutes of 2012) requires state hospitals to update their injury and illness prevention plans once per year and to develop a reporting system for assaults on employees. SB 60 (Evans, 2011) would have required a security and violence assessment of each patient upon admission to a state hospital. That bill was held on the Assembly Appropriations Committee's Suspense File. Staff Comments: The only costs to local agencies that may be incurred under the bill relate to crimes and infractions. Under the California Constitution, such costs are not reimbursable by the state. Author's amendments: The amendments make a number of changes to the policies and processes required by the bill. Amongst other changes, the amendments would: delete the requirement for a separate license for an enhanced treatment program and authorize them to be provided under an existing hospital license; exempt AB 1340 (Achaddjian) Page 3 the development of regulations by the Department of Public Health from the requirements of the Administrative Procedure Act; delete the requirement that the Department of Public Health monitor outcomes and require the Department of State Hospitals to do so; make a number of changes to the requirements and procedures relating to admission and treatment plans for patients in an enhanced treatment program.