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.








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              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.








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          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  








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          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.