BILL ANALYSIS Ó
-----------------------------------------------------------------
|SENATE RULES COMMITTEE | AB 1340|
|Office of Senate Floor Analyses | |
|1020 N Street, Suite 524 | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
-----------------------------------------------------------------
THIRD READING
Bill No: AB 1340
Author: Achadjian (R), et al.
Amended: 8/20/14 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 8-0, 6/11/14
AYES: Hernandez, Morrell, Beall, De León, DeSaulnier, Evans,
Nielsen, Wolk
NO VOTE RECORDED: Monning
SENATE PUBLIC SAFETY COMMITTEE : 7-0, 6/24/14
AYES: Hancock, Anderson, De León, Knight, Liu, Mitchell,
Steinberg
SENATE APPROPRIATIONS COMMITTEE : 6-0, 8/14/14
AYES: De León, Gaines, Hill, Lara, Padilla, Steinberg
NO VOTE RECORDED: Walters
ASSEMBLY FLOOR : 77-0, 5/30/13 - See last page for vote
SUBJECT : Enhanced treatment programs
SOURCE : SEIU Local 1000
DIGEST : This bill, commencing July 1, 2015, and subject to
available funding, authorizes the Department of State Hospitals
(DSH) to establish and maintain pilot enhanced treatment
programs (ETPs), as defined, for the treatment of patients who
are at high risk of most dangerous behavior, as defined, and
when safe treatment is not possible in a standard treatment
CONTINUED
AB 1340
Page
2
environment. This bill authorizes the Department of Public
Health (DPH) to approve, on or after July 1, 2015, an ETP, which
meets specified requirements and regulations, as a supplemental
service for an acute psychiatric hospital. This bill also
requires, if the forensic needs assessment team (FNAP)
determines that the patient requires continued ETP placement,
that the patient's case be referred to a forensic psychiatrist
or psychologist outside of DSH for independent review, that a
hearing be conducted, and notice given, as specified. This bill
requires DSH to monitor the ETPs, evaluate outcomes, and report
its findings and recommendations to the Legislature.
ANALYSIS :
Existing law:
1.Establishes DSH as the lead agency charged with overseeing and
managing the state's five state hospitals: Atascadero,
Coalinga, Metropolitan, Napa, and Patton.
2.Provides for the involuntary commitment of mentally ill
persons to a state hospital, such as when the patient is
deemed incompetent to stand trial (IST) or not guilty by
reason of insanity (NGI), or the patient is a mentally
disordered offender (MDO).
3.Requires DSH, prior to admission of a patient committed as IST
or NGI to Metropolitan or Napa, to evaluate each patient for
risk.
4.Designates Napa and Metropolitan to only treat low-to-moderate
risk patients; requires high-risk patients to only be treated
at Atascadero or Patton, a correctional facility, or other
secure facility; and, designates Coalinga for mostly sexually
violent predators (SVP).
5.Makes a violation of any law or regulation pertaining to
health facilities, including acute psychiatric hospitals, a
misdemeanor, and upon conviction is punishable by a fine not
to exceed $1,000 or imprisonment in a county jail for a period
not to exceed 180 days, or by both the fine and imprisonment.
This bill:
CONTINUED
AB 1340
Page
3
1.Makes several legislative findings and declarations related to
inpatient mental health treatment and pilot enhanced treatment
programs.
2.Defines "patient at high risk of most dangerous behavior"
means the individual has a history of physical violence and
currently poses a demonstrated danger of inflicting
substantial physical harm upon others in an inpatient setting,
as determined by an evidence-based, in-depth violence risk
assessment conducted by DSH.
3.Requires an ETP to meet all of the following requirements:
A. Maintain a staff-to-patient ratio of one to five.
B. Limit each room to one patient.
C. Each patient room shall allow visual access by staff 24
hours per day.
D. Each patient room shall have a toilet and sink in the
room.
E. Each patient room door shall have the capacity to be
locked externally. The door may be locked when clinically
indicated and determined to be the least restrictive
treatment environment for the patient's care and treatment,
as specified, but shall not be considered seclusion, as
defined.
F. Provide emergency egress for ETP patients.
G. Requires all state licensing and regulations to be
followed in the event seclusion or restraints are used in
an ETP.
H. Requires that a full-time independent patient advocate
who provides patients' rights advocacy services be assigned
to each ETP.
1.Requires the ETP to adopt and implement specified policies and
procedures necessary to encourage patient improvement,
recovery, and a return to a standard treatment environment.
CONTINUED
AB 1340
Page
4
2.Requires patients who have been admitted to an ETP to have the
same rights guaranteed to patients not in an ETP, as
specified.
3.Requires DPH and DSH to jointly develop the regulations
governing ETPs.
4.Permits DSH, beginning July 1, 2015, and subject to available
funding, to establish and maintain pilot ETPs, as defined, and
evaluate the effectiveness of intensive, evidence-based
clinical therapy and treatment of patients, as described.
5.Permits a state hospital psychiatrist or psychologist to refer
a patient to a pilot ETP program, as defined, for temporary
placement and risk assessment upon determining that the
patient may be at high risk of most dangerous behavior and
when treatment is not possible in a standard treatment
environment. Permits the referral may occur after admission
to DSH, and after sufficient and documented evaluation of
violence risk of the patient, with notice to the patients'
rights advocate at the time of the referral. A patient shall
not be placed into an ETP as a means of punishment, coercion,
convenience, or retaliation.
6.Requires within three business days of placement in an ETP, a
dedicated forensic evaluator, who is not on the patient's
treatment team, to complete an initial evaluation of the
patient that includes an interview of the patient's treatment
team, an analysis of diagnosis, past violence, current level
of risk, and the need for enhanced treatment.
7.Requires within seven business days of placement in an ETP and
with 72-hour notice to the patient and patient's rights
advocate, the forensic needs assessment panel (FNAP) to
conduct a placement evaluation meeting with the referring
psychiatrist or psychologist, the patient and patient's rights
advocate, and the dedicated forensic evaluator who performed
the initial evaluation. A determination shall be made as to
whether the patient clinically requires ETP treatment.
8.Specifies that the threshold standard for treatment in an ETP
is met if a psychiatrist or psychologist, utilizing standard
forensic methodologies for clinically assessing violence risk,
determines that a patient meets the definition of a patient at
CONTINUED
AB 1340
Page
5
high risk of most dangerous behavior and ETP treatment meets
the identified needs of the patient and safe treatment is not
possible in a standard treatment environment.
9.Specifies that factors used to determine a patient's high risk
of most dangerous behavior 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.
10.Requires the FNAP determination to be in writing and provided
to the patient and patient's rights advocate as soon as
possible, but no later than three business days after the
decision is made.
11.Requires upon admission to an ETP, a forensic needs
assessment team (FNAT) psychologist who is not on the
patient's treatment team to perform an in-depth violence risk
assessment and make an individual treatment plan for the
patient based on the assessment.
12.Requires an ETP patient to receive treatment from a
multidisciplinary team consisting of a psychologist, a
psychiatrist, a nurse, a psychiatric technician, a clinical
social worker, a rehabilitation therapist, and any other
necessary staff who shall meet as often as necessary, but no
less than once a week, to assess the patient's response to
treatment.
13.Requires, prior to the expiration of 90 days from the date of
placement in the ETP and with 72-hour notice provided to the
patient and the patient's rights advocate, the FNAP to convene
a treatment placement meeting with a psychologist from the
treatment team, a patient's rights advocate, the patient, and
the FNAT psychologist who performed the in-depth violence risk
assessment, as specified.
14.Specifies that at any point during the ETP placement, if a
patient's treatment team determines that the patient no longer
clinically requires ETP treatment, a recommendation to
transfer the patient out of the ETP shall be made to the FNAT
or FNAP.
15.Specifies that prior to or at the time of discharge,
CONTINUED
AB 1340
Page
6
transfer, or release from an ETP, each patient shall be
evaluated concerning the patient's need for aftercare
services.
16.Requires DSH to monitor the ETPs, evaluate outcomes, and
report on its findings and recommendations, as specified.
Background
According to DSH, the state hospital patient population has
shifted over the past 20 years, from a 20% forensic population
in 1994 to the current 96%. Forensic patients are committed for
a variety of reasons, including IST, NGI, MDO, and SVP. There
are 4,967 patients at Atascadero, Coalinga, Metropolitan, Napa,
and Patton state hospitals comprising 1,350 NGI; 1,283 IST;
1,154 MDO; 897 SVP; 258 mentally ill California Department of
Corrections and Rehabilitation commitments; and 25 mentally
disordered sex offenders. DSH states that despite the
significant change, there is no current legal, regulatory, or
physical infrastructure in place for state hospitals to
effectively and safely treat patients who have demonstrated
severe psychiatric instability or extremely aggressive behavior.
Incidents of violence . According to DSH, in 2013, there were a
total of 3,344 patient-on-patient assaults and 2,586
patient-on-staff assaults at state hospitals. Of the total
patient population, 62% are non-violent, 36% committed 10 or
fewer violent acts, and 2% committed 10 or more violent acts.
Of all the violent acts committed, 65% are committed by those
with 10 or fewer violent acts, and 35% are committed by those
with 10 or more violent acts. A small subset of the population,
116 people, commits the majority of aggressive acts. Assaults
for the previous years are as follows: 3,803 patient-on-patient
and 3,026 patient-on-staff in 2012; 4,022 patient-on-patient and
2,814 patient-on-staff in 2011; and 4,627 patient-on-patient and
2,703 patient-on-staff in 2010.
The Division of Occupational Safety and Health, known as
Cal/OSHA, within the Department of Industrial Relations, has had
significant and ongoing involvement with DSH as a result of
insufficient protections for staff. According to a Los Angeles
Times article from March 2, 2012, Cal/OSHA has issued nearly
$100,000 in fines against Patton and Atascadero, alleging that
they have failed to protect staff and have deficient alarm
CONTINUED
AB 1340
Page
7
systems. These citations are similar to citations levied in
2011 against Napa and Metropolitan. Cal/OSHA found an average
of 20 patient-caused staff injuries per month at Patton from
2006 through 2011 and eight per month at Atascadero from 2007
through 2011, including severe head trauma, fractures,
contusions, lacerations, and bites. DSH states they have been
working closely with Cal/OSHA to resolve the issues and take all
necessary corrective measures to protect staff at all of the
state hospital facilities.
Prior Legislation
AB 2399 (Allen, Chapter 751, Statutes of 2012) required each of
the five state hospitals to update its injury and illness
prevention plan (IIPP) at least once a year, establish an IIPP
committee to provide recommendations for updates to the plan,
and develop an incident reporting procedure for assaults on
employees.
SB 60 (Evans, 2011) would have required the former Department of
Mental Health (now DSH) to conduct a security and violence risk
assessment, as specified, of each patient upon admission to a
state hospital. SB 60 was held in the Assembly Appropriations
Committee.
SB 391 (Solis, Chapter 294, Statutes of 1997) provided for
patient risk assessments for inmates committed to Napa or
Metropolitan for certain Penal Code violations and requires
patients subject to assessments who are determined to be a high
security risk to be treated in the most secure state hospital
facilities.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes
According to the Senate Appropriations Committee:
One-time costs likely in the low hundreds of thousands to
develop policies and regulations by DSH (General Fund).
One-time costs likely in the tens of millions for the
construction of new enhanced treatment program facilities
(General Fund). DSH intends to renovate existing units of
state hospitals to create units for the new enhanced treatment
CONTINUED
AB 1340
Page
8
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 existing 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 DSH'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
DSH will need about 16 additional nursing positions at a cost
of about $2.5 million per year.
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 DPH (Licensing and Certification Fund).
SUPPORT : (Verified 8/20/14)
SEIU Local 1000 (source)
AFSCME
California Association of Psychiatric Technicians
Department of State Hospitals
Police Officers Research Association of California
Veterans Caucus of the California Democratic Party
OPPOSITION : (Verified 8/20/14)
American Civil Liberties Union of California
Disability Rights California
Legal Services for Prisoners with Children
ARGUMENTS IN SUPPORT : The sponsors of the bill argue that
ETPs will provide additional individualized care to patients
with histories of highly aggressive behavior, until they are
deemed safe to return to the general population, in the safest
possible treatment environment while upholding patients' rights.
CONTINUED
AB 1340
Page
9
ARGUMENTS IN OPPOSITION : Disability Rights California (DRC)
argues that this bill would allow patients to be locked in a
room similar to a prison cell without being afforded adequate
due process, such as a hearing before a judge with appointed
counsel and without the ability to appeal placement in an ETP.
DRC also states that many provisions in this bill are vague and
overbroad, giving great deference to DSH with little or no
oversight or explanation of terms.
ASSEMBLY FLOOR : 77-0, 5/30/13
AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Bigelow, Bloom,
Blumenfield, Bocanegra, Bonilla, Bonta, Bradford, Brown,
Buchanan, Ian Calderon, Campos, Chau, Chávez, Chesbro, Conway,
Cooley, Dahle, Daly, Dickinson, Donnelly, Eggman, Fong, Fox,
Frazier, Beth Gaines, Garcia, Gatto, Gomez, Gonzalez, Gordon,
Gorell, Gray, Grove, Hagman, Hall, Harkey, Roger Hernández,
Jones, Jones-Sawyer, Levine, Linder, Logue, Lowenthal,
Maienschein, Mansoor, Medina, Melendez, Mitchell, Morrell,
Mullin, Muratsuchi, Nazarian, Nestande, Olsen, Pan, Patterson,
Perea, V. Manuel Pérez, Quirk, Quirk-Silva, Rendon, Salas,
Skinner, Stone, Ting, Wagner, Waldron, Weber, Wieckowski,
Williams, Yamada, John A. Pérez
NO VOTE RECORDED: Holden, Wilk, Vacancy
JL:e 8/20/14 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
**** END ****
CONTINUED