BILL ANALYSIS Ó AB 1340 Page 1 Date of Hearing: August 26, 2014 ASSEMBLY COMMITTEE ON HEALTH Richard Pan, Chair AB 1340 (Achadjian) - As Amended: August 20, 2014 SUBJECT : Enhanced treatment programs. SUMMARY : Permits the Department of State Hospitals (DSH) to establish and administer a pilot enhanced treatment program (ETP) at each state hospital, for the duration of five calendar years, for testing the effectiveness of treatment for patients who are at high risk of the most dangerous behavior. Authorizes ETPs to be licensed under the same requirements as acute psychiatric hospital licensing requirements, and makes significant changes to current requirements and procedures related to the admission of patients and the administration of care. Specifically, this bill : 1)Establishes legislative intent regarding the purpose and need for additional enhanced treatment units (ETU) and states findings and declarations accordingly. 2)Permits DSH to establish and maintain a pilot ETP at each state hospital to test the effectiveness of providing treatment for patients who are at high risk of the most dangerous behavior. 3)Permits each pilot ETP to exist until January1st of the fifth calendar year after each pilot ETP has admitted its first patient. 4)Permits DSH to adopt emergency regulations, in accordance with the Administrative Procedure Act (APA), for the administration of ETPs. 5)Establishes ETP requirements, including: a) Maintaining a staff-to-patient ratio of one to five; b) Limiting each room to one patient; c) Requiring that each patient room be allowed visual access by staff 24 hours per day; AB 1340 Page 2 d) Requiring that each patient room have a toilet and sink in the room; e) Requiring that each patient room door have the capacity to be locked externally; f) Permitting the door to be locked when clinically indicated and determined to be the least restrictive treatment environment for the patient's care and treatment; g) Providing emergency egress for ETP patients; h) Requiring that, in the event seclusion or restraints are used in an ETP, all state licensing and regulations be followed; and, i) Requiring that a full-time independent patients' rights advocate who provides patients' rights advocacy services be assigned to each ETP. 6)Deletes the requirement for a new license for an ETP and instead authorizes ETPs to be licensed under existing hospital licensing requirements for acute psychiatric hospitals. 7)Exempts the development of regulations by the Department of Public Health (DPH) from the requirements of the APA. 8)Requires DSH to monitor the pilot ETPs, evaluate outcomes, as specified, and report on its findings and recommendations to the Legislature. 9)Requires ETPs to adopt and implement policies and procedures necessary to encourage patient improvement, recovery, and a return to a standard treatment environment, and to create identifiable facility requirements and bench marks, as specified. 10)Establishes procedures for the evaluation, assessment, and creation of a treatment plan for each admitted patient, as specified. FISCAL EFFECT : According to the Senate Appropriations Committee, one-time costs likely in the low hundreds of thousands to develop policies and regulations by DSH, one-time costs likely in the tens of millions for the construction of new AB 1340 Page 3 ETP facilities, significant costs to renovate portions of current state hospital facilities to create units for the new ETPs, increased staffing costs of about $2.5 million per year to comply with the higher staff-to-patient ratio required in the bill, ongoing costs of $800,000 per year for a contracted patient advocate for ETPs and minor additional costs for licensing of ETPs by DPH. COMMENTS : 1)PURPOSE OF THIS BILL . According to the author, this bill is intended to provide an alternative mechanism for dealing with violent and aggressive offenders who threaten the safety of hospital staff and other patients and disrupt the care and treatment needed by other patients. The author states that this bill will help to protect state hospital staff and patients and decrease the level of violence in these facilities by requiring these offenders to be removed from the general population to receive enhanced treatment. 2)BACKGROUND . DSH oversees a total of five state hospitals for the care, treatment, and education of severely mentally ill individuals. Those hospitals are the Metropolitan State Hospital, Atascadero State Hospital, Napa State Hospital, Patton State Hospital, and Coalinga State Hospital. State hospitals in California currently serve approximately 6,521 patients. The hospitals' population has changed dramatically over time, and now approximately 92% of their population is considered "forensic," meaning patients have been committed to a hospital by the criminal justice system. According to data obtained from DSH, there were a total of 4,283 incidents involving patient-on-patient aggression and 3,050 aggressive acts against staff system-wide in 2012. 3)CURRENT PILOT . Atascadero State Hospital is currently implementing a pilot ETU to address violence due to mental illness that does not respond to standard treatment. The goal of the ETU is to decrease psychiatric symptoms of some of the most violent patients, in order to enable DSH to simultaneously assist the patients in their recovery, thereby increasing the safety of the facility. Patients must meet certain criteria, based on the patient's mental illness and psychiatric symptoms, before being admitted to the ETU. Unlike the pilot ETPs authorized by this bill, the Atascadero State Hospital Pilot does not permit ETU's to have locked AB 1340 Page 4 doors. Outcomes data from the ETU pilot show there have been 16 patients discharged since the unit opened in December 2011. When patient aggression is compared 90 days before ETU admission to 90 days post-discharge, 10 of 16 patients, or 71%, demonstrated a reduction in acts of physical violence; one patient was equally as aggressive before and after treatment in the ETU; and, three patients were neither aggressive before admission, or at follow-up. DSH reports there is no follow-up data available for three other patients who were charged with new offenses and returned to the Department of Corrections and Rehabilitation. Coalinga State Hospital operates a Specialized Services Unit (SSU), which treats individuals committed under the Penal Code who have severe and chronic aggressive behaviors. The therapeutic goal of the SSU is to encourage compliance with treatment and medication in order to decrease aggressive and socially undesirable behaviors. DSH reports that although Coalinga State Hospital is actively tracking outcomes since the SSU opened in September 2011, the data is not readily available. DSH also indicates that a patient's average stay in the SSU is six to nine months. 4)PATIENT COMMITMENT AND EVALUATION . The bill allows a state hospital psychiatrist or psychologist to refer a patient to a pilot ETP for temporary placement and risk assessment upon determining that the individual is at high risk of most dangerous behavior and that safe treatment is not possible in a standard treatment environment. An initial evaluation of the patient must be done within three business days of placement in an ETP and within seven days, a full placement evaluation must be done by a forensic evaluator and a patients' rights advocate. Factors used to determine a patient's high risk of most dangerous behavior include psychosis, environmental factors, adverse medication effects, and others as determined by the California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines. After a full evaluation, the patient may be initially certified for 90 days of treatment in an ETP. Upon admission to an ETP, a forensic needs assessment team (FNAT) must make an individual treatment plan that must be reviewed and updated no less than every 10 days. Prior to the expiration of the 90 day placement in an ETP, the patient must be re-evaluated by the AB 1340 Page 5 FNAT, and if necessary, may be certified for ETP placement for up to a year. If a patient is certified for placement for a year, the FNAT must review the patient's treatment summary at least every 90 days. 5)MONITORING . The bill requires DSH to monitor the pilot ETPs, evaluate outcomes, and report on its findings and recommendations to the Legislature. The evaluation must include information regarding characteristics of the patients served, compliance with staffing requirements, information regarding lengths of stay, restraint and seclusion use, serious injury to staff and residents, staff turnover, the number of patients' rights complaints, and the type of training provided for staff. 6)RELATED LEGISLATION . SB 852 (Leno), Chapter 25, Statutes of 2014, appropriated $2.1 million in funds available for encumbrance and expenditure until June 30, 2016, and are authorized for the development of preliminary plans and working drawings to implement enhanced treatment units at state hospitals. DSH cannot proceed with the construction phase of this project until legislation is enacted authorizing the use of ETUs. 7)SUPPORT . According to the sponsor of the bill, California Association of Psychiatric Technicians, this urgently needed bill would provide additional individualized care and treatment to patients with histories of highly assaultive behavior until they are deemed safe to return to general state-hospital units. The Service Employees International Union, Local 1000 (SEIU 1000), writes in support that this bill provides an added protection for patients and staff in an environment where 1% of the population commits 40% of the violent acts. They further state that their members are on the ground and risk their lives every day to do this work that is so vital to the state and the patients they serve. 8)OPPOSITION . In opposition, California Attorneys for Criminal Justice writes that this bill would increase costs by interrupting treatment and any progress a patient is making by mandating referral for prosecution and requiring extensive and expensive special housing, treatment, and supervision once the patient is returned to the hospital. AB 1340 Page 6 This bill was substantially amended in the Senate, in which the subject matter was not heard in Assembly policy committee this legislative session. REGISTERED SUPPORT / OPPOSITION : Support California Association of Psychiatric Technicians (Sponsor) Service Employees International Union, Local 1000 (Sponsor) American Federation of State, county and Municipal Employees, AFL-CIO Department of State Hospitals Peace Officers Research Association of California Veterans Caucus of the California Democratic Party Opposition American Civil Liberties Union Disability Rights California Legal Services for Prisoners with Children Analysis Prepared by : Paula Villescaz / HEALTH / (916) 319-2097