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;
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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
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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
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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
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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.
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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