BILL ANALYSIS Ó
SENATE COMMITTEE ON VETERANS AFFAIRS
Senator Ben Hueso, Chair
BILL NO: AB 1821 HEARING DATE: 6/24/14
AUTHOR: Gordon
VERSION: 6/17/14
FISCAL: Yes
VOTE: Majority
SUBJECT
Medical foster homes.
DESCRIPTION
Existing law (federal and state):
1.Establishes the U.S. Department of Veterans Affairs (VA),
which is responsible for administering various programs and
services for the benefit of veterans.
2.Provides for the licensure of residential care facilities for
the elderly by the State Department of Social Services (DSS)
under the California Residential Care Facilities for the
Elderly (RCFE) Act.
3.Exempts specified facilities from DSS licensure, including
general acute care hospitals, clinics, and recovery houses for
individuals with drug or alcohol addiction.
4.Authorizes the California State Auditor, upon the request by
the Joint Legislative Audit Committee (JLAC) and to the extent
funding is available, to audit a state or local governmental
agency, as defined, or any other publicly created entity.
This bill:
1.Authorizes - no sooner than June 1, 2015, and only until
January 1, 2018 - a pilot program in which the VA facility may
establish a Medical Foster Home (MFH), which is not subject to
licensure or regulation under the California Residential Care
Facilities for the Elderly Act provided that:
a) Specified federal requirements are satisfied;
b) The VA facility establishing the home agrees to be
subject to the jurisdiction of the California State
Auditor; and
c) The VA obtains criminal background information for
caregivers and specified individuals residing in the home.
2.States the Legislature's intent that the California State
Auditor, through a request to the JLAC, conduct an audit
evaluating the program created by this bill no sooner than
January 1, 2016, as specified.
BACKGROUND
Residential Care Facilities for the Elderly
The Community Care Licensing (CCL) division of DSS develops and
enforces regulations designed to protect the health and safety
of individuals in 24-hour residential care facilities and day
care. These facilities include child care centers, residential
care facilities for the elderly (RCFEs), and foster family homes
and group homes.
The approximately 7,500 RCFEs in California are licensed to
provide housing and a range of supportive services, such as
assistance with activities of daily living, for up to 175,000
people annually.
Traditionally, RCFEs have been used as nonmedical placements for
individuals with less acute medical needs than those who would
qualify for skilled nursing home placement. However, there are
exceptions; for example:
Facilities can apply for waivers to provide hospice
services. Most RCFEs have waivers to provide hospice
services.
Facilities can request permission to provide other
services. To provide services beyond the scope of what is
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normally provided at CCL, RCFEs can request permission from
CCL on a case-by-case basis.
Nearly 80 percent of California's RCFEs are licensed for four to
six beds.
Medical Foster Home Care and Elder Veterans
The federal VA oversees the Medical Foster Home program.
According to the VA, MFHs are private homes in which a trained
caregiver provides services to a few individuals. Some, but not
all, residents are veterans. VA inspects and approves all MFH,
but does not actually provide or pay for the homes.
An MFH often serves as an alternative to a nursing home. It may
be appropriate for veterans, who require nursing home care but
prefer a non-institutional setting with fewer residents.
Medical Foster Homes have a trained caregiver on duty 24/7. This
caregiver can help the Veteran carry out activities of daily
living (e.g., bathing and getting dressed). The VA ensures that
the caregiver is well trained to provide VA planned care. While
living in a Medical Foster Home, Veterans receive Home Based
Primary Care services.
To be eligible for an MFH, a veteran must be enrolled in Home
Based Primary Care, which is a VA program through which health
care services are provided to veterans in their homes. Veterans
must pay for the MFH themselves or rely on other insurance. The
charge for a Medical Foster Home is about $1500 to $3000 each
month based on income level and level of care required.
Typical services provided to veterans by an MFH caregiver
include:
Help with your activities of daily living (e.g., bathing
and getting dressed);
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Help in taking medications;
Some nursing assistance, if the caregiver is a
registered nurse;
All meals;
Planned recreational and social activities.
Public Confidence in the VA
The VA's subsidiary Veteran Health Administration (VNA) manages
America's largest integrated health care system with over 1,700
sites of care, including hospitals, outpatient clinics and other
facilities. It serves almost nine million veterans per year.
In early 2014 a scandal surrounding VHA-managed hospitals and
clinics blasted into the public consciousness. The deaths of at
least 40 veterans have been attributed to willful negligence and
deliberate mismanagement of the appointments process and other
resources.
But the actual problems predate the current crisis. In 2001, the
General Accounting Office issued a report warning that wait
times for medical services at VA clinics already were excessive
and dangerous. Since then, the wars in Afghanistan and Iraq have
created a new generation of veterans. While advances in
battlefield medicine now allow more American troops to survive
serious combat injuries, that has also means more of our young
men and women return home with serious wounds and disabilities,
both physical and mental.
The recent allegations of the VA's negligence toward veterans
and revelations that the department's officials doctored records
to obscure the problem have triggered several investigations by
various entities, including Congress and the FBI. Probes have
spread to 42 VA facilities around the nation. Recent public
opinion polling indicates the public is livid at the federal
government over the VA's failure to properly serve the nation's
elderly, disabled and indigent veterans. In late May 2014,
President Obama accepted VA Secretary Eric Shinseki's
resignation. The investigations are continuing.
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COMMENT
Author's Comments:
MFHs are home-based care models for mostly older and medically
frail veterans needing assisted living care. MFHs provide
24-hour a day, 7-days a week care for up to a maximum of 3
eligible veterans in a private home. MFHs are currently
operational at more than 83 sites in 39 states.
To qualify for the MFH program, a veteran must first be
enrolled in the Veterans Health Administration's (VHA's) Home
Based Primary Care program (HBPC). In this program the
veteran's medical care is provided by an interdisciplinary team
of physicians, nurses, aides, and others which are all provided
by the VHA. The private home, where the veteran is placed, is
also monitored closely by the VHA under strict standards
required of the caregivers. Families who volunteer to
participate in the MFH program must be approved by the VHA's
interdisciplinary team as well as submit income statements, and
train in CPR.
Additionally, the MFHs are routinely inspected by the VHA.
Veterans pay room and board in the MFH program; however, the
Veterans Benefits Administration's "Aid and Attendance" benefit
and Social Security benefits are generally anticipated to cover
these costs. MFHs are distinguished from other typical
residential care homes or facilities because a MFH caregiver is
required to reside in their own private home while providing
24-hour personal care and supervision to the veteran. The
veteran, in turn, receives their medical care through the VHA
in a highly regulated, yet independent, community-based
setting.
Currently, the federal Medical Foster Home program can only
exist in California if operated as and under the Residential
Care Facilities for the Elderly (RCFE) law. Unfortunately, that
law does not envision the MFH model under traditional assisted
living care such that all potential MFH caregivers would need
to have their personal home licensed, they would have to become
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a Certified Administrator for RCFE, and they would also incur
all the costs associated with their training and licensure.
This creates a barrier for caregivers to open their home to a
veteran and limits the growth of the program in our state.
In addition, placements in existing RCFEs are not financially
feasible due to the three- veteran limitation, as most "board
and care" RCFEs have up to 6 residents residing in one
location. Therefore, the RCFE requirements impede California
veterans from having similar opportunities as veterans in other
states who are able to "age in place" with dignity and
independence, in a home-like environment with a loving and
caring foster family.
To ensure the MFH is a feasible alternative to
institutionalization for California's veterans, the bill would
establish the Medical Foster Home Pilot Program. Under the
pilot program, a United States Department of Veterans Affairs
(USDVA) facility, such as a VA hospital, may establish a
Medical Foster Home program as long as the following conditions
are met: the MFH meets the requirements of the federal
regulations; the USDVA facility submits a proposal to establish
a medical foster home program to the Director of Home and
Community-Based Care in Geriatrics and Extended Care Services
in the Central Office of the USDVA and that director authorizes
the program; and finally that the USDVA facility establishing
the MFH agrees to be subject to the jurisdiction of the
California State Auditor and agrees to provide data,
information, and case files as requested by the California
State Auditor to perform all of his or her duties in evaluating
the MFH pilot program.
The MFHs in the pilot program are not subject to existing RCFE
law; however, it is the intention of the author and stated in
the bill that a request will be made to the Joint Legislative
Audit Committee for the California State Auditor to audit and
evaluate the success of the pilot program providing a
safeguarding mechanism to protect California's veterans. In
addition, the State Auditor will make recommendations regarding
the continuation of the program in order to determine if the
state should have a role in the federal MFH program as the
pilot program will sunset on January 1, 2018. This bill would
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allow the MFH program to be a viable option for our veterans
who want to live and receive care in a smaller setting that
feels more like home."
Committee Staff Comments:
1.Should MFHs be exempted from state regulation and oversight,
even a small pilot program with the bill's proposed safeguards
and limits? In light of the ongoing crisis regarding
misconduct within the VA's Veterans Health Administration
(VHA), including destruction of patient records.
Are we confident that our veterans will be properly and safely
cared for without state oversight during the pilot program?
2.If the MFH model does not fit within the RCFE rubric, should
relevant state agencies propose a new regulatory model? The
proposed pilot program will provide a testing period for the
new program, but is it good policy to test this program on
California veterans first and then later decide what the
state's role should be?
POSITIONS
Sponsor: Author.
Support:
AMVETS, Department of California
California Commission on Aging
California State Commanders Veterans Council
Leading Age California
Public Law Center
Vietnam Veterans of America, California State Council
Oppose: None on file.
Analysis by: Wade Cooper Teasdale
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