BILL ANALYSIS Ó
SENATE HUMAN
SERVICES COMMITTEE
Senator Jim Beall, Chair
BILL NO: AB 2044
A
AUTHOR: Rodriguez
B
VERSION: April 21, 2014
HEARING DATE: June 10, 2014
2
FISCAL: Yes
0
4
CONSULTANT: Sara Rogers
4
SUBJECT
Residential care facilities for the elderly
SUMMARY
This bill requires that Residential Care Facilities for the
Elderly (RCFEs) maintain at least one administrator,
facility manager, or other person designated by the
administrator who is at least 21 years of age to be on the
premises 24 hours a day. This bill additionally requires
that at least one RCFE staff member who has cardiopulmonary
resuscitation (CPR) training and first aid training shall
be on duty and on the premises at all times and that
training for direct-care staff include building and fire
safety and the appropriate response to emergencies.
ABSTRACT
Existing Law:
1.Establishes the Residential Care Facilities for the
Elderly (RCFE) Act, which provides for the licensure and
Continued---
STAFF ANALYSIS OF ASSEMBLY BILL 2044 (Rodriguez)
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regulation of RCFEs, defined as a housing arrangement
chosen voluntarily by persons over 60 years of age or
over where varying levels of supervision, or personal
care are provided, as a separate category within the
existing residential care licensing structure of CDSS.
(HSC 1569 et seq.)
2.Requires a license applicant and an RCFE administrator to
successfully complete a certification program approved by
the department, which shall include a minimum of 40 hours
of classroom instruction including a uniform core of
knowledge, as specified. (HSC 1569.23 and HSC 1569.616)
3.Provides that the administrator of an RCFE shall be
present at the facility during normal working hours or
that a facility manager designated by the licensee shall
be responsible for the facility when the administrator is
temporarily absent. Additionally provides that if the
facility manager and the administrator is the same person
then he or she is limited to the management of one
facility. (HSC 1569.618)
4.Through regulation, provides that administrators shall be
on the premises a sufficient number of hours to permit
adequate attention to the administration of the facility,
as specified. Additionally provides that when the
administrator is not in the facility, there shall be
coverage by a designated substitute who shall have
qualifications adequate to be responsible and accountable
for management and administration of the facility as
specified. (Title 22 CCR 87405)
5.Provides that RCFE administrators must be at least 21
years of age and have a valid certificate as an RCFE
administrator and through regulation requires that all
staff must be 18 years of age or older and that staff
providing care be trained in first aid. (HSC 1569.613 and
Title 22 CCR 87411)
6.Requires RCFEs to have an emergency plan that includes
STAFF ANALYSIS OF ASSEMBLY BILL 2044 (Rodriguez)
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evacuation procedures, plans for facilities to be
self-reliant for 72 hours following an emergency or
disaster, procedures to meet resident's needs,
communicate with residents and family members, among
other requirements as specified. (HSC 1569.685)
7.Through regulation, requires an RCFE to enact a
pre-admission appraisal, receive a medical assessment to
evaluate the prospective resident's functional and mental
capabilities and service needs and be updated as needed
and at least annually. Requires the facility to identify
any needs not met by the facility, establish a plan for
meeting those needs and for evaluating progress in
meeting the prospective residents' needs. (Title 22 CCR
87456-87463)
8.Through regulation requires an administrator to provide
or ensure the provision of services for the residents'
physical and mental well-being and needs, including those
services identified in the residents' pre-admission
appraisal, as specified. (Title 22 CCR 87405 (i) (5))
9.Through regulation, requires facility personnel to at all
times be sufficient in numbers and competent to provide
the services necessary to meet resident needs. Permits
CDSS to require a facility to provide additional staff
whenever it determines it is required for the provision
of adequate services. Establishes as a personal right
that residents be accorded safe, healthful and
comfortable accommodations, furnishings and equipment.
(Title 22 CCR 87411 and 87468)
10.Through regulation, requires coverage be provided when
staff are not present by personnel with qualifications
adequate to perform the assigned tasks. Requires that
personnel records shall demonstrate adequate staff
coverage necessary, as specified. (Title 22 CCR 87412 and
87413)
11.Through regulation, requires night supervision by staff
STAFF ANALYSIS OF ASSEMBLY BILL 2044 (Rodriguez)
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familiar with the facility's planned emergency procedures
and trained in first aid. (Title 22 CCR 87415)
This bill:
1.Requires that RCFEs maintain at least one administrator,
facility manager, or other person designated by the
administrator who is at least 21 years of age to be on
the premises 24 hours a day.
2.Requires the facility to employ, and the administrator to
schedule, a sufficient number of staff members to do the
following:
Provide the care required in each resident's
negotiated service agreement.
Ensure the health, safety, comfort and
supervision of the residents.
Ensure that at least one staff member who has
CPR training and first aid training shall be on duty
and on the premises at all times.
Ensure the facility is clean, safe, sanitary
and in good repair at all times.
1.Adds to the required training for direct-care staff to
include building and fire safety and the appropriate
response to emergencies.
FISCAL IMPACT
An Assembly Appropriations analysis states there are minor
and absorbable costs to CDSS to modify their training
regulations and unknown costs to facility owners or
licensees to meet the increased health and safety
requirements and ensure adequate staffing levels.
BACKGROUND AND DISCUSSION
Purpose of the bill:
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This bill, sponsored by California Advocates for Nursing
Home Reform is one of a large package of bills that respond
to a series of recent events calling into question the
adequacy of CDSS oversight and the state's ability to
protect people who reside in RCFEs. Specifically, in July
2013, ProPublica and Frontline reporters wrote and produced
a series of stories on Emeritus, the nation's largest RCFE
provider.<1> Featured in the article was a woman who died
after receiving poor care at in a facility in Auburn,
California. The series documented chronic understaffing and
a lack of required assessments and substandard care.
Additionally, reports in September 2013, prompted by a
consumer watchdog group that had hand-culled through stacks
of documents in San Diego, revealed that more than two
dozen seniors had died in recent years in RCFEs under
questionable circumstances that went ignored or unpunished
by CCL.<2>
Most recently, in late October 2013, 19 frail seniors were
abandoned at Valley Springs Manor in Castro Valley by the
licensee and all but two staff after the state began
license revocation proceedings. CDSS inspectors, noting the
facility had been abandoned, left the two unpaid service
staff to care for the abandoned residents with insufficient
food and medication, handing them a $3,800 citation before
leaving for the weekend. The next day sheriff's deputies
and paramedics sent the patients to local hospitals.
Residential Care Facilities for the Elderly
Within California's continuum of long term care, situated
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<1>
http://www.propublica.org/article/life-and-death-in-assisted
-living-single
<2> "Care Home Deaths Show System Failures," San Diego
Union Tribune, Sept.7, 2013
STAFF ANALYSIS OF ASSEMBLY BILL 2044 (Rodriguez)
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between in-home care and skilled nursing facilities, is the
RCFE, also commonly called Assisted Living, Board and Care,
or Residential Care. There are approximately 8,000 Assisted
Living, Board and Care, and Continuing Care Retirement
homes that are licensed as RCFEs in California. RCFEs are
designed to provide homelike housing options to seniors and
other adults who need some help with activities of daily
living, such as cooking, bathing, or getting dressed, but
otherwise do not need continuous, 24-hour care.
Increasingly, however, residents are entering RCFEs with
significant health needs including diabetes, bedsores, or
require the use of oxygen tanks, catheters, colostomies or
ileostomies.
The RCFE licensure category includes facilities with as few
as six beds to those with hundreds of residents, whose
needs may vary widely. Typically, smaller facilities are
homes in residential neighborhoods while larger facilities
resemble hotels or apartment complexes with structured
activities for their residents. Residents may reside in
their own apartment or bedroom, or may share a bedroom.
Generally, residents are free to leave the facility if they
choose, and may entertain guests, and otherwise maintain a
level of independence. Facilities licensed to serve
residents with dementia or Alzheimer's disease, also known
as "memory care units" may maintain a secure perimeter.
Licensee and Administrator training requirements
Existing law requires prospective licensees and facility
administrators to complete a certification program approved
by the department consisting of 40 hours of classroom
instruction. Statute requires that the curriculum for both
include:
Laws, regulations, policies and procedural
standards that impact RCFE operations, including
residents' personal rights (8 hours);
Business operations (3 hours);
Management and supervision of staff (3 hours);
Psychosocial need of elderly residents (5 hours);
Physical needs for elderly residents (5 hours);
Community and support services (2 hours);
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Use, misuse and interaction of drugs commonly used
by the elderly (5 hours);
Resident admission, retention, and assessment
procedures (5 hours); and
Care of residents with Alzheimer's Disease and
other dementias (4 hours).
Statute and regulation require direct-care staff to receive
10 hours of training,<3> including first aid training, the
aging process, physical limitations and special needs of
the elderly, personal care services techniques and
importance, resident rights, medication procedures
including how to safely assist with self-administration,
psychosocial needs of the elderly and recognition of signs
of dementia.
Care needs of residents
California law provides that RCFEs may accept or retain
clients who are capable of administering their own
medications, or need only be reminded due to forgetfulness
or assisted due to physical limitations, clients who
receive medical care outside the facility or from a
visiting nurse, persons with mild temporary emotional
disturbance, forgetfulness, irritability, wandering,
confusion, or inability to manage money, or persons who are
bedridden, provided fire clearance requirements are met.
RCFEs are prohibited by state law from accepting residents
requiring 24-hour skilled nursing or intermediate care.
Regulation also prohibits RCFEs from accepting residents
who depend on others to perform all activities of daily
living, residents whose primary need for care and
supervision results from an ongoing behavior caused by a
mental disorder and residents with certain medical
conditions including stage 3 or 4 pressure sores,
gastronomy care, naso-gastric tubes, staph infections or
other serious infections.<4>
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<3> HSC 1569.625 and Title 22 CCR 87411 and 87785
<4> Title 22 CCR 87455 and 87615
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However, RCFEs may accept permanently bedridden residents
under specified circumstances, including a statement in the
facility Plan of Operation of how the facility intends to
meet those residents' overall health, safety and care needs
and how it is meeting the needs of those individual
residents.<5> Residents with "restricted health
conditions," which otherwise fall short of a prohibited
condition or hospice care, may be cared for in an RCFE by
"appropriately skilled staff" either through home health
agencies or by hired medical staff. Facilities also are
permitted to care for residents who may be cared for
through a licensed home health agency. In such instances,
the facility and home health agency must agree in writing
on the responsibilities of each party.<6>
Regulation permits a licensee to submit a written exception
request for prohibited and or restricted health conditions,
and CDSS states that it evaluates every exception request
to ensure that the resident's physician has determined that
it remains an appropriate placement for the resident and
that the facility is equipped to address the medical needs
of the resident. CDSS provides facilities that intend to
serve hospice patients with facility-wide hospice waivers
instead of approving case-by-case exceptions determined by
individual department staff.
In addition to a preadmission appraisal, residents must
have a medical assessment on file completed and signed by a
physician within the prior year. A functional assessment is
required to determine a prospective resident's ability to
perform detailed activities of daily living including
bathing, dressing, grooming, continence, eating and
physical condition. RCFEs must complete a needs and
services appraisal to determine the amount of supervision
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<5> CCL Information Release 2007-04 and Title 22 CCR 87606
(f)
<6> Title 22 CCR 87609
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that is necessary.<7>
Staffing requirements
Existing law requires facility personnel to be sufficient
in numbers and competent to provide the services necessary
to meet resident needs. A facility may be required to
provide additional staff whenever CDSS determines that the
needs of the residents, the extent of services provided, or
the physical arrangements of the facility require it.
Additionally, regulations require RCFEs to ensure that a
resident's medical needs are met and in accordance with
physician's orders. Facility staff are required to have the
knowledge and skills to respond to problems and to contact
the physician, appropriately skilled professional or
vendor.
Placement agencies -- defined as county welfare, social
service or mental health departments, county public
guardians, hospital discharge planners or coordinators
public or private agencies providing placement or referral
services, conservators and regional centers -- who assist
in finding homes or other temporary or permanent placements
are required to report to CDSS if a facility has
insufficient or incompetent personnel on duty. Regulations
require facilities to submit a current, definitive plan of
operation to CDSS, which among other things, must include a
statement of admission policies and procedures for
accepting residents as well as the staffing plan,
qualifications and duties. RCFEs also must submit written
reports to the licensing agency and a resident's designated
responsible person when an incident may impact health and
safety of residents.<8>
Additionally, regulations require RCFEs to ensure night
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<7> Title 22 CCR 87458, 87459 and 87461 and LIC forms 602A,
603, 603A, 604A and 625
<8> Title 22 CCR 87211
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staff is familiar with the facility's planned emergency
procedures and trained in first aid, as specified. For
example, between the hours of 10 pm and 6am, facilities
caring for 16 or fewer residents must have a qualified
person on call on the premises; those with for 16 to100
residents must have at least one awake on-duty employee on
the premises with another employee on call and capable of
responding within 10 minutes; facilities with 101 to 200
residents must have one employee on call on the premises,
one awake on-duty employee on the premises and one employee
on call and capable of responding within 10 minutes; and
for every additional 100 residents a facility must have an
additional awake on-duty staff member.<9>
COMMENTS
1.This bill has substantial overlap with existing
regulation but may provide clarification to residents and
facility administrators of existing law requiring at
least one responsible person to be present in the
facility at all times. Additionally, this bill provides a
new requirement that at least one staff member who is
over the age of 21 be present in the facility at all
times and that at least one staff member trained in CPR
shall be present in the facility at all times.
2.The term "negotiated service agreement" referenced in the
bill is not a term used elsewhere in statute or
regulation. Staff recommends amending the bill to refer
to the residents "written record of care," as follows:
1569.618. (c) The facility shall employ, and the
administrator shall schedule, a sufficient number of
staff members to do all of the following:
(1) Provide the care required in each resident's
negotiated service agreement written record of care.
3.The California Assisted Living Association (CALA)
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<9> Title 22 CCR 87415
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recommends clarifying that the requirement for a staff
member trained in CPR to be onsite does not require the
staff member to use CPR contrary to a don-not-resuscitate
order of the resident. Staff recommends the following
amendments:
1569.618. (a) The administrator designated by the licensee
pursuant to subdivision (k) of Section 1569.15 shall be
present at the facility during normal working hours. A
facility manager designated by the licensee with notice to
the department, shall be responsible for the operation of
the facility when the administrator is temporarily absent
from the facility.
(b) (1) At least one administrator, facility manager, or
other person designated substitute who is at least 21 years
of age and who has qualifications adequate to be
responsible and accountable for management and
administration of the facility by the administrator shall
be on the premises 24 hours per day.
When the administrator is not in the facility, there shall
be coverage by a designated substitute as specified in this
section.
(2) A minimum of one staff member who assists residents
with personal activities of daily living per 16 residents
shall be on the premises 24 hours per day.
(c) The facility shall employ, and the administrator shall
schedule, a sufficient number of staff members to do all of
the following:
(1) Provide the care required in each resident's negotiated
service agreement written record of care as described in
Section 1569.80 .
(2) Ensure the health, safety, comfort, and supervision of
the residents.
(3) Ensure that at least one staff member who has
cardiopulmonary resuscitation (CPR) training and first aid
training is on duty and on the premises at all times. Staff
shall not be required to provide CPR to residents who have
requested to forgo resuscitative measures as indicated by a
STAFF ANALYSIS OF ASSEMBLY BILL 2044 (Rodriguez)
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Physician Order for Life-Sustaining Treatment (POLST) or
Do-Not-Resuscitate Order (DNR) and made available to the
facility.
(4) Ensure that the facility is clean, safe, sanitary, and
in good repair at all times.
PRIOR VOTES
Assembly Floor 64 - 1
Assembly Appropriations 13 - 0
Assembly Human Services 6 - 0
POSITIONS
Support: Association of Regional Centers
California Advocates for Nursing Home Reform
California Long-Term Ombudsman Association
Consumer Federation of California
County of San Diego
Long Term Care Ombudsman Association of
San Luis Obispo County
Retired Public Employees Association
Oppose: None received.
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