BILL ANALYSIS                                                                                                                                                                                                    Ó






                                  SENATE HUMAN
                               SERVICES COMMITTEE
                            Senator Carol Liu, Chair


          BILL NO:       SB 911                                       
          S
          AUTHOR:        Block                                        
          B
          VERSION:       March 27, 2014
          HEARING DATE:  April 8, 2014                                
          9
          FISCAL:        Yes                                          
          1
                                                                      
          1
          CONSULTANT:    Sara Rogers                                 

                                        

                                     SUBJECT
                                         
                  Residential Care Facilities for the Elderly

                                     SUMMARY  

          This bill increases the number of hours of classroom  
          instruction, and adds to the uniform core of knowledge,  
          that licensees and administrators of Residential Care  
          Facilities for the Elderly (RCFEs) must meet for initial  
          certification and continuing education training. This bill  
          increases the training requirements for facility staff that  
          assist residents with personal activities, as specified,  
          and adds topics that shall be included in the training.  
          Additionally, this bill requires facilities that accept or  
          retain residents with restricted or prohibited health  
          conditions to employ a registered nurse on a full-time or  
          part-time basis and to provide for a registered nurse to be  
          on call 24 hours per day. 

                                     ABSTRACT  

           Existing Law: 
           
          1.Establishes the Residential Care Facilities for the  

                                                         Continued---




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            Elderly Act which provides for the California Department  
            of Social Services (CDSS) to license and regulate RCFEs  
            as a separate category within the existing residential  
            care licensing structure of CDSS. (HSC 1569 et seq.) 


          2.Requires applicants for an RCFE license to file an  
            application including a criminal record clearance,  
            employment history, character references, evidence of  
            certification, and disclosure of previous service in  
            other RCFEs, outpatient health clinics, health facilities  
            (including hospitals, skilled nursing facilities or  
            intermediate face facilities), or a community care  
            facility, among other requirements. (HSC 1569.15)


          3.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)


          4.Provides that RCFE administrator certification shall be  
            valid for two years and that recertification shall  
            require 40 hours of continuing education. Through  
            regulation provides that an applicant for licensure shall  
            meet the requirements for initial certification of  
            administrators. (HSC 1569.616 (f), Title 22 CCR 87155 and  
            87406) 


          5.Provides that the initial certification of administrators  
            shall include successful completion of a  
            department-approved program, passage of a written test  
            administered by the department within 60 days, and a  
            criminal records clearance. (Title 22 CCR 87406)


          6.Requires CDSS to develop requirements for a uniform core  
            of knowledge for the initial certification and continuing  
            education requirements for licensees, administrators and  
            staff of RCFEs. Provides that this knowledge base shall  
            include basic understanding of the psychosocial and  
            physical care needs of elderly persons. (HSC 1569.62)





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          7.Provides that RCFE staff members who assist residents  
            with activities of daily living shall receive at least 10  
            hours of initial training within the first four weeks of  
            employment and at least four hours annually thereafter.  
            (HSC 1569.625 and Title 22 CCE 87411)


          8.Requires CDSS to develop a uniform assessment tool to be  
            used by all RCFEs in identifying resident needs for  
            service and assistance with daily living. (HSC 1569.62)


          9.Requires facility personnel to be sufficient in numbers  
            and competent to provide the services necessary to meet  
            resident needs. Provides that the department may require  
            any facility to provide additional staff whenever if  
            determines through documentation that the needs of the  
            particular residents, the extent of services provided, or  
            the physical arrangements of the facility require  
            additional staff. (Title 22 CCE 87411)


           This bill:


          1.Requires RCFE licensee certification to consist of 100  
            hours of training, up from the current 40-hour  
            requirement, of which 80 hours shall be classroom  
            instruction. Additionally, expands the uniform core of  
            knowledge to address use of psychotropic drugs,  
            nonpharmacologic approaches to dementia care and the  
            importance of residents' rights training. 


          2.Requires RCFE administrator initial certification  
            training to include 100 hours of in training and 60 hours  
            of continuing education for recertification.  
            Additionally, expands the uniform core of knowledge to  
            address use of psychotropic drugs, nonpharmacologic  
            approaches to dementia care and the importance of  
            residents' rights training. 







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          3.Adds to the CDSS requirement to develop regulations for  
            licensee and administrator certification and testing the  
            additional participation of stakeholder groups and the  
            requirement to review the test annually and update it as  
            necessary to reflect changes in law and regulations.


          4.Prohibits a licensee, or officer or employee of the  
            licensee from discriminating or retaliating against an  
            RCFE resident or employee, on the basis, or for the  
            reason that the person dialed or called 911.


          5.Requires an RCFE that accepts or retains residents with  
            prohibited health conditions, as defined by the  
            department, to ensure that residents receive home health  
            or hospice services sufficient in scope and hours to  
            ensure that residents receive medical care as prescribed  
            by the resident's physician and contained in the  
            resident's service plan.


          6.Requires an RCFE that accepts or retains residents with  
            restricted health conditions, as defined by the  
            department, to ensure that residents receive medical care  
            as prescribed by the resident's physician and contained  
            in the resident's service plan by appropriately skilled  
            professionals acting within their scope of practice.


          7.Defines appropriately skilled professional to mean an  
            individual who has training and is licensed to perform  
            the necessary medical procedures prescribed by a  
            physician. Specifies that this includes, but is not  
            limited to, a registered nurse, licensed vocational  
            nurse, physical therapist, occupational therapist, or  
            respiratory therapist, as defined.


          8.Provides that failure to meet or arrange to meet the  
            needs of residents who require specialized health  
            services, or failure to notify the physician of a  
            resident's illness or injury that poses a danger of death  
            or serious bodily harm is a licensing violation and  
            subject to civil penalty pursuant, as specified.





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          9.Requires CDSS to develop a uniform resident assessment  
            tool to be used by all residential care facilities for  
            the elderly. The assessment tool shall, in lay terms,  
            help to identify resident needs for service and  
            assistance with activities of daily living.


          10.Requires staff who assist residents with activities of  
            daily living to receive 40 hours of training within the  
            first four weeks of employment, an increase from the  
            existing 10-hour requirement. Requires that 24 of them be  
            completed prior to the provision of direct care, and  
            requires staff to receive an additional 20 hours of  
            continuing training annually. Requires the training to be  
            developed in consultation with individuals or  
            organizations with specific expertise in RCFE or assisted  
            living services.


          11.Expands the staff training curriculum to address the  
            use, misuse, and interaction of drugs commonly used by  
            the elderly, the adverse effects of psychotropic drugs  
            for use in controlling the behavior of persons with  
            dementia and nonpharmacologic person-centered approaches  
            to dementia care.


          12.Exempts certified nurse assistants with valid  
            certification from the staff training requirements,  
            except that exempted CNAs shall receive eight hours of  
            training on resident characteristics, resident records  
            and facility practices and procedures.


          13.Permits CDSS to develop a certification training program  
            with a standardized test for RCFE staff.


          14.Requires facilities that advertise or promote special  
            care, special programming or a special environment for  
            persons with dementia to provide to staff 15 hours of  
            resident care orientation (increased from six hours)  
            prior to providing direct care to residents, and removes  





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            the requirement that the requirement that the training  
            must be provided within the first four weeks of  
            employment.

          15.Requires RCFEs that advertise or promote care for  
            persons with dementia to increase in-service training  
            requirements from eight to 12 hours annually.


          16.Requires RCFEs with 16 or more residents to increase  
            training for staff who assist residents with the  
            self-administration of medications from 16 to 32 hours.   
            Of these hours, increases from eight to 12, the number of  
            hours of hands-on shadow training to be completed prior  
            to assisting residents with medications and increases  
            from eight to 20 hours other training or instruction, to  
            be completed within the first four weeks of employment  
            (increased from two weeks). 


          17.Requires RCFEs with 15 or fewer residents to increase  
            training for staff who assist residents with the  
            self-administration of medications from six to 16 hours.  
            Of these hours, increases, from two to eight, the number  
            of hours of hands-on shadow training to be completed  
            prior to assisting residents with medications and from  
            four to eight hours other training or instruction, to be  
            completed within the first two weeks of employment.


          18.Further increases the annual number of continuing  
            training hours, from four to eight, of in-service  
            training on medication-related issues for employees who  
            assist residents with self-administration of medications.


          19.Increases the training curriculum for staff assisting  
            with the self-administration of medication to include and  
            explanation of adverse effects of psychotropic drugs for  
            use in controlling the behavior of persons with dementia  
            and the increased risk of death when elderly residents  
            with dementia are given anti-psychotic medications.


          20.Adds new training requirements for staff working in  





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            facilities that serve residents with postural supports,  
            restricted health conditions, or hospice services as  
            follows: 
                     15 hours on the care, supervision, and special  
                 needs of those residents prior to providing direct  
                 care.
                     12 hours thereafter of in-service training per  
                 year.


                                  FISCAL IMPACT  

          This bill has not been analyzed by a fiscal committee. 

                            BACKGROUND AND DISCUSSION  

           Purpose of the bill: 


           According to the author, California's RCFE law is more than  
          20 years old and has not been updated to reflect changes in  
          medical and industry practices in caring for the elderly.  
          The author states that RCFEs now serve more residents with  
          serious health problems and higher levels of dementia who  
          previously would have been treated in nursing homes and  
          that, as a result, the lack of qualifications and training  
          required of administrators and direct care staff are  
          inadequate to meet the residents' needs for care and  
          supervision.


          The author cites a series of in-depth investigative reports  
          from the San Diego Union Tribune which found that hundreds  
          of seniors have suffered broken bones, deadly bedsores and  
          sexual assaults in San Diego alone. The articles cite  
          repeated incidents in which facility staff failed to  
          contact the residents' physicians or call 911 following  
          serious injuries, often related to falls or severe  
          bedsores.


          Residential Care Facilities for the Elderly


          Within California's continuum of long term care, situated  





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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. These  
          residences 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 assistance or nursing care. Increasingly 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, the smaller facilities  
          are homes in residential neighborhoods while the larger  
          facilities resemble apartment complexes with structured  
          activities for their residents. Residents may reside in  
          their own apartment, or may share a bedroom. Generally,  
          residents are free to leave the facility if they choose,  
          and may entertain guests, and otherwise maintain a high  
          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);





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                 Physical needs for elderly residents (5 hours);
                 Community and support services (2 hours);
                 Use, misuse and interaction of drugs commonly used  
               by the elderly (5 hours);
                 Resident admission, retention, and assessment  
               procedures (5 hours);
                 Care of residents with Alzheimer's Disease and  
               other dementias (4 hours)

          This bill requires a total of 100 hours of initial  
          instruction as well as 60 hours annually of continuing  
          education instruction and would expand the curriculum to  
          additionally include:


                 Adverse effects of psychotropic drugs for use in  
               controlling behavior of persons with dementia;
                 Nonpharmacologic, person centered approaches to  
               dementia care;
                 Residents rights and residents rights and the  
               importance of ongoing training for staff to ensure  
               residents rights.


          Typically, the 40-hour requirements are met through private  
          vendors who have been approved by CDSS to conduct these  
          trainings. The courses are generally scheduled as four,  
          consecutive 10-hour-day trainings, costing approximately  
          $200 to $300. Following the training, prospective  
          administrators are required to pass a 40-question test  
          administered by the Department that has not been changed  
          since its initial release. Approximately 500 individuals  
          take the exam every month. Reportedly, the several versions  
          of the test are available online to be studied in advance  
          and few individuals fail the exam. Licensees must only pass  
          their initial certification and are not required to  
          maintain a current certification which expires after two  
          years. Additionally, corporate owners of a facility, who  
          are not the official licensee, are not themselves required  
          to be licensed or have any training despite having  
          financial and managerial control over the facilities they  
          manage. 


          Restricted or Prohibited Health Conditions





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          California law provides that RCFEs may accept or retain  
          persons who are capable of administering their own  
          medications (or need only be reminded due to forgetfulness  
          or assisted due to physical limitations), 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). (Title 22  
          CCR 87455) 


          California statute prohibits RCFEs from accepting residents  
          who require 24-hour skilled nursing or intermediate care.  
          Additionally, regulation 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<1> and prohibits the acceptance of  
          residents with certain medical conditions including stage 3  
          or 4 pressure sores, gastronomy care, naso-gastric tubes,  
          staph infections or other serious infections, and  
          tracheotomies.<2> 


          RCFEs may accept residents who are permanently bedridden if  
          the facilities meet requirements pertaining to sufficiency  
          and training of staff, availability of appropriate  
          equipment or devices and obtain the proper fire  
          clearances.<3> Regulations require that RCFES that accept  
          bedridden residents must include a statement of how the  
          facility intends to meet those residents' overall health,  
          safety and care needs in the facility Plan of Operation.  
          This plan must include how the facility will meet the needs  
          -------------------------


          <1> Title 22 CCR 87455


          <2> Title 22 CCR 87615


          <3> CCL Information Release 2007-04






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          of bedridden residents with dementia, or those who are  
          terminally ill. In addition, each bedridden resident's  
          record must include documentation to demonstrate the  
          facility is meeting the needs of individual residents,  
          staff must receive training specific to care of bedridden  
          residents, and the facility's register of residents much  
          include information related to bedridden residents.<4>


          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 LPAs. 


          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. Any medical care provided in this manner  
          must be provided consistent with the medical practitioner's  
          scope of practice. Regulation defines "Appropriately  
          Skilled Professional" to mean:


               "[A]n individual that has training and is licensed to  
               perform the necessary medical procedures prescribed by  
               a physician. This includes but is not limited to the  
               following: Registered Nurse (RN), Licensed Vocational  
               Nurse (LVN), Physical Therapist (PT), Occupational  
               Therapist (OT) and Respiratory Therapist (RT). These  
               professionals may include, but are not limited to,  
               those persons employed by a home health agency, the  
               resident, or facilities and who are currently licensed  
               in California."

               ----------------------
          <4> Title 22 CCR 87606 (f)






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          RCFEs are prohibited from permitting facility staff from  
          administering injections, or from forcing or camouflaging  
          medications and staff may assist with the  
          self-administration of medications only when the  
          medications have been prescribed by the resident's  
          physician. If a resident's physician states in writing that  
          the resident is unable to determine his/her need for PRN  
          (as needed) medication and is unable to communicate  
          symptoms clearly then facility staff is only permitted to  
          assist in the self-administration of medications after  
          having contacted the resident's physician. The physician  
          must be contacted prior to each dose being administered,  
          and this information must be recorded in the patient's  
          record, along with the date and time that the medication  
          was taken.<5>  


          Facilities are additionally permitted to accept and retain  
          residents with health conditions that require incidental  
          medical services that may be provided through a licensed  
          home health agency. In such instances, the facility is  
          required to provide the care and supervision to the  
          residents and the facility and home health agency must  
          agree in writing on the responsibilities of each party. The  
          licensee must inform the home health agency of any duties  
          that facility staff members are prohibited from  
                                             performing.<6>








          Staffing requirements


          -------------------------
          <5> Title 22 CCR 87465


          <6> Title 22 CCR 87609






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          Existing law requires facility personnel to be sufficient  
          in numbers and competent to provide the services necessary  
          to meet resident needs. The department may require a  
          facility to provide additional staff whenever it determines  
          that the needs of the particular residents, the extent of  
          services provided, or the physical arrangements of the  
          facility require additional staff. Additionally,  
          regulations require RCFEs to ensure that the resident is  
          cared for in accordance with the physician's orders and  
          that the resident's medical needs are met. Facility staff  
          members are required to have the knowledge and skills to  
          respond to problems and to contact the physician,  
          appropriately skilled professional or vendor as  
          necessary.<7> 


          Residents are required to have a preadmission appraisal  
          performed and documented that includes an evaluation of the  
          resident's functional, mental and social needs, in order to  
          determine the level of care and supervision that each  
          resident requires. Additionally, residents must have a  
          medical assessment completed that must be signed by a  
          physician, made within the last year and kept on file. The  
          functional assessment is required to determine the  
          prospective resident's ability to perform detailed  
          activities of daily living including bathing, dressing,  
          grooming, continence, eating and physical condition.  
          Additionally facilities are required to complete a needs  
          and services appraisal/plan to determine the amount of  
          supervision that is necessary.<8> 


          Placement agencies (defined to include 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 are  
          engaged in finding homes or other places for the placement  
          -------------------------


          <7> Title 22 CCR 87411 and 87611


          <8> Title 22 CCR 87458, 87459 and 87461 and LIC forms 602A,  
          603, 603A, 604A and 625






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          of elderly persons for temporary or permanent care are  
          required to report to the department any situation in which  
          a facility has insufficient personnel or incompetent  
          personnel on duty.


          Regulations additionally require facilities to have and  
          maintain a current, written definitive plan of operation  
          that is required to be submitted to the licensing agency  
          with their application.<9> The plan includes, among other  
          things, a statement of admission policies and procedures  
          for accepting residents as well as the staffing plan,  
          qualifications and duties. Additionally, facilities are  
          required to submit a written report to the licensing agency  
          and the resident's responsible person when certain  
          incidents occur that may impact the health and safety of  
          residents.<10>


          Staff training requirements


          Existing law permits CDSS to adopt regulations to require  
          RCFE staff members who assist residents with activities of  
          daily living to receive ten hours of training. Statute and  
          regulation provide that this training shall include:<11>


                 The aging process and physical limitations and  
               special needs of the elderly (at least two hours).
                 Importance and techniques of personal care  
               services, including bathing, grooming, dressing,  
               feeding, toileting and universal precautions (at least  
               three hours).
                 Residents rights as specified in Title 22 CCR  
               87468.
             -----------------------
          <9> Title 22 CCR 87208


          <10> Title 22 CCR 87211


          <11> HSC 1569.625 and Title 22 CCR 87411






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                 Policies and procedures regarding medications,  
               including knowledge to safely assist with  
               self-administered prescribed medications (at least two  
               hours).
                 Psychosocial needs of the elderly, such as  
               recreation, companionship, independence, etc.
                 Recognizing signs and symptoms of dementia.

          This bill would require staff to receive 40 hours of  
          training within the first four weeks of employment, with 24  
          of them to be provided prior to the provision of direct  
          care, and would require staff to receive an additional 20  
          hours of continuing training annually. The curriculum of  
          the training is expanded under this bill to include:


                 The use, misuse, and interaction of drugs commonly  
               used by the elderly, and the adverse effects of  
               psychotropic drugs for use in controlling the behavior  
               of persons with dementia.
                 The special needs of persons with Alzheimer disease  
               and dementia, including nonpharmacologic  
               person-centered approaches to dementia care.


          This bill would exempt certified nurse assistants (CNAs)  
          with valid certification from these requirements except  
          that exempted CNAs would still be required to receive eight  
          hours of training on resident characteristics, resident  
          records and facility practices and procedures.


          Additionally, this bill requires additional hours of staff  
          training for staff that assist in the self-administration  
          of medication, staff that work in facilities advertising  
          special care for residents with dementia, as well as staff  
          members that serve residents with postural supports, have  
          restricted health conditions, or are receiving hospice  
          services. In total, in facilities serving these residents,  
          staff would be required to complete the following training  
          schedule: 

           ------------------------------------------------------------ 
          |                                                            |
          |Overall requirements:  40 hours total; 24 prior to          |





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          |providing care; and 20 annually                             |
          |Dementia care:             15 hours total prior to          |
          |providing care; and 12 annually                             |
          |Medication Assistance:                                      |
          |         Large facilities - 32 hours total; 12 prior to     |
          |providing care; and 8 annually                              |
          |         Small facilities - 16 hours total; 8 prior to      |
          |providing care; and 8 annually                              |
          |Postural, Restricted, Hospice: 15 hours total prior to      |
          |providing care; and 12 annually                             |
          |                                                            |
           ------------------------------------------------------------ 

          Through regulation, existing law provides that all training  
          shall be conducted by a person who is knowledgeable in a  
          relevant subject area of the training and who has one of  
          the following:
                 a four year degree or graduate degree as well as  
               two years of experience;
                 a license to work as a health care provider;
                 at least two years of experience in California as  
               an RCFE administrator with a record of administering  
               facilities with substantial compliance.


          This bill would require that the training shall be  
          developed in consultation with individuals or organization  
          with specific expertise in RCFE or assisted living  
          services, or by an outside source with such expertise.


          Use of anti-psychotic medications in Assisted Living



          Recent research suggests that between 35% and 53% of  
          assisted living residents receive one or more psychotropic  
          medications.<12> Numerous studies document that older  
          adults are particularly susceptible vulnerable to adverse  
          -------------------------
          -------------------------

          <12> Smith M, Buckwalter KC, Hyunwook K, Ellingrod V,  
          Schultz SK. Dementia-specific assisted living: Clinical  
          factors and psychotropic medication use. Journal of the  
          American Psychiatric Nurses Association. 2008;14:39-49





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          effects of psychotropic medications.<13> Those older than  
          age 70 are 3.5 times more likely than younger individuals  
          to be admitted to the hospital due to adverse drug  
          reactions associated with psychotropic medications.  
          Additionally, the risk for adverse reactions increases  
          dramatically with the number of medications used and with  
          increasing age.<14> 

          In 2012, the Centers for Medicare and Medicaid Services  
          (CMS) launched the National Partnership to Improve Dementia  
          Care and Reduce Unnecessary Antipsychotic Drug Use in  
          Nursing Homes. A recent memorandum submitted to CMS state  
          surveyor agency directors, citing numerous peer reviewed  
          academic studies, states that:


               The problematic use of medications, such as  
               antipsychotics, is part of a larger, growing concern.  
               This concern is that nursing homes and other settings  
               (i.e. hospitals, ambulatory care) may use medications  
               as a "quick fix" for behavioral symptoms or as a  
               substitute for a holistic approach that involves a  
               thorough assessment of underlying causes of behaviors  
               and individualized, person-centered interventions?


               When antipsychotic medications are used without an  
               adequate rationale, or for the purpose of limiting or  
               controlling behavior of an unidentified cause, there  
               is little chance that they will be effective. In  
               addition, they commonly cause complications such as  
               movement disorders, falls, hip fractures,  
               cerebrovascular adverse events (cerebrovascular  
               accidents and transient ischemic events) and increased  
               ----------------------
               ----------------------


          <13> Lindsey, Pamela. Psychotropic Medication Use among  
          Older Adults: What All Nurses Need to Know. Journal of  
          Gerontol Nursing. Sep 2009; 35(9): 28-38

          <14> Brooks JO, Hoblyn JC. Neurocognitive costs and  
          benefits of psychotropic medications in older adults.  
          Journal of Geriatric Psychiatry and Neurology.  
          2007;20:199-214





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               risk of death. <15> 


          Additionally, the memorandum cites a Food and Drug  
          Administration (FDA) public health advisory which found  
          that elderly patients with dementia-related psychosis  
          treated with second generation antipsychotic drugs are at a  
          1.6-1.7 fold increased risk of death compared to  
          placebo.<16> According to the FDA, the specific causes of  
          these deaths were largely either due to heart related  
          events (e.g., heart failure, sudden death) or infections  
          (mostly pneumonia). The FDA notes that none of the  
          antipsychotic drugs have been approved for the treatment of  
          behavioral disorders in patients with dementia and has  
          required drug manufactures to include a boxed warning in  
          their labeling.


          In setting standards for use of these medications in  
          nursing homes, CMS has put forward a series of dementia  
          care principles that attempts to foster a person centered  
          approach to care better ensures the judicial use of  
          pharmalogical approaches to dementia care, that they are  
          clinically indicated and gradually reduced in an effort to  
          discontinue the drugs over time. Although this CMS guidance  
          is directed specifically toward nursing homes, its findings  
          and subsequent policy approaches are substantially relevant  
          to assisted living facilities which presumably serve a  
          similar demographic of residents who are potentially less  
          acute than those of nursing homes.


          Governor's Budget Proposal
          -------------------------


          <15> S&C: 13-35-NH  
           http://www.cms.gov/Medicare/Provider-Enrollment-and-Certific 
          ation/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-L 
          etter-13-35.pdf  


          <16> FDA Public Health Advisory: Deaths with Antipsychotics  
          in Elderly Patients with Behavioral Disturbances.  
           http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInfo 
          rmationforPatientsandProviders/DrugSafetyInformationforHeath 
          careProfessionals/PublicHealthAdvisories/ucm053171.htm  







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          As part of the Governor's 2014-2015 proposed budget the  
          Administration has put forth a Budget Change Proposal that  
          intends to address some of the policy issues that this bill  
          also seeks to address. The Administration does not propose  
          to increase the training hours or curriculum for licensees,  
          administrators or staff of RCFEs. Instead, the proposal  
          seeks to strengthen the administrator certification process  
          by adding three new positions that would enhance current  
          testing policies and procedures establish statewide  
          uniformity in the administration of the test and update the  
          exams themselves. Additionally, the Administration proposes  
          to hire a nurse practitioner position to assist with the  
          development of regulatory policies related to medical care  
          in RCFEs as well as a mental health populations unit to  
          provide technical assistance to enforcement staff. 


           Prior/Related Legislation


           Current legislation


          SB 894 (Corbett) Would expand numerous requirements for  
          RCFE licensees in the event of a temporary license  
          suspension or license revocation. Additionally, would  
          expand the responsibilities of CDSS in overseeing a  
          temporary suspension or revocation of an RCFE license and  
          in protecting the health and safety of affected residents. 


          SB 895 (Corbett) Would require CDSS to conduct annual  
          unannounced comprehensive inspections for all facilities,  
          requires CDSS to verify compliance following deficiencies  
          within 10 days, and requires results of inspections to be  
          available on the CDSS website.


          SB 1153 (Leno) Would permit CDSS to order a suspension of  
          new admissions for an RCFE when the facility has violated  
          applicable laws and regulations that present a direct risk  
          to the health and safety or residents, is not providing  
          adequate care and supervision, has been cited for  





          STAFF ANALYSIS OF SENATE BILL 911 (Block)               
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          subsequent violations of the same law within 12 months, or  
          has failed to pay existing fines.


          SB 1382 (Block) Would increase the annual licensure fees by  
          30 percent and would make related findings and  
          declarations. 


          AB 1571 (Eggman) Would increase disclosure requirements for  
          RCFE licensee applicants and require applicant information  
          to be cross referenced with the State Department of Public  
          Health. Would require, by 2015, CDSS to create an online  
          inquiry system posting detailed information about RCFE  
          facilities including complaints, deficiencies and  
          enforcement actions resulting in fines. In subsequent  
          years, would require CDSS to post additional information,  
          as specified. 


          AB 1572 (Eggman) Would require RCFEs, at the request of two  
          or more residents, to assist the residents in establishing  
          and maintaining a single resident council, as specified,  
          and requires the facility to interact with the council in  
          specified ways.


          AB 1523 (Atkins and Weber) Would require RCFEs to maintain  
          liability insurance covering injury to residents and guests  
          in the amount of $1 million per occurrence and $3 million  
          annually.


          AB 1436 (Waldron) Would require the results of all reports  
          of inspections, evaluations or consultations and lists of  
          deficiencies to be posted on the departments Internet Web  
          site.


          AB 1454 (Calderon) Would require all licensed community  
          care facilities, RCFEs, and child day care centers to be  
          subject to an annual unannounced visits visit by CDSS. 


          AB 1570 (Chesbro) Would increase the certification training  





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          requirements for RCFE administrators, increases training  
          requirements for RCFE staff that care for residents, and  
          increases training requirements for staff providing  
          dementia care.


          AB 1554 (Skinner) Would make various changes to existing  
          RCFE complaint procedures including require the department  
          to make an onsite inspection within 24 hours of a complaint  
          alleging abuse, neglect or a threat of imminent danger.  
          Additionally would require the department to complete its  
          investigation within 90 days of receiving a complaint.  
          Would permit a complainant to file an appeal of  
          departmental findings. 


          AB 1899 (Brown) Would make a person whose license is  
          revoked or forfeited for abandonment of the facility  
          ineligible for reinstatement of the license for a period of  
          10 years following the revocation or forfeiture.  
          Additionally would require CDSS to establish and maintain a  
          telephone hotline and an Internet Web site dedicated to  
          receiving complaints. 
          
          AB 2171 (Wieckowski) Would establish specified RCFE  
          resident's rights and require facilities to inform  
          residents of these rights as specified.


          AB 2044 (Rodriguez) Would require every licensed  
          residential care facility to be subject to an annual  
          unannounced visit by the department, as prescribed.  
          Additionally would require complaints to be inspected  
          within 3 days if the complaint involves alleged abuse or  
          serious neglect, or within 10 days for all other complaints  
          and would require investigations to be completed within 30  
          days. Would provide a complainant with the right to request  
          an informal conference and subsequent appeal, as specified.  
          Also would require certain staff to be present in the  
          facility for specified times.


          Prior legislation







          STAFF ANALYSIS OF SENATE BILL 911 (Block)               
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          AB 313 (Monning, Chapter 365, Statutes of 2011) Requires  
          each RCFE to provide residents, their responsible party,  
          and the local long-term care ombudsman with a 10 day  
          written notice when CDSS commences proceedings to suspend  
          or revoke its license, or a criminal action relating to  
          health or safety of the residents is brought against the  
          facility, and makes other changes related to these actions.


          AB 2066 (Monning, Chapter 643 Statutes of 2012) Requires  
          RCFEs to provide a 60 day written notice to residents or  
          the responsible person within 24 following receipt of CDSSs  
          order of revocation. Permits the licensee to secure an  
          alternative manager, as specified. Requires RCFEs to refund  
          all or a portion of preadmission fees to residents  
          transferring as the result of a license revocation, as  
          specified.


          SB 897 (Leno, Chapter 376, Statutes of 2011) Requires  
          licensed residential care facilities for the elderly  
          (RCFEs) to notify CDSS, the state's Long-Term Care  
          Ombudsman and the facility's residents when the property is  
          subject to foreclosure or certain other events occur due to  
          financial distress.

          AB 419 (Mitchell, 2011) Would have required every community  
          care facility licensed by CDSS to be inspected unannounced  
          at least once per year using research based, field tested  
          inspection protocols, as specified. This bill died in the  
          Assembly Appropriations Committee.


           Comments:


           The California Association for Health Services at Home and  
          the California Assisted Living Association raise a concern  
          that this bill may permit an RCFE to oversee or direct the  
          care of a home health or hospice agency that is caring for  
          a resident that has a prohibited health condition. The  
          author states that the intent of the bill is for a facility  
          to ensure that it has the capacity to safely care for a  
          resident with a prohibited condition, and not to permit the  
          facility to directly oversee the care of the licensed  





          STAFF ANALYSIS OF SENATE BILL 911 (Block)               
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          agency. 


          Staff recommends the author continue working with these  
          organizations to clarify the intent of the bill.


          Provisions of this bill are substantially similar to AB  
          1570 (Chesbro) but have different requirements in terms of  
          the number of hours of training and the scope of the  
          training.  

          Staff recommends the author work with sponsor and author of  
          AB 1570 to seek to address these differences.
          
                                    POSITIONS  

          Support:       Hazel's Army (co-sponsor)
                         Stand Up for Rosie (co-sponsor)
                         AFSCME
                         California Advocates for Nursing Home Reform
                         California Assisted Living Association
                         California Continuing Care Residents  
                         Association
                         California Senior Legislature
                         Catholic Charities Diocese of Stockton
                         Consumer Attorneys of California
                         Consumer Federation of California
                         County of San Diego
                         Elder Law and Advocacy
                         Jewish Family service of Los Angeles
                         Johnson Moore Trial Lawyers
                         Long-Term Care Ombudsman of Ventura County
                         Office of the State Long-Term Care Ombudsman
                         Ombudsman & HICAP Services of Northern  
                         California
                         Ombudsman Services of Contra Costa
                         Valentine Law Group
                         202 individuals

          Oppose:   Angel Care Community Services, Inc.
                         California Assisted Living Association  
          (unless amended)
                         California Assoc. for Health Services at  
                         Home (unless amended)





          STAFF ANALYSIS OF SENATE BILL 911 (Block)               
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                         California Association of Health Facilities  
                         (unless amended)
                         California Right To Life Committee, Inc.
                         Leading Age California (unless amended)





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