BILL ANALYSIS                                                                                                                                                                                                    Ó




                   Senate Appropriations Committee Fiscal Summary
                            Senator Kevin de León, Chair


          SB 911 (Block) - Residential care facilities for the elderly:  
          training.
          
          Amended: March 27, 2014         Policy Vote: Human Services 3-2
          Urgency: No                     Mandate: Yes
          Hearing Date: April 28, 2014                            
          Consultant: Jolie Onodera       
          
          This bill meets the criteria for referral to the Suspense File.
          
          
          Bill Summary: SB 911 would increase the initial and continuing  
          education training requirements for licensees, administrators,  
          and direct care staff of residential care facilities for the  
          elderly (RCFEs), as specified. In addition, this bill would  
          prohibit discrimination or retaliation in any manner against a  
          resident or employee for calling 911.

          Fiscal Impact: 
              Significant one-time costs potentially in excess of  
              $500,000 (General Fund) for DSS to revise regulations and  
              consult with specified groups to update the uniform core of  
              knowledge for RCFE administrators and training for direct  
              care staff. To the extent DSS elects to develop a  
              certification training program and standardized testing tool  
              for direct care staff, costs would be significantly greater.
              No new costs to the Department of Aging to continue  
              existing efforts of collaboration with the DSS in  
              development of training curriculum and a resident assessment  
              tool. 
              Significant ongoing increase in training costs to employees  
              and/or facilities to meet the enhanced initial and  
              continuing education training requirements imposed. 
              Potential minor non-reimbursable local enforcement costs  
              for violations of any of the provisions of this measure. 

          Background: The Community Care Licensing Division (CCLD) of the  
          DSS administers the licensure and oversight of over 7,500  
          assisted living, board and care, and continuing care retirement  
          homes that are licensed as RCFEs in California. These residences  
          are designed to provide home-like environment housing options to  
          elderly residents who need assistance with activities of daily  








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          living but otherwise do not require continuous, 24-hour  
          assistance or nursing care. The RCFE licensure category includes  
          facilities with as few as six beds to facilities with hundreds  
          of residents whose needs may vary widely. 
          
          Over 20 years have passed since existing RCFE licensing  
          certification requirements have been changed. The last noted  
          revision was through the enactment of AB 1615 (Hannigan),  
          Chapter 848/1991, which required prospective licensees to  
          undergo an orientation training prior to commencing the licensee  
          certification process. 

           RCFE administrator requirements  : Currently, licensees and  
          administrators of RCFEs are required to undergo 40 hours of  
          training and complete a written exam. However, as noted by the  
          DSS, "Currently, no proctoring protocol exists, resulting in no  
          statewide uniformity on how the exams are administered. This  
          lack of consistency and guidance results in errors and can  
          ultimately result in candidates getting certified who may not  
          meet the minimum qualifications."

          Concerns have also been raised by advocates about the rigor and  
          relevance of the administrator exam. According to DSS,  
          approximately 500 people take the administrator certification  
          test each month. However, there is no requirement under law that  
          the exam reflects what is provided in the 40 hours of  
          administrator/licensee training required for completion prior to  
          taking the certification exam.  

           RCFE staff requirements  :  Licensees employ a wide range of staff  
          to provide day-to-day support and care for residents of RCFEs.   
          Although many employ individuals with specific expertise and  
          certifications, such as Licensed Vocational Nurses and Certified  
          Nursing Assistants, at minimum, staff who assist residents with  
          personal activities of daily living are required to be at least  
          18 years of age and undergo 10 hours of training within four  
          weeks of being employed by the RCFE and four hours of training  
          each year thereafter. The training is somewhat similar to that  
          required of licensees and administrators, but is limited to  
          covering the physical limitations and needs of the elderly, the  
          importance and techniques for personal care services, residents'  
          rights, policies and procedures regarding medications and the  
          psychosocial needs of the elderly. 









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          There are also additional training requirements for staff who  
          work in RCFEs that "provide" dementia care or who assist  
          residents with managing their medication. Staff who work in a  
          RCFE that advertises or promotes special care, special  
          programming, or a special environment for persons with dementia  
          are required to undergo an additional six hours of training on  
          providing care to persons with dementia. Staff also must  
          annually complete eight hours of continuing training on dementia  
          care. Training for staff who assist residents in the management  
          and self-administration of medication depends on the size of the  
          facility in which they work. For facilities with 16 or more  
          residents, staff must undergo 16 hours of training, and for  
          facilities with 15 or fewer residents, staff must complete six  
          hours of training on medication management. Both training  
          requirements must be completed within the first two weeks of  
          employment and conclude with an examination. Four hours of  
          annual continuing medication management training is required, as  
          well.

          In response to recent health and safety issues discovered at  
          facilities licensed by the CCLD, the 2014-15 Governor's Budget  
          proposes a comprehensive plan to reform the CCLD program. This  
          proposal includes an increase of $7.5 million ($5.8 million  
          General Fund) and 71.5 positions to improve the timeliness of  
          investigations, ensure the CCLD inspects all facilities at least  
          once every five years, increase staff training, and establish  
          clear fiscal, program, and corporate accountability. The  
          proposal also increases civil penalties assessed for violations  
          and increases licensing and application fees by 10 percent.  
          Another component of the plan proposes to strengthen the  
          Administrator Certification Section to develop regulations,  
          protocols, and new examinations to ensure the testing  
          environment and procedures are uniform statewide.

          Proposed Law: This bill would expand both the initial and  
          ongoing training requirements for RCFE licensees,  
          administrators, and staff, as follows:
                 Deletes the existing requirement of 40 hours of  
               classroom instruction for RCFE licensee certification  
               training programs and replaces it with 100 hours of  
               required training, 80 hours of which are to consist of  
               classroom instruction. 
                 Increases continuing education training requirement for  
               administrators from 20 hours to at least 60 hours during  








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               each two-year certification period.
                 Adds the following components to the list of items  
               required to be covered in the RCFE licensee certification  
               training program: adverse effects of psychotropic drugs for  
               use in controlling the behavior of persons with dementia,  
               non-pharmacologic, person-centered approaches to dementia  
               care, and residents' rights.
                 Requires the participation of "other stakeholder groups"  
               (undefined) in the development of regulations of  
               certification program content, testing, process for  
               approving programs, and criteria to be used for authorizing  
               individuals or organizations to conduct certification  
               programs. Further, requires DSS to review the test annually  
               and update as necessary to reflect changes in law and  
               regulations.
                 Prohibits a licensee, or officer or employee of the  
               licensee, from discriminating or retaliating in any manner  
               against a resident or employee of the facility, on the  
               basis or for the reason that the person, employee, or any  
               other person dialed or called 911.
                 Eliminates the requirement that a RCFE staff person must  
               undergo ten hours of training within the first four weeks  
               of employment and, instead, requires a RCFE staff person to  
               undergo 40 hours of training within the first four weeks of  
               employment, at least 24 hours of which must be completed  
               prior to providing direct care to residents, and 20 hours  
               annually thereafter. 
                 Requires DSS to establish the subject matter required  
               for the staff training and develop the training in  
               consultation with individuals or organizations with  
               specific expertise in RCFE or assisted living services, or  
               by an outside source with expertise, as specified. 
                 Expands RCFE staff training components to include 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  
               the special needs of persons with Alzheimer's disease and  
               dementia, including non-pharmacologic person-centered  
               approaches to dementia care.  
                 Authorizes DSS to develop a certification program with a  
               standardized test for RCFE staff.
                 Increases training requirements for RCFE staff at  
               facilities that provide special care from six hours to 15  
               hours of resident care, and requires all 15 hours to be  








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               completed prior to providing direct care to residents. Also  
               increases in-service training from eight hours to 12 hours  
               on the subject of providing care and supervision to  
               residents with dementia.
                 Requires an RCFE that accepts or retains residents with  
               prohibited health conditions or restricted health  
               conditions, as specified, to ensure that residents receive  
               care as prescribed by the resident's physician and  
               contained in the resident's service plan.
                 Requires staff in RCFEs providing care to more than 16  
               persons to complete 32 hours, instead of 16 hours, of  
               initial training, as specified. Requires staff in RCFEs  
               providing care to 15 or fewer persons to complete 16 hours,  
               instead of six hours, of initial training, as specified.
                 Adds new training requirements for RCFE staff at  
               facilities serving residents with postural supports,  
               restricted health conditions or who receive hospice  
               services to include 1) 15 hours of training prior to  
               providing direct care to residents on the care,  
               supervision, and special needs of those residents, and, 2)  
               12 hours annually thereafter of in-service training on the  
               subject of serving those residents.

          Related Legislation: AB 1570 (Chesbro) 2014 would increase the  
          certification training requirements for RCFE administrators,  
          increase training requirements for RCFE staff that care for  
          residents, including staff providing dementia care.  
          Additionally, this bill would require the certification exam to  
          be state-administered. This bill is pending hearing in the  
          Assembly Committee on Appropriations.
          
          The following bills regarding licensing and inspections at  
          community care facilities, and RCFEs specifically, have been  
          introduced this session:
          
          SB 894 (Corbett) RCFEs: revocation of license. 
          SB 895 (Corbett) RCFEs: annual inspections.
          SB 1153 (Leno) RCFEs: suspension of new admissions. 
          SB 1382 (Block) RCFEs: licensure fees.
          AB 1436 (Waldron) RCFEs: internet posting of inspection reports.
          AB 1523 (Atkins) RCFEs: liability insurance.
          AB 1554 (Skinner) RCFEs: complaint procedures.
          AB 1571 (Eggman) RCFEs: disclosure requirements.
          AB 1572 (Eggman) RCFEs: single resident council.








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          AB 1899 (Brown) RCFEs: prohibitions on licensure reinstatement.
          AB 2044 (Rodriguez) RCFEs: 24-hour presence of  
          administrator/staff.
          AB 2171 (Wieckowski) RCFEs: residents' rights.

          Staff Comments: The DSS would likely incur one-time costs  
          potentially in excess of $500,000 (General Fund) to develop  
          revised regulations after consultation with "other stakeholder  
          groups" (undefined) in the development of the uniform core of  
          knowledge for RCFE administrator certification program content,  
          testing, and criteria to be used for authorizing individuals or  
          organizations to conduct the certification programs. The DSS  
          would also incur ongoing workload to review the test annually  
          and update as necessary to reflect changes in law and  
          regulations.

          Additional regulations for RCFE staff training provisions would  
          also be adopted once DSS establishes the subject matter required  
          for staff training and develops the training in consultation  
          with individuals or organizations with specific expertise in  
          RCFE or assisted living services, as required under the  
          provisions of this bill. To the extent DSS chooses to develop a  
          certification training program and standardized testing tool for  
          direct care staff (optional), costs to DSS would be  
          significantly greater.

          Under existing law, any person who violates the California  
          Residential Care Facilities for the Elderly Act (Act), is guilty  
          of a misdemeanor and subject to civil penalties and suspension  
          or revocation of his or her license. To the extent the  
          provisions of this measure result in future violations of the  
          Act, could result in non-reimbursable local enforcement costs.

          Recommended amendments: This bill requires licensees to meet  
          significantly higher training standards as a condition of  
          licensure and RCFE staff to meet enhanced training requirements  
          prior to direct care. The author may wish to consider a delayed  
          implementation date for compliance in order for the revised  
          training standards to be developed and tested, and to ensure  
          existing and prospective licensees, staff, and vendors who  
          administer certification programs are adequately notified of the  
          changes.

          Section 3 of the bill provides that failure of an RCFE to meet  








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          or arrange to meet the needs of those 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, as specified. As currently drafted, "specialized  
          health services" is undefined. For clarity, staff recommends an  
          amendment to define this term or cross-reference an existing  
          code section that provides a definition of this term.