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 SB 911 (Block) Page 1 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. SB 911 (Block) Page 2 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 SB 911 (Block) Page 3 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 SB 911 (Block) Page 4 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. SB 911 (Block) Page 5 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 SB 911 (Block) Page 6 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.