BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                     AB 348


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          Date of Hearing:  April 21, 2015


                   ASSEMBLY COMMITTEE ON AGING AND LONG-TERM CARE


                                 Cheryl Brown, Chair


          AB 348  
          Brown - As Amended April 14, 2015


          SUBJECT:  Long-term health care facilities.


          SUMMARY:  Creates a 40-day timeframe for the Department of  
          Public Health (DPH) to complete a long-term care facility  
          complaint investigation and requires DPH to provide additional  
          information about the investigation of the complainant.   
          Specifically, this bill:  





          1)Requires DPH to complete investigations of complaints against  
            long-term health care facilities within 40 working days of the  
            receipt of the complaint.  



          2)Allows DPH to extend an investigation up to 30 additional  
            working days if DPH has been unable to obtain necessary  
            evidence related to the investigation despite its diligent  
            attempts.  











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          3)Requires DPH, when it extends an investigation under 1) above,  
            to notify the complainant and provide the basis for the  
            extension, a description of outstanding evidence and sources,  
            and the anticipated completion date.  





          4)Effective July 1, 2015, requires DPH to include specific  
            findings concerning each alleged violation and a summary of  
            the evidence in the written determination it is required to  
            make at the investigation's conclusion.  





          5)Increases, from five days to 15 days, the amount of time a  
            complainant has to request an informal conference with DPH, if  
            the complainant is dissatisfied with DPH's determination.  





          6)Expands provisions related to timeframes for a complaint  
            investigation to include self-reports of violations by  
            facilities.  


          EXISTING LAW:  













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          1)Defines Health Facilities in Health and Safety Code Section  
            1250 as "general acute care hospital," "acute psychiatric  
            hospital," "skilled nursing facility," "intermediate care  
            facility," "intermediate care facility/developmentally  
            disabled habilitative," "special hospital," "intermediate care  
            facility/developmentally disabled," "intermediate care  
            facility/developmentally disabled-nursing," "congregate living  
            health facility," "correctional treatment center," "nursing  
            facility," "intermediate care facility/developmentally  
            disabled-continuous nursing," or "hospice facility."  



          2)Requires DPH to initiate investigations within 24 hours, and  
            complete investigations of written or oral complaints made in  
            regards to dangerous situations within acute hospital settings  
            within 45 days.





          3)Requires DPH to initiate an investigation with an onsite  
            inspection within 10 working days of the receipt of a valid  
            written or oral complaint in a skilled nursing facility.  In  
            cases of imminent danger of death, or serious bodily harm, DPH  
            is required to initiate an investigation with an onsite  
            inspection within 24 hours.  There is no corresponding mandate  
            to complete the investigation, as there is for a complaint in  
            a general acute hospital setting.



          4)Provides that any duly authorized officer, employee, or agent  
            of the state department may enter and inspect any long-term  
            health care facility, including, but not limited to,  
            interviewing residents and reviewing records, at any time to  
            enforce the law.









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          5)Requires that inspections conducted pursuant to complaints  
            filed with the state department be conducted in such a manner  
            as to ensure maximum effectiveness while respecting the rights  
            of patients in the facility.  



          6)Forbids advance notice of inspections unless previously and  
            specifically authorized by the director or required by federal  
            law, and provides that any public employee giving any advance  
            notice of an inspection, or a visit related to an  
            investigation, is in violation of law and subject to  
            dismissal, demotion, suspension, or other disciplinary action.  
             



          7)Requires DPH to notify the complainant of the name of the  
            inspector or investigator and permits the complainant to  
            accompany the inspector to the site of the alleged violation.   






          8)Requires DPH to notify the complainant of its determination  
            within 10 working days of the completion of the complaint  
            investigation.  Permits the complainant to request in writing  
            an informal conference within five business days after receipt  
            of the notice.  Offers additional levels of appeals if the  
            complainant is dissatisfied with the determination of DPH.  



          9)Requires a long-term health care facility to report all  
            incidents of alleged abuse or suspected abuse of a resident of  








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            the facility to DPH immediately, or within 24 hours, as  
            specified.  



          10)Under state regulations, requires a long-term health care  
            facility to report unusual occurrences such as epidemic  
            outbreaks, poisonings, fires, major accidents, death from  
            unnatural causes, or other catastrophes which pose health or  
            safety threats within 24 hours to the local health officer and  
            to DPH.  





          11)Excludes, for the purposes of these complaint investigation  
            requirements, a self-report from a facility of an alleged  
            violation of applicable requirements of state or federal law.   




          12)Requires DPH to prepare an annual staffing and systems  
            analysis to, among other things, ensure the effective and  
            efficient utilization of licensing and certification fees and  
            proper allocation of DPH resources to licensing and  
            certification activities.  Requires the analysis to contain  
            specified information, including the number and timeliness of  
            complaint investigations.  


          FISCAL EFFECT:  This bill has not yet been analyzed by a fiscal  
          committee.  


          COMMENTS:  










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          PURPOSE OF THIS BILL:  Unlike investigations of complaints about  
          hospitals, DPH staff members are not required by law to complete  
          investigations of complaints in nursing homes.  The author  
          points to extensive testimony received by the Legislature during  
          two joint oversight hearings of the Assembly Committee on Aging  
          and Long-Term Care and the Assembly Committee on Health which  
          indicates that DPH, despite well-established statutory  
          mechanisms to assure adequate financial and personnel resources  
          to conduct and complete necessary investigations, fails to meet  
          its workload demands.  It should be noted that DPH failed to  
          report to the legislature, for two years, a statutorily required  
          workload analysis that would have demonstrated performance  
          challenges that the DPH staff were confronting, and through  
          licensing fee adjustments - not General Fund allocations - the  
          staff shortages could have been managed.  Despite a continued  
          focus upon the problem, a back-log of uninvestigated complaints  
          about physical abuse, mistreatment, poor care and entity  
          reported incidents (ERIs) continues to grow - now, according to  
          DPH, estimated at nearly 12,000.  Oversight exercises revealed  
          that thousands of complaints have languished with incomplete  
          investigation, some for years.  The author asserts that each  
          complaint represents a potentially serious injustice, potential  
          pain, and ongoing suffering, potentially caused by predators who  
          seek employment among vulnerable populations who become  
          unwitting prey in long-term health care facilities, or, business  
          practices that place individuals at risk of serious harm such as  
          poor staffing patterns, poor management, or other practices over  
          which DPH is charged with state and federal oversight  
          responsibilities.  





          The author asserts that timely investigations are critical to  
          reduce, even eliminate known risk.  According to the author,  
          acting to protect dependent adults in care environments  
          regulated by the state is a governmental priority.  This bill is  
          intended to address this issue by enhancing existing laws which  








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          require investigations to be initiated within no more than 10  
          days.  The specific enhancement AB 348 proposes is to establish  
          a reasonable, statutory timeframe (40 working days, plus one 30  
          working day extension, if necessary) within which the  
          investigation must be completed.  According to the author, AB  
          348 improves current law so that DPH which is already under  
          statutory obligation to open investigations, remains obligated  
          to complete, and close the investigation.  Ongoing reporting  
          requirements will provide periodic evidence establishing a basis  
          for additional resources through licensing-fee adjustments, not  
          tax-payer supported general funds, to assure that abused,  
          mistreated and injured citizens, or their families, receive  
          dignity and justice.  Completed investigations may also help  
          facilities recognize management or business practices which  
          unwittingly create unnecessary risk for a medically frail  
          population, and place their Medicare "Star" rating at risk.


          According to Supporters:  According to the California Advocates  
          for Nursing Home Reform (CANHR), the sponsor of AB 348, "lives  
          are at risk: years often go by before DPH responds when it  
          receives a complaint that a nursing home resident died due to  
          neglect" and provide three recent examples of the types of  
          complaints that become overlooked at DPH:





                 On November 13, 2013, DPH issued a $100,000 fine to  
               Rosewood Post-Acute Rehab, a skilled nursing facility in  
               Carmichael; nearly seven years after the patient died on 
             January 1, 2007 by an overdose of Warfarin, a powerful blood  
               thinning medication.  
             DPH offered no explanation for the extreme delay.



                 An April 12, 2014 article by Kaiser Health News,  








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               "Frustrating Wait for the Nursing Home Inspector," tells  
               the story of Sui Mee Chiu, a former resident of the Arcadia  
               Health Care Center.  Ms. Chiu died in 2011 at age 85 after  
               developing severe bedsores, including one on her backside  
               that was so deep it exposed the bone.  Following her death,  
               her daughter, Mary Chiu, filed a 7-page complaint with the  
               Los Angeles County Department of Public Health in September  
               2011.  At the time of the article in April 2014, the  
               Department had still not completed its investigation.



                 The Department also ignores victims of physical and  
               sexual abuse.  For example, after learning in November 2009  
               that a male nurse sexually assaulted a female resident at  
               the Palos Verdes Health Care Center, the Department took  
               four years before issuing a citation in October 2013.  



          CANHR concludes that "when nursing home residents die from  
          neglect or suffer from abuse, DPH is usually nowhere to be  
          found."





          According to the California Association of Area Agencies on  
          Aging, "although the Department of Public Health reports that it  
          completes 90 percent of their investigations within 40 days, the  
          response time is not sufficient.  These are investigations  
          involving poor care, mistreatment and abuse.  Timely  
          investigations are not only critical because of the threat of  
          danger or death, but the need to investigate and collect  
          evidence before it deteriorates or memories fade."











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          The California Retired Teachers Association states that "by  
          establishing an investigation completion timeline, AB 348  
          provides some certainty about DPH's responsiveness and  
          dedication to completing investigations, thereby prioritizing  
          the health and safety of long-term care residents.  It is  
          critically important that allegations of mistreatment,  
          misconduct, and abuse be fully investigated in timely manner.   
          This bill will strengthen and improve the State oversight and  
          enforcement process for long-term care facilities, making  
          important strides to ensure the safety of California's seniors."


          


          BACKGROUND:  DPH leadership has been scrutinized since  
          revelations about misplaced priorities, poor management, ongoing  
          and persistent lack of accountability and a growing back-log of  
          complaints describing abuse, mistreatment and poor care within  
          facilities which they regulate continues to grow.  The DPH  
          Licensing and Certification (L&C) Program is responsible for the  
          oversight of licensed health care facilities defined in Health  
          and Safety Code 


          Section 1250, about 1275 of which are skilled nursing facilities  
          (SNFs) and intermediate care facilities (ICFs).  SNFs and ICFs  
          account for about 50 percent of the DPH workload - about 6,200  
          other health facilities, such as acute care hospitals, clinics,  
          adult day health centers, and others account for the other 50  
          percent.  



          The Federal Centers for Medicare and Medicaid Services (CMS)  
          contracts with DPH L&C to evaluate facilities accepting payments  
          from Medicare and Medi-Cal, to ensure that they meet federal  








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          requirements mandated as a condition for financial participation  
          in those programs.  As such, DPH L&C leaders, management and  
          staff act as agents for the federal government to assure federal  
          funds, as well as state funds, serve the purposes for which they  
          are appropriated.  The L&C Program evaluates health care  
          facilities for compliance with state and federal laws and  
          regulations through initial and re-licensure surveys,  
          unannounced federal certification surveys, as well as  
          investigations of complaints submitted by citizens who assert  
          that they have received substandard care, or have been abused,  
          mistreated, or exploited in a facility.  Entity Reported  
          Incidents (ERI) are also investigated by DPH employees, and  
          often require a facility visit.  





          The L&C Program relies upon "field operations" that oversee 15  
          district offices, divided between five geographic areas  
          throughout the state.  The majority of L&C activities are  
          performed by health facility evaluator nurses (HFENs).  HFENs  
          must be licensed as registered nurses, and undergo extensive  
          training to perform L&C duties and ensure uniform application  
          and enforcement of state and federal laws, rules, and  
          regulations pertaining to patient care.  





          LA County Contract.  Rather than directly performing L&C  
          activities in Los Angeles (LA) County, DPH contracts with LA  
          County's Department of Public Health, Health Facilities  
          Investigation Division to perform the same activities that state  
          staff perform in the rest of the state.  Pursuant to this  
          contract, county staff is responsible for approximately 385  
          nursing homes operating within the county.  This contracting  
          arrangement has been in place for decades.  The current contract  








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          is set to expire at the end of June 2015.  According to DPH, the  
          department is currently in negotiations with LA County to renew  
          the contract.  





          Additionally, the L&C Program's Professional Certifications  
          Branch (PCB) certifies nurse assistants (a key classification of  
          nursing home employees), home health aides, and hemodialysis  
          technicians.  The PCB is responsible for investigating  
          complaints against and enforcing disciplinary action against the  
          personnel it certifies.  For instance, if a complaint about a  
          facility staff person is received by DPH, and the staff person  
          is found to be at fault for abuse or mistreatment, the PCB  
          receives a referral to begin a licensing action.  However, with  
          nearly 12,000 back-logged complaints, as many as 1,000 of them  
          PCB branch related, the question of to what extent is the  
          ongoing back-log contributing to unnecessary risk, or creating  
          an environment where a suspect may have free passage to escape  
          scrutiny, set-up activities in other environments, such as the  
          burgeoning home care industry, or in another state?  





          Complaint and ERI investigations.  Investigations of nursing  
          home complaints and ERIs are carried out pursuant to both  
          federal and state mandates.  Current law requires DPH to  
          initiate an onsite investigation of a complaint against a  
          nursing home within 10 working days of receipt, though there is  
          no corresponding mandate to complete that investigation.  If the  
          complaint is an immediate jeopardy complaint, meaning that it  
          involves a threat of imminent danger of death or serious bodily  
          harm, DPH is required to make an onsite investigation within 24  
          hours of receipt, though, again, there is no corresponding  
          statutory obligation for the DPH to do anything beyond "an  








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          on-site initiation" of an investigation involving immediate  
          jeopardy.  





          Longstanding concerns and complaints about the manner in which  
          the L&C program managed complaint and ERI investigations have  
          persisted for many years.  In 2006, the Legislative Analyst's  
          Office reported that only one-half of all complaints not  
          classified as immediate jeopardy were investigated within the  
          required10-day timeframe.  Further, in 2007, the California  
          State Auditor issued a report finding that DPH struggled to  
          initiate and close complaint investigations and communicate with  
          complainants in a timely manner.  In July 2012, CMS sent a  
          letter to DPH expressing concern with their ability to meet many  
          of its L&C responsibilities, including timely complaint  
          investigations.  The state was in jeopardy of losing $1 million  
          in federal funds if certain benchmarks were not met.   
          Ultimately, $138,123 in federal funding was withheld.  





          In March 2014, concerns came to light regarding DPH's oversight  
          of its contract with LA County after an investigative reporter  
          uncovered evidence that the county had an unofficial policy to  
          close certain nursing home complaints without fully  
          investigating them.  As a result, DPH performed a review of the  
          county's compliance with state and federal complaint  
          investigation requirements, and directed the county to cease its  
          unsanctioned policy of case closures without proper  
          investigation.  The LA County Board of Supervisors requested an  
          audit by the LA County Department of Auditor-Controller.  The LA  
          County Auditor released two audit reports, concluding, in part,  
          that the county had a significant workload backlog and lacked a  
          mechanism to effectively track and managed its workload.  The LA  








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          County Auditor also found that complaints and ERIs were not  
          always prioritized in accordance with state guidelines,  
          resulting in delays in initiating investigations.  





          In August 2014, DPH published the findings of a comprehensive  
          assessment of the L&C Program that was performed when CMS, DPH's  
          federal partner, demanded it due to chronic departmental  
          performance deficiencies.  DPH contracted privately with Hubbert  
          Systems Consulting, to perform the assessment.  In summary, the  
          assessment found numerous deficiencies within the L&C Program,  
          including timeliness of investigation closures, and set forth 21  
          recommendations to remediate deficiencies identified in its  
          assessment.  Included among these recommendations were the  
          restructure of L&C to improve performance, establishing  
          performance indicators, and improving oversight of LA County  
          workload and management.  DPH has accepted all 21 of the  
          recommendations, and has developed a work plan to fully  
          implement the recommendations, though the timeline for  
          completion of the existing backlog exceeds the Governor's term.   






          At the request of the Chairpersons of the Assembly Committees on  
          Health, and Aging and Long-Term Care, the Bureau of State  
          Audits, directed by the Joint Legislative Audit Committee,  
          studied DPH activities with regard to complaint investigations  
          and assurances of safe living environments for nursing home  
          residents.  In October 2014, the California State Auditor  
          released its report regarding the L&C Program citing ineffective  
          management of nursing home complaint investigations, among other  
          deficiencies - some identified in previous audits.  The key  
          findings of that report included:








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          1)DPH should establish timeframes for complaint investigations;



          2)As of April 2014, there were more than 11,000 open complaints  
            and ERIs backlogged, many of which had relatively high  
            priorities, and had remained open for an average of nearly a  
            year;





          3)Despite backlogs and lengthy investigations, L&C does not have  
            any policies or procedures to ensure prompt completion of  
            complaint/ERI investigations and in many cases did not meet  
            statutory timeframes for initiating complaint investigations;





          4)There was no staffing analysis for any of its district offices  
            to determine how much staff is needed to complete workload.   
            Most of the L&C district offices visited by audit staff  
            reported not having the resources needed to investigate  
            complaints properly, and having to work overtime in order to  
            try to keep pace with workload; and,





          5)DPH failed to report all statutorily required information to  








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            the Legislature in certain years by omitting information  
            related to the timeliness of complaint investigations in their  
            2012 and 2013 reports to the Legislature.  





          According to the State Auditor, DPH did not always lack  
          timeframes for completing investigations.  The State Auditor  
          cited departmental policies and procedures from 2004, which set  
          forth a goal that district offices complete investigations of  
          facility-related complaints within 40 days of receipt.  DPH  
          reported to the State Auditor that it eliminated the 40-day goal  
          because district offices were unable to meet the timeline for  
          various reasons.  For example, DPH cited investigations  
          involving the death of residents that could not be completed  
          pending receipt of coroner reports.  The State Auditor disagreed  
          with DPH's decision to eliminate the 40-day timeframe, stating  
          that, while there may be instances in which district offices  
          cannot comply with established timeframes for valid reasons, a  
          lack of accountability has contributed to its failure to  
          complete investigations within reasonable periods.  





          DPH is in the process of implementing most of the State  
          Auditor's recommendations, but disagrees with the recommendation  
          to establish a timeframe to complete investigations of nursing  
          home complaints (the audit did not address the corresponding  
          existing mandate for DPH to complete investigations in acute  
          hospital settings within 45 days).  According to DPH, they  
          recognize the importance of the timeliness in completing  
          complaint and ERI investigations and remains committed to  
          reducing the average time to complete these investigations  
          through enhanced monitoring of workload activities, public  
          reporting of workload performance, and improved district office  








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          implementation.  However, it should be noted that the response  
          to the audit was composed and issued before the public release  
          of the Governor's request for 237 additional positions at DPH  
          L&C (see below).  Additionally, the committee may wish to  
          consider whether the nature of "enhanced monitoring," "public  
          reporting," or "improved district office implementation" leads  
          to improved investigation performance.  It is difficult to  
          determine how these largely passive administrative activities  
          can affect more timely investigations.  





          For instance, in October 2014, DPH began to release quarterly  
          data regarding the volume, timeliness, and disposition of  
          long-term health care facility complaints and ERIs.  According  
          to most recent data released, as of December 31, 2014, the total  
          number of open complaints and ERIs, including LA County cases  
          and complaints against PCB-certified personnel, was 12,814.  The  
          data indicate that between July and December 2014, DPH completed  
          70 percent of complaint investigations and 77 percent of ERI  
          investigations in 90 days or less.  Despite enhanced monitoring  
          of workload activities, public reporting of workload  
          performance, and improved district office implementation, the  
          backlog has grown.  





          Governor's budget proposal.  For the 2015-16 budget year, the  
          Governor proposes funding to support the implementation of the  
          quality improvement recommendations made by Hubbert Systems  
          Consulting, special funds to improve oversight of its LA County  
          contract, as well as funding to fill and add new LA County  
          positions.  The Governor proposes 237 new L&C positions and  
          increased expenditure authority to reduce complaint/ERI volume,  
          and decrease investigation time.  With these added positions,  








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          DPH estimates that it will take four years to complete pending,  
          back-logged investigation workload while keeping up with new  
          workload and avoiding backlogs.  Given the on-going and  
          historical issues related to DPH's performance, it should be  
          noted that four years places the eventual solution of this well  
          documented problem beyond the authority of the current Governor,  
          and in light of DPH's historical well-documented challenges with  
          accountability, the Legislature may wish to consider if the  
          proposed work-plan to improve DPH performance is at risk of  
          becoming another unaccountable component of the DPH work  
          mandate.  





          Policy note.  Health and Safety Code Section 1279.2 provides for  
          an investigation timeframe of 45 days for acute health care  
          hospital investigations.  Does continued bifurcation of  
          investigation timeframes contribute to the often-raised  
          management and training complexities at DPH?  With the known  
          obstacles to completing investigations, should acute setting  
          investigation timeframes and skilled nursing facility  
          investigation timeframes be synchronized, both settings allowing  
          for 45 working days, and both settings providing for a 30  
          working day extension, if and when necessary?  





          PREVIOUS LEGISLATION:  





          1)AB 1816 (Yamada) of 2014, was generally identical to AB 348  
            though dropped by the author when amendments changed the  








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            "timeframe" articulated in the measure to a "benchmark," a  
            largely administrative performance measurement.  



          2) AB 1710 (Yamada), Chapter 672, Statutes of 2012, revises how  
            nursing home administrator licensing fees are adjusted so that  
            fee revenue is sufficient to cover the regulatory costs to  
            DPH, and revises and increases DPH reporting requirements  
            regarding the Nursing Home Administrator Program.  





          3)SB 799 (Negrete-McLeod) of 2011 would have required DPH to  
            complete long-term care facility complaint investigations  
            within a 90-working day period.  SB 799 was held on the  
            suspense file in Senate Appropriations.  





          4)AB 399 (Feuer) of 2007 contained provisions that are  
            substantially similar to this bill.  


          AB 399 was vetoed by Governor Schwarzenegger with the following  
            message: "While I believe this bill is well-intended, it is  
            premature to place additional investigation requirements on  
            this program as it continues to demonstrate progress in  
            meeting its mandated state and federal workload."



          5)AB 1807 (Committee on Budget), Chapter 74, Statutes of 2006,  
            was the health trailer bill for the Budget Act of 2006.  Among  
            other changes, AB 1807 establishes a new fee structure for  








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            health facilities that are licensed and/or certified by L&C:  
            fees must be calculated based on i) specified workload data  
            provided by DPH to the Legislature and made available to the  
            public on their website; ii) any General Fund support  
            appropriated by the Legislature; iii) any federal grant funds  
            received for this purpose; and iv) any policy adjustments as  
            proposed by the Administration and as adopted by the  
            Legislature.  States intent that L&C become entirely supported  
            by fees and federal funds by no later than July 1, 2009.  





          6)SB 1312 (Alquist), Chapter 895, Statutes of  2006, requires  
            inspections and investigations of long-term care facilities  
            certified by the Medicare or Medicaid program to determine  
            compliance with federal standards and California statutes and  
            regulations.  





          7)AB 1731 (Shelley), Chapter 451, Statutes of 2000, enacts major  
            reforms for skilled nursing facilities and intermediate care  
            facilities, including the expansion of citations and  
            penalties, an increase in disclosure requirements and  
            inspections, requires DPH to provide specified notice to  
            complainants within specified timeframes, and requires initial  
            onsite investigations within 24 hours in response to  
            complaints where there is a serious threat of imminent danger  
            of death or serious bodily harm.  


          REGISTERED SUPPORT / OPPOSITION:











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          Support


          American Association of Retired Persons (AARP)


          The Arc and United Cerebral Palsy California Collaboration


          California Association of Area Agencies On Aging


          California Association of Health Facilities


          California Commission on Aging (CCoA)


          California Communities United Institute


          California Continuing Care Residents Association (CALCRA)


          California Hospital Association (CHA)


          California Long-Term Care Ombudsman Association (CLTCOA)\


          California Retired Teachers Association


          California Senior Legislature


          California State Council of the Service Employees International  
          Union (SEIU California)








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          Consumer Federation of California


          Disability Rights California


          Elder and Dependent Adult Abuse prevention Council of Santa  
          Barbara County


          LeadingAge California


          National Association of Social Workers (NASW)-California Chapter


          Office of the State Long-Term Care Ombudsman


          Tenet Healthcare - Support if Amended


          Three Individuals




          Opposition


          None on file.




          Analysis Prepared by:Robert MacLaughlin / AGING & L.T.C. / (916)  
          319-3990








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