BILL ANALYSIS Ó
AB 848
Page 1
Date of Hearing: April 14, 2015
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
AB 848
(Mark Stone) - As Amended April 6, 2015
NOTE: Double Referral. This bill is double referred, and if
passed by this Co0mmittee, it will be referred to the Assembly
Health Committee.
SUBJECT: Alcoholism and drug abuse treatment facilities.
SUMMARY: Authorizes alcoholism and drug treatment facilities to
allow a licensed physician, or other health care practitioner,
to provide incidental medical services to a resident of the
facility and requires the Department of Health Care Services
(DHCS) to conduct an evaluation of the program on or before
January 1, 2019, and to report the results of the evaluation to
the appropriate fiscal and policy committees of the Legislature.
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EXISTING LAW
1)Provides for the licensure of physicians and surgeons, and the
enforcement of the disciplinary and criminal provisions of the
Medical Practice Act, by the Medical Board of California (MBC)
located within the Department of Consumer Affairs (DCA). (BPC
§ 2000; 2004)
2)Defines a "licensee" as the holder of a physician and surgeons
certificate who is engaged in the professional practice
authorized by the certificate under the jurisdiction of the
MBC. (BPC § 2041)
3)Defines an "alcoholism or drug abuse recovery or treatment
facility" (facility) as a facility that provides 24-hour
residential non-medical services, defined as recovery
services, treatment services and detoxification services, to
adults who are recovering from problems related to alcohol,
drug, or alcohol and drug misuse or abuse. (HSC § 11834.02)
4)Specifies that a licensee shall not operate such a facility
beyond the conditions of the license and if it does, the
facility is subject civil penalties, suspension or revocation
of the license. (HSC §§ 11834.15, 11834.16)
5)Specifies that a license for a drug abuse recovery or
treatment facility is valid for two (2) years. (HSC §
11834.16)
THIS BILL
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1)Specifies that a health care practitioner should submit a
signed certification form to a facility licensed by the DHCS
where they plan to provide alcoholism or drug abuse recovery
or treatment services.
2)Defines "health care practitioner" as a healing arts
professional, licensed under BPC § 500, and who is acting
within the scope of practice of his or her license or
certificate.
3)Specifies that the DHCS shall develop a standard certification
form, for use by a health care practitioner, that:
a) describes the alcoholism and drug abuse recovery or
treatment services provided, and
b) certifies that the health condition or medical or
psychiatric history of the applicant does not require a
level of care that is higher than the level of care that
may legally be provided by a licensed facility.
4)Specifies that on or before January 1, 2017, the DHCS shall
adopt emergency regulations that are exempt from review by the
Office of Administrative Law and shall be submitted for filing
with the Secretary of State.
5)Defines "incidental medical services" as services to address
the physical and mental health issues associated with either
detoxification from alcohol or drugs or the provisions of
alcoholism or drug abuse recovery or treatment services, that
in the opinion of a physician are not required to be performed
in a licensed clinic or health facility.
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6)Specifies that a facility may permit incidental medical
services to be provided to a resident at the facility by one
or more independent physicians and surgeons licensed by the
MBC or the Osteopathic Medical Board who are knowledgeable
about addiction medicine, or one or more other health care
practitioners acting within the scope of practice of his or
her license and under the direction of a physician and
surgeon, and are also knowledgeable about addiction medicine.
7)States that the facility must comply with all other applicable
laws and regulations to meet the needs of a resident receiving
incidental medical services from a physician.
8)Specifies that the physician and surgeon and any other health
care practitioner has signed an acknowledgment on a form
provided by the DHCS that he or she has been advised of and
understands the statutory and regulatory limitations on the
services that may legally be provided by the facility, and the
statutory and regulatory requirements and limitations for the
physician and surgeon or other health care professional and
for the facility.
9)Requires that there is an agreed-upon written protocol between
the physician and surgeon and the facility signed by the
physician and surgeon and the licensee.
10)Specifies that the facility, in its admissions agreement with
a client, shall clearly identify the individual financially
responsible for incidental medical services that are provided.
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11)States there should be ongoing communication between the
physician and the facility about the services provided to the
resident by the physician and surgeon and the frequency and
duration of incidental medical services to be provided.
12)Requires initial and ongoing communication between the
physician and surgeon or other health care practitioner and
the resident's health plan or health insurer prior to the
provision of incidental medical services to ensure
coordination of care.
13)Specifies that the facility will not provide incidental
medical services and will not assist with or interfere with
the physician and surgeon or other health care practitioner
providing incidental medical services.
14)States that the resident must be authorized by the physician
and surgeon as medically appropriate to receive the incidental
medical services at the facility.
15)Requires that before a facility resident receives incidental
medical services, the resident has signed an acknowledgment
and consent to receive those services on a form provided by
the DHCS.
16)Specifies that once incidental medical services are initiated
for a resident, the physician and surgeon and the facility
shall continuously monitor the resident to ensure that the
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services remain appropriate for the resident.
17)Requires the facility to maintain in its files a copy of the
physician and surgeon's license or other written evidence of
licensure to practice medicine in the state.
18)Requires the facility to report, in a timely manner, to the
DHCS, any violation or suspected violation by the physician
and surgeon of the regulations relating to providing
incidental medical services.
19)Indicates that the DHCS shall not evaluate or have any
responsibility or liability with respect to evaluating
incidental medical services provided.
20)States that a facility licensed and approved by the DHCS to
allow for the provision of incidental medical services shall
not be considered a clinic or health facility.
21)Specifies that, other than incidental medical services, minor
first aid, or in the case of a life threatening emergency,
provision of medical or health care services or services that
require a higher level of care than the care that is permitted
to be provided at a facility, is not permitted at a facility.
22)Indicates that if an applicant for facility licensure intends
to permit incidental medical services, the applicant shall
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submit a copy of a valid license of the physician and surgeon
who will provide those services, and any other information the
DHCS deems appropriate, including, but not limited to, a copy
of the facility's accreditation by a nationally recognized
accrediting organization.
23)Allows the DHCS to establish an additional licensure fee for
an application that includes a request for a facility to
provide detoxification services.
24)Requires the DHCS to conduct an evaluation of the program
licensing those facilities and to submit a report to the
appropriate policy and fiscal committees of the Legislature on
or before January 1, 2019.
25)Permits the director of DHCS to temporarily suspend any
license prior to any hearing when, in the opinion of the
director, the action is necessary to protect residents of the
facility from physical or mental abuse, abandonment, or any
other substantial threat to health or safety.
26)Makes other findings and declarations.
FISCAL EFFECT: Unknown. This bill is keyed fiscal by the
Legislative Counsel.
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COMMENTS
1)Purpose. This bill is co-sponsored by the California Society
of Addiction Medicine , Elements Behavioral Health and JANUS of
Santa Cruz . According to the author, "AB 848 protects the
physical and mental health of people seeking alcohol and drug
rehabilitation services in residential treatment facilities.
Under AB 848, physicians and other appropriate medical
personnel can be available on-site to provide 24-hour medical
services related to clients' addictions. Clients of these
facilities often have a variety of medical needs related to
their addictions. Because clients' medical needs can affect
and even interfere with their recovery, they may have better
recovery outcomes when they have on-site access to medical
care including vital sign monitoring, seizure risk assessment,
medication management, and psychiatric therapy?The measure
requires that facilities seeking licensure adhere to protocol
that protect client privacy, notify clients of financial
responsibility for medical care, and clearly define the level
of medical care to be provided. The measure requires DHCS to
promulgate final regulations by July 1, 2017 to implement the
policy. Additionally, the measure requires that DHCS perform
an evaluation of the law's effectiveness by 2019."
2)Background. Alcoholism or drug abuse recovery or treatment
facilities provide 24-hour non-medical care and specialize in
providing services to chemically dependent adults who do not
require treatment in an acute-care medical facility on an
inpatient, intensive outpatient, outpatient, and partial
hospitalization basis. These facilities range in size from
six-bed facilities in residential neighborhoods to centers
that accommodate more than 100 beds (California Senate Office
of Oversight and Outcomes report, Rogue Rehabs: State failed
to police drug and alcohol homes, with deadly results,
September, 2012).
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The basic services provided by facilities include group,
individual and educational sessions, alcoholism or drug abuse
recovery and treatment planning. Detoxification services are
also provided and are defined by the DHCS as, "? a service to
support and to assist and individual in the alcohol and/or
drug withdrawal process and to explore plans for continued
service." These services can be provided by a variety of
health care providers such as alcohol and drug counselors,
mental health therapists, social workers, psychologists,
nurses and physicians.
Currently, the only medical care that facilities are allowed
to provide to clients is first aid and emergency care. If a
patient requires medical care, they must leave the facility to
receive care from a medical professional and the patient must
pay the medical professional directly for services.
Facility Licensing and Oversight. Prior to July 1, 2013, the
Department of Alcohol and Drug Programs (ADP) was responsible
for oversight of alcoholism or drug abuse recovery or
treatment facilities. Effective with the passage of the
2013-2014 Budget Act and associated legislation, all ADP
programs and staff, except the Office of Problem Gambling,
transferred to the DHCS. Now, the DHCS is responsible for
oversight. The DHCS licenses the facilities and conducts
reviews of their operations every two years. As part of the
review process, the DHCS checks for compliance with a variety
of requirements including, whether staff has passed
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tuberculosis tests, that residents have completed health
questionnaires and if at least one staff member is certified
in first aid and CPR.
The DHCS's Substance Use Disorder (SUD) Compliance Division
investigates complaints against facilities. The SUD Compliance
Division also investigates violations of the code of conduct
of registered or certified alcohol and drug counselors.
Additionally, facilities licensed or certified by DHCS are
required to report counselor misconduct to DHCS within 24
hours of the violation. Facilities that do not comply with
existing requirements are subject to civil penalties and
license suspension or revocation.
Facility Accreditation. Two national organizations, the Joint
Commission on Accreditation of Healthcare Organizations
(JCAHO) and the Joint Commission on Accreditation of
Rehabilitation Facilities (CARF), accredit facilities that
provide behavioral health care services such as addiction
treatment, opioid treatment and maintenance programs, crisis
stabilization, case management and care coordination,
employment services and vocational rehabilitation.
JCAHO and CARF each require facilities to demonstrate that
their programs meet the accrediting organizations' quality
standards in order to obtain accreditation. These quality
standards evaluate functions relating to client care and
program management, including administrative requirements,
financial management, personnel qualifications, client
services, performance outcomes, client safety and information
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privacy and security. JCAHO requires accredited organizations
to reapply for accreditation every three years while CARF
accreditation ranges from one to five years, depending on the
type of facility.
Senate Office of Oversight and Outcomes Report. In 2012, the
Senate Office of Oversight and Outcomes (SOOO) published a
report, Rogue Rehabs: State failed to police drug and alcohol
homes, with deadly results. The report focused on "gaps" in
the ADP's regulation of residential programs as well as a
review of the state's ban on medical care at residential drug
and alcohol programs. The SOOO advised that state law be
changed to "better reflect current treatment practices?[there
is a] mismatch between the department's regulation and the
industry's prevalent practices." The SOOO recommended,
"?lifting the ban on medical care as long as it is accompanied
with more extensive oversight."
Other States. As part of the SOOO's aforementioned
investigation in 2012, it contacted nine (9) other highly
populous states. The SOOO found, "California is unusual among
populous states in prohibiting medical care." All but one of
the nine states allowed physicians and other medical
professionals to work in residential rehabilitation
facilities.
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| |Illinois |Indiana |Massachus|New York |North |Ohio |Pennsylva|Texas |Washingto|
| | | |etts | |Carolina | |nia | |n |
| | | | | | | | | | |
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| | | | | | | | | | |
|---------+---------+---------+---------+---------+---------+---------+---------+---------+---------|
|Allows |Y |Y |N* |Y |Y |Y |Y |Y |Y |
|medical | | | | | | | | | |
|care in | | | | | | | | | |
|residenti| | | | | | | | | |
|al | | | | | | | | | |
|rehabilit| | | | | | | | | |
|ation | | | | | | | | | |
|facilitie| | | | | | | | | |
|s | | | | | | | | | |
| | | | | | | | | | |
| | | | | | | | | | |
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NOTE: This data is from the SOOO report: Rogue Rehabs: State
failed to police drug and alcohol homes, with deadly results,
September, 2012.
http://sooo.senate.ca.gov/sites/sooo.senate.ca.gov/files/Rogue%20
Rhab%209_4_12.pdf
*Rehabilitation homes refer clients to local doctors; nurses are
available at homes
3)Prior Related Legislation. AB 395 (Fox) of 2013, would have
expanded the types of facilities licensed by the ADP to
include any facility that has a nationally accredited program
that uses a multidisciplinary team to provide 24-hour
residential medical services to adults recovering from alcohol
and drug abuse problems. NOTE: This bill died on the Senate
Appropriations Committee suspense file.
AB 972 (Butler and Beall) of 2011, would have expanded, until
January 1, 2017, the category of residential treatment
facilities licensed by the ADP to include facilities that
provide limited medical services to adults recovering from
alcohol and drug abuse, provided that the facility is not
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otherwise required to have a separate health facility license.
Would have established a fee for facilities that provide
limited medical services and makes other changes to the
licensing fees for residential treatment facilities. NOTE:
This bill was held in the Senate Appropriations Committee.
AB 2221 (Beall) of 2010, would have permitted 24-hour
residential treatment facilities that provide services to
adults recovering from alcohol and drug abuse that are
licensed by the ADP to provide unspecified medical services
and would have provided that such a facility would not require
a health facility license. NOTE: This bill died on the Senate
Appropriations Committee suspense file.
AB 1055 (Chesbro) of 2009, would have expanded the ADP
licensure authority for alcohol and drug treatment facilities
to include 24-hour facilities that do not require a health
facility license. NOTE: This bill died on the Assembly
Appropriations Committee suspense file.
ARGUMENTS IN SUPPORT
The California Society of Addiction Medicine also writes in
support and notes in its letter, "Passage of this bill will make
it clear that physicians may provide appropriate medical
services to persons undergoing withdrawal in residential
treatment facilities?[the current] ban precludes facilities from
meeting a variety of on-site medical needs of their clients,
including emergency care, psychiatric treatment, or medical
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conditions related to clients' addictions. Instead, when
clients have medical needs during the course of their
residential treatment, facility staff must send them to doctors'
offices of hospital emergency departments, which inefficient and
costly."
Elements Behavioral Health , a division of Promises Treatment
Centers states its concern with the implications of current
statute in its letter of support, "Until very recently the
state's Alcohol and Drug Program (ADP) interpreted "non-medical"
licensure language to distinguish licensed residential
facilities from hospitals. Patients of these facilities
routinely were provided with basic medical care which, much less
a house call, included the prescription ad monitoring of
medicine, taking blood samples and blood pressure, the
provisions of psychiatric evaluations, administration of public
health inoculations and the general oversight of a patient's
health conditions. A few years ago ADP began threatening loss
of licensure if such basic medical care was provided."
JANUS of Santa Cruz writes in support, "Alcoholism or drug abuse
recovery and treatment facilities like Janus provide 24-hour
residential non-medical care to clients...Under current law,
DHCS cannot license facilities that provide on-site medical
personnel to evaluate or provide medical care to
clients?Instead, if clients have medical needs during the course
of their residential treatment, facility staff must transport
them to doctors' offices, clinics, or hospital emergency rooms,
which can be inefficient, costly, and potentially even
dangerous."
The California Naturopathic Doctors Association supports the
bill and writes, "The CNDA urges your support of AB 848?as a
means of improving patients' access to their chosen primary care
provider."
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The California Narcotic Officers' Association also writes in
support, "Alcoholism or drug abuse recovery and treatment
facilities?are required to offer?services that are designed to
help clients taper off or quit substances in a safe environment.
The challenge is that clients?often have a variety of medical
needs related to their addictions. As a result, facility
clients may have better recovery outcomes when they have access
to medical care including vital sign monitoring, seizure risk
assessment, medication management, and psychiatric therapy."
Alkermes Inc. supports the bill and writes, "As you know, the
treatment of substance abuse is complicated from both a
logistical and clinical perspective. Additionally, the
landscape surrounding substance use disorder treatment in
California is in a state of transformation?AB 848 provides the
opportunity to expand access to treatment and care for those
receiving services."
ARGUMENTS IN OPPOSITION
None on file.
IMPLEMENTATION ISSUES
As indicated above, there have been a number of bills that have
attempted to address the issue of removing the ban on provision
of medical services at alcoholism or drug abuse recovery or
treatment facilities. While there have been recent changes to
these facilities, e.g. the licensing and oversight of these
facilities was transferred to the DHCS in 2013, the Committee
may wish to consider requiring additional implementation
safeguards should this bill pass.
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As noted in the SOOO report, it is recommended that the DHCS,
the facility and/or the accrediting organization implement
regulations requiring that the credentials and malpractice
insurance for medical professionals providing medical treatment
be checked before they contract with the facility. It may also
be beneficial to set up a system to require a yearly review of
the medical professional's credentials and insurance to assure
ongoing compliance and patient protection.
As is consistent with practices in other states, it may also be
beneficial for programs that offer any type of medical
detoxification to hire a medical director to oversee the
administration of this treatment.
To safeguard against the state's prohibition against the
corporate practice of medicine, physicians should contract with
the facilities instead of working directly for them. This would
necessitate that the employment contract specify that the
program cannot control or interfere with the physician's
practice and that the physician retains the ability to make
decisions. The contract should also clearly state that the
physician is not paid for the types or amount of services
provided.
REGISTERED SUPPORT / OPPOSITION
Support:
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California Society of Addiction Medicine (co-sponsor)
Elements Behavioral Health (co-sponsor)
JANUS of Santa Cruz (co-sponsor)
Alkermes Inc.
California Naturopathic Doctors Association
California Narcotic Officers' Association
County Behavioral Health Directors Association
Opposition:
None on file.
Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /
(916) 319-3301
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