BILL ANALYSIS                                                                                                                                                                                                    



                                                                     AB 848


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          Date of Hearing:   April 28, 2015


                            ASSEMBLY COMMITTEE ON HEALTH


                                  Rob Bonta, Chair


          AB 848  
          (Mark Stone) - As Amended April 6, 2015


          SUBJECT:  Alcoholism and drug abuse treatment facilities.


          SUMMARY:  Authorizes alcoholism and drug treatment facilities to  
          allow a licensed physician, or other qualified health care  
          practitioner, to provide incidental medical services to a  
          resident of the facility.  Specifically, this bill:  





          1)Requires a health care practitioner to submit a signed  
            certification form to a facility licensed by the Department of  
            Health Care Services (DHCS) where they plan to provide  
            alcoholism or drug abuse recovery or treatment (treatment  
            facility) services.


          2)Defines "health care practitioner" as a licensed healing arts  
            professional, who is acting within the scope of practice of  
            his or her license or certificate.  


          3)Requires DHCS to develop a standard certification form, for  
            use by a health care practitioner, that:








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             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)Requires DHCS, on or before January 1, 2017, to adopt  
            emergency regulations that are only effective for 180 days or  
            once final regulations are adopted, whichever comes first.  


          5)Exempts emergency regulations adopted by DHCS from review by  
            the Office of Administrative Law and requires them to be  
            submitted for filing with the Secretary of State. 


          6)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.


          7)Allows a treatment facility to provide incidental medical  
            services to a resident at the treatment facility by one or  
            more independent physicians and surgeons or other health care  
            practitioners acting within the scope of practice of his or  
            her licensure, as specified. 


          8)Requires the treatment facility to comply with all other  
            applicable laws and regulations to meet the needs of a  








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            resident receiving incidental medical services from a  
            physician.


          9)Requires the physician and surgeon and any other health care  
            practitioner to sign their acknowledgment on a form provided  
            by 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 treatment facility, and the  
            statutory and regulatory requirements and limitations for the  
            physician and surgeon or other health care professional.


          10)Requires an agreed-upon written protocol between the  
            physician and surgeon and the treatment facility signed by the  
            physician and surgeon and the licensee.





          11)Requires the treatment facility, in its admissions agreement  
            with a client, to clearly identify the individual financially  
            responsible for incidental medical services that are provided.



          12)Requires ongoing communication between the physician and the  
            treatment 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.



          13)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.








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          14)Prohibits the treatment facility from providing incidental  
            medical services and from assisting or interfering with the  
            physician and surgeon or other health care practitioner  
            providing incidental medical services.



          15)Requires that before a treatment facility resident receives  
            incidental medical services, the resident has signed an  
            acknowledgment and consent to receive those services on a form  
            provided by DHCS.



          16)Requires that, once incidental medical services are initiated  
            for a resident, the physician and surgeon and the treatment  
            facility continuously monitor the resident to ensure that the  
            services remain appropriate for the resident.



          17)Requires the treatment 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 treatment facility to report, in a timely  
            manner, to DHCS any violation or suspected violation by the  
            physician and surgeon of the regulations relating to providing  
            incidental medical services.



          19)Absolves DHCS from any responsibility or liability with  
            respect to evaluating incidental medical services provided.








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          20)Specifies that a treatment facility licensed and approved by  
            DHCS to allow for the provision of incidental medical services  
            is not considered a clinic or health facility.



          21)Prohibits medical or health care services or services that  
            require a higher level of care than can be provided at a  
            treatment facility from being provided at a treatment  
            facility. 



          22)Requires that, if an applicant for treatment facility  
            licensure intends to permit incidental medical services, the  
            applicant submit a copy of a valid license of the physician  
            and surgeon who will provide those services, and any other  
            information DHCS deems appropriate.



          23)Allows DHCS to establish an additional licensure fee for an  
            application that includes a request for a treatment facility  
            to provide detoxification services.



          24)Requires DHCS to conduct an evaluation of the program  
            licensing treatment 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 the action is necessary to  








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            protect residents of the treatment facility from physical or  
            mental abuse, abandonment, or any other substantial threat to  
            health or safety.



          EXISTING LAW:  


          1)Requires DHCS to license adult alcoholism or drug abuse  
            recovery treatment facilities and specifies that a license for  
            a drug abuse recovery or treatment facility is valid for two  
            years.  


          2)Defines an "alcoholism or drug abuse recovery or treatment  
            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. 


          3)Prohibits a licensee from operating 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. 


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


          COMMENTS:  


          1)PURPOSE OF THIS BILL.  According to the author, this bill  
            protects the physical and mental health of people seeking  
            alcohol and drug rehabilitation services in residential  








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            treatment facilities.  Under the provisions of this bill,  
            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 author states that unfortunately, alcohol and drug  
            rehabilitation facilities cannot be licensed by DHCS if they  
            use on-site doctors or other medical personnel to evaluate or  
            provide medical care to facility clients.  This prohibition  
            precludes facilities from meeting the medical needs of clients  
            that could easily and efficiently be provided on-site.   
            Instead, under current law, 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 and costly.  
             Further, when clients are removed from facilities in the  
            midst of their treatment, their recovery efforts may be  
            disrupted.  By failing to allow these residential  
            rehabilitation facilities to have medical personnel on-site,  
            the state reduces the effectiveness of the critical services  
            being provided to people suffering from substance addiction.

          The author further states that to help ensure that people  
            recovering from addiction remain safe during their stay at  
            treatment facilities and to improve their recovery outlook,  
            facilities should be allowed to use medical personnel to  
            provide appropriate on-site physical and mental health  
            services.  This bill allows DHCS to license a facility that  
            uses a physician or other eligible medical practitioner to  
            provide incidental medical services to treat conditions  
            associated with drug and alcohol addiction and recovery and  
            that are deemed to be treatable on-site rather than in a  
            clinic or hospital.  This bill requires that facilities  








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            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, this bill requires that DHCS perform an  
            evaluation of the law's effectiveness by 2019.

          The author concludes that residential alcohol and drug treatment  
            facilities should provide the best possible care for  
            vulnerable people struggling to overcome addictions, which can  
            include medical treatment related to addiction and recovery.   
            This bill will allow thousands of vulnerable people to recover  
            from addiction safely.

          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.



          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 services 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  








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            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.

             a)   Drug Medi-Cal Waiver Amendment.  On November 21, 2014,  
               DHCS submitted a proposal to amend the Special Terms and  
               Conditions the California Section 1115 Bridge to Reform  
               Waiver.  California's Drug Medi-Cal Organized Delivery  
               System (DMC-ODS) 1115 demonstration waiver provides a  
               continuum of care modeled after the American Society of  
               Addiction Medicine Criteria for substance use disorder  
               treatment services.

             The waiver amendment is intended to make improvements to the  
               DMC service delivery system, create more local control and  
               accountability in selection of high quality providers,  
               improve local coordination of case management services,  
               ensure implementation of evidence based practices in  
               substance abuse treatment, and increase coordination with  
               other systems of care including physical health.  The  
               DMC-ODS waiver amendment is intended to demonstrate how  
               organized substance use disorder care increases the success  
               of DMC beneficiaries while decreasing other system health  
               care costs.  Participation for providing services under  
               this waiver is voluntary; eight to 12 counties are expected  
               to initially opt-in to waiver participation.
             This waiver amendment would allow the state to extend the DMC  
               Residential Treatment Service, as an integral aspect of the  
               continuum of care, to additional beneficiaries.   
               Historically, the Residential Treatment Service was only  
               available to pregnant / postpartum beneficiaries in  
               facilities with a capacity of 16 or less beds.  This waiver  
               will create a Residential Treatment Service operable in  
               facilities with no bed capacity limit.  Should the terms of  
               this waiver be approved, this provisions provided for in  
               this bill will be necessary in order to achieve the DMC-ODS  
               goals of improving and increasing care coordination for  
               individuals recovering from an alcohol or substance abuse  
               disorder in a treatment facility.








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             b)   Senate Office of Oversight and Outcomes Report.  A  
               September 2012 investigative report by the Senate Office of  
               Oversight and Outcomes (SOOO) identified gaps in the  
               Department of Drug and Alcohol Program's (DADP's)  
               regulation of residential programs, including failure to  
               pursue evidence of problems, slow investigative responses  
               to deaths and other serious incidents, and reluctance to  
               use the full spectrum of its statutory powers to shut down  
               programs that pose a danger to the public.  The report also  
               documents widespread flouting of the state's prohibition  
               against residential programs providing medical care.  The  
               regulation responsibility of these residential programs now  
               lies with DHCS.



             The report points out that DADP interprets state law to mean  
               that medical professionals who operate in residential  
               treatment settings must maintain a separate relationship  
               with clients and not receive payments from the program.   
               However, SOOO surveyed websites, press releases, and  
               non-profit tax returns, and identified 34 programs that  
               made claims that appeared to violate state law and  
               regulations barring medical care.  Additionally, program  
               directors interviewed for the report asserted that they  
               must twist themselves into knots to comply with the state  
               ban while also satisfying insurers and accrediting agencies  
               that often require the involvement of medical  
               professionals.

             The report notes that California is unusual among populous  
               states in prohibiting medical care in residential treatment  
               programs.  SOOO contacted nine other states and found that  
               all but one of them allowed physicians and other medical  
               professionals to work in such settings.  Several, according  
               to the report, required the involvement of physicians in  
               programs providing detoxification.  









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             Among the recommendations in the report is for the  
               Legislature to consider approving a bill allowing medical  
               care in residential treatment facilities, given that many  
               experts believe that medical care is an integral part of  
               successful treatment.  However, the report adds that it  
               would not be enough to simply lift the ban and the state  
               may have to strengthen other laws and regulations to make  
               sure that medical care is safe and effective, for instance,  
               and address the question of whether the involvement of  
               doctors would violate a law prohibiting the corporate  
               practice of medicine.

             c)   Facility Licensing and Oversight.  Prior to July 1,  
               2013, DADP 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 DHCS.  DHCS licenses  
               the facilities and conducts reviews of their operations  
               every two years.  As part of the review process, DHCS  
               checks for compliance with a variety of requirements  
               including whether staff has passed tuberculosis tests, that  
               residents have completed health questionnaires and if at  
               least one staff member is certified in first aid and CPR.



             DHCS investigates complaints against facilities and  
               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.

             d)   Facility Accreditation.  Two national organizations, the  
               Joint Commission on Accreditation of Healthcare  
               Organizations (JCAHO) and the Joint Commission on  








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               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 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.

          3)SUPPORT.  The California Society of Addiction Medicine,  
            (CSAM), cosponsors of this bill, state that passage of this  
            bill will make it clear that physicians may provide  
            appropriate medical services to persons undergoing withdrawal  
            in residential treatment facilities.  For many years now, CSAM  
            has been working to resolve the problem in law in which the  
            state licenses residential facilities that treat people  
            addicted to drugs or alcohol, but the licensure requirements  
            do not explicitly allow residential facilities to employ  
            physicians who would provide medical services to a facility's  
            clients.  Such a ban precludes facilities from meeting a  
            variety of on-site medical needs of their clients, including  
            emergency care, psychiatric treatment, or medical 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  
            or hospital emergency departments, which is inefficient and  
            costly. 








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          Janus of Santa Cruz, also cosponsors of this bill, state under  
            current law, DHCS cannot license facilities that provide  
            on-site medical personnel to evaluate or provide medical care  
            to facility clients.  This prohibition precludes facilities  
            from meeting clients' medical needs that could easily and  
            efficiently be provided on-site.  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.  By  
            failing to allow facilities to have medical personnel on-site,  
            the state reduces the effectiveness of the critical services  
                   being provided to people suffering from addiction.

          Janus of Santa Cruz states that to help ensure that people  
            recovering from addiction remain safe during their stay and to  
            improve their recovery outlook, facilities should be allowed  
            to use medical personnel to provide appropriate on-site  
            physical and mental health services. Janus of Santa Cruz  
            concludes that this bill accomplishes this goal by allowing  
            DHCS to license facilities that use on-site doctors or other  
            approved medical personnel to provide to facility clients  
            incidental medical services related to recovery and addiction.

          Promises Treatment Centers, also cosponsors of this bill, state  
            that this bill follows the findings of a recent California  
            Senate report that showed the failure to allow appropriate  
            medical treatment of sick patients resulted in greater illness  
            and even death.  Promises Treatment Centers concludes that  
            this bill simply seeks to allow licensed physicians to treat  
            these individuals when the situation calls for it while  
            remaining consistent with the state's interest in supporting  
            residential care facilities without jeopardizing the  
            residential nature of such facilities.
          
          4)OPPOSITION.  The City of Burbank writes in opposition that  
            this bill will allow regular and ongoing medical treatment and  
            procedures to be administered on site at group homes within  








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            their community.  Although the City of Burbank understands the  
            goal of this bill to provide treatment and medical services to  
            the residents of these homes, this would be a fundamental  
            change in the character on scope of activities that would be  
            allowed to take place in our neighborhoods.  The City of  
            Burbank has a large concentration of homes and in many areas  
            they have substantially changed the nature and quality of life  
            of our community.  Under current law, group homes are supposed  
            to behave and be exactly like any other family residence and  
            that is the rationale for the absence of local control.  This  
            bill will fundamentally change the rules of the game by making  
            group homes quasi-residences and medical treatment facilities.  
             There are existing regulations and requirements including  
            local zoning for medical facilities for good reasons.  The  
            City of Burbank argues that this bill changes the balance from  
            behaving like every other residence, and thus not meriting  
            local control, to behaving like a quasi-medical/quasi  
            residential structure.


          
          5)PREVIOUS LEGISLATION.


          
             a)   AB 395 (Fox) of 2013 would have expanded the types of  
               facilities licensed by DADP 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.  AB 395 was held on the Senate  
               Appropriations Committee Suspense File.

             b)   AB 972 (Butler and Beall) of 2011 would have expanded,  
               until January 1, 2017, the category of residential  
               treatment facilities licensed by the DADP to include  
               facilities that provide limited medical services to adults  
               recovering from alcohol and drug abuse, provided that the  
               facility is not otherwise required to have a separate  








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               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.  AB 972 was held on the Senate  
               Appropriations Committee Suspense File.



             c)   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 DADP to provide unspecified medical  
               services and would have provided that such a facility would  
               not require a health facility license.  AB 2221 was held on  
               the Senate Appropriations Committee Suspense File.



             d)   AB 1055 (Chesbro) of 2009 would have expanded the DADP  
               licensure authority for alcohol and drug treatment  
               facilities to include 24-hour facilities that do not  
               require a health facility license.  This bill was held on  
               the Assembly Appropriations Committee suspense file.





          6)POLICY COMMENT.  Various versions of this bill have been  
            attempted numerous times.  This year, this bill is being  
            presented while the state is also adopting a new alcohol and  
            drug treatment system through the DMC-ODS Waiver Amendment.   
            Should the terms of this waiver be approved, the provisions  
            provided for in this bill will be necessary in order to  
            achieve the DMC-ODS goals of improving and increasing care  
            coordination for individuals recovering from an alcohol or  
            substance abuse disorder in a treatment facility.

          7)DOUBLE REFERRAL.  This bill is double referred; it passed the  








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            Assembly Business and Professions Committee on a vote of 12-2  
            on April 14, 2015.


               


          REGISTERED SUPPORT / OPPOSITION:




          Support


          California Society of Addiction Medicine (cosponsor)


          Elements Behavioral Health (cosponsor)


          JANUS of Santa Cruz (cosponsor)


          Alkermes Inc.


          California Naturopathic Doctors Association


          California Narcotic Officers' Association


          County Behavioral Health Directors Association




          Opposition








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          City of Burbank




          Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097