BILL ANALYSIS Ó
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