BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                       AB 848


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          ASSEMBLY THIRD READING


          AB  
          848 (Mark Stone)


          As Amended  June 1, 2015


          Majority vote


           ------------------------------------------------------------------ 
          |Committee       |Votes |Ayes                |Noes                 |
          |                |      |                    |                     |
          |                |      |                    |                     |
          |----------------+------+--------------------+---------------------|
          |Business &      |12-2  |Bonilla, Jones,     |Gatto, Wilk          |
          |Professions     |      |Baker, Bloom,       |                     |
          |                |      |Campos, Chang,      |                     |
          |                |      |Dodd, Eggman,       |                     |
          |                |      |Holden, Mullin,     |                     |
          |                |      |Ting, Wood          |                     |
          |                |      |                    |                     |
          |----------------+------+--------------------+---------------------|
          |Health          |19-0  |Bonta, Maienschein, |                     |
          |                |      |Bonilla, Burke,     |                     |
          |                |      |Chávez, Chiu,       |                     |
          |                |      |Gomez, Gonzalez,    |                     |
          |                |      |                    |                     |
          |                |      |                    |                     |
          |                |      |Roger Hernández,    |                     |
          |                |      |Lackey, Nazarian,   |                     |
          |                |      |Patterson,          |                     |
          |                |      |                    |                     |
          |                |      |                    |                     |
          |                |      |Ridley-Thomas,      |                     |
          |                |      |Rodriguez,          |                     |








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          |                |      |Santiago,           |                     |
          |                |      |Steinorth,          |                     |
          |                |      |Thurmond, Waldron,  |                     |
          |                |      |Wood                |                     |
          |                |      |                    |                     |
          |----------------+------+--------------------+---------------------|
          |Appropriations  |12-0  |Gomez, Bonta,       |                     |
          |                |      |Calderon, Daly,     |                     |
          |                |      |Eggman,             |                     |
          |                |      |                    |                     |
          |                |      |                    |                     |
          |                |      |Eduardo Garcia,     |                     |
          |                |      |Gordon, Holden,     |                     |
          |                |      |Quirk, Rendon,      |                     |
          |                |      |Weber, Wood         |                     |
          |                |      |                    |                     |
          |                |      |                    |                     |
           ------------------------------------------------------------------ 


          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.  Specifically,  
          this bill:


          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 Business and Professions Code  
            Section 500, and who is acting within the scope of practice of  








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            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)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.


          5)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 Medical  
            Board of California 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.


          6)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.









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          7)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.


          8)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.


          9)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.


          10)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.


          11)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.


          12)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.










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          13)States that the resident must be authorized by the physician  
            and surgeon as medically appropriate to receive the incidental  
            medical services at the facility.


          14)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.


          15)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  
            services remain appropriate for the resident.


          16)Requires the facility to maintain in its files a copy of the  
            physician's and surgeon's license or other written evidence of  
            licensure to practice medicine in the state.


          17)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.


          18)Indicates that the DHCS shall not evaluate or have any  
            responsibility or liability with respect to evaluating  
            incidental medical services provided.


          19)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.


          20)Specifies that, other than incidental medical services, minor  








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            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.


          21)Indicates that if an applicant for facility licensure intends  
            to permit incidental medical services, the applicant shall  
            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.


          22)Allows the DHCS to establish and collect an additional  
            licensure fee for an application that includes a request for a  
            facility to provide detoxification services.


          23)Further specifies that the fee shall be set at an amount  
            sufficient to cover the department's reasonable costs of  
            regulating the provision of those services. 


          24)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.


          25)Makes other findings and declarations.


          FISCAL EFFECT:  According to the Assembly Appropriations  
          Committee:










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          1)Costs to adopt regulations, likely in the range of $200,000 over  
            two years (licensing fees and Substance Abuse Prevention and  
            Treatment Block Grant).


          2)Unknown ongoing costs to oversee this new requirement as a  
            component of licensure, possibly in the range of $100,000  
            annually (licensing fees).


          COMMENTS:


          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." 


          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  








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          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).  


          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 tuberculosis tests, that residents have completed  
          health questionnaires and if at least one staff member is  








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          certified in first aid and cardiopulmonary resuscitation (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 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  








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          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 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.  


          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 Legislature may wish to  
          consider requiring additional implementation safeguards should  
          this bill pass.  


          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  








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          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. 




          Analysis Prepared by:                                               
                          Le Ondra Clark Harvey / B. & P. / (916) 319-3301    
                                                                      FN:  
          0000802