BILL ANALYSIS                                                                                                                                                                                                    



                                                                     AB 848


                                                                    Page  1


          CONCURRENCE IN SENATE AMENDMENTS


          AB  
          848 (Mark Stone)


          As Amended  August 31, 2015


          Majority vote


           -------------------------------------------------------------------- 
          |ASSEMBLY:  |74-3  |(June 3, 2015) |SENATE: |29-9  |(September 1,    |
          |           |      |               |        |      |2015)            |
          |           |      |               |        |      |                 |
          |           |      |               |        |      |                 |
           -------------------------------------------------------------------- 


          Original Committee Reference:  B. & P.




          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 July  
          1, 2018.  Specifically, this bill:


          1)Specifies that a health care practitioner should submit a  
            signed certification form, within a reasonable period of time,  
            as defined by the DHCS in regulations, 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  








                                                                     AB 848


                                                                    Page  2


            professional, licensed under Business and Professions Code  
            Section 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 includes,  
            but is not limited to, a description of the alcoholism and  
            drug abuse recovery or treatment services that an applicant  
            needs.


          4)Defines "incidental medical services" as services that are in  
            compliance with the community standard of practice and are not  
            required to be performed in a licensed clinic or licensed  
            health facility, as defined by Section 1200 or 1250,  
            respectively, to address medical issues associated with either  
            detoxification from alcohol or drugs or the provisions of  
            alcoholism or drug abuse recovery or treatment services,  
            including all of the following categories of services that the  
            DHCS shall further define by regulation:


             a)   Obtaining medical histories.


             b)   Monitoring health status to determine whether the health  
               status warrants transfer of the patient in order to receive  
               urgent or emergent care.


             c)   Testing associated with detoxification from alcohol or  
               drugs.


             d)   Providing alcoholism or drug abuse recovery or treatment  
               services.


             e)   Overseeing patient self-administered medications.










                                                                     AB 848


                                                                    Page  3


             f)   Treating substance abuse disorders, including  
               detoxification.


          5)Specifies that incidental medical services do not include the  
            provision of general primary medical care.


          6)Specifies that a facility may permit incidental medical  
            services to be provided to a resident at the facility by, or  
            under the supervision of, one or more 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 if all of the following  
            conditions are met:


             a)   The facility must comply with all other applicable laws  
               and regulations to meet the needs of a resident receiving  
               incidental medical services.


             b)   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 at the  
               facility, and the statutory and regulatory requirements and  
               limitations for the physician and surgeon or other health  
               care professional and for the facility.


          7)Indicates that a physician and surgeon or other health care  
            practitioner shall assess a resident, prior to that resident  
            receiving incidental medical services, to determine whether it  
            is medically appropriate for the resident to receive these  
            services at the premises of the licensed facility.  A copy of  
            the form provide by the DHCS shall be signed by the physician  
            and surgeon and maintained in the resident's file at the  








                                                                     AB 848


                                                                    Page  4


            facility.


          8)Requires that before a facility resident receives incidental  
            medical services, the resident has signed an admission  
            agreement.  The admission agreement, at a minimum, shall  
            describe the incidental medical services that the facility may  
            permit to be provided and shall state that the permitted  
            incidental medical services will be provided by, or under the  
            supervision of, a physician and surgeon.  The department shall  
            specify in regulations, at a minimum, the content and manner  
            of providing the admission agreement, and any other  
            information that the department deems appropriate.  The  
            facility shall maintain a copy of the signed admission  
            agreement in the resident's file.


          9)Specifies that once incidental medical services are initiated  
            for a resident, the physician and surgeon, and the facility  
            shall monitor the resident to ensure that the services remain  
            appropriate for the resident.  If the physician and surgeon  
            determines that a change in the resident's medical condition  
            requires other medical services or that a higher level of care  
            is required, the facility shall immediately arrange for the  
            other medical services or higher level of care, as  
            appropriate.


          10)Requires the facility to maintain in its files a copy of the  
            relevant professional license or other written evidence of  
            licensure to practice medicine or perform medical services in  
            the state for the physician and surgeon and any other health  
            care practitioner providing incidental medical services at the  
            facility.


          11)Indicates that the DHCS shall not evaluate or have any  
            responsibility or liability with respect to evaluating  
            incidental medical services provided by a physician and  
            surgeon or other health care practitioner at a licensed  
            facility.









                                                                     AB 848


                                                                    Page  5



          12)States that a facility licensed and approved by the DHCS to  
            allow for the provision of incidental medical services shall  
            not be deemed a clinic or health facility.


          13)Specifies that, other than incidental medical services  
            permitted to be provided or any urgent of emergent care  
            required 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.


          14)Specifies that this section does not require a residential  
            treatment facility licensed by the DHCS to provide incidental  
            medical services or any services not otherwise permitted by  
            law.


          15)Specifies that on or before July 1, 2018, the DHCS shall  
            adopt regulations to implement this section I accordance with  
            the Administrative Procedure Act, and notwithstanding the  
            rulemaking provisions of the Administrative Procedure Act, the  
            DHCS, if it deems appropriate, implement, interpret, or make  
            specific this section by means of provider bulletins, written  
            guidelines, or similar instructions from the DHCS until  
            regulations are adopted.


          16)Indicates that if an applicant for facility licensure intends  
            to permit incidental medical services, the applicant shall  
            submit evidence of a valid license of the physician and  
            surgeon who will provide or oversee those services, and any  
            other information the DHCS deems appropriate.


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










                                                                     AB 848


                                                                    Page  6


          18)Further specifies that the fee shall be set at an amount  
            sufficient to cover the reasonable costs to the DHCS of the  
            additional assessment and investigation necessary to license  
            facilities to provide these services, including, but not  
            limited to, processing applications, issuing licenses, and  
            investigating reports of noncompliance with licensing  
            regulations. 


          19)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.


          20)Makes other findings and declarations.


          The Senate amendments delay the deadline for adopting  
          regulations until July 1, 2018, further define incidental  
          medical services and the categories of services that the DHCS  
          shall define by regulation, and make a number of clarifying and  
          technical changes.


          FISCAL EFFECT:  According to the Senate Appropriations  
          Committee, this bill will result in:


          1)One-time costs of about $550,000 to develop program  
            requirements and adopt regulations by the DHCS.


          2)Ongoing costs of about $550,000 per year to perform ongoing  
            licensing, inspection, and enforcement activities relating to  
            facilities licensed to provide incidental medical services by  
            the DHCS, offset by fee revenues.


          3)Unknown additional legal costs relating to future enforcement  
            actions that may result in appeals or litigation. The DHCS has  








                                                                     AB 848


                                                                    Page  7


            indicated that there could be significant additional legal  
            costs due to enforcement activity and the complexities of  
            determining appropriate medical care for residents. Whether or  
            not such costs will occur is not known at this time.


          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  
          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  








                                                                     AB 848


                                                                    Page  8


          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 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.   








                                                                     AB 848


                                                                    Page  9


          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 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."  








                                                                     AB 848


                                                                    Page  10




          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 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  








                                                                     AB 848


                                                                    Page  11


          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: 0001923