BILL ANALYSIS Ó
AB 848
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB
848 (Mark Stone)
As Amended August 31, 2015
Majority vote
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|ASSEMBLY: |74-3 |(June 3, 2015) |SENATE: |29-9 |(September 1, |
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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
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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.
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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
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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.
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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.
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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
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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
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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.
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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."
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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
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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