BILL ANALYSIS Ó
AB 927
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Date of Hearing: January 12, 2016
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 927
McCarty - As Amended January 4, 2016
SUBJECT: Health facilities: nursing homes.
SUMMARY: Establishes the Nursing Home Ownership Disclosure Act
of 2016 within the Department of Public Health (DPH). Imposes
additional transparency and suitability requirements for
ownership and licensure of skilled nursing facilities (SNFs) and
intermediate care facilities (ICFs). Expands disclosure
requirements applicants for ownership or governance of ICFs and
SNFs must provide to DPH. Specifically, this bill:
1)Requires DPH to deny the application of any ICF and SNF
applicant who fails to cooperate with DPH in the completion of
an application for licensure of a specified health facility.
Defines "failure of an applicant to cooperate" as the
inability of the applicant to provide the information required
by existing law and DPH regulations, the inability to provide
the information in the form requested by DPH, or both.
2)Expands the requirements DPH must investigate to determine if
an applicant has demonstrated a pattern and practice of
violations of state or federal laws and regulations, and if
the applicant has the ability to comply with existing law, to
all applicants for licensure of SNFs and ICFs.
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3)Requires DPH to confirm an applicant is in good standing with
the appropriate licensing agency and obtain historical
information on any disciplinary action taken against an
applicant, if the applicant is a professional licensed by the
State of California.
4)Requires applicants for licensure of SNFs and ICFs to disclose
additional information to DPH including the following:
a) Information regarding applicants who have held a direct
or indirect beneficial ownership interest of 5% or more in
any other SNF or ICF in California or any other state, or
in any residential care facility (RCF);
b) Existing relationships of an applicant's parent
organizations, subsidiaries, management or parent
organizations of management companies with any other SNFs
or ICFs within the United States, any community care
facility (CCF), or any RCF; and,
c) History of compliance or noncompliance with applicable
state and federal laws or regulations, as specified.
5)Clarifies that a person, as defined, is prohibited from
acquiring a direct or indirect beneficial interest of 5% or
more in specified business structures without prior written
approval from DPH.
6)Requires DPH to deny approval of a license application for
individuals who maintain 5% or greater direct or indirect
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beneficial interest in licensees, as defined, of a SNF, ICF,
CCF, or RCF for the elderly at a time during the seven-year
period prior to the application in which that facility
committed one or more of the following violations:
a) Issuance of a temporary suspension or revocation of a
facility's license by DPH;
b) Involuntary termination of a facility's Medicare or
Medi-Cal certification; or,
c) Appointment of a court-ordered receiver.
7)Deletes existing criteria for DPH's authorization to deny
approval of a license application of a SNF or ICF, and
establishes new conditions for denial for specified persons,
if those actions have occurred within the seven-year period
prior to the application.
8)Requires DPH to provide additional information on long-term
care (LTC) facilities through the consumer information service
system (CISS).
9)Requires DPH to make current written copies of the LTC
facility profiles available to the public through its district
offices.
10)Defines the following:
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a) "Beneficial interest" means the interest held by any
person, including a private equity firm and real estate
investment trust, that acquires an interest in any entity,
including, but not limited to, any firm, association,
organization, partnership, business trust, investment
trust, corporation, or limited liability company, that is
licensed to operate a SNF or ICF by assuming that entity's
debt;
b) "Indirect beneficial interest" means the interest held
by any person, including a private equity firm and real
estate investment trust that provides capital or assets to
a SNF or ICF, in exchange for a share of 5% or more of the
facility's gross income or profits; and,
c) "Management company" means any company or entity that
has assumed operational or managerial control over the
facility or who directly or indirectly conducts the
day-to-day operations of the facility either under contract
or through some other arrangement.
EXISTING LAW:
1)Requires an applicant for licensure or management of a health
facility, including specified hospitals, SNFs, or ICFs, that
has not filed an application for license to operate that
facility to file an application with DPH with specified
information regarding the applicant and the health facility in
which the applicant seeks licensure or approval of management.
2)Requires DPH to consider any available information, as
specified, regarding whether or not an applicant has
demonstrated a pattern and practice of violations of state or
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federal laws and regulations, and whether the applicant has
the ability to comply with existing law, when considering if
an applicant is qualified for licensure of a general acute
care hospital, an acute psychiatric hospital, or a special
hospital.
3)Authorizes DPH to require an applicant for licensure of a
general acute care hospital, an acute psychiatric hospital, or
a special hospital to provide any documentation or information
DPH deems necessary for the proper administration and
enforcement of existing laws regarding licensure.
4)Requires each applicant seeking licensure to operate a SNF or
ICF to disclose to DPH information regarding ownership,
management, and governance of other SNFs, ICFs, or CCFs, as
specified.
5)On and after January 1, 1990, prohibits a person, as defined,
from acquiring a beneficial interest of 5% or more in any
corporation or partnership licensed to operate a SNF or ICF,
or in any management company under contract with a licensee of
a SNF or ICF, without prior written approval of DPH.
6)Authorizes DPH to deny the license application of a person, as
defined, with a beneficial interest of 5% or more in a
licensee of, or in a management company under contract with a
licensee of, a SNF, ICF, CCF, or RCF for the elderly for any
of the following reasons, unless otherwise specified:
a) Its license was suspended or revoked due to violations
of existing law;
b) A court-ordered receiver was appointed; or,
c) A final Medi-Cal decertification action was taken by the
federal Centers for Medicare and Medicaid Services (CMS);
7)Prohibits DPH from denying an application for licensure of a
SNF or ICF without first providing the applicant with a
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written notice of grounds for the proposed denial of
application, and an opportunity to submit additional evidence
in opposition to the proposed denial.
8)Exempts banks, trust companies, financial institutions, title
insurers, controlled escrow companies, underwritten title
companies to which a license is issued in a fiduciary
capacity, and the directors of specified nonprofit
corporations from specified disclosure requirements and denial
criteria when applying for licensure of a SNF or ICF.
9)Requires DPH to develop and establish a CISS to provide
updated and accurate information to the general public and
consumers regarding LTC facilities in their communities.
10)Requires DPH to interface the CISS with its Automated
Certification and Licensure Information Management System,
wherever feasible.
11)Declares the intent of the Legislature that DPH, in the
establishment and development of the CISS, to maximize the use
of available federal funds.
12)Requires DPH to ensure the confidentiality of personal and
identifying information of residents and employees and
prohibits the disclosure of such information through the CISS.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, as owners of
LTC facilities use increasingly complex forms of ownership, it
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has become virtually impossible to determine if the owner of
one particular home has significant complaints against them at
a different facility, despite many efforts to highlight the
problem and uncover the information. The author asserts it is
incumbent upon the Legislature to ensure the protection of
California's seniors, who are often in their most fragile and
vulnerable state in nursing home settings. The author
contends it is in the best interest of the state to protect
consumers and prevent existing owners with poor track records
from opening new LTC facilities, and that there is currently a
lack of transparency from DPH. The author concludes this bill
will help establish additional oversight and transparency for
nursing home ownership by strengthening suitability
requirements of owners, clarifying DPH's duty to review and
approve ownership changes, and make ownership information more
transparent to the public.
2)BACKGROUND. According to the Department of Finance, the
fasting growing cohort in California's population is 65 to
74-year olds due to baby boomers reaching that milestone.
This group is expected to grow by 25% by 2019. With this
rapid growth rate and a quickly changing healthcare and social
services system, the regulatory challenges for the state are
anticipated to grow in complexity.
a) DPH's Licensing and Certification (L&C) Program. DPH's
L&C Program is the DPH's largest program and is responsible
for the regulatory oversight of over 7,500 licensed health
care facilities, 2,500 of which are LTC facilities such as
SNFs and ICFs. Additionally, the federal CMS contracts
with L&C to evaluate facilities accepting payments from
Medicare and Medi-Cal, the state's Medicaid program, to
ensure that they meet federal requirements. The L&C
Program evaluates health care facilities for compliance
with state and federal laws and regulations through a
variety of required tasks, including initial and
re-licensure surveys, federal certification surveys, and
investigations of complaints and entity-reported incidents
(ERIs).
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b) SNF and ICF Licenses and Ownership. According to the
Office of Statewide Health Planning and Development, most
SNF and ICF facilities are run as for-profit enterprises;
about 13% are not-for-profit. According to DPH, there is
an average of 34 individuals associated with SNF licensing
application, including owners, board members, the director
of nursing, and the administrator. As of May 2015, DPH
stated that since 2008, one SNF or ICF license has been
suspended, 61 decertification actions have been taken, and
six certification termination acts were initiated where the
facility was able to return to compliance. Between July 1,
2007 and March 15, 2015, a total of 549 ICF or SNF
facilities have been issued at least one Class AA or A
citation. A class AA citation is a violation that DPH has
determined to have been a direct proximate cause of death
of a patient or resident of a LTC facility. A class A
citation is a violation that DPH has determined presents
either imminent danger that death or serious harm to the
patients or residents, or that there is substantial
probability that death or serious physical harm to patients
or residents.
c) Nursing Homes in the Media. In the summer of 2013, The
Sacramento Bee published a three-part series of articles
entitled "Nursing Homes Unmasked," highlighting the
challenges in determining ownership of nursing home
facilities in California, and the varying records of
performance of those facilities. The Sacramento Bee
reported that approximately half of California's 120,000
licensed beds are controlled by 25 for-profit nursing home
chains; 10 of them performed below statewide averages in
2013 in more than half of the examined quality-of-care
categories, which measure frequency of incidences such as
falls and infections. Furthermore, the articles stated
that 20 of the top 25 chains fell below state averages in
at least three out of five staffing measures.
d) DPH Complaints and Investigations. Investigations of
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nursing home complaints and ERIs are carried out pursuant
to both federal and state mandates. Current law requires
DPH to make an onsite investigation of a complaint against
a nursing home within 10 working days of receipt. If the
complaint is an immediate jeopardy complaint, meaning that
it involves a threat of imminent danger of death or serious
bodily harm, DPH is required to make an onsite
investigation within 24 hours of receipt. However, current
law does not specify the length of time required to
complete complaint investigations.
Longstanding concerns and complaints about the manner in
which the L&C program managed complaint and ERI
investigations have persisted for many years. In 2006, the
Legislative Analyst's Office reported that only one-half of
all complaints not classified as immediate jeopardy were
investigated within the required 10-day timeframe.
Further, in 2007, the California State Auditor issued a
report finding that the Department of Health Services (now
referred to as DPH) struggled to initiate and close
complaint investigations and communicate with complainants
in a timely manner. In July 2012, CMS sent a letter to DPH
expressing concern with its ability to meet many of its L&C
responsibilities, including timely complaint
investigations. The state was in jeopardy of losing $1
million in federal funds if certain benchmarks were not
met. Ultimately, $138,123 in federal funding was withheld.
e) State Auditor Report. In October 2014, the California
State Auditor released a report regarding the L&C Program
citing ineffective management of nursing home complaint
investigations. The key findings of that report included:
i) As of April 2014, there were more than 11,000 open
complaints and ERIs backlogged, many of which had
relatively high priorities, and had remained open for an
average of nearly a year;
ii) Despite backlogs and lengthy investigations, L&C
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does not have any policies or procedures to ensure prompt
completion of complaint/ERI investigations and in many
cases did not meet statutory timeframes for initiating
complaint investigations;
iii) There was no staffing analysis for any of its
district offices to determine how much staff is needed to
complete workload. Most of the L&C district offices
visited by audit staff reported not having the resources
needed to investigate complaints properly, and having to
work overtime in order to try to keep pace with workload;
and,
iv) DPH failed to report all statutorily required
information to the Legislature in certain years by
omitting information related to the timeliness of
complaint investigations in their 2012 and 2013 reports
to the Legislature.
DPH responded that it agreed with the majority of the
recommendations in the State Auditor's report. However,
DPH disagreed with the suggested implementation of various
timelines, such as establishing timeframes in which to
process and complete complaint and ERI investigations.
According to the State Auditor's most recent update, out of
18 recommendations suggested by the State Auditor in the
report, only four have been fully implemented to date.
3)SUPPORT. The California Advocates for Nursing Home Reform, a
cosponsor of this bill, states this bill makes necessary
reforms that are critically needed to protect nursing home
residents from abuse, including mistreatment and death due to
neglect by operators. The Office of the San Diego County
District Attorney, also a co-sponsor of this bill, contends
the lapse of oversight at DPH and the lack of accountability
by nursing home owners and operators have left many California
elders in grave danger. The sponsors state it is time for
California to take strong steps to begin monitoring nursing
home chains operating in the state to keep those unfit from
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acquiring nursing homes or expanding their operations, and to
provide increased transparency to consumers and patients.
The California Long-Term Care Ombudsman Association supports
this bill, stating this bill is a meaningful step toward
improving transparency and consumer protections for SNF
residents; local ombudsman representatives are often unable to
identify the owners of SNFs are frequently discouraged to
learn after working to assist a resident in transferring from
a facility because of "consistently unsatisfactory care
issues" only to discover later the resident has been
transferred to another facility by the same operators but
under a different corporate name. Supporters of this bill
assert that under the current system, a family member can
unknowingly transfer a loved one from one troubled nursing
home facility to another without even knowing that the
facilities are part of the same chain. Supporters also state
that this bill will strengthen California law governing
acquisition of nursing homes, suitability requirements for
operators, and disclosure to the public on who owns nursing
homes.
4)OPPOSE UNLESS AMENDED. LeadingAge California opposes this
bill unless it is amended, arguing that DPH should maintain
the discretion to deny an application, and that mandating the
denial of an application based solely on specific enforcement
actions would limit DPH's ability to determine the extent to
which an individual was actually culpable for a deficient
practice in the facility's operations. LeadingAge California
further contends some provisions of this bill are too broad
and would leave potential applicants who own or manage even
high-performing facilities at risk for denial. The California
Association of Health Facilities (CAHF) also opposes this bill
unless amended, stating that removing DPH's discretion on
license applications, and requiring mandatory denial of
experienced operators under certain conditions will have a
negative impact on California. CAHF further argues that
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California should not prohibit experienced operators from
applying to own and operate new facilities, when the specifics
of both the purchasing company and the company being acquired
are very likely unique and should be looked at in isolation,
an option that DPH currently has the authority to take action
on. CAHF contends that consolidation is a current reality
within the healthcare system, and because California is not
increasing its bed supply in LTC facilities, ensuring the
state can maintain the supply with experienced and skilled
operators when facilities close is critical to dealing with
consolidation.
5)CONCERNS. The California Hospital Association submitted a
letter of concern to the Committee regarding a previous
version of this bill, stating that it supports transparency
and the appropriate oversight of applications for SNF
ownership and operation, however that the provisions in the
previous version of this bill may discourage quality
providers, including hospitals, health systems, and others, to
acquire and establish SNFs to meet the need of the individuals
and communities they serve.
6)POLICY COMMENTS. This bill imposes a number of requirements
on DPH regarding the collection and publication of information
on SNFs and ICFs. In order to increase efficiency and ensure
the timeliness of these requirements, the author may wish to
consider the following amendments in the future.
a) Searchable database. In an effort to increase
transparency of information to the public regarding LTC
facilities, this bill expands the data required to be
posted on the statewide CISS. The author points to the
current difficulty of obtaining ownership information for
licensed LTC facilities, however the language does not
explicitly dictate that the CISS be created in a user or
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consumer-friendly manner. To further the original intent
of the bill, and to allow DPH staff to more easily access
the compliance history of a particular individual or group,
the author may wish to consider mandating that the CISS be
created in a manner such that the information is able to be
searched via the name of an individual who has an indirect
or direct beneficial interest in an LTC facility.
b) Deadlines for DPH. As stated, this bill increases the
data required to be collected by DPH for publication on the
statewide CISS. However, the bill language does not
specify a deadline by which DPH must collect and publish
the information. The 2014 State Auditor Report on DPH,
discussed previously, highlights DPH's poor history of
timely implementation of the State Auditor's
recommendations and completion of certain tasks, such as
final resolution of complaints at LTC facilities. To help
establish oversight and ensure consumers and patients have
access to LTC information in a timely manner, the author
may wish to consider imposing a deadline on DPH to collect
and publish all new information required for the statewide
CISS under this bill.
7)SUGGESTED AMENDMENTS. This bill establishes a number of
additional disclosure and suitability requirements for
licensure of SNFs and ICFs. Furthermore, this bill requires
DPH to increase the transparency of information regarding
ownership of such facilities. In order to ensure state
resources are used more efficiently, and to better meet the
original intent of the legislation, the Committee may wish to
consider the following amendments:
a) Establish stronger definitions to further intent. This
bill includes additional requirements for applicants who
have a direct and indirect beneficial interest in a
healthcare facility when applying for additional facility
licensure with DPH. The author contends it is in the best
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interest of the State to protect consumers and prevent
existing owners with poor track records from opening new
LTC facilities. However, not all LTC facilities are
operated by management companies; federal law requires ICFs
to have a governing body which meets specified criteria,
but does not require a management company. And although it
is an entity that should be held accountable, the owner or
owners of LTC facilities may not be active in the daily
operations of the facility. As such, the Committee may
wish to amend this bill to instead apply the requirements
to those who control the direction of the management or
policies of a licensed facility, whether through ownership,
contract, or otherwise.
b) Conserve state staffing resources. This bill requires
DPH to update the online profile of each LTC facility on
the CISS, on a regular and timely basis, with current
information regarding any appeal resolution pertaining to a
citation or complaint. As discussed previously, DPH has a
history of complaints with how it manages complaint
investigations at LTC facilities, particularly the length
of time in which it addresses complaints. As such, it is
unknown if DPH would be able to accurately and regularly
update the CISS. The Committee may wish to consider
amending this bill to instead require DPH to update the
online profiles of LTC facilities with the final
disposition of a citation or complaint.
c) Option to confirm with other state agencies. This bill
requires applicants to disclose any history of compliance
and noncompliance with any applicable state or federal law
or regulation regarding specified facilities. It also
requires applicants to disclose their relationships with
other SNFs and ICFs. Although the language specifies
certain circumstances by which to confirm information
provided by an applicant, in order to ensure completeness
and provide DPH with additional information, the Committee
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may wish to consider amending this bill to authorize DPH to
contact other state agencies and departments to obtain
information regarding an applicant's compliance history.
d) Establish consistency with existing law. This bill
authorizes DPH to deny an application for licensure of a
SNF or ICF if the applicant, within the past seven years,
has prevented or attempted to impede the work of any
authorized representative of DPH. Existing law under
Health and Safety Code Section 1431 states it is a
misdemeanor to willfully prevent, interfere with, or
attempt to impede in any way, the work of, examination of
records by, or preservation of evidence by, a duly
authorized DPH representative who is enforcing current law.
The current bill language is not fully consistent with
current statute. The Committee may wish to consider
aligning this bill with Health and Safety Code Section
1431.
The current language of this bill allows for DPH to deny an
application for licensure after one occurrence of specified
infractions. Some of these infractions may occur due to
factors outside of the control of the facility, and may
also be possible for a facility to remedy within 24 hours.
Existing law also authorizes many state authorities to deny
licensure to applicants upon a finding of a pattern of
non-compliance with certain criteria rather than one
occurrence, which protects those individuals who are
impacted by events outside of their control. The Committee
may wish to consider amending this bill to authorize DPH to
deny applications for licensure if an applicant has
demonstrated a pattern of non-compliance involving
specified infractions. The Committee may also wish to
consider excluding those infractions that can be remedied
within 24 hours by a facility, and providing limited
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protection for those applicants who have unintentionally
committed certain infractions, due to factors outside of
their control.
e) Eliminate provisions difficult to define. This bill
authorizes DPH to deny an application if the applicant,
within the past seven years, has failed to demonstrate
competence in operating a facility. There are currently no
standards by which DPH is required to assess one's
competence in operating a facility in statute; in addition,
this bill does not provide guidance as to how this would be
measured. This bill already addresses circumstances in
which an applicant would be denied licensure due to a lack
of compliance during operation of a facility, thus an
additional criteria regarding competence may be
unnecessary. As such, the Committee may wish to consider
striking this provision.
f) Modify mandatory denials to create accountability and
consistency with current law. This bill requires DPH to
deny an application for licensure of an SNF or ICF if the
applicant owned, governed, or managed a LTC facility at a
time during the seven-year period prior to the application
in which that facility had an appointment of a
court-ordered receiver, involuntary termination of federal
certification, or issuance of a temporary suspension order
or revocation of a facility's license by DPH. In order to
create accountability by the applicants, and to be
consistent with current law, the Committee may wish to
consider amending the provisions of this bill related to
the automatic denial as follows:
i) Optional leniency for appointments of court-ordered
receivers. Existing law allows for certain state
agencies to have some discretion in review of license
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applications under these circumstances, if an applicant
demonstrates that the applicant took all reasonable
actions to either prevent or correct violations that led
to the receivership. The Committee may wish to consider
amending this bill to provide DPH this discretion.
ii) Accountability after seven-year probationary period.
The seven-year probationary period in this measure
appears to be arbitrary, and the language is silent as to
what occurs following this timeframe. The provisions
also do not allow for applicants to prove that they are
qualified to own a facility prior to the end of that
seven-year period. Owners, administrators, and managers
of LTC facilities are responsible for the well-being and
health of many of our more fragile Californians. In
order to ensure the safety of the state's LTC residents
and patients, the Committee may wish to consider amending
this bill to require an applicant to prove to DPH that
the applicant is qualified enough, following the
seven-year period, to own, govern, or manage a licensed
SNF or ICF, despite the previous violations. To provide
more fairness to potential applicants during the
timeframe of automatic denial, the Committee may wish
allow an applicant to prove qualifications to own,
govern, or manage a SNF or ICF to DPH, prior to the end
of the seven-year period, under specified extenuating
circumstances.
iii) Establish an appeals process for certain denials.
Existing law allows applicants who have been denied
approval for other licenses, permits, or similar
authorization by a state department or agency to be able
to appeal the decision of that department. The Committee
may wish to consider amending this bill to be consistent
with other areas of the law, and include the opportunity
for an applicant to appeal a denial.
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8)TECHNICAL AMENDMENT. In order to ensure consistency and
clarity within this bill, the Committee may wish to consider
amending this bill to further clarify the meaning of a single
entity, consistent with existing law.
9)PREVIOUS LEGISLATION.
a) AB 348 (Brown) of 2015 would have established a
timeframe under which DPH would be required to complete an
investigation into a complaint about a LTC facility. AB
348 was held in the Senate Appropriations Committee.
b) AB 1710 (Yamada), Chapter 672, Statutes of 2012, revises
how nursing home administrator licensing fees are to be
adjusted so that fee revenue is sufficient to cover the
regulatory costs to DPH, and revises and increases DPH
reporting requirements regarding the Nursing Home
Administrator Program.
c) SB 799 (Negrete-McLeod) of 2011 would have required DPH
to complete LTC facility complaint investigations within a
90-working day period. SB 799 was held on suspense in
Senate Appropriations.
d) SB 535 (Kuehl) of 2008 would have directed DPH to
establish a Website offering specified on-line information
regarding LTC facilities. SB 535 was vetoed by the
Governor.
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e) AB 399 (Feuer) of 2007 would have established a 40 day
timeframe for DPH to complete a LTC facility complaint
investigation. AB 399 was vetoed by the Governor.
f) AB 1807 (Committee on Budget), Chapter 74, Statutes of
2006, was the health trailer bill for the Budget Act of
2006. Among other changes, AB 1807 establishes a new fee
structure for health facilities that are licensed and/or
certified by L&C: fees must be calculated based on: i)
specified workload data provided by DPH to the Legislature
and made available to the public on their Website; ii) any
General Fund support appropriated by the Legislature; iii)
any federal grant funds received for this purpose; and, iv)
any policy adjustments as proposed by the Administration
and as adopted by the Legislature. States intent that L&C
become entirely supported by fees and federal funds by no
later than July 1, 2009.
g) SB 1312 (Alquist) Chapter 895, Statutes of 2006,
requires inspections and investigations of LTC facilities
certified by the Medicare or Medicaid program to determine
compliance with federal standards and California statutes
and regulations.
h) AB 1731 (Shelley), Chapter 451, Statutes of 2000, enacts
major reforms for SNFs and ICFs, including the expansion of
citations and penalties, an increase in disclosure
requirements and inspections, requires DPH to provide
specified notice to complainants within specified
timeframes, and requires initial onsite investigations
within 24 hours in response to complaints where there is a
serious threat of imminent danger of death or serious
bodily harm.
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REGISTERED SUPPORT / OPPOSITION:
Support
California Advocates for Nursing Home Reform (cosponsor)
Office of the San Diego County District Attorney (cosponsor)
AARP
American Federation of State, County and Municipal Employees
(previous version)
The Arc and United Cerebral Palsy California Collaboration
Area 3 Agency on Aging Advisory Council
Asian Law Alliance (previous version)
California Commission on Aging (previous version)
California Long-Term Care Ombudsman Association
California Retired Teachers Association (previous version)
Coalition of California Welfare Rights Organizations, Inc.
(previous version)
Congress of California Seniors (previous version)
Consumer Attorneys of California
Consumer Federation of California
Disability Rights California
National Association of Social Workers - California Chapter
Office of the District Attorney of Alameda County
Office of the State Long-Term Care Ombudsman
Several individuals
Several law firms
Opposition
California Association of Health Facilities
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LeadingAge California
Analysis Prepared by:An-Chi Tsou / HEALTH / (916) 319-2097