BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1147
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|AUTHOR: |Maienschein |
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|VERSION: |June 19, 2015 |
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|HEARING DATE: |July 1, 2015 | | |
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|CONSULTANT: |Vince Marchand |
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SUBJECT : Health facilities: pediatric day health and respite
care facilities.
SUMMARY : Revises the definition of a pediatric day health and respite
care facility, which is currently limited to children 21 years
of age or younger, to also permit an individual who is 22 years
of age or older to receive care if the facility receives
approval for a Transitional Health Care Needs Optional Service
Unit, which is established by this bill.
Existing law:
1)Defines "pediatric day health and respite care facility"
(PDHRCF) as a facility that provides an organized program of
therapeutic social and day health activities and services and
limited 24-hour inpatient respite care to medically fragile
children 21 years of age or younger, including terminally ill
and technology dependent children.
2)Defines "medically fragile," for purposes of PDHRCF, as having
an acute or chronic health problem that requires therapeutic
intervention and skilled nursing care during all or part of
the day.
3)Defines "respite care," for purposes of PDHRCF, as day and
24-hour relief for the parent or guardian and care for the
child. Limits 24-hour inpatient respite care to no more than
30 intermittent or continuous days per patient per calendar
year.
4)Requires pediatric day health care provided by a PDHRCF to be
a covered benefit under the Medi-Cal program. However,
prohibits the Department of Health Care Services from
approving a request for authorization of pediatric day care if
AB 1147 (Maienschein) Page 2 of ?
it determines that the total cost incurred by Medi-Cal for
providing pediatric day health care services and all other
medically necessary services to the beneficiary is greater
than the total cost incurred by the Medi-Cal program in
providing equivalent services at the otherwise appropriate
level of institutional or home care.
5)Requires Department of Public Health (DPH) to adopt
regulations governing the licensure of PDHRCFs no later than
July 1, 1993, but specifies that pending the adoption of these
regulations, DPH may license a PDHRCF if it meets interim
regulations established for congregate living health
facilities (CLHFs).
6)Licenses and regulates CLHFs by DPH, which are defined as
residential homes with a capacity of no more than 12 beds that
provide inpatient care that is generally less intense than
that provided in a general acute care hospital, but more
intense than that provided in a skilled nursing facility
(SNF). Requires DPH to adopt regulations for CLHFs, and until
these regulations are adopted, requires CLHFs to meet certain
statutory requirements (which would become inoperative upon
the adoption of regulations), and to conform to the
regulations that govern SNFs, with specified exceptions.
This bill:
1)Revises the definition of a PDHRCF, which is currently limited
to children 21 years of age or younger, to also permit an
individual who is 22 years of age or older to receive care in
a PDHRCF if the facility receives approval from DPH for a
Transitional Health Care Needs Optional Service Unit, which is
established by this bill.
2)Exempts PDHRCFs from specified regulations that SNFs are
required to meet, including the minimum nursing staff ratio
requirements, and requirements pertaining to the ordering of
prescription drugs, having a pharmacist review the drug
regimen of patients on a monthly basis, and other
pharmaceutical-related requirements;
3)Requires a PDHRCF to have a patient care committee to address
quality of care provided in the facility, including, but not
limited to, patient care policies, pharmacy services, and
infection control. Requires this patient care committee to
include the medical director, dietician, pharmacist, nursing
AB 1147 (Maienschein) Page 3 of ?
staff, nurse supervisor, center administrator or director, and
to meet at least twice per year or more often if a need or
problem is identified by the committee.
4)Requires the PDHRCF patient care committee to be responsible
for all of the following:
a) Reviewing and approving all policies relating
to patient care. Requires the committee, based on
reports received from the PDHRCF's administrator, to
review the effectiveness of policy implementation and
to make recommendations to the administrator of the
facility for the improvement of patient care. Requires
the committee to review patient care policies annually
and revise as necessary;
b) Infection control in the facility, including,
but not limited to, establishing, reviewing,
monitoring, and approving policies and procedures for
investigating, controlling, and preventing infections
in the facility, and maintaining, reviewing, and
reporting statistics of the number, types, sources,
and locations of infection within the facility; and,
c) Establishing, reviewing, and monitoring the
storage and administration of drugs and biologicals,
reviewing and taking appropriate action based on any
findings from a pharmacist hire to consult with the
committee and internal quality assurance review, and
recommending Improvements of services to the
administrator of the facility.
5)Permits DPH, upon written request of an applicant or licensee,
to approve the use of alternate concepts, methods, procedures,
techniques, equipment, personnel qualifications, or conducting
pilot projects, provided those alternatives are carried out
with safe and adequate care for the patients and with the
prior written approval of DPH. Requires DPH's review of
requests to consider the unique nature of services provided to
individuals served by the PDHRCF when compared to the
requirements for CLHFs for individuals requiring inpatient
care.
6)Requires a PDHRCF to provide pharmacy services that satisfy
all of the following:
a) Requires medications to be administered only
AB 1147 (Maienschein) Page 4 of ?
upon written and signed orders of the patient's
attending physician;
b) Requires medications to be supplied to the
licensed nursing personnel of the PDHRCF by the
patient's parent, foster parent, or legal guardian in
the original dispensing container that specifies
administration instructions, and prohibits the PDHRCF
from ordering medications from a pharmacy or from
taking delivery of medications from a pharmacy;
c) Prohibits the PDHRCF from accepting a patient
into the facility if the patient's medications have
expired or are schedule to expire during the patient's
stay at the facility;
d) Requires physician orders to be current and
maintained in the patient's medical record at the
PDHRCF. Requires verbal orders from the attending
physician for services to be rendered at the facility
to be received and recorded by licensed nursing
personnel in the patient's medical record and to be
signed by the attending physician within 30 working
days;
e) Requires the PDHRCF to maintain records of
medication administered for at least one year, unless
a longer period is required by the state or federal
law;
f) Permits the PDHRCF to treat changes in the
patient's condition, such as new onset pain, nausea,
diarrhea, infections, or other similar changes, in
accordance with the patient's plan of care if the
patient has been prescribed medications to treat these
anticipated symptoms, and the treatment does not
present a risk to the health and safety of themselves,
other patients, staff, or other individuals. Prohibits
a patient who presents with symptoms that are not
anticipated or planned for in the plan of care from
remaining in the facility; And,
g) Specifies that only licensed nursing
personnel, acting within their scope of practice, can
accept medications in a PDHRCF, and requires
facilities to comply with specified SNF regulations
regarding the administration of medication.
7)Permits a PDHRCF to implement policies and procedures that
prohibit smoking by patients, parents, staff, visitors, or
consultants within the facility or on the premises, if the
AB 1147 (Maienschein) Page 5 of ?
prohibition is clearly stated in the admission agreement, and
notices are posted at the facility.
8)Specifies that provisions of existing law that require a
PDHRCF to meet the fire safety and seismic safety standards
that apply to licensed community care facilities, and to
comply with local building code requirements, do not prohibit
the use of alternate space utilization, new concepts of
design, treatment techniques, equipment and alternate finish
materials, or other flexibility, if written approval is
granted by the local building authority.
9)Requires DPH, if a PDHRCF has not previously been licensed, to
issue a provisional license to the facility, which is required
to terminate six months from the date of issuance, or the date
that DPH is able to conduct a full and complete inspection,
whichever is later. Prohibits DPH from applying less stringent
criteria when granting a provisional license than it applies
when granting a permanent license.
10)Requires DPH to give a PDHRCF a full and complete inspection
within 30 days prior to the termination of a provisional
license, and if the facility does not meet the requirements
for licensure but has made substantial progress, to renew the
provisional license for another six months.
11)Prohibits DPH from issuing any further license if it
determines there has not been substantial progress towards
meeting licensure requirements at the time of the first full
inspection, or upon its inspection made within 30 days of the
termination of a renewed provisional license that there is a
lack of full compliance with the requirements.
12)Permits an applicant for a provisional license to operate a
PDHRCF who has been denied provisional licensing by DPH to
contest the denial by filing a request for a hearing pursuant
to provisions of existing law.
13)Requires a PDHRCF license to expire 12 months from the date
of issuance, and requires DPH to mail a renewal notice at
least 45 days prior to the expiration of the license, and to
mail the renewed license within 15 calendar days after it
receives the renewal fee.
14)Requires every PDHRCF for which a license has been issued to
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be periodically inspected by DPH.
15)Permits DPH to deny an application for, or suspend or revoke
a license issued to, a PDHRCF for any of the following:
a) A serious violation by the licensee of any of
the provisions of law pertaining to PDHRCFs that
jeopardizes the health and safety of patients;
b) Aiding, abetting, or permitting the commission
of any illegal act; or,
c) Willful omission or falsification of a
material fact in the application for a license.
16)Provides DPH with the authority to make reasonable
accommodation for exceptions to the standards that apply to
PDHRCFs if the health, safety, and quality of patient care is
not compromised, and requires prior written approval
communicating the terms and conditions under which an
exception is granted.
17)Defines a "Transitional Health Care Needs Optional Service
Unit" (optional service unit) as a functional unit of a PDHRCF
that is organized, staff, and equipped to provide care to
individuals who are 22 years of age or older.
18)Requires a PDHRCF who wants approval for an optional service
unit to file an application with DPH, and requires DPH to
approve the optional service unit.
19)Requires patients receiving care in an optional service unit
to be in age-appropriate groupings as provided for in the
PDHRCF's policies and procedures. Specifies that older
children, defined as those who are 18 to 21 years of age, may
be cared for in the same optional service unit as the patients
who are 22 years of age or older. Additionally, permits
patients who are 15 to 17 years of age to be considered for
care in the optional service unit if the PDHRCF obtains an
individual age waiver from the regional center, with the
concurrence of DPH.
20)Requires patients who are 22 years of age or older, in order
to continue receiving care in a PDHRCF, to have a
developmental age of 18 years or younger, as evidenced by the
patient's Individual Education Plan, Regional Center
Assessment, physician's assessment, or other assessment using
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a standardized assessment tool that is nationally recognized
in the field. In addition to allowing the continuation of care
for those older than 21, also permits those who previously
received care but are now 22 years of age or older, to again
receive services in an optional unit of a PDHRCF.
21)Requires care for patients who are 22 years of age or older
to be provided in a distinct part of a PDHRCF, separate from
the area where care is provided to patients who are 21 years
of age or younger, except as authorized elsewhere in this bill
where patients as young as 15 can be considered for care in
the same optional service unit as older patients.
22)Requires a PDHRCF to establish and implement policies and
procedures for determining the age ranges of patients who are
cared for in the optional service unit, and requires these
policies to include consideration of the patient's
chronological age, developmental age, and size, and to reflect
the needs of individual patients through a comprehensive
assessment.
23)Requires a PDHRCF to ensure that its staffing and equipment
are sufficient to provide services to patients who are 22
years of age or older.
24)Requires an optional service unit to have written policies
and procedures for the management of the service, and permits
DPH to review and approve these policies and procedures, and
the Department of Developmental Services and regional centers
to review the policies and procedures.
25)Contains an urgency clause that will make this bill effective
upon enactment.
FISCAL
EFFECT : According to the Assembly Appropriations Committee,
this bill will have the following fiscal effect:
1) Minor one-time costs to DPH Licensing and Certification
Division to revise policies and procedures to be compliant
with this bill.
2) Minor fee-supported workload costs to license
Transitional Health Care Needs Optional Service Units as
authorized by this bill.
AB 1147 (Maienschein) Page 8 of ?
PRIOR
VOTES :
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|Assembly Floor: |78 - 0 |
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|Assembly Appropriations Committee: |17 - 0 |
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|Assembly Health Committee: |19 - 0 |
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COMMENTS :
1)Author's statement. According to the author, medically
fragile children, as they begin to approach the ages of 21 and
22, have been faced with untenable choices of how to cobble
together the types of services that could provide the same
type of care and support received at PDHRCFs. Unfortunately,
these services simply do no exist, and families are again
facing similar unacceptable choices as they faced before
PDHRCFs were established. This bill would guarantee the
continuity of care this population desperately needs by
allowing medically fragile children and young adults to
continue to receive the quality services from PDHRCFs as they
grow older than the age 22. Without this bill,
medically-fragile young adults would be forced to search for
traditional long-term care which is fragmented and does not
provide the same essential choices to medically-fragile adults
and their families. Some limited services are available under
the Medi-Cal Waivers, but very few services are actually
available; and none of those services are coordinated, leaving
families to try to navigate this limited services system.
2)Background on PDHRCFs. PDHRCFs were established by the
Legislature by AB 3413 (Polanco), Chapter 1227, Statutes of
1990. According to DPH, there are currently 16 licensed
PDHRCFs. The author states that prior to the establishment of
these facilities, families with medically-fragile children had
very few choices to find day health and respite care that
would allow the child to remain at home, keep the family
intact, and keep parents working. According to the author,
when this category of facility was enacted, most of the
medically-fragile children were not expected to survive to
become adults, and that this model did not envision a system
of care that would provide a transition for these children as
AB 1147 (Maienschein) Page 9 of ?
they "aged out" of the PDHRCF programs.
3)Lack of regulations by DPH necessitating much of the language
of this bill. While the stated purpose of this bill is to
establish an optional service unit to permit those who are
older than 21 to continue to receive services in a PDHRCF,
this bill contains five pages of new statute that is not
directly related to the age issue that was the impetus for
this bill. Instead, much of the new language in this bill is
to address the fact that DPH has not adopted regulations
specific to PDHRCFs despite a statutory mandate to do so by
1993. Instead, pursuant to statutory requirements, PDHRCFs are
required to meet the "interim regulations" of a CLHF - which,
in turn, are tied to the regulatory framework of SNFs, because
CLHF regulations have also not been promulgated. However, both
CLHFs and SNFs are inpatient facilities, while PDHRCFs are
generally day use facilities (albeit with a limited ability to
provide some inpatient services). Therefore, PDHRCFs have been
required to meet certain regulations and statutory
requirements that are appropriate for inpatient facilities,
but unnecessary for the day respite care PDHRCFs provide. For
example, CLHFs and skilled nursing facilities must provide a
fairly comprehensive pharmacy service, which is something that
is not necessary for a day use facility. In a PDHRCF, parents
or guardians bring the medication that is needed for that day
when they bring the child who is going to be receiving
services. This bill provides a set of statutory requirements
to ensure that this medicine is handled and dispensed by
PDHRCF staff in a safe manner. In addition to addressing the
pharmacy issue, this bill identifies other regulations that
CLHFs are required to meet that PDHRCFs should be exempt from,
establishes procedures for issuing and renewing licenses, and
provides DPH with the ability to deny or revoke a license.
4)Related legislation. AB 1147 (Maienschein), increases the
maximum capacity of CLHFs, except those that are specifically
permitted to have larger capacities due to meeting specified
exemptions, from 12 to 18 beds. AB 1147 is set for hearing on
July 1, 2015 in this committee.
5)Prior legislation. AB 3347 (Wright, Chapter 494, Statutes of
1992), deleted the January 1, 1991 deadline for DPH to adopt
regulations for CLHF licensing standards, and extended
requirements for CLHFs serving the terminally ill or
catastrophically disabled to CLHFs serving the mentally alert
AB 1147 (Maienschein) Page 10 of ?
but physically disabled.
AB 3535 (Wright, Chapter 1459, Statutes of 1986), created the
CLHF licensure category, and defined a CLHF as a residential
home with a capacity of no more than six beds, which provides
inpatient care to mentally alert, physically disabled
residents, who may be ventilator dependent.
6)Support. This bill is sponsored by Together We Grow (TWG),
which states that it has been providing care to
medically-fragile, terminally ill children since 2000.
According to TWG, in many instances, these children cannot
feed themselves, walk, use the bathroom, or speak as a typical
person would do, but despite all of these challenges, they
have a quality of life and are important members of their
family. TWG states that these children will never leave the
care of their family homes unless forced into placement in an
institution by forces beyond their parent's control. TWG
states that pediatric day health care and respite centers make
it possible for family to get that support. Many of the
children who were just babies when they first came to TWG have
thrived into adolescence and young adulthood, but because the
current legislation for PDHRCFs limits the age to under 22
years of age, their services are not available to these
children and their families after they turn 22. TWG states
that this bill keeps these children sleeping in their own
beds, living with their own families, and playing with their
own friends. The Association of Regional Center Agencies
states in support that underfunding of the developmental
services system makes it impossible to provide optimal and
seamless services when individuals age out of these
facilities, and that by letting individuals continue to be
served in PDHRCFs after the age of 21, this bill provides a
carefully tailored workaround to this problem. The California
Children's Hospital (CCH) states in support that as a result
of the advances made in medicine over the past 25 years, more
medically fragile children are living into adulthood and aging
out of PDHRCFs. CCH states that they enter a fragmented adult
system that does not have the same level of service as PDHRCFs
which can be disastrous for patients and families, financially
and emotionally.
7)Policy comment. As noted above, much of the language of this
bill is compensating for the fact that DPH has not adopted
regulations for PDHRCFs. When PDHRCFs were established in
AB 1147 (Maienschein) Page 11 of ?
1990, DPH was required to adopt regulations for these
facilities by 1993. Until these regulations were adopted, DPH
was directed to license these facilities using the same
standards as CLHFs, which is a type of inpatient facility.
According to DPH, it is in the process of hiring and
redirecting staff to address these and other longstanding
licensing and certification regulatory needs, but does not
have an estimated completion date at this time.
This is yet another example of the longstanding problem in DPH
of ignoring mandates to adopt regulations. In some instances,
the lack of the timely adoption of regulations by DPH has left
some facilities unregulated entirely. While this Committee has
approved a piecemeal approach to the problem of outdated or
nonexistent regulations, the longstanding reluctance of DPH to
utilize the standard rulemaking process is troubling. It is
encouraging that DPH is currently engaged in an effort to
update Title 22 regulations. DPH should also examine what the
barriers have been to using the Administrative Procedures Act
process in an effort to make that a more routine part of their
role as a regulator.
8)Suggested amendments.
a) On page 10, beginning on line 14, this bill requires
DPH to issue a provisional license to a PDHRCF if the
facility has not previously been licensed. There is no
reference to an initial inspection, and it is worded in
such a way that could be construed to limit the ability
of DPH to ensure that the facility meets minimal
standards prior to issuing the license. The author has
agreed to the following amendment to address this issue:
On p.10, between lines 17 and 18, the following subdivision
is added:
(b) A provisional license may not be issued unless the
facility has first been found to be in substantial
compliance with the requirements of this Chapter as a
result of an onsite survey.
b) On page 13, beginning on line 32, this bill requires
an optional service unit of a PDHRCF to be approved by
DPH, again without seeming to give any ability for DPH to
deny the optional service unit if it has not met DPH
standards. The author has agreed to the following
amendment to address this issue:
AB 1147 (Maienschein) Page 12 of ?
On page 13, line 32, subdivision (b) is amended as follows:
(b) An optional service unit shall be subject to the
approval of approved by the state department.
SUPPORT AND OPPOSITION :
Support: Together We Grow (sponsor)
American Federation State, County and Municipal
Employees
Association of Regional Center Agencies
California Children's Hospital Association
California Medical Association
Easter Seals
Exceptional Family Resource Center
Home Start, Inc.
Kaplan College, San Diego
Loretta's Little Miracles
San Diego Brain Injury Foundation
San Diego Regional Center
The Arc United Cerebral Palsy California Collaboration
Numerous individuals
Oppose: None received.
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