BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 1147|
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THIRD READING
Bill No: AB 1147
Author: Maienschein (R)
Amended: 7/7/15 in Senate
Vote: 27 - Urgency
SENATE HEALTH COMMITTEE: 8-0, 7/1/15
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,
Pan, Roth
NO VOTE RECORDED: Wolk
SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8
ASSEMBLY FLOOR: 78-0, 5/14/15 - See last page for vote
SUBJECT: Health facilities: pediatric day health and respite
care facilities
SOURCE: Together We Grow
DIGEST: This bill 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.
ANALYSIS:
Existing law:
1)Defines "pediatric day health and respite care facility"
(PDHRCF) as a facility that provides an organized program of
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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
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.
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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 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
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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 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;
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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
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 if,
after an initial onsite inspection, it finds that the
facility is in substantial compliance with requirements for
licensure. Requires the provisional license 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
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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 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
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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 that wants approval for an optional
service unit to file an application for approval with DPH.
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 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.
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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.
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
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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
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.
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4)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
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 the Senate Health
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.
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 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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
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SUPPORT: (Verified7/9/15)
Together We Grow (source)
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
OPPOSITION: (Verified7/9/15)
None received
ARGUMENTS IN 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
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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.
ASSEMBLY FLOOR: 78-0, 5/14/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,
Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,
Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle,
Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina
Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez,
Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden,
Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Lopez, Low,
Maienschein, Mathis, Mayes, McCarty, Melendez, Mullin,
Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea,
Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago,
Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,
Wilk, Williams, Wood, Atkins
NO VOTE RECORDED: Linder, Medina
Prepared by:Vince Marchand / HEALTH /
7/13/15 10:16:47
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