BILL ANALYSIS Ó
AB 1300
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Date of Hearing: April 21, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 1300
Ridley-Thomas - As Amended April 13, 2015
SUBJECT: Mental health: involuntary commitment.
SUMMARY: Makes numerous changes to the provisions regarding
evaluation procedures, terms and lengths of detention, and
criteria for release and transfer protocol related to the
involuntary detention of individuals. Specifically, this bill:
1)Requires the Department of Health Care Services (DHCS) to
create an application for detention for evaluation and
treatment to be used by peace officers and authorized
professionals prior to involuntarily detaining an individual
and by authorized professionals to release a person from
detention.
2)The application for detention for evaluation and treatment
shall be adopted no later than July 1, 2016, and in developing
the form, DHCS must request comments from the California
Mental Health Directors Association, the California Mental
Health Planning Council, and the Office of the Attorney
General.
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DEFINITIONS
3)Defines "assessment" as making the determination of whether a
person, as a result of a mental health disorder, is a danger
to others, or to himself or herself, or gravely disabled; and
if so, what services are needed for the person, and whether
the person can be properly served without being detained.
4)Specifies that an assessment includes, but is not limited to,
mental status determination, analysis of clinical and social
history, analysis of relevant cultural issues and history,
diagnosis, and the use of testing procedures.
5)Defines "authorized professional" as a mental health
professional that is authorized in writing by a county to
provide services related to the evaluation, treatment, or
transfer of an individual who is a danger to him or herself or
others or is gravely disabled.
6)Requires an authorized professional to have appropriate
training in mental health disorders and determination of
probable cause, and in providing services to persons with
mental health disorders.
7)Defines "Crisis stabilization service or unit" as an
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ambulatory service that provides probable cause determinations
and assessments, collateral services, and therapy.
8)Defines a "Designated facility" as a facility or a specific
unit or part of a facility that is licensed or certified as a
mental health evaluation facility, a mental health treatment
facility, or a mental health evaluation and treatment
facility.
9)Defines "Inpatient facility" as a health facility, or an
inpatient unit of a health facility, that is licensed by DHCS
and has the capability to admit and treat persons on an
inpatient basis and is designated by a county. A designated
inpatient facility includes any of the following:
a) A general acute care hospital,
b) An acute psychiatric hospital,
c) A psychiatric health facility, and,
d) A correctional treatment center.
10)Defines "Ambulatory facility" as a facility designated by a
county that provides psychiatric services lasting less than 24
hours in accordance with applicable law and within the scope
of the designation. An ambulatory facility may include an
outpatient hospital department, clinic, crisis stabilization
facility or unit, facility of a medical group, facility of a
provider organization other than a medical group, or other
facility that meets the requirements established by DHCS.
11)Defines "Emergency" as a sudden marked change in the person's
condition such that action to impose treatment over the
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person's objection is immediately necessary for the
preservation of life or the prevention of serious bodily harm
to the patient or others, and it is impracticable to first
gain consent.
12)Defines "Evaluation" as a multidisciplinary professional
analyses of a person's medical, psychological, educational,
social, financial, and legal conditions as may appear to
constitute a problem.
13)Requires persons providing evaluation services to be properly
qualified professionals and may be full-time employees,
part-time employees, or independent contractors of a county,
designated facility, or other agency providing face-to-face
evaluation services.
14)Defines "Mobile crisis team" as a team comprised of one or
more professionals, including peer counselors, who are
authorized by a county to provide probable cause
determinations and other services.
15)Defines "Probable cause determination" to mean a
determination of whether there is probable cause for the
detention of a person and requires that a probable cause
determination be based solely on the criteria for detaining a
person for evaluation and treatment when a person, as a result
of a mental health disorder, is a danger to others, or him or
herself, or gravely disabled.
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16)Prohibits a probable cause determination from considering the
availability of beds or services at designated facilities
within or outside of the county.
17)Specifies that telehealth services may be used by any
licensed professional, including a psychologist, clinical
social worker, and other mental health professional, for
providing evaluation, treatment, consultation, or other mental
health services.
18)Requires DHCS to provide oversight and promote the consistent
statewide application of these provisions to ensure protection
of the personal rights of all persons who are subject to
involuntary detention.
DESIGNATED FACILITIES
19)Requires DHCS to facilitate discussion among stakeholders
including law enforcement agencies, hospitals, mental health
professionals, county patients' rights advocates, the
California Office of Patients' Rights, and other stakeholders
as necessary.
20)Permits each county to designate inpatient and ambulatory
facilities within the county, as approved by DHCS that meet
the applicable requirements established by DHCS.
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21)Specifies that an outpatient or emergency department (ED) of
a nondesignated inpatient facility may be designated as an
ambulatory facility if it meets all the requirements for
certification as an ambulatory facility.
22)Permits each county to designate ambulatory facilities within
the county that meet the behavioral health needs of persons
and directs DHCS to encourage counties to use appropriate
ambulatory facilities for the evaluation and treatment of
persons.
23)Encourages counties, mental health professionals, providers,
and other organizations to establish crisis stabilization
services and other ambulatory facilities that are designated
by a county to provide probable cause determinations and
assessments, and, as applicable, evaluation and treatment
services and crisis stabilization services, in settings that
are appropriate to the needs of persons with severe mental
illness and less restrictive than inpatient health facilities.
24)Requires an ambulatory facility to provide appropriate
services to all persons regardless of their place of
residence.
25)Requires that regulations adopted establishing staffing
standards for designated facilities be consistent with
applicable licensing regulations for the type if facility.
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26)Specifies that in instances where there are no promulgated
licensing regulations, the regulations can vary as appropriate
for the different designated facilities.
27)Repeals and nullifies, on January 1, 2016, the existing
regulations that establish staffing standards for designated
facilities as set forth in Section 663 of Title 9 of the
California Code of Regulations.
28)Prohibits a county from charging or assessing a fee for the
designation of a facility or an authorized professional.
29)Requires a designated facility to accept all categories of
persons for whom it is designated, without regard to insurance
or financial status.
30)Requires counties to maintain an Internet Website that lists
the locations of all designated facilities within the county,
including address, the types of services available at each
designated facility, and the hours of operation for ambulatory
facilities.
31)Requires counties to report to DHCS, on at least an annual
basis, a current list of designated facilities within the
county, including the name and address of each facility and
its facility type.
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32)Requires DHCS to maintain a list of designated facilities, by
county and facility licensure type, on its Internet Website,
and update the list annually.
LOCAL OR REGIONAL LIAISONS
33)Permits counties to authorize one or more qualified persons
to act as a local or regional liaison to assist nondesignated
hospitals in the county.
34)Permits two or more counties to enter into an intercounty
arrangement under which the counties agree to authorize
individuals to act as a local or regional liaison to assist
nondesignated hospitals in the participating counties.
35)Permits a local or regional liaison to assist a person who
has been detained, or may require detention, with arranging
for a prompt probable cause determination, arranging for a
prompt evaluation, and arranging for the transfer or discharge
of a person who has been medically stabilized.
36)Permits a local or regional liaison to be employed by, or
contracted with, a county or counties and or employed by one
or more designated facilities within the county or counties.
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37)Requires a local or regional liaison to be available 24 hours
a day, including weekends and holidays, to provide assistance.
38)Requires counties to provide the nondesignated hospitals in
the county or counties with the contact information for a
local or regional liaison.
DETERMINATIONS FOR INVOLUNTARY DETENTION
39)Specifies that the period of 72-hour detention for evaluation
and treatment begins at the time that the person is initially
detained.
40)Requires that when an individual is detained and taken to a
designated facility for evaluation and treatment, the
individual shall be assessed to determine whether he or she
can be properly served without being detained.
41)Requires a person to be provided evaluation, crisis
intervention, or other inpatient or outpatient services on a
voluntary basis if it is determined that he or she can be
served without being detained.
42)Permits an assessment to be performed using telehealth for
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individuals detained for evaluation and treatment at a
designated ambulatory facility.
43)Specifies that if a detained individual is first taken to the
ED of a non-designated hospital, the person should be detained
only for the time necessary to ensure the patient is medically
stable.
44)Prohibits mental health personnel from instructing a peace
officer or authorized professional employee of an emergency
transport provider acting at the direction of a peace officer
seeking to transport a person to a designated facility for
assessment to take the person to a jail solely because of the
unavailability of an acute bed.
45)Prohibits a peace officer or other authorized professional
employee of an emergency transport provider from being
detained any longer than the time necessary to complete
documentation of the factual basis of the detention for
evaluation and safely complete the transfer of physical
custody of the person.
APPLICATION FOR DETENTION FOR EVALUATION AND TREATMENT
46)Requires a peace officer, or an authorized professional who
takes a person into custody, to complete and sign an
application for detention for evaluation and treatment,
stating the circumstances under which the person's condition
was called to the attention of the peace officer or authorized
professional, and stating that the peace officer or authorized
professional has probable cause to believe that the person is,
as a result of a mental health disorder, a danger to others,
or to himself or herself, or gravely disabled.
47)Requires the presentation of the application to a designated
facility or nondesignated hospital as a condition of
continuation of the detention for evaluation and treatment; if
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the application is not presented to the designated facility or
nondesignated hospital, as applicable, the person must be
immediately released from detention for evaluation and
treatment.
48)Requires that, in the case that a person detained by a peace
officer or authorized professional is in a location other than
a designated facility or nondesignated hospital, the original
or copy of the application for detention for evaluation and
treatment be presented to the designated facility where the
individual is transported.
49)Requires that the application for detention for evaluation
and treatment be retained for the period of time required by
the medical records retention policy of the designated
facility or nondesignated hospital.
EMERGENCY ROOM PROTOCALS
50)Defines "Emergency department of a nondesignated hospital" as
a basic, comprehensive, or standby emergency medical service
that is approved by DHCS as a special or supplemental service
of a nondesignated hospital.
51)Defines a "Nondesignated hospital" as a general acute care
hospital or an acute psychiatric hospital, as specified, that
is not a designated facility.
52)Defines "Psychiatric professional" as a physician and surgeon
who is board certified or pursuing board certification in
psychiatry and who is providing specialty services to the ED
of a nondesignated hospital.
53)Requires that, when a person has been detained in the ED of a
nondesignated hospital, the nondesignated hospital notify
appropriate county officials of the person's detention after
the hospital an initial medical screening of the person and a
probable cause determination has been completed. Requires the
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notification to include:
a) The time when the 72-hour detention period for
evaluation and treatment expires;
b) An estimate of the time when the person will be
medically stable for transfer to a designated facility;
and,
c) The county in which the person resides, if known.
RELEASE FROM DETENTION
54)Allows a treating emergency professional to initiate a
follow-up probable cause determination if the emergency
professional determines that there is no longer probable cause
to continue the detention for evaluation and treatment.
55)Requires that the determination to release a person from
detention for evaluation and treatment be based solely on
whether there is probable cause to continue the detention for
evaluation and treatment.
56)Prohibits the determination to continue the detention or to
release the person from detention from being based on the
availability of beds or services at designated facilities
within or outside of the county, or on anything other than
whether there is probable cause for detention.
57)Requires each county to establish disposition procedures and
guidelines with local law enforcement agencies for the safe
and orderly transfer of persons detained for evaluation and
treatment by a peace officer.
58)Requires disposition procedures and guidelines to include
persons who are not admitted for evaluation and treatment and
who decline alternative mental health services and persons who
have a criminal detention pending.
59)Requires the disposition procedures and guidelines to include
interagency communication between law enforcement agencies
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located within the county, as well as law enforcement agencies
located in other counties.
60)Requires the disposition procedures and guidelines, to be
disseminated to designated facilities and nondesignated
hospitals.
ACUTE CARE REQUIREMENTS
61)Requires the following in instances where a person detained
for evaluation is admitted to a facility for the primary
purpose of receiving acute inpatient services for a medical
condition that is in addition to a person's psychiatric
condition:
a) If the hospital offers to provide assessment,
evaluation, and crisis intervention services and the person
consents to the services on a voluntary basis in addition
to acute medical services, the person shall be released
from detention;
b) If the hospital offers to provide assessment,
evaluation, and crisis intervention services and the person
refuses or is unable to consent to the services on a
voluntary basis in addition to acute medical services, the
individual remain detained;
c) If the hospital does not have the capability to provide
assessment, evaluation, and crisis intervention services,
the person must be released from detention; and,
d) If the person is not able or willing to accept treatment
on a voluntary basis, or to accept the referral or transfer
to a psychiatric facility, the hospital shall obtain a new
probable cause determination for detention for evaluation
and treatment.
TRANSFER FROM UNDESIGNATED FACILITIES TO DESGINATED FACILITIES
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62)Requires designated ambulatory facilities to confirm whether
the facility can meet the needs of the person before a person
is placed there.
63)Requires, if an individual has a psychiatric emergency
medical condition, that they be placed in any designated
facility that has the capability and capacity to provide
evaluation and treatment for the person, whether or not that
designated facility is located within the same county.
64)Requires the treating emergency professional to determine the
mode of transportation, including personnel and equipment that
are appropriate for the transport of the person to the
designated facility.
65)Requires that the placement of a person described in this
subdivision take precedence over provider networks.
66)Requires, in instances where a person detained for evaluation
and treatment is in the ED of a nondesignated hospital, or in
a bed not licensed for psychiatric care, that the
nondesignated hospital make good faith efforts to arrange
placement for the person in a designated facility and, pending
placement, shall provide further screening, treatment, and
monitoring consistent with the needs of the patient.
67)Permits, in instances where a person is detained for
evaluation and treatment by a peace officer or a treating
emergency professional in the ED of the nondesignated
hospital, the nondesignated hospital to contact the local or
regional liaison to assist the hospital in arranging for the
placement of the person in a designated facility.
68)Requires the hospital to inform the county or the local or
regional liaison if the person has a psychiatric emergency
medical condition that requires a transport of the person in
accordance with federal Emergency Medical Treatment & Labor
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Act (EMTALA) obligations for making an appropriate transfer.
69)Requires a nondesignated hospital to make efforts to obtain
placement of the person in a designated facility before
contacting the county or the local or regional liaison.
PROBABLE CAUSE DETERMINATIONS
70)Requires the determination of probable cause to detain a
person for evaluation and treatment to be independent of a
determination as to whether the person has a psychiatric
emergency medical condition requiring emergency services and
care.
71)Prohibits a determination of probable cause to detain a
person for evaluation and treatment by a peace officer or an
authorized professional from being deemed a psychiatric
emergency medical condition unless a health care professional
has determined that the person has a psychiatric emergency
medical condition.
72)Prohibits a determination by a treating emergency
professional or a psychiatric professional that an individual
with a psychiatric emergency medical condition from being the
only reason to establish probable cause and therefore consider
an individual eligible to be detained for evaluation and
treatment.
73)Prohibits a determination by a treating emergency
professional or a psychiatric professional that a person
detained for evaluation and treatment that an individual does
not have a psychiatric emergency medical condition, or that
the person's psychiatric emergency medical condition is
stabilized, from being the only reason a person is eligible
for release from detention for evaluation and treatment.
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RELEASE FROM LIABILITY
74)Absolves a designated facility or nondesignated hospital or a
physician, employee, or other staff person from civil or
criminal liability for any injury resulting from evaluation or
providing services with care, as specified.
75)Absolves a nondesignated hospital and the professional staff
of the nondesignated hospital from civil or criminal liability
for the transfer of a person detained for evaluation and
treatment to a designated facility.
76)Absolves an emergency transport provider from civil or
criminal liability for the continuation of the detention for
evaluation and treatment while transporting the person to a
designated facility at the direction of a peace officer who
detained the person for evaluation and treatment, as
specified.
77)Absolves a peace officer or authorized professional
responsible for the detention of the person who transfers the
custody of the person from civil or criminal liability for the
continuation of detention during the person's stay in the ED
prior to the discharge of the person from the hospital or the
release of the person from detention.
78)Absolves the professional person in charge of the facility
providing intensive treatment, the medical director of the
facility, the psychiatrist directly responsible for the
person's treatment, or the psychologist from civil or criminal
liability for any action by a person prematurely released from
detention.
79)Absolves the attorney or advocate representing the person,
the court-appointed commissioner or referee, the certification
review hearing officer conducting the certification review
hearing, and the peace officer responsible for detaining the
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person from civil or criminal liability for any action by a
person released at or before the end of 30 days pursuant to
this article.
VOLUNTARY PATIENTS
80)Authorizes a provider of ambulance services licensed by the
Department of the California Highway Patrol or operated by a
public safety agency, to transport a person who is in a
hospital or facility on a voluntary basis to a designated
facility for psychiatric treatment.
81)Prohibits a person from being detained for evaluation and
treatment solely for the purpose of transporting the person,
or transferring the person by a provider of ambulance
services, to a designated facility or an ED of a nondesignated
hospital.
82)Requires, not later than July 1, 2016, DHCS to adopt and make
available a standardized form that will enable voluntary
patients to consent to transfer between facilities by a
provider of ambulance services that must be provided to
voluntary patients to sign before the transfer of the patient
and must be kept in the patient's chart.
83)Prohibits an individual from being subject to detention for
the purpose of authorizing or providing evaluation, treatment,
or admission to a facility, or as a condition for providing or
paying for medical services, care, or treatment, unless there
is probable cause to detain the person for evaluation and
treatment and the person cannot be properly served on a
voluntary basis.
ADMISSION TO A DESIGNATED FACILITY
84)Prohibits a designated facility that admits an individual
from detaining that individual for more than 72 hours from the
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time that the person was initially detained.
85)Requires the professional person in charge of the facility to
conduct an assessment of the individual to determine the
appropriateness of the involuntary detention prior to
admitting that individual to the facility for evaluation and
treatment.
86)Requires the designated facility to provide the individual
with appropriate referrals and a list of alternative services
and other resources that are appropriate to their needs if the
assessment results in a determination that the person is in
need of mental health services, but he or she is not admitted
to the facility.
87)Requires a designated facility or nondesignated hospital to
notify the county mental health director and the law
enforcement agency that employs the peace officer who makes
the application for detention for 72-hour evaluation and
treatment, if any of the following occur:
a) The person admitted will be discharged after a 72-hour
inpatient admission;
b) When the person is not admitted by the designated
facility;
c) When the person is discharged before the expiration of
the 72-hour inpatient admission;
d) When the person discharged from detention for evaluation
and treatment is released; or,
e) If the person elopes from a designated facility or
nondesignated hospital,
88)Requires each law enforcement agency to arrange with the
county mental health director for a method for notification of
designated facilities and nondesignated hospitals.
89)Requires that, when possible, officers charged with
apprehension of persons to dress in plain clothes and travel
in unmarked vehicles.
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EXISTING LAW:
1)Declares the intent of the Legislature to end the
inappropriate, indefinite, and involuntary commitment of
persons with mental health disorders, developmental
disabilities, and chronic alcoholism, and to eliminate legal
disabilities.
2)Defines "Referral" as referral of persons by each agency or
facility providing assessment, evaluation, crisis
intervention, or treatment services to other agencies or
individuals.
3)Specifies that the purpose of referral is to provide for
continuity of care, and includes informing the person of
available services, making appointments on the person's
behalf, discussing the person's problem with the agency or
individual to which the person has been referred, appraising
the outcome of referrals, and arranging for personal escort
and transportation when necessary.
4)Requires a referral to be considered complete when the agency
or individual to whom the person has been referred accepts
responsibility for providing the necessary services.
5)Defines "Crisis intervention" as an interview or series of
interviews within a brief period of time, conducted by
qualified professionals, and designed to alleviate personal or
family situations which present a serious and imminent threat
to the health or stability of the person or the family.
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6)Defines "gravely disabled" as either of the following:
a) A condition in which a person, as a result of a mental
health disorder, is unable to provide for his or her basic
personal needs for food, clothing, or shelter.
b) A condition in which a person, has been found mentally
incompetent and all of the following facts exist:
i) The indictment or information pending against the
person at the time of commitment charges a felony
involving death, great bodily harm, or a serious threat
to the physical well-being of another person.
ii) The indictment or information has not been
dismissed.
iii) As a result of a mental health disorder, the
person is unable to understand the nature and purpose
of the proceedings taken against him or her and to
assist counsel in the conduct of his or her defense in
a rational manner.
7)Defines "Emergency" to mean a situation in which action to
impose treatment over the person's objection is immediately
necessary for the preservation of life or the prevention of
serious bodily harm to the patient or others, and it is
impracticable to first gain consent.
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8)Defines "Designated facility" or "facility designated by the
county for evaluation and treatment" means a facility that is
licensed or certified as a mental health treatment facility or
a hospital, as defined by Department of Public Health (DPH)
regulations, and may include, but is not limited to, a
licensed psychiatric hospital, a licensed psychiatric health
facility, and a certified crisis stabilization unit.
9)Provides for the involuntary commitment and treatment of
individuals with specified mental disorders and for the
protection of committed individuals, with the declared goal of
ending inappropriate, indefinite, and involuntary commitment
of mentally disordered persons, developmentally disabled
persons, and persons impaired by chronic alcoholism.
10)Creates a series of processes for individuals to receive
mental health treatment, including:
a) A process for a person to be taken into custody, upon
probable cause that they are a danger to self, a danger to
others, or gravely disabled as a result of a mental health
disorder, for a period of up to 72 hours, as specified;
b) For a person who has been detained for 72 hours, a
process for the person to be detained for up to 14 days of
intensive treatment if the person continues to pose a
danger to self or others, or to be gravely disabled, and
the person has been unwilling or unable to accept voluntary
treatment;
c) For a person who has been detained for 14 days of
intensive treatment, a process for the person to be
detained for up to 30 days of intensive treatment if the
person remains gravely disabled and is unwilling or unable
to accept treatment voluntarily, or up to 180 days if the
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person presents a demonstrated danger to others;
d) A process for the appointment of a conservator, known as
LPS conservatorship, for a person who is gravely disabled
as a result of a mental disorder or impairment by chronic
alcoholism, to provide individualized treatment,
supervision, and placement.
e) Allows the professional person in charge of a facility
providing 72-hour, 14-day, or 30-day treatment to recommend
conservatorship to the conservatorship investigator for a
person who is gravely disabled and is unwilling or unable
to accept voluntary treatment; and,
f) Provides that a person cannot be appointed a
Lanterman-Petris-Short Act (LPS Act) conservator if the
person can survive safely with the help of responsible
family, friends, or others who indicate in writing that
they are willing and able to help provide food, clothing,
or shelter; and,
11)Requires that when determining if probable cause exists to
take a person into custody, consideration must be made of
available relevant information about the historical course of
the person's mental disorder if the authorized person
determines that the information has a reasonable bearing on
the determination as to whether the person is a danger to
others, or to himself or herself, or is gravely disabled as a
result of the mental disorder.
12)Prohibits a peace officer from taking a person to, or keeping
the person at, a jail solely because of the unavailability of
an acute bed, and specifies that no peace officer be forbidden
by a mental health employee from transporting a person
directly to a designated facility.
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FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, the
Lanterman-Petris-Short Act (LPS Act) governs the involuntary
detention of individuals for psychiatric treatment in
California. In the 48 years since its passage, there have
been significant changes in the mental health delivery system,
adversely impacting a patient's ability to obtain prompt
evaluation and treatment as required by current law. In
addition, the fragmented and inconsistent application of the
LPS Act by California's 58 counties has led to an increasing
and often inappropriate dependence on hospital EDs to care for
this population, without the necessary resources. The author
states that this has resulted in individuals with mental
illness languishing for hours, days, and sometimes weeks,
awaiting psychiatric assessment and treatment.
The author states that no one should face involuntary detention
for up to 72 hours without a timely assessment and evaluation
of whether he or she meets the criteria for a behavioral
health hold. The author concludes that this bill will ensure
the safety of the public-at-large and hospital personnel by
removing obstacles to the delivery of critical mental health
services to those who need them, while also protecting the
interests of individuals and their families.
2)BACKGROUND. The LPS Act, enacted in the 1960s, was intended
to balance the goals of maintaining the constitutional right
to personal liberty and choice in mental health treatment,
with the goal of safety when an individual may be a danger to
oneself or others or is gravely disabled. At the time of its
enactment, the LPS Act was considered progressive because it
afforded the mentally disordered more legal rights than most
other states. Since its passage in 1967, the law in the field
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of mental health has continued to evolve toward greater legal
rights for mentally disordered persons. Welfare and
Institutions Code (WIC) Section 5150 of the LPS Act allows
peace officers, staff-members of county-designated evaluation
facilities, or other county-designated professional persons,
to take an individual into custody and place him in a facility
for 72-hour treatment and evaluation if they believe that, due
to a mental disorder, the individual is a danger to himself,
herself, or others, or is gravely disabled-i.e., unable to
provide for basic personal needs for food, clothing, or
shelter due to a mental disability.
a) Designated vs. Non Designated Facilities. Individual
counties are responsible for determining whether general
acute care hospitals, psychiatric health facilities, acute
psychiatric hospitals and other licensed facilities qualify
to be designated facilities. DHCS is responsible for the
approval of designated facilities as determined by the
counties. According to the California Hospital
Association, 25 of 58 counties have no inpatient
psychiatric services or beds available to serve their
populations. While peace officers and other authorized
individuals are required to take an individual first to a
designated facility, if one does not exist individuals are
transported to a non-designated facility, which is also any
facility participating in Medicare that is therefore
required by federal EMTALA laws to provide medical services
to any individual who shows up requiring medical attention.
b) EMTALA. Sometimes referred to as the "Patient
Anti-Dumping Law," EMTALA was passed to address the problem
of hospitals refusing to treat indigent, uninsured, or
Medicaid patients, or "dumping" these patients by
transferring them to county hospitals or other charity
hospitals. According to the federal Centers for Medicare
and Medicaid Services, in 1986, Congress enacted EMTALA to
ensure public access to emergency services regardless of
ability to pay. Section 1867 of the Social Security Act
imposes specific obligations on Medicare-participating
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hospitals that offer emergency services to provide a
medical screening examination when a request is made for
examination or treatment for an emergency medical
condition, including active labor, regardless of an
individual's ability to pay. Hospitals are then required
to provide stabilizing treatment for patients with an
emergency medical condition. If a hospital is unable to
stabilize a patient within its capability, or if the
patient requests, an appropriate transfer should be
implemented. As an enforcement mechanism, EMTALA also
established a private right of action.
3)COMMUNITY-BASED TREATMENT OPTIONS.
a) Crisis Residential Programs. According to a 2010 report
by the California Mental Health Planning Council, crisis
residential programs are a lower-cost, community-based
treatment option in home-like settings that help reduce ED
visits and divert hospitalization and incarcerations.
According to the report, these programs include peer-run
programs such as crisis respites that offer safer,
trauma-informed alternatives to psychiatric emergency units
or other locked facilities. The report indicates that
crisis residential programs reduce unnecessary stays in
psychiatric hospitals, reduce the number and expense of
emergency room visits, and divert inappropriate
incarcerations while producing the same or superior
outcomes to those of institutionalized care. The report
states that, as the costs for inpatient treatment continue
to rise, the need to expand an appropriate array of acute
treatment settings becomes more urgent, and state and
county mental health systems should encourage and support
alternatives to costly institutionalization and improve the
continuum of care to better serve individuals experiencing
an acute psychiatric episode.
b) Mobile Crisis Support Teams. Mobile crisis support
teams can be utilized to provide crisis intervention,
family support, and WIC Section 5150 evaluations. These
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teams meet law enforcement in the field and, among other
things, provide diversion into appropriate treatment
arrangements. These teams have been used in several areas
across the state (for example, Sonoma County's Mobile
Support Team and the City of Berkeley's Mobile Crisis
Team). A mobile crisis team typically consists of an
interdisciplinary team of mental health professionals
(e.g., nurses, social workers, psychiatrists,
psychologists, mental health technicians, addiction
specialists, or peer counselors) that respond to
individuals in the community through home visits or
responses to incidents at other locations.
c) Crisis Stabilization. Crisis stabilization services are
those lasting less than 24 hours for individuals who are in
psychiatric crisis whose needs cannot be accommodated
safely in a residential service setting. Crisis
stabilization must be provided onsite at a 24-hour health
facility or hospital-based outpatient program or at other
certified provider sites. The goal of the crisis
stabilization is to stabilize the consumer and re-integrate
him or her back into the community quickly. According to
various reports, costs for providing care in a crisis
stabilization unit are significantly lower than inpatient
hospitalization. Section 5150 of the LPS Act allows peace
officers, staff-members of county-designated evaluation
facilities, or other county-designated professional
persons, to take an individual into custody and place him
or her in a facility for 72-hour treatment and evaluate
them to determine if, due to a mental disorder, the
individual is a danger to himself, herself, or others, or
is gravely disabled-i.e., unable to provide for basic
personal needs for food, clothing, or shelter due to a
mental disability. The LPS Act, enacted in the 1960s, was
intended to balance the goals of maintaining the
constitutional right to personal liberty and choice in
mental health treatment, with the goal of safety when an
individual may be a danger to oneself or others or is
gravely disabled. At the time of its enactment, the LPS
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Act was considered progressive because it afforded the
mentally disordered more legal rights than most other
states. Since its passage in 1967, the law in the field of
mental health has continued to evolve toward greater legal
rights for mentally disordered persons.
4)SUPPORT. The California Hospital Association (CHA), writes in
support of the bill that this bill would modernize the
involuntary hold law, most commonly known as a "5150" to more
closely conform to the evolving community health care delivery
system, while ensuring consistent civil liberty protections
for all individuals subject to detention as a result of an
involuntary psychiatric hold.
CHA states that this bill would clarify and better define the
various steps of the 5150 detention process to ensure
consistent statewide application across California's 58
counties, so that patients receive the most appropriate care
in the least restrictive environment appropriate to their
needs.
CHA indicates that this bill would strengthen existing law and
accomplish the following:
a) Clearly articulate when a 5150 hold begins, ends, or is
discontinued, and who may perform these decision-making
functions;
b) Specify that the 72-hour hold period begins at the time
a person is initially detained;
c) Give California counties the authority to designate
ambulatory crisis facilities, not just hospitals, to assess
the mental health needs of individuals;
d) Support health care access for rural communities and
workforce shortage areas by allowing 5150 assessments to be
conducted remotely, through a telehealth system;
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e) Give clear authority to an emergency room physician to
expedite the determination of whether a person in custody
requires a 72-hour hold;
f) Increase emphasis on the prompt provision of county
behavioral health services in both LPS-designated and
non-LPS-designated facilities; and,
g) Create optional county mental health 'local or regional
liaisons" to facilitate increased communication between
hospitals, their EDs and the county mental health plans
responsible for referral and care coordination.
Cosponsors of the bill, the California Chapter of the
American College of Emergency Physicians, and the
Association of California Healthcare Districts state in
support of the bill that district hospitals see the results
of the variance in application of the LPS Act across the
state - which results in individuals with mental illness
languishing for hours, days and weeks awaiting psychiatric
assessment and treatment in their hospitals. Supporters
note that this measure increases the emphasis on the prompt
provision of services in both LPS-designated and non-LPS
designated facilities. This bill also incorporates the use
of telehealth for involuntary treatment, assessment and
evaluation purposes.
The California Medical Association adds in support that the
current system is failing psychiatric patients by forcing
them through a fragmented medical delivery system that is
inefficient and wastes valuable ED resources. No one
benefits when a patient waits for days in an ED waiting for
treatment. This bill will remedy this situation, resulting
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in benefits to patients in need of psychiatric treatment
and to our state's EDs.
5)CONCERNS. The County Behavioral Health Directors Association
of California (CBHDA), writes with concerns on the bill,
stating that they worked collaboratively with Senate Pro Tem
Darrell Steinberg and Disability Rights of California to pass
SB 364 (Steinberg), Chapter 567, Statues of 2014, which made
several fundamental and needed changes to the LPS Act
provisions regarding involuntary commitment. These changes
focused on ensuring clarity and consistency in the 5150
process to enable people with mental health disorder needs to
obtain assessment, referral and treatment as appropriate in
the least restrictive setting as possible. SB 364 broadened
the types of facilities a county can designate for 5150
purposes and encourages counties to provide training of
personnel as specified. Further, it restructured and recast
several provisions of the 5150 process to more clearly
articulate the sequencing of events. The language of LPS was
updated to reflect current terminology. CBHDA offers the
following examples: the term "mental health disorders" was
substituted for "severe mental illness" and the use of "people
first" language is used. A reference to the Children's Civil
Commitment and Mental Health Treatment Act of 1988 (Part 1.5)
was added since people detained under Section 5150 should also
generally apply to children detained under Part 1.5. Section
5008 of SB 364 updated the definitions for "evaluation",
"referral", and "Crisis intervention". For the definition of
evaluation, clarification was added to enable the use of both
in person (face to face) as well as telehealth evaluation
services. The "referral" definition was changed to clarify
that the person's problem would be discussed with the agency
(which covers the use of the terms facility, provider or other
organization) as well as the individual. The "Crisis
intervention" definition was updated to include interviews
with family members, significant support persons, providers,
or others as noted as appropriate and as authorized by law.
According to CBHDA, SB 364 improved the 5150 process from all
perspectives, including the client's, designated facilities,
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and county mental health departments. CBHDA does not believe
that additional changes are needed to the LPS Act. CBHDA does
not support specifying the roles and functions of health care
professionals, facilities, and emergency medical
transportation resources in WIC)/LPS. CBHDA states that
instead, they recommend that these health care roles and
functions be specified in Health and Safety Code, with
appropriate cross-references to WIC/ LPS provisions, when
necessary. This assures that the health professional,
facility, and emergency transportation requirements are
aligned with other health and safety requirements governing
emergency treatment and transportation.
CBHDA notes that a number of provisions in this bill must be
examined with Proposition 1A in mind, since they place new
mandates on counties. These include, for example, new
language and a new definition of "prompt" regarding counties'
responsibilities, as well as the addition of "local or
regional liaisons," new county personnel defined and required
to perform certain activities. Regarding the addition of
language requiring a "prompt" response from counties, it is
important to acknowledge that counties are committed to
providing prompt services. CBHDA concludes that the limited
availability of inpatient psychiatric beds is often a
significant factor in determining how quickly an individual
can be safely transferred out of a hospital ED.
6)OPPOSE UNLESS AMENDED. The California Professional
Firefighters (CPF) state in opposition to the bill, unless it
is amended, that this bill would require emergency ambulance
service providers, including fire departments, and
pre-hospital emergency medical care personnel, including
firefighter-emergency medical technicians (EMTs) and
paramedics, to transport involuntarily-detained individuals to
designated and non-designated facilities at the direction of
law enforcement. CPF further states that by empowering
individual peace officers in this regard, particularly if an
officer is untrained or unfamiliar with a jurisdiction's local
emergency medical services (EMS) agency policies and
procedures, CPF is concerned that patient care could be
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negatively impacted and the availability of emergency medical
service resources could be strained throughout the system.
CPF further states that for example, in certain instances, a
pre-hospital medical care provider, upon further examination
of a patient, may disagree with a police officer's initial
assessment. Subsequently, law enforcement's request to
transport is denied because it is determined by EMS personnel
that an individual is not facing a life-threatening emergency.
CPF concludes that this bill, as introduced, would not only
eliminate a pre-hospital medical care provider's critical
expertise and oversight in this regard, but conversely, this
bill would result in putting an unnecessary strain on limited
resources - both at a facility and by reducing the number of
qualified EMS personnel available to respond to an emergency
should one occur while transporting and individual per law
enforcement's direction.
The California Nurses Association (CNA) also states in
opposition that this bill repeals staffing ratios and/or
standards for inpatient facilities operated by the Department
of Mental Health (DMH) found in 9 California Code of
Regulations (CCR) §663. CNA sponsored legislation in 1999
that established nurse-to-patient ratios in general acute care
hospitals. Regulations that were supposed to have been
adopted by DPH for Acute Psychiatric Hospitals and Special
Hospitals were never promulgated despite direction from the
legislature to do so. However, inpatient facilities under DMH
were specifically excluded from the requirements of the
staffing legislation in part because there were staffing
standards in existence at the time. General acute care
hospitals with psychiatric units have nurse to patient ratios
of 1:6 or fewer at all times. CNA notes that the DMH
standards provide for leaner staffing requirements than for
general acute care hospitals for the same patient population,
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but this bill would repeal even those minimum standards
without guaranteed standards that exceed those currently in
place for inpatients in these settings. Furthermore, repeal
of these minimum standards are inconsistent with the subject
of this legislation and the stated goals of providing more
protection for mentally ill persons.
CNA further states that even if this bill were to be amended
to specifically provide for better staffing in inpatient
facilities licensed under DMH, the current standards should
not be repealed. Instead, they should be amended to provide
for stronger staffing standards. CNA concludes that this
could be addressed specifically in this legislation by
establishing minimum nurse-to-patient ratios as defined in 22
CCR § 70217 for inpatients in mental health facilities and
while we would support such enhancements in staffing, the
enhancement of staffing in inpatient mental health facilities
is no more the stated goals of this legislation that the
repeal of existing staffing standards.
The Emergency Medical Services Administrators Association of
California (EMSAAC) also opposes the bill unless it is amended
to maintain the current statutory authority for the medical
director of the local EMS agency to exercise and provide
medical control over all aspects of the EMS system. EMSAAC
notes that local EMS agencies and their physician medical
directors are responsible for planning, implementing and
evaluating the effectiveness of EMS systems. Local EMS
agencies and their physician medical directors work tirelessly
to balance competing interests and resources to design and
redesign EMS systems that best meet the needs of seriously ill
and injured trauma patients. EMSAAC is concerned that
empowering individual peace officers, who may be untrained and
unfamiliar with local EMS agency policies and procedures, to
dictate the use and transport destinations of emergency
ambulances will negatively impact patient care and the
availability of EMS resources throughout the system.
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7)RELATED LEGISLATION. AB 1194 (Eggman), requires that, for
purposes of determining whether a person is a danger to
themselves or others, danger be defined as constituting a
present risk of harm that requires consideration of the
historical course of a person's mental health disorder. This
bill is pending in the Assembly Appropriations Committee.
8)PREVIOUS LEGISLATION.
a) SB 364 revised the law related to 72-hour treatment and
evaluation for individuals with a mental health disorder
(referred to as 5150 in reference to WIC Section 5150) by
adding to the types of facilities that a county is allowed
to designate to provide services and allowing county mental
health directors to develop procedures for the designation
and training of professionals who can perform 5150
functions.
b) AB 110 (Blumenfield), Chapter 20, Statutes of 2013,
enacts the 2013-14 Budget Act, which includes, among its
other provisions, $206 million ($142 million General Fund
one-time) for a major investment in mental health services,
including additional residential treatment capacity, crisis
treatment teams, and triage personnel.
c) SB 585 (Steinberg), Chapter 288, Statutes of 2013,
clarifies that Mental Health Services Act funds and various
County Realignment accounts may be used to provide mental
health services under the Assisted Outpatient Treatment
Demonstration Project Act of 2002, or Laura's Law, and
allows counties to opt to implement Laura's Law through the
county budget process.
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d) SB 1381 (Pavley), Chapter 457, Statutes of 2012, deletes
in state law references to "mental retardation" or a
"mentally retarded person" and instead replaces them with
"intellectual disability" or "a person with an intellectual
disability."
e) SB 665 (Petris), Chapter 681, Statutes of 1991,
establishes the right, under the LPS Act, to refuse
antipsychotic medication and establishes hearing procedures
to determine a person's capacity to refuse treatment with
antipsychotic medication.
f) AB 2541 (Bronzan and Mojonnier), Chapter 1286, Statutes
of 1985, authorizes county mental health programs to
initiate services to various target populations, requires
various studies and planning activities, and prohibits
mental health personnel from instructing law enforcement
personnel to take individuals detained for mental health
evaluations to jail solely due to the unavailability of a
mental health facility bed.
g) AB 1424 (Thomson), Chapter 506, Statutes of 2001, makes
various changes to the LPS Act to: increase the
involvement of family members in commitment hearings for
the mentally ill; require more use of a patient's medical
and psychiatric records in these hearings; and prohibit
health plans and insurers from using the commitment status
of a mentally ill person to determine eligibility for claim
reimbursement.
h) SB 677 (Lanterman, Petris, and Short), Chapter 1667,
Statutes of 1967, enacts the LPS Act, which governs
involuntary civil commitment for individuals with mental
illness, with the intent to end inappropriate, indefinite,
and involuntary commitment and provide for prompt
evaluation and treatment.
9)DOUBLE REFERRAL. This bill is double referred, upon passage
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of this Committee, it will be referred to the Assembly
Committee on Judiciary.
10)POLICY COMMENTS.
a) Too soon? This bill makes significant changes to how
individuals eligible for involuntary detainment are
transported, admitted, assessed, evaluated, and treated.
The last significant statutory changes to the same
provisions were made by SB 364 which also sought to improve
the process for involuntary detainment. Changes included:
i) Allowing a county mental health director to develop
procedures for the designation and training of
professionals who are authorized to detain individuals,
including including license types, practice disciplines,
clinical experience, training and testing requirements,
application and approval processes, and monitoring and
reviewing processes.
ii) Significantly broadening what kind of facilities can
be designated facilities, including licensed psychiatric
hospitals, licensed psychiatric health facilities, and
certified crisis stabilization units.
iii) Allowing individuals to be provided evaluation,
crisis intervention, or other inpatient or outpatient
services on a voluntary basis if appropriate.
iv) Specifying what information must be given to
individuals upon 72-hour admission including notification
that a person may request a facility or treating
professional of his/her choice; a person can contact the
county's Patients' Rights Advocate if they have questions
about their legal rights; and a statement if weekends and
holidays will be excluded from the 72-hour period.
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Making such significant changes to how involuntary
detentions are administered just two years after a previous
wave of modifications could prove difficult for counties,
emergency personnel, peace officers, and various treatment
facilities to implement.
b) When should the 72-hour clock start? This bill indicates
that that the period of 72-hour detention for evaluation
and treatment shall begin at the time that the person is
initially detained. This leaves room for varying
interpretations of when the 72-hour period for detention
begins. Does it begin when the individual is in the
custody of a peace officer or other authorized individual,
or does it begin upon clinical assessment at a treatment
facility? Various statements of intent indicate a desire
to ensure the most appropriate care for individuals, while
protecting their civil liberties, but it is unclear how to
maintain civil liberty protections and provide as much
treatment as possible. If the clock begins when an
individual is in custody of a peace officer, unforeseen
events could take up valuable hours within the 72 hour time
frame, time that may be better spent in clinical assessment
receiving treatment. However, if the clock begins with
clinical assessment, the individual would spend a full
72-hours being assessed and evaluated and receiving
appropriate treatment and care. The author should consider
an amendment to the bill clarifying when treatment begins
in order to ensure more uniform application of these
provisions across counties.
11)COMMITTEE AMENDMENTS.
a) Transportation Clarification. This bill would require
emergency ambulance service providers, including
firefighter-EMTs and paramedics, to transport
involuntarily-detained individuals to designated and
non-designated facilities at the direction of law
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enforcement officials. Current law gives this discretion
to the medical director of the local EMS agency. For this
reason, the Committee suggests amending the bill to clarify
that discretion of the medical director of the local EMS
agency shall remain the same.
b) Regulation Clarification. This bill requires that
regulations be established for designated facilities that
are consistent with applicable licensing regulations for
the type if facility and, in instances where there are no
regulations established, permits regulations to vary
according to various facility licensing requirements. The
bill also repeals, on January 1, 2016, existing regulations
that establish minimum staffing standards for inpatient
services, which require a 5:100 physician-to-patient ratio,
a 2:100 psychologist-to-patient ratio, a 2:100 social
worker-to-patient ratio, and 1:5 nurse-to-patient ratio.
Given the lengthy process of having regulations
promulgated, and without any stated reason to repeal them,
the committee recommends amending the bill to strike the
repeal of these regulations.
c) Technical amendments. The Committee recommends the
following technical amendments:
i) On page 37, line 4, striking "patient chart" and
inserting "patient's medical record".
ii) On page 39, line 3, after "person" insert "is".
REGISTERED SUPPORT / OPPOSITION:
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Support
California Chapter of the American College of Emergency
Physicians (cosponsor)
California Hospital Association (cosponsor)
Association of California Healthcare Districts
California Medical Association
The Arc and United Cerebral Palsy California Collaboration
Oppose Unless Amended
California Nurses Association
California Professional Firefighters
Emergency Medical Services Administrators Association of
California
Concerns
California Behavioral Health Directors Association
Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097
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