BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 2079|
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THIRD READING
Bill No: AB 2079
Author: Calderon (D)
Amended: 8/15/16 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 6-2, 6/22/16
AYES: Hernandez, Hall, Mitchell, Monning, Pan, Wolk
NOES: Nguyen, Nielsen
NO VOTE RECORDED: Roth
SENATE APPROPRIATIONS COMMITTEE: 5-2, 8/11/16
AYES: Lara, Beall, Hill, McGuire, Mendoza
NOES: Bates, Nielsen
ASSEMBLY FLOOR: 43-25, 6/2/16 - See last page for vote
SUBJECT: Skilled nursing facilities: staffing
SOURCE: SEIU California
DIGEST: This bill increases the minimum number of required
nursing hours per patient in a skilled nursing facility (SNF)
from 3.2 hours to 4.1 hours incrementally beginning on January
1, 2018, with full implementation on January 1, 2020, and
specifies that within the required minimum of 4.1 nursing hours
when fully implemented, SNFs are required to have a minimum of
2.8 hours per patient day for certified nursing assistants, and
1.3 hours per patient day for licensed nurses.
ANALYSIS:
AB 2079
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Existing law:
1)Provides for the licensure and regulation by the State
Department of Public Health (DPH) of health facilities,
including skilled nursing facilities.
2)Establishes the minimum number of actual nursing hours per
patient in a SNF to be 3.2 hours, with a specified exception
related to special mental disorder treatment units.
3)Requires the DPH to develop regulations that establish minimum
staff-to-patient ratios for direct caregivers working in a
SNF, and require these ratios to include separate licensed
nurse staff-to-patient ratios in addition to the ratios
established for other direct caregivers.
This bill:
1)Increases the minimum number of required nursing hours, which
it renames "direct care service hours," per patient in a SNF
from 3.2 hours to 4.1 hours over three years commencing
January 1, 2018, including specifying which proportion of
those nursing hours are for certified nursing assistants
(CNAs) and which are for licensed nurses, as follows:
a) Commencing January 1, 2018, requires SNFs to have a
minimum number of 3.5 direct care service hours per patient
day (PPD), with 2.4 hours PPD for CNAs and 1.1 hours PPD
for licensed nurses;
b) Commencing January 1, 2019, requires SNFs to have a
minimum of 3.8 direct care service hours PPD, with 2.6
hours PPD for CNAs and 1.2 hours PPD for licensed nurses;
and,
c) Commencing January 1, 2020, requires SNFs to have a
minimum of 4.1 direct care service hours PPD, with 2.8
hours PPD for CNAs and 1.3 hours PPD for licensed nurses.
2)Excludes from this increase those SNFs that are licensed as a
distinct part of a licensed general acute care hospital or
those operated by the Department of State Hospitals, so this
bill would only apply to "freestanding" SNFs.
3)Repeals obsolete existing law that required DPH to establish
staff-to-patient ratios for direct caregivers, including
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separate ratios for licensed nurses.
4)Defines "licensed nurse" as a registered nurse, a licensed
vocational nurse, and a psychiatric technician, and revises
the definition of "direct caregiver," for purposes of minimum
direct care nursing hours in SNFs, to include a certified
nurse assistant in an approved training program.
5)Revises the existing requirement that DPH consult with
stakeholders to determine the sufficiency of the SNF staffing
standards by requiring this initial consultation no later than
July 1, 2017, while retaining the requirement that this
consultation take place every five years the initial
consultation.
6)Revises provisions of law requiring SNFs to post certain
staffing information by requiring the posting to include an
accurate report of the number of direct care staff working
during the current shift, including a report of the number of
registered nurses, licensed vocational nurses, psychiatric
technicians, and CNAs. Requires the posting to be on paper
that is at least 8.5 inches by 14 inches, in 16 point font,
and to be posted daily in the following three locations: an
area readily accessible to members of the public, an area used
for employee breaks, and an area used by residents for
communal functions, including, but not limited to, dining,
resident council meetings, or activities.
7)Requires every SNF, upon oral or written request, to make
direct caregiver staffing data available to the public for
review at reasonable cost, and to provide the data to the
requestor within 15 days. Specifies that "reasonable cost"
includes, but is not limited to, a $0.10 per page fee for
copying standard documents, or a retrieval or processing fee
not exceeding $60 if the requested data is provided on a
digital or other electronic medium and the requestor requests
delivery of the data in an electronic medium, including
electronic mail.
8)Recasts provisions of law pertaining to the Medi-Cal program
which require the Department of Health Care Services (DHCS) to
adopt regulations establishing minimum number of nursing hours
per patient in SNFs and intermediate care facilities, which
are similar to the provisions of the Health and Safety Code
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that the rest of this bill is amending, by repealing outdated
provisions, and instead increasing the minimum number of
direct care hours per patient day in SNFs from 3.2 to 4.1 in
the same manner as in 1) above.
9)Permits DHCS and DPH to develop regulations to create a
short-term waiver of the direct service hour requirements
established by this bill in order to address a shortage of
available health care professionals. Specifies that in order
to qualify for a waiver, the SNF must demonstrate that it
offers wages that are sufficient to recruit qualified staff,
that the SNF does not have a direct care staff turnover rate
that is higher than the state average, and the facility is
located in a designated workforce shortage area, as specified.
Requires waivers to be reviewed annually and either renewed or
revoked.
Comments
1)Author's statement. According to the author, this bill
requires SNFs to publicly post, at all times, the number of
direct caregivers on duty. This bill would raise the minimum
number of direct care service hours, transforming the care and
environment in nursing homes to provide a more patient
centered level of care. Currently, SNFs are required to
provide a minimum of 3.2 nursing hours per patient day - which
includes certified nursing assistants, licensed vocational
nurses, and registered nurses. However, this standard has not
been evaluated in over a decade. Providing person-centered
care in SNFs requires time, and when rushed, a resident's
quality of life and health suffer. Most importantly, this
bill would establish a minimum number of hours of care
provided by CNAs. CNAs are the primary providers serving the
needs of seniors and people with disabilities in SNFs.
Residents of SNFs and their families deserve a safe living
environment to help patients recover from surgery and heal
from trauma. This bill helps to ensure that CNAs, the primary
direct care staff, are available to meet the needs of seniors,
persons with disabilities, and people recovering from illness
and injury.
2)CNAs. There are an estimated 160,000 CNAs working in
California. An applicant for certification as a CNA is
required to be at least 16 years of age, have successfully
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completed a DPH-approved training program that includes at
least 60 classroom hours and 100 hours of supervised
on-the-job training, and have obtained a criminal record
clearance. A person may only use the title, and hold
themselves out as a CNA if they are working in a health
facility licensed by DPH. The majority of CNAs work in SNFs.
CNAs perform a variety of basic duties for the patient's
comfort and recovery. These tasks vary depending on the
employment setting but typically include: taking temperatures;
pulse; respiration; blood pressure; helping patients with
range-of-motion exercises; assisting patients with their daily
living needs; serving meals; making beds; and, helping
patients eat, dress, and bathe. CNAs are paid, on average,
approximately $14 dollars per hour. According to the Bureau
of Labor Statistics, the workforce categorized under "Nursing
Assistants and Orderlies" is expected to grow by 22.5% over
the next several years, faster than the average of all other
occupations in the U.S. This increase is due, in part, to the
rapidly aging Baby Boomer population and increasing prevalence
of chronic diseases, including dementia, all of which drive
the need for long-term care. The high rate of turnover among
CNAs also impacts demand. While the national trend of CNA
turnover in nursing facilities appears to be improving, in
2012 the turnover rate of CNAs in nursing facilities was the
highest among nursing staff at 42.6%.
3)Background on SNF funding. AB 1629 (Frommer, Chapter 875,
Statutes of 2004), enacted the Medi-Cal Long Term Care
Reimbursement Act of 2004, which established a reimbursement
system that bases Medi-Cal reimbursements to SNFs on the
actual cost of care. According to the Senate Budget Committee,
prior to AB 1629, SNFs were paid a flat rate per Medi-Cal
resident. This flat rate system provided no incentive for
quality care and reimbursed SNFs for less than it cost to care
for their residents. AB 1629 also allowed the state to
leverage new federal Medicaid dollars by imposing a quality
assurance fee (QAF) on SNFs. This new federal funding is used
to increase nursing-home reimbursement rates. (Federal
Medicaid law allows states to impose such fees on certain
health-care service providers and in turn repay the providers
through increased reimbursements.) Because the costs of
Medicaid reimbursements to health care providers are split
between states and the federal government, this arrangement
provides a method by which states can leverage additional
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federal funds for the support of their Medicaid programs and
offset state costs. In 2015-16, it is projected that the SNF
QAF will offset over $500 million in General Fund
expenditures. AB 1629 contained a sunset date of July 1, 2008
and has been extended six times, and is currently scheduled to
sunset on July 31, 2020. SB 853 (Committee on Budget and
Fiscal Review, Chapter 717, Statutes of 2010) established the
Quality and Accountability Supplemental Payment (QASP)
program. Under the QASP program, SNFs that meet minimum
staffing standards can earn incentive payouts from a pool of
supplemental funds. The payouts are awarded based on SNFs'
performance on certain quality measures (including clinical
indicators), as well as SNFs' improvement on these measures
relative to the previous year. Under SB 853, a portion of each
year's weighted average rate increase is to be set aside to
fund the QASP payment pool. The set-aside amount was $43
million in 2013-14, and $90 million in the 2014-15 rate year.
In 2013-14, about 477 out of 1,000 SNFs earned the QASP
payouts. SB 853 is also scheduled to sunset on July 31, 2020.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: Yes
According to the Senate Committee on Appropriations:
1)Annual costs of $52 million per year in 2018-19 rising to $310
million per year by 2021-22 for additional Medi-Cal payments
to skilled nursing facilities (General Fund and federal
funds). Under current law, the DHCS pays skilled nursing
facilities that care for Medi-Cal beneficiaries on a
cost-based system. Under current law, the DHCS is required to
increase reimbursement rates to skilled nursing facilities to
offset any additional costs mandated by the state or federal
government. Currently, while the statutory minimum number of
hours per day is 3.2, the average nursing hours is about 3.6
per patient day. DHCS indicates that because skilled nursing
facilities are generally paid based on their costs, current
rates already cover most of the cost of providing 3.6 hours
per day, on average. Therefore, the state would have to pay
for the cost increase caused by increasing the hours provided
form the current average of 3.6 hours per patient per day to
4.1 hours per patient per day. Staff notes that the
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California Association of Health Facilities (which is in
opposition to the bill) projects annual costs to the Medi-Cal
program could be as high as $440 million per year by 2021.
2)One-time costs, less than $150,000 to adopt regulations and
modify internal tracking systems by the DHCS (General Fund and
federal funds).
3)Minor additional ongoing enforcement costs to the DPH
(Licensing and Certification Fund). Because the DPH already
licenses skilled nursing facilities, including compliance with
existing nursing hours requirements, there is no anticipated
additional cost to enforce the requirements of this bill as
part of the ongoing licensing program.
SUPPORT: (Verified 8/12/16)
SEIU California (source)
California Commission on Aging
California Labor Federation
Clergy and Laity United for Economic Justice
California Department of Justice
OPPOSITION: (Verified8/12/16)
Association of California Healthcare Districts
California Association of Health Facilities
LeadingAge California
ARGUMENTS IN SUPPORT: This bill is sponsored by SEIU
California, which states that in 2004, it worked in a coalition
to transform the reimbursement methodology for freestanding SNFs
through AB 1629 (Frommer), due to the belief that a change in
reimbursement rates as well as instituting a minimum staffing
standard in SNFs would result in improving the quality of care
in nursing homes. More than a decade later, SEIU California
states that reimbursement rates of SNFs have increased, and AB
1629 has been reauthorized several times, but the quality of
care for residents has not increased to the level intended by
the Legislature. According to SEIU California, on average,
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California's SNFs provide 3.7 nursing hours PPD, slightly above
the 3.2 hour minimum, but this average is short of the federal
recommended 4.1 hour minimum. SEIU states this bill raises the
quality of care standards in SNFs to the federal recommended
minimum of 4.1 nursing hours PPD by January 1, 2020 to benefit
society's most vulnerable residents. The California Department
of Justice (DOJ) states that the DOJ's Bureau of Medi-Cal Fraud
and Elder Abuse works aggressively to protect patients in
nursing homes and other long-term care facilities from abuse or
neglect, and that this bill would have a dramatically positive
impact on this work. DOJ states that a significant portion of
the Bureau's caseload is consumed by investigating and
prosecuting nursing facilities and their staff who have failed
to provide adequate care of patients. DOJ states that increasing
the number of direct care service hours will allow each patient
to have more professional care and more attention, reducing
neglect and allowing facility staff to provide the standard of
service they surely wish to provide their patients. The
California Labor Federation states in support that this bill
will bring California nursing homes up to national staffing
standards while improving oversight for the billions of public
dollars spent over the last decade to improve conditions in
California nursing homes. The Clergy and Laity United for
Economic Justice states in support that not only are nursing
homes filled with widows and orphans, they are also places where
people need extra attention because they face the hardest
reality that their bodies are giving way, and they depend on
people like never before. Providing person-center care in SNFs
requires time and sufficient staff, and that short staffing
places residents at risk. The California Commission on Aging
states in supporting that by increasing direct care hours, this
bill will improve both the care provided and the quality of life
of SNF residents.
ARGUMENTS IN OPPOSITION: The California Association of
Health Facilities (CAHF) states in opposition that this bill
would create artificial staffing patterns that do not
necessarily lead to higher quality patient care, while imposing
significant costs on the state and on their facilities.
According to CAHF, SNFs must meet daily minimum nursing hour
requirements at each facility of 3.2 hours per patient day, but
that facilities often exceed these requirements when patient
composition necessitates additional nursing staff. CAHF states
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that this methodology - staffing based on individual patient
need - is far preferable to mandated minimum staffing, and it is
far more reasonable from an expense perspective. CAHF states
that this bill does not take into account the very challenging
task of finding such a large number of trained personnel to meet
the new staffing provisions, stating that it would require SNFs
to employ an estimated additional 10,300 CNAs, which do not
exist in the workforce on such a large scale. CAHF states that
its estimate of the cost of this bill when fully implemented is
nearly $700 million, with $460 million in Medi-Cal costs, and
more than $200 million which would fall on their facilities,
unreimbursed. CAHF argues that if California is inclined to
invest hundreds of millions of dollars into the nursing home
workforce, the money should instead be invested in developing
the current workforce by increasing training levels and reducing
turnover, while simultaneously making sure new staffing
requirements are based on specific patient needs. This bill is
also opposed by the Association of California Healthcare
Districts, which states that the three healthcare districts
operating SNFs are in designated medically underserved areas,
and that it will be very challenging for facilities operating in
these areas with existing workforce shortages to comply with
this mandate. LeadingAge California states in opposition that
patient care staffing is based on a complex set of variables
driven by patient care needs, and that while the vast majority
of its members staff well above the current 3.2 hour minimum, it
believes this bill is unnecessary as existing law already
directs that SNFs must employ additional staff as necessary to
meet the needs of residents. LeadingAge California also states
that staff retention is also a cause for concern, as SNFs are
constantly competing with hospitals and health systems and other
entities for nursing talent
ASSEMBLY FLOOR: 43-25, 6/2/16
AYES: Alejo, Arambula, Atkins, Bloom, Bonilla, Bonta, Brown,
Calderon, Campos, Chau, Chiu, Chu, Cooley, Cooper, Dababneh,
Dodd, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon,
Roger Hernández, Holden, Irwin, Jones-Sawyer, Linder, Lopez,
Low, McCarty, Medina, O'Donnell, Ridley-Thomas, Rodriguez,
Salas, Santiago, Mark Stone, Thurmond, Ting, Weber, Williams,
Wood, Rendon
NOES: Achadjian, Travis Allen, Baker, Brough, Chang, Chávez,
Dahle, Gray, Grove, Harper, Jones, Kim, Lackey, Levine,
Maienschein, Mathis, Mayes, Melendez, Obernolte, Olsen,
AB 2079
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Patterson, Quirk, Steinorth, Wagner, Wilk
NO VOTE RECORDED: Bigelow, Burke, Daly, Eggman, Frazier, Beth
Gaines, Gallagher, Cristina Garcia, Hadley, Mullin, Nazarian,
Waldron
Prepared by:Vince Marchand / HEALTH / (916) 651-4111
8/15/16 19:39:44
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