BILL ANALYSIS Ó SB 938 Page 1 Date of Hearing: June 28, 2016 ASSEMBLY COMMITTEE ON JUDICIARY Mark Stone, Chair SB 938 (Jackson) - As Amended May 31, 2016 As Proposed to be Amended SENATE VOTE: 39-0 SUBJECT: Conservatorships: psychotropic medications KEY ISSUE: IN ORDER TO BETTER PROTECT VULNERABLE CONSERVATEES FROM INAPPROPRIATELY BEING PRESCRIBED POTENT PSYCHOTROPIC DRUGS WITH POTENTIALLY SIGNIFICANT AND EVEN DEADLY HEALTH CONSEQUENCES, SHOULD THE LIMITED COURT OVERSIGHT of prescribing practices today BE IMPROVED? SYNOPSIS If a person is unable to adequately provide for his or her personal needs or incapable of managing his or her assets, a probate court can establish a conservatorship. Because of concerns of mistreatment and misuse of potent psychotropic medication, the Legislature created special judicial oversight to protect conservatees with dementia from being unnecessarily overmedicated. Psychotropic medications, including antipsychotics, antidepressants and psychostimulants, alter SB 938 Page 2 chemical levels in the brain which impact mood and behavior. SB 1481 (Mello), Chapter 910, Statutes of 1996, established protections to provide, within the scheme of a probate conservatorship, the authority to place a person with dementia in a secure perimeter facility and to authorize the administration of dementia medications. This bill, sponsored by California Advocates for Nursing Home Reform, seeks to update those 20-year old rules and provide better guidance to courts when determining whether to authorize a conservator to give psychotropic medication to a conservatee with dementia. To provide better guidance on whether psychotropic medication should be administered to dementia conservatees, the bill requires additional information to be provided in a physician declaration filed in support of the conservator's petition to authorize the administration of psychotropic medication, and requires Judicial Council to update rules and forms to better assist with the reporting. The bill also revises existing law to reflect the various dementia disorders that fall under the new, broader diagnostic category of major neurocognitive disorders and make various conforming changes. This bill is supported by groups and individuals, including the Judicial Council, the Trusts & Estates Section of the State Bar, Disability Rights California, and the California Long-Term Care Ombudsman Association, who argue that the clarifications and updates provided by this bill will better protect vulnerable elderly individuals with dementia from being improperly prescribed strong psychotropic medication without proper court oversight. The bill, as in print, is opposed by a coalition of hospitals, health facilities and assisted living facilities, as well the Alzheimer's Association and the Public Guardian, who are concerned that the additional requirements in the bill could result in harm to the very individuals the bill is trying to protect by making it more difficult for them to get the medication they need and will increase costs for courts, families and conservatees. The author has agreed to amend the bill to, among other things, specifically provide that if a court has granted a conservator the power to administer SB 938 Page 3 psychotropic medication to a conservatee, the conservator may, consistent with the authority granted by the court, change or adjust the psychotropic medications without further notice or approval by the court, as provided. This should significantly reduce concerns about having to go back to court for each dose or medication change, thus easing concerns about timely access to medication, clogged courts and higher costs for conservatees. It is unclear if these amendments change opponents' position on the bill. SUMMARY: Requires additional oversight before psychotropic medication can be prescribed to a conservatee with a major neurocognitive disorder (MNCD, generally dementia). Specifically, this bill: 1)Defines MNCDs as defined in the latest edition of the diagnostic and Statistics Manual of Mental Disorders. Legislative findings define MNCDs to include Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and Parkinson dementia. 2)Defines psychotropic medication, for purposes of this bill, as including, but not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, hypnotics and psychostimulants. "Psychotropic medications" does not include medications approved by the Food and Drug Administration for the treatment of MNCDs or anti-Parkinson agents. 3)Clarifies a conservator's authority to place a conservatee with a MNCD in a secured perimeter residential facility for the elderly (as opposed to a locked facility), provided it is the least restrictive placement appropriate for the conservatee's needs. Deletes the prohibition against placement of a conservatee in a mental health rehabilitation center or institution for mental disease, as specified. SB 938 Page 4 4)Requires that before a conservator can authorize the administration of psychotropic medication to a conservatee, a court must make certain specified findings, already in existing law, by clear and convincing evidence. Requires that the physician's supporting declaration, required for the conservator's petition requesting authority to administer psychotropic medication in existing law, must additionally contain: a) A description of the conservatee's diagnosis and behavior; b) The recommended course of medication; c) A description of the treatments and medications that have been used or proposed, less invasive treatments or medications used or proposed, and why these treatments or medications have not or would not be effective in treating the conservatee; d) The expected effects of the proposed medication on the conservatee's health and treatment plan, including how the medication is expected to improve the conservatee's symptoms; e) The potential side effects of the proposed medication, include any black box warnings; and f) Whether the conservatee and his or her attorney have had an opportunity to provide input on the proposed medications. 5)Provides that, if a court has granted a conservator the power SB 938 Page 5 to administer psychotropic medication to a conservatee, the conservator may, consistent with the authority granted by the court, change or adjust the psychotropic medications without further notice or approval by the court, provided the conservator has received information about the risks, benefits and alternatives before making the change. 6)Provides that, if a court has granted a conservator the power to administer psychotropic medication to a conservatee, the court shall review the authority when periodically reviewing the conservatorship as required by law. 7)Requires, on or before July 1, 2017, the Judicial Council to adopt rules of court and develop appropriate forms for the implementation of this bill, and to provide guidance to the court on how to evaluate the request for authorization, including how to proceed if information, otherwise required to be included in a request for authorization, is not included in a request for authorization submitted to the court. 8)Provides that the requirements of this legislation do not apply to conservatees who are prescribed psychotropic medication by a physician in an acute care hospital or for purposes of diagnostic or therapeutic treatment not directly related to the MNCD, including, but not limited to, sedation prior to an invasive procedure or nausea prevention or relief, and instead, the conservator may make medical decisions if the conservatee lacks capacity, as provided. 9)Revises legislative findings and declarations regarding MNCDs. EXISTING LAW: 1)Allows the court to appoint a conservator to act on behalf of a person who is unable to adequately provide for his or her SB 938 Page 6 personal needs (a conservator of the person) or incapable of managing his or her property or other financial assets (a conservator of the estate). (Probate Code Section 1800 et seq. Unless stated otherwise, all further statutory references are to that code.) 2)Specifies the powers and duties of a conservator and the powers and rights retained by a conservatee subject to a conservatorship. (Section 2350 et seq.) 3)Authorizes the conservator to establish the residence of the conservatee at any place within California without the permission of the court and requires the conservator to select the least restrictive appropriate residence. (Section 2352 (b).) 4)Provides that if the conservatee has not been adjudicated to lack the capacity to give informed consent for medical treatment, the conservatee may consent to his or her medical treatment; the conservator may also give consent to the medical treatment, but the consent of the conservator is not required if the conservatee has the capacity to give informed consent to the medical treatment, and the consent of the conservator alone is not sufficient if the conservatee objects to the medical treatment. After obtaining a court order specifically authorizing medical treatment, authorizes the conservator to require the conservatee to receive medical treatment, whether or not the conservatee consents to the treatment. (Section 2354.) 5)If the conservatee has been adjudicated to lack the capacity to make health care decisions, provides the conservator the exclusive authority to make health care decisions for the conservatee that the conservator in good faith, based on medical advice, determines to be necessary. (Section 2355.) SB 938 Page 7 6)If a conservatee is unable to give an informed consent to medical treatment for an existing or continuing medical condition which is not authorized to be performed, authorizes the conservator to petition the court for an order authorizing the medical treatment and authorizing the conservator to consent on behalf of the conservatee, as provided. (Section 2357.) 7)Makes legislative findings that, among other things the administration of psychotropic medications has been, and can be, abused by caregivers and, therefore, granting powers to a conservator to authorize these medications for the treatment of dementia requires protections. (Section 2356.5 (a).) 8)Allows a conservator to place a conservatee in a secured perimeter residential care facility for the elderly, upon a court making specified findings, by clear and convincing evidence, as provided. (Section 2356.5 (b).) 9)Allows a conservator to authorize the administration of medications appropriate for the care and treatment of dementia, upon a court making specified findings, by clear and convincing evidence, as provided. (Section 2356.5 (c).) 10)Prohibits placement of a conservatee in a mental health rehabilitation center or in an institution for mental disease, as specified. (Section 2356.5 (e).) 11)Requires the conservatee, at a hearing to either place the conservatee in a secured perimeter residential care facility or allow for the administration of medication appropriate for the care and treatment of dementia, to be represented by an attorney, as specified. (Section 2356.5 (f).) SB 938 Page 8 12)Requires the court investigator annually to investigate and report to the court every two years, as specified, if the conservator is authorized to place the conservatee in a secured perimeter residential care facility or administer medication appropriate for the care and treatment of dementia, and the investigator is required to specifically advise the conservatee that he or she has the right to object to the conservator's powers, and the report is required to include whether the powers granted are warranted. (Section 2356.5 (g).) FISCAL EFFECT: As currently in print this bill is keyed fiscal. COMMENTS: If a person is unable to adequately provide for his or her personal needs or incapable of managing his or her assets, a probate court can establish a conservatorship. Because of concerns of mistreatment and misuse of potent psychotropic medication on those with dementia, the Legislature created special judicial oversight to protect conservatees with dementia from being unnecessarily overmedicated. Psychotropic medications, including antipsychotics, antidepressants and psychostimulants, alter chemical levels in the brain which impact mood and behavior. SB 1481 (Mello), Chapter 910, Statutes of 1996, established protections to provide, within the scheme of a probate conservatorship, the authority to place a person with dementia in a secure facility and to authorize the administration of dementia medications. This bill seeks to update those 20-year old rules and provide better guidance to courts when determining whether to authorize a conservator to give psychotropic medication to a conservatee with dementia. To provide better guidance on whether psychotropic medication should be administered to dementia conservatees, the bill requires additional information to be provided in a physician declaration filed in support of the conservator's petition to authorize the administration of psychotropic medication, and requires Judicial Council to update rules and forms to better SB 938 Page 9 assist with the reporting. The bill also revises existing law to reflect the various dementia disorders that fall under the new, broader diagnostic category of MNCDs and make various conforming changes. In support of the bill, the sponsor, California Advocates for Nursing Home Reform (CANHR), writes: The purpose of enacting [SB 1481] was to address the involuntary administration of medication (and locked door residential placement) for people with dementia by establishing a protective review and authorization process within the context of a conservatorship. At the time, psychotropic drugs were known to be used inappropriately, particularly in institutional residential settings like nursing homes, but stood as the primary "treatment" option for people with dementia who presented behavioral challenges. Since the law was created, studies have shown that psychotropic drugs are a particularly poor treatment option for people with dementia. They often exacerbate rather than ameliorate symptoms, have disabling side effects, and in some cases substantially increase mortality rates. Most notably, psychotropic drugs for people with dementia do not resolve an underlying mental health condition; instead, they mask the real problems such as distress, pain, or discomfort that have been expressed through behaviors. In short, psychotropic drugs for people with dementia typically cause more problems than they solve. The Judicial Council writes of its support for this bill, which "seeks to strengthen the law governing the use of psychotropic medications for persons subject to dementia conservatorships. The council recognizes that conservatees with dementia are very vulnerable individuals and we are mindful of the important role SB 938 Page 10 that probate courts perform in helping to ensure their proper care and treatment. Providing more complete information regarding the proposed use of psychotropic medications for these conservatees should help avoid abuse, thereby improving the court's oversight and administration of these important cases." Adds the National Association of Social Workers, California Chapter: "It has been shown that psychotropic drugs can be very dangerous for elderly patients with dementia. Unfortunately, these drugs are widely used and it has alerted advocates to the need for reform. . . . This bill will help to protect seniors from being wrongly or over[-]medicated." Types of Conservatorships: A probate judge may appoint a conservator to act on behalf of a person who is unable to adequately provide for his or her personal needs (a "conservator of the person") or incapable of managing his or her property or other financial assets (a "conservator of the estate"). (Section 1800 et seq.) The Probate Code also offers a "limited conservatorship" for "developmentally disabled adults," under which the court limits the conservator's power so as to preserve the maximum amount of independence and self-sufficiency for the conservatee. (Section 1801 (d).) In addition, the Lanterman-Petris-Short (LPS) Act created a special adult conservatorship for persons who were considered "gravely disabled" by reason of mental illness or chronic alcoholism and subject to confinement in a locked psychiatric facility and administration of psychotropic medication, subject to more extensive oversight than a probate conservatorship. (Welfare & Institutions Code Section 5330 et seq.) Conservatorship with Special Dementia Powers: In 1996, the Legislature created an alternative to the LPS conservatorship for people with dementia. AB 1481 (Mellow), 1996, allows a conservator under a Probate Code conservatorship to seek special SB 938 Page 11 powers to confine a conservatee with dementia in a "secured perimeter" residential care facility and to administer medication for dementia if various conditions, designed to protect the conservatee, are met. These conditions include the appointment of an attorney to represent the conservatee during the court's consideration of the conservator's petition for the dementia powers. While the legislative intent language to the statute discusses psychotropic medication and notes that these drugs have been, and can be, "abused by caregivers and, therefore, granting powers to a conservator to authorize these medications for the treatment of dementia requires the protections specified in this section" (Section 2356.5 (a)(3)), the statutory mandate for court oversight uses the term "medications appropriate for the care and treatment of dementia." There are significant risks to treating dementia patients with certain psychotropic medication. Beginning in 2005 and expanded in 2008, the United States Food and Drug Administration (FDA) required all antipsychotic medications, which are a class of psychotropic drugs, to include a "black box" warning that these medications significantly increase the risk of death in elderly people with dementia. A typical black box warning looks like this: The FDA website warns health care professionals against prescribing antipsychotics to patients with dementia: " Elderly patients with dementia-related psychosis treated with conventional or atypical antipsychotic drugs are at an increased risk of death. " Antipsychotic drugs are not approved for the treatment of dementia-related psychosis. Furthermore, there is no SB 938 Page 12 approved drug for the treatment of dementia-related psychosis. Healthcare professionals should consider other management options. " Physicians who prescribe antipsychotics to elderly patients with dementia-related psychosis should discuss this risk of increased mortality with their patients, patients' families, and caregivers. (FDA, Information for Healthcare Professionals: Conventional Antipsychotics (http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInf ormationforPatientsandProviders/ucm124830.htm).) Following the national movement to reduce the administration of antipsychotic medications to dementia patients, the Centers for Medicare & Medicaid Services Region IX and the California Department of Public Health, together with a diverse group of stakeholders, formed a partnership to develop a collaborative action plan for improving dementia care and reducing the inappropriate use of antipsychotic medication in California Nursing Homes. (Centers for Medicare & Medicaid Services, Region IX, Cal. Dept. of Public Health, Working Together: California Partnership to Improve Dementia Care and Reduce Unnecessary Antipsychotic Medication Drug Use in Nursing Homes, Summary Report (Dec. 2012).) Yet, a 2014 report released by the United States Government Accountability Office on the use of antipsychotic drugs in nursing homes noted that prescribing rates of antipsychotic drugs to nursing home residents with dementia continues to be too high, especially when the FDA has not approved the use of antipsychotic drugs to treat the behavioral symptoms of dementia. (U.S. Government Accountability Office, Report to Congressional Requesters, Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings (GAO-15-211) (Jan. 2015) pp. 1-2.) According to that report, experts and research attribute the high incidence of antipsychotic use on dementia patients to the culture of the nursing facility, the level of physician and staff training and education, and the number of staff at the nursing home. (Id., p. 23.) Further, the report noted that it is estimated that SB 938 Page 13 close to one in five older adults with dementia living outside of a nursing home took an antipsychotic between 2002 and 2004. (Id., p. 3.) According to the sponsor, other types of psychotropic medication, beyond antipsychotics, also pose significant risk for those with dementia: "Antianxiety and hypnotic drugs have proven quite dangerous for elderly people with dementia and often exacerbate, rather than alleviate, anxiety and dementia." (Footnote omitted.) CANHR states that even antidepressants have risks of harm to people with dementia. And, even assuming the risks are reasonable, CAHNR finds that the benefits of these drugs on those with dementia are minimal: The benefits -- if they can be called benefits -- in using psychotropic drugs for people with dementia are sedation and submission. The drugs increase fatigue and decrease activity, thereby rendering a patient more "manageable" while often incapacitating them. The subsequent incapacity and decline in physical activity increases the patient's suseptibility to devastating falls, pressure sores, weight, and infection. These results are the main reason why psychotropic drugs lead to such negative clinical outcomes for elderly people with dementia. This bill is similar to legislation last year that protected foster children from overmedication with psychotropic medication. In response to growing concerns that psychotropic medications have been relied on by California's child welfare and children's mental health systems as a means of controlling, instead of treating, youth who suffer from trauma-related behavioral health challenges, the Legislature last year passed a package of bills designed to reduce the use of psychotropic medication in this most vulnerable population. One bill in that package, SB 238 (Mitchell and Beall), Chapter 534, Statutes of 2015, provides, very similarly to this bill, protections and SB 938 Page 14 oversight over psychotropic medication by requiring the Judicial Council to update forms and rules to ensure improved and regularly updated information is solicited from, and received by, appropriate individuals and entities regarding use of psychotropic medication. While conservatees with dementia are very different from foster children suffering trauma, both are extremely vulnerable and under the watchful oversight of the court. Additional physician declaration requirements. Existing law requires a conservator's petition for authorization to place a conservatee with dementia in a secure residential care facility for the elderly or to authorize the administration of medications for dementia to be supported by a physician's or psychologist's declaration. In order to obtain authorization for the administration of psychotropic medications, the mandatory Judicial Council Form GC-335A, Dementia Attachment to Capacity Declaration - Conservatorship, requires the conservatee's physician or psychologist to list the psychotropic medications to be administered, describe the conservatee's mental function deficits, determine whether the conservatee has capacity to give informed consent to the administration of psychotropic medications appropriate to the care of dementia, and state the reasons the conservatee needs, or would benefit from, the administration of the psychotropic medications. This bill first requires that a declaration on medication can only be provided by a physician (this corrects an ambiguity in current law and is necessary for scope of practice issues, since psychologists cannot prescribe medication). This bill then expands the information to be provided by the physician to include: A description of the conservatee's diagnosis and behavior; The recommended course of medication; A description of the pharmacological and nonpharmacological SB 938 Page 15 treatments and medications that have been previously used or proposed, the less invasive treatments or medications previously used or proposed, and why these treatments and medications have not been or would not be effective in treating the conservatee's symptoms; The expected results of the recommended medication on the conservatee's overall mental health and treatment plan, including how the medication is expected to improve the conservatee's symptoms; A description of the potential side effects of the recommended medication; and Whether the conservatee and his or her attorney have had an opportunity to provide input on the recommended medications. In accordance with the original intent of existing law to protect conservatees with dementia from overmedication by caregivers, the author argues that these new reporting requirements, better defines the criteria upon which a court would determine whether a conservator should have the ability to authorize the administration of psychotropic medications to a conservatee with dementia. In addition to that list, the bill also requires the Judicial Council to adopt rules of court and develop appropriate forms for the implementation of the bill, and provide guidance to the court on how to evaluate the request for authorization, including how to proceed if information, otherwise required to be included in a request for authorization, is not included in a request for authorization submitted to the court. Revised forms should help simplify the process and reduce workload for both physicians and the court. Placement of conservatees with dementia in facilities. This bill strikes from existing law the prohibition on placing a conservatee with an MNCD in a mental health rehabilitation center or institution for mental disease, as specified. It SB 938 Page 16 appears that when the original law was drafted in 1996, this prohibition was included to make certain that conservatees with dementia were not placed in a facility that may not provide appropriate dementia care, as opposed to care appropriate for treating other mental disorders. However, existing law and this bill only authorize placement of the conservatee with dementia in a secured perimeter residential care facility for the elderly (RCFE). Additionally, subject to the provisions of a valid and effective advance health care directive, existing law otherwise prohibits placing a conservatee, regardless of whether the conservatee has been diagnosed with dementia, in a mental health treatment facility against his or her will, and involuntary civil placement of a conservatee in a mental health treatment facility may only be obtained pursuant to the Lanterman-Petris-Short Act, as specified. Further, the removal of the prohibition on placing a conservatee with dementia in a mental health rehabilitation center or institution for mental disease is arguably inconsequential since existing law, and this bill, only authorize placement of conservatees with dementia in RCFEs, which are not licensed as mental health or psychiatric facilities. This bill also cleans-up the incorrect statutory reference to "locked facility," and instead refers to the placement of dementia patients in "secured perimeter" facilities, as opposed to locked facilities. Opposition to bill in print concerned that it could jeopardize patient access to appropriate medical care, clog courts and result in higher costs. The California Assisted Living Association, the California Association of Health Facilities, the California Council of the Alzheimer's Association, the California Hospital Association, the California Psychiatric Association and LeadingAge California jointly oppose the bill in print because they are concerned that the bill, while well-intentioned, will "jeopardize patients' access to timely and appropriate medical care, clog the court system, and result SB 938 Page 17 in higher medical and legal costs for these patients and their families." The opponents add: SB 938 (Jackson) places a huge new burden on patients with a MNCD who have a conservator, their families, their physicians and nurses, and the court system. This bill would require such patients to go to court for judicial approval each time a physician orders a new or different antidepressant, sleeping pill, anti-anxiety medication, antipsychotic, or other psychotherapeutic drug. The patient's medical treatment would be delayed for the time needed to prepare the extensive paperwork for the judge that is required by this bill, get on the judge's calendar, and obtain a judicial decision. Consider the situation where a woman with Alzheimer's disease learns that her husband has passed away, and she is so distraught she cannot sleep. Her physician could not order a sleeping pill or anti-anxiety medication - even with the conservator's approval - without going to court first. This is simply bad patient care. The State Association of Public Administrators, Public Guardian, and Public Conservators concurs with the other opponents and believes that this bill will make it more difficult for the government's conservators of last resort to do their job and could result in people who legitimately need psychotropic medication being "denied proper treatment." In response to these concerns, the author has agreed to amend the bill to specifically provide that if a court has granted a conservator the power to administer psychotropic medication to a conservatee, the conservator may, consistent with the authority granted by the court, change or adjust the psychotropic medications without further notice or approval by the court, provided the conservator has received information about the risks, benefits and alternatives before making the change. This should significantly reduce concerns about having to go back to SB 938 Page 18 court for each dose or medication change, thus easing issues about timely access to medication, clogged courts and higher costs for conservatees. The author's amendments also address concerns raised by hospitals of the need to prescribe drugs both in emergency and nonemergency settings by specifically exempting psychotropic medication given in an acute care hospital and for purposes of diagnostic or therapeutic treatment not directly relates to a MNCD, such as sedation prior to an invasive treatment or nausea relief. The amendments also clean-up a scope of practice problems with existing law that seemed to imply that psychologists could prescribe psychotropic medication, and clarifies that courts, in their annual or bi-annual review of conservatorships, should review the powers given to conservators to place a conservatee with dementia in a secure perimeter facility or authorize the administration of psychotropic medication. What the amendments do not do is limit the bill's application to just antipsychotic drugs that come with the FDA's black box, risk of death, warning. The opponents argue that antipsychotic drugs are the riskiest drugs for those with dementia and thus increased court oversight may be warranted for them, but not necessarily for the broader list of psychotropic drugs. The sponsor counters that existing law already applies to all psychotropic medication and that limiting this bill to just antipsychotic drugs would actually reduce the protections provided by existing law. While existing law contains legislative intent on the dangers of psychotropic medication, the actual language used in the regulating provision is "medications appropriate for the care and treatment of dementia." The Judicial Council, in its required court form (GC-335), combines both language and requires conservators today to seek court approval for administration of "psychotropic medications appropriate to the care of dementia." Moreover, the Trusts & Estates Section of the Bar, a supporter, confirms its SB 938 Page 19 understanding that psychotropic medication is already included in existing law and this bill simply clarifies that fact and "provides a mechanism for the court to ensure that an 'evaluation of the risks,' a considerations of the 'reasonable alternative treatment and risks, and why the health professional is recommending the particular treatment' have in fact been considered by the conservator prior to the grant of authority to authorize the use of such psychotropic medications." Thus, this bill helps clears up any possible ambiguity in existing law, consistent with legislative intent, and provides clear direction of the need to have court oversight of psychotropic medication for this very vulnerable population. It is unclear if these latest amendments change the opponents' position on the bill, but they do go a long way to addressing the issues set forth in their letters of opposition. REGISTERED SUPPORT / OPPOSITION: Support California Advocates for Nursing Home Reform (sponsor) California Long-Term Care Ombudsman Association Consumer Attorneys of California Disability Rights California SB 938 Page 20 Judicial Council of California National Association of Social Workers - California Chapter Trusts and Estates Section of the State Bar of California Some individuals Opposition (to the bill in print) California Assisted Living Association California Association of Health Facilities California Council of the Alzheimer's Association California Hospital Association California Psychiatric Association LeadingAge California State Association of Public Administrators, Public Guardian, and Public Conservators SB 938 Page 21 Analysis Prepared by:Leora Gershenzon / JUD. / (916) 319-2334