BILL ANALYSIS
AB 215
Page 1
Date of Hearing: April 14, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 215 (Feuer) - As Amended: March 19, 2009
SUBJECT : Long-term health care facilities: ratings.
SUMMARY : Requires a long-term health care (LTC) facility to
post, in accordance with prescribed requirements, the overall
facility rating information determined by the Centers for
Medicaid Services (CMS). Specifically, this bill :
1)Requires a LTC facility, that has been certified for purposes
of Medicare or Medicaid and provides skilled nursing care, to
post the overall facility rating information determined by
CMS.
2)Requires the information to be posted in at least the
following locations, including areas of the facility that are:
a) Accessible and visible to members of the public;
b) Used for employee breaks; and,
c) Used by residents for communal functions, such as
dining, resident council meetings, or activities.
3)Requires the information to be posted on a white or
light-colored sheet of paper that is at least 8 " x 11" in
size.
4)Requires the posted information to include all of the
following, in the following order:
a) The full name of the facility, in a clear and easily
readable font of at least 30 points;
b) The full address of the facility in a clear and easily
readable font of at least 20 points;
c) The most recent star rating given by CMS to that
facility. Requires the posting of the star rating to be:
i) Aligned in the center of the page;
ii) Expressed as the number that reflects the number of
stars given to the facility by CMS in a clear and easily
readable font of at least three inches print; and,
iii) Expressed as the number of star symbols given to the
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facility by the CMS, directly below the number in 4) c)
ii) above, in a clear and easily readable font of at
least one-half inch print.
d) The following text placed directly below the star
symbol, in a clear and easily readable font of at least 30
points: "The above number of stars is out of five stars."
e) The following text placed directly below the text
described in 4) d) above, in a clear and easily readable
font of at least 20 points: "The federal Centers for
Medicare and Medicaid Services gave the above rating to
this facility. A detailed explanation of this rating is
maintained at this facility and will be made available upon
request. This information can also be accessed online at
the Nursing Home Care Compare Web site at
www.medicare.gov/NHcompare ."
5)Requires that a facility has five business days from the date
it receives a new rating from CMS to include the updated
rating in the posting.
6)Requires that a copy of the most recent CMS report on the
facility be maintained at the facility, and be made available
to residents or the public upon request.
7)Requires that this posting be in addition to any other
postings or inspections report requirements.
8)Requires that a violation of the provisions of this bill
constitutes a class B violation, as defined, in existing law
and that fines from the violation be deposited into the State
Health Facilities Citation Penalties Account.
EXISTING LAW :
1)Provides for the licensure and regulation by the California
Department of Public Health (DPH) of health care facilities,
including LTC facilities.
2)Establishes a centralized consumer response unit (unit),
including an online inquiry system, to respond to LTC facility
consumer inquiries and complaints. Requires the unit to offer
assistance which may include consumer education and
information about state and federal standards, resident
rights, and other information about complaints and inspections
of LTC facilities.
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3)Creates the State Health Facilities Citation Penalties Account
in the Special Deposit Fund, with moneys in this account to be
used, upon appropriation, for prescribed purposes.
4)Existing law allows DPH to issue citations and levy civil
penalties against LTC facilities for violations of licensing
standards, which vary according to the severity of the
violation. Class "AA" citations, which are issued for
violations that are the proximate cause of death of a patient
or resident, are subject to civil penalties ranging from
$25,000 to $100,000 per citation. Class "A" citations, which
are issued for violations that present actual or potential
immediate danger, death or serious harm to a patient or
resident, are subject to civil penalties ranging from $2,000
to $20,000 per citation. Class "B" citations, which are
issued for violations that are determined to cause, or under
circumstances likely to cause, significant humiliation,
indignity, anxiety, or other emotional trauma, are subject to
a civil penalty in an amount not less than $100 and not
exceeding $1,000 for each and every citation.
FISCAL EFFECT : This bill has not yet been analyzed by a
fiscal committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
designed to increase awareness of information regarding
nursing home quality to assist consumers when they are making
the decision to place their loved one in a nursing home. The
author maintains that the CMS Five-Star Quality Rating System
distills detailed information about health inspection reports,
staffing, and quality measures of Medicare and
Medicaid-certified nursing homes into a quickly recognizable,
easily readable format. The author argues since many
consumers do not have access to the Internet or do not know
how to access the CMS information electronically, requiring
the posted rating will make the information more accessible.
The author further argues that many consumers who are unaware
of the CMS rating system will learn about its existence
through the postings, increasing their ability to make a more
informed decision.
2)BACKGROUND . According to the California HealthCare Foundation
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(CHCF), California has approximately 1,296 nursing facilities,
the vast majority of which are located in urban settings
(1,244). According to CHCF, most of California's nursing
facilities are free-standing - only 160 are hospital-based
nursing facilities. Individuals served in nursing homes
include adults and children with disabilities, the elderly,
and individuals needing temporary assistance while recovering
from an illness or injury. Oversight of nursing homes is a
shared federal-state responsibility. Under federal law, CMS
defines standards that nursing homes must meet to participate
in the Medicare and Medicaid programs and contracts with
states to assess whether homes meet these standards through
annual surveys and complaint investigations. A range of
statutorily defined sanctions is available to help ensure that
homes maintain compliance with federal quality requirements.
CMS is also responsible for monitoring the adequacy of state
survey activities. Under state law, the Licensing and
Certification Division of DPH must survey a skilled nursing
facility (SNF) at least once every two years; under federal
law, once every 15 months, with the statewide average not to
exceed 12 months. DPH also conducts a survey in response to
complaints filed against a nursing home.
3)CMS FIVE-STAR QUALITY RATING SYSTEM . On December 18, 2008,
CMS updated its Nursing Home Compare Web site and launched a
Five-Star Quality Rating System for Nursing Homes. The new
system assigns each nursing home a rating between one and five
stars. Nursing homes with five stars are considered by CMS to
have above average quality compared to other nursing homes in
the state. Those nursing homes assigned one star, according
to CMS, have quality below the state average but still meet
Medicare's minimum requirements.
The overall five-star rating for each nursing home is based on
the star ratings for the following categories:
a) Health Inspections - the health inspections category
contains findings from onsite inspections, including annual
survey visits and complaint investigations for the previous
three years that were conducted to determine whether a
nursing home meets Medicare's minimum requirements for
safety and quality of care;
b) Quality Measures - the quality measures category
contains information on residents collected by nursing
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homes using ten different physical and clinical measures to
try to demonstrate how well nursing homes care for their
residents' physical and clinical needs. Some of the
measures include: the percent of residents with moderate to
severe pain; the percent of residents who have changes in
their ability to move about; and, the percent of residents
with pressure ulcers.
c) Staffing Levels - the staffing levels category includes
information about the average number of hours of care that
is provided by nursing staff to each resident each day.
Nursing home staffing information is collected for
Registered Nurses, Licensed Practical Nurses, Licensed
Vocational Nurses, and Certified Nursing Assistants. This
rating also considers differences in the level of care
residents in different nursing homes need.
4)OTHER NURSING HOME QUALITY RESOURCES . In addition to CMS'
Nursing Home Compare Web site, there are several other Web
sites already in existence which provide information to
consumers using publicly reported data from survey results
based on facility compliance with both federal and state laws
and regulations, such as:
a) DPH's "Health Facility Consumer Information System" Web
site can be accessed at ( www.cdph.ca.gov ) under DPH's
Health Information Page. The purpose of this Web site is
to provide health care consumers and the general public
with information about licensed LTC facilities in
California and provide profile information for each
facility such as ownership, certification status
(acceptance of Medicare and/or Medi-Cal) and performance
history including complaints; reported incidents, state
enforcement actions; and, survey deficiencies.
b) California Advocates for Nursing Home Reform (CANHR)
also posts facility information on their Web site at
http://www.canhr.org/NH_Data/index.html . This Web site is
a database of nursing homes in California. Consumers can
search by name, address, city, or county and find details
on services, staffing, and violations.
c) CHCF, California Nursing Home Search Web site at
http://www.calnhs.org . Provides information regarding
services available at nursing homes in California and
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provides tools to assist with choosing a facility.
d) Healthgrades.com ( http://www/healthgrades.com ) provides
national nursing home data including state inspection
reports, investigated complaints, and analyses of recurring
problems.
5)SUPPORT . Supporters of this bill see requiring skilled
nursing facilities to prominently post quality of care ratings
as a way to provide consumers with enough information to make
a well-informed decision when seeking a nursing home. CANHR
maintains that, despite some concerns with the CMS rating
system, residents deserve to be informed about current ratings
issued by the federal government. Supporters further maintain
that very few nursing home residents have access to the
Internet, so the ratings must be posted within the facility to
give residents access to this information. According to the
Consumer Attorneys of California, this bill also serves to
provide facilities with additional incentives to achieve the
highest possible grade, therein promoting high quality of care
for patients.
6)OPPOSE UNLESS AMENDED . The California Association of Health
Facilities (CAHF) is opposed unless amended to this bill.
While CAHF maintains they are not opposed to the concept of
posting information that could be helpful to the consumer in
determining whether to reside in a particular LTC facility,
according to CAHF, CMS' Five-Star Quality Rating System uses
an arbitrary methodology, including capping the distribution
of stars between facilities in a way that requires 70% of a
state's facilities to receive 3 stars or below, and a reliance
on a defective state survey and certification system. CAHF
argues that the Five-Star Quality Rating System produces
erroneous results that are not subject to review or appeal.
CAHF further argues that the public is not served by hastily
adopting a posting requirement for a rating system that
disseminates inaccurate information. CAHF suggests amendments
that do the following:
a) Provide facilities with more time to respond to a change
in ratings;
b) Provide disclaimer language to provide context for the
rating;
c) Delay the start date for a year to provide CMS to
improve its methodology; and,
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d) Add a sunset date so that the issue of posting can be
revisited some time in the future.
7)OPPOSITION . The California Hospital Association (CHA) states
that while CHA is committed to providing meaningful
information to consumers regarding the quality of patient care
services, CHA's review of the CMS Five-Star Quality Rating
System raises serious concerns about its accuracy and
usefulness, particularly in regards to hospital-based or
distinct-part SNFs. CHA argues that hospital-based SNFs tend
to treat a greater number of more acutely ill and medically
complex patients, and frequently admit patients for brief
transitional stays following acute hospitalization. CHA
further argues that the quality measure element of CMS'
Five-Star Quality Rating System does not adequately adjust for
patient type or for complex health care and specialized care
typically provided in hospital-based SNFs. As a consequence,
according to CHA, a bias is created and hospital-based SNFs
are presented in an unfairly and inaccurately negative light,
not just in terms of the quality measurement element, but also
in an overall rating that is lower than it would be otherwise,
thus substantially undermining the accuracy and utility of the
tool for evaluation of SNFs.
The Aging Services of California argues that small facilities
suffer further from arbitrarily being assigned to the
statewide average when their consensus is too small to be
statistically valid. CHA and Aging Services of California
maintain because the CMS Five-Star Quality Rating System is
not a reliable measure the rating is not of value to consumers
seeking care, therefore, opponents argue, it would be a
disservice to both facilities and consumers to require
facilities to post the rating as required by this bill.
8)RELATED AND PREVIOUS LEGISLATION .
a) AB 773 (Lieu) of 2009 would increase the fine for a
class "B" citation at a LTC facility to an amount not less
than $1,000 and not more than $5,000 for each citation. AB
773 would also increase the fine for a class "AA" citation
at a skilled nursing facility to an amount not less than
$50,000 and not more than $125,000 for each citation, and
the fine for a class "A" citation at a skilled nursing
facility to an amount not less than $5,000 and not more
than $50,000 for each citation. AB 773 is currently in the
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Assembly Health Committee.
b) SB 535 (Kuehl) of 2007, would have required an on-line
information system to be operational by March 1, 2008, to
include specified facility ownership information,
unsubstantiated complaints, deficiencies and citations,
state and federal enforcement actions, and any information
or data beneficial to the public and consumers. SB 535 was
vetoed by Governor Arnold Schwarzenegger who stated in his
veto message that it was duplicative of successful efforts
already underway at DPH and that the information required
by SB 535 could be added administratively.
c) AB 398 (Dymally) of 2007, very similar to SB 535 would
have required DPH to establish and maintain a LTC facility
consumer assistance information system by June 30, 2008.
d) AB 893 (Alquist) Chapter 430, Statutes of 1999, requires
the DPH to make nursing home information accessible to
consumers over the internet.
9)COMMENTS . The CMS' Five-Star Quality Rating System has only
been in operation for a few months. Considering concerns
regarding the CMS methodology raised by both advocates and
nursing home representatives, the author may wish to delay
implementation of mandatory postings for one year to provide
stakeholders an opportunity to work with CMS on improvements
to the system.
REGISTERED SUPPORT / OPPOSITION :
Support
AARP California
Alzheimer's Association
American Federation of State, County and Municipal Employees,
AFL-CIO
Bet Tzedek Legal Services
California Advocates for Nursing Home Reform
California Alliance for Retired Americans
Congress of California Seniors
Consumer Attorneys of California
County of Los Angeles Board of Supervisors
County of San Joaquin, Commission on Aging
Professional Fiduciary Association of California
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Opposition
Aging Services of California
California Hospital Association
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097