BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 215
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AUTHOR: Feuer
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AMENDED: April 21, 2009
HEARING DATE: June 17, 2009
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CONSULTANT:
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Bain/
5
SUBJECT
Long-term health care facilities: ratings
SUMMARY
Requires a long-term health care (LTC) facility that
provides skilled nursing care to post, in accordance with
specified requirements, the overall facility rating
information determined by the federal Centers for Medicare
and Medicaid Services (CMS).
CHANGES TO EXISTING LAW
Existing law:
Existing law defines long-term health care facilities to
include skilled nursing facilities, intermediate care
facilities, congregate living facilities, nursing
facilities, and pediatric day health and respite
facilities.
Existing law requires the Department of Public Health (DPH)
to develop and establish a consumer information service
system to provide updated and accurate information to the
general public and consumers regarding long-term care
facilities in their communities that includes an on-line
inquiry system accessible through a toll-free phone number
and through the internet, that includes long-term care
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facility profiles, and information regarding substantiated
complaints and state citations assessed.
Under existing law, the Long-Term Care, Health, Safety, and
Security Act of 1973, DPH can assess penalties for
violations of prescribed state and federal requirements.
Violations are classified based on the nature of the
violation, and class "B" citations are subject to a civil
penalty between $100 and $1,000, per citation.
Money collected as a result of state and federal civil
penalties imposed under the existing state Long-Term Care,
Health, Safety, and Security Act of 1973, or federal law,
must be deposited into the State Health Facilities Citation
Penalties Account (State Account), which contains money
collected from violations of state law, or the Federal
Account, which contains money collected from violations of
federal law.
This bill:
Requires, effective January 1, 2011, 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 in accordance with
specified requirements.
Requires the information to be posted in at least an area
accessible and visible to members of the public, an area
used for employee breaks, and in an area used by residents
for communal functions, such as dining, resident council
meetings, or activities.
Requires the posted information to meet specified
requirements relating to the size, font and paper size,
including requiring the information to include the full
name and address of the facility and the most recent
overall star rating given by CMS to that facility, except
that a facility is required to have seven business days
from the date when it receives a different rating from the
CMS to include the updated rating in the posting.
Requires the star rating to be 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. Directly below the number, the same number of star
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symbols is required of a size of at least one-half inch
print with text in at least 30 point font stating "The
above number of stars is out of five stars."
Requires the rating to be aligned in the center of the
page, to be in a clear and easily readable font, and to
include a specific written disclosure about the rating,
with information on where more information can be obtained
about the rating.
Requires a copy of the most recent CMS report on the
facility to be maintained at the facility, and to be made
available to residents or the public upon request.
Requires a violation of this bill to constitute a class "B"
violation, prohibits a violation from constituting a crime,
and requires fines from a violation of this bill to be
deposited into the State Health Facilities Citation
Penalties Account.
FISCAL IMPACT
According to the Assembly Appropriations Committee, annual
fee-supported special fund costs to DPH of less than
$50,000 to continue oversight of skilled nursing facilities
and ensure compliance with the specific requirements of the
posting in this bill.
BACKGROUND AND DISCUSSION
According to the author, this bill is designed to help
ensure greater awareness of information about nursing homes
that can then be considered by current residents, potential
residents, and families considering placing their relatives
in nursing homes. The author argues a requirement to post
the federal five-star ratings will ensure that more
consumers have access to information that is already
available online. The author states that because many
consumers do not have access to the Internet or do not know
how to access the CMS information online, requiring the
posted rating will make the information more accessible to
them in their search for a nursing home. Further, many
consumers who are unaware of the rating system could learn
of its existence through the posting, and could access more
detailed information about the system by requesting it at
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the facility.
The author states there is a large amount of information
available about nursing home quality on websites, but the
information is not always formatted to be easily readable
or understandable to consumers, and there is little
guarantee that family members who walk into a nursing home
are aware of these guides or the five-star rating. The
author argues the federal rating system is the national
standard that has detailed information about every Medicare
and Medicaid-certified nursing home in the country, and it
distills detailed information about health inspection
reports, staffing, and quality measures into a quickly
recognizable, easily readable format with the intent of
encouraging and motivating potential and future residents
and their families to ask why a facility has been assigned
a particular rating. The author concludes that the
information is designed to be a starting point for
consumers to ask questions about quality of care, and
posting this information in facilities will allow more
consumers to be aware of the rating system and will give
them easy access to a particular nursing home's rating and
rating explanation.
CMS facility rating information
The CMS "Five-Star Quality Rating System" is located on the
CMS Nursing Home Compare website. It was created to help
consumers, their families, and their caregivers compare
nursing homes more easily and help identify areas where
patients and their families and caregivers may want to ask
further questions. The nursing homes that are shown on
Nursing Home Compare are certified to participate in
Medicare and/or Medi-Cal. Nursing home ratings are taken
from the following three sources of data:
Health Inspections - Measures based on outcomes from
state health inspections for federal standards: Facility
ratings for the health inspection domain are based on the
number, scope, and severity of deficiencies identified
during the three most recent annual inspection surveys,
as well as substantiated findings from the most recent 36
months of complaint investigations. Deficiency findings
are weighted by scope and severity, and take into account
the number of re-visits required to ensure that
deficiencies identified during the health inspection
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survey have been corrected.
Staffing - Measures based on nursing home staffing
levels: Facility ratings on the staffing domain are
based on two measures: 1) registered nurse hours per
resident day; and 2) total staffing hours per resident
day derived from the CMS Online Survey and Certification
Reporting (OSCAR) system, and are case-mix adjusted.
Quality Measures - Facility ratings for the quality
measures are based on performance on 10 of the 19 quality
measures currently posted on the Nursing Home Compare
website, and include seven long-stay measures and three
short-stay measures. Examples of the quality measures
include the percentage of long-term stay residents who
needed help with daily activities has increased, whose
ability to move about in and around their room got worse,
the percentage of long stay residents given pneumonia and
flu vaccines, the percentage of residents with moderate
to severe pain, bed sores, who are physically restrained,
who have urinary tract infections, and who had a catheter
inserted and left in their bladder.
CMS provides a star rating for each of these three sources,
and the three ratings are combined to calculate an overall
rating that gives a "snap shot" of the care individual
nursing homes provide.
Required part of posted rating
The notice required by this bill must have the following
statutorily required language stating the following:
This facility is reviewed annually and has been
licensed by the State of California and certified by
the federal Centers for Medicare and Medicaid Services
(CMS). CMS rates facilities that are certified to
accept Medicare or Medicaid. CMS 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 Compare
Internet Web site at
http://www.medicare.gov/NHcompare. Like any
information, the Five-Star Quality Rating System has
strengths and limits. The criteria upon which the
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rating is determined may not represent all of the
aspects of care that may be important to you. You are
encouraged to discuss the rating with facility staff.
The Five-Star Quality Rating System was created to
help consumers, their families, and caregivers compare
nursing homes more easily and help identify areas
about which you may want to ask questions. Nursing
home ratings are assigned based on ratings given to
health inspections, staffing, and quality measures.
Some areas are assigned a greater weight than other
areas. These ratings are combined to calculate the
overall rating posted here.
Arguments in support
Senior and nursing home advocacy groups write in support
that residents and family members should have access to as
much information about each long-term care facility as
possible, and posting the CMS rating in a public area
allows individuals to view one piece of critical
information needed to make determinations about the home,
and will help ensure individuals are aware of the federal
rating and have access to critical information that is only
available online. Additionally, supporters argue the
posting of the federal rating will provide additional
incentives to achieve the highest possible grade thereby
promoting high quality care for patients.
Arguments in opposition
Crestwood Behavioral Health, Inc. (CBH), a provider of
mental health and neurobehavioral services, writes that it
is opposed to this bill unless it is amended to exempt SNFs
that are special treatment programs (SNF-STP) from the
provisions of this bill. CBH writes that California has 28
facilities with approximately 2,500 beds that are licensed
and certified as SNF with a STP certified by the Department
of Mental Health to provide services to the mentally ill.
CBH argues that SNF-STPs have unique resident populations,
services and staffing standards, and the information
provided by the CMS rating system will not provide
meaningful information about staffing or the quality of
services provided by a SNF-STP because the amount and type
of staffing is different in these facilities from
traditional SNFs. Additionally, CBH writes the quality
measures of the five-star system are based on physical and
clinical measures targeted at elderly residents and are not
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applicable to residents in SNF-STPs needing psychosocial
rehabilitation who are generally younger and more
ambulatory. Finally, CBH argues the purpose of this bill
is to provide consumers and their family members with
useful information about choices in long-term care
services, and admission to a SNF-STP is rarely arranged by
a family member as these facilities contract with counties
who make referrals for admission, usually through a
conservator.
Previous legislation
AB 893 (Alquist), Chapter 430, Statutes of 1999, required
the Department of Health Care Services (now DPH) to post
information on long-term care facilities on the Internet,
and required additional information about facilities to be
provided, including whether the facility accepts Medi-Cal
and Medicare, the number of beds and information regarding
state citations assessed, including the status of the state
citation, the facility's plan of correction and information
as to whether an appeal has been filed.
SB 1312 (Alquist), Chapter 895, Statutes of 2006, contained
a number of provisions related to long-term care facilities
and health facilities, including requiring DPH to inspect
health facilities for compliance with provisions of state
law and regulations during a state or federal periodic
inspection.
SB 535 (Kuehl) of 2008 would have required the DPH website
to include additional information about health facilities,
including information describing federal enforcement
sanctions imposed, including, but not limited to, any
denial of payment, temporary management, termination, or
any civil monetary penalty imposed and information on
compliance with staffing ratio requirements. SB 535 was
vetoed by Governor Schwarzenegger. In his veto message,
the Governor stated the bill was duplicative of successful
efforts already underway at DPH, the DPH website currently
provides information to the public on licensed facilities,
their performance and all enforcement actions, and
additional information required by this bill can already be
added administratively.
AB 398 (Feuer) of 2008 would have required the DPH website
to include additional information about long-term care
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facilities, including a categorical representation of the
percentile ranking of the facility compared to all other
comparable facilities in regard to staffing, deficiencies
and complaints (based on state and federal deficiencies),
spending on resident care per day and the financial status
of the facility. AB 398 was vetoed by Governor
Schwarzenegger. In his veto message, the Governor stated
the bill was premature, overly prescriptive, and would
result in increased state costs. The Governor continued
that efforts underway by DPH will produce a consumer
website so the public can easily access facility licensing
violations, and he directed DPH to consider expanding the
website under development to include data required by this
bill unless doing so would substantially increase costs or
delay development of the website.
COMMENTS
1. CMS rating based on federal standards. This CMS rating
system required to be posted by this bill is based on
health inspections, staffing and quality measures. These
measures are based on federal, but not state standards.
There are several tools to provide information on nursing
homes, including websites maintained by the California
HealthCare Foundation (CHCF) and DPH. DPH's Health
Facilities Consumer Information System website provides
information about licensed long-term care facilities and
hospitals throughout California, including profile
information for each facility such as ownership,
certification status (acceptance of Medicare and/or
Medi-Cal) and performance history including complaints;
entity reported incidents, state enforcement actions, and
survey deficiencies. The CHCF website contains a
three-star rating that incorporates state and federal data
on deficiencies resulting from inspections.
2. Operative date and required part of posting. The
current version of this bill contains provisions that
removed the opposition of Aging Services of California, the
California Association of Health Facilities (CAHF), and the
California Hospital Association. These groups objected to
the use of the CMS five-star rating as an arbitrary
methodology which requires 70 percent of a state's health
facilities to receive three stars and below for the health
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inspection domain, and its reliance on the survey and
inspection system for that domain. CAHF requested an
extension of the operative date of the required posting to
allow its national association to work with CMS to address
the flaws in the methodology. The current version of this
bill delays the operative date of the required posting to
January 1, 2011 and requires the posting to include
information about the rating system, including where to
obtain more information and to encourage readers to discuss
the rating with facility staff.
3. Amendments needed to ensure posted rating fits on one
page. This bill establishes minimum font sizes for the
required posting. However, the font sizes specified make
the posting longer than one page. The author will be
proposing amendments to ensure the posted information can
be included on one page.
PRIOR ACTIONS
Assembly Floor: 65-11
Assembly Appropriations: 13-0
Assembly Health: 13-4
POSITIONS
Support: California Advocates for Nursing Home Reform
(CANHR)
Contra Costa County Advisory Council on Aging
Los Angeles County Board of Supervisors
Support (prior version):
AARP California
American Federation of State, County and
Municipal Employees, AFL-CIO
Bet Tzedek Legal Services
California Alliance for Retired Americans
California Senior Legislature
Congress of California Seniors
Consumer Attorneys of California
Los Angeles County Board of Supervisors
San Joaquin County Commission on Aging
National Union of Healthcare Workers
Professional Fiduciary Association of California
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Oppose (prior version):
Crestwood Behavioral Health (unless amended)
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