BILL ANALYSIS �
AB 2397
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Date of Hearing: May 9, 2012
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Felipe Fuentes, Chair
AB 2397 (Allen) - As Amended: April 24, 2012
Policy Committee: HealthVote:14-5
Urgency: No State Mandated Local Program:
No Reimbursable: No
SUMMARY
This bill requires minimum staff-to-patient ratios at state
hospitals. Specifically, this bill:
1)Requires minimum ancillary clinical staff-to-patient ratios of
1:25, except for admissions teams which are required to
maintain ratios of 1:15, at any point in time, for each
applicable staff classification.
2)Bases ratios on each facility's licensed bed capacity, with a
shift relief factor of 0.2.
3)Defines ancillary clinical staff as a treating psychiatrist,
psychologist, rehabilitation therapist, or social worker.
4)Requires the Department of Mental Health (DMH) to reimburse an
independent entity to conduct a review and analysis of
staffing ratios to determine the appropriate levels for
effective patient treatment.
FISCAL EFFECT
1)Ongoing costs of $60 million GF, based on a comparison between
DMH's current staffing levels and those required by this bill.
2)One-time costs of at least $300,000 GF for an independent
analysis of staffing ratios.
COMMENTS
1)Rationale . According to the author, this bill would establish
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minimum ancillary clinical staff-to-patient ratios of 1:25 in
each of the five state hospitals to ensure adequate mental
health treatment as well as minimum safety standards for staff
and patients. The author argues that reducing clinical staff
levels jeopardizes the treatment required under the federal
consent judgment, opens the door for renewed federal
involvement and possibly federal receivership, and erodes the
minimal safety improvements made over the last 15 months.
2)Background . State hospitals have come under increasing
scrutiny based on high levels of aggression and violence that
puts staff at risk of injury and death, as well as budget
deficiencies that have occurred in recent years. A DMH
self-audit released in December identified a litany of
problems with management, safety, and fiscal accountability.
The governor's 2012-13 budget for DMH proposes reforms and
savings measures designed to improve mental health outcomes,
increase worker and patient safety, and ensure fiscal
transparency and accountability within a limited budget. As
one of the savings measures, DMH proposed changing staffing
ratios for intermediate acuity level patients from 1:25 to
1:35. DMH proposes to maintain staffing levels of 1:15 for
admissions teams and high-acuity patients.
These budget proposals come in the wake of a tumultuous
reassessment of a federal court-ordered plan to improve
patient treatment at state hospitals. Starting in June 2002,
the U.S. DOJ conducted on-site reviews of the state hospitals
and found significant deficiencies with California's
compliance with Civil Rights of Institutionalized Persons Act
(CRIPA). In 2006, the United States Department of Justice and
the state reached a settlement, through a consent judgment,
which required four out of five state hospitals to implement
an "Enhancement Plan" (EP) to improve conditions. The EP
focused on implementing a recovery-oriented model of care with
a reduction in the use of seclusion and restraint,
improvements in staff and patient safety, and improvements in
clinical measures. The EP has resulted in some improvements,
but there remain problems in many of the areas targeted for
improvement. These problems were addressed in the audit
referenced above, which formed the basis for the governor's
2012-13 budget proposal.
3)Staffing Ratios . According to DMH, a 1:25 ratio for the staff
addressed by this bill was used under the enhancement plan to
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improve treatment and bring California into compliance.
However, DMH argues this ratio was put in place to stabilize
patients, improve conditions, and handle increased
documentation requirements on a temporary basis. They
maintain improvements have been made, that two of the four
hospitals are already in compliance, and that as the state
satisfies federal requirements in all hospitals, clinical
staff will have more time to spend with patients as the
significant burden of EP-related paperwork and documentation
will no longer be necessary.
4)Fiscal Concerns .
a) This bill does not allow the minimum ratio to vary based
on acuity of the patients. Is funding a minimum ratio of
1:25 appropriate for each staff classification an
appropriate use of funds, regardless of the acuity level of
patients?
b) The ratios are based on each facility's licensed bed
capacity, not on the actual number of patients housed at
the facility. The reason for tying a ratio to licensed
beds and not patients is unclear. For example, Coalinga
state hospital has 500 more licensed beds than patients.
As currently drafted, this bill appears to require hiring
20 more of each ancillary clinical staff classification
because of the 500 empty beds.
c) There do not appear to be widely accepted numbers on
what constitutes an acceptable minimum ratio. Recent
amendments to this bill acknowledge this fact, and require
an independent review of appropriate staffing levels.
Whether the minimum staffing level in this bill would in
fact improve patient safety, given current severe fiscal
constraints, is not clear. Implementing this ratio commits
the state to certain levels of expenditure for staffing and
would limit the state's options with respect to the ability
to fund other measures that could improve safety, such as
facility redesign or additional hiring security staff.
Analysis Prepared by : Lisa Murawski / APPR. / (916)
319-2081
AB 2397
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