BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 2397
AUTHOR: Allen
AMENDED: May 25, 2012
HEARING DATE: June 27, 2012
CONSULTANT: Marchand
SUBJECT : Mental health: state hospitals: ancillary clinical
staff-to-patient ratios.
SUMMARY : Requires the Department of Mental Health (DMH) to
contract with an entity for the purposes of conducting a review
and analysis of staffing ratios to determine the appropriate
levels for effective patient treatment.
Existing law:
1.Charges DMH with jurisdiction over the execution of laws
relating to the care, custody, and treatment of mentally
disordered persons, including administration of five state
hospitals for the mentally ill.
2.Requires the Department of Public Health (DPH) to adopt
regulations that establish minimum, specific, and numerical
licensed nurse-to-patient ratios, by licensed nurse
classification and by hospital unit, for hospitals, and
requires these ratios to constitute the minimum number of
registered and licensed nurses that must be allocated.
This bill:
1.Requires DMH, to the extent permitted by the California
Constitution and specified provisions of law governing
personal services contracts, to reimburse an entity for the
purposes of conducting a review and analysis of staffing
ratios to determine the appropriate levels for effective
patient treatment.
2.Requires DMH to provide information to this entity as
necessary for it to complete its analysis and to provide
recommendations.
3.States the intent of the Legislature that DMH requests the
independent entity to complete this analysis by March 1, 2013.
4.Requires a report to be submitted to the Legislature by August
Continued---
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1, 2013, regarding the independent entity's findings to ensure
state hospitals are making progress and to enable the
Legislature to consider further action that may be necessary
during the subsequent legislative year.
5.Requires the report required in 4) above to be submitted in
compliance with specified provisions of law governing how
reports are to be made to the Legislature.
6.Sunsets the provisions of this bill on January 1, 2015.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, one-time costs of at least $300,000 General Fund for
an independent analysis of staffing ratios
PRIOR VOTES :
Assembly Health: 14- 5
Assembly Appropriations:12- 5
Assembly Floor: 51- 22
COMMENTS :
1.Author's statement. This bill will help establish minimum
clinical staff-to-patient ratios in each of the five state
hospitals to ensure adequate mental health treatment as well
as minimal standards for a safe working and living environment
for staff and patients.
On May 8, 2006, the United States and the State of California
entered into a consent judgment that required reforms in the
state hospitals to ensure that patients received basic safety
and treatment as required by the United States Constitution
and other federal laws. Some of the major reforms required in
the judgment included improvements to integrated therapeutic
and rehabilitation services in the areas of psychiatric,
psychological, nursing, nutrition, medical, dental, and
special education services as well as discharge planning and
integration, and protection from harm.
In the background of the horrifying conditions that led to the
federal consent judgment are the equally horrifying safety
conditions at the hospitals. Recent reports by the Los Angeles
Times, New York Times, and other papers highlighted by the
tragic death of an employee in October of 2010 at Napa State
Hospital and the brutal beating of another employee just six
weeks later at the same facility, have highlighted the
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inherent danger for both patients and staff at our state
hospitals.
AB 2397 is necessary to establish appropriate clinical staff
caseloads to ensure stability in treatment and safety. Simply
put, reducing staff levels jeopardizes the treatment required
under the federal consent judgment, opens the door for renewed
federal involvement and possibly federal receivership, and
will erode the minimal safety improvements made over the last
fifteen months.
2.Background on state hospitals, and reports required by 2012-13
Budget Act. According to DMH, it operates five state
Hospitals: Atascadero, Coalinga, Metropolitan (in Norwalk),
Napa, and Patton (in San Bernardino County). Additionally, DMH
operates two Psychiatric Programs located at state prison
facilities in Salinas Valley and Vacaville Correctional
Medical Facility. A third Psychiatric Program, at the
Correctional Health Care Facility in Stockton, is slated to
open in July 2013.
The Governor's budget plan included a proposal to eliminate
DMH and create a new Department of State Hospitals (DSH),
shifting the remaining community mental health programs to
various departments. The recently passed 2012-13 Budget Act,
AB 1464 (Blumenfield), adopted this proposal. AB 1464 also
contained language directing the new DSH to reimburse the
Office of State Audits and Evaluations (OSAE) within the
Department of Finance to review its prior audit report of DMH,
and determine the status of implementation of its
recommendations by DMH or its successor, DSH. AB 1464 also
requires DSH, prior to contracting with OSAE, to further
define the scope of the audit in consultation with the
Legislature. DSH was directed by intent language to notify
OSAE that it should proceed with the audit during the fall of
2012, and OSAE is required to submit its audit to the
Legislature by April 1, 2013 in order for the Legislature to
consider what further actions may need to be taken for the
following fiscal year. AB 1464 additionally required DSH to
submit a year-end summary report to the Department of Finance
and the legislative budget committees comparing each
institution's expenditures to its approved allotments for the
2012-13 fiscal year. This year-end summary report is required
to include the number of authorized and vacant positions, and
the clinical and ancillary physician staffing ratios being
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implemented for that fiscal year.
Finally, AB 1470 (Committee on Budget), the DSH trailer bill
passed by the Legislature on June 15, contained legislative
intent language stating that any changes in staffing ratios at
the state's mental hospitals address adequate staff and
patient safety standards, and that staffing ratios may vary
based on patient acuity.
3.Staffing ratios currently in place at state hospitals. DMH
states that its policy is to require a nursing
staff-to-patient ratio of 1 licensed nurse to 8 patients for
the day and afternoon shifts, and 1 licensed nurse for 16
patients for the night shift. DMH states that in addition to
the nursing ratios, there are also staff-to-patient ratios for
patient treatment teams, which are established pursuant to
national standards of mental health practice, and are based on
the acuity of the patient. A treatment team consists of a
psychiatrist, a psychologist, a social worker, a
rehabilitation therapist, a registered nurse, and a
psychiatric technician. However, DMH states that registered
nurses and psychiatric technicians fall under the nursing
ratios, and are not counted in the patient treatment team
ratios. For patients classified as requiring acute care, a 1
to 15 staff-to-patient ratio is followed for treatment team
staff, and for patients classified as intermediate care, this
ratio is 1 to 35 for treatment team staff.
4.Legislative Analyst's Office report and OSAE audit on state
hospitals. According to a March 2012 Legislative Analyst's
Office report entitled "2012-13 Budget: Oversight and
Accountability at State Hospitals" (LAO Report), over the last
10 years, changes in policies and patient demographics forced
state hospitals to adjust their staffing, mental health care
delivery model, and other aspects of state hospital
operations. The major changes include: (1) a rise in the
number of sexually violent predator commitments; (2) the
implementation of the Civil Rights of Institutionalized
Persons Act consent decree, requiring state hospitals to
reform their practices; and (3) an increase in "forensic"
commitments (those with mental illness who are involved in the
court system). The LAO Report pointed to the audit conducted
in 2008-09 by the OSAE within the Department of Finance, which
concluded that the staffing model did not adequately reflect
hospital workload, funding was not sufficient for annual
operating expenditures, and that state hospitals were not
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efficiently using their staff. The LAO Report agreed with
this audit and with a more recent self-audit in which DMH
found many of the same problems. The LAO Report recommended
that an audit be conducted that looks at a number of issues,
including state hospital budgeting practices, the fiscal
controls being put in place, and the level of vacancies and
their impact on the state budget and on hospital performance.
The LAO Report stated that this added oversight with respect
to state hospitals should take place regardless of the
Legislature's decision on the creation of a new DSH.
5.Prior legislation. AB 394 (Kuehl), Chapter 945, Statutes of
1999, required DPH to adopt regulations specifying
nurse-to-patient ratios, by unit, for general acute care
hospitals, acute psychiatric hospitals and special hospitals.
However, AB 394 prohibited these regulations from replacing
existing licensed staff-to-patient ratios for hospitals
operated by DMH.
6.Support. This bill is supported by the American Federation of
State, County and Municipal Employees, AFL-CIO (AFSCME), which
points to the murder of a psychiatric technician at Napa State
Hospital in 2010. AFSCME states that DMH has failed to adjust
to the fact that over the years, the state hospital population
has shifted to include mostly forensic commitments, including
many violent offenders. According to AFSCME, DMH is proposing
to reduce the number of treatment staff working in each
hospital as part of the transition to a newly created DSH.
AFSCME asserts that cutting treatment staff all but guarantees
a continued increase in the number of violent attacks on
workers and patients. The National Association of Social
Workers also supports this bill, stating that maintaining a
minimum ratio of ancillary staff to patients will improve the
quality of mental health services, increase rehabilitation,
and promote a safer atmosphere for patients and staff. The
California Psychological Association states that this bill is
a step in the right direction in providing a better
environment for state-employed psychologists.
7.Policy comment. This bill requires DMH to reimburse an
independent entity for purposes of conducting a review and
analysis of appropriate staffing levels. The bill states the
intent of the Legislature that the analysis be completed by
March 1, 2013, and requires DMH to submit a report to the
Legislature on August 1, 2013 on the independent entity's
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findings. Given that the 2012-13 Budget Act requires a new
OSAE audit to be submitted to the Legislature by April 1, 2013
(see background in comment #2 above), and requires DSH to
refine the scope of this audit in consultation with the
Legislature, the author may wish to consider combining the
staffing analysis required by this bill with the OSAE audit,
as well as conform the timeline to the April 1, 2013 due date
of the OSAE audit.
8.Technical amendment. The 2012-13 Budget Act eliminated DMH,
and replaced the governance of state hospitals with the new
DSH. The references in this bill to DMH should instead refer
to DSH.
SUPPORT AND OPPOSITION :
Support: American Federation of State, County and Municipal
Employees (co-sponsor)
Union of American Physicians and Dentists (co-sponsor)
California Psychological Association
National Association of Social Workers, California
Chapter
Oppose: None received.
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