BILL ANALYSIS �
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 177
S
AUTHOR: Strickland
B
AMENDED: As Introduced
HEARING DATE: April 13, 2011
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CONSULTANT:
7
Hansel
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SUBJECT
Congregate living health facilities
SUMMARY
Raises the bed limit for congregate living health
facilities that serve terminally ill patients in counties
that have populations of more than 400,000, but less than
500,000, persons.
CHANGES TO EXISTING LAW
Existing law:
Provides for the licensure and regulation of health
facilities, including hospitals, skilled nursing
facilities, and congregate living health facilities
(CLHFs).
Under current law, a CLHF is defined as a residential home
with a capacity of no more than 12 beds, that provides
inpatient care, medical supervision, 24-hour skilled
nursing and supportive care, and other services to persons
who meet one of the following:
Persons who are mentally alert who have physical
disabilities, who may be ventilator dependent;
Continued---
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Persons who have a diagnosis of terminal illness,
or life-threatening illness, or both, as defined; or
Persons who are catastrophically and severely
disabled, as defined.
Notwithstanding the 12-bed limit, provides that a CLHF that
is operated by a city and county may have 59 beds, and
provides that a CLHF that is not operated by a city and
county that serves persons who have a diagnosis of terminal
illness or life-threatening illness, or both, that is
located in a county of 500,000 or more persons, may have
not more than 25 beds.
Provides that the primary need of CLHF residents shall be
for skilled nursing care on a recurring, intermittent,
extended, or continuous basis, and provides that this care
is generally less intense than that provided in general
acute care hospitals but more intense than that provided in
skilled nursing facilities.
Provides for the licensure and regulation by the Department
of Public Health (DPH) of persons or agencies that provide
hospice services in a person's home or other care setting,
defined as a specialized form of interdisciplinary health
care that is designed to provide palliative care, alleviate
the physical, emotional, social, and spiritual discomforts
of an individual diagnosed with a terminal illness, and
provide supportive care to the primary caregiver and the
family.
This bill:
Provides that a CLHF that is not operated by a city and
county, that serves persons who have a diagnosis of
terminal illness, or life-threatening illness, or both,
that is located in a county of 400,000 or more persons may
have not more than 25 beds. This would allow counties that
have population between 400,000 and 500,000 persons to site
CLHFs at the higher 25-bed limit. According to current
population estimates, five counties currently fall into
this category: Monterey, Santa Barbara, Solano, Sonoma,
and Tulare.
FISCAL IMPACT
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This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
According to the author, SB 177 would extend the higher
CLHF bed limits that apply to counties with populations of
500,000 or more persons, to counties with populations above
400,000. This change would increase the maximum number of
patient beds allowable under the CLHF regulations for the
purpose of serving persons who are terminally ill or have
been diagnosed with a life-threatening illness.
The author states that Santa Barbara County currently has
only one licensed CLHF facility, Serenity House, which is a
six bed facility operated by the Visiting Nurse and Hospice
Care of Santa Barbara (VNHC). It has become clear that
additional end-of-life beds are required to satisfy the
growing needs of the county's aging population. Between
2008 and 2009, Serenity House saw a 71 percent increase in
the number of patients served, and has developed a growing
waiting list due to a lack of available beds for
end-of-life patients.
The author states that without the enactment of SB 177, a
new Serenity House facility, which is scheduled for opening
in May 2011, will have to operate as a 12-bed facility.
Enactment of SB 177 will allow the six additional beds to
become operative in January 2012 and thus provide more
critical hospice bed capacity to the Santa Barbara region
of the central coast.
CLHFs that serve terminally ill persons
CLHFs are residential-based care facilities that provide
inpatient care, medical supervision, 24-hour skilled
nursing and supportive care, and other services to one of
three categories of persons: (1) Persons who are mentally
alert who have physical disabilities, who may be ventilator
dependent; (2) Persons who have a diagnosis of terminal
illness, or life-threatening illness, or both; or (3)
Persons who are catastrophically and severely disabled.
According DPH, 53 CLHFs are currently licensed in
California to provide services to these populations. Of
these, 12 serve terminally ill patients. CLHFs that serve
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terminally ill patients are sometimes referred to as
CLHF-Bs, which denotes the subparagraph of the statute that
refers to them.
Hospice services that are provided to terminally ill
patients and their families generally fall into four
categories or levels of care - routine home care,
continuous home care, inpatient respite care, and general
inpatient care. Routine home care and continuous home care
services are generally provided in the patient's home,
which can include a licensed health or residential care
facility that they reside in. CLHF-Bs can provide this
level of care, when it is not feasible for a patient to be
cared for at home. When a hospice patient needs an
inpatient level of care, either to provide respite to
family members or due to a need for 24-hour pain control
and symptom management, hospice service providers generally
must arrange to place the patient in a licensed health
facility, such as a hospital, skilled nursing facility or
CLHF-B.
Several hospice service providers currently operate their
own facilities to accommodate hospice patients with these
higher levels of needs. One currently operates a special
hospital in San Diego with 24 beds, which is operating
under a pilot project that was established in 1980. Eleven
hospice service providers operate CLHF-Bs to serve patients
who need inpatient care.
Bed limits and county size
In order to provide options for providing care to
chronically ill patients outside of hospitals, CLHFs were
established as a category of licensed health facilities in
1986. CLHFs were initially limited to having no more than
six beds and were limited to serving mentally alert,
physically disabled residents, who can be
ventilator-dependent. In 1988, a second category of CLHFs
was authorized to provide 24-hour inpatient care to
terminally ill patients. These facilities were allowed to
have 25 beds in counties which have a population of 500,000
or more persons. In 1989, a third category of CLHFs was
established, to serve persons who are catastrophically and
severely disabled, which were allowed to have 12 beds in
counties with more than 500,000 persons. In 2005,
legislation was enacted which raised the bed-size limit for
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CLHFs in all counties to 12 beds, while retaining the
higher 25-bed limit for CLHFs serving terminally ill
patients in counties with more than 500,000 persons.
The impetus for the 1988 legislation establishing the new
CLHF category for terminally ill patients, with a bed limit
of 25 in counties with over 500,000 persons, was to enable
a proposed 25-bed hospice facility serving persons with
AIDS, which was proposed to be operated by Barlow Hospital
in Los Angeles, to be licensed as a CLHF.
Serenity House in Santa Barbara County
In 1994, Visiting Nurse and Hospice Care (VNHC), a
nonprofit provider of hospice services, opened Serenity
House, a six-bed, Medicare-certified CLHF-B serving Santa
Barbara and Ventura counties. Because it is the only
similar facility in Santa Barbara County, VNHC states that
the facility generally has a waiting list of 8 to 12
patients. In 2004, VNHC initiated a community needs study
to determine if the community needed more hospice facility
beds. Based on that study, VNHC decided in 2005 to build a
new 18-bed facility, which it began construction on in
2009. Serenity House representatives state that while they
were aware of the 12 bed limit that applied to CLHF-Bs in
counties with population below 500,000, which includes
Santa Barbara, they believed that it would be possible to
get a waiver from DPH to operate at the larger bed-size.
While DPH does have authority to grant program flexibility
to waive or modify certain requirements that apply to
health facilities, including CLHFs, it cannot modify or
waive the bed limits in statute. As a result, VNHC plans
to serve 12 patients in the new facility, but will expand
that to 18 if SB 177 or another bill is enacted that raises
the bed limit. VNHC plans to transfer patients from its
existing six-bed facility and to close the existing
facility at the end of 2011.
VNHC could have built a second 12-bed facility, which in
conjunction with its existing six-bed facility, would have
provided the same total number of beds for the area as a
single 18-bed facility. However, it concluded, based on
research of hospice facilities across the country, that
efficiently run facilities have 16 to 24 beds. Because of
the need to maintain two staffs at two facilities, have two
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directors, and maintain two grounds, VNHC concluded that a
single 18-bed facility would be more efficient to operate
than two separate facilities.
The new facility was built to comply with I-1 building
standards, as promulgated in the 2007 edition of the
California Building Code. Those standards apply to
buildings housing clients on a 24 hour basis, who because
of age, mental disability or other reasons, live in a
supervised residential environment that provides personal
care services. This occupancy may contain more than six
non-ambulatory and/or bedridden clients, and includes
Residential Care Facilities, Residential Care Facilities
for the Elderly (RCFEs), Congregate Living Health
Facilities, Group homes, Residential Care Facilities for
the Chronically Ill, and CLHF-Bs serving terminally ill
patients. In October 2010, the Office of Statewide Health
Planning and Development (OSHPD) issued a letter to Senator
Alquist, the previous chair of the Senate Health Committee,
stating that the building came under its jurisdiction and
needed to meet construction standards applicable to skilled
nursing facilities or hospitals. After further review,
OSHPD concluded in January 2011 that it did not have
jurisdiction over the building and that it was subject to
local building jurisdiction under the California Building
Code.
Related bills
SB 135 (Hernandez) creates a new health facility licensing
category, and requires DPH to develop regulations for,
hospice facilities, as defined. Imposes various
requirements on these facilities. Provides that DPH may
use specified federal regulations as the basis for hospice
facility licensure until it adopts regulations.
SB 804 (Corbett) requires the Department of Health Care
Services to allow CLHFs, as defined, that solely provide
pediatric subacute care services and do not provide
Medicare services, to participate in the Medi-Cal subacute
care program.
Prior legislation
AB 950 (Hernandez) of 2009-10 Session was substantially
similar to SB 135. Held under submission in Senate
Appropriations Committee.
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AB 2523 (Nava) of 2009-10 Session, in its final amended
form would have made the same changes as SB 177. Died in
Senate Rules Committee.
SB 1164 (Corbett) of 2009-10 would have required the
definition of CLHF to include facilities that provide
services to children who have a diagnosis of terminal
illness or a diagnosis of life-threatening illness.
Referred to Senate Health Committee, hearing canceled at
the request of the author.
SB 666 (Aanestad), Chapter 443, Statutes of 2005, increases
the capacity of a CLHF from no more than six beds to no
more than 12 beds. Maintains an exception to allow CLHFs
which serve terminally ill patients and which are located
in counties with 500,000 or more persons to have 25 beds.
AB 3535 (Wright), Chapter 1459, Statutes of 1986, created
the CLHF licensure category, and defined a CLHF as a
residential home with a capacity of no more than six beds,
which provides inpatient care to mentally alert, physically
disabled residents, who may be ventilator dependent.
AB 4536 (Polanco), Chapter 1478, Statutes of 1988, created
a second category of CLHFs, to provide 24-hour inpatient
care to terminally ill patients. These facilities were
allowed to have 25 beds in counties which have a population
of 500,000 or more persons.
AB 68 (Polanco), Chapter 1393, Statutes of 1989,
established a third category of CLHFs, to serve persons who
are catastrophically and severely disabled, which were
allowed to have 12 beds in counties with more than 500,000
persons.
Arguments in support
VNHC, the sponsor of SB 177, states that as the only
licensed hospice inpatient facility in Santa Barbara
County, Serenity House has struggled to meet demands for
end-of-life beds. Between 2008 and 2009, Serenity House
saw a 71 percent increase in the number of patients served
and has a growing waiting list due to the lack of available
beds for end of life patients. VNHC states that based on
current population projections, the number of people over
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the age of 65 in Santa Barbara County will increase by 24
percent by 2050. While VNHC acknowledges that it made an
error in assuming it would be able to build an 18-bed
facility, because it believed that a waiver or exception
process existed to allow it to operate at the higher
bed-size, VNHC states that the need for additional
end-of-life beds continues to be critical in Santa Barbara
County and SB 177 will enable it to meet these needs and
continue providing compassionate care to persons at the end
of life.
Numerous other entities and individuals, including the
California Hospital Association, Santa Barbara Medical
Society, Alzheimer's Association-Central Coast, and the
Santa Barbara County Board of Supervisors strongly support
SB 177 because it will increase the number of hospice
facility beds in Santa Barbara county and meet the growing
needs for these services.
Arguments in opposition
The California Nurses Association (CNA) objects to the fact
that the one CLFH facility that would benefit from the bed
limit change in SB 177 was built outside of existing bed
limits that apply to CLHFs, and that the administrators of
Serenity House did not abide by state law when planning and
constructing the facility. CNA argues that it is not
appropriate to make an accommodation for this one facility.
CNA further questions whether the building standards for
the Serenity House facility have been correctly applied and
would be sufficient to keep patients and staff safe. CNA
notes that the type of patients that can reside in a CLHF
include persons who are catastrophically and severely
neurologically disabled, and urges the committee to gain a
fuller understanding of why OSHPD reversed its claim of
jurisdiction over the building standards for the facility.
POSITIONS
Support: Visiting Nurse & Hospice Care (sponsor)
All Saints-by-the Sea Episcopal Church
Alliance for Living and Dying Well
Alzheimer's Association, California Central Coast
Chapter
American Dream Concepts
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The Beatitude Society
Brown & Brown Insurance
California Association for Health Services at
Home
California Hospital Association
California Hospice and Palliative Care
Association
California Transplant Donor Network
CenCal Health
City of Goleta
Community Hospice
Cottage Health System
Council on Alcoholism and Drug Abuse
County of Santa Barbara Board of Supervisors
Dream Foundation
Frank Schipper Construction Co.
Friendship Center
Grace House
Hospice of Santa Barbara, Inc.
Hospice of the East Bay
Hospice of the Foothills
Hutton Parker Foundation
Livingston Memorial Visiting Nurse Association
Maravilla
Orfalea Foundations
PMSM Architects
Santa Barbara Cancer Center
Santa Barbara County Medical Society
Santa Barbara Neighborhood Clinics
Santa Barbara Region Chamber of Commerce
Santa Barbara Village
Sharon Kennedy Estate Management
Sharp Hospice Care
St. Francis Foundation
United Way of Santa Barbara County
Visiting Nurse Association of the Inland Counties
Vista Del Monte Retirement Community
182 individuals
Oppose: California Nurses Association
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