BILL ANALYSIS                                                                                                                                                                                                    �






                                 SENATE HEALTH
                               COMMITTEE ANALYSIS
                       Senator Ed Hernandez, O.D., Chair


          BILL NO:       SB 799                                      
          S
          AUTHOR:        Negrete McLeod                              
          B
          AMENDED:       March 30, 2011                              
          HEARING DATE:  April 6, 2011                               
          7
          CONSULTANT:                                                
          9              
          Trueworthy                                                 
          9                                                          
                                         
                                    SUBJECT
                                         
                                 Long-term care


                                     SUMMARY
                                         
          Establishes a 90-working day timeframe in which the 
          Department of Public Health (DPH) must complete a long-term 
          care facility complaint investigation.


                             CHANGES TO EXISTING LAW  

          Existing law:
          Provides for the licensure and regulation of long-term 
          health care facilities by the DPH, Licensing and 
          Certification Division (L&C).  Long-term health care 
          facilities include skilled nursing facilities, intermediate 
          care facilities, congregate living health facilities, 
          nursing facilities, and pediatric day health and respite 
          facilities. 

          Requires DPH upon receipt of a written or oral complaint 
          against a long-term health care facility, to notify the 
          complainant of the name of the assigned inspector within 
          two working days of receipt of the complaint and to make an 
          onsite inspection or investigation of the complaint within 
          ten working days of receipt of the complaint.  If a 
                                                         Continued---



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          complaint involves the threat of imminent danger of death 
          or serious bodily harm, DPH is required to make an onsite 
          inspection or investigation of the facility within 24 hours 
          of receipt of the complaint. 

          Requires DPH, when conducting an onsite inspection or 
          investigation, to collect and evaluate all available 
          evidence, and allows the department to issue a citation 
          based upon specified factors, including observed 
          conditions, statements of witnesses, and facility records.  


          Requires DPH to notify the complainant and the facility 
          licensee, in writing, of its determinations within 10 days 
          of the completion of the inspection or investigation.  If a 
          complainant is dissatisfied with the department's 
          determinations, the law requires DPH to notify the 
          complainant of his or her right to an informal conference, 
          and provides the complainant five days to request such a 
          conference.  

          Existing law does not set a timeframe for completing an 
          investigation.  Prior to June of 2009, DPH had an internal 
          policy for completing investigations within 40-working 
          days.  

          Requires DPH to prepare an annual staffing and systems 
          analysis to, among other things, ensure the effective and 
          efficient utilization of licensing and certification fees, 
          and proper allocation of department resources to licensing 
          and certification activities.  The analysis must contain 
          specified information, including the number and timeliness 
          of complaint investigations. 
          
          This bill:
          Requires the DPH to complete an investigation within 
          90-working days from the receipt of a complaint including 
          receipt of a complaint from the facility of an alleged 
          violation.

          Allows the 90-day timeline to be extended if DPH exercises 
          reasonable diligence in attempting to, but has not been 
          able to, obtain all necessary evidence related to the 
          investigation.





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          Requires the DPH to serve any citation upon the licensee 
          within three days after completion of the investigation, 
          excluding Sundays and holidays, unless the licensee agreed 
          in writing to an extension.

          Requires DPH to analyze its compliance with these 
          requirements in an annual report.

          Allows the complainant 15 working days, rather than 5 
          business days, after receipt of DPH's results of the 
          investigation or inspection to notify the Director in 
          writing a request for an informal conference.
                                         

                                 FISCAL IMPACT  

          This bill has not been analyzed by a fiscal committee.


                            BACKGROUND AND DISCUSSION  

          According to the author, the California Department of 
          Public Health (DPH) often takes too long to complete their 
          investigations regarding long-term care facilities.  This 
          bill will ensure DPH completes its investigations in a 
          timely manner.

          In particular, the author notes that California law 
          requires skilled nursing facilities to report suspected 
          abuse and neglect, but sets no timelines for completing 
          investigations of these complaints.  DPH is only required 
          to make an onsite inspection within 10 working days of the 
          receipt of a written or oral complaint, unless it is 
          determined that the complaint is willfully intended to 
          harass a licensee or is without any reasonable basis.  In 
          cases of imminent danger of death or serious bodily harm, 
          DPH is required to make an onsite inspection or 
          investigation within 24 hours.  The author believes this 
          bill will prevent delays by requiring that complaints be 
          investigated within 90 days, and that any corresponding 
          citations be issued within the statutory timeframes.

          California nursing homes are subject to an extensive body 
          of state and federal requirements.  DPH has over 965 DPH 
          L&C field survey staff, an additional 112 DPH L&C 




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          headquarters management staff and over a $55 million 
          fee-supported budget dedicated to monitoring facility 
          compliance with applicable laws, regulations and policies.  
          The L&C staff conducts federal recertification surveys, 
          extended annual facility surveys and detailed complaint 
          investigations to ensure continuous compliance throughout 
          the state.  Of the total DPH L&C division workload, 71 
          percent are dedicated to nursing facility oversight.  Staff 
          however, are often focused on opening an investigation but 
          current law does not set a time frame to complete the 
          investigation.   

          State and Federal Medicare and Medi-Cal requirements 
          provide for a range of sanctions to address poor provider 
          performance, including a ban on new admissions, termination 
          of Medicare or Medi-Cal certification, assignment of a 
          temporary manager, denial of payment by Medicare or 
          Medi-Cal, and civil monetary penalties up to $10,000 per 
          instance or per day.  

          Overview of the Survey Process
          Skilled nursing facilities are subject to annual federal 
          certification surveys (conducted not less than once every 
          15 months), annual state licensing surveys and complaint 
          surveys. Surveys are unannounced and, for the federal 
          certification surveys, at least 10 percent of standard 
          surveys must be conducted on weekends or in the 
          evening/early morning hours.  

           Federal Certification Survey:   The certification survey 
          begins with a retrospective review of compliance issues for 
          both federal and state regulations prior to entering the 
          facility for the survey.  One person is assigned to 
          complete this analysis and then shares the information with 
          the other survey team members.  The typical survey team is 
          comprised of at least three nurse evaluators and may also 
          include pharmacy consultants or nutritionists.

          Following the record review for past compliance history, 
          the surveyors review the CMS Quality Measures/Quality 
          Indicators Reports to identify potential areas of concern 
          for onsite investigation throughout the survey process. 
          Based on observations, resident and family interviews, 
          and/or staff interviews. Surveyors investigate quality of 
          care, quality of life, abuse/neglect, environmental issues, 




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          and facility administration to determine whether there are 
          system problems that have or will affect outcomes for the 
          residents. Surveyors follow required investigative 
          protocols that are defined in the survey tasks. 

          At the conclusion of the survey process, the survey team 
          determines whether the facility provides substandard 
          quality of care and identifies any standards the facility 
          has violated that require correction in order for the 
          facility to be licensed and certified for another year.  
          The survey concludes with an exit conference, after which 
          the surveyors prepare the written statement of deficiencies 
          for their supervisor's review and release to the facility.  
          The facility is then required to submit a plan of 
          correction for each identified issue. 
           State Licensing Surveys:   State licensing surveys are 
          generally conducted concurrently with the federal 
          certification survey.  Surveyors must evaluate facility 
          compliance with all state laws and regulations that are 
          more stringent or more precise than the federal 
          certification regulations.

          In conducting the state licensing survey, surveyors utilize 
          a 60-page workbook that details state laws and regulations 
          related to: environment, nursing, patient rights, staff 
          development, activities, pharmacy, dietary and 
          administration.  Additionally, surveyors must evaluate 
          staffing to verify a facility's compliance with the state's 
          minimum staffing standard.

          At the conclusion of the state licensing process, the 
          survey team identifies any practices that have resulted in 
          violation of state laws or regulations.  The survey team 
          then prepares a written survey report (statement of 
          deficiencies) that is released to the facility.  The 
          facility must then submit a plan of correction for all 
          identified deficiencies. 

          Facility complaints
          In 2009-10, DPH received 25,397 complaints concerning 
          nursing facilities, the vast majority (19,369) of them were 
          self-reported by facilities.  Of the 5,689 that were 
          investigated by DPH, 62 percent (3,545) of the 
          investigations were closed within 90 days and 46 percent 
          (2,617) of the complaints were closed within 90 days.




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          Related bills
          SB 895 (Alquist) proposes to reduce the frequency of 
          licensing inspections for long-term health care facilities 
          conducted by DPH.  SB 895 is pending in the Senate Health 
          Committee.

          AB 641 (Feuer) is a spot bill that intends to make changes 
          to the nursing home citation process.  AB 641 is pending in 
          the Assembly Health Committee.

          Prior legislation
          AB 399 (Feuer) of 2007 would have established a 40-day 
          timeframe in which DPH must complete a long-term care 
          facility complaint investigation.  AB 399 was vetoed by 
          Governor Schwarzenegger.

          SB 1312 (Alquist) Chapter 895, Statutes of  2006, requires 
          inspections and investigations of long-term care facilities 
          certified by the Medicare or Medicaid program to determine 
          compliance with federal standards and California statutes 
          and regulations.

          AB 1629 (Frommer), Chapter 875, Statues of 2004, provided 
          for the imposition of a quality assurance fee on each 
          skilled nursing facility.

          AB 358 (Jackson) of 2003 would have required DHS to 
          complete a final determination of each long-term health 
          care facility complaint within 65 working days of receipt 
          of the complaint with a 30-day extension for good cause.  
          The provisions of this bill were deleted and replaced with 
          new provisions unrelated to long-term health care 
          facilities.
          
          AB 1731 (Shelley), Chapter 451, Statutes of 2000, increased 
          nursing home oversight and enforcement, including specific 
          procedures and timeframes relating to handling of 
          complaints.   
          
          Arguments in support
          The California Association of Health Facilities (CAHF) 
          writes this bill is needed to restore provider and consumer 
          confidence in the DPH complaint investigation system and to 
          protect nursing home residents from mistreatment.  CAHF 




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          contends that California law requires skilled nursing 
          facilities to report suspected abuse and neglect, but sets 
          no timeline for completing investigations of these 
          complaints.  Crestwood Behavioral, Inc. writes in support 
          that delays in investigating complaints result in a loss of 
          credible evidence, lack of witnesses, and a diminished 
          memory of events that are the subject of the investigation. 
           The California Hospital Association writes they support 
          changes to existing oversight and regulatory processes that 
          will improve their ability to identify concerns and to 
          develop and implement effective corrective actions.  
          Supporters contend investigations can take many months and 
          even years to complete.  Timely investigations and 
          resolutions of complaints are essential.

          Arguments in opposition
          The California Advocates for Nursing Home Reform (CANHR) is 
          opposed to SB 799, arguing that DPH's current policy is to 
          complete a complaint investigation within 40-working days 
          and a 90-working day standard is too long to be acceptable. 
            


                                   POSITIONS  

          Support:  California Association of Health Facilities
                    California Hospital Association
                    Crestwood Behavioral Health, Inc.
          
          Oppose:   California Advocates for Nursing Home Reform (If 
          Amended)


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