BILL ANALYSIS �
SB 1228
Page 1
Date of Hearing: July 3, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 1228 (Alquist) - As Amended: May 29, 2012
SENATE VOTE : 36-0
SUBJECT : Small house skilled nursing facilities.
SUMMARY : Adds "small house skilled nursing facility" (SHSNF),
as defined, to the skilled nursing facility (SNF) category of
facilities licensed by the Department of Public Health (DPH),
and permits an SHSNF to be licensed by DPH beginning on January
1, 2014, if the SHSNF meets specified requirements.
Specifically, this bill :
1)Adds SHSNF, as defined, to the SNF category of facilities
licensed by DPH beginning on January 1, 2014, if the SHSNF
meets specified requirements.
2)Defines "home" as an apartment, home, or other similar unit
that serves 12 or fewer residents.
3)Defines "SHSNF" as an SNF that is licensed for the purposes of
providing skilled nursing care in a homelike,
non-institutional setting and is one of the following:
a) A stand-alone home;
b) A facility that consists of more than one home; or,
c) A distinct area within an existing SNF that otherwise
meets the definition of "home" referenced in 2) above and
has been dedicated to the small house model, has distinct
entry, and has no through traffic of staff, residents, or
visitors not affiliated with the household.
4)Defines "versatile worker," for purposes of SHSNF licensing
requirements, as a certified nursing assistant who provides
personal care, socialization, activity aide services, meal
preparation services, and laundry and housekeeping services.
Requires the SHSNF, to the extent permitted under federal law,
to utilize versatile workers for purposes of resident care.
5)Requires the SHSNF to comply with all state laws and
regulations that govern SNFs, except to the extent that those
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laws and regulations are inconsistent with the provisions of
this bill. Permits DPH or the Office of Statewide Health
Planning and Development (OSHPD) to waive one or more
regulations that conflict with the provisions of this bill in
order to permit SHSNFs to meet licensure requirements, if DPH
or OSHPD determines doing so will not jeopardize the health
and safety of a facility's residents. Requires DPH or OSHPD
to consider whether the practice contained in the provision
has been demonstrated safely in other states and requires them
to consider peer-reviewed research.
6)Requires the SHSNF, to the extent permitted under federal law,
to provide meals cooked on the premises of each home, and not
prepared in a central kitchen and transported to the home.
7)Requires the SHSNF to meet all federal and state direct-care
staffing requirements for SNFs. Requires all direct care
staff to be onsite, awake, and available within each home at
all times.
8)Requires SHSNFs to provide consistent staff assignments and
self-managed work teams of direct care staff. Requires
licensed nursing staff to direct the versatile workers in all
activities delegated under the licensed nurses' scope of
practice. A versatile worker may be supervised by nonclinical
staff at the discretion of the SHSNF.
9)Requires SHSNFs to provide training for all staff involved in
the operation of the home and be completed prior to initial
operation of the home, concerning the philosophy, operations,
and skills required to implement and maintain self-directed
care, self-managed work teams, a noninstitutional approach to
long-term care, safety and emergency skills, food handling and
safety, and other elements necessary for the successful
operation of the home. Requires versatile workers and other
staff interacting with residents in the homes to demonstrate
proficiency in these areas as well as the facility's policies
and procedures, conflict resolution, and self-directed care
principles.
10)Requires replacement staff to undergo the training described
in 9) above, within six weeks of commencing employment with
the facility.
11)Exempts any staff members who are employed on a short-term,
temporary basis due to permanent staff illness or unexpected
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absence from the training requirements set forth in 9) above.
12)Requires the SHSNF, to the extent permitted under federal
law, to consist of a home-like, rather than institutional,
environment having the following characteristics:
a) The home is accessible to disabled persons, and is
designed as a house, an apartment, or a distinct area
within an existing SNF that is similar to housing available
in the surrounding community, and that includes shared
areas that would only be commonly shared in a private home
or apartment;
b) The home does not, to the extent practicable, contain
institutional features, such as nursing stations,
medication carts, room numbers, and wall-mounted licenses
or certificates;
c) The home includes resident rooms that accommodate not
more than two residents per room. Homes are encouraged to
include private, single-occupancy bedrooms that are shared
only at the request of a resident to accommodate a spouse,
partner, family member, or friend, and that contain a full
private and accessible bathroom. Double occupancy rooms
contain a full private and accessible bathroom, and each
resident's bedroom area be visually separated from the
other by a full height wall or a permanently installed
sliding door, folding door, or partition that provide
visual and acoustic separation. Residents have direct use
of, and access to, an exterior window at all times.
d) The home contains a living area where residents and
staff socialize, dine, and prepare food together that
provides, at a minimum, a living room seating area, a
dining area large enough to accommodate all residents and
at least two staff members, and a full kitchen that may be
utilized by residents;
e) The home contains ample natural light;
f) The home has built-in safety features to allow areas of
the facility to be accessible to residents during the
majority of the day and night;
g) The home provides access to secured outdoor space; and,
h) The home endeavors to create an aging in place
environment where long-stay residents may form permanent
homes with each other.
13)Requires the SHSNF to be certified to participate as a
provider of care either as a SNF under the federal Medicare
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Program or as a nursing facility under the federal Medicaid
Program.
14)Requires DPH and OSHPD to consult with providers, employee
organizations, consumer advocates, and other interested
stakeholders including groups with demonstrated experience in
SHSNF operations, on the physical, operational, and other
aspects of SHSNFs.
15)Requires DPH to adopt regulations to implement this bill.
EXISTING LAW :
1)Provides for the licensure of health facilities, including
SNFs, by DPH.
2)Defines "SNF" as a health facility that provides skilled
nursing care and supportive care to patients whose primary
need is for availability of skilled nursing care on an
extended basis.
3)Requires OSHPD, under the Alfred E. Alquist Hospital
Facilities Seismic Safety Act, to assume responsibility for
the enforcement of all building standards related to hospital
buildings, including SNFs.
EXISTING REGULATIONS :
1)Further define "SNF" as a facility providing 24-hour inpatient
care and, at a minimum, includes physician, skilled nursing,
dietary, and pharmaceutical services and an activity program.
2)Require each SNF licensed for 59 or fewer beds to have at
least one registered nurse or a licensed vocational nurse,
awake and on duty, in the facility at all times, day and
night.
3)Require each SNF to employ sufficient nursing staff to provide
a minimum of 3.2 nursing hours per patient day. Requires this
staffing ratio to only include direct caregivers, which is
defined to include registered nurses, licensed vocational
nurses, psychiatric technicians, or certified nurse
assistants, who are performing nursing services.
4)Specify that while all SNFs are required to maintain
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compliance with licensing requirements, these requirements are
not to prohibit the use of alternate concepts, methods,
procedures, techniques, equipment, personnel qualifications,
or the conducting of pilot projects, as long as such
exceptions have prior written approval of DPH.
FISCAL EFFECT : According to the Senate Appropriations
Committee, this bill will result in the following:
1)Startup costs of about $120,000 per year for three years to
develop regulations (Licensing and Certification Program
Fund); and,
2)Minor ongoing costs to license and inspect facilities
(Licensing and Certification Program Fund).
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, SHSNFs
implementing the core practices outlined in this bill are an
important development in long-term care options that many
consumers, family, and staff prefer to traditional settings.
The author states that they also deliver better clinical
outcomes, more direct-care time, and greater resident
engagement at the same operating cost as traditional nursing
homes. The author asserts that this deep culture change model
of small house nursing homes is proliferating in many states
and meets all federal nursing home certification requirements.
Unfortunately, these homes are difficult to develop in
California under current state requirements, and California's
current statutory and regulatory framework did not anticipate
this significant innovation.
According to the author, SHSNFs following the practices outlined
in this bill currently require multiple agency interpretations
and waivers to move forward in California. These
interpretations and waivers add a great deal of time and
expense to implementation - both for the provider
organizations and the state agencies involved. This
additional time and expense discourages their development and
deprives California residents of this important option.
The author states that this bill would create a new health
facility licensing category to assist the development of
SHSNFs implementing the core practices that research has shown
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to reliably deliver improved satisfaction, quality, and cost
outcomes.
2)PERSON-CENTERED CARE IN NURSING HOMES AND THE CULTURE-CHANGE
MOVEMENT . According to the Commonwealth Fund, in the 1980's
consumer groups exposed substandard care in some nursing
homes, as well as instances of even more dire problems like
abuse and neglect. These revelations led to the Institute of
Medicine to issue a report recommending major regulatory
changes and, in 1987, Congress passed a sweeping set of
nursing home reforms that required facilities to provide
individualized, or "person-centered," care. As a result, some
providers began to move away from the institutional model of
nursing home care and toward a more home-like environment in
which residents could have a say in their day-to-day lives.
According to the Commonwealth Fund, proponents of culture
change do not recommend a specific model or set of practices.
Instead, they support principles governing resident care
practices; organizational and human resource practices; and
the design of the physical facility. According to these
principles, an ideal culture change facility would feature:
a) Resident direction. Residents should be offered choices
and encouraged to make their own decision about personal
issues like what to wear or when to go to bed;
b) Homelike atmosphere . Practices and structures should be
more homelike and less institutional. For instance, larger
nursing units with 40 or more residents would be replaced
with smaller "households" of 10 to 15 residents, residents
would have access to refrigerators for snacks, and overhead
public address systems would be eliminated;
c) Close relationships . To foster strong bonds, the same
nurse should always provide care to a resident;
d) Staff empowerment . Staff should have the authority, and
the necessary training, to respond on their own to
residents' needs. The use of care teams should also be
encouraged;
e) Collaborative decision -making. The traditional
management hierarchy should be flattened, with frontline
staff given the authority to make decisions regarding
residents' care; and,
f) Quality improvement processes . Culture change should be
treated as an ongoing process of overall performing
improvement, not just as a superficial change or provision
of amenities.
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According to the California HealthCare Foundation (CHCF),
recent literature shows that nursing homes embracing culture
change have improved quality outcomes and offer preliminary
evidence of positive business impacts. However, CHCF
indicates that California has lagged behind other states in
culture change.
3)THE GREEN HOUSE CONCEPT . This bill is sponsored by NCB
Capital Impact (NCB), which has established The Green House
Project, funded by the Robert Wood Johnson Foundation, to help
spur replication of The Green House concept. NCB describes
The Green House concept as an innovative model for residential
long-term care that involves a total rethinking of the
philosophy of care, architecture, and organizational structure
normally associated with long-term care.
According to NCB, a Green House home is an independent,
self-contained home for six to 12 people, designed to look
like a private home or apartment in the surrounding community.
NCB states that Green House homes are typically licensed as
SNFs and meet all applicable federal and state regulatory
requirements. Each home is staffed by a team of universal
workers, who have core training as Certified Nurse Assistants
(CNA), plus extensive training in the Green House philosophy,
the self-managed work team structure of the Green House home,
culinary skills, and household management. These CNAs provide
personal care, meal preparation, and light housekeeping and
laundry, among other duties.
According to the author, Green House homes are currently
operating in 21 states. The author states that one California
nursing home provider has been working for three years to
implement the Green House model, but the provider has
experienced significant delays and added costs because the
Green House model does not fit well with California's current
law.
4)SUPPORT . Aging Services (AS) writes in support of this bill
that they commend the leadership in bringing SHSNF concept to
the attention of the California Legislature. According to AS,
advocates for resident centered care and culture change in
nursing homes have successfully championed the SHSNF concept
in most Eastern states for many years. The California
Association of Health facilities (CAHF) also writes in support
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that CAHF has ben dedicated to advancing the concepts of
resident-centered care in SNFs. CAHF recognizes that SHSNFs
are an important development in realizing resident-centered
care and that this bill will provide an opportunity to design
a model that meets the needs of residents.
REGISTERED SUPPORT / OPPOSITION :
Support
Aging Services of California
Association of Regional Center Agencies
California Association of Health Facilities
Opposition
None on file.
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097