Community Residential Care in California - Community Care as a Long Term Care Service

r I STATE OF CALIFORNIA GeORGE DEUKMEJIAN, Golftlmor COMMISSION ON CALIFORNIA STATE GOVERNMENT ORGANIZATION AND ECONOMY 11th 81 L BUILDING, SUITE 550, (916) 445·2125 SACRAMENTO 95814 CIN"""n NATHAN SHAPELL Vic.·CINi,,,..n JAMES M. 80USKOS AlFRED E ALQUIST MARY ANNE CHALKER ALBERT GERSTEN. JR MICHAEL E KASSAN BROOKE KNAPP MILTON MARKS s.. .. tor MARK NATHANSON RICHARD S TRUGMAN JEAN KINDY WALKER PHILLIP D. WYMAN Assemblyman BRUCE YOUNG Assemblyman RICHARD C MAHAN becutrve Director 111111177111111111111111111111111111111111111111111111111111111111111111111 COMMUNITY RESIDENTIAL CARE , ; IN CALIFORNIA Community Care as a Long Term Care Service 111111!/iIIIII11117!!!I!III!111111111111111111111111111111111111111[1111171 December 1983 ----------~----------. COMMUNITY RESIDENTIAL CARE IN CALIFORNIA Community Care As A Long Term Care Service A Report of the C01BlISSIO;\ CALIFORNIA STATE GOVERNMENT o:t~ ORGANIZATION AND ECONOMY December 1983 STATE OF CALIFORNIA GEORGE DEUKMEJIAN, Governor COMMISSION ON CALIFORNIA STATE GOVERNMENT ORGANIZATION AND ECONOMY 11th & L BUILDING, SUITE 550, (916) 445-2125 SACRAMENTO 95814 Chllirmlln December 1983 NATHAN SHAPELL Vice-Chairman JAMES M. BOUSKOS ALFRED E. ALOUIST Senator MARY ANNE CHALKER ALBERT GERSTEN. JR MICHAEL E. KASSAN BROOKE KNAPP MILTON MARKS Honorable George Deukmejian Honorable James Nielsen Senator Governor of Cal ifornia Senate Minority Floor Leader MARK NATHANSON RICHARD S. TRUGMAN Honorable David A. Roberti Honorable Robert W. Naylor JEAN KINDY WALKER President pro Tempore of the Senate Assembly Minority Floor Leader PHILLIP D. WYMAN Assemblyman and Members of the Senate BRUCE YOUNG Assemblyman Honorable Wil I ie L. Brown, Jr. RICHARD C MAHAN Executive Director Speaker of the Assembly and Members of the Assembly Dear Governor and Members of the Legislature: As you know, the Little Hoover Commission in August 1983 issued an exhaustive study discussing living conditions in nursing homes and presenting recommendations for improvement. During that study, we received testimony which indicated that problems in community care facil ities are even more severe than in nursing homes. Upon receiving the details of four specific facilities which had abused its residents, the Commission initiated a thorough investigation of the 1 iving condi tions provided in community care facil ities. During the months in which we conducted our investigation, this Commission made unannounced visits to community care facil ities and received extensive testimony on numerous other facilities guilty of subjecting their residents to severe abuse, neglect, and generally unhealthy and uncaring conditions. Daily throughout this State, resi dents of community care facilities are being severely abused, beaten, fed spoiled food, forced to 1 ive with toilets that don't work, generally subjected to a demeaning existence and left unattended. In fact, some residents are actually kil led in facil ities each year. The most disturbing fact is that most of the citizens of this State, as well as most of our elected officials, are generally unaware of these condi- t ions. ,', Conditions such as these leave no question that it would be unthinkable and immoral for government to al low such facil ities to operate, let alone place individuals into them. And yet, these facili ties continue to operate, and thousands of residents continue to be subjected to these horrors. Moreover, where the State has taken action *On page 21 of this report, we provide a sample of the specific conditions. -~~-~~"~--------------------------- -2- against some very bad facil ities by taking away their licenses, many of them have continued to operate without a license, thereby not even being subject to an annual inspection or the minimum health standards. Cal ifornia currently ~3S 22,000 community care facilities licensed to provide "non-medica1" residential care to 151,000 children and adults unable to 1 ive without care or supervision. These numbers alone are staggering and do not lend themselves to traditional government monitoring and enforcement techniques. In response to these special problems, our Commission, in addition to conducting publ ic hearings, held three all-day workshops in which we brought both elected and appointed government officials; facility operators; resi dents and family members; local enforcement officials; and consumer advocates together to work with our commissioners, staff and project consultant towards the objective of developing new approaches and recommendations to solve the problems. Our study findings include the following: Community residential care is not viable as a free-standing system ~ of care and supervision; it can work only in conjunction with periodic review of individual residents by trained social and health service professionals. Elderly residents of community care facil ities, in particular, are 8 subject to abuse because they are rarely monitored by outsiders. System goals and cl ient services are more advanced for the develop mentally disabled than for the elderly or mentally disabled. • In the existing community care system, certification of administra tors is neither mandated nor authorized by State law. • Small facil ities (six or fewer residents) comprise a community care "subsystemll that should be maintained apart from the larger facil i ties. • Data base and information systems do not adequately monitor facil i ties and residents, or assist consumers. • The number of unl icensed community care facilities is increasing at an excessive rate; neither State nor local enforcement agencies are making any meaningful effort to stop it. • The existing enforcement system lacks protections for residents in emergencies. • More Iisets of eyesll are needed to assure that residents are adequately cared for and not abused. • The system for screening individuals applying for facil ity licenses is inadequate; staff working in facilities are not screened for criminal histories, there are no educational requirements to receive a I icense, and operators are not even required to know what the State regulations require. --------------------------------- -3- • State coordination with local law enforcement agencies is virtually non-existent. • Current investigative resources are inadequate in number, expertise, and geographic allocation. • Budget constraints reduce the effectiveness of monitoring and enforce ment activities. • More flexibility in paying for residential care is desirable for all cl ient populations. More money should be made available for community residential care only for changes that would upgrade the qual ity of care. To improve the system for providing community care to residents of these facilities and to ensure that the State adequately protects these individuals, the Little Hoover Commission has developed over thirty detailed recommendations for legislative reform, reorganization of certain State func tions, operational improvements, and sources of new revenue to support certain activities. Included in our recommendations are the following: 1. Integrate community residential care into the long term care system. Coordinate pol icy development, coordinate the definition of services, and extend case management services to the elderly and the mentally disabled. ll 2. Stregthen the "small facilities subsystem by creating cluster administration of these facilities. Identify and reward Ilmodel ll houses to help educate operators and serve as incentives. 3. Recruit and train volunteers to monitor residents. 4. Create an automated 1 icensee information system. 5. Revise applicant screening so that it is more meaningful. 6. Recombine community care licensing and health facil ities licensing and relocate the 1 icensing function in the Attorney General IS Office. 7. Structure coordination of enforcement activities. 8. Clarify definition of unl icensed facil ities and create a citation system similar to traffic tickets, to assist in taking action against them. 9. Increase fines for I icensing violations; triple the fines in cases of repeat violators. 10. Require all licensees to be bonded. 11. Authorize CCl to place a facil ity in receivership. ll 12. Establ ish a Ilcrisis team within CCl to step in and operate extremely bad facil ities temporari ly. -4- 13. Encourage private action against unsatisfactory faci1 ities by allowing recovery of legal fees through attachments of administra torsi property. 14. Impose an annual 1 icensing fee to support increased monitc~:ng. 15. Authorize the establ ishment of an Ombudsman Foundation. The members of this Commission bel ieve government has a legal and moral responsibil ity to protect and ensure that the residents of community care facilities 1 ive in safe and healthy conditions. At the same time, we recog nize that government today must provide services with very 1 imited resources. Therefore, we have attempted to design our recommendations to increase and improve the services and protection government provides community care resi dents without significantly affecting the cost of operations. I JEAN WALKER, Chairwoman ( Community Care Facility Study ames os, SubcOrTll1 i ttee Senator Alfred E. Alquist Mary Anne Chalker Albert Gersten Brooke Knapp Michael Kassan Senator Milton Marks Mark Nathanson Richard S. Trugman Assemblyman Phill ip D. Wyman Assemblyman Bruce Young ~ -----~-------.------------------- TABLE OF CONTENTS SUMMARY 1 1. INTRODUCTION 14 II. CALIFORNIA'S SYSTEM FOR PROVIDING COMMUNITY CARE SERVICES TO DEVELOPMENTALLY DISABLED, MENTALLY DISABLED, AND/OR ELDERLY RESIDENTS 19 A. Major Findings 1. Abusive, Unhealthful, Unsafe, and Uncaring Conditions Are Intolerable 21 7. Fraq~ented Administration Inhibits the: Integration of Communitv Resi dpn~ial Care into the State's Over all Svstern for Long Term Care 24 3. Advoc3tes Seek Case Management Services for the Elderlv and Men t21lv Disabled Comparable to Case M2naoeDent Services Now Provided Only to the Developmentally Dis abled 27 4. SysteM Goals and Client Services Are More Advanced for the Develop menta11v Disabled Than for the Mentally Disabled or Elderly 31 5. Caregivers for the Developmentallv Disabled Are "Certified," But Care givers for the Elderly and Mentally DisablpG !\re Not "Certified" 33 6 . Small Facilities (Six or Fewer Residents) Comprise a Community Care "Subsystem" That Should Be Maintained Apart from the Larger rrl("ilitips 34 7. Data Base and Information Systems Are Inadeauate to Support Efficient Program Management 37 Provider Trainina Is Not Required 41 i 9. Excellence in Providing Community Residential Care Services Goes Un~cknowledged and Unrewarded 43 10. Lack of Community Awareness and Acceptance Causes Developmentally and Mentally Disabled Residents to Be Perceived as "Undesirable Neigh bors" 44 B. Recommendations 1. Integrate Community Residential Care into the Long Term Care System 46 0. Clarifv Roles 46 r. CoordinAte Polic'.' Development 48 Coordinate Definition of Ser 't.~ i c f':=: 49 Case Management Services Ext0n~ ~n the Elderlv and Mentally 50 P. I~Drove Consumer Information 51 ., .... f·t ,-e:lothef tht Co "Small Fccili ties SubS~Tstem " 52 ty for "Cluster :=> c=:::·~"tf' OpDo~tuni Administration" of Small Facil i tiE~S 54 h. De~janate Model Houses 58 c. AWare Certificates for Excel lence 60 III. MONITORING OF COMMUNITY RESIDENTIAL CARE SERVICES AND ENFORCEMENT OF RELATED LAWS AND REGULATIONS 62 1.. lJnlicer:.sed Fa.ci2_i ties Continue to 64 II -------------------------------------------------- 2. Resident Protections in Emergencies Are Secondary to Facility Adminis trators' Right to Due Process 65 3. Residents Lack Protected Rights to Privacy and Participation in Facil ity Decision Making 68 4 . More "Sets of Eyes" Are Needed to Assure That Residents Are Ade quately Cared for and Not Abused 69 5. CCL's Operational Philosophy Is Ambiguous: Enforcement First, or Technical Assistance? 71 r; • Applicants Are Screened for Crimi nAl Histories Onlv 71 Enforcement Mechanisms Do Not Deter ~ Killful Violations of Laws and Rp':Jt:latio:::s 73 Coordination with Local Law En- forcement Agencies Is Lacking 73 Post-licensinq Visits Have Been Eli yr 3_ r: ate d 74 J n and Emergencies Need More }\ttentio::l 75 1 1 Investigative Resources Are Incom ..... ...1 • plete 76 J /' • Potential for Collusion Needs Pre- ve;-,tive Remedv 77 13. Coordination with Health Facilities Licensing Is Lacking 77 1. <! • G(~ographic Restrictions on Commu nity CarE' Facility "Grouping" Do Not Prevent Concentration 78 B. p'pcommendations 1 . Increase and Strengthen Monitoring 80 -'- Recruit and Train Volunteers to (i.. • Monitor Rnsidents 80 iii ------------------------------------------------------ h Estnblish Emergency Response J ..• Capability 82 c. Make Applicant Screening More Meaningful 82 d. Create an Automated Licensee Information System 83 e . Standardize Cost Accounting 85 .c Empower the Residents to Be .L • Monitors 86 2. Make Enforcement Activities More Effective 86 a. Recombine Community Care Licens ing with Health Facilities Licensing. Study and Consider Relocating the Licensing Func tion in the Attorney General's Office. 87 h. Utilizp Licensing Personnel I,'ore E::::ect:ively 88 c. Dpvelop CriteTia for Grantin? Permission to Bear Arms 89 o . Structure Coordinntion En o~ forcement Activities 89 j;puelop Criteria for Seeking C. Cl Temporarv Suspension Order (T80) and Procedures for Noti fication and Relocation of Residents 93 f. Sponsor Enforcement Seminars 94 o. Prepare Handbooks for New Licensees and Residents in the Community Care System 95 h. Clarifv Definition of Unli censed Facilities and Create Citation System That Resembles Traffic Tickets 95 i. Incrense Fines for Licensing Violation? 96 lV --------------------------------------- Pequire All Licensees to Be i • Bonded 97 k. Authorize CCL to Place a Facil ity in Receivership 98 1. Establish a "Crisis Team" with in Community Care Licensing 99 m. Encourage Private Action Against Unsatisfactory Commu nitv Care Facilities by Allow ing Recovery of Legal Fees through Attachments of Adminis trators' Property 100 Require Boarding Houses to ~. Reqister with the State and Auth0rize Long Term Care Om budsman to Enter These Facili- 100 II11l11ediate Dismissals A-,~t-h~:c~i7e of Officers Who Make Place~ent :llesal or Unsafe Placement P.""-p rral s 101 Krcct:>-ict Geographic Concentra t.i0Tl S o£ Community Care Facili- t=-ps 102 IV. FUNDING OF COMMUNITY RESIDENTIAL CARE 103 l. Sources or Punds are Mixed 104 :2 • A~CqU3CV of Funding for Direct Varies by Client Group 105 Ser~jces 3. Rates a~d Payment Arrangements Vary h" Cl ient Group 107 4. Budget Constraints Reduce the Effectiveness of Monitoring and Enforcement Activities 111 Licensing Fees to I~D0S~ An~ual Sur::': ::':ncrea sed Monitoring and Activities and New En"-nrrp~p~t Small Facilities 113 ?~-~r?~s fo~ v ------------------------------------- - -- - 2. Authorize the Establishment of an "Ombudsman Foundation" 115 3. Launch an Aggressive Campaign to Solicit Private Contributions for Increasing the Levels and Quality of Service Provided to Community Care Residents 116 V. APPENDICES 119 A. Historical Derivations of the "Small Facilities Subsystem" 120 B. D2ta SUITL'1laries 124 c. Partiripants in Little Hoover COITL'1lis sion s Community Care \\lorkshops in I (Developmentally Disabled: SAcr~mento ,Jul' 25, 1983; Eloerlv: August 4, 1983; r'ie:-'.t2,11y Disab1t:'!d: Auaust 18, 1983) 132 136 A Srhematic to Show of Actions or ~ Who~ Would Be Required in Order to C~a~a0S thp Commission Recornme':1da Irr~D1e;r:c!:t IS tioYls 138 VI . ACKNOWLEDGEMENTS 142 vi ------------------------------------------------------------ - SUMMARY California's Commission on State Government Organization and Economv (the "Little Hoover Commission") has a long-standinq interest in improving those long term care services which are funded and/or regulated by the state. In addition to this study of community residential care facilities, which are licensed and monitored by the State Department of Social Services' Community Care Licensing division, the Commission also has issued this year an in-depth study of skilled nursing facilities (nursing homes), which are licensed and monitored by the State Department of Health Services' Licensing and Certification Division. In the course of doing these studies, the Commission has concerned =or the safety and well-being of Californians beco~~ who term care services and who rely on the state to nee~ lo~g protect their interests. It is the Commission's intent, in advo cnting the recommendations contained in this report and in our report en skilled nursing facilities, to identify ways in which disahled Californians may receive appropriate care at ch~onicallv ? reason~ble cost. At an absolute minimum, these citizens must D" nrot-e cte~ ag? j.nst abuse and exploi ta tion. Th~s report is specjfically concerned with three major clippt croups re s idiEC in corn:::-:uni ty care fac ili ties: the deve lopmentall v disabled, the mentally disabled, and the elderly. Our findings ann recomJ"P'1dations have to do with three primary aspects of c:JTTL,,::unitv residential care: the system for providing services, mo" i +:0r inc' anf. en forcement , and funding. Our recommendation;:; would affect state, regional, and local entities and in many cases reQuire authorization by the Legislature. CALIFORNIA SYSTEM FOR PROVIDING COMMUNITY CARE SERVICES TO DEVELOPMENTALLY DISABLED, MENTALLY DISABLED, AND/OR ELDERLY RESIDENTS Summary of Findings We found that physical and sexual abuse and harassment of COITlITlUni t,· care residents occur with alarming frequency and sever itv. Yet, the Community Care Licensing offices (which we refer to simnly as "CeL") appear powerless to take timely action either to stop such abuse or to prevent its continuation in the same facilities. At the same time, CCL does nothing to acknowledge, reward, or encourage excellence in providing community care ser "ices. We that the Department of Developmental Services is fou~~ ~0r' adv=~:e! l~ defirina clie~t services and goals and In ----------------------_._--------------- setting policy and rates for all therapeutic and supportive services provided to developmentally disabled individuals residing in cOIT~unity care facilities than are the affected state departments and advocates for the mentally disabled and elderly. This disparity is a sign that community care is not integrated into the overall long term care system in California. Yet, cOIT~unity care is not viable as a free-standing and independent service; residents need to be monitored and to have access to social and health services. We found that the mentally disabled and elderly need the same level of monitoring and personal contact that is provided now only to the developmentally disabled through case management services offered by regional centers. Placements of elderly individu2ls in community care facilities whether they are placed there bv themselves or by family members or conservators -- is rarel~' ~ matter of public record. Consequently, volunteers in thp State Long Term Care Ombudsman Program do not know where p lc1p::.-l ,; C-:l;rL~.U:l.1 t-" care c lien ts are Ii vina and, thus, cannot vi s 1. t them unl0ss compl~ints are received. VC ~O~~~ th~t, because the facility administrators arp not requi:!0c] tn hI' "c<?rt.i::ipd," no training or experience require mpnts ~rp i~pnsp~ on therG. In the early days of family care as 2n 21tprnative to institutionalization in state hospitals, social v:c2'b=-r"" c1 ~ .1 ('"',-+- i +0,., c0111:"1.1ni ty care providprs. In our judgme::lt, certific2+:ion 0' +l:.~ service providers, in additiol! to licensurp o~ thr faciliti~s, affords a highly desirable level of qualitv cortrol. At prespnt, onlv community care providers serving the ~pveloDT11cntallv ~ic=hlec] are certified through a mechanism uti lizpd bv thr r~ jG~~~ centers for approving the providers as "vendors." I"e :nur:(; tL; CC:, lacks a data base and information systems that are needed f0T efficient program management. There is, for e;:amolc, nc licF~:V;sC( tracking system. Thus, service providers whOSe> licenses have bec". revoked in one county may be licensed in an0ther county, their prinr records having escaped notice. There also is P0 information systematically available to prospective residents on the quality or cost of care in the facilities in their areas. N0ither do community care administrators receive inform&tion regarclng the availability of services which their residents need and may have publicly subsidized access to. We ~Gund that the public at large -- including physicians i8 unaware of th~ distinction between skilled nursing and com munity care facilities. This leads to inappropriate placements: individual~ receive either more or less care than they actuallv need. A related problem is that lack of public awareness seems to corresponc with ]Flck of neighborhood acceptance of communitv r; ., ref a c i 1 i t i f S ~, ::.~ r 8 ~; ide r t s . 2 Finally, we found that community care facilities serving six or fewer residents are treated the same as facilities serving 500 residents or more. We believe that the small facilities actually comprise a community care "subsystem," which can be administered and regulated more effectively if defined and treated as such. Summary of Recommendations Legislative Changes We recommend that the Legislature make the following changes in st.21te lAy;: 1. MPnc1 the Torres-Felando Long Term Care Act (Chapter 1453/St21tutes of 1982 (A.B 2860)) to specify that community resi dentinl c~re shAll be included in the array of services referred to genericallv 2n long term care. ") RpstdJ,t the authority of Community Care Licensing to ~vRluati0~ o£ facilities only. In other words, delete all refer (c"'~f'.'" +:0 p'7'''_}.uc;tion of prograrr, activities by licensina personnel. ,~. l\'l+-~,(·)~-~~;r.e the Departm~nt of De\relopmental Spr\7icps (DDS), tht Dppartmen~ o~ Mental Health (DMH) , and the Office of Lone: TeYT Cayp (O/:JTC) tn develop in regulations the program goals, provide~- st?nda rds, and service definitions for communi tv resi dentin} care services provided to the developmentally disabled, ment~l~" disabled, and elderly, respectively. These state units 21ls0 ne~:d nuthorization to certi f1' community care administrators 'dh!) mppt their respective stnnd21rds. ~\Te further recommend they br ?'uthoyizpo to create, in conjunction with related volunteer oyc:anizatio;c:; In eAch community, a system of IIratings. 1I Each COT:,H:l: ".5. t~' rp s i den ti a 1 ca re fac iIi ty shou Id receive a ra tina ba sed on its renord in meeting licensing and certification require m~1jt? 4. :RcoquirF: community care administrators serving the devel opmentallv disabled, mentally disabled, and elderly to be certi fied by DDS, D~R, or O/LTC, respectively, based on the regula tions speri~ving program goals, provider standards and service definitions aeveloped pursuant to #3 above. 5. Require CCL to consult with DDS, DMH, and a/LTC regardino prnncsed chanaes in licensing regulations, prior to circulating such doruments to the public. Require CCL to obtain statements signed bv th"" directors of those entities attesting to their r.='viev: 0:;:: t~lt' nroposeo changes. Require CCL to attach thesl':' ~tateT.p~lt. .i~J. -I:~hp nrODOSec. regll1ations, including any comrnent.s 3 on or opposition to specific proposed changes, prior to their distribution before public hearings. 6. Authorize the development and provision of case manage ment services to all developmentally disabled, mentally disabled, and/or eldel:y individuals residing in community care facilities. 7. Require the Health and Welfare Agency (HWA) to identifv all conflicts in existing and emerging law pertaining to the authority of CCL and the authority of DDS, DMH, and/or O/LTC with respect to community care facilities, and propose appropriate legislative changes. 8. Require HWA to establish procedures whereby the progra~ goals, provider standards, and service definitions developed in regulations by DDS shall be reviewed by DMH and O/LTC -- and vice versa. The intent is to assure that all affected departments will he of adV2nces in services for categorically-defined advi~ed clie'lt arour"". 9. AlClr>:-,(' t.he Torres-Felando Long Term Care Act to specif;' long term care agenci€s shall keep records on th~t co~~~n~~~' in comrnunity care f2cilities. clien-l:-_~ pl~ce(::: 10. Require regional or county representatives of DDS, DMH, an "1 OII.Tr tc develoTJ records on community care facilities in each cc~chment ?,rf":, however defined for each client group cateaor\'. Thi~ consumer information is to be made available to prospective comrr,uni tv cart? reside!lts and/or their family members or other recresentatives. The records shall include facility ratings. We further improving information available to consumers by rec0~~e!ld requirina CCL to ask the Public Utilities Commission to require te2.eDhone comp?nies to Jist comnmnity carp facilities by client group, " each new edition of their telephone directory yellow noqps. 11. Authorize CCL to develop a "small facilities subsystem." P2ri. I of this subsystem shall consist of licensed "cluster administr2tors," who manage the recordkeeping, purchasing, and activity planning in up to 10 small facilities, among other spe cified responsibilities. Part II of the "small facilities sub svstem" shall consist of designating model houses for one-year periods and providing for visits to these model houses by admini of other small facilities. Part III shall consist of strator~ CCL's awarding certificates of excellence to small facility administrators who qualify on the basis of cleanliness and/or meal quality. foo~ 3~~ 4 - -----~-------------------------------- Administrative Changes &~ong changes that can be accomplished through administrative action and require no legislative changes, we recommend that: 1. Com.muni ty Care LiC::~:lsing halt all acti vi ty related to developing IIclient-specificll licensing regulations. As we have indicated, the Departments of Developmental Services and Mental Health and the Office of Long Term Care should be responsible for establishing standards and goals for community care as a service utilized specifically by the client populations they serve. 2. The Health and Welfare Agency require all state depart ments that make decisions affecting residents in community care facilities to establish advisory task forces to review and com ment on the reco~~endations contained in this report. Advisors should be representative of the clients themselves, client advo cates, and service providers. 3. Communi"':v CFl.re Licensing ask the Public Utilities Commis sion tc rec:uire tele;:;ho:itC> companies to list community care facil itiPP, by cJient group, in every new edition of the telephonp . di re cto:"''' ,'(,11o,,: pa crt-~' MONITORING OF COMMUNITY RESIDENTIAL CARE SERVICES AND ENFORCEMENT OF RELATED LAWS AND REGULATIONS Summary of Findings We found thClt the number of unlicensed community care facil itie~ appears to be increasing, thereby posing a danger for unsuEp~ctincr co~~u~~tv care clients. Budget cuts have led to CeLIs decision to target its investigative resources on respond ing to comrlaints in licensed facilities, leaving unlicensed farilitie c unmonitored altogether. Local law enforcement agen cies seprr unAWAre of the problem. ~e found that facility administrators are better protected Clgainst punitive actions taken by CCL than residents are pro tected against abuse and exploitation by administrators. Because the mentally disabled and elderly are seen less frequently than the developmentally disabled by social workers or other client advocates from outside a facility, these two groups especially are At the mercy of those community care administrators who are or become abusive. We found th~~ the existing monitoring and enforcement system lacks 24-hnur, 7-dClF-a-week emergency response mechanism. The Fl. Cnrc,..,.,jsslO"-' b"lif-ves thl=:: state must have the capacity to respond .CT' ti,,",'ly ,no''';-'-·P)," to crises in commur.ity care facilities. 5 We found that the rights of residents to have privacy and to make life style decisions are all but ignored as a focus of moni toring and enforceP1.ent activities in community care facilities. We £ou;'..d that more "sets of eyes" are needed in order to assure the well-being of community care residents. Volunteer ombudsmen are trained to mediate complaints the elderly may have regarding their care or the way they are treated by facility administrators. This low-cost monitoring by volunteers has not been consistently made available, however, to developmentally or mentally disabled community care residents. We found CCL's operational philosophy to be ambiguous. That is, CCL has avoided committing itself to enforcement of laws and regulations, rather than technical assistance to facility admini strators, as its primary responsibility. CCL has not developed standard criteria or procedures, for example, regarding the need for closure of a facility. immedi~t~ found CCL's screening of applicants for licensure to be ~0 Not onlv are applicants not screened for their inadequ2~0. abilitv to handle finances or to assure the availability of persons in the facilities, but they are not Snalish-spca~ing even to know what the regulations specifv regardins ~p~ujred thejy or the care needs of the residents. f~ri!ities Ep :0un~ tha~ CCL's enforcement activities are not credible. i tir;:- orde::ed to close under court injunctions continue to F,~:C'i ~ without negative consequences. Fines assessed are often ~~PTate subs 0 0uentl p waived. Coordination with local law enforcement aqenci~~ i? minimal, contributing to the perception man~' com munitv care administrators share that they have little to fear in the punishment for violating the law. W'l" o~ We found that the Legis°la ture's elimination of the post J:;--;ens i nC} vi s i ~,:: (wi th in 9 days a fter licensure of a cOITLTTluni ty c~rp facilit'·' represents the loss of a useful technique to pre vent tv care administrators from establishing inapprop ('O["'u~uni rrutines within facilities. ri~tp We found that CCL's investigative resources are inadequate. Nin investigators to review and investigate 0 no~-supervisory of abuse or neglect in a 57,OOO-facility system (of complai~ts which 22,000 are residential facilities) cannot complete even all the paoprwork involved in preparing a desirable number of cases for prospcution. Furthermore, investigators often must do with out the assistance and opinions of medical experts in determining th" causes ane/or the seriousness of the various client condi tions thFy observe. Also, CCL investigators historically have permission in every case to carry weapons into com b~pn ~enied csr in which administrators have threatened ~unit" Q ~20iljties )~C)(~::} .. :,-1UT" t" i::vEstiqaton:: or residents, or both. IA!e found that some licensing staff are assigned to evaluate the sa~e facilities year after year. We believe this lack of rotation ca~ lead to the evaluators' reluctance to cite viola- tions. We found that separating community care licensing from healTh facilities licensing has led to community care residents' loss of access to needed health services. Finally, we found that community care facilities are allowed to locate in geographic proximity to each other in some commu nities to the point of forming undesirable concentrations. This problem exacerbates the general perception of community care residents as "undesirable neighbors." Summary of Recommendations Legislative Changes \;r y!~n~~~n~ th0t the Legislature make the followino chanoes 1. Rplocatp the. StatE"' Long Term Care Ombudsman Progra!"l from the Dep2~tm8nt of Aging to either the Attorne~7 General's Office O~ th 0 Departrnont o~ Consu~er Affairs. Also, the Legislature sho~ld eXGan~ thp authority of the program to include recruitment an0 training of volunteers to monitor developmentally and men tal.Iv dis~bled clients as well as the elderly. 2. Authorize CCL to establish an emergency telephone "hot line" i 1" S?cramento, to be accessible 24 hours a d: ., 7 davs a wppk. CCl shou~d then be responsible for contacting tne approp riatt:' office or individual in the local community in which the crisi.<- h?s occurrec1. Ke further recommend that CCL rpquire licensees to post the "hotline" telephone number in an obvious pIRro in P?ch licensed facility. 3. ~cquire CeL to create an automated licensee-tracking system, using Social Securitv numbers as the primary identifier. 4. Require CCL to create a uniform accounting system for use speci=ied categories of community care facilities. J... 5. :Require comm'.mity care facilities licensed to serve 25 or more rpsidents to establish rpsident and/or family member coun cils for the purpose of giving residents greater voice in deci- Fic~s affectina their dailv lives. Such resident councils should be mad0 a co~dition of licensure for all facilities of the speci- -iOipd cClpc::C'it". 7 6. Recombinp Community Care Licensing with the Department of Health Services' Licensing and Certification Division and consider relocating the licensing function in the At torney General' s Off ice. 7. Restore funding and authority to reinstate community care post-licensing visits within 90 days of licensure. 8. Authorize an increase in the number of investigators. Restore funding and authority to locate approximately half of the investigators from CCL's Audits and Investigations Bureau in southern California. 9. Require CCL to notify placement agencies of a community care facility which has been cited or closed down for serious, potentially life-threatening deficiencies in the quality of care. When records of placement agencies which have referred clients to the offending :acility are not available, we recommend that the Leaislature require CCL to notify DDS, DMH, and O/LTC. These aaenC1PS woula be resDonsible for alerting their county or reqiona~ counternarts to CCL's charges and actions. Ie. Recuir0 cel ~o notify clients and their families 0~ other rer:rt·c;(~"'tative~" y,'lwnever the community care facility in which the cl~0~ts are res~~~nn is being cited or closed for serious defi ciencic'c. J ~ • 1~,lltrl(=.~<r ~ ~« eer· to estnl)liSh a.n emergency fund I possibl~l U~i"0 Teven~0 from increased fines, for use in providing for the relocation ?,nc C3re of residents when CCL closes community care facilitipc notice. o~ shnr~ 12. Clari=v the definition of "unlicensed facility" to mean 2"" f2("; Ji h' -1-",+ is (a) providina services allowed only in licP~'lS2c3 :.Jciliti(·~; (Ll housing residents who demonstrate the DPpd for servicp~ which only licensed facilities are authorized to provide; or (c) representing itself as a facility in which services 3Lthorj L~e ~ only in licensed facilities are being pro vidRe! . 13. Authori70 local police and sheriffs' departments to issue citations to owners of unlicensed facilities. These cita tions wculd resemble traffic tickets and the fines would equal fines for other violations of licensing laws and regulations. The revenue from these fines would remain in the community to offset the costs 0& an aggressive effort to close down unlicensed facilities or to force their owners to seek licensure. 14. Provide for automatic increases in fines assessed for sDecified violati0~~. Specifically, fines should increase (or as the case may be) by the same per a~nuall" semi-~~nually, tl-li-' CJ.DDYOved cost of living increase for SSI/SSP re- cr:_,~·tac" :)? p 15. Require eeL to treble fines for repeat violations. This provision should apply to administrators of unlicensed facilities as well as for other violations. 16. Authorize eeL to retain 50 percent of revenue from assessed fines in order to establish an emergency resident relo cation fund and/or to support an increased level of enforcement activit". 1:. Require all community care licensees to be bonded for a minimum of $1,000, and require that such bonds be written to cover the payment of assessed fines in the event a licensee fails to pav the fines or does not pay on time. Require CCL to revoke the license when the amount owed for fines exceeds the amount of the Do!!ci. 18. Authori7e CCL to place a community care facilitv into recei "I;ershi f'. (Thi s would exclude sma 11 facilities which are al~n the administrators' private homes.) 19. Authorize CCL to pstablish a "crisis tea~" that it coulci SF'!',c' fr:r J ifni tpc1 and speci fied periods to operate cOJT1muni tv care ~~sili1ies th2~ are experiencing administrative failures. 2n A~lcw private citizens to recover legal fees in suc cess:fl-.1 lawsuit:::: aoainst abusive or otherwise unsatisfactory C0T"]Tu"it" carp farility administrators by authorizing attachments of admi~is~rators' property as the source of funding to cover cost;.::. the~;0 Require boarding houses (residences where meals are available, but care and supervision are prohibited), to register v;i th Cn'1'J'c1c::.nity Care Licensing. 27. Authorize volunteers in the State Long Term Care Ombuds JT1?!' PrnGra~ to enter boarding houses, as time and other resources perD~t, to det~rmine whether clients needing care and supervision have been inappropriately placed in boarding houses. 23. Specify that any public employee (or a private, non- profit orga~ization's employee who is paid from public funds) shall be immediately dismissed for referring an individual in need of cornTT1un:i_tv residential care to an illegal (unlicensed and/o~: ur;certi:~ied) community care facility, or to an unsafe cOITtmuni t\' carE' facili tv (one in which actions against an adminis trator 2~F pending, due to substantiated charges of abuse or neol~ct o~ the residents). 9 ----------------------------------------- 24. Recruire CCL to give local governments an opportunity to comment on community care licensing applications when the new facilitv \,'ould be located within 300 feet of an existinq commu nitv care facility, OR a skilled nursing facility, OR a boarding house. This rp('fuiremPTlt should not apply, however, to the sJClal1 facilitjPs (six beds or fewer). Administrative Changes Among changes that can be accomplished through administrative action and require no legislative changes, we recommend that: 1. CCL tighten applicant screening procedures bv (a) not accepting incomplete applications, (b) revising the application for~ to include the applicant's plan for assuring the availa bilitv of EnGlish-speaking staff in each licensed facilitv, (c) requirinG ?oplicants to sign release forms authorizing CCL to obtai~ certain soecified information about them, (d) requiring pr'Dl iC0 r;~·8 to supply si]'11i lar re lease forms signed bv each 0: t~ciy PGploveer who will provide direct services to residents, 2?l(; (t.~) l-ec;uirjrlc· c3pplic3nts to sign statern.ents that tl·1~V ha\lp read a-~ understoo~ the pertinent regulations. eel and representatives of the Departments neve lop- ~ o~ r:,cor;t;ol ;::<=>r"ire!=' aDd MpnLll Health and the Office of Long TerJT! (?~0 include mor:itoring of financial records in all routine visit~' t.c> facilities. We recommend that these agencies encourage ?~~jristratc)~s ~ouDd to be having bookkeeping problems to employ a~ (u~side bookkeeper to maintain the facility's accounts in accord~nce with CCL's uniform accounting system. All facility ~0ninistrntor~ should be encouraged to have a certified public conduct an annual review of the books and prepare an Accou~taDt annual report . .3. clhe Stat(~ Loner Term Care Ombudsman Program train volun teers sppcificRllv in the mediation of problems related to a breach of co:n~unitv care reE"idents' riqhts to have privacv ane: to make decisions affecting their daily lives. 4. CCL arrange for licensing evaluators to be trained to ga~her evidence for usp in investigations and prosecutions. 5. CCL rotate personnel assignments to prevent evaluators from reviewing the same facilities year after year. 6. ThF Health and Welfare Agency analyze the circumstances UDder which permission to bear arms has been granted to investi qat0rs from departments other than Social Services. On the basis n::'" t~i? ::;nc:]\"sis, we- recorrunend thi1t the Health and Welfare Agencv 10 develop criteria to assist the affected department directors in deciding on a case-by-case basis when a situation warrants n+-O permission to investigators to carry weapons. gra,,~lng 7. CCL investigators notify the Department of Social Ser- vices' Legal Division irmI'Lc:diately upon determining that one of its investigations could lead to criminal prosecution. At that point, the Legal Division should assign an attorney to advise investigative staff regarding what additional information will be needed, if any, in order to prosecute the case. 8. The highest community care licensing official arrange quarterlv meetings with the directors of Developmental Services, Mental Health, and Long Term Care and the State Long Term Care Ombudsman to discuss problems in the long term care system that require coordinated action by some or all of those entities. 9. eeL organize advisory groups composed of representatives of 21J client groups, advocates, and service providers to advise eeL reqarding monitoring and enforcement problems they are aware o~ a~6 to recommend remedial actions CCL could take. Ie. eeL establish criteria regarding abusive or other life thr('?"'::sninq conCitions that indicate a need for immediate corre("' t i'T(c cJ-:tion, i pc luclinq possible faci Ii ty closure. Such cr iter ':(" s:-;,;; :_(~ no+-~ rerr.::"". eC:L' s ciscretion so much as limit the need for riiSr:if1 j 011 tn sj tUi'itions which are not covered by de~inpc cri t'='::::-ii1. 1J. ceL SDonsnr seminars twice a year for local law enforce me~t agencies, including district and city attorneys and fire marshals. These seminars would afford opportunities to create i0jnt strateqiE~ for addressing enforcement problems identified b-- eeL ar,d to S:lare information on successfully prosecuted caSt'S around the state. ,. . eel, L·repFl.TC a manual on the responsibilities of local la~ enforcement aaencies, as prescribed by existing law. This m2~:1.] '" 1 should include information on how communities can access state-level investigative resources. ~3. ee~ prepa~e handbooks for use by new licensees and resi GP~ts. Thp handbooks would state in clear, nonlegal lanquaqe ~b?t the la~ re0uires of service providers in order to be licers0{. The handbooks would also state in clear, nonlegaJ languaoF the :::-:'.r.l:ts and responsibilities of residents in commu nity care facilities. We further recommend that the Depa~tments o~ Developmental ServiceE and Mental Health and the Office of LonG ~er~ eare prepare, for inclusion in the handbooks, clearly written statements of the program goals, provider standards, and c 1 ier. t ~-.p:cvicp:c th:: t make up the framework within which communi tv re~~dr~ti21 ("'RTf is to be o~fered. 11 ------------------------------------ FUNDING Summary of Findings Ke foune that the primary funding source for community resi dential care services for the elderly and developmentally and mentallv disabled is SSI/SSP. Thus, federal and state funds are used in roughly equal proportions. The cost of the licensinq program, however, is paid 100 percent from the state generai =und. Supplementary payments from state funds are available to the developmentally disabled, but not to the mentally disabled or elderly. These supplements are intended to buy a higher level of care for clients who have been assessed as needing additional "specializec services." Thus, the adequacy of funding for commu residential care services varies from client group to client nit~ C'roun. Fe foune: that the "rate" for community residential care ser is not reaulated. For clients supported by public funds, vi~e~ th~ rat0 l? virtually equivalent to the existing SSI/SSP grant le'Jc~J (rr,irTs the small sums reserved for the clients' personal incide:ltaJ needs). Residents with private resources pay -J!".c' W1VltP"f--':- til"' mi'l_rkE'1 will bear. reductions so far have not resultec: in lower Dec~u?c budge~ S::::/SSp qraJ:t levels, the funding for direct services in comrnu rjt·· C,cv<,' has remained relatively stable and, in fact, has risen tv cost of living increases have been approved for ~hatever SSr!SSp recipients. Funding for monitoring and enforcement, on tb Ocher 11('11'.(!, has been cut. We found that reducing support for monitorinc and enforcement has also diminished the effectiveness n -F t h p ~ t: 2 r t. ~ ~.? j. tie ~ . Summary of Recommendations Legislative Changes 1':':-' recommend that the Legislature adopt the following two guialJ:S in allocating any new revenue that may be pri~ciple~ qenerated F>ursua:,t to adoption of our funding-related recommenda tions: ** New revenue should not replace General Fund support dollar-for-dollar -- at least not until additional revenue poten tial has been identified and realized. RRther, new revenue should be used to increase monitoring and enforcement effective ness and improve the quality of service. ** There should be no increase in rates paid to facility administrators unless the increase is buying a higher quality or level of service. Across-the-board rate increases (other than cost of living adjustments) cannot be justified. With those two guiding principles in mind, we recommend that the make the following changes in state law: L~gislature 1. Require care licensees to pay annual licensing com~unity fees. Require CCL to structure licensing fees in such a way as to offer for compliance with licensing laws and regu i~centives l2tions. Add a $2 per bed annual fee to support the State Long Term Carp Ombuo ,,:r',an Program. 2. Au::~()ri7e thp State Long Term Care Ombudsman Prog-ran tc es::aLli_s:l "Ombudsman Foundation." The Foundation would bp aC', to receive tax-deductible contributions for the purpose ~lin~ble supporting local volunteer ombudsman programs for the elderly o~ dc,'elopmen::allv and mentallv disabled clients resicUna in a~d beth ski 11'""0 r'l:rS i;q and communi ty care faci Ii tie s. ~ 3. Require CCL to notify DDS, DMH, O/LTC, and all licensees of the federal rules governing supplemental funding from private sources to m3intain SSI/SSP recipients in community residential r2ro fac:lities. CCL should also develop standard agreements for the use of facility administrators. Require DDS, DMH, and O/LTC to organize agaressive efforts at the county or regional level to s():icit private contributions to support increased levels and cUedi tv of sPivice provided to community care residents. 13 I. INTRODUCTION The Commission on California State Government Organization ano Economy -- more familiarly known as the Little Hoover Commis- sion -- is committed to improving California's provision of long term care services and has issued earlier reports on related programs. Most recently (August 1983), the Commission completec II ~,~ua', c f thp nur~ i:-w home industrv. 'I'he Co!nmission' s primary objective in issuj:-lg this report is community residential care S\'S+-PI -::.~, e n;;.;:' 1, i J to assure better protection of the resident~ dramat- i c a 11" i ,; c r"" a sin C; p '.1 b lie cos t s . CO;T1rrH.:?'ity res:'d~i.tial care J.n its present form is an unsatis- factor" instrument of public policy. This report is concerned ~it~ state gov('~~~rn~ls responsibility, in generating an alterna- tj ~'( tr:: i!1Stl tutionil.li ~2.tion., to take the necessary steps that the ~a::e+~" Cl',c: well-being of the individuals affected b'J thAt action. Backaround It sounds likn relatively simple idea: instead of keeping ? troIT chronic disabilities in acute care hospi tals (,r skillec nursing facilities, let's remove them from institutions and assist them in finding approp- .' r ~. ": t (' i) ~. ;:. C e.C: tel .... " ,. J . :; the community." More humane, mere 14 rehabilitative, less costly. But, as it turns out, it is also more administratively complex and difficult than anyone antici- pated. Community residential care is not the monolithic structure its label implies. Community residential care services are available to more than 150,000 Californians in 22,000 facilities that have bed capacities ranging from one to 550, or more. The types O~ clients include abandoned or abused or orphaned children (foster cRre), developmentally and mentally disabled individuals 21J ages, elderly persons, alcoholics, drug abusers, and p2rolc~ ~r court-assign~d ward~ of the Youth Authoritv. Dppe~6inq o~ which category, or "label," applies best to any ajve~ i~Ci'7i~ual, substantial differences can ensue in such vari- source of fundina ~or residential care service~; J11.o;;thly rate; availability of assessment interviews, placement assistance, anc follow-up visits (case management services); an~ acc0SC' t-r such generic community services as job training, rec- re3tiG~, or transportation. The perceptions of community resi- dential care's purposes, efficacY, or deficiencies can diverge to surprising degrees, depending on whether one's point of view is that of regulator, provider, or purchaser of services, client advocate, state bureaucrat, or budget analyst. CO%Tunitv residential care can be thought of, for example, as industry which evolved as a market response to a public pur- a"' ~ posp: qovernrr.ent is communi tv care's biggest customer. Yet, it is 2 tl ~~_.q'~J 12 t pd I' industry in name only. The caregivers are 15 ------------------------------------ indeed licensed by the state, and their facilities must meet minimum standards. But qualifications for community care licensees themselves have not been specified, nor have standards for care been determined. The units of state government that are the focus of this studv are: o The Communitv Care Licensinq Division (referred to throuqhout as "CCL") in the Department of Social Services. CCL licenses all community residential facilities. o The DpD2rtment of Developmental Services (DDS). DDS moni- tors the operations of regional centers, which approve facility administrators before case are allowed manag~rs tc place developmentall,,- disabled clients in COn1.:rCiuT'.i ty r0sidcntial care. o The Department of Mental Health (DMH). DMH monitors the operations of county mental health dppartments whose pff()rts to a!:"sist mentally disabled clients find comrTlunitv residential care placements vary substantially from count v tc'l count v . o Office of Long Term Care (O/LTC). The Office of Long Term Care has been established pursuant to the Torres-Felando Long Care Act (Chapter 1453/Statutes of 1982 (AB Ter~ a/LTC is expected to be the driving force in comprehensive system of long term care services crp.2tin~ ~ inc ludinq communi toY long term care agencies -- for elderlv. C~l~fn~nin's 16 o Health and Welfare Agency (HWA). The Secretary for Health and Welfare is directly responsible to the Governor for gRneral policy formulation in social and health services and for sound management of each department and office within the Health and Welfare Agency. o The State Lonq Term Care Ombudsman Program in the Department of Aging. The Ombudsman Program has pioneered th0 development of local volunteer programs to recruit and t~ain volunteers to provide client-monitoring of the elderJ" if' nursirg hemes and communitv care facilities. In Fehrui4rv 19F3, the Litt~le Hoover Commission hired Deanna . ,T prjrcipRl in th~ policy analysis consulting firD, Troubleshooters, as a project consultant to conduct a study of CO:'1.:rnJni"'":" residentiCll care. The initial phase of the project beaan with a search and review of existing documents l~ter~turp and anc;lyses. On Mav 25 and 26, the Commission held a hearing in Los Angplp~ as an additional an~ updating step in the information-gatherins process. In conjunction with this hearing, several Commissioners made unannounced visits to splpcted care facilities. co~~unitv Durinq ,Julv Clnd August, the Commission sponsored three work- shops communi tv re sidenti a 1 care, each one focused on a di:F- o:~ ferent client group: developmentally disabled, mentally dis- Participation in the work groups was limited 17 to 25 persons each; invitations were sent to pertinent organiza tions representativp of the clients themselves, the care provi ders/facility administrators, advocates, law enforcement offi cials, and state departments and agencies. Comments and recom mendations from the hearing and these workshops were used in the development of many of the recommendations the Commission is advocating in this report. 18 II. CALIFORNIA'S SYSTEM FOR PROVIDING COMMUNITY CARE SERVICES TO DEVELOPMENTALLY DISABLED, MENTALLY DISABLED, AND/OR ELDERLY RESIDENTS A. Maior Findings 1. Abusive, Unhealthful, Unsafe, and Uncaring Conditions Are Intolerable 2. Fragmented Administration Inhibits the Integration of Community Residential Care into the State's Overall Sys tem for Term Care Lo~c 3. Advocates Seek Case Management Services for the Elderly 2n~ Mentally Disabled Comparable to Case Management Ser vices !\ow Pro"l'ided Only to the Developmentally Disablec'l / S\1stC?"':': C;o21s ane. Client Ser't\Tices Are More Advanced for - t~r DpvploD~p~tallv Disable~ than for the Mentall,· Dis- 2;--)lec or FJ c~.erl~l C.~areqi \1(:"\-~ fo"!. the Devplopmentall\7 Disabled Are "Certi c. += ~ (' r1 , " Fr' C (; reg j v p r s for the F J e r 1 v a :l d Mentall\' Dis- ahJF-(~ ],r.c: l,ot "Certified" C: • Small Facilities (Six or Fewer Residents) Comprise a COJ"Jnuni ty Cn re "Subsystem" That Should Be Maintained Anart ~rc~ ~t~ Larger Facilities .., i. D c ', · t_-c~-. Basr ~n~ Information Svstems Are Inadequate to Sup- pert E~~icie~~ Frogram Management CJ. Exc~llpnce il1 Providina Community Residental Care Ser vices Goes Unacknowledged and Unrewarded 10. Lack of Community Awareness and Acceptance Causes Developmentally and Mentally Disabled Residents to Be Perceived as "Undesirable Neighbors" B. Reco~me~02tio~c for Improvinq Community Residential Care Services 1. Inteoratp Con-muni ty Residential Care into the Long TerTI', Care Systerr 19 b. Coordinate Policy Development c. Coordinate Definition of Services d. Extend Case Management Services to the Elderly and Mentally Disabled e. Improve Consumer Information 2. Strengthen the "Small Facilities Subsystem" a. Create Opportunity for "Cluster Administration" of Small Facilities b. Designat Model Houses P c. Award Certificates for Excellence 20 A. Major Findings 1. ABUSIVE, UNHEALTHFUL, UNSAFE, AND UNCARING CONDITIONS ARE INTOLERABLE The first finding of this study is the most shocking: Cali- fornia is tolernting the operation of numerous community care facilities in deplorable conditions. The residents are SUbjected to physical and sexual abuse, neglect, and generaly unsafe living conditions. As one representative of the community care industry observed, "the conditions are far more severe than ever existed lD nursing homes fifteen yenrs ago. It's a snake pit out there." Tt~ ~nfortun~te difference is that few people, particularly O'l"pr"1Y'0nt officialf:, are aware of the unconscionable ("onditions wb.ich thousand? of com.rnuni ty care residents, most of whom cannot care ~n~ th~rrsplves, must live in each day. Jv"er''tbers of the Little Hoover Commission visited facilities and saw first-hand the dirt, the neglect, and the emptiness. And ~uring two dn,'s of public hearings, we listened to one indjvidual aftF~ annther describe his or her personal "horror story." There is nc wav to relate adequately the variety and number of stories vn heard and conditions we observed. Below is only a sample: Facilities Do Not Provide Care for Residents 1. Bedridden patients lie in their own excrement. 7. Residents suffer from decubitus ulcers (bedsores) to the point of requiring hospitalization. In one case, the facility's staff did not know what it was, so they simply expnsed the resident's decubitus ulcer to sunlight each C~,- Eventually, the resident had to be hospitalized, at ",chi C!l tiJll(" surgery and skin grafts were required. 21 3. Ir. one facility, a resident was finally hospitalized after gangrene had gone undetected for too long. The individual had several toes amputated. 4. Many facilities employ non-English speaking staff who are unable to communicate with resident~. This condition is particularly dangerous when residents are suffering from or develop medical problems and staff cannot so much as read and understand the instructions on prescription labels. 5. Residents are repeatedly fed boiled cabbage and chicken livers or hot dogs as their primary diet. Actual meals served often do not resemble the posted menus. Threats and Physical and Sexual Abuse 1. Reside~ts are threatened with retaliation, ranging from goino unfed to being hit, if they report how they are beine treated to licensing staff or volunteer ombudsmen. 2. Whe~ one resident became ill with diarrhea and was incon the operator chose to teach him a lesson by tin0~t, into the backyard, undressing hir, and washing t~~~~c hi~ h~r d~~n with a garden hose. 5. P0?idn~~~ a~e fo~ced to have sexual relations with opera or In one case, an elderly female resident trY~ sta~f. was told that if she didn't go along with the operator's ~er?nds, she would never see her family again. U"hea I th\' a:-' (~ Unsa fe Li '\ling Conditions :; cone of our Commission's unannounced visits to Dcl~: we observed: ~ncjlities, c· O:lly two toilets were operative for 45 residents; neither was clean. c Although the residents in the facility were described by the operator as "sometimes violent," a large saw was discovered in an unlocked hall closet. c t'ledications were "stored" in open cabinets in the same room in which ice cream was kept in a locked freezer. a Four of the five fire alarms were inoperative. This facility was described by the Deputy Director of thE Department of Social Services as an "average" facility. facilities, residents sometimes sleep in ~~Jjcensed where mattresses are lined up next to each G~0 :~rqe roo~ on the floor. c~hp~ 22 Privacy Denied to Residents 1. Residents are denied privacy when family or others visit them at the facility. 2. Facility staff listen to conversations at a becroom door. 3. Ombudsmen are banned from entering a facility and visit ing residents, although they have legal access. 4. Residents are subjected to interrogation about what was said after visitors leave. 5. Operators and staff take ombudsmen's business cards away from residents. Residents Denied Personal Dignitv 1. are limitect to one roll of toilet paper per two Resi~entR residents per month. Owners and staff prohihit residents from takinc 2 nap. to bed, turning a channel on the TV, running water goin~ to dentures, or turning on a light without their rle~n 2Dprov21. 3. Private pay residents are given different meals from residents receiving SST/SSP. 4. Residents are treated like children. For example, in one ::acilit': thev were required to clean their plates in order to receive dessert. 5. One resident's clothes were ripped off because she was undressing too slowlv. 6. One woman was threatened with having all her hair cut off, because it took too long to wash it. 7. Residents are refused the right to make telephone calls. The description of the above conditions is not meant to indi- cate that all cO!TlY.lu'1itv care facilities are unhealthy, unsafe, or abusive. This Commission recognizes that a significant number of comrnmi ty care facilities provide very good living conditions on Based this study, our Commission has concluded that there 0:'1 is no single cause for the above conditions. Although we believe significant improvements can be made in the monitoring and en- forcement system, we do not necessarily believe, for example, that these intolerable conditions exist because the Community Care Licensing Division of the Department of Social Services is not doing its job. Given the number of facilities, the lack of program standards or required qualifications for licensees, and reductions in state general fund support for licensing and en- activities, the department's task is in fact over- fn~cement 2. ADMINISTEATION INHIBITS THE INTEGAATION OF FPAG~·1E!\TED cmu':UT'JI'J'Y EESIDE1\TT::AL CARE INTO THE STATE'S LONG TERM C.l\PF SVSTEi,1 CrT"'~1.mi tv residential care is not viable as a free stanci;:q o~ care anc supervision. It can work only in conjuncticr Dpriodic of irdividual residents bv trained social wit~ rev~ew an{ professionals who are capable of assessing the ~p~lth ~0rvice care need~ of those individuals over time. In short, communitv residential care needs to be fully integrated into the array of services referred to generically as "long term care." Implementing a system of community residential care involves s~stem of facilities licensing. In order to assure the provision of adequate services and a safe environ- ment for residents, a network of supportive and therapeutic ser- be developed, maintained, and coordinated. There are vic~~ ~ust 24 inherent difficulties In coordinating such a complex service delivery' s·,/stem. The most glaring problem is the disparity between the rela tivelv diverse services available to the developmentally disabled and the lRck of supportive and/or therapeutic services available to the mentallv disabled and elderly. This disparity results from there being three completely independent service planninq groups. Th0 Department of Developmental Services (DDS) and its "satellitE's" (regional centers, State Council on Developmental related advocacy organizations) have developed DisabilitiE~f a~d stC',nd2rd~ C1nd gOrds :or community residential care serv:i_ces for thF'~;· cJ.i'??1telc· f ap,',rt fron licensing requirements, and created a m~ch~nisrr for s0:(~tina service providers. It mean:=: ('<. COffi.TT'.U- ;:i +-,. cn'·'" pY'('vidp;- ha s been approved by the regional center as able and willinn tr the needs for service that are unique to ~P0~ developmentally disabled individuals. The developmentally dis- acled progrom planni;:c network promotes provider training in tech;:iaups of be~?vior modification that are effective in teach ing developmentally disabled persons to become proficient in such activities of dailv living as eating a meal in the company of others, participating in games and other group activities, and performing household chores. The orqaniz2tional structure that has facilitated these advances i::: progrc;mJring for the developmentally disabled in com me~it\· care f2i:s to facilitate similar advances for the mentally 25 disabled ana elderly. Ideally, when statutes, regulations, poli- cies, and procedures affecting one client group are refined and improved, siDilar processes would be triggered automatically for the client groups who are also in community care but whose pres ence there occurs under separate statutory and administrative auspices. That this does not occur is evidence that community residential care is not integrated into existing long term care svsterrs -- except for the developmentally disabled. Because service planning for the three distinct client groups is no-:: coordinated, there is a tendency to perceive Community CFirp T.icPLsinq (CeL) in the Department of Social ServiceE (DSS) Y,,, (1 S [-,2'. i t \;,-, p>: im3YV adrr:ini stra ti vp re sponsibi Ii ty for cOffi1Y1uni ty as if corrJTH.P1i ty res identia 1 care were c: To some extent, the a:fectec state de~artments appea~ to share this perception. facility administrators are not gener2lly included in planninq improvements in the provision of services. 0: for the administrators to function as members a "tro2 tIT.cr,:' tF:aIT:, " rather than merely as "opera tors II 0 f community At the opposite extreme is the responsibliity assianed to ad~inistrators of residential facilities for the (PF'F' s) • The regulations pertaining to this category of licensure re~uire RFE administrators to assess the care needs of residents and assu~e that appropriate services are secured. The servicp providers, in this case, are being expected to fill the created by the lack of a state-level system for the ~s 26 -----~~~-------------------------- elderly that is comparable to the state-level system for the developmentally disabled. 3. ADVOCATES SEEK CASE MANAGEMENT SERVICES FOR THE ELDERLY AND - MENTALLY DISABLED COMPARABLE TO CASE MANAGEMENT SERVICES~­ PROVIDED ONLY TO THE DEVELOPMENTALLY DISABLED One reason that the severe conditions described earlier can persist in many care facilities is that mentally dis- commu~ity abled and elderly clients are rarely monitored by outsiders. Case not routinelv aV2ilable to the elderly, nor m3~aqement i~ available to the mentRllv disabled. comprehe~~~vely "Case manageme~t" is actually an array of services provide~ It includes, but i2 not limited to, follo~i~~ rrroDo~e~ts: 1. A2sessment of the client's physical, environmental, f_' l. nanClc. L1c , and psYchosocial needs and resource~. 2. Determination of the need for placement assistance and ongoinG case management services, especially periodic tor inc. !T~::;"i 3. Pevelopme"t o~ a~ individual care pIa" to meet the client's immediate and long-term needs. This plan is prepared with the participation of the client and other relevant persons (for exampJE, family members and doc tors). The plan covers not only an individual's needs for income and health services, but also for emotional support, reassurance, social contacts, recreational ac tivities, and supportive living arrangements. 4. Service procurement. Case managers locate, make arrange ments for, and sometimes actually purchase services to be to individual clients. provide~ . ppc::ul;:;r and timely reassessments of each client's prog ~ reS8 and condition. ?7 County mental health departments do monitor mentally disabled residents in comlnuni ty care facilities, but not as frequently as developmentally disabled clients are visited, or over as long a term. Few standards have been developed in the mental health system pertaining to the goals for clients in community residen tial care. Furthermore, the mental health system lacks a certi fication device similar to "vendorization." Consequently, mental healt}l case workers are powerless to affect the conditions in whjch they their clients living. ~ind Assessment of individual clients has to be performed by qual ified p~ofessionBls who have the capacity to determine the health an~ social service needs of the clients. Elderly and mentally disabled clients badly need assessment and periodic reassessment, as their conditions tend to fluctuate rather often. Asspssnent, while desirable, is admittedly an art at this sci.e!1ce. The most advanced assessment system is that US0~ for devplopmentallv disabled clients. Nevertheless, instruments currently ln use for this client group so~ptjmes do not adequately take into account behavioral problems and medical needs. Inaccuracies in client assessments, just as often as no client assessments, lead to "inappropriate place- ments" meaning clients receive either too little or too much ("are. The difference is, in a case management system, reassess- ments create the potential and the mechanism for correcting ini tial errors. 28 During our hearing, the Commission received testimony from £our local ombudsmen who investigate and attempt to resolve com plaints in community care facilities in San Diego, Orange, Napa, and Santa Cruz Counties. Each of these individuals stated that one of the most serious problems in community care facilities today is inappropriate placement. Inappropriate placements result in many of the conditions the ombudsme~ ~ust investigate. For example, ombudsmen see numerous cases of residents who are bedridden patients lying in their own excrement. The facility administrator in such cases obviously is uncualified and incapable of caring for such individuals. These typ0S residents should be in nursing homes. o~ As discussed earlier, assessment of prospective residents by administrators of residential facilities for the elderly (RFE) is the law, but is it actually being done -- or, when it is, is it pffecti"e? RFE administrators are not required to meet any qual j~ications that would make them suitablv able to judge the men tal, ph\"sic?'l, or functional capacities of prospective residents. an administrator has a financial incentive to "keep ru~therm0rer the befs full," whether or not the elderly individual could be truly appropriately received into the administrator's facility. The deqree of resident participation and choice in his or her care arrangement is closely connected with thp rpsidentia~ of case management services that emphasize individu ~vaiJat~!ity alized care anc service planning. Casp managers in the system the disabled point out that assisting clients ~or ~~v~loD~pnt~.lly 29 In choosing an appropriate community care facility is complicated by the fact that a client has the right to choose where he or she is going to live. A community care resident cannot be forced to acrept a recommendation for placement. The principle is a good one and is intended to promote and support the programmatic goal of increasing client independence. Sometimes, however, it is hard to reverse a placement decision that is not in the client's best interests if, for whatever reason, the client chooses to in an inappropriate facility. remai~ Nevertheless, case management offers many client benefits as fcr an individual are tailored to meet his or Service~ her bv the caSE manager, who also maintains more constant nee~s contact with thE client. Consequently, there is another set of c,oes periodicRllv the conditions in a facility. How- observi~g ever, it is also true that certain problems inhere in adding case servicr. to the community care system and they would need to be resolved. The problems are: (1) purchasing power lS generally limited to the SSI/SSP (2) options under this rate~ are limited; (3) developmentally disabled clients have ccnstra~nt supplemental public fundine available for specified purposes while others do not; and (4) there is presently little or no informatior available to prospective residents on quality of care and/or which facilities have good or bad records with respect to violations. lice~si~g 3C 4. SYSTEM GOALS AND CLIENT SERVICES ARE MORE ADVANCED FOR THE DEVELOPMENTALLY DISABLED THAN FOR THE MENTALLY DISABLED OR ELDERLY California lacks a comprehensive concept of what the commu- nity residential care system is supposed to do. Lacking such concept, the state entities with statutorily authorized missions to serve specified client groups have defined their own clien- tele's need for community residential care services. Once again, the state-level system for the developmentally disabled has established service definitions compatible with the clients' needs f0r service, whereas the state-level systems for the elderly disabled have not intervened in the an~ me~tally progra~ of corrununi ty residential care to any sigrd ficant dEvelopr.e~,t Fro~ testimony at the May 1983 hearing and papers produced at the" th:::-p0 w8rkshops, the Commission has identified several 8t~""'.::"pr e leIT'ent s C'.c cornmuni ty re sidential care in which separate goa Is and services should be defined differently for each client clie~t crou;::. Tnesc arE:: stand2rds development, compliance monitoring and provision of health and supportive services enf~~~crnent, within facilities, resident participation in facility decision- makinc and in the co~munity, individualized care and service planning, resident or client tracking, availability of meaningful activities, and the qualifications of providers. Pa:;ti.cioants in the summer workshop concerned with the de- velopmentally disabled felt that the broad service goals estab- 31 lished by Community Care Licensing (CCL) are in some cases inade- quate for developmentally disabled clients. Furthermore, there are areas of conflict between the requirements of the Lanterman Act and those of the Community Care Licensing regulations per taining to services for the developmentally disabled (for example, prone restraints). When conflicts arise, the delinea- tion of authority needed to resolve such issues is unclear. The results are confusion among facility administators and deficien cies i1". the provision of services to residents. Svstem Goals/Service Outcome Goals. "System goals" should community residential care is supposed to be and do for the residents, without reference to categorical disabilities. "Service outcome goals" should clarify thE: developmental, reha- bilit2tive, or functional conditions that community residential carl" ::oer"lCE8 are intended to promote. These vary from client aroup to client group. Therefore, The Departments of Develop- mental Services (DDS) , Mental Health (DMH) , and the Office of Long Term Care have to be responsible for developing service goai::' for the developmentally disabled, mentally disabled, an~ elderlv, respectively. Within client groups, service goals will vary from individual t c inc i \' i d u a 1 . Thus, sensible goal-setting for each client can be achieved onl\' i1". a case management system utilizing individual clie1".t a::osessment. 32 5. CAREGIVERS FOR THE DEVELOPMENTALLY DISABLED ARE "CERTIFIED," BUT CAREGIVERS FOR THE ELDERLY AND MENTALLY DISABLED ARE NOT "CERTIFIED" Licensing is concerned to a great extent with a licensee's physical plant, certification with the caregivers, or facility administrators. In the existing community residential care sys- tern, certification of administrators is neither mandated nor authorized by state law. The regional centers have developed a form of certification for caregivers serving the developmentally disabled. The re- gion21 centers require administrators to be "vendorized," meaning they are approved by a given regional center to serve developmen- tally disabled clients. Case managers place their clients only with vendorized administrators, who also are eligible for supple- funding to extent each administrator is able to pro- menta~ th~ vide "specialized services." Thus, administrators have a finan- cial incentiv( to seek vendorization. This system helps to who are not qualified or able to provide ~crpe'-' '''1+- prc~F:Lders qU21i +-:' care. Before 1973, when the state Community Care Licensing Act was passed, the process of releasinq state hospital patients into community placements involved the "certification" of community care providers by the same social workers who would also continue to follow the progress of or changes in those patients (see Appendix A for more detail). When board and care homes were being actively sought (primarily for the chronically men- an alternative to institutionalization -- startincj c.:. 33 around 1940 and continuing through the early 1970's -- this on- going personal contact constituted a less formal quality control mechanism than licensing. The impact of licensing on quality is unclear. Among social and health service professionals, there is a sense that the humanitarian motivations which were once thought to be the cor- nerstone of effective care and supervision are simply not rele- vant in the "bricks and mortar" system of licensing. centers created vendorization as a quality control Region~l mechanism that allows them to set standards that exceed licensing :::-equiremen+:s for service providers who are interested in meetino th 0 sDeci~lizef care needs of the developmentall~' disabled. Countv mental health departments presently lack a comparable Certi:ication of administrators serving the elderly is not feasible at present, as there is no administrative entity tr this function. avai12~le pprfor~ 6. SMALL FACILITIES (SIX OR FEHER RESIDENTS) COMPRISE A CARE "SUBSYSTEH" THAT SHOULD BE MAINTAINED COI1J,:U~\::T~- APART FROM THE LARGER FACILITIES Throughout the period of this study, the Commission has received comments from diverse sources on the special set of problems that is associated with small community care facilities private homes serving six or fewer residents. Of 22,000 com- munity residential care facilities throughout the state, 18,000 (8) percent) are licensed for six or fewer residents. 34 Of that total of 18,000 small facilities, approximately 4,000 are the elderly and developmentally and mentally housi~g disabled clients, while 14,000 serve foster care children. Before 1946, community residential care was provided predomi nantly by churches or charitable organizations in large facili ties or by families in their own homes as recruited, certified, and supervised by social workers (see Appendix A for more detail) . When CCL began licensing community care facilities in the mid-1970's, the system took on a new aura of entrepreneur ship. Unlike most proprietors, administrators of board and care hOGPS do business in relative isolation. They are protected from the standard market forces that might otherwise drive out the abusivE by the disabilities and fears of the very ad~inistr2tors they serve. This situation apparently brings out the clip~ts wor:::--:-_i '1 certa iJi care providers and, as things stand, residents in small facilities are inadequately protected against abuse, exploitation, and grimness. The setting" of the small facilities represents a "fa~ily tradition in therapeutic environments thought originally to be particularly appropriate to mentally ill patients who no longer need hospitalization, but who do still need care and supervision. Khe!' thp Community Care Licensing Act was passed, these small carne under the auspices of the same regulatory system fac~~ities that evaluates homes for as many as 550 "well elderly," r~ct crphanaaes comparable numbers of children, and other large ~or facilities. non-mpdjc~l r~rp 3S It is IInonmedical care" that places all these quite disparate car(; options into the sing-ICc category" communi ty care" for pur- poses of licensing. The efforts of government to reduce the high costs of professional long term care for various disabilities have led to this categorization and have thereby stimulated the demand for increasing numbers of community care beds. Individ- uaJs without medical training, but with their own homes to offer as a resource, havp come forward to supply this care. This can be expected to continue, given recent changes ~rend in federal fundinc long terro care (effective October 1, fo~ The policy is to eliminate day-rate reimbursement to 19~::'.). ne~ hospit~ls in favor o~ payin~ 2 specified maximum for a diagnos- ~ica} 1 \' de f i ne6 cond i tion. This change will cause hospitals to plac~ (onval~srjnc Datients in skilled nursing facilities (SNFs) in order to reduce their own costs per day. In turn, the SNFs will ~ant to placr th0ir clients -- those whose conditions have ~_ r:to cOmrrtll?li tv' care, to make room for placements that hosnitaJs wi}l soon be paying for at a higher rate than SNFs now receive. The point of this ~s that it is desirable now and will remain desirable for the foreseeable future to keep community residen- tiaJ care decentralizec and to utilize the family care setting. 0: The large number facilities available, the scattered site distribution of facilities, and the diversity in levels of the~p carE availab10 are all characteristics of the "small facilitif'S thn.-:-_ it cOml)2tible with the necessity of reducing subs"~tprr" nal<:~ th of lone torm carc. Q CC~~~ 36 Problems may arlse, however, when options for improving the qUality of care are considered. At that point, it will be impor tant to exempt the small facilities from traditional means of regulating quality -- such as educational requirements of service providers -- and, instead, to create "networks" within which small facilities can function and be supervised. This is desir- able for two reasons: (I) many community care residents prefer to live i~ the family-setting environment in small facilities, and (2) thp lack of extra staffing requirements and provider qualifi- cations makes this care option available at low cost, relative to all other opt~n~s. wit;; thrc clarification of rules and requirements for the fRmi lv-s('"_ t i:1g care option, the rest 0 f the community resident ia 1 care can mature without disrupting the "small facilities indust~~' subsystem." ID the industry as a whole, caregiving specialties aDd con~o~itant training programs should be allowed to emerge in crder that more levels of care can be integrated into the overall lona term care system. 7. DATA BASE AND INFORMATION SYSTEMS ARE INADEQUATE TO SUPPORT EFFICIENT PROGRAM HANAGEMENT Therp is no requirement for community residential care facil- ities to report costs or utilization and no system-wide automated management information system. Thus it is not possible to deter- mine such facts as the following: 37 o Prior Experience of Providers. Although all applicants for lice~sure must provide fingerprints which are checked agal•n s,+-- the Department of Justice's criminal records, there is no system for checking an applicant's prior rec- ord of service as a community residential care provider. There are known cases of individuals whose licenses have been revoked in one county for serious code violations (such as neglect or abuse of residents) who are subse- licensed in a different county; this can occur que~~ly without the licensing agency's being aware of it. Als0, there is at least one known case of a delicensed nursinc home administrator who is currently operating 2 community residential care facilities. This di:=:- seve"~a coverv was made through personal observation rather than throuah svstematic record checks. FiLCllly, only the applicants are screened via the finoerprint check, while staff (i.e., employees of the licensees) in the larger facilities are not screened by the state at all. o Consumer Information on Quality of Care. Not only do licensing personnel have systematically inadequate infor- mation on caregivers, but so does the general public. There is no systematic generation or distribution of in- formation regarding the quality of care in available fa- cilitics by area. Current law and regulations require CCL faciJities rating system. The basis for 38 ratings is to be the extent to which facilities have been found to be in compliance with health and safety stan- dards. eeL, however, has never implemented the required facilities rating system. Furthermore, eeL state and district offices make no svstematic effort to gain press attention to changes or improvements in community residential care. The general public (to say nothing of doctors!) is unaware of what the difference might be between a community care and a skilled nursing facility. Fo:!:" example, even the telephone book foe8 not provide a useful listing of facilities. Gen- prally, facilities are grouped together under a heading sue:: as "rest homes," or "retirement homes," which fre- GUP!!tly cOPlf)ine nursing homes with community carp facili- ties or even room and board houses. This information gap undoubtedly contributes to widespread "inappropriate a~cne throughout the residential care system state- widp. (' The annual cost of public subsidies for community residen- tial (",2-re. Based on the SSI/SSP rate, basic payments for foste:!:" care children, and assuming 60 percent of licensed capacity for adults is occupied by publicly-supported residents, we estimate a minumum of $583 million in public fundina will go into direct service costs during 1983-84. Facilities are not required to report to clients char~es vate incOMe. Consequently, the costs incurred bv p?~i 39 these individuals are unknown. Private-pay residents often pay more, but even if they pay only the SSI/SSP rate, at least another $181 million is going into commu ni ty residential care from private sources. (This estimate assumes a 90 percent occupancy rate. CCL has no data on utilization, however, so the actual occupancy rate may be considerablv lower than we have assumed here.) The above estimates do not include the costs of case management or administration. They also exclude substance abusers, supplemental funding for "specialized services," county supplements for foster care, and residents in unlj- facilities. Thus, community residential care may CPIlSPC be a nearly $900 million a year industry in California. The lack of cost data retards efforts to make community residential care more efficient. Without knowing how much are spending now and what benefits might accrue to the ~P residents as a result of more expenditures, any reorgani- zation of rate-setting, reimbursement, or purchase of additional services would have to be made on the basis of intuition rather than analysis. o Information to Facility Administrators. Lack of knowledge about the special needs of residents and about resources ano. services available in the community are critical im- podimentE to adequate service provision. Providing infor- mation to cOJ11munity care facility administrators regardina cor;-tY'l:ni tv eve:::t.s , activities, and services that residents 40 in their facilities would be eligible to participate in could result in more active lives for community care resi- dents. o Client Tracking. An effective system for tracking resi- dents is lacking for all three client groups. Without information on prior placements, case managers and other service professionals attempting to devise an appropriate care plan for a client have no way of knowing where the client has been, which services have been provided in the P2st, or what was successful or unsuccessful. The result- ing interruptions in service to a client may be damaging to an individual's prospects for rehabilitation and qrellter self-sufficienc,;'. Monitoring elderly residents is particularly difficult hecause far more of the elderly than of developmentally or ITl.-:::ntally disabled either place themselves iY' community care f(';C'ilities or are placed there by family members. Because there is no reporting system or client tracking into which to feed client characteristics, volun- syste~ teers programs such as the Long Term Care Ombudsman f~om have no way of finding out where self-placed elderly resi- dents are livina. 8. PROVIDER TRAINING IS NOT REQUIRED Give;-, the sen~ice providers in community residential carp are not reoui~ed to meet minimum qualifications, it is not 41 surprising that training often is not available to them. Yet, pro\"ider training would have the most immediate and beneficial impact on the quality of life for community care residents. At present, only RFE administrators are required to fulfill training standards: 20 hours of continuing education per year, the content of which is unspecified and left to the administrator to decide. Regional center case managers cite as critical the gap between the expertise of program planners and that of provi ders as a factor in inadequate service delivery. Mental primar~" heal th professionals at the Little Hoover Commission \vorkshop pointed to four deaths of mentally disabled residents thj~ ~ummpr whir;h H(~re 1 i!1kec'. tc thE; u!1skilled application of management of behavior technioues. ass2uJ~ive Wh:i::e it is cleo:,r that the majority of community care provi- ders are inadequately trained for their responsibili a~d staf~ ties, the type of training these persons should receive is actu~l Priorities need to be set. Should the administra- t0YS be trained for example, in the improved management of firs~, safe and clean facjJities or improved provision of care to resi- That administrators are increasingly organizing themselves int8 associations suggests they are interested in upgrading their personal professionalism, as well as their political influence and public irr,a~H . As discussed earlier, our perception is that of small facilities need to be involved in a su- 2dmin~str2tors },pn"iC:'C'G "nptwork" of sf.wll facilities. This arrangement mayor 42 may not include formal training, but it would afford more oppor- tunities for small facility administrators to learn from each other how to upgrade the quality of care they provide. In the larger facilities, on the other hand, we believe that at least those supervising the care given to residents should be professional administrators and/or health service specialists. Thus, they should be required to meet traditional educational or training requirements commensurate with their professional status and le\'el of responsibility in a community care facili tv. 9. EXCELLE:t\CE IN PEOVIDING COM.IvlUNITY RESIDENTIAL CARE SERVICES GOES UNACKNOWLEDGED AND UNREWARDED O:l € c·£" the Dost cornmon complaint s heard from community carE: is ~hat they hear only "bad news" froD the state th~t j~, when their facilities are out of compliance with laws or reaul2tioDS. News stories, too, tend to focus on cases of criminal abuse in cow~unity residential care, causing the indus- trv 0 C' (' \.'bo10 to suffer the loss of public confidence that fol- 10'1'.',:::, • Because we think it is important to the safety and well-bein~ 0: all ::'oFJT,uni ty can' residents that certain deficiencies in the existing system be corrected, we too will be reporting to a great extent on what is now wrong with service delivery, enforcement, a:lG funcina. But we consider it equally important to acknowledge that there are cow~unity care administrators who provide quitE: sati~r2ctor" care at a low cost and, in some cases, operate truly L13 facilities which deserve to be commended and imitated. In addition, if excellent facilities were identified and publicized as such, the medical profession and the general public would be better able to make intelligent selections. 10. LACK OF COMYlUNITY AWARENESS AND ACCEPTANCE CAUSES DEVELOPMENTALLY AND MENTALLY DISABLED RESIDENTS TO BE PERCEIVED AS "UNDESIRABLE NEIGHBORS" COl'L".mni ty care residents are frequently perceived as "unde- sirable neighbors." This is particularly true of developmentallv anc IT\('nt211v disabled clients. The public policy thrust to achiRVr savincs by moving patients out of state hospital8 ar~ into t}ir, communi tv could benefit from a public relations effort, anI," to promote understanding and acceptance but also to no~ recruit volunteers to help generate activities, job opportuni- ties, ('}" :::'2)'"'i1y homes. Renresentatives of all three client groups have decried the laC'K 0~ communi ty involvement and support for comllluni ty care reside~ts and Drc~rams. Since the deinstitutionalization move- mRnt b0s?n, mentally and developmentally disabled clients and their service providers have often experienced resistance from within neighborhoods when attempts were made to establish resi- denti21 facilities or homes. While neighborhood acceptance is an isscc these two client groups, an even greater need ~till ~or o:iS"L: to rpirtegrate disabled individuals into the community at 12~(:0. CO~T'"'--ir:i t'" residelltibl care clients need access to commu- 44 nity resources such as parks, recreation programs, the Y's (YMCA and YWCA), schools, public transportation, and libraries. 45 B. Recommendations 1. INTEGRATE COMMUNITY RESIDENTIAL CARE INTO THE LONG TERM CJI.RE SYSTEM We recommend that the Legislature amend the Torres-Felando Long Term Care Act (Chapter 1453/Statutes of 1982 (AB 2860» to specify that community residential care shall be included in the array of services referred to generically as long term care. Community residential care is not viable as an independent system ef ('are. All adult community care clients need access to health services, some more frequently than others, a:l(~ fer lonqer periods than others. In order for community care so~p to h0 efficaciou8 as a low-cost residential service for chreni- call" 6isabled individuals, it must be compatible with and inte- grated into the overall long term care system that is now emer- California. oin~ i~ Snecifica11y, administrative improvements at the state-level include clarification of roles, coordination of policy she~ld development, of service definitions, and improvement coor~ination of information aVRilable to consumers. The integration of com- munitv residential care into the long term care system also should have the specific result of extendinq case management services to the elderly and mentally disabled. a. Clarifv Roles. We recommend that the Legislature revise state laws in order to clarify the role that the Community Care Licensinc Division is to play in the long term care system vis- 46 a-vis the state departments with responsibilities for developing appropriate goals, standards, and services for specified client groups. We recommend that eeL continue its narrow focus on facilities licensure, based on physical standards. We further recommend that any authority eeL now has in statute to evaluate program- matic aspects of community care facilities be deleted from the law. Most urgently, we recow~end that eeL be prevented from distributing its recently drafted "client-specific" regulations for public revie\\' and cornrnent. We recoITLr:1end that the Departments of Developmental Services and ~ental Hpalth be statutorily authorized to develop program gC'-'ll~" provider standards, and client service definitions for cormlluni tv residential care services provided to the developmen- tally disabled and mentally disabled, respectively. These de- -- not CCL should formulate appropriate imp le- Dartment~ .f • regulations for their respective program goals, provider men~lnc standards, and client service definitions. We further recommend tl12t state laws be amended to require that service providers for thpse two client groups be certified bv the regional or county representataives of these departments in order to be eligible to receive placements of publicly subsidized individuals. \ve recommend that the Office on Long Term Care whatever ultimate organizational status and/or placement in state government turns out to be -- be mandated to develop program standards, and client service definitions and aOci~S, provi(l('~- 47 related reaulations for community residential care services pro- vided to the elderly. We further recommmend that Chapter 1453/- Statutes of 1982 be amended to require the Community Long Term Care Agencies, as they are phased in, to certify administrators of residential facilities for the elderly, based on these goals, standards, and service definitions. Finally, we that CCL develop procedures for re- reco~~end porting violations of programmatic and service standards which licensing e'/aluators observe during their visits to community ca:ce fac~ljties. I,e,€ further recommend that the State Long Term (\;r.bJ08!Tl31' ac;vise all volunteer programs to re::er locally ' unrpsr'~7ed quality or care complaints to the appropriate program agenc'.' rather tr--l:-,r to CCL. Such violations and complaints shou16 be inv0C'tiqatpc D" +.h,~ Departments of Developmental Services or Menti11 BFal t1-) o:c t.he Office of Long Term Care, as appropriate. We rccoI:unenc1 that the se a qencie s deve lop criteria and procedure s for community care facilities, whenever neces- d0c~rtifjc2~in~ n~ sarv 1:C" pr()-:~pct the ,de 1l-being of the residents. h. Co·~rdinatp Policy Development. We recommend that changes in developed by CCL pursuant to our pro- posed restrictions on facilities licensure be discussed with and reviewed h~' the DeFartments of Developmental Services and Mental Health an6 the Office of Long Term Care before public hearings are held on such regulations and/or before they are submitted tn 48 approval. We further recommend that the Legislature require CCL to obtain statements signed by the department directors, at testing to each department's having reviewed the proposed changes in regulations. These statements should include the departments' comments on or opposition to the changes CCL has proposed and be attached to the copies of regulations which are distributed to the public before hearings are held. Ke that the Legislature require the Health and recow~end Welfare Agency to identify all conflicts in existing and emerging l2w between responsiblities assigned to CCL and those assigned to departments regarding community care 2~fpctp~ ~t?t0 n~sidential and propcsr appropriate legislative changes. c . Coordinate Definition of Services. Lecislatucp require the Health and Agency to establish a ~elfare process wherehy the program goals, provider standards, and client serviC0 developed in regulations by the Department of ~rfinitions Dpueloprnental Services will be reviewed bv the Department of Health and the Office of Long Term Care, and vice versa. ~ental The intent of this provision is to assure that all affected de- keep apace of advances in services for categorically- nartffien~~ defined client groups as such advances evolve. We do not mean to imply here that all services available to onp group should necessarily be available to all other clie~t This COTTunission does believe, however that all I the t programs in the cOInlTmni ty care system need to be COrnp0!10n and s)'stematic basis of new developments and ~dV~End ~1 ~ r~0ular We further recommend that the Health and Welfare Agency require the departments to create advisory processes that solicit recommendations RTId comments on proposed changes from affected clients, service providers, and client advocates. d. Extend Case Management Services to the Elderly and Men tally Disabled. To the extent that community residential care is eventually assimilated into the overall long term care system, the elderl,· and mentally disabled will indeed receive case man agement services comparable to these available now only to devel- opmentaLiv disabled community care clients. These services individual assessment, care and services planning, periodic follow-up monitoring, and media- Dlacere~t a~sistance, with service providers. This change is so critical to t~o~ th~ diminishment of abuse and exploitation of community care resi dents, however, that we feel we must specify it. or the pxperience documented by the mUltipurpose senior p~SQ~ se,vices demonstration project (MSSP), case management that e~­ phasizes community placements results in more efficient utiliza- tioD of existing services. All MSSP clients are identified as "fr2i l F'lderl\,fI anc' are eliaible for skilled nursing services funded under MediCal. The average cost in MSSP for providing social and health services to clients in community settings is approxim2telv $900 per client per month. This cost includes case management and compares quite favorably with the average 51,150 per client per month in nursing homes, which is the cost of 50 Providing case management services to the elderly and men tally disabled may require additional funding at first, but there is reason to expect that at least a significant portion of new costs will gradually be offset by reduced expenditures. As the long term care system evolves, all clients, regardless of categorical disability, should receive case management ser- vices at whatever point they enter the system that is, whether as a state hospital patient, a recipient of in-home supportive services, or a community care resident. support of this goal, we recommend that Chapter 1453/ I~ StatutrO' cf" 1983 be amended to require Community Long Care Terrr~ AqEncies to indicate in their planning process how they intend to keep recnrc1s c);; clients placed in community residential facili- e. Impro\7p Consumer Information. We recommend that the the existing mandate to implement a facili Legis~ature trans~er tieR ratinq system from CCL to the Departments of Developmental SP!Tj ces and Mental Health and the Office of Long Term Care. We recomroenc" that this statutory requirement be further amended to spEcify that the county or regional counterparts of these depart ments shall create such rating systems in conjunction with relater volunteer organizations in each community. Thp rating of each community residential care facility should be based on the facility's record in meeting both licensing and certification requirements, including an administrator's having recei v 0 rj oc rt.i fica te S 0 f excellence (see our recommendations for f>cilities subsyster;,"). t),FC "S~,~. 51 We further recommend that regional centers, county mental health departments, and community long term care agencies be required to make their facility ratings available to prospective residents, and/or their family members or other representatives. Prospective community care residents are entitled to have the evaluative summary a rating represents before selecting a facil ity. Finally, we recommend that the Department of Social Services' Community Care Licensing Division ask the Public Utilities COI'l mission (PUC) to require all telephone company offices in Co.li ?or;--,ia to J ist_ licensed community residential care facilities for.- the elderlv 2nd developmentally and mentally disabled vellow I)"'lges by client group. 2. STRENGTHF}; THE "SMALL FACILITIES SUBSYSTEM" Ee u:'corrr.cnd keeping small facilities as a viable care op-::'ion iroprovina the quality of life for the residents housed in ~n~ them. There is a legitimate place for nonprofessional care and particularly in the small, family-settina facili- supervi~ion, ties. However, these facilities need to be brought into a "net ...; ork" cf sm211 facilities that develops apart from the profes sionalizing changes now beginning to take place in community care. Once this has been accomplished, the rest of the industry can mature, diversify by offering ever more specialized services of care, and become professionalized. Decentralized a~{ level~ 52 administration and monitoring of small facilities would allow Community Care Licensing to devote its own monitoring and en forcement activity to regulating conditions and programs in larger facilities, wherein the majority of community residential care clients reside. Enhanced decentralization of services administration and monitoring of quality control in the small facilities can perhaps best be achieved by making room in the system for new entrepre neurs. Currently, only the facility administrators are the entrepreneurs, while the state bears the entire burden of setting improving services, developing new programs, monitor stan~ards, ing for quality control, and investigating complaints. Blenainq public purposes with market forces has already appeers to be a generally adequate statewide supply ~'ielded wha~ of community residential care services. Now, there is a need to create opportunities for entrepreneurs other than caregivers to epter the industry so as to improve quality control, diversify servj. ces avo. i lable to clients, and bui Id community acceptance and support. We believe that the three programs outlined below would pro duce the very desirable results we have just discussed. There fore, we recommend implementation of all three of these programs. However, we believe these proposals should be implemented at first on a two-year pilot project basis only. 53 a. Create Opportunity for "Cluster Administration" of Small Facilities (Six or Fewer Residents) Throuqhout our discussion of this recommendation, we will refer to the small facility operators as "managers," rather than as administrators, to reduce the confusion of talking about the "cluster administrators." By "cluster administration," we are referring to there being one administrator for up to a maximum of 10 small facilities. Obviously, restrictions on geographic proximity would have to be spec i f::.-,~(1. The responsibilities of the cluster administrator but not be limited to, the following: wou}~ ~~clude, ?<=:lecti0!. c)£ cluster house managers that meet the cluster expectations (informal "certification") a~rrinistratcr's c Budqetirg 2nd recordkeeping for all facilities in the cluster o Manace~0nt of pooled resources for purchasing to reduce 0"Cra'] ceets -- for example, food, transportation, tickets to co~~unity events f:;, ir:C respcnsitle for mClkinq sure violations cited by CO!Nrunitv Care Licensinq are remedied by cluster house managers within time frames set by CCL o Solicitin0 residents in order to maintain the highest possible occupancy rate per licensed capacity in each cluster house o Soliciting volunteer participation in organizing and helping to carry out planned programs and activities c Soliciting contributions of money, goods, and services to improve the quality of life in the cluster houses c Develcnina mechanisms to assure resident participation ;>fo,c:2..?ior r. .: :.;:i'1g vlithin each cluster house • y 54 Co-licensure. Community Care Licensing would license the cluster administrators and co-license each cluster house manager participating in a licensed cluster administrator's program. If a cluster house manager were to leave a particular cluster, he or she would have to be relicensed. Similarly, if the cluster administrator leaves, all house managers in the cluster would have to be relicensed whenever a replacement cluster adminis trator became available. A~ a condition of co-licensure, all applicants would be required to sign an agreement to accept SSI/SSP clients to the extent beds available. a~e Incentiups. The financial incentives for participation by small facility managers in a cluster would consist of a $50 per for the first resident. This payment would derive from licensing fees collected by CCL, as discussed in our funding-re lCi tee:_ recoTThllendations later in this report. CCL would administr- the Dav~ents to cluster administrators~ the admini- in turn, would pay the bonuses to the house managers. As added benefits, the cluster house managers would be relieved of rpsponsibilit,:' for many administrative tasks and would have the advantage of operating a facility in a dynamic environment rather than in the relative isolation of a free- standing private homp. As for the cluster adDinistrator, he or she would receive $35 per ~o~~h pe~ resident (that is, for each additional resident after ~_~" fIrst, for whom t_np house manager would receive S50). 55 The cluster administrator would keep client records for all the cluster houses as the basis for submitting monthly claims to CCL and would distributA the payments upon his or her receipt of theP1. In addition, the cluster administrator would charge the house managers modest fees for handling all administrative duties for the entire cluster. A house manager would be willing to pay for such services, presumably, only if the cluster administrator is able to reduce the house managers' costs or reduce their workload or both. Screeninq Bonus. Being able to attract individuals Positiv~ v;:L"'::h hoth Cl.c'1f",ini strati ve ski 11 s and experience in communi tv Dr social services is important to the success of this org~nizirg aDproach. Encouraging applicants to assume the risk of creatine the new entrepreneurial function of cluster administrator neces- S J.. ta t, C DrO\']. c~nq a one-time, first-year-only bonus to ind i v:i.d- uals who possess desirable qualifications. We suggest a $500 bonus to be offered in two equal payments: $250 after the second qU2rter o~ operation, 5250 after the fourth quarter. To qualify as a r~uster admiristrator, an applicant would need to have at least two years of experience in one or more of the following or related areas: c Program, or project, management o Administration of a specified task or unit within an organization o Nursing 56 o Long term care ombudsman program o Social work o Case management o Military service (eight years of experience: screening for training in maintaining orderliness) In order to collect the bonus, a cluster administrator's record during the first year of operation would have to be "clean:" (1) no citation issued to any house manager in the affected cluster for abuse or neglect of a resident, and (2) all cited by CCI, would have to have been corrected with- deficie~cies the time frame set by CCL. i~ A8 a~ additional screening and quality control device, a cluster administrator should be required to provide a 53,000 of deposit as evidence of his or her ability to certi~icate assume liability for whatever consequences may ensue should sub- standard care be aiven in that cluster. The administrator should be allowed to collect the interest on the deposit, but the state would be entitled to recover losses from the deposit for clients have been financially exploited or physically abused or ~ho I.n,;u reG1 in a cluster house. We recommend that CCL be restricted to licensing not more than 20 cluster administrators per year during the two-year pilot project phase. This approach would eliminate the need to iden- tify geographic boundaries for a pilot project and would limit costs to funds available. It would also allow CCL to take advan- t2qe of imDle~entinq the cluster model wherever qualified indi- 57 viduals are ready and willing to participate. At the same time, a potential 40 cluster administration pilots would be adequate for purposes of evaluating the efficacy of this proposal. In our funding-related recommendations, we have identified licensing fees as a possible source of revenue to support this program. b. Desiqnate Model Houses The basic idea in this recommendation is to provide all small facilitv licensees with the opportunity to see and experience the or-'cr3tiorl c,f ct :!"2cility which, in the judgment of Comrrmnity C;:n~E' Licensing, exemplifies high quality and manifests the intention~ of licensina and regulations. la~5 CCL district office evaluators would select model houses on the basis of two criteria: (1) cleanliness and orderliness of the home, 2n~ (2) meal quality, including nutritional value, prepara- tinn, and t2ste. The designation of model houses would be for one-vear periods, with two-year intervals required between desiq- D2tior of the same facility. A.ocE Linn?l Corr.muni t_y Care Li censino Responsibili ties. CCL would be responsible for distributing information and organizing events, as follows: 1. Notification to Licensees. CCL would distribute the names of the selected model house administrators, their addresses ana telephone numbers to all small facility administrators in the (listrico-l=- , ana make this list available as well to all newly licr:""cc' throuahout the year. a('lc:'c '}j~~trat:"rs 58 2. Notification to Model House Administrators. CCL would distribute to the model house administrators the names, ad dresses, and telephone numbers of all small facility administra tors in the district, including new licensees. 3. Notification to Local Media. eeL would issue press releases to explain the model house program and to announce the selection of each year's group of model house administrators. Where possible, eeL would also facilitate the preparation by local media of feature stories on excellent facilities. 4. SponsorshiD of Annual Event. ceL would sponsor an annual event (luncheon or tea, most likely) to honor the "outgoing" model house administrators and to recognize each group of newly selpcted model house administrators. Among licensees, the event would be open only to model house administrators just concluding and those beginning their year of designation as model facility administrators. Case managers in the area who are responsible for pl?cing their clients in the best facilities available should also be invited. The purposes of the event would be to acknowl edae the outstanding administrators and to give them an opportun to share experiences and, for outgoing administrators, to it~' advise the new model house administrators regarding how to organ ize a successful facility tour and meal. Responsibilities and Incentives for the Administrator. As a model house administrator, a licensee would arrange up to 20 visits per year by administrators of other small facilities. The visits w001d include an inspection tour and a meal. 59 A~ an incentive to organize such visits, CCL would pay the administrator $25 per visit. Each visitng administrator would sign a voucher, which the model house manager would then submit to Community Care Licensing. Thus, the total bonus available to a model house administrator for acting as standard-bearer for a year would be $500. There also would be the added intangible benefits of enhanced prestige and respectability. These quali ties, of course, would contribute to an administrator's reputa tion and attractiveness as a service provider and thereby enhance his or her income potential. Tr: our fundins-relatec recommendations, we have identified licercirg feeE as a possible source of revenue to support this proal If th0 number of model houses designated per year is ('1;0 • restricted tn ~ specified percentage, the costs can be predicted and controlled. \'je reCOr:l?:"',e-,r' th?t CCL recognize quality in community residen ti~l c~rr serviees bv awarding to administrators certificates of fer cle~rliness and orderliness, and/or certificates of excellence for food quality (nutritional value, preparation, and taste). Restrictions. In order for them to be meaningful as means of de~inin~ and recog::izing excellence in the mai::taining and adr:lin i ste r inc; 0 f cOIn.l"'luni t:, care fac iIi ties, the certi fica tes awarded "each \,e;:1' shc,uld be rest~rictec1 to not more than 20 percent of all 60 An additional restriction should be that "Model House" admin- istrators would be ineligible to receive certificates (only during the year in which they are designated as model house administrators) . 61 III. MONITORING OF COMMUNITY RESIDENTIAL CARE SERVICES AND ENFORCEMENT OF RELATED LAWS AND REGULATIONS A. Major Findings 1. Unlicensed Facilities Continue to Operate 2. Resident Protections in Emergencies Are Secondary to Facility Administrators' Right to Due Process 3. Residents Lack Protected Rights to Privacy and Partici pation in Facility Decision Making 4. More "Sets of Eyes" Are Needed to Assure That Residents Are Adequately Cared for and Not Abused 5. Operational Philosophy Is Ambiguous: Enforcement First, or Technical Assist2TIce? 6. Applicants Are Screened for Criminal Histories Only 7. Do Not Deter willful Violations of En~orcement ~echanismF Laws Regulations an~ 8. Coordination with Local Law Enforcement Agencies Is L2ckinq 9. Post-licensing Visits Have Been Eliminated and Emergencies Need More Attention Corrplai~t~ 1]. Investigative Resources Are Incomplete Potential for Collusion Needs Preventive Remedv l~. 13. Coordination with Health Facilities Licensing Is Lacking 14. Geographic Restrictions on Community Care Facilitv "Grouping" Do Not Prevent Concentration B. Recommendations 1. Increase and Strengthen Monitoring a. Recruit and Train Volunteers to Monitor Residents b. Establish Emergency Response Capability c. Make Applicant Screening More Meaningful 0. Creat.c ll:tomater:: Licensee Information System a~ 62 e. Standardize Cost Accounting f. Empower the Residents to Be Monitors 2. Make Enforcement Activities More Effective a. Recombine Community Care Licensing and Health Facili ties Licensing. Study and Consider Relocating the Licensing Function in the Attorney General's Office. b. Utilize Licensing Personnel More Effectively c. Develop Criteria for Granting Permission to Bear Arms d. Structure Coordination of Enforcement Activities e. DeveloD Criteria for Seeking a Temporary Suspension Order (TSO) and Procedures for Notification and Relo cation of Residents Snonsor Enforcement Seminars c. Prepare Handbooks for New Licensees and Residents in the Community Care System L. ClarifY Definition of Unlicensed Facilities and Create Citation System That Resembles Traffic Tickets i . Increase Fines for Licensing Violations Require All Licensees to Be Bonded k. Authorize CCL to Place a Facility in Receivership 1. Establish a "Crisis Team" within Community Care Licensi:r:.o m. Encouraae Private Action Aginst Unsatisfactory Commu ni~v Care Facilities by Allowing Recovery of Legal Fees through Attachments of Administrators' Property n. Require Boarding Houses to Register with the State and Authorize Long Term Care Ombudsmen to Enter These Facilities o. Authorize Immediate Dismissals of Placement Officers Who Make Illegal or Unsafe Placement Referrals p. Restrict Geographic Concentrations of Community Care Facilities 63 A. Major Findings 1. UNIJICENSED FACILITIES CONTINUE TO OPERATE One of the most significant monitoring and enforcement prob lems in community residential care is the increasing number of unlicensed facilities. Witnesses who testified before our Com- mission stated that this problem is growing at an excessive rate. In some cases, they are facilities that continue to provide care and supervision, but simply do not seek license renewal. In other words, these administrators appear to have "dropped out" of the liC'F;:!Jsed system of community care rather than continue to be by CCL. However, they continue to pro- mo~itore6 a~~ ev~luated vide care and supervision as if licensed. In other cases, facilities are operated by individuals who are either unaware that licensure is required or they are indif- to the requirement. Or, at the other extreme, facilities ferpn~ that h2ve heen closed down by CCL continue operating. During our hearing, we received testimony on several instances of abuse and neglect in unlicensed facilities. For the Anaeles Deputy District Attorney testified that p~ample, ~GS an unlicensed facility that had been ordered to cease and desist its operation simply moved to a new location and kept operating. One resident in this particular facility developed such severe decubitus ulcers that he required hospitalization. But rather than hospitalize him, the facility simply kept the windows open "beciC,llsr: triO' rottin<; o!' the hod", Kas so bad .... " The resident 64 Budget reductions have caused the Community Care Licensing Division to target complaints and violations in licensed facili- ties as the top priority for investigation and prosecution. This makes sense as a scarce resource policy decision, but quality assurance and client protection are diminished as a result. Local law enforcement agencies have historically considered the policing of communitv care facilities to be a low priority. Policina the operation of unlicensed community care facilities unfortunatelv receive an even lower priority. In addition, many policf: departments also face "scarce resource" problems of their own and have cut back on their limited efforts had been ~hatever RESIDSNT PROTECTIONS IN EMERGENCIES ARE SECONDARY TO ~. FACILITY ADMINISTRATORS' RIGHT TO DUE PROCESS A Pl2 j or \\'"':-> lTnr: s '= in thp exi sting corrununi ty residential care systeT\' is the lac;]: of protections for residents in emergencies. seeks suspension order (TSO) in response to W~f:~ CC~ ~ te~?orar~' conditions discovered in a facility, there often life-threa~eninq is not a,ra11(;81(' se: much as a list of the residents P\'P:1 I members to be contacted in emergencies. This was the case recently, example, when CCL obtained a court order to close a ~or large communi t\' care facili ty in Turlock. T~ ? cOIDG12int about the quality of care is made against 2 facilit\/, the administrator has the right to protest CCL's operatinq the facility until a hearing is cc~tinup 65 held to resolve the complaint. On the other hand, where place- ment agencies do exist, they can be prevented from removing their clients until there is a hearing. This may take weeks, during vlhich time the clients remain in the facility, possibly in con tinued jeopardy. There is unfortunately abundant evidence in the existing system of severe abuse and exploitation of board and care residonts. Beyond the trauma of abuse, life for a large number of residents is inactive and completely lacking in therapeutic substancG. The clients are not institutionalized in the sense thp" are not (usually) locked inside the facility, but nei- thC\~ arc they engaged in activities or therapy intended to pro- th~r their independence. In short, community care residents are very at the mercy of an unmonitored system of providing ~uch residential services. Rprause licensing is a regulatory program, not an array of direct Fervices to be provided, the protections against capri cious or arbitrary actions apply to the regulated entities -- the facility administrators -- and not to the residents. A contested Jjcense no.uQcation involves complex legal proceedings which assure service providers access to due process under the law but which, except in the most extreme cases when clients would die unless transferred to a hospital, do not provide for protective services for the clients. county-level budget reductions have all but removed adult prctective fro~ county welfare departments. Such 66 changes leave especially the elderly and mentally disabled commu nity carp residents without someone to intervene on their behalf when a crisis occurs. The existing monitoring and enforcement system also lacks a 24-hour, emergency number to call when dangerous or 7-d~y-a-week life-threatening conditions are discovered and require an imme diate response from government agencies. The need for such a "hotline" was seen in Los Angeles on a Sunday in March 1983. The police dppartment thprp discovered a number of mentally disabled community carp residents who had been abandoned by the facility operator. The police contacted the city's health department. The city health department staff found five residents who had not. eaten ir, almost two days; the only water available was fro~, either thp bat.htub or garden hose. Once the city health official hac fec and taken care of these residents, he attempted to con Care Licensing, but discovered that there was no t~ct Co~mu~it~· to get if: touch with the state licensing agency in an emer 1,;2" QPncv. Instead, he would have to wait until 8:00 Monday morning. This Commission believes the state must have an emergency hot}i to r1SSl1re a timely to crises in communitv carp r". n~sponse facilities. 67 3. RESIDENTS LACK PROTECTED RIGHTS TO PRIVACY AND PARTICIPATION IN FACILITY DECISION MAKING The right of residents to participate in decision making that affects their quality of life is basically ignored in licensing regulations. There also is no statutory requirement for such mechanisms as resident councils or other means of giving the residents a voice in decisions that determine their care and circumstances of daily living. Again, there is substantial evidence that community care residents are often victims of harassment and are denied basic One volunteer ombudsman for the elderly has reported, diq~itie~. for examDle, that some facility administrators serve lower aU2l- itv roe3lc to their SSI/SSP resident8 than to the private-p2v referring to the former as "welfare cases." residert~, Admini~- trators have been known to cut hair against the residents' will, undressing the residents and/or watching them bathe, insj~t O~ locking the residents' bedroom doors to keep them out (or in) during the d2Y, not allowing residents to change the t.v. channel without p~rrnission. These actions are not, strictly speaking, against the law, but they do go against the grain of what most elected officials would hope for in planning and maintaining a system of community care. 68 4. MORE "SETS OF EYES" ARE NEEDED TO ASSURE THAT RESIDENTS ARE ADEQUATELY CARED FOR AND NOT ABUSED Where trained volunteers are available to respond to com- plaints or, even better, to maintain personal contact with indi- viduals in community care, the whole system benefits from having extra "sets of eyes" to observe with increased frequency the conditions in which community care residents are living. Even conscientious administrators state there is no doubt they pay more attention to what is supposed to be going on in their facil- ities when they know evaluators -- whether from eCL or from a voluntper program -- may drop in at any time. com.rrmni ty care residents need regular intervention anc; rvia~lY aQ\"oci'l but large numbers are not monitored or visited at all. C'J , Annual inspections by Community Care Licensing evaluators cannot rp expected to ensure that residents receive, on a daily basis, the minimum services and protective oversight required by evp~ law. The inadequacy of this centralized monitoring effort lS compounded b)" the lack of expertise among evaluators concerning especia:lv the health and therapeutic needs of residents with specific disabilities. Various efforts are being made throughout California to organize volunteers to visit clients residing in community resi- dential care homes. Volunteers in the Long Term Care Ombudsman Program for the elderly are trained to monitor the well-being of the residents, to negotiate and consult with service providers if care improvements are needed, and to report unsafe or unhealthful 69 conditions to the nearest Community Care Licensing office. This prosram, which relies on a paid volunteer coordinator (usually part-time) to recruit and train volunteers within a given commu nity, is perceived by both clients and service providers to be helpful and effective in resolving complaints. Although "mandated" to include community care facilities in what started out to be a nursing home ombudsman program, the local ombudsman programs do not have adequate fiscal resources to extend their services comprehensively to community care resi- dents. Volunteers to monitor developmentally and mentally dis nr ; r·C co:rmmnitv care residents do exist in places, but they lack the authority that the long term care ombudsmen have to sta"'::utor~' oed:: ent.rv t.c any community residential care facility. Volunteers actually provide services to administrators as well as residents. Because they visit a large number of facili- ties in a given area, they are able to suggest or sometimes even organize activities for participation by the residents. The',' help to crpate c network of service providers by sharing informa- tion. As an adjunct to licensing, this monitoring lS effective ir reducinq t.he isolation in which community residential care services tend to be provided. 5. CCL's OPERATIONAL PHILOSOPHY IS AMBIGUOUS: ENFORCEMENT FIRST OR TECHNICAL ASSISTANCE? Trying to encourage voluntary compliance with laws and regu- lations, but effectively forcing compliance when necessary, requires a delicate balance of consultation and policing. The licensing function would seem to demand a primary emphasis on enforcement and a secondary emphasis on technical assistance. Evidence that CCL has not established these priorities, however, consists in there not being standard criteria for facility cloSl.:rc -- that is, in everv case, it is a "judgment call." 6. P:t-P!.JCANTS ARF SCREENED FOR CRIMINAL HISTORIES ONLY. to chal-acterizc current applicant scrPAning prccp- (l'( h'."\' That is, thev serve tc people out, on the basis of their deficiencies. Current scrcl~'1 orocesses are inadequate in the followino aDDlir~nt scree~~~G specific 'dc.VS: checks are run on applicants for licensure, rcccr~ but not on will be providing the direct services (if st~ff ~ho from the licensee). di~fArpnt o TherA is no automated licensee tracking system for data regardina the histories of individuals who, for per~onal exanple, have had their licenses revoked in one county, but for licensure in another county. ('l,T',]y 7] o There are no educational or experiential requirements which applicants for various categories of licensure must meet. o Applicants are not required to assure the availability at all times of an English-speaking caregiver who can read pre scrip- tion labels and other instructions pertaining to a resident's care. a Incomplete applications are accepted, resulting in there being excessivp staff time devoted to assisting applicants with out forms. fil:~n0 c are not required to know what thp regulations Ap~lic~~ts spprif" their farilities or the care needs of re8j- rp02~ding dents. o Coyr,f'luni tv Care Licensing does not routinely requP8t credit rhecks on applicants. "Positive sc:::-eening criteria," such as education or exper- ience requirements, would make licensure of community care facil- ity administrators selective on the basis of their qualifications to providp community residential care services. Lacking such stancards, the licensina system presently has no basis for the recrui t.ment of communi ty care administrators. 7. ENFORCEMENT MECHANISMS DO NOT DETER WILLFUL VIOLATION OF LAWS AND REGULATIONS For whatever reasons, CCL has not come up with an array of enforcement mechanisms that deter community care facility admin- istrators from ignoring regulations and/or breaking the law. As mentioned earlier, administrators of unlicensed facilities con- tinue to operate those facilities even when the facilities are ordered closed under court injunctions. Fines assessed for vio- lations of law ana regulations are routinely reduced or even Consequently, there is little perception among adminis- trators that violating laws and regulations will have punitive or that whatever punitive consequences may ensue cn~sequences will bf~ onerous. 8. COORDINATION WITH LOCAL LAW ENFORCEMENT AGENCIES IS LACKING So far as we have been able to determine, the Santa Ana :toe ~::"C0 DApa:~:'ment is the only municipal police department ir: California that has established a special unit to investigate and prosecute violations of the law in communitv residential care facilities. There seems to be a general lack of knowledge on the part c? local li'3.v,' enf0rcement agencies of conditions in communi t\' care or procedures for closing seriously substandard reside~tial facilities. ThEre is little coordination between CCL and la~ enforcemAnt agencies, except by the investigators on a case-by- casp Desi:=:. This lack of cooperative effort contributes to the 73 perception many community care administrators must have that they have little to fear from the police. As previously stated, local police departments and district attorneys consider community care facilities a low enforcement priority. When a police department does investigate a facility, state licensing investigators are often excluded from the inves- tigation. Moreover, licensing investigators do not have access to the evidence until the police department closes the case. By that time, the case is too old for an effective investigation. This situation is illustrated by a case at a facility in Pas?den?, where a resident was killed In December 1982. The pclicr~ sti.l1 list the case as open. Consequently, the state licensing investigators cannot initiate any work in the meantime, althouah there is no indication that the case is receiving active attention by the local police. =~ July 1983, the Orange County Board of Supervisors reported on c?~~s of illegal activity and negligence of residents in com rnunjty care facilities to State Attorney General Van de Kamp and reouested that his office investigate the situation. Evidently, the combined efforts of CCL and city or county investigators were not sufficient in that case to reduce the incidence of serious problePlo; . 9. POST LICENSING VISITS HlWE BEEN ELIMINATED Due to budoetary considerations, CCL has been forced to elim iJlo. tE' pc s;~-l~J'py: sing vi s its which previously were scheduled to 74 occur within 90 davs after licensure. New licensees tend to be less familiar with what is expected of them and less confident in establishina routine operating procedures. Early enforcement of regulations helps to minimize long-term problems. With budget cutbacks, however, newly-licensed facilities now are not visited by evaluators until their first renewal deadline is within 120 days of coming due. 10. COMPLAINTS AND EMERGENCIES NEED MORE ATTENTION Although CCL has been able to hasten investigators' response to cOEn12ints of abuse and neglect, it still takes up to 3C days for an investiqator to arrive on the scene once a complaint has been received by the Audits and Investigations Bureau. The Bur- au advises, however, that it hopes to cut response time in the nea:c fu"Lure to maximum of 15 days, with "immediate" 2. response capability in the most serious cases. All of CCL's ~ine investi.gators (plus two supervisors) are located in Sacramento, exacerbatinG the response time problem in the southern part o~ the state. In additi0n, CCL's capacity to respond to emergencies is restricted to taking legal actions intended to close dysfunc- tional facilities. This may be an appropriate enforcement response to the administrators, but it penalizes the residents rather harshly as well. CCL needs ways of smoothing the transi- tion for the residents when facility administration either is turned over to new operators or is completely terminated (in which case, residents must move) tt~ 75 11. INVESTIGATIVE RESOURCES ARE INCOMPLETE Nine non-supervisory investigators just simply aren't enough investigators to reduce the incidence of abuse in 57,000 commu nity care facilities scattered throughout the state (22,000 resi dential and 35,000 day care facilities). Investigations are technic2l processes that require personnel trained in gathering and reporting evidence. The paperwork involved in completing an investigation that can win a conviction in the case of wrongdoing must be painstakingly accurate. Furthermore, CCL investigators need more timely and more con sistently available assistance from nursing and medical experts in ~0terrnining the causes and/or the seriousness of various states. Although CCL does employ a few registered nurses, clie~L this is by coincidence rather than the result of allocated medi cal positions. Because CCL is faced with increasing numbers of cases involvino medical issues, it is imperative that it have access to this exp0rtise. Currently, CCL has great difficulty in takina action against facilities with residents suffering from decubitus ulcers and other medical problems, because it lacks appropriate staff who can make those judgments. Finally, there is the question of whether CCL investigators should be armed when circumstances would seem to warrant it. Although the Director of Social Services has the statutory auth ority to aive permission to CCL investigators on a case-by-case to carry weapons, the investigators' requests have so far basi~ been From our perspective, any facility in which the deni~d. 7~ administrator has threatened an investigator with bodily harm is no place for a disabled client. In such cases, investigators need to be prepared to protect the residents and themselves. Investigators from other departments do occasionally carry wea- pons; in those departments, prior approval by the department director is required in each case. 12. POTENTIAL FOR COLLUSION NEEDS PREVENTIVE REMEDY A familiar problem in all regulatory programs is the poten- tial for collusion between regulators and regulatees. More inno- cent 1y! ane no dou:)-t: r;)c:;e cornman, is the gradual "capture" of the . ., regul ,'" to::: ' s gooe v:l.L-: J by a winsome administrator. Licensing evaluators sometimes arE responsible for inspecting the same facilities over a ~umLer of years. This situation can lead to an evaluator's reluctance to cite violations in a facility which 1S adrrinistered is basically cooperative and with whn~ he or she has become friendly over time. Currently there is no standard procedure for rotating CCL evaluators to ensure that they maintain meaximuffi objectivity when inspecting a facility. 13. COORDINATION WITH HEALTH FACILITIES LICENSING IS LACKING The complete separation of health and community residential care facilities licensing appears to have led to the loss for commu~ity care clients of access to health services. The "clean" conceptuc! distirc-t:icn between "medical" and "nonmedical" care, ser"ec a s the ba si s UDon which comnmni ty care licens ing was \'i1,:~ r:;~ i / ---------------------------------------~-------- separated from health facilities licensing and moved into a dif- ferent depart~ent, turns out not to be quite so easy in the "real world." As we have pointed out several times already, there are residents in community care facilities who should be in skilled nursing facilities. Licensing evaluators are the only government agents who make routine visits to all facilities; yet, they lack the expertise to make judgments regarding the level of care required by individual residents. 14. GEOGRAPHIC RESTRICTIONS ON COMMUNITY CARE FACILITY "GROUPIN(.;" DO NOT PREVENT CONCENTRATION cOP1l'C\uni ty acceptance, a tendency has developed for ~ClC1:i"'0 CC~ffiU~jt~ c~rr facilities to locate in near proximity to each other, usual Iv i~ rundown areas. This problem exacerbates the generAl perception of comrnu!1ity care residents as "undesirable" or "dev?} 1.; (-,:cJ ," obviously impeding their re-entry into life p2t- terns that are as nearly normal as possible. Also, because the sudden visibility of disabled individuals in a neighborhood is alar~ina to the original residents, this practice of grouping comr:mnit" care facilities impedes community acceptance of the program. Thus, a cycle of rejection is established. At prpsent, Cormmni ty Care Licensing gives cities an oppor- tuni ty to comlT,ent 0;' the possibility of licensing a new communi t~' care facilit~' only if the applicant's facility is within 300 feet of an alrc:acv licensed facility. However, a facility may be more 3 C ;'"' fC0t fran another one and still result in a close 78 grouping of facilities. Also, a facility may end up being next door to an unlicensed facility, but more than 300 feet from a licensed one. In this case, the city would not even have an opportunity to comment. B. Recommendations 1. Increase and Strenqthen Monitoring Better monitoring of community care facilities is needed primarily for the sake of the residents to protect their well-beina and rights. Better monitoring will also upgrade the quality of care provided in these facilities, and that will help to make community care a bona fide long term care service. v,7e recommend the six-part strategy outlined below in order to increase and strengthen monitoring. a. Recruit and Train Volunteers to Monitor Residents. The State Lono Term Care Ombudsman Program in the California Depart ment of Aging (CDA) has pioneered the development of local om budsm2n proarams ln California. In 1982, new legislation {Chapte2- 14S7, Statutes of 1982 (AB 2997» extended the authority of thR ombudsman to enter nursing homes to encompass community c?re faciljties as well. The ombudsman program has been success ful not only in reducing the isolation of elderly residents in long term care, but in generating information about conditions and quality of care in the facilities. We recommend that the State Long Term Care Ombudsman be organizationally relocated in the Attorney General's Office -- or other state agency, such as the Department of Consumer Affairs. WR believe the Ombudsman needs to be located in an agency which ha~ legc:l stc..:~, is familiar with complaint handling, and has in RXDprtis~ enr~rcemcnt. 80 \,\1e further recommend that similar programs be initiated to serve developmentally and mentally disabled residents. For example, the State Long Term Care Ombudsman could be responsible for the recruitment and training of new volunteers to fulfill new monitoring responsibilities with respect to clients other than the elderly. The monitoring of the elderly should continue to be funded out of federal Older Americans Act funds, while the state should support an administrator for either the expanded or newly initi ated proorams to include local volunteer ombudsman services, or their counterparts, for the developmentally and mentally dj~- cblen. The primarv benefits of moving the ombudsman function into the Attorney General's Office would be to (1) promote better coordination of enforcement resources and strategies, and (2 ) the effectiveness and credibility of the enforcement heighte~. process by associating it with the highest-ranking peace officer in the stnte. Under current provisions of the Older Americans Act, however, transferring the ombudsmnn program to the Attorney s O:O£ice mG,,' net be compatible with our recommendation to GenprG~' recombine the licensing of health and community care facilities and relocate that function in the Attorney General's Office as well. If it is not, we would recommend locating the State Lono Term Care Ombudsman Program in the Department of Consumer 81 As the elderly would benefit directly from these changes, we do not anticipate that the federal Administration on Aging would object to the use of Older Americans Act funds (or deny a waiver, if one is required) to continue support of that portion of a newly constituted State Long Term Care Ombudsman Program which is charged with monitoring specifically the elderly. As discussed in our funding-related recommendations, we be lieve an "Ombudsman Foundation" could raise at least a signifi cant percentage of the amount of money that would be needed to cover the new costs of significantly expanding the Long Term Care OmbuG Program. SIT:D!, b. Establish Emergency Response Capability. We recommend that the Legislature authorize CCL to establish a telephone "hot line" in Sacramento. CCL should assure that someone is available 24 hours a day, 7 days a week to respond to crises discovered l~ comm'-l~!~ tv care facilities. CCL should then be responsible for contacting the appropriate office or individual in the local community In which the crisis has occurred. Furthermore, we that CCL require licensees to post the "hotline" tele reco"lfte~d phone number in an obvious place in each licensed facility. c. Make Applicant Screening More Meaningful. Applicant screening may be the single weakest link in the existing commu- nJ. tv care svstem. As community residential care matures as a propriet?T" industry, we expect to see the industry itself begin 82 to devote more money and time to increasing the professionalism of facility administrators. Eventually, there will surely be acceptable minimum qualifications that at least certain cate- gories of community care providers will have to meet -- this to protect the interests and image of the administrators as much as to promote a higher quality of care. In the meantime, we recommend tightening applicant screening procedures in the following simple ways: o Do not accept incomplete applications. o Revise the licensing application form to include the ap plicant's plan for assuring the availability of English speaking staff in each licensed facility. o Require applicants to sign a release form authorizina Cornrrmni ty c.:u-e ~ice!1sinc:; to obtain information on past err,ployment, credit, driving, and criminal justice records. c, :t<ec:uire applicants to obtain signed releases for the in formation specified above from all of the applicants' employees who will be providing direct services to the residents_ o Require applicants to sign a statement that they have read a!1n understood the community care licensing reaulations that pert,LL to their category of licensure. d. Create an Automatp~ Licensee Information System. We recol"sreno. that thE', Legi s lCl ture require COTILTTIuni ty Care Licens ing to creClte an auto~at0d licensee information system to keep track of adrrinistrators who move around, both inside and outside Cali- forr:ia. Using Socie1 Securit~, numbers, CCL should develop the capacity to identify applicants for licensure who have been cited for serious violatio!1s in other locations, or whose licenses have 83 been revoked elsewhere. It is unnecessary to lack this rudimen- tary data base in an age of revolutionary information processing techniques and equipment. Certain lower cost enforcement approaches depend for their efficacv on the ease of discovery of past records. For example, a facility administrator who is in jeopardy of losing his or her license and being heavily fined for violations of various laws and/or regulations could be given the option of signing an agree ment not to operate a community care facility or ever again to far Unless it is possible to retrieve a record appl~ lice~sure. of suet 2 transaction, however, this otherwise desirable enforce me~t device is so weak as not to be viable. TJ1P reintegration of Community Care Licensing with the Den~rtment of Health Services' Licensing and Certification Divi sion, wh"l ch we recommend, would be expedient with respect to sharing inforrn2tion. An automated licensee information syste~ could be combined wi~h the Consumer Information System our Com- rr,~SSlor has recommended be developed for nursing homes. with such a system, de licensed nursing home administrators, for eX2mplp, r0,-,ld net operate community care facilities -- at least not without submitting to a period of probationary licensure. But, unless the ComInuni ty Care Licensing and Licensing and Cer tificatio!~ Divisions share a data base, the state has no way to contro:'c Fr.try into the comIlmnity care industry by historicallv unscrup~l~ c service providers. 84 e. Standardize Cost Accounting. We recommend that the Legislature require Community Care Licensing to establish a uni form account ina system with account numbers that are applicable to specified categories of licensed facilities. We further recommend that CCL, the Departments of Developmental Services and Mental Health, and the Office of Long Term Care include moni toring of financial records in all routine visits to facilities. Representatives of these agencies should take advantage of such opportunities to encourage facility administrators who are having recordkeeping problems to employ an outside bookkeeper to main the accounts in accordance with the uniform system. All tai~ adMinistrators should be encouraged to have a certified facilit~· public accountant conduct Rn annual review of the books and pre Rn annual report. p~re Absent standard-format reports on costs and expenditures in cOTIL'Tlunity care facilities, funding adequacy will remain a matter of speculation opportunities to achieve economies and/or an~ improved proaram effectiveness will escape notice. vJe favor eventually requiring community care facilities to report cost anc utilization data annually. Because the community care still lacks such rudimentary components as service syste~ definitions and clarification of administrative roles, however, we feel recommendation to require cost and utilization reports 0 at this is premature. tim~ 85 f. Empower the Residents to Be Monitors. We recommend that the Legislature amend state community care licensing laws to require the establishment of resident and/or family member coun cils in the larger facilities (25 or more residents). In smaller facilities, we recommend that volunteers coming in as monitors should be trained by the State Long Term Care Ombudsman Program to help community care residents negotiate remedies with adminis trators whenever a resident's right to make his or her own deci sions has been ruptured. The riqht of community care residents to become and/or remain as independent as possible requires that mechanisms be created to protect tllE: riaht of residents to make decisions regarding the quality of their own daily lives. To the extent residents and/or of their families are exercising this right, the resi- me~bers dents themselves will be empowered to monitor and correct condi tions in the facilities where they are living. 2 . E!: forcement Acti '1i ties More Effective ~'2l:,? Based on the comments and recommendations the Commissio!1 received during the May 1983 hearing in Los Angeles and the sum mer 1983 workshops in Sacramento, we recommend implementation of the changes proposed on the following pages. They are intended to make the state's enforcement activities more effective In producing a reliable and safe system of community residential Ci'l.re. 86 a. Recombine Community Care Licensing with Health Facilities Licensing. Study and Consider Relocating the Licensing Function in the Attorney General's Office. We recommend that Community Care Licensing and Health Facilities Licensing be recombined. Additionally, we recommend consideration of relocating this function in the Attorney General's Office. Licensing is a law enforcement function. Locating this function in the Departments of Health Services and Social Services has contributed to the ambi guity of operational philosophy observable in both licensing units. That is, the general posture of these two departments is to be helpful to the public. In the case of licensing, however, being "helpful to the public" demands being effective enforcers of laws ano regulations. Placing the licensing function in the Attorney General's Office would reinforce that this primary responsibility is to be discharged by licensing staff. Prior to 1976, Community Care Licensing was a branch of the Licensing and Certification Division of the Department of Social Services. Community Care Licensing was transferred to the Department of Social Services in order to strengthen the emphasis licensing of facilities that provide nonmedical care. That o~ emphasis seems to have been achieved, but at the expense of co~­ munity care residents' having lost adequate access to henlth care. an benefit to be had from reuniting the twc ~hus, i~portant licensing efforts is that medical expertise would be more readily available to community care licensing staff. Also, the opportu nities to "educate" health facilities licensing staff to the c- strengths and weaknesses of community residential care would aid in the process of bringing community care into the overall long term care system. There currently is very little coordination between Community Care Licensing and local law enforcement, except on a case-by-case basis during a criminal investigation. In the stronger "enforcement environment" of the Attorney General's Office, the reconstituted licensing unit would be credible in the role of enforcer and, consequently, would have enhanced to team up with local law enforcement agencies to oppo~tunities close facilities that are not safe or otherwise are not suitable as residential facilities. Finally, we recommend that the Legislature restore funding and authority to CCL to reinstate post-licensing visits within 90 davs rf f2cility licensure. This preventive enforcement activity C2~ s?"e the costs of license revocation proceedings later on and prevent unnecess2ry misery and abuse unsuspecting residents. ~or b. Utilize Licensinq Personnel More Effectively. We recoml11e"o. that eCL make the following personnel management changes to strengthen its enforcement capacity: c Licensing evaluators should be trained in investigative skills enable them to gather evidence which will br t~ utiliZEd in prosecuting more cases successfully. c The number of investigators should be increased, and the be established in a southern Cali- shoul~ PS fornia location. The ability to respond to complaints and to coordinate with local law enforcement agencies in the case of serious violations is too constrained under the present arrangement. o Evaluators should be given rotated assignments; that is, they should not be evaluating the same facilities year after year. This would reduce the potential for collusion or simple reluctance to cite violations when the facility administrator is perceived by the evaluator to be a col leaaue and friend. c. Develop Criteria for Granting Permission to Bear Arms. recornnend that the Health and Welfare Agency gather the neces ~..;re sarv information from each affected department to facilitate the analvsis of circumstances under which permission to bear arms has becT gra!1tec. to investigators going into cormnunity care facili- tjc~s. On the basis of this analysis, we recormnend that the Health an~ Kelfare Agency develop criteria to assist the depart (and the Attorney General, if our recormnendations merl~~ directc'r~ are adopted) in deciding on a case-by-case basis when a given situation warrants granting permission to investigators to carrv weapo!1s. d. Structure Coordination of Enforcement Activities. eCL undert2ke to structure the coordination c: 89 With the Department's Own Legal Division: CCL's Audits and Investigations Bureau should notify the Department of Social Services' Legal Division immediately upon determining that one of its investigations could lead to a criminal prosecu tion. The Legal Division should assign an attorney at that point to advise investigative staff regarding additional j.nformation that will be needed, if any, to prosecute the case. With Other State Departments: The track record of interde- partmental "coordinating committees" is not encouraging. Still, the need is clear for the Departments of Developmental Serv-,-ces and Mental Health and the Office of Long Term Care to knovl what CCL is doing that affects community residential cere -- and vice versa. We recommend that the top official in the COITuTluni ty Care Licensing Division (or in the newly formed licensing unit which we have recommended be placed in the Attorney General's Office) meet quarterly with the direc tors of Developmental Services, Mental Health, and Long Term Care ,ane. thf""" State Long TErlT' Care Ombudsman. These meeting::: ~houla be concerned with problems in the long term care sv~­ tem, solutions to which will require the cooperative effort of all or most of the affected state agencies. This group would have the necessary authority to assign short-term task forces composed of staff from each department or agency to ways of resolvinG conflicts or problems recom~end identifie~ 9(; ~yj. th Advisory Committees: At both the state and district office levels, we recommend that CCL organize advisory groups composed of representatives of all client groups, advocates, and service providers. These groups should have an opportu nity, first, to review and comment on the recommendations in this report. On an ongoing basis, they should be asked to advise CCL regarding problems they are aware of at the indi vidual resident and/or facility level and to recommend reme dial actions CCL could take. With Local Law Enforcement Agencies: District and City At tornevs and most local police departments seem to have little avlareness 0::' the community residential care program: how it differs from skilled nursing facilities, the requirement for the rising of abuse, or the investiga licensu~€, incidenc~ tiVE activities of ceL and the Departments of Developmental and Mental Health. If the licensing function ip Service~ to the Attorney General's Office, linkages with tr2rs~~rre~ enforcement will be strengthened. Regardless of loc~l l~~ the organizational placement of licensing, however, we recom mc':r'l that ceL sponsor seminars and prepare informational handbooks written especially for local law enforcement agen- cie~. Agencies: Any time CCL substantiates a com- Kit~ Placem~nt plaint, it cites the offending community care facility. When the offense iR serious -- one reflecting potentially lif~- in the quality of care -- we recom- t~'0~tp~inr ~~ficiencies 91 mend that the Legislature require CCL to notify placement agencies. To the extent that a daily census is available in each cowmunity care facility indicating the source of the place ment referral for each resident, we recommend that the Legis lature require CCL to notify every affected placement agency. When such information is not available, we recommend that the Legislature require CCL to notify the Departments of Develop mental Services and Mental Health and the Office of Long Term Care when charges of abuse, neglect, or other serious mis of residents have been substantiated. These state treat~ent agencies would then be responsible for alerting their county cr regional counterparts to CCL's charges and actions. e. Develop Criteria for Seeking a Temporary Suspension Order (TSO) and Procedures for Notification and Relocation of Residents. We recommend that CCL develop specific criteria regarding abusive or life-threatening conditions in a community care facility that indicate when CCL should seek a temporary suspension order (TSO) with the intention of revoking the license. Such criteria should not remove CCL's discretion, but rather limit the need for discretion to situations which are not covered by defined criteria. This would help to eliminate criti- cism of CCL as "arbitraryfl or flbiased" in license revocation proceedings and, more important, establish more effective protec of residents in unsafe facilities. t~on \'ir further recommend that the Legislature require CCL to procedures for taking a more direct role in notifying e~t~blish their families or conservators of impending puni- resident~ c~d tive actions aaainst facilities. At present, CCL requires the administrators to notify family members. We find this procedure yields protection of and assistance to residents. We i~2~eauate aaree CeLIs primary responsibility is to regulate facilities tl~at and to provide direct services to residents. In the case of no~ TS(,' or license revocation, however, we recommend that CCL recogni=c that licensee is not adequately meeting the needs th~ of residents and take steps itself to notify family th~ member~. conscrv 2tors, and/or local placement agencies of the residents' iffiITofi3tC to relocate. nep~ 93 Finally, we recommend that the Legislature authorize CCL to establish an emergency fund, possibly out of increased fines (see our recommendations related to fines), to provide for the reloca tion and care of residents when CCL closes facilities on short notice. f. Sponsor Enforcement Seminars. We recommend that Commu- nity Care Licensing sponsor seminars twice a year for local law enforcement agencies. The seminars would allow CCL to educate peace officers, district and city attorneys, and fire marshals reqarding the incidence and distribution of violations espe ciallv abuse, exploitation, and unlicensed facilities that con- tinue to oncrate. The seminars would afford opportunities to create joint strategies for addressing the problems identified by ceL and tc share information on successfully prosecuted cases aroun0 the ~~atc. ::rn keepi ng vii th thi s cooperative approach, we recommend tha~~ Care Licensing prepare a manual on the responsiblities Com~unity 0= loc(',] lE1\'7 e" fcrcement agencies as prescribed by law. The IT',anual should includp information on how to access state-level investigative resources when specialists or additional investi gators are peeded at the cornmuni ty level. g. Prepare Handbooks for New Licensees and Residents ln the Community Care System. In addition to manuals for law en- forcement agencies, as discussed above, we recommend that CCL prepare simplified handbooks that state in clear, nonlegal lan guage what exactly the law requires of community residential care providers. Currently, CCL provides new licensees only with copies of licensing regulations and periodic updates on adminis trative or policy changes at the state level. Residents and their families also need handbooks regarding their rights and responsibilities in community care facilities. \\e further recommend that the Departments of Developmental Services and Mental Health and the Office of Long Term Care pre- pare, for inclusion in the handbooks, clearly-written statements of the program goals, provider standards, and client services that wake up the framework within which community residential to be offered. car~ i~ h. Clarify Definition of Unlicensed Facilities and Create Citatiorc f'vc:tcw That EeseJT1bles "Traffic Tickets". We recomrnend that tte Legislature amend state law to include a three-pronge6 0: definition unlicenseo facilities, as follows: "Unlicensed facilit,-" means any facility without a licensp tha:': (F) Is prouiding services allowed only in licensed fac=-2-ities; (1.\\ J" L(.~::::iDO r c::icerts who derr:r;r:strate the need fer 95 services which only licensed facilities are auth- orized to provide; or (c) Is representing iself as a facility in which services authorized only in licensed facilities are being provided. This clarification would make it easier for district and city attorneys to prosecute administrators of unlicensed facilities, thereby affording greater resident protection. As an incentive for aggressive action by local law enforce- ment to cloSE unlicensed facilities or to encourage such facili- ties to see}: licensure, we recommend that the Legislature auth- orize police and sheriff departments to issue traffic ticket-like citations to administrators. Police and sheriff departments would all fines collected pursuant to these citations. retai~ ThE" should equal fines for other violations of licensing laws and regulations. i. IncreasE" Fines for Licensina Violations. If fines are tn r' deter wi]} f111 violations of law ape' regulations, the\' must be: high enough tn make noncompliancE a financial hardship for the administrator. Currently, the maximum fine for noncompliance with 2 pJan of correction prepared by a licensing evaluator is $SO per day. The actual rate of assessment is determined by CCl to the seriousness of the violation. ~ccordina Pr0\' j_ s i O;-} should be made for keeping fine leve Is commer:surat.r 96 that fines increase automatically every year at the same rate SSI/SSP grant levels are adjusted for cost of living increases. The current maximum fine was set in 1979, when the regulations for assessing civil penalties first took effect. If that maximum had been adjusted at the same rate as SSI/SSP grants, the maximum fine now would be $73.25 per day (and, effective January 1, 1984, it would be $75.90 per day). We further recommend that fines for repeat violations be trebled. This should apply to citations issued to administrators o~ ur.licensed ~acilities as well as for other violations. Ir, 1982 , Community Care Licensing assessed 878 civil penal- If each penalty were S50 for one day, the amount collected would have been $43,900 (assuming the fines were not later 0= l'.t $73.25 for one day, the same number pe~alties wnuld have generated $64,314 -- a difference of $20,414, or 46.5 1:r: J recolr.!nr,r,(i that Communi ty Care I~icensing retain in its mm budgEt 50 percent of the total fines revenue to support F:force- 2("tivitieEj we further recommend that the remc:ining 50 ppr- cP~t b~ used to support monitoring efforts by volunteers. This would give CCL a greater incentive to be aggressive in assessing civiJ penalties. Furthermore, funding for monitoring by volu~- teers could be increased. l . Require All Licensees to Be Bonded. We recommend tho' commu:1itv C2rc q"7 - I licensees to be bonded for a minimum of $1,000 (or more, as required by Title 22, Section 80345, depending on the amount of clients' monev an individual administrator routinely adminis- ters) . Bonding companies will charge administrators an average of $30-$55 every three to five years for preparation and manage- ment of the bond. We further recommend that changes in law specify that the bond has to be written to cover civil penalties. That is, when a licensee refuses to pay assessed fines for violations of law or regulations, or fails to pay the fines on time, Community Care I.icensj no will have tlw right to collect the fines from the bonding entitv. When the amount owed for fines exceeds the of the bond, we rpcommend that the Legislature require amnllI~t CCL tn Automatically initiate license revocation proceedings. Th" boncing entity (either a bonding company or a com.rnunity carp administr~tors association) would require collateral from cash, savings certificate, OT Jer_~c'y.- credit from a b~nk. This demonstration of capacity to :ir:ancia~ Jj.ar:i litv would serve as an applicant screenin(:, device, at nc additional cost to the state and at a reasonable additional cnst to facility administrators. k. Authorize CCL to Place a Facility into Receivership. Commc.L-:i :::..; Care Licensinc: currently lacks statutory authority tc place: 2 comr:runity care facility into receivership. BecausE': a c· _, lJ therefore protracted) process, a receivership option would be highly desirable. We recommend that the Legislature amend state law to give Community Care Licensing this authority, except in the case of small facilities which are also the private homes of the adminis- trators. CCL's authority should include a wide choice of receivers; a mechanism whereby residents can request, or petition for, receivership; and wide discretion for CCL to invoke recei- vership and determine the duration of receivership in anv given situation. 1. Establish a "Crisis Team" within Community Care Licens- inC'. ~'7e recommend that the Legislature authorize CCL to develop an internal "crisjs team" that could be sent to facilities thilt are pxperiencinc ad~inistrative failures, but which CCL considers A crisis team would be particularly valuable in the area ~ 2~-ound the state where the supply of community care facili- lS barely adeauate or not adequate. It would also give eeL ,:':" onportunit'· to fulfill the technical assistance mission perceives itself to have, yet with enforcement as the unmistak- able mct.ivation and goal. Another possibJe benefit is that, through the crisis team's 2.ct.u21 operation a facility for a time, eeL might learn 0: difflculties caused b)' law or regulation that could be change~, tl:preb" reTT1cyi ng barr iers to high quality performance. 99 Having this internal capacity and the option of invoking receivership would greatly enhance Community Care Licensing's ability to take corrective actions short of facility closure. Corrective actions are preferable in that they do not entail displacement of the residents in community care facilities. m. Encourage Private Action Against Unsatisfactory Community Care Facilities by Allowing Recovery of Legal Fees through Attachments of Administrators' Property. We recommend that the Leqislature amend state law to allow private citizens to recover their legal fees for bringing civil suits against abusive or neglige!"'t. community care administrators. Recovery of legal fees Ehould be authorized through the mechanism of attaching the 0dministrators' proDerty. n. Reguire Boarding Houses to Register with the State and Lonq 'Tern' Care Ombudsmen to Enter These Facilities. We Authori~e recomr.tend that thp Leaislature amend state law to require ovmers of boerdi!"'q -- residences where meals are provided, but no housF~ care or supervision to register their facilities in the nearest Comr.mni ty Care Licensing office. Notification of this would be difficult, but perhaps the addresses of reG~irement residenCES that are not licensed as community care facil- SS~/SS:r' ities could serve as the initial source of information regarding the of boarding houses. SSI/SSP computer tapes presen~ locatio~ a :~(' ;:-"2 i lc~bJ {" ',C tr-:e Departr:1ent of Social Services for purposf?f: 100 We further recommend that the Legislature amend state law to authorize volunteers in the State Long Term Care Ombudsman Pro gram to enter boarding houses, as time and other resources per- mit. They would be trying to determine, on the basis of the recommended three-pronged definition of unlicensed facilities, whether a client needing care and supervision has been inapprop riately placed in a boarding house. o. Authorize Immediate Dismissals of Placement Officers Who Make Illegal or Unsafe Placement Referrals. We recommend that the Legislature amend state law to specify that any public employee (or a private, non-profit organization's employee who is paid from funds) shall be immediately dismissed for refer pub~ic rlng ar: individual in need of community residential care to an or unsafe community care facility. An "illegal" facility ille~;iC_l is an unlicensed and/or uncertified facility; an "unsafe" facil it~ lS cne in w}lich actions against an administrator are pending, cue substantiated charges of abuse or neglect of the resi- t~ We that placement officers are often under pressure re~cgnize to make referrals quickly. We recognize also that the available options may be less than ideal. Nevertheless, if com- re~erral resifential care is to become a respected and unfeared murit~ alternati,'e to institutionalization, clients must be confident that the offered by public agents in locating an ~ssistancp 101 p. Restrict Geographic Concentrations of Community Care Facilities. Existing law provides that eeL must give local gov ernments an opportunity to comment on applications for community care licensure when the new facility would be located within 300 feet of an existing community care facility. We recommend that the Legislature amend state law to specify that eeL will give local governments an opportunity to comment on community care licensing applications when the new facility would be located within 300 feet of an existing community care facil ity, OF a skilleC1 nursing facility, OR a boarding house. (This requirement should not apply, however, to the small facilities (six or fewer)). This approach would substantially increase be~8 the local option to express concerns about the undesirable con centration of certc:)j n kinds of commercial development wi thin anv are? gjVE!"'l l (1:-: IV. FUNDING OF COMMUNITY RESIDENTIAL CARE A. Major Findings 1. Sources of Funds Are Mixed 2. Adequacy of Funding for Direct Services Varies by Client Group 3. Rates and Payment Arrangements Vary by Client Group 4. Budget Constraints Reduce the Effectiveness of Monitoring and Enforcement Activities B. Recommendations 1. Impose Annual Licensing Fees to Support Increaseo Moni toring And Enforcement Activities and New Programs for Small Facilities 2. Authorizp thp Establishment of an "Ombudsman Foundation" Launch an Aggressive Campaign to Solicit Private Contri ~. butions for Increasing the Levels and Ouality of Service Pro','ided to Community Care Resident::: 103 A. Major Findings 1. SOURCES OF FUNDS ARE MIXED Federal and state funds support community residential care and, in the case of clothing allowances and other foster care supplements, county funds support residential services as well. Federal Funds. During the period 1969-80, the mentally dis- abled client population in state mental hospitals declined by an average 61 percent throughout the United States (IV-I) . During that same perioo, the average annual cost of keeping an individ- ual in a state hospital rose from 55,600 to $32,800 a mpn~al 485 perrent increase. Most states, including California, re- sGonded predictably to this strong fiscal impetus to shift the rost of caring for specified populations state general funds fro~ for state hospitals to the federal Supplemental Security Income (SSI) program for entitlements to individuals. Today, SST rer:wins ma.in source of payment to communi ty residential care t~hp, CT. G cit i 0 ~l , P.L. 97-35 allows states to seek waivers from tile Sr;r"ret.i"YT \'~~ the C.S. De}Jartme:rt of Health and Human Servic;es to broadp" the definition of "medical assistance" under Meeicaid c.s. on Aging, "Board and Care Homes ane A~~inistration the, luc.endmer't," Washington, D.C. (undated). }-,>-c,'S to include home a~d community-based services. California has requested and received such waivers in order to prevent unneces- sary institutionalization, as in the mUltipurpose senior services project, which serves elderly clients. Conceivably, demo~stration then, community residential care will continue to be paid for increasingly with federal funds. State Funds. The largest single category of state support for cowmunity residential care for the three groups targeted in this report is the State Supplementary Payment (SSP) portion of the SSI/SSP payments to individuals. In addition are the supple- funds available to developmentally disabled residents for me~tarv "specialize(1 services," as discussed earlier. In the Short-Doyle for reentally disabled clients, there are instances of progra~ CCJ"1tractinc by counties directly with community residential care service providers, state and county funds. u~ing Licensing_ Licensing costs are borne 100 percent by the state General Fun6. ADEQUACY OF FUNDING FOR DIRECT SERVICES VARIES BY CLIE"~T G"ROFP We estimate the cost to the public for providing community care services for foster care children, the elderly, reside~tial and and mentally disabled clients will be at dcvelopme~tall\' least S~S3 mj_llio~ in 1983-84. This amount represents direct ~crvice cos~s onlY. That is, it excludes administration, licens- 105 There is no way to evaluate whether that amount is too much, too little, or about right. While community care facility admin istrators would disagree with us that $15 per day may be ade quate, it is nevertheless true that some undeterminable number of community care residents are in fact living in safe, healthful conditions at the current level of funding. Administrators receive most of any increase in SSI/SSP pay- ments approved by the federal and state governments. Thus, while inflation may arguably have caused cost increases over the last ten years that exceed the cost of living adjustments granted to funding recipients, administrators have been able to offset such increases at least to some extent with public funds. The question of adequacy is less easily dismissed ln the case licensees who have only recently purchased the home or facil o~ ity in which they intend to provide residential care services. The cost of housing has increased so dramatically that adminis trators could not realistically expect to amortize that cost complp+:'F:Jy out of public subsidies for community care re::::idents. T~r p~~ect of this particular cost increase is ambiguous: it may inhibi t. entry into the community care indust.ry by inch vidual s who are otherwise inclined to provide this particular service, or it may me~n that these administrators solicit clients who are able to pay much hiaher rates than SSI/SSP clients can pay. Because of the assumptions we have made, we believe our esti mate of $583 million in annual expenditures may be lower than the c:ri-uC' l r'ub~' c cr:,st cf coml'cu:r:i ty residential core, even though it 106 is substantially higher than all other estimates we have seen. In any case, the major funding issues have less to do with the adequacy of the total amount available than with whether adequate funding is available on an individual-by-individual basis to purchase the level of services required to fulfill a given client's plan of care and treatment. We believe that more money should be made available for com munity residential care only for changes that would upgrade the quality of care. On this basis, we contend that across-the-board rate increc8es for service providers cannot be justified. 3. RATES AND PAYMENT ARRANGEMENTS VARY BY CLIENT GROUP Rate-setting for community residential care is subject to all the complexities, inequities, and other imponderables that beset ether social and health services paid for by the government and provided to eligible individuals. In the last two years, o~lv major studies have been written regarding rates alone for th~ee foster rare and care for the developmentally an6 residenti~l Yet another rate-setting study is currentl,- beine) preDare~ bv the State Councjl OD Developmental Disabili ties. An effective rate-setting mechanism should accornmodate varia- tions in the cost o~ client services. Rates should vary accord- ing to differences in client needs and the cost of meeting those protlems of clients in rural settings, BE~Fvicral f02.- JO: concomitant costs) than for those in urban settings. Further- more, to be effective, a rate-setting mechanism must be adminis- tered by an entity that has a reasonably accurate, reliable, and preferably flexible method of developing rates. None of these conditions adheres in the existing system. In the precursors of licensed community residential care for example, family care homes for mentally ill patients released from state hospitals -- the responsible state department auth- orized payment directly to the providers. Rate maximums wer8 set in statute and amended annually on the advice of the Department of Finance. Licpr:£ing community care facility administrators -to solicit residents, without government oversight or regulation of rates to be cha rqecl, and empowering individual clients to purchase their ow:! com.f[,urli tv residentia 1 care services with SSI / SSP enti tlements rn;osideral)ly locsened government s control of rates. Heining it I b2Ck in woulrl :lot be easy. :::Jl c:::'"'ect I the SSI/SSP rate sets the board and care rate for the ~E~oritv cf' beard and care residents. Similarly, the SSI/SSP cost. of living adjustment gO\7e::-~!,:;=·rct-approved dptermines thE annual price increase. In order for providers to pass on cost increases that exceed the SSI/SSP COLA, they must ch2rge thosp residents with private resources more thaT the $459 pEr mo:!th that SSI/SSP clients can pay ($478 after January 1, facilities in Orange County, for example, $2,500 per mc~th lOS for board and care -- an amount which is more than double the average Medi-Cal payment for skilled nursing care. Equity. Rates are equitable if they support similar levels of service for similarly disabled individuals. The simplicity of that statement is defied by variations in existing capacity to assess disability and to respond with accurate levels and types of appropriate services, availability of supplemental funding, restrictions imposed by the funding source, and arrangements for making payments to service providers. Community care administrators who are approved "vendor- jzed" bv a regional center to provide residential care for disabled clients, for example, are eligible to developmentall~7 recej,rp payments directly from the regional center to supplement SS!/SSP-based rates. Such differential funding is limited to approved vendors, and rates are based on the level of staffi~o and/or the rrovision of "specialized services." AdvQC2tes for the developmentally disabled have successfullv the case for differential rates for residential care. ~~de similar provisions be made for the mentally disabled and Sh~uld The Legislature apparently found that inequity compelliDg enough to authorize differential funding for the men tallv disabled (Chapter 1194, Statutes of 1979, (SB 951)), but was constrained h,· insufficient revenue from ever appropriatin~ the YF:quired funds. characteristics 0: the developmentally and mentally dis- 'Th(~ the desirabilitv J09 of having access to differential funding for the mentally dis- abled is evident. Developmental Services programs have time to plan for place- ments, and Developmental Services clients demonstrate physical, developmental, and behavioral characteristics which are measur- able. Consequently, there is a reasonable basis upon which to establish an appropriate rate commensurate to need and to a long-range treatment program. Mentally disabled clients, on the other hand, have the poten- tial for drastic changes in behavior, degree of disability, and placement needs over a relatively short time. The volume of initial placements and subsequent changes in placement is greater for this client group. SucL 0"1f"'f_ _" erences suggest that more flexibility in payino for communitv residential care is desirable for all client popula- :-iO!1s .. In most cases, the SSI/SSP-based rate is adequate to in need of basic residential services. Due to ~UDno~t individual~ client differences or changes, however, that rate indivi~ual so~ptime~ js not adequate to purchase an appropriate level cf carc. In that situation, it is patently inequitable to supplement fundinG available to persons with one set of dis- anc who purchase services in the same system ln which ah~lities with others sets of disabilities are denied supplemental person~ 110 4. BUDGET CONSTRAINTS REDUCE THE EFFECTIVENESS OF MONITORING AND ENFORCEMENT ACTIVITIES Budget reductions in recent years have diminished the state's capacity to monitor community residential care and to enforce the laws and regulations pertaining to this program. Because moni- toring and enforcement activities are supported 100 percent by the state General Fund, the funding for these activities has been "raided" in order to support other of the legislature's or admin- istration's priorities. We de not object to reducing the cost Rnd size of state governmpnt. In this case, however, we believe evidence of abuse anc neglect 0: community care residents and of substandard condi- tions in facilities is sufficient to justify increasing expendi- tures on enforcement. The cuts in support for investigation and felc i 1 i ty e\-a 1 ua tio!) make placement in a community care facility a specter rather than a welcome and affordable alterna- frig~tening t:i to highf-'>} levels of care. ,'C licenspcs pay no fee for the privilege of gaining Curren~l~', aecP" ,: tc tilE: COITG,iuni ty ca re market. Revenue from modest fees could be useo to defrav the considerable costs of monitoring and en:::orcement. III B. Recommendations Except for the "private pay" residents in community care facilities, the support for community care now comes entirely from public sources. We believe it is possible to diversify the funding base in ways that will also serve to strengthen enforce ment and integrate community care with the overall network of long term care services. We support two guiding principles for the use of new funds: o New revenue should not replace General Fund support dollar-for-dollar at least not until additional rev enue potential can be identified and realized. Rather, new reverues should be used to increase monitoring and enforcement effectiveness and improve the quality of servicf'. c There should be no increase in rates paid to facility administrators unless the increase is buying a higher quality or level of service. Across-the-board rate increases (other than cost of !iving adjustments) makE nc sense in this program. 112 1. Impose Annual Licensing Fees to Support Increased Monitoring and Enforcement Activities and New Programs for Small Facilities Early in the development of community care as an alternative to institutionalization, community residential care services were not considered to be appropriate as a profit-making venture. Providers were recruited to perform a humanitarian service. The much smaller payments to service providers at that time were expected to cover only the actual costs incurred in meeting the residents' basic needs and not to supplement the household inCOIT'E:' • The contemporarv community care program has to be viewed as a unique cottaae industry -- that is, for the small facility admin- istrato::s as well as a care alternative for the residents. Kany administrators are in the business of providing residential care they have a house to use as a resource in making a becaus~ living. Their primary motivation, in fact, may be to earn income to provide care and supervision for chroni- an~ ~ot necessaril~' c21Jv disabled individu21s. There i? ro reason to believe that the quality of care i? necessarily diminished because the provision of services has become more proprietary. On the other hand, it is certainl\' appropriate tc collect a fee from licensees in exchange for grant inc the right to offer residential care services on the~ a~ Vr: recomJT1enc that such fees be imposed. ~ J 3 We further reco~mend that licensing and renewal fees should be structured to offer incentives for compliance. We suggest the following: o Basic licensing and annual renewal fee: $100 o Additional increments of $25 per 25 additional beds up to 100 beds per facility, but with small facilities exempt from the first increment. Thus: up to 6 beds $100 7 to 32 beds 125 33 to 58 beds 150 59 to 84 beds 175 85 to 100 beds 200 Additional increments of $100 per 100 additional ~ beds, up to a maximum annual fee of $500. Thus: ur to 200 beds $300 201 to 300 beds 400 301 or more beds 500 c For each civil penalty assessed during the prior year (per violation, not per day), $10 should be added to thp annual licensing fee (, "MoGe' I HOl] 5e" adm: ni stra tors' licensing renewal fee should be reduceG by $10 c Recipients of of excellence should receive certificate~ one-time reductions of their licensing fees at the rate of $10 per certificate The revenue from licensing fees based on this or a comparable would be more than enough to implement the "cluster sche~~]~ "model house" pilot projects recommended Finally, we recommend that the Legislature consider including an additional $2 per bed annual licensing fee to support the State Long Term Care Ombudsman Program. This would allow expan- sion of the program's volunteer work in community residential care facilities. Because this fee would be state revenue, it could be used to expand the ombudsman program into facilities serving client groups other than the elderly without conflicting with existing federal law. 2. Authorize the Establishment of an "Ombudsman Foundation" The Long Term Care Ombudsman Program needs access to the traditional fund-raising methods available to all volunteer organizations. Just as many school districts throughout Cali- have created foundations as fund-raising arms to support for~ia their academic programs, we recommend that the Legislature auth oriz( tl-:c State Long Term Care Ombudsman Program to form a foun is eligible to receive tax-deductible donations in datio~ tlla~ 8upport of activities to be performed at the local ~onitoring level bv volunteer8. It is unlikely, at best, that the Legislature will approp riate S2-3 million in state general funds to monitoring by volun- teer~; ll": communi ty residential care facilities. It is at least possjb10 that enouqh support could be solicited from private sources to begl~ to expand this program. The effort alone would havp the of increasing public awareness of long term care be~e£it S(?~-.. ~: C'r'~ a?'lc t!~0 ir:::Jor-:'a:1cF:' of maintaining an official "presence" 115 in the facilities where such services are provided. The future quality of care will depend to a great extent on the success, or lack of it, of monitoring by volunteers. In addition, as mentioned earlier, 50 percent of the fines collected by Community Care Licensing could justifiably be dedi- cated to supporting the ombudsman program (as part of the overall monitoring and enforcement effort). 3. Launch an Agqressive Campaign to Solicit Private Contribu tions for Increasing the Levels and Quality of Service Pro vided to Community Care Residents The federal Social Security Act requires that private contri- butions to individuaJ SSI/SSP recipients to supplement the costs of maintaining them as residents in community care facilities must he treated as "income." The resulting action in such cases would be that the' Social Security Administration would reduce the to the affected SSI/SSP recipients to reflect this addi- orant~ i nCOIT'!:'~ • Congress has not authorized this provision of federal law to be w?ived upon the request of individual states. FE'deral 1a\\" does not, however, prohibit private contributions alto0ether. A or family member may give money directlv to ~riend the facility administrator (rather than the resident) to purchase service, of a visiting nurse, for example, or someone to th(~ rleaJ the roor, or to enable the resident to attend a res~dent's conrp~t or ball game or movie periodically. So long as the money (or cOCltribution, such as tickets to community events) :' ~:.-kind ~ used to "support and main":enance" cost.s, such su~plemeClt 116 supplements are allowed under existing law. Specifically, "sup- port and maintenance" refers to housing, food, and clothing. We recommend that the Legislature require CCL to advise the Departments of Developmental Services and Mental Health, the Office of Long Term Care and, of course, all licensees of the rules under federal law that apply to supplemental funding from private sources for maintaining SSI/SSP recipients in community residential care facilities. We further recommend that CCL develop standard format agreements for facility administrators to use in negotiating with friends or family members of residents to specify the nature and amount of contributions to be made. \1"(0 also recommend that the Legislature require the Depart Developmental Services and Mental Health and the Office ment~ o~ of Lor:. a Term Care to organize efforts at the county or regional leve! to encourage facility administrators to actively seek addi- tional funding for incrased levels of service. In addition to residents' friends and family members, we believe other private sources of supplemental funding exist. For example, churches or char i t2 ble orca "i za tions !Clay be wi 11 ir,g to serve as "sponsor::::" that: lS, to contribute money, time, transportation, and/or other resourceE in support of either an individual or a particular :2cility. Cluster administrators, as we recommended with respect to the "sn;rJl facilities subsystem," might be expected to iden tifv ane sclicit such cOITununi ty resources for the house managers 2.r thei~ clustt?Y"~. J ] 7 In keeping with the spirit of the times, this Commission believes that government's role in the community care system includes assisting facility administrators to help generate rev enue from nontraditional sources, rather than to seek higher payments from public funds. Increasing the levels and quality of service to community care residents will require an aggressive effort to solicit support in various forms from the private sec- tor. It is in all our best interests for government to make this effort. 118 APPENDICES J J 9 APPENDIX A Historical Derivations of the "Small Facilities Subsystem" Over the period of this study, we discovered there had been a network of "family care homes" prior to implementation of the Community Care Licensing Act. These homes were "certified" by social workers from the Department of Mental Health. This model has been highly praised by former participants in it: both so cial workers and family members of the mentally ill. Family care homes constitute the original version of what we refer to in this report as the "small facilities subsystem." We are including this material on the historical development of this care alternative in order to clarify the distinctions we have tried to make between the large, professionally-run community care institutions and the small, home-setting community care facilitieE we call the small facilities subsystem. Community Care Traditions Co~mu~jty residentiaJ care derives from two major traditions. The first originated in the mid-19th century and consisted pri marily of three institutional arrangements our society has his toricall~- maintained for dependent populations: orphanages, state hospitals. aJ~shouses, a~d ThE: second tradi t.ion began in the 1940 s a s an alternative to r placeMErt in these institutions. Progress in medical science and chanoc::. in fami ly structure converged to create a need for a theraFPutic environment outside institutions. Hjstor\7 (A-I). A principle of English law, parens patriae, provides that the sovereign, or state, has a duty to overse~ who have been abused, neglected, or abandoned, or are ~ppe~dents for other reason unable to care for themselves. Since the so~c middle of the 19th century, this legal principle has prevailed in A.1TIE:'Tic;:J as we]l, and it has influenced the development of com residential care in California. mu~ity A-I. The historical summary presented here is derived from ma terial in Purposes and Functions of Community Care: An- Orchestra without a Conductor, by Dale Carter, et ale ThE: Purposes report was prepared and issued by Steven Thompson 1-.5 soc ia te sin 1980. We recommend that readers interestec1 r. a n.on thorough rendering of community care r S histor,;' Ijr C?lifornia 2n~ elsewhere) refer to this 1980 report. 120 with its population increasing rapidly in the mid-1800's, California found its duty to oversee dependents also expanded as a result of social problems such as gambling and public drunken ness. The high percentage of unattached males and foreigners in California at the time of the gold rush were also thought to contribute to the instability of family life that led to in creasing the state's obligations. Also, the seasonal character of mining and agriculture meant that large numbers of people were without jobs for long stretches during the year. Many became dependent on government subsidies during those times. Early public records show that, in 1853, those deemed "unsafe to be at large" due to insanity were institutionalized in the insane asylum at Stockton. This asylum was authorized by state law as the first such facility in California to be built and operated by the state. In 1855, the Legislature began approp riating funds to locally-operated public and private institutions that provided out-of-home care for various classes of indigents. In 1860, the state initiated subventions through the counties for the support of out-of-home care for indigents. Until well into the 20th century, out-of-home care consisted of large facil ities -- orphanages, almshouses, and state hospitals where peoplp without personal resources and with different sorts of problems were housed and fed. Efforts to habilitate or rehabili tate such persons were not monitored by government and were often motivated and prescribed by religious beliefs and practices. Impetus for Alternatives to Institutionalization. In 1946, the Kational Institute of Mental Health began making federal funds available removing mentally ill patients from state ~or hospitals and placing them in community residential facilities. Ir California, the Bureau of Social Work was in the ~stablished Department of Mental Hygiene to accomplish this transition. the~ 1955, the California State Senate created its Interim I~ whe~ Con;rr.i ttec the Treatment of Mental Illness, there were 36,000 01'. mentallv ill patients in state hospitals. By 1980, there were 6,OCO -- a nearly 85 percent reduction. The first legislation to emerge from the Interim Committee's work was the Community Mental Health Services Act of 1957, better kDown as the Short-Doyle Act. By 1967, subsequent legislation Lac beer. enacted to increase counties' fiscal incentive to uti lize care for mental health clients. At that time, com~unity mental health programs represented 24 percent of state co~~u~ity wide public mental health expenditures. By fiscal year 1971-72, comr.mni ty mental health spending had grown to 65 percent of th'€; total. "!7'a.:rily Care Homes" (A-2). Prior to 1973, when the Co~~unity C: a. r p T_, i C F ~: ~: i 1'. G Act was passed, thp Department of Mental Health 12J (DMH) had field offices which recruited, trained, and certified "family care homes" as the need arose. The process allowed for exclusive use of the homes by the mental health program and was based on a goal-related relationship negotiated by the providers of the residential services and the DMH social workers. The responsibility for the success or failure of a placement was a joint one. The basic purpose of family care in California was to foster the client's ability to assume responsiblity for himself or her self in dealing with the obligations of family and community life. Some of the patients selected for family care placements were from the hospital classification of "continuous treatment." The outlook for their full recovery was not hopeful, but they had responded to institutional treatment and training to such an extent that hospital doctors felt they could adjust to living under supervision in a home and profit from the individual atten tion which came with family life. Family care was also used for patients who had made major progress during periods of intensive hospital treatment. These patients were placed in homes as a therapeutic measure, with the purpose of hastening their full recovery and rehabilitation. Starting in 1946, mental health social workers began to develop family care homes. They evaluated the qualifications of aprlicants, examined the physical facilities, and recommended certification of suitable homes. They provided continuous social work services to clients residing in family care homes, to their and to the family care home owners. The social relative~, workers conducted an annual review of each home prior to recerti fication. Fa!r,i ly re was both custodia 1 and therapeutic. Even those ('2 whc had shown no improvement in the hospital sometimes found in tho life ffiilieu certain therapeutic aids the hospital was ~2mily not able to provide. =n this system, social workers placed the greatest emphasis on the family caregivers' personal qualities. The caregivers needed to be: (1) sympathetic and tolerant people who were not easily upset or irritated; (2) well-adjusted; (3) firm, yet fair and essentially kind; (4) stable and sensible; and (5) able to A-2. This c;'scription of "family care homes" is based on ma f-prial thet Vlas prepared by T. Richard Middlebrook, Chief, of Term Care, State Department of Mental Of~ice Lo~q Hea 1 tl1. }27 relate to a patient on the level at which he or she could func tion, yet not lose sight that, with patience and interest, the patient could improve and become more willing to take part in family and community life. In other words, the potential quality of inter-personal relationships became the highest priority cri terion in selecting family care homes for mentally ill persons. Adoption of such a criterion was neither a product of random selection nor a matter of personal preference on the part of social workers. Rather, social workers found the personality of the caretaker was the single most reliable predictor of whether family care would succeed. The patient's improvement was di rectly related to the interest, help, and understanding they received from the families with whom they were living. In some homes, it was the husband and father who seemed to be the most potent therapeutic aid; in another, the wife; and, in some instances, the younger members of the family seemed to mean the most to the patient. But in every case, the recognition of the therapeutic potential of those personalities was the most important part o£ the social workers' evaluation and certifica tion o£ the home. "Certification" in such a model is a highly subjective pro cess. As a meons of selecting appropriate family care homes, it assumes that social workers have been adequately trained as pro fessionals and are sufficiently mature as adults to exercise good judgment. The objectives were also conceived in subjective terms: certification was perceived as a process of cultivating humanitarian motivations; prestige and a sense of social worth were considered to be the rewards that served as incentives to families to offer the service. The payments to families were meant tc cover the actual cost of caring for a particular patient anc1 not to provide addi tional household income. Licensinq. In the licensing model, community residential care is developing as a business, as well as an alternative to care institutions. Just as the public purpose in providing i~ communi ty resident.ial care has increasingly emphasized cost savings as well as humanitarian considerations, the private in terests of the small facilities administrators have increasingly come to include makinq a living. Under these circumstances, monitoring and enforcement efforts must be carefully conceived and implemented in order to protect the best interests of the residents. APPENDIX B Data Summaries 124 Table 1 COMMUNITY RESIDENTIAL CARE FACILITIES Licensed Capacity As of June 30, 1983 Facilities 6 Beds or 7 Beds or Beds Fewer More Total Adults Small Family Homes 10,578 2,317 2,317 Large Family Homes 1,715 154 154 Group Homes 35,621 1,865 1,865 Elderly (RFE) 51,706 1,719 574 2,293 Social Rehabili- tion 7,841 319 (a) 319 Subtotals 107,461 4,036 2,912 6,948 Children Small Fa~ilv Homes 4,303 1,105 1,105 Foster Family Homes 23,774 12,668(b) 12,668 Large Family Homes 70 8 8 Group Homes 9,890 959 959 Subtotals 38,037 13,773 967 14,740 Adults and Children Small Familv Homes 811 175 175 Laroe Familv Homes 59 6 6 GrC'..ln Eome s 2,751 124 124 Subtotcls 3,621 175 130 305 TO'I}\LS 149,119 17,984 4,009 21,993 Source: S~ate Department of Social Services Kates: (a) A small, but undetermined number of these facilities may be Jicensed for six or fewer beds. (h) A small, but undetermined number of foster family homes would actually be licensed to care for more than six . ('~,ildre:r 175 Table 2 DEVELOPMENTALLY DISABLED INDIVIDUALS Residing in Community Care Centers As of October 1983 Percentage Facility Size Number Residents of Total 6 Beds or Fewer 9,249 58% 7 - 14 Beds 2,034 12.8% 15 - 49 Beds 2,272 14.3% 50 Beds or More 2,369 14.9% TOTALS 15,924 100% Source: State Council on Developmental Disabilities 126 DEVELOPMENTALLY DISABLED RESIDENTS 7 - 14 Beds (12.8%) 15 - 49 Beds (14.3%) 6 Beds or Fewer ( 52/c) 50 Beds or i"bre (14.9%) Eource: state Council on Developmental Disabilities ~ctes: ~his chart depicts the data presented in Table~. Th~s, the percentages shown above indicate the percentages of T~e total 15,924 developmentally disabled individuals who were residing in community care facilities as of 1983. .~cTober 127 Table 3 ELDERLY INDIVIDUALS Licensed Capacity in Comunity Care Facilities As of September 26, 1983 Number Percent Number of Percent Facility Size of Beds of Total Facilities of Total 6 Beds or Fewer 8,775 16.1% 1,719 68.2% 7 - 14 Beds 2,429 4.5 219 8.7 15 - 49 Beds 6,446 11. 8 322 12.8 50 - 99 Beds 7,051 13.0 97 3.8 100 - 199 Beds 15,049 27.7 115 4.6 200 - 299 Beds 7,863 14.4 33 1.3 300 - 399 Beds 2,072 3.8 6 0.2 400 - 499 Beds 2,545 4.7 6 0.2 500 - 599 Beds 2,161 4.0 4 0.2 TOTA-;:',S 54,391 100.0% 2,521 100.0% Source: State Dppartment of Social Services 128 LICENSED BED CRPRCITY: ELDERLY 6 Beds or Fewer (16.1%) 7 - 14 Beds (4.57~) 15 - 49 Beds (11.8%) -~--- 50 Beds or I'wbre (67. 6~: ) cha~t depicts the data presented in Table 3 pe~­ TIf to the nu~ber of beds available for the elderly ii. 1 sensed community care facilities, as of SeptembE~ SF3. The total number of beds is 54,391. L , 129 ------------------------------- ------ RESIDENTIRL FACILITIES FOR THE ELDERLY 7 - 14 Beds (8.7%) 15 - 49 Beds (12.8%) I 50 Beds or i';)re (10.3%) 6 Bed::; or F~Jer (,>-: ')- \ ( '-'--.C/~J ~~a1e Departrrc~t of Social Services This ch2r~ de~icts the data presented in Table 3 per taining to th~ number of facilities licensed to provide c:~mc~j:~ care services for the elderly, as of Septe~­ CSY 2(, 1983. The total number of facilities is 2,5~1. 130 ------------------------------------------------- Table 4 COMMUNITY CARE LICENSING Staffing Levels 1980/1 - 1983/4 1980-81 1981-82 1982-83 1983-84 Evaluators 147.5 180.0 169.0 198.0 Other Field Operations 91. 6 119.5 113.0 121.5 Investigators 10.0 10.0 10.0 12.0 Auditors 7.0 7.0 5.0 5.0 County Liaison 18.0 18.0 12.0 8.0 Central Operations 34.0 33.0 35.0 35.0 TOTAL 308.1 367.5 344.0 379.5 Attorneys Assigned to Licensing from DSS Legc;l Divisiorc 7.0 7.0 7.0 9.0 Sourer': CO!Tl.Guni ty Care Licensing, State DepartmF-"-t of Social Services The fluctuations in CCL staffing levels reflect primarily ~otps: either caseload transfers from counties or the State Depart of Education to CCL or mandated enhancements in moni me~t toring with respect to child day care programs. In short, the increased staffing level in 1983-84 does not indicate an increase in monitoring and enforcement activities related to the community residential facilities that are the subject of thi s report. 131 APPENDIX C Participants in Little Hoover Commission's Community Care Workshops in Sacramento (Developmentally Disabled: July 25, 1983; Elderly: August 4, 1983; Mentally Disabled: August 18, 1983) Community Care Workshop -- Developmentally Disabled July 25, 1983 Name Representing Virginia Carlson Regional Center of Orange County cTake Donovan State Department of Developmental Services Nancy Fleischer Protection and Advocacy, Sacramento David Foster Community Care Licensing, State Department of Social Services Joyce Fukui Community Care Licensing, State Department of Social Services Carol:yYl Ga f fney Sonoma County Citizen Advocacy Galloway Assembly Office of Research, Cha~les Sacramento r<ary GuinJl Alta Regional Center, Sacramento State Council on Developmental Disabilities California Association of Rehabilitation Facilities Fred Mille~- Community Care Licensing, State Department of Social Services Developmental Disabilities Advocacv Services State Department of Developmental Services DevelopmentA 1 Disabili ties Advocac\ Services 132 Ralph Zeledon State Department of Developmental Services Doris Zepezaver Central Valley Regional Center Community Care Workshop -- Elderly August 4, 1983 Name Representing Ingrid Azvedo Governor's Advisory Task Force on Long Term Care Vlilliam Benson State Long Term Care Ombudsman Program Louise Brodprick California Association of Resi dential Care Homes (CARCR) Eristin Casev Long Term Care Ombudsman/Napa County Liza C12vecillCl. Community Care Licensing, State Department of Social Services Office of California State Senator Nicholas Petris Pir:hard Feingolc: Palmcrest North, Long Beach Nursing Home Abuse Unit, Los Angeles County District Attorney'~ Office Long Term Care Ombudsman/Nap~ Countv P2wl Gos~ California Association of Health Facilities (CARF) ELEJ i CP Graham California Association of Resi dential Care Romes (CARCH) Vuriel Greensa~t Long Term Care Ombudsman/Orange County Freda Mohr Multiservice Center, Jewish Family Service of Los Angeles ..., 1 .~j .) Mary Hinschliff Long Term Care Ombudsman/Santa Cruz County Eileen Jackson Long Term Care Ombudsman/Sacramento County and California Nurses Association Derrell Kelch California Association of Homes for the Aging (CAHA) Harry Kendall California Association of Resi dential Care Homes (CARCH) Sandra King Jewish Family Service of Los Angeles Ralph D. Knight Northern California Presbyterian Homes ,Tean Lundstrom Saddleback Community Hospital Harold Mc::.ys Arden Memorial Convalescent Hospital, Sacramento Bill Ruppert State long Term Care Ombudsman Program California Association of Resi dential Care Homes (CARCH) California Association of Resi dential Care Homes (CARCH) Community Care Licensing, State Department of Social Services Community Care Workshop -- Mentally Disabled August 18, 1983 Namp Representinq GeoY'C1P Bukowsk i State Department of Mental Health L i:~ a C 1 a ,: e c ill ci Community Care Licensing, State Department of Social Services Patient Rights Sacrament0 A~vocate, Countv 134 ----------------------------------------- Sharon Dorsey California Association of Resi dential Care Homes (CARCH) Robert Goulet State Department of Mental Health Diane Lockhart State Department of Mental Health Hon. Zoe Lofgram Santa Clara County Supervisor, 2nd District Lori McMahon Mental Health Department, Sacramento County Richard Middlebrook State Department of Mental Health Tom Rossebo California Association of Resi dential Care Homes (CARCH) Kath" Scheidegger Community Care Licensing, State Department of Social Services CherIe" SY:oie!l California Association of Resi dential Care Homes (CARCH) HeIe;; Teischer California Alliance for the Mentally III Neighborhood Association, San Jose Mental Health Advocacy Project, San .Jose The Manor, Santa Monica APPENDIX D Bibliography American Bar Association. Board and Care Report: An Analysis of State Laws and Programs Serving Elderly Persons and Disabled Adults. Washington, D.C.: American Bar Associa tion, 1983. Assuring the Quality of Human Services: A Conceptual Analysis. Berkeley, Cal.: Human Services Research Institute and Berkeley Planning Associates, 1980. Stephen R., and Wadleigh, Elisabeth. The Bureaucracy of B~um, Care: Continuing Policy Issues for Nursing Home Services and Regulation. Sacramento: Commission on California State Government Organization and Economy and the Nursing Home Study Advisory Committee, 1983. Carter, Dalei Bolton, A.i Noelting, N.; Shearer, D.i and Thompson, S. Purposes and Functions of Community Care: An Orchestra without a Conductor. Sacramento: Steven Associates, 1980. Thompso~ Comnlission on State Government Organization and Economy. Placement in Board and Care Facilities. I~appropriate Hearinas before the Commission. Los Angeles, May 1983. Proceedings, Community Care Workshops, July/August 1983. on Community-Based Long-Term Care. Final Report. Co~ferencp FrGncisco: On Lok Senior Health Services, 1983. S~n Dittffiar, Nancy D.i Smith, G. P.; Bell, J.C.; Jones, C. B. C.; and Manzanares, D.L. Board and Care for Elderly and Mentallv Disabled Populations: Final Report. 5 vols. Denver, Col.: Denver Research Institute, 1983. Stanislaus County. Office of Consumer Affairs. Study of Acult Board and Care Homes in Stanislaus County. Cal.: Office of Consumer Affairs, 1980. ~odesto, State Council on Developmental Disabilities. Report on Alternative Reimbursement Mechanisms for Day Programs Servina Persons with Develoomental Disabilities. Sacram~nto: State Council on Developmental Disabilities, (19 f.:) . 136 Stone, Robyn; Newcomer, Robert J.,; and Saunders, Marilyn. Descriptive Analysis of Board and Care Policy Trends. San Francisco: Aging Health Policy Center, 1982. U.S. Administration on Aging. Board and Care Homes and the Keys Amendment. Unpublished paper. Washington, D.C.: U.S. Administration on Aging, (198?). U.S. Congress. House. Select Committee on Aging. Fraud and Abuse in Boarding Homes. Hearings. 97th Cong., 1st sess., 1981. 137 APPENDIX E A Schematic To Show of Whom Actions or Changes Would Be Required in Order to Implement the Commission's Recommendations Legis Ombuds- lature CCL DDS DMH O/LTC man HWA Other SERVICE PROVISION Clarify Roles (p. 46) x x X X X X Licensees Coordinate Policy Development (p. 48) X X X x X X Coordinate Definition of Advisory S e rv ice s ( p. 4 9 ) X X X X X Committees Extend Case Management Services to Elderly and Mentally Disabled (p. 50) X X X f-' LV OJ Improve Consumer Information Community (p. 51) X X x X X Volunteer Organizations Strengthen the "Small Facilities Cluster Adminis- i Sub s Ys tem" ( p. 5 2 ) X X trators/Model House Adminis trators MONITORING AND ENFORCEMENT Recruit and Train Volunteers to Attorney Gen Monitor Residents (p. 80) X X X X eral or Dept. of Consumer Affairs Establish Emergency Response Local Capability (p. 82) X X Entities APPENDIX E (continued) Legis- Ombuds- laturc CCL DDS DMH O/LTC man HWA Other Make Applicant Screening More Meaninqful (p. 82) X Crroa to Automated Licensee Information System (p. 83) X X Standardize Cost Accounting (p. 85) X X X X X Licensees Empower Residents to Be Honitors Licensees (25 (p. 86) X X X Beds or More)/ Residents Recombine Corrununity Care and Health Facilities Licensing/Relocate in I w -' Attorney General's Office (p. 87) X X Dept. of Health '-0 Services/Attor- ney General U:: ilize Licensing Personnel More Effectively (p. 88 ) X X Develop Criteria for Granting Per- mission to Bear Arms (p. 89) X Attorney Gen- eral (poten- tially) Structure Coordination of Enforcement Activities (p. 89) X X X X X DSS Legal Divi- sion/Advisory Committees/ Placement Agencies APPENDIX E (continued) Legis- Ombuds- lature CCL DDS DMH O/LTC man HWA Other ---- Develop Criteria and Procedures - Temporary Suspension Orders (p. 93) X X Sponsor Enforcement Seminars (p. 94) X Local Law En- forcement and Fire Officials Prepare Handbooks for New Licensees and Residents (p. 95) X X X X Clarify Definition of Unlicensed Local Police Facilities/Authorize Local and Sheriff .f.-,.' Citations (p. 95) X Departments 0 Increase Fines for Licensing Violations (p. 96) X X Require All Licensees to Be Bonded (p. 97) X Licensees Authorize CCL to Place Facilities into Receivership (p. 98) X X Establish a "Crisis Team" within CCL (p. 99) X X Encourage Private Action Against Unsatisfactory Facility Private Administrators (p.lOO) X Citizens Require Boarding Houses to Be Registered/Authorize Ombudsman Boarding 1\ccess (p.lOO) X X X Houses APPENDIX E (continued) Leqis- Ombuds- lature CCL DDS DMH O/LTC man HWA Other --- .i\uthorize Immediate Dismissal of Placement Officers for Making Placement Illegal or Unsafe Referrals Agencies (p.lOI) X Restrict Geographic Concen- Local trations (p.I02) X X Governments FUNDING - Impose Licensing Fees (p.113) X X Licensees f--' ,jO. Authorize Establishment of f--' "Ombudsman Foundatic'1" (p.llS) X X Launch Aggressive Campaign to Solicit Private Contribu- tions (p.116) X X X X X Licensees ACKNOWLEDGEMENTS I want to thank the Commission on State Government Organiza tion ano Economy for giving me the opportunity to study Cali fornia's community residential care program for the elderly and developmentally and mentally disabled. The members of the Com mission's Subcommittee on Community Care, which was chaired by Jean Walker, were steadfast in educating themselves regarding a number of very complex issues. Richard Mahan, the Commission's Executive Director, supported the writing of this report with his insight, analytical capabili ties, and extensive assistance with editing. All those persons who testified at the Commission's Los Angeles hearino on community care (May 25 and 26, 1983) provided the first set of findings and offered many recommendations for the Commission's consideration. The individuals who participated in the Commission's commu nity care workshops in Sacramento (July/August 1983 -- see Appen dix C) provided the initial conceptual framework for the analysis of issues and formulated many of the recommendations set forth in report. th~s The Commission received written testimony and comments from ma people whose interest s in community residential care vary, y;\, dependino on their standing in the system as service providers, client advocates, or government monitors or administrators. To the that it was consistent with the Commission's findings, E'):tcn~_ WF havE incorporated much of their material into the final re pnr+:. Finallv, I want to express mv appreciation for the contribu bv the following individuals: t~O~? ~~ri~ r Marjlvn Saunders, Don Forrest, and Richard Mahan for their skill and tenacity facilitators at each of thp 2F summer workshops on conununity care o Marilvn Saunders and Adrienne Rogers for assistance with reseasrch and writing o Phillips -- for sharing his knowledoe of how sys ~ichael tems for providing services work and for helping me con cepturdi ze cmd formulate recommendations pertaining to the "s:nall facilities subsystem" o T. Richard Middlebrook for preparing materials that became a sUmJrar\' description of the historical development r"'" f?n:ilv C2re 2S an alternative to long-term stays in Si:2t( :"'or the mentally disabled (see Appendix A) ho~piU)'C: 143 o Dorothv O'Neil for always cheerful, always prompt assistance with numerous administrative tasks involved in arranging public hearings and workshops DEANNA J. MARQUART Sacramento December 1983 143