Existing law requires a skilled nursing or intermediate care facility to adopt an approved training program, which is required to include a precertification training program consisting of at least 60 classroom hours of training on basic nursing skills, patient safety and rights, the social and psychological problems of patients, and resident abuse prevention, recognition, and reporting and at least 100 hours of supervised and on-the-job training clinical practice. Existing law requires at least 2 hours of the 60 hours of classroom training and at least 4 hours of the 100 hours of the supervised clinical training to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimers disease, cerebral palsy, epilepsy, dementia, Parkinsons disease, and mental illness. Violation of these provisions is a crime.

This bill would require that at least 2 of the 60 hours of classroom training address the special needs of persons with Alzheimers disease and related dementias. By changing the definition of a crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law requires a skilled nursing or intermediate care facility to adopt an approved training program, which is required to include a precertification training program consisting of at least 60 classroom hours of training on basic nursing skills, patient safety and rights, the social and psychological problems of patients, and resident abuse prevention, recognition, and reporting and at least 100 hours of supervised and on-the-job training clinical practice. Existing law requires at least 2 hours of the 60 hours of classroom training and at least 4 hours of the 100 hours of the supervised clinical training to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimers disease, cerebral palsy, epilepsy, dementia, Parkinsons disease, and mental illness. Violation of these provisions is a crime.

This bill would require that at least 2 of the 60 hours of classroom training address the special needs of persons with Alzheimers disease and related dementias. By changing the definition of a crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law requires a skilled nursing or intermediate care facility to adopt an approved training program, which is required to include a precertification training program consisting of at least 60 classroom hours of training on basic nursing skills, patient safety and rights, the social and psychological problems of patients, and resident abuse prevention, recognition, and reporting and at least 100 hours of supervised and on-the-job training clinical practice. Existing law requires at least 2 hours of the 60 hours of classroom training and at least 4 hours of the 100 hours of the supervised clinical training to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimers disease, cerebral palsy, epilepsy, dementia, Parkinsons disease, and mental illness. Violation of these provisions is a crime.

This bill would require that at least 2 of the 60 hours of classroom training address the special needs of persons with Alzheimers disease and related dementias. By changing the definition of a crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law requires a skilled nursing or intermediate care facility to adopt an approved training program, which is required to include a precertification training program consisting of at least 60 classroom hours of training on basic nursing skills, patient safety and rights, the social and psychological problems of patients, and resident abuse prevention, recognition, and reporting and at least 100 hours of supervised and on-the-job training clinical practice. Existing law requires at least 2 hours of the 60 hours of classroom training and at least 4 hours of the 100 hours of the supervised clinical training to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimers disease, cerebral palsy, epilepsy, dementia, Parkinsons disease, and mental illness. Violation of these provisions is a crime.

This bill would require that at least 8 2 of the 60 hours of classroom training address the special needs of persons with Alzheimers disease and related dementias. By changing the definition of a crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law requires a skilled nursing or intermediate care facility to adopt an approved training program, which is required to include a precertification training program consisting of at least 60 classroom hours of training on basic nursing skills, patient safety and rights, the social and psychological problems of patients, and resident abuse prevention, recognition, and reporting and at least 100 hours of supervised and on-the-job training clinical practice. Existing law requires at least 2 hours of the 60 hours of classroom training and at least 4 hours of the 100 hours of the supervised clinical training to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimers disease, cerebral palsy, epilepsy, dementia, Parkinsons disease, and mental illness. Violation of these provisions is a crime.

This bill would require that at least 8 of the 60 hours of classroom training address the special needs of persons with Alzheimers disease and related dementias. By changing the definition of a crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

 UNFINISHED BUSINESS  

Bill No: SB 449

Author:

:

Vote:

SENATE HEALTH COMMITTEE: 9-0, 4/5/17

AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SENATE FLOOR: 36-0, 4/27/17 (Consent)

AYES: Allen, Anderson, Atkins, Bates, Beall, Bradford, Cannella, De León, Dodd, Fuller, Gaines, Galgiani, Glazer, Hernandez, Hertzberg, Hill, Jackson, Lara, Leyva, McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Newman, Nguyen, Nielsen, Pan, Roth, Skinner, Stern, Stone, Wieckowski, Wiener, Wilk

NO VOTE RECORDED: Berryhill, Hueso, Portantino, Vidak

ASSEMBLY FLOOR: 74-0, 7/6/17 (Consent) - See last page for vote

SUBJECT:

SOURCE: Alzheimer’s Association

DIGEST: This bill requires at least two of the 60 hours of classroom training that is required as part of the training program for certified nurse assistants to address the special needs of persons with Alzheimer’s disease and related dementias.

Assembly Amendments reduce the number of classroom training hours to address the special needs of persons with Alzheimer’s disease from eight hours to two hours.

ANALYSIS:

Existing law:

1. Certifies and regulates certified nurse assistants (CNAs) by the Department of Public Health (DPH).
2. Establishes a scope of practice for CNAs as performing basic patient care services directed at the safety, comfort, personal hygiene, and protections of patients, and prohibits CNAs from performing any services which can only be performed by a licensed person, and requires all services to be performed under the supervision of a licensed registered nurse or a licensed vocational nurse.
3. Requires a skilled nursing facility (SNF) or an intermediate care facility (ICF) to adopt an approved training program for CNAs that includes both an orientation program for newly employed CNAs, a precertification training program (unless the SNF or ICF only employs CNAs that are already certified), and continuing in-service training to ensure continuing competency in existing and new nursing skills.
4. Requires an applicant for certification as a CNA to be at least 16 years of age, have successfully completed a DPH-approved precertification training program that includes at least 60 classroom hours and 100 hours of supervised on-the-job training, and have obtained a criminal record clearance.
5. Requires at least two hours of the 60 hours of classroom training, and at least four hours of the 100 hours of supervised clinical training, to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimer’s disease, cerebral palsy, epilepsy, dementia, Parkinson’s disease, and mental illness.
6. Requires at least six hours of the 60 hours of classroom training to include instruction on preventing, recognizing, and reporting instances of resident abuse, and a minimum of one hour of instruction on preventing, recognizing, and reporting residents’ rights violations.
7. Requires CNAs to complete at least two hours of initial dementia-specific training as part of an SNF’s or ICF’s orientation program for newly employed CNAs.
8. Requires a CNA to complete at least five hours of dementia-specific in-service training per year, as part of the facility’s in-service training.
9. Licenses and regulates residential care facilities for the elderly by the Department of Social Services, and requires direct care staff employed in these facilities to complete six hours of dementia care training prior to the staff working directly with residents, another six hours of dementia care training within the first four weeks of employment, and eight hours of in-service training per year on serving residents with dementia.

This bill requires at least two of the 60 hours of the classroom training that is required as part of an approved training program for CNAs to address the special needs of persons with Alzheimer’s disease and related dementias.

Background

1. CNAs. There are an estimated 160,000 CNAs working in California. A person may only use the title, and hold themselves out as, a CNA if they are working in a health facility licensed by DPH. The majority of CNAs work in SNFs. CNAs perform a variety of basic duties for the patient’s comfort and recovery. These tasks vary depending on the employment setting but typically include: taking temperatures; pulse; respiration; blood pressure; helping patients with range-of-motion exercises; assisting patients with their daily living needs; serving meals; making beds; and, helping patients eat, dress and bathe. CNAs are paid, on average, approximately $14 dollars per hour, although the sponsor of this bill, Alzheimer’s Association, states that the average pay for CNAs in San Francisco is more than $19 per hour, and nearly $17 per hour in Alameda County. The United States Bureau of Labor Statistics projects that, between 2008 and 2018, the demand for CNAs will increase by about 19%. As a growing occupation with low education and training requirements, the CNA profession has been a target for welfare-to-work and other training programs.
2. Alzheimer’s disease. According to the federal National Institute on Aging , Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear after age 65. Plaques and tangles in the brain are two of the main features of Alzheimer’s disease. The third is the loss of connections between nerve cells (neurons) in the brain. Although treatment can help manage symptoms in some people, currently there is no cure for this disease. Estimates vary, but experts suggest that as many as five million Americans age 65 and older may have Alzheimer’s disease.
   
   
3. Alzheimer’s disease is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—and behavioral abilities, to such an extent that it interferes with a person’s daily life and activities. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living.
   

Comments

Author’s statement. According to the author, CNAs are the primary providers of direct care to SNF residents with Alzheimer’s disease and related dementias, yet, CNAs receive less than two hours of classroom instruction on this complex and challenging medical condition before they are hired to work in SNFs and other settings, including hospitals, assisted living and home health. In the SNF setting, at least 60% of residents have a cognitive impairment with estimates as high as 80%, totaling as many as 80,000 vulnerable, at-risk Californians. Alzheimer’s disease is not normal aging. It is the fifth leading cause of death in California, affecting 610,000 individuals today and upwards of 840,000 as early as 2025. Medi-Cal spending on this condition is on track to exceed $5 billion within a decade, largely due to institutional costs and poor disease management. Nearly all individuals with Alzheimer’s disease (97%) experience behavioral and psychological symptoms that require specialized training to manage. As the disease progresses, the severity of the behaviors increases, with patients exhibiting agitation, verbal and/or physical aggression, delusions, hallucinations, disinhibition, wandering, pacing and sleep disturbances. Training all CNAs in dementia prior to employment improves patient outcomes and reduces state costs.

Related/Prior Legislation

SB 613 (Allen, Chapter 577, Statutes of 2015) required DPH to convene a workgroup to update the 2008 Guidelines for Alzheimer’s Disease Management in California to address changes in the health care system, and required DPH to submit a report of the updates and recommendations from the working group to the Legislature on or before March 1, 2017.

SB 1384 (Mitchell, Chapter 847, Statutes of 2014) eliminated the requirement that DPH deny, suspend, or revoke a certificate of a CNA if the applicant or certificate holder has been convicted of a violation or attempted violation of one or more specified crimes.

AB 2791 (Simitian, Chapter 270, Statutes of 2004) required the approved training program of an SNF and an ICF to include instruction on preventing, recognizing, and reporting residents’ rights violations as part of the training and instruction required under existing law.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Assembly Appropriations Committee, any impact to DPH is expected to be minor and absorbable (Licensing and Certification Program Fund).

SUPPORT: (Verified 8/31/17)

Alzheimer’s Association (source)

AARP California

Alzheimer’s Greater Los Angeles

Association of California Caregiver Resource Centers

California Advocates for Nursing Home Reform

California Long-Term Care Ombudsman Association

Multipurpose Senior Services Program Site Association

OPPOSITION: (Verified 8/31/17)

None received

ARGUMENTS IN SUPPORT: This bill is sponsored by the Alzheimer’s Association which states the current requirement, less than two hours of classroom instruction on Alzheimer’s disease and related dementias, is inadequate to equip CNAs with the knowledge and skills they need to manage the common behaviors associated with Alzheimer’s disease, including agitation, verbal and/or physical aggressiveness, delusions, hallucinations, disinhibition, hyperactivity (e.g. wandering, pacing, rummaging) and sleep disturbances.

AARP California states in support that CNAs are the backbone of California’s long-term care delivery system, and this bill will help prepare CNAs to enter the workforce equipped with the skills necessary to understand Alzheimer’s disease and related dementias, which are complex and challenging conditions requiring specialized training.

The California Long-Term Care Ombudsman Association (CLTCOA) states in support that all too often it hears about complaints from residents and their family members because of situations where the lack of training for the CNAs has hindered their ability to provide assistance when relating to a senior who may have Alzheimer’s disease, or major neurocognitive disorders. CLTCOA states that the current training requirements for CNAs are insufficient to meet the needs of seniors with intellectual disabilities.

Alzheimer’s Greater Los Angeles states in support that dementia training is essential for those providing care to people with Alzheimer’s disease or a related dementia, and that CNAs trained in behavioral and psycho-socially based intervention strategies are better able to meet the needs of their patients and are less likely to resort to the inappropriate use of psychotropic medications or physical restraints.

This bill is also supported by California Advocates for Nursing Home Reform (CANHR), which states that this bill will improve nursing home quality by ensuring that CNAs have training related to dementia care. CANHR states that approximately 36,000 nursing home residents in California are diagnosed with dementia, with tens of thousands more suffering mild cognitive impairments. CANHR states that the minimal dementia training requirements for CNAs stand in stark contrast for staff at residential care facilities of the elderly, where staff must receive eight hours of training on dementia care annually. CANHR also states that it would like to see this bill amended to add some details to the required dementia care training, such as “non-pharmacologic, person-centered” approaches.

ASSEMBLY FLOOR: 74-0, 7/6/17

AYES: Acosta, Aguiar-Curry, Travis Allen, Arambula, Baker, Berman, Bigelow, Bloom, Bonta, Brough, Burke, Caballero, Cervantes, Chau, Chávez, Chen, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dahle, Daly, Eggman, Flora, Fong, Frazier, Friedman, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gomez, Gonzalez Fletcher, Grayson, Harper, Holden, Irwin, Jones-Sawyer, Kalra, Kiley, Levine, Limón, Low, Maienschein, Mathis, Mayes, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Quirk, Quirk-Silva, Reyes, Ridley-Thomas, Rodriguez, Rubio, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Voepel, Waldron, Weber, Wood, Rendon

NO VOTE RECORDED: Bocanegra, Calderon, Dababneh, Gray, Lackey, McCarty

Prepared by:

8/31/17 18:16:14

**** END ****

SENATE THIRD READING

STR Bill Id:SB 449

Author:(Monning)

As Amended Ver:August 24, 2017

Majority vote

SENATE VOTE: 36-0

SUMMARY: Requires at least two of the 60 hours of classroom training required as part of certified nurse assistant (CNA) training programs address the special needs of persons with Alzheimer's disease and related dementias, and restores the Department of Public Health's (DPH's) ability to include training regarding Alzheimer's in clinical training sections.

FISCAL EFFECT: According to the Assembly Appropriations Committee, any impact to DPH is expected to be minor and absorbable (Licensing and Certification Program Fund).

COMMENTS: According to the author, CNAs are the primary providers of direct care to skilled nursing facility (SNF) residents with Alzheimer's disease and related dementias, yet CNAs receive less than two hours of classroom instruction on this complex and challenging medical condition before they are hired to work in SNFs and other settings, including hospitals, assisted living, and home health. The author states that in the SNF setting, at least 60% of residents have a cognitive impairment with estimates as high as 80%, totaling as many as 80,000 vulnerable, at-risk Californians. The author notes that Alzheimer's disease is not normal aging: it is the 5th leading cause of death in California, affecting 610,000 individuals today and upwards of 840,000 as early as 2025. The author contends that Medi-Cal spending on this condition is on track to exceed $5 billion within a decade, largely due to institutional costs and poor disease management. Nearly all individuals with Alzheimer's disease (97%) experience behavioral and psychological symptoms that require specialized training to manage, and as the disease progresses, the severity of the behaviors increases, with patients exhibiting agitation, verbal and/or physical aggression, delusions, hallucinations, disinhibition, wandering, pacing, and sleep disturbances. The author concludes that training all CNAs in dementia prior to employment improves patient outcomes and reduces state costs.

Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. In most people with Alzheimer's, symptoms first appear in their mid-60s. According to the National Institute on Aging, Alzheimer's disease is the most common cause of dementia among older adults. According to the Alzheimer's Association (AA) there are over 5 million American's living with Alzheimer's, with 630,000 in California.

CNAs. A person may only use the title, and hold themselves out as a CNA if they are working in a health facility licensed by DPH. The majority of CNAs work in SNFs. CNAs perform a variety of basic duties for the patient's comfort and recovery. These tasks typically include: taking temperatures, pulse, respiration, and blood pressure; helping patients with range-of-motion exercises; assisting patients with their daily living needs; serving meals; making beds; and, helping patients eat, dress, and bathe. According to DPH there are approximately 136,000 licensed CNAs in California.

CNA training requirements. As noted in existing law above, CNAs are required to complete 60 classroom hours and 100 hours of supervised on-the-job training before licensure. According to DPH, current law, in statute and regulation, allocates 57 of the 60 classroom hours, with 50 of those hours allocated in regulation, and seven hours in statute. Of the seven hours specified in statute, six hours are on preventing, recognizing, and reporting resident abuse, and one hour on residents' rights violations. The 50 hours in regulations (California Code of Regulations 71835 of Division 5, Title 22) are spread across 16 different modules. The module topics and associated hours are:

The 100 clinical hours are recommended in various areas, but not mandated in statute.

DPH update of Title 22 regulations. According to DPH, it has developed a multi-year plan for completing a comprehensive update of the Title 22 regulations within its authority and has dedicated resources assigned to completing this task. Currently, DPH is working on 20 regulatory packages that are at different stages in the development process, including an update to the CNA training requirements.

AA petition requesting increase in required hours of dementia-specific training for CNAs. In February of 2017, AA petitioned DPH to amend the statute or regulations to require two hours of the 60 classroom hours and four of the 100 hours of supervised clinical training to include, "a general overview of Alzheimer's disease and related dementias with specific instruction on communications, behaviors, and medication unique to this resident population." DPH is currently drafting updates to the CNA training regulations, and has limited authority to create regulatory requirements for clinical training on specific topics or modules. In a letter responding to AAs request, DPH notes, "…the request would be more appropriately addressed via the legislative process." However, DPH can recommend a specific number of supervised clinical training hours and is considering the AA request as part of the rulemaking in process.

AA is the sponsor of this bill and states that AA believes the current requirement, less than two hours of classroom instruction on Alzheimer's disease and related dementias, is insufficient to equip CNAs with the knowledge and skills they need to manage the common behaviors associated with Alzheimer's including agitation, verbal and/or physical aggressiveness, delusions, hallucinations, and sleep disturbances. AA notes that this year California will spend more than $3.3 billion on Medi-Cal long-term care services and supports for persons with dementia. AA contends that these costs are slated to increase by 58% within a decade unless we find new ways of managing the disease, including effective interventions that delay institutionalization and avoid transfers to higher cost settings. AA concludes that when direct care staff lack understanding of Alzheimer's and the challenging behaviors associated with the disease, they often call 9-1-1 to manage a behavior that could have been prevented by training on communication, redirection, and other techniques.

The California Assisted Living Association (CALA) supports this bill and states that the number of seniors with Alzheimer's disease and other forms of dementia continues to increase with no known cure. CALA notes that increased focus on dementia care specifically will create a stronger workforce and result in better care and services to those suffering from this disease. CALA concludes that, because of the recognized need for specific dementia care training, in 2014 CALA worked with AA to significantly increase the dementia specific training for caregivers in residential care facilities for the elderly.

There is no known opposition to this bill.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001219

SENATE THIRD READING

STR Bill Id:SB 449

Author:(Monning)

As Amended Ver:June 22, 2017

Majority vote

SENATE VOTE: 36-0

SUMMARY: Requires at least two of the 60 hours of classroom training required as part of certified nurse assistant (CNA) training programs address the special needs of persons with Alzheimer's disease and related dementias

FISCAL EFFECT: According to the Assembly Appropriations Committee, any impact to the Department of Public Health (DPH) is expected to be minor and absorbable (Licensing and Certification Program Fund).

COMMENTS: According to the author, CNAs are the primary providers of direct care to skilled nursing facility (SNF) residents with Alzheimer's disease and related dementias, yet CNAs receive less than two hours of classroom instruction on this complex and challenging medical condition before they are hired to work in SNFs and other settings, including hospitals, assisted living, and home health. The author states that in the SNF setting, at least 60% of residents have a cognitive impairment with estimates as high as 80%, totaling as many as 80,000 vulnerable, at-risk Californians. The author notes that Alzheimer's disease is not normal aging: it is the 5th leading cause of death in California, affecting 610,000 individuals today and upwards of 840,000 as early as 2025. The author contends that Medi-Cal spending on this condition is on track to exceed $5 billion within a decade, largely due to institutional costs and poor disease management. Nearly all individuals with Alzheimer's disease (97%) experience behavioral and psychological symptoms that require specialized training to manage, and as the disease progresses, the severity of the behaviors increases, with patients exhibiting agitation, verbal and/or physical aggression, delusions, hallucinations, disinhibition, wandering, pacing, and sleep disturbances. The author concludes that training all CNAs in dementia prior to employment improves patient outcomes and reduces state costs.

Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. In most people with Alzheimer's, symptoms first appear in their mid-60s. According to the National Institute on Aging, Alzheimer's disease is the most common cause of dementia among older adults. According to the Alzheimer's Association (AA) there are over 5 million American's living with Alzheimer's, with 630,000 in California.

CNAs. A person may only use the title, and hold themselves out as a CNA if they are working in a health facility licensed by DPH. The majority of CNAs work in SNFs. CNAs perform a variety of basic duties for the patient's comfort and recovery. These tasks typically include: taking temperatures, pulse, respiration, and blood pressure; helping patients with range-of-motion exercises; assisting patients with their daily living needs; serving meals; making beds; and, helping patients eat, dress, and bathe. According to DPH there are approximately 136,000 licensed CNAs in California.

CNA training requirements. As noted in existing law above, CNAs are required to complete 60 classroom hours and 100 hours of supervised on-the-job training before licensure. According to DPH, current law, in statute and regulation, allocates 57 of the 60 classroom hours, with 50 of those hours allocated in regulation, and seven hours in statute. Of the seven hours specified in statute, six hours are on preventing, recognizing, and reporting resident abuse, and one hour on residents' rights violations.

The 50 hours in regulations (California Code of Regulations (CCR) 71835 of Division 5, Title 22) are spread across 16 different modules. The module topics and associated hours are:

The 100 clinical hours are recommended in various areas, but not mandated in statute.

DPH update of Title 22 regulations. According to DPH, it has developed a multi-year plan for completing a comprehensive update of the Title 22 regulations within its authority and has dedicated resources assigned to completing this task. Currently, DPH is working on 20 regulatory packages that are at different stages in the development process, including an update to the CNA training requirements.

AA petition requesting increase in required hours of dementia-specific training for CNAs. In February of 2017, AA petitioned DPH to amend the statute or regulations to require two hours of the 60 classroom hours and four of the 100 hours of supervised clinical training to include, "a general overview of Alzheimer's disease and related dementias with specific instruction on communications, behaviors, and medication unique to this resident population." DPH is currently drafting updates to the CNA training regulations, and has limited authority to create regulatory requirements for clinical training on specific topics or modules. In a letter responding to AAs request, DPH notes, "…the request would be more appropriately addressed via the legislative process." However, DPH can recommend a specific number of supervised clinical training hours and is considering the AA request as part of the rulemaking in process.

AA is the sponsor of this bill and states that AA believes the current requirement, less than two hours of classroom instruction on Alzheimer's disease and related dementias, is insufficient to equip CNAs with the knowledge and skills they need to manage the common behaviors associated with Alzheimer's including agitation, verbal and/or physical aggressiveness, delusions, hallucinations, and sleep disturbances. AA notes that this year California will spend more than $3.3 billion on Medi-Cal long-term care services and supports for persons with dementia. AA contends that these costs are slated to increase by 58% within a decade unless we find new ways of managing the disease, including effective interventions that delay institutionalization and avoid transfers to higher cost settings. AA concludes that when direct care staff lack understanding of Alzheimer's and the challenging behaviors associated with the disease, they often call 9-1-1 to manage a behavior that could have been prevented by training on communication, redirection, and other techniques.

The California Assisted Living Association (CALA) supports this bill and states that the number of seniors with Alzheimer's disease and other forms of dementia continues to increase with no known cure. CALA notes that increased focus on dementia care specifically will create a stronger workforce and result in better care and services to those suffering from this disease. CALA concludes that, because of the recognized need for specific dementia care training, in 2014 CALA worked with AA to significantly increase the dementia specific training for caregivers in residential care facilities for the elderly.

There is no known opposition to this bill.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001214

Date of Hearing: June 28, 2017

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

SBPCA Bill Id:SB 449

Author:(Monning) – As Amended Ver:June 22, 2017

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill requires at least two of the 60 hours of classroom training required as part of certified nurse assistant (CNA) training programs to address the special needs of persons with Alzheimer's disease and related dementias.

FISCAL EFFECT:

Any impact to the California Department of Public Health (CDPH) is expected to be minor and absorbable (Licensing and Certification Program Fund).

COMMENTS:

1. Purpose. This bill, sponsored by the Alzheimer's Association, requires additional training for CNAs on Alzheimer's disease and dementia in order to equip CNAs with the skills to manage common behaviors associated with these disorders, and improve quality of care for patients.
2. Background. Among other requirements, in order to become a CNA, an individual must complete a 60-hour classroom training program approved by CDPH. According to CDPH, current law allocates 57 of the 60 classroom hours to various topics (50 in regulation, and seven in statute). This bill would require two of the remaining three unallocated hours to address Alzheimer's disease and dementia, which are brain disorders that may result in severe behavioral and psychological symptoms. CDPH is currently updating Title 22 regulations, which govern facility licensing, and is considering changes to CNA training as part of the regulatory update.
3. Prior Legislation. SB 613 (Allen), Chapter 577, Statutes of 2015, required CDPH to convene a workgroup to update the 2008 "Guidelines for Alzheimer’s Disease Management in California" to address changes in the health care system, and required DPH to submit a report on workgroup recommendations by March 1, 2017.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: June 20, 2017

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 449

Author:(Monning) – As Introduced Ver:February 15, 2017

SENATE VOTE: 36-0

SUBJECT: Skilled nursing and intermediate care facilities: training programs.

SUMMARY: Requires at least eight of the 60 hours of classroom training required as part of certified nurse assistant (CNA) training programs address the special needs of persons with Alzheimer's disease and related dementias.

EXISTING LAW:

1. Establishes the Department of Public Health (DPH) which, among other functions, certifies and regulates CNAs.
   
2. Establishes a scope of practice for CNAs as performing basic patient care services directed at the safety, comfort, personal hygiene, and protection of patients, prohibits CNAs from performing any services which can only be performed by a licensed person, and requires all services to be performed under the supervision of a licensed registered nurse or a licensed vocational nurse.
3. Requires a skilled nursing facility (SNF) or an intermediate care facility (ICF) to adopt an approved training program for CNAs that includes both an orientation program for newly employed CNAs, a precertification training program (unless the SNF or ICF only employs CNAs that are already certified), and continuing in-service training to ensure continuing competency in existing and new nursing skills.
4. Requires an applicant for certification as a CNA to be at least 16 years of age, have successfully completed a DPH-approved precertification training program that includes at least 60 classroom hours and 100 hours of supervised on-the-job training, and have obtained a criminal record clearance.
5. Requires at least two hours of the 60 hours of classroom training and at least four hours of the 100 hours of supervised clinical training to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimer’s disease, cerebral palsy, epilepsy, dementia, Parkinson’s disease, and mental illness.
6. Requires at least six hours of the 60 hours of classroom training to include instruction on preventing, recognizing, and reporting instances of resident abuse, and a minimum of one hour of instruction on preventing, recognizing, and reporting residents’ rights violations.
7. Requires registered nurses, CNAs, licensed vocational nurses, and physicians working in SNFs to participate in a training program that focuses on preventing and eliminating discrimination based on sexual orientation and gender identity.
8. Requires CNAs to complete at least two hours of initial dementia-specific training as part of a SNF’s or ICF’s orientation program for newly employed CNAs.
9. Requires CNAs to complete 48 hours of in-service training every two years, with at least 21 of the 48 completed in each of the two years. Permits 24 of the 48 hours to be obtained through an online computer training program.
10. Requires a CNA to complete at least five hours of dementia-specific in-service training per year, as part of the facility’s in-service training.
    
11. Licenses and regulates residential care facilities for the elderly (RCFE) by the Department of Social Services, and requires direct care staff employed in these facilities to complete six hours of dementia care training prior to the staff working directly with residents, another six hours of dementia care training within the first four weeks of employment, and eight hours of in-service training per year on serving residents with dementia.
    

FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, CNAs are the primary providers of direct care to SNF residents with Alzheimer’s disease and related dementias, yet CNAs receive less than two hours of classroom instruction on this complex and challenging medical condition before they are hired to work in SNFs and other settings, including hospitals, assisted living, and home health. The author states that in the SNF setting, at least 60% of residents have a cognitive impairment with estimates as high as 80%, totaling as many as 80,000 vulnerable, at-risk Californians. The author notes that Alzheimer’s disease is not normal aging: it is the 5th leading cause of death in California, affecting 610,000 individuals today and upwards of 840,000 as early as 2025. The author contends that Medi-Cal spending on this condition is on track to exceed $5 billion within a decade, largely due to institutional costs and poor disease management. Nearly all individuals with Alzheimer’s disease (97%) experience behavioral and psychological symptoms that require specialized training to manage, and as the disease progresses, the severity of the behaviors increases, with patients exhibiting agitation, verbal and/or physical aggression, delusions, hallucinations, disinhibition, wandering, pacing, and sleep disturbances. The author concludes that training all CNAs in dementia prior to employment improves patient outcomes and reduces state costs.
   
2. BACKGROUND. Alzheimer’s disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear in their mid-60s. According to the National Institute on Aging, Alzheimer’s disease is the most common cause of dementia among older adults. According to the Alzheimer's Association (AA) there are over 5 million American's living with Alzheimer's, with 630,000 in California. AA estimates as many as 16 million American's will have the disease by 2050.
   1. CNAs. A person may only use the title, and hold themselves out as a CNA if they are working in a health facility licensed by DPH. The majority of CNAs work in SNFs. CNAs perform a variety of basic duties for the patient’s comfort and recovery. These tasks vary depending on the employment setting but typically include: taking temperatures, pulse, respiration, and blood pressure; helping patients with range-of-motion exercises; assisting patients with their daily living needs; serving meals; making beds; and, helping patients eat, dress, and bathe. CNAs are paid, on average, approximately $14 per hour, although the sponsor of this bill, AA, states that the average pay for CNAs in San Francisco is more than $19 per hour, and nearly $17 per hour in Alameda County. According to DPH there are approximately 136,000 licensed CNAs in California.
      
   2. CNA training requirements. As noted in existing law above, CNAs are required to complete 60 classroom hours and 100 hours of supervised on-the-job training before licensure. According to DPH, current law, in statute and regulation, allocates 57 of the 60 classroom hours, with 50 of those hours allocated in regulation, and seven hours in statute. Of the seven hours specified in statute, six hours are on preventing, recognizing, and reporting resident abuse, and one hour on residents' rights violations.
      

The 50 hours in regulations (CCR 71835 of Division 5, Title 22) are spread across 16 different modules. The module topics and associated hours are:

The 100 clinical hours are recommended in various areas, but not mandated in statute.

• 1. DPH update of Title 22 regulations. According to DPH, it has developed a multi-year plan for completing a comprehensive update of the Title 22 regulations within its authority and has dedicated resources assigned to completing this task. Currently, DPH is working on 20 regulatory packages that are at different stages in the development process, including an update to the CNA training requirements.
     
  2. AA petition requesting increase in required hours of dementia-specific training for CNAs. In February of 2017, AA petitioned DPH to amend the statute or regulations to require two hours of the 60 classroom hours and four of the 100 hours of supervised clinical training to include, "a general overview of Alzheimer's disease and related dementias with specific instruction on communications, behaviors, and medication unique to this resident population." DPH is currently drafting updates to the CNA training regulations, and has limited authority to create regulatory requirements for clinical training on specific topics or modules. In a letter responding to AAs request, DPH notes, "…the request would be more appropriately addressed via the legislative process." However, DPH can recommend a specific number of supervised clinical training hours and is considering the AA request as part of the rulemaking in process.

1. SUPPORT. AA is the sponsor of this bill and states that AA believes the current requirement, less than two hours of classroom instruction on Alzheimer's disease and related dementias, is insufficient to equip CNAs with the knowledge and skills they need to manage the common behaviors associated with Alzheimer's including agitation, verbal and/or physical aggressiveness, delusions, hallucinations, and sleep disturbances. AA notes that this year California will spend more than $3.3 billion on Medi-Cal long-term care services and supports for persons with dementia. AA contends that these costs are slated to increase by 58% within a decade unless we find new ways of managing the disease, including effective interventions that delay institutionalization and avoid transfers to higher cost settings. AA concludes that when direct care staff lack understanding of Alzheimer's and the challenging behaviors associated with the disease, they often call 9-1-1 to manage a behavior that could have been prevented by training on communication, redirection, and other techniques.
   
   The California Assisted Living Association (CALA) supports this bill and states that the number of seniors with Alzheimer's disease and other forms of dementia continues to increase with no known cure. CALA notes that increased focus on dementia care specifically will create a stronger workforce and result in better care and services to those suffering from this disease. CALA concludes that, because of the recognized need for specific dementia care training, in 2014 CALA worked with AA to significantly increase the dementia specific training for caregivers in RCFEs.
2. RELATED LEGISLATION. AB 1225 (Patterson) requires DPH to report on its efforts to update or modernize regulations. AB 1225 is pending hearing in the Assembly Health Committee.
3. PREVIOUS LEGISLATION.
   1. SB 613 (Allen), Chapter 577, Statutes of 2015, requires DPH to convene a workgroup to update the 2008 Guidelines for Alzheimer’s Disease Management in California to address changes in the health care system, and required DPH to submit a report of the updates and recommendations from the working group to the Legislature on or before March 1, 2017.
   2. SB 1384 (Mitchell), Chapter 847, Statutes of 2014, eliminates the requirement that DPH deny, suspend, or revoke a certificate of a CNA if the applicant or certificate holder has been convicted of a violation or attempted violation of one or more specified crimes.
   3. AB 2791 (Simitian), Chapter 270, Statutes of 2004, requires the approved training program of a SNF and an ICF to include instruction on preventing, recognizing, and reporting residents’ rights violations as part of the training and instruction required under existing law.
4. SUGGESTED AMENDMENT. As currently drafted, this bill requires at least eight of the 60 hours of classroom training to address the special needs of persons with Alzheimer's disease and related dementias. Current law requires at least two hours of classroom and four hours of supervised clinical training to address the special needs of persons with a variety of conditions, including Alzheimer's. There are currently only three unallocated hours of classroom training available, and DPH is considering amending the training regulations they are updating to include more Alzheimer's training. Given the limited number of available hours and the uncertainty regarding updates to regulations, the Committee may wish to amend the bill to require:

(4) At least two 8 of the 60 hours of classroom training shall address the special needs of persons with Alzheimer’s disease and related dementias.

REGISTERED SUPPORT / OPPOSITION:

Support

AARP California

Alzheimer's Association

Alzheimer's Greater Los Angeles

California Advocates for Nursing Home Reform

California Assisted Living Association
California Association of Area Agencies on Aging
California Caregiver Resource Centers

California Commission on Aging

California Long-Term Care Ombudsman Association
Congress of California Seniors

Multipurpose Senior Services Program Site Association

State Council on Developmental Disabilities

Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097

 CONSENT  

Bill No: SB 449

Author: Monning (D), et al.

Introduced: 2/15/17

Vote: 21

SENATE HEALTH COMMITTEE: 9-0, 4/5/17

AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SUBJECT: Skilled nursing and intermediate care facilities: training programs

SOURCE: Alzheimer’s Association

DIGEST: This bill requires at least eight of the 60 hours of classroom training that is required as part of the training program for certified nurse assistants to address the special needs of persons with Alzheimer’s disease and related dementias.

ANALYSIS:

Existing law:

1. Certifies and regulates certified nurse assistants (CNAs) by the Department of Public Health (DPH).
2. Establishes a scope of practice for CNAs as performing basic patient care services directed at the safety, comfort, personal hygiene, and protections of patients, and prohibits CNAs from performing any services which can only be performed by a licensed person, and requires all services to be performed under the supervision of a licensed registered nurse or a licensed vocational nurse.
3. Requires a skilled nursing facility (SNF) or an intermediate care facility (ICF) to adopt an approved training program for CNAs that includes both an orientation program for newly employed CNAs, a precertification training program (unless the SNF or ICF only employs CNAs that are already certified), and continuing in-service training to ensure continuing competency in existing and new nursing skills.
4. Requires an applicant for certification as a CNA to be at least 16 years of age, have successfully completed a DPH-approved precertification training program that includes at least 60 classroom hours and 100 hours of supervised on-the-job training, and have obtained a criminal record clearance.
5. Requires at least two hours of the 60 hours of classroom training, and at least four hours of the 100 hours of supervised clinical training, to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimer’s disease, cerebral palsy, epilepsy, dementia, Parkinson’s disease, and mental illness.
6. Requires at least six hours of the 60 hours of classroom training to include instruction on preventing, recognizing, and reporting instances of resident abuse, and a minimum of one hour of instruction on preventing, recognizing, and reporting residents’ rights violations.
7. Requires CNAs to complete at least two hours of initial dementia-specific training as part of an SNF’s or ICF’s orientation program for newly employed CNAs.
8. Requires CNAs to complete 48 hours of in-service training every two years, with at least 21 of the 48 completed in each of the two years. Permits 24 of the 48 hours to be obtained through an online computer training program.
9. Requires a CNA to complete at least five hours of dementia-specific in-service training per year, as part of the facility’s in-service training.
10. Licenses and regulates residential care facilities for the elderly by the Department of Social Services, and requires direct care staff employed in these facilities to complete six hours of dementia care training prior to the staff working directly with residents, another six hours of dementia care training within the first four weeks of employment, and eight hours of in-service training per year on serving residents with dementia.

This bill:

1. Requires at least eight of the 60 hours of the classroom training that is required as part of an approved training program for CNAs to address the special needs of persons with Alzheimer’s disease and related dementias.
2. Removes Alzheimer’s disease from the list of developmental and mental disorders that an existing law requires be addressed in at least two of the 60 hours of classroom training, and at least four of the 100 hours of clinical training.

Background

1. CNAs. There are an estimated 160,000 CNAs working in California. A person may only use the title, and hold themselves out as, a CNA if they are working in a health facility licensed by DPH. The majority of CNAs work in SNFs. CNAs perform a variety of basic duties for the patient’s comfort and recovery. These tasks vary depending on the employment setting but typically include: taking temperatures; pulse; respiration; blood pressure; helping patients with range-of-motion exercises; assisting patients with their daily living needs; serving meals; making beds; and, helping patients eat, dress and bathe. CNAs are paid, on average, approximately $14 dollars per hour, although the sponsor of this bill, Alzheimer’s Association, states that the average pay for CNAs in San Francisco is more than $19 per hour, and nearly $17 per hour in Alameda County. The United States Bureau of Labor Statistics projects that, between 2008 and 2018, the demand for CNAs will increase by about 19%. As a growing occupation with low education and training requirements, the CNA profession has been a target for welfare-to-work and other training programs.
2. Alzheimer’s disease. According to the federal National Institute on Aging , Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear after age 65. Plaques and tangles in the brain are two of the main features of Alzheimer’s disease. The third is the loss of connections between nerve cells (neurons) in the brain. Although treatment can help manage symptoms in some people, currently there is no cure for this disease. Estimates vary, but experts suggest that as many as five million Americans age 65 and older may have Alzheimer’s disease.
   
   Alzheimer’s disease is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—and behavioral abilities, to such an extent that it interferes with a person’s daily life and activities. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living.
   

Comments

Author’s statement. According to the author, CNAs are the primary providers of direct care to SNF residents with Alzheimer’s disease and related dementias, yet, CNAs receive less than two hours of classroom instruction on this complex and challenging medical condition before they are hired to work in SNFs and other settings, including hospitals, assisted living and home health. In the SNF setting, at least 60% of residents have a cognitive impairment with estimates as high as 80%, totaling as many as 80,000 vulnerable, at-risk Californians. Alzheimer’s disease is not normal aging. It is the fifth leading cause of death in California, affecting 610,000 individuals today and upwards of 840,000 as early as 2025. Medi-Cal spending on this condition is on track to exceed $5 billion within a decade, largely due to institutional costs and poor disease management. Nearly all individuals with Alzheimer’s disease (97%) experience behavioral and psychological symptoms that require specialized training to manage. As the disease progresses, the severity of the behaviors increases, with patients exhibiting agitation, verbal and/or physical aggression, delusions, hallucinations, disinhibition, wandering, pacing and sleep disturbances. Training all CNAs in dementia prior to employment improves patient outcomes and reduces state costs.

Related/Prior Legislation

SB 613 (Allen, Chapter 577, Statutes of 2015) required DPH to convene a workgroup to update the 2008 Guidelines for Alzheimer’s Disease Management in California to address changes in the health care system, and required DPH to submit a report of the updates and recommendations from the working group to the Legislature on or before March 1, 2017.

SB 1384 (Mitchell, Chapter 847, Statutes of 2014) eliminated the requirement that DPH deny, suspend, or revoke a certificate of a CNA if the applicant or certificate holder has been convicted of a violation or attempted violation of one or more specified crimes.

AB 2791 (Simitian, Chapter 270, Statutes of 2004) required the approved training program of an SNF and an ICF to include instruction on preventing, recognizing, and reporting residents’ rights violations as part of the training and instruction required under existing law.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 4/25/17)

Alzheimer’s Association (source)

AARP California

Alzheimer’s Greater Los Angeles

Association of California Caregiver Resource Centers

California Advocates for Nursing Home Reform

California Long-Term Care Ombudsman Association

Multipurpose Senior Services Program Site Association

OPPOSITION: (Verified 4/25/17)

None received

ARGUMENTS IN SUPPORT: This bill is sponsored by the Alzheimer’s Association which states the current requirement, less than two hours of classroom instruction on Alzheimer’s disease and related dementias, is inadequate to equip CNAs with the knowledge and skills they need to manage the common behaviors associated with Alzheimer’s disease, including agitation, verbal and/or physical aggressiveness, delusions, hallucinations, disinhibition, hyperactivity (e.g. wandering, pacing, rummaging) and sleep disturbances.

AARP California states in support that CNAs are the backbone of California’s long-term care delivery system, and this bill will help prepare CNAs to enter the workforce equipped with the skills necessary to understand Alzheimer’s disease and related dementias, which are complex and challenging conditions requiring specialized training.

The California Long-Term Care Ombudsman Association (CLTCOA) states in support that all too often it hears about complaints from residents and their family members because of situations where the lack of training for the CNAs has hindered their ability to provide assistance when relating to a senior who may have Alzheimer’s disease, or major neurocognitive disorders. CLTCOA states that the current training requirements for CNAs are insufficient to meet the needs of seniors with intellectual disabilities.

Alzheimer’s Greater Los Angeles states in support that dementia training is essential for those providing care to people with Alzheimer’s disease or a related dementia, and that CNAs trained in behavioral and psycho-socially based intervention strategies are better able to meet the needs of their patients and are less likely to resort to the inappropriate use of psychotropic medications or physical restraints.

This bill is also supported by California Advocates for Nursing Home Reform (CANHR), which states that this bill will improve nursing home quality by ensuring that CNAs have training related to dementia care. CANHR states that approximately 36,000 nursing home residents in California are diagnosed with dementia, with tens of thousands more suffering mild cognitive impairments. CANHR states that the minimal dementia training requirements for CNAs stand in stark contrast for staff at residential care facilities of the elderly, where staff must receive eight hours of training on dementia care annually. CANHR also states that it would like to see this bill amended to add some details to the required dementia care training, such as “non-pharmacologic, person-centered” approaches.

Prepared by: Vince Marchand / HEALTH /

4/26/17 11:14:25

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 449

SUBJECT: Skilled nursing and intermediate care facilities: training programs

SUMMARY:

Requires at least eight of the 60 hours of classroom training that is required as part of the training program for certified nurse assistants to address the special needs of persons with Alzheimer’s disease and related dementias.

Existing law:

1. Certifies and regulates certified nurse assistants (CNAs) by the Department of Public Health (DPH).
2. Establishes a scope of practice for CNAs as performing basic patient care services directed at the safety, comfort, personal hygiene, and protections of patients, and prohibits CNAs from performing any services which can only be performed by a licensed person, and requires all services to be performed under the supervision of a licensed registered nurse or a licensed vocational nurse.
3. Requires a skilled nursing facility (SNF) or an intermediate care facility (ICF) to adopt an approved training program for CNAs that includes both an orientation program for newly employed CNAs, a precertification training program (unless the SNF or ICF only employs CNAs that are already certified), and continuing in-service training to ensure continuing competency in existing and new nursing skills.
4. Requires an applicant for certification as a CNA to be at least 16 years of age, have successfully completed a DPH-approved precertification training program that includes at least 60 classroom hours and 100 hours of supervised on-the-job training, and have obtained a criminal record clearance.
5. Requires at least two hours of the 60 hours of classroom training, and at least four hours of the 100 hours of supervised clinical training, to address the special needs of persons with developmental and mental disorders, including intellectual disability, Alzheimer’s disease, cerebral palsy, epilepsy, dementia, Parkinson’s disease, and mental illness.
6. Requires at least six hours of the 60 hours of classroom training to include instruction on preventing, recognizing, and reporting instances of resident abuse, and a minimum of one hour of instruction on preventing, recognizing, and reporting residents’ rights violations.
7. Requires CNAs to complete at least two hours of initial dementia-specific training as part of a SNF’s or ICF’s orientation program for newly employed CNAs.
8. Requires CNAs to complete 48 hours of in-service training every two years, with at least 21 of the 48 completed in each of the two years. Permits 24 of the 48 hours to be obtained through an online computer training program.
9. Requires a CNA to complete at least five hours of dementia-specific in-service training per year, as part of the facility’s in-service training.
10. Licenses and regulates residential care facilities for the elderly by the Department of Social Services, and requires direct care staff employed in these facilities to complete six hours of dementia care training prior to the staff working directly with residents, another six hours of dementia care training within the first four weeks of employment, and eight hours of in-service training per year on serving residents with dementia.

This bill:

1. Requires at least eight of the 60 hours of the classroom training that is required as part of an approved training program for CNAs to address the special needs of persons with Alzheimer’s disease and related dementias.
2. Removes Alzheimer’s disease from the list of developmental and mental disorders that an existing law requires be addressed in at least two of the 60 hours of classroom training, and at least four of the 100 hours of clinical training.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, CNAs are the primary providers of direct care to SNF residents with Alzheimer’s disease and related dementias, yet, CNAs receive less than two hours of classroom instruction on this complex and challenging medical condition before they are hired to work in SNFs and other settings, including hospitals, assisted living and home health. In the SNF setting, at least 60% of residents have a cognitive impairment with estimates as high as 80%, totaling as many as 80,000 vulnerable, at-risk Californians. Alzheimer’s disease is not normal aging. It is the fifth leading cause of death in California, affecting 610,000 individuals today and upwards of 840,000 as early as 2025. Medi-Cal spending on this condition is on track to exceed $5 billion within a decade, largely due to institutional costs and poor disease management. Nearly all individuals with Alzheimer’s disease (97%) experience behavioral and psychological symptoms that require specialized training to manage. As the disease progresses, the severity of the behaviors increases, with patients exhibiting agitation, verbal and/or physical aggression, delusions, hallucinations, disinhibition, wandering, pacing and sleep disturbances. Training all CNAs in dementia prior to employment improves patient outcomes and reduces state costs.
2. Background on CNAs. There are an estimated 160,000 CNAs working in California. A person may only use the title, and hold themselves out as, a CNA if they are working in a health facility licensed by DPH. The majority of CNAs work in skilled nursing facilities. CNAs perform a variety of basic duties for the patient’s comfort and recovery. These tasks vary depending on the employment setting but typically include: taking temperatures; pulse; respiration; blood pressure; helping patients with range-of-motion exercises; assisting patients with their daily living needs; serving meals; making beds; and, helping patients eat, dress and bathe. CNAs are paid, on average, approximately $14 dollars per hour, although the sponsor of this bill, Alzheimer’s Association, states that the average pay for CNAs in San Francisco is more than $19 per hour, and nearly $17 per hour in Alameda County. The United States Bureau of Labor Statistics projects that, between 2008 and 2018, the demand for CNAs will increase by about 19%. As a growing occupation with low education and training requirements, the CNA profession has been a target for welfare-to-work and other training programs.
3. Alzheimer’s disease. According to the federal National Institute on Aging (NIA), Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear after age 65. Plaques and tangles in the brain are two of the main features of Alzheimer’s disease. The third is the loss of connections between nerve cells (neurons) in the brain. Although treatment can help manage symptoms in some people, currently there is no cure for this disease. Estimates vary, but experts suggest that as many as five million Americans age 65 and older may have Alzheimer’s disease.
   
   Alzheimer’s disease is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—and behavioral abilities, to such an extent that it interferes with a person’s daily life and activities. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living.
   
4. Prior legislation. SB 613 (Allen, Chapter 577, Statutes of 2015) required DPH to convene a workgroup to update the 2008 Guidelines for Alzheimer’s Disease Management in California to address changes in the health care system, and requires DPH to submit a report of the updates and recommendations from the working group to the Legislature on or before March 1, 2017.
   
   Requires the DPH to convene a workgroup to update the 2008 Guidelines for Alzheimer's Disease Management in California to address changes in the health care system, and requires DPH to submit a report of the updates and recommendations from the working group to the Legislature on or before March 1, 2017.
   
   SB 1384 (Mitchell, Chapter 847, Statutes of 2014) eliminated the requirement that DPH deny, suspend, or revoke a certificate of a CNA if the applicant or certificate holder has been convicted of a violation or attempted violation of one or more specified crimes.
   
   AB 2791 (Simitian, Chapter 270, Statutes of 2004) required the approved training program of a SNF and an ICF to include instruction on preventing, recognizing, and reporting residents’ rights violations as part of the training and instruction required under existing law.
5. Support. This bill is sponsored by the Alzheimer’s Association which states the current requirement, less than two hours of classroom instruction on Alzheimer’s disease and related dementias, is inadequate to equip CNAs with the knowledge and skills they need to manage the common behaviors associated with Alzheimer’s disease, including agitation, verbal and/or physical aggressiveness, delusions, hallucinations, disinhibition, hyperactivity (e.g. wandering, pacing, rummaging) and sleep disturbances. AARP California states in support that CNAs are the backbone of California’s long-term care delivery system, and this bill will help prepare CNAs to enter the workforce equipped with the skills necessary to understand Alzheimer’s disease and related dementias, which are complex and challenging conditions requiring specialized training. The California Long-Term Care Ombudsman Association (CLTCOA) states in support that all too often it hears about complaints from residents and their family members because of situations where the lack of training for the CNAs has hindered their ability to provide assistance when relating to a senior who may have Alzheimer’s disease, or major neurocognitive disorders. CLTCOA states that the current training requirements for CNAs are insufficient to meet the needs of seniors with intellectual disabilities. Alzheimer’s Greater Los Angeles states in support that dementia training is essential for those providing care to people with Alzheimer’s disease or a related dementia, and that CNAs trained in behavioral and psycho-socially based intervention strategies are better able to meet the needs of their patients and are less likely to resort to the inappropriate use of psychotropic medications or physical restraints. This bill is also supported by California Advocates for Nursing Home Reform (CANHR), which states that this bill would improve nursing home quality by ensuring that CNAs have training related to dementia care. CANHR states that approximately 36,000 nursing home residents in California are diagnosed with dementia, with tens of thousands more suffering mild cognitive impairments. CANHR states that the minimal dementia training requirements for CNAs stand in stark contrast for staff at residential care facilities of the elderly, where staff must receive eight hours of training on dementia care annually. CANHR also states that it would like to see this bill amended to add some details to the required dementia care training, such as “non-pharmacologic, person-centered” approaches.

SUPPORT AND OPPOSITION:

Support: Alzheimer’s Association (sponsor)

AARP California

Alzheimer’s Greater Los Angeles

Association of California Caregiver Resource Centers

California Advocates for Nursing Home Reform

California Long-Term Care Ombudsman Association

Multipurpose Senior Services Program Site Association

Oppose: None received

-- END --