THIRD READING  

Bill No: AB 1709

Author: Jones-Sawyer (D)

Amended: 7/11/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 7/10/19

AYES: Pan, Stone, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 74-0, 5/16/19 (Consent) - See last page for vote

SUBJECT: Nursing homes: staff

SOURCE: LeadingAge California

DIGEST:

This bill revises the minimum qualifications for an applicant to take the nursing home administrator licensing exam, when the applicant has a current valid license as a nursing home administrator in another state, to allow the applicant to hold a certification from the American College of Health Care Administrators as an alternative to meeting minimum education requirements, eliminates the continuing education requirements for nursing home administrators for their initial licensure renewal, and makes other modifications to the laws governing nursing home administrators.

ANALYSIS:

Existing law:

1. Provides for the licensure of health facilities, including skilled nursing facilities (SNFs), and intermediate care facilities (ICFs) by the Department of Public Health (DPH). [HSC §1250, et seq.]
2. Defines a “SNF” as a health facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. [HSC §1250(c)]
3. Certifies and regulates Certified Nursing Assistants (CNAs) by DPH. 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. [HSC §1337, et seq.]
4. Establishes the Nursing Home Administrator Program (NHAP) to license and regulate nursing home administrators. [HSC §1416, et seq.]
5. Requires the administrators of SNFs, ICFs, and ICF/developmentally disabled to be licensed under NHAP. [HSC §1416.6]
6. Requires applicants for licensure as a nursing home administrator to be at least 18 years old, and meet one of several pathway requirements, including the following:
   1. A master’s degree in nursing home administration or related health administration field, which included an internship or residency of at least 480 hours in a SNF or ICF;
   2. A baccalaureate degree and the completion of a NHAP-approved Administrator-in-Training (AIT) program of at least 1,000 hours;
   3. Ten years of recent full-time work experience, a current license as a registered nurse, and the completion of a NHAP-approved AIT program of at least 1,000 hours;
   4. Ten years of full-time work experience in any department of a SNF or an ICF with at least 60 semester units of college courses, and the completion of a NHAP-approved AIT program of at least 1,000 hours; or,
   5. Ten years of full-time hospital administration experience in an acute care hospital with at least 60 semester units of college courses, and the completion of a NHAP-approved AIT program of at least 1,000 hours. [HSC §1416.22]
7. Requires applicants for licensure as a nursing home administrator who have a current valid license as a nursing home administrator in another state, to meet the minimum education requirements that existed in this state at the time the applicant was originally licensed in the other state, which has been a baccalaureate degree since 1980, and 60 semester units from 1975 to 1980. [HSC §1416.22(a)(2)]
8. Requires nursing home administrators, in order to renew a license (licenses must be renewed every two years), to have completed 40 hours of NHAP-approved continuing education courses, of which at least 10 total hours are required to be specifically in the area of aging or patient care. [HSC §1416.50]

This bill:

1. Revises the minimum qualifications for an applicant to take the nursing home administrator licensing exam, when the applicant has a current valid license as a nursing home administrator in another state, to allow the applicant to hold a certification as a nursing home administrator from the American College of Health Care Administrators (ACHCA) as an alternative to meeting the minimum education requirements that existed in this state at the time the applicant was originally licensed in the other state.
2. Exempts a licensed nursing home administrator from continuing education requirements for the initial licensure renewal, except when the initial license was based on the applicant being licensed in another state.
3. Permits nursing home administrator continuing education courses that are approved by the National Association of Long Term Care Administrator Boards, including courses that are unavailable to the public or are offered through corporations, to be approved for credit towards the continuing education requirements.
4. Revises the preceptor requirements under NHAP, by clarifying that the directly supervised training provided by the preceptor can include onsite and offsite training, by clarifying that the preceptor can be choose to be available be email instead of only by telephone, and by permitting the preceptor to be a nursing home administrator with central responsibility for the education and training of AITs as an alternative to the designated administrator of the facility where the training is conducted.
5. Deletes the prohibition on a preceptor supervising more than two administrators-in-training during the same time period.
6. Permits NHAP to implement, interpret, or make specific the provisions of law relating to the preceptor requirements by means of letters, bulletins, or similar instructions, without taking regulatory action.
7. Requires DPH, by January 1, 2022, and every 10 years thereafter, to review the current examination for approved training programs for CNAs to ensure the accurate assessment of the knowledge and skills related to basic patient care services, and to develop a plan that encourages career opportunities for CNAs.
8. Requires NHAP, by January 1, 2022, and every 10 years thereafter, to perform a review of the nursing home administrator licensing examination, and to revise the examination, as necessary, to ensure its conformity with federal and state law and regulations.

Comments

1. Author’s statement. According to the author, this bill is an important step in providing patients the care they deserve by helping SNFs recruit and retain nursing home administrators, in addition to streamlining the process for preceptors to better train the next generation of administrators. California’s aging population makes it important that we focus on ensuring that we have enough administrators to oversee our skilled nursing facilities to ensure the best quality of care for their patients. California is experiencing a shortage of well-trained nursing home administrators and it is important that we make it easier for SNFs to retain and train enough administrators in this growing health field. Finally, although DPH reviews the CNA and nursing home administrator exams, there is not a requirement that these exams are regularly reviewed to ensure that they are kept up-to-date. By requiring DPH to conduct a decennial review of each exam we can ensure that California keeps up with best standards in the industry.
2. Nursing home administrator preceptors. A nursing home administrator “preceptor” is someone who is currently licensed as a nursing home administrator who is authorized by DPH to provide a training program in which the preceptor coordinates, supervises, and teaches persons seeking to meet the requirements for licensure as a nursing home administrator. This bill makes several revisions to the preceptor requirements, including deleting the prohibition on a preceptor supervising more than two AITs during the same time period, and by permitting the preceptor to be a nursing home administrator with central responsibility for the education and training of AITs as an alternative to the designated administrator of the facility where the training is conducted. According to the author, this change would allow administrators of multi-facility organizations to precept AITs at multiple locations.
3. ACHCA certification. One of the provisions of this bill permits a nursing home administrator licensed in another state to qualify for the California licensing exam without meeting the educational requirements if the administrator is certified by ACHCA. In order to become certified by ACHCA, the candidate must meet the following requirements:
   1. Complete and submit an application which demonstrates education, experience and continuing education, including a minimum of two years of licensure, and a minimum of 40 hours of continuing education provided through an approved provider, as specified.
   2. Submit a copy of current NHA license if required by the state;
   3. Acknowledge the ACHCA Code of Ethics; and,
   4. Pass both the general Certification Exam (110 questions) and the specialty exam (40 questions).
4. Nursing Home Administrator and CNA test updates. This bill requires DPH to update the CNA exam and the nursing home administrator exam by January 1, 2022, and every 10 years thereafter. According to DPH, for the CNA exam, they certify the American Red Cross and the National Nurse Assistant Training and Assessment Program (NNATAP) as test vendors in California. The Red Cross last updated their CNA test in October 2018, and NNATAP updated their CNA test in July 2018. Regarding the nursing home administrator exam, DPH states that it was last updated in 2008-09, and that it is currently working with the National Association of Long Term Care Administrator Boards to update the exam.

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

SUPPORT: (Verified 8/13/19)

LeadingAge California (source)

Bethel Lutheran Home, Inc.

California Association of Health Facilities

Hollenbeck Palms

Sierra View Homes

St. Paul’s Senior Services

OPPOSITION: (Verified 8/13/19)

California Advocates for Nursing Home Reform

ARGUMENTS IN SUPPORT: This bill is sponsored by LeadingAge California, which states that California is experiencing a crisis-level shortage in the skilled long-term care workforce. In addition to the well-publicized shortage in front-line direct care staff, SNFs are also finding it more difficult to recruit qualified and well-trained nursing home administrators. Nursing home administrators play a critical role in a skilled nursing setting, as they are typically responsible for the broad-based oversight of staff development, financial management and care delivery. LeadingAge California states that this bill creates a pathway for more nursing home administrators to become preceptors, and to help train the next generation of future leaders in long-term care communities. The California Association of Health Facilities makes similar arguments in support.

ARGUMENTS IN OPPOSITION: California Advocates for Nursing Home Reform (CANHR) opposes this bill because it weakens qualifications for nursing home administrators. According to CANHR, this bill allows nursing home administrators from other states to obtain licenses without meeting California’s minimum educational requirements, and also exempts a licensed administrator from continuing education requirements for two years from the date of initial licensure. CANHR states that nursing home administrator standards need to be strengthened, not weakened.

ASSEMBLY FLOOR: 74-0, 5/16/19

AYES: Aguiar-Curry, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Gabriel, Gallagher, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Arambula, Burke, Cooley, Friedman, Cristina Garcia, Ting

Prepared by: Vincent D. Marchand / HEALTH / (916) 651-4111

8/14/19 15:38:16

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 1709

SUBJECT: Nursing homes: staff

SUMMARY:

Revises the minimum qualifications for an applicant to take the nursing home administrator licensing exam, when the applicant has a current valid license as a nursing home administrator in another state, to allow the applicant to hold a certification from the American College of Health Care Administrators as an alternative to meeting minimum education requirements, eliminates the continuing education requirements for nursing home administrators for their initial licensure renewal, and makes other modifications to the laws governing nursing home administrators.

Existing law:

1. Provides for the licensure of health facilities, including skilled nursing facilities (SNFs), and intermediate care facilities (ICFs) by the Department of Public Health (DPH). [HSC §1250, et seq.]
2. Defines a “SNF” as a health facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. [HSC §1250(c)]
3. Certifies and regulates Certified Nursing Assistants (CNAs) by DPH. 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. [HSC §1337, et seq.]
4. Establishes the Nursing Home Administrator Program (NHAP) to license and regulate nursing home administrators. [HSC §1416, et seq.]
5. Requires the administrators of skilled nursing facilities, intermediate care facilities, and ICF/developmentally disabled to be licensed under NHAP. [HSC §1416.6]
6. Requires applicants for licensure as a nursing home administrator to be at least 18 years old, and meet one of several pathway requirements, including the following:
   1. A master’s degree in nursing home administration or related health administration field, which included an internship or residency of at least 480 hours in a SNF or ICF;
   2. A baccalaureate degree and the completion of a NHAP-approved Administrator-in-Training (AIT) program of at least 1,000 hours;
   3. Ten years of recent full-time work experience, a current license as a registered nurse, and the completion of a NHAP-approved AIT program of at least 1,000 hours;
   4. Ten years of full-time work experience in any department of a SNF or an ICF with at least 60 semester units of college courses, and the completion of a NHAP-approved AIT program of at least 1,000 hours; or,
   5. Ten years of full-time hospital administration experience in an acute care hospital with at least 60 semester units of college courses, and the completion of a NHAP-approved AIT program of at least 1,000 hours. [HSC §1416.22]
7. Requires applicants for licensure as a nursing home administrator who have a current valid license as a nursing home administrator in another state, to meet the minimum education requirements that existed in this state at the time the applicant was originally licensed in the other state, which has been a baccalaureate degree since 1980, and 60 semester units from 1975 to 1980. [HSC §1416.22(a)(2)]
8. Requires nursing home administrators, in order to renew a license (licenses must be renewed every two years), to have completed 40 hours of NHAP-approved continuing education courses, of which at least ten total hours are required to be specifically in the area of aging or patient care. [HSC §1416.50]

This bill:

1. Revises the minimum qualifications for an applicant to take the nursing home administrator licensing exam, when the applicant has a current valid license as a nursing home administrator in another state, to allow the applicant to hold a certification as a nursing home administrator from the American College of Health Care Administrators (ACHCA) as an alternative to meeting the minimum education requirements that existed in this state at the time the applicant was originally licensed in the other state.
2. Exempts a licensed nursing home administrator from being required to meet continuing education requirements for the initial licensure renewal.
3. Permits nursing home administrator continuing education courses that are approved by the National Association of Long Term Care Administrator Boards, including courses that are unavailable to the public or are offered through corporations, to be approved for credit towards the continuing education requirements.
4. Revises the preceptor requirements under NHAP, by clarifying that the directly supervised training provided by the preceptor can include onsite and offsite training, by clarifying that the preceptor can be choose to be available be email instead of only by telephone, and by permitting the preceptor to be a nursing home administrator with central responsibility for the education and training of AITs as an alternative to the designated administrator of the facility where the training is conducted.
5. Deletes the prohibition on a preceptor supervising more than two administrators-in-training during the same time period.
6. Permits NHAP to implement, interpret, or make specific the provisions of law relating to the preceptor requirements by means of letters, bulletins, or similar instructions, without taking regulatory action.
7. Requires DPH, by January 1, 2022 and every ten years thereafter, to review the current examination for approved training programs for CNAs to ensure the accurate assessment of the knowledge and skills related to basic patient care services, and to develop a plan that encourages career ladder opportunities for CNAs.
8. Requires NHAP, by January 1, 2022 and every tenyears thereafter, to perform a review of the nursing home administrator licensing examination, and to revise the examination, as necessary, to ensure its conformity with federal and state law and regulations.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, minor and absorbable costs to CDPH to review and revise training program requirements and implement other minor changes required by the bill (Licensing and Certification Fund).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, this bill is an important step in providing patients the care they deserve by helping SNFs recruit and retain nursing home administrators, in addition to streamlining the process for preceptors to better train the next generation of administrators. California’s aging population makes it important that we focus on ensuring that we have enough administrators to oversee our skilled nursing facilities to ensure the best quality of care for their patients. California is experiencing a shortage of well-trained nursing home administrators and it is important that we make it easier for SNFs to retain and train enough administrators in this growing health field. Finally, although DPH reviews the CNA and nursing home administrator exams, there is not a requirement that these exams are regularly reviewed to ensure that they are kept up-to-date. By requiring DPH to conduct a decennial review of each exam we can ensure that California keeps up with best standards in the industry.
2. Nursing home administrator preceptors. A nursing home administrator “preceptor” is someone who is currently licensed as a nursing home administrator who is authorized by DPH to provide a training program in which the preceptor coordinates, supervises, and teaches persons seeking to meet the requirements for licensure as a nursing home administrator. This bill makes several revisions to the preceptor requirements, including deleting the prohibition on a preceptor supervising more than two AITs during the same time period, and by permitting the preceptor to be a nursing home administrator with central responsibility for the education and training of AITs as an alternative to the designated administrator of the facility where the training is conducted. According to the author, this change would allow administrators of multi-facility organizations to precept AITs at multiple locations.
3. ACHCA certification. One of the provisions of this bill permits a nursing home administrator licensed in another state to qualify for the California licensing exam without meeting the educational requirements if the administrator is certified by ACHCA. In order to become certified by ACHCA, the candidate must meet the following requirements:
   1. Complete and submit an application which demonstrates education, experience and continuing education, including a minimum of two years of licensure, and a minimum of 40 hours of continuing education provided through an approved provider, as specified.
   2. Submit a copy of current NHA license if required by the state;
   3. Acknowledge the ACHCA Code of Ethics; and,
   4. Pass both the general Certification Exam (110 questions) and the specialty exam (40 questions).
4. NHA and CNA test updates. This bill requires DPH to update the CNA exam and the nursing home administrator exam by January 1, 2022, and every ten years thereafter. According to DPH, for the CNA exam, they certify the American Red Cross and the National Nurse Assistant Training and Assessment Program (NNATAP) as test vendors in California. The Red Cross last updated their CNA test in October 2018, and NNATAP updated their CNA test in July 2018. Regarding the nursing home administrator exam, DPH states that it was last updated in 2008-09, and that DPH is currently working with the National Association of Long Term Care Administrator Boards to have the exam updated.
5. Related legislation. AB 506 (Kalra) revises the criteria under which the DPH issues civil penalties against long term care facilities (LTC facilities) that were found to have caused the death of a resident, so that instead of having to prove the death of a resident was the “direct proximate cause” of a violation by the facility, DPH would have to prove that the violation was a “substantial factor” in the death of a resident and that the death was a foreseeable result of the violation. Additionally, increases the amount of civil penalties assessed against LTC facilities. AB 506 passed the Senate Health Committee by a vote of 8-0 on June 26, 2019.
   
   AB 1695 (Carrillo), requires a prospective licensee or manager of a SNF to file a notice of intent with the Department of Public Health (DPH) 90 days prior to a transfer of management or a change of ownership, and requires DPH, within 90 days of receipt of this notice of intent, to determine whether the prospective transferee or prospective licensee is suitable for licensure or not. Prohibits DPH from approving a transfer of ownership, or from approving an application to operate or manage a facility, unless the prospective transferee or licensee has been determined suitable. Requires, in the event of a sale or transfer of operation or management, all employees to be retained for a 60-day transition employment period. AB 1695 is set for hearing on July 10, 2019 in this Committee.
6. Prior legislation. AB 1710 (Yamada, Chapter 672, Statutes of 2012) revised how nursing home administrator licensing fees are to be adjusted so that fee revenue is sufficient to cover the regulatory costs to DPH, and revises and increases DPH reporting requirements regarding NHAP.
7. Support. This bill is sponsored by LeadingAge California, which states that California is experiencing a crisis-level shortage in the skilled long-term care workforce. In addition to the well-publicized shortage in front-line direct care staff, SNFs are also finding it more difficult to recruit qualified and well-trained nursing home administrators. Nursing home administrators play a critical role in a skilled nursing setting, as they are typically responsible for the broad-based oversight of staff development, financial management and care delivery. LeadingAge California states that this bill would create a pathway for more nursing home administrators to become preceptors, and to help train the next generation of future leaders in long-term care communities. The California Association of Health Facilities makes similar arguments in support
8. Opposition. California Advocates for Nursing Home Reform (CANHR) opposes this bill because it would weaken qualifications for nursing home administrators. According to CANHR, this bill would allow nursing home administrators from other states to obtain licenses without meeting California’s minimum educational requirements, and also exempts a licensed administrator from continuing education requirements for two years from the date of initial licensure. CANHR states that nursing home administrator standards need to be strengthened, not weakened.

SUPPORT AND OPPOSITION:

Support: LeadingAge California (sponsor)

California Association of Health Facilities

Oppose: California Advocates for Nursing Home Reform

-- END --

Date of Hearing: May 8, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 1709

Author:(Jones-Sawyer) – As Amended Ver:April 25, 2019

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

SUMMARY:

This bill makes minor changes to standards for education, training and licensing of nursing home administrators and requires the California Department of Public Health (CDPH) to regularly review and update examination requirements for certified nursing assistants (CNAs) and nursing home administrators.

FISCAL EFFECT:

Minor and absorbable costs to CDPH to review and revise training program requirements and implement other minor changes required by the bill (Licensing and Certification Fund).

COMMENTS:

Purpose and Background. According to the author, California is experiencing a shortage in the skilled workforce of nursing home administrators. The author states this bill, by permitting alternate and innovative ways of training future administrators-in-training and certifying preceptors, will encourage more training. The author also notes that, although the CDPH reviews the CNA and nursing home administrator exams, there is not a requirement that these exams are regularly reviewed to ensure that they are kept up-to-date.

This bill is sponsored by Leading Age California, which represents nonprofit providers of senior living and care. There was opposition to a prior version of this bill but there is no opposition noted based on the current version.

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

Date of Hearing: April 23, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1709

Author:Jones-Sawyer – As Amended Ver:April 11, 2019

SUBJECT: Nursing homes: staff.

SUMMARY: Requires the Department of Public Health (DPH), by January 1, 2022, and every 10 years thereafter, to review both the current examination for certified nurse assistants (CNAs); and, the nursing home administrator licensing examination, and to revise the examinations, as specified. Specifically, this bill:

1. Requires DPH, by January 1, 2022, and every 10 years thereafter to review the CNA examination and to develop a plan that identifies and encourages career ladder opportunities for CNAs, including the application of on-the-job post-certification hours to educational credits.
2. Requires DPH, in the Nursing Home Administrator Program (NHAP), by January 1, 2022, and every 10 years thereafter, to review the nursing home administrator licensing examination, and to revise the examination, as necessary, to ensure its conformity with federal and state law and regulations.
3. Allows an applicant for a nursing home administrator license, who has a current valid license as an administrator in another state, and holds certification from the American College of Health Care Administrators (ACHCA), to qualify for the licensing examination.
4. Exempts a licensed nursing home administrator for two years from the date of initial licensure, from continuing education (CE) requirements.
5. Permits the NHAP to approve continuing education courses related to nursing home administration that are approved by the National Association of Long Term Care Administrator Boards, for credit towards CE requirements, including courses that are unavailable to the public or are offered through corporations.
6. Exempts a preceptor in an Administrator-in-Training Program (AIT Program) from preceptor training course requirements if they have been actively involved in supervising at least one AIT during the prior two-year period.
7. Authorizes a preceptor to provide onsite and offsite training, and to be available by email, as well as by telephone.
8. Includes in the definition of preceptor, a nursing home administrator with central responsibility for the education and training of AITs.
9. Authorizes the NHAP to implement, interpret, or make specific the provision of this bill by means of letters, bulletins, or similar instructions, without taking regulatory action.

EXISTING LAW:

1. Establishes DPH, to, among other functions, license and regulate specified health facilities including skilled nursing facilities (SNFs), and to certify various healthcare professionals, including CNAs. Establishes NHAP within DPH, for purposes of setting standards for licensing of nursing home administrators (NHAs), administering a training program for NHAs, testing and issuing licenses, and administering an enforcement program for disciplinary action against NHAs.
2. Defines a CNA as any person who holds themselves out as a CNA and who, for compensation, performs basic patient care services directed at the safety, comfort, personal hygiene, and protection of patients and that does not include any services which may only be performed by a licensed person. Requires that a CNA have been certified as having completed the requirements to become a CNA and requires all services performed by a CNA to be provided under the supervision of a registered nurse, or a licensed vocational nurse.
3. Requires an applicant for a NHA license to be at least 18 years of age, a citizen of the United States or a legal resident, be of reputable and responsible character, and to comply with at least one of the following requirements:
   1. Have a master’s degree in nursing home administration or a related health administration field. Requires the master’s program in which the degree was obtained to have included an internship or residency of at least 480 hours in a SNF or intermediate care facility; or,
   2. For applicants who have a current valid license as a nursing home administrator in another state and apply for licensure in this state, meet the minimum education requirements that existed in this state at the time the applicant was originally licensed in the other state. The minimum education requirements that have existed in California are as follows:

1. Requires a NHA, in order to renew a license, to provide evidence that they have completed 40 hours of program-approved CE courses, of which at least 10 total hours are in the area of aging or patient care.
2. Requires a NHA, in order to qualify as a preceptor who is authorized to provide training in a program teaching persons studying to qualify for the NHA examination, to meet all of the following conditions:
   1. Be a current active California licensed NHA;
      
   2. Have no pending disciplinary actions;
      
   3. Have served for at least two years as the designated administrator of a California licensed nursing home or for at least four years as the designated assistant administrator of a California licensed nursing home; and,
      
   4. Have gained experience in all administrative functions of a nursing home.
      
3. Requires a preceptor to meet all of the following conditions:
   1. Requires a preceptor to provide a directly supervised training program that will include a minimum of 20 hours per week and a maximum of 60 hours per week and be available at least by telephone at all other times. Requires regular personal contact between the preceptor and the AIT during the training program. Defines “a directly supervised training program” as supervision by a preceptor of an AIT during the performance of those duties, and requires the preceptor to be available during the AIT’s performance of those duties;

• 1. Requires the preceptor to be the designated administrator of the facility where the training is conducted;
     
  2. Prohibits the preceptor from supervising more than two AIT trainees during the same time period;
     
  3. Requires the preceptor to inform the NHAP of any significant training program changes dealing with their specific AIT; and,
     
  4. Requires the preceptor to rate the AIT’s training performance and complete an AIT evaluation report at the end of the AIT’s training.
     

1. Requires NHAP to evaluate the preceptor based on the examination success and failure history of their AIT trainees and authorizes NHAP to revoke or suspend preceptor certificates as appropriate.
   

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, California is experiencing a shortage in the skilled workforce, and it is important to take steps to address this issue. The author states that by permitting alternate and innovative ways of training future administrators-in-training and certifying preceptors, more NHAs will be willing to become preceptors to train future administrators. The author also notes that, although the DPH reviews the CNA and NHA exams, there is not a requirement that these exams are regularly reviewed to ensure that they are kept up-to-date. The author concludes that by requiring DPH to conduct a decennial review of each exam we can ensure that California keeps up with best standards in the industry.
   
2. BACKGROUND. SNFs are defined as health facilities that provide skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. According to DPH, in 2018, there were 1,244 licensed skilled nursing facilities in California with a total of 119,431 beds.
   1. CNA test updates. This bill requires DPH to update the CNA by January 1, 2022 and every 10 years thereafter. According to DPH, they certify the American Red Cross and the National Nurse Assistant Training and Assessment Program (NNAAP) as test vendors in California. The Red Cross last updated their CNA test in October 2018 and NNAAP updated their CNA test in July 2018.
   2. NHA test updates. This bill requires DPH to update the NHA exam by January 1, 2022 and every 10 years thereafter. DPH notes that the NHA exam was last updated in 2008-09, and that DPH is currently working with the National Association of Long Term Care Administrator Boards (NAB) to have the exam updated. This bill also allows a NHA licensed in another state, who is certified by ACHCA, to quality for the California licensing examination. In order to become ACHCA certified an applicant must meet the following requirements:
      1. Complete and submit an application which demonstrates education, experience and continuing education, including:
         1. A minimum of two years of licensure, as defined by the state board; and,
         2. A minimum of 40 hours of continuing education provided through an approved provider of CE such as NAB or a state approved provider of Long Term Care CE over the past two years immediately preceding the date of the application.
      2. Submit a copy of current NHA license if required by the state;
      3. Acknowledge the ACHCA Code of Ethics;
      4. Pass both the general Certification Exam (110 questions) and the specialty exam (40 questions); and,
      5. Submit credentialing fees once the exam is passed.
   3. Preceptor requirements. Throughout nursing literature, the “preceptor” is described as a nurse who teaches, supports, counsels, coaches, evaluates, serves as role model and aids in the socialization to a new role. Under existing law, NHA preceptors risk losing their certification if the AITs they supervise do not pass the NHA exams. However, preceptors are also required to attend refresher courses on their role as preceptors. According to the author and sponsor of this bill, this requirement is redundant for preceptors whose AITs have been successful in passing the NHA exam, as it means that preceptors must take away time from supervising AITs to attend refresher course based on outdated curriculum. Additionally, by permitting alternate and innovative ways of training future administrators-in-training and certifying preceptors, more nursing home administrators will be willing to become preceptors to train future administrators. According to information provided by the author, there are currently 368 nursing home administrators who hold a preceptor certificate; and approximately 120 administrators-in-training. According to DPH the following updates have been made to the preceptor training curriculum in recent years:
      1. Leadership qualities to model and avoid (2012);
         
      2. Adult learning styles (2012);
      3. Culture change (2013);
      4. Multi-generational diversity in the workplace (2013);
      5. Investigation process, expectations (2014);
      6. Regulations quiz (2014); and,
      7. CNA investigations (2017/18).

Current law limits preceptors to supervising AITs at the location for which they are the administrator. This bill would allow administrators of multi-facility organizations to precept AITs at multiple locations.

1. SUPPORT. LeadingAge California is the sponsor of this bill and states that it creates a pathway for more NHAs to become preceptors, and help train the next generation of nursing home administrators. Preceptors are responsible for training individuals who have met the qualifications to participate in the AIT program to become a licensed NHA. The sponsor notes that current law requires that the preceptor must be the designated administrator of the facility where the training is conducted, however there are currently only 368 administrators qualified as preceptors, thereby limiting the number of individuals who can be mentored at one time. The sponsor states that this bill would provide a flexible approach for training new administrators, allowing organizations the ability to train more than one administrator at a time. This flexibility will ensure that the AIT is trained consistently and comprehensively on all the responsibilities, policies and procedures within the program.
   
   The California Program of All-Inclusive Care for the Elderly (CalPACE) supports this bill and states that the bill offers reasonable solutions to enable long-term supports and services providers such as PACE to address the needs of California’s growing population of seniors and persons with disabilities.
   
2. OPPOSITION. California Advocates for Nursing Home Reform (CAHNR) wrote in opposition to the previous version of this bill, that the bills’ sponsor asserts that cutting in-service training for CNAs will somehow make them better prepared to care for the increasingly ill persons who reside in nursing homes today. CAHNR states that nothing could be further from the truth. CNAs desperately need more training, not less. Rather than cutting training for CNAs, nursing homes should be improving and expanding their training programs. Nor is it true that cutting CNA training hours will help address perceived workforce shortages. CAHNR concludes that making existing CNAs even less prepared for their difficult work is not going to attract others to this work.
   
3. RELATED LEGISLATION. AB 1128 (Petri-Norris) transfers facility licensing authority over CalPACE from DPH to the Department of Health Care Services. AB 1128 is pending in the Assembly Health Committee.
4. PREVIOUS LEGISLATION.
   1. AB 2850 (Rubio), Chapter 769, Statutes of 2018, authorizes the 60 hours of required classroom training for CNAs to be offered through online or distance learning classes. Requires that online or distance learning classes be approved by DPH.
   2. SB 219 (Wiener), Chapter 483, Statutes of 2017, established the Lesbian, Gay, Bisexual, and Transgender Long-Term Care Facility Residents’ Bill of Rights, that in addition to other requirements, required a SNF or Intermediate Care Facilities to provide existing employees and new hires access to the online learning tool, “Building Respect for LGBT Older Adults.”
   3. SB 449 (Monning), Chapter 282, Statutes of 2017, requires at least two of the 60 hours of CNA classroom training to address the special needs of persons with Alzheimer’s disease and related dementias.
   4. AB 1656 (Burke) of 2017 would have required the Employment Training Panel to establish a grant award program to fund training programs for CNAs and would have appropriated $3 million from the General Fund to the Panel to implement the grant award program. AB 1656 was held on the Assembly Appropriations Committee suspense file.
   5. 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.
   6. AB 213 (Logue) of 2013, would have required DPH to accept upon application for licensure or certification, the education, training, and practical experience completed by an applicant in military service toward the qualifications and requirements to receive a license of certificate for specified professions including CNAs. AB 213 was held on the Assembly Appropriations Committee suspense file.
      
5. SUGGESTED AMENDMENT. As currently drafted, this bill would eliminate preceptor training course requirements if they have been actively involved in supervising at least one AIT during the prior two-year period. Because this bill would allow preceptors to work with AITs in more than one location, and legislative and regulatory changes occur so frequently in health care settings, the Committee may wish to strike the provision eliminating preceptor training refresher classes from the bill.
   

REGISTERED SUPPORT / OPPOSITION:

Support
LeadingAge California (sponsor)
Bethany Home Society of San Joaquin County Inc.
California Association of Health Facilities
The California Program of All-Inclusive Care for the Elderly

Opposition
California Advocates for Nursing Home Reform
California Office of the State Long-Term Care Ombudsman

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