SB 227: Health and care facilities: inspections and penalties.
- Session Year: 2019-2020
- House: Senate
- Latest Version Date: 2019-10-12
(1)Existing law generally requires the State Department of Public Health to license, regulate, and inspect health and care facilities. Existing law specifically requires the department to adopt regulations that require a general acute care hospital, an acute psychiatric hospital, and a special hospital to meet minimum nurse-to-patient ratios and assign additional staff according to a documented patient classification system for determining nursing care requirements. Existing law also generally requires the department to periodically inspect every health facility for which a license or special permit has been issued for compliance with state laws and regulations, and to ensure that those periodic inspections are not announced in advance of inspection.
This bill would require the periodic inspections of these specified health facilities to include reviews of compliance with the nurse-to-patient ratios and staff assignment regulations described above. The bill would require the department to conduct these inspections in a manner that is not announced in advance of the date of inspection.
(2)Existing law requires the department to promulgate regulations establishing criteria to assess an administrative penalty against a general acute care hospital, acute psychiatric hospital, or special hospital for a deficiency constituting an immediate jeopardy violation and a violation of the rules and regulations applicable to these types of hospitals that do not constitute an immediate jeopardy. Existing law requires certain penalties collected by the department to be deposited into the Internal Departmental Quality Improvement Account, to be expended, upon appropriation by the Legislature, for internal quality improvement activities in the Licensing and Certification Program.
This bill would require the department to assess specified administrative penalties for a violation of the nurse-to-patient ratios and staff assignment regulations described above. The bill would exempt from those administrative penalties a general acute care hospital that demonstrates to the satisfaction of the department that, among other things, prompt efforts were made to maintain required staffing levels, as specified.
(a)Every health facility for which a license or special permit has been issued shall be periodically inspected by the department, or by another governmental entity under contract with the department. The frequency of inspections shall vary, depending upon the type and complexity of the health facility or special service to be inspected, unless otherwise specified by state or federal law or regulation. The inspection shall include participation by the California Medical Association consistent with the manner in which it participated in inspections, as provided in Section 1282 prior to September 15, 1992.
(b)Except as provided in subdivision (c), inspections shall be conducted no less than once every two years and as often as necessary to ensure the quality of care being provided.
(c)For a health facility specified in subdivision (a), (b), or (f) of Section 1250, inspections shall be conducted no less than once every three years, and as often as necessary to ensure the quality of care being provided.
(d)During the inspection, the representative or representatives shall offer such advice and assistance to the health facility as they deem appropriate.
(e)For acute care hospitals of 100 beds or more, the inspection team shall include at least a physician, registered nurse, and persons experienced in hospital administration and sanitary inspections. During the inspection, the team shall offer advice and assistance to the hospital as it deems appropriate.
(f)The department shall ensure that a periodic inspection conducted pursuant to this section is not announced in advance of the date of inspection. An inspection may be conducted jointly with inspections by entities specified in Section 1282. However, if the department conducts an inspection jointly with an entity specified in Section 1282 that provides notice in advance of the periodic inspection, the department shall conduct an additional periodic inspection that is not announced or noticed to the health facility. The department shall conduct a periodic inspection to inspect compliance with this section and regulations adopted pursuant to Section 1276.4 that is not announced in advance of the date of inspection.
(g)Notwithstanding any other law, the department shall inspect the facility for compliance with provisions of state law and regulations during a state periodic inspection or at the same time as a federal periodic inspection, including, but not limited to, an inspection required under this section. If the department inspects for compliance with state law and regulations at the same time as a federal periodic inspection, the inspection shall be done consistent with the guidance of the federal Centers for Medicare and Medicaid Services for the federal portion of the inspection.
(h)The department shall emphasize consistency across the state and its district offices when conducting licensing and certification surveys and complaint investigations, including the selection of state or federal enforcement remedies in accordance with Section 1423. The department may issue federal deficiencies and recommend federal enforcement actions in those circumstances where they provide more rigorous enforcement action.
SEC. 2.Section 1280.3 of the Health and Safety Code is amended to read:1280.3.(a)Commencing on the effective date of the regulations adopted pursuant to this section, the director may assess an administrative penalty against a licensee of a health facility licensed under subdivision (a), (b), or (f) of Section 1250 for a deficiency constituting an immediate jeopardy violation as determined by the department up to a maximum of seventy-five thousand dollars ($75,000) for the first administrative penalty, up to one hundred thousand dollars ($100,000) for the second subsequent administrative penalty, and up to one hundred twenty-five thousand dollars ($125,000) for the third and every subsequent violation. An administrative penalty issued after three years from the date of the last issued immediate jeopardy violation shall be considered a first administrative penalty so long as the facility has not received additional immediate jeopardy violations and is found by the department to be in substantial compliance with all state and federal licensing laws and regulations. The department shall have full discretion to consider all factors when determining the amount of an administrative penalty pursuant to this section.
(b)Except as provided in subdivision (c), for a violation of this chapter or the rules and regulations promulgated thereunder that does not constitute a violation of subdivision (a), the department may assess an administrative penalty in an amount of up to twenty-five thousand dollars ($25,000) per violation. This subdivision shall also apply to violation of regulations set forth in Article 1 (commencing with Section 127400) of Chapter 2.5 of Part 2 of Division 107 or the rules and regulations promulgated thereunder.
The department shall promulgate regulations establishing the criteria to assess an administrative penalty against a health facility licensed pursuant to subdivision (a), (b), or (f) of Section 1250. The criteria shall include, but need not be limited to, the following:
(1)The patients physical and mental condition.
(2)The probability and severity of the risk that the violation presents to the patient.
(3)The actual financial harm to patients, if any.
(4)The nature, scope, and severity of the violation.
(5)The facilitys history of compliance with related state and federal statutes and regulations.
(6)Factors beyond the facilitys control that restrict the facilitys ability to comply with this chapter or the rules and regulations promulgated thereunder.
(7)The demonstrated willfulness of the violation.
(8)The extent to which the facility detected the violation and took steps to immediately correct the violation and prevent the violation from recurring.
(c)The department shall not assess an administrative penalty for minor violations.
(d)The regulations shall not change the definition of immediate jeopardy as established in this section.
(e)The regulations shall apply only to incidents occurring on or after the effective date of the regulations.
(f)(1)Notwithstanding subdivision (a), if the department determines that a health facility licensed under subdivision (a), (b), or (f) of Section 1250 has violated a regulation adopted pursuant to Section 1276.4, the department shall assess an administrative penalty of fifteen thousand dollars ($15,000) for the first violation and thirty thousand dollars ($30,000) for the second and each subsequent violation. For purposes of this subdivision, multiple violations found on the same inspection survey shall constitute a single violation for purposes of determining whether the violation was a first, second, or subsequent violation.
(2)A violation occurring more than three years after the date of the last violation shall be treated as a first violation.
(3)Notwithstanding any other law, the department may, without taking any regulatory actions pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this subdivision by means of an All Facilities Letter (AFL) or similar instruction.
(4)(A)Notwithstanding paragraph (1), a general acute care hospital shall not be subject to an administrative penalty under that paragraph if the hospital demonstrates to the satisfaction of the department all of the following:
(i)That any fluctuation in required staffing levels was unpredictable and uncontrollable.
(ii)Prompt efforts were made to maintain required staffing levels.
(iii)In making those efforts, the hospital immediately used and subsequently exhausted the hospitals on-call list of nurses and the charge nurse.
(B)Nothing in this paragraph shall be construed to affect the obligation of a general acute care hospital to maintain proper staffing levels as prescribed in Section 70217 of Title 22 of the California Code of Regulations.
(5)Nothing in this section prohibits the department from issuing an administrative penalty for a staffing violation pursuant to this section and an administrative penalty for any resulting harm pursuant to subdivision (a).
(g)If the licensee disputes a determination by the department regarding the alleged deficiency or alleged failure to correct a deficiency, or regarding the reasonableness of the proposed deadline for correction or the amount of the penalty, the licensee may, within 10 working days, request a hearing pursuant to Section 131071. Penalties shall be paid when all appeals have been exhausted and the departments position has been upheld.
(h)For purposes of this section, immediate jeopardy means a situation in which the licensees noncompliance with one or more requirements of licensure has caused, or is likely to cause, serious injury or death to the patient.
(i)In enforcing subdivision (a) and paragraph (1) of subdivision (f), the department shall take into consideration the special circumstances of small and rural hospitals, as defined in Section 124840, in order to protect access to quality care in those hospitals.
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Date
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Status
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| Oct 12, 2019 | Chaptered by Secretary of State. Chapter 843, Statutes of 2019. |
| Oct 12, 2019 | Approved by the Governor. |
| Sep 10, 2019 | Enrolled and presented to the Governor at 4 p.m. |
| Sep 4, 2019 | Assembly amendments concurred in. (Ayes 24. Noes 10.) Ordered to engrossing and enrolling. |
| Sep 3, 2019 | In Senate. Concurrence in Assembly amendments pending. |
| Sep 3, 2019 | Read third time. Passed. Ordered to the Senate. |
| Aug 30, 2019 | Read third time and amended. |
| Jul 11, 2019 | Read second time. Ordered to third reading. |
| Jul 10, 2019 | From committee: Do pass. (Ayes 12. Noes 3.) (July 10). |
| Jun 27, 2019 | Read second time and amended. Re-referred to Com. on APPR. |
| Jun 26, 2019 | From committee: Do pass as amended and re-refer to Com. on APPR. (Ayes 10. Noes 3.) (June 25). |
| Jun 4, 2019 | June 11 hearing postponed by committee. |
| May 16, 2019 | Referred to Com. on HEALTH. |
| May 9, 2019 | In Assembly. Read first time. Held at Desk. |
| May 9, 2019 | Read third time. Passed. (Ayes 21. Noes 13.) Ordered to the Assembly. |
| Apr 30, 2019 | Read second time. Ordered to third reading. |
| Apr 29, 2019 | From committee: Be ordered to second reading pursuant to Senate Rule 28.8. |
| Apr 18, 2019 | Set for hearing April 29. |
| Apr 11, 2019 | From committee: Do pass and re-refer to Com. on APPR. (Ayes 6. Noes 2.) (April 10). Re-referred to Com. on APPR. |
| Mar 12, 2019 | Set for hearing April 10. |
| Feb 21, 2019 | Referred to Com. on HEALTH. |
| Feb 8, 2019 | From printer. May be acted upon on or after March 10. |
| Feb 7, 2019 | Introduced. Read first time. To Com. on RLS. for assignment. To print. |
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Date
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Description
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Location
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Votes
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| Sep 4, 2019 | Unfinished Business SB227 Leyva et al. Concurrence | Senate Floor |
Passed |
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| Sep 3, 2019 | SB 227 Leyva Senate Third Reading By Smith | Assembly Floor |
Passed |
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| Jul 10, 2019 | Do pass. | Assembly Standing Committee on Appropriations |
Passed |
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| Jun 25, 2019 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
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| May 9, 2019 | Senate 3rd Reading SB227 Leyva et al. | Senate Floor |
Passed |
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| Apr 10, 2019 | Do pass, but first be re-referred to the Committee on [Appropriations] | Senate Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | SB 227 |
UNFINISHED BUSINESS
Bill No: SB 227
Amended: 8/30/19
SENATE HEALTH COMMITTEE: 6-2, 4/10/19
AYES: Pan, Durazo, Hurtado, Leyva, Mitchell, Monning
NOES: Stone, Grove
NO VOTE RECORDED: Rubio
SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8
SENATE FLOOR: 22-13, 5/9/19
AYES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Durazo, Hertzberg, Hueso, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Skinner, Stern, Umberg, Wieckowski, Wiener
NOES: Bates, Borgeas, Chang, Dodd, Galgiani, Grove, Hill, Jones, Moorlach, Morrell, Nielsen, Stone, Wilk
NO VOTE RECORDED: Glazer, Hurtado, Rubio
ASSEMBLY FLOOR: 53-17, 9/3/19 - See last page for vote
SUBJECT: Health and care facilities: inspections and penalties
SOURCE: California State Council of the Service Employees International Union
United Nurses Associations of California/Union of Health Care Professionals
DIGEST:
This bill requires periodic inspections of hospitals by the Department of Public Health to include reviews of compliance with nurse staffing ratios, and establishes administrative penalties for nurse staffing ratio violations of $15,000 for a first violation, and $30,000 for each subsequent violation.
Assembly Amendments
:
- Reduce the administrative penalties established by this bill from $30,000 to $15,000 for first violations, and from $60,000 to $30,000 for subsequent violations.
- Reduce the period of time that must elapse between violations for subsequent violations to be treated as a first violation, from six years to three years.
- Provide a safe harbor for hospitals that prevent the hospital from being subject to the administrative penalties established by this bill if the hospital can demonstrate that any fluctuation in required staffing levels was unforeseeable and uncontrollable, that prompt efforts were made to maintain required staffing levels, and that in making those efforts, the hospital immediately used and exhausted its on-call list of nurses and the charge nurse, in that order.
Existing law:
- Licenses and regulates health facilities by the Department of Public Health (DPH), including general acute care hospitals, acute psychiatric hospitals, and special hospitals (hospitals). [HSC §1250, et seq.]
- Requires DPH to inspect for compliance with state laws and regulations during a state periodic inspection or at the same time as a federal periodic inspection. Requires the inspection for hospitals to be conducted no less than once every three years. [HSC §1279 (g)]
- Requires DPH to adopt regulations that establish minimum, specific, and numerical licensed nurse-to-patient ratios, by licensed nurse classification and by hospital unit, for hospitals, and requires these ratios to constitute the minimum number of nurses that must be allocated. [HSC §1276.4]
- Establishes a structure under which DPH is permitted to assess administrative fines to hospitals for violation of any of their licensing laws and regulations. Requires DPH to promulgate regulations establishing the criteria to assess these administrative penalties, and requires these criteria to include, but not be limited to, the probability and severity of the risk that the violation presents to the patient, the facility’s history of compliance with related state and federal statutes and regulations, the demonstrated willfulness of the violation, and the extent to which the facility detected the violation and took steps to immediately correct the violation and prevent the violation from recurring. [HSC §1280.3]
- Permits DPH to assess an administrative penalty against a hospital, for a deficiency constituting an immediate jeopardy violation, as defined, up to a maximum of $75,000 for the first administrative penalty, up to $100,000 for the second administrative penalty, and up to $125,000 for the third and every subsequent administrative penalty. [HSC §1280.3 (a)]
- Permits DPH to assess an administrative penalty of up to $25,000 per violation for those not deemed to constitute immediate jeopardy. Prohibits DPH from assessing a penalty for minor violations. [HSC §1280.3 (b) and (c)]
- Requires DPH to have full discretion to consider all factors when determining the amount of an administrative penalty. [HSC §1280.3 (a)]
This bill:
- Requires DPH to conduct a periodic inspection to inspect compliance with existing law and nurse staffing ratio regulations that is not announced in advance of the date of inspection.
- Requires DPH to assess an administrative penalty of $15,000 for a hospital that violates a nurse staffing ratio regulation for the first time, and $30,000 for the second and each subsequent violation. Specifies that multiple violations found on the same inspection survey constitutes a single violation for purposes of determining whether the violation was a first, second or subsequent violation, and that a violation occurring more than three years after the date of the last violation is to be treated as a first violation.
- Provides a safe harbor for hospitals that prevent the hospital from being subject to the administrative penalties in 2) above if the hospital can demonstrate that any fluctuation in required staffing levels was unpredictable and uncontrollable, that prompt efforts were made to maintain required staffing levels, and that in making those efforts, the hospital immediately used and exhausted its on-call list of nurses and the charge nurse.
- Prohibits the safe harbor provisions in 3) above from being construed to affect the obligation of a hospital to maintain proper staffing levels as required in specified nurse staffing ratio regulations, or prohibiting DPH from issuing an administrative penalty for a staffing violation under existing law and an administrative penalty for any resulting harm pursuant to existing law.
- Permits DPH, without taking any regulatory actions, to implement, interpret, or make specific this bill by means of an All Facilities Letter or similar instruction.
- Includes this new nurse staffing ratio penalty provision in a provision of existing law that requires DPH to take into consideration the special circumstances of small and rural hospitals when taking enforcement action in order to protect access to quality care in those hospitals.
Background
Please refer to Senate Health Committee analysis for background information.
Comments
Author’s statement. According to the author, this bill will empower DPH to enforce the legally mandated nurse-to-patient staffing ratios and therefore improve healthcare quality in California hospitals and make sure that patients receive the care they need and deserve. It has been reported that many California hospitals disregard the current nurse-to-patient ratio requirement of Title 22 regulations. The state must take a more proactive role by conducting unannounced visits at hospitals across California and ensuring that it fully enforces existing law because the stakes are simply too high for patients. It is also important that penalties are increased against repeat offender hospitals that do not comply with existing law. Moreover, beyond the clear safety implications of hospitals not observing ratio requirements, nurses can also be putting their professional livelihoods and licenses at risk due to being required to fulfill job duties outside of legally prescribed ratios.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No
According to the Assembly Appropriations Committee, minor and absorbable administrative staff costs to DPH for increased enforcement (Licensing and Certification Program Fund, potentially offset by unknown revenue associated with penalty assessments for noncompliance with regulations).
SUPPORT: (Verified 9/3/19)
California State Council of the Service Employees International Union (co-source)
United Nurses Associations of California/Union of Health Care Professionals (co-source)
American Federation of State, County, and Municipal Employees, AFL-CIO
California Labor Federation, AFL-CIO
California Nurses Association/National Nurses United, AFL-CIO
California Professional Firefighters
California School Employees Association, AFL-CIO
California School Nurses Organization
California Teamsters Public Affairs Council
Congress of California Seniors
Consumer Attorneys of California
Engineers and Scientists of California Local 20
International Longshore and Warehouse Union, Local 13
San Francisco Aids Foundation
Adventist Health Bakersfield
Adventist Health Clear Lake Medical Center
Adventist Health Glendale
Adventist Health Hanford
Adventist Health Rideout
Adventist Health Simi Valley
Adventist Health Sonora
Adventist Health St. Helena
Alameda Health System
Alliance of Catholic Health Care
Alta Hospitals System
Association of California Healthcare Districts
Bakersfield Memorial Hospital
Ballard Rehab
Banner Lassen Medical Center
Barlow Respiratory Hospital
Bear Valley Community Healthcare District
Beverly Hospital
California Chamber of Commerce
California Children’s Hospital Association
California Hospital Association
Canyon Ridge Hospital
Cedars-Sinai Medical Center
Centinela Hospital Medical Center
Chinese Hospital
Chino Valley Medical Center
Community Hospital of Huntington Park
Community Hospital of San Bernardino
Community Hospital of the Monterey Peninsula
Community Medical Centers
Corona Regional Medical Center
Cottage Health
Del Amo Behavioral Health System
Delano Regional Medical Center
Desert Valley Hospital
Dignity Health California Medical Center
Dignity Health Inland Empire
Dignity Health Marian Regional Medical Center
Dignity Health Mercy San Juan Medical Center
Dignity Health Methodist Hospital
Dignity Health Northridge Hospital Medical Center
Dignity Health Sequoia Hospital
Dignity Health St. Elizabeth Community Hospital
Dignity Health St. Francis Memorial Hospital
Dignity Health St. Josephs Behavioral Health
Dignity Health St. Josephs Medical Center
Dignity Health St. Mary Medical Center
Dignity Health Glendale Memorial Hospital
District Hospital Leadership Forum
Dominican Hospital
Eastern Plumas Health Care
Eisenhower Health
El Camino Health
Emanate Health
Encompass Health Rehabilitation Hospital of Bakersfield
Enloe Medical Center
Fairchild Medical Center
Fremont Hospital
French Hospital Medical Center
Glendale Memorial Hospital and Health Center
Greater Coachella Valley Chamber of Commerce
Hazel Hawkins Memorial Hospital
Healdsburg District Hospital
Henry Mayo Newhall Hospital
Hollywood Chamber of Commerce
Hospital Corporation of America
Huntington Hospital
John C. Fremont Healthcare District
John Muir Health
Kaiser Permanente
Kern Medical
Kern Valley Healthcare District
Kindred Hospital Baldwin Park
Kindred Hospital La Mirada
Kindred Hospital Los Angeles
Kindred Hospital Riverside
Kindred Hospital San Francisco Bay Area
Kindred Hospital San Gabriel Valley
Kindred Hospital South Bay
Kindred Hospitals – California
La Palma Intercommunity Hospital
Loma Linda University Health
Lompoc Valley Medical Center
Los Robles Hospital
Mad River Community Hospital
Marian Regional Medical Center
Marin General Hospital
Marshall Medical Center
Mayers Memorial Hospital District
Memorial Hospital of Gardena
MemorialCare
Mendocino Coast District Hospital
Mercy General Hospital
Mercy Hospital of Folsom
Mercy Hospitals of Bakersfield
Mercy Medical Center
Mercy Medical Center Mt. Shasta
Mercy Medical Center Redding
Mercy San Juan Medical Center
Methodist Hospital of Sacramento
Methodist Hospital of Southern California
Mission Community Hospital
Modoc Medical Center
Monterey Park Hospital
Mountain View Child Care
Mountains Community Hospital
NorthBay Healthcare
Northridge Hospital Medical Center
Oak Valley Hospital District
Olympia Medical Center
Orchard Hospital
Pacifica Hospital of the Valley
Parkview Community Hospital Medical Center
PIH Health
Pioneers Memorial Healthcare District
Plumas District Hospital
Pomona Valley Hospital Medical Center
Providence Little Company of Mary Medical Center San Pedro
Providence St. Joseph Health
Redlands Community Hospital
Regional Medical Center
Ridgecrest Regional Hospital
Riverside Community Hospital
Saint Agnes Medical Center
Saint Francis Memorial Hospital
Salinas Valley Memorial Healthcare System
San Antonio Regional Hospital
San Diego Regional Chamber of Commerce
San Gabriel Valley Economic Partnership
San Gorgonio Memorial Hospital
San Jose Behavioral Health
Select Specialty Hospital
Seneca Healthcare District
Sequoia Hospital
Sharp Healthcare
Shasta Regional Medical Center
Sierra View Medical Center
Sierra Vista Hospital
Sonoma Valley Hospital
Southern Humboldt Community Healthcare District and Jerold Phelps
Southwest California Legislative Council
Southwest Healthcare System
St. Bernardine Medical Center
St. Elizabeth Community Health
St. Francis Medical Center
St. Joseph's Behavioral Health Center
St. Joseph's Medical Center, Stockton
St. Mary’s Medical Center
St. Rose Hospital
Stanford Health Care
Stanford Health Care - ValleyCare
Surprise Valley Health Care District
Sutter Health
Sutter Health Auburn Faith Hospital
Sutter Health Coast Hospital
Sutter Health Roseville Medical Center
Tahoe Forest Health System
Tenet Healthcare
Torrance Memorial Medical Center
Totally Kids Rehabilitation Hospital
Trinity Hospital
United Hospital Association
Valley Children’s Healthcare
Vibra Hospital of Sacramento
Vista del Mar Hospital
West Anaheim Medical Center
West Hills Hospital & Medical Center
Woodland Memorial Hospital
Two individuals
ARGUMENTS IN SUPPORT: This bill is sponsored by the California State Council of the Service Employees International Union (SEIU California) and the United Nurses Associations of California/Union of Health Care Professionals (UNAC/UHCP). According to SEIU California, despite the mandated nursing ratios, hospitals repeatedly violate nurse staffing requirements. According to SEIU California, when DPH discovers staffing requirement violations at a hospital, DPH administers a plan of correction, which has no administrative or criminal penalties attached to it. SEIU California states that DPH rarely circles back with facilities to ensure compliance, and violations continue. According to SEIU California, hospitals that routinely violate minimum staffing requirements jeopardize patient safety and quality of care. Moreover, SEIU California states that when nurses are coerced into unsafe staffing assignments, over their objections about patient safety, a nurse runs the risk of Board of Registered Nursing disciplinary action, and in many cases, losing their license. According to SEIU California, nurses reported that in 45% of the reported Assignment Despite Objection forms, hospitals required them to violate the ratios or risk discipline. SEIU California states that under the penalty structure in this bill, the State of California can improve healthcare quality by ensuring improved compliance with existing law. UNAC/UHCP points out in support that a peer reviewed study found that each additional patient per nurse increases the risk of patient mortality by 7%. UNAC/UHCP states that compliance with nurse staffing ratios has been demonstrated to improve patient outcomes, but many hospitals have refused to consistently adhere to the ratios. The California Nurses Association/National Nurses United, AFL-CIO (CNA) states in support that the nurse-to-patient ratios save lives. According to CNA, with the ratios nurses are able to spend more time delivering care at the bedside, and are more likely to identify and report changes in a patient’s condition early on, thereby avoiding many preventable complications. According to CNA, the regulations were adopted as the minimum staffing requirement, meant for the leanest staffing for the slowest shift when the patients were least acute. CNA states hospitals short-staff to save money, and this bill puts into statute the requirement to inspect for these patient protections and to penalize hospitals using a penalty that fits the violation.
ARGUMENTS IN OPPOSITION: The California Hospital Association (CHA) states in opposition that this bill eliminates DPH’s ability to link the penalty amount to the actual risk of harm to patients. According to CHA, ratios are mandated at all time, which means that when a nurse is late, calls in sick, or leaves early, there must be another nurse available to immediately replace that person, and consequently, it is not always possible to be in compliance at all times. Under this bill, CHA notes that the penalty for the first violation would be $15,000, and each additional penalty would be $30,000. CHA argues that administering these penalties, without consideration of the potential for patient harm, makes it clear that this bill is unnecessarily punitive. The Association of California Healthcare Districts also opposes this bill, arguing that DPH has established a robust process for determining fine amounts that considers the scope and severity of any noncompliance with licensing requirements, including staffing ratios, and this bill undermines DPH’s process without good reason. Numerous hospitals and health systems write in opposition with similar arguments.
ASSEMBLY FLOOR: 53-17, 9/3/19
AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Boerner Horvath, Bonta, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Chu, Cooley, Cooper, Eggman, Friedman, Gabriel, Cristina Garcia, Gipson, Gloria, Gonzalez, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Levine, Limón, Low, Maienschein, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk, Quirk-Silva, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Santiago, Smith, Mark Stone, Ting, Weber, Wicks, Wood, Rendon
NOES: Bigelow, Brough, Choi, Cunningham, Flora, Fong, Gallagher, Kiley, Lackey, Mathis, Mayes, Melendez, Obernolte, Patterson, Salas, Voepel, Waldron
NO VOTE RECORDED: Bloom, Daly, Diep, Frazier, Eduardo Garcia, Gray, Grayson, Ramos, Blanca Rubio
Prepared by: Vincent D. Marchand / HEALTH / (916) 651-4111
9/3/19 19:40:03
SENATE THIRD READING
STR Bill Id:SB 227
Author:(Leyva)
As Amended Ver:August 30, 2019
Majority vote
SUMMARY:
Requires the Department of Public Health (DPH) to conduct periodic inspections to inspect compliance with nurse-to-patient ratio regulations that are not announced in advance, and establishes administrative penalties specific to violations of the nurse-to-patient ratios.
Major Provisions
- Requires DPH, if it determines that a health facility has violated the nurse-to-patient ratios, to assess an administrative penalty of $15,000 for the first violation, and $30,000 for the second and each subsequent violation. Specifies that multiple violations found on the same inspection survey constitute a single violation for purposes of determining whether the violation was a first, second, or subsequent violation. Requires a violation occurring more than three years after the date of the last violation be treated as a first violation.
- Specifies that a hospital will not be subject to an administrative penalty if the hospital demonstrates to DPH that any fluctuation in staffing levels was unpredictable and uncontrollable and prompt efforts were made to maintain required staffing levels.
- Authorizes DPH to implement, interpret, or make specific the provisions of this bill by means of an All Facilities Letter or similar instruction, rather than regulations.
COMMENTS:
In 2004, regulations implementing nurse-to-patient ratios in California hospitals pursuant to AB 394 (Kuehl), Chapter 945, Statutes of 1999, went into effect. The regulations set the minimum ratio of nurses to patient by unit, including 1:1 in operating rooms, 1:2 in intensive care units, and 1:5 in general medical-surgical units. The nurse-to-patient ratio regulations require that minimum ratios be met at all times.
DPH Licensing & Certification (L&C) is responsible for regulatory oversight of licensed health facilities and health care professionals to ensure safe, effective, and quality healthcare for Californians. L&C fulfills this role by conducting periodic inspections and complaint investigation of health facilities to ensure compliance with federal and state laws and regulations. According to DPH, 38.1 months is currently the average time between surveys.
According to DPH, from 2008 to 2019 (through April 2, 2019), there have been a total of 734 nursing staff violations cited by DPH. In 2016-17, there were 88 nursing staff violations, and in 2017-18, there were 74. The most common units where DPH found staffing violations were the telemetry units (which is required to be at 1:5 nurse to patient ratio), medical/surgical units (1:5 ratio), and critical care units (1:2 ratio). DPH states that compliance with nurse staffing ratios is reviewed during the relicensing survey that is conducted every three years.
From January 1, 2004, through April 2, 2019, DPH has issued 987 deficiencies for violations of the staffing ratio, and three administrative penalties for ratio violations, one for $25,000, one for $50,000, and one for $75,000. DPH is authorized to grant rural hospitals waivers to the ratio requirements that do not jeopardize the health, safety, and well-being of patients. This process is known as "program flex." A rural hospital seeking a program flex is required to submit a form that includes the facility's justification for the program flex, the alternative methods for how the facility will meet the intent of the of the regulation being flexed, and supporting documentation substantiating that patient care will not be compromised.
According to the Author:
The author states that this bill helps to improve patient health and safety by ensuring that hospitals comply with legally mandated nurse-to-patient staffing ratios. The state must take a more proactive role by conducting unannounced visits at hospitals across California and do everything the state can to make sure that it fully enforces existing law, since the stakes are simply too high for patients. The author states it is also important that penalties assessed are increased against repeat offender hospitals that do not comply with existing law, particularly since the lives of patients can be at stake. The author concludes, beyond the clear safety implications of hospitals not observing ratio requirements, nurses can also be putting their professional livelihoods and licenses at risk due to being required to fulfill job duties outside of legally prescribed ratios.
Arguments in Support:
SEIU California, SEIU 121RN, and the United Nurses Association of California/Union of Health Care Professionals are the cosponsors of this bill and state, compliance with nurse-staffing ratios has been demonstrated to improve patient outcomes, because they ensure that nurses are not overwhelmed and can give adequate and appropriate care to their patients. Unfortunately, ever since nurse staffing ratios were enacted into law nearly two decades ago, many hospitals have refused to consistently adhere to the ratios, which has placed patient care in jeopardy simply to reduce labor costs for hospital managers and owners. The cosponsors conclude that this bill will contribute directly to a higher quality of care, and improve patient outcomes.
Arguments in Opposition:
The California Hospital Association (CHA) is opposed to this bill and states that every day hospitals staff at levels above the required minimum to account for unpredictable needs, but a single emergency, illness, or family care need throws off the entire calculation. CHA also notes that this bill creates a duplicative penalty system for hospitals if they do not meet the nurse staffing ratios, and that the onerous penalties are counter to the state's current efforts to make care more affordable for all.
FISCAL COMMENTS:
According to the Assembly Appropriations Committee, minor and absorbable administrative staff costs to DPH for increased enforcement (Licensing and Certification Program Fund, potentially offset by unknown revenue associated with penalty assessments for noncompliance with regulations).
VOTES:
SENATE FLOOR: 22-13-3
YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Durazo, Hertzberg, Hueso, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Skinner, Stern, Umberg, Wieckowski, Wiener
NO: Bates, Borgeas, Chang, Dodd, Galgiani, Grove, Hill, Jones, Moorlach, Morrell, Nielsen, Stone, Wilk
ABS, ABST OR NV: Glazer, Hurtado, Rubio
ASM HEALTH: 10-3-2
YES: Wood, Aguiar-Curry, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Rodriguez, Santiago
NO: Mayes, Bigelow, Flora
ABS, ABST OR NV: Ramos, Waldron
ASM APPROPRIATIONS: 12-3-3
YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Maienschein, Petrie-Norris, Quirk, Robert Rivas
NO: Bigelow, Brough, Fong
ABS, ABST OR NV: Diep, Eduardo Garcia, Obernolte
UPDATED:
VERSION: August 30, 2019
CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001573
SENATE THIRD READING
STR Bill Id:SB 227
Author:(Leyva)
As Amended Ver:June 27, 2019
Majority vote
SUMMARY:
Requires the Department of Public Health (DPH) to ensure that periodic inspections conducted to inspect compliance with nurse-to-patient ratio regulations are not announced in advance, and establishes administrative penalties specific to violations of the nurse-to-patient ratios.
Major Provisions
- Requires DPH, if it determines that a health facility has violated the nurse-to-patient ratios, to assess an administrative penalty of $15,000 for the first violation, and $30,000 for the second and each subsequent violation. Specifies that multiple violations found on the same inspection survey constitute a single violation for purposes of determining whether the violations was a first, second, or subsequent violation. Requires a violation occurring more than three years after the date of the last violation be treated as a first violation.
- Specifies that a hospital will not be subject to an administrative penalty if the hospital demonstrates to DPH that any fluctuation in staffing levels was unforeseeable and uncontrollable and prompt efforts were made to maintain required staffing levels.
- Authorizes DPH to implement, interpret, or make specific the provisions of this bill by means of an All Facilities Letter or similar instruction, rather than regulations.
- Requires all penalties collected by DPH pursuant to the provisions of this bill to be deposited into the DPH Licensing and Certification Fund, and to be expended solely for the purpose of enforcing the nurse-to-patient ratio regulations.
COMMENTS:
In 2004, regulations implementing nurse-to-patient ratios in California hospitals pursuant to AB 394 (Kuehl), Chapter 945, Statutes of 1999, went into effect. The regulations set the minimum ratio of nurses to patient by unit, including 1:1 in operating rooms, 1:2 in intensive care units, and 1:5 in general medical-surgical units. The nurse-to-patient ratio regulations require that minimum ratios be met at all times.
DPH Licensing & Certification (L&C) is responsible for regulatory oversight of licensed health facilities and health care professionals to ensure safe, effective, and quality healthcare for Californians. L&C fulfills this role by conducting periodic inspections and complaint investigation of health facilities to ensure compliance with federal and state laws and regulations. According to DPH, 38.1 months is currently the average time between surveys.
According to DPH, from 2008 to 2019 (through April 2, 2019), there have been a total of 734 nursing staff violations cited by DPH. In 2016-17, there were 88 nursing staff violations, and in 2017-18, there were 74. The most common units where DPH found staffing violations were the telemetry units (which is required to be at 1:5 nurse to patient ratio), medical/surgical units (1:5 ratio), and critical care units (1:2 ratio). DPH states that compliance with nurse staffing ratios is reviewed during the relicensing survey that is conducted every three years.
From January 1, 2004, through April 2, 2019, DPH has issued 987 deficiencies for violations of the staffing ratio, and three administrative penalties for ratio violations, one for $25,000, one for $50,000, and one for $75,000. DPH is authorized to grant rural hospitals waivers to the ratio requirements that do not jeopardize the health, safety, and well-being of patients. This process is known as "program flex." A rural hospital seeking a program flex is required to submit a form that includes the facility's justification for the program flex, the alternative methods for how the facility will meet the intent of the of the regulation being flexed, and supporting documentation substantiating that patient care will not be compromised.
According to the Author:
The author states that this bill helps to improve patient health and safety by ensuring that hospitals comply with legally mandated nurse-to-patient staffing ratios. The state must take a more proactive role by conducting unannounced visits at hospitals across California and do everything the state can to make sure that it fully enforces existing law, since the stakes are simply too high for patients. The author states it is also important that penalties assessed are increased against repeat offender hospitals that do not comply with existing law, particularly since the lives of patients can be at stake. The author concludes, beyond the clear safety implications of hospitals not observing ratio requirements, nurses can also be putting their professional livelihoods and licenses at risk due to being required to fulfill job duties outside of legally prescribed ratios.
Arguments in Support:
SEIU California, SEIU 121RN, and the United Nurses Association of California/Union of Health Care Professionals are the cosponsors of this bill and state, compliance with nurse-staffing ratios has been demonstrated to improve patient outcomes, because they ensure that nurses are not overwhelmed and can give adequate and appropriate care to their patients. Unfortunately, ever since nurse staffing ratios were enacted into law nearly two decades ago, many hospitals have refused to consistently adhere to the ratios, which has placed patient care in jeopardy simply to reduce labor costs for hospital managers and owners. The cosponsors conclude that this bill will contribute directly to a higher quality of care, and improve patient outcomes.
Arguments in Opposition:
The California Hospital Association (CHA) is opposed to this bill and states that every day hospitals staff at levels above the required minimum to account for unpredictable needs, but a single emergency, illness, or family care need throws off the entire calculation. CHA also notes that this bill creates a duplicative penalty system for hospitals if they do not meet the nurse staffing ratios, and that the onerous penalties are counter to the state's current efforts to make care more affordable for all.
FISCAL COMMENTS:
According to the Assembly Appropriations Committee, minor and absorbable administrative staff costs to DPH for increased enforcement (Licensing and Certification Program Fund, potentially offset by unknown revenue associated with penalty assessments for noncompliance with regulations).
VOTES:
SENATE FLOOR: 22-13-3
YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Durazo, Hertzberg, Hueso, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Skinner, Stern, Umberg, Wieckowski, Wiener
NO: Bates, Borgeas, Chang, Dodd, Galgiani, Grove, Hill, Jones, Moorlach, Morrell, Nielsen, Stone, Wilk
ABS, ABST OR NV: Glazer, Hurtado, Rubio
ASM HEALTH: 10-3-2
YES: Wood, Aguiar-Curry, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Rodriguez, Santiago
NO: Mayes, Bigelow, Flora
ABS, ABST OR NV: Ramos, Waldron
ASM APPROPRIATIONS: 12-3-3
YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Maienschein, Petrie-Norris, Quirk, Robert Rivas
NO: Bigelow, Brough, Fong
ABS, ABST OR NV: Diep, Eduardo Garcia, Obernolte
UPDATED:
VERSION: June 27, 2019
CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001256
Date of Hearing: July 10, 2019
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Lorena Gonzalez, Chair
SBPCA Bill Id:SB 227
Author:(Leyva) – As Amended Ver:June 27, 2019
Policy Committee: | Health | Vote: | 10 - 3 |
Urgency: No State Mandated Local Program: No Reimbursable: No
SUMMARY:
This bill requires the California Department of Public Health (CDPH) to include reviews of compliance with nurse-to-patient ratios and staff assignment regulations during inspections of hospitals.
It also requires CDPH to assess specific penalties of $15,000 for the first violation and $30,000 for the second and each subsequent violation of the nurse-to-patient ratios and staff assignment regulations, and requires these funds to be used to enforce the above regulations.
FISCAL EFFECT:
Minor and absorbable administrative staff costs to CDPH for increased enforcement (Licensing and Certification Program Fund, potentially offset by unknown revenue associated with penalty assessments for noncompliance with regulations).
COMMENTS:
- Purpose. This bill seeks to increase penalties for violations of nurse staffing requirements.
- Nurse-to-Patient Ratios and Patient Classification Systems. In 2004, regulations went into effect implementing nurse-to-patient ratios in California hospitals pursuant to AB 394 (Kuehl), Chapter 945, Statutes of 1999. However, hospitals were already required by regulation to establish a patient classification system. This patient classification system is a method by which hospitals establish staffing requirements by unit, patient and shift, and includes a method by which the amount of nursing care needed for each category of patient is validated for each unit.
The regulations implementing the AB 394 nurse-to-patient ratios set the minimum ratio of nurses to patient by unit, including 1:1 in operating rooms, 1:2 in intensive care units, and 1:5 in general medical-surgical units. These regulations also incorporated the patient classification system requirement. In essence, the specific nurse-to-patient ratios establish the minimum number of nurses by unit, while the patient classification system determines whether there needs to be a higher level of staffing beyond the minimum ratio after considering factors such as the severity of the illness, the need for specialized equipment and technology, and the complexity of clinical judgment needed to evaluate the patient care plan, among other factors. The nurse-to-patient ratio regulations require that minimum ratios be met at all times.
- Enforcement. CDPH states compliance with nurse staffing ratios is reviewed during the relicensing survey that is conducted every three years. Additionally, if a complaint is submitted, CDPH will assign the complaint to a nurse surveyor for investigation, and if patient care was affected due to the staffing ratio, a statement of deficiencies will be written, along with a request for a plan of correction. From January 1, 2004, through April 2, 2019, CDPH has issued 987 deficiencies for violations of the staffing ratio and three administrative penalties for ratio violations.
- Support. California State Council of the Service Employees International Union (SEIU California), United Nurses Associations of California/Union of Health Care Professionals (UNAC/UHCP) and SEIU 121RN are cosponsors of this bill, arguing hospitals do not currently have proper incentives to comply with staffing ratios. The California Labor Federation, California Nurses Association and other labor groups also support this bill.
- Opposition. Hospitals oppose this bill, noting staffing ratios can be logistically difficult to maintain at all times given unpredictable patient care needs and protected leave for nurses, and note it will subject them to onerous penalties.
- Staff Comment. Requiring penalty funds to be used only for enforcement of staffing ratios has intuitive appeal from a policy perspective but it may be difficult to implement, given the potential mismatch between resources needed for enforcement and the unpredictable level of penalty revenue. The author may wish to consider modifying this requirement to ensure the increased oversight can be effectively implemented and funds can be allocated efficiently.
Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081
Date of Hearing: June 25, 2019
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SBPCA Bill Id:SB 227
Author:(Leyva) – As Introduced Ver:February 7, 2019
SENATE VOTE: 22-13
SUBJECT: Health and care facilities: inspections and penalties.
SUMMARY: Requires the Department of Public Health (DPH) to ensure that periodic inspections conducted to inspect compliance with nurse-to-patient ratio regulations are not announced in advance, and establishes administrative penalties specific to violations of the nurse-to-patient ratios. Specifically, this bill:
- Requires DPH to ensure that a periodic inspection conducted to inspect compliance with nurse-to-patient ratios is not announced in advance of the date of inspection.
- Requires DPH, if it determines that a health facility has violated the nurse-to-patient ratios, to assess an administrative penalty of $30,000 for the first violation, and $60,000 for the second and each subsequent violation. Specifies that multiple violations found on the same inspection survey constitute a single violation for purposes of determining whether the violations was a first, second, or subsequent violation.
- Requires a violation occurring more than six years after the date of the last violation to be treated as a first violation.
- Authorizes DPH to implement, interpret, or make specific the provisions of this bill by means of an All Facilities Letter or similar instruction, rather than regulations.
- Requires all penalties collected by DPH pursuant to the provisions of this bill to be deposited into the DPH Licensing and Certification Fund, and to be expended solely for the purpose of enforcing the nurse-to-patient ratio regulations.
EXISTING LAW:
- Licenses and regulates health facilities by DPH, including general acute care hospitals, acute psychiatric hospitals, and special hospitals (hospitals).
- Requires DPH to inspect for compliance with state laws and regulations during a state periodic inspection or at the same time as a federal periodic inspection. Requires the inspection for hospitals to be conducted no less than once every three years.
- Requires DPH to adopt regulations that establish minimum, specific, and numerical licensed nurse-to-patient ratios, by licensed nurse classification and by hospital unit, for hospitals, and requires these ratios to constitute the minimum number of registered and licensed nurses that must be allocated.
- Authorizes DPH to grant rural hospitals waivers to the ratio requirements that do not jeopardize the health, safety, and well-being of patients affected, and that are needed for increased operational efficiency.
- Establishes a structure under which DPH is permitted to assess administrative fines to hospitals for violation of any of their licensing laws and regulations. Requires DPH to promulgate regulations establishing the criteria to assess these administrative penalties, and requires these criteria to include, but not be limited to, the probability and severity of the risk that the violation presents to the patient, the facility’s history of compliance with related state and federal statutes and regulations, the demonstrated willfulness of the violation, and the extent to which the facility detected the violation and took steps to immediately correct the violation and prevent the violation from recurring.
- Permits DPH to assess an administrative penalty against a hospital, for a deficiency constituting an immediate jeopardy violation, as defined, up to a maximum of $75,000 for the first administrative penalty, up to $100,000 for the second administrative penalty, and up to $125,000 for the third and every subsequent administrative penalty.
- Permits DPH to assess an administrative penalty of up to $25,000 per violation for those not deemed to constitute immediate jeopardy. Prohibits DPH from assessing an administrative penalty for minor violations.
- Defines “immediate jeopardy” as a situation in which the licensee’s noncompliance with one or more requirements of licensure has caused, or is likely to cause, serious injury or death to the patient.
- Gives DPH the discretion to consider all factors when determining the amount of an administrative penalty.
FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.
COMMENTS:
- PURPOSE OF THIS BILL. According to the author, it has been reported that too many California hospitals disregard the current nurse-to-patient ratio requirements as prescribed by Title 22 regulations. The author states that this bill helps to improve patient health and safety by ensuring that hospitals comply with legally mandated nurse-to-patient staffing ratios. The state must take a more proactive role by conducting unannounced visits at hospitals across California and do everything the state can to make sure that it fully enforces existing law, since the stakes are simply too high for patients. The author states it is also important that penalties assessed are increased against repeat offender hospitals that do not comply with existing law, particularly since the lives of patients can be at stake. The author concludes, beyond the clear safety implications of hospitals not observing ratio requirements, nurses can also be putting their professional livelihoods and licenses at risk due to being required to fulfill job duties outside of legally prescribed ratios.
- BACKGROUND.
- Nurse-to-patient ratios and patient classification systems. In 2004, regulations implementing nurse-to-patient ratios in California hospitals pursuant to AB 394 (Kuehl), Chapter 945, Statutes of 1999, went into effect. However, long before California had specific nurse-to-patient ratios, hospitals were required by regulation to establish a patient classification system. This patient classification system is a method by which hospitals establish staffing requirements by unit, patient, and shift, and includes a method by which the amount of nursing care needed for each category of patient is validated for each unit.
The regulations implementing the AB 394 nurse-to-patient ratios set the minimum ratio of nurses to patient by unit, including 1:1 in operating rooms, 1:2 in intensive care units, and 1:5 in general medical-surgical units. These regulations also incorporated the patient classification system requirement. Therefore, the specific nurse-to-patient ratios establish the minimum number of nurses by unit, while the patient classification system determines whether there needs to be a higher level of staffing beyond the minimum ratio after taking into consideration factors such as the severity of the illness, the need for specialized equipment and technology, and the complexity of clinical judgment needed to evaluate the patient care plan, among other factors. The nurse-to-patient ratio regulations require that minimum ratios be met at all times.
- Effectiveness of nurse-to-patient ratios. According to a 2010 study by researchers at the University of Pennsylvania, "Implications of the California Nurse Staffing Mandate for Other States," 29% of nurses in California experienced high burnout, compared with 34% of nurses in New Jersey and 36% of nurses in Pennsylvania, states without minimum staffing ratios during the period of research. The study also found that 20% of nurses in California reported dissatisfaction with their jobs, compared with 26% and 29% in New Jersey and Pennsylvania. California nurse staffing ratios also accompanied a lower likelihood of in-patient death within 30 days of hospital admission than in New Jersey or Pennsylvania; there was also a lower likelihood of death from failing to properly respond to symptoms. A 2013 study from the University of California, Davis, "California's nurse-to-patient ratio law and occupational injury," found that the ratios reduced occupational injury and illness rates for both registered nurses (RNs) and licensed practical nurses by up to 33% compared to the expected rate without the law.
- DPH Licensing and Certification Program (L&C). The DPH L&C is responsible for regulatory oversight of licensed health facilities and health care professionals to ensure safe, effective, and quality healthcare for Californians. L&C fulfills this role by conducting periodic inspections and complaint investigation of health facilities to ensure compliance with federal and state laws and regulations. However, there have been long-standing concerns about the L&C program. A 2014 California State Auditor report highlighted gaps in state oversight of health facilities and certain professionals that work in these facilities. While the focus of the audit was on nursing homes, DPH acknowledged that they also faced a backlog of complaint investigations that are hospital-based. The 2015-16 Budget provided DPH L&C with an additional $19.8 million for 237 positions over two years to address workload and to do licensing surveys of hospitals every three years (36 months), as is statutorily required. According to DPH, 38.1 months is currently the average time between surveys.
- Administrative penalties for hospitals. SB 1312 (Alquist), Chapter 895, Statutes of 2006, gave DPH the authority to assess administrative penalties for violations of the laws pertaining to the licensing of hospitals. Prior to SB 1312, DPH had very limited authority to levy fines on hospitals that violated state licensing laws. SB 1312 created two levels of penalties: violations that constituted immediate jeopardy to the health and safety of a patient; and, violations that do not constitute immediate jeopardy. SB 541 (Alquist), Chapter 605, Statutes of 2008, modified the administrative penalty provisions, and increased the fine amounts. Immediate jeopardy violations are now subject to a fine of up to up to $75,000 for the first penalty, $100,000 for the second penalty, and $125,000 for the third and subsequent penalties. All other violations (except minor violations, for which DPH is prohibited from assessing a violation) are subject to a fine of up to $25,000.
SB 1312 required DPH to promulgate regulations establishing the criteria to assess administrative penalties, and listed eight factors on which to base the criteria, including the patient’s physical and mental condition, the nature, scope and severity of the violation, and the demonstrated willfulness of the violation. DPH adopted these regulations in late 2013, and they went into effect on April 1, 2014. These regulations established the penalty matrix in the table below, which can be modified upward or downward according to certain specified factors. The percentages in the table below are to be applied to the statutory maximum penalty amounts as described in 5) and 6) of existing law above:
SCOPE | ||||
Isolated | Pattern | Widespread | ||
SEVERITY | Level 6: Immediate jeopardy to patient health or safety—Death | 100% | 100% | 100% |
Level 5: Immediate jeopardy to patient health or safety—Serious injury | 60% | 70% | 80% | |
Level 4: Immediate jeopardy to patient health or safety—Likely to cause serious injury or death | 40% | 50% | 60% | |
Level 3: Actual patient harm that is not immediate jeopardy | 60% | 80% | 100% | |
Level 2: No actual patient harm but with potential for more than minimal harm, not immediate jeopardy | 20% | 50% | 70% | |
Level 1: No actual patient harm but with potential for no more than minimal harm | No penalty | |||
Minor Violation | No penalty | |||
- Nurse-to-Patient Ratio violations and enforcement. According to DPH, from 2008 to 2019 (through April 2, 2019), there have been a total of 734 nursing staff violations cited by DPH. In 2016-17, there were 88 nursing staff violations, and in 2017-18, there were 74. The most common units where DPH found staffing violations were the telemetry units (which is required to be at 1:5 nurse to patient ratio), medical/surgical units (1:5 ratio), and critical care units (1:2 ratio). DPH states that compliance with nurse staffing ratios is reviewed during the relicensing survey that is conducted every three years. Additionally, if a complaint is submitted, DPH will assign this to a nurse surveyor for investigation, and if patient care was affected due to the staffing ratio, a statement of deficiencies will be written, along with a request for a plan of correction. According to DPH, nurse staffing was added to the statewide survey tool used during hospital inspections beginning in 2016. Prior to inclusion in the survey tool, verification of staffing requirements was conducted in response to complaints.
Nurse To Patient Staffing Ratio Violations by Unit Type | ||||||||||||
GACH UNIT TYPE | State Fiscal Year During Which Violation was Cited (based on Survey Exit Date) | TOTAL | ||||||||||
08-09 | 09-10 | 10-11 | 11-12 | 12-13 | 13-14 | 14-15 | 15-16 | 16-17 | 17-18 | 18-19* | ||
Total | 68 | 42 | 62 | 75 | 50 | 85 | 69 | 62 | 88 | 74 | 59 | 734 |
Nursing Service Staff | 17 | 9 | 14 | 13 | 7 | 10 | 11 | 8 | 8 | 8 | 11 | 116 |
Critical Care | 19 | 3 | 10 | 9 | 3 | 6 | 9 | 2 | 16 | 8 | 7 | 92 |
Surgical Operating Room | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 |
Labor and Delivery | 0 | 0 | 0 | 3 | 0 | 3 | 1 | 0 | 1 | 3 | 4 | 15 |
Perinatal Postpartum | 1 | 1 | 0 | 4 | 1 | 5 | 0 | 1 | 2 | 2 | 2 | 19 |
Labor/Delivery/Postpartum | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 2 |
Pediatric | 0 | 2 | 1 | 4 | 0 | 0 | 1 | 1 | 0 | 0 | 1 | 10 |
Post-anesthesia Recovery | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 2 | 0 | 3 |
Emergency | 6 | 4 | 5 | 10 | 4 | 3 | 5 | 8 | 5 | 11 | 5 | 66 |
Step-down | 0 | 1 | 3 | 2 | 3 | 5 | 2 | 7 | 4 | 5 | 6 | 38 |
Telemetry | 6 | 7 | 13 | 14 | 17 | 27 | 25 | 20 | 23 | 19 | 12 | 183 |
Medical/Surgical Care | 10 | 13 | 13 | 12 | 14 | 21 | 14 | 13 | 25 | 8 | 7 | 150 |
Specialty Care | 2 | 1 | 2 | 1 | 1 | 2 | 1 | 0 | 3 | 6 | 2 | 21 |
Psychiatric | 5 | 1 | 1 | 2 | 0 | 1 | 0 | 1 | 1 | 1 | 1 | 14 |
Other | 1 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 4 |
*through 04/02/2019
From January 1, 2004, through April 2, 2019, DPH has issued 987 deficiencies for violations of the staffing ratio, and three administrative penalties for ratio violations, one for $25,000, one for $50,000, and one for $75,000.
f) Rural hospital waivers. As noted in existing law above, DPH is authorized to grant rural hospitals waivers to the ratio requirements that do not jeopardize the health, safety, and well-being of patients. This process is known as “program flex.” A rural hospital seeking a program flex is required to submit a form that includes the facility’s justification for the program flex, the alternative methods for how the facility will meet the intent of the regulation being flexed, and supporting documentation substantiating that patient care will not be compromised. DPH staff reviews the request and may request additional information necessary to complete DPH’s review. If DPH approves the program flexibility, the hospital is notified of the approval and of any terms and conditions the facility must comply with. The facility is required to post the program flex approval next to their license in the facility in a manner that ensures members of the public are aware that the facility has a program flex. According to DPH, the following rural hospitals have waivers of the nurse-to-patient ratio requirements:
- Twin Cities Community Hospital;
- Colusa Medical Center;
- Eastern Plumas Hospital-Portola Campus;
- Seneca District Hospital;
- Adventist Health Ukiah Valley;
- St. Elizabeth Community Hospital;
- Mercy Medical Center Mt. Shasta;
- Tahoe Forest Hospital;
- George L. Mee Memorial Hospital; and,
- Hazel Hawkins Memorial Hospital.
According to DPH, rural hospitals with ratio waivers would not be subject to the penalty provisions proposed by this bill.
- SUPPORT. SEIU California, SEIU 121RN, and the United Nurses Association of California/Union of Health Care Professionals are the cosponsors of this bill and state, compliance with nurse-staffing ratios has been demonstrated to improve patient outcomes, because they ensure that nurses are not overwhelmed and can give adequate and appropriate care to their patients. Unfortunately, ever since nurse staffing ratios were enacted into law nearly two decades ago, many hospitals have refused to consistently adhere to the ratios, which has placed patient care in jeopardy simply to reduce labor costs for hospital managers and owners. The cosponsors conclude that this bill will contribute directly to a higher quality of care, and improve patient outcomes.
- OPPOSITION. The California Hospital Association (CHA) is opposed to this bill and states that every day hospitals staff at levels above the required minimum to account for unpredictable needs, but a single emergency, illness, or family care need throws off the entire calculation. CHA states that the significant increases in protected time for California workers, the Family Medical Leave Act, Paid Sick Leave, Kin Care, and more, along with the maldistribution of nurses in some areas, staffing ratios are a logistical nightmare for nurse leaders. CHA also notes that this bill creates a duplicative penalty system for hospitals if they do not meet the nurse staffing ratios, and that the onerous penalties are counter to the state’s current efforts to make care more affordable for all.
- OPPOSE UNLESS AMENDED. Pioneers Memorial Healthcare District (PMHD) is opposed to this bill unless it is amended. PMHD states that they are located in a rural and remote area of the state that is continually challenged with recruiting and retaining health professionals, particularly nurses. PMHD requests an exemption to Health Professional Shortage areas in this bill.
- PREVIOUS LEGISLATION.
- SB 1288 (Leyva) of 2018 was substantially similar to this bill, and would have required periodic inspections of hospitals by DPH to include reviews of compliance with nurse staffing ratios, and established administrative penalties for nurse staffing ratio violations of $15,000 for a first violation, and $30,000 for subsequent violations. SB 1288 was vetoed by Governor Brown, who stated, “California hospitals are regularly inspected to assure patient safety and quality of care. When violations are found, penalties are imposed based on an overall assessment of the severity and duration of the violations, including for any failure to meet the required staffing ratio. Nurse-to-patient ratios are a vital part of the state's regulatory scheme. Hospitals, however, are best evaluated in a comprehensive manner and I am reluctant to start singling out specific violations for a separate penalty.”
- SB 455 (Hernandez) of 2013 would have codified existing regulations requiring hospitals to have a committee annually review the reliability of its patient classification system, including regulations requiring at least one-half of this committee be composed of RNs who provide direct patient care. This bill required the RNs appointed to this committee to be selected by the collective bargaining agent, if any. SB 455 would have required DPH, during every periodic state inspection of a hospital, to inspect for compliance with nurse-to-patient ratios, as specified. SB 455 was vetoed by the Governor, who wrote, "This bill restates current law, which requires the Department of Public Health to inspect hospital compliance with nurse-to-patient ratios, and specifies that each individual hospital committee that reviews a patient classification system shall be comprised of registered nurses appointed by the bargaining agent, unless none exists. This bill directs decisions that are best left at the local level."
- SB 1246 (Hernandez) of 2012 contained similar provisions to SB 455. SB 1246 was vetoed by the Governor, who wrote, "This bill seeks to grant the Department of Public Health greater authority to enforce hospital nurse staffing ratios and patient classification system requirements. Everything is already on track to get this job done. The department will soon release proposed regulations on administrative penalties that will apply to a broad range of violations. The rulemaking process should be completed next year."
- SB 554 (Yee) of 2011 would have required DPH to inspect for compliance with nurse-to-patient staffing ratios during periodic inspections of hospitals, similar to this bill. SB 554 also proposed to require DPH to inspect hospitals that have been cited for deficiencies related to nurse-to-patient staffing ratios for their compliance with the plan of correction. SB 554 also would have required DPH to assess administrative penalties for violations of nurse-to-patient staffing ratios and for failure to comply with an approved plan of correction related to nurse-to-patient ratios. The penalties included a $10,000 penalty for the fourth and each subsequent violation of the nurse-to-patient ratio requirements within a six-month period, and $10,000 for the failure of the hospital to comply with an approved plan of correction. These provisions were later amended out of SB 554.
- SB 360 (Yee) of 2009 would have required each new direct care registered nursing hire to receive and complete an orientation to the hospital and patient care unit in which he or she will be working. SB 360 would also have prohibited nurses who had not completed this orientation from being assigned to direct patient care or being counted as staff in computing nurse-to-patient ratios. SB 360 was held on the Senate Appropriations suspense file.
- SB 541 increased the level of administrative penalties DPH may assess against hospitals, including for deficiencies that constitute immediate jeopardy to the health or safety of patients. Required health care facilities to prevent unlawful or unauthorized access to use, or disclosure of, patients' medical information, and to established safeguards protecting the privacy of patients' medical information.
- SB 1312 authorizes DPH to assess administrative penalties on hospitals for deficiencies constituting immediate jeopardy to the health and safety of a patient and those that do not constitute immediate jeopardy to patients.
- AB 394 required DPH to adopt regulations specifying nurse-to-patient ratios, by unit, for general acute care hospitals, acute psychiatric hospitals and special hospitals. AB 394 also required hospitals to adopt written policies and procedures for nursing staff training; provided that the ratios constitute the minimum number of registered and licensed nurses that must be provided; and, requires hospitals to assign additional staff in accordance with a documented patient classification system.
- SUGGESTED AMENDMENTS.
- Penalties. The current penalty structure for any violation of a hospital law or regulation provides for a maximum penalty of $25,000, unless the violation constituted “immediate jeopardy,” which means the violation caused or is likely to cause serious injury or death to the patient. For immediate jeopardy penalties, the maximum penalty amounts are $75,000, $100,000, and $125,000 for the first, second, or subsequent violations, respectively. However these are maximum amounts, and the statute permits DPH to fine hospitals in an amount “up to” these maximums. The penalty amounts in this bill do not provide any flexibility to DPH. For example, for a second or third violation, it is a flat $60,000 fine, not “up to” $60,000. Existing law also specifies that DPH will not assess an administrative penalty for minor violations. The Committee may wish to amend this bill to lower the amount of fines to $15,000 and $30,000, to balance DPH’s lack of discretion on the amount of the fine based on the severity of the violation.
- Exceptions. Existing law specifies that DPH will not assess an administrative penalty for minor violations. As currently drafted, this bill requires DPH to assess a penalty for every ratio violation, even for violations that occur when a nurse has an unexpected illness or injury, and either calls out or is late to work, or in other unforeseen circumstances, such as a car accident. The Committee may wish to amend the bill to provide an exception to the mandatory penalty in these types of instances, if the hospital can show it made immediate efforts to maintain required staffing levels.
- Timeline. As currently drafted, the bill “resets” the penalty clock every six years. The Committee may wish to amend the bill to reset the penalty provisions every three years, to provide consistency with other hospital penalty provisions, and again, to mitigate the fact that DPH has no discretion in the fine amounts.
REGISTERED SUPPORT / OPPOSITION:
Support
California State Council of Service Employees (cosponsor)
SEIU 121RN (cosponsor)
United Nurses Association of California/Union of Health Care Professionals (cosponsor)
American Federation of State, County and Municipal Employees, AFL-CIO
California Labor Federation, AFL-CIO
California Nurses Association
California Professional Firefighters
California School Employees Association
California School Nurses Organization
California Teamsters Public Affairs Council
Congress of California Seniors
Consumer Attorneys of California
Engineers and Scientists of California Local 20, IFPTE AFL-CIO & CLC
International Longshore & Warehouse Union Local 13
San Francisco AIDS Foundation
Opposition
Adventist Health
Adventist Health and Rideout
Adventist Health Bakersfield
Adventist Health Glendale
Adventist Health Hanford
Adventist Health Sonora
Adventist Health, Clear Lake
Adventist Health, St. Helena
Adventist Health Simi Valley
Alameda Health System
Alliance of Catholic Health Care, Inc.
Alta Hospitals System
Association of California Healthcare Districts, and Affiliated Entity Alpha Fund
Bakersfield Memorial Hospital
Ballard Rehabilitation Hospital
Banner Lassen Medical Center
Barlow Respiratory Hospital
Barstow Community Hospital
Barton Health
Bear Valley Community Healthcare District
Beverly Community Hospital Association
California Chamber of Commerce
California Children's Hospital Association
California Hospital Association
California Hospital Medical Center
Canyon Ridge Hospital
Cedars-Sinai Medical Center
Centinela Hospital Medical Center
Chinese Hospital
Chino Valley Medical
Community Hospital of Huntington Park
Community Hospital of San Bernardino
Community Hospital of the Monterey Peninsula
Community Medical Centers
Corona Regional Medical Center
Cottage Health
Del Amo Behavioral Health System Of Southern California
Delano Regional Medical Center
Desert Valley Hospital
Dignity Health
Dignity Health - Inland Empire
District Hospital Leadership Forum
Dominican Hospital
Eastern Plumas Health Care
Eisenhower Health Medical Center
El Camino Health
Emanate Health
Emanate Health – Queen of the Valley Hospital
Encompass Health Rehabilitation Hospital Of Bakersfield
Enloe Medical Center
Fairchild Medical Center
Fremont Hospital
French Hospital Medical Center
Glendale Memorial Hospital And Health Center
Hazel Hawkins Memorial Hospital
HCA - Hospital Corporation of America
Healdsburg District Hospital
Henry Mayo Newhall Hospital
Hospital Corporation Of America
Huntington Hospital
Inland Valley Medical Center
John C. Fremont Healthcare District
John Muir Health
Kaiser Permanente
Kern Medical
Kern Valley Healthcare District
Kindred Healthcare
Kindred Hospital Baldwin Park
Kindred Hospital La Mirada
Kindred Hospital Los Angeles
Kindred Hospital Riverside
Kindred Hospital San Francisco Bay Area
Kindred Hospital San Gabriel Valley
Kindred Hospital South Bay
La Palma Intercommunity Hospital
Loma Linda University Adventist Health Sciences Center and its Affiliated Entities
Lompoc Valley Medical Center
Los Robles Hospital & Medical Center
Mad River Community Hospital
Marian Regional Medical Center
Marin General Hospital
Marshall Medical Center
Mayers Memorial Hospital District
Memorial Hospital of Gardena
Memorialcare Health System
Mendocino Coast District Hospital
Mercy General Hospital
Mercy Hospital of Folsom
Mercy Hospitals of Bakersfield
Mercy Medical Center
Mercy Medical Center Mt. Shasta
Mercy Medical Center Redding
Mercy San Juan Medical Center
Methodist Hospital Of Sacramento
Methodist Hospital Of Southern California
Mission Community Hospital
Modoc Medical Center
Monterey Park Hospital
Mountain Communities Healthcare District
Mountain View Child Care, Inc
Northbay Healthcare
Northridge Hospital Medical Center
Oak Valley Hospital District
Olympia Medical Center
Orchard Hospital
Parkview Community Hospital Medical Center
PIH Health
Plumas District Hospital
Pomona Valley Hospital Medical Center
Providence Little Company of Mary Medical Center San Pedro
Providence St. Joseph Health
Rancho Springs Medical Centers
Redlands Community Hospital
Redwood Memorial Hospital
Regional Medical Center
Ridgecrest Regional Hospital
Riverside Community Hospital
Saint Agnes Medical Center
Saint Francis Memorial Hospital
Salinas Valley Memorial Healthcare System
San Antonio Regional Medical Center
San Diego Regional Chamber Of Commerce
San Gabriel Valley Economic Partnership
San Gorgonio Memorial Hospital
San Jose Behavioral Health
Scripps Health
Select Specialty Hospital - San Diego
Seneca Healthcare District
Sequoia Hospital
Sharp Healthcare
Shasta Regional Medical Center
Sierra View Medical Center
Sierra Vista Hospital
Sierra Vista Regional Medical Center
Sohum Health
Sonoma Valley Hospital
Southern Humboldt Community Healthcare District and Jerold Phelps Community Hospital
Southwest California Legislative Council
Southwest Healthcare System
St. Bernardine Medical Center
St. Elizabeth Community Hospital
St. Francis Medical Center
St. Joseph Health – Humboldt County
St. Joseph’s Behavioral Health Center
St. Joseph’s Medical Center
St. Mary Medical Center
St. Rose Hospital
Stanford Health Care
Stanford Health Care Valleycare
Stanford Hospital & Clinics
Surprise Valley Health Care District
Sutter Health
Sutter Health Sutter Auburn Faith Hospital
Sutter Health Sutter Coast Hospital
Tahoe Forest Health System
Tenet Healthcare Corporation
The Chamber Greater Coachella Valley
Torrance Memorial Medical Center
Totally Kids Rehabilitation Hospital
Trinity Hospital
Trinity Hospital, Mountain Communities Healthcare District
United Hospital Association
Valley Children’s Healthcare
Vibra Hospital Of Northern California
Vibra Hospital of Sacramento
Vista Del Mar
West Anaheim Medical Center
West Hills Hospital & Medical Center
Woodland Memorial Hospital
Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | SB 227 |
THIRD READING
Bill No: SB 227
Introduced: 2/7/19
SENATE HEALTH COMMITTEE: 6-2, 4/10/19
AYES: Pan, Durazo, Hurtado, Leyva, Mitchell, Monning
NOES: Stone, Grove
NO VOTE RECORDED: Rubio
SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8
SUBJECT: Health and care facilities: inspections and penalties
SOURCE: California State Council of the Service Employees International Union
United Nurses Associations of California/Union of Health Care Professionals
DIGEST:
This bill requires periodic inspections of hospitals by the Department of Public Health to include reviews of compliance with nurse staffing ratios, and establishes administrative penalties for nurse staffing ratio violations of $30,000 for a first violation, and $60,000 for each subsequent violation.
Existing law:
- Licenses and regulates health facilities by the Department of Public Health (DPH), including general acute care hospitals, acute psychiatric hospitals, and special hospitals (hospitals). [HSC §1250, et seq.]
- Requires DPH to inspect for compliance with state laws and regulations during a state periodic inspection or at the same time as a federal periodic inspection. Requires the inspection for hospitals to be conducted no less than once every three years. [HSC §1279 (g)]
- Requires DPH to adopt regulations that establish minimum, specific, and numerical licensed nurse-to-patient ratios, by licensed nurse classification and by hospital unit, for hospitals, and requires these ratios to constitute the minimum number of nurses that must be allocated. [HSC §1276.4]
- Establishes a structure under which DPH is permitted to assess administrative fines to hospitals for violation of any of their licensing laws and regulations. Requires DPH to promulgate regulations establishing the criteria to assess these administrative penalties, and requires these criteria to include, but not be limited to, the probability and severity of the risk that the violation presents to the patient, the facility’s history of compliance with related state and federal statutes and regulations, the demonstrated willfulness of the violation, and the extent to which the facility detected the violation and took steps to immediately correct the violation and prevent the violation from recurring. [HSC §1280.3]
- Permits DPH to assess an administrative penalty against a hospital, for a deficiency constituting an immediate jeopardy violation, as defined, up to a maximum of $75,000 for the first administrative penalty, up to $100,000 for the second administrative penalty, and up to $125,000 for the third and every subsequent administrative penalty. [HSC §1280.3 (a)]
- Permits DPH to assess an administrative penalty of up to $25,000 per violation for those not deemed to constitute immediate jeopardy. Prohibits DPH from assessing a penalty for minor violations. [HSC §1280.3 (b) and (c)]
- Requires DPH to have full discretion to consider all factors when determining the amount of an administrative penalty. [HSC §1280.3 (a)]
This bill:
- Requires that periodic DPH inspections of hospitals to ensure compliance with laws and regulations include reviews of compliance with nurse staffing ratios. Prohibits a periodic inspection to inspect compliance with nurse staffing ratios from being announced in advance, consistent with existing law that prohibits periodic inspections of health facilities from being announced in advance.
- Requires DPH to assess an administrative penalty of $30,000 for a hospital that violates a nurse staffing ratio regulation for the first time, and $60,000 for the second and each subsequent violation. Specifies that multiple violations found on the same inspection survey constitutes a single violation for purposes of determining whether the violation was a first, second or subsequent violation, and that a violation occurring more than six years after the date of the last violation is to be treated as a first violation.
- Permits DPH, without taking any regulatory actions, to implement, interpret, or make specific this bill by means of an All Facilities Letter or similar instruction.
- Requires all penalties collected by DPH under this bill to be deposited into DPH’s Licensing and Certification Program Fund, as specified, and requires penalty revenues to be expended solely for the purpose of enforcing nurse staffing regulations.
- Includes this new nurse staffing ratio penalty provision in a provision of existing law that requires DPH to take into consideration the special circumstances of small and rural hospitals when taking enforcement action in order to protect access to quality care in those hospitals.
Background
NOTE: For background, see Senate Health Committee analysis.
Comments
Author’s statement. According to the author, this bill will empower DPH to enforce the legally mandated nurse-to-patient staffing ratios and therefore improve healthcare quality in California hospitals and make sure that patients receive the care they need and deserve. It has been reported that many California hospitals disregard the current nurse-to-patient ratio requirement of Title 22 regulations. The state must take a more proactive role by conducting unannounced visits at hospitals across California and ensuring that it fully enforces existing law because the stakes are simply too high for patients. It is also important that penalties are increased against repeat offender hospitals that do not comply with existing law. Moreover, beyond the clear safety implications of hospitals not observing ratio requirements, nurses can also be putting their professional livelihoods and licenses at risk due to being required to fulfill job duties outside of legally prescribed ratios.
Related/Prior Legislation
SB 1288 (Leyva, 2018), substantially similar to this bill, would have required periodic inspections of hospitals by the DPH to include reviews of compliance with nurse staffing ratios, and established administrative penalties for nurse staffing ratio violations of $15,000 for a first violation, and $30,000 for subsequent
violations. SB 1288 was vetoed by Governor Brown, who stated:
California hospitals are regularly inspected to assure patient safety and quality of care. When violations are found, penalties are imposed based on an overall assessment of the severity and duration of the violations, including for any failure to meet the required staffing ratio.
Nurse-to-patient ratios are a vital part of the state's regulatory scheme. Hospitals, however, are best evaluated in a comprehensive manner and I am reluctant to start singling out specific violations for a separate penalty.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No
California State Council of the Service Employees International Union (co-source)
United Nurses Associations of California/Union of Health Care Professionals (co-source)
American Federation of State, County, and Municipal Employees, AFL-CIO
California Labor Federation, AFL-CIO
California Nurses Association/National Nurses United, AFL-CIO
California Professional Firefighters
California School Employees Association, AFL-CIO
California School Nurses Organization
California Teamsters Public Affairs Council
Congress of California Seniors
Consumer Attorneys of California
Engineers and Scientists of California Local 20
International Longshore and Warehouse Union, Local 13
San Francisco Aids Foundation
Adventist Health Bakersfield
Adventist Health Clear Lake Medical Center
Adventist Health Glendale
Adventist Health Hanford
Adventist Health Sonora
Alliance of Catholic Health Care
Alta Hospitals System
Association of California Healthcare Districts
Bakersfield Memorial Hospital
Banner Lassen Medical Center
Barlow Respiratory Hospital
Bear Valley Community Healthcare District
Beverly Hospital
California Chamber of Commerce
California Children’s Hospital Association
California Hospital Association
Canyon Ridge Hospital
Cedars-Sinai Medical Center
Centinela Hospital Medical Center
Chinese Hospital
Chino Valley Medical Center
Community Hospital of Huntington Park
Community Hospital of San Bernardino
Community Hospital of the Monterey Peninsula
Community Medical Centers
Corona Regional Medical Center
Cottage Health
Desert Valley Hospital
Dignity Health
District Hospital Leadership Forum
Dominican Hospital
Eastern Plumas Health Care
Eisenhower Health
Encompass Health Rehabilitation Hospital of Bakersfield
Enloe Medical Center
French Hospital Medical Center
Glendale Memorial Hospital and Health Center
Good Samaritan Hospital
Hazel Hawkins Memorial Hospital
Healdsburg District Hospital
Henry Mayo Newhall Hospital
John C. Fremont Healthcare District
John Muir Health
Kern Medical
Kern Valley Healthcare District
Kindred Hospital Baldwin Park
Kindred Hospital La Mirada
Kindred Hospital San Diego
Kindred Hospital San Francisco Bay Area
Kindred Hospital San Gabriel Valley
Kindred Hospital South Bay
Kindred Hospitals – California
Lompoc Valley Medical Center
Mammoth Hospital
Marian Regional Medical Center
Marin General Hospital
Mark Twain Medical Center
Marshall Medical Center
Mayers Memorial Hospital District
Memorial Hospital of Gardena
MemorialCare
Mendocino Coast District Hospital
Mercy General Hospital
Mercy Hospital of Folsom
Mercy Hospitals of Bakersfield
Mercy Medical Center
Mercy Medical Center Mt. Shasta
Mercy Medical Center Redding
Mercy San Juan Medical Center
Methodist Hospital of Sacramento
Methodist Hospital of Southern California
Monterey Park Hospital
Mountains Community Hospital
NorthBay Healthcare
Northridge Hospital Medical Center
Oak Valley Hospital District
Orchard Hospital
Palmdale Regional Medical Center
Palo Verde Hospital
Palomar Health
PIH Health
Plumas District Hospital
Pomona Valley Hospital Medical Center
Providence Little Company of Mary Medical Center San Pedro
Providence Little Company of Mary Medical Center Tarzana
Providence St. Joseph Health
Redlands Community Hospital
Ridgecrest Regional Hospital
Saint Agnes Medical Center
Saint Francis Memorial Hospital
San Antonio Regional Hospital
San Bernardino Mountains Community Hospital District
San Gorgonio Memorial Hospital
Scripps Health
Sequoia Hospital
Sharp Healthcare
Shasta Regional Medical Center
Sierra View Medical Center
Sierra Vista Hospital
Southern Humboldt Community Healthcare District and Jerold Phelps
Southwest Healthcare System
St. Bernardine Medical Center
St. Elizabeth Community Health
St. Joseph's Behavioral Health Center
St. Joseph's Medical Center, Stockton
St. Mary’s Medical Center
St. Rose Hospital
Stanford Health Care
Stanford Health Care - ValleyCare
Tahoe Forest Health System
Tenet Healthcare
Trinity Hospital
United Hospital Association
Vibra Hospital of Sacramento
Vista del Mar Hospital
Woodland Memorial Hospital
Two individuals
ARGUMENTS IN SUPPORT: This bill is sponsored by the California State Council of the Service Employees International Union (SEIU California) and the United Nurses Associations of California/Union of Health Care Professionals (UNAC/UHCP). According to SEIU California, despite the mandated nursing ratios, hospitals repeatedly violate nurse staffing requirements. According to SEIU California, when DPH discovers staffing requirement violations at a hospital, DPH administers a plan of correction, which has no administrative or criminal penalties attached to it. SEIU California states that DPH rarely circles back with facilities to ensure compliance, and violations continue. According to SEIU California, hospitals that routinely violate minimum staffing requirements jeopardize patient safety and quality of care. Moreover, SEIU California states that when nurses are coerced into unsafe staffing assignments, over their objections about patient safety, a nurse runs the risk of Board of Registered Nursing disciplinary action, and in many cases, losing their license. According to SEIU California, nurses reported that in 45% of the reported Assignment Despite Objection forms, hospitals required them to violate the ratios or risk discipline. SEIU California states that under the penalty structure in this bill, the State of California can improve healthcare quality by ensuring improved compliance with existing law. UNAC/UHCP points out in support that a peer reviewed study found that each additional patient per nurse increases the risk of patient mortality by 7%. UNAC/UHCP states that compliance with nurse staffing ratios has been demonstrated to improve patient outcomes, but many hospitals have refused to consistently adhere to the ratios. The California Nurses Association/National Nurses United (CNA) states in support that the nurse-to-patient ratios save lives. According to CNA, with the ratios nurses are able to spend more time delivering care at the bedside, and are more likely to identify and report changes in a patient’s condition early on, thereby avoiding many preventable complications. According to CNA, the regulations were adopted as the minimum staffing requirement, meant for the leanest staffing for the slowest shift when the patients were least acute. CNA states hospitals short-staff to save money, and this bill puts into statute the requirement to inspect for these patient protections and to penalize hospitals using a penalty that fits the violation.
ARGUMENTS IN OPPOSITION: The California Hospital Association (CHA) states in opposition that this bill eliminates DPH’s ability to link the penalty amount to the actual risk of harm to patients. According to CHA, ratios are mandated at all time, which means that when a nurse is late, calls in sick, or leaves early, there must be another nurse available to immediately replace that person, and consequently, it is not always possible to be in compliance at all times. Under this bill, CHA notes that the penalty for the first violation would be $30,000, and each additional penalty would be $60,000. CHA argues that administering these penalties, without consideration of the potential for patient harm, makes it clear that this bill is unnecessarily punitive. The Association of California Healthcare Districts (ACHD) also opposes this bill, arguing that DPH has established a robust process for determining fine amounts that considers the scope and severity of any noncompliance with licensing requirements, including staffing ratios, and this bill undermines DPH’s process without good reason. Numerous hospitals and health systems write in opposition with similar arguments.
Prepared by: Vincent D. Marchand / HEALTH / (916) 651-4111
5/1/19 15:33:18
SENATE COMMITTEE ON HEALTH
Senator Dr. Richard Pan, Chair
BILL NO: SB 227
AUTHOR: | Leyva | ||
VERSION: | February 7, 2019 | ||
HEARING DATE: | April 10, 2019 | ||
CONSULTANT: | Vincent D. Marchand | ||
SUBJECT: Health and care facilities: inspections and penalties
SUMMARY:
Requires periodic inspections of hospitals by the Department of Public Health to include reviews of compliance with nurse staffing ratios, and establishes administrative penalties for nurse staffing ratio violations of $30,000 for a first violation, and $60,000 for each subsequent violation.
Existing law:
- Licenses and regulates health facilities by the Department of Public Health (DPH), including general acute care hospitals, acute psychiatric hospitals, and special hospitals (hospitals). [HSC §1250, et seq.]
- Requires DPH to inspect for compliance with state laws and regulations during a state periodic inspection or at the same time as a federal periodic inspection. Requires the inspection for hospitals to be conducted no less than once every three years. [HSC §1279 (g)]
- Requires DPH to adopt regulations that establish minimum, specific, and numerical licensed nurse-to-patient ratios, by licensed nurse classification and by hospital unit, for hospitals, and requires these ratios to constitute the minimum number of registered and licensed nurses that must be allocated. [HSC §1276.4]
- Establishes a structure under which DPH is permitted to assess administrative fines to hospitals for violation of any of their licensing laws and regulations. Requires DPH to promulgate regulations establishing the criteria to assess these administrative penalties, and requires these criteria to include, but not be limited to, the probability and severity of the risk that the violation presents to the patient, the facility’s history of compliance with related state and federal statutes and regulations, the demonstrated willfulness of the violation, and the extent to which the facility detected the violation and took steps to immediately correct the violation and prevent the violation from recurring. [HSC §1280.3]
- Permits DPH to assess an administrative penalty against a hospital, for a deficiency constituting an immediate jeopardy violation, as defined, up to a maximum of $75,000 for the first administrative penalty, up to $100,000 for the second administrative penalty, and up to $125,000 for the third and every subsequent administrative penalty. [HSC §1280.3 (a)]
- Permits DPH to assess an administrative penalty of up to $25,000 per violation for those not deemed to constitute immediate jeopardy. Prohibits DPH from assessing an administrative penalty for minor violations. [HSC §1280.3 (b) and (c)]
- Defines “immediate jeopardy” as a situation in which the licensee’s noncompliance with one or more requirements of licensure has caused, or is likely to cause, serious injury or death to the patient. [HSC §1280.3 (h)]
- Requires DPH to have full discretion to consider all factors when determining the amount of an administrative penalty. [HSC §1280.3 (a)]
This bill:
- Requires that periodic DPH inspections of hospitals to ensure compliance with state laws and regulations include reviews of compliance with nurse staffing ratios. Prohibits a periodic inspection conducted to inspect compliance with nurse staffing ratios from being announced in advance, consistent with existing law that prohibits periodic inspections of health facilities from being announced in advance.
- Requires DPH to assess an administrative penalty of $30,000 for a hospital that violates a nurse staffing ratio regulation for the first time, and $60,000 for the second and each subsequent violation. Specifies that multiple violations found on the same inspection survey constitutes a single violation for purposes of determining whether the violation was a first, second or subsequent violation, and that a violation occurring more than six years after the date of the last violation is to be treated as a first violation.
- Permits DPH, without taking any regulatory actions, to implement, interpret, or make specific this bill by means of an All Facilities Letter or similar instruction.
- Requires all penalties collected by DPH under this bill to be deposited into DPH’s Licensing and Certification Program Fund, as specified, and requires penalty revenues to be expended solely for the purpose of enforcing nurse staffing regulations.
- Includes this new nurse staffing ratio penalty provision in a provision of existing law that requires DPH to take into consideration the special circumstances of small and rural hospitals when taking enforcement action in order to protect access to quality care in those hospitals.
FISCAL EFFECT:
This bill has not been analyzed by a fiscal committee.
COMMENTS:
- Author’s statement. According to the author, this bill will empower DPH to enforce the legally mandated nurse-to-patient staffing ratios and therefore improve healthcare quality in California hospitals and make sure that patients receive the care they need and deserve. It has been reported that many California hospitals disregard the current nurse-to-patient ratio requirement of Title 22 regulations. The state must take a more proactive role by conducting unannounced visits at hospitals across California and ensuring that it fully enforces existing law because the stakes are simply too high for patients. It is also important that penalties are increased against repeat offender hospitals that do not comply with existing law. Moreover, beyond the clear safety implications of hospitals not observing ratio requirements, nurses can also be putting their professional livelihoods and licenses at risk due to being required to fulfill job duties outside of legally prescribed ratios.
- Nurse to patient ratios and patient classification systems. In 2004, regulations implementing nurse-to-patient ratios in California hospitals pursuant to AB 394 (Kuehl, Chapter 945, Statutes of 1999) went into effect. However, long before California had specific nurse-to-patient ratios, hospitals were required by regulation to establish a patient classification system. This patient classification system is a method by which hospitals establish staffing requirements by unit, patient, and shift, and includes a method by which the amount of nursing care needed for each category of patient is validated for each unit.
The regulations implementing the AB 394 nurse-to-patient ratios law set the minimum ratio of nurses to patient by unit, including one-to-one in operating rooms, one-to-two in intensive care units, and one-to-five in general medical-surgical units. These regulations also incorporated the patient classification system requirement. In essence, the specific nurse-to-patient ratios establish the minimum number of nurses by unit, while the patient classification system determines whether there needs to be a higher level of staffing beyond the minimum ratio after taking into consideration factors such as the severity of the illness, the need for specialized equipment and technology, and the complexity of clinical judgment needed to evaluate the patient care plan, among other factors. The nurse-to-patient ratio regulations require that the minimum ratios must be met at all times.
Finally, the regulations require the reliability of the patient classification system for validating staffing requirements to be reviewed at least annually by a committee appointed by the nursing administrator to determine whether the system accurately measures patient care needs. At least half of the members of this committee are required to be registered nurses who provide direct patient care. - DPH enforcement of nurse-to-patient staffing requirements. According to DPH, from 2008 to 2017, there have been a total of 634 nursing staff violations cited by DPH. In the most recently completed fiscal year (2016-17, there were 88 nursing staff violations. The most common units where DPH found staffing violations were the telemetry units (which is required to be at 1:5 nurse to patient ratio), medical/surgical units (1:5 ratio), and critical care units (1:2 ratio). DPH states that compliance with nurse staffing ratios is reviewed during the relicensing survey that is conducted every three years. Additionally, if a complaint is submitted, DPH will assign this to a nurse surveyor for investigation, and if patient care was affected due to the staffing ratio, a statement of deficiencies will be written and along with a request for a plan of correction. According to DPH, if there are negative patient outcomes and serious consequences due to staffing issues, then DPH will conduct a complaint validation survey.
In October of 2010, at a hearing of the Senate Health Committee on DPH’s implementation of the nurse staffing ratio law, DPH reported that it had issued 465 deficiencies since January 2004 related to nurse staffing ratio. Because this was prior to the adoption of regulations governing administrative fines, the only monetary penalty available to DPH at the time were “immediate jeopardy” penalties of $25,000, $50,000, and $75,0000 for first, second, and subsequent violations (these penalty amounts have since been increased). DPH reported that during this time period it had issued two penalties of $25,000 each for staffing violations that it determined constituted immediate jeopardy to patients. - Administrative penalties for hospitals. SB 1312 (Alquist, Chapter 895, Statutes of 2006) gave DPH the authority to assess administrative penalties for violations of the laws pertaining to the licensing of hospitals. Prior to SB 1312, DPH had very limited authority to levy fines on hospitals that violated state licensing laws. SB 1312 created two levels of penalties: violations that constituted immediate jeopardy to the health and safety of a patient, and violations that do not constitute immediate jeopardy. SB 541 (Alquist, Chapter 605, Statutes of 2008), modified the administrative penalty provisions, and increased the fine amounts. Immediate jeopardy violations are now subject to a fine of up to up to $75,000 for the first penalty, $100,000 for the second penalty, and $125,000 for the third and subsequent penalties. All other violations (except minor violations, for which DPH is prohibited from assessing a violation) are subject to a fine of up to $25,000.
SB 1312 required DPH to promulgate regulations establishing the criteria to assess administrative penalties, and listed eight factors on which to base the criteria, including the patient’s physical and mental condition, the nature, scope and severity of the violation, and the demonstrated willfulness of the violation. DPH adopted these regulations in late 2013, and they went into effect on April 1, 2014. These regulations established the penalty matrix in the table below, which can be modified upward or downward according to certain specified factors. The percentages in the table below are to be applied to the statutory maximum penalty amounts as described in 5) and 6) of existing law above:
SCOPE | ||||
Isolated | Pattern | Widespread | ||
S V I T Y | Severity Level 6— Immediate jeopardy to patient health or safety—Death | 100% | 100% | 100% |
Severity Level 5— Immediate jeopardy to patient health or safety—Serious injury | 60% | 70% | 80% | |
Severity Level 4— Immediate jeopardy to patient health or safety—Likely to cause serious injury or death | 40% | 50% | 60% | |
Severity Level 3— Actual patient harm that is not immediate jeopardy | 60% | 80% | 100% | |
Severity Level 2— No actual patient harm but with potential for more than minimal harm, not immediate jeopardy | 20% | 50% | 70% | |
Severity Level 1— No actual patient harm but with potential for no more than minimal harm | No penalty | |||
Minor Violation | No penalty | |||
- Prior legislation. SB 1288 (Leyva of 2018) substantially similar to this bill, requires periodic inspections of hospitals by the DPH to include reviews of compliance with nurse staffing ratios, and establishes administrative penalties for nurse staffing ratio violations of $15,000 for a first violation, and $30,000 for subsequent violations. SB 1288 was vetoed by Governor Brown, who stated:
California hospitals are regularly inspected to assure patient safety and quality of care. When violations are found, penalties are imposed based on an overall assessment of the severity and duration of the violations, including for any failure to meet the required staffing ratio.
Nurse-to-patient ratios are a vital part of the state's regulatory scheme. Hospitals, however, are best evaluated in a comprehensive manner and I am reluctant to start singling out specific violations for a separate penalty.
SB 455 (Hernandez of 2013) would have codified existing regulations requiring hospitals to have a committee annually review the reliability of its patient classification system, including regulations requiring at least one-half of this committee be composed of registered nurses (RNs) who provide direct patient care. This bill required the RNs appointed to this committee to be selected by the collective bargaining agent, if any. SB 455 would have required DPH, during every periodic state inspection of a hospital, to inspect for compliance with nurse-to-patient ratios, as specified. SB 455 was vetoed by Governor Brown, that stated that it restated existing law, which requires DPH to inspect hospital compliance with nurse-to-patient rations, and that the bill directs decisions that are best left at the local level.
SB 1246 (Hernandez of 2012) contained similar provisions to SB 455. SB 1246 was vetoed by Governor Brown, who stated that DPH would soon release proposed regulations on administrative penalties that would apply to a broad range of violations.
SB 554 (Yee of 2011) would have required DPH to inspect for compliance with nurse-to-patient staffing ratios during periodic inspections of hospitals, similar to this bill. SB 554 also proposed to require DPH to inspect hospitals that have been cited for deficiencies related to nurse-to-patient staffing ratios for their compliance with the plan of correction. SB 554 also would have required DPH to assess administrative penalties for violations of nurse-to-patient staffing ratios and for failure to comply with an approved plan of correction related to nurse-to-patient ratios. The penalties included a $10,000 penalty for the fourth and each subsequent violation of the nurse-to-patient ratio requirements within a six-month period, and $10,000 for the failure of the hospital to comply with an approved plan of correction. These provisions were later amended out of SB 455.
SB 360 (Yee of 2009) would have required each new direct care registered nursing hire to receive and complete an orientation to the hospital and patient care unit in which he or she will be working. Nurses who have not completed this orientation would not be allowed to be assigned to direct patient care or be counted as staff in computing nurse-to-patient ratios. SB 360 was held on the Senate Appropriations suspense file.
SB 541 increased the level of administrative penalties DPH may assess against hospitals, including for deficiencies that constitute immediate jeopardy to the health or safety of patients. Required health care facilities to prevent unlawful or unauthorized access to use, or disclosure of, patients' medical information, and to established safeguards protecting the privacy of patients' medical information.
SB 1312 authorizes DPH to assess administrative penalties on hospitals for deficiencies constituting immediate jeopardy to the health and safety of a patient and those that do not constitute immediate jeopardy to patients.
AB 394 required DPH to adopt regulations specifying nurse-to-patient ratios, by unit, for general acute care hospitals, acute psychiatric hospitals and special hospitals. Required hospitals to adopt written policies and procedures for nursing staff training. Provided that the ratios shall constitute the minimum number of registered and licensed nurses that must be provided; requires hospitals to assign additional staff in accordance with a documented patient classification system.
- Support. This bill is sponsored by the California State Council of the Service Employees International Union (SEIU California) and the United Nurses Associations of California/Union of Health Care Professionals (UNAC/UHCP). According to SEIU California, despite the mandated nursing ratios, hospitals repeatedly violate nurse staffing requirements. According to SEIU California, when DPH discovers staffing requirement violations at a hospital, DPH administers a plan of correction, which has no administrative or criminal penalties attached to it. SEIU California states that DPH rarely circles back with facilities to ensure compliance, and violations continue. According to SEIU California, hospitals that routinely violate minimum staffing requirements jeopardize patient safety and quality of care. Moreover, SEIU California states that when nurses are coerced into unsafe staffing assignments, over their objections about patient safety, a nurse runs the risk of Board of Registered Nursing disciplinary action, and in many cases, losing their license. According to SEIU California, nurses reported that in 45% of the reported Assignment Despite Objection forms, hospitals required them to violate the ratios or risk discipline. SEIU California states that under the penalty structure in this bill, the State of California can improve healthcare quality by ensuring improved compliance with existing law. UNAC/UHCP points out in support that a peer reviewed study found that each additional patient per nurse increases the risk of patient mortality by 7%. UNAC/UHCP states that compliance with nurse staffing ratios has been demonstrated to improve patient outcomes, but many hospitals have refused to consistently adhere to the ratios.
The California Nurses Association/National Nurses United (CNA) states in support that the nurse-to-patient ratios save lives. According to CNA, with the ratios nurses are able to spend more time delivering care at the bedside, and are more likely to identify and report changes in a patient’s condition early on, thereby avoiding many preventable complications. According to CNA, the regulations were adopted as the minimum staffing requirement, meant for the leanest staffing for the slowest shift when the patients were least acute. CNA states hospitals short-staff to save money, and this bill puts into statute the requirement to inspect for these patient protections and to penalize hospitals using a penalty that fits the violation. - Opposition. The California Hospital Association (CHA) states in opposition that this bill would eliminate DPH’s ability to link the penalty amount to the actual risk of harm to patients. According to CHA, ratios are mandated at all time, which means that when a nurse is late, calls in sick, or leaves early, there must be another nurse available to immediately replace that person, and consequently, it is not always possible to be in compliance at all times. Under this bill, CHA notes that the penalty for the first violation would be $30,000, and each additional penalty would be $60,000. CHA argues that administering these penalties, without consideration of the potential for patient harm, makes it clear that this bill is unnecessarily punitive. The Association of California Healthcare Districts (ACHD) also opposes this bill, arguing that DPH has established a robust process for determining fine amounts that considers the scope and severity of any noncompliance with licensing requirements, including staffing ratios, and this bill undermines DPH’s process without good reason. Numerous hospitals and health systems write in opposition with similar arguments.
SUPPORT AND OPPOSITION:
Support: California State Council of the Service Employees International Union (co-sponsor)
United Nurses Associations of California/Union of Health Care Professionals (co-sponsor)
American Federation of State, County, and Municipal Employees, AFL-CIO
California Labor Federation, AFL-CIO
California Nurses Association/ National Nurses United, AFL-CIO
California Professional Firefighters
California School Employees Association, AFL-CIO
California School Nurses Organization
California Teamsters Public Affairs Council
Congress of California Seniors
Consumer Attorneys of California
Engineers and Scientists of California Local 20
International Longshore and Warehouse Union, Local 13
San Francisco Aids Foundation
Oppose: Adventist Health Clear Lake Medical Center
Adventist Health Bakersfield
Adventist Health Glendale
Adventist Health Hanford
Adventist Health Sonora
Alliance of Catholic Health Care
Alta Hospitals System
Association of California Healthcare Districts
Aurora Vista del Mar
Bakersfield Memorial Hospital
Ballard Rehabilitation Hospital
Banner Lassen Medical Center
Barlow Respiratory Hospital
Bear Valley Community Healthcare District
Beverly Hospital
California Chamber of Commerce
California Children’s Hospital Association
California Hospital Association
Canyon Ridge Hospital
Cedars-Sinai Medical Center
Centinela Hospital Medical Center
Chinese Hospital
Chino Valley Medical
Community Hospital of Huntington Park
Community Hospital of the Monterey Peninsula
Community Hospital of San Bernardino
Community Medical Centers
Corona Regional Medical Center
Cottage Health
Desert Valley Hospital
Dignity Health
District Hospital Leadership Forum
Dominican Hospital
Eastern Plumas Health Care
Eisenhower Health
Encompass Health Rehabilitation Hospital of Bakersfield
Enloe Medical Center
French Hospital Medical Center
Glendale Memorial Hospital and Health Center
Good Samaritan Hospital
Good Samaritan Hospital - Los Angeles
Hazel Hawkins Memorial Hospital
Healdsburg District Hospital
Henry Mayo Newhall Hospital
Hoag Hospital Irvine
Hoag Memorials Hospital Presbyterian
Hospital Corporation of America
Inland Valley
John C. Fremont Healthcare District
John Muir Health
John Muir Medical Center - Concord
John Muir Medical Center – Walnut Creek Campus
Kentfield Hospital
Kern Medical
Kern Valley Healthcare District
Kindred Hospitals – California
Kindred Hospital - Baldwin Park
Kindred Hospital La Mirada
Kindred Hospital San Diego
Kindred Hospital San Francisco Bay Area
Kindred Hospital San Gabriel Valley
Kindred Hospital South Bay
Lompoc Valley Medical Center
Long Beach Memorial
Los Angeles Community Hospital at Bellflower
Los Angeles Community Hospital at Los Angeles
Los Angeles Community Hospital at Norwalk
Mammoth Hospital
Marian Regional Medical Center
Marin General Hospital
Mark Twain Medical Center
Marshall Medical Center
Mayers Memorial Hospital District
MemorialCare
Memorial Hospital of Gardena
Mendocino Coast District Hospital
Mercy General Hospital
Mercy Hospital of Folsom
Mercy Hospitals of Bakersfield
Mercy Medical Center
Mercy Medical Center Mt. Shasta
Mercy Medical Center Redding
Mercy San Juan Medical Center
Methodist Hospital of Sacramento
Methodist Hospital of Southern California
Miller Children's & Women's Hospital Long Beach
Mission Hospital Laguna Beach
Mission Hospital Mission Viejo
Monterey Park Hospital
Mountains Community Hospital
Mountain Communities Healthcare District
NorthBay Healthcare
Northridge Hospital Medical Center
Oak Valley Hospital District
Orange Coast Memorial Medical Center
Orchard Hospital
Palmdale Regional Medical Center
Palo Verde Hospital
Palomar Health
Petaluma Valley Hospital
PIH Health
PIH Health Hospital - Downey
PIH Health Hospital - Whittier
Plumas District Hospital
Pomona Valley Hospital Medical Center
Providence Holy Cross Medical Center
Providence Little Company of Mary Medical Center San Pedro
Providence Little Company of Mary Medical Center Tarzana
Providence Saint John's Health Center
Providence St. Joseph Health
Providence Tarzana Medical Center
Queen of the Valley Medical Center
Rancho Springs Medical Centers
Redlands Community Hospital
Redwood Memorial Hospital
Ridgecrest Regional Hospital
Saddleback Memorial Medical Center
Shasta Regional Medical Center
Saint Agnes Medical Center
Saint Francis Memorial Hospital
San Bernardino Mountains Community Hospital District
San Gorgonio Memorial Hospital
San Joaquin Valley Rehabilitation Hospital
Santa Rosa Memorial Hospital
Scripps Green Hospital
Scripps Health
Scripps Memorial Hospital - Encinitas
Scripps Memorial Hospital - La Jolla
Scripps Mercy Hospital
Scripps Mercy Hospital Chula Vista
Sequoia Hospital
Sharp Chula Vista Medical Center
Sharp Coronado Hospital and Healthcare Center
Sharp Grossmont Hospital
Sharp Healthcare
Sharp Mary Birch Hospital for Women & Newborns
Sharp Memorial Hospital
Sharp Mesa Vista Hospital
Shasta Regional Medical Center
Sierra View Medical Center
Sierra Vista Hospital
Southern Humboldt Community Healthcare District and Jerold Phelps Community Hospital
Southwest Healthcare System
St. Bernardine Medical Center
St. Elizabeth Community Health
St. Joseph Hospital, Eureka
St. Joseph Hospital, Orange
St. Joseph's Behavioral Health Center
St. Joseph's Medical Center
St. Jude Medical Center
St. Mary’s Medical Center
St. Rose Hospital
Stanford Health Care
Stanford Health Care - ValleyCare
Tahoe Forest Health System
Tenet Healthcare
Trinity Hospital
United Hospital Association
Vibra Hospital of Northern California
Vibra Hospital of Sacramento
Vibra Hospital of San Diego
Vista del Mar Hospital
Woodland Memorial Hospital
Two Individuals
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Bill Author
