Date of Hearing: July 2, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 590

Author:(Stone) – As Amended Ver:March 27, 2019

SENATE VOTE: 38-0

SUBJECT: Mental health evaluations: gravely disabled due to impairment by chronic alcoholism.

SUMMARY: Adds persons with chronic alcoholism to the existing prepetition screening process in the Lanterman-Petris-Short (LPS) Act that permits any individual to request a county-designated entity to provide a comprehensive screening to determine if the person impaired by chronic alcoholism is a danger to self or others, or gravely disabled.

EXISTING LAW:

1. Establishes the LPS Act to end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorders, developmental disabilities, and chronic alcoholism, as well as to safeguard a person’s rights, provide prompt evaluation and treatment, and provide services in the least restrictive setting appropriate to the needs of each person.
2. Defines “gravely disabled” as a condition in which a person, as a result of a mental disorder or impairment by chronic alcoholism, is unable to provide for their basic personal needs for food, clothing, or shelter, or a condition in which a person has been found mentally incompetent, as specified, for purposes of detaining the person for assessment, evaluation, and treatment; providing a court-ordered evaluation, as specified; certifying the person for intensive treatment; and, placing the person under conservatorship.
3. Defines the phrase “a danger to himself or herself or others, or gravely disabled” throughout the LPS Act to refer also to the condition of being a danger to self or others, or gravely disabled, as a result of the use of controlled substances rather than by mental disorder.
4. Permits any individual to apply to the person or agency designated by the county for a “prepetition screening,” as defined, alleging that there is in the county another person who is, as a result of mental disorder or the use of controlled substances, a danger to self or others, or is gravely disabled, and requesting that an evaluation of the person’s condition be made.
5. Authorizes a person to be involuntarily detained for a period of up to 72 hours (commonly referred to as a 5150 hold) by a peace officer or other authorized person for assessment, evaluation, and crisis intervention, when, as a result of a mental disorder, chronic alcoholism, or use of controlled substances, as specified, the person is a danger to self or others, or is gravely disabled.
6. Permits a person to be certified for not more than 14 days of intensive treatment related to a mental health disorder or impairment by chronic alcoholism after being placed on a 5150 hold if professional staff of an agency or facility providing evaluation services has found the person to be a danger to self or others, or gravely disabled; the facility providing intensive treatment is designated by the county to provide intensive treatment, as specified, and agrees to admit the person; and, the person has been advised of the need for treatment but has not been willing or able to accept treatment voluntarily.
7. Permits a conservator of a person, or the estate, or of both the person and the estate, to be appointed for a person who is gravely disabled as a result of a mental health disorder or impairment by chronic alcoholism.
8. Permits, until January 1, 2024, San Diego, San Francisco, and Los Angeles Counties to place in a conservatorship, as specified, a person who is incapable of caring for his or her own health and well-being due to serious mental illness and substance use disorder (SUD), as specified.
9. Deems a person not to be gravely disabled, for purposes of an involuntary hold for up to an additional 14-day intensive treatment and appointing a conservator, if the person can survive safely without involuntary detention with the help of responsible family, friends, or others who are both willing and able to help provide the person’s basic personal needs for food, clothing, or shelter.
10. Defines “prepetition screening” as a screening of all petitions for court-ordered evaluations, which are initiated by any person who suspects another person is gravely disabled or a danger to self or others due to a mental disorder or use of controlled substances. Prepetition screenings consist of a professional review of all petitions and an interview with the petitioner and the person alleged to be gravely disabled or a danger to self or others. Requires a prepetition screening to include efforts to persuade a person to receive, on a voluntary basis, comprehensive evaluation, crisis intervention, referral, and other services specified in the LPS Act.

FISCAL EFFECT: According to the Senate Appropriations Committee, there are unknown, potentially-significant costs to county-designated persons and agencies tasked to conduct prepetition screenings whenever requested by persons who allege that a person is gravely disabled as a result of chronic alcoholism. Even if implementation or workload costs to each county to conduct the screenings are as low as $1,000, costs associated with this measure would exceed $50,000. Local costs to comply with this measure would be subject to reimbursement by the state to the extent that the Commission on State Mandates determines that this bill imposes a state-mandated local program. (General Fund/local funds)

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill provides another tool in the tool box to try and help those who suffer with chronic alcoholism. Alcohol consumption is a major part of contemporary American life. However, alcohol dependence and abuse imposes an enormous burden on individuals, families, and our State. Alcohol abuse has serious medical consequences, including cardiovascular disease, hypertension, diabetes, liver disease, fetal abnormalities, and cancer. In the U. S., about 5% of all deaths are attributed to alcohol misuse. It is also estimated that $184.6 billion is spent every year in the U.S. on alcohol related problems like lost productivity due to alcohol-related illness, health care expenditures, motor vehicle crashes, crime, and other social costs. Closer to home, in 2018, about 19% of Californians reported either binge drinking or chronic drinking. This bill amends the LPS Act by including those suffering from chronic alcoholism in the existing prepetition screening process. This inclusion would therefore allow any person to petition to a county designated entity to have an individual suffering from chronic alcoholism who is suspected of being a danger to themselves or others, or is gravely disabled, to be screened and assessed for the purposes of initiating a 5150 hold, intensive treatment, or conservatorship, if necessary. The author concludes, this bill is a small change in the already existing framework of the law in order to give hope and save one more life.
2. BACKGROUND.
   1. LPS Act. The LPS Act provides for involuntary commitment for varying lengths of time for the purpose of treatment and evaluation, provided certain requirements are met. Additionally, the LPS Act provides for LPS conservatorships, resulting in involuntary commitment for the purposes of treatment if an individual is found to meet the criteria of being a danger to themselves or others or is gravely disabled as defined. Typically one first interacts with the LPS Act through what is known as a 5150 hold, which allows a peace officer or other authorized individual as specified to commit a person for an involuntary detention of 72 hours for evaluation and treatment if they are determined to be, as a result of a mental health disorder, a threat to self or others, or gravely disabled. The peace officer or other authorized individual who initially detains the individual must determine and document that the individual meets this standard. When making the determination, the peace officer or other authorized person may consider the individual’s historical course, which includes evidence presented by a person who has provided or is providing mental health or related support services to the person on the 5150 hold; evidence presented by one or more members of the family of the person on the 5150 hold; and, evidence presented by the person on the 5150 hold, or anyone designated by that person, if the historical course of the person’s mental disorder has a reasonable bearing on making a determination that the person requires a 5150 hold.

Following the 72-hour detention, a person may be certified for intensive treatment, which initially permits a person to be held for an additional period not to exceed 14-days, without court review, if they are found to still be a danger to self or others, or gravely disabled. When determining whether the person is eligible for a 14-day detention, the professional staff of the agency or facility providing evaluation services must find that the person has been advised of the need for, but has not been willing or able to accept, treatment on a voluntary basis. A notice of certification is required for all persons certified for intensive treatment, and a copy of the notice for certification is required to be personally delivered to the person certified, the person’s attorney, or the attorney or advocate, as specified. If after the initial 14 days a person is still found to remain gravely disabled and unwilling or unable to accept voluntary treatment, the person may be certified for an additional period of not more than 30 days of intensive treatment. A person cannot be found at this point to be gravely disabled if they can survive safely without involuntary detention with the help of responsible family, friends, or others who indicate they are both willing and able to help. 

The LPS Act provides for a conservator of the person, of the estate, or of both the person and the estate for a person who is gravely disabled as a result of a mental health disorder or impairment by chronic alcoholism or use of controlled substances. The person for whom such a conservatorship is sought has the right to demand a court or jury trial on the issue of whether they meet the gravely disabled requirement. The purpose of an LPS conservatorship is to provide individualized treatment, supervision, and placement for the gravely disabled person. Current law also deems a person as not being gravely disabled for purposes of a conservatorship if they can survive safely without involuntary detention with the help of responsible family, friends, or others who indicate they are both willing and able to help. SB 1045 (Wiener and Stern), Chapter 845, Statutes of 2018, established, under a five-year pilot project in San Francisco, Los Angeles, and San Diego Counties, a conservatorship process for individuals who are incapable of caring for their own health and well-being due to a serious mental illness and SUD as evidenced by “frequent detention” for evaluation and treatment under 72-hour (5150) involuntary detentions. Frequent detention is defined as having eight or more 72-hour detentions in the preceding 12 months.

• 1. Prepetition screenings. The LPS Act also contains a provision that permits any individual to apply to a county-designated person or agency for a petition alleging that there is in the county a person who is, as a result of a mental disorder or use of controlled substances, a danger to self or others, or is gravely disabled, and requesting that an evaluation of the person’s condition be made. Prior to filing the petition, the county-designated person or agency is required to request a county-designated person or agency that is also approved by DHCS to provide a prepetition screening to determine if there is probable cause to believe the allegations, including conducting an investigation and making a reasonable effort to personally interview the subject of the petition. The screening is also required to include a determination whether or not the person who is the subject of the petition will agree to voluntarily receive crisis intervention services, referral, or a comprehensive evaluation in his or her own home or in a county-designated facility. A petition can proceed if the county-designated individual determines there is probable cause to believe a person is a danger to self or other, or gravely disabled, and the person will not voluntarily receive evaluation or crisis intervention. The processes outlined in the LPS Act for involuntary detention, intensive treatment, and conservatorship also apply in this situation, if deemed necessary. The LPS Act specifies that if any individual who seeks a petition for court-ordered evaluation against a person knows that the person who is the subject of a petition is not a danger to self or others, or gravely disabled, the individual who sought the petition is guilty of a misdemeanor and may be held liable in civil damages by the person against whom the petition was sought.
  2. Joint Legislative Audit Committee (JLAC). At its June 26, 2019, hearing, JLAC approved a request by Senator Henry Stern to conduct a comprehensive audit of the LPS Act. The goal of the audit is to examine the application of LPS laws throughout the state to determine if any updates, clarifications or improvements are needed to ensure the equal application of California’s mental health commitment procedures. Because each county has its own administrative infrastructure, budget, and significantly different levels and types of mental health services available, this audit should ultimately result in a better understanding of how California’s involuntary patient population is being determined and how they are receiving care.

The audit will select three counties, including Los Angeles County and two counties chosen by the State Auditor and will include, but not be limited to the following:

• • 1. A review and evaluation of the laws, rules, and regulations significant to the audit objectives;
    2. A review of the statewide oversight of the implementation of the LPS Act;
    3. Collection of specific LPS data for each of the counties for the most recent three years, including the following:
       1. Number of individuals placed under involuntary holds, referral sources for those holds and number of individuals placed under consecutive initial holds;
       2. The number of individuals placed under subsequent holds;
       3. The number of individual placed into new and renewed conservatorships;
       4. The average length of conservatorships; and,
       5. The number of terminated conservatorships and the reasons for the termination;
    4. An assessment of the counties’ implementation of the LPS Act for the last three years and comparison of the counties to one another by reviewing at least the following:
       1. The counties’ definition of the criteria for involuntary treatment holds (probable cause, mental disorder, and danger to self or others, grave disability) and whether each county has consistently applied its definitions; and,
       2. The counties’ criteria for placing individuals into conservatorship and making least restrictive environment determinations, and whether the counties have consistently followed those criteria.
    5. A determination of how the counties fund their implementation of the LPS Act and whether access to funding is a barrier to LPS implementation;
    6. An assessment of the availability of treatment resources in each county and to the extent possible determination of whether there are barriers to achieving the intent of the LPS Act; and,
    7. A review and assessment of any other issues that are significant to the audit.

1. SUPPORT. Tenent Health (TH) states they support the ability of families, friends and others involved in the lives of patients in crisis to seek support in order to compel appropriate treatment. On any given day, most hospital emergency departments (EDs) are impacted by a high number of homeless, involuntary 5150 mental health holds. TH notes that it is also true that California’s healthcare system lacks a coordinated system of support, so we welcome any efforts to facilitate placement and coordination of services.
2. OPPOSITION. Disability Rights Commission (DRC) is opposed to this bill and they state that however well-intended this bill may be, it ignores that coerced and involuntary treatment is ineffective and often dangerous. The bill is also premised on the presumption that family members should guide the course of identification and treatment of adult substance abuse disorders. As a general rule, family members mostly lack the knowledge, qualifications and unemotional discretion in determining the existence and the appropriate course of treatment of the substance abuse disorder needs of their relatives. DRC notes that the LPS Act has continuously served to balance an individual’s need for involuntary treatment and limits on an individual’s rights to independence and self-determination. This bill, an amendment to LPS, fails to strike the appropriate balance that has been the hallmark of the Act. It tips heavily against individual rights and self-determination. DRC concludes that it supports treatment that is based on the recovery model and is self-directed, empowering, peer supported, and self-empowering. This bill lacks those principles.
3. RELATED LEGISLATION.
   1. AB 1275 (Santiago) requires each county to establish an outreach team to provide outreach services to individuals with a history of mental illness or SUD who are unable to provide for urgently needed medical care and who are homeless or at risk of experiencing homelessness. AB 1275 is pending in the Senate Health Committee.
   2. AB 1572 (Chen) and SB 640 (Moorlach) change the definition of “gravely disabled” to mean a condition in which a person, as a result of a mental health disorder, is incapable of making informed decisions about, or providing for, the person’s own basic personal needs for food, clothing, shelter without significant supervision and assistance from another person and, as a result of being incapable of making these informed decisions, the person is at risk of substantial bodily harm, dangerous worsening of a concomitant serious physical illness, significant psychiatric deterioration, or mismanagement of the person’s essential needs that could result in bodily harm. AB 1572 is currently pending in the Assembly Health Committee and SB 640 is pending in the Senate Health Committee.
   3. SB 40 (Wiener) authorizes a court to establish a temporary conservatorship for individuals who are incapable of caring for their own health and well-being due to a serious mental illness and SUD for a period of 30 days or less if the court is satisfied of the necessity, as specified. Makes conservatorships for those individuals subject to a finding by the court that the behavioral health director or the director’s designee has previously attempted to obtain the above-described court order and that the petition was denied, as specified, has evaluated whether assisted outpatient treatment is appropriate for the person and concluded that the person is not eligible for that treatment or that the treatment would be insufficient to treat the person in lieu of a conservatorship. SB 40 is pending in the Assembly Judiciary Committee.
4. PREVIOUS LEGISLATION.
   1. AB 1971 (Santiago, Friedman, and Chen) of 2018, would have expanded the definition of “gravely disabled” in existing law until January 1, 2024, as implemented in the County of Los Angeles, to include a person’s inability to provide for his or her basic personal needs for medical treatment, as specified, and contained specified reporting requirements. AB 1971 died on the Senate inactive file.
   2. AB 2099 (Gloria), Chapter 258, Statutes of 2018, requires a copy of the application required under existing law that states the circumstances under which a person’s condition was called to the attention of an authorized person to place a 5150 hold to be treated as the original.

SB 1045 (Wiener and Stern) establishes a five-year pilot project in San Francisco, Los Angeles, and San Diego Counties, a conservatorship process for individuals who are incapable of caring for their own health and well-being due to a serious mental illness and SUD as evidenced by “frequent detention” for evaluation and treatment under a 72-hour (5150) involuntary holds. Defines frequent detention as having eight or more 72-hour involuntary detention in the preceding 12 months.

• 1. SB 565 (Portantino), Chapter 218, Statutes of 2017, requires a mental health facility to make reasonable attempts to notify family members or any other person designated by the patient at least 36 hours prior to a review hearing for certification to be held involuntarily for an extended 14 days or 30 days, after an initial 5150 hold, as specified.
  2. AB 191 (Wood), Chapter 184, Statutes of 2017, adds licensed marriage and family therapists and licensed professional clinical counselors to the list of authorized health providers permitted to sign a notice of certification when a patient is certified as needing intensive treatment pursuant to a 5150 hold.
  3. AB 1539 (Chen) of 2017 would have expanded the definition of “gravely disabled” to include an individual who is unable to provide for his or her basic need for medical care as a result of a mental health disorder or chronic alcoholism. AB 1539 was not heard in the Assembly Health Committee.
  4. AB 1194 (Eggman), Chapter 570, Statutes of 2015, requires, for purposes of determining whether a person is a danger to self or others, an individual making that determination to consider available relevant information about the historical course of the person’s mental disorder if the individual concludes that the information has a reasonable bearing on the determination, and that the individual shall not be limited to consideration of the danger of imminent harm.
  5. SB 364 (Steinberg), Chapter 567, Statues of 2014, makes several changes to the LPS Act regarding involuntary commitment that ensures clarity and consistency in the 5150 process to enable people with a mental health disorder or chronic alcoholism to obtain assessment, referral, and treatment as appropriate in the least restrictive setting as possible; broadened the types of facilities a county can designate for 5150 purposes; and encouraged counties to provide training of personnel authorized to write and release 5150 holds.
  6. AB 1800 (Thompson and Perata) of 2000 would have, among other things, expanded the definition of “gravely disabled” to include when, as a result of a mental disorder, a person has an acute risk of physical or psychiatric harm to self in the absence of treatment. AB 1800 was held in the Senate Rules Committee, and the subject matter of the bill was referred to the Joint Committee on Mental Health Reform.’

1. POLICY COMMENT. The Joint Legislative Audit Committee at its June 26, 2019, meeting approved a request by Senator Henry Stern to conduct an audit of the LPS Act. The goal of the audit is to examine the application of the LPS laws throughout the state to determine if any updates, clarifications or improvements are needed to ensure the equal application of California’s mental health commitment procedures. The proposed audit will select three counties, including Los Angeles County and two counties chosen by the State Auditor and will include, but not be limited to the following:
   1. A review and evaluation of the laws, rules, and regulations significant to the audit objectives;
   2. A review of the statewide oversight of the implementation of the LPS Act;
   3. Collection of specific LPS data for each of the counties for the most recent three years including, but not limited to:
      1. Number of individuals placed under involuntary holds, referral sources for those holds and number of individuals placed under consecutive initial holds;
      2. the number of individual placed into new and renewed conservatorships; and,
      3. the average length of conservatorships;
   4. An Assessment of the counties’ implementation of the LPS Act for the last three years and comparison of the counties to one another;
   5. Determination of how the counties fund their implementation of the LPS Act and whether access to funding is a barrier to LPS implementation;
   6. Assessment of the availability of treatment resources in each county and to the extent possible determination of whether there are barriers to achieving the intent of the LPS Act; and,
   7. A review and assessment of any other issues that are significant to the audit.

REGISTERED SUPPORT / OPPOSITION:

Support

Advocates for Responsible Treatment
City of Santa Monica
Tenet Healthcare Corporation

Opposition

California Association of Public Administrators, Public Guardians and Public Conservators
California State Council of Service Employees
Disability Rights California
Los Angeles Dependency Lawyers, Inc.
Mental Health America of Los Angeles

Analysis Prepared by: Judith Babcock / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SB 590

Author: Stone (R)

Amended: 3/27/19

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 4/3/19

AYES: Pan, Stone, Durazo, Hurtado, Leyva, Mitchell, Monning, Rubio

NO VOTE RECORDED: Grove

SENATE JUDICIARY COMMITTEE: 9-0, 4/23/19

AYES: Jackson, Borgeas, Allen, Caballero, Jones, Monning, Stern, Umberg, Wieckowski

SENATE APPROPRIATIONS COMMITTEE: 6-0, 5/16/19

AYES: Portantino, Bates, Bradford, Hill, Jones, Wieckowski

SUBJECT: Mental health evaluations: gravely disabled due to impairment by chronic alcoholism

SOURCE: Author

DIGEST:

This bill adds a person who is impaired by chronic alcoholism to the existing prepetition screening process in the Lanterman-Petris-Short Act, which permits any individual to request a county-designated entity to provide a comprehensive screening to determine if the person impaired by chronic alcoholism is a danger to self or others, or gravely disabled.

ANALYSIS:

Existing law:

1. Establishes the Lanterman-Petris-Short (LPS) Act to end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorders, developmental disabilities, and chronic alcoholism, as well as to safeguard a person’s rights, provide prompt evaluation and treatment, and provide services in the least restrictive setting appropriate to the needs of each person. [WIC §5000, et seq.]

1. Defines “gravely disabled” as a condition in which a person, as a result of a mental disorder or impairment by chronic alcoholism, is unable to provide for his or her basic personal needs for food, clothing, or shelter, or a condition in which a person has been found mentally incompetent, as specified, for purposes of detaining the person for assessment, evaluation, and treatment; providing a court-ordered evaluation, as specified; certifying the person for intensive treatment; and, placing the person under conservatorship. [WIC §5008]
2. Requires the phrase “a danger to himself or herself or others, or gravely disabled” throughout the LPS Act to refer also to the condition of being a danger to self or others, or gravely disabled, as a result of the use of controlled substances rather than by mental disorder. [WIC §5342]
3. Permits any individual to apply to the person or agency designated by the county for a “prepetition screening,” as defined, alleging that there is in the county another person who is, as a result of mental disorder or the use of controlled substances, a danger to self or others, or is gravely disabled, and requesting that an evaluation of the person’s condition be made. [WIC 5201]
4. Authorizes a person to be involuntarily detained for a period of up to 72 hours (“5150 hold”) by a peace officer or other authorized person for assessment, evaluation, and crisis intervention, when, as a result of a mental disorder, chronic alcoholism, or use of controlled substances, as specified, the person is a danger to self or others, or is gravely disabled. [WIC §5150]
5. Permits a person to be certified for not more than 14 days of intensive treatment related to a mental health disorder or impairment by chronic alcoholism after being placed on a 5150 hold if professional staff of an agency or facility providing evaluation services has found the person to be a danger to self of others, or gravely disabled; the facility providing intensive treatment is designated by the county to provide intensive treatment, as specified, and agrees to admit the person; and, the person has been advised of the need for treatment but has not been willing or able to accept treatment voluntarily. [WIC §5250]
6. Permits a conservator of a person, or the estate, or of both the person and the estate, to be appointed for a person who is gravely disabled as a result of a mental health disorder or impairment by chronic alcoholism. [WIC §5350]
7. Permits, until January 1, 2024, San Diego, San Francisco, and Los Angeles Counties to place in a conservatorship, as specified, a person who is chronically homeless and incapable of caring for his or her own health and well-being due to serious mental illness and substance use disorder, as specified. [WIC §5450, et seq.]
8. Deems a person not to be gravely disabled, for purposes of up to 14-day intensive treatment and appointing a conservator, if the person can survive safely without involuntary detention with the help of responsible family, friends, or others who are both willing and able to help provide the person’s basic personal needs for food, clothing, or shelter. [WIC §5250]
9. Defines “prepetition screening” as a screening of all petitions for court-ordered evaluations, which are initiated by any person who suspects another person is gravely disabled or a danger to self or others due to a mental disorder or use of controlled substances, consisting of a professional review of all petitions and an interview with the petitioner and the person alleged to be gravely disabled or a danger to self or others. Requires a prepetition screening to include efforts to persuade a person to receive, on a voluntary basis, comprehensive evaluation, crisis intervention, referral, and other services specified in the LPS Act.
10. Defines a “designated facility” or “facility designated by the county for evaluation and treatment” as a facility that is licensed or certified as a mental health treatment facility or a hospital, as specified, by the Department of Public Health, and includes a licensed psychiatric hospital, a licensed psychiatric health facility, and a certified crisis stabilization unit. [WIC §5008] 

This bill:

1. Adds a person who is impaired by chronic alcoholism to the existing prepetition screening process in the LPS Act, which permits any individual to request a county-designated entity to provide a comprehensive screening to determine if the person impaired by chronic alcoholism is a danger to self or others, or gravely disabled.
2. Makes other clarifying, nonsubstantive changes.

Comments

1. Author’s statement. According to the author, this bill provides another tool in the tool box to try and help those who suffer with chronic alcoholism. Alcohol consumption is a major part of the contemporary American life. However, alcohol dependence and abuse imposes an enormous burden on individuals, families, and our state. Alcohol abuse has serious medical consequences, including cardiovascular disease, hypertensions, diabetes, liver disease, fetal abnormalities, and cancer. In the U.S., about 5% of all deaths are attributed to alcohol misuse. It is also estimated, that a whopping $184.6 billion is spent every year in the U.S. on alcohol related problems like lost productivity due to alcohol-related illness, health care expenditures, motor vehicle crashes, crime, and other social costs. In 2018, about 19% of Californians reported either binge drinking or chronic drinking. This bill amends the LPS Act to include those suffering from chronic alcoholism in the existing prepetition screening process. This inclusion would therefore allow any person to petition to a county-designated entity to have an individual suffering from chronic alcoholism who is suspected of being a danger to themselves or others, or is gravely disabled, to be screened and assessed for the purposes of initiating a 5150, intensive treatment, or conservatorship, if necessary.
2. LPS Act. The LPS Act provides for involuntary commitment for varying lengths of time for the purpose of treatment and evaluation, provided certain requirements are met. Additionally, the LPS Act provides for LPS conservatorships, resulting in involuntary commitment for the purposes of treatment if an individual is found to meet the grave disability criteria. Typically one first interacts with the LPS Act through a 5150 hold, which allows a designated facility to involuntarily commit a person for 72 hours for evaluation and treatment if they are determined to be, as a result of a mental health disorder, a threat to self or others, or gravely disabled. The peace officer or other authorized person who detains the individual must determine and document that the individual meets this standard. When making the determination, the peace officer or other authorized person may consider the individual’s historical course, which includes evidence presented by a person who has provided or is providing mental health or related support services to the person on the 5150 hold; evidence presented by one or more members of the family of the person on the 5150 hold; and, evidence presented by the person on the 5150 hold, or anyone designated by that person, if the historical course of the person’s mental disorder has a reasonable bearing on making a determination that the person requires a 5150 hold.

Following an initial 5150 hold, a person may be certified for intensive treatment, which initially permits a person to be held for an additional up to 14-days, without court review, if they are found to still be a danger to self or others, or gravely disabled. When determining whether the person is eligible for a 14-day detention, the professional staff of the agency or facility providing evaluation services must find that the person has been advised of the need for, but has not been willing or able to accept, treatment on a voluntary basis. A notice of certification is required for all persons certified for intensive treatment, and a copy of the notice for certification is required to be personally delivered to the person certified, the person’s attorney, or the attorney or advocate, as specified. If after the initial 14 days a person is still found to remain gravely disabled and unwilling or unable to accept voluntary treatment, the person may be certified for an additional period of not more than 30 days of intensive treatment. A person cannot be found at this point to be gravely disabled if he or she can survive safely without involuntary detention with the help of responsible family, friends, or others who indicate they are both willing and able to help. 

The LPS Act provides for a conservator of the person, of the estate, or of both the person and the estate for a person who is gravely disabled as a result of a mental health disorder or impairment by chronic alcoholism or use of controlled substances. The person for whom such a conservatorship is sought has the right to demand a court or jury trial on the issue of whether they meet the gravely disabled requirement. The purpose of an LPS conservatorship is to provide individualized treatment, supervision, and placement for the gravely disabled person. Current law also deems a person as not being gravely disabled for purposes of a conservatorship if he or she can survive safely without involuntary detention with the help of responsible family, friends, or others who indicate they are both willing and able to help. SB 1045 (Wiener and Stern, Chapter 845, Statutes of 2018) established, under a five-year pilot project in San Francisco, Los Angeles, and San Diego Counties, a conservatorship process for individuals who are incapable of caring for their own health and well-being due to a serious mental illness and substance use disorder as evidenced by “frequent detention” for evaluation and treatment under 72-hour involuntary holds. Frequent detention is defined as having eight or more 5150 detentions in the preceding 12 months.

1. Prepetition screenings. The LPS Act contains a provision that permits any individual to apply to a county-designated person or agency for a petition alleging that there is in the county a person who is, as a result of a mental disorder or use of controlled substances, a danger to self or others, or is gravely disabled, and requesting that an evaluation of the person’s condition be made. Prior to filing the petition, the county-designated person or agency is required to request a county-designated person or agency that is also approved by DHCS to provide a prepetition screening to determine if there is probable cause to believe the allegations, including conducting an investigation and making a reasonable effort to personally interview the subject of the petition. The screening is also required to include a determination whether or not the person who is the subject of the petition will agree to voluntarily receive crisis intervention services, referral, or a comprehensive evaluation in his or her own home or in a county-designated facility. A petition can proceed if the county-designated individual determines there is probable cause to believe a person is a danger to self or other, or gravely disabled, and the person will not voluntarily receive evaluation or crisis intervention. The processes outlined in the LPS Act for involuntary detention, intensive treatment, and conservatorship also apply in this situation, if deemed necessary. The LPS Act specifies that if any individual who seeks a petition for court-ordered evaluation against a person knows that the person who is the subject of a petition is not a danger to self or others, or gravely disabled, the individual who sought the petition is guilty of a misdemeanor and may be held liable in civil damages by the person against whom the petition was sought.

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

According to the Senate Appropriations Committee, unknown, potentially significant costs to county-designated persons and agencies tasked to conduct prepetition screenings whenever requested by persons who allege that a person is gravely disabled as a result from impairment of chronic alcoholism. Even if implementation or workload costs to each county to conduct the screenings are as low as $1,000, costs associated with this measure would exceed $50,000. Local costs to comply with this measure would be subject to reimbursement by the state to the extent that the Commission on State Mandates determines that this bill imposes a state-mandated local program. (General Fund/local funds)

SUPPORT: (Verified 5/16/19)

Tenet Healthcare

OPPOSITION: (Verified 5/16/19)

Mental Health America of Los Angeles

ARGUMENTS IN SUPPORT: Tenet Healthcare states that it supports the ability of families, friends, and others in the lives of patients in crisis to seek support in order to compel appropriate treatment, and this bill provides an important inclusion of chronic alcoholism for county evaluation of treatment. Tenet states that California’s health care system lacks a coordinated system of support, so it welcomes any efforts to facilitate placement and coordination of services.

ARGUMENTS IN OPPOSITION: Mental Health America of Los Angeles (MHALA) states that it has a long history of opposing attempts to expand the ability to force treatment on individuals and instead supports treatment that is based on the recovery paradigm and is self-directed, empowering, peer supported, and self-empowering. MHALA argues this bill runs counter to those principles and ignores that coerced and involuntary treatment is ineffective and often dangerous. MHALA states this is another attempt at making it easier to round up homeless individuals and does nothing to address the primary cause of homelessness—the lack of affordable housing.

Prepared by: Reyes Diaz / HEALTH / (916) 651-4111

5/18/19 11:18:09

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SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

SB 590 (Stone) - Mental health evaluations: gravely disabled due to impairment by chronic alcoholism

Bill Summary:

SB 590 would include impairment by chronic alcoholism in the definition of “gravely disabled” for the purpose of requesting a prepetition screening under the Lanterman-Petris-Short (LPS) Act.

Fiscal Impact:

Unknown, potentially-significant costs to county-designated persons and agencies tasked to conduct prepetition screenings whenever requested by persons who allege that a person is gravely disabled as a result from impairment of chronic alcoholism. Even if implementation or workload costs to each county to conduct the screenings are as low as $1,000, costs associated with this measure would exceed $50,000. Local costs to comply with this measure would be subject to reimbursement by the state to the extent that the Commission on State Mandates determines that this bill imposes a state-mandated local program. (General Fund/local funds)

Background:

As stated in the analysis of this bill by the Senate Committee on Health:

The LPS Act contains a provision that permits any individual to apply to a county-designated person or agency for a petition alleging that there is in the county a person who is, as a result of a mental disorder or use of controlled substances, a danger to self or others, or is gravely disabled, and requesting that an evaluation of the person’s condition be made. Prior to filing the petition, the county-designated person or agency is required to request a county-designated person or agency that is also approved by [the Department of Health Care Services] to provide a prepetition screening to determine if there is probable cause to believe the allegations, including conducting an investigation and making a reasonable effort to personally interview the subject of the petition. The screening is also required to include a determination whether or not the person who is the subject of the petition will agree to voluntarily receive crisis intervention services, referral, or a comprehensive evaluation in his or her own home or in a county-designated facility. A petition can proceed if the county-designated individual determines there is probable cause to believe a person is a danger to self or other, or gravely disabled, and the person will not voluntarily receive evaluation or crisis intervention. The processes outlined in the LPS Act for involuntary detention, intensive treatment, and conservatorship also apply in this situation, if deemed necessary. The LPS Act specifies that if any individual who seeks a petition for court-ordered evaluation against a person knows that the person who is the subject of a petition is not a danger to self or others, or gravely disabled, the individual who sought the petition is guilty of a misdemeanor and may be held liable in civil damages by the person against whom the petition was sought.

Proposed Law:

This bill would include impairment by chronic alcoholism that makes a person unable to provide for their own basic personal needs for food, clothing, or shelter in the definition of “gravely disabled” for the purpose of requesting a prepetition screening under the LPS Act by a county-designated person or agency.

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SENATE JUDICIARY COMMITTEE

Senator Hannah-Beth Jackson, Chair

2019-2020 Regular Session

Bill No: SB 590 (Author:Stone)

Version: March 27, 2019

Hearing Date: April 23, 2019

Fiscal: Yes

Urgency: No

Consultant: JDT

SUBJECT

Mental health evaluations: gravely disabled due to impairment by chronic alcoholism

DIGEST

Existing law establishes a process for obtaining a court order to subject a person to an evaluation to determine if they are gravely disabled due to a mental illness or controlled substance use disorder. This bill would extend that process to individuals alleged to be gravely disabled due to chronic alcoholism.

EXECUTIVE SUMMARY

The Lanterman-Petris Short (LPS) Act establishes a conservatorship procedure for a person who is “gravely disabled” and thus unable to provide for the person’s basic personal needs for food, clothing, or shelter as a result of a mental disorder or impairment by chronic alcoholism. Certain components of the LPS Act also apply to a person who is a danger to self or others as a result of the use of controlled substances.

The LPS Act includes a process for subjecting a person to a court-ordered evaluation to determine if they are gravely disabled or a danger to self or others. This procedure can culminate in a temporary detention, certification for intensive treatment, or a conservatorship. Under existing law, the process is applicable only to persons alleged to have a mental illness or a controlled substance use disorder.

The author, citing the dangers of excessive alcohol consumption, has sponsored this bill to apply that court-ordered evaluation process to a person alleged to be gravely disabled due to chronic alcoholism. The bill is supported by Tenet Healthcare, and has no known opposition. It passed out of the Senate Health Committee by a vote of 8-0.

PROPOSED CHANGES TO THE LAW

Existing law:

1. Provides, among other things, that the Legislative intent of the LPS Act is to end inappropriate, indefinite, and involuntary commitment of mentally disordered persons, developmentally disabled persons, and persons impaired by chronic alcoholism. Existing law also establishes that the LPS Act is intended to eliminate legal disabilities and protect mentally disordered and developmentally disabled persons. (Welf. & Inst. Code § 5001; all further statutory references are to the Welfare & Institutions Code, unless otherwise specified.)
2. Defines, as a basis for involuntary commitment under the LPS Act, “grave disability” as a condition in which a person, as a result of a mental disorder, or impairment by chronic alcoholism, is unable to provide for the person’s basic personal needs for food, clothing, or shelter. (§ 5008(h)(1)(A),(2).)
   1. Excludes from this definition persons with intellectual disabilities by reason of that disability alone. (§ 5008(h)(3).)
   2. Provides that when applying the definition of mental disorder for the purposes of the LPS Act, the historical course of the person’s mental illness, as determined by available relevant information, shall be considered when it has a direct bearing on the determination of whether the person is a danger to others, or to themselves, or is gravely disabled. (§ 5008.2(a).)
3. Provides that, if a person is gravely disabled as a result of mental illness, or a danger to self or others, then a peace officer, staff of a designated treatment facility or crisis team, or other professional person designated by the county, may, upon probable cause, take that person into custody for a period of up to 72 hours for assessment, evaluation, crisis intervention, or placement in a designated treatment facility. (§ 5150.)
4. Provides that a person who has been detained for 72 hours may be detained for up to 14 days of intensive treatment if the person continues to pose a danger to self or others, or to be gravely disabled, and the person has been unwilling or unable to accept voluntary treatment. (§ 5250.)
   1. Provides that a person who has been detained for 14 days of intensive treatment may be detained for up to 30 additional days of intensive treatment if the person remains gravely disabled and is unwilling or unable to voluntarily accept treatment. (§ 5270.15.)
   2. Allows a court to order an imminently dangerous person to be confined for further inpatient intensive health treatment for an additional 180 days, as provided. (§ 5300 et seq.)
5. Allows the professional person in charge of a facility providing 72-hour, 14-day, or 30-day treatment to recommend an LPS conservatorship to the county conservatorship investigator for a person who is gravely disabled and is unwilling or unable to voluntarily accept treatment, and requires the conservatorship investigator, if they concur with the recommendation, to petition the superior court to establish an LPS conservatorship. (§ 5350 et seq.)
6. Establishes a process for any individual or agency designated by the county to petition a superior court to obtain an order to evaluate a person alleged to be, as a result of a mental disorder, a danger to others or self, or gravely disabled. (§5200 et seq.)
   1. Specifies that the phrase “a danger to himself or herself or others, or gravely disabled,” as used in the LPS Act, refers to the condition of danger to self or others or grave disability as a result of the use of controlled substances, rather than by mental disorder, as such. (§ 5342.)
   2. Provides that, before the filing, the person or agency must request that the State Department of Health Care Services (DHCS) provide a prepetition screening to determine if there is probable cause to believe the allegations. Provided that probable cause is found and the person refuses voluntary evaluation or crisis intervention, the prepetition screening report must be submitted to the court along with the petition. (§ 5202.)
   3. Provides that a person who knowingly falsifies these allegations is guilty of a misdemeanor. (§ 5203.)
   4. Requires the judge, if it appears in the petition that the person is a danger to self or others or gravely disabled and has refused voluntary treatment, to issue an order to the person to submit to an evaluation. (§ 5206.)
   5. Provides that the person may be permitted to remain in their home or place of choosing before the evaluation, and may be permitted to be accompanied by individuals designated by the person to the place of, and during, the evaluation. (Id.)
   6. Provides that if the person does not appear for evaluation, the person may be detained for evaluation for up to 72 hours. (Id.)
   7. Requires that persons who have been detained for evaluation be released, referred for care and treatment on a voluntary basis, certified for intensive treatment, or recommended for conservatorship pursuant to the LPS Act, as required. (Id.)

This bill provides that the process described in 6) applies to a person who, as a result of impairment by chronic alcoholism, is unable to provide for the person’s basic personal needs for food, clothing, or shelter.

COMMENTS

1. Purpose of the bill

According to the author:

SB 590 provides another tool in the tool box to try and help those who suffer with chronic alcoholism. Alcohol consumption is a major part of the contemporary American life. However, alcohol dependence and abuse imposes an enormous burden on individuals, families, and our State. Alcohol abuse has serious medical consequences, including cardiovascular disease, hypertensions, diabetes, liver disease, fetal abnormalities, [and] cancer.

In the United States, about 5% of all deaths are attributed to alcohol misuse. It is also estimated, that a whopping $184.6 billion is spent every year in the United States on alcohol related problems like lost productivity due to alcohol-related illness, health care expenditures, moto-vehicle crashes, crime, and other social costs. More close to home, in 2018, about 19% of Californians reported either binge drinking or chronic drinking.

This bill amends the Lanterman-Petris-Short Act to include those suffering from chronic alcoholism in the existing prepetition screening process. This inclusion would therefore allow any person to petition to a county designated entity to have an individual suffering from chronic alcoholism who is suspected of being a danger to themselves or others, or is gravely disabled, to be screened and assessed for the purposes of initiating a 5150, intensive treatment, or conservatorship, if necessary. SB 590 is a small change in the already existing framework of the law in order to give hope and save one more life.

Writing in support, Tenet Healthcare states that it “supports the ability of families, friends and others involved in the lives of patients in crisis to seek support in order to compel appropriate treatment. SB 590 provides an important inclusion of chronic alcoholism for county evaluation of treatment.”

2. The LPS Act framework

The California Legislature has long sought to achieve the right balance between providing for the safety and well-being of those suffering from severe mental illness, those who are seen as gravely disabled or at risk of harming themselves or others, and recognizing their inherent due process and civil rights. In the 1960s, the Legislature enacted the LPS Act to develop a statutory process under which individuals could be involuntarily held and treated in a mental health facility in a manner that safeguarded their constitutional rights.

Under the LPS Act, existing law provides for involuntary commitment for varying lengths of time for the purpose of treatment and evaluation, provided certain requirements are met. Additionally, the LPS Act provides for LPS conservatorships, resulting in involuntary commitment for the purposes of treatment, if an individual is found to meet the “grave disability” standard. (§ 5001 et seq.)

“Before a person may be found to be gravely disabled and subject to a year-long confinement, the LPS Act provides for a carefully calibrated series of temporary detentions for evaluation and treatment.” (Conservatorship of Ben C. (2007) 40 Cal.4th 529, 541.) The common thread within the existing LPS framework is that the person must be found to have a “grave disability” that results in physical danger or harm to the person. Currently, a “grave disability” finding requires that the person presently be unable to provide for food, clothing, and shelter due to a mental disorder, or severe alcoholism, to the extent that this inability results in physical danger or harm to the person. In making this determination, the trier of fact must consider whether the person would be able to provide for these needs with a family member, friend, or other third party’s assistance if credible evidence of such assistance is produced at the LPS conservatorship hearing. (§ 5008(h)(1)(A),(2); Conservatorship of Benevuto (1986) 180 Cal.App.3d 1030; Conservatorship of Early (1983) 35 Cal.App.3d 244; Conservatorship of Jesse G. (2016) 248 Cal.App.4th 453.) The courts have found that this definition of “gravely disabled” is not unconstitutionally vague or overbroad, but rather is sufficiently precise in that it excludes “unusual or nonconformist lifestyles” and turns on an inability or refusal on the part of the individual to care for their basic personal needs. (Conservatorship of Chambers (1977) 71 Cal.App.3d 277.)

Typically, one first interacts with the LPS Act through what is commonly referred to as a “5150 hold.” This allows an approved facility to involuntarily commit a person for 72 hours for evaluation and treatment if they are determined to be, as a result of a mental health disorder, a threat to themselves or others, or gravely disabled. (§ 5150.) The peace officer, or other authorized person, who detains the individual must know of a state of facts that would lead a person of ordinary care and prudence to believe that the individual meets this standard. (People v. Triplett (1983) 144 Cal.App.3rd 283, pp. 287-288.) When making this determination, the peace officer, or other authorized person, may consider the individual’s past conduct, character, and reputation, so long as the case is decided on facts and circumstances presented to the detaining person at the time of detention. (Heater v. Southwood Psychiatric Center (1996) 42 Cal.App.4th 1068.)

Following a 72-hour hold, the individual may be held for an additional 14 days, without court review, if they are found to continue to be, as a result of a mental health disorder, a threat to themselves or others, or gravely disabled. (§ 5250.) When determining whether the individual is eligible for an additional 14-day confinement, the professional staff of the agency or facility providing evaluation services must find that the individual has additionally been advised of the need for, but has not been willing or able to accept, treatment on a voluntary basis. (§ 5250(c).) Additionally, the individual cannot be found at this point to be gravely disabled if they can survive safely without involuntary detention with the help of responsible family, friends, or third parties who are both willing and able to help. (§ 5250(d).)

If a person is still found to remain gravely disabled and unwilling or unable to accept voluntary treatment following their additional 14 days of intensive treatment, they may be certified for an additional period of not more than 30 days of intensive treatment. (§ 5270.15.) This “temporary conservatorship” means that the individual may request judicial review of this involuntary detention, and if judicial review is not requested, the individual must be provided a certification review hearing. Additionally, the professional staff of the agency or facility providing the treatment must analyze the person’s condition at intervals not to exceed 10 days, and determine whether the person continues to meet the criteria for continued confinement. If the person is found to no longer meet the requirements for the 30-day hold, then their certification must be terminated. (§ 5270.15(b).)

“This series of temporary detentions may culminate in a proceeding to determine whether the person is so disabled that he or she should be involuntarily confined for up to one year.” (Conservatorship of Ben C., supra, 40 Cal.4th at p. 541.) The LPS Act provides for a conservator of the person, of the estate, or of both the person and the estate for a person who is gravely disabled as a result of a mental health disorder or impairment by chronic alcoholism. (§ 5350.) The purpose of an LPS conservatorship is to provide individualized treatment, supervision, and placement for the gravely disabled individual. (§ 5350.1.)

Because an LPS conservator’s powers often include the power to confine a person in a treatment facility, courts have recognized that the liberty, property, and reputational interests at stake are comparable to those in criminal proceedings; consequently, the party seeking imposition of the conservatorship must prove the proposed conservatee's grave disability beyond a reasonable doubt, and the verdict must be issued by a unanimous jury. (Conservatorship of Roulet (1979) 23 Cal.3d 219, 235; Conservatorship of Ben C., supra, 40 Cal.4th at p. 537-538.) Statutory provisions provide that the proposed conservatee is entitled to demand a jury trial on the issue of their grave disability, and has a right to counsel at trial, appointed if necessary. (§§ 5350, 5365.) During a one-year conservatorship, a conservatee may twice petition for rehearing. (§ 5364.) At a rehearing, a conservatee need only prove by a preponderance of the evidence that the conservatee is no longer gravely disabled. (Conservatorship of Everette M. (1990) 219 Cal. App. 3d 1567, 1573.)

3. Liberty interests at stake in a conservatorship

Under the LPS framework, “[o]ne of the principal powers which the court may grant a conservator is the right to place a conservatee in an institution.” (Conservatorship of Roulet (1979) 23 Cal.3d 219, 223 (Roulet).) A person found to be gravely disabled may be involuntarily confined for up to one year. (§ 5361.) If, at the end of that year, the conservator determines that the conservatorship is still required, the conservator may petition the superior court for reappointment (id.), a process that may repeat itself for as long as the person remains gravely disabled. “In effect, these statutes assure in many cases an unbroken and indefinite period of state-sanctioned confinement. ‘The theoretical maximum period of detention is life as successive petitions may be filed . . . .’ [Citation.]” (Roulet, supra, 23 Cal.3d at p. 224; italics in original.)

Courts have recognized that the stakes of civil commitment are comparable to criminal punishment. “From the perspective of the person who resists this confinement, there is little to distinguish it from incarceration in a penal institution. Because the mental facility is authorized to administer drugs to him against his will, detention there might be considered more severe than confinement in a penal institution.” (Doe v. Gallinot (C.D.Cal. 1979) 486 F.Supp. 983, 991-992, aff’d, (9th Cir. 1981) 657 F2.d 1017.) The United States Supreme Court has stated in this regard that “commitment is a deprivation of liberty. It is incarceration against one’s will, whether it is called ‘criminal’ or ‘civil.’” (In re Gault (1967) 387 U.S. 1, 50.) In a subsequent opinion, the Supreme Court reiterated that “civil labels and good intentions do not themselves obviate the need for criminal due process safeguards . . . .” (In re Winship (1970) 397 U.S. 358, 365-366.) And the California Supreme Court, rejecting a respondent’s “reliance on a civil label,” stated that the “respondent takes false comfort in the fact that appellant’s commitment is only a ‘civil’ confinement for remedial purposes. However, these are mere labels. Appellant’s stay in Camarillo State Hospital was not any less involuntary because the state called her incarceration by one name rather than another.”(Roulet, supra, 23 Cal.3d at p. 225.)

Justice Brennan, in his concurring and dissenting opinion, in Parham v. J. R. (1979) 442 U.S. 584 described the consequences of institutionalization as follows:

Commitment to a mental institution necessarily entails a “massive curtailment of liberty,” [citation], and inevitably affects “fundamental rights.” [Citation.] Persons incarcerated in mental hospitals are not only deprived of their physical liberty, they are also deprived of friends, family, and community. Institutionalized mental patients must live in unnatural surroundings under the continuous and detailed control of strangers. They are subject to intrusive treatment which, especially if unwarranted, may violate their right to bodily integrity. […] Furthermore, as the Court recognizes, [citation] persons confined in mental institutions are stigmatized as sick and abnormal during confinement and, in some cases, even after release.

(Id. at pp. 626-627.)

4. Compulsory evaluations for individuals struggling with alcoholism

The LPS Act conservatorship procedure applies to a person who is “gravely disabled” and thus unable to provide for the person’s basic personal needs for food, clothing, or shelter as a result of a mental disorder or impairment by chronic alcoholism. Certain components of the LPS Act also apply to a person who is a danger to self or others as a result of the use of controlled substances. (See § 5343.)

The LPS process for subjecting a person to a court-ordered evaluation to determine if they are gravely disabled or a danger to self or others is contained in Welfare and Institutions Code section 5200 et seq. Under this process, before filing a petition, the person or agency seeking the evaluation order must request that the DHCS provide a prepetition screening to determine if there is probable cause to believe the allegations. If probable cause is found and the person refuses voluntary evaluation or crisis intervention, the prepetition screening report must be submitted to the court along with the petition. (§ 5202.) If it appears in the petition that the person is a danger to self or others, or gravely disabled, and has refused voluntary treatment, the judge must issue an order to the person to submit to an evaluation. (§ 5206.) This procedure can culminate in a temporary detention, certification for intensive treatment, or a conservatorship. (§ 5206.) Under existing law, the process is applicable only to persons alleged to have a mental illness or a controlled substance use disorder. (See §§ 5200, 5201, 5342.)

This bill would extend that process to a person alleged to be gravely disabled due to chronic alcoholism. The author cites statistics regarding the dangers of alcohol consumption: Alcohol abuse has serious medical consequences, including cardiovascular disease, hypertensions, diabetes, liver disease, fetal abnormalities, and cancer. In the U.S., about five percent of all deaths are attributed to alcohol misuse. It is also estimated that $184.6 billion is spent every year in the U.S. on alcohol related problems like lost productivity due to alcohol-related illness, health care expenditures, motor vehicle crashes, crime, and other social costs. In 2018, about 19 percent of Californians reported either binge drinking or chronic drinking.

However, these statistics are specific to alcohol abuse rather than chronic alcoholism. Moreover, they do not show the percentage of people whose chronic alcoholism rises to the level of a grave disability necessitating the imposition of a conservatorship. In general, LPS conservatorships are rarely used for individuals struggling with alcoholism, unless their condition is so advanced that they have alcohol-induced dementia. Upon detention, most of these individuals will sober up and demonstrate the ability to function independently, thereby making an LPS conservatorship—which is designed for people whose mental deterioration is presently at the level that renders them incapable of carrying out the transactions necessary for survival—inappropriate and inapplicable.

On the other hand, a goal of the evaluation process is to encourage people with a deteriorating mental illness or substance use problem to engage with voluntary services. This bill, while unlikely to result in a substantially higher number of chronic alcoholics in conservatorships, could have the effect of inducing some people who abuse alcohol to seek voluntary treatment. Writing in support, Tenet Healthcare states that “models for brief intervention by social workers and navigators in hospital [emergency departments] have demonstrated the benefits of connecting patients with community services (where such programs and services exist).

SUPPORT

Tenet Healthcare

OPPOSITION

None known

RELATED LEGISLATION

Pending Legislation:

SB 40 (Wiener, 2019) amends a pilot program that, for participating counties, establishes a conservatorship procedure applicable to individuals who are incapable of caring for their own health and well-being due to a serious mental illness and substance use disorder. That bill passed out of the Senate Judiciary Committee and is pending in the Senate Public Safety Committee.

SB 640 (Moorlach, 2019) would expand the “gravely disabled” standard to apply to a person who, as a result of a mental health disorder, is incapable of making informed decisions about, or providing for, the person’s own basic personal needs for food, clothing, or shelter without significant supervision and assistance from another person and, as a result of being incapable of making these informed decisions, the person is at risk of substantial bodily harm, dangerous worsening of concomitant serious physical illness, significant psychiatric deterioration, or mismanagement of the person’s essential needs. This bill was held in the Senate Health Committee.

AB 1055 (Levine, 2019) would require a person who is released from a 72-hour involuntary detention to also be referred for further care and treatment on a voluntary basis, and would require a psychiatrist, psychologist, or medical director approving the release, to, prior to that release, ensure that an initial outpatient appointment with a psychiatrist or psychologist within five business days of the release is scheduled. The bill is pending in the Assembly Health Committee.

AB 1275 (Santiago, 2019) would require each county to establish an outreach team to provide outreach services to individuals with a history of mental illness or substance use disorders who are unable to provide for urgently needed medical care and who are homeless or at risk of experiencing homelessness. The bill is pending in the Assembly Health Committee.

AB 1572 (Chen, 2019) is virtually identical to SB 640 above, but additionally applies to the person’s inability to provide for their own medical care. The bill also appropriates $20 million to the DHCS to establish a 4-year grant program to assist local jurisdictions to maintain appropriate caseloads for individuals who manage conservatorship cases. The bill would require DHCS, in consultation with the Mental Health Services Oversight and Accountability Commission, the California State Association of Public Administrators, Public Guardians, and Public Conservators, and the California Behavioral Health Directors Association, to establish guidelines for appropriate caseloads for case managers in public guardian and public conservator offices. The bill would specify requirements for applying for grants, including establishing a 4-year plan to meet and maintain the appropriate caseload goals. The bill would require the department to submit a report, as specified, on or before September 30, 2021, and each following year, to the Governor and the Legislature, as specified. The bill is pending in the Assembly Health Committee.

Prior Legislation:

SB 931 (Hertzberg, Ch. 458, Stats. 2018) expanded the scope of individuals eligible to conduct an investigation to establish an LPS conservatorship to include a professional person in charge of providing mental health treatment at a county jail or that person's designee. SB 931 also provided that the custody status of a person who is subject to a conservatorship evaluation shall not be the sole reason for not scheduling an investigation by the conservatorship investigator.

AB 1971 (Santiago, Chen, and Friedman, 2018) would have, in a pilot program in Los Angeles County, expanded the definition of “gravely disabled” for the purpose of the LPS Act to also include a condition in which a person, as a result of a mental health disorder, is unable to provide for their basic personal needs for medical treatment, if the failure to receive medical treatment, as defined, results in a deteriorating physical condition that a medical professional, in their best medical judgment, attests in writing, will more likely than not, lead to death within six months, as specified. This bill died on the Senate Inactive File.

AB 2156 (Chen, 2018) would have changed the definition of “gravely disabled” for LPS Act purposes to read, in part, a condition in which a person, as a result of a mental health disorder, is incapable of making informed decisions about, or providing for, their own basic personal needs for food, clothing, shelter, or medical care without significant supervision and assistance from another person and, as a result of being incapable of making these informed decisions, the person is at risk of substantial bodily harm, dangerous worsening of a concomitant serious physical illness, significant psychiatric deterioration, or mismanagement of their essential needs that could result in bodily harm. The bill was held in the Assembly Health Committee.

AB 2442 (Santiago, 2018) would have required that if a person is placed under a 72-hour detention for evaluation and treatment, and the person is experiencing homelessness but may be treated without being further detained, that the person must be provided written information about local housing options, employment opportunities, and available public social services. The bill was held in the Assembly Health Committee.

AB 59 (Waldron, Ch. 251, Stats. 2016) extended the repeal date of the AOT Demonstration Project Act of 2002, or “Laura’s Law,” by five years, to January 1, 2022, and deleted and recast in existing law DHCS reporting requirement, as specified, regarding the AOT services a county provides.

AB 193 (Maienschein, 2015) would have authorized the probate court, after a hearing attended by a proposed conservatee’s counsel, to recommend the LPS Act conservatorship and order an investigation, as specified, if the court determines that a person for whom a probate conservatorship has been established may be gravely disabled and is unwilling or incapable of accepting treatment voluntarily. The Governor vetoed the bill because he felt that this bill bypassed the clinical expertise of the mental health professionals who are currently in charge of recommending an investigation for an LPS conservatorship.

AB 2266 (Waldron, 2014) would have increased the maximum period of imposed outpatient treatment under the AOT Demonstration Project from six months to one year. AB 2266 failed in the Assembly Judiciary Committee.

AB 1265 (Conway, 2013) would have increased the maximum period of imposed outpatient treatment under the AOT Demonstration Project from six months to one year. AB 1265 failed in the Assembly Judiciary Committee.

SB 364 (Steinberg, Ch. 567, Stats. 2013) broadened the types of facilities that can be used for purposes of a 72-hour treatment and evaluation under the LPS Act and permits county mental health directors to develop procedures for the designation and training of professionals that carry out functions related to 72-hour holds.

AB 1569 (Allen, Ch. 441, Stats. 2012) extended authorization for Laura's Law to January 1, 2017 and required DHCS to submit a report to the Legislature regarding the program by July 1, 2015.

AB 2357 (Karnette, Ch. 774, Stats. 2006) extended the initial sunset provision found within Laura’s Law until January 1, 2013.

AB 1421 (Thomson, Ch. 1017, Stats. 2002) created the Assisted Outpatient Treatment Demonstration Project Act of 2002, otherwise known as Laura’s Law, to supplement the LPS Act and provide court-ordered outpatient mental health services to individuals with serious mental illness. This bill authorized counties to provide court-ordered outpatient treatment services for people with serious mental illnesses when a court finds that a person's recent history of hospitalizations or violent behavior, coupled with noncompliance with voluntary treatment, indicate the person is likely to become dangerous or gravely disabled without the court-ordered outpatient treatment.

SB 677 (Lanterman-Petris, Short, Ch. 1667, Stats. 1967) expressed Legislative intent to end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorders and provide for the prompt evaluation and treatment of persons with serious mental disorders.

PRIOR VOTES:

Senate Health Committee (Ayes 8, Noes 0)

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SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: SB 590

SUBJECT: Mental health evaluations: gravely disabled due to impairment by chronic alcoholism.

SUMMARY:

Adds a person who is impaired by chronic alcoholism to the existing prepetition screening process in the Lanterman-Petris-Short Act, which permits any individual to request a county-designated entity to provide a comprehensive screening to determine if the person impaired by chronic alcoholism is a danger to self or others, or gravely disabled.

Existing law:

1. Establishes the Lanterman-Petris-Short (LPS) Act to end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorders, developmental disabilities, and chronic alcoholism, as well as to safeguard a person’s rights, provide prompt evaluation and treatment, and provide services in the least restrictive setting appropriate to the needs of each person. [WIC §5000, et seq.]

1. Defines “gravely disabled” as a condition in which a person, as a result of a mental disorder or impairment by chronic alcoholism, is unable to provide for his or her basic personal needs for food, clothing, or shelter, or a condition in which a person has been found mentally incompetent, as specified, for purposes of detaining the person for assessment, evaluation, and treatment; providing a court-ordered evaluation, as specified; certifying the person for intensive treatment; and, placing the person under conservatorship. [WIC §5008]
2. Requires the phrase “a danger to himself or herself or others, or gravely disabled” throughout the LPS Act to refer also to the condition of being a danger to self or others, or gravely disabled, as a result of the use of controlled substances rather than by mental disorder. [WIC §5342]
3. Permits any individual to apply to the person or agency designated by the county for a “prepetition screening,” as defined, alleging that there is in the county another person who is, as a result of mental disorder or the use of controlled substances, a danger to self or others, or is gravely disabled, and requesting that an evaluation of the person’s condition be made. [WIC 5201]
4. Authorizes a person to be involuntarily detained for a period of up to 72 hours (“5150 hold”) by a peace officer or other authorized person for assessment, evaluation, and crisis intervention, when, as a result of a mental disorder, chronic alcoholism, or use of controlled substances, as specified, the person is a danger to self or others, or is gravely disabled. [WIC §5150]
5. Permits a person to be certified for not more than 14 days of intensive treatment related to a mental health disorder or impairment by chronic alcoholism after being placed on a 5150 hold if professional staff of an agency or facility providing evaluation services has found the person to be a danger to self of others, or gravely disabled; the facility providing intensive treatment is designated by the county to provide intensive treatment, as specified, and agrees to admit the person; and, the person has been advised of the need for treatment but has not been willing or able to accept treatment voluntarily. [WIC §5250]
6. Permits a conservator of a person, or the estate, or of both the person and the estate, to be appointed for a person who is gravely disabled as a result of a mental health disorder or impairment by chronic alcoholism. [WIC §5350]
7. Permits, until January 1, 2024, San Diego, San Francisco, and Los Angeles Counties to place in a conservatorship, as specified, a person who is chronically homeless and incapable of caring for his or her own health and well-being due to serious mental illness and substance use disorder, as specified. [WIC §5450, et seq.]
8. Deems a person not to be gravely disabled, for purposes of up to 14-day intensive treatment and appointing a conservator, if the person can survive safely without involuntary detention with the help of responsible family, friends, or others who are both willing and able to help provide the person’s basic personal needs for food, clothing, or shelter. [WIC §5250]
9. Defines “prepetition screening” as a screening of all petitions for court-ordered evaluations, which are initiated by any person who suspects another person is gravely disabled or a danger to self or others due to a mental disorder or use of controlled substances, consisting of a professional review of all petitions and an interview with the petitioner and the person alleged to be gravely disabled or a danger to self or others. Requires a prepetition screening to include efforts to persuade a person to receive, on a voluntary basis, comprehensive evaluation, crisis intervention, referral, and other services specified in the LPS Act.
10. Defines a “designated facility” or “facility designated by the county for evaluation and treatment” as a facility that is licensed or certified as a mental health treatment facility or a hospital, as specified, by the Department of Public Health, and includes a licensed psychiatric hospital, a licensed psychiatric health facility, and a certified crisis stabilization unit. [WIC §5008] 

This bill:

1. Adds a person who is impaired by chronic alcoholism to the existing prepetition screening process in the LPS Act, which permits any individual to request a county-designated entity to provide a comprehensive screening to determine if the person impaired by chronic alcoholism is a danger to self or others, or gravely disabled.
2. Makes other clarifying, nonsubstantive changes.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, this bill provides another tool in the tool box to try and help those who suffer with chronic alcoholism. Alcohol consumption is a major part of the contemporary American life. However, alcohol dependence and abuse imposes an enormous burden on individuals, families, and our state. Alcohol abuse has serious medical consequences, including cardiovascular disease, hypertensions, diabetes, liver disease, fetal abnormalities, and cancer. In the U.S., about 5% of all deaths are attributed to alcohol misuse. It is also estimated, that a whopping $184.6 billion is spent every year in the U.S. on alcohol related problems like lost productivity due to alcohol-related illness, health care expenditures, motor vehicle crashes, crime, and other social costs. In 2018, about 19% of Californians reported either binge drinking or chronic drinking. This bill amends the LPS Act to include those suffering from chronic alcoholism in the existing prepetition screening process. This inclusion would therefore allow any person to petition to a county-designated entity to have an individual suffering from chronic alcoholism who is suspected of being a danger to themselves or others, or is gravely disabled, to be screened and assessed for the purposes of initiating a 5150, intensive treatment, or conservatorship, if necessary.
2. LPS Act. The LPS Act provides for involuntary commitment for varying lengths of time for the purpose of treatment and evaluation, provided certain requirements are met. Additionally, the LPS Act provides for LPS conservatorships, resulting in involuntary commitment for the purposes of treatment if an individual is found to meet the grave disability criteria. Typically one first interacts with the LPS Act through a 5150 hold, which allows a designated facility to involuntarily commit a person for 72 hours for evaluation and treatment if they are determined to be, as a result of a mental health disorder, a threat to self or others, or gravely disabled. The peace officer or other authorized person who detains the individual must determine and document that the individual meets this standard. When making the determination, the peace officer or other authorized person may consider the individual’s historical course, which includes evidence presented by a person who has provided or is providing mental health or related support services to the person on the 5150 hold; evidence presented by one or more members of the family of the person on the 5150 hold; and, evidence presented by the person on the 5150 hold, or anyone designated by that person, if the historical course of the person’s mental disorder has a reasonable bearing on making a determination that the person requires a 5150 hold.

Following an initial 5150 hold, a person may be certified for intensive treatment, which initially permits a person to be held for an additional up to 14-days, without court review, if they are found to still be a danger to self or others, or gravely disabled. When determining whether the person is eligible for a 14-day detention, the professional staff of the agency or facility providing evaluation services must find that the person has been advised of the need for, but has not been willing or able to accept, treatment on a voluntary basis. A notice of certification is required for all persons certified for intensive treatment, and a copy of the notice for certification is required to be personally delivered to the person certified, the person’s attorney, or the attorney or advocate, as specified. If after the initial 14 days a person is still found to remain gravely disabled and unwilling or unable to accept voluntary treatment, the person may be certified for an additional period of not more than 30 days of intensive treatment. A person cannot be found at this point to be gravely disabled if he or she can survive safely without involuntary detention with the help of responsible family, friends, or others who indicate they are both willing and able to help. 

The LPS Act provides for a conservator of the person, of the estate, or of both the person and the estate for a person who is gravely disabled as a result of a mental health disorder or impairment by chronic alcoholism or use of controlled substances. The person for whom such a conservatorship is sought has the right to demand a court or jury trial on the issue of whether they meet the gravely disabled requirement. The purpose of an LPS conservatorship is to provide individualized treatment, supervision, and placement for the gravely disabled person. Current law also deems a person as not being gravely disabled for purposes of a conservatorship if he or she can survive safely without involuntary detention with the help of responsible family, friends, or others who indicate they are both willing and able to help. SB 1045 (Wiener and Stern, Chapter 845, Statutes of 2018) established, under a five-year pilot project in San Francisco, Los Angeles, and San Diego Counties, a conservatorship process for individuals who are incapable of caring for their own health and well-being due to a serious mental illness and substance use disorder as evidenced by “frequent detention” for evaluation and treatment under 72-hour involuntary holds. Frequent detention is defined as having eight or more 5150 detentions in the preceding 12 months.

1. Prepetition screenings. The LPS Act contains a provision that permits any individual to apply to a county-designated person or agency for a petition alleging that there is in the county a person who is, as a result of a mental disorder or use of controlled substances, a danger to self or others, or is gravely disabled, and requesting that an evaluation of the person’s condition be made. Prior to filing the petition, the county-designated person or agency is required to request a county-designated person or agency that is also approved by DHCS to provide a prepetition screening to determine if there is probable cause to believe the allegations, including conducting an investigation and making a reasonable effort to personally interview the subject of the petition. The screening is also required to include a determination whether or not the person who is the subject of the petition will agree to voluntarily receive crisis intervention services, referral, or a comprehensive evaluation in his or her own home or in a county-designated facility. A petition can proceed if the county-designated individual determines there is probable cause to believe a person is a danger to self or other, or gravely disabled, and the person will not voluntarily receive evaluation or crisis intervention. The processes outlined in the LPS Act for involuntary detention, intensive treatment, and conservatorship also apply in this situation, if deemed necessary. The LPS Act specifies that if any individual who seeks a petition for court-ordered evaluation against a person knows that the person who is the subject of a petition is not a danger to self or others, or gravely disabled, the individual who sought the petition is guilty of a misdemeanor and may be held liable in civil damages by the person against whom the petition was sought.
2. Triple referral. This bill is triple referred. If it passes out of this Committee, it will be referred to the Senate Judiciary Committee and the Senate Rules Committee.
3. Related legislation. AB 1055 (Levine) requires a person who is released from a 72-hour involuntary detention to also be referred for further care and treatment on a voluntary basis, and would require a psychiatrist, psychologist, or medical director approving the release, to, prior to that release, ensure that an initial outpatient appointment with a psychiatrist or psychologist within five business days of the release is scheduled. AB 1055 is pending in the Assembly Health Committee.

AB 1275 (Santiago) requires each county to establish an outreach team to provide outreach services to individuals with a history of mental illness or substance use disorders who are unable to provide for urgently needed medical care and who are homeless or at risk of experiencing homelessness. AB 1275 is set to be heard in the Assembly Health Committee on April 23, 2019.

AB 1572 (Chen) and SB 640 (Moorlach) change the definition of “gravely disabled” to mean a condition in which a person, as a result of a mental health disorder, is incapable of making informed decisions about, or providing for, the person’s own basic personal needs for food, clothing, shelter without significant supervision and assistance from another person and, as a result of being incapable of making these informed decisions, the person is at risk of substantial bodily harm, dangerous worsening of a concomitant serious physical illness, significant psychiatric deterioration, or mismanagement of the person’s essential needs that could result in bodily harm. AB 1572 is set to be heard in the Assembly Health Committee on April 9, 2019. SB 640 is set to be heard in this Committee on April 10, 2019.

SB 40 (Wiener) authorizes a court to establish a temporary conservatorship for individuals who are incapable of caring for their own health and well-being due to a serious mental illness and substance use disorder for a period of 30 days or less if the court is satisfied of the necessity, as specified. Makes conservatorships for those individuals subject to a finding by the court that the behavioral health director or the director’s designee has previously attempted to obtain the above-described court order and that the petition was denied, as specified, has evaluated whether assisted outpatient treatment is appropriate for the person and concluded that the person is not eligible for that treatment or that the treatment would be insufficient to treat the person in lieu of a conservatorship. SB 40 is set to be heard in the Senate Judiciary Committee on April 9, 2019.

1. Prior legislation. AB 1971 (Santiago, Friedman, and Chen of 2018) would have expanded the definition of “gravely disabled” in existing law until January 1, 2024, as implemented in the County of Los Angeles, to include a person’s inability to provide for his or her basic personal needs for medical treatment, as specified, and contained specified reporting requirements. AB 1971 was held on the Senate Floor inactive file.

AB 2099 (Gloria, Chapter 258, Statutes of 2018) requires a copy of the application required under existing law that states the circumstances under which a person’s condition was called to the attention of an authorized person to place a 5150 hold to be treated as the original. AB 2099 passed out of this Committee by a vote of 8-0 on June 13, 2018.

SB 1045 (Wiener and Stern, Chapter 845, Statutes of 2018).

SB 565 (Portantino, Chapter 218, of 2017) requires a mental health facility to make reasonable attempts to notify family members or any other person designated by the patient at least 36 hours prior to a review hearing for certification to be held involuntarily for an extended 14 days or 30 days, after an initial 5150 hold, as specified.

AB 191 (Wood, Chapter 184, Statutes of 2017) adds licensed marriage and family therapists and licensed professional clinical counselors to the list of authorized health providers permitted to sign a notice of certification when a patient is certified as needing intensive treatment pursuant to a 5150 hold.

AB 1539 (Chen of 2017) would have expanded the definition of “gravely disabled” to include an individual who is unable to provide for his or her basic need for medical care as a result of a mental health disorder or chronic alcoholism. AB 1539 was not heard in the Assembly Health Committee.

AB 1194 (Eggman, Chapter 570, Statutes of 2015) requires, for purposes of determining whether a person is a danger to self or others, an individual making that determination to consider available relevant information about the historical course of the person’s mental disorder if the individual concludes that the information has a reasonable bearing on the determination, and that the individual shall not be limited to consideration of the danger of imminent harm.

SB 364 (Steinberg, Chapter 567, Statues of 2014) makes several changes to the LPS Act regarding involuntary commitment that ensures clarity and consistency in the 5150 process to enable people with a mental health disorder or chronic alcoholism to obtain assessment, referral, and treatment as appropriate in the least restrictive setting as possible; broadened the types of facilities a county can designate for 5150 purposes; and encouraged counties to provide training of personnel authorized to write and release 5150 holds.

AB 1800 (Thompson and Perata of 2000) would have, among other things, expanded the definition of “gravely disabled” to include when, as a result of a mental disorder, a person has an acute risk of physical or psychiatric harm to self in the absence of treatment. AB 1800 was held in the Senate Rules Committee, and the subject matter of the bill was referred to the Joint Committee on Mental Health Reform.

1. Support. Tenet Healthcare states that it supports the ability of families, friends, and others in the lives of patients in crisis to seek support in order to compel appropriate treatment, and this bill provides an important inclusion of chronic alcoholism for county evaluation of treatment. Tenet states that California’s health care system lacks a coordinated system of support, so it welcomes any efforts to facilitate placement and coordination of services.

SUPPORT AND OPPOSITION:

Support: Tenet Healthcare

Oppose: None received

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