Chapter 17

A. Background

In California, the state Department of Health Services, Licensing and Certification Division regulates acute and long-term care health facilities. In addition, the state Department of Mental Health has regulatory responsibility for psychiatric health facilities, mental health rehabilitation centers and skilled nursing facilities with special treatment programs. Community care facilities are regulated by the state Department of Social Services, Community Care Licensing Division.

B. Types of Facilities

1. General Acute Hospitals (22 C.C.R. § 70001 et. seq., specific provisions for the psychiatric unit, 22 C.C.R. § 70575)

These psychiatric units are located within or adjacent to general acute care hospitals. They are separate psychiatric units, often, but not required to be, locked. They are licensed and regulated by the Department of Health Services. They provide short term care for acutely ill patients, but do not care for chronically ill patients on a long-term basis. Services are Medi-cal reimbursable.

2. Acute Psychiatric Hospitals (22 C.C.R. § 71001 et. seq.)

These are free-standing, usually private, psychiatric hospitals licensed and regulated by the Department of Health Services. The regulations cover physical space, staffing, records, service activities and procedures with different, somewhat high standards for psychiatric services than general acute care-psychiatric standards. Acute Psychiatric facilities are often, but not required to be, locked and provide treatment on a short-term basis.

3. Psychiatric Health Facilities (PHF) (22 C.C.R. § 77001 et. seq.)

These facilities are licensed and regulated by the Department of Mental Health, which has more limited enforcement options and does less monitoring than the Department of Health Services. The regulations cover physical space, staffing, records, service activities and procedures. They have lower staffing ratios and fewer licensed staff than other acute facility. They provide minimal medical services. Services are Medi-Cal reimbursable if the facility has less than 17 beds.

4. Institutes for Mental Disease (IMD) (22 C.C.R. §§ 72001, 72443 et. seq).

These facilities are long term nursing homes. When more than 50% of the patients are mental health patients, the facilities are considered IMDs and ineligible for Medi-Cal reimbursement. Counties contract with the facilities to provide beds for conservatee in exchange for patient fees (paid out of SSI) and supplemental payments made by the counties. SNF/IMDs are licensed and regulated by the Department of Health Services. Special psychiatric programming is covered under section 72443 et seq. The regulations cover physical space, staffing, records, service activities and procedures. In addition, federal law covering nursing homes applies to these facilities.

5. Skilled Nursing Facilities (22 C.C.R. § 72001 et. seq.)

Skilled nursing facilities provides 24 hour nursing supervision for residents and are licensed and regulated by the Department of Health Services. The minimum services which should be available in a SNF include: physician services, skilled nursing services, dietary services, pharmaceutical services, activity program, special disability resources/social services, transportation to medical and therapeutic services and emergency access to physician’s services. The SNF is for the individual who requires continuous skilled nursing care but does meet the requirements either for acute hospital care or for home health care-related services.

6. Mental Health Rehabilitation Center (MHRC) (9 C.C.R. § 781 et. seq.)

These are long term care facilities created under legislation with the intent of providing more individualized treatment for clients in a treatment intensive setting. Staffing levels are lower than those of Skilled Nursing Facilities and other health care settings. Unlike other treatment centers, MHRC’s are regulated by the Department of Mental Health in conjunction with local county mental health authorities.

7. Adult Residential Facilities (Board & Cares) (22 C.C.R. § 85000 et. seq).

These community care facilities provides services to persons who need assistance with activities of daily living such as dressing, bathing, receiving an adequate diet, etc. Residents may have some functional disabilities, but should not require medical care and supervision on a daily basis.. Adult Residential Facilities are licensed and regulated by the Department of Social Services, Community Care Licensing. Regulations are very specific on physical space, care provided, food and the provision of a Needs and Services Plan for each resident.

8. Residential Treatment Center/Group Homes and Community Treatment Facilities

For a discussion of facilities for minors, see Chapter XVI. Minors.

C. Enforcement

1. Licensure

Licensing a facility is the most basic enforcement mechanism available to the state. If there are serious problems at a facility, and licensing regulations are being violated, the state may levy penalties, suspend or revoke a facility's license, although this drastic remedy is generally reserved for the most serious violations.

2. Inspections

Regulatory agencies are required to make unannounced inspection visits at regular intervals. They are

guaranteed access to the facility, and need not base access rights on a particular complaint or

patient request. Complaints received about facilities must be investigated promptly (in the care of community care facilities, within 10 days).

Inspection reports are public records and may be examined by members of the public, with removal of clients identities.

3. Complaints

A licensing inspection can also be initiated by a complaint. Anyone can make a complaint about a facility and request than an inspection be made. Unless the licensing agency determined that the complaint is willfully intended to harass a license or is without any reasonable basis, it must make an on site inspection. The complainant must be promptly informed of the licensing departments' proposed course of action.

Upon the request of either the complainant or the licensing division, the complainant, or his or her representative, or both, may be allowed to accompany the inspector on the tour of the facility, unless the inspector determines that the privacy of any patient would be violated. All inspections must be unannounced.

4. Citations and Penalties

If the evaluator determines that a deficiency in standards exists, a notice of deficiency is given, a plan of correction is developed with the administrator of the facility, and a date for correcting the deficiency is established by the evaluator (usually within 30 days). Sometimes, a deficiency can be corrected during the inspection visit (like replacing a defective light bulb in a hallway). Other corrective actions will take time. A follow-up visit within 10 working days from the date for correction, is required to determine if the deficiency was corrected by the scheduled correction date.

When conducting an on site inspection or investigation pursuant to a complaint, the Department must collect and evaluate all available evidence. It may issue a citation based upon, but not limited to:

  • Observed conditions

  • Statements of witnesses (including oral statements)

  • Facility records

A complainant who is dissatisfied with the department's determination may request an informal conference. If the complainant is still dissatisfied, he or she may request a review by the Deputy Director of Licensing and Certification.

Licensing personnel are obligated to take immediate action to insure the correction of deficiencies or unacceptable conditions of care. If a deficiency is not corrected by the date set by the evaluator, a civil penalty may be assessed for serious deficiencies. Violations of patients' rights are also licensing violations and may subject the facility to civil penalties. Additional penalties may be assessed for failure to correct the condition, willful or repeated violations, or willful falsification of information. In addition, if facilities receiving federal or state funding are in serious violation of licensing or related regulations (like the Joint Commission on Accreditation of Health Care Organizations standards for acute care facilities), they risk becoming ineligible to receive Medi-Cal or Medicare reimbursement for services.

5. Patients’ Rights Advocates' Role

The role of Advocates in bringing complaints and violations to the attention of licensing agencies is very important. Patients’ Rights Advocates should establish and maintain good working relationships with staff in the Department of Health Services, Department of Social Services Licensing Divisions. Advocates and licensing personnel can be resources to each other for information and enforcement strategies.

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