Senator Alfred E. Alquist|
Arthur F. Gerdes
Senator Milton Marks
Barbara S. Stone
Assemblyman Phillip D. Wyman
Mary Anne Chalker|
Assemblywoman Gwen Moore
Richard R. Terzian
TURNING POLICY RECOMMENDATIONS
Medi-CalAppendix - Chronological List of Commission Reports
Public Employment Relations Board
Fish and Game
Boards and Commissions
Skilled Nursing Facilities
Formally known as the Commission on California State Government Organization and Economy, the Little Hoover Commission is an independent bipartisan watchdog agency that was created in 1962. Under its statutory authority, which includes the power of subpoena and the right to free access to all internal governmental documents, the Commission investigates state government operations and, through its findings and recommendations, promotes efficiency, economy and effectiveness. The Commission's enabling statute, as interpreted by case law, defines the Commission as a policy-making, rather than advisory, body and places the Commission outside of both the executive and legislative branches.
The Commission is made up of 13 members: five citizen members appointed by the Governor, four citizen members appointed by the Legislature, two Senators and two Assembly members. No more than five of the nine citizen members may belong to the same political party, a provision that ensures the bipartisan nature of the Commission's approach to evaluating programs and making recommendations.
Between 1962 and the end of 1990, the Commission produced 106 reports examining government programs as diverse as the Department of Transportation, the State Lottery, education, cash management, professional and business licensing and health care (please see Appendix A for a chronological listing of all reports). These reports are part of a long and thorough process that includes:
The next section of this report is a summary of legislation for the two-year period. The final section summarizes the studies conducted.
Because of the bipartisan nature of its makeup and the credibility of its reports, the Commission has enjoyed a high level of success over the years. A heightened commitment to working on legislation led to both 1989 and 1990 being record-setting years, with the Commission winning enactment of 20 bills in each of the two years.
Of course, the Commission is not always successful with its efforts. The Commission sponsored 81 bills during the two-year 1989-90 legislative session on topics ranging from children's services and elder care to solid waste and education. The charts on the next page show the overall activity on legislation, separated into two categories--social service issues and non-social service issues.
The Commission had a high rate of success with recommendations from its reports on state commissions, solid waste and workers' compensation. With a total bill package in the non-social service area of 20 measures, the Commission achieved a 70.0 percent success rate, with 14 becoming law and 6 failing.
The results were not as encouraging on social service issues, although the legislation involving residential care facilities for the elderly was an exception (out of 21 residential care bills, 17 became law--an 81 percent success rate). The total bill package in the social services arena was 61 measures, with 26 becoming law, for a 43 percent success rate.
Overall, the Commission worked on 81 measures during the two-year session. Forty of the measures became law for a 50 percent success rate. Sixteen bills were vetoed (20 percent) and 25 bills failed to move out of the Legislature before the close of session (31 percent).
Organized alphabetically by topic, the summary beginning on the next page gives the title of the report, each bill reflecting the recommendations in the report and the resulting outcome.
"California's Coordination of AIDS Services," May 1990
SB 2699 (KEENE): Requires Department of Health Services to establish a Northern California pilot project for AIDS case management.
Status of measure: Vetoed by Governor. The Governor called the bill an unnecessary statutory requirement for the Department of Health Services.
BOARDS AND COMMISSIONS
"Boards and Commissions: California's Hidden Government," July 1989
AB 1272 (EASTIN): Requires Auditor General to conduct consolidation study of professional regulatory agencies; study to cover both function and areas of jurisdiction.
Status of measure: Auditor General directed to perform study by Joint Audit Committee; now in progress.
AB 2572 (EASTIN): Requires Joint Budget Committee to develop and operate "sunrise/sunset" reviews for all proposed boards, commissions and committees.
Status of measure: Chapter 832, Statutes of 1990.
AB 2374 (PRESLEY): Abolishes 22 non-functional advisory committees and bodies. Also requires addendum to 1992-93 proposed budget identifying all General Fund-supported advisory bodies, and removing all such funding effective January 1, 1993 unless specifically justified and authorized by the Legislature and Governor.
Status of measure: Chapter 1455, Statutes of 1990
"Children's Services Delivery System in California Preliminary Report," March 1987
"Children's Services Delivery System in California Final Report," October 1987
"Runaway/Homeless Youths: California's Efforts to Recycle Society's Throwaways," April 1990
AB 77 (MOORE): Establishes a nonpaid family care leave policy for persons employed by a company with more than 25 employees. Unpaid leave would be available for those employees who need to take up to four months within a 24-month period to care for a family member.
Status of measure: Vetoed by Governor. The Governor stated that leave policy is a bargaining issue that should not be superseded by state law, and that the bill would disrupt business and would add to operating costs.
AB 870 (BATES): Requires public buildings, both state and local, to provide child care facilities.
Status of measure: Vetoed by Governor. The Governor said it would increase state-reimbursable costs to local governments.
AB 1776 (FRIEDMAN): Requires local planners to consider child care needs when establishing or revising local plans and ordinances.
Status of measure: Vetoed by Governor. The Governor said local governments may already consider such needs and that the bill would add to state-reimbursable costs to local governments.
AB 2979 (MOORE): Makes additional appropriations through the Office of Criminal Justice Planning (OCJP) to Los Angeles Homeless Youth program to establish programs outside the Hollywood area. Program would be funded beginning July 1991.
Status of measure: Died.
AB 3130 (WATERS): Establishes an Interagency Commission of Youth Programs and Services, to be responsible for developing a master plan for children's services; coordinating the State's various children's services programs; and evaluating the feasibility of establishing a Department of Youth.
Status of measure: Vetoed by Governor. The Governor said there was no need to create a new body and that other funding needs for the state are more pressing.
AB 3420 (WOODRUFF): Requires the OCJP and the Department of Drug and Alcohol Programs to develop a two-year pilot project treating substance abuse among homeless youth, especially juvenile prostitutes. Project to be run through current homeless youth project in Los Angeles.
Status of measure: Chapter 1029, Statutes of 1990.
AB 3654 (VASCONCELLOS): Establishes runaway/homeless youth programs in San Diego and Santa Clara Counties, based upon OCJP models. Programs would be funded beginning July 1991.
Status of measure: Chapter 1396, Statutes of 1990.
AB 3893 (WYMAN): Establishes pilot runaway/homeless youth demonstration programs in three rural counties; OCJP to administer programs. Programs would be funded beginning July 1991.
Status of measure: Died.
SB 257 (TORRES): Requires that leaves of absence to take care of disabled or sick children or family members will be covered by the provisions of the Federal Civil Rights Act regarding discrimination.
Status of measure: Died.
SB 259 (TORRES): Establishes a mechanism for public and private partnerships to deliver or expand child care services; requires Department of Education to coordinate state child care and development programs, and to develop a state plan for child care.
Status of measure: Vetoed by Governor. The Governor cited a $40.3 million annual cost, as well as questions about the availability of matching federal funds.
SB 260 (TORRES): Establishes a Commission on Children and Youth; adopts policy for provision of children's services by the state.
Status of measure: Vetoed by Governor. The Governor said the Commission would be unnecessary, duplicative and another layer of bureaucracy.
SB 2370 (MARKS): Provides health care services for participants in San Francisco homeless youth program.
Status of measure: Vetoed by Governor. The Governor said it was unclear how the health services in the bill would differ from others already provided.
"K-12 Education in California: A Look at Some Policy Issues," February 1990
AB 2918 (WYMAN): Requires Department of Education to adhere to the Administrative Procedures Act (APA) in issuing program guidelines; prohibits state administrative restrictions on "sunsetted" categorical programs.
Status of measure: Died.
AB 3693 (MOORE): Provides separate budgeting authority to State Board of Education for its own budget. Also provides for change in number and appointment authority of State Board.
Status of measure: Died.
AB 3489 (HUNTER): States legislative intent that all categorical funds to be granted on the basis of defined indicators of need by each district. Department of Education, Legislative Analyst and Department of Finance to conduct study of district needs for categorical programs, as defined.
Status of measure: Died.
AB 3842 (ALLEN): States legislative intent that all categorical funds to be granted on the basis of defined indicators of need by each district. Department of Education, Legislative Analyst and Department of Finance to conduct study of district needs for categorical programs, as defined.
Status of measure: Chapter 703, Statutes of 1990.
AB 4096 (FRIZELLE): Make state requirements for commingling categorical funds concurrent with federal requirements for the same programs.
Status of measure: Died.
SB 611 (C. GREENE): Revises current average daily attendance system to reflect actual attendance, rather than current "weighted" system. Includes one-time funding adjustment.
Status of measure: Chapter 1540, Statutes of 1990.
FISH AND GAME
"Report on California's Fish and Game Commission and Department of Fish and Game," January 1990
AB 3419 (WOODRUFF): Specifies procedures for notice to adjacent landowners prior to purchase of property by Department.
Status of measure: Chapter 1287, Statutes of 1990.
AB 3878 (WOODRUFF): Requires Department of Fish and Game to develop and use empirically defined standards for game taking.
Status of measure: Died.
"Meeting the Needs of California's Homeless: It Takes More Than A Roof," May 1989 AB 597 (HAUSER): Makes the Department of Housing and Community Development a clearinghouse for all state homeless programs.
Status of measure: Vetoed by Governor. The Governor said it would redundant and duplicative.
AB 795 (MOORE): Establishes a statewide coordinated intake system for homeless persons.
Status of measure: Died.
AB 1393 (WYMAN): Changes the legal definition of "gravely disabled" to include persons likely to deteriorate to the point of becoming a danger to themselves and others.
Status of measure: Died.
AB 1691 (BRONZAN): Establishes a commission authorized to lease state hospital lands and develop homeless housing.
Status of measure: Vetoed by Governor. The Governor said the commission would be duplicative and unwieldy and that the state is already engaged in steps to pro-actively manage its land.
AB 1714 (HAYDEN): Authorizes involuntary out-patient status for those persons who have been committed as an in-patient in a psychiatric or other mental hospital three times in the past five years.
Status of measure: Died.
ACR 46 (HAUSER): Creates a joint committee on housing preservation, charged with studying the loss of rental housing in the state.
Status of measure: Died.
SB 502 (LOCKYER): Requires charitable fundraisers to register with the Attorney General.
Status of measure: Chapter 307, Statutes of 1989.
SB 691 (ALQUIST): Requires the Business, Transportation and Housing Agency to determine what single agency will be responsible for all state building standards.
Status of measure: Vetoed by Governor. The Governor said the measure was premature because a state task force has not completed its report on building standards.
SB 820 (ALQUIST): Adds a documentary transfer surcharge to be used to fund housing for the homeless.
Status of measure: Died.
SB 1205 (ALQUIST): Establishes specified funding for housing programs for the homeless, low-income and other specified groups.
Status of measure: Died.
SB 1286 (SEYMOUR): Provides tax incentives to owners of previously federally subsidized (Section 8) low-income housing in order to continue low-income housing availability.
Status of measure: Chapter 1436, Statutes of 1990.
SB 2288 (ROBERTI): Designates the Health and Welfare Agency as the lead state agency for coordination and integration of homeless programs. Encourages the Agency to continue the work of the Interagency Task Force, based on specified input from local agencies and individuals.
Status of measure: Vetoed by Governor.The Governor called the bill unnecessary and duplicative of existing efforts to coordinate programs.
"A Report on the Financial Management and Accountability in the State's K-12 Public School System," November 1987
AB 226 (CORTESE): Establishes funded professional review and enforcement program at Board of Accountancy; will reduce number of faulty school district and other audits.
Status of measure: Chapter 200, Statutes of 1989.
"The Public Employment Relations Board: Costly, Slow and Unsure," April 1990
AB 943 (ELDER): Imposes minimum experience requirements for appointment of Public Employment Relations Board (PERB) General Counsel. Requires Board members to make determinations on cases within 90 days of submission for decision. Requires specific progress and statistical reports to the Governor and Legislature.
Status of measure: Vetoed by Governor. The Governor said the bill would place an unacceptable limitation on an appointing power and would create an artificial deadline for decisions.
AB 1431 (EASTIN): Requires the Legislative Counsel to track all reports required to be submitted to the Legislature by state and local agencies.
Status of measure: Chapter 528, Statutes of 1989.
"A Review of the Organization, Operation and Performance of the California State Lottery," May 1989
SB 906 (DILLS): Makes several revisions to the California State Lottery Act and other related statutes; requires all unclaimed LOTTO prizes to revert to the Public Education Fund; changes disqualification rules for Lottery employees and family; and makes other changes.
Status of measure: Chapter 917, Statutes of 1989.
"A Report on Community Residential Care for the Elderly," January 1989
AB 314 (LESLIE): Requires the Department of Social Services to determine if an applicant for residential care facility licensure has been arrested for specific crimes.
Status of measure: Chapter 825, Statutes of 1989.
AB 1043 (HANSEN): Establishes an amnesty program for unlicensed residential care facilities for the elderly.
Status of measure: Died.
AB 1112 (BENTLEY): Requires the Department of Social Services to establish regulations and criteria for locked facilities for the elderly.
Status of measure: Provisions amended into Senate Bill 481.
AB 1451 (SPEIER): Requires third-party notification by the facility of substantiated complaints or citations. Also requires posting in facility of substantiated complaints or citations.
Status of measure: Chapter 565, Statutes of 1989.
AB 1455 (PRINGLE): Allows counties to license residential care facilities for the elderly having six beds or less.
Status of measure: Chapter 488, Statutes of 1989.
AB 1484 (BENTLEY): Requires State Fire Board to hear appeals from local fire standards for residential care facilities for the elderly. Also requires State Fire Marshal to develop new fire code classification for these facilities.
Status of measure: Chapter 1261, Statutes of 1989.
AB 1554 (WYMAN): Allows both district attorneys and city attorneys to prosecute violations regarding residential care facilities.
Status of measure: Chapter 675, Statutes of 1989.
AB 1556 (WYMAN): Requires the Department of Social Services to establish in-service training for employees of residential care facilities for the elderly.
Status of measure: Died.
AB 1815 (CONNELLY): Establishes emergency protocols for transfers of residents or residential care facilities. Requires DSS to establish regulations regarding procedures to be used to close facilities.
Status of measure: Died.
AB 1989 (HANNIGAN): Redefines residential care facility fire regulations to allow non-ambulatory residents into a wider range of selected facilities.
Status of measure: Chapter 436, Statutes of 1990.
AB 2323 (HANNIGAN): Requires Department of Social Services and other specified agencies to complete a study to establish criteria for certification of administrators for residential care facilities for the elderly. Also requires DSS to survey training requirements and education requirements for other hands-on employees of residential care facilities for the elderly. Appropriates funds from DSS licensing fees.
Status of measure: Chapter 434, Statutes of 1989.AB 2414 (WATERS, N.): Requires residential care facilities for the elderly and child day care facilities to post and use license number in all public advertisements and documents.
Status of measure: Chapter 458, Statutes of 1989.
AB 2989 (HUNTER/HARVEY): Establishes doubled fines for unlicensed facilities who, when detected, refuse to apply for licensure, or cannot become licensed. Also allows criminal prosecution of such facilities when necessary.
Status of measure: Chapter 1488, Statutes of 1990.
ACR 41 (PRINGLE): Requires Health and Welfare Agency to identify new funding sources, outside of new taxes, for residential care facilities for the elderly.
Status of measure: Chapter R116, Statutes of 1989.
SB 481 (MELLO): Allows licensure of residential care facilities that provide "restricted facility" care to residents withirreversible dementia; establishes pilot programs for same.
Status of measure: Chapter 1372, Statutes of 1989.
SB 944 (ROSENTHAL): Provides for criminal penalties for state employees who divulge information regarding residential care facilities for the elderly to any member of the public.
Status of measure: Chapter 694, Statutes of 1989.
SB 1076 (BERGESON): Requires written notice of public access to DSS facility licensing reports.
Status of measure: Chapter 911, Statutes of 1989.
SB 1077 (BERGESON): Requires inclusion of facility license number in all advertising and correspondence.
Status of measure: Chapter 465, Statutes of 1989.
SB 1102 (ROBERTI): Allows family councils in residential care facilities.
Status of measure: Chapter 466, Statutes of 1989.
SB 1166 (MELLO): Omnibus reform bill for residential care facilities for the elderly. Deals with licensure, enforcement, and minimum requirements for housing and funding.
Status of measure: Chapter 1115, Statutes of 1989.
SB 1502 (AYALA): Establishes amnesty program for unlicensed residential care facilities; also requires the State Fire Marshal to establish specific fire code classifications for residential care facilities for the elderly.
Status of measure: Vetoed by Governor. The Governor said he had concerns about provisions that would prevent the placement of juveniles in facilities near their homes.
"A Report on Crime and Violence in California's Public School System," December 1988
AB 450 (LA FOLLETTE): Encourages, and makes grants available for schools to develop specified school safety plans.
Status of measure: Chapter 1253, Statutes of 1989.
AB 1113 (BADER): Expands the duties of the Department of Education and the Attorney General's School Safety Partnership.
Status of measure: Died.
AB 1114 (BADER): Establishes a California School Safety Institute to do research and act as a clearinghouse for information on school crime.
Status of measure: Died.
AB 1395 (WYMAN): Mandates attendance by school district employees at Department of Education sponsored workshops on school crime reporting.
Status of measure: Died.
"Report on Solid Waste Management: The Trashing of California," July 1989
AB 80 (KILLEA): Omnibus Recycling Act of 1989; makes changes in local and state planning for solid waste disposal.
Status of measure: Major provisions amended into AB 939.
AB 939 (SHER): Omnibus Solid Waste Management, Source Reduction, Recycling, Composting and Marketing Development Act of 1989. Makes numerous changes and establishes new statutes to encourage source reduction, recycling and composting of solid waste.
Status of measure: Chapter 1095, Statutes of 1989.
AJR 13 (FARR): Resolution to the U.S. Congress to encourage national recycling policy.
Status of measure: Chapter R107, Statutes of 1989.
SKILLED NURSING FACILITIES
"The Medical Care of California's Nursing Home Residents: Inadequate Care, Inadequate Oversight," February 1989
AB 1370 (CONNELLY): Establishes voluntary facility-based fingerprinting and criminal background check system for employees of skilled nursing facilities.
Status of measure: Vetoed by Governor. The Governor said the bill is too costly and that it puts the state in the undesirable role of determining qualifications for employment.
AB 1945 (EASTIN): Allows for suspension or revocation of skilled nursing facility licenses for failure to pay unappealed or finalized court fines or penalties.
Status of measure: Provisions amended into AB 3536.
AB 3536 (EASTIN): Establishes requirements and procedures for Department of Health Services to speed citation hearing process and fine/penalty collection. Increases specified penalties and limits for binding arbitration.
Status of measure: Chapter 1133, Statutes of 1990.
AB 4088 (FRIEDMAN): Defines abuse, neglect or abandonment of an elderly patient of an acute care or skilled nursing facility by a licensed health care practitioner as a felony, and provides appropriate criminal penalties.
Status of measure: Died.
SB 660 (WATSON): Establishes pilot projects for physician peer review panels in skilled nursing facilities in three specified counties. The Office of Statewide Health Planning and Development would administer the pilot project, to be operated through June 30, 1993.
Status of measure: Vetoed by Governor. The Governor said the $140,000 cost was too expensive.
SB 778 (HART): Establishes legal guidelines for use of psychotropic drugs on patients in skilled nursing facilities. Defines "informed consent" to be given by patient or guardian for the use of drugs.
Status of measure: Died.
SB 1087 (MELLO): Makes major structural reforms in Medi-Cal rate and audit system for long term care. States that this measure's requirements are equal to or exceed federal long-term care requirements.
Status of measure: Chapter 502, Statutes of 1990.
SB 2114 (HART): Establishes quality assurance committees in skilled nursing facilities to complement the work of peer review panels and oversee non-physician aspects of health care. Defines duties and responsibilities of the Medical Director of a skilled nursing facility, including roles in policy making, enforcement, peer review and quality assurance. Limits responsibility to a maximum of four facilities or 400 beds.
Status of measure: Died.
SB 2426 (MELLO): Makes legislative findings regarding apparent inappropriate use of physicians and nurses in skilled nursing facilities. Requires the Department of Health Services, in consultation with specific groups, to define in regulation "a significant change in the patients' condition" as a "trigger" for physician treatment.
Status of measure: Chapter 945, Statutes of 1990.
SB 2481 (HART): Requires registration of temporary nursing services with Department of Health Services.
Status of measure: Died.
SB 2507 (PETRIS): Prohibits skilled nursing facilities in the Medi-Cal program from holding beds unoccupied if Medi-Cal patients have applied for admission to the facility.
Status of measure: Died.
"A Review of the Current Problems in California's Workers' Compensation System," March 1988
AB 993 (BADER): Requires the Department of Insurance, Bureau of Fraudulent Claims to establish criteria for investigation and referral of potential cases of workers' compensation insurance fraud.
Status of measure: Provisions amended into AB 276.
AB 276 (MARGOLIN): Omnibus Workers' Compensation Bill of 1989; deals with eligibility, claims processing, benefit levels and other related matters.
Status of measure: Chapter 892, Statutes of 1989.
Altogether, the Commission's reports set forth 85 findings and 138 recommendations in 13 different areas of state government.
The charts on the next two pages graphically depict the hearings conducted and the reports issued by the Commission during 1989 and 1990.
The next section of this report describes each of the Commission's studies during the past two years, beginning with the most recent report. But the Commission's main achievements can be summarized as:
The Commission continued its examination of the education system, highlighting the often-ignored authority given to the State Board of Education under the Constitution and state law and seeking ways to funnel more education dollars directly into classrooms.
The Commission also examined the Medi-Cal system and found that it is failing to live up to its promises of comprehensive medical care for the poor.
In the area of elder care, the Commission issued reports on residential care facilities and skilled nursing homes early in 1989 and then conducted hearings late in 1990 as a prelude to a new study on the continuing problems of how the state treats its elderly citizens.
Finally, the Commission also concentrated on programs for the homeless and for runaway/homeless youths, recommending steps to break the cycle of poverty that entraps these vulnerable populations.
The Commission continued its long-term efforts to prod the state into actively managing its real property to more fully benefit the citizenry.
In addition, the Commission pinpointed the existence of more than 400 boards, commissions, councils and other bodies that function as part of state government with very little oversight.
The Commission conducted major studies of the way the state handles solid waste and of the Department of Fish and Game, concluding in both cases that the state was falling far short of its goals as guardian of natural resources.
Overall, the Little Hoover Commission in 1989 and 1990 aggressively met its mandate to act as an independent watchdog over state programs and policies.
The study notes three persistent problems:
1. Recipients have difficulty accessing treatment. The supply of medical providers is limited because many private doctors refuse to participate in Medi-Cal. Many patients live in geographical areas (either rural or inner city) with very few medical care providers.
2. The quality of medical care given recipients is often poor or inconsistent throughout the state. Few receive adequate preventive care that might head off later, more expensive medical problems. With the bulk of Medi-Cal dollars concentrated on long-term care and emergency hospital services, relatively few resources are dedicated to early detection and prevention of diseases.
3. Provider participation is low. Providers complain about two facets of Medi-Cal: They believe the reimbursement rate structure is too low, but more importantly they find the reimbursement and prior authorization process too time-consuming, cumbersome and frustrating. As a result, many refuse to accept Medi-Cal patients.
The Medi-Cal report contains 12 findings and 28 recommendations.
FINDING 1: Medi-Cal cannot meet the needs of the future without altering its basic approach to providing health care for the poor.
FINDING 2: Implementation of the eligibility process varies from county to county, resulting in unequal treatment of Medi-Cal applicants.
FINDING 3: An overly complex application form is a barrier to eligibility for many otherwise qualified Medi-Cal recipients.
FINDING 4: Specialized categories of Medi-Cal applicants, including pregnant women, SSI recipients, nursing home residents and share-of-cost patients, face particular barriers to eligibility.
FINDING 5: The State has failed to pursue vigorously capitated care systems that have the potential of improving medical care for recipients and lowering long-term costs.
FINDING 6: The State has not maximized the use of case management systems in an effort to improve medical care and lower long-term costs.
FINDING 7: The State has failed to avail itself fully of the latest computer capabilities and statistical analysis methods to ensure efficient operation of Medi-Cal.
FINDING 8: Claim forms, procedure designations and other processes for submitting bills to Medi-Cal constitute a complex burden for providers.
FINDING 9: The process for addressing suspended claims and denials is complicated and frequently unresponsive to providers.
FINDING 10: The system of incorporating a check in each Explanation of Benefit form is inefficient and costly both for the State and for the providers.
FINDING 11: The State has not taken full advantage of the fiscal intermediary's expertise in providing Medicaid services.
FINDING 12: The Department of Health Services has achieved key reforms of the drug purchasing system that should improve both the efficiency and the effectiveness of the pharmaceutical portion of Medi-Cal.
The Medi-Cal report, which was issued after the close of the 1990 legislative session, has prompted considerable interest from legislators. It is anticipated that multiple bills will be sponsored by the Commission to enact the recommendations in this report when the 1991 legislative session begins.
The result of the state's failure to improve its management techniques is that assets are not used to the fullest extent to obtain the maximum benefit for citizens.
The property management report contains four findings and 17 recommendations.
FINDING 1: The state's organizational structure for developing and implementing a proactive property management system is incomplete and inadequate.
FINDING 2: The state's system of planning for its long-term real property and capital outlay needs is fragmented and incomplete.
FINDING 3: The statewide property inventory, although finally completed after long delays, will require additional work to be more effective in the proactive management of individual properties.
FINDING 4: Current state statutes, policies, and procedures inhibit the proactive management of the state's real property.
Like the Commission's Medi-Cal report, the report on property management was issued too late in the year to be pursued in the legislative arena in 1990. Bills are expected to be sponsored, however, in the 1991 legislative session.
In addition, the report says that a lack of firm leadership, commitment and sense of direction at the State level has meant that the State's steps toward coordination have been tentative, halting and, in general, unsuccessful.
The AIDS report contains four findings and four recommendations.
FINDING 1: The State Office of AIDS lacks the authority to act as a lead agency for the State on all matters relating to AIDS.
FINDING 2: The State Office of AIDS fails to exert the leadership required to act as a clearinghouse for statewide AIDS information.
FINDING 3: The State has crafted an updated comprehensive plan for addressing AIDS but has sent mixed signals about its intentions for implementing the plan.
FINDING 4: The Office of AIDS appears to be unable to administer its grant programs in a timely and efficient manner.
During the 1990 legislative session, the Little Hoover Commission supported one bill dealing with AIDS. In addition to supporting legislation in 1991 to implement the report's recommendations, the Commission will be asking the State Office of AIDS to report back on any administrative steps it has taken to redress problems with state AIDS programs.
In addition, the study shows that the state is providing an unlimited subsidy for school district collective bargaining costs that in 1989-90 exceeded $30 million per year.
The PERB report contains three findings and seven recommendations.
FINDING 1: The PERB takes too long to issues its decisions.
FINDING 2: PERB members are not qualified by expertise or experience to carry out their essentially judicial functions.
FINDING 3: The state is providing an unlimited subsidy for school districts' collective bargaining expenses at a cost of more than $30 million annually.
The Commission supported one bill dealing with the PERB in 1990 and it anticipates supporting similar legislation in the coming session. In addition, the PERB has indicated it is improving its procedures. The Commission will review the status of the recommendations and PERB's performance in mid-1991.
The initial report found that there were few services directed toward runaway/homeless youths, but that pilot projects were just beginning in Los Angeles and San Francisco. The 1990 report reviewed the results of the pilot projects, which have since become permanent state programs. The report concludes that the programs have worked well. Not only have medical care, shelter, food and counseling been provided to youths in need, but also a significant success rate has been achieved in removing youths from the streets permanently.
The runaway/homeless youth report contains three findings and five recommendations.
Finding 1: The San Francisco and Los Angeles runaway/homeless youth projects are working well and efficiently, but despite their success the state's runaway youths still have unmet needs.
Finding 2: In addition to unmet needs in various geographical areas, runaway youths also face gaps in services that are critical if they are to be weaned from the streets.
Finding 3: The probation system does not appear to be the appropriate mechanism for handling runaway/homeless youths who have committed no crimes.
The Commission sponsored four bills in the 1990 session. Based on the Commission's commendation of a program that has proven both effective and efficient, policy committees in the Legislature approved all four bills from the report. But the state's tight fiscal circumstances derailed two of the measures and forced a delay in the implementation of a third. The Commission will continue to monitor the status of these runaway/homeless youth programs.
The 1990 report concludes that the structures put in place by the Constitution and statutes to govern state education policy are fundamentally flawed; that regulatory processes are routinely ignored; and that categorical programs are not allowed to operate effectively. In addition, the report makes recommendations about district reorganization and the attendance reporting system.
The report includes seven findings and eight recommendations.
FINDING 1: The state's governance structure for education is not operating as statutorily intended.
FINDING 2: The superintendent may be circumventing the state's regulatory process through the use of policy guidelines.
FINDING 3: The state's system of funding categorical programs is neither effective nor efficient.
FINDING 4: The categorical "sunset laws" have not been working as statutorily intended.
FINDING 5: The reorganization of some school districts needs to be considered.
FINDING 6: The organization of offices of education by county boundary is inefficient and does not maximize service delivery.
FINDING 7: The state's system for reporting attendance is inefficient and does not encourage attendance.
The Little Hoover Commission sponsored six pieces of legislation based on the February 1990 education report. Although not all the bills were successful, the report has had a significant impact on the way education policy is created in California. Among other outgrowths of the report, the State Board of Education itself has taken steps to regain authority over the education system. The Commission will continue to pursue legislative changes and to monitor the progress of the State Board of Education.
The report notes that where once the highest priority was managing wildlife for hunters and fishermen, the Fish and Game Commission and Department now have the much broader mandate of protecting all fish, game and native plants; conserving wildlife habitat; acquiring land, water and water rights to ensure fish and game propagation; protecting aquatic resources; monitoring dammed waters; and identifying, inventorying and managing endangered and/or rare species. This broader mandate has come without a commensurate increase in resources and without the required shifting of focus from top to bottom at the Fish and Game hierarchy.
FINDING 1: There are no clear or publicly understood criteria for selection and appointment of Fish and Game Commissioners.
FINDING 2: The Commission has not and, as presently structured, cannot adequately exercise its statutory authority over the Department of Fish and Game.
FINDING 3: The Commission has difficulty meeting its mandate because of external pressures and factors outside of its control.
FINDING 4: The Department of Fish and Game has exercised inappropriate bargaining tactics with respect to habitat mitigation.
FINDING 5: The Department has been unsystematic and inconsistent in its acquisition and maintenance of State refuge lands.
FINDING 6: The Department has no comprehensive management information system.
FINDING 7: The Department is not capable of appropriately allocating resources.
FINDING 8: The Department does not have adequate oversight and authority over Fish and Game Regional administrators.
The Commission sponsored two bills based on the Fish and Game report. The Department of Fish and Game entered a time of budget crisis after the Little Hoover Commission's report was issued, requiring an extra appropriation from the Legislature. The Commission will continue to track the problems in this department and any progress on the recommendations.
The May 1989 letter report addresses the convoluted situation that had evolved around unclaimed, low-tier Lotto and instant game prizes. At various points, the State Lottery Commission had adopted and/or modified policies to sweep these unclaimed prizes into, first, the Education Fund and, second, into the game prize fund. The Little Hoover Commission letter report assesses the Lottery's policy and urges changes.
The December 1989 letter report was a followup review of a report issued almost three years earlier. This review says that, in general, the Lottery has matured well since voters approved its creation in 1984 and that fine-tuning rather than a major overhaul is needed.
In the original January 1987 report, the Commission cited problems with the then-new Lottery in three major areas: procurement procedures, relationships with contractors and financial accountability. The 1989 review shows that most of the recommendations to resolve these problems had been enacted or were in the process of taking place.
There are two problem areas where the Little Hoover Commission continues to find fault in 1989: budgetary oversight and the monitoring of contracts. In addition, the Commission identifies new areas of concern: research and development procedures, and methods of evaluating advertising efforts.
The Little Hoover Commission's May 1989 letter report contains two findings and two corresponding recommendations.
FINDING 1: The purpose of the Lottery Act and the intent of the people would be better served by mandating the allocation of unclaimed low-tier Lotto prizes to the State Education Fund.
FINDING 2: The Lottery Commission's rule making process does not provide adequate time for public input.
The Little Hoover Commission December 1989 letter report contains four findings and four corresponding recommendations.
FINDING 1: The Lottery is exempt from external budgetary oversight.
FINDING 2: The Lottery does not have the operational flexibility necessary to effectively deal with future project development issues.
FINDING 3: The Lottery currently does not have an adequate system for evaluating the effectiveness of its advertising and promotional expenditures.
FINDING 4: The Lottery has not adequately monitored contract performance.
The Little Hoover Commission's early recommendations when the Lottery was still in its developmental stages in 1987 were for the most part implemented. The Commission added to these recommendations in two 1989 letter reports and sponsored two bills during 1989. While a portion of the Commission's concerns have since been addressed, there are still some remaining recommendations. Other bills may be developed in future years to carry out unfulfilled recommendations, particularly from the December 1989 report.
The letter report concludes that the state's boards and commissions are proliferating without adequate evaluation of need, effectiveness and efficiency. This lack of control may cost the state not only dollars, but also wasted resources, duplicated efforts and the adoption of policies that may run counter to the general public's interest.
The Commission's study was the third it has conducted on the use of plural bodies in California state government. The first concerned boards and commissions in the Resources Agency (April 1965) and the second considered those in the predecessor to the Department of Consumer Affairs, the Department of Professional and Vocational Standards (September 1967). In its latest review, the Commission focuses on overall state problems with boards and commissions, rather than evaluating the need and/or performance of any single entity.
The Little Hoover Commission letter report on boards and commissions contains three findings and five recommendations.
FINDING 1: Statutory boards, commissions, authorities, associations, committees and councils are created without any systematic evaluation of the most effective approach to solving the perceived problem.
FINDING 2: Few organizations are subject to periodic review subsequent to their creation.
FINDING 3: Some boards, commissions, authorities, associations, committees and councils have overlapping functions.
The Little Hoover Commission sponsored three bills out of the boards and commissions report. While all three were successful, the impact of the changes required in the bills is not expected to be immediate. The Commission will continue to track the proliferation of government bodies.
The report says that, despite a state law that outlines an effective policy of solid waste management, California continues to rely on landfills to get rid of its garbage. This is because, in part, California's lead agency responsible for solid waste management policies has emphasized landfilling in past years and there has been little pressure to develop disposal alternatives, including recycling. With landfills rapidly filling, the state has allowed a situation to develop that threatens the health of citizens and the environment, as well as depletes natural resources and engenders escalating costs.
The Commission's solid waste management report details three findings and five corresponding recommendations.
FINDING 1: California lacks an integrated system for managing its solid waste.
FINDING 2: The state lacks a comprehensive statewide recycling program.
FINDING 3: The California Waste Management Board has been ineffective. The board has failed to meet its responsibilities to encourage integrated waste management, as already required by state law, and has failed to discourage the use of landfills. The board's effectiveness is hampered by the public's attitude to solid waste and the common perception that the board is not independent of certain interests in the waste industry.
The Little Hoover Commission's report on solid waste management was issued at a time when there was widespread unhappiness with the state's handling of solid waste. The report served to document the severity of the crisis and focus attention on the need for immediate solutions, and the Commission sponsored three pieces of legislation based on the report. With the passage of a major overhaul of the state's solid waste management structure now in law, this area will be ripe for a review in the future to determine if all recommendations have been implemented effectively.
In its report, the Commission concludes that despite the intense interest in meeting the needs of the homeless and despite the allocation of considerable resources to do so, the state has failed to provide an effective safety net that ensures people will be adequately housed.
The report contains three findings and 13 recommendations flowing from those findings.
FINDING 1: Because of diffused state leadership, services provided for the homeless are fragmented. As a result, some segments of the homeless population are not served or are served inadequately.
FINDING 2: Availability of the three main types of homeless programs (emergency, transitional and permanent) is uneven, and there is no efficient, coordinated method of moving the homeless through the different programs.
FINDING 3: Because there is no cohesive approach to a statewide housing policy, many actions at various levels of government drive up the cost of housing and/or discourage the availability of adequate, affordable housing.
The Commission sponsored 12 bills relating to the homeless report. Although major shifts in the state's approach to homeless programs were not immediately adopted, the Little Hoover Commission's efforts to increase the efficiency and effectiveness of state programs will continue in future years. The Commission sees a clear linkage between this initial homeless report and its planned study of affordable housing in 1991.
The current report follows in the footsteps of its predecessor reports in that substantial recommendations are made for improving the quality of life of those in nursing homes. A review of the earlier reports shows that progress has been made: "The Bureaucracy of Care," issued in 1983, resulted in the enactment of the Nursing Home Patients' Protection Act and further changes in law came out of recommendations in "New and Continuing Impediments to Improving the Quality of Life and Quality of Care in California's Nursing Homes," issued in 1987. Those two reports can be briefly summarized as follows:
Specific recommendation areas included eliminating Medi-Cal patient "dumping;" overhauling the enforcement/fining system; better defining the oversight role of the Department of Health Services; increased criminal penalties for willful and repeated violators; greater statutory rights for complainants; and creating better information systems and public access to that information. Among the changes achieved were a new class of penalties ranging from $5,000 to $25,000 when the facility is responsible for the death of a resident.
AB 180 (Isenberg): Redefines and strengthens penalty system and increased fines for violation of patient rights and endangering patient health and safety (A and B citations).
Status of measure: Chapter 10, 1985 Statutes
AB 3580 (Duffy): Revises membership of committee on nursing homes that advises the director of the Department of Health Services.
Status of measure: Chapter 1351, 1986 Statutes
AB 3644 (Stirling): Gives priority status to criminal cases where the elderly are victims or material witnesses.
Status of measure: Chapter 588, 1986 Statutes
SB 3923 (McClintock): Makes falsification of skilled nursing facility records a Class "A" or "B" citation (as defined).
Status of measure: Chapter 1126, 1986 Statutes
SB 53 (Mello): Requires acceptance of Medi-Cal patients in licensed skilled nursing facilities.
Status of measure: Chapter 11, 1985 Statutes
SB 26 (Mello): Increases penalties for repeat facility offenders from $1,000 to $2,500.
Status of measure: Chapter 856, 1986 Statutes
SB 274 (Watson): Requires the Department of Health Services to develop programs for facilities to contract with or employ geriatric nurse practitioners.
Status of measure: Chapter 119, 1986 Statutes
AB 1834 (Connelly): Requires Department of Health Services to report enforcement actions to the Board of Examiners for Nursing Home Administrators for disciplinary action.
Status of measure: Chapter 816, 1987 Statutes
AB 2047 (Katz): Requires facilities to reimburse for or replace articles lost or stolen if facility did not have reasonable safeguards.
Status of measure: Chapter 1235, 1987 Statutes
SB 73 (Lockyer): Mandates expeditious resolution of contested "B" citations and permits families to meet privately with residents.
Status of measure: Chapter 1125, 1987 Statutes
SB 526 (Mello): Designates Attorney General's Office responsible for investigation and prosecution of cases of abuse in nursing homes.
Status of measure: Chapter 637, 1987 Statutes
SB 1220 (Mello): Allows State to place insolvent homes in receivership so as to continue caring for the patients.
Status of measure: Chapter 666, 1987 Statutes
SB 1330 (McCorquodale): Specifies contents, terms and conditions for admissions agreements.
Status of measure: Chapter 625, 1987 Statutes
New and Continuing Impediments To Improving
Significant recommendation areas included increasing enforcement and penalty collection efforts by the State, allowing state receivership for certain skilled nursing facilities as an intermediate sanction, ensuring that voluntary Medi-Cal decertification would not penalize current residents, and increasing consumer information services.
AB 258 (Wyman): Requires the Department of Health Services to develop theft and loss protection and recovery policies for facilities.
AB 688 (Isenberg): Requires facilities that voluntarily decertify from Medi-Cal to continue to care for all patients in the facility at the time of decertification.
SB 860 (Campbell): Expedites the hearing process on AA, A and B citations.
The Medical Care of California's Nursing Home Residents:
Unlike the two reports detailed above, the 1989 report focuses solely on medical care provided to nursing home residents. In essence the report determines that high quality medical care was not the top priority of any state agency or any industry group involved with nursing homes.
The 1989 report included 18 findings and 18 corresponding recommendations.
FINDING 1: There is no regular formal procedure or process to regularly and systematically review and evaluate the quality of medical care provided to nursing home patients.
FINDING 2: There has been little attempt made to develop guidelines for standards of medical practice in nursing homes.
FINDING 3: For a number of people in nursing homes, effective contact with their physician is extremely difficult to either establish or maintain.
FINDING 4: Despite the fact that the Board of Medical Quality Assurance has the legal authority to issue citations and fines, this has not been done.
FINDING 5: To a certain extent, the Board of Medical Quality Assurance has been hampered in its oversight activities by restrictive guidelines and enabling legislation and regulations.
FINDING 6: There is a lack of coordination between the Licensing and Certification Division and the Board of Medical Quality Assurance.
FINDING 7: The Licensing and Certification Division does not have a centralized referral process for complaints about medical care in nursing homes.
FINDING 8: It is difficult for the ordinary citizen to determine where or how to complain about conditions or treatment in long-term care facilities.
FINDING 9: There are an inadequate number of "eyes and ears" observing the care needs of the residents of long-term care facilities.
FINDING 10: There is an insufficient number of physicians who work effectively in long-term care settings.
FINDING 11: Although there may be a substantial oversupply of physicians in the United States, it is unlikely that this will, of itself, guide physicians to work in geriatric medicine in long-term care settings.
FINDING 12: Given the shortages in available physicians to work in long-term care settings, the use of physician extenders has not been adequately explored.
FINDING 13: The position of Medical Director of a long-term care facility is a critically important one.
FINDING 14: The role of the Medical Director needs to be expanded in terms of the training and experience that he or she must have in order to provide medical leadership for the facility.
FINDING 15: The number of patients and nursing homes that a Medical Director can be responsible for is unlimited.
FINDING 16: California long-term care facilities are the home for a large number of persons who present some of the major bioethical discussion, decisions and dilemmas of our time.
FINDING 17: Many residents of nursing homes are receiving too many psychoactive drugs.
FINDING 18: The severe and ongoing nursing shortage has resulted in nursing homes having to depend on nursing registries to secure the services of part-time nurses.
Since it first began investigating skilled nursing facilities in 1984, the Little Hoover Commission has repeatedly expressed grave concerns about the treatment of California's elderly citizens who cannot spend their final days in their own homes. With a trilogy of reports, the Commission has tackled nursing home problems from a wide range of perspectives: administrative, medical and simple humanity. Over the years, the Commission's sponsorship and support have resulted in the passage of more than a dozen new laws to increase the effective monitoring of facilities, to safeguard the rights of patients and their families and to improve the quality of care. It is anticipated that the Commission will monitor progress in this type of facility in the future and continue to pursue the implementation of the recommendations that it has forged in the past six years.
The earlier reports can be summarized as follows:
The major areas for findings in this December 1983 report included the need for case management services for the elderly, the need for training and certification for caregivers, the fact that the State's data base and information management systems were not adequate, the need for more "eyes and ears" to inspect facilities and the failure of the state to root out unlicensed facilities.
AB 3474 (Wyman): Establishes automated license information system to maintain records for facilities.
AB 3589 (Mojonnier): Permits residents of community care facilities to organize resident councils.
AB 3662 (Filante): Creates 24-hour hotline from community care facilities to State Ombudsman.
AB 3839 (Rogers): Authorizes State Ombudsman to form a foundation eligible for tax deductible donations.
AB 3906 (Allen): Requires publication of a consumer brochure for licensed community care facilities.
AB 133 (Allen): Develops yellow pages listing for community care facilities according to major group served.
This February 1985 letter report focused on the failure of the Department of Social Services to respond to and resolve complaints, to coordinate its monitoring efforts with other governmental units and to manage its resources more effectively. In addition, the letter report urged adoption of all the recommendations from the previous report that had not yet been implemented.
AB 17 (Wright): Requires placement agencies to place persons only in licensed facilities.
AB 83 (Herger): Requires community care facilities to adhere to the rules for all "long-term care facilities."
AB 384 (Filante): Prohibits operation of unlicensed community care facilities in the State.
AB 1539 (Seastrand): Encourages regular family involvement with residents of care facilities.
AB 1674 (Wyman): Requires timely processing of license revocations.
AB 1676 (Wyman): Allows the Department of Social Services to take stronger enforcement action against deficient care facilities.
AB 1940 (Bates): Establishes additional enforcement mechanisms for Department of Social Services against unlicensed facilities.
SB 185 (Mello): "Residential Facilities for the Elderly Act" establishes separate licensing procedure for elderly care facilities.
The Commission's January 1989 report, entitled "Report on Community Residential Care for the Elderly," continued to focus on the state's role as a watchdog over board and care facilities.
The report notes that one in every six residential care facilities is unlicensed and found that a backlogged, time-consuming licensing process actually encourages operators to begin their businesses with no licenses. An increased fine structure recommended in earlier Little Hoover Commission reports is either not used at all by the state or is enforced so haphazardly that its deterrent effect is little. Overworked ombudsmen can only reach about 40 percent of the facilities each year, and they estimate at least 550 cases of abuse a year in the small numbers of places they visit.
All in all, the 1989 report found little positive about the state's oversight of board and care facilities.
The January 1989 report included 11 findings and 10 areas of recommendations. (Since recommendations may spring from more than one finding, the recommendations are presented separately below. The original report lists multiple, specific actions to be taken under each general recommendation.)
FINDING 1: Abuse and neglect of residents are ongoing problems.
FINDING 2: Performance by the Community Care Licensing Division often is characterized as arbitrary and slow.
FINDING 3: The Department of Social Service's enforcement program suffers from underutilization of penalties, fines and relationships with local law enforcement agencies.
FINDING 4: Unlicensed facilities are undeterred by current enforcement efforts.
FINDING 5: Case management services are not systematically available to older Californians.
FINDING 6: State fire regulations do not recognize residential facilities as a special case.
FINDING 7: Small facilities lack the special oversight they need to function in the residential care network.
FINDING 8: Quality is a low priority in California's residential care regulatory program.
FINDING 9: Emergency relocation procedures are not standardized and are underfunded.
FINDING 10: The costs of providing residential care are not documented by the state.
FINDING 11: Private funding mechanisms are too new and untried to relieve the public sector's financial burden.
The Little Hoover Commission, through its reports, recommendations and significant legislative success, has been able to have substantial impact on the issue of residential care facilities. Progress has been made on ensuring that the public is well-informed when it chooses a facility, on educating and training those who work in the facilities and on prodding the state into a more effective oversight mode. The long-term effect of these measures, however, will have to be assessed in the future.