(a) (1) The Small House Skilled Nursing Facilities Pilot
Program (SHSNF PP) is hereby established within the department. The
purpose of the pilot program is to allow the department to authorize
the development and operation of up to 10 small house skilled nursing
facilities that are licensed to provide skilled nursing care and
supportive care to patients in small, homelike, residential settings
that incorporate emerging patient-centered health care concepts. The
long-range goal of the pilot program is to evaluate the models
developed under the pilot program to determine if each model improves
patient satisfaction and clinical outcomes in a cost-effective
manner. The models developed shall also be eligible for certification
for participation in the federal Medicare Program under Title XVIII
of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.) as
skilled nursing facilities or in the federal Medicaid Program under
Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et
seq.), as nursing facilities, or as both.
(2) For purposes of the pilot program, the department shall permit
the formulation of standards for long-term care that may extend
beyond, or vary from, traditional long-term health care facility
models, including, but not limited to, facility layout and design
consistent with newly adopted revisions to the California Building
Standards Code, nursing care levels, staffing levels, infection
control, sanitation, dietary services, and other personal care and
habilitation provisions that may be more flexible than those
currently required in California for skilled nursing facilities and
continuous nursing facilities.
(3) The department shall establish criteria to measure the
benefits and successes of this type of long-term care facility, as a
whole, and to compare the results achieved by each model variant. The
department shall evaluate and analyze the emerging concepts in
long-term skilled nursing care developed pursuant to the pilot
program for purposes of considering future regulatory modification.
(b) Facilities that are eligible for participation in the pilot
program shall have all of the following characteristics:
(1) To the extent permitted under federal law, each home shall
consist of a homelike, rather than institutional, environment,
including the following characteristics:
(A) The home shall be accessible to disabled persons, and shall be
designed as a house, an apartment, or a distinct area within an
existing skilled nursing facility that meets the standards described
in paragraph (2) of subdivision (a) that is similar to housing
available within the surrounding community, and that includes shared
areas that would only be commonly shared in a private home or
(B) The home shall not, to the extent practicable, contain
institutional features. These include, but are not limited to,
nursing stations, medication carts, room numbers, and wall-mounted
licenses or certificates that could appropriately be accessed through
(C) (i) The home shall include resident rooms that accommodate not
more than two residents per room. Facilities are encouraged to
include private, single-occupancy bedrooms that are shared only at
the request of a resident to accommodate a spouse, partner, family
member, or friend, and that contain a full private and accessible
(ii) Double-occupancy rooms shall contain a full private and
accessible bathroom, and each resident's bedroom area shall be
visually separated from the other by a full height wall or a
permanently installed sliding door, folding door, or partition.
Walls, doors, or partitions used to separate resident bedroom areas
shall provide visual and acoustic separation. A door leading to each
resident's bedroom area in addition to the corridor door is not
required, unless needed to achieve visual or acoustic separation.
(iii) Each resident shall have direct use of, and access to, an
exterior window at all times.
(D) The home shall contain a living area where residents and staff
may socialize, dine, and prepare food together that provides, at a
minimum, a living room seating area, and a dining area large enough
to accommodate all residents and at least two staff members. The home
shall contain a full kitchen open to the living and dining rooms
that may be utilized by residents that shall provide for separation
in accordance with the California Building Standards Code.
(E) The home shall contain ample natural light.
(F) The home shall have built-in safety features to allow all
areas of the facility to be accessible to residents during the
majority of the day and night.
(G) The home shall provide access to secured outdoor space.
(H) The home shall endeavor to create an aging-in-place
environment where long-stay residents may form permanent homes with
(I) The home shall prepare, cook, and serve meals on a daily basis
for residents in the home. Nothing in this subparagraph shall
prohibit a home from utilizing outside resources in a manner approved
by the department.
(c) As used in this article, the following definitions apply:
(1) "Pilot facility" means a Small House Skilled Nursing Facility
(SHSNF) participating in the Small House Skilled Nursing Facilities
Pilot Program (SHSNF PP) established by this article.
(2) "Small house skilled nursing facility" (SHSNF) means a health
facility that provides skilled nursing care and supportive care in a
small, homelike, residential setting in an apartment, cottage, house,
or similar residential unit, to patients whose primary need is for
the availability of skilled nursing care on an extended basis. A
SHSNF may consist of a group or cluster of such residential homes,
each home having 12 or fewer beds, or a distinct area within an
existing skilled nursing facility that otherwise meets the definition
of a SHSNF, is physically separate and distinguishable from the
remainder of the skilled nursing facility, and has a distinct entry
with no through traffic of staff, residents, or visitors not
affiliated with the SHSNF. A SHSNF may also be a distinct part of a
general acute care hospital or an acute psychiatric hospital,
pursuant to subdivision (c) of Section 1418. Regardless of location,
all SHSNFs shall meet all standards.
(3) "Home" means an apartment, cottage, house, or other similar
residential unit that serves 12 or fewer residents.
(4) "Supportive care" includes the provision of socialization,
activity aide services, and homemaker services.
(5) "Homemaker services" means food preparation, housekeeping,
laundry, and maintenance services.
(6) "Versatile worker" means a certified nursing assistant who
provides personal care, socialization, activity aide services, meal
preparation services, and laundry and housekeeping services.
(d) Each pilot facility shall be subject to all licensing
enforcement provisions to which other skilled nursing facilities are
subject, including, but not limited to, Section 1424.5, Article 7.6
(commencing with Section 1324.20), and Article 8 (commencing with
(e) Unless otherwise operating on an existing skilled nursing
facility license, each pilot facility shall be subject to the
Licensing and Certification program fee for skilled nursing
facilities pursuant to Section 1266.
(f) Each pilot facility shall receive a peer group weighted
average Medi-Cal reimbursement rate as calculated by the State
Department of Health Care Services.
(g) (1) Each pilot facility shall provide for consistent staff
assignments and self-managed work teams of direct care staff,
including staff working as versatile workers. Licensed nursing staff
shall direct the versatile workers in all activities delegated under
the licensed nurses' scope of practice. A versatile worker may be
supervised by nonclinical staff when performing nonclinical duties,
at the discretion of the facility.
(2) (A) The pilot facility shall provide training for all staff
involved in the operation of the home, to be completed prior to
initial operation of the home, concerning the philosophy, operations,
and skills required to implement and maintain self-directed care,
self-managed work teams, a noninstitutional approach to long-term
care, safety and emergency skills, food handling and safety, and
other elements necessary for the successful operation of the home.
Versatile workers and other staff interacting with residents in the
homes shall demonstrate proficiency in these areas as well as the
facility's policies and procedures, conflict resolution, and
self-directed care principles.
(B) Replacement staff shall undergo the training described in
subparagraph (A) within two weeks of commencing employment with the
(h) A facility may be licensed by the department as a pilot
facility pursuant to this article if the facility meets both of the
(1) The facility has been determined by the department to comply
with all provisions necessary to be certified to participate as a
provider of care either as a skilled nursing facility in the federal
Medicare Program under Title XVIII of the federal Social Security Act
(42 U.S.C. Sec. 1395 et seq.) or as a nursing facility in the
federal Medicaid Program under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.), or as both.
(2) The facility has been determined by the department and the
Office of Statewide Health Planning and Development (OSHPD) to fully
comply with all pilot program requirements required under the
provisions of this article, including payment of the licensing fee
for a skilled nursing facility pursuant to Section 1266.
(i) In developing standards for this pilot program, the department
shall, together with OSHPD and the Office of the State Long-Term
Care Ombudsman, consult long-term care providers, health care
advocacy organizations, health care employee organizations, consumer
advocates, elder care advocates, and others identified as having a
vested interest in long-term health care.
(j) The department shall issue, by July 1, 2013, one or more all
facilities letters that provide the standards to be used by providers
accepted into the pilot program for the development and operation of
all pilot facilities.
(k) The department shall have authority to waive any standard for
skilled nursing facilities established elsewhere in this chapter,
Chapter 2.4 (commencing with Section 1417), and any regulations
adopted thereunder, if the health, safety, and quality of patient
care is not adversely affected. Prior written approval communicating
the terms and conditions under which the waiver is granted shall be
required. Applicants shall request the waiver in writing, accompanied
by detailed, supporting documentation.
(l) (1) Consistent with this article, the department shall invite
all eligible providers to submit an application to participate in the
SHSNF PP at specified intervals over the first two years of the
pilot program. The applications shall include sufficient information
to demonstrate the provider's experience in establishing and
operating one or more care facilities offering the level of care to
be furnished by pilot facilities, including the name and location of
each facility currently or previously licensed to the provider,
whether within California or in another state.
(2) The department may require that additional information and
documents be submitted with, or subsequently in support of, the
application. Failure to provide any required information or
documentation shall disqualify the applicant from the application
process and from consideration for participation in the pilot
program. The department may select providers for participation in the
SHSNF PP based on the applicant's ability to meet or exceed the
criteria described in this article.
(m) If, at any time, a pilot facility fails to meet the criteria
set forth in this article for being a pilot facility, or fails to
safeguard patient health, safety, welfare, and security as determined
by the department, the department shall remove that pilot facility
from participation in the pilot program.
(n) The costs of the creation, administration, and evaluation of
the pilot program shall be borne by the facilities participating in
the pilot project.
(o) Each pilot facility shall provide any reports to the
department that the department deems necessary for modifications to
the pilot program, the guidance or regulations governing the pilot
facilities, and any other information the pilot facilities deem
relevant in evaluating the success of the pilot program in delivering
improved patient care. The department may inspect any participating
pilot facility at any time.
(p) The department shall prepare and submit a report to the
Legislature on the results of the SHSNF PP. The department may
prepare the evaluation, analysis, and report itself, or may do so
under contract. The report shall be submitted to the Legislature at
least 24 months prior to the termination of the pilot program, and
shall include an evaluation of the pilot program's cost, safety, and
quality of care.
(q) Nothing in this section or pilot program shall be construed to
limit providers not participating in the pilot from pursuing
approval for similar practices through program flexibility or similar
existing process allowed by law.