STATE OF CALIFORNIA Budget Change Proposal - Cover Sheet DF-46(REV 08/17)

Fiscal Year Business Unit Department Priority No. FY 2019-20 4260 Health Care Services Budget Request Name Program Subprogram 4260-402-BCP-2019-MR 3960 3960050 Budget Request Description SUD Emerging Epidemics, Disaster Response and Licensing Workload Budget Request Summary The Department of Health Care Services (DHCS), Substance Use Disorder Compliance Division (SUDCD), requests 7.0 permanent positions and expenditure authority of $1,060,000 (100% Residential and Outpatient Program Licensing Fund (ROPLF)), in fiscal year (FY) 2019-20, to address the increased workload of responding to: 1) natural disasters and other State Emergencies; 2) the opioid epidemic; 3) the resurgence of methamphetamine abuse; and 4) the rise in number of treatment facilities. In addition, DHCS requests a one-time expense of $100,000 from General Fund (GF) to migrate DHCS's disaster collection and reporting process into the web-based reporting platform, NC4 through an interagency agreement with the California Department of Public Health (CDPH).

Requires Legislation Code Section(s) to be Added/Amended/Repealed • Yes • No

Does this BCP contain information technology (IT) Department QIC Date components? • Yes El No

If yes, departmental Chief Information Officer must sign. For IT requests, specify the project number, the most recent project approval document (FSR, SPR, S1BA, S2AA, S3SD, S4PRA), and the approval date.

Project No. Project Approval Document: Approval Date: If proposal affects another department, does other department concur with proposal? • Yes • No Attach comments of affected department, signed and dated by the department director or designee. Prepared By Date Reviewed By Date

Department Director Date Agency Secretary Date

Department of Finance Use Only

Additional Review: • Capital Cutlay • ITCU • FSCU • CSAE • CALSTARS • Dept. of Technology

PPBA Original Signed By. Date submitted to the Legislature Kris Cook

MAY 09 20iii SUD Emerging Epidemics, Disaster Response, and Licensing Workload

4260-402-BCP-2019-MR Analysis of Problem

A. Budget Request Summary

The Department of Health Care Services (DHCS), Substance Use Disorder Compliance Division (SUDCD), requests 7.0 permanent positions and expenditure authority of $1,060,000 (100% Residential and Outpatient Program Licensing Fund (ROPLF)), in fiscal year (FY) 2019-20, to address the increased workload of responding to: 1) natural disasters and other State Emergencies; 2) the opioid epidemic; 3) the resurgence of methamphetamine abuse; and 4) the rise in number of treatment facilities. In addition, DHCS requests a one-time expense of $100,000 from General Fund (GF) to migrate DHCS's disaster collection and reporting process into the web-based reporting platform, NC4 through an interagency agreement with the California Department of Public Health (CDPH). This proposal will provide DHCS the staffing and resources to effectively develop and implement policies, and achieve program integrity efforts.

Total funding request: Fiscal Year Total Funds 2019-20 $1,160,000 Disasters, Emergencies and Drug Epidemics $615,000 (ROPLF) Licensing $445,000 (ROPLF) NC4 Database Migration $100,000 (GF) 2020-21 and ongoing $997,000 Disasters and Drug Epidemics $579,000 (ROPLF) Licensing $418,000 (ROPLF)

The following chart identifies the positions requested with the corresponding activity.

Division Request Tenure/Effective Activity Date Counselors 4.0 Permanent Positions Permanent Disasters, and • 1.0 Staff Services Effective 7/1/19 emergencies and Medication Manager II (SSM II) opioid and Assisted • 1.0 Health Program methamphetamine Treatment Specialist II (HPS II) epidemics (CMAT) • 2.0 Associate Section Governmental Program Analysts (AGPAs) Licensing 3.0 Permanent Positions Permanent Substantial (LCS) • 1.0 Staff Services Effective 7/1/19 increase in Section Manager 1 (SSM 1) substance use • 2.0 AGPAs disorder licensing facilities

B. Background/History

The leading cause of death nationally is from drug or alcohol abuse. The average life expectancy of Americans dropped in 2015, stayed stable in 2016 and dropped again in 2017 primarily due to alcohol and drug overdoses. In all, there were 70,237 drug overdose deaths in 2017. Opioids remain to be the leading cause of drug overdose deaths, causing two-thirds

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Analysis of Problem of the overdose deaths in 2017. The nation's opioid epidemic continues to reach new proportions, while each year the deaths from synthetic and prescribed opioids outpace the prior year. California is also experiencing this crisis, but in different ways. The US Centers for Disease Control and Prevention (CDC) reported illegally manufactured fentanyl was the driving force behind a 45.2% increase in deaths involving synthetic opioids from 2016 to 2017. As the east coast is crippled with deaths from synthetic opioids, fentanyl and carfentenayl, California has had relatively low numbers of deaths from these drugs. This changed dramatically in 2018. The National Center for Health Statistics indicated that prior to 2017, deaths involving synthetic opioids mainly occurred east of the Mississippi River. The available data now show eight states west of the Mississippi had significant increases in such deaths: Arizona, California, Colorado, Minnesota, Missouri, Oregon, Texas, and Washington.

Also, on the rise is the combination of sedative and stimulant drugs. In particular, mixing an opiate with a stimulant, commonly referred to as a "speedball" is a popular method of obtaining an intense high. In the past, cocaine has been used with heroin or other opiates to create the combination. However, according to research from Pharmacology Biochemistry Behavior, methamphetamine is currently used in the same capacity. This research, along with other studies, shows that combining methamphetamines with morphine or heroin (based on the dosages of each) produces a more potent effect than either drug alone. As a result, fentanyl and heroin, which significantly Increases the risk of overdose, are frequently involved in fatal methamphetamine overdoses. While the opiate may slow breathing, the stimulant might accelerate it, making an individual feel like breathing is normal. This can make it harder to feel when the dose of heroin that is tolerated may have been exceeded, which can then lead to overdose and even result in death.

The rates of overdose deaths involving cocaine and psychostimulants, including methamphetamine increased by more than 33% respectively. Opioids were involved in 67.8%, or 47,600 of those deaths. Of those opioid-involved overdose deaths, 59.8% of them, or 28,466, were due to synthetic opioids. The nationwide increase in methamphetamine use and the opioid epidemic highlights the need for treatment services; however, it has also uncovered the current inadequate number of treatment facilities available. In 2017, CDPH's opioid surveillance dashboard reported 2,196 opioid overdose deaths, 500 of those deaths had methamphetamine in their system, and 1,900 deaths from methamphetamines, of which 500 individuals had opioids in their system.

Currently no medications have proven to be effective for people in recovery for methamphetamine polydrug abuse, so treatment focuses heavily on behavioral therapy such as cognitive behavioral therapy, contingency management, and the Matrix Model. In addition to addressing the opioid epidemic, DHCS must address the rise in methamphetamine use. Research projects that deaths from methamphetamine use will continue to rise due to the availability, potency and low cost.

With advances in implementation of Affordable Care Act (ACA), the landscape of healthcare access for individuals has changed dramatically. Linking individuals to healthcare in the community can improve public safety, increase public health, and save money, as lack of access to care in the community is associated with increased recidivism, particularly for individuals with an SUD. ACA parity protections require that coverage for SUD services be no more restrictive than coverage provided for substantially all medical/surgical services. In

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Analysis of Problem anticipation of meeting access demands due to healthcare reform, DHCS had identified current gaps in the existing system. DHCS has addressed some of the identified gaps with the approval and implementation of the Drug Medi-Cal Organized Delivery System (DMC- ODS) Waiver by expanding services. The DMC-ODS Waiver provides the beneficiary with access to the care and system interaction needed in order to achieve sustainable recovery. In addition, with the passage of Assembly Bill 848, it allows incidental medical services to be provided within the residential treatment programs and increase the care afforded to clients. The expansion of government and non-government funded services, due to state and national efforts, requires an increase in licensing and monitoring activity across all treatment modalities.

California is also the nation's most populous state and is one of the most disaster prone due to wildfires, landslides, flooding, winter storms, severe freeze, tsunami waves, and earthquakes. In December 2017, a series of 29 wildfires ignited across Southern California which caused a series of mudflows in early January 2018. The 2018 wildfire season is the deadliest and most destructive wildfire season on record in California, with a total of 8,527 fires burning an area of 1,893,913 acres, the largest amount of burned acreage recorded in a fire season, according to the California Department of Forestry and Fire Protection (Cal Fire) and the National Interagency Fire Center. The fires have caused more than $3.5 billion in damages. The Mendocino Complex Fire burned more than 459,000 acres becoming the largest complex fire in the state's history, with the complex's Ranch Fire surpassing the Thomas Fire and the Santiago Canyon Fire of 1889 to become California's single-largest recorded wildfire. With licensed and/or certified substance use disorder treatment facilities located across California, DHCS must assist facilities in the impacted areas.

Counselor and Medication Assisted Treatment Section (CMATS) CMATS is responsible for the statutory and regulatory compliance of all narcotic treatment programs (NTPs) in California through mandated annual on-site inspections. CMATS responsibilities include the review of initial NTP licensure and annual renewal applications, follow-up on-site inspections for programs that present imminent danger to patients, administrative functions such as grant and contract management, facility complaint investigations, patient death investigations, the monitoring of requests for exceptions to regulations through the Center for Substance Abuse Treatment extranet, providing technical assistance for the submission of various protocol amendments, capacity changes, and oversight of the counselor certifying organizations. In addition to complying with Health and Safety Code (HSC), Sections 11839 through 11839.34, NTPs also must adhere to Title 42 Code of Federal Regulations, Part 8 and Title 9 of California Code of Regulations (CCR), Division 4, Chapter 4, Sections 10000 through 10425.

NTPs are authorized to provide all Food and Drug Administration (FDA) approved medications for the treatment of SUDs, which include narcotic replacement therapy (NRT) medications; a form of medication assisted treatment (MAT) specific to the treatment of an opioid use disorder (OUD). These NRT medications include methadone, a scheduled II controlled substance and buprenorphine, a scheduled III controlled substance and naltrexone a non-scheduled medication. NRT is comprehensive treatment with synthetic opiates approved by the FDA for opiate-addicted patients. MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of SUD. Research shows that when treating SUDs, a combination of medication and behavioral therapies is most successful. Both methadone and

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Analysis of Problem buprenorphine are administered daily and unless approved for take-home medications; NTP patients will attend the NTP daily to receive their dose.

The goals of NRT are to prevent relapse, reduce narcotic cravings, and block the euphoric effects of illicit opiate use. MAT access, as prescribed, is critical for a NTP patient's long- term recovery. According to CCR Title 9, Chapter 4, Section 10030(a)(32), NTPs must have procedures in place for use in the event of an emergency or disaster to protect the health and safety of clients and make certain the smooth continuation of treatment services. Requirements include an operational telephone number available 24 hours a day for patients to contact a staff member or be directed to an appropriate referral service. Licensed NTPs may also request temporary exceptions to the regulations adopted under this chapter as outlined in California Code of Regulations (CCR), Title 9, Chapter 4, Section 10425. As shown in the recent disasters, NTPs have utilized their disaster plans to allow patients to have access to services during the events. Without a comprehensive disaster plan to address any potential program relocations or closures due to a disaster, NTP patients would be at a greater risk of experiencing a break in treatment and potential relapse. Additionally, CCR Title 9, Chapter 4 requires NTPs to have protocols in place designed to secure patient medications and prevent diversion. Similar planning and implementation of these protocols, including detection and resolution of multiple registrations, supervised dosing and appropriate medication record keeping are critically necessary for an effective disaster response to make certain ongoing and appropriate access to care as well as the prevention of unsafe distribution of controlled substances.

Contrary to NTPs' disaster plans, the other licensed and/or certified SUD facilities, under the oversight of SUDCD's Driving-Under-the-lnfluence & Criminal Justice Section (DUI-CJS) and LCS, do not have the same extensive disaster plan requirements. During an emergency, these programs follow their standard emergency protocols, which may not be as comprehensive as NTPs' disaster plans. In the current regulations, a facility is only required to notify DHCS when they have to relocate a facility either in an emergency or non-emergency. There are no existing regulations or statutes that mandate licensed residential facilities to have an emergency plan in place. While some facilities may choose to implement emergency protocols or procedures, there is no consistency statewide on how facilities will address an emergency or disaster. This inconsistency or lack of protocols and procedures only contributes to the confusion while an emergency is occurring. When an emergency or natural disaster occurs, programs may be required to evacuate due to mandatory evacuation orders. Other programs may need to evacuate due to loss of water, electricity, program inaccessibility, or imminent danger caused by the natural disaster. In order to allow no break in treatment, programs must have a comprehensive disaster plan in place to handle and dispense client's medication appropriately.

During the recent disasters, DHCS has become more cognizant of the importance of disaster response and has taken a more active role in disaster reporting and ensuring that programs are following their individual emergency protocols. Within LCS, residential programs follow their standard emergency plan, which have placed patients in situations that are not always the most conducive to their treatment and recovery. Some programs were forced to relocate their clients to the nearest public lodging, while others in rural areas have relocated to campgrounds. Programs have reported that they have done their best to maintain continuity of treatment, but in these events it has not been easy. Not having an organized and comprehensive disaster plan can be more disruptive to the patient's

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Analysis of Problem treatment during these emergencies. For example, patients may not have access to MAT and other treatment services during the time of relocation. The lapse in services such as individual counseling, group counseling, treatment planning, identification of goals, cognitive behavioral interventions, and routine activities increases the likelihood that patients leave treatment and relapse.

According to Substance Abuse and Mental Health Services Administration (SAMHSA), natural disasters can have a lasting impact on those who are forced to flee nature's path causing post-traumatic stress disorders (PTSD). Many patients diagnosed with SUD also have a co-occurring disorder and already suffer PTSD from previous traumas, therefore SUD programs need to be prepared to coordinate with other entities and provide the support system necessary to maintain continuity of care. Inadequate treatment services and access to medications increases the likelihood that patients will leave treatment and relapse.

The recent surge of natural disasters has also shown the significant need of having a more efficient method for disaster reporting. Currently, CDPH notifies DHCS of counties and/or zip codes impact by emergency disaster and requires the completion of an excel spreadsheet named the Facility Status Report (FSR), which is eventually submitted to the Office of Emergency Services (OES). In many cases, DHCS is responsible for trying to determine the potential facilities impacted by the disaster with very limited information. Upon notification of a disaster, SUDCD has redirected existing staff to assess the status of the programs in the affected area(s) and the magnitude of the disaster by manually mapping the disaster location and identifying the facilities that may be impacted. Once the FSR is completed, SUDCD routes it to the main DHCS emergency coordinator who compiles it with the FSRs for other impacted DHCS Divisions, including Mental Health and Primary Rural Indian Health. The consolidated DHCS FSR is submitted to CDPH via email and blended into the excel spreadsheet FSR for other impacted Departments. Through this cumbersome process, DHCS has identified the need for a more efficient reporting structure to make disaster reporting more timely and accurate.

On April 26, 2017, NC4 Public Sector, LLC was awarded a contract (RFC 16-PHE-3742) to provide CDPH with a SaaS Incident Management System. Through this system, CDPH will be able to upload facility status data directly into the NC4 FSR tab, eliminating the need for excel spreadsheets. Multiple staff can complete data entries at the same time and the NC4 database will track events in real time. The data from NC4 is fed into Tableau, a web-based dashboard, which can be utilized to generate detailed reports for the California Health and Human Services (CHHS) Agency and provide a visual "at-a-glance" dashboard summary report.

Licensing and Certification Section (LCS) LCS has sole authority in state government to license and certify all facilities, regardless of their funding source, that provide residential and outpatient alcohol and other drug (AOD) treatment, detoxification, or recovery services to adults. LCS is responsible for processing initial and renewal applications for residential, outpatient, detoxification, adolescent waivers, incidental medical services, and for conducting site visits for each initial and renewal. LCS is also responsible for monitoring compliance with state, federal and local laws, statutes, and regulations by conducting on-site reviews every two years. Lastly, LCS collects fees and fines, and provides technical assistance to facilities. DHCS currently has a total of 1,895

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Analysis of Problem

residential and outpatient facilities. This includes 394 residential licensed, 618 residential licensed and AOD certified, and 883 AOD outpatient.

Senate Bill (SB) 84 (Chapter 177, Statutes of 2007), Health and Safety Code (HSC) Section 11833.02 was signed into law on August 24, 2007 and requires DHCS to charge fees for licensure and certification of all residential AOD recovery or treatment facilities and for certification of outpatient AOD programs. The ROPLF consists of all fines, fees, and penalties assessed to licensed and certified AOD providers. HSC Section 11833.03 establishes the ROPLF in the State Treasury into which all fees, fines, and penalties collected from residential and outpatient programs, which are deposited and made available upon appropriation by the Legislature for supporting the licensing and certification activities of residential and outpatient facilities.

Resource History (Dollars in thousands) Substance Use Disorder - Compliance Division SUDCD) Program Budget 2013-14 2014-15 2015-16 2016-17 2017-18 Authorized Expenditures 11,221 13,092 16,067 18,386 17,817 Actual Expenditures 6,982 7,619 9,284 13,120 14,127 Revenues N/A N/A N/A N/A N/A Authorized Positions 72.0 80.0 90.2 93.5 108.0 Filled Positions 64.0 70.2 85.2 88.5 91.0 Vacancies 8.0 9.8 5.0 5.0 17.0

Workload History

Workload Measure 2013-14 2014-15 2015-16 2016-17 2017-18 Total Licensed and/or 1,113 1,388 1,777 1,784 1,930 Certified Programs Initial Applications 184 275 233 245 376

Renewal Applications N/A N/A 620 670 870 Other Applications 163 81 121 146 262 Total Applications 347 356 974 1,061 1,508 Processed

Counselor and Medication Assisted Treatment Section (CMATS Workload Measure 2013-14 2014-15 2015-16 2016-17 2017-18 N/A N/A N/A N/A N/A N/A * There is no workload history for disaster plans. Due to the rise in natural disasters, this is a new workload the Department will undertake.

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4260-402-BCP-2019-MR Analysis of Problem

C. State Level Considerations

The DHCS Strategic Plan states that nearly one in three Californians receive health care services financed or organized by DHCS. One of the key commitments in DHCS' Strategic Plan is to develop effective, efficient and sustainable delivery systems. SUDCD oversees the SUD provider system in California regardless of the payment source for services. Providing sufficient access to SUD treatment facilities is essential for Medi-Cal, insurance, private pay, criminal justice programs, grant, federal and other SUD funded programs that utilize DHCS licensed facilities. Maintaining effective oversight is an imperative function of DHCS and without the sufficient resources, SUDCD is unable to achieve the commitments outlined in the Strategic Plan. SUDCD is responsible for making certain that clients are provided treatment services even during state emergencies and natural disasters by qualified providers and for protecting client health and safety in all 1,895 licensed and/or certified programs, 165 narcotic treatment programs, and 258 DUI programs.

With the rising overdose deaths resulting from the nationwide opioid epidemic and rise in methamphetamine use, it is essential that the State implement solutions that end this crisis. Implementing the DMC-ODS is one solution, which is outlined in the Strategic Plan; however, there are other federal efforts underway that require DHCS' attention. Federal regulatory changes, new federal grant opportunities, educational opportunities, innovations from CMS, other state collaborative taskforce and efforts and projects with foundations are all potential solutions that DHCS needs to pursue in order to remedy this situation. DHCS programs emphasize prevention-oriented health care that promotes health and well-being. DHCS can improve the consumer experience by focusing attention on these multiple efforts in order to implement lasting solutions.

D. Justification

While DHCS is committed to Californians that require and utilize services provided by residential treatment programs, outpatient programs, DUI, and NTPs, due to the tremendous focus on the SUD field, SUDCD cannot sustain the substantial increase in licensing workload, and other byproducts of health care reform. Currently, there are backlogs of new applications, applications for the expansion of current facilities, and license and certification renewals. These backlogs delay the expansion of treatment services for new clients and create wait lists at the local level. Inadequate staffing at DHCS also delays the implementation of new government funding and creates risks without proper monitoring at the state level.

Counselor and Medication Assisted Treatment Section (4.0 positions) • 1.0 SSM II • 1.0 HPS II • 2.0 AGPAs

Disaster Response SUDCD is responsible for the licensure and/or certification of over 2,288 SUD treatment providers, which serves thousands of vulnerable individuals. With the unprecedented increase in natural disasters, the risk for SUD program closures and/or treatment service disruption has increased tremendously. The additional resources, 1.0 SSM I, 1.0 HPS II and 2.0 AGPAs, within CMATS are necessary to address the increased workload as a result of

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Analysis of Problem

the rise in natural disasters, which includes emergency preparedness, disaster response and reporting. With the additional resources, CMATS will form an Emergency Plan Team, which can work with the other SUDCD Sections in developing an extensive "SUDCD Emergency Response Plan" for all residential and outpatient programs licensed and/or certified with DHCS.

Consistent with current NTP procedures, the Emergency Response Plan will include the regular approval and review of program disaster plans. This includes guidelines for patient records, security, diversion prevention measures, inspection of the programs, evacuation routes, operational 24 hours a day telephone numbers to contact program staff or an appropriate referral service, and program staff designated to have backup copies of medication dispensing sheets off program premises that identify patients and their dosage levels. The Emergency Response Plan will contain a whole host of areas critical to maintaining a clinically safe and fully functioning facility. The Emergency Plan Team will also provide disaster response training to key SUDCD staff and coordinate the functions outlined in the newly developed SUDCD Emergency Response Plan. The new CMATS staff will work with the other SUDCD Sections to determine if any programs were affected or patient displacement occurred.

During the recent disasters, SUDCD identified the need for improvement in DHCS' emergency preparedness and response. SUDCD observed that residential and outpatient programs did not always have organized and comprehensive disaster plans, which led to some disruption in treatment services for SUD patients. In some cases, clients did not have access to MAT, individual counseling, group counseling, treatment planning, identification of goals, cognitive behavioral interventions, and routine activities during the time of relocation. As a result, some clients did not return to treatment programs.

AOD Facility Totals

Licensed and/or Certified Residential Programs 1,012 Certified Outpatient Programs 883 Narcotic Treatment Programs 165 Driving Under the Influence Programs 228 Total Number of Disaster Plan Protocols to Review and implement 2,288 * The table below lists the total amount of SUDCD Program Facilities.

According to the SUDCD Disaster Totals Table for the 2018 Southern California Mudslide/Flooding, at least 14,761 patients and 279 programs were impacted in areas such as Pawnee, Carr, River, Ranch, Valley, Donnell, Ferguson, Holy, Hill, Camp and Woolsey Fires.

Currently, CDPH notifies DHCS of counties and/or zip codes impact by emergency disaster and requires the completion of a FSR, which is eventually submitted to OES. Upon notification of an emergency, SUDCD will redirect existing staff to assess the status of the programs in the affected area(s) and the magnitude of the emergency by mapping the disaster location and identifying the facilities that may be impacted. On top of notifications from CDPH, at any given day of the week, such as Hill, Camp, and Woolsey Fires, DHCS

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Analysis of Problem

also maintains daily communication with facilities that are close to and surrounded by the disaster lines.

The Woolsey Fire caused an unprecedented 49 facilities to completely evacuate and become non-operational. 12 programs were also completely destroyed by the Woolsey Fire. Of the 12 programs destroyed, one program was approved for relocation and seven are currently in the process of relocating. Clients that were required to evacuate are now relocated in alternative facilities. During the course of this wildfire emergency, more than 150 residential and outpatient program patients were evacuated and in need of repopulation in order to regain access to necessary health care.

SUDCD Disaster Totals (December 2017 to Present) Consecutive days Potentially Potentially contacting affected Facilities Counties affected facilities patients contacted affected facilities (including Disaster Name/Type (per day) (per day) (per day) (per day) weekends) Thomas, Creek, Rye 27,706 202 6 202 16 Fires 2017 Southern OA 6,911 80 2 80 8 Mudslide/Flooding 2018 Pawnee Fire 2018 40* 7 1 7 1 Carr, River, Ranch, Valley, Donnell, 4,417 47 8 47 12 Ferguson, Holy Fires 2018 Hill Fire 2018 1,740* 33 1 33 14 Camp Fire 2018 1,120* 16 2 16 14 Woolsey Fire 2018 533* 96 2 96 15 *Number is likely much higher due to lack of baseline capacity for outpatient programs.

The new CMATS Emergency Response Team will work with the other SUDCD Sections to keep current the contact information for county liaisons, providers, and community resources. The CMATS Emergency Response Team will verify the appropriate county liaison, in the affected counties, are contacted to determine the extent of damages in the area and how the county is assisting providers in their area. CMATS will also provide liaisons to programs, within the identified disaster area, to report programmatic challenges and search for other programs nearby that might be able to assist. If necessary, the CMATS Emergency Response Team will work with counties and programs to assist with the smooth transition and coordination of care.

With the increase in natural disasters, specific to NTPs, CMATS will be encumbered with a greater number of patient and program exception requests. NTP statute allows DHCS to approve exceptions to the state laws. Most exceptions pertain directly to patient services. Cn average, CMATS receives 8,000 exemption requests a year. During disasters, the number of exemptions increase dramatically. Due to the nature of the services provided at

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Analysis of Problem

NTPs and the negative impact on patients who are unable to receive their prescribed NRT medication, CMATS currently has a rotating Cfficer of the Day; whose primary focus is on reviewing exception requests. These exceptions serve as a temporary modification to CCR Title 9, which are granted to improve treatment services and afford greater protections to the health, safety, or welfare of patients, community, or the public. During emergencies and natural disasters, the amount of NTP exception requests in these events increases tremendously. Barriers to treatment, such as patient displacement tend to occur during natural disasters and NTPs need exceptions to regulations to allow patients to have access to treatment. The increase in the number of exception requests could potentially require a greater allocation of resources by the Section and prevent adequate resources channeled to initial applications, annual inspections, and other critical areas overseen by the CMATS. The projected increase in all areas of CMATS workload will result In the current staff levels being severely overextended. The additional resources will help to mitigate this workload.

Without the requested resources, the CMATS' core responsibilities combined with the unprecedented opioid epidemic, increase in methamphetamines, and natural disasters will overextend staff. This could conceivably prove disastrous in the efficacy of the Section, resulting in a substantial decline in patient care and treatment.

SUD Emerginp Epidemics The nation is currently facing a significate increase in methamphetamine and opioid use of historic proportions. On average, per CDC reports, 130 Americans die each day due to an opioid overdose. In 2014, CDC also reported that there were more than 28,000 opioid related deaths, an increase of 400% since the year 2000. Since 2013, the United States has seen an overwhelming rise in overdose deaths resulting from synthetic opioids which include Tramadol and Fentanyl. According to CDC data, the number of deaths per a 100,000 population due to synthetic opioid overdoses rose 0-1 in 2013 to 9-10 in 2017, greatly surpassing the number of opioid overdose deaths related to prescribed opioids and heroin. As a result, the United States Department of Health and Human Services (HHS) has made addressing opioid abuse, dependence, methamphetamine use, and overdose a priority. The current HHS evidence-based Initiative focuses on three promising areas: informing opioid prescribing practices, increasing the use of naloxone, and using MAT to move people out of opioid addiction. In the spring of 2014, the CDPH convened the Prescription Opioid Misuse and Overdose Prevention Workgroup, exploring opportunities to expand and strengthen prevention strategies and improving monitoring and surveillance. On October 26, 2017, President Trump announced that the opioid crisis as a National Public Health Emergency under federal law, effective immediately.

One-step taken to address the Nation's need for an increase in access to MAT services is the DMC-ODS Waiver, approved by CMS in August 2015. The Waiver includes a requirement for all participating counties to have access to licensed NTPs, resulting in expected increases in new program applications and leading to an increased number of programs licensed and monitored by SUDCD. The provisions of the Waiver also require existing NTPs, which are currently required only to administer methadone, to now order, prescribe and administer three additional medications, buprenorphine, disulfiram and naloxone, in addition to optionally utilizing Vivitrol. Each medication has complex pharmacological requirements and ongoing State guidance is essential to protect the health and safety of patients and the public. The introduction of these new medications will require regulatory amendments, revised or amended protocols from all existing NTPs utilizing the

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Analysis of Problem new medications, staff training and subsequent development of tracking and monitoring tools as well as additional on-site inspection policies and procedures. The additional HPS II will assist in adequately addressing these new projects for CMATS. The HPS II will also research, develop policies, program implementation, and conduct training to address the opioid epidemic and resurgence of methamphetamine abuse across all SUD programs licensed by DHCS.

NC4 Database Migration The one-time expenditure of $100,000 from GF would allow DHCS, through an interagency agreement with CDPH to migrate its disaster collection and reporting along with other California HHS Agency Departments into the already developed NC4 database. This migration would benefit not only SUDCD, but the Mental Health and Primary Rural Indian Health Divisions by helping to standardize the reporting process and improving coordination, resulting in more consistent reporting among all departments in the California HHS Agency. With access to the NC4 database, DHCS could upload all facility information for Substance Use Disorder programs. Mental Health programs and Primary Rural Indian Health Programs into the database. When a disaster occurs, the system would be able to utilize geocoding to identify a subset of facilities, potentially impacted by the disaster, eliminating the need for DHCS staff to manually map and identify the potentially impacted facilities. Within NC4, DHCS staff could complete a questionnaire form for each potentially impacted facility, which will identify potential impacts and resource needs for the facilities. Cnce all data entries are completed, the main approver for each Division would review the information before finalizing the submission to the NC4 system.

Since the NC4 system could identify the potentially impacted facilities and data would be directly inputted into the NC4 system, which feeds into the web based Tableau dashboard, it would streamline the disaster collection and reporting process, eliminate the need for cumbersome excel spreadsheets, allow for more accurate and timely reporting, provide Individuals with a real-time view of the disaster impact and provide Agency with detailed disaster reports for multiple Departments.

Licensing and Certification Section (3.0 positions) • 1.0 SSM i . 2.0 AGPAs

LCS is responsible for the licensure of residential facilities statewide with clients entering into treatment through various funding sources. The funding sources include Drug Medi-Cal, private pay and private insurance. Since ACA and parity to require coverage of mental health and substance use disorders, LCS has seen an increase in applications for licensure, which has created an increase in the availability of treatment facilities.

LCS requires the additional resources due to the ongoing nature of the work. For the past three years, workload is neither temporary, leveling off, or decreasing in the submission of applications for new licensed and certified facilities. With the additional resources, LCS will be able to process applications within the regulatory requirements and conduct compliance visits within an appropriate time. In accordance with the regulations, DHCS is required to issue or deny a license within 120 working days after an initial application is completed. The 120 days pertains to all applications. Due to the extensive volume of residential applications there are various timelines for processing applications: initial applications 120 days-150

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Analysis of Problem

days, renewals 90 days and incidental medical services 120 days-150 days. The range in application processing timelines varies depending on the completeness of the applications received. Once licensed and/or certified, program is subject to a biennial site visit from a LCS staff to determine whether it is eligible for license or certification renewal. Based on historical data from the past three fiscal years, there has been a steady increase in the receipt of initial applications for licensing and/or certification.

Fiscal Year Number of Applications Processed 2015-2016 233 2016-2017 245 2017-2018 376

The table below shows the percentage of initial applications to be licensed and/or certified in FY 2018-19:

Initial Applications Licenses and/or Percentage Fiscal Year Processed Certifications Issued Licensed and/or Certified 2017-2018 376 288 77% 2018-2019 244 132 82%

Based on the initial applications received, processed and Issued in FY 2017-18, LCS was able to license and/or certify 77% of the applications received. The remaining applications were either withdrawn by the facility, denied, or the review was terminated because the licensing process was not completed for issues such as: facility did not receive a fire clearance, failed to pay civil penalties or correct deficiencies. Based on the number of Initial applications received in FY 2018-19, it is estimated that LCS will be able to process 82% of total applications received in the current FY.

In addition to the increase in applications received, LCS is currently facing a backlog of over 100 applications. The backlog varies from programs trying to obtain initial licensure and/or certification, renewal of licensure and/or certification, and amendments to the providers' licensure and/or certification. Due to the perpetual increase in applications over the last five years, there continues to be a backlog. As the number of licensed facilities increases, so does the number of overall applications received. Access to treatment and services are limited to the public and clients in need of treatment because of the current backlog challenges.

On top of application challenges, LCS is currently facing a backlog of 349 biennial compliance reviews. The analysts who review the applications are also the same analysts who are responsible for conducting all of the compliance visits, which causes delays for a compliance review to be conducted and results in a compliance review backlog. Moreover, the delay in biennial compliance reviews severely impacts program integrity, and LCS inability to prevent programs from providing inappropriate services that result in overwhelming concerns for client health safety. In addition, the backlog restricts mandated oversight, and the implementation and monitoring of the DMC-CDS Waiver.

Along with the changes due to the expansion of services from ACA, the opioid epidemic and the implementation of the DMC-CDS Waiver, DHCS anticipates that the numbers of

12 5/9/19 SUD Emerging Epidemics, Disaster Response, and Licensing Workload 4260-402-BCP-2019-MR

Analysis of Problem

licensure applications received will continue to grow. In addition to the expected influx of new applications and in order to meet regulatory timelines, DHCS needs to address the significant backlog of applications from programs. With the additional licensure of ACD facilities, DHCS will not only see an increase in the number of applications, but an increase in ongoing workload related to the licensure of a facility. This includes renewal applications, routine site inspections, and follow-up of any deficiencies cited In order to comply with statutory mandates to protect health and safety of clients in DHCS licensed and/or certified facilities.

Based off projections from the last three FYs due to the increased volume of applications received identified in the Workload History chart and the 15.25% growth trend of new licensed and/or certified programs, it is expected that DHCS will have 294 new facilities in FY 2018-19. Currently, 132 licenses and/or certifications have been issued for FY 2018-19. In addition to the increase of the workload that the additional facilities create, there is also an additional workload associated with renewal and amendments of licenses and/or certifications.

Additional resources, 1.0 SSM I and 2.0 AGPAs, will allow LCS to review all licensing and/or certification components in a timely manner. It will also permit LCS to conduct any follow-up compliance visits for deficiencies of concern. Furthermore, the additional resources will help reduce the average number of programs in each LCS analysts' caseload, and allow LCS staff to meet mandated requirements and critical deadlines.

LCS currently monitors the following programs Type of Program Amount Residential License Cnly 394 Residential License and ACD Certification 618 ACD Certified Cutpatient Cnly 883 Total 1,895

Total Resident Capacity for the Licensed Residential Facilities: Resident Capacity Total Facilities Total Capacity 6 or fewer residents 506 2,978 7-20 residents 234 2,801 21-50 residents 180 5,926 Cver 50 residents 92 8,836 Total 1,012 20,541

13 5/9/19 SUD Emerging Epidemics, Disaster Response, and Licensing Workload 4260-402-BCP-2019-MR

Analysis of Problem

Current Workload Gap: Current Staffing 1 SSA and 23 AGPAs Caseload that meets statutory mandates for SSA 50 cases x 1 SSA's = 50 total cases level Caseload that meets statutory mandates for 70 cases x 23 AGPAs = 1,610 total AGRA level cases Total Caseload Abilities 1,660 Current Facilities 1,895 Current Application Backlog 108 Total number of Facilities 2,003 ^Gap of Licensing Workload 343 (total of projected facilities - total caseload abilities)

Based on the above workload gap, LCS is requesting the additional positions to meet increased demand in workload that has resulted in a significant backlog of applications. Further exacerbation of this backlog may be attributed to factors such as the ACA and the approval of the DMC-CDS Waiver.

Currently, the average number of programs assigned to an AGFA is 85. The addition of the 2.0 AGPAs will reduce the average caseload to 78, which will be closer to workload capability of 70 cases for an AGFA level.

E. Outcomes and Accountability

SUDCD engages in multiple stakeholder efforts in order to demonstrate DHCS' commitment to transparency and accountability. Through consultation with stakeholders, SUDCD will seek input on current and upcoming projects, including developing Disaster Plan Protocols for programs and coordinate with agencies such as the County Alcohol and Drug Administrators, police. Red Cross, etc. to protect the health, safety and welfare of patients.

In addition, SUDCD will be able to identify regulations in need of revision, initiate regulations packages, create Division natural disaster procedures and disaster plan requirements for all SUDCD programs, and develop and implement new on-site monitoring tools. LCS will continue to process the backlog of applications for residential and outpatient facilities, relocation applications due to the profound natural disasters, and to address increased workload based on the significant number of licensing and certification applications and the increase in treatment facilities providing incidental medical services.

The long-term benefits include SUDCD's ability to conduct site which assist in reviewing SUDCD programs' disaster plans for compliance. CMATS Disaster Plan Projected Cutcomes Table depicts the amount of disaster plans to review, implement, and continuously monitor. SUDCD will also reduce the existing backlog throughout the division, to develop long-term goals and strategic processes to avoid future backlog issues. After resolving the backlog, there is still ongoing workload for the staff to complete. Analysts will

^ The gap in the licensing workload is determined by taking the total number of facilities (which includes established facilities and facility applications currently under review) and subtracting the total caseload abilities.

14 5/9/19 SUD Emerging Epidemics, Disaster Response, and Licensing Workioad 4260-402-BCP-2019-MR

Analysis of Problem

have the ability to maintain caseloads that are more manageable by allowing for timely compliance reviews and to provide additional monitoring oversite of residential and outpatient treatment facilities by conducting frequent follow-up compliance visits. Long-term benefits also include the development, adoption and implementation of more stringent regulations pertaining to residential and outpatient treatment facilities, securing the health and safety of residential and outpatient clients. SUDCD has internal policy in place to confirm that resources are continually monitored, so that SUDCD's desired and projected outcomes are realized while maintaining accountability.

Projected Outcomes

L censing & Certification Section (LCS) Workload Measure 2018-19 2019-20 2020-21 2021-22 2022-23 2023-24 Total Licensed and 2,224 2,563 2,954 3,405 3,924 3,939 Certified Programs Initial Applications 493 646 846 1,108 1,452 1,902 Renewal Applications 1,035 1,232 1,466 1,745 2,077 2,472 ether Applications 328 410 512 640 800 1,000

CMATS Disaster Plan 2018- 2019- Workload Measure 2020-21 2021-22 2022-23 2023-24 19 20 Develop an Finalize Begin Cversee Cversee Cversee Emergency Response Emergency N/A Draft Response Response Response Plan for all SUDCD Response Plan Plans Plans Plans Programs Plan Review Program 0 250 250 250 250 250 Disaster Plans Implement Disaster 0 50 50 50 50 50 Plans Site Inspections (Monitor and Provide appropriate oversight 0 0 20 20 20 20 of SUDCD Programs for Natural Disaster Readiness)

F. Analysis of All Feasible Alternatives

Alternative 1: DHCS requests 7.0 permanent positions and expenditure authority of $1,060,000 (RCPLF) in FY 2019-20 and $997,000 in FY 2020-21 and ongoing to address workload regarding natural disasters, the opioid epidemic, substance abuse, and treatment facilities. In addition, DHCS requests a one-time cost of $100,000 from GF to migrate DHCS's disaster collection and reporting process into the web-based reporting platform.

15 5/9/19 SUD Emerging Epidemics, Disaster Response, and Licensing Workioad

4260-402-BCP-2019-MR Analysis of Problem

Pros: • Expands much needed access to SUD treatment services. • Improves DHCS' ability to be prepared and allow continuation of treatment services during a state of emergency or natural disaster. • Provides state level guidance and innovations to combat the opioid epidemic and the resurgence of methamphetamine use. • Assists in timely review of the existing backlog of licensing applications Division wide. • Increases DHCS' ability to conduct timely and thorough application reviews. • Allows timely on-site compliance reviews. • Increases ability to provide additional follow-up visits and reporting on unlicensed facilities. • Follow-up visits will improve public safety through the reduction of regulatory violations and increased statutory compliance.

Cons: • Increases state staff. • Requires resources to fund salary and associated costs. • Burdens the ROPLF and additional request of GF.

Alternative 2: Request five-year limited (LT) resources equivalent to 7.0 positions (ROPLF) and one-time cost of $100,000 (GF) for the web-based reporting platform.

Pros: • Temporarily responds to the oversight of SUD licensed and/or certified programs during a state of emergency or natural disaster. • Provides for temporary ability for state staff to handle some application backlogs. • Provides for temporary ability to complete timely compliance reviews. • Provides minimal resources for the state to combat the opioid epidemic in California.

Cons: • Puts clients at risk due to a lack of staff to perform thorough site visits. • Will not be able to resolve the issue of applications backlogs as the ability to maintain the oversight will drastically reduce or cease when positions are abolished. • Will not be able to monitor SUDCD programs' Disaster Plans for compliance on an ongoing basis. • SUDCD protocols and SUDCD Programs' Disaster Plans will not advance nor progress when new state of emergencies or natural disasters occurs. • Due to ongoing workload, it would place a necessary administrative burden on the state to continue requesting the extension of positions. • Hinders recruitment, as many qualified candidates will not apply for a limited term position. • Potential loss of staff knowledge once the positions expire.

16 5/9/19 SUD Emerging Epidemics, Disaster Response, and Licensing Workload 4260-402-BCP-2019-MR

Analysis of Problem

Alternative 3: Redirect existing staff.

Pros: • No additional funding or staffing is required. • Does not expand staff government. • No increase in workspace or equipment purchases to accommodate new staff. • Decrease expenditures in the ROPLF.

Cons: • Decreases the ability to improve and maintain client health and safety during state emergencies and natural disasters. • Does not increase access to SUD services in California. • Fails to address all of the current staffing and workload issues within SUDCD. • Delays SUDCD's ability to review licensing applications backlog timely and thoroughly. • Allows application backlog to increase. • Reduces the ability to take action against licensed and unlicensed facilities, including temporary suspensions and/or revocations at problem facilities. • Decreases the number of programs and services available to the clients. • Overextended staff. • Loss of staff due to overwhelming workload. • Not able to meet Division's core responsibilities. • Would not fully address the impact of the opioid epidemic and the resurgence of methamphetamines in California.

G. Implementation Plan

Upon approval, SUDCD will fill and manage the new positions using fees deposited in the RCPLF. SUDCD will begin hiring for the positions immediately upon receiving position funding and authority.

H. Supplemental Information

This request includes one-time funding for cubicle build outs and office automation at a cost of $63,000 and ongoing in-state travel at a cost of $69,000. In addition, this request also includes one-time cost of $100,000 for the web-based reporting platform.

I. Recommendation

DHCS recommends Alternative 1: approves the request of staff resources (7.0 permanent positions) and expenditure authority of $1,060,000 RCPLF. In addition, DHCS also requests one-time cost of $100,000 from GF for the web-based reporting platform. Specifically, the resources will build upon the existing infrastructure to: 1) Reduce the application and complaint backlogs and conduct initial and renewal monitoring visits; 2) Provide state level guidance and innovations to combat the opioid epidemic and the resurgence of methamphetamine abuse in California; 3) Address requirements to effectively regulate alcohol and other drug (ACD) treatment facilities; and

17 5/9/19 SUD Emerging Epidemics, Disaster Response, and Licensing Workload 4260-402-BCP-2019-MR

Analysis of Problem

4) Approve, monitor, and implement disaster plans from licensed and/or certified AOD treatment facilities. 5) Migrate DHCS's disaster collection and reporting process into the web-based reporting platform, NC4.

18 5/9/19 Attachment A

WORKLOAD STANDARDS Substance Use Disorder Compliance Division Licensing & Certification Section 1.0 Staff Services Manager I (808-954-4800-XXX) Permanent

Activities Number Hours Total of Items per Item Hours Weekly, Monthly, Etc. Provide guidance and expertise to Licensing and 7 115 805 Certification unit staff including: • Counsel staff regarding personnel-related issues and/or make appropriate referrals to the Employee Assistance Program • Planning, organizing and managing the operations of field staff to include accompanying staff on more complex compliance reviews • Setting priorities and due dates for special assignments • Providing guidance on corrective action plans • Leading and assisting with service of temporary suspension orders, license revocations and the service of inspection warrants • Conduct sensitive programmatic and program integrity compliance reviews • Reviewing staff work for accuracy, consistency and compliance with laws, policy, regulations and standards Propose, develop and review legislation, regulations and 7 90 630 standards, which includes: • Consulting and working with legal counsel on administrative actions • Assist with reviewing and developing internal policies and procedures • Responding to requests and issues regarding procedures, compliance reviews and findings • Developing and reviewing data collections systems • Conducting time management studies • Assisting with servicing Temporary Suspension Orders, revocations and inspection warrants • Submitting revised regulations packages pertaining to Title 9, Chapter 5 • Assist with bill analyses, budget change proposals, 3 125 375 and regulatory amendments • Participate in the implementation and support of quality improvement with the division and Department Total hours worked 1,810

19 5/9/19 Attachment A

Activities Number Hours Total of Items per Item Hours Weekly, Monthly, Etc. 1,800 hours = 1.0 Position Actual number of Positions requested 1.0

20 5/9/19 Attachment A

WORKLOAD STANDARDS Substance Use Disorder Compliance Division Licensing & Certification Section 2.0 Associate Governmental Program Analyst (808-954-5393-XXX) Permanent

Activities Number of Hours Total Items per Item Hours Weekly, Monthly, Etc. Independently conduct compliance reviews at licensed 30 55 1,650 and/or certified drug treatment and recovery programs, which includes: • Researching program history • Creating a work plan for site visit • Preparing site visit documents • Meeting with Program Director or representative • Conducting facility walk-through inspection • Interviewing residents and program staff • Review and scanning documents, including resident files and personnel records • Preparing Notice of Deficiency for Class A violations on-site • Conducting an exit interview Preparing reports for licensed and/or certified programs, 20 55 1,100 which include: • Developing and writing reports of findings, as related to statutory and regulatory requirements, within specified timeframes • Analyzing reports of finding to determine if further action is needed • Organizing evidence and identifying statutory and regulatory violations • Reviewing and subsequently approving or denying corrective action plans (CAP) received from provider addressing deficiencies • Assessing and tracking civil penalties

Conduct necessary actions on licensed and/or certified 10 35 350 SUD programs such as: • Suspend and/or revoke a SUD treatment program's license and/or certification; • Deny application for licensure; • Deny extension of the licensee's licensing and/or certification period; • Deny modifications to a license and/or certification; • And provide recommendations for disciplinary actions against licensed professionals to their respective licensing boards.

21 5/9/19 Attachment A

Activities Number of Hours Total Items per Item Hours Weekly, Monthly, Etc. Preparing appeal documents from programs: 20 15 300 • Participating in informal hearings and assisting with the service of Temporary Suspension Orders, revocations and inspection warrants; • Preparing Legal Service Requests for action or consultation • Assisting with the development of internal policies and procedures • Drafting memos and controlled correspondence • Responding to inquiries from the public; service providers; complainants; certifying organizations and other agencies

Assisting with special projects bill analyses, budget 20 10 200 change proposals and regulatory amendments Total hours worked 3,600 1,800 hours = 1.0 Position Actual number of Positions requested 2.0

22 5/9/19 Attachment A

WORKLOAD STANDARDS Substance Use Disorder Compliance Division Counselor & Medication Assisted Treatment Section 1.0 Staff Services Manager II (808-958-4801-XXX) Permanent

Activities Number of Hours Total Items per Item Hours Weekly, Monthly, Etc. Provide guidance and expertise to the Counselor & 10 90 900 Medication Assisted Treatment Section including: • Develop an Emergency Plan Team, which can work with the other SUDCD Sections in developing an extensive "SUDCD Emergency Response Plan" for all residential and outpatient programs licensed and/or certified with DHCS. • Support for adherence to ongoing preparedness for natural disasters. • Develop new policies and procedures to implement efficient response measures during natural disasters and emergencies. • Review staff work for accuracy, consistency and compliance with laws, policy, regulations and standards • Oversee the development of on-site monitoring tools for disaster preparedness and response procedures • Oversee the coordination with other departments, counties, agencies, and providers related to disaster response • Make certain staff compliance with oversight of provider disaster plans. • Analyze the needs of clients and staff at licensed and certified facilities during natural disasters and other emergencies. • Travel to disaster impacted locations to review relocation applications. Provide disaster training to facilities through webinars, onsite, TA and other resources. Plan, direct, supervise and manage activities related to 10 45 450 policies, program implementation, and adherence of all licensed and/or certified SUD treatment facilities related to disaster preparedness and response. Oversee the adherence of NTPs to state regulations and 10 30 300 statues, including; • Annual site inspections are completed timely and 1 meet regulatory requirements

23 5/9/19 Attachment A

Activities Number of Hours Total items per item Hours Weekly, Monthly, Etc. • Review serious non-compliance citations and issues to determine appropriate response, which may lead to license revocation or suspension. Oversee the development of the SUDCD Emergency 5 10 50 Response Plan and disaster related activities • Develop and implement processes to achieve smooth coordination of all SUDCD • Direct staff in the efforts of ensuring efficient response measures during natural disasters.

Guide the development of regulations in need of revision 3 50 150 in response to, initiate regulations packages, create, and develop and implement new on-site monitoring tools. Participate in the implementation and support of quality improvement with the division and Department. Total hours worked 1,850 1,800 hours = 1.0 Position Actual number of Positions requested 1.0

24 5/9/19 Attachment A

WORKLOAD STANDARDS Substance Use Disorder Compliance Division Counselor & Medication Assisted Treatment Section 1.0 Health Program Specialist ii (808-950-8336-XXX) Permanent

Activities Number of Hours Total Items per Item Hours Weekly, Monthly, Etc. Serve as technical and subject matter expert in SUD 10 90 900 treatment services, programs, and resources. • Perform the project coordination of SUD policy related initiatives and projects that intersect with physical and mental health services. • Coordinate with the SSM III and Division Chief to obtain input and assure implementation of consistent policy. • Research and train staff on the impact of methamphetamine abuse including clinical options, trends, and impact on facilities. Lead and participate Statewide Cpioid Initiatives and 5 30 150 Statewide Cpioid Safety Workgroup Meetings and methamphetamine workgroups. Develop complex policy decisions and consult with DHCS 10 10 100 management and stakeholders regarding State and federal laws and regulations related to the policy and contractual components of SUD treatment services.

Coordinate the development of policies and procedures 5 50 250 regarding response measures during natural disasters. Independently conduct annual on-site inspections to 10 30 300 licensed and/or certified ACD treatment facilities ensuring Disaster Procedures are accessible and in compliance.

Provide technical assistance to counties and stakeholders 30 5 150 regarding interpretation of applications and policies regarding SUD treatment services.

Total hours worked 1,850 1,800 hours = 1.0 Position Actual number of Positions requested 1.0

25 5/9/19 Attachment A

WORKLOAD STANDARDS Substance Use Disorder Compliance Division Counselor & Medication Assisted Treatment Section 2.0 Associate Governmental Program Analyst (808-958-5393-XXX) Permanent

Activities Number of Hours Total items per item Hours Weekly, Monthly, Disaster Plan Implementation and Oversight: 35 75 2,625 • Review, approve, monitor, and implement Disaster Plans from all licensed and/or certified AOD treatment facilities. • Conduct regular on-site facility visits for review of facility disaster plans. • Prepare reports and corrective action plans for any related deficiency identified in the disaster plan. • Analyze the impact on clients and staff at licensed and certified facilities during and after natural disasters and other emergencies through communications and activities outlined in the facility's disaster plan. • Travel to disaster impacted locations to review relocation applications. • Collect data and prepare DHCS, state and federal disaster reports. • Provide disaster training to facilities through webinars, onsite, TA and other resources. Independently conduct annual and follow-up inspections of 24 25 600 assigned NTPs to determine and promote compliance according to CCR Title IX and Health and Safety Code Article 1. • Analyze and evaluate the NTP facility operations • Review patient and personnel files • Evaluate written protocol on program administration • Prepare site inspection reports, review and approve corrective actions plans in response to deficiencies cited during the site inspection. Provide administrative support to CMAT section 5 15 75 • Review initial NTP applications • Assist in the development of bill analyses • Prepare correspondence for the public, state, federal, local agencies, providers, and other stakeholders. Perform Officer of the Day duties as scheduled monthly. 40 8 320 Total hours worked 3,620 1,800 hours = 1.0 Position Actual number of Positions requested 2.0

26 5/9/19 Department of Health Care Services Substance Use Disorders Compliance Division Current

CEA HPSI SSA Oivisian Chief

DUI. Criminal Justice, and Counselor B Complainls. Lbensing B Certification Branch Medication Assisted Treatment Branch HPSi SSM ill

Ccunselor B Medication Assisted Treatment Section

SSM II

lbensing B Cert. Servics I licensing/Monitorhg Compiaints Unit I CMAT Unit i Unit I lbensing and Cert. Unit ServicElinitS SSMI SSMi SSMI SSMI SSMi lbensing BCert. SenvicE DUi Policy B Quality Cnniplainls Unit 2 CMAT Unit 2 lbensing and Cert. Assurance Unit SSMi ServicBUnitA SSMI SSMI SSMi JSMI lbensing S Cert. ServicB Complaints Unit 2 Criminal Justice Unit CMAT Unit 3 Units

SSMI SSMi SSMi SSMI

Compiaints Unit A CMAT Unit A

SSMI SSMi

Limited-Term Position per BCP4260-017-2017-GB SUD Licensing Workload; Expire 6/30/2022 Vacant Position Department of Health Care Services Substance Use Disorders Compliance Division Licensing & Certification Section I

Licensing & Certification Section i

SSM ii

Licensing & Certification Licensing & Certification Services Unit 1 Services Unit 2

SSM 1 SSM i

AGFA DT(T) AG PA AG PA

AG PA DT(T) AGPA AGPA

AGPA DT(T) AGPA AGPA

Vacant Position Limited-Term Position per BCP 4260-017-2017-GB SUD Licensing Workload; Expire 6/30/2022 Department of Health Care Services Substance Use Disorders Compliance Division Licensing & Certification Section II

Licensing & Certificafion Section ii

SSMi

Licensing & Licensing & Certification Licensing & Certification Certifcation Services Services Unit 4 Services Unit 5 Units SSM I SSM I SSM i

AGPA AGPA AGPA AGPA AGPA AGPA

AGPA SSA AGPA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA Department of Health Care Services Substance Use Disorders Compliance Division Driving Under the Influence (DUI) & Criminal Justice Section

DUI & Criminal Justice Section

SSM ii

DUi Licensing/ DUi Policy & Quality Criminal Justice Unit Monitoring Unit Assurance Unit

SSMi SSM i SSMI

AGPA AGPA AGPA

AGPA AGPA AGPA

AGPA AGPA AGPA

AGPA AGPA AGPA

AGPA OT(T)

Vacant Position Department of Health Care Services Substance Use Disorders Compliance Division Complaints Section

Complaints Section SSMii DT(T)

Complaints Unit 1 Complaints Unit 2 Complaints Unit 3 Complal Its Unit 4

SSMI SSM I SSM i >Mi

AGPA AGPA AGPA AGPA AGPA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA AGPA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA Department of Health Care Services -Substance Use Disorders Compliance Division Counselors Medication Assisted Treatment Section

Counselor & Medication Assisted Treatment Section NE il SSMii

I

CMAT Unit 1 CMAT Unit 4

SSMI SSMi

SSA AGPA AGPA AGPA

SSA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA

AGPA

I I Vacant Position Department of Health Care Services Substance Use Disorders Compliance Division

Proposed CEA BCP SSA Division Chief January 2019

Jl. Criminal Justice, and CounsebrB Complaints, lbensing B Cetlifittatinn Medication Assisted Treatment HPSI Branch Branch

SSMII! New Vacant SSM Hi HPS II

Lbensing B Certification Section Counselor fi Medication Assisted Counselor B Medication Assisted I S Criminal Justice Section II Treatment Section I Treatment Section II New Vac ant SSMII SSMII SSMII SSMII

Lbensing B Cert. Services Lbensing and Cert. I ticensing/Monitorrg Complaints Unit i CMAT Unit i CMAT Unit 3 Unit I ServicEUnitS Unit

SSMI SSMI SSMI SSMI SSMI SSMI

Lbensing B Cert. Servics Lbensing and Cert. )UI Policv S Quality Complaints Unit 2 CMAT Unit 2 CMAT Unit 4 Unit 2 ServicE Unit 4 Assurance Unit

SSMI SSMI SSMI SSMI SSMI SSMI

Lbensing BCert.Services Lbensing BCert.ServicE Complaints Unit S Criminal Justice Unit Units Units NewVacatit SSMI SSMI SSMI SSMI

Complaints Unit 4

SSHI

1 Limited-Term Position per BCP 4260-017-2017-GB SUD Licensing Workload; Expire 6/30/2022 I I Vacant Position Department of Health Care Services Substance Use Disorders Compliance Division Driving Under the Influence (DUI) & Criminal Justice Section

DUI & Criminal Justice Section

SSM ii

DUi Licensing/ DUi Policy & Quality Criminal Justice Unit Monitoring Unit Assurance Unit

SSMi SSM i SSMI

AGPA AGPA AGPA

AGPA AGPA AGPA

AGPA AGPA AGPA

AGPA AGPA AGPA

AGPA DT(T)

Vacant Position Department of Health Care Services Substance Use Disorders Compliance Division Proposed Licensing & Certification Section I L&CIBCP January 2019

Licensing & Certilication Section i HPSI SSMii

Licensing & Certilication Licensing & Certification Licensing & Certification Services Unit 1 Services Unit 2 Services Unit 3 New Vacant SSliA I SSM 1 SSM I

AGPA OT(T) AGPA AGPA

1

New Vacant New Vacant AGPA OT(T) AGPA AGPA

AGPA DT(T)

n Vacant Position 1 Limited-Term Position per BCP 4260-017-2017-GB SUD Licensing Workload; Expire 6/30/2022 Department of Health Care Services Substance Use Disorders Compliance Division Licensing & Certification Section II

Licensing & Certification Sectton Ii

SSM ii

1

Licensing & Licensing & Certilication Licensing & Certilication Certilication Services Services Unit 4 Services Unit 5 Units SSM i SSM 1 SSM i

AGPA AGPA AGPA AGPA AGPA AGPA

AGPA SSA AGPA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA Department of Health Care Services

I Substance Use Disorders Compliance Division Complaints Section

i Complaints Section SSM ii OT(T)

Complaints Unit 1 Compiaints Unit 2 Complai nts Unit 3 Complai nts Unit 4

SSMi SSM i M i SJ ;Mi

AGPA AGPA AGPA AGPA AGPA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA AGPA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA Department of Health Care Services Substance Use Disorders Compliance Division Counselor & Medication Assisted Treatment Section

Proposed CMATS BCP January 2019

Counselor & Medication Assisted Counselor & Medication Assisted Treatment Section i Treatment Section ii NEII New Vacant SSM Ii SSM ii 808-958-4801-XXX

CMAT Unit 1 CMAT Unit 2 CMAT Unit 3 CMAT Unit 4

SSMi SSM I SSMI SSM i

IT IT

SSA AGPA AGPA AGPA

SSA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA

AGPA AGPA AGPA AGPA

New Vacant AGPA AGPA AGPA AGPA

New Vacant AGPA

I I Vacant Position BCP Fiscal Detail Sheet BCP Title: SUD Emerging Epidemics, Disaster Response, and Licensing Workioad BR Name: 4260-402-BCP-2019-MR

Budget Request Summary FY19 CY BY BY+1 BY+2 BY+3 BY+4 Personal Services Positions - Permanent 0.0 7.0 7.0 7.0 7.0 7.0 Total Positions 0.0 7.0 7.0 7.0 7.0 7.0

Salaries and Wages Earnings - Permanent 0 521 521 521 521 521 Total Salaries and Wages $0 $521 $521 $521 $521 $521

Total Staff Benefits 0 274 274 274 274 274 Total Personal Services $0 $795 $795 $795 $795 $795 Operating Expenses and Equipment 5301 - General Expense 0 42 28 28 28 28 5302 - Printing 0 14 14 14 14 14 5304 - Communications 0 14 14 14 14 14 5320 - Travel: In-State 0 69 69 69 69 69 5322 - Training 0 7 7 7 7 7 5324 - Facilities Operation 0 63 63 63 63 63 5340 - Consulting and Professional Services - Interdepartmental 0 100 0 0 0 0 5344 - Consolidated Data Centers 0 7 7 7 7 7 539X - Other 0 49 0 0 0 0 Total Operating Expenses and Equipment $0 $365 $202 $202 $202 $202 Total Budget Request $0 $1,160 $997 $997 $997 $997 Fund Summary Fund Source - State Operations 0001 - General Fund 0 100 0 0 0 0 3113 - Residential and Outpatient Program Licensing Fund 0 1,060 997 997 997 997 Total State Operations Expenditures $0 $1,160 $997 $997 $997 $997 Total All Funds $0 $1,160 $997 $997 $997 $997 Program Funding 3960050 - Other Care Services 0 1,160 997 997 997 997 Total All Programs $0 $1,160 $997 $997 $997 $997 BCP Title: SUD Emerging Epidemics, Disaster Response, and Licensing Workload BR Name: 4260-402-BCP-2019-MR

Personal Services Details

Salary Information Positions Min Mid Max CY BY BY+1 BY+2 BY+3 BY+4 4800 - Staff SvcsMgrI (Eff. 07-01-2019) 0.0 1.0 1.0 1.0 1.0 1.0 4801 - Staff SvcsMgr II (Supvry) (Eff. 07-01-2019) 0.0 1.0 1.0 1.0 1.0 1.0 5393 - Assoc Govtl Program Analyst (Eff. 07-01-2019) 0.0 4.0 4.0 4.0 4.0 4.0 8336 - HIth Program Specll (Eff. 07-01-2019) 0.0 1.0 1.0 1.0 1.0 1.0

Total Positions 0.0 7.0 7.0 7.0 7.0 7.0

Salaries and Wages CY BY BY+1 BY+2 BY+3 BY+4

4800 - Staff Svcs Mgr 1 (Eff. 07-01-2019) 0 80 80 80 80 80 4801 - Staff Svcs Mgr II (Supvry) (Eff. 07-01-2019) 0 87 87 87 87 87 5393 - Assoc Govtl Program Analyst (Eff. 07-01-2019) 0 273 273 273 273 273 8336 - HIth Program Specll (Eff. 07-01-2019) 0 81 81 81 81 81 Total Salaries and Wages $0 $521 $521 $521 $521 $521

Staff Benefits 5150350 - Health Insurance 0 126 126 126 126 126 5150600 - Retirement - General 0 148 148 148 148 148 Total Staff Benefits $0 $274 $274 $274 $274 $274 Total Personal Services $0 $795 $795 $795 $795 $795