                                     TO BE PUBLISHED IN THE OFFICIAL REPORTS

                                          OFFICE OF THE ATTORNEY GENERAL
                                                    State of California

                                                  DANIEL E. LUNGREN
                                                     Attorney General
                                         ______________________________________

                                     OPINION                :
                                                            :           No. 97-311
                                     of                     :
                                                            :           July 21, 1997
                           DANIEL E. LUNGREN                :
                              Attorney General              :
                                                            :
                          ANTHONY M. SUMMERS                :
                           Deputy Attorney General          :
                                                            :
                    ______________________________________________________________________

                     THE HONORABLE TOM J. BORDONARO, JR., MEMBER OF THE CALIFORNIA
         ASSEMBLY, has requested an opinion on the following question:

                         May trained, unlicensed staff members of a community care facility perform incidental
         medical services with respect to a gastrostomy, colostomy, ileostomy, and the use of urinary catheters?

                                                         CONCLUSION

                         Trained, unlicensed staff members of a community care facility may perform incidental
         medical services with respect to a gastrostomy, colostomy, ileostomy, and the use of urinary catheters.

                                                           ANALYSIS

                          The Legislature has enacted a comprehensive statutory scheme, the Community Care
         Facilities Act (Health & Saf. Code, §§ 1500-1567.8; "Act"), Footnote No. 1 to provide "a coordinated and
         comprehensive statewide service system of quality community care for mentally ill, developmentally and
         physically disabled, and children and adults . . . ." (§ 501, subd. (a).) A "community care facility" is defined
         as:

                           ". . . any facility, place, or building that is maintained and operated to provide
               nonmedical residential care, day treatment, adult day care, or foster family agency services for
               children, adults, or children and adults, including, but not limited to, the physically handicapped,
               mentally impaired, incompetent persons, and abused or neglected children . . . ." (§ 1502, subd.
               (a).)

         The question presented for resolution is whether trained but unlicensed staff members of a community care
         facility may perform "incidental medical services" with respect to a gastrostomy, colostomy, ileostomy, and
         the use of urinary catheters. Footnote No. 2 We conclude that they may.

                          In 71 Ops.Cal.Atty.Gen. 190, 204 (1988), we concluded that nasogastric and gastrostomy


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         feeding could not be performed by an unlicensed home care companion because "substantial scientific
         knowledge and technical skill are necessary to their proper performance." What developments, if any, have
         occurred since 1988 that would cause a different conclusion with respect to unlicensed community care
         facility staff members?

                          In 1996 the Legislature amended section 1507 to provide:

                           "(a) A community care facility may provide incidental medical services. If the
               medical services constitute a substantial component of the services provided by the community
               care facility as defined by the director in regulations, the medical services component shall be
               approved as set forth in Chapter 1 (commencing with Section 1200) or Chapter 2 (commencing
               with Section 1250).

                           "(b) The department shall adopt emergency regulations for community care facilities
               for adults by February 1, 1997, to do all of the following:

                          "(1) Specify incidental medical services that may be provided. These incidental
               medical services shall include, but need not be limited to, any of the following: gastrostomy,
               colostomy, ileostomy, and urinary catheters.

                          "(2) Specify the conditions under which incidental medical services may be provided.

                            "(3) Specify the medical services that, due to the level of care required, are prohibited
               services. . . ." Footnote No. 3

         Under the terms of section 1507, a community care facility is expressly authorized to provide incidental
         medical services including those furnished with respect to a gastrostomy, colostomy, ileostomy, and the use
         of urinary catheters. The issue to be resolved is whether such services must be performed by licensed health
         care professionals on behalf of the facility or whether trained but unlicensed staff members of the facility
         may perform the services.

                           In construing the language of section 1507, we are guided by well-established principles of
         statutory construction. The primary "objective of statutory interpretation is to ascertain and effectuate
         legislative intent." (Burden v. Snowden (1992) 2 Cal.4th 556, 562.) "Every word, phrase, and sentence in a
         statute should, if possible, be given significance. [Citation.]" (Larson v. State Personnel Bd. (1994) 28
         Cal.App.4th 265, 276-277.) "The words of the statute must be construed in context, keeping in mind the
         statutory purpose, and statutes or statutory sections relating to the same subject must be harmonized, both
         internally and with each other, to the extent possible. [Citations.]" (Dyna-Med, Inc. v. Fair Employment and
         Housing Com. (1987) 43 Cal.3d 1379, 1387.) "`Statements in legislative committee reports concerning the
         statutory purposes which are in accordance with a reasonable interpretation of the statute will be followed by
         the courts.'" (O'Brien v. Dudenhoeffer (1993) 16 Cal.App.4th 327, 334.) "If possible, the words should be
         interpreted to make them workable and reasonable [citations], practical [citation], in accord with common
         sense and justice, and to avoid an absurd result [citations]." (Halbert's Lumber, Inc. v. Lucky Stores, Inc.
         (1992) 6 Cal.App.4th 1233, 1239-1240.)

                           With these principles of statutory construction in mind, we find that in 1989 the Legislature
         enacted a statutory scheme (Stats. 1989, ch. 1437, § 1), authorizing incidental medical services with respect
         to a gastrostomy, colostomy, ileostomy, the use of urinary catheters, and other medical or surgical procedures
         for certain children with special health care needs to be performed by the following persons:

                           "(1) A parent trained by health care professionals where the child is being placed in,
               or is currently in, a specialized foster care home.


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                           "(2) Group home staff trained by health care professionals pursuant to the discharge
               plan of the facility releasing the child where the child was placed in the home as of November 1,
               1993, and who is currently in the home.

                        "(3) A health care professional, where the child is placed in a group home after
               November 1, 1993. . . ." (Welf. & Inst. Code, § 17710, subd. (h).)

         Thus, while the Legislature has elected to have incidental medical services provided by health care
         professionals for children placed in group homes after November 1, 1993, prior to that date unlicensed staff
         members were authorized to provide such services.

                         In 1990, in connection with supportive services for children with developmental disabilities
         cared for at home, the Legislature provided:

                           "(a) Notwithstanding any other provision of law, an in-home respite worker may
               perform gastrostomy care and feeding of clients of regional centers, after successful completion
               of training as provided in this section.

                          "(b) In order to be eligible to receive training for purposes of this section, an in-home
               respite worker shall submit to the trainer proof of successful completion of a first aid course and
               successful completion of a cardiopulmonary resuscitation course within the preceding year.

                           "(c) The training in gastrostomy care and feeding required under this section shall be
               provided by physicians or registered nurses through a gastroenterology or surgical center in an
               acute care hospital, as defined in subdivision (a) of Section 1250 of the Health and Safety Code,
               which meets California Children Services' Program standards for centers for children with
               congenital gastrointestinal disorders, or comparable standards for adults, or by a physician or
               registered nurse who has been certified to provide training by the center.

                           "(d) The gastroenterology or surgical center providing the training shall develop a
               training protocol which shall be submitted for approval to the State Department of
               Developmental Services. The department shall approve those protocols which specifically
               address all of the following:

                          "(1) Care of the gastrostomy site.

                          "(2) Performance of gastrostomy tube feeding.

                          "(3) Identification of, and appropriate response to, problems and complications
               associated with gastrostomy care and feeding.

                          "(4) Continuing education requirements.

                           "(e) Training by the gastroenterology or surgical center, of the certified physician or
               registered nurse, shall be done in accordance with the approved training protocol. Training of
               in-home respite workers shall be specific to the individual needs of the developmentally disabled
               regional center client receiving the gastrostomy feeding and shall be in accordance with orders
               from the client's treating physician or surgeon.

                           "(f) The primary care physician shall give assurances to the regional center that the
               patient's condition is stable prior to the regional center's purchasing in-home gastrostomy care
               for the client through an appropriately trained respite worker.



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                          "(g) Prior to the purchase of in-home gastrostomy care through a trained respite
               worker, the regional center shall do all of the following:

                           "(1) Ensure that a nursing assessment of the client, performed by a registered nurse, is
               conducted to determine whether an in-home respite worker, licensed vocational nurse, or
               registered nurse may perform the services.

                         "(2) Ensure that a nursing assessment of the home has been conducted to determine
               whether gastrostomy care and feeding can appropriately be provided in that setting.

                           "(h) The agency providing in-home respite services shall do all of the following:

                           "(1) Ensure adequate training of the in-home respite worker.

                          "(2) Ensure that telephone backup and emergency consultation by a registered nurse
               or physician is available.

                           "(3) Develop a plan for care of the gastrostomy site and for gastrostomy tube feeding
               to be carried out by the respite worker.

                           "(4) Ensure that the in-home respite worker and the gastrostomy services provided by
               the respite worker are adequately supervised by a registered nurse.

                          "(I) For purposes of this section, `in-home respite worker' means an individual
               employed by an agency which is vendored by a regional center to provide in-home respite
               services. These agencies include, but are not limited to, in-home respite services agencies, home
               health agencies, or other agencies providing these services." (Welf. & Inst. Code, § 4686.)

         Here, again, the Legislature has enacted a special statute allowing trained but unlicensed persons to perform
         gastrostomy care and feeding in specified circumstances.

                          These related statutory enactments indicate that the Legislature believes incidental medical
         services with respect to gastrostomies, colostomies, ileostomies, and the use of urinary catheters may be
         performed by unlicensed persons when appropriately trained. Returning to the provisions of section 1507, we
         believe it would be unreasonable to conclude that the sentence "[a] community care facility may provide
         incidental medical services" was intended by the Legislature to authorize community care facilities to
         provide the services in question only through licensed health care professionals such as physicians and
         registered nurses. In 1996, when section 1507 was amended to specifically refer to incidental medical
         services performed in connection with gastrostomies, colostomies, ileostomies, and the use of urinary
         catheters, physicians and registered nurses were already authorized to perform such services. (71
         Ops.Cal.Atty.Gen. 190, supra.) Rather, then, in keeping with Welfare and Institutions Code sections 4686
         and 17710, the Legislature amended section 1507 in 1996 as a special statute authorizing trained but
         unlicensed persons to perform incidental medical services in conjunction with the specified surgeries and
         procedures under the described circumstances.

                          This interpretation of section 1507 is consistent with the statute's legislative history. At the
         time of the 1996 amendment, the proposed changes in statutory language were explained in the report of the
         Assembly Committee on Human Services for its hearing of April 16, 1996, in part as follows:

                            "Adult day care facilities provide non-medical care and incidental medical services
               for adults who are developmentally or mentally disabled and to persons 60 years of age or older.
               More and more, facilities are accepting disabled adults who are in greater need of assistance with
               the activities of daily living and who require incidental medical services. The [Department of


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                Developmental Services] is committed to placing larger numbers of these individuals into the
                community. This bill would require [the Department of Developmental Services] to adopt
                emergency regulations by February 1, 1997 that do the following:

                             "1) Specific incidental medical services that may be provided by a [community care
                facility], including, but not limited to, gastrostomy, colostomy, ileostomy, and urinary catheters
                . . . ."

         In the report of the Assembly Committee on Appropriations for its hearing on May 8, 1996, the fiscal effects
         of the proposed legislation were described in part as follows:

                            "Unknown, probably minor, costs to community care facilities for staff training on
                the care of persons needing these incidental medical services. To some extent, these costs could
                be recovered through higher rates paid to the facility for care. General Fund costs would increase
                for the state share of any rate increases."

         The report of the Senate Health and Human Services Committee for its hearing on July 3, 1996, stated in
         part:

                            "Supporters argue that AB 2835 increases community placement options for persons
                in need of incidental medical services. This measure would enable clients to receive incidental
                medical services in a setting that is less costly than a health facility. It would provide regulations
                and specificity as to what is considered incidental medical services."

         When the legislation was adopted, it contained the following declaration of legislative purpose: "It is the
         intent of the Legislature to ensure that adults with incidental medical needs have access to community care
         facilities." (Stats. 1996, ch. 517, § 1.)

                           We believe that the above legislative history fully supports the conclusion that the
         Legislature amended section 1507 in 1996 to allow trained but unlicensed staff members of a community
         care facility to perform incidental medical services with respect to gastrostomies, colostomies, ileostomies,
         and the use of urinary catheters. Such construction of section 1507 gives significance to every word of the
         statute and provides a practical, reasonable result consistent with related statutory provisions. Whatever
         conditions or restrictions are necessary in performing the specified services by unlicensed staff members of a
         community care facility may be imposed by regulations adopted by the Department of Social Services.

                          We conclude that trained, unlicensed staff members of a community care facility may
         perform incidental medical services with respect to a gastrostomy, colostomy, ileostomy, and the use of
         urinary catheters.

                                                                   *****

         Footnote No. 1
         All references hereafter to the Health and Safety Code are by section number only.
         Footnote No. 2
         A gastrostomy is a surgical operation creating an opening into the stomach, a colostomy surgically creates an opening into
         the colon, an ileostomy establishes an opening in the lower third of the small intestine, and a urinary catheter is a tube
         inserted through the urethra into the bladder. (Stedman's Medical Dict. (5th lawyers' ed. 1982) pp. 237, 301, 578, 691.)
         Footnote No. 3
         The "director" is the Director of Social Services (§ 1502, subd. (c)), "Chapter 1" licenses clinics, "Chapter 2" licenses heath
         facilities, and the "department" is the Department of Social Services (§ 1502, subd. (b)).




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