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SB-534 Dental hygienists.(2021-2022)

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Date Published: 04/29/2021 09:00 PM
SB534:v96#DOCUMENT

Amended  IN  Senate  April 29, 2021
Amended  IN  Senate  March 22, 2021
Amended  IN  Senate  March 04, 2021

CALIFORNIA LEGISLATURE— 2021–2022 REGULAR SESSION

Senate Bill
No. 534

Introduced by Senator Jones

February 17, 2021

An act to amend Sections 1902.3, 1903, 1917.1, 1926.1, 1926.3, 1941, 1950.5, and 1951 of the Business and Professions Code, relating to healing arts.


LEGISLATIVE COUNSEL'S DIGEST


SB 534, as amended, Jones. Dental hygienists.
(1) Existing law, the Dental Practice Act, provides for the licensure and regulation of the practice of dental hygienists by the Dental Hygiene Board of California within the Department of Consumer Affairs. Existing law requires the board to consist of 9 members and requires the Governor to appoint 7 members, as specified. Under existing law, members are appointed for a term of 4 years, except as otherwise specified for the term commencing on January 1, 2012. Existing law prohibits a person from serving as a member of the board for more than 2 consecutive terms and requires a vacancy to be filled by appointment to the unexpired term.
This bill, for the term commencing on January 1, 2022, would require specified members appointed by the Governor to each serve a term of 3 years, expiring January 1, 2025. The bill would delete the provision relating to the term commencing on January 1, 2012. The bill would provide that, notwithstanding the 2 consecutive term limit, a member who is appointed to fill an unexpired term is eligible to serve 2 complete consecutive terms.
(2) Existing law requires applicants for licensure to provide fingerprint images for submission to governmental agencies, in order to, among other things, establish the identity of the applicant.
Existing law permits a registered dental hygienist licensed in another state to teach in a dental hygiene college without being licensed in this state if the dental hygienist satisfies various eligibility requirements, including furnishing satisfactory evidence of having graduated from a dental hygiene college approved by the board, and is issued a special permit. Existing law requires an applicant for a special permit to pay an application fee, subject to a biennial renewal fee, as provided.
This bill would require a special permit to remain valid for 4 years and would thereafter prohibit the board from renewing it. The bill would specify that an applicant for a special permit is required to comply with the fingerprint submission requirements described above and would require an applicant, if teaching during clinical practice sessions, to furnish satisfactory evidence of having successfully completed a course in periodontal soft-tissue curettage, local anesthesia, and nitrous oxide-oxygen analgesia approved by the board.
(3) Existing law requires the board to grant initial licensure as a registered dental hygienist to a person who satisfies specified requirements and authorizes the board to grant a license as a registered dental hygienist to an applicant who has not taken a clinical examination before the board if the applicant submits specified documentation, including proof of graduation from a school of dental hygiene accredited by the Commission on Dental Accreditation of the American Dental Association.
This bill would require an applicant for licensure who has not taken a clinical examination before the board to additionally submit satisfactory evidence of having successfully completed a course or education and training in local anesthesia, nitrous oxide-oxygen analgesia, and periodontal soft-tissue curettage approved by the board.
(4) Existing law requires a new educational program for registered dental hygienists, as defined, to submit a feasibility study demonstrating a need for a new educational program and to apply for approval from the board before seeking approval for initial accreditation from the Commission on Dental Accreditation or an equivalent body, as determined by the board.
This bill would also require a new or existing educational program for registered dental hygienists, registered dental hygienists in alternative practice, practice or registered dental hygienists in extended functions to comply with the above-described requirements.
(5) Existing law authorizes the board to discipline, as specified, a licensee for unprofessional conduct and provides a nonexhaustive list of acts that constitute unprofessional conduct, including the willful misrepresentation of facts relating to a disciplinary action to the patients of a disciplined licensee.
This bill would make it unprofessional conduct for a licensee to knowingly make a statement or sign a certificate or other document that falsely represents the existence or nonexistence of a fact directly or indirectly related to the practice of dental hygiene.
(6) Existing law authorizes the board to discipline a licensee by placing the licensee on probation under various terms and conditions, including, but not limited to, requiring the licensee to obtain additional training or pass an examination upon completion of training, or both.
This bill would require the training to be in a remedial education course approved by the board.
(7) Existing law provides for the licensure and regulation of registered dental hygienists in alternative practice by the board. Existing law authorizes a registered dental hygienist in alternative practice to perform any of the duties or functions authorized to be performed by a registered dental hygienist as an employee of a dentist or of another registered dental hygienist in alternative practice, as an independent contractor, as a sole proprietor of an alternative dental hygiene practice, in specified clinics, or in a professional corporation. Existing law further authorizes a registered dental hygienist in alternative practice to perform certain additional duties and functions in residences of the homebound, schools, residential facilities, dental health professional shortage areas, and dental offices.
Existing law authorizes a registered dental hygienist in alternative practice to operate a mobile dental hygiene clinic provided by the licensee’s property and casualty insurer as a temporary substitute site if the registered place of practice has been rendered and remains unusable due to loss or calamity and the licensee’s insurer registers the mobile dental hygiene clinic with the board, as specified.
This bill would authorize a registered dental hygienist in alternative practice to operate a mobile dental hygiene clinic in specified settings, if the registered dental hygienist in alternative practice registers mobile dental hygiene clinic with the board, as specified. In this regard, the bill would remove the requirement that a mobile dental hygiene clinic be provided by the property and casualty insurer as a temporary substitute site because the registered place of practice has been rendered and remains unusable due to loss or calamity. The bill would authorize the board to conduct announced and unannounced reviews and inspections of a mobile dental hygiene clinic, as specified. The bill would make it unprofessional conduct for a registered dental hygienist in alternative practice to operate a mobile dental hygiene clinic in a manner that does not comply with these provisions. The bill would authorize the board to issue citations that contain fines and orders of abatement to a registered dental hygienist in alternative practice for a violation of these provisions and related provisions, as specified.
(8) Existing law requires a registered dental hygienist in alternative practice to register with the executive officer of the dental hygiene board the person’s place of practice, as specified. Existing law requires a person licensed by the dental hygiene board to register with the executive officer within 30 days after the date of the issuance of the person’s license as a registered dental hygienist in alternative practice.
This bill would instead impose these registration requirements on the physical facilities of the registered dental hygienist in alternative practice. The bill would require a registered dental hygienist in alternative practice who utilizes portable equipment to practice dental hygiene to register the physical facility where the portable equipment is maintained with the executive officer of the dental hygiene board. The bill would authorize the board to conduct announced and unannounced reviews and inspections of the physical facilities and equipment of a registered dental hygienist in alternative practice, as specified. The bill would make it unprofessional conduct for a registered dental hygienist in alternative practice to maintain a physical facility or equipment in a manner that does not comply with these provisions. The bill would authorize the board to issue citations that contain fines and orders of abatement to a registered dental hygienist in alternative practice for a violation of these provisions and related provisions, as specified.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

The people of the State of California do enact as follows:


SECTION 1.

 Section 1902.3 of the Business and Professions Code is amended to read:

1902.3.
 A registered dental hygienist licensed in another state may teach in a dental hygiene college without being licensed in this state if the person has a special permit. A special permit shall remain valid for a period of four years, subject to subdivision (g), after which time the permit shall not be renewed. The dental hygiene board may issue a special permit to practice dental hygiene in a discipline at a dental hygiene college in this state to any person who submits an application and satisfies all of the following eligibility requirements:
(a) Furnishing satisfactory evidence of having a pending contract with a California dental hygiene college approved by the dental hygiene board as a full-time or part-time professor, associate professor, assistant professor, faculty member, or instructor.
(b) Furnishing satisfactory evidence of having graduated from a dental hygiene college approved by the dental hygiene board.
(c) Furnishing satisfactory evidence of having been certified as a diplomate of a specialty committee or, in lieu thereof, establishing qualifications to take a specialty committee examination or furnishing satisfactory evidence of having completed an advanced educational program in a discipline from a dental hygiene college approved by the dental hygiene board.
(d) Furnishing satisfactory evidence of having successfully completed an examination in California law and ethics developed and administered by the dental hygiene board.
(e) If teaching during clinical practice sessions, furnishing satisfactory evidence of having successfully completed a course in periodontal soft-tissue curettage, local anesthesia, and nitrous oxide-oxygen analgesia approved by the dental hygiene board.
(f) Complying with the fingerprint submission requirements as provided by Section 1916.
(g) Paying an application fee, subject to a biennial renewal fee, as provided by subdivision (k) of Section 1944.

SEC. 2.

 Section 1903 of the Business and Professions Code is amended to read:

1903.
 (a) (1) The dental hygiene board shall consist of nine members as follows:
(A) Seven members appointed by the Governor as follows:
(i) Two members shall be public members.
(ii) One member shall be a practicing general or public health dentist who holds a current license in California.
(iii) Four members shall be registered dental hygienists who hold current licenses in California. Of the registered dental hygienist members, one shall be licensed either in alternative practice or in extended functions, one shall be a dental hygiene educator, and two shall be registered dental hygienists. No public member shall have been licensed under this chapter within five years of the date of their appointment or have any current financial interest in a dental-related business.
(B) One public member appointed by the Senate Committee on Rules.
(C) One public member appointed by the Speaker of the Assembly.
(2) (A) The first appointment by the Senate Committee on Rules or the Speaker of the Assembly pursuant to this subdivision shall be made upon the expiration of the term of a public member that is scheduled to occur, or otherwise occurs, on or after January 1, 2019.
(B) It is the intent of the Legislature that committee members appointed prior to January 1, 2019, remain as hygiene board members until their term expires or except as otherwise provided in law, whichever occurs first.
(3) For purposes of this subdivision, a public health dentist is a dentist whose primary employer or place of employment is in any of the following:
(A) A primary care clinic licensed under subdivision (a) of Section 1204 of the Health and Safety Code.
(B) A primary care clinic exempt from licensure pursuant to subdivision (c) of Section 1206 of the Health and Safety Code.
(C) A clinic owned or operated by a public hospital or health system.
(D) A clinic owned and operated by a hospital that maintains the primary contract with a county government to fill the county’s role under Section 17000 of the Welfare and Institutions Code.
(b) (1) Except as specified in paragraph (2), members of the dental hygiene board shall be appointed for a term of four years. Each member shall hold office until the appointment and qualification of the member’s successor or until one year shall have lapsed since the expiration of the term for which the member was appointed, whichever comes first.
(2) For the term commencing on January 1, 2022, the general or public health dentist member and one of the registered dental hygienist members, other than the dental hygiene educator member or the registered dental hygienist member licensed in alternative practice or in extended functions, shall each serve a term of three years, expiring January 1, 2025.
(3) No more than three members’ terms shall expire in any given calendar year.
(c) Notwithstanding any other provision of law and subject to subdivision (e), the Governor may appoint to the dental hygiene board a person who previously served as a member of the former committee or hygiene board even if the person’s previous term expired.
(d) The dental hygiene board shall elect a president, a vice president, and a secretary from its membership.
(e) No person shall serve as a member of the dental hygiene board for more than two consecutive terms.
(f) A vacancy in the dental hygiene board shall be filled by appointment to the unexpired term. Notwithstanding subdivision (e), a member who is appointed to fill an unexpired term shall be eligible to serve two complete consecutive terms.
(g) Each member of the dental hygiene board shall receive a per diem and expenses as provided in Section 103.
(h) The Governor shall have the power to remove any member from the dental hygiene board for neglect of a duty required by law, for incompetence, or for unprofessional or dishonorable conduct.
(i) The dental hygiene board, with the approval of the director, may appoint a person exempt from civil service who shall be designated as an executive officer and who shall exercise the powers and perform the duties delegated by the dental hygiene board and vested in the executive officer by this article.
(j) This section shall remain in effect only until January 1, 2023, and as of that date is repealed.

SEC. 3.

 Section 1917.1 of the Business and Professions Code is amended to read:

1917.1.
 (a) The dental hygiene board may grant a license as a registered dental hygienist to an applicant who has not taken a clinical examination before the dental hygiene board, if the applicant submits all of the following to the dental hygiene board:
(1) A completed application form and all fees required by the dental hygiene board.
(2) Proof of a current license as a registered dental hygienist issued by another state that is not revoked, suspended, or otherwise restricted.
(3) Proof that the applicant has been in clinical practice as a registered dental hygienist or has been a full-time faculty member in an accredited dental hygiene education program for a minimum of 750 hours per year for at least five years immediately preceding the date of application under this section. The clinical practice requirement shall be deemed met if the applicant provides proof of at least three years of clinical practice and commits to completing the remaining two years of clinical practice by filing with the dental hygiene board a copy of a pending contract to practice dental hygiene in any of the following facilities:
(A) A primary care clinic licensed under subdivision (a) of Section 1204 of the Health and Safety Code.
(B) A primary care clinic exempt from licensure pursuant to subdivision (c) of Section 1206 of the Health and Safety Code.
(C) A clinic owned or operated by a public hospital or health system.
(D) A clinic owned and operated by a hospital that maintains the primary contract with a county government to fill the county’s role under Section 17000 of the Welfare and Institutions Code.
(4) Satisfactory performance on a California law and ethics examination and any examination that may be required by the dental hygiene board.
(5) Proof that the applicant has not been subject to disciplinary action by any state in which the applicant is or has been previously issued any professional or vocational license. If the applicant has been subject to disciplinary action, the dental hygiene board shall review that action to determine if it warrants refusal to issue a license to the applicant.
(6) Proof of graduation from a school of dental hygiene accredited by the Commission on Dental Accreditation.
(7) Proof of satisfactory completion of the National Board Dental Hygiene Examination and of a state clinical examination, regional clinical licensure examination, or any other clinical dental hygiene examination approved by the dental hygiene board.
(8) Proof that the applicant has not failed the state clinical examination, the examination given by the Western Regional Examining Board, or any other clinical dental hygiene examination approved by the dental hygiene board for licensure to practice dental hygiene under this chapter more than once or once within five years prior to the date of application for a license under this section.
(9) Documentation of completion of a minimum of 25 units of continuing education earned in the two years preceding application, including completion of any continuing education requirements imposed by the dental hygiene board on registered dental hygienists licensed in this state at the time of application.
(10) Satisfactory evidence of having successfully completed a course or education and training in local anesthesia, nitrous oxide-oxygen analgesia, and periodontal soft-tissue curettage approved by the dental hygiene board.
(11) Any other information as specified by the dental hygiene board to the extent that it is required of applicants for licensure by examination under this article.
(b) The dental hygiene board may periodically request verification of compliance with the requirements of paragraph (3) of subdivision (a) and may revoke the license upon a finding that the employment requirement or any other requirement of paragraph (3) of subdivision (a) has not been met.
(c) The dental hygiene board shall provide in the application packet to each out-of-state dental hygienist pursuant to this section the following information:
(1) The location of dental manpower shortage areas in the state.
(2) Any nonprofit clinics, public hospitals, and accredited dental hygiene education programs seeking to contract with licensees for dental hygiene service delivery or training purposes.

SEC. 4.

 Section 1926.1 of the Business and Professions Code is amended to read:

1926.1.
 (a) Notwithstanding any other provision of law, a registered dental hygienist in alternative practice may operate a mobile dental hygiene clinic in the settings listed in Section 1926.
(b) The registered dental hygienist in alternative practice shall register the mobile dental hygiene clinic with the dental hygiene board in compliance with Sections 1926.2 and 1926.3.
(c) The dental hygiene board may conduct announced and unannounced reviews and inspections of a mobile dental hygiene clinic to ensure continued compliance with the requirements for continued approval under this article.
(d) It shall constitute unprofessional conduct if the mobile dental hygiene clinic is found to be noncompliant with any requirements necessary for licensure, and the registered dental hygienist in alternative practice may be placed on probation with terms, issued a citation and fine, or have the mobile dental hygiene clinic registration withdrawn if compliance is not demonstrated within reasonable timelines, as established by the dental hygiene board.
(e) The dental hygiene board, by itself or through an authorized representative, may issue a citation containing fines and orders of abatement to the registered dental hygienist in alternative practice for any violation of this section, Section 1926.2, Section 1926.3, or any regulations adopted thereunder. Any fine collected pursuant to this section shall be deposited into the State Dental Hygiene Fund established pursuant to Section 1944.

SEC. 5.

 Section 1926.3 of the Business and Professions Code is amended to read:

1926.3.
 (a) Every person who is now or hereafter licensed as a registered dental hygienist in alternative practice in this state shall register with the executive officer, on forms prescribed by the dental hygiene board, the physical facility of registered dental hygienist in alternative practice or, if the registered dental hygienist in alternative practice has more than one physical facility pursuant to Section 1926.4, all of the physical facilities. If the registered dental hygienist in alternative practice does not have a physical facility, the registered dental hygienist in alternative practice shall notify the executive officer. A person licensed by the dental hygiene board shall register with the executive officer within 30 days after the date of the issuance of the person’s license as a registered dental hygienist in alternative practice.
(b) (1) A registered dental hygienist in alternative practice who utilizes portable equipment to practice dental hygiene shall register with the executive officer, on forms prescribed by the dental hygiene board, the registered dental hygienist in alternative practice’s physical facility where the portable equipment is maintained.
(2) The dental hygiene board may conduct announced and unannounced reviews and inspections of a registered dental hygienist in alternative practice’s physical facilities and equipment described in paragraph (1) to ensure continued compliance with the requirements for continued approval under this article.
(c) It shall constitute unprofessional conduct if the registered dental hygienist in alternative practice’s physical facility or equipment is found to be noncompliant with any requirements necessary for licensure and a registered dental hygienist in alternative practice may be placed on probation with terms, issued a citation and fine, or have the owned physical facility registration withdrawn if compliance is not demonstrated within reasonable timelines, as established by the dental hygiene board.
(d) The dental hygiene board, by itself or through an authorized representative, may issue a citation containing fines and orders of abatement to the registered dental hygienist in alternative practice for any violation of this section, Section 1925, Section 1926.4, or any regulations adopted thereunder. Any fine collected pursuant to this section shall be deposited into the State Dental Hygiene Fund established pursuant to Section 1944.

SEC. 6.

 Section 1941 of the Business and Professions Code is amended to read:

1941.
 (a) The dental hygiene board shall grant or renew approval of only those educational programs for RDHs that continuously maintain a high-quality standard of instruction and, where appropriate, meet the minimum standards set by the Commission on Dental Accreditation of the American Dental Association or an equivalent body, as determined by the dental hygiene board.
(b) A new or existing educational program for RDHs shall submit a feasibility study demonstrating a need for a new or existing educational program and shall apply for approval from the dental hygiene board before seeking any required approval for initial accreditation from the Commission on Dental Accreditation of the American Dental Association or an equivalent body, as determined by the dental hygiene board. The dental hygiene board may approve, provisionally approve, or deny approval of a new educational program for RDHs.
(c) For purposes of this section, a new or existing educational program for RDHs means a program provided by a college or institution of higher education that is accredited by a regional accrediting agency recognized by the United States Department of Education and that has as its primary purpose providing college level courses leading to an associate or higher degree, that is either affiliated with or conducted by a dental school approved by the dental board, or that is accredited to offer college level or college parallel programs by the Commission on Dental Accreditation of the American Dental Association or an equivalent body, as determined by the dental hygiene board.
(d) For purposes of this section, “RDHs” means registered dental hygienists, registered dental hygienists in alternative practice, or registered dental hygienists in extended functions.

SEC. 7.

 Section 1950.5 of the Business and Professions Code is amended to read:

1950.5.
 Unprofessional conduct by a person licensed under this article is defined as, but is not limited to, any one of the following:
(a) The obtaining of any fee by fraud or misrepresentation.
(b) The aiding or abetting of any unlicensed person to practice dentistry or dental hygiene.
(c) The aiding or abetting of a licensed person to practice dentistry or dental hygiene unlawfully.
(d) The committing of any act or acts of sexual abuse, misconduct, or relations with a patient that are substantially related to the practice of dental hygiene.
(e) The use of any false, assumed, or fictitious name, either as an individual, firm, corporation, or otherwise, or any name other than the name under which the person is licensed to practice, in advertising or in any other manner indicating that the person is practicing or will practice dentistry, except the name specified in a valid permit issued pursuant to Section 1962.
(f) The practice of accepting or receiving any commission or the rebating in any form or manner of fees for professional services, radiographs, prescriptions, or other services or articles supplied to patients.
(g) The making use by the licensee or any agent of the licensee of any advertising statements of a character tending to deceive or mislead the public.
(h) The advertising of either professional superiority or the advertising of performance of professional services in a superior manner. This subdivision shall not prohibit advertising permitted by subdivision (h) of Section 651.
(i) The employing or the making use of solicitors.
(j) Advertising in violation of Section 651.
(k) Advertising to guarantee any dental hygiene service, or to perform any dental hygiene procedure painlessly. This subdivision shall not prohibit advertising permitted by Section 651.
(l) The violation of any of the provisions of this division.
(m) The permitting of any person to operate dental radiographic equipment who has not met the requirements to do so, as determined by the dental hygiene board.
(n) The clearly excessive administering of drugs or treatment, or the clearly excessive use of treatment procedures, or the clearly excessive use of treatment facilities, as determined by the customary practice and standards of the dental hygiene profession.
Any person who violates this subdivision is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) or more than six hundred dollars ($600), or by imprisonment for a term of not less than 60 days or more than 180 days, or by both a fine and imprisonment.
(o) The use of threats or harassment against any patient or licensee for providing evidence in any possible or actual disciplinary action, or other legal action; or the discharge of an employee primarily based on the employee’s attempt to comply with the provisions of this chapter or to aid in the compliance.
(p) Suspension or revocation of a license issued, or discipline imposed, by another state or territory on grounds that would be the basis of discipline in this state.
(q) The alteration of a patient’s record with intent to deceive.
(r) Unsanitary or unsafe office conditions, as determined by the customary practice and standards of the dental hygiene profession.
(s) The abandonment of the patient by the licensee, without written notice to the patient that treatment is to be discontinued and before the patient has ample opportunity to secure the services of another registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions and provided the health of the patient is not jeopardized.
(t) The willful misrepresentation of facts relating to a disciplinary action to the patients of a disciplined licensee.
(u) Use of fraud in the procurement of any license issued pursuant to this article.
(v) Any action or conduct that would have warranted the denial of the license.
(w) The aiding or abetting of a registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions to practice dental hygiene in a negligent or incompetent manner.
(x) The failure to report to the dental hygiene board in writing within seven days any of the following: (1) the death of the licensee’s patient during the performance of any dental hygiene procedure; (2) the discovery of the death of a patient whose death is related to a dental hygiene procedure performed by the licensee; or (3) except for a scheduled hospitalization, the removal to a hospital or emergency center for medical treatment for a period exceeding 24 hours of any patient as a result of dental or dental hygiene treatment. Upon receipt of a report pursuant to this subdivision, the dental hygiene board may conduct an inspection of the dental hygiene practice office if the dental hygiene board finds that it is necessary.
(y) A registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions shall report to the dental hygiene board all deaths occurring in their practice with a copy sent to the dental board if the death occurred while working as an employee in a dental office. A dentist shall report to the dental board all deaths occurring in their practice with a copy sent to the dental hygiene board if the death was the result of treatment by a registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions.
(z) Knowingly making a statement or signing a certificate or other document that falsely represents the existence or nonexistence of a fact directly or indirectly related to the practice of dental hygiene.

SEC. 8.

 Section 1951 of the Business and Professions Code is amended to read:

1951.
 The dental hygiene board may discipline a licensee by placing the licensee on probation under various terms and conditions that may include, but are not limited to, the following:
(a) Requiring the licensee to obtain additional training in a remedial education course approved by the dental hygiene board or pass an examination upon completion of training in a remedial education course approved by the dental hygiene board, or both. The examination may be a written or oral examination, or both, and may be a practical or clinical examination, or both, at the option of the dental hygiene board.
(b) Requiring the licensee to submit to a complete diagnostic examination by one or more physicians appointed by the dental hygiene board, if warranted by the physical or mental condition of the licensee. If the dental hygiene board requires the licensee to submit to an examination, the dental hygiene board shall receive and consider any other report of a complete diagnostic examination given by one or more physicians of the licensee’s choice.
(c) Restricting or limiting the extent, scope, or type of practice of the licensee.
(d) Requiring restitution of fees to the licensee’s patients or payers of services, unless restitution has already been made.
(e) Providing the option of alternative community service in lieu of all or part of a period of suspension in cases other than violations relating to quality of care.