MINUTES OF THE ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES Sixty-eighth Session June 14, 1995 The Committee on Health and Human Services was called to order at 2:10 p.m., on Wednesday, June 14, 1995, Chairman Vivian Freeman presiding in Room 330 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. COMMITTEE MEMBERS PRESENT: Mrs. Vivian L. Freeman, Chairman Mrs. Jan Monaghan, Chairman Mrs. Jan Evans, Vice Chairman Dr. William Z. (Bill) Harrington, Vice Chairman Mrs. Deanna Braunlin Ms. Barbara E. Buckley Mr. David Goldwater Ms. Saundra (Sandi) Krenzer Mr. Dennis Nolan Ms. Dianne Steel Ms. Patricia A. Tripple Mr. Wendell P. Williams GUEST LEGISLATORS PRESENT: Ms. Chris Giunchigliani Senator Dina Titus STAFF MEMBERS PRESENT: H. Pepper Sturm, Chief Principal Research Analyst OTHERS PRESENT: Rick Panelli, Health Division, Bureau of Licensure and Certification Shelley Berkley, Vice President, Sands Hotel Casino Edward Barnard, Nevada Physical Therapy Association Larry Matheis, Nevada State Medical Association Bill Welch, Nevada Rural Hospital Project Robert Barengo, Sunrise Hospital Medical Center Fred Hillerby, Assoc. Pathology Labs and Washoe Medical Center Mary Jo Greenlee, Clark County Economic Opportunity Board John Vergiels, Nevada Physical Therapy Association ASSEMBLY BILL 634 - Revises provisions governing procedure for involuntary court-ordered admission of persons into mental health facilities. Chairman Freeman directed committee members' attention to proposed amendments to A.B. 634, (Exhibit C). Assemblywoman Chris Giunchigliani, representing Assembly District Nine, explained her most recent amendment would require hearings within seven days as of October 1, 1995. Hearings within three days would be phased in and become effective January 1, 1997 but sunset as of July 1, 1997. The amendment would also require a report on court impacts, costs and other expenses or problems so the legislature would have a "window period" to see how three day hearings were working out. ASSEMBLYWOMAN JAN MONAGHAN MOVED TO AMEND AND DO PASS A.B. 634. ASSEMBLYWOMAN BARBARA BUCKLEY SECONDED THE MOTION. Ms. Buckley expressed approval for A.B. 634 stating it is a very good bill and that people's liberty and constitutional rights must be protected by ensuring a court hearing. She added the bill recognizes the realities of the situation and should be passed. Assemblyman Harrington agreed A.B. 634 is a good bill. He stated before people are restrained against their will for any longer than what is reasonable they must be allowed judicial intervention. He pointed out adequate financing must be provided so judges would be able to go out to mental health facilities to conduct hearings. Assemblywoman Evans inquired whether the amendment satisfied the mental health facilities' problems with the courts. Ms. Giunchigliani testified the courts had said they would accept a seven day hearing schedule and that is what her amendment would do. She also explained phasing in the three day hearing schedule gave the courts ample time to prepare for any impact the increase in costs might have. Dr. Harrington disclosed he is a physician, sees mental patients as they come into the hospital and refers them to both public and private entities. A.B. 634 will not effect him any differently than any other provider, therefore he will be voting on the bill. THE MOTION CARRIED. ********* SENATE BILL 477 - Exempts convention halls from requirement of providing sufficient number of water closets and urinals to comply with Uniform Plumbing Code. Shelley Berkley, Vice President of Government Affairs for the Sands Hotel Casino, explained S.B. 477 had nothing to do with "potty parity". The intent of the legislation is to develop a way to provide enough toilet facilities for the convention center users while creating a standard that is sensible and not overly burdensome. She stated the genesis of S.B. 477 came after the Sands Expo Center built its original facility in compliance with the Uniform Plumbing Code. Once the facility was opened, it became apparent that many toilets were never used by the public. When the Sands began plans for phase two of its Expo Center they were informed by the Clark County building department that even though they could demonstrate that the toilet facilities were underutilized, they were bound by state law to comply with the Uniform Plumbing Code. Ms. Berkley provided committee members with a definition of a "convention hall", (Exhibit D). She stated convention centers are different from sports arenas in that there are no innings or halftimes during which people would be rushing to use the toilet facilities. A toilet use study the Sands conducted at its Expo Center during the course of several conventions, indicated the Sands has excess capacity based on peak hour use, (Exhibit E). Ms. Berkley's suggestion to the committee was the number of toilets in a convention center exhibit hall shall be no more than 70 percent of the number required by the Uniform Plumbing Code. That standard, coupled with the limiting definition of a convention center, would provide protection for the users and flexibility for the convention centers. Ms. Berkley testified she had spoken with the Las Vegas Convention Center and they authorized her to state they agree with her position on this issue. She mentioned how expensive it is to install toilet facilities and the fact that those costs are passed on to the consumer. Mrs. Freeman inquired whether Ms. Berkley had seen the letter from Clark County dated June 14, 1995 opposing S.B. 477, (Exhibit F). Ms. Berkley stated she had not seen that letter. Assemblyman Nolan commented the Uniform Plumbing Code is based upon 100 percent capacity of the facility and even though the Sands Expo is very innovative in providing excess capacity, other facilities might not be as innovative. Assemblywoman Monaghan stated she wanted to speak with Ronald Taylor, author of the letter from the Clark County building department. She inquired whether "convention center" was defined anywhere in the Nevada Revised Statutes (NRS). Ms. Berkley replied it was not and that was why she had provided the standard industry definition from the International Association of Auditorium Managers. Mrs. Monaghan agreed the definition should be included in NRS. Senator Dina Titus, Senate District Seven, emphasized after working so hard last session getting the original "potty parity" bill through, she would not support anything that would upset the carefully established ratio that gave women more restrooms than men because they need more time. Mrs. Freeman, noting Mrs. Monaghan wanted to check with Clark County, closed the hearing on S.B. 477. ********* SENATE BILL 363 - Exempts certain facilities for care of adults from payment of fees related to licensure. Senator Titus explained S.B. 363 was a simple bill that had no opposition when heard in the Senate. She stated most adult day care centers operate on a "shoe string" and if they must pay fees for the individual people who stay there, most would be put out of business. Ms. Titus indicated there would be no lessening of oversight or regulations because those facilities are already certified and regulated by Medicare and the federal and county governments. Mrs. Freeman mentioned the fiscal note reads $6,300 but noted earlier testimony indicated a cost closer to $20,000. Rick Panelli with the Bureau of Licensure and Certification, testified the fiscal note of $6,300 was correct and presented testimony in support of S.B. 363, (Exhibit G). He maintained oversight provided by the Division of Aging and the Welfare Division is very similar to that provided by the Bureau of Licensure with the exception that the bureau is only mandated to do an annual inspection whereas the other agencies must inspect weekly, monthly or quarterly. As a result, Mr. Panelli recommended an amendment to S.B. 363 which would entirely delete NRS 449.045 and the applicable provision of Nevada Administrative Code with respect to additional licensure of facility. Ms. Steel expressed concern about growth and whether exempting licensure fees while still issuing licenses might eventually become much more expensive. Mr. Panelli explained it took 60 staff hours to license one large facility in Las Vegas. Mary Jo Greenlee, Economic Opportunity Board of Clark County (EOB), presented her testimony in support of S.B. 363, (Exhibit H). She mentioned the costs for licensure of the two adult day care centers EOB operates runs around $6,000 per year. She noted last year the deficit for operating those two facilities was around $40,000. Ms. Greenlee pointed out adult day care was not profitable yet was a wonderful alternative to nursing home placement and saves the state many dollars. Ms. Greenlee also expressed support for the Bureau of Licensure's proposed amendment. She stated adult day care centers are monitored by all their funding sources, which she felt to be more than adequate. Assemblyman Williams mentioned the Division of Aging Services is monitoring adult day care centers and their oversight is basically a duplication of what the licensure would be. As a result he is in full support of S.B. 363. ASSEMBLYWOMAN JAN MONAGHAN MOVED DO PASS S.B. 363. ASSEMBLYWOMAN JAN EVANS SECONDED THE MOTION. THE MOTION CARRIED. ********* ASSEMBLY BILL 709 - Specifies persons who may obtain results of laboratory tests regarding patients of rural hospitals. Bill Welch, Executive Director of the Nevada Rural Hospital Project, testified on behalf of A.B. 709 which had been requested by his organization. He handed out copies of his testimony with the proposed amendments to the bill and several letters of support from a number of Nevada's rural hospitals, (Exhibit I). Fred Hillerby, representing Associated Pathology Laboratories and Washoe Medical Center, stated he was in support of A.B. 709 however, in addition to the amendments proposed by Mr. Welch, he recommended additional amendments, (Exhibit J). The first part of the amendment relates to section 7 which requires that a health care provider give medical records to the patient because they belong to the patient. He noted laboratory statutes conflict because they do not allow records to be given to the patient. Mr. Hillerby explained the second part of the amendment addressed a new issue that had arisen involving a number of laboratory tests that can now be done by the patient with equipment approved by the Federal Drug Administration. Because of this new equipment, hospital nursing staff think better patient care is rendered if those kinds of tests can be done at bedside, but current laboratory statutes read that only certified medical technologists or technicians can perform those tests, not nurses. As a result, Mr. Hillerby, with assistance from Rick Panelli of the State Health Department, also recommended amending NRS 652 to allow a licensed professional nurse to perform bedside testing. Mrs. Monaghan agreed with the first part of Mr. Hillerby's amendment, however she wanted to investigate the second part because she was concerned it might be a scope of practice change. Mrs. Monaghan commented scope of practice changes are handled by a different Assembly committee. Mr. Welch stated the rural hospitals were not in opposition to Mr. Hillerby's amendments. He also indicated the state board of nursing believes nurses are already certified to perform bedside laboratory procedures. Mrs. Freeman pointed out the board of nursing had just spent several months reviewing their nurse practice act and both she and Mrs. Monaghan were not comfortable about the expansion of scope of practice at this time. She then closed the hearing on A.B. 709. ********* ASSEMBLY BILL 659 - Establishes procedures pursuant to which person may choose not to be resuscitated in event of cardiac or respiratory arrest. Mrs. Freeman directed committee members' attention to amendments proposed for A.B. 659 which were listed on page 3 of the work session document, (Exhibit K). Mr. Nolan also offered amendments to A.B. 659 and explained those to committee members, (Exhibit L). Dr. Harrington stated his preference for the first set of proposed amendments. ASSEMBLYMAN WILLIAM Z. HARRINGTON MOVED TO AMEND AND DO PASS A.B. 659. THE AMENDMENTS WERE TO BE THE FIRST SET OF PROPOSED AMENDMENTS. ASSEMBLYWOMAN JAN MONAGHAN SECONDED THE MOTION. THE MOTION CARRIED. ********* SENATE BILL 362 - Expands circumstances under which practitioner may refer patient to health care facility in which he has financial interest. Mrs. Braunlin disclosed she is married to a physician and would not be voting on S.B. 362. Senator Titus explained S.B. 362 would allow a physician to refer patients to some other facility he has a monetary interest in for other kinds of medical services. The bill would rectify language problems from past legislation which arose over the definition of "group practice" which was interpreted to mean the practice had to be in one location. Ms. Titus explained it turned out to be unenforceable and also had unintended results. She said a physician whose main office was in town was barred from referring his own patients to or from any satellite office he might have. Dr. Harrington disclosed he is a physician and would not be voting on S.B. 362 or taking part in any discussion. Ms. Krenzer disclosed she works for Sierra Health Services however she would be voting on S.B. 362. Larry Matheis, representing the Nevada State Medical Association (NSMA), testified S.B. 362 will just clean up an unenforceable law passed in the closing hours of the last session of the Legislature. Mr. Matheis stated the medical association supported defining limits on referrals to facilities and services in which physicians and other practitioners had investments. The changes in S.B. 362 are meant to implement the intention in last session's bill which was to allow referrals to arms- length investments that did not have a direct bearing on the referring physician's practice. Mr. Matheis, referring to page 1, lines 21 through 25 and lines 1 and 2 on page 2 of S.B. 362, stated there are pieces of equipment certain specialists need as part of their practice such as ultrasound equipment for obstetricians/gynecologists and treadmills for cardiologists. S.B. 362 would clarify that the practitioner who is actually performing or supervising the use of the equipment, or a group practice that was utilizing the equipment, was not an extraneous or outside service. Ms. Buckley queried the interpretation of lines 1 and 2 on page 2 and whether lab tests and x-rays would be within a doctor's scope of practice. Mr. Matheis agreed x-rays certainly could be, but thought the intent was for more sophisticated equipment such as ultrasound which is now fairly widely used. The limitations within the bill are that the equipment must be within a group practice site, must be personally operated or supervised by the practitioner or member of the group and that it be linked to the physician's specialty. Ms. Buckley still disputed Mr. Matheis' interpretation and hypothesized S.B. 362 could be read as saying that "subsection 1 would not apply if a practitioner, in practice with another physician in a facility providing primary care, if those two physicians owned another facility, for instance a lab, then as long as those two individuals supervised the other operation and as long as the other operation is within an area of medical competence, I would argue, if I was the physicians' attorney, that I am covered in that exemption and that, in fact, guts the original bill." Mr. Matheis reiterated that is not the NSMA's interpretation. For instance laboratory services in a free-standing laboratory physicians have invested in, are clearly covered under section 1. Mrs. Freeman indicated no action on S.B. 362 would be taken by the committee today and suggested Mrs. Monaghan and she work with the interested parties and make a recommendation Monday. Edward Barnard, President of the Nevada Physical Therapy Association (NPTA), spoke against S.B. 362 from a prepared text, (Exhibit M). He testified the physical therapy association of Nevada is very interested in the problems of self-referral abuse and supports clarification of last session's law, so the law will be implemented as intended. John Vergiels, representing the physical therapists, stated the NPTA had requested a legal interpretation by a deputy attorney general for some of the definitions of terms in S.B. 362. Robert Barengo, representing Sunrise Hospital Medical Center, stated his support for S.B. 362. He commented if the bill needed technical corrections he would be happy to work to facilitate those. He emphasized passage of S.B. 362 is necessary because there has been no enforcement of the provisions of the last session's bill. Mrs. Evans, noting there is little time left in the session, inquired when the committee could expect answers to their concerns. Mr. Barengo, assuming Ms. Buckley's concerns to be the issue, stated he would be happy to work with her and the two chairwomen to address that issue. ********* ASSEMBLY BILL 605 - Provides that certain persons arrested must be tested for sexually transmitted disease. Dr. Harrington explained the subcommittee report on A.B. 605, (Exhibit N). Mrs. Evans stated as a member of the subcommittee she had voted for the changes outlined by Dr. Harrington. However her vote was conditional, pending additional word from the HIV/AIDS Coalition. Mrs. Evans pointed out a fax had been received which still indicates some concerns with A.B. 605, (Exhibit O). Ms. Buckley stated she had mixed feelings about the matter because she knows the people from Parole and Probation did try to work out the differences even if it was apparently not successful. She believed all parties should work together to be certain the health and safety of the public is protected. However, she did not want a bill to refocus the health department's time and cost it money without supplying sufficient financial resources. Dr. Harrington commented he would like to see money allocated to fund the program however, he noted that was probably impossible at this late date. Referring to other concerns in the letter from the coalition, he stated there would always be disagreement between those who think they may have been exposed and those who were the exposers. The exposers do not want to be tested and want absolute and complete confidentiality and Dr. Harrington expressed his opinion that those two groups would never be in agreement. He stated the committee must make a choice and he felt those serving the community had a reasonable right and expectation to try and protect themselves from potentially deadly diseases. He emphasized A.B. 605 reaches an acceptable balance. ASSEMBLYMAN WILLIAM Z. HARRINGTON MOVED TO AMEND AND DO PASS A.B. 605. ASSEMBLYWOMAN JAN EVANS SECONDED THE MOTION. THE MOTION FAILED. (ASSEMBLYMEN GOLDWATER, BRAUNLIN AND BUCKLEY VOTED NO. ASSEMBLYMEN WILLIAMS, MONAGHAN AND KRENZER WERE NOT PRESENT AT THE TIME OF THE VOTE.) There being no further business, the meeting was adjourned at 4:00 p.m. RESPECTFULLY SUBMITTED: Terry Horgan, Committee Secretary APPROVED BY: Assemblywoman Vivian L. Freeman, Chairman Assemblywoman Jan Monaghan, Chairman Assembly Committee on Health and Human Services June 14, 1995 Page