MINUTES OF THE JOINT SUBCOMMITTEE MEETING OF SENATE COMMITTEE ON FINANCE AND ASSEMBLY COMMITTEE ON WAYS AND MEANS Sixty-eighth Session May 9, 1995 The joint subcommittee meeting on Human Resources/K-12 of the Senate Committee on Finance and the Assembly Committee on Ways and Means was called to order by Chairman Raymond D. Rawson, at 8:00 a.m., on Tuesday, May 9, 1995, in Room 352 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. SENATE COMMITTEE MEMBERS PRESENT: Senator Raymond D. Rawson, Chairman Senator William J. Raggio Senator Bob Coffin Senator Dean A. Rhoads ASSEMBLY COMMITTEE MEMBERS PRESENT: Mrs. Jan Evans, Chairman Mr. Lynn Hettrick, Chairman Mr. Dennis L. Allard Mrs. Vonne Chowning Mr. Joseph E. Dini, Jr. Ms. Sandra Tiffany STAFF MEMBERS PRESENT: Mark Stevens, Fiscal Analyst Bob Guernsey, Principal Deputy Fiscal Analyst Marion Entrekin, Committee Secretary OTHERS PRESENT: Carlos Brandenburg, Ph.D., Acting Administrator, Mental Hygiene and Mental Retardation Division Nevada Mental Health Institute - Page 1039 Carlos Brandenburg, Ph.D., Acting Administrator, Mental Hygiene and Mental Retardation Division (MH/MR) distributed Exhibit C, a memorandum dated May 8, 1995, from the division regarding a certification completed by the (Federal) Health Care Financing Administration (HCFA) at the Nevada Mental Health Institute during the last week of April, 1995. Dr. Brandenburg said on April 27, 1995, an exit conference was held and the HCFA survey team indicated there were multiple standards the facility failed to meet. HCFA advised the division a written report defining numerous deficiencies found in the facility would be issued, and the facility would have 90 days from the date of the written notice to bring the defined areas into compliance. The failures were primarily related to an inadequate staffing level in the institute, and inadequate documentation of client records. Dr. Brandenburg stated the division's failure to submit a written plan for correction within the 90-day period will result in a loss to the institute and the mental health delivery system, and will result in a monetary loss within the department of approximately $1.4 million in Medicare and Medicaid revenue. Senator Rawson opined to bring the program back to an acceptable operating level will cost the state in excess of $1.4 million. Dr. Brandenburg stated he has met with the acting medical director for the institute, other department heads, and line staff to review the issues. He said HCFA detected a lack of documentation, leadership, and inconsistent psychiatric treatment. Dr. Brandenburg indicated HCFA was armed with specific complaints they had received prior to the survey regarding the quality of patient care, and consequently looked specifically at the institute's treatment plans and documentation process. Dr. Brandenburg indicated the staff at the institute feels confused, demoralized, and distressed about the changes that have occurred. One of the main issues precipitating much of their concern is the lack of a medical director, and that "the institute's study was driven toward a private psychiatric facility." Once the staff was informed the division is committed to public mental health, and wants to do everything possible to make the institute a viable psychiatric hospital, many of the staff's fears were abated, Dr. Brandenburg said. Dr. Brandenburg continued his testimony by highlighting the information contained in Exhibit C concerning additional positions requested by the division. Senator Rawson stated during his legislative tenure commencing in 1985, there has been concern the state will lose certification in some facility connected with the MH/MR Division, resulting in the loss of revenue to the state. He stated he would like to see this stop. He asked Dr. Brandenburg to concentrate on raising the division's overall standards for mental hygiene to avoid the loss of certification by HCFA. Senator Raggio echoed Senator Rawson's remark. He also expressed his disbelief that institute records were not properly documented, or that documentation was not considered to be an obvious necessity. He stated the committee needs assurance the problem of inadequate documentation will be addressed by the division's proposal for additional positions. Dr. Brandenburg replied: The suggestion of the positions will address the documentation for a specific discipline...the social workers. The other disciplines have been placed on administrative notice. We have done some internal changes at the institute that will make certain we have the ongoing documentation. There was a helplessness feeling at the institute where people stopped caring about what was going on because they did not know what to expect in their own lives. They felt they might be without a job. There was a lack of ownership as part of a team. Each department was like a kingdom within themselves, with very little interaction or communication with other departments. There were morale problems that we have subsequently addressed with department heads and staff. Senator Rawson stated since 1990 the division has lost approximately 200 positions through budget cuts and reorganization. He asked if the work load has decreased since 1990. Dr. Brandenburg replied he does not have the figures readily available, but he believes the outpatient work load is heavier at the present time. The inpatient work load census has gradually and consistently increased since 1990, Dr. Brandenburg stated. Senator Raggio referred to Exhibit C and asked how the ratio of admissions and discharges per social worker will be altered by filling the (two) Psychiatric Social Worker II positions. The ratios are 865 admissions, 216 per social worker; and 875 discharges, 219 per social worker. He pointed out at the facility in southern Nevada, the admissions are currently 629, 90 per social worker, and the discharges are 645, 92 per social worker. Dr. Brandenburg stated the additional positions will change the number of admissions per social worker from 216 to 144, and the number of discharges per social worker from 219 to 146. Senator Raggio asked if there is an indication the HCFA survey team will be satisfied with the decreased number of admissions and discharges per social worker. Dr. Brandenburg stated although he has not received specific assurance from HCFA they will be satisfied with the decrease in the number of admissions and discharges per social worker, one of the issues the HCFA survey team raised was that no discharge documentation was being done for psychiatric-social histories. He opined the additional positions will assure HCFA each social worker will perform adequate documentation. Senator Rawson said by filling three Psychiatric Social Worker II positions, the number of adminissions and discharges to be processed by each social worker will decrease to about 120. He asked if there is adequate space to house a third position. Dr. Brandenburg replied in the affirmative. Mrs. Evans noted in addition to the HCFA certification, the division is also facing an accreditation problem with the Joint Commission on Accreditation of Health Care Organizations (JCHO). She stated the joint subcommittee does not want a short- term commitment to help the division "catch up," but a long-term commitment that will keep the division caught up. Senator Rawson noted the division indicated a reduction in the required vacancy savings, equivalent to approximately one full-time position ($36,000) will further assist the facility in maintaining necessary staffing levels. He asked if the requested intern position will be filled by a social worker. Dr. Brandenburg stated the intern would be a third year clinical psychology intern from the University of Nevada's Clinical Psychology Program to work 20 hours per week, 52 weeks per year, at a salary level of $12,000 per annum. Senator Rawson suggested the division should fill more than one intern position. MRS. EVANS MOVED TO RECOMMEND CLOSING THE BUDGET IN ACCORDANCE WITH STAFF PROPOSALS ON PAGE 2 OF THE BUDGET CLOSING ACTION SHEET (EXHIBIT D) AND TO FILL THREE PSYCHIATRIC SOCIAL WORKER II POSITIONS, ONE MANAGEMENT ASSISTANT II POSITION, TWO CLINICAL PSYCHOLOGY INTERNS, AND INCLUDE A REDUCTION IN THE REQUIRED VACANCY SAVINGS. MR. HETTRICK SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED. (MS. TIFFANY WAS ABSENT FOR THE VOTE.) SENATE: THE MOTION CARRIED UNANIMOUSLY. * * * * * Regarding the aforementioned budget closing, Bob Guernsey, Principal Fiscal Analyst, Fiscal Analysis Division, Legislative Counsel Bureau, emphasized the technical adjustments contained in the Nevada Mental Health Institute budget were reviewed by the joint subcommittee at a previous hearing, and the motion includes the acceptance of the adjustments reflected in Exhibit D. Community Training Center - Page 1081 Mr. Guernsey explained the proposed technical adjustments exhibited on pages 5 and 6 of Exhibit D. He reminded the joint subcommittee the MH/MR Division prepared two possible modifications to adjust payment rates, and the adjustment would include the regular rate as the base resulting in additional costs shown in item 2 (a) on pages 5 of Exhibit D. Item (b) on page 6 of the aforementioned exhibit reflects a second adjustment method based on the use of the pre-work rate on the base resulting in the additional costs shown. Referring to item 3, page 6 ( Exhibit D), Mr. Guernsey indicated the Community Training Centers (CTCs) are concerned about a $83,699 reduction from the base budget that should be added back in to meet waiting list demands. He distributed Exhibit E, a worksheet prepared by MH/MR to add $83,699 back into the base budget. He indicated the division's calculations are very close to those reflected in Exhibit D. Mr. Guernsey called the joint subcommittee's attention to item 5 shown on page 6 of Exhibit D that indicates the CTCs have also requested funding to eliminate any remaining waiting lists. It is anticipated this will cost an additional $102,100 in Fiscal Year 1996, and $105,668 in Fiscal Year 1997. This will provide services for approximately 23 additional clients. Senator Rawson stated: There were changes in the budget this time...people were not prepared for that. We have returned that ending-fund balance...we put it into reducing the waiting list. I think we need to make everyone aware that by adjusting the rates, looking at the pre-work, returning the ending-fund balance...trying to make all of these internal corrections in the way the budget is constructed that next time around there should be no surprises to them. That money will revert to the General Fund, and the budget will be made the way we make all of the other budgets. I want everybody to realize going into it that we will not make these kinds of adjustments again in the budget because we are trying to make it fair and whole now. SENATOR COFFIN MOVED TO RECOMMEND CLOSING THE BUDGET IN ACCORDANCE WITH THE TECHNICAL ADJUSTMENTS RECOMMENDED BY STAFF ON PAGES 5 AND 6 OF EXHIBIT D. MRS. EVANS SECONDED THE MOTION. Senator Rawson asked if the client waiting list at the CTCs will now be eliminated. Mr. Guernsey responded if the joint subcommittee fully approves the division's additional funding request of approximately $100,000 in each year of the biennium, the client waiting list will be addressed, and services will be provided for approximately 23 additional clients. Using the pre-work rate as the adjustment basis rather than the regular rate, Mr. Guernsey testified, will result in a General Fund cost of $193,137 in the first year of the biennium, and approximately $198,000 in the second year of the biennium. Mr. Guernsey said this action would restore $83,699 to the Base Budget, include the adjustments based on the pre-work rate that will address 19 clients that are on a waiting list, and services for an additional 23 clients. If the joint subcommittee wishes to make a change that was suggested in reference to the reversion provision, a bill draft request (BDR) will be required, Mr. Guernsey said. He opined by approving the proposed funding level, the joint subcommittee may want to consider having the remaining funds revert to the General Fund rather than having the funds disbursed to the CTCs. It was Senator Raggio's understanding the motion includes the pre-work rate, and the cost for the 19 clients on a waiting list that will be added back into the base budget. He asked if the motion also includes the technical adjustment to fully eliminate the CTC waiting list as indicated in item 5, page 6, of Exhibit D. Senator Rawson replied in the affirmative. He stated the motion includes all of the technical adjustments proposed by staff on pages 5 and 6 of Exhibit D. Senator Raggio pointed out the motion does not include the aforementioned reversion provision. ASSEMBLY THE MOTION CARRIED. (MS. TIFFANY VOTED NO.) SENATE: THE MOTION CARRIED UNANIMOUSLY. * * * * * Backtracking to the reversion provision, Senator Rawson remarked the budget for the CTCs should be processed the same as all the other (division) budgets. SENATOR COFFIN MOVED TO REQUEST A BDR TO INCLUDE THE REVERSION PROVISION FOR THE CTC BUDGET TO THE STATE GENERAL FUND. MRS. EVANS SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED UNANIMOUSLY. SENATE: THE MOTION CARRIED UNANIMOUSLY. * * * * * Senator Rawson cautioned the joint subcommittee the waiting list can be perceived to be a driver for the CTC budget, and counseled staff regarding the use of a client waiting list as the only budget indicator. He stated growth and inflation factors should also be considered. Senator Coffin remarked the Legislature will adjourn within the next 4 to 6 weeks, but there are still issues at the federal level that are yet to be resolved involving cuts in Medicare/Medicaid. He asked Dr. Brandenburg if, by meeting the HCFA prescribed standards, he anticipates changes in the event Medicaid or federal matching funds are reduced. Senator Coffin also questioned whether the state will be less obligated to meet the federal match if funds are reduced. He remarked: There are standards that have to be met. The humane standards that must be maintained, and the standards set before us by the federal government that we have to meet,... is why we have added to the budget today. Dr. Brandenburg responded if Medicare and Medicaid funding cuts are imposed, he is certain the division will be looking at significant changes in the budget. He plans to work in unison with Charlotte Crawford, the Deputy Director of the Department of Human Resources, who will be in a position to assist the division in an effort to continue to provide quality care should the cuts occur. Senator Rawson said since the budget for the Nevada Mental Health Institute has now been closed, will there continue to be a delay in filling the Medical Director position at the institute. Mr. Guernsey replied the division continues to have full funding for the position. The question the Legislature still must decide is whether one of the Medical Program Coordinator positions should be granted an additional salary allocation to assume statewide responsibility. He pointed out funding for the Medical Program Coordinator positions is included in the institute's budget. The final salary issues for unclassified and medical personnel that are listed specifically in state law must be considered through separate legislation, Mr. Guernsey said, and is the remaining issue that must be addressed. Senator Rawson asked if the division is currently attempting to fill the Medical Director position. Dr. Brandenburg replied the division has interviewed three applicants, and hopes to make a selection by the end of May, 1995. He stated the division is attempting to make the applicants acutely aware of the issues facing the institute and the division. Mrs. Evans remarked due to the budget cuts and resulting problems that have occurred in the last few years within the division, she has had a number of community groups inquire about the possibility of an interim study at the MH/MR Division She stated she has discouraged such a study, but has encouraged the groups to approach the division for informal discussions, and to establish an informal task force to look at MH/MR facilities across the state. There is a need among the advocates and community groups to talk with representatives of the division, and Mrs. Evans has encouraged them to do so. Dr. Brandenburg concurred an interim study during the division's current period of transition would be counterproductive, but the division will welcome informal discussions with advocacy groups within the community to listen to any issues they may wish to discuss concerning mental health and mental retardation. Senator Rawson adjourned the meeting at 9:00 a.m. RESPECTFULLY SUBMITTED: Marion Entrekin, Committee Secretary APPROVED BY: Senator Raymond D. Rawson, Chairman DATE: Assemblywoman Jan Evans, Chairman DATE: Asemblyman Lynn Hettrick, Chairman DATE: Senate Committee on Finance Assembly Committee on Ways and Means Joint Subcommittee on Human Resources/K-12 May 9, 1995