MINUTES OF THE meeting

of the

ASSEMBLY Committee on Health and Human Services

 

Seventy-Second Session

April 2, 2003

 

 

The Committee on Health and Human Serviceswas called to order at 1:07 p.m., on Wednesday, April 2, 2003.  Chairwoman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada, and, via simultaneous videoconference, in Room 4412 of the Grant Sawyer State Office Building, Las Vegas, Nevada.  Exhibit A is the Agenda.  Exhibit B is the Guest List.  All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

 

Note:  These minutes are compiled in the modified verbatim style.  Bracketed material indicates language used to clarify and further describe testimony.  Actions of the Committee are presented in the traditional legislative style.

 

COMMITTEE MEMBERS PRESENT:

 

Mrs. Ellen Koivisto, Chairwoman

Ms. Kathy McClain, Vice Chairwoman

Mrs. Sharron Angle

Mr. Joe Hardy

Mr. William Horne

Ms. Sheila Leslie

Mr. Garn Mabey

Ms. Peggy Pierce

Ms. Valerie Weber

Mr. Wendell P. Williams

 

COMMITTEE MEMBERS ABSENT:

 

None

 

GUEST LEGISLATORS PRESENT:

 

Ms. Barbara Buckley, Assembly District No. 8

Mr. John Carpenter, Assembly District No. 33

Ms. Chris Giunchigliani, Assembly District No. 9

 

STAFF MEMBERS PRESENT:

 

Marla McDade Williams, Committee Policy Analyst

Terry Horgan, Committee Secretary

 

OTHERS PRESENT:

 

Larry Spitler, American Association of Retired Persons (AARP)

Carla Sloan, AARP

Michael Clark, Southwest Ambulance

Larry Fry, Legislative Chair, Coalition of Assisted Residential Environments (CARE)

Wendy Simons, CARE

Margaret McConnell, Chair, Board of Examiners for Administrators of Facilities for Long-Term Care; Administrator/Owner, The Charleston, Retirement & Assisted Living Center

Mary Liveratti, Deputy Director, Department of Human Resources

Terry Clodt, Citizen

Bonnie Parnell, National Alzheimer’s Association

Charles Duarte, Administrator, Division of Health Care Financing and Policy

Shawna Judd, Citizen

Kim Hathcock, Registered Nurse, Geriatric Nurse Practitioner

Jim Brusstar, President, Northern Nevada Alzheimer’s Association

Brandy Gregg, Regional Director, Alzheimer’s Association of Southern Nevada

Linda Branch, Regional Leadership Council, Desert Southwest Region, Alzheimer’s Association

Maryanne Salm, Political Director, SEIU Nurse Alliance

Glenda Canfield, Nursing Policy Director, SEIU Nurse Alliance, California

Jerri Strasser, Registered Nurse

Carin Ralls, Registered Nurse, Operating Engineers Local No. 3

Lila Alabed, Registered Nurse

Lisa Black, Registered Nurse, Executive Director, Nevada Nurses Association

Jim Wadhams, Nevada Hospital Association

Bill Welch, President/CEO Nevada Hospital Association

Don Henderson, Acting Director, Department of Agriculture

Renny Ashleman, representing Nevada Health Care Association

Chairwoman Koivisto:

The Committee on Health and Human Services will come to order, please.  [Roll taken.]  For the information of the audience, we are hearing the bills out of order today.  We are going to start with A.B. 326, and follow that with A.B. 323.  A.B. 313 is the third bill on the agenda today.  If we could have our majority leader, Ms. Buckley, come forward to tell us about Assembly Bill 326.

 

 

Assembly Bill 326:  Provides for licensing and regulation of facilities for assisted living. (BDR 40-954)

 

Assemblywoman Barbara Buckley, Clark County Assembly District No. 8:

Thank you very much, Madam Chair, members of the Committee.  [Introduced herself.]  I am pleased to be the sponsor of Assembly Bill 326.  Last session I sponsored a bill to appropriate $6 million to start a non-profit model assisted living project in Las Vegas.  We have a number of very beautiful assisted living facilities throughout the state and in Las Vegas; unfortunately, not many of them are available and affordable to seniors on fixed incomes.  Many individuals in my district earn anywhere between $600 and $1,100 a month, and some of the newer assisted living facilities in Las Vegas cost $4,000 a month.  We wanted to see what the barriers were to trying to create more non-profit assisted living facilities.

 

The bill did not get funded because there was no money, but sometimes good things happen even when there are obstacles in the way.  During the session, Harrah’s agreed to donate $150,000 toward the project.  The state Housing Division was so impressed they agreed to match that with the Governor’s assistance, and after the session ended, the City of Las Vegas appropriated $1 million in matching funds.  Between last session and this session, Senator Harry Reid, through a special act of Congress, got a bill passed to give Bureau of Land Management land for the project.  So we now have the land, almost $3 million, and have selected a non-profit sponsor who is applying for low-income-housing-tax-credit money to get the rest of the funds available to build the rest of the project, which will be built in Las Vegas.  We hope the groundbreaking will be next year.

 

It has been a real educational process for me.  We put together a little advisory committee and looked at all the barriers that there are to creating affordable assisted living.  Assembly Bill 326 is an outgrowth of that work.  One of the issues that was brought up to me through this advisory committee was that there was no definition of “assisted living” in our statutes.  One of the reasons this is important, [as] I was educated by Carla Sloan of AARP [American Association of Retired Persons] and other senior advocates, is that consumers, seniors, should know what their choices are.  Sometimes by using monikers indiscriminately a great deal of services that are to be provided [can be described but not] very well. 

 

[Ms. Buckley, continued]  Assembly Bill 326 attempts to add some definition to our statute.  I have an amendment (Exhibit C) which I am going to ask the secretary to distribute to you.  I worked on the bill with AARP and their model national legislation, as well as [with] the State Division of Aging, Bureau of Licensure and Certification, Medicaid, and Health care Financing.  Finally, we had Mike Willden get all the agencies into one room so we could get one position.  They worked very hard on the bill even though some members of industry had some concerns about the definition.  They did a great job and that is what is in this amended version [of A.B. 326].  I do not think there is any opposition, and I believe it is a good consensus approach by some folks who have been involved in the industry and do a superb job at helping our seniors.

 

The guts of the bill is on the third page of the amendment, and it basically says “residential facilities for groups, which provide assisted living services based upon the following principles,” and it sets forth the principles that go with assisted living:  A residential environment that supports and promotes quality of life, privacy, dignity, choice, and independence; that offers individualized supportive services and resident-centered services with an emphasis on the needs [of the individual]; and supports a resident’s decision-making process.  These are all of the nationally recognized principles that need to be followed in assisted living. 

 

Basically, our suggestion to the Committee and this legislative body is that we do this through the regulatory process.  The state, AARP, the advocates, and the industry all thought [the regulatory process] would be conducive to having more hearings and more time [to discuss the issue and] still lead to the result that assisted living would now be defined, and [it would be] easier for consumers to understand what choices were being offered.  The agencies and the industry representatives are all here to answer any questions and also to provide supportive testimony.

 

Chairwoman Koivisto:

Thank you.  Questions from the Committee?  Ms. Weber.

 

Assemblywoman Weber:

I just want to find out [about] the advisory committee that was put together.  Is there a published report that we could look at?

 

Assemblywoman Buckley:

We do not have anything published but we actually are adding a historian who is going to put together everything that the committee did.  I think we will have something available, maybe after session ends, and I will make sure you get a copy of it.

 

Assemblywoman Weber:

That would be great, thank you.

 

Assemblywoman Leslie:

Ms. Buckley, essentially it looks like we have added a class of regulations to address this problem, which I think is a good approach.  Does the bill give a timeline for when the regulations by the state Board of Health have to be completed, or is that up to their discretion?

 

Assemblywoman Buckley:

They are here to answer that question.  I believe it should be a rather quick timeline, but I will have them directly answer that.

 

Chairwoman Koivisto:

Thank you, Ms. Buckley.  If we could have Larry Spitler and Carla Sloan [speak from southern Nevada].

 

Larry Spitler, Associate State Director for Advocacy, AARP Nevada

Good afternoon, Madam Chair and members of the Committee. [Introduced himself.]  We are pleased to testify in favor of A.B. 326 as amended.  AARP is a nonprofit, nonpartisan membership organization dedicated to making life better for people [aged] 50 and over.  We provide information and resources, engage in legislative, regulatory, and legal advocacy, assist members in serving their communities, and offer a wide range of unique benefits, special products and services for our members. 

 

In Nevada, AARP has over 258,000 members.  AARP supports assisted living facilities that are group facilities providing personal care to residents who need assistance with daily activities such as bathing, dressing, taking medication, and preparing meals.  Assisted living facilities are apartment-like rooms with simple dining facilities and activity rooms.  Assisted living has become uniquely identified as the vehicle to develop a consumer-focused, outcome-oriented philosophy to long-term care, an approach traditionally lacking in the nursing home and boarding home industries.  The philosophy of assisted living emphasizes providing physically and cognitively impaired older people with personal and health-related services needed to age in place in a homelike environment that maximizes dignity, privacy, independence, and autonomy.  To that end, AARP supports three major goals:  Maximizing the ability to age in place, balancing safety and autonomy, and maximizing privacy. 

 

[Mr. Spitler, continued]  With those goals in mind, AARP feels that A.B. 326 sets the beginning stages for the Board of Health to adopt separate regulations governing the licensing and operation of residential facilities for groups that provide assisted living within residential facilities for groups, just as there is now a separate category for residential facilities for groups that provide care to persons with Alzheimer’s disease.  AARP is very supportive of A.B. 326 and feels that the seven regulatory principles identified in the amendment will give the Board of Health the direction needed to achieve a beneficial outcome.  We are pleased this afternoon to support this bill and encourage its passage.  Thank you, Madam Chair and members of the Committee.  We would be happy to answer any questions.

 

Chairwoman Koivisto:

Thank you, Larry.  Questions from the Committee?  Ms. Sloan.

 

Carla Sloan, AARP:

Actually, Mr. Spitler has provided the testimony for AARP.  I am just here in support.  Thank you.

 

Chairwoman Koivisto:

Thank you.  While we are talking with southern Nevada, Michael Clark from Southwest Ambulance signed in as neutral on this bill.  Do you have the amendment down there and do you wish to speak on the bill?

 

Michael Clark, Southwest Ambulance:

[Introduced himself.]  Southwest Ambulance provides services to health care facilities throughout Clark County and we are merely here to see the outcome.  We do not have a position one way or the other.

 

Chairwoman Koivisto:

Thank you.  I have Larry Fry signed in, but I do not know if he is for or against.  Is Larry Fry here?  Please identify yourself and proceed.

 

Larry Fry, Legislative Chair, Coalition of Assisted Residential Environments (CARE); Member, Board of Directors, Dayton Parkview Adult Residence:

Good afternoon, everyone.  I certainly appreciate the opportunity to share with you a little insight, a portrait, of the assisted living industry in Nevada as it has evolved over the years and as it is related to the amended version of A.B. 326 (Exhibit D).  Besides being the Legislative Chair for the CARE [Coalition of Assisted Residential Environments] organization, I am also on the Board of Directors at Dayton Parkview Adult Residence, a 54-bed assisted living facility in Dayton.  We cater primarily to residents on welfare, SSI [Supplemental Security Income], the Medicaid group waiver program, [but we have] some private-pays also. 

 

[Mr. Fry, continued]  The CARE organization represents 60 care facilities in Nevada with about 1,400 beds.  We have about 4,800 residential care beds in Nevada representing about 367 facilities, and they come in all shapes and sizes.  The main thing is that they are all licensed and regulated by the Bureau of Licensure and Certification.  The Division of Aging Services provides guidance, help, and support with residents’ rights oversights.  Those are the two main agencies we interact with.  The Bureau of Licensure and Certification will be implementing the new regulations under the amended bill and [under] the Division of Aging Services.

 

The first assisted living facility in Nevada opened in 1948, and we have grown since that time.  We range in size from 2-bed homes for individual residential care to 100-plus-bed facilities.  We have 700 beds dedicated to Alzheimer’s care and we have about 120 beds dedicated to mental health and mental retardation clients.  We cover a broad spectrum of elderly and also people with disabilities.  One thing we need to keep in mind is that the recent drive to contain long-term care costs has resulted, and allowed, changes in the assisted living industry in Nevada.  The main focus of that change is that we have evolved from just being board and care homes to providing assisted living services because our residents are typically more frail and require more assistance with the activities of daily living.  The Bureau of Licensure created a Level II facility to address those residents that were restricted, mobility-wise.  In 1994, the Legislature passed operator training certification and testing, and we were very much in support of that and continue to assist in the ongoing education efforts for our administrators.

 

The Medicaid waiver program was another step in that direction, which allowed people in medical settings to move to less restricted assisted living [facilities].  Because in the last 20 years our focus has been more toward help with the activities of daily living, it became natural that residential care facilities and assisted living came to mean the same thing. 

 

Last summer the Board of Health wanted to formalize a good working relationship between industry and some of the regulators, so the Assisted Living Advisory Council was formed, an ongoing group that meets every month to look at issues of concern to both the industry and the regulators. 

 

We have met the challenge and are growing with the needs of the marketplace and look forward to doing the same good job with this amended version of A.B. 326, which has become a very good, collaborative effort.  Everyone looks at the long-term perspective from their own angle, but in reality, it is a universe, it is a long-term care continuum, so it is very good for us to all come together in this regard.  I would like to turn this over to Wendy Simons, who will look into the amended bill further.  Thank you.

 

Chairwoman Koivisto:

Thank you, Larry.  Any questions from the Committee?  We have a long agenda today so if you can [be brief, it would be appreciated].

 

Wendy Simons:

Madam Chair, members of the Committee, I am distributing a very brief statement (Exhibit E) that I wanted to get into the record, and I would also like to acknowledge that there is a really large representation from our industry here, too. 

 

We are extremely pleased and want to thank Assemblywoman Buckley for her efforts on this behalf, and I want to thank you for the opportunity to present our industry perspective.  As Larry suggested, the first facility was formed [by my mother] in Nevada in 1948.  I grew up in this industry and have been an administrator and advocate since 1972.  I do want to say that, during the past week, we had occasion to meet with several members of this Committee, and I want to extend my personal gratitude for the reception that we received in those meetings, the attention that was given to us, and the sincere interest from those who we had the opportunity to speak with.  Legislative process can be intimidating at times, but I am so proud to be a Nevadan and to have the accessibility that we had to all our representatives, and I want to extend a personal, heartfelt “thank you” for that.

 

When we met with Assemblywoman Buckley last Friday to review the intent and direction of the bill, she very intelligently directed us to all meet together with partners within this industry:  The Coalition of Assisted Residential Environments, myself and Larry Fry; Carol Sala, Division of Aging Services; Tina Gerber-Winn from Medicaid; Mike Willden and Mary Liveratti from the Department of Human Resources; Carla Sloan from AARP; and Alex Haartz of the State Health Division.  It was a great meeting and at the conclusion of the meeting the consensus was to gut the bill and bring back the amendment that you have before you today.

 

We had not had the opportunity to see it as amended, but it came out just exactly as we ended up discussing.  We feel that by directing the Board of Health to craft regulations that integrate the terminology “assisted living” with the principles identified by Ms. Buckley in her testimony, the bill is on the right track.  As a long time provider and an industry representative of all the facilities you heard about today, we are eternally grateful for the reception that we received and the open dialogue.  We really look forward to continued dialogue and partnership as we continue to define our industry.  Thank you so much, all of you, for meeting with us, and thank you, Assemblywoman Buckley, for your courtesy and your vision to put this together.  I appreciate it.

 

Chairwoman Koivisto:

Thank you.  Any questions from the Committee?  Are there others who are speaking in support of A.B. 326?  Please come forward.  There are a number of people who have signed [the guest list] in opposition, we have a long agenda, and a lot of people who want to speak.

 

Margaret McConnell, Chair, Board of Examiners for Administrators of Facilities for Long-Term Care; Administrator/Owner, The Charleston, Retirement & Assisted Living Center:

[Introduced herself.]  I am here today wearing two hats.  I would like to first testify as Chairperson of the Board of Examiners for Long-Term Care Administrators [Nevada State Board of Examiners for Administrators of Facilities for Long-Term Care].  In discussing the effects of A.B. 326 on our Board, the Executive Secretary states, “that it appears the bill, as amended, would not have a fiscal impact upon our Board because assisted living administrators as such in the amended bill would obtain the same administrator’s license as an administrator of a residential facility for groups.  Our Board therefore should not have to implement any new regulatory changes, testing procedures, or other operating procedures.”

 

Now I would like to switch hats and testify as a licensed residential care assisted living administrator who has worked in the long-term care field for the past 18 years, serving Nevada’s frail elderly.  I have served as administrator of Charleston Retirement and Assisted Living in Las Vegas for over 18 years.  It appears that A.B. 326, as amended, would offer a more clear definition of assisted living, outlining the philosophy of assisted living and enhanced group care service.  As such, I personally support passage of this amended bill and would like to compliment and congratulate Ms. Buckley, the bill’s sponsor, as well as all the other parties who worked so diligently to refine the bill’s provisions and make it a useful, user-friendly, and cost-effective bill.  Thank you to everyone who worked so hard to bring us this amended bill today.  Madam Chair and members of the Committee, thank you for the opportunity to address you this afternoon.

 

Mary Liveratti, Deputy Director, Department of Human Resources:

Good afternoon, Chairman Koivisto and members of the Committee.  [Introduced herself.]  You have in front of you my comments (Exhibit F).  I am going to be very brief.  We would like to also thank Assemblywoman Buckley for her leadership in bringing forward this legislation and also in helping all interested groups to be involved in the process. 

 

Throughout the process, the focus has always been on the residents of assisted living and their families, while at the same time encouraging this much-needed industry.  If you will turn to page 3, I would like to just note for the record that the initial fiscal note submitted by the Health Division was $235,550 for fiscal year 2004 and $212,937 for fiscal year 2005.  If [A.B. 326 is] amended as suggested by Assemblywoman Buckley, the fiscal note would be reduced to about $10,000, which would cover the costs to adopt regulations.  Thank you for this opportunity, and I would be pleased to answer any questions you might have.

 

Chairwoman Koivisto:

Thank you.  Questions from the Committee? [There were none.] Is there anyone else who has signed [the guest list] in favor of the bill or who has something new to add?  [There was no response.]

 

We have a number of people who have marked the [guest list] that they are in opposition.  Down south we have Terry Clodt in opposition.

 

Terry Clodt, citizen, Las Vegas, Nevada:

Madam Chairman, I am in favor of the bill after I heard the amendments.  Thank you.

 

Chairwoman Koivisto:

Thank you.  Do we have anyone up here who has further testimony on A.B. 326 either for or against or neutral?  [There was no response.]  I will bring A.B. 326 back to Committee.

 

ASSEMBLYMAN HARDY MOVED TO AMEND AND DO PASS A.B. 326.

 

ASSEMBLYWOMAN McCLAIN SECONDED THE MOTION.

 

THE MOTION CARRIED.  (Assemblywoman Leslie was absent for the vote.)

Chairwoman Koivisto:

We will move to A.B. 323.  That is Ms. McClain’s bill.

 

Assembly Bill 323:  Makes various changes concerning long-term care provided to persons with dementia. (BDR 38-1194)

 

Assemblywoman Kathy McClain, Clark County Assembly District No. 15:

Thank you, Madam Chair.  [Introduced herself.]  With me today is Bonnie Parnell who will be speaking to the bill specifically.  I would just like to make a few comments on it. 

 

In my other life, I am the Clark County Senior Advocate and run the Senior Advocate Program.  We deal with a lot of different senior issues, and one of the issues I have run across through the SALT Association, which is Seniors and Law Enforcement Together, is the Safe Return Program for Alzheimer’s patients.  [The program] is an identification bracelet and a “1-800” number so that if you find an Alzheimer’s person wandering, law enforcement can call this number and discover where the person belongs.  Working on establishing that kind of program [brought] to my attention so many different things about Alzheimer’s patients and dementia-related patients in general.  Dementia is not just Alzheimer’s; there are several different forms of it.  It is a problem that almost everyone has been touched by.  Currently, there are not enough placements in long-term care facilities in Nevada, [so] they get shipped out of state and you cannot get them back.

 

Part of this bill addresses a plan to not let that happen to our loved ones.  The other part is training on dementia-related illnesses for anyone who works with people with dementia.  This bill addresses the need for workers in long-term care facilities, but as I stated last week when we heard Assemblywoman Ohrenschall’s bill, I think [everybody should have] gerontology training in general and I think it is vitally important [there be] dementia-related training for people who work with Alzheimer’s patients.  I really appreciate Bonnie letting me sponsor this bill and I will let her go through the specifics of the bill.

 

Bonnie Parnell, National Alzheimer’s Association:

Good afternoon, Madam Chairwoman and members of the Committee.  [Introduced herself.]  Before I begin I would like to thank Assemblywoman McClain for sponsoring Assembly Bill 323. 

 

Let me first say to all of you, and to everyone in the room, what an honor it is for me to be present today and present to you A.B. 323.  Alzheimer’s is a disease that many of us still have difficulty even discussing.  It is frightening for
most of us to think about, and those who have been touched by it know why it is called “the long goodbye.”  It is time for our state to ensure, as best we can, that those suffering from dementia-related diseases and their families have the options and care available that are in their best interests.

 

[Ms. Parnell, continued]  Before I get into the bill’s specifics, I would like to [explain the] amendments.  Section 1, the new language, asks the Department of Human Resources to develop a plan to increase capacity of long-term beds in this state.  It references such options as Medicaid reimbursement, solutions which would facilitate economic development, and utilization of existing facilities, both state and non-state.  After I speak, you will be hearing from people in the Department of Human Resources and they will go into that a little more.  That plan has actually already started, so the fiscal note on the jacket of this bill has pretty much been eliminated.  The cost to the Department of Human Resources is nonexistent, and the cost for Section 2, “implementing new regulations,” runs between about $5,000 and $10,000.  As you can tell today, from both previous testimony and mine, we are trying to be as fiscally conservative and responsible as possible.

 

Section 1 addresses the practicality of when this can be done and eliminates any fiscal note.  The intent of Section 1 is to ensure that individuals suffering from dementia-related conditions are able to remain in this state if so desired.  In 2002, approximately 60 nursing home residents over the age of 65 were placed in out-of-state facilities.  Of these residents, the majority were placed in out-of-state facilities because they needed a secure facility due to wandering or behavior problems, problems that required specialized staff training.  State staff has indicated that many Nevada facilities are reluctant to accept individuals with behavior issues and that no Nevada facility was able to accept those who were eventually moved out of state.

 

Those of you who were here in 2001 probably remember the passage of A.B. 513 [of the Seventy-first Session], which asked the Department of Human Resources to come up with a strategic plan to look at certain issues that were of a concern, and senior-related issues were one.  Some of the comments I will be making actually reference that recommendation, and, because of that strategic plan, eliminate much of the fiscal cost that might have been there.

 

Applying percentage estimates from a 1996 consensus panel organized by the Agency for Health Care Policy and Research, and population projections prepared by the Nevada State Demographer, the strategic plan concluded that an estimated 15,400 seniors in Nevada have Alzheimer’s disease.  As Alzheimer’s disease progresses, many seniors have difficulty supporting their [afflicted] loved ones at home.  Because the number of people with Alzheimer’s will continue to increase over the coming years, the strategy calls for the state to determine the best way to address this growing need.  The plan went on to say that alternatives to placing seniors in out-of-state facilities can be implemented, and that each biennium the number of such placements should be analyzed and progress toward eliminating these placements should be continued until no seniors with Alzheimer’s disease are forced to be placed out of state.

 

[Ms. Parnell, continued]  Section 3 ensures that a person with dementia will be placed in a facility where caregivers have been trained in dealing with dementia.  Direct-care staff involved [in caring for] people with dementia need good quality training.  This is to ensure they have the appropriate skills and understanding to meet the needs of the people in their care.  Good quality training enables staff to provide care for people with dementia in a way that treats each person with respect and preserves their dignity.  In the book titled Practical Dementia Care, it is noted that most aggressive behavior exhibited by dementia patients can be treated or minimized by facilities and their staff through the expanded use of behavior management strategies.  Training of staff on the front line of resident care is key because they are in the best position to identify behavioral changes and to respond.  Noted as one reason [for the] inadequate supply of caregivers working in long-term care is a combination of resident aggression and poor staff training on how to handle such challenging behaviors.  This would seem to me a win-win situation for both the patient and the caregiver.

 

The National Conference of State Legislatures’ Alzheimer’s Disease and Related Dementias Guide, states that federal law establishes minimum staffing requirements for certified nurse aides and licensed staff in nursing facilities.  [It] goes on to say that states may go further to assure that direct care staff who work with residents with dementia have the training to meet the particular challenges of Alzheimer’s disease.  The prevalence of Alzheimer’s disease is expected to grow from 4 million people in 2000 to 8.7 million in 2020, [and] to 14.3 million in 2050.  With the ever-increasing older population in Nevada, we should be especially cognizant of these numbers and the potential impact to our state. 

 

I believe that Assembly Bill 323 is fiscally responsible, compassionate, and pro-active, and I urge your support.

 

Chairwoman Koivisto:

Thank you, Ms. Parnell.  I want to welcome Mr. Carpenter, our esteemed colleague from Elko.  Please proceed, Mr. Carpenter.

Assemblyman John Carpenter, Assembly District No. 33 (Elko County and portions of Humboldt County):

Thank you, Madam Chairwoman and members of the Committee.  [Introduced himself.]  I just wanted to come today to lend my support to this bill.  I have had personal experience with members of my family, my father-in-law, and some of my best friends who have had this affliction.  I do not think I have seen anything in my lifetime that had such a profound effect on people.  It was heartbreaking to see my father-in-law when he got Alzheimer’s.  I have had other friends [develop Alzheimer’s] too and it was terrible to see them in the care centers.  I want to thank Assemblywoman McClain and former Assemblywoman Parnell for bringing this tragedy to [public awareness] and [I hope] we can do [something] to help those people and to help the families.  Hopefully, some day there will be a cure and we will no longer have this terrible affliction with us.  I just want to be here and express my thanks to these two ladies and to impress upon the Committee how important this is and hopefully [the bill] will come out of here with a unanimous “yes” vote.  Thank you.

 

Chairwoman Koivisto:

Thank you, Mr. Carpenter.  Questions from the Committee? 

 

Assemblywoman Angle:

I, too, have had personal experience with this and I know how invaluable education is.  My mother-in-law, who is 70, is the caregiver for my great-grandmother-in-law, who is 95.  It is very difficult and all our family has had to learn what this disease is about, because we all know that it is better for her to be with her family as long as she can.

 

My question has to do with the unfunded mandate with this bill.  I am so concerned that this will not happen because of the budgetary restraints.  I just want you to reassure me that we will go someplace with education even if it does not get paid for this way, that something will be done.  Thank you, Madam Chair.

 

Bonnie Parnell:

The Department of Human Resources will be speaking, as will the State Board of Health.  Both feel very comfortable in saying that the maximum cost would be $10,000 and it could even be as low as $5,000, and that would be strictly to engage the new regulations.  That was similar, I believe, to the figure Assemblywoman Buckley gave as well.

 

Assemblywoman McClain:

If I could follow up as well, [this] would not just be keeping people in Nevada, but when you look at this over the years, watching a wife, for instance, take care of a husband with dementia/Alzheimer’s, it is total burnout.  It almost destroys the family, but they will hang in there.  By the time the wife cannot take care of the husband, or the other way around, and the spouse needs to be put into a long-term care facility, to add insult to injury, the spouse needs to be shipped out of state.  I am sure you probably all got an e-mail from a lady who went through just that.  She was stuck in Nevada, they shipped her husband to Washington state, where he went downhill, and within a month or so he had died.  What a tragic end to an already tragic story.  What are we going to do to keep our families together?

 

Chairwoman Koivisto:

Thank you.  I think Mr. Duarte can probably answer Mrs. Angle’s question.

 

Charles Duarte, Administrator, Division of Health Care Financing and Policy:

I will summarize my testimony because I think Ms. Parnell gave a very good description of the current situation that we have in Nevada.  We have negotiated in the past with nursing facilities throughout the state to try and take some of our clients, who have severe behavioral disorders as well as long-term medical needs, into their facilities to no avail.  Today we have about 80 recipients who are located outside the state receiving care in specialized facilities.  I will also add that the state has already undertaken an effort to identify what the potential costs and availability of services might be.  Last month we issued a Request For Information (RFI) in order to see if we could get operators of specialized facilities from other states to come in and propose alternatives to the care that is available, or not available, in-state.  The options could include having an operator come into the state or use existing bed capacity in private or public facilities, and training staff in-state to take care of patients in-state.  Our initial effort would be to divert patients who are currently in acute care institutions, hospitals, namely, from going out of state.  Certainly, if we had the capacity and the funding to pay the additional reimbursements for these services, we would put our efforts into trying to bring people, as appropriate, back into the state.

 

We do have an RFI out and two proposals have been submitted as of today with requests to present to the state, and possibly a third, which still needs confirmation, was received this morning.  The Division stands in support of the bill as amended.  We have not been able to develop an estimate of the costs associated with this yet.  We are trying to gather information right now so that we can develop and refine costs.  We have made some rough estimates, but I would really rather not put those numbers out right now until I get better information as a part of our Request For Information from operators.

Assemblywoman Angle:

The unfunded part of it, though, you do not think will be a problem in implementation as far as going forward with what the bill proposes?

 

Charles Duarte:

In response to your question, Mrs. Angle, I do not want to speak for the Bureau of Licensure and Certification, but for my Division, because we are already in the process of gathering information, it should not be any additional cost for us to prepare the report and provide that to the Legislature or to any interim committee that is developed as a result of this.

 

Assemblywoman McClain:

To my colleague Mrs. Angle, this amendment has changed it now to develop a plan, and that plan has already begun.  That is why there is no fiscal note.

 

Shawna Judd:

My father, aged 69, died early as a result of being sent out of state to a Utah nursing facility.  He was in the late stages of Alzheimer’s, requiring 24-hour care.  My mother was my father’s primary caregiver up until the last two months of his life.  My father began to show episodes of aggression toward my mother and himself and the family convinced her to put him in a home.  He was referred to Senior Bridges.  Their goal was to control my father’s aggressive behavior while keeping him ambulatory, and then be able to transfer him to a local nursing home.  Prior to admitting my father to Senior Bridges, he was walking a mile a day, drinking and eating by himself, and was in excellent physical condition.  He had participated in over 30 marathons and was a tri-athlete.  During the one-month stay at Senior Bridges, he was stabilized on various medications to control his aggression while keeping him ambulatory with the assistance of a Merry Walker.  Unfortunately, my father’s one-month history at Senior Bridges reflected combative behavior and because of this, no nursing home in Nevada would admit my father even though he was now stabilized and there were beds available. 

 

Because there were no local placement options, we were forced to place him in Utah in order to keep him on the Medicaid program.  During his stay at Senior Bridges there was one drug the doctor determined my father should not be on because it made him somnolent.  Senior Bridges recommended that drug not be used, but the Utah facility ignored those recommendations because when my father showed up, they gave him a Merry Walker.  After he broke it they did not know what to do, so they drugged him.  Unfortunately, the family was unable to show up until six days later and by then my father could not sit up, was not walking, could not swallow, and he was on oxygen.

 

[Ms. Judd, continued]  The medication had caused an acute deterioration of my father.  By the time I got there, his second week there, he was very dehydrated.  I forced them to call emergency.  He was transferred to an ER [emergency room] where the doctors confirmed that he was overmedicated.  We then had him transferred to another facility that specialized in geriatrics and people like my father.  They gave my dad two weeks to live.  Medicaid did fly my dad back, prior to his death.  The impact affected my mother tremendously because the ability to visit every day and monitor his condition and his welfare was taken away.  Because no one was there to monitor him on a daily basis, my dad declined rapidly.  The point was my dad was only there 14 days in that particular nursing home and they caused his rapid deterioration, which later caused his subsequent death.  I think he was treated unfairly and the family was unable to monitor my dad.  Any way we can find the money to pay for whatever is necessary to educate the nursing staff, or even particular people within the nursing facilities, so that we can keep these patients in-house so their loved ones do not have to go out of state, would be wonderful.  If you could support the bill, we would appreciate it.  Thank you very much.

 

Chairwoman Koivisto:

Thank you, Ms. Judd; I know how difficult it was for you.  Questions from the Committee?  [There were none.]

 

Kim Hathcock, Registered Nurse, Geriatric Nurse Practitioner:

I have provided long-term care, home care, and outpatient clinic care to the geriatric population of northern Nevada for the past five and a half years.  During this time, I have seen a dwindling of resources to care for Nevada’s elderly population, especially for those who have Alzheimer’s disease, with the closing of at least three long-term care facilities and four dementia units.  This has occurred during a time of rapid growth of the 65-and-older population.  No lack of resources for the elderly has become more evident as medical providers seek to place Alzheimer’s patients with behavior problems in safe, healthy environments.  It is almost impossible to do this in Nevada, even if the family has the monetary resources to buy the best care.  This is due to the lack of physical space and the lack of Alzheimer’s disease and behavioral management education by the direct-care-giving community.

 

Even five years ago, when space was not at a premium, the long-term care system was inept in managing the Alzheimer’s patient.  I noted on numerous occasions that it was a staff action that caused a patient to strike out physically and verbally.  Often this was done by startling the patient and then overreacting to the patient’s action.  For example, one staff member who was working in a locked dementia unit walked up behind a patient and grabbed the arm.  The patient was alarmed by the touch and hit out at the staff member.  The patient’s hand hit the staff member, who in turn acted out with anger, yelling at the patient.  In the end, the patient was transferred to an acute facility [because of] the long-term facility’s fear that the regulatory board would look at the case if the patient resided in the facility on review.  The patient was not readmitted and was sent to another state away from the family, who had visited often.  Appropriate education for the staff would have most likely resulted in a very different and, hopefully, more positive outcome. 

 

[Ms. Hathcock, continued]  Later, as space became a premium and staffing shortages increased, facilities grew more selective in their admission process, even for their locked units.  If an Alzheimer’s patient was noted to “act out” even occasionally, admission was denied, causing the acute facilities to seek other placement, more likely outside the state.  Even after admission, if behavior became an issue, it became commonplace for the facility to want the patient out due to its inability to manage the patient.  For example, when one patient acted out and yelled constantly, the provider on several occasions was pressured by the facility to write orders to remove the patient for acute management.  On refusal, the facility went to the collaborating physician, who did write the orders.  The patient was not readmitted to the facility after the acute care stay, due to the facility being full.  The bed was given away to another patient.  This required the first patient to be placed outside the state of Nevada.

 

These days, as a provider in the community, I am experiencing the displacement of an Alzheimer’s patient from their family in a new light.  Families are experiencing extreme frustration as they have no option [other] than out-of-state placement for their loved ones.  I, as a provider, am also experiencing this frustration, as I can offer suggestions, but ultimately it is their responsibility to deal with a person who has reverted to a child with little impulse control, their own role reversal, and the loss of a loved one.  It has made me wonder and ponder several points.  Why is Nevada taking a reactive approach in caring for its own and not being more pro-active in its response?  Why does it take years to implement programs that are needed today?  Will this reactive approach to the graying of Nevada threaten society as we know it?  Why are we using our Medicaid and private dollars to pay for care outside Nevada?  Why are we permitting the separation of families and causing undue emotional hardships?  What are the legal ramifications for the provision of care outside of the state that is paying for the care without monitoring it?  Is the care that the out-of-state Alzheimer’s patient is receiving what is mandated by the state of Nevada, and if not, what could be the consequences?

Jim Brusstar, President, Northern Nevada Alzheimer’s Association

Good afternoon, Madam Chair.  [Introduced himself.]  I am also a provider of long-term health care services in Sparks, Nevada.  I see all these issues almost every day.  In the last two weeks, I have had three or four families that have had to make this decision about where they want to go.  When we have an episode with a particular resident or patient, we send them to Senior Bridges for evaluation and if Senior Bridges cannot care for them, they ask if we will take [the patient] back.  Reluctantly, but for good reasons, we cannot take the person back to our particular facility because we cannot provide an environment for that person to be safe in.  A lot of providers will not take a patient back because they are concerned about lawsuits and what would happen should a patient strike another resident.  We are responsible for making certain the other residents are safe. 

 

You need a very specific type of unit to care for someone who has dementia and behavioral issues.  You also need a well-trained staff.  I have been dealing with Alzheimer’s care for about 30 years, both on the East Coast and here in Nevada.  I will tell you that it is a tough job for the caregivers.  The training needs to be there, there needs to be an incentive of some type for the provider to take these cases, because you are dealing with issues that in a skilled nursing environment you would be cited [for].

 

Reimbursement is one issue for facilities that do provide this needed service.  Education and training of their staff are also needed to make this work in this state.  I was asked by the Department [of Human Resources] to look at the facilities in Utah.  I cannot say that I would want to go to any one of them.  They were not giving bad care in some cases, but in others, I would not go there.  My assessment is that we really need to get people back to Nevada and provide the services, and there are things we can do to make that happen.  We do not get enough from Medicaid to pay for skilled nursing, much less when you are dealing with an [Alzheimer’s] population.  I get involved with these tough decisions and it tears all our staff apart.  We are helpless and we look for some way to rectify the problem by keeping people in the state, but providing an environment where they will be able to be cared for is a problem.  I urge you to support this bill and move on it.

 

Chairwoman Koivisto:

Thank you.  Questions from the Committee?  [There were none.]  We have some people in Las Vegas who have signed up in support: Larry Spitler, Carla Sloan, and Linda Branch.  If there is anyone else in support, move up so that you are ready to speak when Mr. Spitler is done.

Larry Spitler, Associate State Director for Advocacy, AARP Nevada:

For the second time, it is a pleasure to address you.  In general, new developments in medicine, technological advances, and greater knowledge about healthy lifestyles promise continued improvements in longevity for Americans.  Longer lifespans also mean increased survival of those with serious, persistent illnesses.  Common chronic conditions limiting daily activities among older Americans include circulatory disorders, such as hypertension and heart disease, arthritis, and diabetes.  Among those [aged] 70 and over, visual impairments and osteoporosis also become increasingly prevalent.  Dementia, which is most commonly due to Alzheimer’s disease, increases from 10 percent among people aged 65 and over, to more than 47 percent among those aged 85 and older.  While AARP strongly supports greater investments in research on the aging process, particularly on diseases associated with aging such as Alzheimer’s disease and Parkinson’s disease, we also recognize and support the need for a trained work force caring for patients with these illnesses.

 

AARP believes that states should ensure that all long-term care training programs, particularly in the nurses aide training programs, include content regarding the care of people with mental disorders such as serious mental illness, mental retardation, developmental disabilities, Alzheimer’s disease, and other dementias.  We are pleased to support A.B. 323, as we feel it moves in the right direction to provide care with dignity for patients suffering from Alzheimer’s and other forms of dementia.  Thank you very much for the opportunity to share these thoughts.

 

Chairwoman Koivisto:

Thank you, Larry.  Questions from the Committee?  [There were none.]  For the other folks down south, please identify yourselves for the record and proceed with your testimony.

 

Brandy Gregg, Regional Director, Alzheimer’s Association of Southern Nevada:

As the regional director of the Southern Nevada Alzheimer’s Association, I often find myself speaking for those who have lost the ability to speak for themselves.  I am referring to those who have been affected by Alzheimer’s disease and other forms of dementia.  I am here today as an advocate for those people who at one time, like you and I, were active, spirited, and fully capable of making their own choices.  Unfortunately, everyone who suffers from Alzheimer’s disease can count on one thing: they will all lose their ability to make their own choices.  Simple choices such as what to eat, what to wear, and what memories they will be able to keep will no longer be in their control.  Families and the people who care for them will suddenly find themselves having to make difficult decisions about how to care for their loved one and at the same time manage their own grief at slowly losing the person they have known and loved for so long.  I have a hard time imagining how difficult it must be for a wife to watch her husband’s memories of the life they have shared for 50 years simply vanish from his mind, but that is the reality of this devastating disease.  At times I would think that this is very unbearable, but for some of these folks, the decision becomes even more difficult.  Some of our families are forced to place their loved ones out of state for care because there is no place within the state that can manage some types of behaviors and care needs common with dementia, specifically Alzheimer’s disease. 

 

There are currently thousands of people who suffer from Alzheimer’s disease in the state and thousands more in the state who are directly impacted by this devastating disease.  The Alzheimer’s Association understands that this is a complex issue and we need to look at multifaceted solutions.  We are willing and committed to support solutions that make sense economically and socially, and on behalf of those I am speaking for today, I ask for you to support our efforts in finding services and resources for those families who are dealing with this devastating disease.  Thank you.

 

Linda Branch, Regional Leadership Council, Desert Southwest Region, Alzheimer’s Association:

I only echo what those who have gone before me [have said] in support of this bill [A.B. 323].  When I think of out-of-state forced placement of individuals with this dreaded disease, I think of depression, helplessness, fear, misplacement, abandonment, disconnection, desertion, and powerlessness.  I can only imagine that these are some emotions that may enter into the minds of those individuals and their families when this out-of-state placement becomes necessary or is mandated.  Making the decision to place a loved one in a nursing home brings its own set of emotions, but coupled with forced out-of-state placement, the emotions can be overwhelming for both the person being placed as well as the family members.  The social and psychological impact of this decision can be devastating to the family and their relationships and the emotional well-being of all that are involved.  It has been proven that familiarity with surroundings for an individual with dementia-related cognitive impairment is vital.  Removing that individual from their home is a devastating event that can trigger many adverse reactions, and moving them to another state, completely away from their loved ones and all that is familiar, could be fatal.  I plead with you to personalize this very real situation and vote to pass the amended bill addressing the out-of-state placement of Nevada state residents with dementia-related cognitive impairment in nursing homes.  Thank you, Madam Chair.

Chairwoman Koivisto:

Thank you for your testimony.  Questions from the Committee?  [No response.]  Is there anyone else in southern Nevada who wants to testify on A.B. 323?  [No response.]  Thank you.  We will come back up to Carson City.  Are there people up here who want to offer testimony on A.B. 323?  [No response.]  I will bring A.B. 323 back to Committee.

 

ASSEMBLYWOMAN ANGLE MOVED TO AMEND AND DO PASS A.B. 323.

 

ASSEMBLYMAN HORNE SECONDED THE MOTION.

 

THE MOTION PASSED UNANIMOUSLY.

 

Ms. Leslie, we passed out A.B. 326 while you were in your committee.  Would you like to place your name as supporting the bill?

 

Assemblywoman Leslie:

Yes, thank you very much.

 

Chairwoman Koivisto: 

You’re welcome.  The next bill on our agenda is A.B. 313.  We have a lot of people who have signed up to testify on this bill, so what I will do is limit testimony to five minutes a person and even then I am not certain we will be able to fit everyone in, but we will do our best.

 

Assemblywoman Chris Giunchigliani, Clark County District No. 9:

Thank you, Madam Chair, members of the Committee.  [Introduced herself.]  Assembly Bill 313 tries to deal with the fact that Nevada has a severe nursing shortage and that it is not going to get any better.  The Nevada Hospital Association released a report in 2002, which said at that time 650 registered nursing positions were unfilled, 38 LPNs [licensed practical nurse], and 117 CNA [certified nursing assistant] positions were unfilled.  Therefore, the need for establishing safe nurse-to-patient ratios that hospitals must meet was the genesis of Assembly Bill 313.  It helps protect patient care by ensuring that hospitals have enough nurses at the patient’s bedside.  There are others here who are far more qualified than I to make the case for staffing ratios but I do believe that our constituents deserve quality care and we would be remiss if we did not find a mechanism to determine what is fair, manageable, and meets Nevada’s needs.  I might suggest to the Committee, if you choose to process this, that we consider an amendment on page 6 which deals with the 50 percent, so that there is an exemption for the acute area in rural hospitals, which have a concern with some of the language in this bill. 

There are quite a few nurses, both here and in southern Nevada, and if I might ask two of them to join me here [at the witness table] to talk about how the life situation affects them as nurses who are caring for our patients.  Then we will try to [answer] questions.

 

Maryanne Salm, Political Director, SEIU [Service Employees International Union] Nurse Alliance

Thank you, Madam Chair, members of the Committee.  [Introduced herself.]  [The SEIU Nurse Alliance] represents approximately 4,000 nurses in southern Nevada.  I am joined by Glenda Canfield, a nurse and SEIU Nurse Alliance Nurse Policy Director from California.  She was instrumental in winning passage of the safe staffing bill in California.  Behind me is Jerri Strasser, a registered nurse at UMC [University Medical Center] who has been practicing nursing for more than 20 years.  In addition, I am joined by nurses from Las Vegas who support A.B. 313.  For them, this bill represents the work of thousands of nurses, developed with the input of many more thousands of nurses who care for patients at their bedsides in our hospitals every day. 

 

A.B. 313 establishes safe nurse-to-patient ratios that hospitals must meet.  These are minimums that are meant to establish a baseline of care.  The actual staffing plan for any particular hospital must meet these minimums, but must also be drawn up with the input of nurses from various departments throughout the hospitals and must be based on acuity, or the severity of a patient’s condition.  This bill also places limits on mandatory overtime for nurses and there are whistle-blower protections for nurses who report violations of the minimum nurse-to-patient ratios.  This bill presents a broad approach to addressing patient care concerns and our concerns with the mass exodus of nurses from hospitals and the nursing profession, an exodus that is giving rise to a nursing shortage.

 

Long before there was a nurse shortage, bedside nurses had sounded the alarm.  Nurses in hospitals are caring for many more patients than they did 20 years ago, and these staffing levels are too low to provide the quality of care patients need to get well.  Study after study shows that patient care suffers when there are not enough nurses at the bedside to care for patients.  Linda Aiken reported in 2002 in the Journal of the American Medical Association, and that has been included in our materials (Exhibit G), that for each additional patient over four in a registered nurse’s care, the risk of death increases by 7 percent per surgical patient.  In hospitals with eight patients per nurse, patients have a 31 percent greater risk of dying than those in hospitals with four patients per nurse.  JCAHO [Joint Commission on Accreditation of Health Care Organizations] reported in 2002 that understaffing was a contributing factor in 24 percent of sentinel events, events that were unexpected and led to patient death or injury in the hospital.  According to a study by Dr. Jack Needleman of the Harvard School of Public Health, in hospitals with fewer registered nurses, patients are 2-9 percent more likely to suffer complications like urinary infections and pneumonia, 3-5 percent more likely to have to stay in the hospital longer, and 2.5 percent more likely to die.  The bottom line is, nurses save lives and when there are not enough of them, patient care suffers.  While hospital representatives like the lobbyists here today have pointed to the nursing shortage as an excuse for short staffing in the hospitals, there has been a deliberate, concerted effort by hospital administrators to reduce staffing in the hospitals for more than a decade.

 

[Ms. Salm, continued]  Well before the present-day nurse shortage, hospitals were reducing their nursing staff.  Responding to financial pressures from the growth of managed care, hospitals began, in 1990, to reduce their labor costs with the layoff of tens of thousands of registered nurses across the United States.  Nurses have documented chronic understaffing in Las Vegas hospitals for more than five years through Assignment Despite Objection forms and staffing notebooks that tracked staffing over 30-day periods.  Short staffing is an everyday problem confronted by bedside nurses, and the problem is reaching dangerous levels.

 

It should come as no surprise that this deliberate understaffing would take its toll on nurses.  The nurses that are left to care for patients are overloaded.  They are overworked, experiencing high levels of stress, chronic fatigue, and work-related injuries.  As a result, nurses are leaving hospitals and the profession altogether for less demanding jobs.  Last year our union conducted a study of nurses who had terminated employment at a union hospital over the last two years.  When asked why they left their jobs, 72 percent of those nurses pointed to working conditions like hours of work, overtime, and staffing.  In fact, 64 percent of nurses who left hospital nursing cited staffing as their reason for leaving.  We should be especially concerned that 45 percent of those nurses who had left hospital work did not return to work in another hospital.  This led us to conclude that there are thousands more nurses who are licensed but not practicing nursing.  Figures provided [last year] by the Nevada Hospital Association and the Nursing Board support these findings.  In 2001 there were approximately 700 more licensed nurses than vacant nursing positions.  Nationally, Department of Labor statistics indicate that only 82 percent of licensed nurses work as nurses, and only 48 percent work in hospitals.  Overwhelmingly, nurses are telling us that staffing ratios and limits on overtime, like those contained in A.B. 313, will help us retain nurses and bring others back to the nursing profession.

 

[Ms. Salm, continued]  But this is not limited to anecdotal evidence.  Low nurse-turnover rates are found at hospitals with better than average staffing.  According to statistics provided by hospital administration, turnover rates for Las Vegas hospitals for 2000–2002 were 10.3 percent at UMC, 26.9 percent at Sunrise Hospital, 26.2 percent at Valley Hospital, and 23.5 percent at Desert Springs.  This compares to a national average of about 15 percent.  The  Lewin Report asserts that staffing levels are higher than average in some units at UMC where nurse turnover is lowest. 

 

The California experience is very similar where Kaiser Hospital, which has already begun implementing nurse-to-patient ratios, reports low nurse turnover.  There is further proof that nurse staffing ratios will bring nurses back to the profession.  Glenda will tell you that they have seen an increase in license applications as the California nurse ratios are being implemented.  Additionally, in September 2001 in Victoria, Australia, they implemented nurse-to-patient ratios.  Less than nine months later, the Australian Nursing Federation reported in a July 25, 2002, press release that more than 3,000 nurses have been recruited back to the health system.  Victoria, Australia, has a population of about 4.9 million and this represents about a 15 percent increase in licensed nurses.

 

In California, hospitals are beginning to realize the value of appealing to nurses with attractive nurse-to-patient ratios.  Kaiser Hospital sent this letter (Exhibit H) to potential nurse recruits, citing 4-to-1 ratios in medical/surgical departments and 1-to-3 in step-down units.  It is no surprise that Kaiser Hospital in Los Angeles reports only a 2 percent vacancy rate.  Hospitals like Kaiser realize that in the long run, staffing legislation and limits on overtime, like those in A.B. 313, will save hospitals money and pay for themselves.  Safe staffing ratios will encourage more nurses to stay or return to the bedside, a much smarter approach than increasing spending on education alone. 

 

High nurse turnover costs hospitals money.  It is estimated that it costs, on average, $46,000 to replace one [medical/surgical] nurse and about $64,000 to replace an ICU [Intensive Care Unit] nurse.  This was based on “The Business Case for Work Force Stability,” a report prepared by the Voluntary Hospital Association. 

 

Better retention reduces the need for traveler nurses who cost about $10 more per hour than permanent nurses.  Better staffing and better working conditions for nurses will save money for insurers as well.  According to “The Business Case,” hospitals with turnover rates below 12 percent had lower mortality rates and shorter lengths of stay.  A Harvard School of Public Health study shows that hospitals with a higher percentage of registered nursing staff had 3-6 percent shorter stays, which again saves health care costs.

 

[Ms. Salm, continued]  In closing, this Committee has heard a lot of testimony about the nurse shortage, and there are several nurse recruitment proposals being debated.  The federal government and our state legislators are being called upon to increase funding for nursing schools and nurse recruitment.  Before you vote to spend millions of dollars to expand enrollment in nursing schools, keep this in mind.  The International Hospital Outcomes Research Consortium released a report two years ago that shows that 33 percent of nurses younger than 30 plan to leave the profession within a year of graduation, primarily because of working conditions.  I urge you to spend some time after this hearing to speak with the nurses who are here with me today.  You will hear how important nursing is to them.  You will also hear the frustration in not being able to give the kind of care patients need to get well.  They call it “the extra touch.”  Barb Kahn, a pediatrics nurse in Las Vegas who could not be here, laments that the time she spends holding the babies in her unit is as important to their care as administering medication and taking vital signs, yet there is no time to sit and stroke a baby’s face or rock it to sleep.  She recently left bedside nursing because it has become less satisfying.  In her words, A.B. 313 is about giving nursing back to nurses.  We urge your support.

 

Chairwoman Koivisto:

Thank you.  Questions from the Committee?  Mr. Horne.

 

Assemblyman Horne:

Thank you, Madam Chair.  Thank you Ms. Salm, it’s good to see you.  I have a question.  I heard testimony earlier this session about funding nursing programs because of the shortages.  One of the questions I asked was,  “If we spend this money but the hospitals are not hiring, are we throwing money away?”  I want to make sure I understand your testimony that there really is not a shortage.  Nurses have just chosen to leave the profession because of conditions.  Is that correct?

 

Maryanne Salm:

We believe that there have been decisions and that deliberate understaffing in hospitals has driven nurses away.  We support efforts to increase nurse recruitment, we think that is vital, but it is not enough to increase nurse-school funding unless we pair that with strong retention proposals that will keep nurses and bring nurses back.

Assemblyman Horne:

I have received countless e-mails on this bill, both for and against.  [One] argument was that, assuming there is a [nursing] shortage and there are no nurses to fill those positions, if we [vote in] this type of mandate, beds would be eliminated from the facilities.  Could you address that?

 

Maryanne Salm:

If you would allow me, I would like Glenda to talk about that because they addressed that issue in California.

 

Assemblywoman Angle:

I would like clarification on the definition of “registered nurse” mentioned in Section 12.  I know that there are other staff who give care, such as LPNs and CNAs, and I was wondering if they were included in the staffing requirements or ratios addressed in the bill.

 

Maryanne Salm:

Not at this time.  This bill specifically addresses registered nurses.  We do think we need to examine the role of LPNs and CNAs in the staffing mix.

 

Mr. Horne:

Also, on your statistics about the number of nurses who have left [nursing] but were still living in the state, did you take a poll to come up with those numbers or is this anecdotal evidence?

 

Maryanne Salm:

We surveyed nurses and we have provided the Committee with the study “Where Have All The Nurses Gone?” (Exhibit I), which was prepared last year.  We surveyed about 1,600 nurses who had left hospital work at one of the hospitals where we had turnover information.  We had a 13 percent response rate, and the statistics you heard are based on the responses to the surveys.

 

Assemblywoman Leslie:

I want to get this question out early so other people can also respond to it.  I do get a lot of complaints from people who are in hospitals who feel like there are not enough nurses.  I heard the other day in the hallway that in Las Vegas that there is a private agency that rents nurses for people to take [with them] to the hospital.  Is that possible?

 

Maryanne Salm:

There is a private consulting company that rents a nurse’s assistant so patients will have a nurse with them in the hospital.

 

Assemblywoman Leslie:

So, if you are wealthy, concerned about your loved one who is in the hospital, and concerned the staffing is not going to be adequate, then you call this service and hire a private nursing assistant?

 

Maryanne Salm:

That is what is happening.

 

Assemblywoman Leslie:

I think that points to the problem.  I do not know if this bill is the solution, but clearly, there is a problem.

 

Assemblyman Mabey:

Thank you, Madam Chair.  Just a point on that, Ms. Leslie.  There has always been that option.  Everyone could always hire their own nurse if they wanted to.  I must disclose that my mother was a registered nurse and my father is a doctor and I am a doctor.

 

I have received more e-mails on this [A.B. 313] than any other bill.  When you say [the hospitals] are deliberately understaffing, when I go to the hospitals, I see they are taking trips to the Philippines to get nurses.  I do not know if that goes along with “deliberate understaffing” if they are leaving the country to recruit nurses.  Could you respond to that?

 

Maryanne Salm:

You have to look at what has been happening for more than ten years.  What we see today in terms of trying to recruit nurses and fill nurse shortages, that situation was developed by many years of intentional understaffing.  Nurses became just another labor cost that could be cut to raise profits.

 

Assemblywoman Giunchigliani:

Approximately six or eight years ago we started dealing in the Legislature with the issue of hiring CNAs out-of-state.  Many of the hospitals at that time approached the Nursing Board to try to water down that standard so they did not have to have a registered nurse or LPN but could bring in a CNA, and they began recruitment programs.  That was stopped.  CNAs were necessary, but it was a way to skew the balance of the more qualified, more educated registered nurse who had a different job to do versus someone with a CNA.  It is the same thing that occurred in the teaching profession.  Teaching was primarily female, nursing was primarily female.  Raising of salary was always an issue because of the basis of gender, but even more importantly, the working conditions were  always more key to everyone.  Burnout and turnover is driving part of the shortage.  There are licensed nurses in this state who would love to go back to their job.  Salary aside, taking care of the patient is still of utmost [importance] because it is that type of career.  This bill is an attempt to recognize that they want to do their job and they want to do it well and they want to make sure they are there to take care of the patient.  As they see the labor market shifting and crunching the ability for them to do the job that they want, some are just making the decision to leave their profession, and that is unfortunate.

 

Will you still need some education programs?  Will you still need recruitment programs?  Yes, but nowhere near the extent that you would if you really dealt with the [hospital] staffing ratios.

 

Assemblywoman Angle:

Just a follow-up on the staffing ratios.  You suggest it be 1-to-5 in each rehabilitation [unit] and 1-to-6 in each of two other categories.  What are those ratios right now and how many CNAs and LPNs are working alongside the RNs with the current ratios?

 

Maryanne Salm:

It varies widely by hospital.  I would defer the question to nurses with experience in those units.

 

Assemblyman Hardy:

You mentioned JCAHO and the ratios.  If you could share with us what the suggested JCAHO ratios are as well as any hospitals that have not been accredited because of violation of JCAHO regulations, and do we have an [actual] number for the nurses “out there” that we could bring back into the hospitals?  I, being a family doctor, have experienced the issue of a nursing shortage for office nurses.  If there is a burnout in the hospital, traditionally the nurse would be interested in a 5-day, 40-hour-a-week job, [but] still there is a shortage. 

 

Perhaps you have the numbers for how many nurses we actually have in Nevada, working or not, and where we stand with the actual number of people with nursing degrees that live in Nevada, per capita, versus the other states.

 

Maryanne Salm:

It is contained in the report [“Where Have All The Nurses Gone?”] but I do not have those numbers off the top of my head.

 

Assemblywoman Leslie:

I do not think I heard any testimony on this and I think it is a really important part of this bill, which is the mandatory overtime provision.  Could you say a few words about what Section 24 [of A.B. 313] does and the whistle-blower protection.  That is a concern I have had for a long time.  If you have a nurse working 12-16 hours [a day] and she is required to continue working, that is a lot of hours.

 

Assemblywoman Giunchigliani:

I do not have the actual numbers, but I have a neighbor who is a nurse and she called me about this exact matter.  One of the reasons she left the profession was because of the overtime. 

 

We have requirements for driving trucks, flying airplanes, and driving a school bus, but we do not have a standard for nurses and patient care.  That is absolutely key to the job because you do not want someone accidentally making a mistake.  [Referring] to the Interim medical malpractice issue, we put in whistle-blower language for the very purpose of protecting doctors, nurses, and other hospital personnel so they would not make careless errors solely because of someone’s tiredness.  I would argue that the doctors should have one as well.  It just makes common sense.  The whistle-blower language is absolutely key to me.  No matter what we do with this legislation, I think we have to have good numbers and we do not have good numbers now.

 

We need to have the hospitals begin reporting all staffing by area, by RN, LPN, CNA, so we have a good picture of what is going on in Nevada, rather than just always being compared to other states.  Those are two key provisions in [A.B. 313].

 

I received e-mails from a lot of nurses as well as administrators.  I know that there is a concern about this.  I have a concern about one woman who was mandated to come in and oppose this bill as one of the employees.

 

My answer to the hospital associations is, “let us work together.”  This is not about “us against you,” this is a partnership for patient care.  If they are threatening employees, what are they afraid of?

 

Glenda Canfield, Nursing Policy Director, Service Employees International Union Nurse Alliance, California:

We represent approximately 30,000 registered nurses in California.  In California it is important to know we have almost all the provisions, currently in law or regulation, that are being proposed in [A.B. 313].  We have whistle-blower protection for acute care hospital workers, we have some limits on mandatory overtime, almost identical to the ones in this bill, that were adopted by the Industrial Welfare Commission in California two years ago.  California was the first state in the nation to set any limits on the use of mandatory overtime for health care workers.  Since then, there have been eight or nine states that have passed similar provisions. 

 

[Ms. Canfield, continued]  Why ratios?  Seven acute care units in California hospitals have had exact minimum nurse-to-patient ratios for over 20 years.  They are part of the California Code of Regulations.  They cover nurses who work in critical care units, well-baby nursery, cardiovascular surgery, the operating room, and respiratory care units.  Nurses in California know that ratios work because they have been used for many years.  In 1998, when hospitals began to lay nurses off because of the advent of managed care, nurses got the message and said, “We do not want to work where it is not safe.”  By 1999, California was last in the nation in the number of nurses per 100,000 population. 

 

In 1999, as a result of testimony by nurses in California and over the opposition of every hospital in the state, Governor Gray Davis signed [a bill] that required the Department of Health Services to implement exact numerical minimum nurse-to-patient ratios in every acute care hospital unit in acute care hospitals in California.  There were some exceptions, and small rural hospitals can be granted program flexibility if they can prove that they can deliver care safely in an alternative fashion.

 

The bill did not set exact ratios for every hospital unit, so the state Department of Health Services has been going through the process of adopting, through regulation, these ratios.  Because no ratios were indicated in the [California] bill, several organizations submitted proposals for ratios.  [You were provided with a] chart (Exhibit J) of some of the [staffing ratios and standards] proposed by different organizations.  SEIU presented a complete bibliography and did a study to back up our numbers (Exhibit K).  We researched and contacted every professional organization we could locate in the United States.  Where we could find professional standards, we looked at those in committees of working nurses, and, [where deemed] safe and workable, were adopted.  As a result of our proposal, [California], in the first round of the regulatory process, has produced ratios very similar to the nurse-to-patient ratios in the SEIU proposal.

 

During this process, Kaiser Permanente of California agreed to implement the SEIU ratios and they are currently being enacted in every Kaiser hospital in California.  Before Kaiser started, in southern California alone, Kaiser hospitals had over 2,000 openings for registered nurses.  The last time I talked to Kaiser Los Angeles, a huge hospital employing 1,200 registered nurses, their vacancy rate was under 2 percent.  You might [argue] that Kaiser pays better.  Yes, they do, but they had the better pay before implementation of the ratios, so we know that working conditions [matter].  Nurses will work where they feel it is safe. 

 

[Ms. Canfield, continued]  In the midst of all this process, Governor Davis announced a $60 million nursing workforce initiative package to provide for regional grants in all areas of California so groups, working together, could produce more nurses in underserved areas.  This has resulted in the awarding of grants where employers and colleges can partner together to produce career ladders where employers and labor are partnering together successfully.  The Governor has also signed a bill requiring the colleges to get their acts together to enable nurses to advance up the career ladder.  One complaint of nurses has been that there was nowhere to advance to in nursing.  The community colleges and the California State University system are having to coordinate their prerequisites and their programs so that nurses can matriculate faster.

 

As a result, California is no longer last in the nation in its nurse/population ratio; Nevada is.  For the first time since 1989, there were more nurses coming into California than leaving. 

 

Assemblywoman Angle:

Could you [explain California’s] ratios and are they the same as in A.B. 313?  Also, how do you deal with staffing by CNAs and LPNs and how does that work into the whole care system?

 

Glenda Canfield:

The first question was, “are the ratios [in California] similar to what are in this bill,” and how do we deal with unlicensed support personnel.  The state is still going through the regulatory process to produce the ratios.  The numbers the state has come up with thus far are, in some cases, identical or maybe one number different that what has been proposed in [A.B. 313].  We have every indication that there will be changes to the first proposed regulations that contain ratios. 

 

As far as addressing other staffing in hospitals, in California there is a state-mandated patient classification regulation similar to what is in [A.B. 313].  Those regulations say that hospitals should have a staffing plan based on the severity of illness and acuity of the patient, for licensed and unlicensed staff.  The systems are a mess and do not work and 63 percent of California hospitals were cited for failure to implement the plans. 

Assemblywoman Angle:

I still do not understand how the LPNs and CNAs would work into this [nurse-to-patient ratio].  It sounds as though your ratios are not in statute but in regulation.  Did you pattern yours after another state?

 

Glenda Canfield:

California was the only state in the nation, and continues to be the only state in the nation, with minimum nurse-to-patient ratios, and those now exist in seven hospital units and they are in regulations.  Up until Linda Aiken published her study in October 2002, there had not been a study showing the effects of ratios on patients.  Linda Aiken was able to show that there is a 7 percent increase in mortality for every patient a nurse accepts over four [in number].  The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists make recommendations on ratios and now the Emergency Nurses Association has produced a recommendation on ratios.

 

Unlicensed staff [numbers] in California are determined by the patient classification system staffing plan, an acuity staffing tool.  It looks at the patients on each unit and how sick they are and then the system is supposed to determine the numbers of LPNs, nurse’s aides, and support staff.  JCAHO requires hospitals to produce a staffing system.

 

Chairwoman Koivisto:

Any more questions by the Committee of this panel?  Could I have three people come up to testify at a time and if you have given us written testimony, would you summarize it, please.  We would like to give equal time to both sides to testify, but we are limited in time.

 

Jerri Strasser, Registered Nurse:

[Introduced herself.]  I work in the pediatric intensive care unit at University Medical Center in Las Vegas.  A lot of the testimony you will hear today will focus on the difficulties that nurses face in Nevada hospitals.  You will hear about the disillusionment of nurses who entered the profession to provide personal care but find that they are locked [into] an impersonal system that is increasingly focused on profits rather than on patients.

 

Fortunately, that’s not the story I’m here to tell.  I work at a hospital and in a department where it’s still possible to provide the kind of care that we were trained to give in nursing school.  Because the nurse staffing at UMC is better than any other hospital in southern Nevada, I still have the time to develop a real bond with the children I care for.

 

[Ms. Strasser, continued]  Especially with children, it’s so important to care for their emotional and physical needs.  We can’t just dispense meds and move on.  We need to take the time to sit with a frightened child or a worried parent and ease their fears.  That’s what nursing is all about and that’s why I love this job as much now as when I began 21 years ago.

 

One of the things that gives me the greatest satisfaction is that my daughter has now begun classes to prepare for nursing school, and she sees nursing as I do, as a real calling and not just a profession.  I would hate to see her idealism tarnished, as it is for so many young nurses, by being thrown into a situation with dangerously low staffing.  That’s why A.B. 313 is so important.  Only by ensuring that our hospitals have safe staffing can we ensure that my generation and the next generation of Nevada nurses will be there to give the best possible patient care.  Thank you.

 

Carin Ralls, Registered Nurse, Operating Engineers Local No. 3:

[Introduced herself.]  I am here today to urge you to support A.B. 313.  Technology, which was once thought to decrease the need for nursing care, has actually increased the need for nurses at the bedside.  Our advancements in technology have allowed us to perform surgeries on an outpatient basis today which required a two or three-day stay in hospitals only a few years ago.  Disease processes that were once a death sentence are now being treated with great success.  Yet with these accomplishments our patients are being left in the hospitals sicker.  We have improved the quality of life but have placed quality care in jeopardy.

 

Communities have lost their hospitals to large corporations that appear to be concerned about the bottom line and not the individual.  Nurses are confronted with meeting budget demands, when we need to be concerned about our patients’ needs.  Our own Nurse Practice Act requires us to determine the necessity and appropriateness of health care services for our patients, yet also requires that we know the patient’s eligibility for payment of those health care services.  Our health care system has become a profit-based corporation.  Registered nurses have been assigned more and more job duties and responsibilities.  This has left us with less and less time at the bedside to teach our patients and families proper post-hospital care. 

 

Our time is spent filling out paper forms and not holding someone’s hand.  Nurses are taught in school that their number one job duty is to be a patient advocate, to protect the patient and their rights, and to treat them with dignity and respect.  High patient loads are not allowing us to perform even our basic tasks.  The Nurse Practice Act gives us the right to refuse an assignment that is beyond our ability to care for our patients, yet this option is rarely used for several reasons.

 

[Ms. Ralls, continued]  Nurses run through their minds questions like, “Who will take my patients if I refuse my assignment?  Will I be adding to my colleague’s workload if I refuse?  Will my employer fire me for refusing, or construe my refusal as abandonment?”  Unfortunately, all are valid points in the profit corporation we are employed in today.

 

All of these situations have demoralized the nursing profession.  We are no longer telling our children how rewarding our profession can be.  Nurses are leaving the hospitals and looking for less stressful, less hazardous positions or leaving the profession altogether and changing their careers. 

 

Hospitals and clinics have seen this trend and are now using their staffing levels as an advertisement and recruitment tool.  This vicious cycle of leaving one facility for another, or leaving the profession, only plays against itself and leaves our patients at harm.  Nurses have reported to me having 13 patient-care assignments in a 12-hour day.  Do the math.  Those patients don’t get one hour of that nurse’s time.

 

One nurse told me she had a cancer patient [who] was near the end of his life.  He had no family there to support him.  In the morning when she assessed him, he told her he was scared of dying alone.  She assured him that she would stop by and check him frequently during the day and sit with him if he needed to talk.  She also instructed him on how to use his call bell and to call whenever he needed anything.  I will never forget how she cried when she told me how she had broken her promise.  She said she had been given another patient on her already heavy assignment and when she finally had time to check on her other patient, he had passed away.  She has now left the nursing profession, claiming she will return when she can be a patient advocate for her community.

 

As stated earlier, our hospital patients are sicker, therefore their acuity, or nursing care needs, are higher.  Staffing needs must reflect the acuity of our patients, not the number of beds in a specific area.  Hospitals are required to have an acuity system that calculates the required needs of the patients in their facility.  It is the responsibility of the state Health Bureau of Licensure and Certification to regulate our hospitals.  In August 2001, I reported to the Bureau that during a two-month period of time the neo-natal intensive care unit at Washoe Medical Center was understaffed 69.9 percent of the time.  During that time a traveling nurse had also inappropriately fed three of the babies.  I received confirmation of the investigation which stated they had issued no citation.  I called the investigator to question further.  I was told, “Yes, we found that the nurse had violated Washoe Medical Center’s policy on feeding the infants individually and supervised.”  Washoe Medical Center had removed the nurse and did follow-up education.  As to the understaffing of Washoe Medical Center’s own policy, we feel the nursing shortage in Nevada has affected their ability to staff appropriately.  No patient was harmed, so therefore no issue of complaint.  I was sad to report to the nurses who had been overworked that understaffing is immoral, but not illegal.

 

[Ms. Ralls, continued]  I feel staffing should be addressed at the hospital level.  The nurses and the administration are the first to see the changes in the patients.  I’m sorry to say that the hospital administration has not taken the high road in this controversy.  Both Operating Engineers and SEIU have addressed this issue numerous times with administration and they refuse to acknowledge [there is] even a problem.  Both of us have addressed these issues in our communities, only to hear from the hospitals that staffing levels are adequate.  “Adequate” is not appropriate when it is your child crying and in pain and the nurse has too many children to care for.  Why should we have limits on our daycare systems and not in our pediatric units.  I urge you to support A.B. 313.

 

Lila Alabed, Registered Nurse:

I’ve worked in health care for over 22 years, starting out as a nurse’s aide, graduating as an LPN in 1984, and then as an RN in 1985.  The bulk of my experience has been in cardiac intensive care (CIC), where I have worked since early 1988.  Despite having about three years of experience working with cardiac patients on the telemetry unit, it was necessary for me to have extensive training and complete critical care classes and many weeks of mentorship to qualify to work in CIC.  The reason was because I would be caring for critically ill patients who often needed close monitoring and intervention to survive. 

 

In my early years working in CIC, I never had more than two patients.  Even with only two patients, oftentimes I would have a patient “crash” and my second patient would be reassigned to another nurse, affording me precious time that I could direct to my severely ill patient.  This would enable me to troubleshoot and oftentimes prevent a life-altering or life-threatening event.  The last several years working in CIC has been dangerous.  We hire new graduates  and expect them to hit the floor running with all the knowledge and experience of seasoned critical care nurses.  The patients are at great risk due to the fact that these nurses have practically no knowledge base to draw from and there is often no veteran nurse available to direct them.  They are left to fend for themselves, and though they may try, they often don’t make correct or appropriate decisions.  As a result of this, and the lack of support from management, they find themselves looking elsewhere for employment. 

 

[Ms. Alabed, continued]  As a seasoned nurse, I find that I’m often given an unsafe patient assignment with management expecting me to either “handle it” or be considered inept.  They send patients in and out of the unit with little or no consideration for their health, safety, or comfort.  Many times patients are sent through the system in such a fashion they crash on the new unit and return to the CIC in time to die.  There have been many times that I don’t get a break during my 12-hour shift.  Just because I care for my patients and cannot afford the time away from them, I’m often late in leaving to go home because 12 hours is just not enough time to accomplish all that is expected of me.

 

Sometimes I stay late because the night shift is so badly staffed I stay to help out with the new nurses when they have crashing patients.  For years I did this without indicating it on my time card, but now we have a clock-in and clock-out system, so now management is coming down on nurses who “abuse” the time system. 

 

I have often enlisted the assistance of ancillary staff to help me with patient care despite the fact that it is out of the realm of their responsibility or training.  I cannot remember a time when I didn’t have a family member helping me with their loved one, simply because there was no one else to help.  I will never forget the time I had a monitor tech hold pressure on a patient’s bleeding artery while I went to another room to stabilize a plummeting blood pressure.  This left the entire unit without monitoring from the central monitoring station.  In summary, patients are people.  I refuse to treat them as though they’re products whisking down the conveyer belt in a factory.  I’m tired of trying to continue this façade of quality patient care.  Believe me, it is not the heart that it starts from, it is you, and we need you to make a difference.  Thank you.

 

Assemblywoman Angle:

Looking through the bill, [did] you see the requirements there for reporting and how would that affect your job?  I had an aunt who was a nurse and she became more and more frustrated because more and more of her time was spent doing paperwork rather than caring for patients.  I have found that when I go to the hospital, it is the LPN or the CNA who I see and the RN is at the desk taking care of business there.

 

You were talking about the pediatric care [unit] and who takes care of the babies.  I thought that some of the other unlicensed personnel also took care of babies. 

 

Jerri Strasser:

We do have an all-RN staff in the pediatric intensive care unit where I work.  In the pediatric unit right next door to us, we do have some CNAs, but all assessments are the responsibility of the RN.  They can’t even chart vital signs or take vital signs.  They do help with feeding [and] they do, at the direction of the RN, help with the care.

 

As far as reporting, I have not looked at this bill.  At University Medical Center, I don’t have a problem reporting what goes on.  I know I can go across town and get another job.  I cannot get another license, so l am not afraid to report anything that needs to be reported.  I am the chief steward at the hospital and I do talk to a lot of nurses who are afraid.  I have not read the whistle-blower part of the bill, but I am not afraid to do that.

 

Assemblywoman Angle:

In the bill [A.B. 313] it says that you’ll have to post documentation of your staffing each day.  That was the “reporting” I was referring to.

 

Carin Ralls:

That is the reporting by the facility, which must document and report their staffing levels.  The nurses are covered by the whistle-blowing protection, so if we find that the facility is inappropriately staffing, then we report that part of the problem.

 

Chairwoman Koivisto:

You sound a little confused.

 

Assemblywoman Angle:

Only in that I feel like it will be delegated to the nurse that’s on duty at the time to actually post how many RNs are in that unit that day, rather than an administrator counting noses and posting.

 

Chairwoman Koivisto:

I think what Mrs. Angle is asking is, who’s going to be the one who tracks the staffing levels and makes that report?

 

Jerri Strasser:

The facility is required to keep paperwork for the [number] of nurses and the [number] of patients each day, each shift, [over] a certain [period] of time.  I am a charge nurse.  I make assignments.  I have the number of nurses, the number of patients, a census run by the hospital computer, and I am responsible for keeping those numbers and turning them in to my manager.  Where they go after that is up to the hospital.

 

Chairwoman Koivisto:

We have about 25 minutes left.  Could Lisa Black and a representative of the group down south come to the table, and please limit your testimony to five minutes.

 

Lisa Black, Registered Nurse, Executive Director, Nevada Nurses Association:

On behalf of the Association, I’d like to thank Ms. Giunchigliani for bringing this issue to the attention of the Committee, and would like to thank you for the opportunity to present to you this afternoon. 

 

For the past several years we have been talking about the need to address inadequate registered nurse staffing in the hospital setting as a step toward ensuring patient safety.  Multiple research studies have demonstrated that the safety and quality of care provided in our nation’s health care facilities is directly related to the number and skill mix of the direct-care nursing staff.  More than a decade of research shows that nurse staffing levels and skill mix do make a difference in the outcomes of patients.

 

We have submitted detailed, written testimony to the Committee for review (Exhibit L), so in the interest of time, I will not go into the significant details on the multitude of studies that have examined this issue, but will provide just a brief overview of the pertinent findings.

 

Studies by four U.S. Health and Human Services agencies have found strong and consistent evidence that increased registered nurse staffing is directly related to decreases in the incidences of urinary tract infections, pneumonias, shock, upper gastrointestinal bleeding, and decreased lengths of hospital stay.

 

Our union colleagues have presented data to you from the Journal of the American Medical Association and JCAHO indicating the significant correlation between registered nurse staffing and patient safety.  I won’t repeat this information previously presented, but that information is in my written testimony. 

 

Additionally, when we appeared before this Committee in February, we distributed to this Committee copies of packets that included those actual studies.  A couple of the other relevant studies I offer for your consideration are a 2002 study by Health Insight, Nevada’s contracted Medicare peer review organization.  They conducted a study of medication errors in Nevada and Utah in which over 70 percent of the respondents were nurses.  This study showed that 60 percent had observed at least one stage of a medication error during the last month.  The study also included a “comment” section allowing the respondents to describe what they felt contributed to the error.  Responses included descriptions of time pressures and excessive work loads. 

 

[Ms. Black, continued]  The last study I would like to offer for your consideration is presented in a 2003 study conducted by the National Council of State Boards of Nursing in which the new nursing graduates who had been practicing for six months were surveyed to determine workplace factors that contributed to medical errors.  Seventy percent of these new registered nurses cited inadequate staffing as the primary contributing factor to medical errors in the workplace.

 

In short, the testimony you’ve heard offers compelling evidence that nurse staffing remains a significant problem in our health care facilities.  Adequate staffing allows nurses the time they need to make patient assessments, to complete nursing tasks, to respond to health care emergencies, and to provide the level of care that our patients deserve.  More importantly, increased registered nurse staffing levels lead to increased patient safety.  Fundamentally this is not a nursing issue, this is a safety issue for all of those who seek care in Nevada’s health care facilities.

 

As you will hear shortly, there are many in the health care industry who do not feel that it is appropriate to legislatively dictate issues such as registered nurse staffing.  Multiple other options have been sought and, regrettably, have consistently failed.  Many of the same people who will come before you today have participated with the Nevada State Health Division four years ago to promulgate regulations that require nurse staffing levels to be based on patient acuity as measured by a direct care registered nurse.  These regulations have not adequately improved nurse staffing in Nevada’s hospitals and have done little, if anything, to improve patient safety.

 

We do recognize that addressing and remediating this issue is truly a monumental task and that it may quite possibly be beyond the scope of this Committee to fully address this issue during this session.  We ask that this issue be commissioned for study by the Interim Health Care Committee so it can be adequately and thoughtfully deliberated and sound solutions can be achieved to ensure the future of Nevada’s nursing workforce.

 

The nursing shortage we face will remain and likely worsen if adequate steps are not taken to address it from multiple angles.  Changes in the workplace must be addressed simultaneously with any effort to recruit nurses into the profession or we will not be able to retain the nurses we train.  The profession of nursing will be unable to compete with the myriad of other career opportunities available in today’s economy unless we improve working conditions simultaneously with recruiting new nurses.  We must address the concerns of registered nurses at the bedside.  Registered nurses, hospital administrators, nursing administrators, and other health care providers, health system planners, consumers, and the legislative community must come together in a meaningful way to create a system that supports quality patient care and all health care providers.

 

[Ms. Black, continued]  In conclusion, the Nevada Nurses Association looks forward to working with you and others to make our current health care environment conducive to high quality nursing care.  Improvements in the environment of nursing care, combined with aggressive and innovative recruitment efforts, will help avert the potentially catastrophic consequences of this very real nursing crisis.  The resulting stable nursing workforce will improve health care for all Nevadans.

 

Chairwoman Koivisto:

Thank you, Lisa.  Questions from the Committee?  [There were none.]

 

We have about 10 pages of people who have signed in to testify either in support or in opposition to this bill [A.B. 313].  We have given a lot of time to the supporters of the bill.  I know a lot of nurses flew up and drove up from Las Vegas, but unfortunately we will not be able to take any more testimony from the nurses.  Could we have all the nurses and [other] folks in support of this bill stand up, please.  Thank you.

 

If I could have the folks who signed up to speak in opposition to [A.B. 313] come forward as panels as well, I’d appreciate that.  Thank you.

 

Jim Wadhams, Nevada Hospital Association:

[Introduced himself.]  I would like to make a couple of more general comments to start this part of the presentation.  I am perplexed in some respects at this issue because, particularly those of you who reside in southern Nevada, are very well aware of the critical situation we face down there in terms of medical resources.  We had a day during the legislative session when, for four hours, there was a shutdown in Clark County.  That did not occur for any reason other than a lack of personnel.  The problem is we have exacerbated our tremendous nursing shortage and now [there is] a physician shortage as well.  You have probably read in the newspaper how that issue is affecting emergency rooms in such hospitals as Desert Springs. 

 

Against this backdrop, I have to take issue with some of the statistics we heard.  While many of those may have been derived from national studies, they are not supported by an analysis of Nevada numbers.  The number of registered nurses [from the State Board of Nursing] has increased each year.  We have surveyed our hospitals and have been unable to find any hospital that reduced the number of registered nurses in the 1990s.  We have more nurses employed today than we did a year ago, and more a year ago than we did two years ago.  We echo the position that I believe the SEIU and other prior speakers take, [that] we need more nurses.

 

[Mr. Wadhams, continued]  The acuity of our hospitals, in many respects due to managed care, is much, much higher.  The number of surgeries that are done on an outpatient basis is multiples today of what it was ten years ago.  The intensity of the activity in a hospital is going to be great.  Against that backdrop, we have the tremendous growth in southern Nevada.  The issue becomes community access to care.  It is not a hospital issue, it is a community issue.  It is a citizen issue.

 

I understand that this legislation [A.B. 313] is patterned after California.  I would suggest that it is not.  California has done this by regulation, which has not yet gone into effect, rather than by statute.  As this body knows, when you [enact] a statute, that’s the end of the discussion for two years.

 

Arbitrary staffing ratios ought not to be set in that environment.  The current state system, mandatory staffing ratios, the Bureau of Licensure and Certification is responsible for that.  All of the major hospitals in southern Nevada are JCAHO accredited and they also have mandatory staffing ratios.  The suggestion that there are no staffing ratios is not correct.  What this bill does is legislates mandatory, arbitrary staffing ratios as opposed to the flexible standard that can be adjusted to the circumstances at the time. 

 

During the 17th Special Session, Ms. Leslie personally oversaw whistle-blower protection on life safety issues.  That is important and she did a tremendous job negotiating after about 92 consecutive hours of legislative activity. 

 

The point I want to make is that the numbers of registered nurses have increased from year to year.  That doesn’t mean there hasn’t been turnover, but there’s not been a deterioration in the [numbers] of nurses working in hospitals.  The statistics from the Nevada State Board of Nursing indicated we had [approximately] 14,000 employed nurses resident in Nevada; 6,500 of those work in hospitals.

 

If the suggestion is that we should just cross-recruit against the other employers of nurses, that just shifts the shortage, currently about 1,300 nurses, from the hospitals to the other employers of nurses, which would be the clinics, the outpatient surgery centers, health plans, and the like.  That shortage needs to be addressed.  The Nevada Hospital Association has attempted to organize a broad-based coalition that would increase the number of nurses.  They have instituted legislation supported by the Board of Regents for a “nurse doubling plan” because our nursing programs have not kept up with the pace. 

 

[Mr. Wadhams, continued]  I think the point that I would like to leave the Committee with is this is not a hospital issue.  It is a patient care issue, it is a citizen issue.  If this bill [A.B. 313] were to go into law today, the hospital shrinkage would be dramatic and it would impact no one except your constituents.  Our ambulances now are required to idle at the hospital door for up to 60 minutes before going back out and picking up other critically injured patients.  If we restrict the capacity of the hospitals by imposing an arbitrary standard such as this, your constituents will be in the parking lot rather than inside.  That is not in any way to suggest that nursing care [is not important].  We need more nurses, but this is not an issue of setting an arbitrary ratio; it is an issue of generating the capacity to treat the community and treat them in a timely manner.  I appreciate your attention and I suspect I’ll have some people who have far more information with more ability to answer questions than I, but I offer myself to questions, Madam Chair.

 

Assemblyman Horne:

You talk about the arbitrary ratios, but if we have flexible staffing from hospital to hospital [and therefore] different standards, wouldn’t that itself be arbitrary?  From the testimony I heard today, it seems that the flexible staffing ratios isn’t working.  Assuming that that’s true, what would be your solution?

 

Jim Wadhams:

The problem is a misunderstanding of the “mandatory staffing” that is currently incumbent upon the hospitals.  It is based on a shift-by-shift determination.  It depends on the acuity of the patients in the unit and the nurses available.  You’ll have a registered nurse that will actually make the appropriate assignments for that shift.  If the acuity of the patients in that unit changes, then the staffing pattern will change as well.  Hospitals are required to maintain those records and the state Bureau of Licensure and Certification, which Session before last had their budget increased to increase the number of [examiners], [monitors] that issue.

 

The problem I’m suggesting here, Mr. Horne, and this was testified to by a prior witness, they went through a considerable period of deliberation with different proposals as to what this might be if you were going to set an arbitrary number, irrespective of the acuity of the patients at any one time in a facility.  That really suggests the problem.  You have to do two things:  You have to consider the acuity of the moment of that shift; and you have to do it in a deliberative process rather than legislate it and hope it works.  If you were to pass this bill [A.B. 313] today, the problem you will cause—[those staffing ratios] cannot be met.  The numbers I have been given is that 106,000 admissions will not occur because the capacity will not be able to absorb those admissions.  When you translate that to people, that means that human beings will not be able to [gain admittance] into the hospital or a bed for their care.

 

[Mr. Wadhams, continued]  We’ve got to understand the difference between setting an arbitrary level today in the Legislative body, versus registered nurses on site, on a shift, evaluating the criticalness, or the acuity, of the patients in that unit and making a professional judgment at that time.   

 

Assemblyman Horne:

I don’t know if you answered my question.  If the current method isn’t working, which is the testimony we’ve been hearing, what would be the solution?  We can’t just [take] the position that the testimony we just heard was wrong.

 

Jim Wadhams:

I’m not suggesting it’s wrong.  We need more nurses.  We need 1,300 nurses today to fill the staffing patterns we have.  There is no system, whether it be legislated or developed on-site by nurses, that will meet that need until we have the requisite number of nurses.  That is the problem.  We need to develop an adequate number of nurses.  I agree that when we have more nurses, the care is likely to be more comfortable for the patient.  The current system could work better and to make it work better we need more full-time nurses rather than temporaries we have to bring in to fill the vacancies that we have.

 

Assemblyman Horne:

Can you address Ms. Salm’s testimony that our turnover rate is higher than the national average?

 

Jim Wadhams:

Our turnover rate is high because we have a relatively transient population.  The fact that we have more nurses employed today than we did last year does not suggest that we have a net decrease in nurses.  It suggests that people are willing to come, but the turnover occurs for two reasons:  Either their circumstances have changed and they’ve gone someplace else, or they’ve made a choice of the various modes of employment.  Out of 14,000 employed nurses, 6,500 are in hospitals.  That doesn’t mean that the other nurses aren’t employed utilizing their skill, training, and experience, but they’ve made a choice, as we all do, [about] how we might use our skill, training, and experience.  [For instance], not every lawyer has to be a litigator.

 

Chairwoman Koivisto:

I have an amendment here, offered by the maker of the bill [A.B. 313].  If the Committee believes that this is an important issue, but that we won’t have time to come to any kind of agreement on numbers or even to get the sides to come close to any kind of agreement, she is requesting that the Committee rewrite the bill as an interim study and rerefer it to Elections, Procedures, and Ethics, and then it can be looked at.

 

We’ve had a number of these hearings and they’ve all been very rushed, and there’s not enough time to take all the testimony that should be heard.  I’m mentioning that for consideration by the Committee.

 

Mr. Welch, go ahead, please.

 

Bill Welch, President/CEO, Nevada Hospital Association:

We have a number of people who would like to have the opportunity to speak, whether that would be today, or whether it would be more appropriate to present our testimony to the [interim] committee.

 

Chairwoman Koivisto:

Thank you, Mr. Welch.  We are going to recess as a Committee and reconvene at whatever time the Education Committee gets done tonight.  For the information of the Committee, we have some [bills] to vote out tonight, so you’ll need to be here.

 

I don’t think we’ll come to any kind of conclusion on the discussion of staffing levels or having staffing standards in place.  I agree with your thought that the discussion can take place in the Elections, Procedures, and Ethics Committee.  I do apologize to all the folks who came to testify.  This is just one of the things that is the result of the 120-day session.  We’re very limited in time that we can allow people to testify, and it is important.  Public testimony is so important and we are not getting all that we should.

 

Mr. Welch?

 

Bill Welch:

Thank you, Madam Chair.  If I could take about three minutes, I would like to clarify a couple of points.  I promise to keep it very brief.

 

A couple of points need to be clarified as this bill [A.B. 313] moves in another direction to another Committee.  As Assemblywoman Chris Giunchigliani presented, when we produced our report in 2002, the shortage of nurses was 670 in the hospital environment only.  Since that time, that has evolved, based on our update of that study, to approximately 1,300 nurses.  This bill [A.B. 313], if it had [become law], could potentially have increased that shortage to 2,900.  The suggestion that there are nurses “out there” in the environment to pull back into the hospitals is a concern to me. 

 

[Mr. Welch, continued]  We know that the challenges are great in the health care industry and the challenges are great in the nursing environment, but one of the things that has happened that gives nurses an alternative today that was not in place 20 years ago is that over 50 percent of health care is now initiated outside the hospital setting.  [This creates] many opportunities for nurses to work outside the hospital setting.  In fact, more than 50 percent of the nurses nationally as well as in this state do work outside the hospital setting.

 

When I was a hospital CEO [chief executive officer] back in the early 1980s and I did my strategic planning, fewer than 15 percent of our surgeries were done on an outpatient basis.  As I left that hospital in 1990, more than 50 percent were done on an outpatient basis, and that trend has continued to grow since.

 

We need 700 new nurses a year, 65 percent to deal with the growth that others have testified to.  Our education system, with a lot of financial support from many folks, predominately the hospital community, delivers approximately 380 nurses.  Each year we fall behind just [because of] the growth.  It is an extremely difficult situation, yet our population continues to grow, almost at double digits.  It is the fastest-growing population in the Union. 

 

We are committed, and, Madam Chair, as you know, we have been working with you and other leadership in the Assembly to try to come up with strategies and funding to help expand the nursing education opportunities in the state so that we can produce more nurses.  The hospital community agrees [that] we need to employ more nurses.  We’ve been doing many, many things to do that.  We spend approximately $24 million, as you know, Madam Chair,  annually to try to address this problem, and we are committed to continuing to do that.

 

The last thing that needs to be really clear is that California did pass numerical staffing ratios in 1999.  It is now 2003, they have not been able to apply those [staffing ratios], and as the witnesses testified, there are many reasons for that.  One of the main reasons was that they did not have adequate [numbers of] nurses to deliver the ratios and still meet the patient volume that they were providing care for.  [Staffing ratios] have been deferred and it has been a very complicated issue in California.  We have tracked it very carefully.  I would just like to clarify that mandatory numerical staffing ratios in California are not in law at this point in time; they are scheduled to go in law in January 2004, and at that time, they will be phased in over a number of years.  They will not be implemented in their entirety on day one.  If you look at the California law, the ratios will be phased in over time.

 

I felt it was important that you understand some of those points that were made today.  Thank you, and I would be happy to answer any questions.

 

Assemblyman Horne:

I’m curious [about] the absence of physicians [testifying] on this bill [A.B. 313] and how it affects them in how they care for their patients in hospitals where the ratios are adequate or inadequate.  I think that would be important information, and maybe the doctors on our panel have some anecdotal evidence.

 

Assemblyman Hardy:

We love nurses.  They take wonderful care of our patients.  They keep us out of trouble!  They keep us honest, so staffing is important and we recognize the shortage that is statewide, nationwide, in reality.  We’re recruiting against other states and other areas.  The 4,000 [nursing applications] that are waiting to be processed [indicate that] we need to perhaps look at legislation to have a very short application to come here.

 

Assemblyman Mabey:

I’ve had a lot of personal experiences with this.  I work mainly in labor and delivery at the hospital and it’s not uncommon [that], if there needs to be an induction and there’s just not enough nurses, it gets cancelled.  You get postponed until there’s enough nurses to take care of your wife.  I really appreciate the testimony.  I think both sides are right and I think we need to sit down and work out these issues.  Thank you.

 

Assemblywoman Pierce:

I just want to say that when you’re looking for an executive, an administrator, and you send a “head hunter” out, basically, in order to entice someone away from another company, you offer them more money and better working conditions.  It just seems odd to me that somehow we don’t think that’ll work with nurses.  If you want to end the nursing shortage, raise the pay and make the working conditions better.  It works with executives.  It’s a basic tenet of business, but somehow when it comes to nurses and teachers, we think that somehow that won’t work, that we need to try something different, because women don’t want more money and better working conditions?  I think that that’s not true.

Bill Welch:

Madam Chair, if I might address Assemblywoman Pierce.  I don’t disagree with your comment and in fact, we were prepared to testify to that today, however, out of respect to the Committee, we are deferring that testimony.  The Nurse Institute, if you will review our testimony here (Exhibit M), many things are being done to try to improve the workplace environment because we recognize many of the issues the nurses are raising are valid issues.  We are working collaboratively with the body Mr. Wadhams referred to in testimony, to try and change that.  We can’t change what has evolved over many decades, in [just] a few years.

 

When Assemblywoman Koivisto brought this [idea] in 1999, we listened and have been trying to be responsive ever since.  We created our Nurse Institute in January 2000 as a result of the legislative issues we dealt with in the 1999 Legislative Session.  Many of our hospitals had instituted retention programs.  We have a “chief retention officer” now in 22 of the hospitals in the state.

 

We’re giving signing bonuses, as you would to a CEO.  We’re giving retention bonuses, as you would give to a CEO.  All those things are being done.  At the appropriate time we have many witnesses who are prepared to testify to that.

 

Chairwoman Koivisto:

Thank you.  The suggested amendment is that we have the bill rewritten as an interim study and forward it to [the Assembly Committee on] Elections, Procedures, and Ethics.  Pleasure of the Committee?

 

ASSEMBLYMAN HORNE MOVED TO AMEND A.B. 313 AND REREFER IT TO THE ASSEMBLY COMMITTEE ON ELECTIONS, PROCEDURES, AND ETHICS.

 

ASSEMBLYMAN HARDY SECONDED THE MOTION.

 

THE MOTION PASSED UNANIMOUSLY.

 

Again, let me offer my apologies to all of you who came to testify and were not able to testify.  If you’ve signed in, in order to testify, you are on the record whether you were in opposition or support.

 

Committee, we are not adjourned, we are recessing and will reconvene at the end of [the meeting of the Assembly Committee on] Education.  For those of you who might have subcommittees scheduled, a standing Committee takes precedence.

 

[The Committee recessed at 4:00 p.m. and reconvened as a subcommittee at 6:46 p.m.]

 

Chairwoman Koivisto:

We’ll come back to order and we’ll start as a subcommittee on A.B. 503.

 

 

Assembly Bill 503:  Revises provisions relating to medical use of marijuana. (BDR 40-1248)

 

Don Henderson, Acting Director, Department of Agriculture:

Thank you for this opportunity to present to the Committee an introduction on A.B. 503.  Basically the provisions of this bill resulted from a year and a half of the Department administrating the Medical Marijuana Program.  We’re offering several improvements to the program.  The intent of these changes is to provide clarification and to close some loopholes that have been identified in existing statutes governing this program.  The overall intent is to clean up some of the loose ends for more efficient and cost-effective administration of the program. 

 

Madam Chair, we’ve handed out an information packet to you (Exhibit N) that summarizes the program’s statistics to date and goes into depth on the major provisions associated with A.B. 503. 

 

Chairwoman Koivisto:

Because it’s still against federal law, where do we stand with that?

 

Don Henderson:

Being in possession of marijuana is still against federal laws.  The existing program was very carefully crafted to try to stay below the federal “radar screen.”  The participants in the program get a disclosure statement from their doctor saying that they have some qualifying disease.  In effect, all we’re really doing through this program is eliminating state prosecution for the possession of marijuana for those persons registered in this program, as long as they retain less than an ounce in their possession and [have fewer than a certain number of] plants.

 

The other characteristic of this program that’s unique is that it’s actually a grow-at-home program.  These participants in this program need to acquire the medical marijuana seeds or plants on their own, the state does not assist them, and there’s a [maximum] amount that they can grow.  [The participants] are still open to federal prosecution.  What’s unique and built into A.B. 503 is the thought of keeping [the number of marijuana plants] below [a certain number].  We do not want to have caregivers or participants in this program to get together and grow a massive amount of medical marijuana at a single location, like the situation we see in California.  One of the provisions [in A.B. 503 would] clarify that [there be] no more than two participants or caregivers having one production site or facility.  That’s important [because] the statutes today are rather silent in that regard and we wanted to clarify that point.

 

Assemblyman Hardy:

This is more a statement.  I have a problem with things that are illegal in one place [where] I live and semi-legal in another place [where] I live and us participating in that process.  Likewise, I have a problem with the basic concept of medical marijuana. 

 

Assemblywoman McClain:

Who actually enforces this on the state level?  Who knows whether somebody’s got 1 or 2 or 50 plants?  Where do we get the seeds?

 

Don Henderson:

I think there’s a variety of options for the citizenry to get the seeds and start growing.  I understand that on the Internet that [instructions about] how to do it [are] readily available.  State employees cannot advise or give advice in that area and my staff does not.  We leave them to their own devices. 

 

In terms of who enforces it, the enforcement would come from local law enforcement.  If for some reason they go into a residence and see numerous medical marijuana plants, the first thing that they’ll do is to check and make sure they’re [participants] in our program.  The participants in our program are registered through NHP [Nevada Highway Patrol] records, so it’s readily available through their monitors.  If they’re not in our program, then [local law enforcement] would proceed through their normal course of legal action.  If they are in our program, [local law enforcement officers] must make a determination [whether] they are in compliance with our program, which is to have not more than seven plants, three mature and four immature plants.

 

Assemblywoman McClain:

Are you raising the [number] of plants they can have?

 

Don Henderson:

No, we’re not.  All we’re trying to do is define that you can have no more than two participants, or one caregiver and a participant, or two caregivers, growing or producing medical marijuana at one site.

Chairwoman Koivisto:

Are they limited in how many plants they can have?  [Mr. Henderson reiterated that they can have a total of seven plants per registrant in the program.]  Does that get them under the level where they would be liable for federal prosecution?

 

Don Henderson:

I don’t think that’s the case.  I’m not too familiar with the federal requirements, [but] I think if you’re in possession of any marijuana, you’re not in compliance with federal requirements.  All this program does is remove [the participant] from state or local prosecution.

 

Assemblywoman McClain:

As I recall, when we passed this, we were going to make it [possession of marijuana] legal if you need it for medicinal purposes, but we’re not going to help you get it, tell you where you can get it, [or] show you how to grow it. 

 

Don Henderson:

That is correct, and that’s still the case with A.B. 503.

 

Chairwoman Koivisto:

So [A.B.] 503 is just defining a “propagation facility,” “attending physician,” and “useable marijuana,” adds an additional exemption for situations exempt from prosecution, and clarifies that the state Department of Agriculture is only authorized to issue registry identification cards.  [A.B. 503] makes changes about the type of identifying information that must be provided to a person’s primary caregiver and authorizes the Department of Agriculture to establish regulations governing fees for an application for a registry identification card and for processing and issuing the card.

 

Don Henderson:

That is correct, Madam Chair.  The only thing I might add to those points that you bring out in A.B. 503 is [that] we also are clarifying what a “resident of Nevada” is.  The preamble in the original act stated that this is for residents of Nevada, but the actual statutes involved with that did not define what a “resident” was.  We’re clarifying that by basically adopting the definition of NRS [Nevada Revised Statutes] 483.141, which is what DMV [Department of Motor Vehicles] uses for drivers’ licenses.

 

Chairwoman Koivisto:

Though in actual fact, all the state really does is issue identification cards and maintain a registry.  [Mr. Henderson agreed with Chairwoman Koivisto.]

 

Assemblywoman Angle:

Could you clarify “propagation facility” for me?  It says that it is “privately owned, real property.”  Does that mean that someone who’s growing [marijuana] has to own real property, they couldn’t be renting?  It would have to be their property and they would have to have the [registry identification] card in order to grow [marijuana], is that what that means?

 

Don Henderson:

Yes, it has to be on private property.  There’s several options.  A participant in this program can identify a “caregiver” and the caregiver can grow the medical marijuana on their property.  The actual wording in [A.B. 503 of] “real property” was something that the Legislative Counsel Bureau [LCB] added during bill drafting.  In my mind, and not being a lawyer I’ll Iet LCB legal staff clarify this, but it does not say that it has to be the real property of the registrant or the program participant, I don’t believe.  I think it just says it has to be on real property, or private property.

 

Assemblywoman Angle:

It says, “who holds a valid registry identification card issued to him pursuant...,” and earlier on it says “means parcel of privately owned real property on which a person who holds...,“ so to me, it’s the guy who has the registry card.  It has to be property that’s owned by him.  My question [would be] if he’s renting from someone, then he can’t grow in his back yard because he doesn’t own that property.  Is that correct?

 

Don Henderson:

I don’t read it that way.  I think there’s enough “wiggle room” in that definition that it could be a rental situation.

 

Assemblyman Hardy:

When I read it, I read it that same [way] on rentals, and I thought it was probably wise to not have a rental property being used for propagation simply because if there were one too many plants and then it became illegal [in Nevada], then you get into drugs and seizure laws.  Then you seize things that may not pertain to the person who [propagated the plants] and may not be the owner [of the property].

 

Assemblyman Horne:

As I read this, it is only stating that the property on which it’s grown has to be private property but the person growing it has to hold a valid registry [card].  However, [Assemblyman Hardy] makes a very good point.  Even if we pass this [A.B. 503], there is nothing to stop the feds from coming in and seizing that property.  Even if I’m a property owner and I rent [my property] to somebody who has a registry [card] and chooses to grow marijuana on it, they do that at their own risk.  The feds could come in and seize that property.  They’ve been known to do that in other jurisdictions, but I don’t believe that’s on us.

 

Assemblywoman Angle:

That was the point I was getting to.  I believe that we should make very clear that we’re protecting property rights here, because if a renter were to do that and someone’s property [were seized]--I have some rental properties and I don’t know if they’re growing in their back yard.  I don’t even have the right to go in there and find that out.  If they were to violate the law and then my property [got] seized, I’m left kind of loose there.

 

Assemblyman Horne:

I don’t believe that the state can protect your property rights in this because of the federal issues.  You may be able to protect it from the state if the state were to have something in the statutes saying that “where you use your property to grow illicit drugs, we can seize your property,” but you can’t put a provision in the statute to protect the property from the federal government if the federal government is exercising its rights to enforce a federal law.

 

Chairwoman Koivisto:

Mrs. Angle’s concern is that someone renting a piece of property could grow the marijuana and the property owner would be the one who would lose the property.  [Is] there were some way we could clarify in that section that they couldn’t grow these seven plants except on property they owned themselves?

 

Assemblywoman McClain:

Now you have just eliminated a class of people who don’t own property and probably qualify for medical marijuana.

 

Don Henderson:

The “propagation facility” concept in this definition came from LCB legal staff.  This is not something the Department requested.  We just requested provisions and wording that would prevent more than two individuals growing medical marijuana at one site.  The legalities associated with that definition is something we need to take up with LCB legal staff.

 

Assemblywoman Weber:

[Referring] to the “propagation facility,” can this [medical marijuana] be grown anywhere on the property?  Does it have to be behind a block wall?  Does it have to be covered?  I’m just trying to think of neighbors.  Do dogs get sick if they eat it?  I really would like to understand how this is going to work.

 

Don Henderson:

The ability of an individual to grow medical marijuana is already in the statutes.  As I understand the statute, there’s no provisions; all the individual needs to do is identify to the state where they are growing it, and that information is kept confidential, by statute.  There are provisions within the existing statutes that restrict or limit where you can use medical marijuana.

 

Assemblywoman Weber:

In other words, it’s in a different [statute] than what we’re looking at tonight.

 

Don Henderson:

That is correct.

 

Chairwoman Koivisto:

I see more confusion that when we started.  Let me [explain] for the new folks on the Committee.  This bill is clarifying the bill that we passed last session to legalize medical marijuana.  This bill [A.B. 503] makes some definition and technical changes to that statute.

 

Don Henderson:

Madam Chair, if it would help the Committee, I can explain the existing program to you.  [Chairwoman Koivisto agreed to the suggestion.]

 

I anticipated this might come up, so I brought this flow chart, which basically outlines the registration process and many of the important components.  This medical marijuana bill was passed by the last session.  Basically, you have a patient that comes to the Department of Agriculture and they request an application form. 

 

The application form is actually several forms, there’s a waiver form, acknowledgement forms, and information forms telling them what their legal rights are and are not under this program.  The information packet goes out to the patient.  The patient has to get from an attending physician a diagnosis, a statement from the physician that they have one of the qualifying chronic, debilitating diseases.  What the legislation identifies as “chronic, debilitating diseases” are AIDS, cancer, glaucoma, and medical conditions involving cachexia, muscle spasms, seizures, severe nausea, and severe pain.

 

They fill out all the information we asked for in those application packets, such as where they planned to grow the medical marijuana, and, if they are having a caregiver, who that caregiver is and what their address is.  They include the physician statements, submit a fingerprint card, sign an acknowledgement that they understand all the limitations and restrictions associated with this program, and submit it back to the Department of Agriculture. 

 

[Mr. Henderson, continued]  The Department of Agriculture sends the physician’s statement to the Board of Medical Examiners to make sure that doctor is qualified under this program, which [would be] those physicians currently registered under NRS Chapter 630.  The Board of Medical Examiners reports back to us.  At the same time, we submit the application to NHP [Nevada Highway Patrol] records to check if this individual has had, in the past, a conviction [for] selling a controlled substance.  Those are the two qualifying criteria for this program.  If either one comes back negative, we cannot, by statute, approve that application.

 

Assuming that they both come back affirmative, the Department of Agriculture notifies the applicant and DMV that this person can obtain a registry card into the program.  We have 30 days to do this whole process once we receive the completed application.

 

At that point the individual would go down to DMV and obtain the registry card, which looks just like a Nevada driver’s license card.  If they have a caregiver, information on the caregiver is also printed on that card.  At the same time, NHP enters it into their database so local law enforcement and state law enforcement are aware that this individual and/or this caregiver are enrolled in this program.

 

Assemblywoman Angle:

Where are they growing it?  That’s where our questions have been and why I have concerns about property owners and [what] their liabilities are going to be in this.  I think Ms. Weber brought up some good points about who’s going to have access to [medical marijuana] if it’s grown out in the open.

 

Chairwoman Koivisto:

I’m not sure that anybody would grow it out in the open.  I don’t see that happening; somebody’d steal it.

 

Mr. Henderson:

I think that’s a very good point.  These plants do have some value. 

 

From a program requirement perspective, all they have to do is disclose to us where they’re growing [the medical marijuana].  All the information is confidential information.  If they move they must notify [the Department] within a short period of time.  If we find out about [a change in residence] we can cancel their card.  The registration card is only good for one year.  They have to go through the same process after a year, get a physician’s statement and reapply.  The only thing they do not have to resubmit is the fingerprint card, which we will maintain permanently.

 

Chairwoman Koivisto:

Are there more questions from the Committee?  This [A.B. 503] is just cleanup language to help the Department do what they have to do.  You’re offering an amendment?

 

Don Henderson:

Yes, Madam Chair.  We are offering a friendly amendment (Exhibit O).  By statute, “qualifying attending physicians” are those registered under the state [Board of] Medical Examiners.  There is another whole area of doctors that get involved with medical marijuana, the osteopaths.  A.B. 503 would modify the existing statutes to allow those doctors that are registered with the Board of Osteopathic Physicians to also be qualified as attending physicians and sign the attending physician’s form.

 

With that change being made, we noticed that there are a couple of other places that needed [amending].  If you approve A.B. 503 we would put a provision in that the Department also send, where appropriate, [one copy of the application] to the Board of Osteopathic Medicine.  Similarly, there’s an existing statute that says that if a physician who signed that statement was not in good standing [with their professional board], that’s reason for the Department to deny the application for this program and we’d like to add to that wording on page 5, lines 30-31, “or Board of Osteopathic Medicine.”  

 

It’s a housekeeping thing, one of those things that got missed through the bill draft that we’d like to add if you’re going to move ahead on this bill.

 

[Without discussion, Chairwoman Koivisto indicated she would accept a motion on the bill.]

 

ASSEMBLYMAN HORNE MOVED TO AMEND AND DO PASS A.B. 503.

 

ASSEMBLYWOMAN McCLAIN SECONDED THE MOTION.

 

Assemblywoman Angle:

I’m going to disclose that I won’t be voting on this bill until I have some clarification from Legal on property rights.

 

THE MOTION CARRIED.  (ASSEMBLYWOMAN ANGLE ABSTAINED.  ASSEMBLYWOMAN WEBER AND ASSEMBLYMEN HARDY AND MABEY VOTED NO.)

 

[The Committee took a short recess.]

 

Chairwoman Koivisto:

We are going to go into our Work Session (Exhibit P) and start with A.B. 112.  We heard this on February 19 and I’m going to have Marla [McDade Williams, Committee Policy Analyst] explain it to us.

 

 

Assembly Bill 112:  Requires examination by trained provider of health care of each child under age of 3 years who is reported as physically abused. (BDR 38-692)

 

Marla McDade Williams, Committee Policy Analyst:

We heard Assembly Bill 112 on February 19.  This bill requires examination by a trained provider of health care of each child under the age of three years old who is reported as physically abused.  When we heard the bill, we had asked people who were interested in it to go back and see if they could come back with an amendment to accommodate everyone’s concerns. 

 

They were not able to do that.  Mr. Cotton, who’s the Administrator for the Division of Child and Family Services, indicated that he had support of all the other participants, Clark County and Washoe County, to draft regulations to move forward in this respect.  Right now, that’s where it stands.

 

Assemblywoman Weber:

Was the fiscal note revised on that or was that discussed at all?

 

Marla McDade Williams:

I don’t believe so.  I think that was one of the issues they still needed to overcome.

 

Chairwoman Koivisto:

I think our option with this bill is we can IP [Indefinitely Postpone] this bill and we can send a letter supporting the concept to the Division, if that’s agreeable to the Committee.

 

Assemblyman Hardy:

The issue was that the medical costs are not covered by the state unless already under Medicaid.  So the children under Medicaid would be covered and the children not under Medicaid wouldn’t be covered by the state, but one of the issues would be [that] the parent who is accused of abusing the kid becomes responsible for the [emergency room] bill, [or the bill from whoever the medical provider was].  We’ve put a financial burden on [the parent] even if it was a wrongful accusation.

 

Chairwoman Koivisto:

That may have been one of the issues we were dealing with that [could] not be worked out.

 

Assemblywoman Leslie:

Having served on the interim committee, I think the real issue is that we don’t have enough trained health providers in child abuse.  Until we can get the training, and a lot of people don’t want to be trained in that particular subject, and until we can have adequate trained providers, it’s impossible.  I would be in favor of reluctantly IP-ing [A.B. 112].

 

ASSEMBLYWOMAN LESLIE MOVED TO INDEFINITELY POSTPONE A.B. 112.

 

ASSEMBLYWOMAN ANGLE SECONDED THE MOTION.

 

Assemblyman Hardy:

I still like the intent of the bill.  There are medical professionals that are familiar with child abuse.  If we don’t do something [it will] be two years before we do something for the kids.  I want to protect some kids.

 

Chairwoman Koivisto:

That’s one of the frustrations of dealing with the child abuse issue.  We always feel like we’re taking one step forward and two steps back.

 

Assemblywoman Leslie:

Madam Chair, I do like the idea of a letter being sent to the Division asking them to work on this issue and expressing the Committee’s wish.  It’s not that people aren’t trained to recognize child abuse, but in order to comply with the intent of the bill, we would need health providers that had extensive training.  Some kind of letter from the Committee encouraging them to increase the number of adequately trained health providers would be in order.

 

Chairwoman Koivisto:

Perhaps we could ask that they report their progress to us in the next session.

 

THE MOTION CARRIED UNANIMOUSLY.

 

Assembly Bill 349:  Makes various changes concerning older Nevadans. (BDR 38-973)

 

Chairwoman Koivisto:

You should have an amendment, and I will let Marla explain that to you.

 

Marla McDade Williams:

Theproposed amendment by Assemblywoman Ohrenschall for A.B. 349 was developed in consultation with Assemblywoman Ohrenschall and others who had concerns initially with the bill.  The goal of the amendment is to remove the requirement of particular training and education for certain health care professionals and facilities and replaces it with provisions directing certain regulatory boards to encourage their licensees to take training and education in geriatrics and gerontology as part of their current continuing education requirement.

 

If you recall, the original bill applied to a number of licensing boards.  The amendment only applies to the Board of Medical Examiners and the State Board of Nursing, and it would replace the current section 1 in the bill with this new language stating that:

 “these Boards are to encourage their licensees who treat or care for persons who are more than 60 years of age to include, as a portion of their continuing training or education required for the renewal of their professional licenses, geriatrics and gerontology, including such topics as the skills and knowledge that the person needs to address aging issues, approaches to providing health care to older persons, including both didactic and clinical approaches, the biological, behavioral, social, and emotional aspects of the aging process, and the importance of maintenance of function and independence for older persons.”

 

Section 2 would stay the same.  The effective dates would change to July 1, 2003, and the title of the bill would change.

 

Chairwoman Koivisto:

Any discussion or questions on the amendment?

 

Assemblywoman Angle:

I think that’s still my concern.  If we’re trying to attract nurses and keep nurses, we’re putting one more thing on nurses.  It’s almost the same as we were doing to physicians.  If you’re in a hospital setting there’s no telling when you’re going to be dealing with someone 60 years or older and all of a sudden, you don’t have the training.  I’m just very hesitant to put any [more requirements] on nurses.

 

Chairwoman Koivisto:

This only directs them to encourage their licensees to get that training, it’s not mandating it.

 

Assemblywoman McClain:

Geriatrics is going to be the biggest field in the next few years.  It would behoove anybody in medicine to get that kind of training.  I think this [A.B. 349] is great, and I would make a motion to amend and do pass.

 

ASSEMBLYWOMAN McCLAIN MOVED TO AMEND AND DO PASS A.B. 349.

 

ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.

 

Assemblyman Hardy:

Anybody in the state of Nevada has to get so many continuing medical education credits in a year.  Right now, we don’t just necessarily go to an “aging” course as much as [we go to a course on] “chronic pulmonary disease,” “congestive heart failure,” “diabetes,” [and] all of those qualify.  It is something everybody already does who treats somebody over 60 [because] in essence they have to do this anyway.  I don’t think it hurts anything to pass it and I think “encouraging” is good.  This gets rid of the social workers’ “heartburn” with [the bill]. 

 

The comment Assemblywoman Angle made is appropriate.  You could have a nurse who was a pediatric nurse and is coming back into [the workplace].  [Now], all of a sudden, he or she is thrown onto the ward with somebody who’s over 60 years old.  Now [that nurse] doesn’t have a license [to practice nursing].

 

I would be reluctant to underline “encourage” because somebody could go out and make a regulation that then would limit the recruitment process [of medical personnel].

 

Assemblyman Mabey:

If we just “encourage,” what good does that do?

 

Marla McDade Williams:

They’ve been encouraged.

 

Chairwoman Koivisto:

I guess it means they won’t get in trouble if they don’t do it.

 

Assemblywoman McClain:

It also establishes the intent of the Legislature that this is something we feel is important.  Even though we can’t mandate it, we can certainly say “you should be doing this,” because if we don’t say that, it won’t get done at all.

 

Assemblywoman Pierce:

[The wording in A.B. 349] doesn’t seem very strong, but I just want to reiterate what Ms. McClain said.  The biggest generation in history is about to get old, and we’re going to need [lots] of people to take care of us.

 

THE MOTION CARRIED UNANIMOUSLY.

 

 

Assembly Bill 395:  Provides for assessment of fee on facilities for intermediate care and facilities for skilled nursing. (BDR 38-999)

 

Chairwoman Koivisto:

Do we have anyone here on A.B. 395?  We heard it last week and I understand people have worked out some kind of amendment.

 

Renny Ashleman, Representing Nevada Health Care Association:

That’s true, Madam Chairwoman.  I’m only here in case you’ve got questions.

 

Marla McDade Williams:

A conference call was held on Friday, March 28 with people who were involved in the bill.  Essentially they agreed on four points:

 

1. Be sure the measure does not apply to any intermediate care facilities for the mentally retarded [ICFMR].  Representatives of the Division of Health Care Financing and Policy assert that Section 3 of the bill would require fees be assessed to ICFMRs since they’re not separately defined in the NRS.  The Nevada Health Care Association notes that their intention is for the Division only to collect fees from nursing facilities and that Title 42 U.S. Code permits a state to limit such fees to selected classes of providers.  They agreed on language that would amend Section 3 by deleting lines 10 and 11 and inserting the following, “. . . which meets the requirements of a general, other special hospital, or intermediate care facility for the mentally retarded pursuant to Chapter 449 of the NRS.”  They believe that this language will exempt the institutions they don’t want to collect fees from.
2. Allow the Division to use a portion of the total amount of the proceeds of the fees for the purposes of administering the program.  The portion would be limited to not more than 1 percent of the proceeds of the fees and is subject to authorization by the Legislature.
3. Amend subsection 3 of Section 8 specifying that the proceeds of the fund must be used, to the extent possible under federal regulations, to match federal funds and to increase rates paid to nursing facilities.
4. Delete subsection 4.  The Division is not able to deposit federal funds into a separate account.  Those are federal rules.  Federal funds are only drawn when the expenditure is made.  The amendment in item 3, above, which requires matching the tax proceeds to the extent possible, meets the intent of subsection 4.

 

Chairwoman Koivisto:

Questions from the Committee?

 

ASSEMBLYMAN HARDY MOVED TO AMEND AND DO PASS A.B. 395.

 

ASSEMBLYMAN HORNE SECONDED THE MOTION.

 

THE MOTION CARRIED UNANIMOUSLY.

 

 

Assembly Bill 501:  Makes various changes to provisions governing welfare and other programs of public assistance. (BDR 38-516)

 

Chairwoman Koivisto:

We heard A.B. 501 on Monday, March 31 and Mr. Horne had concerns.

 

Marla McDade Williams:

The first concern started with the language concerning domestic violence.  Based on the discussion of the Committee and the fact that I was hearing that Members appeared to not want to make any changes in those requirements, this amendment proposes to delete Section 9, which would not make any changes in the current domestic violence program.

 

Assemblywoman McClain:

It said “delete Section 9,” which means delete the word “may.”

 

Marla McDade Williams:

I think it accomplishes the same thing, because if we delete the section it means we won’t be touching the statute.

 

[Ms. McDade Williams, continued]  The second point which was brought forward in Ms. Ford’s presentation on the bill would delete Sections 11-14 which are provisions that are included in Assembly Bill 445 which has already passed out of Committee.

 

The third point would add the word “terminated” after the word “reduced” at section 22 on page 13, line 35.  The Division notes that this term brings the bill in line with the provisions for termination that are included in subsection 1(d)2 of language that’s being struck from the statute.

 

Number four.  In Section 23 on page 13, at line 43, delete the word “may” and leave the word “shall.”  In the same section on page 14, at line 21, delete the word “may” and leave the word “must.”  This change keeps the Kinship Care program intact but allows for the other changes to the program that were recommended in the bill.  These provisions include eliminating the requirement to check criminal histories of grandparents, because these checks are performed in any legal guardianship situation by the court, and allowing the definition for “qualifying relative” to be that used in the Code of Federal Regulations.

 

The proposed change in the bill for the Kinship Care program would have made the program permissive, but language in the statute already says that the program is subject to legislative appropriation, or something along those lines.  Right now, that wouldn’t change.

 

Point five.  In conjunction with Assembly Bill 445, it would delete Sections 24-28. 

 

ASSEMBLYMAN HORNE MOVED TO AMEND AND DO PASS A.B. 501.

 

ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.

 

THE MOTION CARRIED UNANIMOUSLY.

Chairwoman Koivisto:

Thank you very much, Committee.  It was a long day; we got a lot done.  I really appreciate it.  With nothing further to come before the Committee, we are adjourned [at 8:00 p.m.]. 

RESPECTFULLY SUBMITTED:

 

 

 

                                                           

Terry Horgan

Committee Secretary

 

APPROVED BY:

 

 

 

                                                                                         

Assemblywoman Ellen Koivisto, Chairwoman

 

 

DATE: