MINUTES OF THE JOINT MEETING OF
SENATE COMMITTEE ON FINANCE
AND
ASSEMBLY COMMITTEE ON WAYS AND MEANS
Sixty-seventh Session
February 10, 1993
The joint meeting of the Senate Committee on Finance and the Assembly Committee on Ways and Means was called to order by Chairman William J. Raggio, at 8:00 a.m., on Wednesday, February 10, 1993, in Room 119 of the Legislative Building, Carson City, Nevada. Exhibit A is the Meeting Agenda. Exhibit B is the Attendance Roster.
SENATE COMMITTEE MEMBERS PRESENT:
Senator William J. Raggio, Chairman
Senator Raymond D. Rawson, Vice Chairman
Senator Lawrence E. Jacobsen
Senator Bob Coffin
Senator Diana M. Glomb
Senator Matthew Q. Callister
ASSEMBLY COMMITTEE MEMBERS PRESENT:
Mr. Morse Arberry, Jr., Chairman
Mr. Larry L. Spitler, Vice Chairman
Mrs. Vonne Chowning
Mr. Joseph E. Dini, Jr.
Mrs. Jan Evans
Ms. Christina R. Giunchigliani
Mr. Dean A. Heller
Mr. David E. Humke
Mr. John W. Marvel
Mr. Richard Perkins
Mr. Robert E. Price
Ms. Sandra Tiffany
Mrs. Myrna T. Williams
SENATE COMMITTEE MEMBERS ABSENT:
Senator William R. O'Donnell (Excused)
STAFF MEMBERS PRESENT:
Daniel G. Miles, Fiscal Analyst
Mark W. Stevens, Fiscal Analyst
Robert A. Guernsey, Principal Deputy Fiscal Analyst
Gary Ghiggeri, Principal Deputy Fiscal Analyst
Judy Jacobs, Committee Secretary
Dale Gray, Committee Secretary
OTHERS PRESENT:
John Sarb, Administrator, Division of Child and Family Services,
Department of Human Resources
Robert A. Cavakis, Director, Youth Correctional Services
Judy Matteucci, Director, Department of Administration
Jerry Zadny, Ph.D., Administrator, Mental Hygiene and Mental Retardation Division, Department of Human Resources
Duane Nimke, Director, Southern Nevada Adult Mental Health Services, Mental Hygiene and Mental Retardation Division, Department of Human Resources
David Askew, Ph.D., Deputy Administrator, Mental Hygiene and Mental Retardation Division, Department of Human Resources
Eugene Brown, Business Manager, Mental Hygiene and Mental Retardation Division, Department of Human Resources
Brian Lahren, Associate Executive Director, Washoe Association for Retarded Citizens
Gail Burks, Staff Attorney, Nevada Legal Services
Ann Smith, State President, Alliance for the Mentally Ill
Bill Couey, President, Northern Nevada Alliance for the Mentally Ill
Kevin Christensen, Director, Office of Protection and Advocacy
Robert S. Hadfield, Executive Director, Nevada Association of Counties
Mary Henderson, Administrative Analyst II, Finance Division, Washoe County
Richard H. Rahe, M.D., Medical Director, Nevada Mental Health Institute
Carlos Brandenburg, Ph.D., Director of Forensic Services, Lake's Crossing Center for the Mentally Disordered Offender
Wilford M. (Bill) Beck, Ph.D., Clinic Director, Rural Clinics Community Mental Health Services
Kyle Workman, Chairman, Advisory Committee for Relay Nevada
Mary Paradiso, Secretary, Nevada Association for the Deaf
Carol Haynes, Head Injury Association of Nevada
Maureen Maccutti, Deaf Service Coordinator for Telephone Device for the Deaf Distribution Program, Northern Nevada Center for Independent Living
Jim Boscacci, Member, Board of Directors, Northern Nevada Center for Independent Living
Ralph Baker, Member, Board of Directors, Northern Nevada Center for Independent Living
Jack Mayes, Independent Living Advocate, Northern Nevada Center for Independent Living
Clyde Carvey
Lisa Martinez
Michael Goodman, Community Services Agency
Christine Tower, Professor of Social Work, University of Nevada, Reno
Dorothy North, Chairman, Commission on Substance Abuse Education, Prevention, Enforcement and Treatment
Bill Jost, Treasurer, Nevada Association of State Alcohol and Drug Programs, Executive Director of Transition House
Mary Piasecki, Vice President, Nevada Association of State Alcohol and Drug Abuse Programs
Stanlee Dodd, Regional Director, Southern Nevada Mental Retardation Services, Desert Development Center
Steven Shaw, Administrator, Rehabilitation Division, Department of Human Resources
Jack Middleton, Director, Rural Nevada Mental Retardation
Services, Department of Human Resources
David E. Luke, Ph.D., Regional Director, Sierra Developmental Center
Jean Laird, Senior Management Analyst, Mental Hygiene and Mental Retardation Division, Department of Human Resources
Senator Raggio announced he would commence the hearing with the items agendized for the previous day which had not been heard due to time constraints (Exhibit C).
Senator Raggio promised he would reserve time following the hearings on rural clinic budgets and mental health budgets for public testimony. He read a list of people who wished to testify, and asked others desiring to do so to inform Robert A. Guernsey, Principal Deputy Fiscal Analyst, prior to the allotted time.
Probation Subsidies - Page 984
Senator Raggio stated the counties and the budget office had been asked to provide the committees with a compilation of their programs for Youth Parole, Probation Subsidies, and the fiscal impact of recommended changes.
John Sarb, Administrator, Division of Child and Family Services, Department of Human Resources, said the purpose of Probation Subsidies is to prevent youngsters from having to be sent to state institutions. He admitted the effectiveness of the account had been questionable prior to last August. He said testimony on the National Council on Crime and Delinquency (NCCD) presented the previous day had convinced him:
We're committing far too many kids or the wrong kinds of kids, and Probation Subsidies was designed to stop that. Obviously, it was not doing that. After the advent of the [Clark County Juvenile Court Services] Freedom program which was mentioned a lot yesterday, Probation Subsidies is functioning...like it was intended to do.
He conceded there is still much to be done to make the program effective, which is why an increase in the Executive Budget is being requested. He said the budget had been scheduled for elimination until there was a turnaround in its effectiveness in Clark County.
Senator Raggio indicated more discussion would be forthcoming on the budget on probation subsidies as hearings continue on youth parole matters.
Nevada Youth Training Center - Page 986
Mr. Sarb described the Nevada Youth Training Center (NYTC) at Elko as a principal facility for male delinquent offenders. He stated the facility was designed with a capacity of 160 inmates, yet the average daily population last year was 178. He stated the administration has determined the occupancy should be no higher than 10 percent above capacity. He said the present number of youths at NYTC has dropped to 140, which he attributed in part to following NCCD recommendations, but primarily to the Freedom program in Clark County.
Senator Raggio asked how many times during the biennium the capacity had exceeded 160. Mr. Sarb replied it had only been above 160 during July and August of 1992.
Senator Raggio inquired if any problems have arisen due to keeping the high-risk inmates at the NYTC in Elko, and if the practice of transferring those people to out-of-state facilities was continuing. Mr. Sarb responded the Elko facility has a contract capacity of ten, and generally seven or eight young men are incarcerated there.
Mr. Dini said there used to be a backlog of 30 to 40 youths waiting to be transferred to Elko. He asked if that was still the case. Mr. Sarb answered there are none waiting.
Mr. Humke asked what the reference was to in-state rehabilitation programs under the Performance Indicators on page 989. Robert A. Cavakis, Director, Youth Correctional Services, explained it referred to the number of youth placed in custody for correctional care by the state. Mr. Humke voiced the opinion the list of Performance Indicators was "woefully inadequate." Mr. Cavakis responded his department maintains a list of seven indicators, although only the two key indicators were printed in the Governor's Executive Budget.
Mr. Marvel asked if Mr. Cavakis felt his department was in compliance with recommendations from the last legislative audit. Mr. Cavakis indicated he was "in compliance or close...making progress in all of them." He said it may take some time before compliance is reached for a perpetual inventory.
Mrs. Williams inquired how counseling was being provided since psychological services had been canceled. Mr. Cavakis said there are staff members with specialized advanced degrees who provide limited counseling. The main result of the loss of the psychologist means testing must be contracted when necessary, which he stated "works all right."
Mrs. Williams expressed surprise the athletic program had been discontinued in an institutional setting, in which she felt it would be very beneficial. Mr. Sarb said the discontinued athletic program referred to interscholastic athletics, but general athletics on the campus continue. He said the superintendent recommended discontinuing the interscholastic program because it benefitted very few, and it required staff time to travel with those who participated in sporting events while leaving the institution short of staff.
Mrs. Williams surmised the program was important in order to provide transitional living skills to those youths and to give them a feeling of self-esteem. Mr. Cavakis pointed out interscholastic activity had been eliminated at Caliente several years ago when the institution became coeducational and was replaced by an intramural program. He alleged, "The staff will tell you it far exceeds any expectations in terms of the end result...what those kids are getting out of the program." He stated more youngsters are able to participate in the intramural program. A similar program is being instituted at Elko to replace the interscholastic program, he said.
Senator Raggio, with the concurrence of Mr. Arberry, asked Mr. Marvel to obtain more information on the program from Edwin Burgess, Superintendent of the NYTC at Elko.
Mr. Price described a visit he had made to the Spring Mountain Youth Camp for a football program awards night. He agreed the program provided a commendable psychology of competition and pride in self.
Senator Jacobsen commented he had visited the facility at Elko, which he found clean, run properly, and with good food. He acknowledged gang members had been transferred out of the facility. At that time he had suggested to Mr. Burgess the youths might assist the Division of Forestry camp located adjacent to the NYTC on fire crews.
Farm Account - Youth Training Center - Page 990
Mr. Sarb stated the farm account pertained to a work farm at NYTC at Elko, where, among other products, game birds are raised. He testified over 3,500 birds had been sold the previous year.
Senator Raggio asked if the $18,000 budgeted for the farm account per year was a realistic figure. Mr. Sarb responded the funding should be adequate, especially if bird sales are good. He said about 30 youths are involved in the program.
Chapter I and II Education Program - Page 992
Mr. Sarb said Chapter I is a federal program for remedial education for inmates in training schools. Mr. Cavakis interjected the Department of Education informs him how much funding is available for the programs, instructors and materials based on the number of students. He said the funding would provide three and one-half positions.
Senator Raggio asked how the program is coordinated with the regular educational program. Mr. Cavakis said there is no coordination with Elko County schools, but he works through the state Department of Education to be sure minimum standards are met.
The three and one-half positions refer to only the special programs.
Mr. Cavakis described the entire educational program. He said the school is operated similarly to any high school in the state, with
a principal, vice principal, nurse, teachers, and a typical curriculum. There are special remedial programs which focus on an attempt to bring each student up two months' worth of academic standing for every month in the NYTC. He indicated there is a similar program at Caliente provided through the Lincoln County School District.
Ms. Giunchigliani inquired about the cost-effectiveness of the NYTC program. Mr. Cavakis stated he and Dr. Eugene Paslov, Superintendent of Public Instruction, had met with the school superintendent of Elko County three years ago to discuss the possibility of Elko taking over the school program at NYTC. He said Elko did not have any interest at that time in doing so, although recent discussions with Elko school officials have given him the impression they may be more receptive to the idea now. He expressed concern the cost would be greater if the school was run by Elko County. Ms. Giunchigliani suggested it would be worth investigation.
Mr. Heller asked why there were no performance indicators to show the rate of success for the program's purported intent to elevate each student's performance by two months for every month of incarceration. Mr. Cavakis replied his department had the information, but he did not know what method of determination was made as to which indicators to include in the budget recommendations. He agreed to provide the information to the committees.
Senator Raggio concurred the performance indicators in many of the budgets were not living up to expectations. He felt the need for more information could be developed as the budgets were examined. Judy Matteucci, Director, Department of Administration, said:
That is exactly...the evolutionary process we're involved in now with this new format. As you recall, during the interim, there was a legislative subcommittee that took ten pilot agencies--this happened to be one of the pilot agencies--so the numbers you're seeing...are the ones that were approved on behalf of this division. ...They were worked out with your staff and my staff because, the child and family division, being newly constituted, was having some trouble getting together some numbers that the legislative committee really felt comfortable with.
Ms. Matteucci declared the programs should be reviewed after the reorganization proposed by the Governor. She said:
We had thought we could do some proportion of the agencies during the next couple of years. However,...I think we probably are going to want to...expedite that process and get more...agencies in the loop, so that we have reached agreement with you as to which performance indicators you'd like, and some special contract with you for the agencies as to what you expect them to achieve with the money that you're going to be recommending.
Senator Raggio told Ms. Matteucci he would prefer that the individual in charge of each budget be present at the hearings and that he had expected Mr. Burgess to be present as well as the superintendent of the Caliente Youth Center. He added he would like the directors of each penal institution to be present when the prison budgets are reviewed. He expressed the opinion the new format of the budgets should not preclude the appearance of the directors. Ms. Matteucci said she did not believe the new format had anything to do with their attendance. She stated, "That was really a decision made by the division, and I will certainly pass on your information." Senator Raggio explained, although it may inconvenience people, their presence presents an opportunity for the committees to obtain more insight when there are questions relating to indicators. Ms. Matteucci said she was looking forward to working with the committees on performance indicators.
Senator Callister offered support for Senator Raggio's request that agency representatives attend hearings. He pointed out the senate has just one opportunity every two years in which to get input from them. He also urged members of the committee to feel free to participate in crafting performance indicators through the budget hearing process.
According to Mr. Cavakis, his department has been keeping track of seven Performance Indicators for internal use. Ms. Giunchigliani asked him to share that information with the committee for use in a dialogue "to see whether or not we are properly funding, or if that's the direction we want a particular budget to go." Mr. Cavakis pointed out some of the indicators are questionable as to their meaningfulness or their accuracy as measurements, but he agreed to provide the information to Ms. Giunchigliani.
Caliente Youth Center - Page 995
Mr. Sarb testified the training center in Caliente has beds for 80 boys and 60 girls. The average daily population last year was 148, but yesterday, he said, it was down to 113, with 65 boys and 48 girls. Senator Raggio asked if the reduced number was due to the Freedom program. Mr. Sarb indicated the female population was normally low, but he attributed the lower number of boys in part to the Freedom program, in part to decreased average length of stay, and in part due to "taking a harder look at technical violations of parole."
Mr. Humke inquired if the population at Caliente was impacted by the practice of paroling youngsters during school semester breaks at a time when they can return to normal class schedules. Mr. Cavakis agreed that was the custom at NYTC, but he was unsure as to whether that was normal practice by the Lincoln County School District at Caliente.
Mrs. Williams asked how the average length of stay of seven months
compared to other states and to recommendations by national consultants. Mr. Cavakis replied national consultants recommended 6 to 7 months in general, and a shorter stay of 3 to 4 months for selected offenders at Caliente. He acknowledged they are experimenting now on a case-by-case basis to see what effect reduced incarceration time may have overall.
Ms. Tiffany called attention to audit information from June 1991 which referred to inventory and dispensing records of medications. Mr. Cavakis stated a log had been set up with the cooperation of the local medical community and the prison system.
Ms. Tiffany asked if progress was being made in taking inventory of food supplies. Mr. Cavakis responded that was a much more difficult task, citing, as an example, the thousands of spices to be counted. Since the audit report, he said, inventories of items are being entered in a computer program, and inventories of major items are complete.
Mr. Marvel wanted to know if compliance was being met regarding inmate trust accounts and regarding the outside commissary. Mr. Cavakis affirmed full compliance had been met with all requirements except the perpetual inventory. He admitted the commissary had been closed because it posed too much of a problem. He stated the director's office is working with the budget division to create a statewide program for all the inmate trust accounts.
Senator Raggio asked for a report on the status of a public works project approved at the last legislative session. Mr. Cavakis replied a new academic building had been designed, but he was doubtful that the bid had been awarded yet. He agreed to inform the committee on its progress.
Chapter I - Special Education - Page 999
Mr. Sarb reported the budget represents federal funding for special services for early childhood from birth to school age and for developmental disabilities in children. He described the programs as mental health services and developmental services in accordance with federal mandates.
Mr. Sarb pointed to a large increase in the budget for the coming biennium, which he said will be accompanied by increased federal requirements. He added one of those requirements will mandate no waiting lists for those children, but since the federal definition of an eligible child is in flux, there is difficulty in determining who is eligible for services.
Ms. Giunchigliani suggested the special education programs may more naturally belong under the Department of Education, regardless of what may happen from the reorganization of the government. She referred to past problems coordinating which providers should handle which programs.
Ms. Giunchigliani asked if the new grants were part of a transition program and if there was a movement to transfer the programs to the Department of Education, especially the federal Individuals with Disabilities Education Act (IDEA) program, Part B of Chapter I, referred to on page 1001. Mr. Sarb said Part B has a very small budget, but Part H is a large program encompassing mental health services for children. Ms. Giunchigliani asked if the programs were statewide or only in the rural areas. Mr. Sarb answered they were statewide programs.
Mrs. Williams commented she believed the programs belong under the Mental Hygiene and Mental Retardation Division (MH/MR), where they have traditionally been. She asked what percentage of people on the waiting lists come from the rural areas. Mr. Sarb replied
there were about 45 youngsters from the northern rural regions and 17 from the southern area, in 1992.
In response to a query by Senator Raggio, Mr. Sarb explained the grant enhancement of $476,911 on page 1002 represents the increased federal award.
Mr. Spitler inquired what kinds of services would be provided for young adults, as referred to under the program description on page 1003. Mr. Sarb replied federal funding for IDEA was intended to force integration of the mental health population and education population, sometimes including those who are institutionalized. Thus, he said, part of the funding goes for technical support for special education. As to what specific services are provided for young adults, Mr. Sarb said he would have to get back to Mr. Spitler with the information.
Mrs. Chowning asked for details on the program to help families with mentally handicapped children. Senator Raggio interjected $80,000 is budgeted each year for the Home Activities Program for Parents and Youngsters (HAPPY). Mr. Sarb said the HAPPY Program would stay in the base budget. He called the HAPPY Program "one of the most loved programs out there." He felt he would not do the program justice if he attempted to explain it to Mrs. Chowning, and indicated he would supply Mrs. Chowning with a written description. He said the program is provided in rural Nevada, anywhere 50 miles outside of major cities.
Senator Rawson said young children with some developmental disabilities, who cannot be handled in school settings, are stimulated by various activities offered by the HAPPY Program. He said, "In essence it prepares them to be able to go to school." He indicated some of the children may be in special education programs all their lives, while others may be able to participate in classroom programs. Without the early intervention, he declared, many of those children may not progress at all and may ultimately be institutionalized. He asserted the program probably saves money in the long run by keeping children out of institutions.
Mr. Sarb agreed the fact the program is home-based is one of the reasons the program is so well received. He said the parents involved are linked to each other and offer each other support. Senator Rawson stressed one advantage of the program is the education of the parents on how to stimulate the children. He added there is physical therapy as well as intellectual therapy included in the program.
Southern Nevada Children's Home - Page 1005
Mr. Sarb continued his testimony with a description of a proposed lease of the Boulder City Southern Nevada Children's Home campus to a private provider. He said there are seven cottages, each with a capacity of 10 children. Although the facility operates under laws for the care of orphans, like the Northern Nevada Children's Home, he stated, there have been only three orphans in the facility in the last twenty years. The home is used primarily for abused and neglected children who are under the state's custody, he said.
Mr. Sarb asserted it is not cost-effective for the state to run such an operation. He said it costs about $70 per day per child at the Southern Nevada Children's Home compared to a cost of $35 at the Saint Jude's Children's Home in Boulder City for care of the same kinds of children. He alleged there is no difference in the quality of care at one home or the other.
Mr. Sarb indicated there is a legal action by cottage parents pending against the state which may force the costs higher. He averred the parents want to be paid overtime for everything over 8 hours, and they are asking for pay for 24 hours a day. He said there has been a settlement conference, but the plaintiffs and the state are over $2 million apart at the present time, so he expects a trial to take place in April.
Senator Raggio recalled a discussion during the last session of the legislature regarding the potential for liability in such cases. He remembered hearing the cottage couples had accepted their positions with full understanding there would be no overtime. He asserted it is essential that couples willing to serve as cottage parents be available full time.
Senator Raggio asked what the likelihood was that private providers would take over the home. Mr. Sarb responded there have been expressions of interest, particularly among the present cottage parents. He said some of the parents are forming a corporation to make an offer to the state when the project goes to bid. He guessed the leases would be written for two years.
Mr. Spitler asked if the state would have liability if the premises are leased to a private entity. Mr. Sarb answered that generally there would be no liability, because, although the children are in custody of the state, the state is not their guardian.
Ms. Giunchigliani remarked there had been no discussion regarding the intent to privatize the home last session. She concluded the recommendation must be a fairly new idea. Mr. Sarb responded it was not a new concept to him, because he felt the program has not been cost-effective for a long time. Ms. Giunchigliani averred the program did not appear to be a result of retribution against those who had filed the lawsuit, but she felt that intention was not clearly delineated. Mr. Sarb concurred, and said the state had not acted to privatize sooner out of fear it might have been construed to be retribution and also had not acted until several months after the employees had approached the state about privatization.
Ms. Matteucci stepped forward to corroborate the opinion both children's homes have been deemed somewhat expensive. She asserted the Fair Labor Standards settlement had increased costs through mandating pay for overtime. She alleged the Northern Nevada Children's Home was closed because of increased costs due to overtime pay obligations. She said,
As the private contractors get much more competitive for taking care of the same kinds of kids, you have to start looking at it with the...financial aggravation of Fair Labor Standards driving the costs up from both those two state facilities simply because they're 24 hour care.
Ms. Giunchigliani admitted there is a statewide problem. She declared she does not want to see the state attempting to circumvent lawsuits, and she wanted assurance the privatization was not an issue of retribution. She declared there needs to be a definition of management, and contracts need to be drawn rather than trying to circumvent the problem or consider the Fair Labor Standards as an approbation.
Mr. Spitler opined a five-year lease would be better than a two-year lease. Mr. Sarb responded a two-year lease is under consideration because of a reluctance to commit money beyond bienniums, although, he admitted, there are exceptions. He suggested a two-year lease should not be an issue when no capital outlay is required. He declared the absence of a requirement for capital outlay is an attractive feature for a group operator, who can move right into the 13 acres and seven buildings.
Senator Raggio said:
We've had an opinion from bond counsel that under the Hancock decision any...state lease that obligates the state to pay money beyond four years would be considered a debt to the state and therefore must be included in the amount of the debt of the state.
He explained that would add to the total bonded indebtedness of the state, which would affect the bond rating. Thus, he said, the bond counsel has taken the position that any lease or contract should have a maximum of 4 years.
Mr. Spitler asked if any clients would be placed in the facility by anyone other than the state according to the request for proposal (RFP). Mr. Sarb replied it had been done both ways in the past, but he anticipated the RFP for the Southern Nevada Children's Home would be exclusive to the state. He assured Mr. Spitler the same standards would apply under a new contract as those presently being observed at the facility.
Mr. Spitler compared the expenditure of approximately $30,000 per year for older children at the facility in Elko and the expenditure of $20,000 per year on younger children at the Southern Nevada Children's Home. He pointed out many of these children, who come from abused backgrounds, frequently wind up in the court system. He wondered if it would not be wise to "look at fixing the problem at the beginning as opposed to fixing it at the end." He called the home a very good investment for abused youngsters. He said, "We seem to be getting an awful lot out for a lot less money by making this investment when they're young." He asked if those kinds of discussions are held when Mr. Sarb's division changes philosophy. Mr. Sarb replied, "Absolutely."
Mr. Spitler asked why, then, there was a move away from a program that costs less money. Mr. Sarb acknowledged there is a clear recognition that services must be provided to younger children and earlier in the problem cycle. He stated there are statutory mandates as to whom will be served, such as delinquent children or abused children. He said:
While we have made some improvements on front-end services in the last 18 months, the available funds are going to take care of the kids that we are statutorily mandated to take care of, and those do tend to be the long term, deep end of the system kids, who are more costly, as a unit of service, and with less prognosis for success.
Senator Coffin cited a suggestion he attributed to the administration to close most of the honor camps in the prison system. He asked if Mr. Sarb had considered use of any of those camps for his division. Mr. Sarb said any use of the remote camps would be used for delinquent children, and the existing facilities at Elko and Caliente for those children are below capacity. Senator Coffin remarked that "mothballing" tends to cause deterioration, and he would like to see the camps used in some way.
Senator Raggio reminded the gathering he would invite public testimony on public health issues following the hearings on Rural
Clinics. He repeated his request that all those wishing to testify give their names to Mr. Guernsey.
Mental Hygiene and Mental Retardation - Page 713
Jerry Zadny, Ph.D., Administrator, Mental Hygiene and Mental Retardation Division, Department of Human Resources, distributed copies of information to supplement testimony on the mental health budgets (Exhibit D). He gave the committee gave an overview of the way in which the mental health budgets were put together.
Dr. Zadny cited three objectives. He indicated the first was to meet demand for care by offering community-based services which would be low in cost and would foster independence on the part of the recipient. The second objective was to strengthen inpatient and residential programs to continue to qualify for federal reimbursement for the services. The third, he said, was to increase the value of services by cutting costs while maintaining quality.
According to Dr. Zadny, the mental health budgets "took the brunt of last February's reductions, because they contained the lion's share of the state appropriations made to the division." He declared the intent of his department to make a fresh start rather than to simply restore services. He pointed out the main proposals are for case managers, for funds for supportive living, and for crisis follow-up services. He stated the requests for inpatient services are primarily limited to those essential to maintain federal certification and to continue the Clozaril program started by the last legislature.
Dr. Zadny called attention to the second page of Exhibit D on which the mental health initiatives are summarized. He explained the new concept of residential care under Supported Living Arrangements (SLA). He said housing was formerly developed along a continuum, ranging from intensively supervised group homes to independent living. He declared the positive aspect was to put the person in the setting most appropriate for his skill level. The downside, he said, occurred each time skill levels changed and the client was obligated to change residency. He averred such moves were disruptive, often took too long to accomplish, and it became difficult to maintain the right mix of group homes to meet each consumer's needs.
Dr. Zadny proposed to use existing housing and to provide whatever services that may be needed through contract services. Those services would entail supervision, instruction in daily living skills and job placement. He stated the amount and kind of assistance would be reviewed and adjusted quarterly.
Dr. Zadny declared the SLAs work very well with mental retardation clients, with 156 people living in SLAs. Although some group care facilities will continue, and the transition from group care to SLAs will be gradual, he stated the emphasis on SLAs will be the preferred alternative.
Continuing his overview as set forth in Exhibit D, Dr. Zadny elaborated on crisis follow-up services. He said people suffering short-term distress, who are not sufficiently impaired to require hospitalization, but who should not be left on their own, come for inpatient services.
Dr. Zadny envisioned a situation in which a psychologist would interview those people on the next working day, and either handle the case personally or refer the person to someone under contract to the state when long-term care is required. The contract would provide up to six outpatient visits. He explained the state would pay the difference between what the person could afford and a rate negotiated with a private counselor, not to exceed $80.96, the current Medicaid rate for outpatient therapy.
Dr. Zadny stated the counselor would work with a business person to be sure that the client was satisfied the quality of services was up to the standards set by the Mental Hygiene and Mental Retardation (MH/MR) Division. He opined costs would be reduced below the $90 to $116 per hour presently incurred when state staffers are used for the same counseling.
Turning to inpatient services, Mr. Zadny proposed an increase in the number of nurses at Southern Nevada Adult Mental Health Services (SNAMHS) as well as an increase in the number of medical records personnel. He recommended the addition of an activity therapist to the Nevada Mental Health Institute (NMHI).
Dr. Zadny declared the drug Clozaril is effective with approximately one-third of those suffering from schizophrenia who have not responded to other drugs. He admitted Clozaril is costly, but it can lead to ultimate discharge of long-term inpatients. He said one or two percent of those using Clozaril experience a side effect, which, if undetected, can lead to death, so weekly blood tests must be administered.
Dr. Zadny stated Clozaril had been given to 55 division clients through December of 1992. Of those, 20 responded sufficiently to continue administration of the drug, and 13 were discharged from inpatient care as a result of the success of the treatment. He said the average inpatient service for those patients had been 323 days. If they had remained as inpatients through December, he asserted the cost would have been $896,700, as contrasted to the $146,839 actual cost for administration of Clozaril. He commended the decision made at the last legislative session to try Clozaril.
Dr. Zadny called attention to two organizational changes being proposed not related to those under the Governor's proposed changes. He suggested the business and administrative offices of the rural clinics be moved to the NMHI campus in Sparks in order to consolidate and strengthen the institute's community services. The director would then be able to spend one-half of his time on the management of the rural clinics, and the other half managing community services at the institute. He claimed having the business manager at NMHI run both offices would strengthen the rural clinics' business office.
Dr. Zadny outlined a proposal to transfer supervision of the staff at the southern Nevada jail detention center to the director of Lake's Crossing Center for the Mentally Disordered Offender, Carlos Brandenburg (Director of Forensic Services). He said Dr. Brandenburg and his staff are the only forensic specialists within the system, and it would make sense to have them supervise those working in the jail and detention center.
Mental Hygiene/Retardation - Regional Training - Page 719
Dr. Zadny said the summaries in the handout (Exhibit D) were put together after consultation with a number of parties, including some of the staff at the Legislative Counsel Bureau (LCB). He stated:
We tried to show you where we stood in FY [Fiscal Year] '92 in the first column, where we stand this year in terms of the service at issue, a waiting list of any...and then the recommended column perhaps is the most interesting one. It shows you where we would stand if you were to approve the Base,...and where we would stand cumulatively if you were to approve Maintenance and Enhancement items that are proposed in the budget.
Senator Raggio pointed out one issue of great public concern, and of the committee, is the effect the budget reductions had over the last biennium. He said there had been a reduction in the General Fund of about $3.8 million in FY 1992 and of $5.1 million in FY 1993 with total budget reductions for all funds being $11.6 million. He asked Dr. Zadny to indicate any impact the reductions may have had on the functioning of each particular budget and steps being taken to deal with those problems.
Senator Raggio said, "We were given some assurance by the Governor at the time that those budget reductions would not seriously impact those programs."
Mr. Heller expressed the opinion the information given to the committee does not go far enough. He suggested the emphasis in the Executive Budget shows what new positions or programs will be offered through the base, maintenance or enhancements in the budget. He said he could not support enhancements without knowing what improved services the state would attain if the enhancements are approved.
Dr. Zadny said, although it is very difficult to measure the economic impact of mental health services, he shared Mr. Heller's discomfort that the performance indicators did not reveal more information. He agreed to try to respond to Mr. Heller's requests.
Dr. Zadny declared it is important that staff be able to perform well as the division is asked to do more with fewer positions. He said funds are necessary for regional certification training of mental health technicians and forensic specialists and continuing education of professional and support staff as required by Nevada Revised Statutes (NRS) 433.279. He stated the budget was reduced by $19,170 in Fiscal Year 1992, primarily withholding expenditures for professional training, while technician certification training remained intact.
Dr. Zadny continued:
The Base budget would continue the level of the expenditure in FY `92, less amounts that were spent on training personnel that now work for DCFS [Division of Child and Family Services]. The Enhancement...would permit providing an additional ten courses of certification training per year, and eight professional continuing education workshops per year, and would also fund 25 additional support staff to attend short-term job-related training courses. All told, the base and enhancement packages would support 40 technician training courses, 18 professional workshops, and training of 50 support staff statewide.
Such training, he asserted, will result in better quality care for clients.
In response to a query by Mr. Arberry, Dr. Zadny said the training personnel officer position is currently vacant and may be eliminated as part of reorganization. He proposed assigning
regional training to the grants manager position, if it is restored to the central office budget.
Dr. Zadny said he is currently taking part of the personnel officer's responsibilities, and Dr. Brandenburg at Lake's Crossing is assisting in regional technician training.
Mr. Arberry asked Dr. Zadny to explain how he would use $17,603 in enhancements each year. Dr. Zadny replied, "This budget is driven by the number of staff within the division." He said the $17,603 would train all the technicians, professional staff, and support staff referred to in the Base on page 719 and in Item 710 Training Increases Enhancement. He asserted the training would allow the people involved to be certified within two years, the professional staff would have enough continuing education units (CEU) credits to maintain their licensure, and support staff could be trained on computers or other equipment necessary for their jobs.
Mr. Arberry inquired if Dr. Zadny and Dr. Brandenburg would have enough time to devote to the training. Dr. Zadny answered that he had done regional training when he held the position of grants manager, and he felt he would have adequate time to do the training.
Senator Raggio wanted to know how the $12,500 authorized in the base budget for sexual offender training was used. Dr. Zadny replied the funds were used by the Division of Child and Family Services (DCFS). He summarized a DCFS report on expenses for 1992. DCFS sent one person to a conference on sexual abuse in Texas costing $593; 53 staff from the state and counties participated in what Dr. Zadny described as a two-day training event on adolescent sex offenders in Las Vegas for a cost of $8,425; a course called the Juvenile Sex Offender, Components for Successful Assessment and Intervention was held in Las Vegas for a cost of $400; a course called Specialized Sex Offender Case Loads on Parole and Probation in Las Vegas, Reno and Winnemucca for a cost of $2,061; another $820 was spent on publications; and $96 was spent on travel.
Mrs. Williams reminded Dr. Zadny the intent was to spend the $12,500 to train professional personnel from the facilities dealing with youthful sex offenders, who then would return and train their fellow workers. She stated:
I have some problem with spending $10,000 going to a conference. I'm not sure...in terms of short money, where we needed to get some trained personnel...how appropriate that was to spend $10,000 that way, or $8,000. $8,000 sounded like in-house...staff training.
Dr. Zadny admitted he was not familiar with the DCFS training plan or expenditures, but he agreed to obtain more information for Mrs. Williams.
Southern Nevada Adult Mental Health Services - Page 721
Dr. Zadny stated the total reductions to the Southern Nevada Adult Mental Health Services (SNAMHS) over the biennium were $5,092,000. He declared the impact caused the deletion of 91 full-time positions for the entire biennium and some reductions in operating expenses during 1992 which were restored in FY 1993. The services curtailed or eliminated in the SNAMHS included outpatient counseling, day treatment services, and a reduction in the number of clients in case management from 500 to the present caseload of 254. He said 19 of the latter who were eligible under Title XIII were referred to the Nevada Family Practice Residency Program.
Dr. Zadny said there were 1,335 outpatients for whom service was discontinued, some of whom were sent to the private sector, and 350 of them also were referred to the Family Practice Residency Program. He acknowledged remote offices were closed and services were consolidated with the SNAMHS offices on West Charleston Boulevard in Las Vegas. Placements were made in 26 sub-acute placements, which he declared were the most costly housing placements.
Dr. Zadny stated one of the inpatient units was closed, and the staff was redeployed to create a crisis observation unit with ten beds. He said:
The advantage of that unit is that, folks who could come under the inpatient and stayed a very short period of time consumed a lot of resources, because much of the evaluation and paperwork is created in the first couple of days of admission, were deflected into those crisis observation beds. The net effect has been to reduce the burden on inpatient and also provide folks with more appropriate care.
Dr. Zadny said a drop-in center has been opened 3 days a week for former day-training clients to socialize with their peers and to receive some guidance.
Dr. Zadny referred to pages four and five of the handout (Exhibit D) on which appear contemplated changes. He proposed an increase in the number of case managers from 8 to 15, who could serve over 525 clients instead of the current 254.
Senator Glomb inquired if the figures indicate that over 200 cases are being left with no treatment. Dr. Zadny admitted that was true and that shrinking resources have forced the staff to determine for whom service is absolutely mandatory.
Duane Nimke, Director, Southern Nevada Adult Mental Health Services, Mental Hygiene and Mental Retardation Division, Department of Human Resources, reiterated the primary proposals for the budget call for seven new case managers. He added the proposed budget also calls for upgrades of six mental health technicians to meet federal standards for inpatient nursing coverage, a psychologist and management assistant, $139,899 in contract funds for crisis follow-up services, two medical records assistants, and funding for four new Supportive Living Arrangements (SLAs) per month through the biennium.
Mr. Nimke called attention to the description of recommendations for Maintenance on page 722 and to the Enhancements on page 724. He said the two psychiatric case worker positions to be funded under Maintenance were necessary to manage the approximately 32 new cases coming under their jurisdiction each year. The five positions requested under Enhancement would serve another 175 clients in FY 1994, and 67 in FY 1995, he said.
Mr. Nimke indicated the reclassification of six Mental Health Technicians III to Psychiatric Nurses II appears on page 725 as an Enhancement. He said:
Currently there are 19 RNs assigned to two to four inpatient units, with approximately one RN [registered nurse] per shift per unit. The recommendation is to increase coverage to two RNs per unit for the day's shift. Three of the reclassifications would be funded to
start in October 1993, and three to start in July of 1994.
Mr. Nimke referred to a third personnel recommendation for SNAMHS on page 725 to hire a Psychologist and Management Assistant II to provide crisis follow-up to people in distress who do not require hospitalization. Dr. Zadny interjected the person would respond to a limited number of those most in need who were affected earlier by the curtailment of outpatient counseling services. Mr. Nimke continued to say there is currently one psychologist assigned to the task, whereas two could handle 324 persons per year, and contract counselors would be able to see an additional 288.
Mr. Nimke turned to the Enhancement on page 726 which recommends two Medical Office Assistants II to handle medical records. He said those would bring the medical records staff up to seven, which would permit development of a unified medical records system in order to meet federal standards.
The final personnel recommendations, Mr. Nimke said, involve transfers which appear in the Base budget. They include transfers of three custodians, an Accountant II, and a Maintenance Repair Specialist I as part of the final separation of adolescent services programs from the Division of MH/MR. He added a Psychologist and a Clinical Social Worker currently assigned to jail services in Clark County would be transferred under the supervision of the Lake's Crossing budget although they would continue to work in the detention center at the jail.
Mr. Nimke called attention to the funding for Clozaril appearing under the Base on page 721 and on page 722 as an Inflation item and also as a Demographic item. He stated the cost is $27,770 to start ten patients on Clozaril for a 12-week trial period, and to continue with ongoing therapy for a year for the average three who respond to treatment. He declared, "Of the three who respond, two typically can be discharged 9 months after the start of therapy and have the drug's cost paid by Medicaid. One of the three typically will not qualify for Medicaid, and the state pays for the drug's cost."
Mr. Nimke said there are currently six clients being continued indefinitely on Clozaril at state expense. He averred the base funding would provide for those six plus expenses for another four new clients for one year. He indicated 15 new clients could be started in FY 1994 and 22 in FY 1995 if funding for demographics and inflation are added to the base.
Mr. Nimke discussed the figures for Transitional Housing appearing on pages 721, 722 and 725. He said the Base would support the current 248 cases, Demographics would add four new cases in housing per month, and the Enhancement would provide living skills training and job placement assistance to 100 clients in FY 1994 and to 119 clients in FY 1995.
Dr. Zadny interjected the four housing placements per month would offset the reduction of 26 placements made in FY 1992. He added the living skills training, which had been discontinued except at the drop-in center, would be restored through day training on a contract basis. He described the types of individualized training to be offered, such as housekeeping skills.
Mr. Nimke drew attention to the medication tables on page 7 of Exhibit D, which indicate patient numbers have remained constant and staffing levels are appropriate.
Mr. Nimke turned to the revenue section on page 721. He pointed out:
The federal funds revenue is lower to adjust the base to the Actual cost report reimbursement, which is expected in Fiscal Year `94 and `95, which will be lower than in the Fiscal Year `92, which included reimbursements for 3 prior years rather than just 1 year.
Mr. Nimke continued:
Medicaid receipts are projected at a lower amount because the day treatment programs were closed and many of the Title XIX eligible case-management clients were transferred to Mojave, a private care provider. Also the line item is reduced by the state's share of Title XIX, which appears as part of the regular appropriation.
Mr. Nimke noted the sum for the Psychiatrist Contracts, which are made with the university, are recommended for each year of the biennium.
Mr. Nimke summed up the inflation, maintenance, and enhancement requests at a total of $1,410,841 for Fiscal Year 1995, which would be an 11% increase over the fiscal year base budget. He added there is one agency Capital Improvement Project (CIP) request to replace the existing cooling tower for the administration and clinical building.
Mr. Arberry asked why the Clozaril expense makes such a dramatic jump under the Work Program column.
David Askew, Ph.D., Deputy Administrator, Mental Hygiene and Mental Retardation Division, Department of Human Resources, came forward to explain why the SNAMHS figures are the same across the page except for the Work Program. He said, "That is flat because inflation factors were taken out of that part and put in the inflation factor as a separate line item."
Dr. Zadny explained it had to do with the start-up of the program. He stated:
The way this was funded the last biennium, we funded 25 starts the first year...and 50 starts the second year of the biennium. The way this document was prepared,...we just carried the figure of $51,000 for the first year of the biennium as the base all the way across. So you will have to look to the demographics and the enhancement item to see what the total is that we're proposing.
Mr. Arberry asked how the homeless and jail populations were getting psychiatric help with such reductions. Dr. Zadny replied there is a grant from Catholic Community Services in Las Vegas which provides referral for the homeless to SNAMHS, and the jail staff refers inmates who receive counseling or other, more appropriate, care.
Mr. Arberry repeated his query whether they were still receiving service, since there is a reduction in total services. Dr. Zadny said the services no longer provided, such as day training and outpatient counseling, may be available through the Family Practice Residency Program to those who are eligible under Title XIX. He added there are a few limited lower-cost services for those who have a little money.
Senator Glomb asked if some patients leaving the hospital did so without being assigned a case manager. Based on her experience working with the mentally ill, she stressed the cost-effectiveness of at lest one follow-up visit. Dr. Zadny affirmed her assessment. He said the alternative would be to provide housing, medication, case-management and day programs in the community, which he called more therapeutic, more humane, and less costly.
Senator Glomb asked how long before follow-up appointments are made to check medications. Dr. Askew responded they occur between 2 and 3 months, or within 2 weeks to a month for those who have been in a crisis situation.
Senator Glomb asserted medication compliance among those patients is very low unless they can be seen on a regular, frequent basis, and the number of their subsequent returns to the hospital is thus reduced. She wanted to know if there were provisions in the budget to make those appointments sooner for patients leaving the hospital. Dr. Zadny said there are funds budgeted for more frequent medication follow-ups, but SNAMHS has had difficulty recruiting psychiatrists to fill the 10 budgeted positions. He stated, "Normally we run with a total of 8, with a combination of employees, folks working for the university, and temporary positions that we hire on contract."
Dr. Zadny assured the committee facilitating follow-ups is a priority. He said his people are using considerable care to follow up on missed appointments, and to make sure people get back into the system.
Senator Glomb asked if standards of care in transitional housing were being improved after the audit report had indicated some problems. Dr. Askew replied the homes are assigned to a case manager who monitors the care in each. He said he had personally visited all the houses, apartments and group homes and had caused some to be closed or improvements to be made.
Senator Glomb questioned the administration of services by personnel at Lake's Crossing to jail inmates in southern Nevada. Dr. Zadny answered, "Right, Carlos Brandenburg has always been involved in the jail and detention center down south. This is basically formalizing what we've been doing for a number of years." He explained at one time there was a forensic services staff, with a local supervisor. He said, "We no longer have those staff, so it makes sense to transfer supervision to Carlos."
Senator Glomb asked if there was anyone coordinating services to the mental health patients in jail in southern Nevada. Dr. Zadny replied there is and has been as long as he has been working with the division. He lauded Nevada for showing the foresight during the 1970s in responding to the problem of incarcerated mental health patients. He described the purpose as being to identify those who are placed in jail inappropriately and to make provision for treatment there or referral to a mental health facility.
Dr. Zadny asserted his division works very closely with the police and county management of Washoe County to set up protocols to deflect people out of the jail and over to Lake's Crossing. He said negotiations are under way to improve the system so those people will never be put in jail in the first place. He indicated a preliminary agreement has been reached take those people to Lake's Crossing where they will be given a free physical examination and, when appropriate, be referred into the mental health system.
Mrs. Williams asked if the new positions requested would bring the staff to the same level of staffing authorized by the last budget, prior to budget cuts. Dr. Askew replied the request would not restore the number of authorized positions, but it would restore approximately the same number of actual case managers that were employed at the time. He indicated it would not restore the outpatient counselors except for one psychologist for crisis counseling, nor would it restore the day program staff, the occupational therapy staff, the vocational staff, or a number of miscellaneous positions that had been deleted.
Dr. Zadny said they had 298 positions before the cuts and are down to 207 today. If all the requests are approved the division would have 217.5 positions. Dr. Askew stated staff would be restored for outpatient service with a limited capacity only for immediate response which would provide just one or two visits and a possible referral to contract counselors for an extension of six visits. The contractual service, he said, could benefit approximately 288 people.
Mrs. Williams indicated she understood those under crisis would continue to be served, but she expressed concern for those with chronic problems. She declared six visits would not suffice for those people, whereas outpatient service would benefit them. She said she had received telephone calls from many of the nearly 1,200 outpatients in the state. She suggested some of the chronic outpatients may become residential patients if they do not have outpatient service.
Mrs. Williams concurred with Senator Glomb's concern that coordination and supervision by people in Reno of those servicing the jail some 500 miles away may be difficult, especially in unexpected situations.
Dr. Zadny remarked, "The reason we're going to this model, we have a psychologist and a financial person screen people, and then either treat them directly or send them out to a contractor." He admitted he had assigned the jail workers to Dr. Brandenburg several months ago. Dr. Brandenburg visits southern Nevada frequently, and so far there have been no problems.
Mrs. Williams asked how federal Title XIX funds end up in the General Fund. Dr. Zadny responded about half of those funds are state funds, which previously had been included in the welfare budget. He said those funds were moved to this budget to indicate the total investment being made in mental health services, rather than have the figures appear in two separate budgets.
Senator Raggio asked Daniel G. Miles, Fiscal Analyst, to clarify the way the federal funding is integrated into the state funds. Mr. Miles indicated the funds matching the Title XIX funds now appear in the SNAMHS budget rather than the welfare division budget and thus the total amount in the General Fund under the mental health division budget is higher.
Senator Coffin expressed his regrets over the necessity for past reductions in the SNAMHS budget, which he characterized as "the most brutal cut of all." He said:
We have a constituency which really can't rationally speak for itself. It is a noisy but relatively ineffective constituency.... Particularly in southern Nevada we have seen these cuts graphically...cause at least one, perhaps two deaths.... There could be other
serious problems created by the lack of an outpatient program.
He advocated restoring the old outpatient program. He asked how much it would cost to bring the old program "back to life." Dr. Zadny agreed to provide the figures to Senator Coffin.
Mr. Humke concurred there is some question about the methods of accounting for the General Fund match to the federal Medicaid spending. He expressed his frustration over the Medicaid program. He described a conference he had attended, along with Senators Rawson and Callister and Dr. Askew, sponsored by the National Institute of Mental Health. He declared local entities must make it known to the national government that Medicaid reimbursement rates must be done on a fairer basis. He said Nevada receives approximately a 50 percent reimbursement, while Utah receives nearly 85 percent. He called the rating schedule, based on per capita income, "strange." He insisted the current national administration must make the changes.
Mr. Marvel asked if the SNAMHS is in compliance with the federal mandates. Eugene Brown, Business Manager, Mental Hygiene and Mental Retardation Division, Department of Human Resources, averred the SNAMHS is in compliance, including the use of those psychiatrists under contract.
Dr. Askew interjected the SNAMHS has commenced contracting with psychiatrists through the university medical school. Although there are funds available, he acknowledged the full quota of ten psychiatrists has not been filled although they have been recruiting. One new psychiatrist will start on March 29, and another will start in April or May.
Ms. Tiffany asked if SNAMHS monitors the contracts made with psychiatrists to make sure the services have been rendered. Dr. Askew replied they do make sure the psychiatrists are present during their appointed times. He said everyone works a regular schedule in the hospital, in the medication clinic or in the crisis center.
Ms. Tiffany inquired if the billings were being made on time. Mr. Brown answered that the new outpatient billing system was fully operational to bill all insurance carriers, including Medicaid. He said the new program for billing for inpatients has not been tested yet, but will be operational soon. Ms. Tiffany said she would like to see some statistics on accounts receivable to be sure they were under control.
Ms. Tiffany declared her experience working in a hospital made her aware there are some street people who do not stay on their medications and who frequently go to the hospital rather than going to a primary care physician. She asked if a managed care program would impact the hospitalization process. She stated, "With most managed care you can't just go check in through the ER [emergency room]." She wanted to know how they would be entered into a primary care system.
Dr. Askew offered the opinion that the present crisis system of intake is working very well as to who needs hospitalization and who does not. He said:
I would expect that this kind of screening and pre-evaluation would stay in place...so I do not think that we would be overwhelmed with inappropriate admissions through any kind of a managed care system. Whether a managed care system would make an appropriate decision about sending people...for further hospitalization either to us or to whoever they have arrangements with, the private sector, I really don't know how that would work out.
Ms. Tiffany suggested he pay attention to that when negotiating new contracts. She stated people normally cannot get hospitalization without the consent of a primary care physician. She said, "If they see this as abuse of the system, they may end up out on the street without any care."
Dr. Askew said there have been discussions about making the private providers responsible for all care, including inpatient hospitalization, with a capped rate. He suggested it would be in their best interest to not overuse inpatient care, and patients should not be "dumped" into the public mental health system.
Ms. Tiffany asked, "Aren't these mental health people on Medicaid?" Dr. Askew replied:
You can go out and find providers that will provide either physical care or mental health care to a fixed eligible population. You can define that eligible population as you will. It might be that eligible population is currently receiving...reimbursed services from providers other than the division.
Ms. Giunchigliani suggested adding performance indicators that deal with billings which would show how many were sent, the collections and the outstanding balances. She requested a copy of the job description for the case managers. She asked how many clients who had previously received services were no longer being helped under the budget cuts.
Dr. Zadny said there were approximately 1,335 people enrolled in outpatient counseling, but the December figures showed only 323 had been counseled leaving over 1,000 for whom there was no accounting.
He said there had been 507 in case management, but now 130 are no longer being served. He was unable to provide figures for day training, but estimated most of the 323 eligible for outpatient counseling were being served.
Dr. Zadny said the housing figures are nearly what they were prior to the cuts except for 26 housing-intensive beds. He suggested intensive services be added to the housing already available.
Ms. Giunchigliani said she envisioned the community-based program as a tool for prevention, which should take priority on any budget. She noted 88 positions had been cut based on recommendations from the last legislative session, but she noted the total cut for the entire MH/MR agency was 195 positions. Dr. Zadny corrected the figure to 203 positions which had been removed.
Ms. Giunchigliani suggested a prevention budget be provided to the committee which would focus on a support mechanism to replace the community programs. She opined many of those former clients may be found in other programs, such as welfare, or may be homeless and going without any assistance. She said, "I'd really like our focus to be one of compassion." She admitted the budget crisis was the major cause, while she advocated returning to compassion as a social policy.
Mr. Perkins agreed with the frustration over the lack of tangible performance indicators. He related the frustration he had observed among law enforcement personnel who lacked the skills to deal with the mentally ill, especially among the homeless, when no alternative sources of assistance were available after the cuts were made. He attributed a lack of assistance from the private sector because the homeless are difficult to treat and because such assistance is "dollar driven."
Mr. Perkins asked if the number of long distance telephone billings referred to in the audit had been reviewed. Mr. Zadny said the billings are routinely reviewed every month.
Senator Glomb said, "I too would be interested in some type of an analysis...in terms of the case managers and what, if there's some way you can show some figures in terms of cost savings." Dr. Zadny responded a study had been done in 1980 when the legislature first funded the expansion of community services. He estimated hospital uses dropped to about one-half what they had been.
Senator Glomb asked if there had been any thought to change Nevada law in terms of admissions to hospitals. She pointed out there is a small segment of the population which poses no threat to others or to themselves under the way the statutes are presently worded, but who she described as actually being a danger to themselves because they are oblivious to traffic or other hazards. She suggested many of those people end up in jail.
Dr. Zadny replied a proposal is pending before the judiciary committees to expand the coverage of public guardians to include seriously mentally ill adults, because many of them are misdirected. He said they frequently refuse services which a prudent person would accept, such as decent housing, and they will not avail themselves of voluntary admission to an inpatient unit. He said, "If we could find someone to serve and substitute judgement for theirs, I think the world would be a much better place."
Senator Raggio pointed out many of the questions will be more intensely addressed by the subcommittees. He called for a ten minute break.
When the meeting resumed Senator Raggio announced he would open the meeting to public testimony.
Brian Lahren, Associate Executive Director, Washoe Association for Retarded Citizens, commended the members of the committee for being well informed on issues of mental health and mental retardation. He declared the state had one of the best MH/MR systems in the country up until the time of the budget cuts last year. He said the system had the ability to deliver preventive services in the community, to prevent moderate problems from becoming severe problems. He congratulated Dr. Zadny and his staff for making wise use of the resources available.
Dr. Lahren called the present system an unfortunate one designed only to deal with crises. He encouraged support for more case managers, for care beyond simple responses to crisis and for restoration of the system similar to its former configuration.
He asserted the institutional components of the system have been cut so much that further cuts would severely hurt the MH/MR division. He said the inpatient services are just adequate.
Dr. Lahren pointed out the state presently spends less than $16 million per year to provide inpatient care to about 184 mentally retarded individuals. Of the 184, he said there are 24 living in intermediate care small facilities with less than six beds. He characterized use of the small intermediate care facilities as an excellent program. He indicated there are more individuals in inpatient care than necessary, at a higher cost than necessary. He suggested administrators in the division, and other departments, be given the flexibility to appear before the legislature to suggest implementation of cost-effective measures within their budgets. He said it may be possible to move 24 people into the community at a lower cost than serving 12 within an institution. He continued:
As long as it's revenue neutral, the budget division say in the matter...ought to be nothing more than to check off that it is in fact revenue neutral, and they should be able to come before you as professionals to argue on a client service basis on an improvement to the system that this is the right thing to be doing. It doesn't make sense to hire professionals to administer divisions where the issues are highly technical and then have those initiatives cut off because the budget division doesn't think that they're appropriate.... It's not an effective way to run state government.
Dr. Lahren reiterated his support for community-based services in mental health and for endeavoring to move the mentally retarded out into the community. He asserted moving those people into the community would provide better care than that offered by institutionalization while it would save the state a considerable amount of money. He felt there should be a structured plan over the biennium to achieve that goal.
Dr. Lahren said he works closely with the Truckee Meadows Human Services Agency, which represents 90 human service agencies in Washoe County. The Truckee Meadows Human Services Agency, along with a similar agency in Las Vegas, would like to see the Office of Protection and Advocacy moved out of state control. He declared:
A long-term systemic change to get advocacy focused on appropriate and quality care in the system, one of the best things that can happen, is for there to be independent advocacy in the state. Federal money can follow that office out into a private, nonprofit entity in the community. It would have to be totally separate from any service providers so that it wouldn't in any way represent a conflict of interest.
He said, "I think there's an inherent structural conflict with that office being in state government and trying to supervise state government agencies." He admitted that was not a legislative issue but asked support for his position.
Senator Raggio asked if Dr. Lahren had any other comments on the recommendations that had been made. Dr. Lahren replied he felt there was an inadequate ability to deliver counseling services to people out in the community, especially in the SNAMHS budget. He reiterated his belief the case-management services should be expanded in order to serve the numbers of clients that were served prior to the budget cuts. Those would include the persistently ill and moderately ill who could deteriorate to the point where they would need crisis services. He advocated investing in "the most cost-effective end of the care system, and not simply maintain a system which...forces people into only expensive levels of care."
Senator Raggio wanted to know if Dr. Lahren could agree to use of the resources as proposed if no other funds were available. Dr.
Lahren said he felt the proposals were carefully thought out with the funds available.
Gail Burks, Staff Attorney, Nevada Legal Services, quoted a report (Exhibit E) outlining the effects of the mental health cuts on southern Nevada. She declared the two areas most effected are the homeless and the prison population.
Ms. Burks called attention to Table 3 in her report which indicates that 60 percent of non-traffic related misdemeanor cases before the municipal court involve mentally ill defendants.
Ms. Burks stated since the budget cuts mid-level services, such as sub-acute facilities outlined on Table 4, are no longer available to those high-risk individuals who are not severe enough to be institutionalized. Now the only options open to those people are to go into an institution or into a group home. She declared it is not cost-effective to put those people into supported housing if they are able to function on managed care.
Ms. Burks requested the committee to use present resources to restore the mid-level services. She suggested there may be less liability to the state if a minimum level of services is provided to the mentally ill.
Mr. Spitler asked what the estimated costs were for the Level 3 supported housing referred to on Table 4. Ms. Burks answered normally those using supported housing receive some disability benefits from social security which is signed over for the housing, while the balance is paid by the state. She said the average social security disability benefit ranges from $406 to $428.
Ann Smith, State President, Alliance for the Mentally Ill, read from prepared text (Exhibit F). She advocated restoration of funding for community-based services.
Senator Glomb thanked Ms. Smith for the Mental Health Reference Guide she had provided earlier in the year to members of the legislature.
Bill Couey, President, Northern Nevada Alliance for the Mentally Ill (NNAMI), said the NNAMI has chapters statewide and is affiliated with the National Alliance for the Mentally Ill (NAMI). He described the organization as a voice for parents, relatives and friends of the mentally ill, those who make use of the services, not the providers.
Mr. Couey concurred with earlier statements that the staff and directors of the MH/MR Division have done well "reworking a system that was nearly destroyed by past budget cuts." He said, "Unfortunately and tragically there were some very heartbreaking events that occurred before they could plug up this hole, and at best this hole is still just a temporary patch...."
Mr. Couey recalled that a computer system to link the north, south and rural areas had been promised 3 years ago to keep a closer reign on clients who might be "falling through the cracks." He wanted to know what had happened to that promise.
Mr. Couey complained that mentally ill are put in jail as a convenience because of a lack of other places for them, since they do not meet the criteria for institutionalization in mental health hospitals. He said there is a need for more halfway houses to prepare those people to return to community life. He declared there is a desperate need for more crisis beds in the north, and more trained caseworkers are needed. He judged the Supportive Living Arrangement (SLA) housing to be a great innovation.
Mr. Couey stated there are about 200 people on a list waiting to see doctors. After the north lost three staff doctors some patients were sent to contract doctors, often a different person each time, who changed medications frequently to the detriment of the patients.
Mr. Couey commended the "triage system" in the northern sector of the state which has brought together departments from Reno, Sparks, Washoe County and the state to place mentally ill picked up by the police. He contended an infusion of $600,000, combined with funds from those entities, "would...put this thing...into motion."
Mr. Couey referred to a September 10, 1992, article in the Reno Gazette-Journal which called the local jail a "dumping ground for the mentally ill." According to the article the number of mentally ill in the Washoe County Jail on that date was 9 percent of the inmate population, higher than the Nevada average of mentally ill of 2.64 percent and a national average of 7.2 percent. Mr. Couey attributed the high percentage partly to the large number of transients in the area and partly to the fact the state has failed to care for its mentally ill properly.
Mr. Couey declared, "It's your moral commitment...to see that a substantial monetary increase to the presented budget request be forthcoming." He reiterated any cuts in the budget would cause pain, disappointments and further setbacks to a group of people who can least defend themselves.
Mr. Couey acknowledged that guardianship poses a tremendous responsibility to the person who accepts that role.
Mr. Couey conceded there is a tremendous problem getting people into the hospital. He contended those people often refuse to take their medication, so they must be a danger to themselves or to someone else before they can be hospitalized. He said, "Until they fall to the point where they cannot possibly care for themselves, and they're raving and yelling and screaming and somebody calls the police...that's too far down the tubes. There's something wrong with the law." He advocated supporting a proposed law which will include a phrase similar to "gravely disabled" as it once did. Dr. Zadny interjected:
That change in the law is not proposed by the division, it is proposed by another group of folks. I think it's in accord with national standards which protect the rights of persons from unreasonable institutionalization or hospitalization. The bill's pointing out the downside; you have folks who can't make good choices and wander the streets.
Mr. Humke said he had a request from a district court judge in Reno to include sanity hearings under the jurisdiction of the Family Court. He asked Mr. Couey how he felt about that concept. Mr. Couey replied he had not considered such a change but would discuss it later with Mr. Humke.
Kevin Christensen, Director, Office of Protection and Advocacy, testified from a written statement(Exhibit G). He read a letter from Naomi Costello, a mentally ill person (Exhibit H), who had been one of his colleagues at one time. He said she would be number 201 on a waiting list for outpatient services at the Nevada Mental Health Institute. Because she will have to sacrifice her medication in order to keep up her education, Mr. Christensen proposed a system of pro bono psychiatric care and a sliding-fee basis for prescriptions at the Nevada Mental Health Institute.
Mr. Christensen pleaded with the committee to fund the budget to "meet the realities for the mentally ill and the developmentally disabled in a Nevada of the 1990s, and not the 1880s."
Senator Raggio asked Dr. Zadny to comment on the proposed sliding scale for medication. Dr. Zadny responded he had discussed the proposal with Mr. Christensen. He indicated those within the system would receive medication on a sliding scale. He said, "The problem you have is you have to have folks that...accept the script from physicians outside of our system." He concurred with Senator Raggio that such a system is worthy of consideration.
Senator Glomb said she was appalled that there are people who cannot get medications, especially after the state has spent the money to have them assessed. She asked if there were plans to alter the situation.
Dr. Zadny replied there are six psychiatrists normally assigned to the Nevada Mental Health Institute, with one vacancy at the present time. He said vacancies have been filled in the past through contract services, while there has been an increase in referrals to the medication clinic. However, he said, the number on the waiting list is shrinking, and those most acutely in need of assistance can be seen within 3 days.
Senator Glomb recounted a situation when she was an advocate for a mentally ill client, and she had to arrange for an emergency appointment because the client was unable to do so. She directed her frustration toward the system, saying it does not have good fiscal management, nor was it humane under such situations. She asked what could be done when people have no funds for medications. Dr. Zadny replied once they are in the system, even as outpatients, they should be provided with medications by the state.
Senator Glomb asked if the Office of Protection and Advocacy would remain under the Department of Commerce under the Governor's reorganization plan. Mr. Christensen answered it was scheduled to go to the Department of Employment Training and Rehabilitation.
Senator Callister changed the focus of the discussion from the humanistic to the fiscal aspects. He suggested there was a recurring theme that decreasing expenditures in MH/MR funding were manifesting increased expenditures elsewhere in the system, such as in the state prison or county jail populations or for the homeless. He asked if cost-shifting was, in fact, the case, and if any of those testifying could give him hard data to that effect.
Senator Callister inquired if community-based treatment is truly the most cost-effective vehicle for providing services, as had been repeatedly expressed. He asked if allegations are true that the system is crisis-based with little to offer otherwise. He asked how those problems will be met while staff is already at a minimum and with the loss of two deputies and the training director. He said:
I wonder how you're going to find the time to do all of those things when you're confronted with diminishing, available revenues.... Can we spend not more money...can we spend it wiser, or ought we look at where we're spending it elsewhere in the system and engage in some longer-term macro-management...instead of the micro-management that this committee is so frequently wont to do, and decide if we ought to address the budget as a whole....
Dr. Zadny responded he felt the committees would be "pleasantly surprised" with the improvements in the cost-effectiveness of the budgets. He said the budgets call for reinvesting existing resources in areas that are deemed more productive. As an example, he said the contract for food service at NMHI will save over $250,000 per year, which could be spent on housing and case-management services. He said they plan to take funds for nine nursing staff positions at NMHI and devote those to community-based care. He endorsed a commitment to community-based care and asked the committees to fund those requests.
Dr. Zadny stated it is difficult to prove whether there is cost-shifting. He explained there are two mental-health populations, those being the persistently or severely ill, and those who are moderately ill. He said most of the remaining services have been concentrated on the severely ill, while those mildly impaired have not been served to any great extent except in rural areas.
Dr. Zadny expressed a personal belief there is no evidence that the moderately ill become chronically ill. He said, "You don't have somebody become a chronically mentally ill person because you didn't give them outpatient counseling over on Kietzke." He conceded there is a degree of human suffering among the moderately ill.
Dr. Zadny expressed doubt that mildly impaired people would become severely ill, break the law, and wind up in the county jail. He said a count of people in jail during October showed that of 1,576 bookings there were 64 seriously mentally ill, eight were institute clients, and only 11 more were past clients of the system, which meant only one-half of a percent of the bookings for the month were institute clients. He said the 4 percent incarcerated who were seriously mentally ill was well below the national average of 7.2 percent.
Dr. Zadny added he had seen no evidence that the number of mentally ill people in the Washoe County Jail had increased since last October when the cuts were made. He surmised there had not been cost-shifting, but he conceded there were many former outpatients who are dissatisfied due to a lack of services.
Senator Coffin asked what happened to those in southern Nevada who formerly were receiving outpatient care. Dr. Zadny replied he could not give a precise answer. He said there formerly had been 1,335 in outpatient care, 323 of whom he knows are now being seen by a private provider. He stated the staff has not had the time or resources to track the rest of the former patients. Senator Coffin expressed the opinion the budget, as submitted, was inadequate, and stated he would like to see a workable budget.
Ms. Giunchigliani inquired:
When we do contracts with doctors...do we have a mechanism in place so that, say they were in a hospital and the beds were not filled, therefore they're not able to do their full-time duty. Is there a mechanism for that to be automatically shifted over to...an outpatient, or are there other duties they can do other than just monitoring what's going on.... Is there any way to reassign them based on the fluctuation that comes and goes?
Dr. Zadny replied, "Yes, that's completely within the latitude of the director of the agency." He said that is being done.
Dr. Zadny declared he is not unsympathetic to those not being served, for whom he cares deeply, but he had seen no evidence of the indices being alluded to by the advocates.
Robert S. Hadfield, Executive Director, Nevada Association of Counties (NACO), testified the counties have received many referrals to local mental health services since the budget cuts were made. He asserted the counties are not in a position to provide those services.
Mr. Hadfield said his understanding of the budget leads him to believe rural clinic service will decline, which will result in increased waiting time for clients as well as less services. He agreed that savings can be accrued from early intervention. He declared putting greater reliance on community-based programs cannot be achieved if the rural clinics close. He expressed his concern for "those people who have crises from time to time...." He said:
If we don't get them a little bit of help...I've read where...some abuse takes place in the family.... Dysfunctional families need help from time to time. These people do show up in other parts of the system, both state and county.... It's going to be very hard to quantify, but that's our feeling that without those resources available in the community there are impacts that go farther and beyond not only with the state but with the county.
Mr. Hadfield said he would attempt to quantify the impact of the cuts on the communities.
Mary Henderson, Administrative Analyst II, Finance Division, Washoe County, acknowledged the changes in state law over the past several years, although intended to reduce inappropriate involuntary hospitalization of mental health patients, have created problems for counties. She said those problems have affected acute mentally ill patients and the jail population, especially in areas employing outpatient medication and counseling.
Ms. Henderson said local agencies have been working together in an attempt to address the problems. She complained, "Whether this is caused by stringent admission regulations and guidelines, or budget cutbacks at the state level, the impact is very real on our jail."
Ms. Henderson described the procedure when a person is picked up by the police department. According to Ms. Henderson, when found on the street in a vagrant situation, perhaps evidencing bizarre behavior, the person will be taken by an officer to the emergency room at Washoe Medical Center. If it is determined there is no medical problem, but the person has a substance abuse problem, he or she is transported to NASAC (Northern Area Substance Abuse Council Inc.). Ms. Henderson said that will take the police officer 1 to 3 hours to accomplish. If NASAC determines the person is mentally ill, rather than suffering solely from substance abuse, the person is taken to NMHI for a review. If the person has an alcohol level of .10 or higher, the person will not be accepted by NMHI and is taken to the jail. At the jail the person is booked on a misdemeanor charge and usually kept there for about 34 days.
After release from jail, Ms. Henderson continued, the person usually goes back on the street, and may be picked up two, three or four more times for bizarre behavior. After several such encounters, she said the officer occasionally takes the person directly to jail.
Ms. Henderson stated there have been 139 inmates over the past 5 months who received mental health care. The average stay was 34 days, and the average cost was $1,904 per inmate, for a total over the 5 months of $264,000. She declared:
It is more than a dollars and cents issue, because it is not appropriate for these folks to be placed into our jails.... They're vulnerable, they can be victimized by other inmates, we have a terrible problem of security for them if they get into violent behavior...and our detention center...is already overcrowded.
Senator Callister asked Ms. Henderson to provide any documentation she had to verify her allegations that decreased state spending had caused corresponding increases in Washoe jail admissions involving the same clients.
Senator Raggio called a recess at 12:30 for the lunch hour. When the meeting reconvened at 1:30, Senator Raggio announced he would commence with the budget for the Nevada Mental Health Institute (NMHI).
Nevada Mental Health Institute - Page 734
Dr. Zadny gave a brief summary of the budget reductions affecting NMHI. He said those reductions totaled $1,433,849 in FY 1992, and in the second year of the biennium they will total $1,970,312, for a total of $3,404,161. He explained 64.5 physicians were eliminated through those budget reductions, and an outpatient clinic on Kietzke Avenue which served 234 clients was closed. Of those clients, he said, 144 were then enrolled in the medication clinic at the Galletti Way facility, and the other 90 clients were referred to private sector service providers.
Dr. Zadny added one of the remaining two halfway houses was closed, whose clients were placed in the community. The geriatrics unit was closed, and those nine clients were placed either in inpatient facilities or in community residences. He said the balance of the savings were in support areas.
Dr. Zadny suggested the committee members turn to page 6 of his handout (Exhibit D) to review the budget recommendations for NMHI.
Richard H. Rahe, M.D., Medical Director, Nevada Mental Health Institute, stated the institute provides inpatient care to approximately 44 persons, case-management service to 397 clients, medication clinics to 760 clients, day training for 131 clients, vocational services for 54 clients, and housing assistance for 82 clients.
Dr. Rahe pointed out there are two capital improvement projects requested, as recommended by the State Public Works Board. One is an upgrade of the fire alarm system at NMHI, as delineated on page A36 of the Governor's budget. He explained replacement parts are no longer available for the existing system.
Dr. Rahe said the other project, Upgrade Electric Phase Protection, can be found on page A31. The protection would be installed on all large motors. In July of 1991 an electrical storm caused extensive damage to the air-conditioning system serving three buildings, and repairs, which took 3 weeks to effect, cost in excess of $15,000.
He recommended the installation of the system because the institute has numerous electrical and mechanical systems which are susceptible to such damage.
Dr. Rahe called attention to the primary budget proposals, which ask for one and a half new case managers, one-quarter support staff, the deletion of nine nursing positions, five additional work skills training persons, a new therapeutic recreational specialist for inpatients, and two positions and contract funding for crisis counseling. It also calls for two new housing placements per month to start in September 1993, the relocation of the rural clinics' business office to the institute, and the transfer of one position from the rural clinics to NMHI to handle program evaluation. Additionally, it is recommended that half of the rural director's time be devoted to management of community services.
Dr. Rahe referred to pages six and seven of the handout (Exhibit D) which lists the number of case managers requested and the number of clients they would serve. He correlated the figures on his handout with the demographics in the Executive Budget shown on page 735.
He explained NMHI had sufficient staff to handle 63 inpatients, but during the past year the number of those served ranged from the high 30s to the low 50s. Hence, the table on page six indicates the proposed reduction of nurses. He drew attention to the increase in the number of proposed patient workers, who train clients in living skills, from 7 to 12, which would add another $10,400 to the annual budget.
Dr. Rahe said the need for new housing is anticipated to grow at the rate of two per month, which is reflected by the recommendations on page six of Exhibit D. One cost-saving recommendation would place clients in apartments with Supportive Living Arrangements (SLAs) to assist them to live independently.
Dr. Rahe said NMHI is asking for a recreational specialist to aid the present four and one-half activity therapy persons for inpatients. The new specialist would bring the activity services to a level deemed acceptable by the federal auditors, as reflected on page 737. He declared it is vital to pass the federal reviews for NMHI to receive federal reimbursements.
Dr. Rahe stated the request for a psychologist and management assistant is set forth on page six of the handout and on page 738 of the Executive Budget. The psychologist would provide counseling for persons, usually indigents, who are acutely disturbed but do not need inpatient services. The funds for that position would provide counseling for 108 patients and referral to private contractors for an average of six visits per patient.
Turning to page seven of Exhibit D, Dr. Rahe described the Enhancement it would fund as provided on page 739 of the budget. It will cover the transfer of the rural clinics administrative and business offices from Carson City to NMHI in Sparks. He echoed Dr. Zadny's opinion the move would strengthen the community services at NMHI by assigning the director to use half his time supervising the rural clinics and by improving the efficiency of the rural clinics business office by putting it under the supervision of the northern region business manager.
Dr. Rahe commented:
A related change requests transfer and reclassification of a rural clinics personnel analyst to NMHI, a management analyst to do program evaluation. NMHI is the only division agency currently lacking dedicated program evaluation staff, which are needed to keep accurate track and update records of caseloads and services.
Dr. Rahe asserted contracting for food service could save up to $272,741 annually. Hence the recommendations for contracting food service as listed on page 740 of the budget and page seven of the handout. Although 18 food service workers would be laid off, a dietician would be retained, and the meals would be provided under contract. He noted NMHI alone would save $68,426 in food costs in FY 1995, and an additional $20,239 in utilities.
Dr. Rahe advised continuation of the Clozaril program funding for FY 1994 and FY 1995 at the 1993 FY level, with small adjustments for inflation. He said:
We have already provided this drug to many of our chronic patients who were eligible to respond and also agreed to take part in a weekly blood draw...because of potentially dangerous side effects.... A third of these patients have responded.... The patients who have responded were not eligible for payment for the drug, and if they're not they have to be continued on our...state expense. If they're Medicaid eligible we can use that.
Referring to the next item, Dr. Rahe declared:
Prior to the creation of the Division of Child and Family Services the institute business office performed business-related functions for the Northern Nevada Child and Adolescent Services. The transfer of a principal accountant position...to provide accounting services to the new division is included in the base budget.
Dr. Rahe drew attention to the summary on page 741. He noted the federal revenues are over $300,000 lower than the actual costs in FY 1992 actual costs. He stated:
This reduction represents a $250,000 adjustment for prior year Medicaid/Medicare cost report settlements, and other prior year service recoveries, which will not reoccur. Medicare revenues for FY 1994-95 represent anticipated recurrent revenues. Additionally, the state portion of the Medicaid collections has been moved from this category to state appropriations, or the General Fund.
Dr. Rahe said the federal funds line-item includes social services grant revenues for the first time, which will provide reimbursement for the treatment component of SLA and day training services.
Dr. Rahe listed equipment purchases requested under the budget. Funds for Occupational Safety and Health Administration (OSHA) requirements are listed on page 737, primarily for a lockable vaccine refrigerator with an alarm and an explosion-proof paint mixer and exhaust fan for the paint shop. Replacement furniture is requested on page 738, which would include beds, refrigerators, chairs, and office equipment. He asserted new dictation equipment is needed for medical records vitally needed to keep the psychiatric records up-to-date. The funds enumerated on page 739 will be used to replace eight computer systems originally purchased 7 years ago, which Dr. Rahe asserted have outlived their usefulness.
The expenditures sought for inflation, maintenance and enhancement total $350,893 in FY 1995. Dr. Rahe pointed out, "If you ignore the food savings and transfer of rural clinics administrative services, this represents a 3.1 percent increase over the FY `95 adjusted base budget."
Senator Raggio asked how many psychiatrists are on the staff. Dr. Rahe answered there are five, although they are allowed six under the current budget.
Senator Raggio inquired, "What can you share with us about security in view of the recent incident that occurred on the campus?" Dr. Rahe replied:
The security issue has been...a very, very important topic for all employees at the institute. And I have formed a committee which represented every employee, not just the professionals...not only at our institute.... People contract for space at the institute...so even the contractors have provided input into security issues.
Dr. Rahe explained the ongoing committee has suggested measures which NMHI can afford to do immediately and is planning for future security steps which may be more costly. The current measures include improved visibility by trimming the shrubbery and augmenting the lighting, and people are escorted out of the building at night. Future steps will include courses on self-defense.
Mrs. Williams expressed surprise that indigent patients who are treated pro bono and are given prescriptions are not eligible to obtain their medications on a sliding scale from the medication clinic. She also asked Dr. Zadny, "Do you really believe that early intervention does not affect the acute or progressive illness?"
Dr. Zadny responded:
In terms of the pharmacy, Dr. Rahe and I discussed that...in addition to adding cost to this budget, if we have the money we'd be delighted to do it, but there are some other considerations you may want to keep in mind. The physicians that would be writing those prescriptions are folks that may not be known to us,...so the state could be placed in the awkward position of filling a prescription that is an inappropriate drug for a client or a too high a dosage....
He suggested other mechanisms need to be in place to screen those prescriptions to be sure they would not subject the state to additional liability. He concurred, "...that it is silly not to medicate somebody when you've got other pieces of the system in place is well taken."
Mrs. Williams reiterated the problem she had with the refusal to fill prescriptions, saying "We live in a state that licenses medical personnel. We have passed legislation that says that a physician coming from another state who has committed an act of gross medical negligence can't be licensed in this state." She repeated her question why it should be so difficult to telephone an unknown psychiatrist who is willing to do pro bono work. She said, "It seems to me...that's something that needs very careful attention, because down the road,...residential care for that person...is going to be a...lot more."
Dr. Zadny repeated that he had no objections in principle to Mrs. William's premise, but he pointed out there are some people who are "prescription shoppers" who go from one physician to another until they obtain the desired prescriptions. He recalled that 6 or 7 years ago there were patients who were receiving prescriptions from three or four doctors, who used them unlawfully, including overdosing leading to death. Because of that, he reiterated that prescriptions need careful screening to be sure the drug and dosage are appropriate.
Mrs. Williams opined those occurrences are probably rare. She added, "I am very disappointed...with all the budgets in general because none of them have a mission statement attached to them." She attested it is very difficult to make determinations about the budgets with no mission statements.
Senator Raggio reminded the committee of the limited time in which to hear the mental hygiene and mental retardation budgets and that a number of people wished to testify on vocational rehabilitation. He asked that questions be concise and not go over ground already addressed, and he noted there will be opportunities to obtain more detail during subcommittee meetings.
Mr. Arberry was curious about the usage of the paint shop. Dr. Rahe responded it was included under the miscellaneous equipment requests mandated by OSHA, set forth on page 737 of the Executive Budget. As to usage, he explained there is a lot of wear and tear on the mental health ward, so walls must be painted frequently.
Senator Glomb inquired how many patients cannot afford medications and how much it would cost to provide the medication. Dr. Rahe commented it would not be acceptable to prescribe medication without making an evaluation of the patient and taking the time to do follow-up after medication commenced. He asserted the number of patients treated is limited due to limited personnel.
Senator Glomb continued, "Do we have clients who are being turned away, who are not being medicated because they can't afford it?" Dr. Zadny responded there are less than 20. He agreed to provide the exact number and to find out the cost to medicate those people.
Mr. Dini asked for the reasoning behind the proposal to move the rural clinic administration and business office and the personnel analyst to NMHI. He wondered if the institute is big enough to handle the additional work load without transferring some employees out. He offered the opinion it would be better to "shore up the rurals" by transferring the administrative and personnel analysts into case management. He asserted crime and caseloads are getting worse for rural district attorneys since the budget cuts.
Dr. Zadny responded, "We're business people. I don't think we'd put a small remote office 30 miles from our main office, which is what we've done historically by creating the rural clinics business office here in Carson City." By bringing the two offices together, he said, the personnel cut equals the total number in the rural clinics. He asserted that should enable the NMHI to get along with one less person. Instead of putting the person to work as a clinician, he suggested, "we thought, instead, since this committee and other committees have needs for information that we have dedicated staff to provide information at the one agency in the division that lacks such staff all together."
Dr. Zadny continued:
The other thing that's happened at the institute is the principle account...has been transferred to DCFS [Division of Child and Family Services]. If we move the rural clinics business office over to the institute the business manager for rural clinics can occupy that higher-level function. So by merging the two offices together you reconstitute the whole. You have that higher-level position that would be missing if we didn't make the consolidation.
He said it takes two people to run one of those facilities, one for inpatient service and one for community service. If one person is asked to do both, he asserted:
It's often a stretch, both in terms of time and in terms of disciplinary training. It's not usual for folks to have training and experience in both areas. The current director in rural clinics has some experience in community services...and would add...to the effort at the institute.
He concluded there is no intention to diminish services to rural clinics.
Facility for the Mental Offender - Page 744
Dr. Zadny enumerated the budget reductions over the last biennium which were $136,328 in the first year and $122,823 in the second year, for a total of $259,151. He stated:
The positions affected were the reduction of a social worker.... We also eliminated a facility maintenance supervisor and we reduced the psychiatrist to .5 FTE [Full Time Equivalency] instead of a full FTE.
He called attention to the summary on pages eight and nine of the handouts (Exhibit D) which delineates the changes.
Carlos Brandenburg, Ph.D., Director of Forensic Services, Lake's Crossing Center for the Mentally Disordered Offender, indicated there are 38 in the facility at Lake's Crossing which is designed for 36. He described Lake's Crossing as a maximum security forensic facility which provides services to mentally disordered offenders from the entire state. Services are given to those who have been adjudicated within the criminal justice system as well as within the penal system who have been found in need of residential services in a maximum security mental health program.
Dr. Brandenburg referred to pages eight and nine of the handout in which requests are detailed. He asked that the half-time psychiatrist be funded for full time to provide daily psychiatric intervention to seriously mentally ill offenders. He declared another new clinical social worker is needed to provide social worker staffing at the ratio of one social worker for each 18 clients. The third request, he said, would provide a second facility supervisor in order to maintain and repair equipment in the security system "in a 25,000 square foot facility surrounded by extensive courtyards and grounds."
Under Enhancements, Dr. Brandenburg requested the addition of a forensic specialist in each year of the biennium. He said there are currently 32 staff members providing coverage 24 hours a day, 7 days a week, over the facility. Additional forensic specialists are needed to provide adequate coverage for an anticipated increase of offenders. He also asked for reclassification of a Management Assistant I to a Management Assistant II. The security equipment requested is listed on page 746 and replacement equipment is listed on page 747 of the Executive Budget.
Dr. Brandenburg explained the reduction for food costs on page 748 reflects the savings anticipated through conversion of NMHI meal services to contract services. He said the supervision of meal services in Las Vegas at the Clark County Jail and the municipal jail is being transferred to the Lake's Crossing Center.
Dr. Brandenburg said small sums are requested for data processing on page 744 under the Base for supplies and maintenance, and on page 747 for the purchase of another computer and software for use by academic services training. The latter would track educational programs, staff training and requirements for promotion "as well as for tracking quality assurance, court dates and staff credentialing." He summarized the requests at $289,531 for an 11 percent increase.
In response to a query by Senator Raggio, Dr. Brandenburg guessed a new facility for mental offenders in southern Nevada will probably be requested at the next legislative session. He offered assurances he would have the ability to supervise the consolidation of the jail programs, which he attributed in part to the 8 years experience at detention facilities by a senior level psychologist at the Clark County Jail. He indicated he would primarily provide guidelines. He said, "What we're trying to do is centralize those services because eventually...those two people that are working in the Clark County Jail will be working as part and parcel of the new southern Nevada forensic facility."
Senator Glomb inquired if the mental health facilities have accreditation and whether any federal dollars have been lost due to lack of accreditation. Dr. Brandenburg said the NMHI is accredited, but Lake's Crossing is not and never has been licensed or accredited. He assured her no funds have been lost due to a lack of accreditation at any of the facilities.
Senator Glomb wanted to know how medical and physical care is provided for the clients. Dr. Brandenburg responded a contract physician takes care of physical examinations.
Ms. Giunchigliani asked why there is a decrease in the food services set forth on page 748, but an increase is included on page 749. Dr. Zadny explained:
It has to do with whether you continue staffing the food service, in which case there would be an increase in food costs, or whether you opt to follow our recommendation to contract, in which case there would be a reduction in costs.
Ms. Giunchigliani asked for a definition of forensics. Dr. Brandenburg replied:
It's basically any individual that is found within the criminal justice system. It's usually those individuals that have been either adjudicated incompetent to stand trial, or found not guilty by reason of insanity. The difference between Lake's Crossing and Southern Nevada Adult Mental Health Authority or the Nevada Mental Health Institute are, the folks we have at Lake's Crossing have some type of legal charges against them.... All our people are pre-trial.
Rural Clinics - Page 750
Dr. Zadny testified the budget reduction for the rural clinics amounted to $1,034,265 over the biennium, and 17.5 positions were eliminated. The offices closed were in Zephyr Cove, Fernley, Lovelock and Caliente, and the Battle Mountain office is closed temporarily, while the Tonapah office is open just four days per month. He added Instate Travel was cut back during the first year of the biennium, and the cuts continued into the second year of the biennium were only those in personnel. He said, "The net reduction early on in cases was over 400; if you look at it overall, it's been down about 615 cases...since the reductions occurred."
Wilford M. (Bill) Beck, Ph.D., Clinic Director, Rural Clinics Community Mental Health Services, presented details of the budget requests for the rural clinics. He said the budget, commencing on page 748, provides outpatient care in 15 rural counties for 2,353 clients per month, for an 11-bed supportive living program in Carson City, day training for 50 persons per month, case management for 341 clients, and a medication clinic for approximately 652 clients.
Dr. Beck repeated earlier testimony that the main proposals are for two new case managers, funding for five new SLAs, partial computer automation in the administrative office and rural centers, and transfer of the administrative office from Carson City to NMHI in Sparks. He called attention to the major initiatives summarized in the handout (Exhibit D) on page 10. He described the clientele assigned to those doing case management as severely mentally ill adults and seriously emotionally disturbed youth, all outpatients. Another two new clinical social workers to handle case management are requested as enhancement items for FY 1994 for Hawthorne and Carson City. He alleged those areas have the highest severely mentally ill adult and seriously emotionally disturbed youth populations, where an additional 70 clients are not currently receiving treatment
Dr. Beck said the third table concerns office automation which appears as Enhancement 709 on page 753. He declared the Base on page 750 supports the purchase of a computer and modifications to the Management Information System (MIS) of the agency, while the Enhancement will allow replacement of worn typewriters with computers and associated software and operational costs.
Dr. Beck glossed over the fourth table on page 10 of the handout which relates to the transfer of administrative offices to NMHI, as discussed previously. The last items, listing the numbers of monthly clients and counselors, he said, were for informational purposes. He said no increases to those programs have been planned for the coming biennium.
Dr. Beck informed the committee the monthly total hours per FTE devoted to outpatients in 1992 since the staff reductions has exceeded the 1991 figure. He declared those figures indicate the staff is working harder to meet the demands of their clients.
Dr. Beck directed attention to page 750 of the Executive Budget. He pointed out the Federal Funds line item had been reduced. He said:
It includes the federal Comprehensive Mental Health Service (CMHS) block grant and also Title XIX Medicaid revenues. The CMHS block grant...shows a reduction for FY `94-`95 over the FY `92 base.... These funds have been reallocated to the Division of Child and Family Services. The Title XIX revenue figure for FY `94 and `95 shows a decrease projected on the FY `92 base recoveries and FY `92 reductions to outpatient staffing and treatment hours. The reduction reflects only the federal share, however. The state share is added to the general appropriation figure.
Dr. Beck continued:
Other...flex revenue categories including patient collections, insurance collections and contractual service collections, is part of our revenue generating capacity. The increase to this item, however, reflects the addition of the reversion figure resulting from budget reductions in FY `93.
Senator Raggio inquired if the budget would accommodate reopening any clinic offices which had been closed. Dr. Beck replied the Tonopah office had already been reopened on a limited basis, and he anticipated being able to increase services in Battle Mountain with help from the county government. He commended the county government for providing free space for the rural clinic. He admitted there are no plans at this time to reopen the other offices listed by Dr. Zadny.
Senator Raggio asked how services are being provided in those locales with no clinics. Dr. Beck said clients from Fernley receive services in Fallon or Yerington. Services formerly provided for Lovelock clients are also available in Fallon.
Senator Glomb expressed concern that only two new positions were going to be added, while 17 1/2 had been lost when the seven clinics closed. She noted the lack of clinics would affect child welfare budgets because the clinics provided services for children in foster care and for families working with the child protective services agency.
Mrs. Evans requested Dr. Beck to provide her with information on the use of funds being redirected to the children's division. She said the Division of Child and Family Services has claimed it will be unable to provide services in rural Nevada.
Mr. Marvel asked what the negative impacts had been when the first reductions were made in the rural areas. Dr. Beck repeated Dr. Zadny's statement that 615 cases had been closed as a result of shutting down the rural clinics. He indicated the attempt had been to focus on severely mentally ill (SMI) adults or severely emotionally disturbed children and provide service to the most severely disturbed clients. At that time it was determined several clients were not in immediate danger.
Mr. Marvel wondered if the population of local jails had been impacted due to the cutbacks. Dr. Beck stated his understanding there had been no adverse impact, that no more clients were found in jail than previously. He said service is still provided to the jails on an on-call basis for crisis services.
Mr. Dini asked for an update on the closure of the Fernley clinic. He indicated Fernley citizens had complained they had to wait for several weeks to get appointments with case managers in Fallon. Dr. Beck said he was attempting to fill two open positions in Fallon. He agreed Fallon had a high number of people moving through which necessitates more treatment hours.
Senator Jacobsen asked if there would be adequate space at NMHI to provide for the services formerly provided at the rural clinics. Dr. Beck replied he had not heard that there would not be adequate space and that no clients needing hospitalization had been turned away. Dr. Zadny interjected space in one of the cottages presently being used temporarily for the mental retardation program and the basement of another building were being made available for additional business office space.
At the conclusion of testimony on the mental health portion of the budget, Senator Raggio announced he would invite public comment first in respect to local vocational rehabilitation and then regarding alcohol and drug abuse. In order to accommodate as many people as possible, he requested that remarks be concise and not repetitive.
Kyle Workman, Chairman, Advisory Committee for Relay Nevada, came forward to testify on behalf of services to the deaf. His remarks were conveyed via sign language by Carolyn Gearhart. Mr. Workman said he received a telephone device for the deaf (TDD) when he first moved to Nevada, which was disappointing to him due to a poor, often inoperable, relay station. He then appealed to members of the rehabilitation agency in Carson City, who worked with others in southern Nevada to provide service similar to that available in other states.
Mr. Workman declared the result is a relay station "that is second to none in the United States." He described the operation of the relay station and said it is "almost like...talking." With the TDD he stated he no longer needs a person to sign for him, and he would be able to operate a business without help. Under the former system the deaf made about 2,000 calls per month, but now they make from 10,000 to 12,000 per month.
Mr. Workman thanked the Rehabilitation Division for giving the deaf a chance to communicate. He attributed much of the success to the cooperation of all the telephone companies in Nevada. He solicited for support for a senate joint resolution (S.J.R.) which would allow the Nevada legislature to meet in towns outside of Carson City.
SENATE JOINT RESOLUTION 4: Proposes to amend Nevada constitution to authorize legislature to convene temporarily at places other than seat of government.
He said the meetings taking place in Las Vegas are providing an opportunity for the deaf to observe the proceedings when interpretation is done through sign language.
Mary Paradiso, Secretary, Nevada Association for the Deaf, came before the committee to request support for the Rehabilitation Division. Diana Callahan interpreted sign language for Ms. Paradiso, who informed the committee a workshop was scheduled to be held for one week in Las Vegas to train the deaf and interpreters in evaluating their skills for certification. Prior to this time no program for certification has been available in Nevada. She said a grant for the certification program was received through the support of the Rehabilitation Division and from SPRINT. She commended members of the Rehabilitation Division for their constant support.
Senator Raggio declared:
I think we'd like to indicate the legislature in this state has taken a great deal of pride in the fact that we were able to be one of the first, if not the first, to provide the TDD program through a telephone surcharge and that we have been able to provide a statewide relay system with centers in Reno and Las Vegas. We now understand that under ADA [Americans with Disabilities Act] that has to be and will be a 24-hour service, and there will be no limits on calls.
He told those who are hearing impaired the members of the legislature are cognizant of their needs and intend to serve that need.
Ms. Giunchigliani suggested more information should be conveyed to other areas of the state through telecommunications in order to include those areas into the legislative process. She asked if Ms. Paradiso felt interpreters should be used during meetings using telecommunications. Mr. Paradiso responded that would be one method of keeping the deaf informed of activities within the state. She said, "Anything that would make us equal with you is wonderful."
Carol Haynes, Head Injury Association of Nevada, said she was the parent of a traumatic brain injury (TBI) survivor. She stated she was not present to ask for anything, but to express thanks on behalf of survivors of TBI, their families, and those who provide rehabilitation services. She provided a packet (Exhibit I. Original is on file in the Research Library.) of information which narrates results of funds allocated to TBI victims during the previous legislative session. She said the programs described have given renewed hope for the future quality of life for loved ones who have been victims of TBI. She declared, "Now we even dare to hope for appropriate jobs and lifetime opportunities."
Ms. Haynes said, "We are now encouraged to dream impossible dreams, and we will beat unbeatable foes." She attributed such success to the support of the legislature, which will allow survivors of TBI to lead productive lives. She also asked for support for S.J.R. 4 to enable individuals with disabilities, and their care providers, to participate in the legislative process.
Maureen Maccutti, Deaf Service Coordinator for Telephone Device for the Deaf Distribution Program, Northern Nevada Center for Independent Living, offered support for an increase in the budget for the Governor's hearing devices program (Exhibit J). She declared, through her interpreter, funding is needed for an interpreter to serve the hearing impaired to provide communications within the community. As an example, she needs an interpreter to train business and agencies as well as community members on the proper use of TDDs. She stated she has had no interpreter for 8 months, which has delayed outreach to the deaf and hearing for the TDD program.
Ms. Maccutti declared there is a need for clerical support to complete the daily and monthly reports required by the state. She asserted the time consumed in preparation of the reports, some over 25 pages per month, takes time away from her duties as coordinator for the distribution of TDDs.
Ms. Maccutti averred the state should provide an allowance to cover the administrative overhead cost. She asked, "Why shouldn't a nonprofit agency, who runs the program, receive reasonable compensation?" She indicated she was attempting to rectify the problem through working with the Public Service Commission (PSC), which would be helped by funding through the legislature.
Mr. Spitler asked if the PSC had enough money in reserve for the funding requested, or if an increased charge was needed on each
telephone line. Ms. Maccutti denied any knowledge of the amount of PSC funds available.
Jim Boscacci, Member, Board of Directors, Northern Nevada Center for Independent Living (NNCIL), read from prepared testimony (Exhibit K). His testimony made reference to the number and condition of people awaiting personal assistance services (PAS). He advocated additional funding for the Rehabilitation Division. He maintained the PAS program could save the state more than $778,182 per year compared to the costs of nursing homes or hospitals. He closed by saying, "It isn't often that the quality of life can be improved by spending less."
Ms. Giunchigliani asked if the PAS program was run through United Cerebral Palsy. Mr. Boscacci said he was not sure if United Cerebral Palsy had anything to do with PAS. The three basic programs which support PAS are through the Community Home-Based Initiatives Program (CHIP) at the Division of Aging, Medicaid, and the state attendant care program.
Senator Raggio thanked Diana Callahan and Carolyn Gearhart
for their services interpreting for the deaf through sign language.
Ralph Baker, Member, Board of Directors, Northern Nevada Center for Independent Living, added his gratitude to the legislature to that expressed earlier for support provided for the home-based attendant care program. He called the PAS program a model for the rest of the nation which is "deinstitutionalizing people in favor of keeping them in their own homes in the community at much less cost." Because those under the program can live at home, out of expensive nursing homes or hospitals, many are able to pursue an education or hold jobs.
Mr. Baker said the only problem with the program is the lack of adequate funding, leaving approximately 78 on a waiting list. He alleged the only way one could get into the program is if another dies. His remarks are included as Exhibit L.
Mr. Baker spoke out regarding the Deaf Resource Centers on behalf of David Daviton, as set forth in Exhibit M. The testimony alleged funds for the hearing impaired were cut 100 percent when the budget cuts took effect. A plea was made to restore those funds.
Jack Mayes, Independent Living Advocate, Northern Nevada Center for Independent Living, read a dramatic letter (Exhibit N) written by Robert J. Lani. Mr. Mayes said Mr. Lani, who uses the attendant care services program, was unable to attend due to illness. Mr. Lani is blind, in a wheel chair, and must use dialysis three days a week. The letter cites the low cost of care under attendant living programs compared to hospitalization or convalescent home care.
Senator Glomb asked if people using PAS receive reimbursement. Mr. Mayes replied Medicaid pays for care for some who are eligible, but there is a large population ineligible for Medicaid services. The funds for those ineligible for Medicaid come out of state general funds.
Referring to his personal involvement with Mr. Mayes, Senator Raggio commended him for excellent work and for his compassion and understanding.
Clyde Carvey echoed support for the Rehabilitation Division. He stated he had nothing new to add to previous testimony.
Lisa Martinez came forward to discuss financial assistance for the disabled. She declared she is not eligible to receive Supplemental Security Income (SSI) nor Medicaid. Without a personal care attendant she averred she would be unable to go to work, attend classes or participate in activities in which she is involved. She described the services she is receiving on a temporary basis from an attendant provided to her by another agency.
Ms. Martinez said she is on two waiting lists. She urged the legislature to provide funds which would enable people like herself to live independently.
Ms. Giunchigliani asked if Ms. Martinez meant either SSI funds or Medicaid funds were provided through the state, but if a person failed to qualify for SSI or Medicaid he or she would be blocked from state assistance. Ms. Martinez responded that was her understanding.
Michael Goodman, Community Services Agency, confirmed comments made by others in support of personal care services. He said the services are presently provided to 43 individuals, and there is a waiting list of 43. He agreed with Ms. Martinez that "a lot of clients fall into the cracks." He said the lack of funding prevents the agency from helping those people. He stated the sole source of funding for his agency comes from a grant by vocational rehabilitation services.
Christine Tower, Professor of Social Work, University of Nevada, Reno, explained why some people are not eligible for attendant care programs. She said:
People who've never worked, or who've only worked for a brief period of time, who haven't paid in sufficiently into the social security system, are those people who've become eligible for SSI and then Medicaid. People who have worked and have paid in for a significant period of time become eligible for social security disability, which then, after a waiting period of 2 years, makes them eligible for Medicare. Medicare doesn't cover attending care. So...people who've worked...are the ones less likely to be covered with attendant care services. It's almost a penalty for having paid in on your taxes for a long enough period of time.
Ms. Tower stated the people who are at the highest risk for institutionalization are those who have worked the longest and paid into the system.
Senator Jacobsen polled the audience, many of whom had disabilities, on the facilities for the disabled in the legislative building. One member of the audience pointed out a couple of places in the building which are not wide enough for wheel chairs. Senator Jacobsen apprised the audience that the legislature is attempting to comply with ADA requirements.
Dorothy North, Chairman, Commission on Substance Abuse Education, Prevention, Enforcement and Treatment, who had recently undergone replacement of both knees, declared she had become aware of a great many problems the handicapped face within the past 3 months.
Ms. North asked if the Base budget would be referred to a subcommittee and who the members of the committees were. Senator Raggio responded subcommittees would be assigned. He indicated Mrs. Williams probably would serve on the subcommittee for the
assembly side, and Senators Glomb and Rawson probably would sit on the senate subcommittee.
Ms. North asserted, "The cuts that have been made since the legislative session have severely impacted the treatment service delivery system." She alleged the adverse affects have been more severe in northern and rural Nevada than in southern Nevada.
Ms. North urged the committee to stop any further cuts for direct treatment or for the Bureau of Alcohol and Drug Abuse staff. She concurred with Mr. Dini no cuts should be made in the rural areas due to negative impacts on the criminal justice system. She stated:
The prison system is the most expensive place to deal with alcohol and drug problems, and with significant cuts planned for corrections it makes no sense to further cut a cheaper alternative that may provide the only real hope of keeping many of these people out of the prison system.
Ms. North alleged drug or alcohol abusers eventually come into contact with the criminal justice system. Citing her experience running a pre-release program in the prison system in 1982 and her continuing contact with people in the prisons, Ms. North attested many of them would not be there if they did not have a problem with substance abuse. She declared the impairment prevented people from making proper choices.
Ms. North said:
We sometime pride ourselves that we have more folks incarcerated than any other state. I can tell you that with having the second highest per capita alcohol consumption, and being second in per capita in hard-core cocaine addicts,...there is a logical correlation between these two problems.
Ms. North asserted the alternative of treatment would be much cheaper than incarceration. She offered to provide the subcommittees with any information requested to assist them.
Ms. Matteucci said she believed there would be a consolidation of drug programs through the proposed governmental reorganization. She said:
We hope there would be an approach...to try to streamline so that there is less of a duplication so the dollars go further for more of the prevention and rehabilitative issues.
She inferred there is a duplication of educational programs. Ms. North responded the commission is interested in providing the most cost-efficient services not only for prevention education, but also for enforcement and treatment. She cautioned against making a decision which would appear to save money, but in the long run would cost more. She advocated holding a serious dialogue with the subcommittees prior to making any decisions.
Bill Jost, Treasurer, Nevada Association of State Alcohol and Drug Programs (NASADAP), Executive Director of Transition House, described NASADAP as an association of community-based nonprofit alcohol and drug treatment programs. He said:
The BADA [Bureau of Alcohol and Drug Abuse] budget affects us in that we receive monies through a competitive grant process, and how their budget's affected drastically affects the statewide treatment system.
Mr. Jost estimated the budget would be cut about 25 percent. He said the two best federal studies, DARP (Drug Abuse Respond Program) and TOPS (Treatment Outcome Program Study), which tracked addicts for 10 and 12 years showed not only that treatment was effective, but also showed $11.54 was saved for every dollar spent in treatment.
Senator Raggio stated his understanding the level of grant funds available would not be changed, but that there would be new grant monies forthcoming, primarily for southern Nevada programs.
Ms. Matteucci declared there would be no reduction in state funds. Mr. Jost called attention to figures on page 848 of the Executive Budget which indicate increases in the Alcohol Drug Abuse Mental Health Service (ADMS) block grant funds of approximately $200,000 in the first year of the biennium, and over $300,000 in the second year. He opined, "With the present federal situation it may be questionable whether that may become a reality."
Senator Raggio expressed concern some of the present recipients would not share in any enhanced funding that might be available. Mr. Jost repeated his concern is with the state budget, not with the federal funds. He pointed out the Governor's recommendation of $2,303,390 is some $800,000 less than the $3,195,830 being spent under the current budget.
Mr. Jost acknowledged the fiscal problems faced by the state are severe, but he urged prevention of what he interpreted as a 25 percent reduction. He said the system had provided services to 31,000 people in Nevada over the past biennium. He declared state law requires service to indigents, the working poor, and the homeless, those for whom there is no advocate, who have no money to find help elsewhere.
Ms. Matteucci alleged:
The problem here is they're looking at the state appropriation, they're not looking at the state grant line. The state grant line stays the same as what it is this year.... There were some positions that were moved that were state funded, but that has nothing to do with the grant.
She offered to clarify some of the provisions of the budget for Ms. North. In response to further inquiry by Senator Rawson, Ms. Matteucci assured him the grants would not be reduced.
Mary Piasecki, Vice President, Nevada Association of State Alcohol and Drug Abuse Programs (NASADAP), spoke on the impact of communicable diseases and treatment in Nevada. She recalled discussions in 1985 on the impact of HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immune Deficiency Syndrome) infections. At that time, she said:
We had to augment our service delivery system. We had to treat the client that not only had a dual diagnosis in terms of a psycho-socio issue but also now a very serious medical issue in terms of being HIV-infected as well as what impact this would have on the community, and most importantly, the tourism industry when we're dealing with individuals that are, for the most part, either gainfully employed, coming into the community looking for employment, and also suffering from a substance abuse problem.
Ms. Piasecki said NASADAP and BADA:
devised a service delivery system. We included testing on site, we looked at the one-stop shopping, and we also attempted to empower the community so that we didn't ask for extra dollars.... We went after education, we networked with the public health authorities to intervene and provide a very valuable service so that we could address both issues.
Ms. Piasecki declared the situation has become more devastating due to the impact of tuberculosis. She said tuberculosis is transmitted casually, and it is drug-resistant. Individuals that are HIV-positive are extremely vulnerable to tuberculosis. She said people who provide treatment and services are also vulnerable. Because of the array of medical problems that arise from substance abuse and the lifestyle of those people, public health officials have to be included in treatment programs.
Ms. Piasecki asserted any reduction in funds could be devastating, due to the expanded problems. She said:
Treatment providers have a captive audience. We serve the same people that go into the casinos, into the markets. We have an ability to intervene, and this is what has changed.... Now we can be legitimately defined as...public health workers.
Ms. Piasecki indicated a delicate balance must be maintained regarding outreach activities and the effect on the tourism business. She declared those administrating treatment must work hard to avoid duplicating services while dealing with accountability. She voiced the opinion there is much misconception as to what is deemed success. She said:
If we had to be very clinical in our evaluation we would look at seven different life areas that are impacted by a substance abuse problem. Now you add to that the array of diseases that are manifesting themselves, and you say...then what bowl of soup are we in now.
She reiterated her mission to raise the level of awareness of the issues facing treatment providers.
Mental Retardation - Overview - Page 757
Dr. Zadny gave an overview of the mental retardation budgets. He declared, "The mental retardation budgets continue a commitment to meet growth and demand with community-based services." He again turned to Exhibit D and called attention to the summary of requests on page 11.
Enumerating the requested expansion of vocational programs, Dr. Zadny said they would be "distributed between the community training center budget and between the region." He said,
Half the slots in FY `94 and 75 percent of the slots in FY `95 appear in the regions and support job placements. Doing this will permit vendors other than the community training centers to bid on providing the services, because some in some locales have been reluctant to offer job placement. We know from the experience of other states that many of our mentally retarded citizens and clients can and want to work. We'd like to provide them with opportunities to do just that.
Dr. Zadny pointed out there are three organizational changes, including a proposed raise in salary for the director of the Sierra Regional Center (formerly called the Sierra Developmental Center) to compensate him for serving as a statewide coordinator of mental retardation programs. He added, "I have requested that the northern deputy administrator be reclassed to fill a central office position transfer to DCFS [Division of Child and Family Services]."
Dr. Zadny noted the personnel and staff for mental retardation services, once part of the Community Training Center (CTC) budget, were being moved to a separate budget. He averred the change will allow rural mental retardation services to function autonomously. Dr. Zadny said, "The change...will permit me to reassign supervision of the manager of the CTC program to the division-wide coordinator for mental retardation services."
Dr. Zadny stated the residential placement fund would be apportioned between the southern, northern and rural regions, instead of leaving all the control in a central office. He explained such a change would permit the regions to plan for the number of beds to be developed and would give control over resources to staff who are close to those being served. He asserted the change would eliminate duplication of paperwork between the regions and central office.
Southern MH/MR Food Services - Page 730
Stanlee Dodd, Regional Director, Southern Nevada Mental Retardation Services, Desert Development Center, explained the Base budget provides funds for a state-owned vendor-operated central kitchen located on the MH/MR campus. The kitchen provides prepared meals, snacks and raw foods to the Desert Development Center (DDC, also referred to as the Desert Regional Center), Southern Nevada Adult Mental Health Services (SNAMHS), and Southern Nevada Child and Adolescent Services.
Mr. Dodd said a contract, negotiated with a private food service company for 3 years, will expire on June 30, 1993. A fixed rate is set for each prepared meal and snack, and bulk foods are billed at cost plus the contracted handling charge.
Mr. Dodd said the primary proposal in the budget is to increase the Dietician I from half time to full time. He called attention to items appearing under Demographics/Caseload Changes on page 731 which recommend increases based on projections for the proportionate share of meals served to each user group. The southern Nevada food service program presently employs one and one-half dieticians for 199 beds, which would be better served with two full time dieticians.
Senator Raggio asked which kitchen is used for the food services, and what each meal cost. Mr. Dodd answered it is in a state-owned kitchen located on the MH/MR campus. The meal costs are $2.77 per meal and $1.02 per snack.
Mr. Dodd summarized the inflation, maintenance and enhancement proposals at $54,866 for FY 1995, a seven percent increase over the FY `95 Base budget. He added there is a proposal for a Capital Improvements Program (CIP) project to renovate the central kitchen, and a letter of intent to fund increased food costs while they are prepared off site during the renovation. He requested extension of the letter of intent until the completion of the renovation.
Senator Jacobsen recalled hearing about problems leading to the renovation. He asked for clarification. Mr. Dodd replied the facility has had difficulty passing health inspections due to the age of the kitchen, the floor and the dishwasher.
Mr. Arberry asked for an explanation of the Other Direct Costs line item, and why the figure doubled. Mr. Dodd replied the costs include liners for each insulated food container that cost $4,700 in the first year for mental health facility, $4,500 for the DDC, and $1,200 for children's services. Additionally, there is a $22,995 charge for the raw food provided to the Intensive Care Facility for Mentally Retarded (ICFMR).
Mrs. Williams inquired why two dieticians were necessary for 199 clients. Mr. Dodd replied about two-thirds of the patients at the developmental center have special diets, and the mental health facility has a similar need. Bureau of Health Facility (BHF) regulations require dieticians on staff.
Mrs. Williams asked if the purveyor absorbs any of the costs for equipment replacement, since the purveyor uses the central kitchen. Mr. Dodd answered the purveyor is responsible for maintenance of the equipment, but some replacement is subject to negotiation. He cited the condition of the dishwasher as an example. Because the dishwasher does not reach the required temperatures for sanitizing, chemicals are being used instead.
Senator Raggio announced a consensus between himself, Mr. Arberry and the staff that there would not be time to delve into the budgets in depth because of the limited time. He asked Steven Shaw, Administrator, Rehabilitation Division, Department of Rehabilitation, who was waiting in the audience, if it would cause any great inconvenience to defer the budgets to a later date. Mr. Shaw agreed to accept a rescheduling of the hearings on his budgets.
Mr. Heller asked why no performance indicators had been included with the Southern MH/MR Food Services budget. Mr. Dodd said the only performance indicator from his service would be the number of clients served, a fixed number. The recommendations would add nine clients at Southern Nevada Adult Mental Health Services and three clients at the Division of Child and Adolescent Services.
Community Training Center Fund - Page 773
Dr. Zadny announced the Community Training Center Fund (CTC) budget had been reduced by $144,110 in FY 1992 and by $48,998 in FY 1993, for a total reduction of $193,108. The reductions were achieved by leaving one Psychologist position vacant and not filling 19 training center slots which had been authorized by the last legislature. He said leaving the CTC slots unfilled has resulted in a waiting list.
Senator Raggio was called out of the meeting, and Mr. Arberry took over as chairman.
Jack Middleton, Director, Rural Nevada Mental Retardation
Services, Department of Human Resources, quipped the waiting list was either 28 or zero. He said, "The funds are there, there's no waiting list, effectively."
Returning to the food service budget, Mr. Heller said he would like performance indicators for actual and projected prices per meal, how many complaints were received regarding the meals served, if health inspections were passed satisfactorily, and if not, why not. At Mr. Arberry's request, Dr. Zadny agreed to provide the subcommittee with as much information as possible in reply to Mr. Heller's request.
Mr. Price asked, "Have there in fact been any cases...where something had been condemned..., or where there had been some type of citation...in the food service?" Dr. Zadny replied the inspectors issue a report each time they come through, and he would share those reports with Mr. Heller.
Assuming complaint calls had been made to his colleagues, Mr. Price suggested calls regarding the food service often indicate there may be a problem. He pressed for more information. Mr. Dodd replied his agency must meet and maintain certification standards set by the Bureau of Licensing and Certification. He said the bureau, which inspects the kitchen every 6 months, has continually cited major problems with the central kitchen and threatened to close it down. Mr. Dodd stated he has endeavored to keep the kitchen going until the renovations can be done. He averred not only the dishwasher but all the kitchen equipment needs to be replaced.
Mr. Arberry called for a 5-minute break before resuming the hearing on page 773.
Mr. Middleton explained the budget for the CTC provides funding to private, nonprofit corporations who give prevocational and vocational services to mentally retarded adults. He stated there are 13 community training centers which serve 638 clients.
Mr. Middleton stated the regular funding amounts to $17.57 per day per client, under a ratio of one staff person per eight clients. He said, "Pre-work clients, a one to five staff ratio, is $28.51, and...intensive, which is an individualized training program which ranges anywhere from about 75 cents an hour to $9 and some odd cents an hour."
Mr. Middleton said the request for the CTC budget is funded at the FY 1993 level in the Base budget, with growth projections indicated on page 774 under Demographics/Caseload Changes for FY 1994 and FY 1995.
Mr. Middleton reminded the committee he had presented a new program to the legislature in 1989 which supported job placement. During the 1991 session of the legislature, the budget for job placement was doubled, at which time the legislators asked for a progress report. He stated 16 people had been placed in jobs in 1991, and there were 40 placed as of December 31, 1992. He reported those folks work an average of over 30 hours per week, and they earn an average $4.81 per hour, which he calculated at nearly $300,000 annually.
Mr. Middleton pointed out those clients are nearly all in some form of residential care. With their earnings they purchase many of the services provided to them, thus effecting a considerable offset to the state. Based on that success, he proposed an additional 25 slots in job placement services be funded in the first year of the biennium to be split between the northern and southern regions. In the second year of the biennium the addition of another 19 placements are requested to buy additional vocational services.
Mr. Middleton said:
In addition to the Community Training Center portion of this budget, it has also provided for rural Nevada mental retardation services, which is the rural service component providing case management and residential services throughout the 15 rural counties.
He proposed that the rural budget be transferred to budget account 3167, Residential Placement. He said, with the staff and operating expenses transferred, only the Community Training Center grants would remain in the CTC budget, number 3160, which would amount to about $2.6 million.
Mr. Middleton said:
In addition to the transfer of the staff, we're also proposing the transfer of a...half-time nurse from 3180, which is the SDC (Sierra Development Center) budget.... This particular position has provided nursing services to rural Nevada since the inception of the program and we finally are going to align that position with the proper budget in the transfer.
Mr. Middleton noted the state appropriations in the budget increase by the amount of match from Title XIX, which will no longer be found in the welfare Medicaid budget. He explained the primary funding comes from Medicaid, social services and state appropriations.
Mrs. Williams asked what benefit would be achieved by transferring the rural programs out of the CTC budget, and whether the budget would provide enough places in the vocational training to do away with a waiting list. Mr. Middleton replied positions in the CTC were left vacant when the budget cuts took place a year earlier, and a waiting list developed. As savings were generated, the positions have been filled. He admitted there continue to be more clients in Las Vegas than can be served, but he attributed the problem not to the cash shortage but to the fact the case managers have been unable to process the clients to get them into the program. He said, "Technically there is no waiting list, but practically there is a waiting list of about 28 clients in southern Nevada...."
In explanation of the transfer, Mr. Middleton said:
What you've got...is two distinctly different programs. You've got the Community Training Center program, which is basically a state purchase-of-service program to private nonprofit corporations, and the rural mental retardation services budget, which is a client service budget, which is similar to the northern and southern regional budgets except there's no ICF [Intensive Care Facility] component with the rural.
Mr. Middleton continued to say there are case managers and clerical staff which have nothing to do with the CTC. He alleged, "This budget just kind of grew on the shoulders of the CTC budget." He declared it had grown to the point where it should be separated out of the CTC budget and identified as a separate program.
Dr. Zadny interjected there would be two separate budgets with two sets of performance indicators, which would provide more accountability. Thus it should be easier for the legislature to determine the funding for the two services.
Mrs. Williams asked, "What kind of delay is there as a result of case management...? Shall I assume from that you're short on personnel for case management?" Dr. Zadny replied there was a request for additional case managers in the two regional budgets. Mr. Middleton added he was confident there would be sufficient growth in the CTC program to accommodate additional clients coming out of school if the demographic and caseload changes are funded.
Mr. Middleton said he hoped they would be able to place clients into the competitive labor market without the need to put all individuals through a training center program. He pointed out it is possible for mentally retarded people to compete successfully in the labor market. He said the salary range is from about $8 per hour to $4.25 per hour, and, although many work just 20 to 25 hours per week, there are several in Las Vegas who work 40 hours per week. Some of those are eligible for the benefit packages offered by their employers and are no longer under the benefit programs of the state. He asserted there is no need for long-term placement in the sheltered workshop setting for many clients. He expressed hope many clients could be placed in alternative programs, which would reduce the need for growth in the CTC budget.
Ms. Giunchigliani suggested, if the mission was to find placement in the community, the use of placement, wages, and benefits would make excellent performance indicators.
Residential Placement - Page 778
Dr. Zadny stated the budget had been reduced by $215,926 in the first year of the biennium, but had not been reduced in the second year of the biennium. He explained the budget pays for residential placement as well as respite for families who care for mentally retarded persons at home. He said the respite funds had been cut by 25 percent, and no placements had been made during the first year of the biennium. Some high-cost clients were moved into lower-cost facilities.
Dr. Zadny asked the committee to look at page 14 of the handout (Exhibit D).
Mr. Middleton said the fund would provide placement in community settings for all noninstitutional placements of mentally retarded persons throughout the state. He declared it is the largest residential program offered by the division on MH/MR, and it serves 380 clients. Of the 380, he said, 156 were in Supportive Living Arrangements (SLAs) at the end of December, 1992. In December of 1989, when the SLA program commenced, there were 42 people living in apartments and other alternatives. Of the 156, he said:
The average cost is $658 per client per month. This program has reduced and has become the most cost-effective program.... When we froze placements last January, the cost for 121 of those placements was $702. Those same clients, this past December, were costing the state $626....
He attributed much of the reduction to the fact many of those people were working and do not require as much supervision, so they can function in a less restrictive environment. He asserted:
The one thing that's absolutely certain, if we serve people in residential facilities or group homes or any other form of residential care offered by this state, is whatever it costs today, it's going to cost you more tomorrow because of inflation and growth.
Mr. Middleton stated the aim is to provide more normal alternatives, and lacking other types of more expensive care, the program must be funded and grow. He pointed out the demographics provide for an additional 44 placements in the first year of the biennium and 20 in the second. He admitted many of the 44 are being placed this year with funds which were not cut. He said there are 162 individuals living in apartments right now.
Mr. Middleton claimed people are being transferred from group homes and other more restrictive environments into supportive living. Supportive living is available in Elko, Ely and other communities. He related there is a client in Tonopah, supervised out of Hawthorne, who lives in his own apartment and works in a grocery store who now costs the state less than $150 per month. There are five clients who live in apartments that cost the state less than $250 per month, while two clients cost over $3,000 per month and only two clients cost over $2,000 per month.
Mr. Middleton asserted the program should be emphasized, and suggested it would work better if it were regionalist. If it were split between the north, south and rural areas, each region could have direct control over its revenue and resources and could implement services at the lowest administrative level.
In addition to regionalization, Mr. Middleton said:
We will be transferring the rural mental retardation staff from budget account 3160 and leave only that portion of this budget, which is the residential services portion, for rural Nevada, and then this will become the rural regional budget, and then the half-time nurse will also transfer in from that particular package.
Mr. Middleton added that family respite is also part of the budget. He described respite care as a service offered to families to offset their need for more costly institutional or residential care. He portrayed it as anything from baby sitting to care for a client when the care giver needs, for example, medical service, or just a weekend away.
Mr. Middleton said the budget provides an average $32 per day for an average of 9 days a year to each of 225 families. He requested the number of families to be served be increased, that the number of days be increased to 14, and that there be an increase of $1 per day to provide what he called a "vital service." Those funds are requested under the enhancement portion of the budget.
Mr. Middleton recalled the program had been vividly presented 2 years ago by a number of Las Vegas families. He offered the opinion the committee members will probably receive input from those families. He stated the program has been a very needed service, and although only $8,000 had been cut from the budget last year, it had an adverse impact on those families, who were vocal about it.
Ms. Giunchigliani asked how many more families would be served by the proposed increase of $34,000. Mr. Middleton replied 25 more families could be served with those funds. Dr. Zadny interjected there had been 224 families being served prior to the budget cut, but then the caseload decreased to 78 families. He said families are being re-enrolled and he anticipates being back at 224 families soon. Thereafter he hoped to add another 25 families for a total
of 249, which he also hoped to be able to pay up to $33 per day on a sliding fee scale.
Mental Retardation Home Care - Page 783
Mr. Middleton declared there had been no budget cuts for the home care budget. He asserted, "Dollar-wise it's a very small budget; impact-wise it's a very large budget."
Mr. Middleton said the home care budget provides a cash subsidy or assistance to family members who care for a severe or profoundly retarded relative in their own home in the State of Nevada. He declared, "These clients would clearly be in an ICF [Intensive Care Facility] if it wasn't for the interest and ability of the family to care for this individual in their home." He said it is typical for severely retarded individuals to be very handicapped, often not ambulatory, usually nonverbal, incontinent, and unable to feed themselves. He declared they are very difficult to care for.
Mr. Middleton claimed the cash subsidy program has continued to grow as the state grows, and yet only a minimal payment is provided. He said the average payment last year was $217 per month, less than the cost for one day in an institutional setting. He conceded many families do become eligible for other services for which they might not otherwise be eligible. Those programs include SSI (Supplemental Security Income) and Title XIX medical benefits. He declared the cost is very minimal to the state, even with the additional benefits.
Mr. Middleton said 115 families are being assisted under the program, with a budget of $280,000, and with a projected increase of families to 136 in the first year of the biennium and to 152 in the second year of the biennium. He stated the projection is based on growth experienced over the past 3 years. He admitted there is a high turnover in the program, because it serves many at high risk, and many pass away.
Mr. Middleton acknowledged there had been concern whether the program was successful as an alternative to institutional care. He studied the budgets and concluded since 1982 only nine percent of those in the program had been placed in an intensive care facility.
Senator Glomb asked if the program was based on need. Mr. Middleton responded families make application based on financial need. They receive from $25 to $250 per month based upon gross family income and family size. He said the maximum is $286, which could be paid if there were sufficient funds available. He stated there is no waiting list, because the law mandates that assistance must be provided to all who are eligible.
Southern Nevada Mental Retardation Services - Page 757
Dr. Zadny pointed out the budget applies to the Desert Developmental Center, which is now called the Desert Regional Center. He explained some clients felt the word "Developmental" was stigmatizing, so the centers have been renamed "Regional."
Dr. Zadny said the budget was reduced by $480,152 in the first year of the biennium and by $337,318 in the second year of the biennium for a total of $817,470. He said:
The reductions included 17.5 new positions that had been approved for the newly-built dual diagnosis units. What we've been able to do is to occupy those buildings but not provide the level of programming that was originally anticipated and there's a closure of 12 beds in addition to that.
Mr. Dodd said:
There was a $25,000 one-shot for Tenth Street, which is residential...a state-owned facility, and one of our vendors was providing services there.... As a result of the deletion of this one-shot, the buildings are closed and vacant at the present time.
Mr. Zadny added $100,000 in CTC funds had been returned because not as many clients were being served. Also vehicle purchases were reduced by $24,622, and there was a $13,380 reduction in operating expenses in FY 1992. The only reductions in FY 1993 have been the failure to fill the 17.5 positions.
Northern Nevada Mental Retardation Services - Page 765
Dr. Zadny said the budget was reduced by $443,766 in FY 1992 and by $114,544 in FY 1993, for a total of $558,310. He stated the budget reductions included a failure to fill nine positions with a salary savings of $223,000 in the first year of the biennium and $29,612 which had been earmarked for the CTC.
David E. Luke, Ph.D., Regional Director, Sierra Developmental Center (SDC, also called the Sierra Regional Center), called attention to page 19 of Exhibit D. He stated the center operates 78 intermediate care beds, 12 in two homes in the community, and 66 beds in 12 homes at the Sierra Developmental Center campus. He added, "In addition this budget supports case management for 321 clients, including community residential placements for 126 clients, and respite for 34 clients."
Dr. Luke stated there are no capital improvements requested for the budget, but the main proposals ask for one case manager, 15 competitive work placements, and six intermediate care beds to be purchased from a private care provider. The budget also recommends the transfer of residential placement funds from the central resident placement account to the Sierra Regional Center in order to regionalize the management of those placements in the community.
Mrs. Williams asked:
In the past, in the 24-hour facilities, particularly for mental retardation, I don't recall having seen vacancy savings, because that sometimes pushes people into keeping slots open in a facility where the staffing levels are required to be there 24 hours. Could you comment on that?
Dr. Luke responded there is a vacancy savings figure in the budget, which is calculated from tracking overtime costs and from using part-time positions. He declared, "We have been able to achieve those vacancy savings as indicated in the budget."
Senator Glomb wanted to know if the budget included money to recruit and develop group-home parents. Dr. Luke replied:
We do develop placements that are the results of the residential placements in the community, and currently there are 126 such placements that have all been developed by our case management staff. So case managers, along with the private vendors that we utilize are the ones that develop the various living options.
Senator Glomb voiced her understanding that is a cheaper and more effective form of care. Dr. Luke responded dramatic results have been achieved when clients move into community settings where they are more independent and have more ability to participate in the community. He agreed those care situations are often less costly.
Senator Glomb repeated her request for performance indicators.
Mental Hygiene and Mental Retardation - Page 713
Dr. Zadny stated the Mental Hygiene/Mental Retardation (MH/MR) budget provides for the overall management of the MH/MR services, which oversees 13 budgets with over 900 employees and approximately $60 million per year in expenditures. He pointed out the budget is reviewed on page 20 of the handout (Exhibit D), which lists the approved positions for fiscal years 1992 and 1993, and the recommendations.
Dr. Zadny explained said there is a proposal to reduce the 17 employees to 15. A Management Assistant III is proposed to be transferred to Southern Nevada Adult Mental Health Services (SNAMHS) and to be reclassified as an Accounting Technician. Because SNAMHS has transferred two accountants to the children's program, and had requested two additional accountants, Dr. Zadny felt an accountant would be much more useful than a support clerical position in the south.
Dr. Zadny also recommended the transfer of a program manager to DCFS (Division of Child and Family Services) who manages the CMHS (Comprehensive Mental Health Service) block grant and the homeless block grant and agency audits. He proposed reclassifying the northern deputy administrator to carry on those functions and to absorb supervision of the regional training budget.
Turning to page 715 in the Executive Budget, Dr. Zadny said:
E [Enhancement] 700...would increase commission of MH/MR stipends and travel to permit attendance by the seven members at three 2-day and three 1-day meetings per year; would fund attendance by the administrator at two annual meetings per year, one of the state directors of mental health and the other of the state directors of mental retardation; and would adjust operating to expected levels.
Dr. Zadny said DCFS had agreed to assume responsibility for the United States Crime Victims, Indian Victims Assistance, and Family Violence grants that were formerly administered by the division. Those transfers would be made if the enhancement on page 716 is approved.
Dr. Zadny reported the division has had continuing difficulties with its management information system (MIS). He stated reports are often late and sometimes inaccurate. He said:
Computerization of the southern agencies was made more difficult by issuing instructions through managers like myself who may or may not be computer-conversant, though I do know about program evaluation.... To remedy the situation I've proposed that the division's management analyst be given a line authority over all MIS personnel and compensated by an additional 5 percent salary adjustment.... I think it's a little bit silly to issue MIS instructions to folks who may be very good
administrators but don't know a whole lot about computers.
Dr. Zadny called attention to Enhancement 703 on page 716 which would provide for computerizing the southern agencies' fiscal client service data bases. He indicated the AIMS (Administrators in Medicine) system is nearly complete. Continuation costs amount to $59,911 per year. He suggested subcommittees may want to take additional testimony on the development of the AIMS system.
Mrs. Williams agreed the subcommittee may want more detail. She asked if it would be possible for the AIMS system to network with the north and the rural areas. Dr. Zadny answered budget estimates were made for that, but they were not recommended as part of the Executive Budget. He said minimum start-up investment would amount to $375,000, and the full system would cost about $1.1 million.
Mr. Spitler cited knowledge of grievances from employees in southern Nevada who feel they are so short of staff they do not have adequate coverage for vacations, lunches or other breaks. He asked if those problems would be alleviated through the budget requests. Dr. Zadny doubted those problems apply to the central office budget, stating he had no knowledge of grievances from those employees. Mr. Spitler said:
I thought...for the people at the MH/MR facility in southern Nevada...these positions were to set up so there would be training programs and better management so that people would be able to do their jobs more effectively.... Are you going to be addressing those things?
Dr. Zadny replied:
We do routinely address such issues. In some of the agencies we've experienced difficulty in recruiting to fill hard positions like nursing positions. Sometimes when morale goes down you see a rash of injuries, and then it takes a while to get SIIS [State Industrial Insurance System] overlaps so you can fill those positions and keep the work flowing. I think things are going fairly smoothly down there now, but I would be happy to check.
Senator Glomb asked, "In terms of the audit report about the employment of administrative officers and outside employment.... Have you reached a resolution on that?" Dr. Zadny replied, "I issued an instruction upon receiving the audit findings that all folks shall cease and desist and made them aware of the law on the issue." He acknowledged the administrator cannot have outside employment and stated he has none.
Victims of Domestic Violence - Page 950
Jean Laird, Senior Management Analyst, Mental Hygiene and Mental Retardation Division, Department of Human Resources, characterized the program as one which provides emergency and ongoing services to victims of domestic violence. Those include 24-hour counseling, referral services, food and shelter.
Ms. Laird said the programs are funded through grants to nonprofit entities that provide direct services to the individuals, and the only source of funding comes from a portion of marriage license fees. The fees are collected by the counties and remitted to the
state treasurer for deposit to the Victims of Domestic Violence account.
Ms. Laird pointed out the major recommendation in the budget is to move it from MH/MR to the Division of Child and Family Services (DCFS). She indicated the federal grants in the MH/MR administrative budget referred to earlier by Dr. Zadny also would be transferred as would the program manager position he mentioned.
Ms. Laird informed the committee in the second year the amount of revenue is underestimated due to a statutory increase in marriage license fees from $10 to $12. Those additional fees will be added to the Victims of Domestic Violence account. She estimated the amount should be increased by $245,000, which would bring the total for the second year to $1,471,800.
Repeating the Performance Indicators, Senator Glomb asked if the number of clients served referred to women or both women and children. Ms. Laird replied, "It is the sum of all contacts, all the people who were served."
Mrs. Williams declared she was not entirely comfortable with transferring the budget out of MH/MR. She opined some situations of domestic violence do not fall into the category of child and family. She suggested the proposed transfer be discussed in subcommittee.
Ms. Giunchigliani inquired if records were kept to show if there are repeat clients, how many ultimately leave the family, and how many families are reunited. She asked that those figures be available to the subcommittee.
Mr. Arberry commended Mr. Middleton for being able to present his budget without use of the budget book. Mr. Arberry announced the two committees would meet on the following morning at 8:00 a.m. He adjourned the meeting at 5:15 p.m.
RESPECTFULLY SUBMITTED:
Judy Jacobs,
Committee Secretary
APPROVED BY:
Senator William J. Raggio, Chairman
DATE:
Mr. Morse Arberry, Jr., Chairman
DATE:
??
Senate Committee on Finance
Assembly Committee on Ways and Means
February 10, 1993
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