The Committee on Health and Human Services was called to order at 1:45 p.m., on Monday, February 8, 1999. Chairman Vivian Freeman presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All Exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

COMMITTEE MEMBERS PRESENT:

Mrs. Vivian Freeman, Chairman

Mrs. Ellen Koivisto, Vice Chairman

Ms. Sharron Angle

Ms. Merle Berman

Ms. Barbara Buckley

Ms. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Kathy McClain

Mr. Kelly Thomas

Ms. Kathy Von Tobel

COMMITTEE MEMBERS ABSENT:

Mr. Wendell Williams

GUEST LEGISLATORS PRESENT:

Assemblywoman Gene Segerblom

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Richard J. Panelli, Chief, Bureau of Licensure and Certification,

Nevada Department of Human Resources, Health Division

Myla C. Florence, Administrator, Nevada Department of Human Resources, Welfare Division

Winthrop Cashdollar, Nevada Health Care Association

Jim Gubbbels, REMSA

Phil Lehrman, Voices of Seniors

May Shelton, Washoe County Social Services

Janice C. Pine, St. Mary's Hospital

Stephanie Beck, RN, Washoe County District Health Department

Gary Milliken, American Medical Response

Lucille Lusk, Nevada Concerned Citizens

John W. Riggs, Sr

Chairman Freeman opened the work session on A.B. 73.

Assembly Bill 73: Revises provisions governing withholding of life- resuscitating treatment pursuant to do-not-resuscitate order. (BDR 40-205)

Chairman Freeman asked Assemblywoman Gene Segerblom to discuss her bill from last session, A.B. 73.

Assemblywoman Segerblom stated that was her bill from last session and was not being changed but corrected. The first correction intended to replace the words "Health Authority" with the word "Board." Additionally, she had received many calls from people who wanted to know how to obtain the Do-Not-Resuscitate (DNR) bracelet, what was the cost, and who would pay for it. For that reason, the cost and method of obtaining a Do-Not-Resuscitate (DNR) bracelet had been established.

Ms. Segerblom provided the "Do-Not-Resuscitate Identification Application" (Exhibit C).

Richard J. Panelli identified himself as the Chief of Bureau of Licensure and Certification, Health Division, Department of Human Resources. He testified in support of A.B. 73, indicating it was a "housekeeping" bill submitted to clarify existing statute and create consistency with the existing practice in Nevada Revised Statutes (NRS) and the Board of Health's role to adopt regulations. Additionally, the bill allowed the State Board of Health to establish a fee for actual costs of obtaining a DNR identification. The Health Division recommended legislation be effective immediately upon passage to allow adequate program implementation. His testimony is provided in Exhibit D.

Jim Gubbels, Reno Emergency Medical Services Association (REMSA) testified in support of the clarifications in A.B. 73.. He stated enactment of this bill would help both paramedics and emergency medical technicians (EMT's) assist people to die with dignity.

Stephanie Beck, RN, Emergency Medical Services Coordinator, Washoe County District Health Department, stated her support of A.B. 73.

Gary Milliken, representing American Medical Response, stated his support of A.B. 73.

VICE-CHAIRMAN KOIVISTO MOTIONED TO DO PASS.

ASSEMBLYWOMAN VON TOBEL SECONDED THE MOTION.

MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the work session on A.J. R. 5

Assembly Joint Resolution 5: Urges Congress to enact legislation to provide

Chairman Freeman asked Assemblyman Manendo to discuss his bill.

Assemblyman Mark Manendo, District 18, brought forth A.J.R. 5 on behalf of his friend and constituent Sylvia Delton. Mr. Manendo stated that "notch babies," those persons born between 1917-1926, "were in a little notch." They did not receive the same type Social Security benefits as those born before or after that period. He added the committee had previously supported resolutions dealing with "notch babies." The intention of A.J.R. 5 was to support the 105^th Congress' H.R. 3008 and Senate's 2003 bills encouraging lump-sum payment to that "notch" group. Passage of A.J.R. 5 would benefit the economy; recipients would be more likely to spend the money rather than save it. Further, lump-sum payments could bring tourist dollars into the state.

Chairman Freeman agreed the group's exclusion from receiving the same Social Security benefits was unfair, and felt passage was a good idea.

Assemblywoman Von Tobel asked if lump-sum benefits would go to the surviving spouse. Assemblyman Manendo responded he felt it was a valid suggestion, however Congress had rejected that provision in the past. He believed the lump sum would be paid only to the primary recipient.

John W. Riggs, Sr., a "notch baby," testified in support of A.J.R. 5. He stated bills of that nature had been around a long time without results; it was time to take action and let Congress know the people of the State of Nevada wanted something accomplished. He suggested an addendum to the resolution stating "Give us the damn money before we die." Mr. Riggs further stated part of the reason for the delay could be that Congress was hoping some of the "notch babies" died off so they would not have to pay them. But "the point is, we have it coming, let's get it. And let's do whatever we can to get it."

Chairman Freeman asked Assemblyman Manendo how he felt about the addition of such wording to the resolution. Mr. Manendo demurred, stating the wording was "kinda strong."

Assemblywoman Buckley supported Mr. Manendo's desire to get the bill passed quickly and not get bogged down in the amendment process with the shortened legislative session.

VICE-CHAIRMAN KOIVISTO MOTIONED TO DO PASS.

ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.

MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the work session on Assembly Bill 7.

Chairman Freeman offered introductory remarks on how the State Board of Nursing regulated certified nursing assistants (CNAs). There were 25 approved training sites, including community colleges and nursing homes, in Nevada that provided a minimum of 75 hours training. The number of nursing assistants produced in Nevada during federal fiscal year 1997 was 795, and 245 nursing assistants were endorsed to Nevada from other states.

Winthrop Cashdollar, identified himself as the executive director of the Nevada Health Care Association (NHCA) and testified in support of A.B. 7. He stated NHCA had made a request to the Legislative Committee on Health Care which led to the drafting of A.B. 7. He expressed appreciation for the committee's work on the bill, for having brought the bill before the Committee on Health and Human Services early in the session, and for NHCA having been named in the bill as the cooperating organization.

Mr. Cashdollar stated in anticipation of the population growth and increased future needs, long-term care providers in the State of Nevada were expanding the capacity for long-term care. New facilities in Carson City, Washoe Village, and Reno Health Care, in south Reno, were due to open soon and represented hundreds of beds. He added staffing those facilities with registered nurses, Licensed Vocational Nurses's (LVNs), and Certified Nursing Assistant's (CNAs) would go from difficult to desperate. NHCA favored a "kitchen sink" approach to long-term care staffing, anything that might work they wanted to start as soon as possible. The Committee on Health Care asked to initiate a program to train welfare recipients as long-term caregivers. The committee decided to undertake a study to determine the need and feasibility of such a program.

Myla Florence, Administrator, Nevada State Welfare Division, testified A.B. 7 would require the Welfare Division and the NHCA conduct a study to determine if a shortage of nursing personnel in nursing homes existed, further, to study the feasibility of training Temporary Assistance to Needy Families (TANF) or welfare recipients as CNAs, and determine child care needs for TANF recipients who went through the training sessions. The Welfare Division would be willing to work with the NHCA and Nevada Nurses Association to assess labor market analysis statistics specifically with the Department of Employment Training and Rehabilitation. That analysis would be helpful to determine the shortage of CNAs and other positions in the long-term care industry.

Ms. Florence added the study required under A.B. 7 took into consideration the following:

• Any program designed would require the NHCA's input in developing the training curriculum.

• The testing process required for CNAs to meet industry standards.

• The certification was rigorous and required a combination of classroom and clinical experiences in the nursing home.

• The child care needs of any TANF recipient who accepted employment. Demand for child care exceeded the available resources, and would for sometime into the future. For that reason, the NHCA would need to encourage long-term care facilities to develop on-site child care.

• The geographic need for CNAs in rural parts of the state and whether there were sufficient TANF recipients to fill any void that existed.

• The fiscal impact to train and hire personnel for long-term care facilities and the impact on rates and charges as they affected Medicaid and other payers, as well as any other licensure issues.

Ms. Florence stated the Welfare Division had projected a modest fiscal impact to A.B. 7. They would use Welfare Division resources to develop a Request for Proposal (RFP) to initiate the process, until such time as a contractor could be hired. Estimated contractor cost would be about $28,000, based on 60 hours research, 40 hours for a feasibility study, and 40 hours to prepare a final report with findings to be presented to the legislature. She stated they had used current contractor rates of $200 per hour to calculate the cost for contract services. Following the RFP process, the study would begin in October 1999 and be completed by June 2000, to produce a report by July 2000 to the Legislative Committee on Health Care.

Ms. Florence stated TANF participants went through an assessment process which involved employability, included past employment history, future employment goals, and a personal responsibility plan. They also contracted with the Rehabilitation Division's Vocational Assessment Center for more in-depth assessment and testing. Between the participant's self-declaration of the type of employment desired, and the in-depth assessments being completed by Welfare Division and Vocational Assessments staff, potential for those interested in becoming a certified nursing assistant (CNA) or gaining any other type of nursing home employment was explored and identified. The work of the CNA required individuals in good physical health, the ability to assist and lift patients, who liked working with the aged or disabled, and were able to deal with death and dying.

Ms. Florence reported the Welfare Division had conducted a 6 month pilot project with Horizon Health Care Corporation to train public assistance recipients for nursing home employment opportunities. However, the pilot, conducted in Reno, had an unsuccessful outcome for two reasons:

1. Some of the people referred to the facility were unable to fulfill the classroom and clinical requirements course necessary to become certified.
2. Midway through the pilot, Horizon Health Care Corporation was sold and the new management was not committed to the project.

In conclusion, Ms. Florence stated the Welfare Division had actively reached out to all Nevada employers in an effort to secure employment for TANF participants. Labor market shortages were frequently due to the unique characteristics of an occupation, such as certified nursing assistants or child care workers, often mentioned as an employment opportunities for welfare recipients. However, the welfare recipient had to possess the skills and desire to work with targeted populations of the labor market shortage, occupational groups.

Chairman Freeman asked if further study was needed to determine if there was enough understanding of the issue to start training. Ms. Florence responded although the Welfare Division was anxious to work with any employer group seeking to train and work with their clients, she was not convinced a study was necessary. Other training programs had met with success.

Chairman Freeman concurred no further study would be necessary and recommended a Request for Proposal be undertaken as described earlier in Ms. Florence's testimony. Ms. Florence responded the $28,000 cost for the RFP was not in the budget.

Assemblywoman Buckley felt the issue was one worthy of being explored in greater detail, in view of needs of the health care industry as discussed in the interim committee; however she was uncertain how to proceed. She did not want to simply leave the issue with no progress having been made, because that was the concern of the NHCA. She added welfare reform had generated additional job training funds, but expressed her concern about how focused job training efforts were in disbursing the monies available. If A.B. 7 were not passed, she asked if there was any way to further the issue by working with Mr. Cashdollar to make sure something would be accomplished, so the issue did not come up again in 2 years.

Ms. Florence responded it would be worthwhile for the NHCA to talk with the principals at Horizon to find out specifically, what kinds of issues had emerged from the pilot study. She added the Welfare Division would gladly work with the NHCA and others to reexamine the situation. What had been unique with the Horizon pilot program was that Horizon had been willing to provide the training on site, plus a small stipend to participants. The Welfare Division (WD) provided child care transportation as supportive services. Curriculum developed from that pilot provided a good foundation on which to build.

Ms. Florence stated her division had developed a number of customized training programs for employers that needed a specific skill set, and that could be done in conjunction with the industry and community colleges. She added WD had the ability to pay for training in conjunction with a bona fide job offer. The greater challenge, she said, would be finding individuals with that kind of employment goal.

Chairman Freeman asked, if the study were to go forward, would it be possible to get reports back before July 1, 2000, as the bill required. Ms. Florence responded any study would require an outside resource. If the scope of the study was narrowed, it could be accomplished in less time though not necessarily at less cost.

Chairman Freeman asked if there would be a fiscal note on A.B. 7. Ms. Florence responded if the bill passed out of committee it would be referred to interim finance.

Assemblywoman McClain stated she had received a fax from the Nevada Nurses Association and asked if someone was present to testify. Chairman Freeman responded, "No." Ms. McClain suggested no action be taken at that time so the Nevada Nurses Association could be included in the bill as they had requested.

Chairman Freeman recommended that another hearing on A.B. 7 be scheduled on Monday, February 15, 1999.

Winthrop Cashdollar, NHCA, asked to pursue clarification of the study issue. He stated when the NHCA went before the Committee on Health Care, it was to obtain more resources focused on welfare-to-work, targeted on long-term care, and to do a demonstration of child care. Any study undertaken to determine whether a shortage of personnel existed, would show there was indeed a shortage. He wondered if he should re-focus his efforts, or if undertaking a study was still the issue. Chairman Freeman said she believed they would do a study.

Assemblywoman Buckley stated in serving on the Health Care Committee with Ms. Freeman, their thought had been to try to blend the need with the program. However, in view of the budget, she was doubtful there would be money for optional studies. She added if Ms.. Florence and the WD were willing to explore a pilot project, the committee could learn from the results.

Mr. Cashdollar concurred with Ms. Buckley's suggestion, stating he would work with Ms. Florence on that issue and legislation.

Chairman Freeman asked Mr. Cashdollar to report back to the committee on Monday, February 15. Further, the Board of Nursing and NNA would be contacted so they would be able to participate.

With no further business before the committee, the meeting was adjourned at 2:30 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

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