Following roll call, Chairman Freeman announced that due to an Education Committee meeting in Las Vegas, some of the committee members were absent.

Mrs. Freeman also announced an amendment had been received on A.B. 429 and would be the first measure discussed.

Marla Williams, Committee Policy Analyst, referred committee members to the Request for Committee Amendment, EXHIBIT C. That bill was heard earlier to eliminate the sunset provision for the Division of Health Care Financing and Policy (HCFP). At that time the administrator, Janice Wright, indicated she had two items that would require amendment. EXHIBIT C was the language for the amendment. Ms. Williams explained it ensured that the Charge Master program expired by limitation on June 30, 1999, and established a system for hearing rights within the Division of Health Care Financing and Policy. The sections added to the bill included Nevada Revised Statutes (NRS) 422.294, 422.296, 422.298, and 422.299. It also allowed service on a petition from 10 days to 30 days. Included in EXHIBIT C was a memo from Ms. Wright that added "or a claim for services" to those NRS's mentioned, and changed the "welfare division" to the "department." An explanation of those changes was given by Nancy Ford Angres, Chief Deputy Attorney General, in a memo dated March 29, 1999, and made a part of EXHIBIT C.

Assemblywoman Buckley asked for clarification on the amendment concerning due process and appeals for Nevada Check-Up.

Jon Sasser, Statewide Advocacy Coordinator, Washoe Legal Services, stated he had met with Laurie Buck and Nancy Angres, from the attorney general's office, and Janice Wright, HCFP, regarding the amendment. There were two changes regarding due process: (1) it clarified there would be a hearing and an appeal on denial of medical services and for eligibility determinations for Medicaid (2) it gave a review process on eligibility and a judicial review for Nevada Check-Up. What it did not do was give a full range of the Goldberg vs. Kelly hearing rights with a separate hearing examiner and officer. It was more of a paper review of income eligibility with no assets test; but there was a judicial review.

Ms. Buckley said she was a big believer in due process. "We are a government, the state is a government, why don't we have a full due process hearing if we're cutting someone off or finding them not eligible?"

Laurie Buck, attorney general's office, said they talked about that at some length and there was additional expense and time involved with a full due process hearing. It involved the hearing officer's time, and those hearing officer duties had been contracted out for the new Division of Health Care Financing and Policy because they did not have their own staff of hearing officers. Since the Nevada Check-Up eligibility was a more straightforward process than a full entitlement, such as welfare eligibility and/or Medicaid eligibility determination, it would not be cost effective to do a full fair hearing process.

Ms. Buckley was still unsure, perhaps because she did not agree. She felt government should always give due process to anyone. Even though it was not an entitlement program, if one met the eligibility criteria the state should have a check against acting arbitrarily. That was not the goal of government, but that happened sometimes in a bureaucracy. She did not understand what the downside would be besides cost and asked if cost had been estimated.

Ms. Buck responded some of the hearing officers were budgeted at an hourly rate and she offered to obtain those figures for Ms. Buckley. However, as Nevada Check-Up eligibility was a straightforward paper case regarding income, it was felt that a desk review already in place was an adequate and appropriate process. That was the process due under that type program.

Charlotte Crawford, Director, Department of Human Resources, said the department absolutely agreed with Assemblywoman Buckley that due process should be provided and the goal was never to be arbitrary, capricious, or unreasonable. The department did have limited resources and they were allocated between entitlement programs and non entitlement programs. She offered to provide an assessment of what the department believed it would take to provide a full due process for Nevada Check-Up. As the committee could determine from the budget, the department was not able to support an attempt to provide a more comprehensive hearing process at the department level. That was not affordable in the biennium.

Ms. Buckley believed the argument cut both ways. If the Nevada Check-Up eligibility criteria were easy, either the income was there or it was not, then the hearing costs would go down if there were a good faith dispute about someone's income. So it did not appear that affording due process would be too expensive. There would not be much to argue about, except whether certain income was exempt or circumstances had changed.

Ms. Crawford agreed it would not take a great deal and the department would do the assessment and provide it to the committee.

Chairman Freeman asked to have the assessment provided by the next committee meeting. She asked members to retain the amendment and they would vote on the bill at the next meeting.

Ms. Freeman closed the work session on A.B. 429 and opened the hearing on A.B. 373.

Chairman Freeman asked Assemblywoman Giunchigliani if she had spoken to Assemblywoman Leslie about her bill.

Assemblywoman Chris Giunchigliani, Assembly District 9, identified herself and stated she had spoken to Ms. Leslie and had no problem about certain language being taken out of the bill, if it was the committee's decision.

Assemblywoman Leslie said Senator Titus would be present to discuss the bill.

Ms. Giunchigliani said A.B. 373 was an attempt to give protection to individuals who resided in residential facilities. There were no penalties for unlicensed facilities. She had discovered a facility where six seniors resided by themselves with no caregiver in the home. She reported it to the division and they simply sent a letter asking the homeowner to advise if the home was unlicensed. The division was short staffed and that was all they could do. It was a frustrating situation. However, those facilities were necessary and it was not the intent of A.B. 373 to over-regulate, but it provided a way to reward those facilities that functioned well and were licensed.

The bill did not regulate the amount a facility charged its residents, but the facility had to post what care was provided and what the charges were. Charges ranged from $600 to $3,000 to rent a room in a home. People should know what care they could expect.

Another section of the bill addressed referral services. Some individuals claimed to be a referral service and might hold a business license, but in fact there were no legitimate referral services. There had been no regulatory authority to license or oversee referral services and no prescribed training. Ms. Giunchigliani had two amendments for the committee to review. On page 2, subsection 2(b), the following would be added: "Regulations shall prohibit referral fees from being paid by the facility. Nothing would prevent a consumer from paying a referral fee." In that way the burden would be shifted. The suggested language came from the Florida statutes and had been recommended to her by the Long- Term Care Board.

In section 5, the intent was to eliminate registered homes. Current regulations stated a home care provider could take in one to two people who were not related to the provider, charge them, and become registered. The dilemma was there had been no authority for oversight and no way to followup complaints in a registered home. Additionally, when homes were located within close proximity and a complaint was lodged with Social Services Department, people were often shifted to another nearby home and it had been difficult to determine who was whom. The bill section would close that loophole with the provision that if one took in residents and charged them, the home had to be licensed by the state. She also recommended a population cap of 100,000 because in rural areas there had been a different set of circumstances.

Parts of sections 7 and 8 were modeled after the child care act. There had been a mix of ambulatory and nonambulatory residents in some homes and it was vital to have safe emergency exits for all residents. The fire department would go into a facility to inspect upon request at time of application but did not reinspect later.

Ms. Giunchigliani said there were many facilities that were unlicensed.

Unlicensed facilities, if caught, were fined $10,000 for a first offense, $20,000 for second offense and a license would not be granted for a period of time. What the bill would do, she said, was to empower well-run businesses.

Assemblywoman Berman asked for an explanation why the bill sought to put referral services out of business. Ms. Giunchigliani said those who called themselves a "licensed referral service" were not, because there was no licensing mechanism in the State of Nevada. In meeting with hospitals she found they had concerns about untrained or unknowledgeable individuals making referrals. The hospitals felt they should have some background in social work or medical care to refer people to group homes. Those were not "nursing homes," they were private residences. The person making the referral had to know the needs of the individual, whether elderly, infirm, or whatever the condition, and only a skilled or professional in the health field could adequately assess that.

Ms. Berman asked if anyone had been making referrals. Ms. Giunchigliani said there had been nurses or social workers in Washoe County. In Clark County referrals had been made by the Adult Homes Referral Service who called itself a "licensed" referral service, however, she said the license was a business license. Ms. Berman asked if holding only a business license would still be found offensive. Ms. Giunchigliani said it was not a matter of being offensive, rather she did not want to encourage headhunting. It was a vulnerable population and concerned family members wanted to have the assurance their loved one had been placed in the best facility to meet their needs. Ms. Berman asked had there been instances of abuse by the referral services. Ms. Giunchigliani offered no specific instances but said others would be testifying about that.

Senator Dina Titus, representing District 7, came forward to report that she had a similar bill in the senate. It had been prompted by her concern about situations in the older Las Vegas neighborhoods. Homes purchased by individuals were then turned into halfway houses. There were no regulations or licenses, and the city could not do anything about it because they met the zoning requirements. Those neighborhoods abutted the neighborhoods where the home care facilities in Ms. Giunchigliani's bill were and it seemed it might be wise legislatively to merge the bills. Unfortunately, when the bill was drafted by the Legislative Counsel Bureau (LCB), "halfway house" was incorrectly defined as a facility for treatment. In truth, a halfway house was transitional housing for individuals who were receiving counseling. Her bill was in the process of being amended with language from the Bureau of Alcohol and Drug Abuse (BADA). What Ms. Titus hoped to accomplish was to bring the halfway houses under some kind of regulation.

Chairman Freeman remarked similar situations had happened in Reno neighborhoods where homes could be purchased inexpensively and used in ways not subject to regulation.

Mrs. Freeman asked how Senator Titus's bill fit into Assemblywoman Giunchigliani's bill. Ms. Giunchigliani said Nevada Revised Statutes (NRS) Chapter 449 listed every type of residential facility or home that was licensed or regulated in the state. She felt the LCB would choose to place the home care facilities in that section and then the regulations would coincide.

Assemblywoman Von Tobel asked Senator Titus if she planned to blend her bill, S.B. 161, into A.B. 373, Ms. Giunchigliani's bill. She advised her bill had been heard in Senate Committee on Human Resources, they voted "amend and do pass," and they were waiting for the amendment which had not been received due to the backlog. Therefore, she felt it could be blended into A.B. 373.

Ms. Giunchigliani provided a suggested amendment and articles in connection with her bill, marked as EXHIBIT D.

Next to speak was Susan Robinson, Social Work Supervisor of the Long-Term Care Unit at Clark County Social Service. She had been the unit supervisor for more than 5 years. Prior to that she was a field social worker at the unit for 6 years. She provided written testimony, marked EXHIBIT E, which stated in part:

In closing, Ms. Robinson stated Clark County Social Services strongly supported passage of A.B. 373 as written.

Chairman Freeman remarked those kinds of disturbing incidents had often been discussed through the years. The bottom line was usually money and very often the state agencies were not adequately funded. They had to live on the fees collected rather than receiving money from the general fund, so their hands were tied insofar as making inspections or monitoring. She asked if Clark County had sufficient staff to take care of the problems on a local level. Mr. Robinson said she was "very biased" but felt their division had some of the best social workers in the department and gave their all to the residents. They had responded amazingly well under the circumstances in which they had to work.

Ms. Freeman then asked the cost to become licensed. Ms. Robinson was not certain of the amount, but in conversation with her division they believed it was less than $2,000, which she equated to one month's fee for one bed. She said further some of the homes were leased properties and many were owned and operated by the same individual who also lived at the property.

Ms. Freeman spoke of a bill passed in the 1997 session that allowed local entities to go after owners of property defined as "nuisance."

Assemblywoman Buckley if there had been direct evidence of "body shuffling," moving residents from one home to another, in Nevada. Ms. Robinson reported they had found several occasions of people being moved from home to home, although she could not relate details on how or why that had happened. Ms. Buckley followed up by asking about a criminal statute one could be charged under for moving someone to collect a fee. Ms. Robinson said only the elder abuse statute, and some cases had been referred for prosecution under that statute.

Assemblywoman Leslie wanted to know about nonprofit or senior centers that provided referral services. Ms. Robinson said her unit in Clark County Social Services was the only one of which she knew. They placed individuals who came to them into licensed nursing homes or group care homes in accord with the individual's level of need. The unit received over 900 new referrals a year. Ms. Leslie asked how the private referral agencies got their clients. Ms. Robinson understood they got them from hospitals.

Chairman Freeman said testimony on the issue would be limited because of a previously scheduled meeting for another committee which some of the members had to attend, and her vice chair, Assemblywoman Koivisto, was in Las Vegas at still another meeting. Also for that reason the next two bills on the agenda, A.B. 573 and A.B. 681, would be rescheduled.

Testimony on A.B. 373 continued with Sandie Durgin, Supervisor/Investigator, Las Vegas Metro Police Department, who spoke briefly and submitted written testimony, EXHIBIT F, which stated in part the police were concerned about licensure of home care facilities because they had been called to those facilities on occasion and found:

Police departments needed responsible caregivers for the large numbers of seniors who became severely dependent. Experience had shown that regulations were needed to prevent abuse and neglect. Responsible, well-run facilities safeguarded dependent adults from abuse, assault, and financial exploitation. Many cases went unreported because victims were unable to ask for help, afraid of retaliation, further institutionalization, or dependent upon their abuser for needed care. The degree of knowledgeable caregiving and personal and financial commitment of licensed homes tended to be higher. With licensing there were checks and balances and accountability. For those and other reasons, Ms. Durgin urged support of A.B. 373.

Chairman Freeman asked if the bill were passed and unlicensed homes closed down, would there be sufficient licensed homes to take in the seniors who had to be moved. Ms. Durgin said to date they had been able to accommodate the seniors found in poor conditions, but sometimes seniors had to be left behind because the law did not say everyone could be moved. The law stated if the home was registered and had two or fewer residents, the senior could stay. If depended upon the kind of neglectful or abusive situations which were uncovered that determined seniors were moved.

Mrs. Freeman asked how many poorly run unlicensed homes were in Las Vegas and the average number of residents. Ms. Durgin said there were over 400 registered and unregistered homes in Clark County, and more than the two people allowed were in residence most of the time. She also said there were appropriate operators they had not seen as well but inappropriate operators were numerous.

Next to testify was Judy Johnston, Assistant Public Administrator/Public Guardian, Clark County, who voiced support for A.B. 373, and provided written remarks, EXHIBIT G. She explained her office was a consumer, the legal guardian of approximately 500 individuals in the State of Nevada. There were about 80 to 100 who lived in group care. It had been the policy of the public guardian to prohibit the use of registered homes, unlicensed homes, and businesses that provided referrals due to the lack of regulations and best standard practices. Substandard care, substandard housing, and financial exploitation were problems her office saw on a regular basis. Incapable or incompetent individuals with no family or responsible party to help them had no voice until a legal guardian was appointed. When placed in a group care facility without a proper advocate, those individuals became barter for businesses that collected finders fees up to $750. Beds for fees with no practice standards and regulations resulted in placements in homes that did not provide an appropriate level of care. She further pointed out that referral services had:

Similar problems had occurred with registered homes and included:

In closing, Ms. Johnston stated current law allowed abuses to take place in environments with no safeguards and no accountability. When vulnerable adults who depended on the system became pawns for pay and their lives and well-being were compromised, changes had to be made.

Thelma Clark, representing the Nevada Silver Haired Legislative Forum, introduced herself and said that anyone with one senior in their home should be licensed. She felt an amendment was needed on page 3 to change the line that read "a person who operates a residential facility for groups" to read "a person who operates a residential facility for groups and/or for profit." She said there were people who took in a friend and did not charge them. Further, if a group homeowner was in violation in one home and also owned other group homes, then all the homes would be closed. That would preclude residents being moved from one home to another. Ms. Clark also suggested that monies paid for fines should be earmarked for the enforcement of those laws, in essence money would then be available to hire staff to enforce the law.

Ed Fend, Chair of the Legislative Committee, American Association of Retired Persons (AARP) next testified in support of A.B. 373; however, he had suggestions for some changes. He agreed with Thelma Clark that poor operation in one home probably meant other homes owned by the same individual would be poorly run. Therefore, a violation in one should result in closure of all homes under the same ownership. The problem, Mr. Fend said, was that there were some unscrupulous people who had found home care to be a very lucrative business. Those individuals had taken advantage of any loopholes to make money on senior citizens. Seniors needed protection and A.B. 373 provided some of it but more was needed.

In Las Vegas, groups like B'nai B'rith provided a partner for certain people and matched them. They lived together providing support and companionship which made it affordable for them to stay in a group home. Mr. Fend said he would not want to see any regulations developed that would prevent people from doing that. The group homes all should be licensed and inspected regularly. Those homes were needed in Nevada to provide housing and protection for seniors.

Mrs. Freeman asked Rick Panelli, Chief of the Bureau of Licensure and Certification, about enforcement ramifications regarding the closure of all homes owned by the same individual if there had been a violation in one of the homes. Mr. Panelli came forward, identified himself, and responded it would not be a problem in terms of enforcement. The problem might occur in the displacement of individuals in those homes

Mr. Fend recalled a Sparks case where a senior wandered away from a group home and froze to death, and a senior in another home had been scalded and died; both homes were owned by the same person. That owner went to jail, was later released, and returned to being a home care provider. Mr. Fend believed a statute had been created in 1997 stating anyone convicted of abuse of a senior citizen would not be permitted to return to that business. If that had not been the case then it should be done.

Assemblywoman Giunchigliani said the wording Mr. Fend recommended was absent from her bill and she was in agreement that it should be contained in the amendment.

Chairman Freeman asked Mr. Panelli to make a statement on the matter. Mr. Panelli stated he had discussed with Ms. Giunchigliani an amendment to section 7, paragraph 7, that changed the word from "plan" to "regulation." Mr. Panelli also had prepared testimony, marked as EXHIBIT H, which stated in part:

Assemblywoman McClain asked Mr. Panelli about workers health care checks in licensed care homes. Mr. Panelli said current regulations required annual tests for tuberculosis, a criminal background check, and other health related records had to be in place in the facility. It would include other communicable diseases. Ms. McClain asked if it would include drug and alcohol abuse. Mr. Panelli said "No."

Assemblywoman Gibbons asked when the bill had to be out of the Committee on Ways and Means. Chairman Freeman said A.B. 373 did not have to go to the Committee on Ways and Means.

Chairman Freeman apologized for cutting the meeting short due to another meeting where she was required, but that voting would take place at the next meeting.

With no further business before the committee, the meeting was adjourned at 3:00 p.m.