ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES

MINUTES OF THE meeting

of the

ASSEMBLY Committee on Health and Human Services

Seventy-First Session

April 16, 2001

The Committee on Health and Human Serviceswas called to order at 1:30 p.m., on Monday, April 16, 2001. Chairman Ellen Koivisto 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. Ellen Koivisto, Chairman

Ms. Kathy McClain, Vice Chairman

Mrs. Sharron Angle

Ms. Merle Berman

Mrs. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Bonnie Parnell

Mrs. Debbie Smith

Ms. Sandra Tiffany

Mr. Wendell Williams

COMMITTEE MEMBERS ABSENT:

Mrs. Vivian Freeman

GUEST LEGISLATORS PRESENT:

Assemblywoman Genie Ohrenschall, District 12

STAFF MEMBERS PRESENT:

Marla McDade Williams, Committee Policy Analyst

Darlene Rubin, Committee Secretary

OTHERS PRESENT:

Dr. Johanna Fricke, Associate Professor, University of Nevada School of Medicine, Department of Pediatrics

Dave Luke, Ph.D., Associate Administrator, Division of Mental Health and Developmental Services

Randy Figurski, Speech Pathologist

Bob Dickens, Director of Governmental Relations, University of Reno

Lynn Chapman, Nevada Eagle Forum

Michael Diamond, Parent

Jackie Roundtree, Parent

Jan Crandy, Families for Effective Autism Treatment (FEAT)

Flo LeRoy, Parent

Janice Pine, Director of Governmental Relations, Saint Mary’s Health Center

Steven Horsford, Southwest Ambulance

Dr. David Rosin, State Medical Director, Nevada Mental Health Institutes

Jim Spinello, Clark County

Stephanie Beck, R.N., Washoe County District Health Department

Jim Gubbels, Regional Emergency Medical Services Authority

Terra Sisco, Parent

Darlene Schottle, Assistant Superintendent, Washoe County School District

Jennifer Lamb, Washoe County School District

Mary Sullivan Bryan, R.N., Parent

Shelly Bellamy, Health Ecology Student, University of Nevada, Reno

John Pappageorge, Public Industries of Nevada

Joe Johnson, Sierra Club

Gemma Waldron, Deputy District Attorney, Washoe County

Mary Lau, Nevada Retail Association

Captain Jim Nadeau, Washoe County Sheriff’s Office

From Las Vegas:

Korri Ward, Parent

Dr. Dale Carrison, University Medical Center

Barbara Webb, Citizen

Michele Tombari, Parent

Louis De George, Citizen

Diane Butler, Parent

Jacqueline Taylor, University Medical Center

Chairman Koivisto announced the hearing would start as a subcommittee until missing members returned from other committees. She then opened the hearing on A. B. 635.

Assembly Bill 635: Creates commission on autism. (BDR 39-225)

The first to speak was Jackie Roundtree, a 31-year-old single parent of three children, whose 13-year-old daughter, Ashley, was handicapped by autism. Ashley had recently started home schooling, with teachers coming in twice a day, because the public school did not understand autism. Ms. Roundtree helped those teachers with her daughter. She was disappointed to learn that only two teachers in the last eight years had gone to one autism seminar. She felt that was not enough education to help her daughter, let alone serve the needs of Elko County. Meanwhile, she had been the school’s “911 line” for Ashley, which made it impossible for her to work and consequently put her in the low-income level. She could not afford a car. All of Ashley’s doctors were out-of-town, from Reno to Idaho and Salt Lake City. It was very expensive to travel and she made at least one trip every month.

Ms. Roundtree explained that the normal, simple things in life were tragic for Ashley, who had a fear of crowds and strange unfamiliar environments. She was worried what would happen to Ashley if she was not there one day to care for her. She said she could benefit from respite care and other resources if Elko had them to offer. Ms. Roundtree also provided her written testimony (Exhibit C).

Chairman Koivisto asked how the autism center would be of help. Ms. Roundtree said it would help her daughter who needed to learn daily life skills. Ashley was nonverbal and wore diapers, she became aggressive and it was “like a circus” when someone tried to teach her, because the teachers had not understood autism. People needed to understand autism to be able to relate to autistic children. She added that having a center would be a beginning.

Dr. Johanna Fricke, Associate Professor, University of Nevada School of Medicine, Department of Pediatrics, said her subspecialty was developmental and behavioral pediatrics. She explained that part of her job was to teach general practitioners, including pediatricians and family practitioners, how to identify autism early. The purpose of her testimony, she said, was to provide an understanding of what autism meant and what the issues were, once diagnosed, especially in young children. She stated as follows:

Autism was from a Greek word, autismos, meaning into one’s self, and when you have time to peruse the literature (Exhibit D) it means that there are behavioral manifestations of a neurobiological condition. This is a medical condition. One of the issues and one of the problems is many of the insurances refuse to pay for autism
services. As a matter of fact, my own insurance, which is Nevada State Self-Funded PPO says, “no services for autism.” So the question becomes then, if we teach practitioners how to identify early, that is, how to identify the child who has a delay or disconnect in social reciprocity and communication and has repetitive or stereotyped interests or movements, then where do we send them? What tends to happen is I rely on the women who are about to present to you, they are parents of children with autism, they have the most invested in learning about autism, and they indeed function as a resource for other parents. I think that the purpose of the commission and the centers, in my mind, is to make the services that exist cohesive, because we do have early intervention services such as special children’s clinic and what used to be called the “happy program” in the rural areas, and then as the children get to be three, the school district. What happens is the treatment becomes based on what is available, so it is not just a two-tiered system, it is sometimes a three or four-tiered system with children in Pahrump getting much less than children in Las Vegas. Basically that is why I am supporting the concept of having the centers so we can put together the knowledge that we do have and continue to have a place to refer the children once we do identify the problems.

Chairman Koivisto said she stated the issue very well; it was a resource for people to turn to.

Assemblywoman Leslie asked about the staffing pattern at the two centers. Dr. Fricke deferred to Flo LeRoy.

Flo LeRoy, parent of an autistic child, thanked the committee for giving her an opportunity to move forward on services for children with autism. She reported she had been a member of numerous committees, task forces, parent support groups, referrals for families throughout the community, and had spoken to families statewide who had children with autism. She had even coordinated a national conference to try to enlighten the people in Nevada so they could learn more about autism and provide appropriate services.

Mrs. LeRoy said her son was 16-years-old and she was looking at the future, which in Nevada did not look bright. Her son needed the intense intervention that was required for autistic children, as well as the trained personnel. She was still on the “911 list” for the school. He received referrals from the dean because of his behavior, which frequently occurred because people who did not understand autism were unable to deal with him.

For adolescents and adults who had not had intensive early intervention, such as her son, there were areas that had not been addressed. For example, social skills; her son did not know how to make friends, and he had limited opportunity at the high school to even interact with his typical peers. The autism population was difficult to understand and to deal with. Someone like her 6-foot-tall son could be very intimidating to those who did not understand the disability and tried to interact with him.

Mrs. LeRoy said families had done as much as they could do. Service providers had made attempts to provide some additional services through the different agencies, however, it was not a comprehensive system but a fractured one, with families going from one agency to another until they happened onto the right person who could give them some guidance. Currently, many agencies were paying for out-of-state providers from California. However, Nevada’s population was increasing and centers where resources, expertise, and training were available were needed in Nevada so that people could be enlightened about the disability and the children had a future.

Chairman Koivisto asked what the centers would do in addition to serving as a clearinghouse for information. Mrs. LeRoy said they would provide training for parents, relatives, and professionals who worked with autistic children, as well as for community providers. She mentioned parks and recreation programs, and other areas where children accessed services, could be a source for the community. The community would be aware of an autism center and those who wanted to serve those children would know where to go. Currently there was a loosely knit networking system where families heard about individuals who were interested and, through the family network, names were exchanged and parents could get in touch with individuals who could provide support to the families. Something more was needed, she added, a comprehensive system where a family, upon learning they had an autistic child, could find out what to do and where to get services.

Vice Chairman McClain asked how many children in Nevada were autistic. Mrs. LeRoy said the number was difficult to obtain. Another purpose of the centers would be to collect such data. Currently, according to Kids Count, ages 3 to 21, there were 327 individuals in the state. However, children with autism might have multiple diagnoses, or multiple categories, within the school district. For example, they might be categorized as mentally challenged, emotionally disturbed, learning disabled, or speech and language impaired. Many children had been diagnosed as developmentally delayed. Some autistic children who were at the milder end of the spectrum might look like attention-deficit disordered (ADD). Mrs. LeRoy said she had recently obtained the births for the
state of Nevada and based on an estimated 1 in 500 incidences of autism, in the year 2000 there were 60 new cases of autism that went unknown because those children would just be turning one year old. As the population grew, the number of cases would increase. She did not know how many autistic adults there were, but the Division of Mental Health and Developmental Services (MHDS) served 111 people and 50 percent were children. The Division of Child and Family Services (DCFS) provided for 15 children. Mrs. LeRoy provided a magazine article (Exhibit E) entitled, State Officials Cite Problems with Early Identification of Autistic Children.

Chairman Koivisto asked if the school districts would have some interaction with the centers so their staff would be better able to work with the children. Mrs. LeRoy said yes, the centers could be a place for training and information for the entire community including all agencies. Currently, the Clark County School District, at a great expense, was utilizing autism partnerships from California to provide training to their staff and parents. Unfortunately, parents had to wait until the consultant or trainers came into town, and if any weeks were missed the parent and child had to wait for the next time, which was frustrating.

Assemblywoman Leslie noted Section 10 of the bill stated there would be two centers, one north, one south, and each center would have a director, an evaluator, a diagnostician, a program designer, and one or more behavioral interventionists and case managers. She asked if any of those positions existed already or would they be new positions.

Jan Crandy, a parent and the founder of Families for Effective Autism Treatment (FEAT) in southern Nevada, responded to the question. Currently they were bringing in out-of-state people at a cost of about $1,000 per family for behavioral interventionists to set up home programs for children. Clark County School District board approved $270,000 to pay for an out-of-state consultant to show them how to work with children with autism. Those dollars could be kept in Nevada if the state had its own experts, and more children could be served. Parents had been funding those programs themselves, however, because of some lawsuits, Clark County School District now funded the programs. Ms. Crandy provided an amendment to A.B. 635 (Exhibit F).

Ms. Crandy said they wanted the centers to deal with all types of intervention, because each child was different and the programs needed to be child-specific. She explained how difficult it was to even get a diagnosis in Nevada, although that situation had improved since FEAT was organized in 1996. At that time children were not diagnosed in Nevada and Ms. Crandy helped families go out of state to get a diagnosis. She noted that FEAT had accomplished so much with no money; it was a parent group that provided training, set up home programs, and built a therapist pool of in-home therapists. However, FEAT families could not continue to do that because there were too many children and they could not provide adequate service. Additionally, the FEAT families were only parents, not trained professionals; everything they learned had come from attending seminars and training out-of-state, and they had their own children to care for. The state of Nevada should be providing those services, Ms. Crandy added.

Mrs. LeRoy added in terms of expenditures, the families, the various agencies, and the school district who funded some of the programs, paid a large fee; plus travel, and per diem, that she felt was exorbitant and the cost would be less expensive if done in Nevada. There were areas of expertise in Nevada; there were people in the state who had expertise in behavioral interventions. She noted that A.B. 280 of the Seventieth Session, which prohibited use of aversive intervention on persons with disabilities under certain circumstances, was a positive behavioral support for Nevada. It was necessary to continue to expand the number of trained people. The proposed legislation would provide an opportunity to do that as well as bring cohesiveness to the service delivery that existed. Families did not know where to go; there needed to be a single point of entry for young families with autistic children, or newcomers to the state; they needed to know who to call and what to do.

Assemblyman Manendo asked Ms. Crandy to elaborate on her comment that the state was paying to bring in specialists. Ms. Crandy responded that it was Clark County School District who paid to bring in out-of-state consultants to supervise home programs. Other interventions were being done in the district and in the city, the home program was but one methodology, other methodologies were needed. Mr. Manendo asked the cost for that consultant service, and Ms. Crandy said $270,000 was approved for the current year; however, she believed the district spent $300,000, and that was just for consulting with the school district. The district funded home programs for 20 families that she knew of, at a cost of about $1,300 each. For her daughter’s program, she said someone came in every other month.

Mr. Manendo asked if she was seeking to have the state rather than the school district pay the $270,000. Ms. Crandy felt the state should want the services in Nevada so families with autistic children would have resources and the availability of experts. The professionals were needed in Nevada so that parents and children did not have to rely on the visits of out-of-state people.

Mr. Manendo asked about the fiscal note. Ms. Crandy said it was $700,000. But, although she would not want to jeopardize the bill, she asked that the committee consider including autism-related disorders in the Medicaid waiver, as other states had done, so that behavioral intervention would be paid. That would solve a majority of the families’ problems. Currently, Medicaid would give them $6,000 but it could only be used for speech therapy and occupational therapy. Consequently, they could not use the money because there were no CPT codes for behavioral intervention.

Mr. Manendo asked if the $700,000 was in the Governor’s Budget. Marla McDade Williams, Committee Policy Analyst, said it was not. Mr. Manendo assumed then, that it would be necessary to find another $700,000.

Ms. Crandy said if the bill was passed without having the funding that was acceptable. At least, she added, it would be looked at. Currently, autism had been underfunded in the state. Only in 1998 had the state allowed families to be placed on a waiting list to receive services for an autistic child. That only came about as a result of a lawsuit against the state of Nevada. However, if a child did not have an IQ of under 70, which excluded many children, they were not allowed to receive mental health services. Ms. Crandy added that even if one got on the waiting list, there were no experts in Nevada to provide the services, so it was a moot point.

Mrs. LeRoy said that if all the families who currently were not utilizing agency support would go to an agency and enroll, there would be an incredible surge of people on the waiting list, because they would not be able to provide what the families needed.

Ms. Crandy stated the statistics nationwide showed a tremendous rise in autism; it used to be 1 in 10,000, now it was 1 in 275. California had a 273 percent increase. Many children would be placed in institutions in the future if something was not done now. Families needed answers.

Mrs. LeRoy said currently the children were not getting what they needed. They were referred to deans, they were expelled from school, and the cycle was repeated over and over. If they were not learning, they were not moving forward and their skills were not improving. What was needed was to get appropriate services to the children who needed them; otherwise, more and more children would be institutionalized.

Next to speak, from Las Vegas, was Korri Ward, who expressed support for A.B. 635 and agreed with the majority of opinions voiced earlier. She did say, however, that she and her husband had been able to obtain education on autism intervention and the needed services and/or therapists in the Las Vegas area; consequently her child had progressed. When comparing her son to others in the same range, she did not see that same level of progress and felt those services had been responsible for the improvement. Mrs. Ward said she was a second-generation autism mother and recalled the struggles her own mother had had with services not available in Clark County for her brother. Her great fear, she explained, was that more and more children would be institutionalized, or that they would not be able to function in society, because the parents and the community did not have the needed education and services.

Barbara Webb, from Las Vegas, stated that in completion of her doctorate program at University of Nevada, Las Vegas, she completed a research project, a copy of which she provided to the committee, entitled “Family Perceptions of Services Received for Children with Autism Spectrum Disorder” (Exhibit G). One of her findings was that regarding the parents’ ability to obtain and maintain resources for their children, the parents accessed 4.4 agencies and 7.7 service providers at one time. Her concern with the parents was that, first they had a very difficult time dealing with the exceptionality, then they were asked to go from place to place to find different service providers to access their needs. Her research found that half of the respondents reported no collaboration between service providers and only 10 percent reported collaboration most or all of the time between service providers. The range of providers in Nevada was zero to eight. If a child had eight different service providers and half were never communicating, the treatment plan might not be effectively addressed. Ms. Webb believed that a continued examination of the services provided in Nevada was needed, along with the benefits available, and the needs of the families with children who had autism spectrum disorder. That examination should include how those services were offered from early childhood through adulthood.

Michele Tombari, from Las Vegas, reported she had an autistic son and was a volunteer for FEAT. She provided her written testimony and supporting documentation (Exhibit H): A report from Cambridge University stating autism had reached epidemic proportions affecting 1 out 175 children; information from the California Department of Developmental Services that revealed a 273 percent increase in autism cases between 1987 and 1998; a report entitled Mental Health from the Surgeon General of the United States, who stated that Applied Behavioral Analysis (ABA) treatment was the effective treatment for autism; unfortunately, however, that was not available in Nevada; and, finally, a plan document for Nevada Power Company’s health care plan that specifically excluded autism. In closing, Mrs. Tombari strongly supported A.B. 635 as the first step in providing services for Nevada children.

Next, Diane Butler, from Las Vegas, reported she had a three and one-half-year-old autistic daughter. In order to get a diagnosis she had to go through Special Children’s Clinic, Desert Regional, Children’s Behavioral Center, pediatric neurologists, genetic workups, a nutritionist, an occupational therapist, and a speech pathologist. Finally, when she happened upon the FEAT group, she went to see a specialist. She had taken her daughter out of state to try to satisfy her insurance company. So far they had denied all claims for any therapy. The insurer claimed that the program she was in, an ABA program, although proven to be beneficial to some children in research studies, was not considered medically necessary for every child with autism but would be considered optimal, which would be the equivalent in medical necessity terms of optimal elective treatment, cosmetic treatment, or experimental treatment. She was not clear why they would categorize it in that way. In order to get therapists to work with her daughter, she had to place newspaper ads, or rely on other therapists to train new aides, and there was no funding for her to get that therapy. It was only because she heard so many stories of older children and their problems that she realized the need for early intervention if she had any hope for her daughter to recover.

Mrs. Butler said currently the costs for her daughter’s program were in excess of $3,000 per month. That included the therapist from out of state, plus airfare, hotel, rental car, and per diem. She had received some help from the school district, however so many families received no help at all.

Chairman Koivisto returned to the witnesses from Carson City.

Johanna Fricke, who had spoken earlier, wanted to point out that autism was a neurobiological condition with many associated medical conditions. The only treatment known to work was the intensive repetitive behavioral intervention. That treatment was very confusing to the insurance companies as it made them think it was a mental illness or an educational, or developmental problem. She added that when the genes that predisposed autism were found, there would be much less trouble getting what was needed for the children. The nature of the science currently was akin to where infectious disease was in the 1940s.

Randy Figurski, a speech language pathologist licensed in the state of Nevada and a member of the Autism Task Force formed three years ago, spoke in favor of the bill. He reported he had been asked to consult with a number of school districts in Nevada, some of which could not afford his services. He noted some of the larger school districts had excellent therapists, special educators, speech pathologists, and so on, and excellent behavioral interventionists. In fact, most of those professions were behavioral interventionists. The concern expressed by many school districts was that “behavioral interventionist” meant only those who were trained by the ABA program out of a university. However, it was not limited to that, Mr. Figurski stated, as he had discovered from the Autism Task Force that lead to the development of A. B. 635.

Mr. Figurski conducted autism diagnoses and accordingly offered an amendment (Exhibit I) which asked for a change in line 7-1 of Section 17.1 (a) as follows:

Be a physician, psychiatrist, psychologist or speech-language pathologist, who is licensed to practice in this state.

Mr. Figurski reported that one of the school districts he consulted with showed an autism rate, based on their records, of 1 in 300 children, a huge increase, he added, over ten years earlier when he had diagnosed only one or two children per year. At the Special Children’s Clinic, where he also worked, the diagnosis rate now was from two to four children per month. The cost factor was also devastating to families and he recalled several families he had referred to behavioral programs at the university who had paid in excess of $30,000 a year with no outside financial help. The recommendation was for intensive services, whether a discreet trial training program through an ABA provider, or through any of the other intervention means that could be found and had some research basis. The disadvantage to other intervention methodologies was that there was no research behind them to support effectiveness. One of the benefits of establishing an autism center that had a research component available was that other effective treatments, besides discreet trial training, could be identified.

Chairman Koivisto asked Mr. Figurski to explain ABA. Mr. Figurski said that applied behavioral analysis was a discipline in the department of psychology that involved behavioral intervention techniques of many varieties, not just discreet trial training, which was the “hot” topic in the intervention for children with the disorder. It included behavioral interventions that other professions used including speech pathologists and special educators.

Assemblywoman Parnell asked Mr. Figurski if it was his recommendation to create the commission asked for in A.B. 635. He said it had not come from him personally, however it was a recommendation from the Autism Task Force.

Chairman Koivisto invited Mrs. LeRoy, who had worked extensively on the matter, to respond to Assemblywoman Parnell.

Mrs. LeRoy said that a number of parents had gathered over a year ago to discuss interventions for children with autism. What was known at that time was that there were a number of different agencies in the system, specifically, the Division of Child and Family Services (DCFS), Mental Health and Developmental Services (MHDS), and Special Children’s Clinics, that served children with autism. However, the training level in the disability area and the experience of working with autistic children varied greatly; some individuals were skilled, others were not. Families were accessing different services. A commission was needed to investigate what existed currently, to be able to take what was working well and put it together into a cohesive unit so that when families came to look for services for a child or an adult, they could find out where to go. Mrs. LeRoy said that after ten years she had tapped all the agencies for her son, and none had been adequate to meet his needs. Most of the information and intervention she had discovered on her own, including a home program for him at a later age and with less effectiveness than had he been able to start much younger. Therefore, the commission would be designed to investigate what agencies and resources were available and combine that with the expertise available in Nevada.

Mrs. LeRoy noted there were “secrets” about what was available, depending upon whom one spoke to. She was still getting stories about what was available from the Division of Mental Health and Developmental Services. That division’s name was changed from the Division of Mental Health and Mental Retardation, until the Perry case, and under its former name was open to related services that included autism and developmental disabilities in children that had IQs above 70. Her son, she said, had been refused early intervention services through Special Children’s Clinic and the school district. He had an average IQ of 90 and was not eligible for services. All the services he received had been outside. She reiterated that a good unit of services was needed and they should not be fractured as they were now; a commission would bring that together.

Assemblywoman Parnell asked if there would be a tracking system for cases of autism. Mrs. LeRoy said they wanted to have a tracking system. Currently the Department of Education tracked some of the developmental disabilities in different categories as required by Individuals with Disability Education Act (IDEA) and the federal government, however, those children fell into numerous categories and they might not have the diagnosis of autism, even though the family knew that was the case. Ms. Parnell felt the tracking was critical and she also offered into evidence the written report (Exhibit J) of June Rigsby, the mother of a high-achieving autistic son, which she said was also part of the puzzle of autism and one she hoped would not be overlooked.

Assemblywoman Berman asked if it would be the commission’s wish to create a Web site, so that parents could readily access information and resources. Mrs. LeRoy said that would be wonderful, although it had not been her initial objective. She added that technology had enabled many families to link together.

Chairman Koivisto reported she had received from Las Vegas a petition containing 20 signatures (Exhibit K) in support of the bill. Also, she noted several people on the sign-in sheet faxed from Las Vegas who indicated support of the bill but had not indicated a desire to testify.

Next, from Las Vegas, Mary Sullivan Bryan, a registered nurse and the mother of a six year-old daughter with autism, presented petitions containing thousands of signatures (Exhibit L) in support of the bill. Mrs. Bryan reported that when her family moved to Las Vegas from Portland, Oregon, in 1997, there were very few services available in Clark County. Her husband, a practicing physician, stayed with their son in Clark County while she and her daughter moved to Montgomery County, Maryland, where they resided for a year and one-half so her daughter could receive appropriate services. It was a difficult separation, she recalled, and they moved back to Nevada. Since then she had been in contact with FEAT families and now had services similar to those she received in Maryland, in her home, with some cooperation from the school district. Her daughter was doing very well. She reported there were programs and centers in other states similar to those being sought in the bill, and those programs and centers could be investigated and modeled. Mrs. Bryan described the Wisconsin Early Autism Program that had four sites throughout the state. It provided one-on-one behavioral intervention for ages 2 to 16, in the home as well as shadow aides in the school to help the children transition. The program was paid under Medicaid funds and supervised by M.D.s and Ph.D.s, based on research.

Terra Sisco, from Las Vegas, a mother of a four-year-old son, reported that one year ago he was diagnosed with autism after eight months of questioning his pediatrician about the changes she had seen in him; for instance, he had talked and then he stopped. The pediatrician said he might be speech-delayed. A month before his third birthday she took him to a second pediatrician for an opinion who evaluated him, but did not see any developmental delays. She returned to the first pediatrician and another evaluation and the only things she noticed was that he would not “look her in the eyes.” The pediatrician then said, “Maybe he has autism.” Neither Mrs. Sisco nor her husband were familiar with autism, and the pediatrician could not explain it. Finally they were referred to Special Children’s Clinic where, since he was just one day short of the age three cutoff, they did diagnose him with autism but could not work with him. They were then referred to the school district, which she said surprised her because, like so many other people, she thought of school in terms of starting at kindergarten age. She was unaware of an early childhood program. Over the last year she had done extensive research and found a lot of information but little that was helpful, in fact some, she said, could be harmful. Mrs. Sisco noted also that their health insurer, Hometown Health Plan (HHP), considered autism “unrecoverable,” however, that was not true because there were doctors and scientists who once had autism. But in any event, HHP would not pay for any services. She pointed out that the program her son was on used some ABA but it was considered an eclectic program, and she hoped the centers requested under A.B. 635 would utilize other programs in addition to ABA.

Michele Tombari, who had spoken earlier, said she had obtained petitions with nearly 300 signatures and that the Nevada Legislative Web site placed A.B. 635 as one of the top 30 highest-voted bills with a total vote of 179; 178 for and 1 against. Chairman Koivisto asked her to fax the petitions to the committee.

Chairman Koivisto then asked for the people who were opposed to the bill to come forward.

First was Dr. Dave Luke, Associate Administrator, Division of Mental Health and Developmental Services (MHDS), Department of Human Resources (DHR), who was opposed to A.B. 635, which would create a commission on autism within his division, because it would impact the division’s ability to provide services. In addition, he cited among the bill’s further disadvantages:

· The $700,000 appropriation was not in the Executive Budget;

· Section 7.3 required the division to provide staff support to the commission, however, there was no funding for that staff;

· It provided for the commission to establish autism service centers, autism residential facilities, hire employees and to pay travel expenses for commissioners, which would likely be an added burden for the division or the regional centers to support; and

several other points, as shown in his written testimony (Exhibit M). He added that the division understood the intent of the bill was to enhance service to persons with autism, however, A. B. 635 used valuable resources for additional administration and assessment but failed to add services or coordinate with other service systems. Dr. Luke felt the issues of concern raised by the bill might be better addressed in the DHR’s comprehensive long-range health care strategic plan currently in the Governor’s Budget, funded at $550,000. That plan would address the current and future health care needs of Nevada citizens and provide a blue print to guide the development of public and private resources necessary to meet those needs.

Chairman Koivisto asked if the division served any autistic persons. Dr. Luke said currently they served between 150 and 200 people diagnosed with autism. In order to be served by the division, Dr. Luke said the individual would also need to qualify under the federal definition of mental retardation or the federal definition of related conditions, which included some autistic, cerebral palsied, and other individuals, but only to the extent those individuals required the same services that a person with mental retardation would need.

Michael Diamond, the parent of a child with autism, said it was difficult for him to speak against something that he hoped would help his child. He admired Flo LeRoy and Jan Crandy, and others with whom he had worked, nevertheless he did not believe the bill would help their children. He was on several committees for disabled children and felt that whenever a report of a piece of legislation became known, parents grabbed onto it with great hope that it would alleviate the hopelessness they felt. He believed the bill would create another barrier toward receiving appropriate treatment and services for families, as well as create an ineffective, inefficient bureaucracy. Further, he believed the bulk of the $700,000 would be spent on administration, salaries, support staff, and rent, and would not go to provide direct services to families and children.

Mr. Diamond said his most pressing concerns were navigating the Social Security and Medicaid maze; assessing, identifying, and locating needed services, supports, and treatments; and affordability of those treatments and services. He believed A. B. 635 did not address those concerns. Mr. Diamond provided his written testimony (Exhibit N).

Chairman Koivisto asked Mr. Diamond if he could propose a different solution. He then recommended the following:

Legislation to expand insurance coverage for autism and autism treatment; and
Health care services that included respite care and Medicaid.

Mrs. Koivisto said everyone would like those things, as well. Mr. Diamond said it “broke his heart” not to be able to support the bill, but that was an indication of how strongly he felt that the proposed legislation would not help.

Lynn Chapman, State Vice President, Nevada Eagle Forum, said they were not against the bill, but were neutral. However, she wanted to submit information about the growing connection between autism and vaccinations. The Chair asked her to give that information to the Committee Secretary, as that was not the issue being discussed. Ms. Chapman submitted “The Autism Explosion” (Exhibit O).

Next to speak was Bob Dickens, Director of Governmental Relations, University of Nevada, Reno (UNR), who was neutral on the bill, and said the university was written into the bill and they would be pleased to serve on the commission, if the legislation was passed.

Chairman Koivisto noted the bill also had to go to the Committee on Ways and Means and many of the concerns would be addressed at that time.

Shelly Bellamy, a student in the Health Ecology Department, UNR, said that in view of the fact that money was going to the state of California for services to families in Nevada, why could those funds not be put into the bill. She felt it would cut the cost of the program in half.

Darlene Schottle, Assistant Superintendent, Washoe County School District, served as oversight for the special education department and had been a member of the Task Force on Autism statewide. She acknowledged that autism was a very challenging disability to treat and required experts broad-based in many kinds of support. Further, that statewide support was needed for parents, community members, and school districts in the area of training and a central repository of knowledge was needed. However, she was concerned about the following:

As a school district, she believed they had provided some very supportive programs. She did not believe that a single focus in ABA was appropriate; there were other interventions that were also appropriate;
The commission would not have a great deal of input from educators and the only member of that committee was a member of the Educational Equity Team, which was not the same as having school district support; and
The cost to school districts. She believed it could put the school district and the parents in a more litigious situation. It appeared that if there was to be an assessment center in northern and in southern Nevada, the recommendations that could come out of that for a direct service would be for one-on-one discreet trial training ABA-type intervention. That was a very expensive intervention. She felt $700,000 would not go very far in providing that to parents and as a result she believed that when IAPs were written between school districts and parents and they were collaborating to find a program, there would be disagreements, a request for due process, and requests for school districts to assume the entire burden for the cost of discreet trial training.

For those reasons, Ms. Schottle believed there would be a significant impact on school districts if they were asked to provide that training directly and her reading of the bill led her to believe that could be a possibility.

Jennifer Lamb, Program Facilitator, Washoe County School District, stated her focus had been on coordinating the programs in autism for the school district and for community services. She reported a variety of programs based on state grants that the Department of Education had funded. Training would also be provided in the summer of 2001 geared specifically toward Washoe and the outlying counties to address some of the concerns expressed by other witnesses. The school district was proactive as far as providing services for the parents and for training opportunities for other teachers. In fact, that morning the district hired a person from the New England Center for Children, which was an applied behavior analysis center, to act as a consultant for Washoe County School District, so they could provide the wrap-around services for the parents and teachers. She thought that Clark County School District, although paying for consultants to come from California, had also established a low incidence department in their student support services to directly address students with autism and how to provide the training and programming for students in their school district. She said Washoe County was also working in conjunction with UNR, providing services with the consultation out of the ABA approach through the university. She added that much had been written and was available on the various approaches and their advantages, and the school district provided all those approaches. Although there were many people in support of ABA, there would be just as many others who would support other approaches and interventions. Ms. Lamb provided a Cost Analysis of A.B. 635 (Exhibit P).

Assemblywoman Gibbons asked if Ms. Lamb had any specifics on the number of autistic students. Ms. Lamb said it was difficult to know because, as stated earlier by another witness, the disability could fall under another diagnosis. However, she said she tracked about 90 students in Washoe County School District with a diagnosis of autism or autism spectrum disorder, and that could mean they were very low-functioning to very high-functioning. National statistics indicated about 3 to 5 percent of the population with autism. Ms. Schottle said the state count was about 370 students.

Assemblywoman Smith asked about the cost for treatment, as it had not been mentioned in the bill, and also about residential treatment, which seemed like a more expensive avenue. Chairman Koivisto asked if Mrs. Smith would mind waiting until the bill went to the Committee on Ways and Means to get those figures. Mrs. Smith agreed, but added she also saw it as a policy matter if a system was being created.

Flo LeRoy, who had spoken earlier, added that they did not anticipate the centers would provide every service, and the reason for establishing the commission was to look at what existed currently. They did not want to set up group homes across the state, but they did want to look at the quality of residential services for people with autism. They were a difficult population and especially if they were in residential homes. There were varying degrees of residential services, from very intense to lower key services, and she wanted to make sure that the individuals with autism were appropriately addressed according to current best practices. There were areas in the document she provided (Exhibit E) on adolescents and adults that mentioned the lack of trained support staff. She often spoke to providers of residential services about the lack of consistent staff; if there was trained staff and a provider could not pay them enough money, they left. It was not easy to find a trained person to work with an adult with severe autism, consequently there was lack of adequate client-to-staff ratio. They were looking at enhancing what currently existed for residential and adding whatever was needed.

Mrs. LeRoy discussed the ABA and the discreet trial. Applied behavior analysis was a scientific approach to dealing with behavior that started with a functional assessment, looking at the potential causes and what triggered them. It was not a particular person’s approach. Discreet trial training was an ABA approach that was developed and enhanced by Dr. Lovas and there were other agencies and centers that used ABA. The same approach was also being used for the Positive Behavioral Supports Nevada. They also looked at functional assessments of behavior; it was an ABA approach, a scientific method. ABA was very effective for many children. Also, she noted, the bill did not state that ABA was the only approach being considered. She saw the centers as clearinghouses of information; there were families who used discreet trial training, dietary regimens, pharmacological agents, sensory integration therapy, and speech and language therapy.

Chairman Koivisto asked the committee’s desire with regard to the bill. She noted that to move the bill it had to be rereferred to the Committee on Ways and Means.

Assemblywoman Gibbons commented that Chairman Koivisto’s interim committee had done a wonderful job on the bill, accordingly she would like to make the motion.

ASSEMBLYWOMAN GIBBONS MOVED TO AMEND IN ACCORDANCE WITH THE AMENDMENT TO INCLUDE SPEECH THERAPISTS AND DO PASS A.B. 635 AND REREFER TO THE COMMITTEE ON WAYS AND MEANS.

VICE CHAIRMAN MCCLAIN SECONDED THE MOTION.

Assemblywoman Leslie said she would not vote against the bill, however, she shared the reservations of Mr. Diamond. She felt there was clearly an issue and more needed to be done for autism, but she was unsure A.B. 635 was the avenue. As a member of the Committee on Ways and Means she said the state was looking at a shortfall of around $109 million. There was not a lot of money available, therefore, if it was rereferred to the Committee on Ways and Means, she would ask the parties involved to get with the state staff to come up with a reduced first step. For example, the need for a clearinghouse might be a good place to start, because, as a member of Ways and Means, she did not feel she could support it and she doubted the money was there.

Assemblywoman Smith echoed Assemblywoman Leslie’s comments and was therefore going to abstain. The bill, she felt, was so all encompassing she was concerned about the many layers of what was being requested.

Chairman Koivisto pointed out than an abstention was a “no” vote and would kill the bill. There were committee members unavailable because they were in other committees. She added, however, the bill could be passed with no recommendation to Ways and Means.

Vice Chairman McClain said that committee members could also vote to pass the bill out of committee and rerefer to Ways and Means and reserve the right to change their vote when it reached the floor.

Assemblywoman Gibbons withdrew her motion and said she would support the motion her colleagues wished to make. Vice Chairman McClain withdrew her second in the same manner. Chairman Koivisto asked if the committee wanted to forward the bill to Ways and Means without a recommendation.

ASSEMBLYWOMAN LESLIE MOVED TO DO PASS A. B. 635 WITHOUT RECOMMENDATION TO THE COMMITTEE ON WAYS AND MEANS.

Assemblywoman Leslie again urged the makers of the bill to proceed as she had suggested earlier.

ASSEMBLYWOMAN SMITH SECONDED THE MOTION.

Assemblyman Manendo hoped there was time for the Ways and Means Committee to look at the issue regardless of whether there was money or not; those were important issues that demanded another look. He noted, too, that people in the audience were looking uneasy about perhaps losing the bill; however, that was a repercussion of the voter-approved 120-day session. The bill deserved more time but the committee had run out of time, the bill had to be out today or be lost.

Assemblywoman Gibbons thanked Chairman Koivisto for bringing the bill forward and being persistent, and said she would support it.

Chairman Koivisto noted that the women who testified earlier, Flo LeRoy and Jan Crandy, had worked extremely hard to put the bill together. Mrs. Koivisto called for the vote.

THE MOTION PASSED UNANIMOUSLY BY THOSE PRESENT.

Chairman Koivisto then opened the hearing on A.B. 636 and announced there was only a short period of time remaining for testimony to be heard.

Assembly Bill 636: Makes various changes to provisions governing admission of allegedly mentally ill person to mental health facility. (BDR 39-1077)

Chairman Koivisto noted the bill was a discussion item in the interim committee and she was surprised to see a $2 million fiscal note. She reported that the bill had come about because of the frequency of hospital emergency rooms having to go on “divert status” in Clark County, and the interim committee also heard testimony that the same thing happened in Washoe County on occasion, as well. The bill was suggested as a means to deal with that problem.

First to testify was Janice Pine, representing Saint Mary’s Health Network and a coalition of providers in Washoe County, who met on the issue and, concurrently with a group in the south, supported A. B. 636 wholeheartedly. She did however have three amendments to suggest:

Delete Section 4;
Page 2, lines 27 and 28, where it stated “allowing an advanced practitioner of nursing” add “or a physician’s assistant” to that language to allow more flexibility; and
Page 2, lines 33 and 35, were probably covered under the Practice Act of the Nurse Practitioner. If not, and it was necessary to leave that language, then the “physician’s assistant” language should be added to that, as well.

She added there were also some transport issues but she would leave those to others to address.

Steven Horsford, representing Southwest Ambulance, apologized for coming late to the debate but they had only recently been approved as a franchisee in Clark County and the bill had just come to their attention. He voiced support for the bill but wanted to add a provision in Section 1 and Section 3 that would require transport to be handled either by a nonmedically supervised transport, which in Clark County were the Medicar or Medicoaches, which were regulated by the Transportation Services Authority, and if deemed medically necessary, an ambulance carrier-provider. Mr. Horsford felt that allowed them to meet their first priority, which was the 911 life-threatening emergencies, and then where it required medical supervision, they would be available to provide those transports, but they wanted to include others who could help meet the need in the community. Mr. Horsford provided a written copy of his amendment (Exhibit Q).

Vice Chairman McClain asked if the present language said they could not provide the service. Mr. Horsford said the provisions in Chapter 450B only applied to ambulance providers. Medicoaches and Medicars were regulated under Chapter 706 of the Nevada Revised Statutes (NRS).

Stephanie Beck, R.N., Emergency Medical Services Coordinator, Washoe District Health Department, voiced support for the bill and the amendments, which she felt provided a safe, cost-effective alternative for medical clearance for people other than in the ERs. Diversion was a complex problem and the bill would prevent bottlenecks and help individuals avoid the stigma of going in for mental health clearances on an involuntary commitment basis. She commented that the county was looking for enabling language to allow people to have alternatives and looking at funding sources for that within Washoe County. Therefore, she was in agreement with removing the fiscal note.

Jim Gubbels, Vice President, Regional Emergency Medical Services Authority (REMSA), the not-for-profit ambulance provider for Washoe County, expressed support for the bill as well as the transportation amendments introduced by Mr. Horsford. It was the most cost-effective means for transport. There was also MedExpress Transport, in Washoe County, which could take patients who were mentally ill but not physically ill to Nevada Mental Health for commitment and treatment.

Jim Spinello, representing Clark County, thanked Chairman Koivisto for bringing the bill forward. He explained the “divert” situation occurred when hospitals were unable to accept more patients into their emergency rooms and ambulances were diverted from the hospital they might normally go to in an emergency to one that could accept them. Diversion caused great disruption in trying to get emergency patients to proper medical facilities. The situation was intense in southern Nevada for two reasons: A large percentage of persons taken to emergency rooms were mentally ill; they did not need to be in a medical facility, rather needed to be in a facility that could provide proper care. Also, a significant percentage of persons taken to emergency rooms needed a detox program. Mr. Spinello said other ways of dealing with that situation were being investigated.

In the case of the mentally ill, there was a need to make sure people were properly medically screened. The procedure in place for some time was to take the person to an emergency room first for a medical screening and then they were sent to a mental health facility. A. B. 636 allowed for some options in the form of other transport, operations, facilities, and staffing available in the community.

Dr. David Rosin, Statewide Medical Director for the Division of Mental Health and Developmental Services (MHDS), explained that in his capacity he had the responsibility for all medical and psychiatric issues for the division. He was opposed to A.B. 636, however, was in support of the amendment to delete Section 4.

Dr. Rosin reported there were several issues related to medical screenings of persons suspected of mental illness prior to involuntary detention, an act that interfered with usual civil rights. Many illnesses such as diabetes, thyroid disease, acute infectious processes and some forms of heart disease that presented with mental decompensation. For example, the diabetic who was experiencing low blood sugar would have increasing mental confusion. Furthermore, clients with serious mental illnesses had a higher rate of diabetes, high blood pressure, heart disease, and stroke. In fact, the life expectancy for persons with chronic mental illness was significantly shorter than that of the general public.

Chairman Koivisto asked Dr. Rosin if he had another solution. Dr. Rosin responded that in the last two months his division had recreated the admissions processes from the emergency rooms in Clark County to MHDS facilities, because of the issues of trying to streamline care in the emergency rooms. Since then, they had had no occurrences of problems they had not been able to resolve expeditiously. Also, he was part of a blue ribbon subcommittee of the Facility Advisory Board of Clark County Health District, which had as its task decreasing the crowding in the emergency rooms. Thus far, they had identified areas that had nothing to do with mental health, instead concerned internal operations within the hospitals and would be a recommendation of the subcommittee to the facilities in Clark County which he felt would reduce some of the crowding.

However, he said, if the responsibility was given to MHDS to perform those medical clearances the appropriation of $1 million would be insufficient for the division to assume that role. The division estimated the fiscal impact as follows:

In the first biennium they would have to construct and furnish a place to house psychiatric services in Clark County, at an estimated cost of $4 million;
The statewide startup category 5 equipment cost would be over $370,000;
Estimated projected revenue to the state per year of $452,000, however the total net expenditure for medical clearances in the first year of the biennium would be $10,705,000.
Over the biennium, to assume the responsibility of statewide medical clearances the net expenditure to the division would be $16,381,000.
Recreate an already existing resource in the community by establishing an emergency room at Nevada Mental Health Institute (NMHI) and an emergency room at Southern Nevada Adult Mental Health Services (SNAMHS), to provide those same services currently available in emergency rooms. That would mean 24 hours a day, 7 days a week, 365 days a year staffing of physicians, nurses, sitters, technicians, medical records personnel, and administrative personnel.

Dr. Rosin believed there were other options and he was an active partner in working with Clark County to decrease the problems they were having.

One concern Dr. Rosin had was with the section of the bill dealing with advanced-practice nurses. The division employed advanced-practice nurses especially at the NMHI, where the advanced-practice nurse operated under protocol. There was a clearly defined rule under medical supervision but the bill did not identify where the medical supervision would take place. He believed that if advanced-practice nurses were going to be treating or triaging chronically mentally ill clients with higher incidences of very serious diseases and more serious presentations of those diseases, then a physician supervising that advanced-practice nurse should be on-site. Dr. Rosin recommended that provision be placed in the bill and he provided his written testimony (Exhibit R) and fiscal note.

Chairman Koivisto asked what currently happened to the people when the hospitals did not have the facilities to care for the mentally ill. Dr. Rosin said the issue was not that they were not equipped to handle the mentally ill, but that they were no longer able to restrain people, therefore there was an added cost to the hospital of hiring sitters, which, Dr. Rosin pointed out, the division would also have to do if it assumed that responsibility. The issue, as it was in Clark County, was that there were long delays in admitting people after they had been medically screened and cleared for admission to a division facility. In working to avoid that problem they had revised their admitting procedure, shortening the time they had to be in an emergency room before being accepted. That meant going to a place for medical screening but not staying there very long before being transported expeditiously to NMHI.

Jim Spinello said the practice of mentally ill people being transported to an emergency room in an ambulance, often as a result of police at the scene who had summoned an ambulance, would not change. However, all mentally ill people did not need to go to the emergency room for the medical screening, even though it was necessary to determine there was no impaired health condition in addition to the mental illness. But, when people could only be transported in an ambulance, they could only be taken to the emergency room. What was needed, explained Mr. Spinello, were some options to where that medical screening could take place. State law required that the county pay for the medical screening; no change was anticipated. Although he did not believe it was as extensive as what Dr. Rosin suggested the fiscal note might be, but the county was absorbing those costs currently and would continue to do so.

The question was, did the medical screening have to be done in the emergency room, where it was more expensive as well as disruptive to the emergency room system, or could it be done elsewhere, like urgent-care centers, or at the mental health facility.

Dr. Rosin said that screening could be done at an urgent-care center if there was an advanced-practice nurse and an on-site physician for supervision of the client. He pointed out that a state agency psychiatric hospital was not a medical facility; no acute medical care was provided. All medical cases were transported to nearby emergency rooms for diagnosis and treatment. Therefore, if the mental health facilities were to assume screening responsibility, it would be necessary to install basic laboratory examination equipment; like centrifuges and blood analyzing equipment, things that an urgent-care facility would have, and then provide the appropriate staff. All those things were already in place at existing medical facilities.

Chairman Koivisto asked if that was part of Dr. Rosin’s amendment. He said he had not proposed that as an amendment. However, if the screening could be done at an urgent-care center with a physician in attendance, that would be acceptable and he could propose that as an amendment.

Chairman Koivisto noted that Janice Pine, Saint Mary’s Health Network, had said that was already part of their scope of practice, they needed to be overseen on-site by a medical practitioner. Dr. Rosin said his understanding was that on-site was not the issue, and when it had been discussed at the legislature one or two sessions past, it was not required; they were discussing advanced-practice nurses riding on ambulances to a scene and then being supervised by radio and telemetry, but Dr. Rosin did not think that was adequate for the mentally ill population. It would create a level of care significantly less than people without mental illness had in the state.

Janice Pine asked to clarify that the Nurse Practice Act required supervision by the physician. She did not think it stated on-site at the exact moment, as Dr. Rosin suggested. However, the advanced-practice nurses were very well qualified to do the examination and, although she said she was not an expert on the Nurse Practice Act, she believed if they had any concerns at all it would stipulate that they consult with a physician immediately. Ms. Pine also wanted to clarify that the bill did not suggest that the Nevada Mental Health Institute provide the laboratory equipment or anything else that Dr. Rosin included in his list of expenses. The bill only sought an opportunity to provide some flexibility in where the examinations were conducted, and instead of costing more money, would, it was hoped, cost less for the counties, hospitals, and others involved in providing the pre-admission exam.

Next to speak from Las Vegas was Dr. Dale Carrison, Chairman of the Department of Emergency Medicine, University Medical Center, and the Nevada Regional Director responsible for Pediatric Emergency Department and the two emergency departments at the St. Rose Hospitals, Henderson, Nevada. Dr. Carrison expressed concern about lines 33 through 35 of the bill regarding the nurse practitioner or the physician assistant, they were covered under the Medical Practice Act and they operated under protocols. With regard to Dr. Rosin’s concerns about establishing a new laboratory, he had a physician do a retrospective study of over 6,000 patients that had gone to Las Vegas Mental Health, reviewing the appropriateness of the laboratories they were asking for at that time. That study, which was presented nationally at the American College of Emergency Physicians, revealed that for 99 percent of the people the laboratory evaluations were not necessary.

Dr. Carrison pointed out that the bill did not intend to take patients out of the emergency department who needed to be there; rather it was to provide options. Many people seen in the emergency rooms did not require laboratories; they needed to be seen by a practitioner. A physician, a physician’s assistant, or a nurse practitioner could examine the patient, take a history along with a physical examination, and determine if the patient needed any further evaluation. Dr. Rosin indicated that the problem had been solved in Clark County and there were no longer any delays, however, although the delays had been improved, the problem had not been solved. Instead of patients waiting 24 to 36 hours to be accepted by Las Vegas Mental Health, the length of time had been reduced to several hours. There was still a problem, Dr. Carrison said, and one he had been addressing for the past two years; although it was only two months ago that he finally got someone’s attention, and only then because of the extreme “divert” situation, and apparently that was when Dr. Rosin became aware of it.

Dr. Carrison explained that the “divert” situation came about as a result of the lack of patient beds for those patients who had medical emergencies but could not be seen in the emergency departments in the Las Vegas Valley, because a significant number of beds were taken up by mentally ill patients who had already completed a medical clearance and then could not be sent to the NMHI. For many patients, the medical clearance examination took from 10 to 15 minutes and then they spent many hours waiting in the emergency department. A. B. 636 provided options.

Jacqueline Taylor, Chief Administrative Officer, University Medical Center, Las Vegas, said she had been actively involved on the Medical Advisory Board at the EMS (Emergency Medical Services) System, and the chairperson representing all the major general hospitals that had been meeting during the last two months to address the extensive delays in the emergency department which had been attributed to the mental health assessments. She was looking for alternatives or other protocols that could be established in the field by the paramedic who did not necessarily need to take every patient to an emergency department.

Chairman Koivisto asked the committee’s wishes with regard to the bill.

ASSEMBLYWOMAN LESLIE MOVED TO AMEND AND DO PASS A.B. 636 WITH THE AMENDMENTS BEING TO ADD “PHYSICIAN’S ASSISTANT” ON PAGE 2, LINE 28; TO DELETE IN SECTION 2, SUBSECTION 2 AT LINE 33 WHAT WAS ALREADY COVERED BY THE NURSING ACT; TO DELETE SECTION 4; AND TO ADD THE AMENDMENT FROM SOUTHWEST AMBULANCE.

ASSEMBLYWOMAN SMITH SECONDED THE MOTION.

THE MOTION PASSED UNANIMOUSLY BY THOSE PRESENT.

ASSEMBLYWOMAN FREEMAN WAS ABSENT FOR THE VOTE.

Chairman Koivisto opened the hearing on A. B. 173.

Assembly Bill 173: Expands circumstances under which emergency life-resuscitating treatment may be withheld from patient in terminal condition. (BDR 40-437)

No new testimony was heard, however Chairman Koivisto said Marla McDade Williams would explain the amendments to the bill, which had been presented at the last hearing, which committee members requested be brought back to the committee before the bill was heard on the floor.

Marla McDade Williams, Committee Policy Analyst, provided a memorandum (Exhibit S) of the changes, the highlights of which were as follows:

Sections 1 through 7 were new provisions: Sections 1 and 2 brought the definitions of attending physician and terminal condition from Chapter 449 of the NRS into Chapter 450B. Section 4 permitted the State Board of Health or the Clark County District Board of Health to enter into an agreement for the manufacture of a bracelet or medallion. Section 5 allowed a parent or legal guardian of certain minors to apply to the Health Department for a DNR (Do Not Resuscitate) identification, and it specified the circumstances under which a parent might do so. Section 6 was a new section that brought existing statute into compliance with the provisions relating to children. Section 7 changed the definition of a qualified patient in Chapter 450B.
Section 8 was Section 1 from the first version of the bill, amended to include the term “prepared to be transferred,” requested by representatives of the Clark County Health District.
Section 9 was a new section authorizing the State Board of Health or the Clark County District Board of Health to charge a fee for the issuance of a bracelet or medallion that identified a qualified DNR patient.
Section 10 was a new section specifying that a physician could issue a written DNR order only to a patient determined to be in a terminal condition. If the patient was a minor the DNR order was effective only if the minor had agreed to its terms in writing.
Section 11 was a new section specifying that an application for a DNR identification could be made if the patient’s attending physician certified that he was issued a DNR order pursuant to NRS 450B.510.
Section 12 was a new section bringing the existing statute into compliance with the provisions relating to children.
Section 13 was previously Section 2 and included the term “prepared to be transferred.”
Section 14 was previously Section 3 and substantively unchanged.
Sections 15 to 19 were new sections to bring existing statute into compliance with the provisions relating to children.
Sections 20 was the effective date that was unchanged.

There were no questions from the committee.

VICE CHAIRMAN MCCLAIN MOVED TO DO PASS THE FIRST REPRINT OF A. B. 173.

ASSEMBLYWOMAN PARNELL SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY BY THOSE PRESENT.

ASSEMBLYWOMAN FREEMAN WAS ABSENT FOR THE VOTE.

Chairman Koivisto then opened the hearing on A. B. 442.

Assembly Bill 442: Increases maximum penalty for dumping sewage or garbage unlawfully. (BDR 40-252)

Assemblywoman Genie Ohrenschall, District 12, introduced A.B. 442 and explained the problem was well known throughout Nevada by city and county health and safety officials who were forced to address the issue of unlawful dumping. The beauty of the desert had been marred and many unhealthful conditions proliferated, particularly in southern Nevada. Many of the people who participated in unlawful dumping did not see it as being criminal activity. Nevertheless, those who had seen the extent of the problem could appreciate the intent of the legislation.

When material was dumped unlawfully it provided hazards which many in the community were unaware of. For example, biochemical waste recently discovered prompted a Congressional committee to investigate limiting possible health hazards.

A. B. 442 would assist the efforts to decrease the amount of unlawful dumping that occurred in Nevada by increasing the maximum penalty for disposing of sewage, garbage, and other substances in an unlawful manner. It was a positive step in the development of cleaner, healthier, and safer neighborhoods and communities. The bill increased the amount of community service from 10 hours up to a maximum of not more than 200 hours, and it provided that when practicable, the court could order that the efforts be concentrated completely on the parcel which had been defiled by the unlawful dumping to the point of trying to clean the dumping in that area, thus a cause-and-effect relationship.

Assemblywoman Ohrenschall gave credit for the bill to the Honorable James Bilbray who had unlawful dumping as one of his pet projects many years ago but was unable to get it enacted at that time.

John Pappageorge, representing the Republic Industries of Nevada, formerly Silver State Disposal, expressed strong support for the bill.

Joe Johnson, representing the Toiyabe Chapter of the Sierra Club expressed strong support for the bill.

From Las Vegas, Louis De George, a resident of Henderson, Nevada, expressed strong support for the bill for many good reasons, which he detailed at length in a packet of material (Exhibit T) that he provided to the committee members. Due to the constraints of time, Chairman Koivisto thanked Mr. De George for his efforts in the matter and assured him his material would be included in the permanent record of the meeting.

Chairman Koivisto asked the committee’s wishes on the bill.

ASSEMBLYWOMAN GIBBONS MOVED DO PASS A. B. 442.

ASSEMBLYWOMAN PARNELL SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY BY THOSE PRESENT.

ASSEMBLYWOMAN FREEMAN WAS ABSENT FOR THE VOTE.

Chairman Koivisto turned to the continuing matter of A. B. 387 which she noted still had serious problems.

Assembly Bill 387: Makes various changes concerning certain immediate precursors to controlled substances. (BDR 40-101)

Gemma Waldron, Deputy District Attorney, Criminal Division, Washoe County District Attorney, presented an amendment (Exhibit U). She explained that the amendment was a consensus of all parties involved, including the Nevada Retail Association, manufacturers, law enforcement, and the District Attorneys Association.

Chairman Koivisto thanked Ms. Waldron for her hard work on the issue. She noted, however, that anyone could, for example, go into Walgren’s on one corner and purchase the maximum quantity of Sudafed, then cross the street and go into Rite-Aid and repeat the process indefinitely. Ms. Waldron said that was correct. Unfortunately, she said, they could not stop people who were determined to do that. However, the bill succeeded in limiting the sale at one location at one time.

Vice Chairman McClain commented that the bill had been a “nightmare,” and she felt the issue needed to be looked at longer; however, because the current meeting was already 45 minutes overtime, it was not possible, and she was not ready to vote it out of committee and in fact wanted to move to indefinitely postpone.

Assemblywoman Leslie said she had spoken to the sponsor and others instrumental in bringing the bill forward. She noted their intent was good, however, she would also vote to indefinitely postpone because the issue should go to the Judiciary Committee, not the Health and Human Services Committee. She offered to help “push” the bill in the next session.

Captain Jim Nadeau, representing the Washoe County Sheriff’s Office and Nevada Sheriffs and Chiefs Association, thanked Chairman Koivisto for letting the bill sponsors return for a second hearing, and also the Nevada Retail Association and manufacturers for their time in trying to make the bill work.

Chairman Koivisto said it was a very serious issue. Everyone was aware there were meth labs operating in many districts and she felt it needed to be addressed, but time had run out this session.

Mary Lau, Nevada Retail Association, concurred that the bill should not have been brought to the Health and Human Services Committee. She noted they had tried in three sessions to bring in pieces of legislation that would assist in
curtailing the meth lab operations, such as the “flea market” legislation brought with Wal-Mart, and stale-dated products, and currently a bill involving the altering of UPC codes. She said she had a 45-minute videotape about a man who started with UPC codes to fund his meth operations and was finally arrested in Bullhead City, Arizona.

Ms. Lau said although from she had not asked permission from cosponsors, she said that if the bill could be passed out of the committee on that last day, she would promise that it went to the Senate Judiciary Committee. She would ask Assemblymen Anderson and Manendo if they would take the bill on and see that both judiciary committees were happy with the final product.

Vice Chairman McClain said she understood the problem of “crack” houses and such, however, she felt the bill did not have enough thought put into it and was unsure the proposed legislation was an answer. She thought “busting crack houses and throwing the people in jail, ruining their operations was the way to stop this.” She noted she had a bill in Government Affairs that would help local government do that in a more efficient manner. She also did not have too much faith that the two judiciary committees, working together to produce a bill in the time allotted, would accomplish the objective.

Gemma Waldron reported that the District Attorneys Association had a manufacturing bill, S. B. 204, that had passed out of the Senate Judiciary Committee, that committee members on the Assembly Judiciary Committee would be able to revisit the issue when it came before them.

Captain Nadeau commented that if the committee saw the current bill again it would be in much better form.

VICE CHAIRMAN MCCLAIN MOVED TO INDEFINITELY POSTPONE

A. B. 387.

ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY BY THOSE PRESENT.

ASSEMBLYWOMAN FREEMAN WAS ABSENT FOR THE VOTE.

There being no further business before the committee, Chairman Koivisto adjourned the meeting at 4:30 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin

Committee Secretary

APPROVED BY:

Assemblywoman Ellen Koivisto, Chairman

DATE: