MINUTES OF THE meeting

of the

ASSEMBLY Committee on Health and Human Services

 

Seventy-Second Session

February 19, 2003

 

 

The Committee on Health and Human Serviceswas called to order at 1:34 p.m., on Wednesday, February 19, 2003.  Chairwoman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada and, via simultaneous videoconference, in Room 4406 of the Grant Sawyer State Office Building, Las Vegas, Nevada.  Exhibit A is the Agenda.  Exhibit B is the Guest List.  All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

 

 

COMMITTEE MEMBERS PRESENT:

 

Mrs. Ellen Koivisto, Chairwoman

Ms. Kathy McClain, Vice Chairwoman

Mrs. Sharron Angle

Mr. Joe Hardy

Mr. William Horne

Ms. Sheila Leslie

Mr. Garn Mabey

Ms. Peggy Pierce

Ms. Valerie Weber

Mr. Wendell P. Williams

 

COMMITTEE MEMBERS ABSENT:

 

None

 

GUEST LEGISLATORS PRESENT:

 

Assemblywoman Barbara Buckley, District No. 8

 

STAFF MEMBERS PRESENT:

 

Marla McDade Williams, Committee Policy Analyst

Terry Horgan, Committee Secretary

 

OTHERS PRESENT:

 

Allison Combs, Principal Research Analyst, Legislative Counsel Bureau

Judge Gerald W. Hardcastle, Department D, Family Division, Eighth Judicial District Court

Edward E. Cotton, Administrator, Nevada Division of Child and Family Services

Susan Klein-Rothschild, Director, Clark County Department of Family Services

Mike Capello, Director, Washoe County Department of Social Services

 

 

Chairwoman Koivisto explained that Assemblywoman Buckley had chaired the interim Legislative Committee on Children, Youth and Families and also the study committee, and that she would be presenting today’s bills.

 

Assemblywoman Barbara Buckley, District No. 8, explained that in 1999 the Assembly Judiciary Committee had heard a bill draft from Speaker Joe Dini concerning constituents’ complaints about the foster care system.  At the time of the hearing, Ms. Buckley continued, the director of the Division of Child and Family Services had warned that the federal government had just passed the Adoption and Safe Families Act, and that if Nevada did not act, it would be seriously out of compliance with the federal law.  As a result, a subcommittee, chaired by Assemblywoman Koivisto, was formed and began delving into Nevada’s foster care issues.

 

Ms. Buckley explained that in Washoe and Clark Counties, the counties took care of the “front end,” which meant if there were a report of child abuse or neglect, the county would investigate and remove the child if there was danger.  In Clark the child went to Child Haven; in Washoe the child was placed in an emergency shelter home.  The county would try to work with the parents, offer services, and try to reunite the family.  After about six months, if the situation had not been resolved, she continued, the state would take control of the child, which meant the child would change case workers, change homes, and usually change therapists.  Ms. Buckley explained that such a system was termed “bifurcated” and that it had many other problems such as poor pay for foster parents, caseload ratios of 40 to 45 children per case worker, siblings who became separated, and children who would be moved time and time again.

 

Assemblywoman Buckley indicated that a series of recommendations were made by the interim Committee and had been compiled into a report (Exhibit C).  The next legislative session had approved ending the bifurcated system and had increased pay for foster parents; however, Ms. Buckley noted, after September 11, 2001, the Governor had put a hold on fixing the system in Clark County.  As a result, she said, the bifurcated system had been ended in Washoe County, but not in Clark County.  Ending the bifurcated system in Clark County was in the Governor’s budget this session, Ms. Buckley announced.

 

Because the interim committee had discovered that 30 percent of the children in the program with severe emotional disturbances were not getting treated, Ms. Buckley stated that last session’s budget had included funds for treatment.  She added that even though full funding was approved by the last Legislature, after September 11, the program was cut.

 

Ms. Buckley mentioned that the rural communities had never had a bifurcated system because the state handled the child from the beginning.  Noting that the state suffered from many of the same problems of poor caseload ratios, the bill requested the same caseload ratios for all Nevada children. 

 

Allison Combs, Principal Research Analyst, Legislative Counsel Bureau, pointed out that the Committee report summarized the current funding and the funding changes Ms. Buckley referenced.

 

Judge Gerald Hardcastle, Clark County Juvenile Court, stated that how the state treated foster children reflected Nevada’s priorities, kindness, and fairness, and he noted that the Children’s Advocacy Alliance had awarded Nevada a D‑ grade.  He stressed the state had a fundamental obligation to help foster children, and he reiterated elimination of the bifurcated system in Clark County was a paramount need.

 

Chairwoman Koivisto invited Ms. Buckley to proceed with her presentation of the bills.

 

Assemblywoman Buckley indicated she would start with A.B. 5, but first wanted to acknowledge that both committees had been greatly aided by the judiciary, who had given guidance and testimony, in addition to many others from the counties and the advocates of foster care.

 

 

Assembly Bill 5:  Requires Director of Department of Human Resources to include in State Plan for Medicaid requirement that young adults who have "aged out" of foster care are eligible for Medicaid. (BDR 38-691)

 

Assemblywoman Buckley explained that A.B. 5 would require that young adults aging out of foster care be eligible for Medicaid.  She indicated that, for the most part, when a child turned 18, government assistance ended.  Ms. Buckley acknowledged that there were some funds available under the Chaffee Act for the purpose of teaching life skills to children who were aging out while under the system’s care. 

 

Assemblywoman Buckley stated that Thom Reilly, a former social worker, had been given a small grant to follow some of the children who had aged out of the foster system, and his results, she emphasized, were “amazing.”  He sent out letters in an attempt to locate former foster children and reported that so many came back “undeliverable,” “not here,” “in jail,” or “in prison.”

 

This bill, Ms. Buckley continued, attempted to take advantage of an existing program, so Nevada would receive a 55 percent match from the federal government to provide insurance coverage to former foster children ages 18, 19, and 20.  She acknowledged that A.B. 5 would be going to the Ways and Means Committee and that this Committee would simply be considering policy.

 

Assemblyman Hardy inquired whether the bill addressed children in any of the state’s children’s homes, such as St. Jude’s, who would not technically be considered foster children.  He also asked whether there were any state orphanages still in existence.  Mr. Hardy noted that many special needs children, who were covered by Medicaid, were adopted into families and would be in a similar situation as far as coverage of medical needs.  He inquired whether those children would be covered under the terms of A.B. 5.

 

Assemblywoman Buckley replied that if a child at St. Jude’s or a similar facility were a ward of the state, then that child would be paid a certain amount.  The state’s financial participation and automatic inclusion for Medicaid coverage, she explained, came with wardship or another eligible category.

 

Referring to state orphanages, Ms. Buckley noted that the children’s home had been closed several years ago.  In addressing the issue of adoptions, she mentioned there were adoption subsidy programs for special needs children.

 

Assemblyman Hardy inquired whether an adopted child would continue to be covered under Medicaid.

 

Assemblywoman Buckley replied that the state provided an adoption subsidy for special needs children.  If the child were ultimately adopted, the adoption would end Medicaid coverage, she added.

 

Assemblyman Hardy disclosed that he was a family physician and, though he might be voting on the measure, he would not receive more than anyone else did in the same profession.  He said when families officially brought children into their homes, as with adoption, he encouraged them to make sure they kept their Medicaid coverage because they would not get private insurance to accept them, and that problem, he noted, would continue at ages 18, 19, and 20.  Mr. Hardy asked if the financial needs of a family trying to adopt a child with special needs had been discussed during the interim studies.

 

Assemblywoman Buckley answered that she did not recall any discussions about those issues, and indicated they needed to address one part of the issue at a time, and this was seen as a priority.  Ms. Buckley emphasized that adopted children had not been included in the fiscal note for A.B. 5.

 

Assemblyman Horne inquired whether coverage for children in the kinship care program had been included in A.B. 5.

 

Assemblywoman Buckley replied that they would be covered.  She explained that there had been a kinship care bill that gave additional support to the foster care payments to older grandparents who took legal guardianship of a child and kept that child for six months.  Ms. Buckley indicated that so many grandparents were on fixed incomes and needed help but did not want their grandchildren to enter the foster care system.  Because they were not adopted, those children would be aging out of the foster care system and covered by A.B. 5, she added.

 

Assemblywoman Weber, in recapping the situation, said that the children were covered under Medicaid but when the time came to leave the foster care environment, the children were dropped off the rolls.  She asked if passage of A.B. 5 would result in a continuation of that care until age 21.

 

Assemblywoman Buckley agreed that it would.

 

Chairwoman Koivisto requested all supporters of the various Assembly bills wait until Ms. Buckley had described all the bills, then she would ask for public comment.

 

 

Assembly Bill 6:  Changes dates by which mental health consortia are required to prepare recommended plans and submit plans to Department of Human Resources and to Legislative Committee on Children, Youth and Families. (BDR 39-693)

 

Assemblywoman Buckley described A.B. 6 as a simple bill that changed the date by which the mental health consortia was required to submit plans to the Department of Human Resources and to the Legislative Committee on Children, Youth and Families.  Ms. Buckley stated the issue had to do with funds being used to treat children with mental health problems.  She thought that if children got earlier treatment, their behavior might not escalate, and they might be kept out of the more expensive residential treatment system.  The interim Committee had decided the children would be better off if the money were shifted from residential treatment to earlier treatment in a therapeutic foster home, coupled with intensive counseling. 

 

Ms. Buckley explained the mental health consortia would consist of the counties, the state, and some outsiders, who would study spending and give advice on how to do a better job.  She reiterated that A.B. 6 simply changed due dates to make it more convenient to submit bills to the Legislature.

 

Assembly Bill 25:  Makes various changes concerning provision of public services for children. (BDR 38-690)

 

Assemblywoman Buckley introduced A.B. 25 and indicated it had been discussed during the last legislative session.  A.B. 25 would allow a child to enter into an agreement with an agency that provided child welfare services to receive maintenance if the child went on to a university, college, trade, or technical school.  The additional services, she elaborated, would be money for rent or utilities, money that could provide a bridge that might enable the child to succeed after leaving the system.

 

Allison Combs clarified that “child,” for purposes of the agreements, was a person 18 years of age or older, but less than 22.  She mentioned the bill also included an additional provision to allow the employees of child welfare service agencies to serve as foster parents under certain conditions, if the child was not on their caseload or had not been on their caseload within the prior three years.

 

Assemblywoman Buckley announced that Ed Cotton would be adding testimony on the issue.

 

Assemblyman Horne, referencing Section 1, paragraph 5, which stated ”through age 21,” claimed that college was frequently not completed in four years, and asked whether any consideration had been given to a student being in school full time, but needing five years to graduate.

 

Assemblywoman Buckley agreed that graduation from college could take more than four years, but said she just wanted to ask for a small part of the whole.  She explained that if the fiscal note was too high, there would be no chance for the bill to pass. 

 

Judge Hardcastle referenced page 2, subsection 3, which stated that a “child” meant a person who was “less than 18 years of age or 18 years of age or over and attending high school.”  He explained that the way the statute currently read, a child automatically left jurisdiction at age 18, whether or not they had graduated from high school.  Mr. Hardcastle believed the new language in the bill was critical because it would allow continued jurisdiction over children who were still in high school, and he requested the Committee keep that language in the bill, regardless of what it felt about the other language in the bill.

 

Assemblyman Hardy indicated that there probably should be some language limiting how long an individual could be in high school, noting that some people never graduated from high school.

 

Judge Hardcastle said that for purposes of child support in Nevada, if a child were still in school at age 18, then the obligation of a parent to pay child support ended at age 19.  He suggested that language be copied so the statute would read that jurisdiction would terminate at age 19 if the child were still in high school.

 

Assemblyman Hardy agreed it would make sense.

 

 

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

 

Assemblywoman Buckley explained that A.B. 112 was an idea presented to the interim Committee by Ed Cotton.  Ms. Buckley admitted that the counties were concerned about fiscal impact, but the interim Committee had decided to adopt the idea and forward it on for full review.  She requested that Mr. Cotton be allowed to present the merits of his proposal.

 

Assemblywoman McClain thought she remembered a bill from the preceding session concerning children who had turned 18 but who had not graduated from high school, and asked whether that bill had passed.

 

Assemblywoman Buckley replied that, as a practical matter, Judge Hardcastle would not abandon a child who had turned 18 but who still had a few months of high school left until graduation.  She acknowledged that the previous session this Committee had set policy and approved similar bills, only to have them die later.

 

Assemblywoman McClain responded, “So we didn’t get it done.”  She asked whether, the way the law currently read, a child could reach 18 in February, for instance, and if the foster parents no longer got support, the child would be out on the street.

 

Assemblywoman Buckley replied that she did not believe “our judiciary” would let that happen.

 

Judge Hardcastle agreed, adding that it would be inhumane.  He said what one really hoped for was that there would be a time when the services provided by the state would end, but that there would still be some support services in place.  Realistically, he added, what he did was try to hang onto the child and push him to get some support services so a successful transition could be accomplished.  “We do a very, very poor job of preparing them for 18,” he admitted. 

 

Judge Hardcastle pointed out that there were federal funds under the Chaffee Act that allowed services to children who were leaving the system.  He also praised the Medicaid bill currently before the Committee, stating that it was part of the fundamental basic protection that should be provided to children who were on their own.  The Medicaid bill, he added, could prevent University Medical Center from being burdened with children who came in with emergency needs.

 

Assemblywoman McClain inquired how many such foster children turned 18.

 

Judge Hardcastle responded about 100 a year in Clark County.

 

Chairwoman Koivisto asked whether the purpose of the bill was to codify what Judge Hardcastle was trying to do.

 

Judge Hardcastle agreed that it was, adding that the children were “his” once every six months, at which time he had to make certain they were “on the right track.”  He reiterated that they were “our” children, that they desperately needed assistance, and that “we did a poor job.”

 

Assemblywoman Angle mentioned that special needs children could remain in high school beyond the age of 18, and asked whether they were included in the bill.

 

Judge Hardcastle replied that children with very high special needs received assistance from other agencies that followed them even into adulthood.  The reality, he continued, was that there were more services for those who had great special needs.  The population being discussed today, he added, was a population of children who had been abused and neglected, and who had gone through the foster care system but were not prepared for the real world.  Judge Hardcastle suggested that those children would face greater periods of homelessness, incarceration, and joblessness, and he stressed that they were alone. 

 

Judge Hardcastle explained that because the children had frequently been abused and neglected, they did not come out of those experiences very strong.  He related the experience of one 18-year-old who had not paid attention to his schooling and, as a result, had no real job skills.  When he was injured working for a landscaper, he had nowhere to turn once worker’s compensation had ended.  This youth had walked into Judge Hardcastle’s courtroom and said, “What about me?”  The judge had been forced to say services had been terminated.  He added that there were some very fundamental services available, and that the youth had been temporarily sent to a Chaffee-funded center.  This was a child the state was responsible for, Mr. Hardcastle emphasized, a child who lived in this community, who was the state’s responsibility, and who the state of Nevada raised.  The obligation to care for these children was a fundamental one, he stressed.

 

Chairwoman Koivisto requested that Ed Cotton, Susan Klein-Rothschild, and Mike Capello come to the witness table and testify on the bills in numerical order.

 

Edward Cotton, Administrator, Nevada Division of Children and Family Services, began his testimony by discussing A.B. 5.  He explained that he, Ms. Klein-Rothschild, and Mr. Capello had worked with the interim Committee.  Mr. Cotton believed the bill would be very good for children; however, he cautioned, the fiscal note was very high and as a result the state was neutral on A.B. 5.  Funding for A.B. 112 was not part of the Governor’s recommended budget, he added.

 

Susan Klein-Rothschild, Director, Clark County Department of Family Services, testified that Clark County did not provide services to that age group (over age 18), but saw the need and value of provision of the services.

 

Mike Capello, Director, Washoe County Department of Social Services, explained Washoe County had fully integrated its child welfare system, so the county had assumed responsibility for providing services across the entire range of children within the foster care system.  He expressed strong support for A.B. 5.  He agreed that it was a costly measure, but, rather than continuing to be “penny wise and pound foolish,” he would like to help the youths who were leaving the foster care system meet their basic health care and mental health needs.  He stated that some children were receiving psychotropic medications that enabled them to maintain stability and function normally.  When they left the foster care system, he added, they generally did not have Medicaid or other coverage, so were not able to obtain the medications that kept them stable.

 

Mr. Cotton, announcing that he had been a foster parent to 27 children, explained that what made it even more difficult for a foster parent was trying to parent those children who had aged out of the system.  He described having 15 foster children who had all aged out at about the same time, and even though he had done everything he could to make the children independent and direct them to services, it had became very difficult as the numbers increased.

 

Assemblywoman McClain asked how many children in Washoe County aged out per year.

 

Mr. Capello answered that between 30 and 40 children left the system annually in Washoe County.

 

Assemblywoman McClain then inquired how many children aged out in the rural areas.

 

Mr. Cotton replied that the numbers were probably about the same as in Washoe County.

 

Assemblywoman McClain concluded that there were probably fewer than 200 children aging out annually statewide.

 

Assemblywoman Weber asked whether the Riley study had been included in the handout.

 

Chairwoman Koivisto stated that Allison Combs had indicated she could get copies to the Committee members.

 

Ms. Koivisto then asked the panel to move on to testifying about A.B. 6.

 

Mr. Cotton emphasized that the Division of Family Services and the Department of Human Resources was very much in favor of A.B. 6, which would change the due date of the report from the mental health consortia from January 15 to July 15.  He noted that it also changed the date for submission of that report to the Legislative Committee on Children, Youth and Families from July 15 to August 15.  The changes, he stressed, would better fit their budget and planning cycles, but more importantly, the change would allow a month to review the plan, consult with consortia members, and clarify any issues identified.  Mr. Cotton explained that under current law, the report should be submitted to the Department of Human Resources for review and comment, but there was no time for review or comment because the date it was to be submitted to the Department was the same as the date it was to be sent to the Legislative Committee on Children, Youth and Families.  Mr. Cotton added that there appeared to be no fiscal impact or side effects to the bill.

 

Chairwoman Koivisto commented that the bill appeared to be very straightforward.  She next requested testimony from the panel on A.B. 25.

 

Mr. Cotton stated that he had not planned to testify on A.B. 25 and that the Department had submitted a fiscal note.  He explained that passage of the bill would allow a child who was leaving the system to continue to receive maintenance and special services if the child were enrolled as a student at a university, college, or trade school.  A.B. 25, he added, would allow the Division of Child and Family Services (DCFS) to continue to give the child board payments similar to those the foster parent was receiving after the child turned 18.  Mr. Cotton stated he believed that part of the bill was good public policy, but added that it was expensive and not in the Governor’s recommended budget.

 

Mr. Cotton said he heartily endorsed the second section of A.B. 25 that would allow a current DCFS or county worker to become a foster or adoptive parent.  He believed social workers made excellent foster parents, and he described the “hoops” they currently must “jump through” as “unbelievable.”  The second part of the bill had no fiscal impact, Mr. Cotton added, and would allow for an increase in the numbers of specialized foster homes and adoptive homes for special needs children.  Safeguards had also been added to the bill, Mr. Cotton noted, so as to avoid conflicts of interest.

 

Susan Klein-Rothschild testified in support of that portion of A.B. 25.  She mentioned that there were a number of Clark County employees currently providing foster care and warned that when the bifurcated system was eliminated, a conflict of interest could develop.  She emphasized that staff members were good resources for children, and she reiterated her support of the ability of employees who had not had the children on their caseloads to be foster care providers.  She also stressed the importance of helping children finish their education, saying that Social Services was trying to help them become independent, and that education was essential to independence.

 

Mr. Capello testified that Washoe County concurred with the previous testimony regarding A.B. 25.  He added that the county also supported the provision that allowed welfare workers and agency staff to become foster parents, assuming they met the criteria that would help prevent any potential conflicts.

 

Assemblywoman Angle, stating that she was not certain her question belonged in a discussion about A.B. 25, mentioned that people had told her they were no longer caring for foster children because of the liability.  She inquired whether foster children could be placed under a county’s liability cap of $50,000. 

 

Mr. Capello agreed that liability for foster parents was a huge issue.  He noted that the state’s insurance carrier, which also insured Washoe County, had decided not to renew the policy.  The Washoe County risk manager, he continued, had been searching for another insurance carrier to provide liability insurance coverage for foster parents, to no avail.  Current practice in Washoe County, therefore, was to reimburse foster parents for taking out additional coverage under their homeowner’s policy and then as a secondary insurance, the county’s general liability obligation “backfilled” that coverage.  The difficulty about the situation for both the foster parent and the county, Mr. Capello explained, was that the insurance did not cover “intentional” acts by foster parents, but it would assist in the case of an accident.

 

Mr. Cotton added that the insurance carrier had cancelled because of just two incidents that had had a major financial impact.  He noted that Clark County was also searching for insurance, but had been unable to find any.

 

Chairwoman Koivisto requested the panel proceed to a discussion of A.B. 112.

 

Mr. Cotton wanted Committee members to be aware that the fiscal note on A.B. 112 would be greatly revised, explaining that the way the bill was originally drafted, it had applied to any child under the age of three who was reported as having been abused or neglected.  Mr. Cotton explained that the language in the bill had been changed to apply only to children who actually had physical injuries, which would greatly reduce the fiscal note.  The fiscal note would be completed the next day, he added.

 

Mr. Cotton supplied Committee members with a brief letter of explanation concerning A.B. 112 (Exhibit D).  He explained that it would require the three agencies that conducted child abuse investigations--DCFS in the rural areas, Washoe and Clark Counties in their areas--to take an additional step to ensure that a thorough investigation was conducted on Nevada’s most vulnerable population, children under the age of three.  Mr. Cotton noted that those were children who received injuries, but could not tell someone what had happened.  Mr. Cotton testified that during the past fiscal year, more than 4,200 children under the age of three had been investigated as being abused or neglected in Nevada.  He added that in most of the situations, the child had been unable to articulate how he or she received their injuries.  He explained that child protective investigators or police officers were often in the position of determining whether the injuries were in a manner consistent with the parent’s explanation.  Mr. Cotton said that it was believed this determination required a degree of medical expertise that most investigators did not have.  He added that he believed the determination was a medical one and A.B. 112 would mandate a medical determination.  He emphasized that consistency was necessary, noting that there were three separate child protection entities conducting investigations, along with many police jurisdictions.

 

Mr. Cotton explained that because Nevada law required that the state’s central child abuse registry expunge unsubstantiated reports of child abuse or neglect, it was not possible to identify the exact number of children who were injured, reported, the report then unsubstantiated, and then re-reported.  However, he added, they did know of and could identify several documented cases of children being critically injured or killed after injuries were investigated but were described as being “consistent with the parent’s explanation” by a person who was not medically trained to make that determination.  A.B. 112, he added, would also help ensure that a parent whose explanation was not substantiated based on an investigator’s belief that the explanation was not consistent with the injury could have it overturned if a medical person made a different determination.

 

Mr. Cotton added that if A.B. 112 passed, he would write regulations that would require a medical exam for the child before the investigator could conclude the investigation or make a determination of “substantiated” or “unsubstantiated.”  He noted passage of the bill was a key element in efforts to create a “best practice model” and would ensure that investigations of abuse and neglect were thorough, competent, and reached the right conclusion about what had happened.

 

Assemblywoman McClain asked about the fiscal note.

 

Mr. Cotton replied that the original draft upon which the fiscal note was based required a physical for all children under the age of three who were reported.  The revised version focused on those children who were reported and who had some physical signs or potential signs of abuse or neglect.  As an example, Mr. Cotton emphasized it would not include a child who was left alone for two hours.

 

Assemblywoman McClain, referring to page 3, noted the language read, “agency investigating a report of abuse or neglect,“ but she noted the language went on to say, “has to involve some physical” type of abuse.

 

Mr. Cotton agreed.

 

Assemblywoman McClain then asked if being locked in a closet for three days would involve physical abuse.

 

Mr. Cotton answered that a case like that would probably be handled as neglect.  The major purpose behind the bill, he reiterated, was to determine, when there were physical marks and/or bruises, whether the story told to investigators was consistent with the bruising.  Mr. Cotton claimed that the investigative staff currently deciding whether an explanation sounded reasonable or not had different levels of training.  A.B. 112 would require evaluation of a non-verbal child by a medical professional who would make a determination about the reasonableness of the explanation.

 

Assemblywoman McClain asked if it were determined that the injuries were not consistent with what had been reported, and the case went to court but was thrown out, whether the parent or guardian would still be expunged from the state registry.

 

Mr. Cotton explained that there were two different decision-making processes and that not all situations that were investigated for abuse and neglect, even if it were determined they were substantiated, ended up in court.  He noted that the investigator would determine what was substantiated or not.  If it were substantiated, it would go into the central state register.  The way to get it out of the central register, he added, would be for the person to appeal.  As an example, Mr. Cotton hypothesized that if someone were arrested for child abuse and subsequently was found not guilty, that would not mean that the person was removed from the register.  The standard of evidence for the register was different, he noted, and not “beyond a reasonable doubt.”  The job of protecting children required a lower standard of evidence, he added.

 

Assemblywoman McClain inquired whether someone could be reported to the registry so that they would have to go to court and appeal to have it removed.

 

Mr. Cotton said an individual would not be reported to the registry, but to one of the three child welfare entities.  If an investigation substantiated the report, then the person would be entered into the registry.  The alleged abuser would have the right to appeal through a hearing officer, not through a court.  The hearing officer, he continued, would hear both sides of the testimony, read the file, talk to whoever had information, and determine whether or not there was sufficient evidence to keep that information in the register.  The hearing officer could order it removed from the register, amended, or retained, he added. 

 

Assemblywoman McClain asserted that A.B. 112 would help with that because one would have more information about whether a child was really abused.

 

Mr. Cotton agreed, adding that the bill would help the investigations and would also provide for a medical person to exonerate the parent or guardian by agreeing with the explanation given.

 

Chairwoman Koivisto interjected that Assemblyman Carpenter had a concern about some of the rural areas and accessibility to medical personnel who would be able to examine the children.

 

Mr. Cotton explained that training would be set up to deal with that problem.  He also indicated most of the examinations would utilize emergency rooms.  He emphasized that not all the children would be taken into custody. 

 

Assemblyman Hardy, noting the terms “medical personnel” and “health care provider,” inquired whether those were physician’s assistants, registered nurses, medical doctors, chiropractors, or dentists. 

 

Mr. Cotton, stating that his original suggestion had been to utilize physicians, added that problems regarding access to physicians had been raised. 

 

Assemblyman Hardy opined that one of the things he struggled with in practice was removal of the victim, but the perpetrator not being punished.  The victim said, “I was victimized, but I am now being taken away from my mom, my dog,” and similar sentiments.  Mr. Hardy continued that from the child’s perspective, they were being removed from the people they loved.  He also asked whether the perpetrator would be elsewhere while the examination was being conducted.  He then described a personal experience when his son’s school called him and said that his son had a bruise on his back.  The Hardy family tried to identify where the bruise had come from, and had finally ascertained that the mark had been caused by a suction device on the bottom of their swimming pool.

 

Mr. Cotton replied that another task he and a few others had been given by the interim Committee had been to develop a standardized safety assessment that would help make the decision about whether a child was safe, and tied to that was development of a safety plan, which could include leaving the child in the home.  Mr. Cotton assured the Committee that his group was very close to finalizing the assessment.  Utilizing national studies and national research, the safety assessment would identify a list of certain factors that the investigator on the scene should look at from the beginning.  If any of those were present, he cautioned, then he or she must determine whether the child would be safe, and if not, what actions could be taken to alleviate that situation.  The solution, he noted, might not always include removing the child from the home, depending upon who else was living there.  The child would then be safe, but not long-term, he cautioned, because the problem still needed to be fixed.  Mr. Cotton reiterated that A.B. 112 was attempting to address, through a very standardized, extensive safety protocol, whether the child “is safe tonight.”

 

Assemblyman Horne asked whether emergency rooms generally had personnel trained to recognize whether or not a fracture could be from abuse.  Simply because one was a doctor did not mean one had the training to recognize abuse, he asserted, and he expressed concern that if the language simply said “medical workers,” those people might not really be able to make that assessment, that it might be more just an educated guess.

 

Mr. Cotton acknowledged that training would be required.  However, he noted that non-medical people were currently making the assessments.

 

Assemblyman Horne, stating he liked the bill, wondered about using physicians not so much as a default but in combination with the social worker, the observations, and the totality of the circumstances.

 

Mr. Cotton responded, “Yes, in combination.”  He expressed his concern that, in some cases, social workers had discounted medical information.  Part of the training they would give their employees, he explained, would include asking for a second opinion to back up their argument in cases where the social worker disagreed with the medical person. 

 

Assemblywoman Angle inquired whether any other states had adopted similar regulations.

 

Mr. Cotton answered that Illinois had gone far beyond A.B. 112.  The model developed there listed every type of abuse or neglect and listed exactly what must be done to investigate and when to involve law enforcement.  He acknowledged that Nevada would not want to get that detailed because the state did not have nearly the numbers of investigators or staff.  What Mr. Cotton wanted for Nevada was thorough investigations that would keep children safe and protected the rights of the person alleged abuser.  He believed involving “medical” would accomplish those goals.

 

Susan Klein-Rothschild, Director, Clark County Department of Family Services, testified that requiring medical examinations of the most vulnerable children, those under the age of three, was a step toward protection.  However, she also expressed concern (Exhibit E) that A.B. 112 did not discriminate among types of injuries, so any physical injury would require a medical examination.  She referred to the safety protocol they were working on that would give specific guidelines about when certain steps needed to be taken and what circumstances might indicate there was a future risk of harm to a child.  She mentioned one alternative would be to direct that there be protocol concerning when to get a medical examination for what types and locations of injuries, and that medical personnel with expertise in the field develop the protocol. 

 

The fiscal and workload impacts of A.B. 112 were significant, Ms. Klein-Rothschild testified.  She indicated Clark County had approximately 573 cases last year with physical abuse allegations of children under the age of three.  It was estimated that taking each of those children for emergency room visits would take anywhere from four to six hours, similar to what Ed Cotton and the state had estimated.  The fiscal note did address the additional time for the workers to be with the children, but there was no fiscal note about the impact of the actual cost of the medical exams, she pointed out.  Mentioning a current article in the Journal for Child Maltreatment, Ms. Klein-Rothschild said there was an article from the physician’s perspective on what the barriers were to them doing physical examinations.

 

Ms. Klein-Rothschild asked who would pay for the medical examination.  She acknowledged that the fiscal note had estimated approximately 72 percent of the children who were removed from their homes would be covered by Medicaid.  Ms. Klein-Rothschild noted that for the children who were not removed from their homes, or who were going into foster care, 30-40 percent would be on Medicaid.  As a result, she explained, in a great many cases the agency would be working with the parent’s medical insurance to get coverage.  Ms. Klein-Rothschild said if a child had a scrape on her knee and, based on all the factors in the protocol developed by medical professionals it did not look like child abuse or neglect, but they had to take the child to the emergency room to get the check because it had been reported, the child’s parent could say that they did not want their insurance to have to pay for the visit to the emergency room.  Then Social Services must remove the child to get the checkup, she explained.

 

Ms. Klein-Rothschild expressed an interest in knowing exactly who a “medical provider” would be, what their level of training in the area would be and how it would be assured, and how available those people would be when the child needed the evaluation.

 

Ms. Klein-Rothschild applauded the intent of A. B. 112, which was to protect young children, especially those who could not speak for themselves.  She added that the question became how to do that efficiently and effectively, and she introduced some alternatives for the Committee members’ consideration.  She suggested mandating training at regular intervals for medical professionals and child welfare professionals on recognizing the signs and symptoms of abuse.  She also wanted to train specialized staff to deal with those cases, noting that in Clark County there was a unit whose sole task was to focus on children three years old and younger.  The unit worked very closely with medical professionals who focused on this and who therefore had developed extra expertise and could help train the rest of the agency staff in knowing what to look for.  Ms. Klein-Rothschild also recommended consideration of the protocol being established by medical and child welfare professionals that would indicate when to request a medical exam, and what factors, such as the location and timing of the injuries, were known to lead to risk.

 

Assemblywoman Leslie, noting that she had served on the interim Committee, stated she did not recall any of these objections being made at that time.  She asked whether Nevada had already mandated training of child welfare workers on the signs and symptoms of child abuse.      

 

Ms. Klein-Rothschild replied that it was her understanding the workers received “core training” when they were first hired but added that there were no requirements for refresher courses.  She noted there were people who had been working for 15-25 years, and that much about the topic had been learned during that time.

 

Assemblywoman Leslie expressed amazement that the agency was not already conducting refresher courses.

 

Ms. Klein-Rothschild explained that they were organizing it by bringing in specialists from the hospitals but, she added, it should be mandated for all staff and made an integral part of the training and not simply on an “as needed” basis.  She mentioned that, along with Washoe County and the state, they were developing a child welfare training academy.

 

Assemblywoman Leslie inquired whether a state law was necessary to mandate further training or whether it could be left to the agencies.

 

Ms. Klein-Rothschild replied that she did not believe a state law was necessary because it was a necessary step for good practice.

 

Assemblywoman Leslie asked whether Ms. Klein-Rothschild would rather A.B. 112 not be processed and allow the counties to develop the protocol and the specialized training and staffing.

 

Ms. Klein-Rothschild responded that the “Committee could make decisions that make the most sense.”  She reiterated her belief in the importance of protecting vulnerable children but added that her biggest concern was that something mandated for every single child left no leeway for flexibility of decision-making in individual cases.

 

Assemblywoman Leslie expressed her concern that there had been plenty of opportunity to put things in place, yet she had not seen evidence of it having been done.  She wondered how the legislators would know “that those things are going to happen.”  Ms. Leslie suggested the interim Committee could monitor happenings, but said that it was “too little, too late.”

 

Chairwoman Koivisto pointed out that Ms. Klein-Rothschild had not been with Clark County long enough to make those kinds of changes and improvements.

 

Mr. Capello testified that Washoe County was in support of A.B. 112, saying the basic premise was sound, and making it statutory would drive it to a policy and regulation level to ensure that it was implemented statewide with a much greater degree of consistency.  He admitted Clark County had a much greater volume to deal with than either Washoe County or rural Nevada.  Mr. Capello claimed the weakness in A.B. 112 was in the provider aspect.  He pointed out that Washoe County had been trying for some time to implement a more regular evaluation of young children with injuries, but what they had discovered in their medical community was that more often than not, the physicians would defer decision-making to one person.  In Washoe County, he noted, that person was a forensic pathologist, an expert in evaluating injuries and testifying at all levels as to the potential cause of those injuries.  Mr. Capello explained that some of the general practitioners and emergency room physicians were hesitant “to make that call in terms of definitive diagnosis” of what appeared to be child abuse. 

 

Mr. Capello explained that the troubling part of the bill, for him, was the statute that one must do the medical evaluation, and then finding those providers who could make the diagnoses.  Mr. Capello testified that he had advocated, early in the study, that there be a two-pronged effort.  If the child welfare agencies were going to be required to arrange the evaluations, the medical community’s level of training in emergency rooms needed to be brought to a higher level.  All children could not be referred to one practitioner.

 

Mr. Capello agreed that taking the children to an emergency room was better than them being evaluated by a social worker who was not medically trained, but he believed that was not the answer.  Mr. Capello would like to have personnel who clearly had the forensic background to diagnose injuries.  The problematic cases, he noted, were those where there were relatively small or isolated injuries.  Without expertise or investigation of the whole family constellation and the underlying dynamics that went along with that injury, he noted it would be difficult to prevent that child from being severely injured again.  Mr. Capello said that A.B. 112 was a great bill, but cautioned that a lot of development was needed so the evaluations would actually help protect young children.  He reiterated that the difficult cases were not the obvious ones.  They were the ones in which there might be just a small grab mark or something much less significant, and then three or four months later a severe injury occurred.  He admitted he was not certain how to build capacity on the medical evaluation side.

 

Assemblyman Hardy concurred with the dilemma.  He stated he had gone to training for child abuse and that usually the severe cases would show on the x‑rays.  He recognized the point about the little things, saying that every child had occasional bruises on their shin or forehead.  Noting that anyone in Nevada who suspected child abuse had to report it, Mr. Hardy expressed the concern that a well-meaning person could say there had been child abuse because there was a mark.  This could become a full-employment act for health care providers, he added.  In explanation, Mr. Hardy said because abuse must be reported, a report was made about a bruise on the shin, the social worker went to the home, saw it was bruise on the shin, did not think it was a problem, but now that it was in statute, it had to be seen by a doctor.  It was a problem, he reiterated, and referring to the personal example he had used earlier, reminded Committee members that frequently it was not known how an injury happened.  Now, Mr. Hardy continued, because people had to report, children were going to be sent to the doctor and Mr. Hardy believed it would be difficult to put into practice, stating that it was a “tar baby.”

 

Mr. Cotton pointed out that the vast majority of children’s bruises were not reported or investigated.  The law, he stated, mandated reporting if one suspected the bruise was from abuse or neglect.

 

Chairwoman Koivisto commented that people working in the field must use common sense, and would probably not be reporting every bruised child.

 

Pam Becker, Chairman, Washoe County Children’s Mental Health Coalition, provided Committee members with copies of her letter (Exhibit F) expressing support for the changes in reporting dates recommended in A.B. 6. 

Allison Combs, referring to A.B. 5, clarified that kinship care children were not included in the fiscal note because they were not technically considered foster care children.  A.B. 5, she added, was specific to what the federal law authorized, which was only for foster children.

 

Chairwoman Koivisto, noting that all four bills, with the exception of A.B. 6, would have to be re-referred to the Assembly Ways and Means Committee, requested that Ed Cotton, Mike Capello, and Susan Klein-Rothschild attempt to work out some of the details in A.B. 112 within the next two weeks. 

 

Chairwoman Koivisto, stating that A.B. 6 was simply making changes to dates, asked if the Committee had any concerns about the bill.

 

ASSEMBLYWOMAN LESLIE MOVED TO DO PASS A.B. 6.

 

ASSEMBLYWOMAN McCLAIN SECONDED THE MOTION.

 

THE MOTION CARRIED.  (Assemblyman Williams was not present for the vote.)

 

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ASSEMBLYWOMAN McCLAIN MOVED TO DO PASS A.B. 5 AND RE-REFER TO WAYS AND MEANS.

 

ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.

 

THE MOTION CARRIED.  (Assemblyman Williams was not present for the vote.)

 

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ASSEMBLYWOMAN McCLAIN MOVED TO DO PASS A.B. 25 AND RE-REFER TO WAYS AND MEANS.

 

ASSEMBLYWOMAN PIERCE SECONDED THE MOTION.

 

Assemblyman Mabey stated he had thought there would be changes made to the bill regarding youth aged 18 and enrolled in high school.

 

Judge Hardcastle referred to Section 3, subsection b, and indicated the language should read, “or 19 years of age if still attending high school on the child’s 18^th birthday” was how it read for child support purposes.

Chairwoman Koivisto referred to page 2, line 21 where the language stated “Eighteen years of age or older and is attending high school, until graduation from high school.”

 

Judge Hardcastle tried again to craft the language saying, “a child who is 18 years of age and still attending school but not more than 19 years of age” might be how it could read.

 

Chairwoman Koivisto explained that the concept was if the child were still in school and still dependent.

 

Judge Hardcastle reiterated that a child, for purposes of statute, meant one who was either less than 18 years of age, or if on his 18^th birthday was still in high school, then it extended until the child turned 19.  He reiterated the child support statute had the same requirements in it and should be used.

 

Chairwoman Koivisto agreed the Committee had wanted the language in A.B. 25 to mirror that statute.

 

Judge Hardcastle agreed.

 

Allison Combs, for clarification, referred Committee members to the current language on lines 19 through 22 on page 2, which stated, “child means a person less than 18 years of age, or if in school, until graduation from high school.”  That was the current law, she reiterated.

 

Assemblywoman McClain indicated the idea had been to not have professional high school seniors.

 

Allison Combs said she had just wanted to clarify that there were existing practices when children were past the age of 18 but still in high school and under the jurisdiction of the court.

 

Assemblyman Horne commented that there could be instances where a child had been retained a year in school, that child might not even graduate at age 19, and that child would then not be included.

 

Chairwoman Koivisto asked if adding the phrase, “under the jurisdiction” would help.

 

Ms. Combs replied that adding the phrase, “19 and under the jurisdiction” could clarify it.  If a specific age were used in the language, then the cutoff would be at a particular month of the year. 

Chairwoman Koivisto inquired whether the language should read, “or under the jurisdiction,” and change the “and” to an “or.”  What, she requested, was the age when they were cut off no matter what.

 

Mr. Capello replied that current practice would not allow a person over the age of 21 to remain under the direction of the court.  In reality, he explained, very few children over the age of 18 remained in foster care or under their jurisdiction.  He added that placing the age of 19 in statute would make it more restrictive than it currently was.  As of today, a child who had failed a couple of grades and was struggling as in Mr. Horne’s example, but was making some progress, could hypothetically remain in the system until age 21.  He reiterated that very few ever stayed in the system that long.

 

Chairwoman Koivisto decided to hold A. B. 25 until the language could be clarified.

 

ASSEMBLYWOMAN McCLAIN WITHDREW HER MOTION ON A.B. 25.

 

ASSEMBLYWOMAN PIERCE WITHDREW HER SECOND.

 

Chairwoman Koivisto thanked the people who had testified that day for all their hard work and adjourned the Committee at 3:27 p.m.

 

RESPECTFULLY SUBMITTED:

 

 

 

                                                           

Terry Horgan

Committee Secretary

 

 

APPROVED BY:

 

 

 

                                                                                         

Assemblywoman Ellen Koivisto, Chairwoman

 

 

DATE: