Legislature(2017 - 2018)CAPITOL 106

04/10/2018 03:00 PM HEALTH & SOCIAL SERVICES

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03:03:23 PM Start
03:04:03 PM Presentation: Alaska Psychiatric Institute
05:37:20 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation & Discussion: The AK Psychiatric TELECONFERENCED
Institute by the Dept. of Health & Social
Services & community members
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         April 10, 2018                                                                                         
                           3:03 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Ivy Spohnholz, Chair                                                                                             
Representative Tiffany Zulkosky, Vice Chair                                                                                     
Representative Sam Kito                                                                                                         
Representative Geran Tarr                                                                                                       
Representative Jennifer Johnston                                                                                                
Representative Colleen Sullivan-Leonard                                                                                         
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative David Eastman                                                                                                    
Representative Matt Claman (alternate)                                                                                          
Representative Dan Saddler (alternate)                                                                                          
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
PRESENTATION: ALASKA PSYCHIATRIC INSTITUTE                                                                                      
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
No previous action to record                                                                                                    
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
RANDALL BURNS, Director                                                                                                         
Division of Behavioral Health                                                                                                   
Department of Health and Social Services                                                                                        
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Presented the PowerPoint "The Alaska                                                                     
Psychiatric Institute.                                                                                                          
                                                                                                                                
FAITH MYERS                                                                                                                     
Mental Health Advocate                                                                                                          
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of Alaska                                                                    
Psychiatric Institute (API).                                                                                                    
                                                                                                                                
DORRANCE COLLINS                                                                                                                
Mental Health Advocate                                                                                                          
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of API.                                                                      
                                                                                                                                
JAMELIA SAIED                                                                                                                   
Counselor                                                                                                                       
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of API.                                                                      
                                                                                                                                
ANGELIKA FEY MERRIT                                                                                                             
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of API.                                                                      
                                                                                                                                
RICH RADUEGE, Psychiatric Nursing Assistant (PNA)                                                                               
Alaska Psychiatric Institute (API)                                                                                              
Shop Steward, Alaska State Employees Association Local 52                                                                       
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of API.                                                                      
                                                                                                                                
SHEILA LITTLE, Registered Nurse (RN)                                                                                            
Alaska Psychiatric Institute                                                                                                    
Shop Steward, Alaska State Employees Association Local 52                                                                       
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of API.                                                                      
                                                                                                                                
MUSA KANTEH, Psychiatric Nursing Assistant (PNA)                                                                                
Alaska Psychiatric Institute                                                                                                    
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of API.                                                                      
                                                                                                                                
JASON LESSARD                                                                                                                   
NAMI (National Alliance for Mental Illness) Anchorage                                                                           
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of API.                                                                      
                                                                                                                                
ALISON KULAS, Executive Director                                                                                                
Alaska Mental Health Board                                                                                                      
Division of Behavioral Health                                                                                                   
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified during discussion of API.                                                                      
                                                                                                                                
STEVE WILLIAMS, COO                                                                                                             
Alaska Mental Health Trust Authority                                                                                            
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during the discussion on API.                                                                  
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
3:03:23 PM                                                                                                                    
                                                                                                                                
CHAIR IVY SPOHNHOLZ called the  House Health and Social Services                                                              
Standing   Committee    meeting   to   order   at    3:03   p.m.                                                                
Representatives  Spohnholz,   Johnston,   Sullivan-Leonard,  and                                                                
Zulkosky were  present at  the call  to order.   Representatives                                                                
Tarr and Kito arrived as the meeting was in progress.                                                                           
                                                                                                                                
^Presentation: Alaska Psychiatric Institute                                                                                   
           Presentation: Alaska Psychiatric Institute                                                                       
                                                                                                                                
3:04:03 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ announced that the  only order of business would                                                                
be a presentation by the Alaska Psychiatric Institute which will                                                                
include:   an  in-depth   discussion   surrounding  the   Alaska                                                                
Psychiatric Institute (API); the Department of Health and Social                                                                
Services,   Division  of   Behavioral  Health;   a  variety   of                                                                
stakeholders; patient and  employee advocates; and organizations                                                                
that may  be able  to offer insight  and background as  to API's                                                                
issues and how to chart a course forward to ensure that patients                                                                
and employees are safe and well.                                                                                                
                                                                                                                                
3:05:24 PM                                                                                                                    
                                                                                                                                
RANDALL BURNS,  Director of  the Division of  Behavioral Health,                                                                
Department of  Health and Social Services,  paraphrased slide 2,                                                                
"Alaska Psychiatric Institute: the Basics," as follows [original                                                                
punctuation provided]:                                                                                                          
                                                                                                                                
     API's proposed SFY19 budget is $33,360.0                                                                                   
                                                                                                                                
     Only 22% of API's funding is UGF: $7.2 Million                                                                             
                                                                                                                                
       More than half of the remainder of API's budget is                                                                       
        funded by DSH (Disproportionate Share Hospital)                                                                         
     Medicaid Funds: $18.7 Million                                                                                              
                                                                                                                                
     The  remainder of  API's budget  comes  from Statutory                                                                     
     Designated  Program Receipts  (SDPR  - $7.4  Million),                                                                     
     including  Medicare,   Medicaid,  third  party/private                                                                     
     payers, grants, etc.                                                                                                       
                                                                                                                                
     API is the largest user of the State's DSH funds                                                                           
                                                                                                                                
     DHSS currently uses  its other available  DSH funds to                                                                     
     pay  for   the  Division's  support  for   Alaska's  3                                                                     
     important  designated hospitals  providing psychiatric                                                                     
     evaluation and treatment  services [Fairbanks Memorial                                                                     
     Hospital (FMH);  Providence Alaska Medical  Center for                                                                     
     the   Providence   Psychiatric  Emergency   Department                                                                     
     (PPED); and Bartlett Regional Hospital (BRH)]                                                                              
                                                                                                                                
     FMH has  a  20 bed  mental health  unit, with  4 acute                                                                     
     beds; BRH has 12 mental health beds;                                                                                       
     and the  Providence Psychiatric  Emergency Department,                                                                     
     which acts as a behavioral health                                                                                          
     triage center for the Anchorage  area, has 7 beds. All                                                                     
     three have psychiatrists at the head of                                                                                    
     their units.                                                                                                               
                                                                                                                                
3:07:39 PM                                                                                                                    
                                                                                                                                
MR. BURNS, paraphrased slide 3, "An 80 Bed Hospital" as follows                                                                 
[original punctuation provided]:                                                                                                
                                                                                                                                
     API is an 80 bed hospital with 5 distinct units:                                                                           
                                                                                                                                
     Two adult  acute units:  Katmai (24 beds)  and Susitna                                                                     
     (26 beds) for a total of 50 adult acute patient beds                                                                       
                                                                                                                                
     One 10  bed unit  for adolescent patients  (Chilkat)                                                                       
     ages 13 through 17                                                                                                         
                                                                                                                                
     One  10  bed  unit  for  longer  term  adult  patients                                                                     
     (Denali)  with a  real  mix  of  diagnoses, from  TBI,                                                                     
     autism, dementia, IDD, and all with very difficult and                                                                     
     complex behavioral issues                                                                                                  
                                                                                                                                
     One 10 bed  unit for "forensic" patients  (Taku)   for                                                                     
     defendants' whose criminal trials  are on hold because                                                                     
     of  concerns for  their mental  status  (competency to                                                                     
     stand trial)                                                                                                               
                                                                                                                                
3:08:00 PM                                                                                                                    
                                                                                                                                
MR. BURNS advised that slide 4,  "Average Length of Stay by Unit                                                                
by Year, 2014-2017" is an example of the length of stay over the                                                                
last  four years  of each  unit  and they  have  been relatively                                                                
stable across these years.                                                                                                      
                                                                                                                                
MR. BURNS, paraphrased slide 5, "History: A Range of Bed                                                                        
Options: From 162 Beds to Just 45 Beds" as follows [original                                                                    
punctuation provided]:                                                                                                          
                                                                                                                                
     Beginning in 1986,  and over the next  14 years, there                                                                     
     were a  variety of  scenarios proposed to  replace the                                                                     
     aging API                                                                                                                  
                                                                                                                                
     Most of  the scenarios ended up  being primarily based                                                                     
     on  the funding  available and  did  not significantly                                                                     
     rely on  the approximately  $6 Million  in programming                                                                     
     work DHSS  had contracted for  as it prepared  its CON                                                                     
     for the replacement hospital                                                                                               
                                                                                                                                
     DHSS issued is preliminary  study in February of 1992,                                                                     
     summarizing the work of  many of its consultants; this                                                                     
     study targeted the  new API as requiring  162 beds: 72                                                                     
     Adult,  18 adolescent,  36  forensic,  and 36  elderly                                                                     
     (although a  year later, in  1993, a final  DHSS study                                                                     
     suggested Alaska would need between 198 and 237 beds)                                                                      
                                                                                                                                
     DHSS'  early  1992  report  was highly  criticized  by                                                                     
     advocates  and community  behavioral  health providers                                                                     
     who supported a focus on more community-based services                                                                     
                                                                                                                                
3:09:38 PM                                                                                                                    
                                                                                                                                
MR. BURNS, paraphrased slide 6, " History: The 'Alyeska Accord':                                                                
Finding Stakeholder Agreement on the Bed Capacity of the New                                                                    
API," as follows [original punctuation provided]:                                                                               
                                                                                                                                
     The  Alaska Mental  Health  Board  held  a meeting  at                                                                     
     Alyeska of  42 community  mental health  advocates and                                                                     
     mental health service providers in  June 1992 (over 25                                                                     
     years ago)                                                                                                                 
                                                                                                                                
     The results from this  weekend meeting became known as                                                                     
     the "Alyeska Accord" and was a set of principles which                                                                     
     were to guide the AMHB's response to DHSS' Certificate                                                                     
     of Need (CON) application for a new API                                                                                    
                                                                                                                                
     Agreements  reached  included the  decision  that  the                                                                     
     central purpose of API  was to provide "tertiary" care                                                                     
     and agreement that the new API should be built at 114-                                                                     
     beds, as follows:   Adolescents: 18 beds   Elderly: 18                                                                     
     beds    Adults: 36 beds    Swing  (complex adults): 18                                                                     
     beds   Forensic:  24 beds (not a  part of the original                                                                     
     accord, but adopted by the AMHB a month later, in July                                                                     
     of 1992                                                                                                                    
                                                                                                                                
                                                                                                                                
3:11:00 PM                                                                                                                    
                                                                                                                                
MR. BURNS, paraphrased slide  7, " History: From 114  beds to 57                                                                
to 72 to 80!" as follows [original punctuation provided]:                                                                       
                                                                                                                                
     Based on the Alyeska Accord result,  a CON for the 114                                                                     
     beds was submitted in August of 1993 by DHSS                                                                               
                                                                                                                                
     However, this  CON and  its  cost ($64.9  Million) was                                                                     
     DOA. Four years later,  in 1997, the DHSS Commissioner                                                                     
     reviewed a report with different five scenarios, based                                                                     
     primarily on funding availability:  a 72-bed option, a                                                                     
     63-bed option, two different  54-bed options, and even                                                                     
     a 45-bed option.                                                                                                           
                                                                                                                                
     Based on  this report, the  DHSS Commissioner selected                                                                     
     one of  the 54-bed options  (which included adolescent                                                                     
     beds).                                                                                                                     
                                                                                                                                
3:11:58 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ referred to the Certificate of Need for 114 beds                                                                
for the roughly $65 million API facility, and asked Mr. Burns to                                                                
explain why it was "dead on arrival."                                                                                           
                                                                                                                                
MR. BURNS responded that  it was due to the  cost.  He explained                                                                
that there  was no  support from the  legislature for  a capitol                                                                
budget of  which would have  been essentially $40  million above                                                                
the funding that  the department had available at  that point in                                                                
time.                                                                                                                           
                                                                                                                                
3:12:50 PM                                                                                                                    
                                                                                                                                
MR. BURNS  continued paraphrasing slide 7,  as follows [original                                                                
punctuation provided]:                                                                                                          
                                                                                                                                
     After four more years, in  2001, with over $16 Million                                                                     
     in   legislative-approved    COP   bonds,    the   re-                                                                     
     appropriation  of $19  Million  in  existing committed                                                                     
     capital funds,  and a Trust  Authority contribution of                                                                     
     $3 Million,  DHSS finally had  the funds to  procure a                                                                     
     72-bed facility. Another controversy: the construction                                                                     
     proposal was issued as design-build.                                                                                       
                                                                                                                                
     Because of concerns for the ability  of the 72 beds to                                                                     
     handle API's capacity issues in  2001, DHSS issued API                                                                     
     a CON for 72 beds but did allow for an expansion to 80                                                                     
     beds with  proof  of a  history of  needing additional                                                                     
     beds. API opened with 80 beds in 2005.                                                                                     
                                                                                                                                
     As a part of this  effort to fund a new hospital, DHSS                                                                     
     also applied for and was awarded a SAMHSA grant for $5                                                                     
     Million a year  for three years to  help fund expanded                                                                     
     community-based treatment  to  support  the downsized-                                                                     
     hospital. These  funds primarily were used  to support                                                                     
     the  development  of   additional  DET  capacity,  and                                                                     
     training in  role  recovery, dual  diagnosis, cultural                                                                     
     competence, and crisis intervention.                                                                                       
                                                                                                                                
3:15:05 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ requested the definition of DET.                                                                                
                                                                                                                                
MR.  BURNS  answered  that   it  is  Designated  Evaluation  and                                                                
Treatment (DET).   During the downsizing of API,  it was decided                                                                
that more  regional-based mental health  options were necessary.                                                                
The  Fairbanks  Memorial  Hospital  and  the  Bartlett  Regional                                                                
Hospital mental  unit are both  considered designated evaluation                                                                
and treatment  facilities, he  explained.  Those  facilities are                                                                
also designated to  receive a portion  of the DSH  each year, he                                                                
said.                                                                                                                           
                                                                                                                                
3:15:48 PM                                                                                                                    
                                                                                                                                
MR. BURNS paraphrased  slide 8, "Calendar Year Snap  Shot of API                                                                
Utilization," and noted  that in 1990,  API had 160 beds  and in                                                                
2017, it had 80 beds.  He referred to the column titled, "No. of                                                                
Unduplicated Admits With Just a Single Stay during the Year" and                                                                
pointed out that in 2017  there were 839 unduplicated admits and                                                                
of those, 486  were admitted and had never been  admitted to API                                                                
previously.  He described it  as one-third of the admissions for                                                                
that year, which is typical.                                                                                                    
                                                                                                                                
3:17:11 PM                                                                                                                    
                                                                                                                                
MR.  BURNS  paraphrased slide  9,  "The  Current Bed  "Capacity"                                                                
Issue" as follows [original punctuation provided]:                                                                              
                                                                                                                                
     As members  of this Committee  are aware, API  needs                                                                       
     and has  been going  through    an expensive  but very                                                                     
     necessary face-lift,  retrofitting every  bathroom and                                                                     
     portions  of  every  bedroom  to  meet  revised  Joint                                                                     
     Commission safety requirements                                                                                             
                                                                                                                                
     Since mid-November of last  year, this six-month long,                                                                     
     temporary closure of each of API's five hospital units                                                                     
     for  repairs  has  had  a  major impact  on  community                                                                     
     hospital  EDs  and  Alaskans experiencing  psychiatric                                                                     
     emergencies:   patients   with    court   orders   for                                                                     
     hospitalization for evaluation  at API have  been held                                                                     
     for days   not hours    sometimes up to a week or more                                                                     
        awaiting   transfer  to  API   for  evaluation  and                                                                     
     treatment  [or  transfer  to  one  of  the  two  other                                                                     
     hospitals  with  Designated Evaluation  and  Treatment                                                                     
     (DET) mental health units]                                                                                                 
                                                                                                                                
     The API contractor  has been working on  the last unit                                                                     
     for   about   a   month   now  (the   Susitna   Unit);                                                                     
     unfortunately, it is the hospital's largest unit, with                                                                     
     26 adult acute beds, so API's census capacity has been                                                                     
     set at just 54 patients, not 80 (or even 70)                                                                               
                                                                                                                                
MR. BURNS paraphrased slide 10, "API's Current Estimated Bed                                                                    
Capacity " as follows [original punctuation provided]:                                                                          
                                                                                                                                
     The  construction on  the Susitna  unit  was completed                                                                     
     last week; other  off-patient-unit bathrooms were also                                                                     
     being repaired last week  (e.g., restrooms off the gym                                                                     
     and dining room); the Susitna Unit is being thoroughly                                                                     
     cleaned and should be ready  to open back-up this very                                                                     
     week                                                                                                                       
                                                                                                                                
     However, because of  a shortage of nursing  staff   on                                                                     
     April  11th     when   API  will  have  completed  the                                                                     
     renovation project on  time and the  contractor is out                                                                     
     of the  building  at this  time, and for at  least the                                                                     
     next several months, we believe  API will only be able                                                                     
     to run a  census of 58  beds, down a total  of 22 beds                                                                     
     for the foreseeable future.                                                                                                
                                                                                                                                
     We are not going to be able to open up the Denali Unit                                                                     
     (10 beds) and we will be forced to run the Katmai unit                                                                     
     at half of its normal  census, or just 12 beds instead                                                                     
     of the normal 24 beds.                                                                                                     
                                                                                                                                
     Until we are able to hire more RNs (travelers or full-                                                                     
     time  positions),  or  the  staff  curren,tly  out  on                                                                     
     various types of leave (whether it be workers' comp or                                                                     
     FMLA) are able to return to  work, we are not going to                                                                     
     be able to  fully staff the Katmai unit,  nor open the                                                                     
     Denali Unit                                                                                                                
                                                                                                                                
3:19:30 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SULLIVAN-LEONARD offered  concern regarding  the                                                                
shortage of  nurses at  API, and  asked how  Mr. Burns  plans to                                                                
overcome  this  challenge.   She  further  asked whether  he  is                                                                
working  through the  University of  Alaska  nursing program  or                                                                
recruiting from out-of-state or out-of-country.                                                                                 
                                                                                                                                
MR.  BURNS responded  that  API's recruitment  problems are  due                                                                
mainly to  its salaries, and  later in the  presentation he will                                                                
address that issue.                                                                                                             
                                                                                                                                
3:20:34 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR referred  to  slide  7,  and its  different                                                                
scenarios  and offered  that in  addition to  the  funding issue                                                                
there were some  challenges in the location.   She asked whether                                                                
any challenges  to the location  had influence over the  size of                                                                
the facility.                                                                                                                   
                                                                                                                                
MR. BURNS  answered that the  community in that area  has always                                                                
been  highly supportive  of  API, and  it  was  not a  community                                                                
objection to the size.  He explained that the acreage API sat on                                                                
was  considered  to  be  highly  valuable and  there  were  many                                                                
competing  (indisc.), the  university, Providence  Hospital, and                                                                
the Alaska  Mental Health Trust and  its ability to use  part of                                                                
that land for profit or  for the beneficiaries.  The real debate                                                                
related to what the footprint of API would look like, and how to                                                                
get it onto that property, which is  how it ended up back in the                                                                
corner of that much larger lot (indisc.), he explained.                                                                         
                                                                                                                                
3:22:16 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR referred to the  first paragraph on slide 9,                                                                
which read as follows [original punctuation provided]:                                                                          
                                                                                                                                
     As members  of this Committee  are aware, API  needs                                                                       
     and has  been going  through    an expensive  but very                                                                     
     necessary face-lift,  retrofitting every  bathroom and                                                                     
     portions  of  every  bedroom  to  meet  revised  Joint                                                                     
     Commission safety requirements                                                                                             
                                                                                                                                
REPRESENTATIVE  TARR  requested  a   description  of  the  Joint                                                                
Commission, and whether there is  a report the legislature would                                                                
have received.                                                                                                                  
                                                                                                                                
MR. BURNS described that the Joint Commission is the entity that                                                                
credits all (indisc.)  seeking new accreditation so  it can bill                                                                
for Medicaid clients.  The Centers for Medicare & Medicaid (CMS)                                                                
has given its  authority to the Joint  Commission, and the Joint                                                                
Commission  regularly visits  hospitals around  the country  and                                                                
accredits  them to  make sure  they meet  the  standards jointly                                                                
produced by the Joint Commission and CMS.                                                                                       
                                                                                                                                
3:23:28 PM                                                                                                                    
                                                                                                                                
MR.  BURNS paraphrased  slide 11,  "API's Current  Estimated Bed                                                                
Capacity " as follows [original punctuation provided]:                                                                          
                                                                                                                                
     We have hired four  (4) traveling RNs, but we continue                                                                     
     to run at an RN deficit. The salaries that API is able                                                                     
     to  pay  for  starting  RNs is  not  competitive  with                                                                     
     private sector hospitals                                                                                                   
                                                                                                                                
     DHSS is  presently exploring hiring  bonuses and other                                                                     
     types  of incentive  pay  in an  attempt  to make  the                                                                     
     positions   more   attractive   to   prospective   RNs                                                                     
     (incentives used by other departments, like DOC)                                                                           
                                                                                                                                
     We   have  been   meeting  with   Southcentral  Alaska                                                                     
     hospitals  and  are  going  to  be  implementing  some                                                                     
     admissions changes that  should somewhat help mitigate                                                                     
     the stress on hospital  ED's during this perfect storm                                                                     
     of problems affecting API                                                                                                  
                                                                                                                                
     While we  have  been pleased  with the  Certificate of                                                                     
     Need  (CON)  applications  from both  Alaska  Regional                                                                     
     Hospital and MatSu Regional  Medical Center, CONs that                                                                     
     Commissioner  Davidson has  approved,  we are  anxious                                                                     
     about the actual  dates that these  facilities will be                                                                     
     able to  open and actually  begin accepting behavioral                                                                     
     health patients                                                                                                            
                                                                                                                                
     Finally, in Governor Walker's capital budget for FY19,                                                                     
     there is  a request  to remodel the  Anchorage Pioneer                                                                     
     Home to add at least six beds for psychiatric patients                                                                     
     needing dementia care.                                                                                                     
                                                                                                                                
                                                                                                                                
MR.  BURNS,  in  response  to  Representative Sullivan-Leonard's                                                                
previous question, advised that recently API  spent a great deal                                                                
of time looking into what the department would need to bring API                                                                
fully online.  Subsequent to  API's research, it determined that                                                                
API had approximately 10 RNs out on  a variety of leave, with 10                                                                
vacancies.   Therefore, in order to  keep the unit open,  API is                                                                
seeking 10  new positions to cover  those out on  leave and five                                                                
positions to cover  those vacancies.  Clearly,  he stressed, the                                                                
state's  nursing salaries  are  simply not  competitive, and  18                                                                
years ago  in order  to solve  a similar problem  the department                                                                
raised all of the nursing  salaries by two ranges and it worked.                                                                
He said that API is  suggesting the state try that same solution                                                                
at this time, and fund the  15 new positions as well as increase                                                                
the salaries of the existing RNs at  API.  The total funding, he                                                                
explained,  would   be  approximately   $2.5  million   to  have                                                                
competitive salaries.  For example, he advised, API learned that                                                                
a  current API  nurse  also  works on  the  Psychiatric Unit  at                                                                
Providence Hospital and  earns $8.00 more an  hour at Providence                                                                
Hospital than she does at API.  However, he said, API also needs                                                                
funding for  programing for staff; it  is particularly concerned                                                                
about the  need to  increase salaries for  physician assistants,                                                                
Adult  Nurse Practitioners  (ANPs), forensic  psychologists, and                                                                
pharmacists.   These issues  have been  closely reviewed  and he                                                                
would be  happy to provide more  details in going  forward as to                                                                
what API believes its true needs are for its staff.                                                                             
                                                                                                                                
3:27:36 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE ZULKOSKY  surmised that over  25 years  ago there                                                                
was an acknowledgement that the  capacity needs of API were well                                                                
over what  was actually constructed, and asked  whether that is,                                                                
in part, due to the costs of construction.                                                                                      
                                                                                                                                
MR. BURNS  responded that it  was a  combination of construction                                                                
costs but mostly  it was (indisc.) around the  hospital with the                                                                
amount of capitol funds and eventually some bonding that allowed                                                                
API to cobble together the funding.                                                                                             
                                                                                                                                
REPRESENTATIVE  ZULKOSKY  advised that  in  coming  from  travel                                                                
health recently she understands the challenges around recruiting                                                                
needs, the  need  to operate  at capacity,  and to  provide some                                                                
market adjustments  to make  sure the salaries  are competitive.                                                                
She asked  whether API  has found  that there  is a  shortage of                                                                
medical  professionals nationwide  as  she  knows the  shortages                                                                
exist for hospitals.  She  further asked whether the facility is                                                                
HIPPA compliant.                                                                                                                
                                                                                                                                
MR.  BURNS responded  that  API is  compliant  with all  patient                                                                
privacy requirements,  and he  agrees that  there is  a national                                                                
shortage of  RNs and medical  staff, so  Alaska is not  alone in                                                                
that regard.   Given the shortages, it is  an employee market in                                                                
the  healthcare  industry  and  medical providers  can  probably                                                                
choose where they  want to work given their skills  set if given                                                                
competitive salaries.                                                                                                           
                                                                                                                                
3:30:42 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JOHNSTON asked  that Mr. Burns  repeat the number                                                                
of nursing vacancies.                                                                                                           
                                                                                                                                
MR.  BURNS replied  that  API  has 10  vacant  positions and  10                                                                
positions that  are essentially vacant  because the staff  is on                                                                
some type of leave.                                                                                                             
                                                                                                                                
REPRESENTATIVE JOHNSTON  surmised that API  must have  a "pretty                                                                
high" vacancy factor.                                                                                                           
                                                                                                                                
MR. BURNS answered that it  has the normal budget vacancy factor                                                                
of 8 percent.                                                                                                                   
                                                                                                                                
REPRESENTATIVE JOHNSTON related that she is trying to understand                                                                
how  API can  operate  as well  as  it is  currently, and  asked                                                                
whether there are duties an LPN can perform for an RN to relieve                                                                
some of the pressure on the RN.                                                                                                 
                                                                                                                                
MR. BURNS answered  that there are some jobs an  LPN can perform                                                                
rather than an RN,  the API physician descriptions (indisc.) for                                                                
them, and these are  site nursing positions.  As long  as API is                                                                
meeting the Joint Commission standards for its nursing staff, it                                                                
can use  LPNs for RNs if  they have had  the appropriate medical                                                                
training, he said.                                                                                                              
                                                                                                                                
REPRESENTATIVE  JOHNSTON  explained   that  she  is   trying  to                                                                
understand how API can transform when  it has an RN shortage and                                                                
a need, and how some of those duties are transformed in order to                                                                
make it all  work.  She related that  with the vacant positions,                                                                
API could  possibly revise  some of its  salary structure  to be                                                                
competitive and review its job descriptions to put "more feet in                                                                
the building."  She asked  whether Mr. Burns had been looking at                                                                
those  possibilities  in   API's  organizational  management  to                                                                
determine how  to work with  what it  has currently in  order to                                                                
meet some of these chronic needs.                                                                                               
                                                                                                                                
MR.  BURN   responded  that  in  using   API's  existing  salary                                                                
schedules, it  was suggested  that it  simply take  the existing                                                                
salary schedule and boost the ranges of those positions in order                                                                
to make them more competitive.  He reiterated that that approach                                                                
was made some time ago and it was successful.                                                                                   
                                                                                                                                
REPRESENTATIVE JOHNSTON  asked whether API  would be  looking at                                                                
what its  needs are on the  floor to determine  whether it could                                                                
shift  some  of  those  needs  to an  LPN,  or  another  medical                                                                
provider, to make it all work.                                                                                                  
                                                                                                                                
MR. BURNS  replied that  API has  been looking  at a  variety of                                                                
options to  get those positions  filled and it will  continue to                                                                
review options.                                                                                                                 
                                                                                                                                
REPRESENTATIVE JOHNSTON  said that she  did not mean  a licensed                                                                
practical nurse, but  other healthcare providers who  are not an                                                                
RN but have the capability to be effective on the floor.                                                                        
                                                                                                                                
MR. BURNS advised  that those are where the  limitations come in                                                                
in  terms of  the  Joint  Commission standards,  there are  very                                                                
strict standards about the nature of the positions that can work                                                                
in a hospital and the duties of those positions.  Therefore, API                                                                
must make sure it  is recruiting and staffing at the appropriate                                                                
level of clinical expertise.                                                                                                    
                                                                                                                                
3:35:30 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ  noted that  Mr. Burns testified  that he  had a                                                                
requested  $2.5 million  to  assist in  addressing the  staffing                                                                
shortage, and asked where that request was located.                                                                             
                                                                                                                                
MR. BURNS  answered that that  is not a  request API has  in any                                                                
budget.   In the event  API could get  its staff up  and running                                                                
again as  quickly as possible  and assuming it could  fund those                                                                
positions at a  higher level, the cost would be  $2.5 million to                                                                
fully staff API  and empty out  the emergency departments across                                                                
the state.                                                                                                                      
                                                                                                                                
CHAIR  SPOHNHOLZ surmised  that that  is both  an  adjustment of                                                                
salaries in order to be more competitive and also an increase in                                                                
the number of personnel.                                                                                                        
                                                                                                                                
MR. BURNS stated that Chair Spohnholz was exactly correct.                                                                      
                                                                                                                                
CHAIR SPOHNHOLZ, for  context, noted that  psychiatric nurses in                                                                
API are working in the absolute most complex working environment                                                                
in the State of Alaska in terms of the acuity and the complexity                                                                
of the patients admitted into API.   She stressed that she could                                                                
not state strongly enough how important it is to make sure these                                                                
salaries are at the correct range to attract and retain the most                                                                
qualified personnel possible.   The State of  Alaska must employ                                                                
the best  of the  best in  these positions because  the patients                                                                
cannot  go anywhere  else,  and they  are  the  most challenging                                                                
simply because API is  the state's only psychiatric institution.                                                                
She stated that she will follow up with Mr. Burns and department                                                                
representatives to try to figure out some of the fiscal elements                                                                
of these problems.  These issues about patient safety and worker                                                                
safety  cannot continue  to  be  neglected when  it  is a  known                                                                
problem  and  there  are  clear  straight-forward  solutions  to                                                                
resolving these  problems.   She pointed out  that API  has been                                                                
neglected for "a  very, very long time."   Chair Spohnholz noted                                                                
that she had read API's PowerPoint presentation earlier and read                                                                
some of  the reports and  history, and  she was struck  that the                                                                
legislature has refused  to address the  known problems directly                                                                
and as forthrightly as necessary.                                                                                               
                                                                                                                                
3:38:39 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE   ZULKOSKY   noted   that    according   to   the                                                                
presentation, currently API is only running 58 beds, and is down                                                                
22 beds.   She asked  Mr. Burns to  speak to the total  count of                                                                
staff necessary for the current number of beds in operation, and                                                                
the necessary staff if API operated at full capacity.                                                                           
                                                                                                                                
MR.  BURNS replied  that  22 of  the  58 beds  is  based on  the                                                                
staffing it currently has available,  particularly RNs.  The API                                                                
does have a total of 56 RN positions, but it is down 20 of those                                                                
positions due to the vacancies and/or personnel out on a variety                                                                
of leave, it is down to 36  beds.  He explained that that is the                                                                
reason API is currently staffing the  hospital at 58 beds rather                                                                
than 80 beds.                                                                                                                   
                                                                                                                                
REPRESENTATIVE  ZULKOSKY restated  her  question  and asked  the                                                                
number  of full-time  exempt position  (travel health), and  the                                                                
total number of employees necessary to run however many beds are                                                                
currently in operation versus how many full-time employees would                                                                
be required to run a full-capacity facility.                                                                                    
                                                                                                                                
MR.  BURNS answered  that API  would need  56  nursing positions                                                                
filled in  order to  fully staff  the facility,  obviously other                                                                
staff  is needed  for every  shift.   The  RNs  are particularly                                                                
important because if there is not an  RN on shift, the unit must                                                                
be closed.  He  related that that is why API looks  to the RN in                                                                
order to set the capacity of the hospital because it is staffing                                                                
24/7 and  those units would need  all 56 RN  positions filled in                                                                
order to keep the units open on a 24/7 basis.                                                                                   
                                                                                                                                
REPRESENTATIVE ZULKOSKY surmised that 20 full-time positions.                                                                   
                                                                                                                                
MR. BURNS responded  that API would need an  additional 20 full-                                                                
time positions,  currently 10  positions are vacant  because API                                                                
cannot fill the positions.  The  facility is not counting on all                                                                
of the staff that are on  leave will return, which is why it set                                                                
15 as the number "we really are looking to" in order to have the                                                                
hospital up and running.                                                                                                        
                                                                                                                                
3:42:48 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR referred to the $2.5 million figure and said                                                                
that  when  she  spreads  it   out  among  20  positions  it  is                                                                
approximately $125,000  per position.   She  asked how  the $2.5                                                                
million translates into those  positions relative to the private                                                                
sector  and whether  it  is  necessary to  add  $125,000 to  the                                                                
overall  compensation   package  to  be   competitive  with  the                                                                
positions of the private sector.  Previously, Mr. Burns had said                                                                
that  the   $8.00  per   hour  for   a  full-time   employee  is                                                                
approximately $16,000 more per year, and  she asked Mr. Burns to                                                                
explain the numbers.                                                                                                            
                                                                                                                                
MR.  BURNS apologized  for not  providing the  information in  a                                                                
format that  would be useful.   He  explained that API  took the                                                                
existing RN position range of 19,  and the $62,000 per year with                                                                
benefits equals  $108,000, if that range  is bumped up  two full                                                                
ranges to make  it more competitive with the  private sector, it                                                                
becomes  $70,800 per  year  and with  benefits  it is  $120,591.                                                                
Thereby, API  would be increasing the  cost of that  position of                                                                
$108,000 to $120,000, he explained.                                                                                             
                                                                                                                                
REPRESENTATIVE TARR surmised that the $2.5 million roughly is 10                                                                
of those range 21 positions.                                                                                                    
                                                                                                                                
MR. BURNS clarified that it is 15 positions plus the addition of                                                                
the  funding necessary to  also  bring, not  just the  10 vacant                                                                
unfilled  positions, but  bring  up the  salaries  of the  other                                                                
positions, which is another $500,000.                                                                                           
                                                                                                                                
3:45:57 PM                                                                                                                    
                                                                                                                                
MR.  BURNS   paraphrased  slide  13,   "API  and   its  Forensic                                                                
Population," as follows [original punctuation provided]:                                                                        
                                                                                                                                
     There is  another population besides  adolescents that                                                                     
     pose a particular problem for API.                                                                                         
                                                                                                                                
     The Alaska  Court System's demand  for DHSS's forensic                                                                     
     services  has  simply  outstripped  API's  ability  to                                                                     
     manage the  caseload assigned  to its  staff utilizing                                                                     
     API's 10-bed, medium  security unit   the  Taku Unit                                                                       
     to  serve  the  defendants  court-ordered to  API  for                                                                     
     treatment                                                                                                                  
                                                                                                                                
     API  did  seek  consultation on  this  issue  and  Dr.                                                                     
     Patrick  K.  Fox,   a  psychiatrist  with  significant                                                                     
     forensic  experience,   was  hired   by   the  Western                                                                     
     Interstate Commission for  Higher Education (WICHE) to                                                                     
     provide API  with a report.  His report was  issued in                                                                     
     November 2016.                                                                                                             
                                                                                                                                
     The  report  offered   a  number  of  recommendations,                                                                     
     including   additional   education   to   API   staff,                                                                     
     consideration of  a jail-based  competency restoration                                                                     
     program, an  evidenced-based jail-  diversion program,                                                                     
     involvement  of  more   experienced  outside  forensic                                                                     
     examiners,  and  training  for judges  and  the  legal                                                                     
     community  on  forensic  issues  (including  the  Sell                                                                     
     involuntary medication standard)                                                                                           
                                                                                                                                
     The API  Forensic  Evaluation Team was  served  with a                                                                     
     notice  last month  that  an  Anchorage Mental  Health                                                                     
     Court Judge had  set April 16th for an  "Order to Show                                                                     
     Cause Hearing"  as to  why API should  not be  held in                                                                     
     contempt  of  court  for  not evaluating  a  defendant                                                                     
     within  the judge's  requested  time  frame. This  was                                                                     
     recently  resolved,   but  it   shows  the   level  of                                                                     
     frustration.                                                                                                               
                                                                                                                                
     In  partial response  to  this  crisis,  and with  the                                                                     
     original support  of this  Committee and  the eventual                                                                     
     support of the  House Finance Committee,  the House of                                                                     
     Representative  is  seeking   Legislative  and  Alaska                                                                     
     Mental   Health   Trust   Authority  support   for   a                                                                     
     feasibility study to explore the value of establishing                                                                     
     a  forensic  hospital  in  Alaska, given  the  various                                                                     
     demands  on API  and  the  general  needs of  Alaska's                                                                     
     mentally ill correctional population.                                                                                      
                                                                                                                                
MR. BURNS advised  that prior to the  late 1980s, API's forensic                                                                
patients  were sent  out of  state  to (indisc.)  a hospital  in                                                                
California.  At  some point, California decided  it was finished                                                                
with taking  care of another  state's patients and  returned the                                                                
patients to Alaska  and then to  API.  Since that  time, API has                                                                
worked  with  this population  and  the  court system  has  been                                                                
unhappy with the  delays in API's ability  to perform competency                                                                
examinations of  those people accused of  crimes who may  not be                                                                
competent to stand trial.  While API is behind in that issue, it                                                                
has only  three staff  members to handle  those numbers  and API                                                                
feels fortunate in their abilities.  In the event the patient is                                                                
reviewed and determined to be incompetent but could be restored,                                                                
they  are admitted  to the  API  10-bed unit  for  treatment and                                                                
restoration, he offered.   Due to the  fact that API  has so few                                                                
beds, a  number of those  defendants found to  be non-restorable                                                                
are waiting  in the Department  of Corrections (DOC) for  API to                                                                
admit them  into the hospital.   In order to  show the committee                                                                
the court system's level of frustration, last month an Anchorage                                                                
judge in the mental health court sent API an Order to Show Cause                                                                
as to  why it  shouldn't be held  in contempt for  not accepting                                                                
this particular  client within a certain  period of time.   That                                                                
order has since been resolved,  he said, and API appreciates the                                                                
House Health  and Social Services Standing  Committee, the House                                                                
Finance  Committee,  and  the  Mental Health  Trust  Authority's                                                                
support in funding  a forensic feasibility study  for a forensic                                                                
hospital.                                                                                                                       
                                                                                                                                
3:48:52 PM                                                                                                                    
                                                                                                                                
MR. BURNS  paraphrased slide 14,  "Studying Alaska's Need  for a                                                                
Forensic Hospital," as follows [original punctuation provided]:                                                                 
                                                                                                                                
     The study  would look  at Alaska's needs  for forensic                                                                     
     beds in  order to admit, evaluate,  and treat criminal                                                                     
     defendant with issues around  the insanity defense and                                                                     
     their competency  to stand  trial (see AS  12.47). The                                                                     
     list of issues  is long and complex  and would involve                                                                     
     defendants:   needing  competency evaluations;   found                                                                     
     incompetent  to  stand  trial who  need  treatment  to                                                                     
     determine if  they can  be  restored to  competency in                                                                     
     order stand trial;    found non-restorable and who are                                                                     
     then  civilly committed  to  API  (including dangerous                                                                     
     persons who often have  committed serious felonies);                                                                       
     found  Guilty  but  Mentally Ill  (GMI)  and  held  in                                                                     
     prisons;    found  Not  Guilty by  Reason  of Insanity                                                                     
     (NGRI)  and committed  to  API's forensic  unit; or                                                                        
     found guilty of  a variety of  crimes where competency                                                                     
     was not raised and  who have been incarcerated but who                                                                     
     are  experiencing a  mental illness  and  need ongoing                                                                     
     treatment because of the  severity of their symptoms                                                                       
     and just as often  the severity of their crimes.                                                                           
                                                                                                                                
MR. BURNS  described this as  an incredibly complex area  with a                                                                
long list of needs for this population.                                                                                         
                                                                                                                                
3:49:43 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ asked how many  people have been admitted to API                                                                
who  were  found  to   be  non-restorable  and  are  essentially                                                                
committed for an indeterminate amount of time.                                                                                  
                                                                                                                                
MR. BURNS  answered that there  are 10 patients in  the forensic                                                                
unit that  API is  trying to  restore, there are  currently four                                                                
patients on  the civil  side who were  determined non-restorable                                                                
and committed to  API.  He advised that  three of those patients                                                                
committed very serious crimes.                                                                                                  
                                                                                                                                
CHAIR  SPOHNHOLZ  asked  how  many  are  in  the  Department  of                                                                
Corrections (DOC) when they should rightly be in API.                                                                           
                                                                                                                                
MR. BURNS apologized and  said he does not have  that number off                                                                
the top of his head.                                                                                                            
                                                                                                                                
CHAIR SPOHNHOLZ asked that Mr. Burns follow up with that number.                                                                
                                                                                                                                
MR. BURNS agreed.                                                                                                               
                                                                                                                                
3:51:24 PM                                                                                                                    
                                                                                                                                
MR.  BURNS paraphrased  slide 15,  "So:  the Short  List of  API                                                                
Current Challenges:" as follows [original punctuation provided]:                                                                
                                                                                                                                
     Admissions   pressures:      Continuing   demand   for                                                                     
     treatment beds at API from  all regions of the state                                                                       
     Long waits for patients (boarding) in hospital EDs for                                                                     
     an evaluation and/or a treatment bed at API because of                                                                     
     API's general lack of  an adequate number of treatment                                                                     
     beds                                                                                                                       
                                                                                                                                
     Staffing    related    budget   concerns,    including                                                                     
     recruitment,  retention,   appropriate  unit  staffing                                                                     
     coverage,  quality  of  care   (i.e.,  need  for  unit                                                                     
     programming /  therapeutic activities for  patients in                                                                     
     treatment), and the  reliance on overtime  to keep the                                                                     
     hospital minimally staffed (Premium Pay)                                                                                   
                                                                                                                                
     Concerns  for the  safety  of staff  and  patients and                                                                     
     staff training to  ensure their safety  and the safety                                                                     
     of patients  when staff  are appropriately redirecting                                                                     
     or  intervening  with  challenging  patients;  ongoing                                                                     
     concerns for the use of seclusion and restraint                                                                            
                                                                                                                                
     Current inadequate  local community  behavioral health                                                                     
     programming  to support  patients  who are  discharged                                                                     
     from  API or  either  Fairbanks  Memorial or  Bartlett                                                                     
     Regional,    including    inadequate   community-based                                                                     
     medication management  services, and  an  ongoing need                                                                     
     for  community  mental   health  (MH)  treatment,  for                                                                     
     substance use/misuse  disorder (SUD) treatment,  for a                                                                     
     combination  of   both   MH  and   SUD  (Co-occurring)                                                                     
     treatment, and /  or because of  a lack  of housing or                                                                     
     appropriate living arrangements                                                                                            
                                                                                                                                
     In  partial  response  to  the  clear  need  for  more                                                                     
     community based services, and to address the substance                                                                     
     use /  opioid crisis in  this state, the  Governor has                                                                     
     introduced  an  FY18   supplemental  request  for  $18                                                                     
     Million  to assist  in  providing  greatly needed  SUD                                                                     
     treatment  programs in  local  communities, especially                                                                     
     withdrawal   management   and  residential   treatment                                                                     
     programs                                                                                                                   
                                                                                                                                
3:53:02 PM                                                                                                                    
                                                                                                                                
MR. BURNS paraphrased slide 16, "A Summary of Potential Projects                                                                
that Could Significantly Improve API," as follows [original                                                                     
punctuation provided]:                                                                                                          
                                                                                                                                
     There  are  a   number  of  projects  presently  being                                                                     
     considered by the Legislature that would have a direct                                                                     
        and highly  beneficial    impact  on  API's current                                                                     
     crisis:                                                                                                                    
                                                                                                                                
     Support  for an  expansion  of  Alaska's DSH  Program,                                                                     
     allowing DHSS  to explore  ways to  financially assist                                                                     
     those hospitals  highly impacted  by the  reduction in                                                                     
     treatment bed capacity at API                                                                                              
                                                                                                                                
     Support for  the $18  Million in  additional substance                                                                     
     use/misuse disorder  treatment, providing  funding for                                                                     
     inpatient   and   ambulatory   withdrawal   management                                                                     
     services,   residential   and   intensive   outpatient                                                                     
     residential treatment services, sobering center or 72-                                                                     
     hour  SUD  crisis  evaluation  services,  and  housing                                                                     
     assistance and support services                                                                                            
                                                                                                                                
     Support for  the $318.0  feasibility study  to explore                                                                     
     the need for a forensic hospital in Alaska                                                                                 
                                                                                                                                
     Support for API's budget  and recognition that present                                                                     
     funding is inadequate to  meet the dramatic admission,                                                                     
     discharge,  and  patient  and staff  safety  pressures                                                                     
     facing the hospital                                                                                                        
                                                                                                                                
3:54:09 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ acknowledged  Mr. Burn's long  service time with                                                                
the department, and asked whether  he feels the legislature made                                                                
the  right decision  in terms  of building  API with  an 80  bed                                                                
capacity, or does he feel  the legislature should have built API                                                                
out larger in the 1990s proposals.                                                                                              
                                                                                                                                
MR. BURNS answered that part of the appeal in building a smaller                                                                
API was that there would be 16 beds of designated evaluation and                                                                
treatment directly in  Anchorage with the  understanding that 80                                                                
beds would have been adequate.   He related that that particular                                                                
portion of the commitment was never followed up on, there was an                                                                
attempt but it failed which meant the facility was down 16 beds.                                                                
In  addition,   he  opined,   there  was  a   real  expectation,                                                                
particularly by advocates  in the communities,  that there would                                                                
be substantial ongoing support to  make sure the communities had                                                                
adequate  local  support  for   those  individuals  with  mental                                                                
health/substances abuse  issues.   Unfortunately, he  said, that                                                                
commitment   would  have   required   a   continuing  additional                                                                
commitment to those communities which has been hard to maintain.                                                                
In a  perfect world, if  everyone had  done what the  plans said                                                                
they would do, API would probably be okay but that didn't really                                                                
take place.                                                                                                                     
                                                                                                                                
3:57:29 PM                                                                                                                    
                                                                                                                                
FAITH MYERS, Mental Health Advocate, advised that she volunteers                                                                
as  a mental  health advocate,  she has  served on  numerous API                                                                
committees,  and  is  a  board  member (indisc.).    Psychiatric                                                                
hospitals and  (indisc.) operate in  self-interest, "we  are not                                                                
going  to voluntarily  improve  rights of  care  for psychiatric                                                                
patients."    Thereby, leaving  the  legislature and  the  court                                                                
system  to  protect psychiatric  patients  wherein thousands  of                                                                
individuals are  brought into  forced psychiatric  evaluation or                                                                
treatment each year  in Alaska at over  $1,500 per day.   In the                                                                
process, 47 percent will experience  sexual trauma or harm which                                                                
may  cause  exacerbate  post-traumatic stress  disorder  (PTSD).                                                                
Evidence  indicates that  PTSD  is associated  with the  highest                                                                
rates of  medical and mental  health services, making it  one of                                                                
the costliest  mental disorders.   There  is a  real correlation                                                                
between  the  lack  of  rights  for acute  care  of  psychiatric                                                                
patients and the  poor system of care,  as at API.   Among those                                                                
rights,  psychiatric patients  should  have  the  right to  have                                                                
(indisc.) trauma  recognized by  the Alaska hospitals  and units                                                                
and treatment  provided.  Providing care  rights for psychiatric                                                                
patients will  force  the various  state departments  to develop                                                                
proper systems of care  that reach best practices in psychiatric                                                                
hospitals and units.  Best practices for the state, she offered,                                                                
would be for the legislature to  pass a bill similar to the 2008                                                                
Georgia  House Bill  535, a  summary  of which  read as  follows                                                                
[original punctuation provided]:                                                                                                
                                                                                                                                
     This legislation  repeals current law providing  for a                                                                     
     State  and a  Community Ombudsman  for  Mental Health,                                                                     
     Mental Retardation,  and Substance Abuse,  and instead                                                                     
     provides  for   the  Office  of   Disability  Services                                                                     
     Ombudsman (Office). The Ombudsman  will serve as chief                                                                     
     officer of the office.  The Ombudsman will promote the                                                                     
     safety,  well-being,  and   rights  of  mental  health                                                                     
     consumers; will establish procedures for investigating                                                                     
     and  resolving  complaints;   investigate  actions  of                                                                     
     service  providers;  establish   a  uniform  statewide                                                                     
     complaint  process;  enter   and  inspect  facilities;                                                                     
     access  clinical  and   agency  records;  promote  the                                                                     
     interests  of consumers  to  government agencies;  and                                                                     
     report to  law enforcement when  appropriate. The bill                                                                     
     also includes a separate                                                                                                   
     clause   to    cover   persons    with   developmental                                                                     
     disabilities and addictions.                                                                                               
                                                                                                                                
4:00:20 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  shared that Legislative Legal  and Research                                                                
Services is drafting legislation based on Georgia House Bill 535                                                                
for the committee's review and study.                                                                                           
                                                                                                                                
4:00:51 PM                                                                                                                    
                                                                                                                                
DORRANCE  COLLINS,  Mental  Health  Advocate,  advised  that  he                                                                
volunteers as  a mental health  advocate.   In 2010, he  said he                                                                
served as  a board  member on  the Alaska  Psychiatric Institute                                                                
Advisory Board, made a tour of  three of the hospital units, and                                                                
wrote a  four-page report with  16 constructive criticisms.   He                                                                
described that a patient was lying in a urine soaked bed at 3:00                                                                
p.m., and  he was informed that  the hospital had  no policy for                                                                
when to  change the sheets of  the patients.  The  API and other                                                                
hospitals have  never voluntarily developed  psychiatric patient                                                                
policies that  properly protect disabled patients and  help with                                                                
recovery.   He referred to  the 2008 Georgia House Bill 535, and                                                                
advised that  10 years  ago, the Georgia  legislature determined                                                                
that its equivalent of the Department of Health and Services and                                                                
the providers  of services  of psychiatric patients  operated in                                                                
self-interests.    So much  so,  he  said,  it was  proven  that                                                                
Georgia's Department of Health and Social Services was incapable                                                                
of writing  or enforcing  fair rules  to protect  their clients.                                                                
(Indisc.) cost of investigating their  client's basic rights.  A                                                                
number of years  ago, he said he went  to the Ombudsman's Office                                                                
and it was determined  that Behavior Health had not investigated                                                                
patients' complaints in five years as  it was not their priority                                                                
list  to  investigate complaints.    He  noted  that as  to  the                                                                
testimony today,  his group is  totally against practice  of the                                                                
transfer of  criminals into non-criminal units  in API and  if a                                                                
larger hospital  was built the  rights of the patients  would be                                                                
improved.   Patrons of  API  and the  people who  make decisions                                                                
believe that the patients have no clear right to fair treatment,                                                                
or fair rights, he said.                                                                                                        
                                                                                                                                
4:04:13 PM                                                                                                                    
                                                                                                                                
JAMELIA SAIED, Counselor, advised that she grew up in Fairbanks,                                                                
is a professional mental  health counselor, has had interactions                                                                
with API over 25 years, and has served on the boards for several                                                                
mental health  organizations.  For  several years, she  said she                                                                
offered  weekly presentations  at  API  on particular  treatment                                                                
programs,  and  worked  with  her own  patients  at  API.    She                                                                
applauded  the  committee  for   performing  this  long  overdue                                                                
investigation and she considers most the employee concerns to be                                                                
valid  because they  often are  not adequately  trained in  best                                                                
practices and  often work  in conditions without  supervision or                                                                
support.   She  asked  the committee  to  strongly consider  the                                                                
impact that the inadequate employee conditions have on patients.                                                                
During the time she conducted the presentations at API, numerous                                                                
patients  were always  asking her  for  help with  some kind  of                                                                
problem, sometimes  the issues were  easily resolved by  a staff                                                                
members, and  other issues were fundamental  problems with their                                                                
treatment.  For example, there were constant problems with their                                                                
medications due to a revolving door of providers, and being told                                                                
they were about to be discharged with no plan in place.  Working                                                                
as a clinician for patients at API, she said she would generally                                                                
have difficulty reaching the attending doctor to discuss ongoing                                                                
outpatient  care, and  oftentimes they  could  not remember  the                                                                
patient to whom  she was inquiring.  She  described that she had                                                                
advocated for  a larger  institution, API is  too small  for its                                                                
community especially when  considering that API  not only serves                                                                
Anchorage, it  serves rural communities  statewide.  Due  to the                                                                
constant shortage of beds, many individuals who need help end up                                                                
in jail, thereby  resulting in the DOC being  the largest mental                                                                
health provider  in the  state.   Also,  she remarked,  many API                                                                
patients have  co-existing substance abuse disorders  and opined                                                                
that there  are only eight  de-tox beds available  in Anchorage.                                                                
The API  has serious problems  for both employees  and patients,                                                                
and  the  other states  that  have  examined  these issues  have                                                                
successfully corrected  the problems.   It will cost  money, she                                                                
offered,  because  nurses  and  the  other  medical  staff  need                                                                
competitive wages  when the  committee considers  the additional                                                                
stress in  working with  API patients.   She expressed  that the                                                                
salaries should actually be  higher at psychiatric institutions.                                                                
The inadequate care  the patients are receiving  ends up costing                                                                
the   state  more   dollars   in  terms   of   increased  crime,                                                                
homelessness,  and  the  substance   abuse  epidemic  Alaska  is                                                                
experiencing.                                                                                                                   
                                                                                                                                
4:09:09 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ commented that she appreciates Ms. Saied drawing                                                                
the  link  between   appropriate  staffing  levels,  appropriate                                                                
training,  and  how  that  translates to  appropriate  care  for                                                                
patients.                                                                                                                       
                                                                                                                                
4:09:30 PM                                                                                                                    
                                                                                                                                
ANGELIKA  FEY  MERRIT  shared  anecdotes  about  her  daughter's                                                                
experiences at API.   After sharing  her daughter's experiences,                                                                
she stated that API is not a  safe place for the patients or the                                                                
staff, it is  not a stable environment for her  daughter, and no                                                                
treatment is  provided for the patients  other than medications.                                                                
She urged the legislature to provide treatment programs for long                                                                
term patients,  like her  daughter, rather  than re-traumatizing                                                                
the patients.                                                                                                                   
                                                                                                                                
4:18:54 PM                                                                                                                    
                                                                                                                                
RICH  RADUEGE,  Psychiatric   Nursing  Assistant  (PNA),  Alaska                                                                
Psychiatric  Institute,  Shop  Steward   for  the  Alaska  State                                                                
Employees Association  Local 52,  said that  API is  a dangerous                                                                
place to work and he shared his experiences working at API since                                                                
1987.      In  2018,   the   Occupational   Safety  and   Health                                                                
Administration  (OSHA)  found  API  to  be  a  generally  unsafe                                                                
workplace,   and  in   2015,   Dr.   Joshua  Dvorkin,   forensic                                                                
phycologist, law  professor at  the  University of  Arizona, was                                                                
hired by  then CEO Melissa  Ring at API  to make recommendations                                                                
regarding  the unsafe  workplace issues.   He  related that  Dr.                                                                
Dvorkin wrote as follows:                                                                                                       
                                                                                                                                
     In  my  opinion, API  is  significantly  and at  times                                                                     
     dangerously understaffed.   When staff is inadequately                                                                     
     staffed, staff members become  fearful of patients and                                                                     
     as  a result  they  may  spend too  much  time in  the                                                                     
     nursing station  and not enough  time interacting with                                                                     
     their  patients.     Understaffing  also  reduces  the                                                                     
     ability  of   staff   to  intervene   early   in  non-                                                                     
     confrontational ways which  would allow them  to avoid                                                                     
     many of the circumstances which lead to ... end up use                                                                     
     of force."                                                                                                                 
                                                                                                                                
Dr. Dvorkin  also recommended that  24 permanent floor  staff be                                                                
added and noting that CEO Dr. Ring had previously made that same                                                                
recommendation as well.   The staffing  of permanent experienced                                                                
PNAs is inadequate and API recently started a program of filling                                                                
the lack  of those permanent  staff positions with  on-call non-                                                                
permanent  staff.   He described  that these  staff  members are                                                                
inexperienced, can only work a  certain number of hours, and are                                                                
supposed to  be used as  substitutes for the  permanent staff on                                                                
leave or  workmen's compensation.   Staff are reluctant  to take                                                                
the  lead  in controlling  a  disruptive  patient because  every                                                                
restraint is likely to result in blame by the lead staff person,                                                                
he  stressed, the  PNA performing  the restraint  should not  be                                                                
subject  to blame  because  this prevents  open  debriefing when                                                                
blame occurs  and it  prevents interventions that  would benefit                                                                
the other  patients, and  no standardize policy  exists allowing                                                                
for the restraint type of  intervention.  Staff are reluctant to                                                                
open up  in debriefing for  fear of blame  and punishment, which                                                                
prevents adequate recordkeeping  for the benefit of  the patient                                                                
involved as well as the staff  who must deal with the patient on                                                                
the next  shift.  Code Grey,  he explained, is  called when more                                                                
staff are needed for a behavioral emergency, oftentimes the code                                                                
is for  a show  of support  and moving more  PNA staff  onto the                                                                
floor, which has  the calming effect of safety in  numbers.  The                                                                
theory behind the  101 and the  201 is that it  prevents harm to                                                                
the patient  as well as  the staff and  often this is  enough to                                                                
prevent what otherwise might be a restraint.  The staff receives                                                                
only  a  couple of  days  of training  per  year  by the  PNA-4;                                                                
however, many PNA-4s  are themselves investigated for performing                                                                
restraints incorrectly.   He  said, API was  found to  have four                                                                
times the number of  assaults as other residential mental health                                                                
facilities.                                                                                                                     
                                                                                                                                
4:25:28 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE ZULKOSKY requested the definition of PNA, and the                                                                
ratio  of staff  to  patient.   She  said she  thought that  Mr.                                                                
Raduege had said  there was an additional 12, and  he had stated                                                                
another number.                                                                                                                 
                                                                                                                                
MR. RADUEGE answered  that a psychiatric nursing  assistant is a                                                                
PNA.   Previously, staffing was  based on acuity wherein  a high                                                                
acuity patient would be a four, a low acuity patients would be a                                                                
one, and the unit would be staffed for the day or the next shift                                                                
by that acuity.  Currently, he  explained, it is a core of three                                                                
staff members no  matter the height of the acuity,  and there is                                                                
extra staff if a patient is on a one-to-one which means they are                                                                
observed by one person 24 hours per day sometimes.                                                                              
                                                                                                                                
4:26:40 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  ZULKOSKY  asked   Mr.  Raduege  to   repeat  his                                                                
testimony  wherein he  had mentioned  additional recommendations                                                                
for additional positions.                                                                                                       
                                                                                                                                
MR.  RADUEGE reiterated  that  the way  staffing was  previously                                                                
followed was by an acuity on the severity of the milieu, and now                                                                
it is a flat three number, if  that is the number, of staff that                                                                
come in every day.                                                                                                              
                                                                                                                                
REPRESENTATIVE ZULKOSKY commented  that she thought  Mr. Raduege                                                                
had mentioned an additional 12 staff per shift.                                                                                 
                                                                                                                                
MR. RADUEGE clarified that  he meant 12 staff for  the whole 24-                                                                
hour period.                                                                                                                    
                                                                                                                                
4:27:30 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JOHNSTON  said  she   thought  Mr.  Raduege  had                                                                
mentioned an additional 8 staff for the weekend.                                                                                
                                                                                                                                
MR. RADUEGE answered  that on the weekends,  staff works 12-hour                                                                
shifts.  There are three shifts on the weekdays and then 12-hour                                                                
shifts which  would decrease  the number  needed on  the weekend                                                                
because they work 12-hour shifts on the weekends.                                                                               
                                                                                                                                
REPRESENTATIVE JOHNSTON requested  the current number  of vacant                                                                
PNA positions.                                                                                                                  
                                                                                                                                
MR. RADUEGE responded that he does not know the number of vacant                                                                
positions.                                                                                                                      
                                                                                                                                
REPRESENTATIVE JOHNSTON surmised that Mr. Raduege suggested that                                                                
even with API's current positions, staff is basically put on the                                                                
floor according to a flat  number versus the level of acuity and                                                                
there is room for a management change here.                                                                                     
                                                                                                                                
MR. RADUEGE answered that Representative Johnston was correct.                                                                  
                                                                                                                                
REPRESENTATIVE JOHNSTON  surmised that the  plan for  acuity has                                                                
changed as far as management's approach.                                                                                        
                                                                                                                                
MR. RADUEGE answered that Representative Johnston was correct.                                                                  
                                                                                                                                
4:28:32 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ commented  that Mr. Raduege  has been performing                                                                
this work for 30 years, which is a longtime for a public servant                                                                
in any line of work but particularly in this line of work.                                                                      
                                                                                                                                
4:29:04 PM                                                                                                                    
                                                                                                                                
SHEILA  LITTLE,   Registered  Nurse  (RN),   Alaska  Psychiatric                                                                
Institute (API),  Shop  Steward for  the Alaska  State Employees                                                                
Association Local 52,  advised that she is a  level 2 registered                                                                
nurse (RN) at API and she  usually works a 12-hour shift on a 10                                                                
bed unit  and supervises anywhere from  two to five  PNAs during                                                                
her shift.  First of all, she pointed out, some of API's members                                                                
had a  peaceful demonstration in front of API,  which was posted                                                                
on social  media.   After reading  some of  the comments  on the                                                                
post, it occurred  to her that there is  a rather negative image                                                                
of the people who work at API, and state workers in general, but                                                                
especially people who  work with the mentally ill.   She advised                                                                
that she  has been  in the  workforce for  42 years  and without                                                                
reservation she could say that the staff  at API are some of the                                                                
finest  people she  has  ever worked  with,  these people  bring                                                                
integrity, experience, and knowledge to this  job.  The staff is                                                                
from all over the world  and they are the most diverse workforce                                                                
she has ever seen.  She described the mental health field as the                                                                
least desirable of  all healthcare fields to work in  due to its                                                                
very nature, it is  a complex series of illnesses and disorders,                                                                
it is hard to  interpret, hard to understand, and hard to treat.                                                                
There is not  a great deal of job  satisfaction and feeling like                                                                
"you are  really accomplishing  something" because  the patients                                                                
suffer  with  these  illnesses  for the  rest  of  their  lives.                                                                
Sometimes, she offered, the best that  the staff can do is patch                                                                
them up  and send  them back  out again,  and that  becomes very                                                                
disheartening.   In addition, when  patients are admitted  to an                                                                
acute care facility, they are ill to begin with, they have often                                                                
been off  of their  medications, and are  frustrated and  fed up                                                                
with their  illness and  the changes it  brings to  their lives.                                                                
Consider that these patients usually do  not have a good support                                                                
system  or housing,  they  are  not working,  they  do not  have                                                                
insurance, and  on top of  that they  are now committed  to this                                                                
facility  by family  members or  someone in  the  community, she                                                                
remarked.  By  the time these patients are admitted  to API they                                                                
are quite  upset and  spoiling for  a fight,  unfortunately, the                                                                
PNAs  are   the  closest   staff  upon   which  to   vent  their                                                                
frustrations, she advised.                                                                                                      
                                                                                                                                
4:32:03 PM                                                                                                                    
                                                                                                                                
MS. LITTLE  stressed that  the first  24-hours, the  first three                                                                
days, the patients admitted to  API are incredibly dangerous for                                                                
the PNAs.   The PNAs have suffered injuries, such  as: injury to                                                                
their backs; legs; knees when  patients kick their legs out from                                                                
under them; bones  have been broken including  their fingers and                                                                
faces; staff have  endured the patients spitting  blood on them;                                                                
and throwing urine  into their eyes and mouths to  cause as much                                                                
damage as  they possibly can because the  patients are extremely                                                                
angry people.  Ms. Little stressed that these wounds are carried                                                                
by the staff for the rest  of their lives.  She advised that her                                                                
rotator  cuff had  to be  repaired  because she  happened to  be                                                                
walking down the  hallway when a patient grabbed  her arm, threw                                                                
it behind her,  ripped it, and in just a  matter of seconds, she                                                                
could not lift her arm.                                                                                                         
                                                                                                                                
4:33:02 PM                                                                                                                    
                                                                                                                                
MS.  LITTLE  explained  that  as  difficult  as  these  physical                                                                
injuries are, the  worst parts are the  constant verbal assaults                                                                
with  vile  and  vicious  attacks regarding  the  staff's  race,                                                                
gender,  the shape  of  staff's  bodies, and  so  forth.   These                                                                
attacks  are  meant to  disarm  the  staff  and make  them  lose                                                                
confidence in themselves, and even though the staff expects this                                                                
type of treatment, it is not  always easy to put things, such as                                                                
those verbal attacks,  away.  She advised that  the staff shared                                                                
with her  that the  greatest current issue  facing them  is this                                                                
culture of fear that began approximately seven years ago.  Seven                                                                
years ago, the safety  department was staffed with nursing staff                                                                
who understood the  interactions on the floor,  when the cameras                                                                
were  installed, the  safety  department was  then staffed  with                                                                
social workers  who had no  experience with the  interactions on                                                                
the floor  or with  patients.   Currently, everything  the staff                                                                
does is judged and judged quite harshly, and there is no nursing                                                                
staff  input  when it  comes  to  reviewing  the tapes  when  an                                                                
incident takes place, she expressed.   A Code Grey is not called                                                                
as it  should be  called, when  a Code  Grey is  called everyone                                                                
knows it is  serious and everyone needs to  respond.  Currently,                                                                
the  staff is  hearing things  like the  staff needs  a show  of                                                                
support  because  the  difference there  is  that  there  is  no                                                                
paperwork for  a show  of support,  the paperwork  generates the                                                                
reviews, and once  the reviews take place,  people start getting                                                                
suspended, she advised.   She reiterated that this  is a culture                                                                
of fear wherein people no longer want to respond.  She described                                                                
a "bystander  effect" wherein  when the staff  does show  up for                                                                
codes, the staff  stand around waiting for someone  else to take                                                                
the first move.  The  common attitude is, she remarked, if staff                                                                
does  not touch  anyone and  does  not say  anything, the  staff                                                                
cannot get in trouble.                                                                                                          
                                                                                                                                
4:35:25 PM                                                                                                                    
                                                                                                                                
MS. LITTLE explained that together with the culture of fear, the                                                                
staff shortage  definitely contributes  to a  cycle of  ill will                                                                
between  the patients  and  staff, and  it  interferes with  the                                                                
staff's ability to give the patients the help they need.  Due to                                                                
the shortage  of staff, they  are not  available to talk  to the                                                                
patients,  calm  their fears,  and  give  them what  they  need.                                                                
Therefore,  she   explained,  the  patients  become   even  more                                                                
disgruntled  with the  staff,  become more  aggressive and  more                                                                
demeaning toward the  staff, thereby causing the  staff to "kind                                                                
of drift into the nurses' station and stay away from them, it is                                                                
a cycle."                                                                                                                       
                                                                                                                                
MS.  LITTLE pointed  out that  this entire  situation from  poor                                                                
staffing to  poor  management and  a hostile  safety environment                                                                
makes it  almost impossible to work  at API, and  during the two                                                                
years she  has returned to API,  it lost a good  majority of its                                                                
experienced  staff.   She  advised that  PNAs  are not  formally                                                                
trained, they learn everything they know about mental illness on                                                                
the  job.   The  on-call  staff currently  working  at API  know                                                                
absolutely  nothing about  mental health  so  they cannot  bring                                                                
their concerns  to the  nurses because  they do  not necessarily                                                                
know how  to read a  situation, they do  not know what  it looks                                                                
like  when  a  patient  is  escalating, or  when  a  patient  is                                                                
decompensating and looking for a quiet place to slip away and do                                                                
danger to themselves.   Documentation from the on  call staff is                                                                
proof of  this situation because time  and time over  again what                                                                
they have written  in the documentation is very  generic with no                                                                
useful information whatsoever, and from what  she has been told,                                                                
on any given day, 35 percent of the staff are the on-call people                                                                
coming  in.    She  stressed  that  API  is  no  longer  a  safe                                                                
environment.                                                                                                                    
                                                                                                                                
4:37:24 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SULLIVAN-LEONARD  requested information regarding                                                                
her   interactions  with   the  nursing   supervisors  and   the                                                                
administration in  order to  seek problem solving  solutions for                                                                
the issues she discussed.                                                                                                       
                                                                                                                                
MS. LITTLE  shared that previously,  she worked on  the forensic                                                                
unit but was recently moved  to another unit because an incident                                                                
took place on the floor of  the forensic unit.  She stated, "I'm                                                                
going  to be  very  careful  here because  I  don't  want to  be                                                                
retaliated against."   Ms.  Little explained  that the  ball was                                                                
dropped for a  particular patient by the  psychiatric staff, the                                                                
psychologist, wherein  the  PNA staff  was put  in  the position                                                                
where  someone was  injured and  then  someone was  fired.   She                                                                
stressed  that  none of  this  would  have  taken place  if  the                                                                
psychology staff had  handled this issue in the  manner it would                                                                
normally  have   been  handled  for   this  particular  patient.                                                                
Wherein, she and all of the PNAs involved complained and advised                                                                
that "this  is where everything  went wrong, if this  would have                                                                
been fixed,  none of this  would have  happened."  As  a result,                                                                
within three weeks  of the incident, each  person who complained                                                                
received a letter  to be interviewed and they  all received some                                                                
sort of  instruction.  There  was an  interview with one  of the                                                                
PNAs because  he was looking  at a  newspaper between performing                                                                
his locator rounds.  She explained that every 15 minutes the PNA                                                                
has a  slip of paper with  everyone's name on it,  and they walk                                                                
around and make eye contact with each patient and write down the                                                                
time, and this takes place four times in  one hour.  On the very                                                                
back of  the slip  of paper,  it actually  read, "While  you are                                                                
doing the locator,  you are not to do  anything else, you cannot                                                                
be distracted."   The PNA had performed his  rounds as required,                                                                
then stood at the  desk flipping through a newspaper while still                                                                
looking out  and keeping  an eye  on what  was happening  on the                                                                
unit, with eight  patients in bed asleep  at the time.   The PNA                                                                
was  called  upstairs  for  reading that  newspaper  in  between                                                                
performing his rounds,  and she was called  upstairs for failing                                                                
to supervise him and allowing him to read that newspaper between                                                                
rounds.  Now,  she said, they both have  a letter of instruction                                                                
and  she  believes  this  was  simply  retaliation  because  the                                                                
administration was  so insistent in  not holding  the psychology                                                                
staff  responsible for  what  had  taken  place with  this  very                                                                
volatile patient.                                                                                                               
                                                                                                                                
4:40:03 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SULLIVAN-LEONARD asked whether  she could explain                                                                
whether  there   were  pro-active  meetings  and   not  reactive                                                                
meetings.     She  further  asked  whether   the  nursing  staff                                                                
supervisors hold weekly meetings to discuss what had taken place                                                                
with the patients on  the floor, whether they discuss continuing                                                                
education unit (CEU) for educational purposes for the staff, and                                                                
whether there are  meetings with the administration  where it is                                                                
looking at pro-active solutions.                                                                                                
                                                                                                                                
MS. LITTLE responded that each of the five units are supposed to                                                                
have a nurse manager, and for  almost a year, three of the units                                                                
have not had a nurse manager with the Taku Unit being one of the                                                                
units.   The Taku Unit did  not have a supervisor  or a liaison,                                                                
and occasionally the Director of Nursing would hold a meeting in                                                                
the Taku  Unit once a  week, usually at  6:00 a.m.   She advised                                                                
that the  meeting was  on her  day off and  she rarely  made the                                                                
meeting because  she lives  45  miles away.   The  nursing shift                                                                
supervisors  usually  have   their  meeting  amongst  themselves                                                                
upstairs and  the floor  staff has its  meetings daily  at shift                                                                
change.   She  related that  when concerns  are shared  with the                                                                
shift supervisors,  it is on  a very  casual basis as  they make                                                                
their rounds.                                                                                                                   
                                                                                                                                
4:41:25 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JOHNSTON  referred to  Ms. Little  statement that                                                                
outsourced nurses  come in, and  in looking back at  the earlier                                                                
presentation,  there  are  four  traveling nurses.    She  asked                                                                
whether  these  are  two  different approaches,  one  group  are                                                                
traveling nurses and the other group are outsourced nurses.                                                                     
                                                                                                                                
MS. LITTLE answered that the traveling nurses are different from                                                                
the on-call staff,  the on-call staff are PNAs and  they are all                                                                
the unschooled PNA  staff, psychiatric nursing  assistants.  The                                                                
traveling nurses are  a recent new approach in  filling those 11                                                                
nursing vacancies,  and she has  not yet encountered any  of the                                                                
traveling nurses.                                                                                                               
                                                                                                                                
4:42:35 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JOHNSTON  referred to  the  11  nursing  [leave]                                                                
vacancies due to various reasons, and asked whether any of those                                                                
leave vacancies were due to suspensions, fear, knowledge, or are                                                                
they all related to illnesses, birth of babies, and so forth.                                                                   
                                                                                                                                
MS. LITTLE  replied that she  was unsure, although, a  couple of                                                                
months ago there was an exodus of approximately three nurses who                                                                
had been  employed at API  for some time.   She opined  that the                                                                
exodus  had something  to do  with discontent  over  the nurse-3                                                                
positions, the  nurse manager positions.   These are  nurses who                                                                
wanted these positions and yet the positions were not being made                                                                
available, at least one nurse moved on because she was unable to                                                                
apply for a position that she was well qualified for even though                                                                
the need was there.                                                                                                             
                                                                                                                                
4:43:46 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JOHNSTON  asked whether  it was  seven  years ago                                                                
that API  installed the cameras, or  seven years ago  it changed                                                                
from nurses reviewing the cameras to social workers.                                                                            
                                                                                                                                
MS.  LITTLE  responded  that  both  of  those  actions  occurred                                                                
approximately  seven years  ago  and  at  the  same time.    She                                                                
explained that she first  went to work at API  in 2009, and when                                                                
the new prison in valley, that was close to her home, opened she                                                                
moved to the prison and worked for two years.  She then returned                                                                
to API in 2016 and has  been there for two years wherein she has                                                                
noticed  a  big change.    She  related  that the  cameras  were                                                                
installed  and the  safety  department switched  over to  social                                                                
services type  individuals rather than the  nursing staff around                                                                
the time she left API.                                                                                                          
                                                                                                                                
REPRESENTATIVE  JOHNSTON  asked  whether   the  social  services                                                                
individuals have Master of Social Work Degrees (MSW) or are just                                                                
people with  a social  services backgrounds and  risk assessment                                                                
backgrounds.                                                                                                                    
                                                                                                                                
MS. LITTLE opined that that is the  case, but there is not a lot                                                                
of  personal interaction  from  the people  downstairs with  the                                                                
people upstairs.  She related that  about the only time they see                                                                
the people upstairs is when staff has been called upstairs.                                                                     
                                                                                                                                
4:45:54 PM                                                                                                                    
                                                                                                                                
MUSA  KANTEH,   Psychiatric  Nursing  Assistant   (PNA),  Alaska                                                                
Psychiatric Institute (API),  advised that he  has been employed                                                                
at API  since 2011, he is  graduate of (indisc.).   He explained                                                                
that he had been on-call staff for four years, and the last five                                                                
years he  has been full-time staff.   He described  that API has                                                                
been sliding downhill since 2011  with staffing being the number                                                                
one issue,  and he has  observed that the  training is currently                                                                
quite different  from 2011, such that,  "When we got  cited last                                                                
time  by OSHA,  we used  to  (indisc.).   With man  some of  the                                                                
patients are violent  toward themselves or the  patient peers or                                                                
staff so you can  hold them down, we decide what  we need to do,                                                                
call  the  doctor,  and  the   doctor  will  write  the  order."                                                                
Previously, the training department staff had been there for 25-                                                                
30 years  and they all left.   Currently, the staff  must find a                                                                
place to  hide when the  patients are violent toward  the staff,                                                                
and there are  people training the staff that he  has never seen                                                                
on the floor, and if  he sees them, after 5-10 minutes they have                                                                
left the  floor.  He  commented that a person  cannot train when                                                                
they have  no idea  of the  job duties,  and requested  that the                                                                
staff receive professional training, which  would help the staff                                                                
train  themselves.   For example,  two years  ago,  a supervisor                                                                
trained the  staff, which  resulted in four  out of  seven staff                                                                
members cited  for mishandling  the patients, and  he questioned                                                                
how someone could teach him who was cited based on doing the job                                                                
right.  He stated that  has received verbal assault and has been                                                                
beat up  while performing his job  duties, and now, most  of the                                                                
experienced staff  are  all leaving  by retiring  or  moving on.                                                                
Most of  the staff have five  years invested, and  he said, "you                                                                
take a hike,  you don't want to  go into be on  medical care for                                                                
the rest of your life."  For example, a couple of his co-workers                                                                
were beat up  in front of him  and now they can  no longer walk.                                                                
He related that he is scared going to work and prays to God that                                                                
he completes  the day in  one piece  and continues to  enjoy his                                                                
life with his family.  Another example, a supervisor was beat up                                                                
a couple of times, suffered broken ribs, and due to the violence                                                                
stepped down and is  now going to school and  leaving.  There is                                                                
no communication  between the  upstairs and the  downstairs, and                                                                
working as a  team is not happening  because everyone is scared.                                                                
The staff is  afraid that if they do  something, they might lose                                                                
their job making it very stressful to  work at API.  He stressed                                                                
that he loves his  work, but he is scared as  to whether he will                                                                
lose his job or be injured.                                                                                                     
                                                                                                                                
4:51:21 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SULLIVAN-LEONARD  referred to the  situations the                                                                
staff has been experiencing and said that she knows the staff is                                                                
working closely with  their union.  She asked  whether the staff                                                                
is  unable  to   all  band  together  and  have   the  types  of                                                                
interactions with the administrators at API as he is having with                                                                
the  committee.   Obviously, she  said, the  administrators must                                                                
know and hear about these situations.                                                                                           
                                                                                                                                
MR. KANTEH explained  that he has a  good relationship with most                                                                
of the supervisors  he works with, but there is  no contact with                                                                
the administrators  because "they pass  by, they're gone."   The                                                                
staff is supposed to have  a monthly meeting with the management                                                                
but that  is not  taking place,  he noted that  the staff  has a                                                                
safety  committee but  if the  staff's comments  are unlikeable,                                                                
they will be dropped from the safety committee.                                                                                 
                                                                                                                                
REPRESENTATIVE JOHNSTON  related that part  of her  challenge is                                                                
that he has no authority  with the operations of API itself, but                                                                
the staff  collectively at least has  its union.   She suggested                                                                
that  the staff  "very strongly"  have those  meetings with  the                                                                
administrators  and have  a  "come to  Jesus  meeting."   It  is                                                                
clearly unacceptable  for people  to  be hurt  consecutively and                                                                
continually at the  API, and it  is a real challenge  to see the                                                                
dollars, the  low numbers of staff,  and so forth.   She offered                                                                
her appreciation for Mr. Kanteh to travel to Juneau to offer his                                                                
testimony.                                                                                                                      
                                                                                                                                
MR. KANTEH added that a  couple of on-calls have been hired, but                                                                
the on-calls have no job guarantee or benefits, so when you want                                                                
to  train those  people they  are not  interested and  they make                                                                
clear that their  jobs are not guaranteed and they  will not get                                                                
into  anything.   He noted  that when  patients bang  their head                                                                
against the  wall, the staff now  walk away and  cry because the                                                                
patients cannot be touched until someone gives the order to hold                                                                
the patient  down.  Previously,  when a patient  started banging                                                                
their head, the  staff would put a pillow  under their head, but                                                                
now  the staff  cannot  do that.    For example,  he advised,  a                                                                
patient said a bad  word to him and he said,  "yeah, I like it,"                                                                
and he was pulled off the floor for six weeks, plus there was an                                                                
incident where six  staff members were pulled off  the floor for                                                                
six weeks.                                                                                                                      
                                                                                                                                
4:55:16 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ offered appreciation for his testimony and noted                                                                
that one  of the reasons  he was asked  to testify was  to share                                                                
some his concerns.                                                                                                              
                                                                                                                                
4:55:40 PM                                                                                                                    
                                                                                                                                
JASON  LESSARD, National  Alliance on  Mental  Illness Anchorage                                                                
(NAMI), pointed  out that  API is the  only organization  of its                                                                
kind in the  state and it is a  critical component to the safety                                                                
and recovery  of many Alaskan.   He said that  when the National                                                                
Alliance on  Mental  Illness (NAMI)  hears reports  of concerned                                                                
safety  issues and  workplace  violence,  it  worries about  the                                                                
safety of Alaskans in the  acute phase of serious mental illness                                                                
who may have symptoms causing them  to be violent or have severe                                                                
cognitive impairments and/or  a danger to  themselves or others.                                                                
The NAMI also greatly worries about the safety of those who have                                                                
chosen to work  in this field in  any capacity that     supports                                                                
those suffering  from serious mental  illness and their  path to                                                                
recovery.  He pointed out that if the API environment is unsafe,                                                                
there are really no other  options for those patients in API who                                                                
are in  a state that puts  them among the most  vulnerable.  All                                                                
too often, [DOC] becomes the  de facto provider of mental health                                                                
services,  which is  not  only  inadequate  with regard  to  the                                                                
services and support of patient needs but it is also not the job                                                                
of the  (indisc.).  The staff  are not trained  as mental health                                                                
professionals and it  is unfair to all involved  when it becomes                                                                
the only other option.  The  fact that such a vital component in                                                                
the continuum of care does not  have an alternative and that the                                                                
environment is  unsafe is extremely  disconcerting, he stressed.                                                                
For these reasons,  those at NAMI believe it  is imperative that                                                                
the safety concerns  and staff shortages be  addressed, not just                                                                
quickly, but thoughtfully, collaboratively, and  with a holistic                                                                
approach in  relation to the  larger mental health  community in                                                                
the state.   He related that  NAMI is confident  that in working                                                                
together a solution will be found.                                                                                              
                                                                                                                                
4:58:10 PM                                                                                                                    
                                                                                                                                
ALISON KULAS,  Executive Director,  Alaska Mental  Health Board,                                                                
advised that she is the Executive Director of the Advisory Board                                                                
of  Alcoholism and  Drug  Abuse, and  the  board is  statutorily                                                                
charged with advising the governor, the related departments, and                                                                
the  legislature  in  planning  and coordinating  mental  health                                                                
services funded  by State of  Alaska.  This  board advocates for                                                                
programs and  services that serve people  with behavioral health                                                                
disorders, their  families, care providers, and  communities, it                                                                
has long partnered with Department of Health and Social Services                                                                
(DHSS) and EPI.  This board has a standing seat on the API board                                                                
to better  understand the  service needs and  identify resources                                                                
for Alaskans experiencing a mental health disorder episode.  The                                                                
Alaska  Mental   Health  Board   believes  it   has   long  been                                                                
demonstrated  that  there   is  a  need   for  additional  acute                                                                
behavioral health care services in Alaska and she noted the lack                                                                
of residential  facilities for  adults with acute  mental health                                                                
needs.    The   inpatient  psychiatric  emergency  services  and                                                                
inpatient  psychiatric  hospitals,  emergency  departments,  and                                                                
inpatient general hospitals, are the  primary location for these                                                                
services.    This board  is  working  with  partners across  the                                                                
spectrum to truly  understand the current needs  of API patients                                                                
and staff, and  she advised that it  is gathering information as                                                                
to other  state's promising best practices, such  as the Georgia                                                                
legislation, and some promising work out of the Unity Program in                                                                
Portland, Oregon.   She stated  that this board is  committed to                                                                
continuing this conversation  with providers, patient advocates,                                                                
and  the   department  to  identify   short-term  and  long-term                                                                
solutions.   This board will  then pull all  of this information                                                                
together with  some proposed  solutions wherein  the legislature                                                                
and  all stakeholders  involved can  share back  their comments.                                                                
Additionally,  this  board  is  advocating  for  allowing  other                                                                
hospitals  and community  health programs  across  the state  to                                                                
increase capacity through the enhanced DSH funding that Director                                                                
Burns  mentioned.   This additional  funding, together  with the                                                                
federal funds,  will alleviate the  immediate needs in  order to                                                                
provide the appropriate level of care to Alaskans experiencing a                                                                
mental  health crisis.   Long-term  solutions are  underway, she                                                                
advised,  to  increase  behavioral  health  treatment  with  the                                                                
additional  Certificates of  Need  that  addresses Title  11.15,                                                                
Division of Behavioral Health  Demonstration Waiver.  This board                                                                
wants to look at the big  picture of the structure of all of the                                                                
above services in Alaska and identify where those situations are                                                                
occurring and how to meet the needs of Alaskans, she explained.                                                                 
                                                                                                                                
5:01:43 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SULLIVAN-LEONARD asked whether Ms. Kulas said she                                                                
is on the API board.                                                                                                            
                                                                                                                                
MS. KULAS  responded that  the Alaska  Mental Health  Board does                                                                
have  a  seat on  API's  board  (indisc.)  current board  member                                                                
working with API.                                                                                                               
                                                                                                                                
5:02:07 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SULLIVAN-LEONARD referred to the testimony of the                                                                
psychiatric nursing assistant and the  nurse working at API, and                                                                
requested her comments as to these great concerns.                                                                              
                                                                                                                                
MS.  KULAS answered  that she  had been  taking a  lot  of notes                                                                
during this  entire hearing,  and this  is something  the Alaska                                                                
Mental Health  Board has  heard about and  has discussed.   This                                                                
board will have this quarter's  full board meeting next week and                                                                
this discussion  will be continued.   She  said that one  of the                                                                
questions the board has  asked, particularly when it pertains to                                                                
the violence piece, is where the violence is occurring, on which                                                                
unit, and  whether it is  patient to patient, patient  to staff,                                                                
staff  to  patient,  in  order  to  understand  the  issues  and                                                                
incorporate that  information into its  proposed solution.   The                                                                
board members are definitely asking  those questions in order to                                                                
support the staff and patients at API.                                                                                          
                                                                                                                                
5:03:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JOHNSTON  referred to  slide 22,  "Patient Injury                                                                
Rate  - Number  of  Client  Injury Events  for  all Causes  that                                                                
Occurred for Every 1000 Inpatient Days"  from 2014 to the second                                                                
half of 2017; and slide 23, "Staff Injury Rate - Number of Staff                                                                
Injury  Events of  any  Severity that  Occurred  for Every  1000                                                                
Inpatient  Days"  from  2014  to the  second  quarter  of  2017.                                                                
Representative   Johnston  commented   that   both  slides   are                                                                
interesting graphs because  the incidents are from  zero to 3.5,                                                                
and they look fairly dramatic.   She asked whether Ms. Kulas had                                                                
reviewed  these  slides and  studied  why  there are  peaks  and                                                                
sometimes drops in injuries.  She further asked whether this has                                                                
been part of the board's discussions, whether the board is aware                                                                
of these  graphs because it  appears things have changed  on the                                                                
floor since 2013, and she  would like to see the stats beginning                                                                
in 2011.                                                                                                                        
                                                                                                                                
MS. KULAS  answered that  she is not  entirely sure  about those                                                                
graphs in particular, but she knows this board does have some of                                                                
that information and she would  follow up with Director Burns to                                                                
be sure she  has a copy.   This board is also  interested in the                                                                
peaks of  injury, and what  changes were taking place  to really                                                                
understand  what  that  data  means.    One  of  the  testifiers                                                                
mentioned that during the last seven years the staff has noticed                                                                
the change, and it is  important for the board to ask additional                                                                
questions, she commented.                                                                                                       
                                                                                                                                
5:06:15 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ noted  that Ms. Kulas mentioned  other assets in                                                                
the  community,  and  a  couple  of Certificate  of  Needs  were                                                                
recently approved  for Alaska  Regional Hospital  and Matanuska-                                                                
Susitna  Regional  Hospital  to  add  a  significant  number  of                                                                
additional behavioral health beds.   She asked whether Ms. Kulas                                                                
believes that is an important remedy, whether it is just a piece                                                                
of the  puzzle, and  whether that remedy  will be  a significant                                                                
contributor from her perspective.                                                                                               
                                                                                                                                
MS.  KULAS  replied that  definitely  it  is  critical that  the                                                                
members of the communities follow this issue  so it does not all                                                                
fall  directly onto API,  and  asked what  other support  can be                                                                
given to  the communities.  The  additional Certificates of Need                                                                
is one  piece and  it is  a little bit  more of  an intermediate                                                                
solution,  and  just to  make  sure  that  those facilities  are                                                                
getting up  and running and  able to serve  the needs.   That is                                                                
where this  board also sees the  Disproportionate Share Hospital                                                                
(DSH) funding that is currently in the House of Representative's                                                                
budget in  giving (indisc.)  in addition  to getting  that other                                                                
(indisc.) match to increase the  services across the state.  She                                                                
related that originally, when they put this proposal together as                                                                
Director Burns mentioned,  they were anticipating a  lot more of                                                                
that community support  piece but that really  has not happened.                                                                
She opined that with the  Certificates of Need and potential DSH                                                                
funding, there  can be more  community based support  to relieve                                                                
some of that pressure.                                                                                                          
                                                                                                                                
5:08:04 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ requested information regarding the forensic bed                                                                
capacity challenges, and pointed out that the committee is aware                                                                
that the Department of Corrections (DOC)  has turned into the de                                                                
facto provider  of mental health care  when there is  not enough                                                                
capacity at  API.   She asked  whether the Alaska  Mental Health                                                                
Board has been looking into that issue.                                                                                         
                                                                                                                                
MS. KULAS responded that this  board is especially interested in                                                                
the forensic  bed study as  this is  something that some  of the                                                                
board members  have taken  a particular interest  in as  to what                                                                
other  states are  doing, how  does Alaska  differ, what  can be                                                                
pulled from other state's  models, and definitely supporting the                                                                
Alaska Mental Health Trust Authority in the forensic bed study.                                                                 
                                                                                                                                
5:09:19 PM                                                                                                                    
                                                                                                                                
STEVE WILLIAMS,  Chief Operating  Officer, Alaska  Mental Health                                                                
Trust Authority,  offered that due  to time constraints  and the                                                                
wealth  of  information offered  today,  he  will defer  to  any                                                                
outstanding questions  or verifications  the committee  may have                                                                
wherein the trust could provide additional information.                                                                         
                                                                                                                                
5:09:48 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR referred to the testimony that PNA positions                                                                
are not  formally trained,  and noted her  surprise in  terms of                                                                
making  sure people  have  the background  and  resources to  be                                                                
successful in  their positions, even  absent staffing challenges                                                                
and  behavioral challenges.    It appears,  she  said, that  the                                                                
Alaska  Mental Health  Trust  Authority,  because it  funds  the                                                                
initial phrase of  work, or start up projects, could  be a place                                                                
to fill that gap and provide some additional support.  She asked                                                                
whether that is something the  Trust has considered or how could                                                                
the legislature look to the Trust to help address that issue.                                                                   
                                                                                                                                
MR.  WILLIAMS  asked  whether  Representative Tarr  was  talking                                                                
specifically about  the Trust providing  some additional support                                                                
as it relates to workforce training, and in particular API.                                                                     
                                                                                                                                
REPRESENTATIVE   TARR   answered   in   the   affirmative,   and                                                                
specifically for these  individuals who are doing  the best they                                                                
can but  given the  staffing and safety  challenges, are  put in                                                                
harm's way just to go to work every day.  She explained that she                                                                
was talking about training  in de-escalation or other behavioral                                                                
modification training.                                                                                                          
                                                                                                                                
MR. WILLIAMS answered that for several years, the Trust has been                                                                
heavily focused on workforce training and development, and it is                                                                
largely focused in community behavioral health and other systems                                                                
of care that  serve Trust beneficiaries.  In order  to make sure                                                                
there is  a well trained  field workforce that can  provide that                                                                
quality  of care,  and  in listening  to  the  discussion today,                                                                
certainly this is an area in which the Trust could work with the                                                                
department and  Director Burns  in looking at  the opportunities                                                                
here where  the Trust might be  able to partner  to help provide                                                                
additional training to staff on an ongoing basis.                                                                               
                                                                                                                                
5:12:29 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  asked whether the  Trust has  the authority                                                                
to, within  its own budget,  have funding available  because the                                                                
legislature is not quite finished with the budget for the Alaska                                                                
Mental Health  Trust Authority, and  if there is  something that                                                                
needs to  be included, now  would be  time.  The  state is  in a                                                                
crisis  situation,  she  described,  and   she  is  thinking  of                                                                
something more immediate and "very  near term kind of activity."                                                                
Even  if it  was just  more in  a  therapeutic sense,  it almost                                                                
sounds like  the trauma  associated with  the positions  must be                                                                
taking its toll.  She  asked whether that is something the Trust                                                                
could independently  do given the  authority and the  dollars it                                                                
has,  or  is  it  something  the legislature  must  specifically                                                                
outline as a priority.                                                                                                          
                                                                                                                                
MR. WILLIAMS answered that it would be something the Trust would                                                                
want to discuss with API  as to its staffing and training needs.                                                                
The Trust certainly has the ability  to help in a short-term and                                                                
quick manner if there is a need,  and it has the ability to pull                                                                
in the additional  training these folks need.   He stressed that                                                                
it would require sitting down  to really understand the training                                                                
needs and what is missing in getting the staff that training.                                                                   
                                                                                                                                
5:13:55 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR commented that that suggestion sounds like a                                                                
good  idea, and  she  truly hopes  that that  is  an issue  that                                                                
receive attention in the very near future for everyone's safety,                                                                
the safety  of vulnerable Alaskans who  need tremendous support,                                                                
and also  the safety of  the staff.   She expressed that  she is                                                                
thankful  there  are  people  who  are  willing  to  take  those                                                                
positions, especially  given the challenges,  and she  hopes the                                                                
Trust and  API can talk soon  so the legislature  will learn the                                                                
results of that discussion soon.                                                                                                
                                                                                                                                
MR. WILLIAMS replied that  the Trust will be happy  to share the                                                                
results of those conversations with the legislature.                                                                            
                                                                                                                                
5:14:36 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JOHNSTON referred to slide 28, "What is DBH Doing                                                                
to Work  these Problems?  Staff Injuries (continued)"  and noted                                                                
that  it appears  API  is working  with  the  Western Interstate                                                                
Commission for Higher  Education (WICHE) to access  the value of                                                                
the API  training programs.   It appears that with  Mr. Williams                                                                
having a discussion with  [API], and hopefully outside resources                                                                
are being pulled in which can  be of great benefit, that this is                                                                
something  the  Trust   could  be  doing  no   matter  what  the                                                                
legislature ends up doing.                                                                                                      
                                                                                                                                
MR. WILLIAMS answered  that that is exactly what  the Trust does                                                                
with these and  other types of situations, and  the WICHE report                                                                
is one, there have been  several others in talking with API that                                                                
pointed out areas for improvement or  for services and the Trust                                                                
can sit down with the department and look at how to get to those                                                                
ends and "get this recommendation."                                                                                             
                                                                                                                                
5:15:51 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE ZULKOSKY  commented that  in trying  to  wrap her                                                                
mind  about  this  discussion,  it  is  clear  that  not  enough                                                                
resources have  been put forward  for API in  understanding what                                                                
the  facility  staffing  needs  are,  married  with  the  actual                                                                
facility needs,  infrastructure needs, as  well as the  needs of                                                                
ongoing continuing education.   Having had this conversation, it                                                                
is important to  know the numbers of  staffing needs versus what                                                                
has actively  been budgeted,  so the legislature  can understand                                                                
from  a high  level of  perspective what  the funding  needs are                                                                
overall and how the legislature can help API get positioned to a                                                                
place where  the staff  are safe and  the patients  are actually                                                                
receiving the resources and care they  need at such an important                                                                
facility she said.                                                                                                              
                                                                                                                                
MR. WILLIAMS asked whether hers was an overarching statement and                                                                
that  when the  information is  provided back  to  the committee                                                                
members,  having  some  of   this  detailed  information  better                                                                
illustrated would be helpful.                                                                                                   
                                                                                                                                
REPRESENTATIVE ZULKOSKY answered in the  affirmative and that it                                                                
was an  overall request that was  not so much  focused solely on                                                                
the Alaska Mental Health Trust Authority.                                                                                       
                                                                                                                                
5:17:47 PM                                                                                                                    
                                                                                                                                
CHAIR  SPOHNHOLZ  referred  to  the capacity  level,  and  asked                                                                
whether  there is  the  capacity to  meet  the  needs for  acute                                                                
psychiatric care in  the state.  She  related that she continues                                                                
to be concerned when  speaking with patient advocates, about the                                                                
state's tendency "for lack of a  better word, sort of get people                                                                
stabilized or  tuned up  and then  send them  back out  into the                                                                
community" without a lot  care, and the fact that  the state has                                                                
many folks with severe mental illness in prisons.  She asked Mr.                                                                
Williams  to  describe the  discussions  around looking  at  the                                                                
forensic bed capacity within API.                                                                                               
                                                                                                                                
MR. WILLIAMS answered that Director Burns talked about it in his                                                                
presentation  when walking  through the  beds  and services  API                                                                
provides to Alaskans with mental  health issues.  Director Burns                                                                
mentioned that API carved out  10 beds dedicated to the forensic                                                                
unit and  those beds are  generally used for  individuals with a                                                                
pending criminal charge wherein  their legal competency has been                                                                
raised.  He explained that  the person's criminal case is stayed                                                                
until a  staff psychologist has performed  a forensic competency                                                                
evaluation for the court.  He further explained that the results                                                                
of  a competency  evaluation are as  follows: in  the  event the                                                                
evaluation determines the  person competent to  stand trial, the                                                                
trial will commence; if the person is not competent but there is                                                                
a potential for competency and restoration, the criminal case is                                                                
stayed until the person is restored to legal competency and they                                                                
are aware of the court's surroundings, the charges against them,                                                                
and  are able  to assist  their attorney  in their  own defense,                                                                
wherein the  criminal  case proceeds;  and there  are situations                                                                
where  a  person is  found  not  competent  and not  capable  of                                                                
restoration, in which case the determination is reported back to                                                                
the court and the charges are generally dismissed.                                                                              
                                                                                                                                
5:20:52 PM                                                                                                                    
                                                                                                                                
MR.  WILLIAMS  advised   that  the  impact   of  the  competency                                                                
evaluations are significant because currently  there are 10 beds                                                                
for this service and the  courts have a steady referral rate for                                                                
these types  of evaluations.    The evaluations are  timely, and                                                                
when a person  cannot access the restoration piece  and also the                                                                
initial evaluation, the person ends up  staying in DOC until the                                                                
evaluation or restoration can  take place.  He  pointed out that                                                                
that poses  problems for the  DOC and it  certainly poses issues                                                                
for  the due  process  of the  person  in terms  of the  pending                                                                
charges.  The Trust is looking  at where that type of service is                                                                
delivered and  how it is  delivered in an  effort to potentially                                                                
free up  some space at  API and the  people not involved  in the                                                                
criminal justice system can  access additional beds or treatment                                                                
in a  more expedited  manner.   Also, he  said, to  expedite the                                                                
process itself so people are  not languishing in the DOC waiting                                                                
for this process  to take place and their  criminal case to come                                                                
to resolution in some fashion.                                                                                                  
                                                                                                                                
5:22:39 PM                                                                                                                    
                                                                                                                                
CHAIR  SPOHNHOLZ referred  to slide  13, "API  and  its Forensic                                                                
Population" and  noted  that Director  Burns described  that the                                                                
Alaska Court System's demand for forensic services exceeds API's                                                                
capacity to manage the caseload, and  he used the word "crisis."                                                                
Director Burns  is seeking  support for  a feasibility  study to                                                                
explore the value of establishing a forensic hospital in Alaska.                                                                
                                                                                                                                
MR. WILLIAMS  responded that part  of that  study is to:  try to                                                                
find another  location; what is  that location; is  it feasible;                                                                
and then  start looking  at: accreditation; staffing  needs; the                                                                
operations; transportation  needs because individuals  are often                                                                
transported  back and  forth  to the  court  for their  hearing;                                                                
wherein all  of these  issues will  be taken  into consideration                                                                
together with looking at how  other states manage their forensic                                                                
population and competency issues.                                                                                               
                                                                                                                                
5:23:57 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ asked whether  he has a sense of  the numbers in                                                                
terms of  people sitting in the  Department of Corrections (DOC)                                                                
awaiting entry into API for psychiatric stabilization.                                                                          
                                                                                                                                
MR. WILLIAMS  answered that he  does not have the  exact number,                                                                
but roughly  160 Alaskans received  competency evaluation orders                                                                
in FY  2017.   As to  the delay  and someone  is sitting  in DOC                                                                
awaiting those types of evaluations, there are variables in play                                                                
as to  how long someone sits  in DOC.  For  example, he offered,                                                                
there is a difference when  someone has a pending serious felony                                                                
level charge and the  defendant's competency is in question, and                                                                
there  is someone  else with  a lower  level charge  where their                                                                
legal  exposure in  terms  of the  amount of  time  they may  be                                                                
sentenced to  a crime if convicted  is much less.   He explained                                                                
that API does  what it can to try to  triage and prioritize, but                                                                
the judicial  system is  set up  with different  court locations                                                                
statewide    ordering   these    evaluations   which    includes                                                                
transportation.  For  example, because all  of these evaluations                                                                
take place through  API, and defendants are  flown in statewide,                                                                
clearly "things can  get stacked up pretty quickly."   Also, due                                                                
to staffing and  the amount of time required for  these types of                                                                
evaluations, defendants  can end up  sitting DOC for  periods of                                                                
time that one would hope would be shortened, he offered.                                                                        
                                                                                                                                
5:26:06 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ noted that  stakeholders and the legislature are                                                                
looking for ways  to strategize and free up space  for folks who                                                                
really  need  serious  mental  health  services,  and  that  the                                                                
forensic patients tend to  be at API for twice  as long as other                                                                
patients.   She referred to Slide  4, which lists  the length of                                                                
stay, and  noted that it  depicted an average  of 44 days  for a                                                                
forensic  patient in  API  versus a  much  lower number  ranging                                                                
between  10 and  24  days  for the  non-forensic  patients.   It                                                                
appears, she pointed out,  that addressing that forensic patient                                                                
needs would be a useful strategy.                                                                                               
                                                                                                                                
MR. WILLIAMS explained that part of that differential can be the                                                                
amount  of time  required  for someone  to  be re-stabilized  on                                                                
medications in  order to  understand the upcoming  legal process                                                                
with their pending criminal charge, and assist in the defense of                                                                
their own  processing of  the case.   In  fact, he  pointed out,                                                                
there are longer periods of time because the requirement is that                                                                
a person  is at  the legal  competency threshold.   He described                                                                
that it is not "apples to apples."                                                                                              
                                                                                                                                
5:27:49 PM                                                                                                                    
                                                                                                                                
CHAIR  SPOHNHOLZ noted  that  she had  heard  the Alaska  Mental                                                                
Health Trust Authority may  be exploring preparing a feasibility                                                                
study for the  needs gap or the  capacity gap currently existing                                                                
at API, and she requested an update.                                                                                            
                                                                                                                                
MR. WILLIAMS responded that that  is something the Alaska Mental                                                                
Health Trust Authority and the department are preparing separate                                                                
from  this forensic  look.   He  explained that  the feasibility                                                                
study is  working with the department  all the way  back to when                                                                
the current API facility was designed and built, and he has been                                                                
discussing  the design  and  building  with  Director Burns  and                                                                
reviewing documents from history, noting that  it was built with                                                                
the potential  to possibly expand or  add an  additional wing in                                                                
the future.  Therefore, he  said, the Trust, in partnership with                                                                
the department  and API, will  go back and  look at how  API was                                                                
originally designed and  built to determine  whether the current                                                                
facility  has  the capacity  to  literally  add  a wing  to  the                                                                
existing facility.  In the event that is the case, then taking a                                                                
step further and looking at  the planning and zoning issues that                                                                
might be attached within the municipality.   In the event all of                                                                
those issues play out and it  is possible not only from a campus                                                                
and  facility  perspective   and  but  a   planning  and  zoning                                                                
perspective, they will start looking at what the additional wing                                                                
would  look  like,  its  capacity,  how  many  beds,  conceptual                                                                
designs,  ultimate  construction costs,  contingencies,  and  so                                                                
forth.   He advised that the  Trust would not be  looking at the                                                                
operating  costs  associated  with   that  expansion,  it  would                                                                
literally look at the capital costs for an additional wing.                                                                     
                                                                                                                                
5:30:30 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SULLIVAN-LEONARD referred  to  slide  13,  third                                                                
bullet and noted  that Dr. Patrick Fox provided  a November 2016                                                                
report regarding  the forensic needs  for API.   Considering the                                                                
that report of November 2016 is available, she asked whether Mr.                                                                
Williams believes there is a need for a new forensic study.                                                                     
                                                                                                                                
MR.  WILLIAMS answered that  that study  looked at  API  and its                                                                
forensic service process  and the way API managed  its cases, it                                                                
was not  necessarily looking at  the possibility of  having that                                                                
service in a different location and serving that population in a                                                                
separate manner.   Certainly, he said,  the Trust has  access to                                                                
that report  and it will be  reviewing that report, there  is no                                                                
interest in  re-inventing the  wheel, especially given  that the                                                                
report is only two years old.                                                                                                   
                                                                                                                                
5:32:14 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SULLIVAN-LEONARD  offered that  her  interest was                                                                
peaked when Mr.  Williams talked about expanding a  wing at API,                                                                
which is  why she believes  this study may  correlate with those                                                                
efforts.                                                                                                                        
                                                                                                                                
5:32:38 PM                                                                                                                    
                                                                                                                                
MR. WILLIAMS thanked  the committee for taking the  time to look                                                                
into this issue,  obviously it is a  complex situation with many                                                                
people interested in providing quality care.   Many Alaskans are                                                                
looking for  that quality  of care  from the  Alaska Psychiatric                                                                
Institute (API), and the Trust is certainly interested in making                                                                
sure that goal is reached.   He also thanked those who testified                                                                
previously, including the department, patient advocates, and the                                                                
staff members.   These are  very complex needs for  Alaskans and                                                                
the  community  behavioral  health   system  cannot  meet  their                                                                
psychiatric  needs, thereby  for whatever  reasons, these  needs                                                                
have moved into a psychiatric crisis.   This is a safety net, he                                                                
described, and there  must be a  safety net to  meet those needs                                                                
and get  people back  into the  community in positive  manner as                                                                
quickly as possible.                                                                                                            
                                                                                                                                
CHAIR SPOHNHOLZ remarked that the people  who count on the state                                                                
to care for  them at API are the most vulnerable  and are at API                                                                
because they have no other place to go, and it is incumbent upon                                                                
the legislature to make sure  it is thoughtful about their care.                                                                
She noted  that many  topics had been  discussed today,  but the                                                                
committee did not cover in great detail the access issues of the                                                                
lack  of community  health  supports for  people who  inevitably                                                                
leave API and go back out  into the community for whom there are                                                                
not many supports.   She opined that  Ms. Merrit referenced that                                                                
issue when she described the  challenges her daughter suffers in                                                                
finding appropriate  community supports  for her  serious mental                                                                
health  issues.   There are  serious acute  psychiatric services                                                                
needs with gaps in  terms of community supports, in which "we'll                                                                
see  more of  being  offered  in the  private  sector" at  MatSu                                                                
Regional Hospital and Alaska Regional  Hospital soon.  There was                                                                
a small discussion regarding the forensic needs for the State of                                                                
Alaska, and she commented that  its criminal justice system only                                                                
works when the  people tried for crimes  actually understand the                                                                
crimes  for which  they've been  accused, and  are  competent to                                                                
stand trial.   She stressed that that is  definitely a "big need                                                                
gap."   Also, a topic not  discussed today, she  advised, is the                                                                
shortage  for  adolescent  acute care  behavioral  needs.    She                                                                
described  long stays  for  children  in emergency  departments,                                                                
sometimes as long as 14 days in Anchorage, Fairbanks, and MatSu,                                                                
and the  community providers of  these services are not  able to                                                                
keep up  with those needs,  thereby leaving children  sitting in                                                                
emergency departments.  She noted that the commissioner has been                                                                
in attendance since the beginning of  this meeting for those who                                                                
are listening in  and watching, as have  her deputy commissioner                                                                
and assistant commissioners.                                                                                                    
                                                                                                                                
5:37:20 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being no further  business before the committee, the House                                                                
Health  and  Social  Services  Standing  Committee  meeting  was                                                                
adjourned at 5:37 p.m.                                                                                                          
                                                                                                                                

Document Name Date/Time Subjects
DHSS presentation before HHSS 4.10.2018.pdf HHSS 4/10/2018 3:00:00 PM
API
Violence and Aggression in an Inpatient Psychiatric Hospital G. Martone.pdf HHSS 4/10/2018 3:00:00 PM
API
Dvoskin Final Report on API March 17 2015.pdf HHSS 4/10/2018 3:00:00 PM
API
Vitae for Joel Dvoskin.pdf HHSS 4/10/2018 3:00:00 PM
API