Legislature(2019 - 2020)BUTROVICH 205

02/13/2019 01:30 PM HEALTH & SOCIAL SERVICES

Note: the audio and video recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.

Download Mp3. <- Right click and save file as
Download Video part 1. <- Right click and save file as

Audio Topic
01:33:53 PM Start
01:34:05 PM Overview: Alaska Psychiatric Institute Dhss Division of Behavioral Health
02:49:09 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Uniform Rule 23 Waived --
Overview: Alaska Psychiatric Institute
DHSS Division of Behavioral Health
-- Testimony <Invitation Only> --
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                       February 13, 2019                                                                                        
                           1:33 p.m.                                                                                            
                                                                                                                                
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Senator David Wilson, Chair                                                                                                     
Senator Gary Stevens                                                                                                            
Senator Cathy Giessel                                                                                                           
Senator Tom Begich                                                                                                              
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Senator John Coghill, Vice Chair                                                                                                
                                                                                                                                
OTHER LEGISLATORS PRESENT                                                                                                     
                                                                                                                                
Representative Andi Story                                                                                                       
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
OVERVIEW: ALASKA PSYCHIATRIC INSTITUTE DHSS DIVISION OF                                                                         
BEHAVIORAL HEALTH                                                                                                               
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
No previous action to record                                                                                                    
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
ADAM CRUM, Commissioner Designee                                                                                                
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Gave an overview of decision to issue                                                                     
private contract for the Alaska Psychiatric Institute (API).                                                                    
                                                                                                                                
ALBERT WALL, Deputy Commissioner                                                                                                
Family, Community, and Integrated Services                                                                                      
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Gave an overview of the decision to issue a                                                               
private contract for the Alaska Psychiatric Institute.                                                                          
                                                                                                                                
KATE BURKHART, Ombudsman                                                                                                        
Office of the Ombudsman                                                                                                         
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT: Answered  questions  about the  role of  the                                                             
ombudsman.                                                                                                                      
                                                                                                                                
JEREMY BARR, Senior Vice President                                                                                              
Wellpath Recovery Solution                                                                                                      
Nashville, Tennessee                                                                                                            
POSITION  STATEMENT:  Testified  about the  contract  for  Alaska                                                             
Psychiatric Institute.                                                                                                          
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
                                                                                                                                
1:33:53 PM                                                                                                                    
CHAIR DAVID WILSON  called the Senate Health  and Social Services                                                             
Standing Committee meeting  to order at 1:33 p.m.  Present at the                                                               
call to order  were Senators Begich, Stevens,  Giessel, and Chair                                                               
Wilson.                                                                                                                         
                                                                                                                                
^Overview:   Alaska  Psychiatric   Institute  DHSS   Division  of                                                               
Behavioral Health                                                                                                               
    Overview: Alaska Psychiatric Institute DHSS Division of                                                                 
                       Behavioral Health                                                                                    
                                                                                                                                
1:34:05 PM                                                                                                                    
Chair  Wilson  announced  the Department  of  Health  and  Social                                                               
Services (DHSS) presentation on  the Alaska Psychiatric Institute                                                               
by  Commissioner  Designee  Adam  Crum  and  Deputy  Commissioner                                                               
Albert  Wall.  He  noted  that  Jeremy Barr  and  Dr.  Kevin  Ann                                                               
Huckshorn  from Wellpath  Recovery Solutions  would be  available                                                               
for questions  online. Chair Wilson  asked the committee  to wait                                                               
until the end  of the presentation for questions  and pointed out                                                               
that  the  committee  would have  another  opportunity  for  DHSS                                                               
budgetary questions.                                                                                                            
                                                                                                                                
1:35:25 PM                                                                                                                    
ADAM  CRUM,  Commissioner  Designee,  Department  of  Health  and                                                               
Social  Services (DHSS),  Anchorage,  Alaska, noted  that he  had                                                               
shared his  history of  volunteering to work  with those  in need                                                               
during his confirmation hearing.  Joining DHSS was an opportunity                                                               
to further work  with the most vulnerable and to  fight for them,                                                               
to provide for  them, and to protect them. He  is responsible for                                                               
the patients  at the Alaska  Psychiatric Institute (API).  He was                                                               
aware  that  API had  some  issues,  but  he  had never  seen  an                                                               
organization in  such disarray as  API. The current  situation is                                                               
the result  of ongoing neglect  and turmoil that  has accumulated                                                               
over the years, culminating with  this recent crisis. Others have                                                               
worked diligently  to address  API's issues,  but the  methods of                                                               
the past have not worked.                                                                                                       
                                                                                                                                
1:36:50 PM                                                                                                                    
COMMISSIONER  DESIGNEE   CRUM  said  that,  according   to  their                                                               
records, 2010  was the last  time API  went more than  six months                                                               
without  a major  citation or  violation. "We,  as a  state, have                                                               
failed. We have  failed the patients and  those seeking treatment                                                               
by  having  diminished capacity  and  quality  of care.  We  have                                                               
failed the employees by having  constant management turnover," he                                                               
said.  Employees are  fearful of  being injured  or losing  their                                                               
professional   licenses.  Senator   Begich  told   him  that   as                                                               
commissioner, he is  the voice and advocate for those  who do not                                                               
have a  voice. By addressing  head-on this very serious  issue at                                                               
API, he  is working  to give  voice to those  in need.  He cannot                                                               
stand by  and watch patients and  staff struggle when he  has the                                                               
ability  to do  something.  They  have put  forward  a plan  with                                                               
defined  deliverables   that  will  bring   stability,  training,                                                               
guidance, and support to API.                                                                                                   
                                                                                                                                
1:38:09 PM                                                                                                                    
ALBERT   WALL,  Deputy   Commissioner,  Family,   Community,  and                                                               
Integrated  Services, Department  of Health  and Social  Services                                                               
(DHSS), Anchorage,  Alaska, said he  would walk them  through the                                                               
gravity of  the issues at  API and exactly  how they came  to the                                                               
decision to contract.                                                                                                           
                                                                                                                                
MR. WALL gave an overview of the presentation:                                                                                  
                                                                                                                                
        1. Staff and Patient Safety                                                                                             
        2. Inability to Fulfill Its Mission                                                                                     
        3. Pending Legal Issues with Extreme Risk of High Cost to                                                               
          the State                                                                                                             
        4. Ethical Treatment of Alaskans.                                                                                       
                                                                                                                                
MR. WALL said he  wanted to start with a brief  history of API to                                                               
underscore  a few  issues.  They knew  there  were many  problems                                                               
coming. They knew there was a  bed shortage. They knew there were                                                               
patients backing up in hospitals, but  they did not know the full                                                               
extent. In 1962,  API was built with 225 beds.  A 1992 study said                                                               
that  to  facilitate  inpatient psychiatric  care  in  the  state                                                               
properly, 162  beds were needed.  The old building was  not fully                                                               
utilized and  that is what  the study  indicated. A group  met in                                                               
1992  about the  question of  funding  those beds  and created  a                                                               
compromise  called the  Alyeska  Accord. All  parties agreed  the                                                               
state  could get  by with  114 beds.  In 1993,  DHSS submitted  a                                                               
Certificate of Need  for 114 beds, but only 72  were funded. From                                                               
the start  API has not been  enough. It was not  enough then, and                                                               
it is not enough now. It is  a highly volatile focal point. It is                                                               
always in the news. It  is the epicenter of inpatient psychiatric                                                               
care for the state, but it is  not the entire system of care, and                                                               
the entire system of care is in jeopardy as well.                                                                               
                                                                                                                                
MR. WALL  said that in 2005  the facility expanded from  72 to 80                                                               
beds,  well below  the  number  in the  1992  study  and with  an                                                               
increase in  population. More  than one study  a year  since 2005                                                               
have had  the same  findings with growing  alarm each  year. They                                                               
have repeatedly  warned of the  crisis and offered  solutions and                                                               
none  worked. Some  progress  has  been made  at  API to  rectify                                                               
certain circumstances, but  it was too little, too  slow, and too                                                               
late.                                                                                                                           
                                                                                                                                
MR. WALL  said that the  Centers for Medicare and  Medicaid (CMS)                                                               
services   warned  in   2017  that   they   would  remove   API's                                                               
certification if it  was not substantively in line  with the plan                                                               
of  correction. There  have been  repeated assaults  and injuries                                                               
and at the present time, only enough  staff for 35 beds out of 80                                                               
in the building.                                                                                                                
                                                                                                                                
MR. WALL  said the  culmination of  this was  that in  January of                                                               
this year,  at what was supposed  to be the last  CMS survey team                                                               
onsite to approve  compliance with the recently  accepted plan of                                                               
correction,  an  unreported  assault  that caused  a  finding  of                                                               
Immediate Jeopardy was discovered.  "The commissioner said enough                                                               
is enough.  We need  help. We  need expert help,  and we  need it                                                               
immediately," said Mr. Wall.                                                                                                    
                                                                                                                                
MR. WALL said  he wanted to talk about external  forces that have                                                               
an impact on operations and care.  All eyes are on API. The media                                                               
has a  lot to say  about it. Everyone  has an opinion,  but there                                                               
are forces with authority over API.                                                                                             
                                                                                                                                
MR.  WALL  said  the  level of  scrutiny  is  intense,  sometimes                                                               
demoralizing to  staff, but the  organizations are there  to keep                                                               
them on point with issues of safety of patient care.                                                                            
                                                                                                                                
MR.  WALL reviewed  the role  of Occupational  Safety and  Health                                                               
Administration (OSHA):                                                                                                          
                                                                                                                                
        • Federal agency that   sets  and  enforces  protective                                                                 
          workplace safety and health standards.                                                                                
        • May levy fines on agencies not in compliance.                                                                         
                                                                                                                                
MR. WALL said OSHA is  primarily concerned with staff safety. API                                                               
has had OSHA findings with plans of correction.                                                                                 
                                                                                                                                
MR. WALL reviewed the role of the Alaska ombudsman:                                                                             
                                                                                                                                
        • Among many   services    this   agency   investigates                                                                 
          complaints that involve state agencies and determines                                                                 
          appropriate remedies.                                                                                                 
        • The Alaska Ombudsman  initiated an  investigation  in                                                                 
          July of 2018 and a preliminary report of findings was                                                                 
          given to the Department yesterday evening.                                                                            
                                                                                                                                
MR. WALL said  there were findings in that report,  and they look                                                               
forward  to  conversations  with   the  ombudsman  as  they  move                                                               
forward.                                                                                                                        
                                                                                                                                
MR. WALL reviewed the role of the Joint Commission:                                                                             
                                                                                                                                
        • Is a national, not-for-profit accrediting organization                                                                
          which currently accredits nearly 21,000 health care                                                                   
          organizations.                                                                                                        
        • Provides peer-to-peer standards  for  members,  joint                                                                 
          evaluations,   hold   each    other   to   professional                                                               
          standards, and certify each other by those standards.                                                                 
        • May inform the  Centers  for  Medicaid  and  Medicare                                                                 
          Services of deficiencies.                                                                                             
                                                                                                                                
MR.  WALL said  the  Joint Commission  can remove  accreditation,                                                               
which  affects state  licensure. They  can act  as agents  of CMS                                                               
under  certain  circumstances, and  they  can  give a  report  of                                                               
findings.                                                                                                                       
                                                                                                                                
MR.  WALL reviewed  the state's  Health Facilities  Licensing and                                                               
Certification:                                                                                                                  
                                                                                                                                
        • To operate in Alaska, a hospital must be  licensed by                                                                 
          the state under AS 47.32.                                                                                             
        • The Department sets  standards and  requirements  for                                                                 
          licensure (through state regulations).                                                                                
        • If API does not maintain  state licensure,  it cannot                                                                 
          operate.                                                                                                              
                                                                                                                                
MR. WALL reviewed the role  for Centers for Medicare and Medicaid                                                               
Services (CMS):                                                                                                                 
                                                                                                                                
        • Federal agency that provides oversight for healthcare                                                                 
          services that receive federal funding                                                                                 
        • API receives approximately $23 million per year in                                                                    
          federal funding (CMS)                                                                                                 
        • API must meet federal requirements to receive funding                                                                 
             o Conditions of Participation (CoP) (certification                                                                 
               of compliance with the health and safety                                                                         
               requirements)                                                                                                    
        • Survey: an on-site inspection                                                                                         
             o Triggered by a complaint/event or overall                                                                        
               re/certification surveys                                                                                         
                                                                                                                                
MR. WALL  said CMS  has a very  strict survey,  or investigation,                                                               
process. A survey can happen at  any time. It can be triggered by                                                               
a complaint,  an event, an  overall recertification survey,  or a                                                               
scheduled  event.  A  report  is received  some  time  after  the                                                               
survey,  and CMS  will  work  on any  deficiencies  noted in  the                                                               
report.                                                                                                                         
                                                                                                                                
MR.  WALL  reviewed  Conditions   of  Participation  for  federal                                                               
funding:                                                                                                                        
                                                                                                                                
        • Requirement: API must be in "substantial" compliance                                                                  
          with each Condition of Participation (CoP).                                                                           
        • If a hospital is not in substantial compliance and                                                                    
          does not correct by the deadline, CMS will de-certify                                                                 
          the hospital and terminate its participation in                                                                       
          Medicare and Medicaid.                                                                                                
        • Termination results in a complete loss of this federal                                                                
          funding.                                                                                                              
                                                                                                                                
MR. WALL  reviewed the  three levels  of citations  that agencies                                                               
can give. He noted that it  is more complicated than can be shown                                                               
on a slide.                                                                                                                     
                                                                                                                                
     Standard Level Deficiency                                                                                                  
        • Out of compliance with regulation                                                                                     
     Condition Level Deficiency                                                                                                 
        • Very serious                                                                                                          
        • Hospital is not in substantial compliance with CoP                                                                    
     Immediate Jeopardy                                                                                                         
        • The hospital's deviation from regulatory standards is                                                                 
          an immediate threat to patient health and safety                                                                      
                                                                                                                                
MR.  WALL explained  that the  Standard Level  Deficiency usually                                                               
has to do with proper  credentialing or proper documentation. One                                                               
finding  was   that  staff  responsible  for   signing  biohazard                                                               
manifest  documents  at  the  time  they  arrived  did  not  have                                                               
evidence of  EPA (Environmental  Protection Agency)  training for                                                               
that substance.                                                                                                                 
                                                                                                                                
MR. WALL  said that  an example of  a Condition  Level Deficiency                                                               
was a  finding that the  forensic beds, the  criminal restoration                                                               
ward or Taku ward, did not  meet the new ligature standards. That                                                               
meant that there  were items on the bed that  a patient could use                                                               
to harm themselves. New beds had to be purchased for that.                                                                      
                                                                                                                                
1:50:51 PM                                                                                                                    
MR.  WALL said  that Immediate  Jeopardy is  the showstopper  and                                                               
shared a definition of Immediate Jeopardy:                                                                                      
                                                                                                                                
     "[a] situation  in which  the provider's  noncompliance with                                                               
     one or more requirements of  participation has caused, or is                                                               
     likely to  cause, serious injury, harm,  impairment or death                                                               
     to a resident."                                                                                                            
          - CMS State Operations Manual                                                                                         
                                                                                                                                
MR. WALL said that CMS and  the Joint Commission focus on patient                                                               
safety and OSHA  focuses on staff safety. On January  29 they did                                                               
receive an Immediate Jeopardy finding.                                                                                          
                                                                                                                                
MR. WALL reviewed the steps following a CMS report:                                                                             
                                                                                                                                
        • Statement of Deficiencies is provided to hospital.                                                                    
        • Hospital has 10 calendar days to provide an acceptable                                                                
         Plan of Correction for each cited deficiency.                                                                          
        • If the hospital doesn't come into compliance by the                                                                   
          deadline, the state agency certifies "noncompliance."                                                                 
                                                                                                                                
MR. WALL  said the  negotiation to create  an acceptable  plan of                                                               
correction  can   take  a  while.   When  the   commissioner  was                                                               
appointed, they were under a plan  of correction that had not yet                                                               
been accepted.  The timeline  on that is  critical. The  July CMS                                                               
survey had  substantial findings.  They had 90  days to  create a                                                               
plan, have  it accepted,  and then show  they were  in compliance                                                               
with the  plan before  the survey  team came  back. When  the CMS                                                               
survey team returned  at the end of 90 days,  they found DHSS did                                                               
not  have a  plan and  was still  out of  compliance. The  senior                                                               
leadership team  had resigned at  that time and they  entered the                                                               
second 90-day phase. After the  second 90-day phase, there are no                                                               
extensions. That was due November  26. On November 30, the survey                                                               
team showed up  for the final inspection and was  in the building                                                               
when the earthquake hit. They went  home and gave DHSS another 90                                                               
days to  produce the plan of  correction because of the  state of                                                               
emergency. That  is when  the commissioner came  in and  found no                                                               
plan  of correction  and, without  continuity in  leadership, did                                                               
not know what was in the plan in the first place.                                                                               
                                                                                                                                
MR. WALL reviewed API plans of correction:                                                                                      
                                                                                                                                
        • API has been under 2 Plans of Correction in the last                                                                  
          12 months, and 2 OSHA citations pending resolution.                                                                   
        • API has had 13 site visits from regulatory agencies in                                                                
          the last 12 months.                                                                                                   
        • The most recent two surveys identified 3 Condition                                                                    
          Level Deficiencies and an incident of Immediate                                                                       
          Jeopardy.                                                                                                             
        • Most recently, the incident of Immediate Jeopardy was                                                                 
          identified on January 29th, after API had submitted                                                                   
          its final Plan of Correction.                                                                                         
                                                                                                                                
MR.  WALL repeated  that a  finding  of Immediate  Jeopardy is  a                                                               
showstopper--someone  is  in  immediate   danger  of  harm.  That                                                               
incident involved  unwanted contact  between two patients  and is                                                               
still under investigation.  They are still waiting  for the final                                                               
report from CMS.                                                                                                                
                                                                                                                                
MR. WALL said  they were successful in certain  regards. They had                                                               
made some  movement. They had  had until  the end of  December to                                                               
complete the plan of correction  and get approval from CMS, which                                                               
they  did.  After over  180  days  of  working with  the  federal                                                               
government, a plan  of correction was accepted  in early January.                                                               
He thought they were headed in  the right direction, and then the                                                               
survey team came back and found this.                                                                                           
                                                                                                                                
MR. WALL said  he wanted to segue between  the conversation about                                                               
oversight and investigations and  regulatory bodies and take them                                                               
to where  the rubber  hits the  road, what it  looks like  in the                                                               
hospital. He asked  what an investigatory body looks  for when it                                                               
comes into  a hospital. The biggest  issue they have had  is with                                                               
seclusion and restraint. He reviewed the following CMS standard:                                                                
                                                                                                                                
        • All patients have the right to be free from physical                                                                  
          or mental abuse, and corporal punishment.                                                                             
        • All patients have the right to be free from restraint                                                                 
          or seclusion, of any form, imposed as a means of                                                                      
          coercion, discipline, convenience, or retaliation by                                                                  
          staff.                                                                                                                
        • Restraint or seclusion may only be imposed to ensure                                                                  
          the immediate physical safety of the patient, a staff                                                                 
          member, or others and must be discontinued at the                                                                     
          earliest possible time.                                                                                               
               42 CFR ? 482.13                                                                                                  
                                                                                                                                
MR.  WALL  said  it  is  a  difficult  balance  in  an  inpatient                                                               
psychiatric  unit  because  patients   are  inherently  at  times                                                               
dangerous to themselves  and others. If they are in  a high state                                                               
of agitation,  sometimes restraint  and seclusion  are necessary,                                                               
but only for  the safety of the patient or  staff member and must                                                               
be discontinued at the earliest possible time.                                                                                  
                                                                                                                                
MR. WALL  reviewed the reports  about seclusion and  restraint at                                                               
API:                                                                                                                            
                                                                                                                                
        • Since 2011, there have been 7 separate independent                                                                    
          reports indicating API uses seclusion & restraint                                                                     
          inappropriately and/or excessively.                                                                                   
        • Since 2017, API has been cited at least 7 separate                                                                    
          times for deficiencies including violations of patient                                                                
          rights and use of seclusion & restraint.                                                                              
        • In June of 2018, the Alaska Ombudsman initiated an                                                                    
         investigation into API based on 3 allegations:                                                                         
             1. API does not take reasonable and necessary action                                                               
               to prevent and/or mitigate the risk of harm to                                                                   
               patients from use of force by API staff;                                                                         
             2. API does not take reasonable and necessary action                                                               
               to prevent and/or mitigate the risk of harm to                                                                   
               patients due to violence by other patients;                                                                      
             3. API does not consistently comply with AS                                                                        
               47.30.825(d) or 42 CFR 482.13(e) in the use of                                                                   
               seclusion and restraint.                                                                                         
                                                                                                                                
1:58:29 PM                                                                                                                    
MR. WALL said this brings them to  the issue of staff safety.  He                                                               
reviewed  the  multiple  Alaska Occupational  Safety  and  Health                                                               
citations:                                                                                                                      
                                                                                                                                
   • Multiple citations by Alaska Occupational Safety and Health                                                                
     (AKOSH)                                                                                                                    
        o December 2014 findings: API failed to provide its                                                                     
          employees with a safe work  environment; and API failed                                                               
          to maintain its  OSHA log from 2011  to 2013, including                                                               
          not   accurately   reporting    injuries   or   related                                                               
          incidents.                                                                                                            
        o November 2017 findings: 24 reportable incidents during                                                                
          6 month timeframe; and API  failed to maintain its OSHA                                                               
          log and accurately report injuries from 2014-2017.                                                                    
   • 2015 report found that API is seriously and "dangerously"                                                                  
     understaffed, compensation is too low, and hiring takes too                                                                
     long. (Dvoskin report.)                                                                                                    
   • September 2018 report by attorney Bill Evans found that the                                                                
     hospital was an unsafe work environment for staff                                                                          
     (including a cultural divide on the use of seclusion and                                                                   
     restraints).                                                                                                               
   • September of 2018  injury rates at API doubled.                                                                            
   • January 29, 2019  surveyors found unreported "immediate                                                                    
     jeopardy" incident.                                                                                                        
                                                                                                                                
MR. WALL  pointed out that from  2011 to 2017 API  was failing to                                                               
track and  report injuries. There  was a litany of  reports about                                                               
unsafe  conditions   at  API  culminating  in   the  incident  of                                                               
Immediate Jeopardy.                                                                                                             
                                                                                                                                
MR. WALL said he went through  the stack of reports starting with                                                               
2005 and found what he considered the most poignant statement:                                                                  
                                                                                                                                
     November 2011 WICHE Report "Critical area of need"                                                                         
                                                                                                                                
          "The pressures  created by the combination  of resource                                                               
          limitations,     staffing    shortages,     recruitment                                                               
          challenges,   admission  and   census  increases,   and                                                               
          limited access  to decision  support tools  all combine                                                               
          to increase risk for the  facility and the patients and                                                               
          staff  of  API.  This  set of  challenges  has  reached                                                             
          crisis proportions and it is  not realistic to approach                                                             
          these  issues  with   modest  adjustments  to  existing                                                             
          processes                                                                                                           
                                                                                                                                
MR. WALL  said that  was written  in 2011. For  the next  8 years                                                               
they have attempted  to fix these issues  with modest adjustments                                                               
to existing processes and it has failed to work.                                                                                
                                                                                                                                
MR.  WALL said  most  reports indicated  staffing  was a  serious                                                               
issue:                                                                                                                          
                                                                                                                                
     "Alaska has  unique staffing challenges, no  doubt far above                                                               
     other rural  communities. Staffing agencies are  not readily                                                               
     available  to provide  experienced  psychiatric nurses.  API                                                               
     went through  a period of using  frequent mandatory overtime                                                               
     due to the severe staff shortages."  May 2012 WICHE report                                                                 
                                                                                                                                
     "Many  of the  leadership challenges  cited?were related  to                                                               
     difficulties in  hiring senior staff."    March 2015 Dvoskin                                                               
     Report                                                                                                                     
                                                                                                                                
     "High-level RN  Supervisor staff spend 60-70%  of their time                                                               
     in  the nursing  office trying  to 'call  in staff  to cover                                                               
     vacancies  for  the  next shift.'"     November  2016  WICHE                                                               
     Report                                                                                                                     
                                                                                                                                
MR.  WALL said  they  have all  tried to  fix  this problem.  The                                                               
legislature tried to fix this  problem. The legislature took PCNs                                                               
[Position Control Number] from other  areas and 102 new PCNs went                                                               
into API's  budget over the last  two years. The issues  are very                                                               
complex when it comes to  this. This morning recruitment was open                                                               
for 87 positions.                                                                                                               
                                                                                                                                
MR. WALL  said there  are unique  challenges. One  is the  way in                                                               
which staff is classified:                                                                                                      
                                                                                                                                
        • Classification studies are not performed specific to                                                                  
          API (rather, examine defined job classes across all                                                                   
          departments).                                                                                                         
        • There has not been a significant review completed of                                                                  
          nurse job classes since the 1980s.                                                                                    
             o Some adjustments to salaries were made in 1989,                                                                  
               2001, and 2006.                                                                                                  
        • Current class study in progress: Phase 2 of Nurses                                                                    
          Review                                                                                                                
             o Will impact 674 positions, 18 job classes, from 3                                                                
               departments (DHSS, DMVA, DOC).                                                                                   
             o Began October 2018, tentative completion date                                                                    
               estimated March 2019.                                                                                            
        • Identified project: reviewing pay structures for                                                                      
          exempt      medical       professionals      (including                                                               
          psychiatrists).                                                                                                       
             o No current implementation date.                                                                                  
                                                                                                                                
MR. WALL  said the system has  arisen over time to  be a problem.                                                               
No differentiation  is made  between all nurses  and nurses  at a                                                               
psychiatric  institute. A  licensed  professional  is faced  with                                                               
working for  30 percent  less pay and  being subject  to violence                                                               
and being  cursed at,  at a  place where  there is  great trouble                                                               
among  the  staff,  or  going  across the  street  to  two  other                                                               
hospitals  and   getting  paid  more.  Someone   must  be  called                                                               
ideologically  to work  at  API. There  has  been no  significant                                                               
review of  the nurse  jobs classes, which  is where  the greatest                                                               
need  is. There  have  been  salary increases,  but  not a  whole                                                               
classification study.  There is  a classification study  going on                                                               
now, but,  again, it is too  little, too late. They  have arrived                                                               
at a place of crisis.                                                                                                           
                                                                                                                                
2:03:09 PM                                                                                                                    
MR. WALL said some encouraging  things have happened and reviewed                                                               
recent recruitment efforts:                                                                                                     
                                                                                                                                
        • GGU All Nursing Department staff  are eligible  for a                                                                 
          specialized alternate workweek since July of 2016.                                                                    
        • GGU Health Practitioners I-II received a step increase                                                                
          effective August 2016.                                                                                                
        • GGU Health Practitioner I's are eligible for a $15,000                                                                
          sign on bonus effective February of 2018.                                                                             
        • SU Nurse IIIs were converted to overtime  eligible in                                                                 
          June 2018.                                                                                                            
        • GGU Health Practitioners  I's  can  volunteer  for  a                                                                 
          weekend shift and receive a flat rate of $500                                                                         
          effective July of 2018.                                                                                               
        • Sign on bonus  of  $10,000   was  offered  for  Nurse                                                                 
          positions beginning September 2018.                                                                                   
                                                                                                                                
MR.  WALL  said the  pay  and  bonus improvements  happened  very                                                               
recently and have  not made a significant impact  yet. They hired                                                               
six new nurses and lost six nurses.                                                                                             
                                                                                                                                
MR.  WALL  said not  all  problems  have  to  do with  the  whole                                                               
classification.  He presented  a case  study of  a position  that                                                               
pays too little to attract anyone:                                                                                              
                                                                                                                                
     Occupational Therapist position has been vacant since                                                                      
     December 19, 2017; in active recruitment for over a year                                                                   
     with 0 qualified applicants.                                                                                               
        • Position  requirements    include   national    board                                                                 
          certification as occupational therapist and Alaska                                                                    
          state licensure.                                                                                                      
        • Position is only range 17.                                                                                            
        • API requested job classification study in  2018. None                                                                 
          has been conducted.                                                                                                   
                                                                                                                                
MR. WALL reviewed clinical vacancies at API:                                                                                    
                                                                                                                                
     Current unfilled clinical positions:                                                                                       
        • 30 nurse vacancies (including Director of Nursing);                                                                   
        • 5 psychiatrist vacancies (including Director of                                                                       
          Psychiatry);                                                                                                          
        • 1 medical officer vacancy (API's only general                                                                         
          practitioner);                                                                                                        
        • 3 psychologist vacancies; and                                                                                         
        • 4 forensic evaluator vacancies.                                                                                       
                                                                                                                                
     Locum Tenens/contract staff                                                                                                
        • Initial nurse contract for 90 days.                                                                                   
        • Must train and onboard (approximately 3 weeks)                                                                        
          followed by additional education prior to being on the                                                                
          floor.                                                                                                                
        • Generally unsuccessful and depart API quickly.                                                                        
                                                                                                                                
MR. WALL  said many of these,  with the exception of  the nurses,                                                               
have had  no applicants.  When people see  ongoing trouble  in an                                                               
organization, new applicants don't want  to work there. A medical                                                               
doctor looking  at where to work  would have to think  hard about                                                               
whether to work there.                                                                                                          
                                                                                                                                
COMMISSIONER  DESIGNEE CRUM  said  overall morale  is not  helped                                                               
when  newspapers  call  API  the worst  hospital  in  the  United                                                               
States.                                                                                                                         
                                                                                                                                
MR. WALL  said he has  talked about  some of the  challenges they                                                               
face with  the regulatory oversight.  Another problem is  an even                                                               
deeper   issue,  a   human,  ethical   question.  Two   types  of                                                               
individuals  go to  API. Sometimes  they  are there  for a  civil                                                               
commitment. Sometimes  criminal charges  bring someone to  API, a                                                               
forensic  patient. He  reviewed  the statutory  obligation for  a                                                               
forensic patient:                                                                                                               
                                                                                                                                
     Forensic Psychiatric Services AS 12.47.010                                                                                 
                                                                                                                                
     Forensic patient:                                                                                                          
        • Has been charged with a crime.                                                                                        
        • Suspected to be incompetent to stand trial.                                                                           
        • Two stages:                                                                                                           
             1. Must be evaluated to see if they are incompetent.                                                               
             2. If found incompetent, is sent to API for                                                                        
               "restoration" to competency.  Can be recommitted                                                                 
               to API for multiple periods of restoration.                                                                      
        • If "restored," criminal case proceeds.                                                                                
        • Otherwise, person is deemed "unrestorable" and                                                                        
          criminal case is dismissed.                                                                                           
             o (following dismissal, various possible outcomes                                                                  
               including    unconditional   release    or   civil                                                               
               commitment).                                                                                                     
        • Often, but not always, in custody at DOC.                                                                             
        • Criminal case cannot go forward until competency                                                                      
          proceedings resolve.                                                                                                  
                                                                                                                                
MR. WALL said  they must evaluate and provide care  to a forensic                                                               
patient as  a statutory requirement.  It is complicated  and they                                                               
are  not in  compliance.  The examination  requires two  forensic                                                               
psychiatrists. They don't have two  forensic psychiatrists in the                                                               
state.  They  simply don't  have  the  staff  and beds  to  treat                                                               
individuals  in this  category. Unfortunately,  an unconscionable                                                               
thing  occurs.   These  individuals   end  up  in   jail  without                                                               
diagnosis. They have charges but  no conviction. They sit in jail                                                               
for a long time without treatment.                                                                                              
                                                                                                                                
2:08:40 PM                                                                                                                    
MR.  WALL presented  information  on the  API  forensic unit.  He                                                               
noted that these were yesterday's figures:                                                                                      
                                                                                                                                
        • API has only 10 forensic beds (Taku unit).                                                                            
        • Waitlist for initial evaluation: 54                                                                                   
        • Waitlist for admission: 28                                                                                            
        • Multiple judges threatening to hold state in contempt                                                                 
         for failure to evaluate/admit for restoration.                                                                         
        • Due process challenges to delayed evaluation and                                                                      
          admission (resulting in potential dismissal of                                                                        
          criminal case).                                                                                                       
        • Defendants being held longer in DOC waiting for API                                                                   
          than the length of their potential sentence if                                                                        
          convicted.                                                                                                            
        • Statutes require DHSS to conduct restoration.                                                                         
        • Statutes do not require that DHSS perform the                                                                         
          evaluations, but API has traditionally been held                                                                      
          responsible for them.                                                                                                 
                                                                                                                                
MR. WALL  said they have  evaluated 28 people who  need treatment                                                               
who can't get  in the hospital because they have  no place to put                                                               
them.  "There is  a very  in-depth legal  and financial  question                                                               
that we have with this problem, but  I want to sit on the ethical                                                               
thing  for  just  a second  and  ask  you,  if  you walk  into  a                                                               
situation that  we did, and you  are appointed to take  care of a                                                               
group of  people, and  you find  50, 60, 70,  80 plus  sitting in                                                               
jail without treatment  and some of them  without conviction, and                                                               
no place to go,  what is your choice and what do  you do. We have                                                               
a very limited bandwidth to take  care of people. It is our moral                                                               
obligation to do so," he said.                                                                                                  
                                                                                                                                
MR. WALL said that on the legal  side, they end up in court. They                                                               
have an ongoing  case that he cannot talk much  about, but it has                                                               
immense  ramifications.  He  reviewed legal  involvement  on  the                                                               
civil and criminal side:                                                                                                        
                                                                                                                                
        • October 19, 2018  DLC complaint filed [CIVIL]                                                                         
             o Alleging due process violations for those facing                                                                 
               civil  commitment      being  held  for  prolonged                                                               
               period  without  opportunity  to be  heard;  being                                                               
               held in DOC pending admission to API.                                                                            
             o Seeking injunction for immediate admission to API                                                              
               for all court-referred patients  and for API staff                                                               
               to  conduct  evaluations  for  30-day  commitments                                                               
               anywhere in the state.                                                                                           
             o This case has been consolidated with Public                                                                      
               Defender  Agency cases  involving delays  in civil                                                               
               commitment evaluations.                                                                                          
        • November 2018: Public Defender Agency begins filing                                                                   
          "habeas corpus" motions in criminal cases [FORENSIC]                                                                  
             o Complaining    of   delay    in   admission    for                                                               
               restoration. The relief requested is release.                                                                    
        • 2018: Public Defender Agency begins filing motions for                                                                
          "alternatives to evaluation at designated evaluation                                                                  
          facilities"                                                                                                           
             o Requesting that the judge order DHSS to                                                                          
               immediately   evaluate  individuals   waiting  for                                                               
               transfer to API.                                                                                                 
                                                                                                                                
                                                                                                                                
2:10:29 PM                                                                                                                    
MR. WALL reviewed Civil Commitments AS 47.30.700:                                                                               
                                                                                                                                
        • Two methods of initiating a civil commitment:                                                                         
             1. "Any adult" petitions a judge                                                                                   
             2. A           peace           officer            or                                                               
               psychiatrist/physician/psychologist   applies  for                                                               
               examination.                                                                                                     
        • If the judge grants the petition, the person is                                                                       
          delivered to an evaluation facility designated by DHSS                                                                
          to receive a 72 hour evaluation.                                                                                      
             o If the facility determines that the person meets                                                                 
               commitment  criteria: that  is the  person suffers                                                               
               from a mental illness  and (1) is gravely disabled                                                               
               or (2)  is a threat  to self or others,  they will                                                               
               petition the court for a 30 day commitment;                                                                      
             o If at any time in the process the facility                                                                       
               determines  that   the  person  no   longer  meets                                                               
               criteria, the person must be released;                                                                           
             o If there is a petition for a commitment, an                                                                      
               evidentiary hearing  is held and a  superior court                                                               
               judge determine whether the  person can be civilly                                                               
               committed   for   up   to  30   days,   successive                                                               
               commitment can  occur at  90 and  180 days  and at                                                               
               those latter  hearings the individual  is entitled                                                               
               to a jury trial.  Through this entire process they                                                               
               are represented by the Public Defender Agency.                                                                   
        • There are only three Designated Evaluation and                                                                        
          Treatment (DET) facilities. Only DET facilities can                                                                   
          perform the 72 hour evaluation.                                                                                       
             o API, Fairbanks Memorial Hospital (20 bed, 4                                                                      
               acute), and Bartlett Regional Hospital (12 bed);                                                                 
             o All other facilities including Emergency Rooms                                                                   
               are  not designated  to provide  evaluation and/or                                                               
               treatment services  because they have  not applied                                                               
               to become a DET.                                                                                                 
                                                                                                                                
MR. WALL  said the system on  the civil commitment side  is borne                                                               
on the back of a single  evaluation by a clinician, usually in an                                                               
emergency  room. The  outcome is  either someone  is a  danger to                                                               
themselves or  others and must  go somewhere to get  treatment or                                                               
someone is  not. The hospitals are  left in a terrible  bind with                                                               
patients in the  emergency room that they cannot let  go but they                                                               
also cannot treat.  Today 14 people are in  that situation, three                                                               
of whom  are juveniles and two  of them are in  the Department of                                                               
Corrections because they have no other  place to put them. So now                                                               
people are there without criminal charges.                                                                                      
                                                                                                                                
2:11:45 PM                                                                                                                    
MR. WALL said  that what happens to states  in Alaska's situation                                                               
is a  legal issue. They are  obligated by federal and  state laws                                                               
to take care of inpatient  psychiatric patients in a certain way.                                                               
They are failing  to do so. "And  when you fail to  obey your own                                                               
laws, there are consequences," he said.                                                                                         
                                                                                                                                
MR. WALL presented a slide on the Trueblood case:                                                                               
                                                                                                                                
     Trueblood case      federal class action lawsuit for                                                                       
     unconstitutional delays in forensic cases                                                                                  
        • 2015 trial resulted in ruling that DSHS was violating                                                                 
          class members' constitutional rights.                                                                                 
        • Court ordered the   Washington  State  Department  of                                                                 
          Social and  Health Services (DSHS) to  move individuals                                                               
          facing criminal charges out of  jail and into treatment                                                               
          facilities within seven or fourteen  days when they are                                                               
          eligible  for  competency  evaluation  and  restoration                                                               
          services (respectively).                                                                                              
        • Contempt order of July 7, 2016 fined DSHS $500 per day                                                                
          per  person  (for exceeding  the  7  day deadline)  and                                                               
          $1,000 per  day per  person (for  exceeding the  14 day                                                               
          deadline).                                                                                                            
        • As of June 2018,  fines for  failure  to comply  with                                                                 
          court orders exceeded $55 million.                                                                                    
        • Settlement agreement approved by court  December 2018                                                                 
          requires the State to make  changes in five substantive                                                               
          areas:                                                                                                                
             o competency evaluations; competency restoration                                                                   
               services; crisis triage and diversion support;                                                                   
               education    and     training;    and    workforce                                                               
               development.                                                                                                     
                                                                                                                                
     CMS decertified (July 2018)  loss of $53 million federal                                                                   
     funding per year                                                                                                           
        • Hospital had been at  risk  of  losing funding  since                                                                 
          2015.                                                                                                                 
        • State had recently  spent  $360  million  into  state                                                                 
          hospitals and $560 million in mental health spending.                                                                 
        • Federal officials cited   hospital  for  its  quality                                                                 
          assessment and  improvement program,  nursing services,                                                               
          and safety issues.                                                                                                    
                                                                                                                                
MR. WALL said  the ramifications of being in  their situation are                                                               
immense. In  the Trueblood  case in 2015,  the court  ordered the                                                               
state to  pay for patient treatment  and at one point,  fined the                                                               
Washington State  Department of  Social and Health  Services over                                                               
$100,000  a day  in general  funds. As  of June  2018, fines  for                                                               
failure  to comply  with the  court order  exceeded $55  million.                                                               
That  does  not  include  paying for  treatment.  The  settlement                                                               
agreement approved by the court  in December ordered the state to                                                               
designate  funding  to  pay  for   services.  In  July  2018  CMS                                                               
decertified  the hospital  and  it lost  $53  million of  federal                                                               
funding per year.                                                                                                               
                                                                                                                                
MR. WALL  said they have two  sides of this problem,  patient and                                                               
staff safety. They  also have clinical compliance.  They must fix                                                               
the problem before the court  intervenes and there is the ethical                                                               
dilemma of  how to care  for people with  no voice. That  is what                                                               
they are faced with.                                                                                                            
                                                                                                                                
MR. WALL said  he would move from the dilemma  to the decision to                                                               
hire Wellpath. They  started talking to contractors  early in the                                                               
process because when  they got into office, there was  no plan of                                                               
correction.  They were  out of  compliance  and being  threatened                                                               
with decertification, so they sought help.                                                                                      
                                                                                                                                
MR. WALL reviewed what they were looking for in a contractor.                                                                   
                                                                                                                                
       1. To ensure the safety of our staff and patients;                                                                       
        2. To bring the hospital into rapid compliance with                                                                     
          regulatory authorities; and                                                                                           
        3. To prepare the facility to increase its bed capacity                                                                 
          to 80 beds by 1 July.                                                                                                 
                                                                                                                                
MR. WALL  called these goals ambitious,  but absolutely critical.                                                               
He reviewed the following timeline:                                                                                             
                                                                                                                                
        • National Association of State Mental Health Program                                                                   
          Directors was contacted on December 18th.                                                                             
        • Wellpath Recovery Solutions contacted on December                                                                     
          20th.                                                                                                                 
        • Liberty Healthcare Corporation was contacted on                                                                       
          January 8th.                                                                                                          
        • Noel Rae of NetworxHealth (Virginia Mason Health                                                                      
          System) was met with on January 22nd.                                                                                 
                                                                                                                                
2:16:38 PM                                                                                                                    
MR. WALL explained that the  National Association of State Mental                                                               
Health Program Directors (NASHMPD)  is the association for states                                                               
that run inpatient psychiatric  facilities. They have specialists                                                               
and  can give  guidance  and give  information  about what  other                                                               
states are doing.  The conversation in his head at  that time was                                                               
how were they going to move  through this issue, should he hire a                                                               
contractor to get  the plan of correction  together and submitted                                                               
to  CMS, should  he  hire a  contractor that  does  some sort  of                                                               
administrative services  oversight of the whole  thing, should he                                                               
hire  a contractor  and do  a  privatization of  the whole  thing                                                               
immediately, what were their options and could they intervene.                                                                  
                                                                                                                                
MR. WALL said his first contact  with Wellpath was not even about                                                               
API. It was about health care  in other facilities, but it led to                                                               
a conversation  about that. He  asked the same kind  of questions                                                               
with Liberty  Healthcare Corporation  on January  8. He  met with                                                               
Noel  Rae  of  NetworxHealth  at  API  January  22.  During  this                                                               
timeline,  each  day they  were  learning  more concerning  facts                                                               
about API. The depth of issue was bigger than they had thought.                                                                 
                                                                                                                                
MR.  WALL said  the  plan  of correction  was  accepted in  early                                                               
January. He thought  they had more breathing room  at this point,                                                               
except that  on January 29 the  CMS survey team returned  and had                                                               
an Immediate  Jeopardy finding. He  wanted to stress  how unusual                                                               
and grave that was. To his  knowledge, they had never have had an                                                               
Immediate Jeopardy finding before at API.                                                                                       
                                                                                                                                
MR. WALL said the steps had to be immediate:                                                                                    
                                                                                                                                
        • Removed the perpetrator to another ward alone;                                                                        
        • Implemented new safety protocol including 24/7 video                                                                  
         surveillance with communication to the wards;                                                                          
        • Implemented an hourly reporting system for each ward                                                                  
          to monitor every patient on an hourly basis including                                                                 
          behavioral risk mitigation; and                                                                                       
        • Requested a nationally recognized specialist in                                                                       
          psychiatric treatment and safety, and NASHMPD to come                                                                 
          to API immediately for safety oversight.                                                                              
                                                                                                                                
MR. WALL  said that  the amount of  time between  discovering the                                                               
incident and getting  a specialist on the ground  was very quick.                                                               
They  found out  about it  Thursday  night and  a specialist  was                                                               
there on the  ground Monday with the safety protocol  in place in                                                               
the interim.                                                                                                                    
                                                                                                                                
MR. WALL  said the final decision  on Wellpath had to  made right                                                               
after the Immediate  Jeopardy was found. He  reviewed the reasons                                                               
Wellpath Recovery Solutions was chosen:                                                                                         
                                                                                                                                
        1. Was available immediately;                                                                                           
        2. Had   specific   inpatient    psychiatric   experience                                                               
         including both civil and criminal commitments;                                                                         
        3. Has a team of nationally recognized experts that has                                                                 
          the experience and track record to bring noncompliant                                                                 
          hospitals back into compliance rapidly                                                                                
                                                                                                                                
MR.  WALL said  not many  companies  have a  pool of  psychiatric                                                               
specialists who can jet out immediately and intervene.                                                                          
                                                                                                                                
MR.   WALL    gave   the    website   for    the   documentation:                                                               
http://dhss.alaska.gov/API/Pages/AdminChanges.aspx.  He  said  an                                                               
email address had  been set up for all questions  and concerns at                                                               
api.info@alaska.gov.                                                                                                            
                                                                                                                                
CHAIR WILSON recognized Representative Andi Story in the room.                                                                  
                                                                                                                                
2:22:07 PM                                                                                                                    
SENATOR STEVENS asked if hiring  Wellpath gives them more time to                                                               
deal  with the  certification or  accreditation process.  He also                                                               
asked if  there were a  lawsuit, would  the state or  Wellpath be                                                               
sued.                                                                                                                           
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM answered  that as they  evaluated the                                                               
process and saw the depth of  the crisis, they reached out to the                                                               
accrediting bodies. Their  biggest concern was that  the state of                                                               
Alaska had  failed to  correct problems over  the years,  to make                                                               
substantive change.  Alaska had gotten  good at saying  they were                                                               
going to  address the  problem, but nothing  truly was  done. API                                                               
was not  shut down years ago  because it is a  critical aspect of                                                               
the behavioral  health system in  Alaska. He told them  that they                                                               
would  take  a  proactive  and aggressive  approach  to  actually                                                               
improving  patient and  employee  safety as  well as  psychiatric                                                               
outcomes. They are  working with the accrediting  bodies, but the                                                               
accrediting bodies  have given them  no guarantees. This  is them                                                               
showing they are taking truly substantive steps.                                                                                
                                                                                                                                
SENATOR  STEVENS  said  then  they   had  more  time  to  address                                                               
certification and restated his question  about who is responsible                                                               
legally.                                                                                                                        
                                                                                                                                
MR. WALL  responded that this did  not give them more  time. They                                                               
are  still waiting  for  the CMS  report. They  could  get a  CMS                                                               
report  any day  that they  have been  decertified or  they could                                                               
receive  a report  that they  are  being conditionally  certified                                                               
under certain conditions.  They could also receive  a report that                                                               
says they are  certified with a plan of  correction. The contract                                                               
with  Wellpath takes  those eventualities  into account.  If they                                                               
are decertified,  their task is  to recertify them within  the 90                                                               
days CMS  window. If they are  not decertified, their task  is to                                                               
implement the plan  of correction and bring them  back into rapid                                                               
compliance. Decertification is a huge  issue, but they still have                                                               
the ombudsman report, the OSHA  violations, the Joint Commission,                                                               
and  another finding  by CMS.  This is  going to  be an  ongoing,                                                               
reiterative process.  He did  not think they  would be  given any                                                               
more extensions.                                                                                                                
                                                                                                                                
MR.   WALL  said   the  legal   responsibility  depends   on  the                                                               
circumstances--a  direct patient  care  issue, an  administration                                                               
issue. He would  refer to the Department of Law  for any specific                                                               
questions.                                                                                                                      
                                                                                                                                
CHAIR  WILSON asked  for clarification  about  the vacancies.  He                                                               
asked if  these are going  to be  state employees going  forth or                                                               
Wellpath employees. He  wanted to know more about  what was being                                                               
contracted.                                                                                                                     
                                                                                                                                
MR. WALL  replied that the contract  is in two phases.  The first                                                               
phase  includes the  deliverables he  showed earlier,  bring them                                                               
into  rapid compliance,  ensure  patient safety,  and prepare  to                                                               
have beds open by July 1.  If Wellpath meets those, then the next                                                               
phase  is privatization.  Between now  and that  period of  time,                                                               
state employees  will remain state  employees and they  are still                                                               
hiring. They want  as many applicants as they can  get. When they                                                               
segue into Wellpath  taking over, there will be a  plan in place.                                                               
He is having  ongoing conversations with union heads  and said he                                                               
would leave it at that.                                                                                                         
                                                                                                                                
SENATOR GIESSEL  asked if  the state  ombudsman would  still have                                                               
authority  to   do  investigations  if  API   was  contracted  to                                                               
Wellpath.                                                                                                                       
                                                                                                                                
COMMISSIONER  DESIGNEE   CRUM  referred   the  question   to  the                                                               
ombudsman.                                                                                                                      
                                                                                                                                
2:28:40 PM                                                                                                                    
KATE BURKHART,  Ombudsman, Office of the  Ombudsman, Alaska State                                                               
Legislature,  Juneau,   Alaska,  answered   that  with   the  way                                                               
commissioner and deputy commissioner  described it, the ombudsman                                                               
still has jurisdiction  over actions at the hospital,  but if the                                                               
hospital moves  into private  management with  private employees,                                                               
the ombudsman would not have jurisdiction.                                                                                      
2:29:32 PM                                                                                                                    
SENATOR BEGICH  said no one  doubts the seriousness of  the issue                                                               
and  its emergency  nature. He  asked whether  they were  already                                                               
thinking of privatization when the  National Association of State                                                               
Mental Health Program Directors was contacted on December 18.                                                                   
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM replied  that they were  reaching out                                                               
at  that  time because  they  did  not  have  an active  plan  of                                                               
correction accepted by CMS. As  they were scrambling, they looked                                                               
at  the lack  of leadership  at API  because there  were so  many                                                               
vacant positions,  so they  asked if  there were  contractors who                                                               
could at  least consult, help  with the plan of  correction, what                                                               
were other  options, could it  possibly be on  the administrative                                                               
services side. That  was the intent of the  conversation. At that                                                               
point he thought that he had been on the job two weeks.                                                                         
                                                                                                                                
SENATOR  BEGICH asked  if he  could  provide that  correspondence                                                               
with  the National  Association  of State  Mental Health  Program                                                               
Directors to the committee.                                                                                                     
                                                                                                                                
MR. WALL  answered the website  has the email  conversations with                                                               
the association.  Those are  after the  date of  initial contact,                                                               
which  was  by  telephone.  He  used   to  be  a  member  of  the                                                               
association,  so  he  called  their  fellows  to  ask  for  their                                                               
suggestions.                                                                                                                    
                                                                                                                                
SENATOR  BEGICH  said  he  noticed   the  contact  with  Wellpath                                                               
Recovery Solutions  was two days  later on December 20.  He asked                                                               
if  that was  before or  after Mr.  Wall began  to correspond  by                                                               
email with the national association.                                                                                            
                                                                                                                                
MR.  WALL replied  that was  prior to  email correspondence.  The                                                               
national association  took a while to  get back to him  by email.                                                               
He reiterated that his first  contact with Wellpath was not about                                                               
this issue.  The email on  December 20  was about health  care in                                                               
juvenile justice facilities.                                                                                                    
                                                                                                                                
SENATOR  BEGICH said  slide 2  referred to  pending legal  issues                                                               
with extreme risk of  high cost to the state. He  asked if he was                                                               
aware of the  two parent companies of Wellpath  having over 1,300                                                               
lawsuits filed against them in  the last decade and hundreds more                                                               
for Correct Care medical group.                                                                                                 
                                                                                                                                
COMMISSIONER  DESIGNEE  CRUM  deferred  to  representatives  from                                                               
Wellpath.                                                                                                                       
                                                                                                                                
SENATOR BEGICH  asked if those  representing the state  of Alaska                                                               
were aware of the lawsuits.                                                                                                     
                                                                                                                                
COMMISSIONER DESIGNEE CRUM  said they were aware of  those, but a                                                               
lot  of those  were  in prison  or  correctional facilities.  The                                                               
entire  focus of  Wellpath Recovery  Solutions is  on psychiatric                                                               
hospitals and behavioral  health issues. Wellpath representatives                                                               
can provide clarification on that.                                                                                              
                                                                                                                                
2:33:36 PM                                                                                                                    
JEREMY BARR,  Senior Vice President, Wellpath  Recovery Solution,                                                               
Nashville,  Tennessee, said  Wellpath  partners exclusively  with                                                               
state behavioral health agencies  to provide services to patients                                                               
like those  served at API. As  it relates to the  larger question                                                               
of litigation, they  are a division within  a larger organization                                                               
that provides health care services  in a variety of public health                                                               
settings. Some of  those are prisons and jail  settings. There is                                                               
a certain  amount of  litigation associated  with that.  The vast                                                               
majority of  those, more  than 90 percent,  are dismissed  out of                                                               
hand.  The  bulk   of  that  information  vs.   the  total  daily                                                               
population  across the  company, which  is about  a quarter  of a                                                               
million  patients, looks  like a  community emergency  room. When                                                               
they are compared to a like  health care system, because they are                                                               
a  health  care company,  the  incidents  of litigation  where  a                                                               
settlement is made  is less than a fourth of  what would be found                                                               
in a community ER setting.                                                                                                      
                                                                                                                                
SENATOR BEGICH asked how long Wellpath has been in existence.                                                                   
                                                                                                                                
MR. BARR  answered that Wellpath  was the combination  of Correct                                                               
Care Solutions  and Correctional Medical Group  Companies made in                                                               
October of last  year. Wellpath Recovery Solutions  was an entity                                                               
associated with Correct  Care Solution. As part of  the merger, a                                                               
new name was chosen that expressed  their vision as a health care                                                               
company.                                                                                                                        
                                                                                                                                
SENATOR BEGICH said  this was an $84 million  contract done under                                                               
emergency  procurement powers.  He asked  Mr.  Wall if  he got  a                                                               
legal  opinion   and  was  it   posted  online  with   the  other                                                               
information.                                                                                                                    
                                                                                                                                
MR. WALL answered yes to both questions.                                                                                        
                                                                                                                                
SENATOR BEGICH  said "temporary" is  ill defined in  the statute.                                                               
He asked  for his definition of  "temporary emergency." Emergency                                                               
procurement  is for  a temporary  period because  procurement law                                                               
requires competitive  bidding. Senator Begich wanted  to know Mr.                                                               
Wall's  sense of  "temporary" so  the committee  would know  what                                                               
"temporary" is.                                                                                                                 
                                                                                                                                
MR. WALL  said he had  learned a great  deal in this  process. He                                                               
used the wrong word in  certain places with procurement initially                                                               
and  then the  lawyers  straightened him  out.  Initially he  was                                                               
using "emergency,"  and they  were talking  single source,  so he                                                               
was using single  source emergency. He was using  the wrong words                                                               
for  it. He  recommended getting  clarification from  procurement                                                               
and attorneys  because they have  a written explanation of  it in                                                               
the packet,  but it  would behoove  them to  get them  a specific                                                               
answer.                                                                                                                         
                                                                                                                                
CHAIR WILSON asked him to provide that to the committee.                                                                        
                                                                                                                                
SENATOR BEGICH  said he was  looking at  a statement made  by the                                                               
commissioner, which  the deputy  commissioner repeated,  "if they                                                               
are  successful  in  the  first phase,  through  June  30,  2019,                                                               
Wellpath will  assume full  responsibility of  API after  July 1,                                                               
2019." He said he was  bringing that specific phrasing up because                                                               
it  sounds  like  they  move   from  some  temporary  procurement                                                               
responsibility  to  an actual,  long-term  action  that has  gone                                                               
through  no competitive  process,  has had  no  process that  the                                                               
procurement code  requires so that other  entities could consider                                                               
managing  this or  to see  whether they  could do  it within  the                                                               
state  service. He  asked  how they  can get  to  the point  five                                                               
months from  now, as part  of the  contract, in which  they would                                                               
take full responsibility of API without a competitive process.                                                                  
                                                                                                                                
COMMISSIONER DESIGNEE CRUM said that  when they reached out, they                                                               
had an immediate  crisis and found out Wellpath was  the only one                                                               
who  could  get  boots  on  ground. If  they  can  meet  the  key                                                               
deliverables in  four months  whereas the  state has  failed over                                                               
the  last  two  decades,  then  this is  the  company  they  want                                                               
managing this group.                                                                                                            
                                                                                                                                
SENATOR BEGICH responded that this  may be the company they want,                                                               
but this is  not what the law says. This  is really important for                                                               
them to  understand as commissioner  and deputy  commissioner. If                                                               
they bring API to a point  where there is no longer an emergency,                                                               
there  is a  procurement code  that is  statutory and  regulatory                                                               
that binds  them. He asked whether  they will be opening  this up                                                               
to competitive  bid or at least  do the work required  by statute                                                               
for   background   review  for   findings   of   fact  that   are                                                               
considerable. If they  look at the statute, they will  see that a                                                               
considerable  burden  is placed  upon  the  department for  these                                                               
kinds of actions.  While they may like  their performance, unless                                                               
they  craft a  contract  that is  specific  to that  performance,                                                               
there is a  state requirement that this goes  to competitive bid.                                                               
He  applauds  them  for dealing  with  the  emergency  situation,                                                               
although he questions a company  that may have existed only since                                                               
October, but  at the same  time, he was questioning  whether they                                                               
were abiding by the law of the state.                                                                                           
                                                                                                                                
2:41:51 PM                                                                                                                    
MR.  WALL responded  that he  greatly  appreciated his  question.                                                               
They have  a great deal of  respect for the law  and particularly                                                               
the procurement statutes.  There are more than  just that statute                                                               
that  they are  discussing. He  would like  to get  him a  legal,                                                               
written explanation of what the choice was when they made it.                                                                   
                                                                                                                                
CHAIR WILSON asked him to get that to the committee.                                                                            
                                                                                                                                
SENATOR BEGICH  said he understood  the choice that was  made. He                                                               
is  talking about  an  action on  July 1,  2019,  that under  the                                                               
procurement  code,  needs  to  be   a  competitive  process  with                                                               
findings of fact. That is what he was putting on the record.                                                                    
                                                                                                                                
CHAIR  WILSON clarified  that  they were  still  waiting for  the                                                               
final  letter from  CMS.  They  are not  out  of  woods with  the                                                               
current emergency situation  until they know the  findings in the                                                               
CMS letter.                                                                                                                     
                                                                                                                                
MR. WALL answered correct.                                                                                                      
                                                                                                                                
CHAIR WILSON said  they had a privatization study done  by the PC                                                               
Group  in  February 2017.  In  the  committee overview,  the  API                                                               
recommendation  was 18.1  nurses on  the floor  at all  times and                                                               
they  recommended   about  21.2   nurses  under   their  staffing                                                               
recommendations  and scenarios.  He  asked  whether Wellpath  was                                                               
providing recommended  staffing for nurses  or was there  still a                                                               
deficit of nurses to run the facility.                                                                                          
                                                                                                                                
MR.  WALL replied  that  they  still have  a  deficit of  nurses.                                                               
Wellpath's immediate focus is to  bring them into compliance with                                                               
CMS, to  ensure the safety  of patients,  and to prepare  for the                                                               
future, at which  time Wellpath will address  the staffing issue.                                                               
They  are still  recruiting and  Wellpath will  be recruiting  as                                                               
they move forward.  The instant workforce for  putting the nurses                                                               
on the ward  is something they will grow over  the next couple of                                                               
months.                                                                                                                         
                                                                                                                                
CHAIR WILSON  asked if that meant  that they are not  looking for                                                               
locum tenens  doctors or  agency nurses to  fill that  need, that                                                               
they  were  doing  overtime  with  the  current  nurses.  He  was                                                               
concerned about the staffing level of the nurses.                                                                               
                                                                                                                                
MR. WALL  answered that  he was  deeply concerned  about staffing                                                               
levels.  They  have  had  locum  agreements  for  some  time  for                                                               
positions that  they don't have  any applicants at all  for, like                                                               
forensic  psychologist,  like  a   psychiatrist.  They  have  had                                                               
psychiatrist positions vacant for years.  They tend to fill those                                                               
when  they  can  with   midlevel  practitioners,  advanced  nurse                                                               
practitioners with psychiatric specialty,  but they don't fit the                                                               
exact  PCN  in  the  classification structure.  They  are  trying                                                               
everything they  can to  get new staff  on the  ground, including                                                               
locums.                                                                                                                         
                                                                                                                                
CHAIR  WILSON  said  the privatization  study  talked  about  the                                                               
benefits   and  drawbacks   of   comprehensive  outsourcing.   He                                                               
mentioned concerns about  a reduction of staffing  levels to save                                                               
money as part of privatization. They  have had a number of emails                                                               
about  safety, a  lot  of  it regarding  staffing  levels of  the                                                               
nurses. API is  a huge part of their  behavioral health continuum                                                               
in Alaska.  Another concern with  privatization was  having those                                                               
key  partnerships  with  local   community  hospitals  and  local                                                               
providers.  He asked  if they  could provide  a statement  to the                                                               
committee addressing those issues.                                                                                              
                                                                                                                                
MR. WALL said they would provide  a statement on those issues. He                                                               
wanted to point out that  would be updating the feasibility study                                                               
to the level that they can with the time they have.                                                                             
                                                                                                                                
CHAIR  WILSON said  he appreciated  the transparency  from having                                                               
the  different communications  on the  website. He  asked if  the                                                               
copy of the contract was on the website.                                                                                        
                                                                                                                                
MR. WALL answered yes.                                                                                                          
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM said that  API is such a  focal point                                                               
for the  entire rest  of the  system. As he  has sat  in meetings                                                               
with the Alaska Native Health  Board and the Alaska Mental Health                                                               
Trust Board, board members have told  him that the state must fix                                                               
API as soon  as possible so they  can move the focus  to the rest                                                               
of  the  system  of  care.  There  has  been  such  a  vacuum  of                                                               
attention. API is  absorbing all of this. It is  a bottleneck for                                                               
the rest  of the system. It  places an undue burden  on emergency                                                               
departments, on  their local partners.  A number of  key partners                                                               
supported  them  with  this  decision. This  will  give  them  an                                                               
opportunity  to   address  the  entire  continuum   of  care  for                                                               
behavioral health.  He did not  want it to  come at it  with this                                                               
rapid  pace, but  with Immediate  Jeopardy and  these items  that                                                               
popped up right away, he had to step in.                                                                                        
                                                                                                                                
2:49:09 PM                                                                                                                    
There being  no further  business to  come before  the committee,                                                               
Chair  Wilson adjourned  the Senate  Health  and Social  Services                                                               
Standing Committee at 2:49 p.m.                                                                                                 
                                                                                                                                

Document Name Date/Time Subjects
API Presentation Feb 13 2019.pdf SHSS 2/13/2019 1:30:00 PM
DHSS Briefing on Alaska Psychiatric Institute