Legislature(2019 - 2020)BELTZ 105 (TSBldg)

02/07/2019 01:30 PM LABOR & COMMERCE

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Moved SB 36 Out of Committee
-Invited Testimony Followed by Public Testimony-
Moved SB 29 Out of Committee
-Invited Testimony Followed by Public Testimony-
Moved SB 25 Out of Committee
-Invited Testimony Followed by Public Testimony-
                 SB 36-EXTEND BOARD OF NURSING                                                                              
1:32:50 PM                                                                                                                    
CHAIR REINBOLD announced  that the first order  of business would                                                               
be SENATE BILL NO. 36, "An  Act extending the termination date of                                                               
the Board of Nursing; and providing for an effective date."                                                                     
CHAIR REINBOLD  stated her intention to  move SB 36 if  it is the                                                               
will  of  the  committee.  She solicited  a  motion  and  Senator                                                               
Costello made a  clarifying motion to bring  the original version                                                               
before the committee.                                                                                                           
SENATOR BISHOP objected for discussion purposes.                                                                                
1:33:59 PM                                                                                                                    
SENATOR CATHY GIESSEL, Alaska State  Legislature, said she wanted                                                               
to declare that  she does not have a conflict  of interest as the                                                               
sponsor  of  SB 36.  She  explained  that  she has  two  licenses                                                               
regulated by  the Board  of Nursing,  but she  will not  gain any                                                               
benefit or  harm in sponsoring  this bill. The board's  charge is                                                               
to protect  the public through  safe practice of nursing,  not to                                                               
protect her licenses in any way.                                                                                                
She related her understanding that  the Legislative sunset review                                                               
audit is  in members' packets.  She directed attention to  page 7                                                               
of the  audit, related to  licensing activity for the  board from                                                               
FY  15-18. She  said  she  served two  terms  on  this board  and                                                               
chaired this board  for five years. The total  number of licenses                                                               
at the end  of January 2018 is nearly 20,000.  She estimated that                                                               
when she was  chair, the total number of licensees  for the Board                                                               
of Nursing  represented about 25  percent of the  total licensees                                                               
regulated by the state and she  is not certain if that percentage                                                               
has changed.                                                                                                                    
SENATOR  GIESSEL   pointed  out  that  the   board  oversees  six                                                               
categories  of licenses.  She listed  them: Certified  Nurse Aide                                                               
(CNA),   Advanced   Nurse  Practitioner   Preceptorship   (ANPP),                                                               
Advanced Practice  Registered Nurse (APRN),  Certified Registered                                                               
Nurse  Anesthetist (CRNA),  Licensed Practical  Nurse (LPN),  and                                                               
Registered Nurse (RN).                                                                                                          
She  said  the  Board  of  Nursing  regulates  the  most  diverse                                                               
population  of   licensees.  Each  category  on   this  list  has                                                               
different  education  and  training requirements  for  licensure,                                                               
ranging  from high  school to  a doctoral  degree. She  said that                                                               
this  is a  huge task.  For example,  the CNA  is an  entry level                                                               
position and  for certification,  a CNA must  have a  high school                                                               
diploma, undergo training for several months, and pass an exam.                                                                 
SENATOR GIESSEL  said the audit  report highlights some  gaps the                                                               
board needs  to address. One  gap the auditor identified  was the                                                               
need to better  monitor the CNA programs, another  gap related to                                                               
nursing  services   being  provided  via  distance   delivery  or                                                               
telemedicine. The nursing profession  also refers to telemedicine                                                               
as telehealth. During the time  she chaired the Board of Nursing,                                                               
the board felt that this authority  had already been given to the                                                               
Advanced Practice Registered Nurses  (APRNs). In fact, APRNs have                                                               
been  providing telehealth  services  since the  late 1990s,  she                                                               
said.  In 1998,  an APRN  conducted a  model or  test program  in                                                               
Girdwood   using  telemedicine.   Avalanches  often   cause  road                                                               
closures  and limit  travel between  Anchorage and  Girdwood, she                                                               
said.  If a  skier had  an  injury, using  telemedicine the  APRN                                                               
could  transmit the  skier's X-ray  to an  orthopedic surgeon  in                                                               
Anchorage,  who  would suggest  treatment.  This  same APRN  also                                                               
began a  clinic in Hope,  a small community across  Turnagain Arm                                                               
that did not  have health care services.  Using telemedicine, the                                                               
clinic communicated  telephonically and  via computer  imaging to                                                               
provide  medical  services to  Hope.  Until  recently, the  board                                                               
thought it had the authority  to authorize telemedicine services.                                                               
She suggested that members may  wish to ask the board's executive                                                               
administrator how the board is progressing on telemedicine.                                                                     
1:40:17 PM                                                                                                                    
SENATOR BIRCH  asked for further clarification  on the difference                                                               
in training and qualifications for nurses and paramedics.                                                                       
SENATOR GIESSEL responded  that RNs are educated to  care for the                                                               
"entire" person,  and either  are diploma  graduates with  a two-                                                               
year college degree or have  earned a bachelor's degree. She said                                                               
that  RNs  can  practice  in   hospitals  or  clinics  and  their                                                               
practices range  from orthopedic  care to  obstetrics. Paramedics                                                               
have  extensive  and intensive  training,  are  regulated by  the                                                               
State  Medical Board,  and have  focused  education on  emergency                                                               
medical situations. She described  the difference that paramedics                                                               
provide very urgent care and  RNs provide long-term global health                                                               
care and public health nursing services.                                                                                        
1:41:42 PM                                                                                                                    
KRIS  CURTIS, Legislative  Auditor,  Legislative Audit  Division,                                                               
Legislative Agencies and Offices,  related the division conducted                                                               
a sunset audit on the Board of Nursing [Audit Control Number 08-                                                                
20113-18].  She explained  the purpose  of a  sunset audit  is to                                                               
determine whether a  board or commission is  serving the public's                                                               
interest  and if  its termination  date should  be extended.  The                                                               
legislative  audit  determined  that  the  Board  of  Nursing  is                                                               
serving  the   public's  interest   by  conducting   meetings  in                                                               
accordance  with state  law, by  amending certain  regulations to                                                               
improve  the  CNA and  nursing  occupations,  and by  effectively                                                               
licensing CNAs  and nurses.  The audit  also determined  that the                                                               
board failed to serve the  public's interest because it failed to                                                               
establish telehealth regulations, did  not adequately monitor the                                                               
CNA  training program,  and did  not notify  appropriate entities                                                               
when a licensee's prescription  authority was suspended, revoked,                                                               
or  surrendered.  The  audit determined  that  improvements  were                                                               
needed   with   the   Division  of   Corporation,   Business,   &                                                               
Professional Licensing's (DCBPL)  investigative process. She said                                                               
the  auditors  recommend  the legislature  extend  the  Board  of                                                               
Nursing for six years.                                                                                                          
She  remarked  Senator  Giessel already  reviewed  the  licensing                                                               
statistics.  She directed  attention  to page  11  of the  sunset                                                               
audit to  the schedule of  revenues and expenditures.  This board                                                               
had a  deficit of $337,000  at the end  of March 2018,  she said.                                                               
According to DCBPL's  management, a fee analysis  was planned for                                                               
May 2018. She  directed attention to the board's  license fees on                                                               
page 12 for more detail.                                                                                                        
MS.   CURTIS  said   page   14  of   the   audit  included   four                                                               
recommendations  for  improvements.  Audit Recommendation  No.  1                                                               
recommended  that  the board  adopt  regulations  to address  the                                                               
distance delivery  of nursing  services through  technology, also                                                               
referred to  as telehealth. In  FY 15, a licensee  approached the                                                               
board requesting  guidance to  provide telehealth  services. This                                                               
prompted the  board to issue  an advisory opinion,  which defined                                                               
telehealth  and  provided  limited   guidance  on  the  scope  of                                                               
practice.  However, this  guidance was  insufficient to  promote,                                                               
preserve or protect  the public health, safety,  and welfare, she                                                               
said.  Although  the  board discussed  the  need  for  telehealth                                                               
regulations,  it  could  not agree  on  the  specific  regulatory                                                               
language. Providing insufficient  guidance to licensees increases                                                               
the risk  that nurses  may not  maintain acceptable  standards of                                                               
practice and may not adequately protect patient confidentiality.                                                                
She said  Recommendation No. 2 asked  the board to take  steps to                                                               
ensure  that  the  appropriate   entities  are  notified  when  a                                                               
licensee's  prescription  authority   is  suspended,  revoked  or                                                               
surrendered.  The  audit identified  eight  APRNs  who had  their                                                               
prescription authority  revoked or surrendered between  the dates                                                               
of July  2014 through January 2018.  In all cases, the  board did                                                               
not  notify  the Board  of  Pharmacy  or  the federal  DEA  [Drug                                                               
Enforcement Agency]  about the  licensing action.  These entities                                                               
were not  notified because the  statutes or regulations  were not                                                               
in place to  require the notification. Failure to  notify the DEA                                                               
or  the Board  of  Pharmacy increases  the  risk that  controlled                                                               
substances are abused or diverted, she said.                                                                                    
1:44:54 PM                                                                                                                    
MS.  CURTIS referred  to page  15  to Recommendation  No. 3.  The                                                               
audit  recommended that  the  DCBPL's  chief investigator  ensure                                                               
nurse  investigations  are  adequately documented  and  performed                                                               
timely.  The audit  identified 273  cases  that were  open for  a                                                               
period of more  than 180 days. The auditors found  that 13 of the                                                               
28 cases it  reviewed had unjustified periods  of inactivity that                                                               
ranged from 61  days to 3.6 years. The delays  were mainly caused                                                               
by  investigative staff  turnover and  competing priorities.  The                                                               
auditors also  found two licensees  who had been  recommended for                                                               
investigation  by the  Long-term  Care  Ombudsman as  potentially                                                               
practicing outside  their scope  of practice. Auditors  could not                                                               
evaluate  these cases  due  to  a lack  of  documentation in  the                                                               
files.  However, auditors  did  note that  these  cases had  been                                                               
placed in storage for 1.5 years  due to an office remodel and did                                                               
not  progress  during  that  time.   One  of  the  two  licensees                                                               
continued  to practice  during the  4 years  that the  cases were                                                               
outstanding, potentially posing a risk to public safety.                                                                        
1:46:08 PM                                                                                                                    
MS. CURTIS  referred to  page 16 to  Recommendation No.  4, which                                                               
recommends  the  board  chair  take  steps  to  ensure  that  the                                                               
required  Certified  Nurse  Aide (CNA)  onsite  training  program                                                               
reviews and self-evaluations are  conducted prior to re-approving                                                               
the programs.  The regulations require the  CNA training programs                                                               
be "board approved" every two  years with an onsite review. Self-                                                               
evaluations are  required in the  year that the onsite  review is                                                               
not conducted. The  audit found the onsite reviews  and the self-                                                               
evaluation  forms  were  not being  conducted  during  the  audit                                                               
period.  According  to  board  staff,  the  onsite  reviews  were                                                               
performed by  a contractor who was  terminated in FY 14  due to a                                                               
conflict  of interest.  The  procurement process  to  hire a  new                                                               
contractor was  not successful. Eventually the  division was able                                                               
to  re-designate  a PCN  [Position  Control  Number] as  a  nurse                                                               
consultant position, hired and trained  a person, and the reviews                                                               
resumed in  the spring  of 2016. The  board continued  to approve                                                               
these  training programs  due to  the  need for  the programs  to                                                               
continue to be available to train CNAs.                                                                                         
She  said that  responses to  this audit  begin on  page 27.  The                                                               
department stated that procedures  had been implemented to notify                                                               
the Board of  Pharmacy and the federal DEA  when the prescription                                                               
authority  has been  revoked  or  surrendered. Additionally,  the                                                               
department stated  it has instituted  procedures to  help improve                                                               
the timeliness of investigations.                                                                                               
MS. CURTIS said the board's response  to the audit begins on page                                                               
29. The board agreed with  all four recommendations and stated it                                                               
will take corrective actions. The  board also stated it will work                                                               
on the telehealth regulations at its November 2018 meeting.                                                                     
1:48:00 PM                                                                                                                    
CHAIR REINBOLD  asked for further  clarification on  the $337,000                                                               
deficit for license fees.                                                                                                       
MS. CURTIS  said the  audit does not  have any  recommendation on                                                               
fees. She noted  that the board has operated in  a surplus except                                                               
for this  year. The  way the  statute reads,  the board  must set                                                               
license  fees  to cover  its  operating  costs. This  results  in                                                               
alternating years of  deficit with increased fees,  followed by a                                                               
surplus with decreased fees. Unless  auditors see a pattern arise                                                               
in  which  the  board  fails  to increase  fees  when  the  board                                                               
routinely   has  deficits,   the  auditors   will  not   write  a                                                               
recommendation and will allow the process to carry out.                                                                         
CHAIR REINBOLD asked for the next  audit date to follow up on the                                                               
audit recommendations.                                                                                                          
MS. CURTIS answered  that it depends on how  long the legislature                                                               
extends  the termination  date.  If SB  36 were  to  pass in  its                                                               
current form,  it would extend the  board for six years,  and the                                                               
legislative  auditors will  conduct another  sunset audit  in six                                                               
1:49:22 PM                                                                                                                    
SENATOR COSTELLO  asked if the division  takes into consideration                                                               
the  board's  response to  the  audit  when  the agency  makes  a                                                               
recommendation for  the length of  time to extend the  board. She                                                               
said six  years seemed like a  long time, but it  seemed that the                                                               
Division  of  Legislative  Audit received  information  that  the                                                               
board agrees  with the  audit recommendations  and is  willing to                                                               
address the concerns.                                                                                                           
MS. CURTIS answered  that the division relies  on the legislative                                                               
oversight  process and  the  committee process  in  terms of  the                                                               
legislature holding  the board and  the division  accountable for                                                               
implementing any recommendations and  determining the status. She                                                               
said that  a lag time  of eight  to ten months  typically happens                                                               
between the audit  and the legislative review.  During that time,                                                               
the board has an opportunity  to take corrective action. She said                                                               
the Division of  Legislative Audit does not have  a standard, but                                                               
its auditors review prior recommendations  during the next sunset                                                               
audit to determine  how well the board has  implemented them. She                                                               
said the  2010 sunset  audit had  four recommendations,  three of                                                               
which are still outstanding.                                                                                                    
CHAIR REINBOLD  said she read  the board's letter that  the board                                                               
agreed with all  four recommendations and indicated  it will take                                                               
corrective  action. She  said  she was  very  impressed with  the                                                               
board's response.                                                                                                               
1:50:56 PM                                                                                                                    
SENATOR GIESSEL  referred to the  budget report on page  14 dated                                                               
March 2018.  In November 2018  most license renewals are  due and                                                               
"a glut" of revenue will be collected.                                                                                          
1:51:52 PM                                                                                                                    
CHAIR REINBOLD opened  public testimony on SB 36  and after first                                                               
determining no one wished to  testify, closed public testimony on                                                               
SB 36.                                                                                                                          
1:54:03 PM                                                                                                                    
SENATOR GIESSEL  said she urged  the board  to act on  two items,                                                               
including  monitoring the  CNA  program.  The federal  government                                                               
supplies  $100,000 per  year to  fund a  position to  examine the                                                               
program. She  acknowledged it does involve  travel throughout the                                                               
state. She emphasized that the  board needs to fill the position.                                                               
She will  hold the board's "feet  to the fire" on  telehealth and                                                               
the auditor mentioned the division will also monitor it.                                                                        
1:54:43 PM                                                                                                                    
SENATOR BISHOP removed his objection.                                                                                           
1:54:54 PM                                                                                                                    
SENATOR BISHOP  reviewed the fiscal  note from the  Department of                                                               
Commerce,  Community   and  Economic  Development   (DCCED).  The                                                               
appropriation is  to the Division of  Corporations, Business, and                                                               
Professional  Licensing, the  allocation  is to  the Division  of                                                               
Corporations, Business,  and Professional Licensing, and  the OMB                                                               
component  number is  2360. The  bill would  extend the  Board of                                                               
Nursing until  June 30, 2025.  The source of the  total operating                                                               
costs of  $28,400 are designated  general fund (DGF)  dollars. He                                                               
reviewed  the breakdown  of expenditures:  $26,000  is for  seven                                                               
board members and one examiner  to travel to board meetings, $400                                                               
is for advertising,  $1,000 is for training  and conference fees,                                                               
and $100 is for stipends.                                                                                                       
1:56:31 PM                                                                                                                    
SENATOR  COSTELLO moved  to report  SB  36, Version  31-LS0314\A,                                                               
from  committee  with  individual  recommendations  and  attached                                                               
fiscal note.  There being no  objection, SB 36 was  reported from                                                               
the Senate Labor and Commerce Standing Committee.                                                                               

Document Name Date/Time Subjects
SB36 Ver. A.PDF HL&C 4/24/2019 3:15:00 PM
SL&C 2/7/2019 1:30:00 PM
SB 36
SB36 Sponsor Statement 1-28-19.pdf HL&C 4/24/2019 3:15:00 PM
SFIN 3/1/2019 9:00:00 AM
SL&C 2/7/2019 1:30:00 PM
SB 36
SB36 Fiscal Note - SB036-DCCED-CBPL-02-01-19.pdf HL&C 4/24/2019 3:15:00 PM
SL&C 2/7/2019 1:30:00 PM
SB 36
SB36 Supporting Document Division of Legislative Audit Sunset Review April 2017.pdf HL&C 4/24/2019 3:15:00 PM
SFIN 3/1/2019 9:00:00 AM
SL&C 2/7/2019 1:30:00 PM
SB 36
SB36 Supporting Document Division of Legislative Audit Sunset Review Summary 08-20113-18.pdf SFIN 3/1/2019 9:00:00 AM
SL&C 2/7/2019 1:30:00 PM
SB 36
SB29 Version A.PDF SL&C 2/7/2019 1:30:00 PM
SB 29
SB29 Sponsor Statement Version A.pdf SFIN 3/1/2019 9:00:00 AM
SL&C 2/7/2019 1:30:00 PM
SB 29
SB29 Supporting Document Division of Legislative Audit Board of Marine Pilots Sunset Review.pdf SFIN 3/1/2019 9:00:00 AM
SL&C 2/7/2019 1:30:00 PM
SB 29
SB 29 - Letter of Support SEAPA.pdf HL&C 4/24/2019 3:15:00 PM
SL&C 2/7/2019 1:30:00 PM
SB 29
SB29 Fiscal Note - SB029-DCCED-CBPL-02-01-19.pdf SL&C 2/7/2019 1:30:00 PM
SB 29
SB25 Version A.PDF SL&C 2/7/2019 1:30:00 PM
SB 25
SB25 Sponsor Statement.pdf SFIN 3/1/2019 9:00:00 AM
SL&C 2/7/2019 1:30:00 PM
SB 25
SB25 Letter of Support ADS.pdf SL&C 2/7/2019 1:30:00 PM
SB 25
SB25 Board of Dental Examiners Division of Legislative Audit Sunset Review.pdf SL&C 2/7/2019 1:30:00 PM
SB 25
SB25 Fiscal Note - SB025-DCCED-CBPL-02-01-19.pdf SL&C 2/7/2019 1:30:00 PM
SB 25